Smoking, Alcohol & Substance Misuse - Bradford VTS

🚭 Smoking, Alcohol & Substance Misuse

A Comprehensive Clinical Guide for Primary Care

🍵 Tea-Friendly Learning

Digestible content perfect for your coffee break

⏰ For GP Trainees Short on Time

Quick reference guides and essential knowledge

🚩 Red Flag Focused

Critical warning signs you cannot miss

📅 Last Updated: December 2024 | Next Review: June 2025

"The complexity of addiction requires a compassionate, evidence-based approach. As GPs, we're often the first point of contact and sometimes the last hope. Every interaction matters."

— Dr. Ramesh Mehay, Bradford VTS Programme Director

📊 Quick Facts at a Glance

1 in 10

adults still smoke

1 in 10

adults vape

30%

of men drink too much

15%

of women drink too much

1 in 50

people use cocaine (age 15-65)

0.2%

people inject drugs (age 15-65)

📚 Downloads & Web Resources

📥 Downloads

path: ALCOHOL, SMOKING & DRUGS

🌐 Web Resources

Drinkaware
Comprehensive alcohol information, unit calculators, and support resources for patients and healthcare professionals.
FRANK - Drug Information
Honest information about drugs including effects, risks, and where to get help. Essential resource for drug-related queries.
NHS Better Health - Quit Smoking
Official NHS smoking cessation support with tools, advice, and local service finder for patients wanting to quit smoking.

📋 Overview

Substance misuse encompasses a spectrum from occasional recreational use to severe dependency, affecting individuals across all demographics. As primary care physicians, we encounter these issues daily, often masked by seemingly unrelated presentations.

💡 Clinical Pearl: The patient presenting with recurrent UTIs, frequent falls, or "anxiety" may be struggling with alcohol dependency. Always consider substance use in your differential diagnosis.

Key Principles for Primary Care

Non-judgmental approach: Addiction is a medical condition, not a moral failing
Harm reduction: Sometimes abstinence isn't immediately achievable
Holistic assessment: Consider physical, psychological, and social factors
Safety first: Identify and manage immediate risks
Collaborative care: Work with specialists, social services, and support networks

🔍 Data-Gathering & Examination Tips

📝 History Taking

🩺 Physical Examination

📊 Screening Tools

🗣️ Effective History Taking

🎯 The FRAMES Approach:
Feedback - Share objective findings
Responsibility - Emphasize patient choice
Advice - Provide clear, specific guidance
Menu - Offer options for change
Empathy - Show understanding
Self-efficacy - Build confidence in ability to change

Essential Questions

Quantity & Frequency: "Walk me through a typical week - what do you drink/use each day?"
Pattern Recognition: "When did you first notice this becoming a problem?"
Functional Impact: "How is this affecting your work/relationships/health?"
Previous Attempts: "What have you tried before to cut down or stop?"
Motivation Assessment: "On a scale of 1-10, how ready are you to make changes?"

🔍 Physical Examination Focus

Alcohol-Related Signs

General: Tremor, sweating, poor hygiene, alcohol odor
Cardiovascular: Hypertension, cardiomyopathy, arrhythmias
Hepatic: Hepatomegaly, jaundice, ascites, spider naevi
Neurological: Peripheral neuropathy, cerebellar signs, cognitive impairment
Gastrointestinal: Epigastric tenderness, signs of GI bleeding

Drug Use Indicators

Injection sites: Track marks, abscesses, thrombosed veins
Nasal examination: Septal perforation, chronic rhinitis
Dental health: Poor dentition, "meth mouth"
Skin: Excoriation marks, poor wound healing
Eyes: Pupil size, conjunctival injection, nystagmus

📋 Validated Screening Tools

🎯 AUDIT-C (Alcohol):
Quick 3-question screen:
1. How often do you have a drink containing alcohol?
2. How many drinks containing alcohol do you have on a typical day?
3. How often do you have 6 or more drinks on one occasion?
Score ≥4 (men) or ≥3 (women) indicates hazardous drinking

Other Useful Tools

CAGE Questions: Cut down, Annoyed, Guilty, Eye-opener
DAST-10: Drug Abuse Screening Test
PHQ-9: Depression screening (high comorbidity)
GAD-7: Anxiety screening

🧪 Diagnostic Approach & Investigations

🩸 Blood Tests

🧪 Urine Tests

📷 Imaging

Essential Blood Investigations

🍷 Alcohol-Related Tests

FBC: Macrocytosis (MCV >100), thrombocytopenia
LFTs: Raised GGT (most sensitive), AST:ALT ratio >2:1
CDT (Carbohydrate Deficient Transferrin): Specific for heavy drinking
B12/Folate: Often deficient
Magnesium, Phosphate: Commonly low

💊 Drug Misuse Investigations

Hepatitis B & C, HIV: Risk assessment for injecting drug users
Cardiac enzymes: If cocaine use suspected
Glucose: Hypoglycemia with alcohol, hyperglycemia with stimulants
Electrolytes: Dehydration, hyponatremia

Urine Drug Screening

⚠️ Detection Windows:
• Cannabis: 3-30 days (depending on use pattern)
• Cocaine: 1-3 days
• Amphetamines: 1-3 days
• Opiates: 1-3 days
• Alcohol: 12-24 hours (ethyl glucuronide up to 80 hours)

When to Test

Suspected intoxication or withdrawal
Unexplained altered mental state
Pre-employment or legal requirements
Monitoring compliance with treatment
Safeguarding concerns

Imaging Considerations

When to Consider Imaging

Chest X-ray: Recurrent pneumonia, TB risk, cardiac enlargement
Abdominal USS: Hepatomegaly, ascites, pancreatic changes
CT Head: Altered consciousness, head injury, cognitive changes
Echocardiogram: Suspected cardiomyopathy

🎯 Differential Diagnosis

🧠 Psychiatric Conditions ▼

Depression: High comorbidity with substance use
Anxiety disorders: Often self-medicated with alcohol/drugs
Bipolar disorder: Manic episodes may involve substance use
PTSD: Trauma-related substance use
Personality disorders: Particularly borderline and antisocial

⚕️ Medical Conditions ▼

Liver disease: Hepatitis, cirrhosis, fatty liver
Neurological: Seizure disorders, dementia, neuropathy
Cardiovascular: Cardiomyopathy, hypertension, arrhythmias
Gastrointestinal: Peptic ulcer disease, pancreatitis, malnutrition
Endocrine: Diabetes, thyroid disorders

🏠 Social Factors ▼

Domestic violence: Both cause and consequence
Homelessness: Complex bidirectional relationship
Financial problems: Debt, unemployment
Legal issues: Criminal activity, driving offenses
Family breakdown: Relationship difficulties, child protection

📝 Common Conditions & Clinical Presentations

🍷 Alcohol-Related

💊 Drug-Related

🔄 Withdrawal Syndromes

Alcohol-Related Presentations

🫀 Cardiovascular Complications ▼

Alcoholic cardiomyopathy: Dilated heart, reduced ejection fraction
Hypertension: Often improves with abstinence
Arrhythmias: Atrial fibrillation, "holiday heart syndrome"
Sudden cardiac death: Risk increased with binge drinking

🍃 Hepatic Complications ▼

Fatty liver: Reversible with abstinence
Alcoholic hepatitis: Acute inflammation, high mortality
Cirrhosis: Irreversible scarring, portal hypertension
Hepatocellular carcinoma: Increased risk with cirrhosis

Drug-Related Presentations

💉 Injection-Related Complications ▼

Abscesses: Local infection, may require surgical drainage
Cellulitis: Spreading soft tissue infection
Endocarditis: Heart valve infection, high mortality
DVT/PE: Thrombotic complications
Hepatitis B/C, HIV: Blood-borne virus transmission

🧠 Neurological Complications ▼

Overdose: Respiratory depression, coma
Seizures: Stimulant use, withdrawal
Stroke: Cocaine-induced hemorrhage/infarction
Cognitive impairment: Chronic use effects

Withdrawal Syndromes

🚨 Medical Emergency: Alcohol withdrawal can be life-threatening. Delirium tremens has 5-15% mortality if untreated.

🍷 Alcohol Withdrawal Timeline

6-12 hours: Tremor, sweating, anxiety, nausea
12-24 hours: Hallucinations (usually visual)
24-48 hours: Seizures (peak risk)
48-96 hours: Delirium tremens (confusion, hyperthermia, cardiovascular instability)

💊 Opioid Withdrawal

Symptoms: Muscle aches, runny nose, lacrimation, diarrhea, vomiting, dilated pupils
Timeline: 6-12 hours after last use, peaks 1-3 days
Management: Symptomatic relief, consider buprenorphine substitution

💊 Common UK Street Drugs Reference

Drug Name	Street Names	Effects	Typical Price	Addictive Potential	GP-Relevant Harms
Cannabis	Weed, Skunk, Hash, Ganja	Relaxation, altered perception, increased appetite	£10-15/gram	Low-Moderate	Respiratory issues, mental health problems, motivation loss
Cocaine	Coke, Charlie, Snow, Blow	Euphoria, increased energy, confidence	£80-100/gram	High	Cardiac arrhythmias, stroke, nasal septum damage
Heroin	Smack, H, Brown, Gear	Intense euphoria, pain relief, sedation	£40-60/gram	Very High	Overdose risk, injection site infections, blood-borne viruses
MDMA/Ecstasy	E, Pills, Molly, Mandy	Empathy, energy, sensory enhancement	£5-15/pill	Moderate	Hyperthermia, dehydration, serotonin syndrome
Amphetamines	Speed, Whizz, Billy	Increased alertness, energy, appetite suppression	£10-20/gram	Moderate-High	Psychosis, cardiovascular problems, malnutrition
Methamphetamine	Crystal Meth, Ice, Glass	Intense stimulation, hyperfocus	£200-300/gram	Very High	Severe dental problems, psychosis, violent behavior
Ketamine	K, Ket, Special K	Dissociation, anesthesia, hallucinations	£25-35/gram	Moderate	Bladder damage, cognitive impairment, accidents
LSD	Acid, Tabs, Lucy	Visual hallucinations, altered thinking	£5-15/tab	Low	Psychological distress, accidents during intoxication

🚩 GP Red Flag Tips for Drug Misuse

Frequent A&E attendances - especially for injuries, overdoses, or psychiatric presentations
Requesting specific medications - particularly opioids, benzodiazepines, or pregabalin
Multiple GP registrations - "doctor shopping" for prescriptions
Unexplained weight loss - especially with stimulant use
Dental problems in young adults - "meth mouth" or poor oral hygiene
Recurrent infections - particularly skin/soft tissue in injection drug users
Erratic behavior or mood swings - may indicate intoxication or withdrawal
Social decline - job loss, relationship breakdown, housing issues
Missed appointments followed by urgent requests - pattern of chaotic lifestyle
Family concerns - relatives reporting behavioral changes or drug paraphernalia

🚨 Red Flags & Emergency Presentations

⚠️ IMMEDIATE ACTION REQUIRED
These presentations require urgent assessment and may need emergency referral

🍷 Alcohol Emergencies

💊 Drug Emergencies

🧠 Psychiatric Emergencies

🚨 Alcohol-Related Emergencies

Delirium Tremens (DTs)

Confusion, disorientation
Visual/tactile hallucinations
Hyperthermia (>38.5°C)
Tachycardia, hypertension
Profuse sweating
Action: Immediate hospital admission, IV benzodiazepines

Other Alcohol Emergencies

Seizures: Usually generalized tonic-clonic, may be status epilepticus
GI bleeding: Varices, Mallory-Weiss tear, peptic ulcer
Acute pancreatitis: Severe epigastric pain, vomiting
Alcoholic ketoacidosis: Metabolic acidosis, ketones
Wernicke's encephalopathy: Confusion, ataxia, ophthalmoplegia

💊 Drug-Related Emergencies

Opioid Overdose

Respiratory depression (<10 breaths/min)
Pinpoint pupils
Reduced consciousness
Cyanosis
Action: Naloxone 0.4-2mg IV/IM, may need repeating

Stimulant Toxicity

Cocaine/Amphetamine: Chest pain, arrhythmias, hyperthermia, seizures
MDMA: Hyperthermia, hyponatremia, serotonin syndrome
Management: Cooling, benzodiazepines, avoid beta-blockers

Other Drug Emergencies

Synthetic drugs: Unpredictable effects, aggressive behavior
Injection complications: Endocarditis, sepsis, abscesses
Drug-induced psychosis: Paranoia, violence, self-harm risk

🧠 Psychiatric Emergencies

Suicide Risk Assessment

Active suicidal ideation with plan
Previous suicide attempts
Severe depression with substance use
Social isolation, hopelessness
Action: Mental Health Act assessment, crisis team referral

Violence Risk

Intoxication-related aggression: Alcohol, stimulants, synthetic drugs
Paranoid psychosis: Methamphetamine, cannabis, cocaine
Withdrawal agitation: Alcohol, benzodiazepines
Management: De-escalation, security, rapid tranquilization if needed

⚕️ Management Frameworks

🍷 Alcohol Management Pathway ▼

Brief Intervention (FRAMES Model)

Feedback: "Your liver tests show some changes that could be related to alcohol"
Responsibility: "The choice to change is entirely yours"
Advice: "I'd recommend reducing to within safe limits"
Menu: "We could try gradual reduction, or complete abstinence, or..."
Empathy: "I understand this isn't easy to hear"
Self-efficacy: "I believe you have the strength to make these changes"

Pharmacological Support

Detoxification:
• Chlordiazepoxide: 10-40mg QDS, reducing regime
• Thiamine: 100mg TDS (Pabrinex if severe deficiency)
• Multivitamins, folate supplementation

Relapse Prevention

Acamprosate: Reduces craving, 666mg TDS
Naltrexone: Blocks euphoric effects, 50mg daily
Disulfiram: Aversion therapy, 200mg daily

💊 Drug Misuse Management ▼

Opioid Substitution Therapy

Methadone: Long-acting, daily supervised consumption
Buprenorphine: Partial agonist, less respiratory depression
Suboxone: Buprenorphine + naloxone combination

Harm Reduction Strategies

Needle exchange: Reduce blood-borne virus transmission
Supervised consumption: Prevent diversion, ensure compliance
Naloxone provision: Take-home kits for overdose reversal
Hepatitis B vaccination: All injecting drug users

Psychosocial Interventions

Motivational interviewing: Enhance motivation to change
Cognitive behavioral therapy: Address thinking patterns
Contingency management: Rewards for abstinence
12-step programs: Peer support groups

🎯 Smoking Cessation ▼

Pharmacological Options

Nicotine replacement: Patches, gum, lozenges, inhalator
Varenicline: Partial nicotinic receptor agonist
Bupropion: Antidepressant with anti-smoking properties

Behavioral Support

Stop smoking services: Group or individual support
Quitline: Telephone counseling
Mobile apps: Digital behavior change tools
E-cigarettes: Harm reduction approach (controversial)

💡 Success Tip: Combination therapy (NRT + behavioral support) doubles quit rates compared to either intervention alone.

🛡️ Keeping Ex-Alcohol-Dependent Patients Off Alcohol – GP Guide

🎯 Three-Part Approach:
1. Psychological support - Counseling, peer groups, lifestyle changes
2. Social interventions - Family therapy, housing, employment support
3. Pharmacological prevention - Anti-craving medications

💊 Relapse Prevention Medications ▼

Pre-Medication Steps

Confirm abstinence for minimum 5-7 days
Baseline LFTs, FBC, U&Es
Assess motivation and support systems
Exclude contraindications
Discuss realistic expectations

Main Medications

Acamprosate (Campral):
• Dose: 666mg TDS (reduce if <60kg or elderly)
• Mechanism: Modulates GABA/glutamate balance
• Benefits: Reduces craving, well-tolerated
• Contraindications: Severe renal/hepatic impairment
• Duration: 6-12 months minimum

Naltrexone:
• Dose: 50mg daily
• Mechanism: Opioid receptor antagonist
• Benefits: Blocks euphoric effects of alcohol
• Contraindications: Opioid dependence, severe hepatitis
• Monitoring: Monthly LFTs for first 3 months

Disulfiram (Antabuse):
• Dose: 200mg daily
• Mechanism: Aldehyde dehydrogenase inhibitor
• Benefits: Strong deterrent effect
• Risks: Severe reaction with alcohol (flushing, vomiting, hypotension)
• Contraindications: Cardiac disease, psychosis

Other Options

Nalmefene: As-needed basis, reduces heavy drinking days
Baclofen: Off-label use, may help with anxiety and craving
Topiramate: Off-label, some evidence for craving reduction

🏥 GP Starting Process ▼

Initial Assessment Checklist

✅ Confirmed abstinence (minimum 5 days)
✅ Motivated for long-term sobriety
✅ Adequate social support
✅ No active psychiatric crisis
✅ Baseline investigations completed
✅ Patient understands medication purpose

Drug Selection Guide

First-line: Acamprosate (safest, best evidence)
If acamprosate unsuitable: Naltrexone
High relapse risk: Consider disulfiram (with caution)
Combination therapy: Acamprosate + naltrexone (specialist advice)

Follow-up Schedule

Week 1: Check tolerance, side effects
Month 1: Assess compliance, craving levels
Month 3: Review effectiveness, blood tests
Month 6: Consider continuation vs. tapering
Month 12: Long-term maintenance decision

📋 Safety Scripts & Monitoring ▼

Patient Safety Information

Essential Patient Advice:
"This medication helps reduce your urge to drink, but it's not a magic cure. You still need to avoid situations where you might be tempted. If you do drink while taking this medication, stop the tablets and contact us immediately."

Red Flag Symptoms to Report

Severe nausea or vomiting
Yellowing of skin or eyes
Dark urine or pale stools
Severe abdominal pain
Unusual mood changes or suicidal thoughts
Any alcohol consumption while on disulfiram

Monitoring Requirements

Acamprosate: Renal function every 6 months
Naltrexone: LFTs monthly × 3, then 3-monthly
Disulfiram: LFTs 2-weekly × 2 months, then monthly
All medications: Mental state assessment at each visit

👥 Safeguarding & Social Considerations

🚨 Mandatory Reporting: Child protection concerns must be reported to local safeguarding team within 24 hours

👶 Child Protection

🏠 Domestic Violence

👴 Vulnerable Adults

Child Protection Concerns

Risk Factors

Parental substance use affecting care capacity
Children exposed to drug paraphernalia
Neglect due to intoxication or withdrawal
Domestic violence in substance-using households
Financial hardship affecting basic needs

Assessment Questions

"Who looks after the children when you're using/drinking?"
"Have the children ever seen you intoxicated?"
"Are there any drugs or alcohol in the house where children could access them?"
"How is your substance use affecting your parenting?"

Action Required: Any concerns about child welfare must trigger safeguarding referral, regardless of patient consent.

Domestic Violence & Substance Use

The Connection

Substance use increases risk of perpetrating violence
Victims may use substances to cope with trauma
Abusers may force substance use for control
Both issues often co-exist and reinforce each other

Screening Approach

HARK Questions:
• Humiliation - "Has your partner humiliated you?"
• Afraid - "Are you afraid of your partner?"
• Rape - "Has your partner forced you into sexual activity?"
• Kick - "Has your partner kicked, hit, or physically hurt you?"

Safety Planning

Emergency contact numbers
Safe places to go
Important documents location
Code words with family/friends
Local refuge services information

Vulnerable Adult Safeguarding

Vulnerability Indicators

Cognitive impairment from chronic substance use
Physical frailty or disability
Mental health conditions
Social isolation
Financial exploitation

Types of Abuse

Financial: Theft of benefits, coercion to buy drugs
Physical: Violence, neglect, inappropriate restraint
Emotional: Intimidation, isolation, humiliation
Sexual: Non-consensual activity, exploitation
Neglect: Failure to provide care, abandonment

Remember: Adults have the right to make unwise decisions, but they must have capacity and be free from coercion.

🚗 DVLA Requirements & Fitness to Drive

⚠️ Legal Obligation: GPs have a duty to advise patients about fitness to drive and may need to breach confidentiality if public safety is at risk.

🍷 Alcohol & Driving

💊 Drugs & Driving

⚕️ Medical Fitness

Alcohol-Related Driving Issues

DVLA Notification Required

Alcohol dependency or abuse
Persistent alcohol misuse
Alcohol-related seizures
Delirium tremens
Alcohol-related liver disease

License Restrictions

Group 1 (Car/Motorcycle):
• 1 year off driving after alcohol dependency
• 6 months for alcohol misuse
• Medical review required before reinstatement

Group 2 (HGV/PCV):
• 3 years off driving after dependency
• 1 year for misuse
• Stricter medical requirements

Reinstatement Criteria

Period of abstinence completed
Normal liver function tests
No evidence of ongoing dependency
Satisfactory medical report
May require independent medical examination

Drug Use & Driving

Prescribed Medications

Opioid substitution therapy: Stable patients may drive
Benzodiazepines: Impairment assessment required
Antipsychotics: Consider sedation effects
Anticonvulsants: Seizure control essential

Illegal Drug Use

Zero Tolerance: Any illegal drug use is incompatible with driving. Patients must not drive and should surrender license if dependent.

Drug Driving Offenses

Specified limits for 17 drugs (including cannabis, cocaine, MDMA)
Police roadside testing available
Penalties: 12-month ban, fine up to £5,000, possible imprisonment
Criminal record affects insurance and employment

Medical Fitness Assessment

Conditions Affecting Fitness

Seizures: Alcohol/drug withdrawal seizures
Cognitive impairment: Chronic substance use effects
Visual problems: Alcohol-related neuropathy
Cardiovascular: Cardiomyopathy, arrhythmias
Psychiatric: Psychosis, severe depression

GP Responsibilities

Advise patient of fitness concerns
Document advice given
Encourage voluntary notification to DVLA
Consider breach of confidentiality if public risk
Complete medical reports when requested

💡 Documentation Tip: Always record driving advice in notes: "Patient advised not to drive due to [condition]. Informed of duty to notify DVLA. Patient states understanding."

📚 Exam Relevance & Key Learning Points

🎭 CSA Scenarios

📖 Applied Knowledge

🩺 Clinical Skills

Common CSA Presentations

🎯 "I want to cut down my drinking" ▼

Key Consultation Skills

Explore ICE: Ideas, Concerns, Expectations about drinking
Quantify intake: Use units, typical week approach
Assess readiness: Stages of change model
Identify triggers: Stress, social situations, emotions
Negotiate plan: Gradual vs. immediate reduction

Safety Netting

Withdrawal symptoms to watch for
When to seek urgent help
Follow-up arrangements
Support service contacts

👨‍👩‍👧‍👦 "I'm worried about my partner's drug use" ▼

Consultation Approach

Validate concerns: Acknowledge impact on family
Assess safety: Domestic violence, child protection
Explore options: What they've tried, what they want
Confidentiality limits: Explain when you must act
Support resources: Family support groups, counseling

Ethical Considerations

Cannot discuss partner's care without consent
Duty of care to children overrides confidentiality
Balancing family needs with individual rights

Applied Knowledge Test Areas

🧪 Pharmacology

Benzodiazepine withdrawal: Cross-tolerance, tapering regimes
Opioid pharmacology: Agonists, partial agonists, antagonists
Drug interactions: Alcohol + medications, enzyme induction
Overdose management: Naloxone, flumazenil, supportive care

📊 Epidemiology & Statistics

UK prevalence of substance use disorders
Mortality statistics and causes
Economic burden on healthcare
Effectiveness of interventions (NNT, NNH)

⚖️ Legal & Ethical Issues

Capacity assessment in intoxicated patients
Confidentiality vs. public safety
Mandatory reporting requirements
Consent for treatment in dependency

Clinical Skills Assessment

🔍 History Taking

Substance use history: Systematic approach to all substances
Functional assessment: Impact on work, relationships, health
Risk assessment: Self-harm, violence, neglect
Motivational interviewing: Eliciting change talk

🩺 Examination Skills

Focused examination: Relevant to substance type
Mental state exam: Cognitive function, mood, psychosis
Injection site examination: Technique and interpretation
Withdrawal assessment: Severity scoring tools

📋 Management Planning

Shared decision making: Involving patient in treatment choices
Multidisciplinary approach: When and how to refer
Monitoring plans: Follow-up schedules, outcome measures
Relapse planning: Identifying triggers, coping strategies

📖 Useful Resources & Downloads

📋 Guidelines

🛠️ Assessment Tools

🤝 Support Services

Clinical Guidelines

🏥 NICE Guidelines

CG115: Alcohol-use disorders: diagnosis, assessment and management
CG51: Drug misuse in over 16s: opioid detoxification
CG52: Drug misuse in over 16s: psychosocial interventions
PH24: Alcohol-use disorders: prevention
NG58: Coexisting severe mental illness and substance misuse

🏴󠁧󠁢󠁥󠁮󠁧󠁿 Other Key Guidelines

RCGP: Substance Misuse and Associated Health Guidance
BMA: Alcohol and Drug Misuse Guidance
Faculty of Addictions: Clinical Guidelines
DVLA: Medical Standards of Fitness to Drive

Assessment & Screening Tools

🍷 Alcohol Screening

AUDIT: Alcohol Use Disorders Identification Test (10 questions)
AUDIT-C: Shortened version (3 questions)
CAGE: Cut down, Annoyed, Guilty, Eye-opener
FAST: Fast Alcohol Screening Test

💊 Drug Screening

DAST-10: Drug Abuse Screening Test
DUDIT: Drug Use Disorders Identification Test
ASSIST: Alcohol, Smoking and Substance Involvement Screening Test

🧠 Mental Health

PHQ-9: Depression screening
GAD-7: Anxiety screening
CIWA-Ar: Clinical Institute Withdrawal Assessment for Alcohol

Support Services & Contacts

🆘 Emergency Contacts

Emergency Services: 999
NHS 111: Non-emergency medical advice
Samaritans: 116 123 (free, 24/7)
Crisis Text Line: Text SHOUT to 85258

🍷 Alcohol Support

Alcoholics Anonymous: 0800 9177 650
Al-Anon (families): 020 7403 0888
Drinkline: 0300 123 1110
Alcohol Change UK: Information and support

💊 Drug Support

Narcotics Anonymous: 0300 999 1212
FRANK: 0300 123 6600 (drug information)
Release: 020 7324 2989 (legal advice)
Turning Point: Local drug and alcohol services

👨‍👩‍👧‍👦 Family Support

Adfam: Support for families affected by drugs and alcohol
Nar-Anon: Support for families of drug users
NSPCC: 0808 800 5000 (child protection)
Women's Aid: 0808 2000 247 (domestic violence)

🚭 Smoking, Alcohol & Substance Misuse

🍵 Tea-Friendly Learning

⏰ For GP Trainees Short on Time

🚩 Red Flag Focused

📊 Quick Facts at a Glance

🧭 Page Contents / Index

📚 Downloads & Web Resources

📥 Downloads

🌐 Web Resources

📋 Overview

Key Principles for Primary Care

🔍 Data-Gathering & Examination Tips

🗣️ Effective History Taking

Essential Questions

🔍 Physical Examination Focus

Alcohol-Related Signs

Drug Use Indicators

📋 Validated Screening Tools

Other Useful Tools

🧪 Diagnostic Approach & Investigations

Essential Blood Investigations

🍷 Alcohol-Related Tests

💊 Drug Misuse Investigations

Urine Drug Screening

When to Test

Imaging Considerations

When to Consider Imaging

🎯 Differential Diagnosis

📝 Common Conditions & Clinical Presentations

Alcohol-Related Presentations

Drug-Related Presentations

Withdrawal Syndromes

🍷 Alcohol Withdrawal Timeline

💊 Opioid Withdrawal

💊 Common UK Street Drugs Reference

🚩 GP Red Flag Tips for Drug Misuse

🚨 Red Flags & Emergency Presentations

🚨 Alcohol-Related Emergencies

Delirium Tremens (DTs)

Other Alcohol Emergencies

💊 Drug-Related Emergencies

Opioid Overdose

Stimulant Toxicity

Other Drug Emergencies

🧠 Psychiatric Emergencies

Suicide Risk Assessment

Violence Risk

⚕️ Management Frameworks

Brief Intervention (FRAMES Model)

Pharmacological Support

Relapse Prevention

Opioid Substitution Therapy

Harm Reduction Strategies

Psychosocial Interventions

Pharmacological Options

Behavioral Support

🛡️ Keeping Ex-Alcohol-Dependent Patients Off Alcohol – GP Guide

Pre-Medication Steps

Main Medications

Other Options

Initial Assessment Checklist

Drug Selection Guide

Follow-up Schedule

Patient Safety Information

Red Flag Symptoms to Report

Monitoring Requirements

👥 Safeguarding & Social Considerations

Child Protection Concerns

Risk Factors

Assessment Questions

Domestic Violence & Substance Use

The Connection

Screening Approach

Safety Planning

Vulnerable Adult Safeguarding

Vulnerability Indicators

Types of Abuse

🚗 DVLA Requirements & Fitness to Drive

Alcohol-Related Driving Issues

DVLA Notification Required

How IT ALL STARTED
WHAT WE'RE ABOUT
WHO ARE WE FOR?