Psychiatry - signs of drug use and abuse on general history and examination, and impact on presentation

Overview

Substance use can produce recognisable signs on general physical and mental state examination - track marks and skin changes from injecting drug use, characteristic pupil size changes, autonomic signs, and specific mental state findings - recognising these signs supports identification of substance use that may not be volunteered in the history alone
Relevant across general medical and psychiatric assessment given the high prevalence of unrecognised or under-disclosed substance use affecting clinical presentation, and the potential for substance use to significantly influence or complicate the primary presenting problem

Physical examination findings from substance use reflect either direct pharmacological effects (pupil size changes from opioids or stimulants, autonomic signs) or physical sequelae of the mode of use (track marks/skin changes from injecting, nasal septum changes from insufflation) - systematically incorporating these specific examination elements into routine assessment increases detection of substance use that patients may not volunteer, whether from stigma, minimisation, or simply not being specifically asked

A structured, comprehensive examination specifically including relevant substance-use-related signs (skin/injection sites, pupils, oral/dental signs, cardiovascular signs) should be part of routine assessment when substance use is suspected or the presentation is otherwise unexplained
Combining examination findings with the mental state examination (see ) provides a more complete picture of possible intoxication, withdrawal, or chronic use effects

Identified physical signs suggestive of substance use should prompt direct, non-judgemental enquiry about substance use history, rather than being noted without follow-up or used to make assumptions without patient discussion
Findings should inform, not replace, direct screening conversation and appropriate referral where substance use disorder is identified or suspected

Injecting drug use physical signs (track marks, skin/vascular changes), stimulant/opioid pupillary and autonomic signs, nasal/oral signs from specific routes of use, examination as a complement to (not replacement for) direct history-taking

Physical examination findings suggestive of substance use should prompt direct, non-judgemental follow-up conversation with the patient, not silent assumption or note-taking without discussion - these findings are most clinically useful as a trigger for open enquiry that may uncover substance use the patient had not otherwise volunteered, supporting more accurate overall assessment and appropriate support/referral

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