The role of the GP in smoking, alcohol and substance misuse
All GPs have a responsibility to provide both holistic general medical care and specific treatment for people who smoke or have alcohol or substance misuse problems. As a GP, your role is to:
- recognise that smoking, alcohol, and substance misuse are common problems in the community and understand their relationship to disease and premature death
- understand that harmful use of alcohol and other substances is often unrecognised and can take a range of forms (including regular excessive use, binges and dependency)
- identify and offer interventions, including advice and treatment, to people who smoke or misuse alcohol or other substances
- refer to and develop partnerships with wider local services
- recognise and manage medical consequences of smoking, alcohol and substance misuse
- recognise the importance of holistic care and management for patients with substance or alcohol misuse
- be aware of wider social issues, including the need to protect children and family members from the potential impact of smoking, alcohol or substance misuse, and respond to any safeguarding concerns
- appreciate that helping people to stop smoking or overcome alcohol and substance misuse, while challenging at times, can be very rewarding for the doctor and life-changing for the patient
- be non-judgemental in your approach to managing patients that smoke and people with alcohol and substance misuse problems, as they can often be stigmatised by society and health professionals.
Emerging issues in smoking cessation, alcohol and substance misuse
E-cigarettes are increasingly used to aid smoking cessation. Ongoing research into the safety of e-cigarettes and their use for smoking cessation is underway. As a GP you should be aware of the latest evidence and guidance on e-cigarettes, and smoking cessation more generally, and use your clinical judgement on an individual patient basis.
Dependence on over-the-counter, internet-acquired or prescribed medication is a growing problem, particularly involving anabolic steroids, analgesics (such as opioids and gabapentinoids), antidepressants, benzodiazepines, stimulants and z-drugs.1,2 Misused ‘prescription-only’ drugs are increasingly being obtained through illegal street sales. As people live longer, and patients are successfully treated, doctors are facing increasing complexity in managing long-term alcohol and substance misuse in the context of ageing patients with multiple comorbidities.
Knowledge and skills guide
Smoking
Within the context of primary care, consider the theoretical and practical aspects of the following.
- Types of tobacco (such as cigarettes, chewing tobacco, hookah)
- Health effects of tobacco, including:
- its effects on the body
- as a risk or causative factor for a range of diseases (for example, cardiovascular, respiratory, metabolic)
- morbidity in people with established diseases
- its impact on the mental health of individuals and their wider social network
- in specific groups (such as pregnant women, adolescents)
- risks of passive smoking
- Tobacco dependence and why people struggle to stop smoking
- Nicotine addiction (including risk factors) and withdrawal (including physical and psychological symptoms)
- Relationship between tobacco use and socio-economic status
- The concept of compensatory smoking, especially related to cutting down as a harm-reduction technique
- Assessment of the individual, including relevant focused physical and mental health examinations and investigations (such as carbon monoxide testing, spirometry, chest X-ray) where appropriate
- Benefits of cessation, including:
- in the prevention of conditions such as chronic obstructive pulmonary disease (COPD), cardiovascular disease (CVD) and cancer
- first-line treatment for long-term conditions such as COPD in improving morbidity in conditions such as lung cancer
- Treatment of tobacco dependence, including:
- pathways to successful quitting and their effectiveness
- theory and practice of evidence-based primary care strategies for smoking cessation (such as brief interventions, Very Brief Advice)
- pharmacotherapy for smoking cessation (including nicotine replacement therapy (NRT), varenicline, buproprion)
- the role of e-cigarettes in smoking cessation
- the role of behavioural support in smoking cessation
- Conversations with smokers in the GP consultation
Alcohol and substance misuse
For each substance problem, consider the following areas within the general context of primary care:
- the natural history of the untreated condition, including whether acute or chronic
- the prevalence and incidence across all ages and any changes over time
- typical and atypical presentations
- recognition of normal variations throughout life
- risk factors, including lifestyle, socio-economic and cultural factors
- diagnostic features and differential diagnosis
- recognition of ‘alarm’ or ‘red flag’ features
- appropriate and relevant investigations
- interpretation of test results
- management, including self-care, initial, emergency and continuing care, chronic disease monitoring
- patient information and education, including self-care
- prognosis.
Symptoms and signs
Alcohol and substance misuse in primary care may present directly or indirectly, including through third-party concerns, for example, from a friend, family member or school.
As a GP you should be alert to a wide range of possible presentations of alcohol or substance misuse. These include:
- accidents and injuries occurring while under the influence of drugs or alcohol
- behavioural changes such as neglecting other activities, poor hygiene, secrecy, self-neglect and social withdrawal
- drug-seeking behaviour (including criminal activity, diversion of prescribed medication, neglecting children, risk-taking behaviour, sex work)
- intoxication
- increasing use of substance
- malnourishment
- mental health problems related to substance misuse, including mood disorders, post-traumatic stress disorder (PTSD) and psychosis
- overdose – accidental or intentional, such as opioid overdose and how to treat it
- poor oral hygiene
- social consequences of substance misuse, such as contact with the criminal justice system (including incarceration), domestic violence, homelessness, poor attendance or functioning at school or work, relationship issues, safeguarding concerns, unemployment
- signs of dependency: neglecting other aspects of life to be able to support dependency (for example, other health conditions, unable to keep job, home circumstances)
- signs of alcohol liver disease: ascites, confusion, hematemesis, jaundice, melena, features of Wernicke-Korsakoff syndrome
- signs and symptoms of medical conditions related to substance misuse, including cachexia and weight loss, chest pain, cough, fever, injection site problems, jaundice, limb erythema, pain or swelling, respiratory depression, shortness of breath
- signs and symptoms of withdrawal and potential life-threatening consequences, such as shakes or delirium tremens (DT), feeling feverish, confusion, fits.
Common and important conditions
Dependent and non-dependent misuse of alcohol and substances, and the effects and risks of misuse (short-term and long-term, medical and non-medical), including:
- common effects of the main problem drugs, including anabolic steroids, antidepressants, benzodiazepines, cannabis, cocaine, gabapentinoids, new psychoactive substances (NPS), opiates, solvents, stimulants and z-drugs
- complications of alcohol and substance misuse in pregnancy, including fetal alcohol spectrum disorder (FASD), growth retardation, neonatal withdrawal and preterm delivery. Antenatal care for women misusing substances and alcohol, including involvement of social services and safeguarding of unborn children if required
- crises occurring in relation to substance and alcohol misuse, including intoxication, mental health emergencies, overdose, safeguarding emergencies, trauma and withdrawal
- medical complications of substance misuse, including:
- infections
- local infection in injecting drug misuse: cellulitis and abscess
- systemic infection directly related to injecting drug misuse, including blood-borne viruses (BBVs) (hepatitis B and C and human immunodeficiency virus (HIV)) and endocarditis
- opportunistic infection, including tuberculosis (TB)
- malnutrition
- nasal and respiratory symptoms secondary to nasal substance (such as cocaine) use
- non-infective cardiac complications, for example, acute coronary syndrome, arrhythmia, ischaemic heart disease
- venous thromboembolic disease
- infections
- medical complications of long-term alcohol misuse, including:
- alcoholic liver disease including ascites, cirrhosis, pancreatitis, portal hypertension and varices
- common health conditions where alcohol use may be a contributing factor, including cancer and hypertension
- neurological complications, including encephalopathy, peripheral neuropathy and Wernicke-Korsakoff syndrome
- malnourishment, including vitamin deficiencies
- misuse of prescribed and over-the-counter medications
- polysubstance abuse of drugs and combined misuse of drugs and alcohol
- mental health problems in the context of alcohol and substance misuse, including dual diagnosis and ‘self-medication’ of mental health problems with drugs or alcohol
- tolerance, dependence and withdrawal
- methadone prescribing.
Examinations and procedures
- Assessment of alcohol problem-drinking to assess the nature and severity of misuse
- Assessment of social circumstances and functioning of alcohol and substance misusers
- Substance misuse assessment, including identifying substances used, quantity, frequency and pattern of use, routes of administration, sources of drugs and evidence of dependence
- Injection site assessment
- Mental health assessment
- Relevant physical examinations (including cardiovascular and abdominal examination and examination for stigmata of chronic liver disease)
Investigations
- Assessment of liver damage due to alcohol misuse, including blood tests and imaging
- Blood tests, including for BBVs (hepatitis B and C and HIV), full blood count, haematinics, liver function, renal function, thyroid function
- Electrocardiogram (ECG) monitoring of QT interval in methadone prescribing
- Evidence-based screening tools to identify alcohol misuse, such as AUDIT-C
- Near-patient testing for drug misuse
- Methods for testing for illicit drug misuse, such as urine testing
Service issues
- Barriers to care and difficulties in co-ordinating care. Particular challenges relating to individuals who are chaotic, homeless or in contact with the criminal justice system
- Coordinated care and partnerships with the wider healthcare team and other agencies, including public health, addictions specialists, criminal justice system, dentists, homeless services, mental health teams, pharmacies, social services, voluntary sector
- Local arrangements for smoking cessation, drug or alcohol detoxification and rehabilitation
- Local patterns and prevalence of smoking, alcohol and substance misuse
- Opportunistic and planned general medical care and health promotion for smokers and alcohol or substance misusers, including chronic disease care, contraception, general health promotion, safe sex advice, screening processes such as cervical screening, smoking cessation advice
- Public health, policymaking and commissioning in relation to tobacco control, alcohol and substance use (see also the Population and planetary health topic guide)
- Relevant local and national guidelines, standards and legislation
- Role of the primary care team in interventions
- Support for the families of those misusing alcohol or substances, in particular children, partners and parents, including signposting to support services and other resources such as third sector and charities
- Additional important content
- Behaviour change, including psychosocial interventions
- Driving regulations (Driver and Vehicle Licensing Agency (DVLA) guidance) in relation to drug and alcohol use (including prescribed and over-the-counter drugs) and the responsibility of the GP in relation to this
- Harm reduction in alcohol and substance misuse, including needle exchanges, patient education, safer injecting education, sharps bins
- Impact of parental alcohol and drug misuse, including ability to function as a parent, domestic violence, safeguarding concerns, funding of drug habit, storage of drugs and paraphernalia
- Impact of parental smoking on children (for example, sudden infant death syndrome (SIDS), asthma)
- Particular considerations regarding children and young people who smoke or misuse alcohol or drugs, including risk of grooming or abuse
- Preventing drug-related deaths, including identifying patients at high risk, local knowledge relating to drug supplies, identifying and treating overdose and withdrawal (role of naloxone), patient education, safe substitute prescribing
- Prevention, screening or treatment of medical complications related to alcohol or substance misuse (such as treatment of BBVs, thiamine supplementation, vaccination against hepatitis A and B)
- Relapse prevention strategies, including psychosocial and pharmacological methods, and management of continued smoking or alcohol and drug misuse among patients
- Risk minimisation strategies and safe prescribing (such as benzodiazepines, analgesics, NRT)
- Risks to general health while misusing drugs and alcohol (such as smoking, risky sexual activity, non-participation in screening programmes, neglect of chronic disease care, poor nutrition)
- The concept of ‘street slang’ terms for drugs and how they are used
- Substitute prescribing of heroin with methadone and buprenorphine – medical, legal, practical and safety aspects, including shared care with addictions services
Case discussion
Olivia Bell is a 29-year-old woman who is living in a local homeless hostel. Her support worker has encouraged her to come and see you because she has noticed that Olivia has become more withdrawn, is neglecting her personal hygiene and seems to be drinking more alcohol.
Having established a rapport with Olivia, she tells you she is drinking around eight cans of cider a day. She has also started injecting heroin again and is using cocaine. She is working as a sex worker to fund her habit. She tells you that she grew up in care, had a child when she was 18 who was taken into care at birth and has since had three pregnancies terminated. A recent partner subjected her to domestic violence. She tells you she has a criminal record for multiple episodes of shoplifting, which makes it very difficult to get employment.
Olivia tells you she is ready to try to address her alcohol and substance misuse and would like help for this. You refer her to the local addictions service, where she is seen under a shared care arrangement.
Things seem to be going reasonably well over the next six months, but then Olivia fails to keep appointments with you and eventually turns up in your surgery two months later demanding to be seen urgently. She tells you she has started drinking again and that this is in response to the news that her hostel is being closed due to lack of funding and she is worried about where she will live. She is requesting a script for an alcohol detox.
Questions
These questions are provided to prompt you to consider the key points of the case. They can form the basis for a case-based discussion with your educational supervisor and will assist you in writing reflective entries in your ePortfolio. The questions are examples to trigger reflection and are not intended to be comprehensive.
| Core capabilities | Questions |
|---|---|
Fitness to practise This is about professionalism and the actions expected to protect people from harm. This includes the awareness of when an individual’s performance, conduct or health, or that of others, might put patients, themselves or their colleagues at risk. | How do I feel about treating persistent drug and alcohol misusers? How do I feel towards patients who seem to be spurning my attempts to help them? Am I at risk of alcohol or substance misuse myself? |
An ethical approach This is about practising ethically with integrity and a respect for equality and diversity. | What would I do if I knew Olivia was driving a car while under the influence of drugs and alcohol and refused to stop driving? How do I engage with the issue around Olivia’s criminal record and the challenges that poses to employment opportunities? What do I feel about her work as a sex worker to fund her habit? |
Communicating and consulting This is about communication with patients, the use of recognised consultation techniques, establishing and maintaining patient partnerships, managing challenging consultations, third-party consulting, the use of interpreters and consulting modalities across the range of in-person and remote methods. | What strategies can I use to develop an effective therapeutic relationship with Olivia? What skills can I use to motivate Olivia towards making positive changes? Do I have to alter my consultation style to cope when I think patients might be deceiving me – such as to persuade me to issue prescriptions for medications that they might intend to misuse or sell? |
Data gathering and interpretation This is about the gathering, interpretation and use of data for clinical judgement, including information gathered from the history, clinical records, examination and investigations. | How do I assess and quantify cigarette use and drug and alcohol misuse? How do I assess risks of pregnancy, sexually transmitted infection (STI), HIV and hepatitis B and C with Olivia? How do I assess ‘readiness to change’? Do I need to think about offering contraception or sexual health advice? |
Clinical examination and procedural skills This is about clinical examination and procedural skills. By the end of training, the GP registrar must have demonstrated competence in general and systemic examinations of all the clinical curriculum areas, including the five mandatory examinations and a range of skills relevant to general practice. | How would I assess acute confusion in a patient with known chronic liver disease? Am I confident in identifying acute alcohol withdrawal in a patient? |
Decision-making and diagnosis This is about having a conscious, organised approach to making diagnosis and decisions that are tailored to the particular circumstances in which they are required. | Which of Olivia’s problems are the most damaging to her health? As a GP, how do I prioritise the actions needed to address Olivia’s problems? How do I assess any safeguarding concerns this case may raise? How do I assess if a request for a community alcohol detoxification is appropriate? How do I follow up a patient who has a chaotic lifestyle and may not engage in follow-up? |
Clinical management This is about the recognition and a generalist’s management of patients’ problems. | How do I balance risks in deciding Olivia’s management plan? Am I aware of the safety issues around methadone use in substitute prescribing? Do I know how to treat tobacco addiction? In what ways is it similar to, or different from, addiction to other drugs and alcohol? |
Medical complexity This is about aspects of care beyond the acute problem, including the management of comorbidity, uncertainty, risk and health promotion. | Which of Olivia’s issues can I deal with – and which are beyond the scope of a GP? How do I cope when patients present with multiple issues, many of which are not medical, and which are likely to take much longer than a 10-minute consultation? |
Team working This is about working effectively with others to ensure good patient care and includes sharing information with colleagues and using the skills of a multiprofessional team. | Which support services are available in my area to help patients and families affected by substance and alcohol misuse? What factors determine good ‘shared care’ in smoking cessation, drug and alcohol services? What are the challenges of providing this? |
Performance, learning and teaching This is about maintaining the performance and effective CPD of oneself and others. The evidence for these activities should be shared in a timely manner within the portfolio. | How can I learn about the substance misuse problems particular to my locality? How can I keep up to date with current substances of misuse and how they are used? What activities might help me reflect on uncomfortable issues and feelings raised by patients like Olivia? |
Organisation, management and leadership This is about understanding how primary care is organised within the NHS, how teams are managed and the development of clinical leadership skills. | How do I help the practice reception team cope with patients like Olivia, who can be challenging and make unreasonable demands of medical receptionists? How can we help individuals like Olivia, who are often chaotic, to make best use of primary healthcare? Do we have systems in place to offer health checks and appropriate monitoring and immunisation to substance and alcohol users? |
Holistic practice, health promotion and safeguarding This is about the ability of the doctor to operate in physical, psychological, socio-economic and cultural dimensions. The doctor is able to take into account the patient’s feelings and opinions. The doctor encourages health improvement, self-management, preventative medicine and shared care planning with patients and their carers. The doctor has the skills and knowledge to consider and take appropriate safeguarding actions. | Olivia is likely to be moving on to new accommodation, or the streets, soon – what impacts does the transient nature of her difficult living situation have on her healthcare provision? What steps can be taken to try and improve this situation for her? How might the inverse care law apply in provision of healthcare to someone like Olivia? |
Community health and environmental sustainability This is about the management of the health and social care of the practice population and local community. It incorporates an understanding of the interconnectedness of health of populations and the planet. | How do I feel about funding cuts to local services such as stop smoking services or homeless hostels? What response might be appropriate in my role as a local GP? As a GP, in what ways can I be involved in helping vulnerable young people to reduce the risk of them becoming involved in substance and alcohol misuse? |
How to learn this area of practice
Work-based learning
There is no substitute for actually working with patients with substance and alcohol problems or tobacco dependence to learn how to provide good care in often challenging situations. As a GP registrar, you should spend time observing a more experienced GP and then, under proper supervision, take on your own primary care patients with these problems. By doing so you will come into contact with a broad range of service providers and develop an understanding of how the treatment system should work– and how often it does not. You will also become familiar with wider health and psychosocial issues that often exist in the context of smoking, alcohol and substance misuse.
A placement in a specialist substance or alcohol service, either residential or in the community, would provide valuable experience. Unfortunately, few placements of this type are available, however a placement in general adult psychiatry should give you some exposure to substance and alcohol problems, as well as invaluable general psychiatric training. Time spent with other providers of care in the field of smoking cessation, alcohol and substance misuse, including those from non-statutory agencies and independent sector providers, can help you to get a broader overview of available services.
Self-directed learning
You can find an eLearning module(s) relevant to this topic guide at elearning for healthcare and at the RCGP eLearning website.
In addition to eLearning resources on this area, the RCGP has produced a policy statement on the use of e-cigarettes3. The National Centre for Smoking Cessation and Training (NCSCT) is funded by Public Health England to support the delivery of effective evidence-based tobacco control programmes and smoking cessation interventions and provides a range of resources. The Royal College of Physicians (RCP) has also produced a number of reports on the subject4.
The Drug misuse and dependence: UK guidelines on clinical management (2017) provide a comprehensive overview of this field (sometimes referred to as ‘The Orange Book’). You will find it informative to find out more about mutual aid groups such as Alcoholics Anonymous, Narcotics Anonymous and SMART Recovery from their websites and if possible by attending open meetings. Local and regional groups for doctors with a special interest in addictions also exist, which you may find useful to attend. Talk To Frank is a drug education service aimed at patients, but has useful information about different drugs, their appearance, street names, mode of use, effects and dangers. As in other areas the RCGP eLearning website has several modules covering this topic. GP registrars should be able to bring interesting and complex cases to tutorials and peer group meetings.
Learning with other healthcare professionals
Effective tobacco control requires multidisciplinary approaches at the level of both the population and the individual; therefore a number of professionals and teams will be involved in smoking cessation interventions. As a GP registrar you should spend time with members of the primary care team trained in smoking cessation and find out more about your local model of delivery for NHS smoking cessation.
In relation to drug and alcohol misuse, the certificate courses mentioned in ‘Formal learning’ are multidisciplinary and so provide an excellent insight into other professionals and workers in the field. The RCGP’s annual Managing addictions in primary care conference is well attended by many different professionals, workers and service users. Some regions have multidisciplinary learning meetings.
Formal learning
There are several opportunities (such as through courses and conferences) to learn how to deliver effective smoking cessation interventions in a GP setting. These may be accessed via your GP specialty training scheme, the RCGP and other organisations such as the NCSCT and RCP.
The RCGP Part 1 Certificate in the Management of Drug Misuse is well worth doing even if you do not envisage developing a special interest in this field. The Part 2 certificate is especially useful if you wish to develop a special interest, become a GP with an Extended Role (GPwER) and/or participate in local shared care schemes and enhanced services.
The Certificate in the Management of Alcohol Problems in Primary Care is also valuable for all GPs. Details are available in the mental health toolkit on the RCGP eLearning website.
Examples of how this area of practice may be tested in the MRCGP
Applied Knowledge Test (AKT)
- Psychological and physical effects of alcohol misuse
- Signs and symptoms of substance misuse in adults and children
- Health promotion for smokers and substance misusers
Simulated Consultation Assessment (SCA)
- A bus driver asks for help to break his habit of heavy drinking
- A final-year school student complains of irritability and low mood likely to be associated with his regular marijuana use
- Two A&E notifications: two falls while inebriated. The woman cares for her grandchildren but denies drinking when she is responsible for them
Workplace-based Assessment (WPBA)
- Case-based Discussion (CbD) about a woman who is concerned about her husband’s alcohol intake and subsequent violent behaviour
- Consultation Observation Tool (COT) about a young woman who wishes to stop smoking
- Log entry about your understanding of the local drug and alcohol service following a patient’s referral
- Clinical examination and procedural skills (CEPS) relating to clinical examination of a patient with possible venous thrombosis from self-injection
References
- Davies J, Rae TC and Montagu L. Long-term benzodiazepine and Z-drugs use in England: a survey of general practice. British Journal of General Practice 2017; 67(662):e609–e613. https://doi.org/10.3399/bjgp17X691865
- British Medical Association. Prescribed drugs associated with dependence and withdrawal (2015, updated 2024). www.bma.org.uk/what-we-do/population-health/improving-care-and-peoples-experience-of-services/prescribed-drugs-associated-with-dependence-and-withdrawal
- https://www.rcgp.org.uk/representing-you/policy-areas/e-cigarettes
- For example, https://www.rcp.ac.uk/policy-and-campaigns/policy-documents/e-cigarettes-and-harm-reduction-an-evidence-review/