General MedicineTier 1Disease (DEADMAN)

Psychiatry - substance use disorders, such as overdose and withdrawal

Description

Substance use disorders across alcohol, opioids, sedatives/benzodiazepines, stimulants, cannabis and nicotine - see dedicated pharm-tox notes for substance-specific detail
General medicine perspective: recognising overdose/withdrawal as the acute presentation of an underlying chronic disorder, not an isolated event

Substance use disorders are highly comorbid with mental illness (dual diagnosis), chronic pain, and social disadvantage
Presentations cluster - EDs, general medical wards, and perioperative settings all encounter withdrawal in patients admitted for unrelated reasons

Chronic substance exposure -> neuroadaptation (receptor up/down-regulation) -> tolerance and physical dependence
Withdrawal syndromes reflect the opposite of the substance's acute effect (CNS depressants -> hyperexcitability on withdrawal; stimulants -> dysphoria/hypersomnia on withdrawal)
Unrecognised withdrawal in an inpatient admitted for an unrelated reason is a common and preventable cause of clinical deterioration

Proactive screening on admission - substance use history should be routine, not only asked when intoxication is obvious
Withdrawal scales: CIWA-Ar (alcohol), COWS (opioid), specific scales less standardised for stimulants/cannabis
Collateral history, urine drug screen (supportive, not diagnostic - misses novel synthetics)

Anticipate withdrawal in every admission with a positive substance use history, regardless of admission reason - proactive prescribing (e.g., benzodiazepine taper for alcohol dependence, nicotine replacement) prevents deterioration
Manage acute overdose/toxicity per substance-specific toxidrome protocol (see pharm-tox notes)
Manage withdrawal per substance-specific protocol - alcohol/benzodiazepine withdrawal can be life-threatening (seizures, delirium tremens); opioid withdrawal is distressing but not life-threatening
Engage drug and alcohol liaison services early for relapse-prevention planning and discharge support
Harm reduction principles - do not require abstinence commitment as a precondition for medical care

Blood-borne virus exposure, malnutrition, chronic organ damage (liver, cardiac, neurological) depending on substance
Comorbid mental illness, homelessness, social disadvantage
Increased perioperative/procedural complications if withdrawal is not anticipated and managed

Untreated withdrawal in hospital prolongs admission, increases complication rates, and damages therapeutic engagement
Proactive, non-judgemental management improves both acute outcomes and the likelihood of the patient engaging with longer-term treatment
Relapse is a normal part of the recovery trajectory for chronic substance use disorders, not a treatment failure

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