6.1.6 Assessment and Management of Drug Misusers

The Assessment and Management of Drug Misusers, Including Signs and Symptoms of Substance Use, and Withdrawal Phenomena

The assessment and management of drug and alcohol misuse involve a comprehensive approach that considers the individual’s history of substance use, physical and mental health status, social and cultural background, and treatment preferences. The assessment process typically involves a combination of self-report measures, clinical interviews, physical examinations, and laboratory tests.

Signs and symptoms:

Signs and symptoms of substance use and withdrawal phenomena can vary depending on the type of substance and the individual’s level of dependence. Common symptoms of substance use can include changes in mood and behaviour, impaired cognition and memory, physical health problems, and social and occupational dysfunction (American Psychiatric Association, 2013). Withdrawal phenomena can include physical symptoms such as tremors, nausea, and seizures, as well as psychological symptoms such as anxiety, depression, and cravings (National Institute on Drug Abuse, 2021).

Substance	Signs and Symptoms
Alcohol	Slurred speech, impaired coordination, mood changes, blackouts
Cannabis	Red eyes, increased appetite, impaired memory and cognition
Cocaine	Dilated pupils, restlessness, elevated heart rate, paranoia
Opioids	Constricted pupils, drowsiness, slowed breathing, constipation
Amphetamines	Dilated pupils, increased energy, rapid speech, anxiety
Benzodiazepines	Slurred speech, dizziness, sedation, memory impairment
Hallucinogens	Altered perception, hallucinations, anxiety, paranoia
Inhalants	Slurred speech, dizziness, nausea, impaired coordination

Note that this is not an exhaustive list and that signs and symptoms can vary depending on the individual and the specific substance used.

Withdrawal phenomena:

Effective management of drug and alcohol misuse typically involves a combination of pharmacological and psychosocial interventions. Pharmacological interventions can include medications to manage withdrawal symptoms, reduce cravings, or treat co-occurring mental health disorders (National Institute on Drug Abuse, 2020). Psychosocial interventions can include behavioural therapies, cognitive-behavioural therapy, motivational interviewing, and support groups (Substance Abuse and Mental Health Services Administration, 2018).

A table summarizing some common withdrawal symptoms for various recreational drugs:

Substance	Withdrawal Symptoms
Alcohol	Tremors, seizures, sweating, anxiety, insomnia, hallucinations
Cannabis	Irritability, insomnia, decreased appetite, cravings
Cocaine	Fatigue, depression, anxiety, sleep disturbances, cravings
Opioids	Nausea, vomiting, muscle aches, sweating, anxiety, cravings
Amphetamines	Fatigue, depression, anxiety, irritability, sleep disturbances
Benzodiazepines	Anxiety, insomnia, seizures, agitation, irritability
Hallucinogens	Flashbacks, anxiety, depression, mood changes, cravings
Inhalants	Headaches, nausea, vomiting, seizures, irritability

Note that withdrawal symptoms can vary in intensity and duration depending on the individual, the specific substance used, and the duration and frequency of use. If you or someone you know is experiencing withdrawal symptoms after stopping drug use, it is important to seek help from a healthcare professional.

The assessment and management of drug and alcohol misuse require a collaborative and individualized approach that addresses the complex interplay between biological, psychological, and social factors. By providing effective and evidence-based interventions, it is possible to improve outcomes for individuals affected by substance misuse.

Withdrawal management:

In the UK, specific withdrawal management guidelines have been developed for a number of substances, including alcohol, opioids, benzodiazepines, and stimulants. These guidelines provide recommendations for the management of withdrawal symptoms and the use of pharmacological and psychosocial interventions to support recovery.

Substance	Withdrawal Management (UK/NICE Guidelines)
Alcohol	1. Assess for the severity of withdrawal symptoms using Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale. 2. Administer benzodiazepines, preferably chlordiazepoxide or diazepam, for symptom-triggered or fixed-schedule regimens to manage withdrawal symptoms. 3. Consider using adjunctive medications such as antipsychotics for severe agitation or hallucinations, and anticonvulsants for seizure prophylaxis if indicated. 4. Provide supportive care, including monitoring vital signs, hydration, and nutrition. 5. Refer for psychosocial interventions and ongoing support after detoxification.
Cannabis	1. Provide reassurance, psychoeducation, and supportive care for mild to moderate withdrawal symptoms. 2. Consider short-term use of sleep aids, such as antihistamines or melatonin, for insomnia. 3. Encourage engagement in psychosocial interventions and ongoing support for cannabis use disorder.
Cocaine	1. Provide supportive care, reassurance, and monitoring of vital signs. 2. Consider short-term use of benzodiazepines for anxiety, agitation, or sleep disturbances. 3. Encourage engagement in psychosocial interventions and ongoing support for cocaine use disorder.
Opioids	1. Assess the severity of withdrawal symptoms using Clinical Opiate Withdrawal Scale (COWS) or similar tools. 2. Consider using opioid agonist medications such as methadone or buprenorphine for managing withdrawal symptoms. 3. If opioid agonist treatment is not appropriate, consider using alpha-2 adrenergic agonists such as clonidine or lofexidine to manage withdrawal symptoms. 4. Provide supportive care, including monitoring vital signs, hydration, and nutrition. 5. Refer for psychosocial interventions and ongoing support after detoxification.
Amphetamines	1. Provide supportive care, reassurance, and monitoring of vital signs. 2. Consider short-term use of benzodiazepines for anxiety, agitation, or sleep disturbances. 3. Encourage engagement in psychosocial interventions and ongoing support for amphetamine use disorder.
Benzodiazepines	1. Assess the severity of withdrawal symptoms and the risk of complications, such as seizures. 2. Gradually taper the dose of the benzodiazepine or switch to a long-acting benzodiazepine (e.g., diazepam) and taper the dose over a period of weeks to months. 3. Provide supportive care, including monitoring vital signs, hydration, and nutrition. 4. Refer for psychosocial interventions and ongoing support after detoxification.
Hallucinogens	1. Provide reassurance, psychoeducation, and supportive care for mild to moderate withdrawal symptoms. 2. Consider short-term use of benzodiazepines for anxiety, agitation, or sleep disturbances if needed. 3. Encourage engagement in psychosocial interventions and ongoing support for hallucinogen use disorder.
Inhalants	1. Provide supportive care, reassurance, and monitoring of vital signs. 2. Assess and manage potential complications, such as cardiac arrhythmias, respiratory depression, or electrolyte imbalances.

The National Institute for Health and Care Excellence (NICE) provides guidelines for the management of alcohol dependence, which include recommendations for the management of withdrawal symptoms using benzodiazepines or other medications, as well as psychological interventions such as cognitive-behavioural therapy and motivational interviewing (NICE, 2018).

For opioid withdrawal, the UK Clinical Guidelines on Drug Misuse and Dependence recommend the use of pharmacological interventions such as buprenorphine, methadone, or clonidine to manage withdrawal symptoms, as well as psychological interventions such as counselling and support groups (Department of Health and Social Care, 2017).

For benzodiazepine withdrawal, the NICE guidelines recommend a gradual reduction in dosage over a period of weeks or months, with monitoring of symptoms and support from healthcare professionals (NICE, 2020).

For stimulant withdrawal, the guidelines recommend the use of psychological interventions such as cognitive-behavioural therapy, contingency management, and relapse prevention strategies, as well as support from healthcare professionals (National Treatment Agency for Substance Misuse, 2010).

Overall, the management of substance withdrawal should be tailored to the individual and involve a multidisciplinary approach that addresses both physical and psychological symptoms. It is important to seek guidance from a healthcare professional when managing withdrawal symptoms to ensure safe and effective treatment.

Detection Times of Common Illicit Substances in Blood and Urine:

Substance	Detection Time in Blood	Detection Time in Urine
Amphetamines	Up to 12 hours	1-3 days
Barbiturates	1-2 days	2-4 days (short-acting)
		1-3 weeks (long-acting)
Benzodiazepines	Up to 2-3 days	3 days to 6 weeks
Cannabis	Up to 36 hours	3 days to 30 days
Cocaine	Up to 2 days	2-3 days
Heroin (Opiates)	Up to 12 hours	1-3 days
LSD	2-24 hours	1-3 days
MDMA (Ecstasy)	Up to 2 days	2-4 days
Methamphetamine	Up to 37 hours	3-6 days
Phencyclidine (PCP)	14 hours to 4 days	7-14 days
Synthetic cannabinoids	Up to 72 hours	Days to weeks
Synthetic stimulants	Varies	1-3 days

References:

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Association.
2. Department of Health and Social Care. (2017). Drug misuse and dependence: UK guidelines on clinical management. Retrieved from https://www.gov.uk/government/publications/drug-misuse-and-dependence-uk-guidelines-on-clinical-management
3. National Institute for Health and Care Excellence. (2018). Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. Retrieved from https://www.nice.org.uk/guidance/cg115
4. National Institute for Health and Care Excellence. (2020). Benzodiazepine and z-drug withdrawal: management. Retrieved from https://www.nice.org.uk/guidance/ng87
5. National Institute on Drug Abuse. (2021). Commonly Used Drugs Charts. Retrieved from https://www.drugabuse.gov/drug-topics/commonly-used-drugs-charts
6. National Institute on Drug Abuse. (2020). Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition). Retrieved from https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/evidence-based-approaches-to-drug-addiction-treatment/pharmacotherapies
7. National Treatment Agency for Substance Misuse. (2010). Drug misuse and dependence: UK guidelines on clinical management: evidence review. Retrieved from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/215667/dh_113177.pdf
8. Substance Abuse and Mental Health Services Administration. (2018). TIP 63: Medications for Opioid Use Disorder. Retrieved from https://store.samhsa.gov/product/TIP-63-Medications-for-Opioid-Use-Disorder-Executive-Summary/SMA18-5063EXSUMM