Smoking, Alcohol & Substance Misuse - Bradford VTS

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Smoking, Alcohol & Substance Misuse: Your GP Survival Guide

Because "just say no" isn't exactly evidence-based medicine (and your patients deserve better than a leaflet)

☕ Tea-Friendly Learning ⏰ For GP Trainees Short on Time 🚩 Red Flag Focused

Date Updated: November 17, 2024

⭐ Executive Summary: What You'll Master Today

Because you have 47 other things to do before lunch, and that's just the morning list

✓ What This Page Covers:

• Data-gathering & examination strategies that actually work
• Diagnostic frameworks (because AUDIT isn't just for accountants)
• Red flags that'll keep you awake at night (in a good way)
• Management approaches beyond "have you tried stopping?"
• Safeguarding essentials for vulnerable patients
• DVLA requirements (yes, they matter)
• Exam-focused content for AKT, SCA, and WPBA

⚡ Quick Facts at a Glance:

15%

of GP consultations involve substance misuse

1 in 5

adults drink above recommended limits

13.9%

of UK adults still smoke (2023)

£21bn

annual NHS cost of alcohol-related harm

📖 Quick Navigation

🩺 1. Data-Gathering & Examination 🎯 2. Diagnostic Approach 🧠 3. Differential Diagnosis 💊 4. Common Street Drugs 📄 5. Common Conditions ⚠️ 6. Red Flags 🚨 7. Street Drug Red Flags ❤️ 8. Management Frameworks 🛡️ 9. Relapse Prevention

⬇️ Downloads

📄 AUDIT & AUDIT-C Tools

📄 Alcohol Detox Protocols

📄 Smoking Cessation Resources

📄 Drug Misuse Protocols

🌐 Web Resources

⚡ Brainy Bites: Essential Addiction Medicine Wisdom

✓ Key Questions for Data Gathering

💡

"When did you last feel in control of your drinking/smoking/drug use?" - This reveals insight and motivation better than quantity questions.

💡

"What would need to change for you to consider stopping?" - Explores readiness without being confrontational.

💡

"Who else is affected by this?" - Opens safeguarding discussions naturally.

💡

"Have you ever tried to cut down or stop before?" - Assesses previous attempts and withdrawal experiences.

⚠️ Red Flags – What Not to Miss!

🚨 Wernicke's Triad: Confusion + Ophthalmoplegia + Ataxia

Give thiamine BEFORE glucose!

🚨 Cocaine Chest Pain = Potential MI

Don't give beta-blockers (unopposed alpha stimulation)

🚨 Children + Chaotic Substance Use = Safeguarding

Think neglect, unsafe storage, domestic violence

🚨 IV Drug Use + Fever = Endocarditis Until Proven Otherwise

Blood cultures, echo, urgent cardiology

🩺 1. Data-Gathering & Examination Tips

General Principles

Creating safety and reducing stigma in consultations

The Golden Rule

Approach with curiosity, not judgment. Your patient is the expert on their own experience - you're just helping them find a way forward that works for them.

Validated Screening Tools

• AUDIT-C: 3 questions, perfect for busy consultations
• Full AUDIT: When you need the complete picture
• ASSIST: Multi-substance screening tool
• Fagerström Test: Nicotine dependence assessment

Creating Safety

• Start with open questions
• Normalize the conversation
• Avoid "why" questions (sound judgmental)
• Use their language, not medical jargon

Focused History Taking Approach

The FRAMES Approach

Feedback - Share what you've observed
Responsibility - Emphasize their choice
Advice - Give clear, specific guidance
Menu - Offer options, not ultimatums
Empathy - Show understanding
Self-efficacy - Build confidence they can change

Focused Smoking History

Essential Questions

• Amount & Duration: "How many per day? For how long?"
• Type: Cigarettes, roll-ups, vapes, heated tobacco, shisha
• Triggers: Stress, social, routine, emotional
• Previous Attempts: What worked? What didn't?
• Quit Aids Used: NRT, varenicline, bupropion, e-cigarettes
• Withdrawal Symptoms: Cravings, irritability, weight gain

Readiness Assessment

"On a scale of 1-10, how ready are you to quit smoking?"

• 1-3: Not ready (focus on motivation)
• 4-6: Ambivalent (explore pros/cons)
• 7-10: Ready (action planning)

Focused Alcohol History

Quantity & Pattern

• Units per week: Use specific examples
• Pattern: Daily vs weekend binge
• Morning drinking: Red flag for dependence
• Loss of control: "Do you drink more than intended?"
• Tolerance: "Do you need more to feel the same effect?"

Impact Assessment

• Work: Absences, performance issues
• Relationships: Arguments, isolation
• Finances: Money spent on alcohol
• Health: Sleep, mood, physical symptoms
• Legal: Driving, public order offences

CAGE Questions (Classic but Limited)

• Cut down - Ever felt you should cut down?
• Annoyed - Annoyed by criticism of drinking?
• Guilty - Felt guilty about drinking?
• Eye opener - Morning drink to steady nerves?

2+ positive = likely alcohol problem

Focused Drug Misuse History

Substance Details

• Substances used: Be specific (heroin, cocaine, cannabis, etc.)
• Route: Oral, snorting, smoking, IV injection
• Frequency: Daily, weekly, binge patterns
• Poly-drug use: Very common in primary care
• Sourcing: Street dealers, online, prescription drugs

Risk Assessment

• Injecting risks: Needle sharing, vein damage
• Overdose history: Previous episodes, naloxone use
• Blood-borne viruses: Hep B/C, HIV status
• Mental health: Depression, psychosis, anxiety
• Social impact: Housing, employment, relationships

High-Risk Combinations

• Opioids + Alcohol/Benzos: Respiratory depression risk
• Stimulants + Depressants: Masking effects, overdose risk
• Multiple CNS depressants: Additive sedation

Red-Flag Questions to Ask

Immediate Safety

• "Have you had thoughts of harming yourself?"
• "Any confusion or memory problems?"
• "Any fits or seizures?"
• "Seeing or hearing things that aren't there?"

Withdrawal Symptoms

• "What happens when you try to stop?"
• "Ever had shakes or sweats?"
• "Any nausea or vomiting when cutting down?"
• "Sleep problems when not using?"

Safeguarding Concerns

• "Are there children in your household?"
• "How do you store your substances?"
• "Any domestic violence or abuse?"
• "Financial problems due to substance use?"

Functional Impact

• "Are you still driving?"
• "Any problems at work?"
• "Relationship difficulties?"
• "Legal problems?"

Physical Examination

General Assessment

• Vital signs: BP, pulse, temperature, oxygen sats
• Hydration status: Mucous membranes, skin turgor
• Nutritional state: Weight loss, muscle wasting
• Mental state: Mood, cognition, psychosis
• Neurological: Tremor, ataxia, nystagmus

Specific Signs

• Injection sites: Track marks, abscesses, thrombosis
• Liver disease: Jaundice, hepatomegaly, ascites
• Alcohol neuropathy: Peripheral sensation
• Smoking-related: Finger staining, dental health
• Cardiac: Murmurs (endocarditis), arrhythmias

Wernicke's Encephalopathy Signs

Confusion

• Disorientation
• Memory problems
• Altered consciousness

Ophthalmoplegia

• Nystagmus
• Diplopia
• Gaze palsies

Ataxia

• Unsteady gait
• Truncal instability
• Coordination problems

Only 10% have complete triad - high index of suspicion needed!

🎯 2. Diagnostic Approach & Investigations

The 5-Step Framework

1. Identify misuse: Is there a problem?
2. Quantify severity: Hazardous, harmful, or dependent?
3. Assess harm: Physical, psychological, social
4. Consider safeguarding: Vulnerable adults, children
5. Plan management: Brief intervention, referral, or specialist care

Hazardous Use

Pattern likely to cause harm if continued

Harmful Use

Already causing physical/psychological harm

Dependent Use

Loss of control, tolerance, withdrawal

Essential Blood Tests

• FBC: Macrocytosis (MCV >100), thrombocytopenia
• LFTs: AST:ALT ratio >2:1 suggests alcohol
• GGT: Sensitive but not specific marker
• U&E: Dehydration, electrolyte imbalance
• Glucose: Hypoglycemia risk
• Lipids: Hypertriglyceridemia

Additional Considerations

• Liver fibrosis tests: FIB-4, NAFLD score (local pathways)
• Thiamine deficiency: Clinical assessment
• Folate/B12: If macrocytic anemia
• Magnesium: Often low in chronic alcohol use
• Phosphate: Refeeding syndrome risk

Interpretation Tips

• Normal LFTs don't exclude alcohol problems
• GGT can be raised by many medications
• MCV >100 in young person = think alcohol
• AST:ALT ratio >2:1 is suggestive but not diagnostic

🧠 3. Differential Diagnosis

Common Presentations & Differentials

Unexplained Weight Loss

• Alcohol-related malnutrition
• Stimulant misuse (cocaine, amphetamines)
• Malignancy (GI, lung)
• Hyperthyroidism
• Chronic infection (TB, HIV)

Cognitive Impairment

• Alcohol-related brain damage
• Wernicke-Korsakoff syndrome
• Substance-induced psychosis
• Early-onset dementia
• Vitamin deficiencies (B1, B12)

💊 4. Common Street Drugs

Common Street Drugs: Stimulants & Hallucinogens

Drug	Official Name / Class	Common Street Names	What It Does (Effects)	Typical UK Price	Addictive?	Major Harms / Risks (GP-relevant)
Cannabis	Cannabis (Class B)	Weed, skunk, hash, bud, grass	Relaxation, euphoria, altered perception, increased appetite	£10–£20 per gram	Psychologically addictive	Anxiety, panic, psychosis in vulnerable individuals, amotivation, impaired concentration, cannabis hyperemesis. Smoking ↑ COPD risk.
Cocaine (powder)	Cocaine hydrochloride (Class A)	Coke, charlie, gear, sniff	Euphoria, energy, confidence	£40–£80 per gram	Highly addictive	Arrhythmias, MI, stroke, agitation, dependence, nasal septum damage, paranoia.
Crack cocaine	Cocaine freebase (Class A)	Crack, rocks, hard	Intense 5–10-min high, rush, cravings	£10–£20 per "rock"	Extremely addictive	Severe dependency, respiratory problems (if smoked), violence risk, psychosis, high overdose risk.
MDMA	3,4-Methylenedioxymethamphetamine (Class A)	Ecstasy, molly, mandy	Empathy, energy, sensory enhancement	£20–£30 per pill; £40–£60 per gram	Moderately addictive	Hyperthermia, dehydration, hyponatraemia, serotonin syndrome, comedown depression/anxiety.
Amphetamines	Amphetamine sulphate (Class B)	Speed, whizz, billy	Alertness, energy, reduced appetite	£10 per gram (low-purity "base" typically used)	Moderately addictive	Insomnia, anxiety, arrhythmias, weight loss, psychosis risk.
Methamphetamine	Methamphetamine (Class A)	Crystal meth, ice, tina	Intense stimulation, euphoria	£40–£80 per gram	Extremely addictive	Severe mental health harm, tooth decay ("meth mouth"), paranoia, very high dependency.
LSD	Lysergic acid diethylamide (Class A)	Acid, tabs, trips	Hallucinations, altered perception, emotional shifts	£5–£10 per tab	Not physically addictive	Anxiety, panic, "bad trips", triggering psychosis, dangerous behaviour due to altered reality.
Magic Mushrooms	Psilocybin (Class A)	Shrooms, mushies	Hallucinations, introspection	£10–£20 per dose	Low addiction risk	Panic, nausea, vomiting, psychological distress, accidental injuries.

Common Street Drugs: Depressants & Others

Drug	Official Name / Class	Common Street Names	What It Does (Effects)	Typical UK Price	Addictive?	Major Harms / Risks (GP-relevant)
Heroin	Diamorphine (Class A, opioid)	Brown, gear, H, smack	Sedation, euphoria, pain relief	£30–£50 per gram	Very addictive (physical + psychological)	Overdose → respiratory depression & death, constipation, infections, BBVs if injected, skin ulcers/abscesses.
Ketamine	Ketamine hydrochloride (Class B)	K, ket, special K	Dissociation, floating sensation, pain-numbing	£20–£40 per gram	Low–moderate addiction risk	Bladder damage ("ketamine bladder"), ulcers, memory issues, falls/accidents, tachycardia.
GHB/GBL	Gamma-hydroxybutyrate / lactone (Class B)	G, Gina	Sedative, euphoria, increased libido	£50–£100 for 100 ml	Highly addictive	Very narrow dose window → respiratory arrest, coma, memory loss, dependency withdrawal → life-threatening.
Benzodiazepines (street)	Diazepam/alprazolam counterfeit tablets (Class C without prescription)	Blues, vallies, benzos, zannies	Sedation, anxiolytic	£1–£5 per tablet	High dependence risk	Respiratory depression esp. with alcohol, blackouts, severe withdrawal seizures.
Nitrous oxide	Nitrous oxide (Class C)	Nos, balloons, whippets	Euphoria, giggling, brief dissociation	£1–£3 per canister	Low physical addiction; psychological possible	B12 depletion → neuropathy, falls, frostbite burns, hypoxia if misused in large volumes.
Spice	Synthetic cannabinoids (Class B)	Spice, Mamba	Extreme intoxication, unpredictable effects	£10–£30 per gram	Moderately addictive	Psychosis, seizures, collapse, erratic behaviour; especially harmful in homeless/prison settings.
Methadone (illicit)	Methadone (Class A without script)	Green, phy	Opioid sedation	£5–£20 per 10–20 ml illicit	Addictive	Overdose, respiratory depression, long QT.
Pregabalin / Gabapentin (misused)	Pregabalin (Class C), Gabapentin (Class C)	Buds, gabbies, pregabs	Sedation, dissociation, euphoria in high doses	50p–£3 per tablet	Moderately addictive	Respiratory depression esp. with opioids/benzos/alcohol, overdose risk.

📄 5. Common Conditions

Substance-Related Conditions

Alcohol-Related

• Alcohol use disorder
• Alcoholic liver disease
• Alcohol withdrawal syndrome
• Wernicke-Korsakoff syndrome
• Alcoholic cardiomyopathy

Smoking-Related

• Nicotine dependence
• COPD
• Lung cancer
• Cardiovascular disease
• Peripheral vascular disease

Drug-Related

• Opioid use disorder
• Stimulant-induced psychosis
• Cannabis hyperemesis syndrome
• Injection-related infections
• Substance-induced mood disorders

⚠️ 6. Red Flags & Conditions Not to Miss

🛡️ Safeguarding Concerns

Children at Risk

• Parental substance misuse → neglect
• Unsafe storage of substances
• SIDS risk (smoking, alcohol)
• Chaotic home environment
• Domestic violence

Vulnerable Adults

• Financial exploitation
• Cuckooing (home takeover)
• Sexual exploitation
• Debt to dealers
• Unsafe living conditions

⚠️ Medical Red Flags

🚨 Immediate Threats

• Wernicke's triad (confusion + eye signs + ataxia)
• Delirium tremens (hallucinations + hyperthermia)
• Cocaine chest pain (MI risk)
• Opioid overdose (respiratory depression)
• Severe withdrawal (seizures)

🚨 IV Drug Use Complications

• Endocarditis (fever + murmur + IV use)
• Necrotizing fasciitis
• Deep vein thrombosis
• Septic emboli

📄 Legal/Medico-Legal

DVLA Obligations

• Alcohol dependence → inform DVLA
• Drug misuse → assess fitness to drive
• Seizure history → driving restrictions
• Patient must inform DVLA

Prescribing Responsibilities

• Controlled drug regulations
• Diversion risk assessment
• Safe storage advice
• Monitoring requirements

🚨 7. Red Flags for Street Drugs

💀 High Overdose Risk

Heroin, methadone, benzodiazepines, GHB, pregabalin especially when mixed with alcohol.
Co-ingestion is the biggest factor in fatal toxicity.

🔗 High Dependence Risk

Heroin, crack, cocaine, methamphetamine, benzos, GHB, pregabalin.

⚠️ Major GP-relevant Harms

Psychosis: cannabis (high-potency), cocaine, amphetamines, spice, LSD.
Acute MI / arrhythmia: cocaine, amphetamines.
BBVs: injecting heroin/crack → Hep B/C, HIV.
Urological harm: ketamine → severe bladder damage.
Neurological harm: Nitrous oxide → B12 deficiency neuropathy.
Mental health deterioration: almost all stimulants + synthetic cannabinoids.

❤️ 8. Management Frameworks

Treatment Approaches

Brief Interventions

• 5As model (Ask, Advise, Assess, Assist, Arrange)
• FRAMES approach
• Motivational interviewing
• Harm reduction strategies
• Relapse prevention planning

Pharmacological Options

• Nicotine replacement therapy
• Varenicline for smoking cessation
• Acamprosate for alcohol dependence
• Methadone/buprenorphine for opioid dependence
• Naltrexone for alcohol/opioid dependence

🛡️ 9. Keeping Ex-alcoholics off the Alcohol: Relapse Prevention

✔ Confirm abstinence

Patient should usually be abstinent for 7–14 days (varies by drug).
Ensure no acute withdrawal symptoms (CIWA-Ar should be 0–7).
If still drinking daily → specialist alcohol service referral; don't start relapse-prevention meds during active drinking.

✔ Baseline bloods

LFTs
U&E
FBC
INR if liver disease suspected
Consider ECG if heart problems (disulfiram risk)
Check pregnancy status if relevant

✔ Assess suitability

Past reactions, liver status, mental health stability, motivation, family support.

Purpose & Evidence

Purpose: Reduces cravings and helps maintain abstinence.
Evidence: Most widely used first-line medication in UK relapse prevention.

Dosing

666 mg (two 333 mg tablets) TDS
If weight < 60 kg → 333 mg TDS
Start ASAP after abstinence is achieved—ideally within 7 days of stopping alcohol.

Duration & GP Initiation

How long? Minimum 6 months, often up to 12 months.
Can GPs start it? Yes. Safe for GP initiation, especially with local guidelines.

Warnings & Monitoring

Very safe drug overall.
Causes diarrhoea in up to 33%.
Not hepatotoxic (good for patients with liver disease).
Continue even if slip occurs UNLESS they return to heavy drinking—seek review.
Monitoring: LFTs at baseline, then only if clinically indicated.

Purpose & Dosing

Purpose: Reduces the rewarding effects of alcohol → fewer cravings, fewer heavy-drinking days.
Dosing: Start 25 mg daily for 3 days, then 50 mg OD.

GP Initiation

Can GPs start it? Yes, but local pathways differ. Many areas suggest specialist initiation with GP continuation under shared care.
Avoid in opioid users — can precipitate immediate withdrawal.

Warnings

Must be opioid-free for 7–10 days.
Causes nausea, headache, low mood in some.
Avoid in acute hepatitis or liver failure.

Monitoring

Baseline LFTs
Repeat at 1 month, then 3 months, then every 6 months.
Stop if LFTs > 3× ULN or symptoms of hepatitis.

Purpose & Mechanism

Purpose: Creates very unpleasant reaction if alcohol is consumed—deterrent therapy.
How it works: Blocks aldehyde dehydrogenase → alcohol consumption causes:
- flushing
- nausea/vomiting
- palpitations
- chest pain
- hypotension
- potentially life-threatening collapse

Dosing & GP Initiation

Dosing: 500 mg OD for 1–2 weeks, then maintenance 200 mg OD (range 100–200 mg).
Can GPs start it? Yes, BUT ensure:
- Patient is highly motivated.
- Good supervision from family/friend (if possible).
- No cognitive impairment.

Absolute Warnings to Tell Patients

This is vital and MUST be clearly explained:

Do NOT drink alcohol at all — even tiny amounts.
- mouthwash
- perfumes/aftershave
- cooking wine
- vinegar (some types)
- alcohol-based hand gels
- cough syrups
The reaction can occur for up to 7 days after last dose.
Can cause hepatitis → watch for jaundice, abdominal pain, dark urine.
Avoid if:
- severe cardiac disease
- psychosis/pregnancy
- significant liver disease
Interaction with metronidazole → can cause psychosis.

Monitoring

Baseline LFTs
Repeat: 2 weeks, 3 months, 6 months, then PRN.
BP and mental health review periodically.

D. Nalmefene (Selincro)

Used for reduction in alcohol consumption (NOT for abstinence).
Taken as needed → 1 tablet on days the patient anticipates drinking.
Requires ongoing psychosocial support.
Start only if drinking > risk levels.

E. Thiamine + Vitamin Support

Essential in anyone with past alcohol dependence:
Oral thiamine 100 mg TDS for several months.
Give Pabrinex IV only in hospital/urgent care if high risk of Wernicke's.

Confirm abstinence
Assess readiness & motivation
Order baseline labs
Choose medication (Acamprosate first-line unless contraindicated)
Provide written and verbal safety info
Involve alcohol services if possible
Arrange close follow-up
- 1–2 weeks after start
- Monthly for 3 months
- Then every 3 months

Situation	Best Option
Wants to reduce cravings	Acamprosate
Has strong "reward" drive from alcohol	Naltrexone
Needs a psychological deterrent	Disulfiram
Unsafe to give hepatotoxic meds	Acamprosate
Poor supervision / chaotic life	Avoid disulfiram
Wants "as needed" drinking reduction	Nalmefene

"Severe Warning" Script You Can Say to a Patient (Disulfiram)

"If you take disulfiram, you absolutely must not drink alcohol at all. Even tiny amounts in mouthwash, aftershave, perfumes, hand gels, or cooking sauces can cause a dangerous reaction — flushing, vomiting, chest pain, collapse. This reaction can still happen for up to seven days after the last tablet. If you accidentally drink, seek urgent medical help."

📖 10. Exams & GP Training Relevance

AKT Favorites

• AUDIT-C scoring: 3-question screening tool
• Hepatitis B/C natural history: Chronic infection rates
• Cocaine cardiac risks: MI, arrhythmias, avoid beta-blockers
• Substitute prescribing: Methadone vs buprenorphine
• Wernicke's triad: Only 10% have complete triad
• Cannabis hyperemesis: Hot baths provide relief
• DVLA regulations: Notification requirements

SCA Scenarios

• Heavy drinking bus driver: DVLA obligations, fitness to drive
• Teenager with cannabis use: Motivational interviewing, harm reduction
• Grandmother with A&E alcohol notifications: Safeguarding concerns
• Pregnant woman smoking: Brief intervention, NRT safety
• IV drug user with fever: Endocarditis risk, urgent referral
• Benzodiazepine dependence: Withdrawal risks, slow reduction

WPBA Opportunities

• COT: Smoking cessation consultation
• CAT: Domestic violence linked to alcohol misuse
• CEPS: Injection-site complications management
• Mini-CEX: AUDIT questionnaire administration
• CbD: Safeguarding referral for chaotic drug use
• PSQ: Patient feedback on addiction consultations

🌐 11. Useful Resources

Clinical Guidelines

Support Services

❤️

You've Got This! 💪

Remember: You don't need to be an addiction specialist to provide excellent substance misuse care. You just need to know when to worry, when to treat, and when to refer.

Every conversation about substance use is a chance to plant a seed of change. Even if they're not ready today, your non-judgmental approach and genuine concern will be remembered when they are ready to make that change.

☕ Now go reward yourself with that well-deserved coffee ☕