Smoking, Alcohol and Substance Misuse

Smoking, alcohol, and substance misuse are important AKT topics that test your knowledge of screening tools, brief interventions, pharmacological treatments, and harm reduction approaches.

Smoking cessation is the single most effective intervention a GP can offer. NICE recommends Very Brief Advice (VBA): ask about smoking status, advise on the best way to quit, and act on the patient's response. Pharmacological options include nicotine replacement therapy (NRT, available in patches, gum, lozenges, inhalers), varenicline (most effective single agent, partial nicotine receptor agonist), and bupropion (alternative, contraindicated in epilepsy). Combination NRT (patch plus short-acting form) is as effective as varenicline. E-cigarettes are increasingly used and NICE acknowledges they are substantially less harmful than smoking, though they are not licensed as medicines.

Alcohol use is screened using the AUDIT questionnaire (10 questions, score 0-40). AUDIT-C is a shorter screening version (3 questions). Scores of 8 or above on the full AUDIT indicate hazardous or harmful drinking. Brief interventions (feedback, responsibility, advice, menu of options, empathy, self-efficacy) are effective and should be offered opportunistically.

Alcohol dependence is characterised by tolerance, withdrawal symptoms, compulsive drinking, and continued use despite harm. Alcohol withdrawal can be life-threatening (seizures, delirium tremens). Community detoxification with reducing dose chlordiazepoxide is appropriate for patients without a history of complicated withdrawal, seizures, or delirium tremens. Those with severe dependence or comorbidities need inpatient detoxification. Post-detox relapse prevention options include acamprosate (reduces craving), naltrexone (blocks rewarding effects of alcohol), and disulfiram (causes unpleasant reaction if alcohol is consumed).

Opioid dependence is managed with opioid substitution therapy (OST): methadone (oral liquid, daily supervised consumption initially) or buprenorphine (sublingual, less risk of respiratory depression). Treatment is usually initiated by a specialist service, but GPs may take over prescribing under shared care arrangements. Naloxone for emergency reversal of opioid overdose is available to patients, families, and hostels.

Drug-related harm reduction includes needle exchange programmes, naloxone distribution, hepatitis B vaccination for people who inject drugs, and hepatitis C testing and treatment (now curable with direct-acting antivirals).

Cannabis is the most commonly used illicit drug. Regular use is associated with psychosis, particularly in adolescents and those with a family history. Synthetic cannabinoids (e.g. Spice) carry much higher risks including severe psychiatric symptoms and physical harm.