Psychiatry: Alcohol, drugs and addiction

🍺 Alcohol, drugs and addiction -substance misuse affects every specialty: alcohol withdrawal on surgical wards, opioid users with abscesses or endocarditis, cocaine chest pain in the emergency department. Key skills are a non-judgemental history, recognising and safely treating withdrawal, giving thiamine to prevent Wernicke's encephalopathy, and continuing opioid substitution safely in hospital.
Your four questions for every patient: What, how much, how often, and by what route? Is the person dependent (and at risk of withdrawal)? Are there complications (physical, mental, social, blood-borne viruses)? Are they ready to change, and who else is at risk (children, partners)?

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Substance Misuse -Overview

• Harmful use -a pattern of use that is damaging physical or mental health (or, in ICD-11, harming others).
• Dependence (ICD-11) -a strong internal drive to use, with at least two of:
  • Impaired control -over starting, amount, stopping.
  • Increasing priority over other interests, responsibilities and health; continued use despite harm.
  • Physiological features -tolerance (needing more for the same effect), withdrawal when stopping or reducing, using to relieve withdrawal.
• History -substances (alcohol, tobacco, cannabis, cocaine, opioids, benzodiazepines, prescribed drugs, new psychoactive substances), amount, frequency, route (injecting -sharing equipment?), first use, longest abstinence, previous treatment, withdrawal symptoms and complications (seizures, DTs), physical, psychological, social and legal consequences, motivation to change; children and dependants (safeguarding); driving.
• Examination -intoxication or withdrawal signs; liver disease stigmata; injection sites (track marks, abscesses, DVT), nasal septum (cocaine), weight, heart murmurs (endocarditis), neurological signs (neuropathy, cerebellar signs).
• Tests -FBC (MCV), LFTs (GGT), U&E, clotting, glucose; urine drug screen; HIV, hepatitis B and C; ECG (methadone, cocaine); breath or blood alcohol.
• Services -local community drug and alcohol services (self-referral), alcohol care teams in hospitals, mutual aid (AA, NA, SMART Recovery), residential rehabilitation.

Brief Interventions and Motivation

• Stages of change (Prochaska and DiClemente) -precontemplation (not considering change), contemplation (thinking about it), preparation, action, maintenance, and (often) relapse -match the approach to the stage.
• Very brief and brief interventions -short, structured conversations in any consultation (5–10 minutes); reduce drinking in hazardous and harmful drinkers.
• FRAMES approach:
  • Feedback about risk (e.g. AUDIT score, liver tests).
  • Responsibility for change is the person's.
  • Advice to change, clearly given.
  • Menu of options.
  • Empathy -non-judgemental.
  • Self-efficacy -belief they can change.
• Motivational interviewing -open questions, affirmations, reflective listening, summarising; explore ambivalence; "roll with resistance" rather than arguing.
• Language -avoid stigmatising terms ("addict", "abuser"); say "person who uses drugs" or "alcohol dependence".

Units and Screening

• 1 UK unit = 10 mL (8 g) of pure alcohol. Units = % ABV × volume (litres).
  • Pint of 5% beer -about 2.8 units.
  • 175 mL glass of 12% wine -about 2.1 units; a bottle of wine (750 mL, 12.5%) -about 9.4 units.
  • 25 mL single spirit (40%) -1 unit; a 70 cL bottle of vodka -28 units.
• UK Chief Medical Officers' guidance -men and women: no more than 14 units a week, spread over 3 or more days, with several drink-free days; no alcohol in pregnancy.
• Screening:
  • AUDIT-C (3 questions) -5 or more is positive -complete the full AUDIT.
  • AUDIT (10 questions, 0–40) -8–15 increasing risk (brief advice); 16–19 higher risk (brief intervention, follow-up); 20 or more possible dependence (refer to specialist services).
  • SADQ (Severity of Alcohol Dependence Questionnaire) -15 or less mild, 16–30 moderate, over 30 severe dependence.
  • FAST and PAT -quick screens in the emergency department.
• Blood markers -raised GGT, MCV (macrocytosis), ALT, AST (AST:ALT over 2 suggests alcohol), CDT (carbohydrate-deficient transferrin); low platelets.

Alcohol-related Harm

• Gut and liver -fatty liver, alcohol-related hepatitis, cirrhosis, varices, pancreatitis (acute and chronic), gastritis, Mallory–Weiss tears, oesophageal varices.
• Heart -hypertension, atrial fibrillation ("holiday heart"), dilated cardiomyopathy, stroke.
• Nervous system -Wernicke–Korsakoff, peripheral neuropathy, cerebellar degeneration (gait ataxia), alcohol-related brain damage and dementia, withdrawal seizures, head injury (subdural haematoma), central pontine myelinolysis (rapid sodium correction).
• Cancers -mouth, throat, oesophagus, liver, bowel, breast.
• Blood -macrocytosis, thrombocytopenia, folate deficiency.
• Metabolic -hypoglycaemia, alcoholic ketoacidosis, low potassium, magnesium and phosphate (refeeding syndrome), gout.
• Other -osteoporosis, infections (pneumonia, TB), sexual dysfunction, fetal alcohol spectrum disorder, trauma, falls.
• Mental health -depression, anxiety, suicide (alcohol is involved in many suicides), alcoholic hallucinosis, morbid jealousy, memory blackouts.
• Social -relationship breakdown, domestic violence, child neglect, job loss, debt, crime, drink-driving.

Alcohol Withdrawal

Time since last drink	Features
6–12 hours	Tremor, sweating, anxiety, agitation, nausea, vomiting, tachycardia, insomnia, craving.
12–24 hours	Alcoholic hallucinosis -hallucinations (often visual or auditory) with clear consciousness.
24–48 hours	Withdrawal seizures (generalised tonic-clonic).
48–72 hours	Delirium tremens -confusion, visual hallucinations, coarse tremor, fever, autonomic instability.

• Assessment -the CIWA-Ar score (or GMAWS) to measure severity and guide treatment; history of seizures or DTs; blood alcohol (withdrawal can begin while levels are still raised).
• Treatment (NICE CG100 and CG115):
  • Long-acting benzodiazepine -chlordiazepoxide (first-line) or diazepam, as a fixed reducing dose over about 5–7 days or symptom-triggered dosing (in hospital with trained staff) -follow local protocol.
  • Lorazepam or oxazepam (shorter-acting) in severe liver disease (reduced metabolism) or older people.
  • Thiamine -oral for low risk; parenteral (Pabrinex) for those at risk of Wernicke's (malnourished, liver disease, acutely unwell, in hospital for withdrawal).
  • Fluids, electrolytes (potassium, magnesium, phosphate), glucose; treat infection.
  • Don't use benzodiazepines for long periods (dependence); don't prescribe them to people who keep drinking (respiratory depression).
• Where to manage:
  • Hospital (inpatient) withdrawal -high risk: history of withdrawal seizures or DTs, severe dependence (SADQ over 30), significant physical or mental illness, under 18, older or frail, cognitive impairment, homeless or no support, pregnancy.
  • Community (assisted) withdrawal -for others, with a planned programme and daily review.

⚠️ Safety Pearl: Patients admitted for something else often hide heavy drinking. New tremor, sweating, agitation or confusion 1–3 days after admission is alcohol withdrawal until proven otherwise -ask, check CIWA, and give a benzodiazepine and parenteral thiamine.

Delirium Tremens and Withdrawal Seizures

• Delirium tremens (DTs) -a medical emergency (mortality up to 5% treated, much higher untreated):
  • Usually 48–72 hours after the last drink.
  • Confusion, disorientation, visual and tactile hallucinations (often small animals or insects), paranoia, terror.
  • Coarse tremor, sweating, fever, tachycardia, hypertension, dehydration.
  • Risks -seizures, arrhythmias, aspiration, injuries.
• Treatment -oral lorazepam (or parenteral lorazepam or diazepam if oral is refused or not possible); if persistent, an antipsychotic (e.g. haloperidol) with care (lowers seizure threshold); IV Pabrinex; fluids and electrolytes; nurse in a calm, well-lit room; look for infection, head injury, hypoglycaemia, liver failure, GI bleeding; HDU or ICU if severe.
• Withdrawal seizures -usually 24–48 hours; generalised; quick-acting benzodiazepine (lorazepam); don't use phenytoin (doesn't work for withdrawal seizures); look for other causes (head injury, hypoglycaemia, low sodium or magnesium).

Wernicke–Korsakoff Syndrome

• Cause -thiamine (vitamin B1) deficiency -alcohol misuse (poor diet, poor absorption), also hyperemesis gravidarum, malnutrition, eating disorders, bariatric surgery, refeeding.
• Wernicke's encephalopathy -an acute, reversible emergency:
  • Classic triad -confusion, ataxia (wide-based gait), eye signs (nystagmus, ophthalmoplegia -often lateral rectus palsy). All three are present in only about 10% -have a low threshold.
  • Also -hypothermia, hypotension, drowsiness, memory problems.
• Treatment -IV Pabrinex (thiamine with other B vitamins) -e.g. 2 pairs three times a day for 3–5 days, then 1 pair daily for a further 3–5 days if improving (follow local or BNF guidance); prophylaxis for at-risk patients -e.g. 1 pair daily for 3–5 days; then oral thiamine.
• Give thiamine before or with glucose in at-risk patients (glucose can precipitate Wernicke's) -but never delay treating hypoglycaemia.
• Anaphylaxis with IV Pabrinex is rare -have resuscitation facilities available.
• Korsakoff syndrome -the chronic, often permanent result:
  • Severe anterograde amnesia (can't form new memories) and retrograde amnesia.
  • Confabulation -filling memory gaps with invented stories.
  • Other cognitive functions relatively preserved; lack of insight; apathy.
  • Damage to the mammillary bodies and thalamus.
  • Thiamine, abstinence, rehabilitation and supported living.

💡 Clinical Pearl: Don't wait for the full Wernicke triad -any heavy drinker who is confused, unsteady or has unexplained drowsiness should get IV Pabrinex. It is cheap and safe; untreated Wernicke's can kill or leave permanent amnesia.

Staying Off Alcohol

• Psychological support -CBT, motivational enhancement, behavioural couples therapy, social network therapy; mutual aid (Alcoholics Anonymous, SMART Recovery); residential rehabilitation.
• Medication after withdrawal (NICE CG115) -with psychological support:
  • Acamprosate -reduces craving (glutamate modulator); start as soon as possible after withdrawal; continue up to 6 months; avoid in severe renal impairment.
  • Naltrexone -opioid antagonist; reduces the pleasure of drinking and relapse to heavy drinking; don't give with opioids (precipitates withdrawal and blocks analgesia); check LFTs.
  • Disulfiram -blocks aldehyde dehydrogenase: drinking causes flushing, nausea, vomiting, palpitations, hypotension (the "disulfiram–alcohol reaction"); for motivated people with supervision; avoid in heart disease, psychosis, stroke; avoid all alcohol (including in foods, toiletries).
  • Nalmefene -to reduce drinking (not abstain) in people with high-risk drinking without withdrawal (NICE TA325), as needed.
• Thiamine -oral for people with harmful drinking or dependence and poor diet.
• Liver disease -refer for assessment (fibrosis scanning); abstinence is the key treatment for alcohol-related liver disease.
• Relapse is common -treat as part of recovery, not failure.

Opioid Dependence

• Opioids -heroin (diamorphine -smoked or injected), prescribed opioids (codeine, tramadol, oxycodone, fentanyl patches), and new synthetic opioids (nitazenes -very potent; overdose deaths).
• Intoxication -pinpoint pupils, drowsiness, slow breathing, low BP, itching, nausea.
• Overdose -respiratory depression, reduced consciousness, pinpoint pupils -naloxone (IM/IV/intranasal); risk higher after a period of abstinence (prison release, detox, hospital discharge), with alcohol, benzodiazepines or gabapentinoids.
• Withdrawal (starts 6–24 hours after heroin; peaks at 1–3 days; longer with methadone):
  • Dilated pupils, yawning, runny eyes and nose (lacrimation, rhinorrhoea), goosebumps (piloerection), sweating.
  • Abdominal cramps, diarrhoea, nausea, vomiting.
  • Muscle aches, restlessness, anxiety, insomnia, craving, tachycardia.
  • Unpleasant but rarely life-threatening (unlike alcohol and benzodiazepine withdrawal) -measured with the COWS scale.
• Complications of injecting -abscesses, cellulitis, necrotising fasciitis, DVT and femoral pseudoaneurysm (groin injecting), infective endocarditis (tricuspid valve, Staph aureus), septic emboli, HIV, hepatitis B and C, wound botulism, tetanus, anthrax (contaminated heroin), "chasing the dragon" leukoencephalopathy.
• Other problems -constipation, low testosterone, poverty, crime, homelessness, mental illness, children (safeguarding).

Opioid Substitution Treatment

• Opioid substitution treatment (OST) -reduces illicit drug use, overdose deaths, BBV transmission and crime; the mainstay of treatment (NICE TA114; UK clinical guidelines).
• Methadone (oral liquid) -full agonist; long half-life; titrated slowly (overdose risk early in treatment); QT prolongation (ECG at higher doses or with risk factors); supervised consumption at first; interactions (enzyme inducers, e.g. rifampicin, reduce levels).
• Buprenorphine (sublingual, or long-acting injection weekly or monthly) -partial agonist with high receptor affinity -safer in overdose ("ceiling effect"); can precipitate withdrawal if started while full opioids are still active -start when the person is in moderate withdrawal.
• Naloxone -take-home naloxone kits for people who use opioids, their families and friends.
• Detoxification -gradual reduction of methadone or buprenorphine when the person is stable and ready; lofexidine for symptoms; high relapse and overdose risk after detox (tolerance lost).
• Naltrexone -relapse prevention after detox in motivated people.
• Psychosocial support -keyworking, contingency management, mutual aid, housing and employment support.
• Heroin-assisted treatment (injectable diamorphine) -for a small group in specialist services.

Opioid Users in Hospital

• Confirm the OST dose with the prescriber and dispensing pharmacy -and when the last dose was taken (don't rely on the patient's report alone; don't give a missed dose blindly -risk of double-dosing).
• Continue OST -stopping causes withdrawal, discharge against advice and relapse; if 3 or more consecutive doses missed, reassess before restarting at the full dose (tolerance may have dropped).
• Pain relief -OST doesn't cover acute pain; patients often need higher doses of opioid analgesia on top (tolerance); use multimodal analgesia (paracetamol, NSAIDs, regional blocks); avoid naltrexone.
• Withdrawal in an untreated user -symptomatic treatment (loperamide, antiemetics, lofexidine) or start OST with specialist advice.
• Overdose risk on discharge -naloxone kit, harm reduction advice, link back to community services.
• Look for and treat infections (endocarditis, abscesses), BBV testing, vaccination.

Cocaine, Amphetamines and MDMA

• Cocaine (powder snorted; crack cocaine smoked):
  • Effects -euphoria, energy, confidence, dilated pupils, tachycardia, hypertension, agitation, paranoia.
  • Complications -chest pain and MI (coronary spasm and thrombosis -in young people), arrhythmias, aortic dissection, stroke, seizures, hyperthermia, rhabdomyolysis, nasal septum perforation, psychosis.
  • Cocaine chest pain -ECG, troponin; benzodiazepines (reduce sympathetic drive), aspirin, GTN; calcium channel blockers; avoid beta-blockers in the acute phase (debated).
  • Cocaine with alcohol -forms cocaethylene (more cardiotoxic).
  • Comedown -low mood, exhaustion, craving.
• Amphetamines and methamphetamine -similar sympathomimetic effects; prolonged use causes psychosis, weight loss, dental damage.
• MDMA ("ecstasy"):
  • Hyperthermia (dancing, hot clubs), hyponatraemia (drinking lots of water plus SIADH -confusion, seizures), serotonin syndrome, rhabdomyolysis, AKI, DIC.
  • Treatment -cooling, benzodiazepines, fluid restriction or hypertonic saline for hyponatraemia (specialist), dantrolene (rarely), ICU.
• Treatment of stimulant dependence -psychological (CBT, contingency management); no effective substitute drug.

Cannabis, Ketamine, GHB and Newer Drugs

• Cannabis:
  • Relaxation, euphoria, red eyes, increased appetite; anxiety and paranoia; impaired memory and driving.
  • Psychosis and schizophrenia risk (high-potency, daily, adolescent use); dependence (withdrawal -irritability, insomnia, low mood).
  • Cannabinoid hyperemesis syndrome -cyclical severe vomiting and abdominal pain in long-term heavy users, relieved by hot showers or baths; treat with fluids, antiemetics (haloperidol helps), topical capsaicin; the cure is stopping cannabis.
  • Synthetic cannabinoids ("spice") -far more potent: agitation, psychosis, seizures, cardiac arrest.
• Ketamine -dissociation ("k-hole"); long-term use causes ketamine uropathy (painful, small, scarred bladder; frequency, haematuria; hydronephrosis), abdominal pain ("k-cramps"), biliary dilatation; stop ketamine; urology.
• GHB/GBL ("G") -sedation, coma, respiratory depression (especially with alcohol); used in "chemsex"; severe withdrawal in dependent users (rapid onset, delirium, seizures -like alcohol withdrawal but faster) -specialist benzodiazepine (and baclofen) treatment.
• Nitrous oxide ("laughing gas" -now a controlled drug) -heavy use inactivates vitamin B12: subacute combined degeneration of the cord (numb, tingling legs, unsteady gait), neuropathy -check B12 (may be normal), homocysteine and MMA; treat with B12 injections and stop use.
• Benzodiazepines (street) -etizolam, bromazolam -overdoses, especially with opioids.
• Chemsex drugs (methamphetamine, mephedrone, GHB) -sexual health risks; specialist sexual health and drug services.
• New psychoactive substances -unpredictable content; xylazine (sedative -wounds) and nitazenes contaminating heroin.
• Anabolic steroids -mood changes, aggression, acne, testicular atrophy, gynaecomastia, cardiomyopathy, polycythaemia.

Prescribed Drug Dependence

• Common drugs -opioid painkillers, benzodiazepines and Z-drugs, gabapentinoids (gabapentin, pregabalin -controlled drugs since 2019), antidepressants (withdrawal rather than addiction).
• Problems -tolerance, dependence, side effects (falls, sedation), overdose (especially combinations -opioids with benzodiazepines or gabapentinoids cause respiratory depression).
• Prevention -prescribe for the shortest time, review regularly, avoid opioids for chronic primary pain (NICE NG193), avoid combinations, check controlled drug histories.
• Tapering (NICE NG215 -medicines associated with dependence or withdrawal) -shared decision; gradual dose reductions (slower near the end); support; not abrupt.
• High-dose opioids for chronic pain -over about 120 mg oral morphine a day: risk outweighs benefit; taper with support.

Harm Reduction and Blood-borne Viruses

• Harm reduction -reducing harm without requiring abstinence:
  • Needle and syringe programmes (pharmacies, drug services); safer injecting advice (rotate sites, avoid the groin and neck).
  • Take-home naloxone.
  • Drug checking; never using alone; reduced tolerance warnings.
  • Opioid substitution treatment.
• Blood-borne viruses:
  • Test people who inject (or have ever injected) for HIV, hepatitis B and hepatitis C -regularly.
  • Hepatitis B vaccination (accelerated schedule).
  • Hepatitis C -highly curable with direct-acting antivirals (8–12 weeks); NHS elimination programme.
  • HIV -treatment and PrEP where relevant.
• Other -tetanus vaccine, wound care, sexual health, TB screening (homeless, prison).

Smoking and Vaping

• Smoking -the biggest preventable cause of death; very common in people with severe mental illness and substance misuse.
• Very brief advice -Ask (and record smoking status), Advise (the best way to stop is with medication and support), Act (refer to stop-smoking services or prescribe) -takes 30 seconds.
• Treatments (NICE NG209) -behavioural support plus:
  • Varenicline (partial nicotine receptor agonist) -12 weeks; available again in the UK (reformulated); nausea, vivid dreams.
  • Cytisine (cytisinicline) -available in the UK since 2024; similar action; tapering course over about 25 days; well tolerated.
  • Combination nicotine replacement therapy -a long-acting patch plus a short-acting form (gum, lozenge, inhalator, mouth spray).
  • Nicotine e-cigarettes (vapes) -effective for quitting; much less harmful than smoking (not risk-free); not for non-smokers or young people.
  • Bupropion -lowers seizure threshold; avoid in epilepsy and eating disorders.
• Smoking and psychiatric drugs -tobacco smoke induces CYP1A2; stopping smoking raises clozapine and olanzapine levels (toxicity) -reduce doses and monitor.
• Pregnancy -carbon monoxide testing at booking; refer for support; NRT is safer than smoking.

Gambling

• Gambling disorder -persistent gambling with impaired control, increasing priority and continuation despite harm; online gambling and gaming make it easier.
• Harms -debt, relationship breakdown, crime, depression, anxiety, alcohol and drug misuse, suicide (much higher risk); harm to family members.
• NICE NG248 (2025) -ask about gambling at routine contacts (e.g. health checks, mental health assessments, GP consultations about anxiety, depression, debt or substance use); use the Problem Gambling Severity Index (PGSI).
• Treatment -CBT (individual or group), NHS gambling clinics (refer for more severe harm), GamCare and the National Gambling Helpline, debt advice, blocking software and bank gambling blocks, self-exclusion schemes; treat coexisting mental illness; ask about suicidal thoughts.
• Dopamine agonists (Parkinson's disease, restless legs) and aripiprazole can cause impulse-control disorders including gambling -ask, and reduce or stop the drug.

Pregnancy, Young People and Dual Diagnosis

• Pregnancy:
  • Alcohol -fetal alcohol spectrum disorder; advise no alcohol; assisted withdrawal under specialist care.
  • Opioids -don't stop OST suddenly (fetal distress, miscarriage); methadone or buprenorphine continued; neonatal abstinence syndrome (irritability, high-pitched cry, poor feeding, sweating, diarrhoea, seizures) -observe the baby for several days.
  • Cocaine -placental abruption, growth restriction, preterm birth.
  • Smoking -growth restriction, stillbirth, SIDS.
  • Specialist midwives, safeguarding plans, breastfeeding advice (usually supported on stable OST).
• Young people -alcohol, cannabis, nitrous oxide, ketamine and vaping; exploitation (county lines); young people's substance misuse services; safeguarding.
• Older people -alcohol misuse often hidden (falls, confusion, interactions); prescribed drug dependence.
• Dual diagnosis (mental illness with substance misuse) -common; worse outcomes; treat both together -mental health services should not exclude people because of substance use (NICE NG58).
• Prisons -high rates of substance misuse; overdose risk after release (naloxone, continuity of OST).

Drug Reference Table

Drug	Key points
Chlordiazepoxide	First-line for alcohol withdrawal -fixed reducing or symptom-triggered over about 5–7 days.
Lorazepam / oxazepam	Alcohol withdrawal with severe liver disease; lorazepam for DTs and withdrawal seizures.
Pabrinex (IV thiamine with B vitamins)	Wernicke's -2 pairs three times a day for 3–5 days; prophylaxis 1 pair daily; give before or with glucose.
Thiamine (oral)	Harmful drinkers with poor diet.
Acamprosate	Reduces craving after alcohol withdrawal; up to 6 months.
Naltrexone	Alcohol and opioid relapse prevention; never with opioids.
Disulfiram	Alcohol deterrent -reaction with any alcohol; avoid in heart disease.
Nalmefene	Reducing alcohol consumption without abstinence.
Methadone	Opioid substitution -full agonist; QT; slow titration; supervised consumption.
Buprenorphine	Opioid substitution -partial agonist, safer in overdose; can precipitate withdrawal; long-acting injection available.
Naloxone	Opioid overdose -IM, IV or intranasal; take-home kits.
Lofexidine	Opioid withdrawal symptoms during detox.
Varenicline / cytisine	Smoking cessation -most effective single drugs.
Nicotine replacement	Patch plus short-acting form; safe in heart disease and pregnancy.
Hydroxocobalamin	Nitrous oxide-induced B12 deficiency and myelopathy.

Spot the Diagnosis

Clue	Diagnosis
Tremor, sweating and anxiety 10 hours after the last drink	Early alcohol withdrawal
Confusion, fever and seeing insects 3 days after admission in a heavy drinker	Delirium tremens
Generalised seizure 36 hours after stopping drinking	Alcohol withdrawal seizure
Confused heavy drinker with nystagmus and a wide-based gait	Wernicke's encephalopathy
Can't remember the last 10 minutes but tells detailed invented stories	Korsakoff syndrome
Flushing and vomiting after a sip of wine	Disulfiram–alcohol reaction
Pinpoint pupils, RR 6, unresponsive	Opioid overdose -naloxone
Yawning, runny nose, goosebumps, diarrhoea and dilated pupils	Opioid withdrawal
Sudden withdrawal after first buprenorphine dose	Precipitated withdrawal
Injecting drug user with fever and a tricuspid murmur	Right-sided infective endocarditis
Young man with chest pain and ST elevation after a night out	Cocaine-induced MI
Confused and seizing after ecstasy and drinking lots of water	MDMA hyponatraemia
Recurrent vomiting relieved by hot showers in a daily cannabis user	Cannabinoid hyperemesis syndrome
Painful frequency and small bladder in a regular ketamine user	Ketamine uropathy
Numb legs and unsteady gait after heavy balloon (nitrous oxide) use	Subacute combined degeneration (functional B12 deficiency)
Agitated and delirious within hours of stopping GBL	GHB/GBL withdrawal
Man with Parkinson's on ropinirole has run up gambling debts	Dopamine agonist impulse-control disorder
Irritable newborn with high-pitched cry, mother on methadone	Neonatal abstinence syndrome

Exam-style Scenarios

1. A 54-year-old man admitted 2 days ago with a fractured ankle is sweaty, tremulous and picking at the bedsheets. He drinks a bottle of vodka a day. He is disoriented and says there are spiders on the wall.
Answer: Delirium tremens.

• Benzodiazepine (oral lorazepam, or parenteral if refused) and IV Pabrinex.
• Fluids, potassium, magnesium, phosphate, glucose; look for infection, head injury, GI bleeding.
• Calm, well-lit environment; HDU review if severe; refer to the alcohol care team.

2. A 47-year-old woman who drinks heavily is brought in confused and unsteady, with nystagmus. Her glucose is 2.8 mmol/L.
Answer: Wernicke's encephalopathy with hypoglycaemia.

• Give IV Pabrinex (2 pairs) -ideally with or before glucose, but don't delay correcting hypoglycaemia.
• Continue Pabrinex 2 pairs three times a day for 3–5 days.
• Assess for withdrawal, liver disease and infection.

3. A 31-year-old man on methadone 80 mg daily is admitted with a groin abscess. He says he missed today's dose.
Answer: Continue opioid substitution safely in hospital.

• Confirm the dose and last collection with his pharmacy and prescriber before prescribing.
• Continue methadone; add analgesia on top (he will need higher doses).
• Drain the abscess, check for DVT and pseudoaneurysm; test for HIV, hepatitis B and C; naloxone and harm reduction advice at discharge.

4. A 26-year-old woman has had a third admission with severe vomiting and abdominal pain. She showers several times a day for relief and smokes cannabis daily.
Answer: Cannabinoid hyperemesis syndrome.

• IV fluids and electrolytes; antiemetics (haloperidol may help), topical capsaicin.
• Explain that the only cure is stopping cannabis; refer to drug services.
• Avoid repeated unnecessary investigations.

5. A 60-year-old man has completed alcohol withdrawal and wants help to stay abstinent. He has no liver failure and normal kidney function.
Answer: Relapse prevention.

• Acamprosate or oral naltrexone, with psychological support (CBT, mutual aid).
• Disulfiram if he wants a deterrent and has no contraindications.
• Oral thiamine; liver assessment; follow-up with community alcohol services.

Key Points

• 1 unit = 10 mL (8 g) alcohol; units = ABV × litres; limit 14 units a week.
• AUDIT 20 or more suggests dependence; AUDIT-C 5 or more is a positive screen.
• Alcohol withdrawal: tremor (6–12 h), hallucinosis (12–24 h), seizures (24–48 h), DTs (48–72 h).
• Chlordiazepoxide first-line; lorazepam in severe liver disease.
• Admit for withdrawal if previous seizures or DTs, severe dependence, or vulnerability.
• Wernicke's: confusion, ataxia, eye signs -triad often incomplete; IV Pabrinex; thiamine with glucose.
• Korsakoff: amnesia with confabulation, often permanent.
• Relapse prevention: acamprosate, naltrexone, disulfiram -with psychological support.
• Opioid withdrawal is unpleasant but rarely dangerous; overdose is -give naloxone.
• Methadone: QT, slow titration; buprenorphine: partial agonist, start when in withdrawal.
• In hospital, confirm OST doses with the pharmacy; continue OST and give analgesia on top.
• Overdose risk rises after loss of tolerance (prison, detox, hospital).
• Cocaine chest pain: benzodiazepines, aspirin, GTN; think MI in young people.
• MDMA: hyperthermia, hyponatraemia, serotonin syndrome.
• Cannabinoid hyperemesis: hot showers help; stop cannabis.
• Nitrous oxide: functional B12 deficiency and subacute combined degeneration.
• Test people who inject for HIV, hepatitis B and C; vaccinate against hepatitis B.
• Stopping smoking raises clozapine and olanzapine levels.
• Ask about gambling (NICE NG248) -high suicide risk.

Guidelines and Further Reading

• NICE CG100: Alcohol-use disorders -diagnosis and management of physical complications
• NICE CG115: Alcohol-use disorders -diagnosis, assessment and management of harmful drinking and dependence
• UK Chief Medical Officers' Low Risk Drinking Guidelines
• Department of Health: Drug misuse and dependence -UK guidelines on clinical management ("Orange Book")
• NICE TA114: Methadone and buprenorphine for the management of opioid dependence
• NICE NG58: Coexisting severe mental illness and substance misuse
• NICE NG215: Medicines associated with dependence or withdrawal symptoms
• NICE NG209: Tobacco -preventing uptake, promoting quitting and treating dependence
• NICE NG248: Gambling-related harms -identification, assessment and management
• BNF -for current doses