Psychiatry: Alcohol, drugs and addiction

• Basics: Substance Misuse — Overview | Brief Interventions and Motivation
• Alcohol: Units and Screening | Alcohol-related Harm | Alcohol Withdrawal | Delirium Tremens and Withdrawal Seizures | Wernicke–Korsakoff Syndrome | Staying Off Alcohol
• Drugs: Opioid Dependence | Opioid Substitution Treatment | Opioid Users in Hospital | Cocaine, Amphetamines and MDMA | Cannabis, Ketamine, GHB and Newer Drugs | Prescribed Drug Dependence | Harm Reduction and Blood-borne Viruses
• Other addictions and groups: Smoking and Vaping | Gambling | Pregnancy, Young People and Dual Diagnosis
• Revision: Drug Reference Table | Spot the Diagnosis | Exam-style Scenarios | Key Points | Guidelines and Further Reading

🍺 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)?

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

• 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

Spot the Diagnosis

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