The First 72 Hours in Custody: Intake Screening, Withdrawal and Escalation

By Kanwar Partap Singh Gill, MD · Family medicine physician · 5 November 2026

• Why the first days carry concentrated risk
• What receiving screening is meant to capture
• Verifying community medications
• Recognizing withdrawal at the generalist level
• Monitoring and escalation thresholds
• Two sets of eyes: custody and health staff
• What the record usually contains, and what it often lacks
• Which standard, which edition
• Where this review ends
• What a fair review can conclude
• What a review of this issue can deliver

Why the first days carry concentrated risk

People arrive in jail intoxicated or already in withdrawal, with medications interrupted at the moment of arrest, with injuries no one has examined, and usually without records. The person doing the initial screen may have minutes, an incomplete history and a patient who is frightened, impaired or unwilling to talk. Meanwhile several of the most dangerous conditions in custody declare themselves on a schedule. Alcohol withdrawal commonly begins within hours to a day of the last drink, and its most serious complications follow a recognizable course: seizures most often within about 6 to 48 hours, and delirium typically 48 to 96 hours after the last drink. Benzodiazepine withdrawal can begin later, depending on the drug, and can also cause seizures. Opioid withdrawal is rarely fatal by itself but becomes dangerous through vomiting, diarrhea, dehydration and electrolyte loss, and through its capacity to mask or be mistaken for other illness.

This article describes how a physician reviews that period from the vantage of front-line jail medicine. Dr. Gill's clinical experience includes several years as a staff physician in county jail medical care: intake and sick-call medicine, medication continuity, care of seriously ill patients in a jail medical unit, and decisions to send patients to the hospital. The review addresses the generalist's clinical questions; specialist causation and legal conclusions belong elsewhere.

What receiving screening is meant to capture

In California local detention facilities, Title 15 §1207 addresses medical receiving screening at intake. Whatever form a facility uses, the screen has a narrow and essential job: to identify, at the door, the people who need clinical attention sooner than routine processes would provide it. A typical screen asks about current medications, chronic conditions, recent substance use (substance, amount, time of last use), prior withdrawal seizures or delirium, pregnancy, injury, and mental-health and suicide risk, and records the screener's own observations.

The screen is a triage instrument, not an examination. Its essential output is a disposition: routine processing, expedited clinician review, placement under medical observation, or referral for outside evaluation before the person is accepted. A reviewer looks at that disposition first, then asks whether it fit the answers recorded and what the screener observed. "Denies" in a screening field means the person said no at that moment, to that question, in that state. It is information, not clearance.

Who performed the screen matters. Depending on the facility, it may be completed by health staff or by trained custody staff, and the same answer carries different weight depending on who asked and what that person could do next. Public audits have examined this stage: California State Auditor Report 2021-109, which reviewed in-custody deaths in one county's jail system, reported findings on intake screening, follow-up care and records.

Verifying community medications

A reported medication is a claim; a verified medication is a fact a clinician can act on. Verification may come from a community pharmacy, the prescriber's office, outside records, a state prescription-monitoring database or medications brought in at booking. Each takes time, and the clock matters most for drugs whose interruption causes harm within days: insulin, antiseizure medications, anticoagulants, some cardiac and psychiatric medications, HIV therapy and medications for opioid use disorder.

The review looks for the interval from screening to clinician review, whether a bridge order was written while verification was pending, how nights and weekends were handled, and whether the medication administration record shows doses actually given. A Friday-night booking with a Monday-morning clinician review is a familiar pattern; whether that interval was clinically acceptable depends on the drug, the patient and the interim measures available. Title 15 §1216 addresses pharmaceutical management, and the BJA/NCCHC guidelines discuss continuing medications for opioid use disorder; both frame the questions without answering them for a given patient.

Recognizing withdrawal at the generalist level

Withdrawal is recognized through history, observation and repeated measurement. Standardized scales such as the CIWA-Ar for alcohol and the COWS for opioids turn observations (tremor, sweating, agitation, pupil size, heart rate, gastrointestinal symptoms) into scores that can be compared across shifts. A score is only as reliable as its scoring: who performed it, how often, whether the patient was awake and cooperative, and whether the scorer was trained to use the scale.

Most jails manage withdrawal through protocols: standing orders that let nursing staff begin monitoring and certain treatments, with defined thresholds at which a clinician must be called. Title 15 §1213 addresses detoxification treatment. The 2023 Guidelines for Managing Substance Withdrawal in Jails, published by the Bureau of Justice Assistance with NCCHC, address screening, standardized assessment, monitoring and escalation for several substances, including alcohol, opioids and benzodiazepines. They are a useful reference for what a protocol is meant to accomplish, but they do not by themselves establish what was required at a particular facility on a particular date.

Monitoring and escalation thresholds

The clinical question at every assessment is whether the patient can be managed safely where he or she is. Escalation to a clinician, and from the facility to a hospital, is typically prompted by rising scores despite treatment; abnormal vital signs, especially persistent tachycardia, fever or marked hypertension; hallucinations, confusion or disorientation; a seizure; inability to keep down fluids or medication; and signs of a co-occurring illness.

That last category is where generalist judgment matters most. Withdrawal can mimic or mask low blood sugar, head injury, infection, gastrointestinal bleeding, liver failure and intoxication with another substance. A patient whose "withdrawal" does not follow the expected course may have something else, or something more. Medications such as beta-blockers can blunt the heart-rate and tremor responses that scales and clinicians rely on. The reviewer asks whether the record shows that alternatives were considered when the picture did not fit.

The reviewer reads trends rather than single values; three moderate scores rising over twelve hours may say more than one high score. The decision to escalate is also kept apart from its execution: the time a clinician decided to send a patient out, the time transport was requested and the time the patient left are different clocks, and delay between them is a separate question from the clinical decision.

Two sets of eyes: custody and health staff

In the first days, custody officers often see a patient more often than health staff do. Their safety checks, housing logs and incident reports may record vomiting, refusal of food, shaking, a fall or a patient who will not respond. Whether those observations reached health staff is often the hinge of a case. The review asks what officers were expected to report and how, whether a report appears in the health record, and what response followed.

Housing matters as well: a sobering cell, a medical observation cell and general housing offer different monitoring. Dr. Gill can address the clinical significance of the observations recorded and of the monitoring each location could provide. Custody procedures, staffing and training are questions for a corrections-operations specialist.

What the record usually contains, and what it often lacks

After an in-custody death, further review documents may exist under California's in-custody death requirements for local detention facilities (15 CCR §1046, as amended effective July 1, 2024) and the Director of In-Custody Death Review established under Penal Code §6034. Whether such materials are available or discoverable in a matter is a question for counsel.

Which standard, which edition

The sources that bear on intake and withdrawal serve different purposes. Title 15 sets California's minimum standards for local detention facilities. NCCHC's Standards for Health Services in Jails are accreditation standards: the 2026 edition is required for accreditation from January 1, 2026, and for earlier events the edition then in effect, typically the 2018 edition, is the relevant reference. The BJA/NCCHC withdrawal guidelines date from 2023. Applying a later edition to an earlier event is a common error; the AMA's ethics opinion on medical testimony points physicians to the standards prevailing when the care occurred.

The legal frameworks are separate again. For convicted prisoners, Estelle v. Gamble addresses deliberate indifference to serious medical needs and holds that malpractice does not become a constitutional violation merely because the patient is a prisoner. For pretrial detainees, Ninth Circuit Model Civil Jury Instruction 9.34 sets out objective elements based on 2018 Ninth Circuit authority. A departure from a protocol is not automatically malpractice or a constitutional violation. Those questions belong to counsel and the tribunal. The physician addresses the clinical facts: what the record showed about the patient's condition, what clinical options existed in that setting, what was done, and when.

Where this review ends

What a fair review can conclude

Reviews of this period can support the care provided. A screen that captured the risk, a protocol started promptly, scores repeated as ordered, a clinician called when thresholds were crossed and a timely transfer when the patient worsened: that record supports a favorable finding even when the outcome was bad, because withdrawal and co-occurring illness can progress despite appropriate care. A review may equally find that a disclosed risk never reached a clinician, that monitoring lapsed overnight, or that deterioration was logged by officers but never assessed by health staff. Often it finds a sound protocol inconsistently carried out, with gaps the record cannot explain. Each conclusion is stated with its evidence and limits.

What a review of this issue can deliver

An intake-to-escalation chronology for the first days of custody, with each event's clock and source; a comparison of what the facility's protocol required with what the record shows; an analysis of when a higher level of care became clinically indicated; and a list of records still needed, from flowsheets to custody logs. This work forms part of Correctional Medicine and Jail Healthcare Review, with medication questions covered in Medication Continuity and Transitions of Care. A related scenario appears in the scenario library.