Substance misuse

Alcohol Misuse

Chronic alcohol dependence: Characterized by a strong desire to drink, difficulty controlling alcohol use, and withdrawal symptoms on cessation.
Alcohol withdrawal syndrome: Symptoms include tremors, agitation, seizures, and delirium tremens, typically occurring within hours to days of cessation in a dependent individual.
Alcohol-related liver disease: Ranges from fatty liver to alcoholic hepatitis and cirrhosis, often presenting with jaundice, ascites, and hepatic encephalopathy.
Wernicke-Korsakoff syndrome: Thiamine deficiency related to chronic alcohol use, presenting with confusion, ataxia, and ophthalmoplegia (Wernicke’s encephalopathy), progressing to memory loss and confabulation (Korsakoff’s syndrome).
Alcoholic cardiomyopathy: Heart failure secondary to chronic alcohol misuse, presenting with dyspnoea, fatigue, and peripheral edema.
Alcoholic neuropathy: Peripheral nerve damage caused by chronic alcohol misuse, presenting with numbness, tingling, and weakness in the extremities.
Gastrointestinal issues: Includes gastritis, pancreatitis, and esophagitis related to alcohol misuse.

Drug Misuse

Opiate misuse: Includes heroin and prescription opioids, with signs of dependence, withdrawal (e.g., myalgia, nausea, agitation), and risk of overdose (respiratory depression, miosis).
Stimulant misuse: Includes cocaine, amphetamines, MDMA, presenting with euphoria, increased energy, but also paranoia, psychosis, cardiovascular complications (e.g., myocardial infarction, stroke).
Cannabis misuse: Chronic use may lead to cognitive impairment, motivation loss, and, in some cases, cannabis hyperemesis syndrome or exacerbation of mental health conditions.
Benzodiazepine misuse: Sedative dependence with withdrawal symptoms including anxiety, insomnia, seizures, and in severe cases, withdrawal delirium.
Hallucinogen misuse: Includes LSD, psilocybin, which may cause acute psychological effects (e.g., hallucinations, paranoia) and, rarely, persistent psychosis or flashbacks (hallucinogen persisting perception disorder).
Inhalant misuse: Abuse of volatile substances (e.g., glue, aerosols) leading to acute euphoria, but also neurological damage, respiratory complications, and sudden death from arrhythmias.
New psychoactive substances (NPS): Synthetic drugs with unpredictable effects, including synthetic cannabinoids, stimulants, and hallucinogens, associated with acute toxicity, seizures, and psychiatric complications.

Substance Use History

Type and amount: Document the substances used, frequency, quantity, route of administration, and duration of use.
Onset and triggers: Explore when and why substance use began, including any associated stressors or mental health issues.
Attempts to quit: Previous attempts to reduce or cease use, including withdrawal symptoms experienced and any treatments tried.
Impact on life: Assess the impact on work, relationships, physical and mental health, and legal issues related to substance use.
High-risk behaviours: Include sharing needles, unprotected sex, or driving under the influence, which may indicate risk of harm.
Concurrent mental health issues: Screen for anxiety, depression, psychosis, or other psychiatric conditions, as these are commonly co-morbid with substance misuse.

Background

Medical history: Chronic conditions exacerbated by substance misuse (e.g., liver disease, respiratory conditions, HIV/HCV status in IV drug users).
Family history: Family history of substance misuse or psychiatric disorders that may indicate a genetic predisposition.
Social history: Housing stability, employment status, support networks, and any legal or financial issues that may impact treatment.
Drug history: Current medications, adherence, and any interactions or contraindications related to substance misuse.
Childhood trauma: History of childhood abuse, neglect, or other traumatic experiences that may contribute to substance misuse.

Laboratory Tests

Liver function tests (LFTs): To assess for alcohol-related liver disease or hepatotoxicity from substances like paracetamol.
Full blood count (FBC): To check for anaemia, infection, or thrombocytopenia, which may indicate chronic alcohol misuse or IV drug use complications.
Urine drug screen: To identify substances currently being used and guide management, especially in acute settings.
Electrolytes and renal function: To assess for electrolyte disturbances or renal impairment, often seen in chronic alcohol or drug misuse.
Infectious disease screening: HIV, hepatitis B and C, especially in those with a history of IV drug use.
Thiamine levels: Often deficient in chronic alcoholics, predisposing to Wernicke-Korsakoff syndrome.
Toxicology screen: In cases of suspected overdose or poisoning to identify and quantify specific toxins.

Imaging and Specialist Tests

Chest X-ray: In IV drug users to check for signs of pulmonary infection, tuberculosis, or embolic disease.
ECG: To detect arrhythmias or myocardial infarction, which may be precipitated by substances like cocaine or amphetamines.
Ultrasound liver: For those with suspected alcohol-related liver disease, to assess for cirrhosis or hepatomegaly.
CT/MRI brain: If there is concern for intracranial pathology such as stroke, haemorrhage, or cerebral atrophy in chronic alcohol misuse.
Dual-energy X-ray absorptiometry (DEXA): In chronic alcoholics to assess bone density and screen for osteoporosis.
Psychiatric assessment: Comprehensive assessment by a mental health professional to evaluate co-morbid psychiatric disorders and guide management.
Hepatic ultrasound: To assess for fatty liver, fibrosis, or cirrhosis in patients with a history of chronic alcohol misuse.

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