Mental Health · Full case

Drug Dependence

NICE NG215 / CG52Prescribed & illicitOverdose · withdrawal

Dependence ≠ addiction ≠ tolerancePhysical dependence (withdrawal on stopping) can occur with prescribed medicines without "addiction" (compulsive use despite harm). Distinguish tolerance, dependence and harmful/addictive use — the language shapes a non-judgmental, accurate conversation

Prescribed dependence is commonOpioids, benzodiazepines, z-drugs, gabapentinoids and some antidepressants cause dependence — often iatrogenic. NICE NG215 stresses informed consent before starting, regular review, the lowest effective dose/shortest duration, and supported, gradual withdrawal — not abrupt stopping

Don't stop abruptlyAbrupt withdrawal of benzodiazepines or alcohol can cause seizures/delirium; opioid withdrawal is very unpleasant and drives relapse/illicit use. Withdraw GRADUALLY with a shared, flexible plan; in pregnancy and complex cases, specialist input

Opioid overdose & naloxoneOpioid overdose (pinpoint pupils, reduced consciousness, respiratory depression) is a 999 emergency — give naloxone & support breathing. Offer take-home naloxone & training to those at risk (and carers), incl. on release from prison and after detox (tolerance falls)

OST saves livesOpioid substitution treatment (methadone or buprenorphine) reduces overdose deaths, illicit use, injecting and crime, and improves engagement. Harm reduction (needle exchange, naloxone, BBV testing/vaccination) is core — abstinence is one goal among several, not a precondition for help

Screen the whole personAssess mental health (depression/anxiety/PTSD/self-harm), other substances incl. alcohol, blood-borne viruses (HIV/hep B&C — test & vaccinate), social situation, dependents/safeguarding, and physical complications (injecting, endocarditis, DVT, overdose)

Stigma kills engagementA non-judgmental, respectful, person-first approach is therapeutic and evidence-based. Shame and fear of being "cut off" drive concealment and risk. Build trust, support autonomy, and keep the door open — relapse is part of recovery, not failure

Safeguarding & the lawAlways consider children/dependents (parental substance use → safeguarding), driving (DVLA), and prescribing governance (controlled-drug monitoring, avoid co-prescribing opioids + benzodiazepines/gabapentinoids — additive respiratory depression). Work with specialist drug services

📋 Clinical Stem — Drug Dependence

A 41-year-old woman on long-term codeine for back pain, now taking far more than prescribed and buying extra online, frightened she's "addicted" and that the doctor will stop her tablets

Dawn Fletcher, 41, has taken codeine for chronic low back pain for several years. She now takes well above the prescribed dose, has started buying extra co-codamol online, and gets anxious, sweaty and unwell if she runs out — taking more for the withdrawal than the pain. She feels ashamed, is frightened she's "an addict", and is terrified the doctor will simply stop her tablets and leave her in pain and withdrawal. Her mood is low, she sleeps poorly, and she also drinks a bottle of wine most evenings. She has two school-age children. She has come, hesitantly, because a friend nearly died of an overdose and it scared her.

This stem tests the ability to: recognise iatrogenic opioid dependence (escalating dose, supplementing from non-prescribed sources, withdrawal symptoms, taking the drug for withdrawal rather than analgesia) sensitively and without stigma; to distinguish dependence from addiction and to use non-judgmental, person-first language; to assess the whole person (mood/self-harm, co-use of alcohol — relevant to overdose risk and to abrupt-withdrawal seizure risk, blood-borne virus and social/safeguarding assessment given dependent children); to plan a SUPPORTED, GRADUAL withdrawal rather than abrupt stopping, with shared decision-making and the door kept open; to provide harm reduction (overdose/naloxone advice, especially with alcohol co-use), and to involve specialist drug services; and to address the chronic pain appropriately (opioids are poor for chronic primary pain). The SCA challenge is engaging a frightened, ashamed patient, reassuring her she won't be abandoned or simply "cut off", and converting fear into a collaborative plan.

Scenario A — Prescribed opioid dependence (this stem) Iatrogenic; escalating + non-prescribed supplementation; withdrawal-driven use; alcohol co-use; dependent children. Non-judgmental assessment; supported gradual taper; harm reduction/naloxone; treat mood/pain; safeguarding; specialist support.

Scenario B — Benzodiazepine/z-drug or gabapentinoid dependence Long-term use, tolerance, withdrawal. Gradual tapered withdrawal (never abrupt — seizure risk for benzodiazepines); avoid co-prescribing with opioids.

Scenario C — Illicit opioid use / OST Heroin use, injecting. Harm reduction (needle exchange, naloxone, BBV testing/vaccination), opioid substitution (methadone/buprenorphine), specialist drug service.

Scenario D — Overdose / emergency Reduced consciousness, pinpoint pupils, respiratory depression → 999 + naloxone + airway/breathing support; alcohol/benzodiazepine co-ingestion worsens risk.

Scenario E — Stimulants / polydrug / pregnancy Cocaine/amphetamine (cardiac/mental-health risks), polydrug use, or dependence in pregnancy — specialist, multidisciplinary, never abrupt withdrawal.

Key variables to adapt for Prescribed vs illicit; substance (opioid/benzo/gabapentinoid/stimulant/alcohol); dependence vs addiction vs tolerance; withdrawal & abrupt-stop risks (seizures); overdose/naloxone; co-use (alcohol/benzodiazepines); mental health; BBV/physical complications; safeguarding/dependents; pregnancy; stigma & engagement; the underlying pain.

Steps:

Step 1

History — Engage Without Stigma · Pattern & Dependence · Risk · Co-use · ICE

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The history's first job is engagement: a frightened, ashamed patient who fears being judged and "cut off" will only disclose the true picture if met with warmth and non-judgmental, person-first language. Then characterise the dependence (escalation, non-prescribed sources, withdrawal-driven use), assess risk (overdose, mental health, co-use of alcohol/benzodiazepines), and the social/safeguarding context. The underlying pain matters too — opioids are poor for chronic primary pain.

🎓 SCA framing — reassure, don't threaten to stop

"Thank you for telling me this — it took courage, and I'm not here to judge you or to suddenly stop your tablets and leave you in withdrawal. What's happened to you is really common and it's not a moral failing. Let's work out a plan together, at a pace that's safe for you."

Dawn's biggest fear is being abandoned/cut off. Naming that fear and committing to a supported, gradual, collaborative plan is what unlocks honest disclosure and engagement.

1A — Pattern, dependence, risk and co-use

Question	Why it matters	Changes what?
🟢 OPEN QUESTION"Tell me how things have got to this point — in your own words, no judgement."	A warm, open invitation enables disclosure. It captures how the prescribed opioid escalated, the move to non-prescribed sources, and the shift from taking it for pain to taking it for withdrawal — the hallmarks of dependence. Dawn's story is iatrogenic dependence, and hearing it without judgement is the foundation of everything that follows.In SCA: non-judgmental, person-first engagement is itself heavily scored — it is the clinical skill of the case.	Escalation + withdrawal-driven use → dependence
Dependence features"How much are you taking now vs prescribed? Where do you get the extra? What happens if you run out — and are you taking it for pain or to stop feeling unwell?"	Tolerance (needing more), non-prescribed supplementation, withdrawal on stopping, and taking the drug to relieve withdrawal rather than pain define dependence. This distinguishes it from appropriate analgesia and from "addiction" (compulsive use despite harm) — language that shapes a respectful, accurate conversation.	Confirms dependence; frames a supported withdrawal plan.	Supported gradual taper, not abrupt stop
🚩 Risk & co-use (overdose)"Do you drink alcohol or take anything else — sleeping tablets, diazepam, anything illicit? How much, and together?"	The overdose-risk core. Opioids combined with alcohol (Dawn — a bottle of wine nightly), benzodiazepines or gabapentinoids cause additive respiratory depression and overdose. Alcohol co-use also raises the risk of seizures with abrupt withdrawal. Quantify all substances; never co-prescribe opioids with benzodiazepines/gabapentinoids casually.	Alcohol/benzodiazepine co-use → high overdose risk; naloxone; address alcohol; cautious withdrawal.	Co-use → overdose risk + naloxone
🚩 Mental health & self-harm"How's your mood and sleep been? Have you had thoughts of harming yourself or that life isn't worth living?"	Depression, anxiety, PTSD and self-harm are common and bidirectional with substance use, and raise overdose risk. Dawn's low mood and poor sleep need assessment and treatment. A risk assessment is mandatory.	Low mood/self-harm → assess/treat; raises urgency & overdose risk.	Mood/self-harm assessment
🚩 Social, dependents & safeguarding"Who's at home with you? You mentioned children — how are things for them?"	Parental substance use is a safeguarding consideration for dependent children (Dawn has two). Assess the home situation, support, and any risk to the children — sensitively, supportively, and following local safeguarding procedures where indicated.	Dependent children → safeguarding assessment/support.	Children → safeguarding pathway
Blood-borne viruses & physical (if injecting)"Have you ever injected? Any testing for hepatitis or HIV? Any abscesses, blood clots, or chest problems?"	Injecting raises BBV (HIV, hepatitis B&C — test & vaccinate), and complications (abscess, DVT, endocarditis). Even without injecting, physical health and overdose history matter. Dawn's route is oral, but BBV/physical screening is part of a complete assessment.	Injecting → BBV testing/vaccination; physical complications.	BBV testing & vaccination if injecting

1B — Red flags

🚨

Red Flags — the dangers in dependence

Red flag	Why dangerous	Action
Opioid overdose — reduced consciousness, pinpoint pupils, respiratory depression	Rapidly fatal; risk multiplied by alcohol/benzodiazepine co-use, and after detox/prison release (lost tolerance).	999; naloxone; support airway/breathing; take-home naloxone & training for those at risk
Abrupt benzodiazepine/alcohol withdrawal — seizures, delirium	Life-threatening; never stop these abruptly.	Gradual tapered withdrawal; medically supported detox; do not stop abruptly
Active suicidality / severe mental illness	Markedly raised in substance dependence.	Urgent mental-health assessment; safety plan
Safeguarding — children/vulnerable dependents	Parental substance use can endanger children.	Safeguarding assessment per local procedures; support the family
Injecting complications — abscess, DVT, endocarditis, BBV	Serious infection/thrombosis; transmissible disease.	Treat/admit as needed; BBV testing & vaccination; harm reduction
Dangerous co-prescribing (opioid + benzodiazepine/gabapentinoid)	Additive respiratory depression and overdose.	Avoid; review & rationalise; controlled-drug governance

1C — ICE

💭 Ideas

"What do you make of what's happening — you mentioned the word 'addict'?"

Dawn fears she is "an addict" and morally failing. Surfacing this lets you reframe with accurate, compassionate language (this is dependence, often iatrogenic, very common, and treatable), reducing shame and self-blame — which is itself therapeutic and improves engagement.

😟 Concerns

"What's frightened you most about coming today?"

Her central fear is being cut off and left in pain/withdrawal, and being judged. Naming and directly addressing this — committing to a supported, gradual plan and to not abandoning her — is what builds the trust the whole consultation depends on.

🎯 Expectations

"What were you hoping might come from today?"

She may want help but fear the process. Naming her expectations lets you offer a realistic, collaborative plan (gradual reduction, support, harm reduction, treating mood and pain), so she leaves with hope and a clear, shared way forward rather than fear.

1D — Psychosocial context

Drug dependence — especially when it began with a doctor's prescription — is steeped in shame, secrecy and a fear of being judged or "cut off". That fear is dangerous: it drives concealment, supplementation from unsafe sources, and avoidance of help. The single most powerful clinical move is non-judgmental, person-first engagement that distinguishes dependence from moral failing, reassures the patient they won't be abandoned, and builds a collaborative, harm-reduction-informed plan. Relapse is part of recovery, not a reason to withdraw care.

🙇 Reducing shame

Reframe dependence accurately and kindly.

"This isn't a moral failing — your body has become dependent on a medicine you were prescribed. That happens to lots of people, and we can help you through it."

🤝 "I won't cut you off"

Directly address the abandonment fear.

"I'm not going to stop your tablets suddenly and leave you struggling. We'll reduce slowly, together, at a pace you can manage — and I'll keep supporting you whatever happens."

🛟 Harm reduction first

Safety doesn't depend on stopping.

"While we work on this, let's keep you safe — I'd like to talk about overdose, especially mixing with alcohol, and give you naloxone, a medicine that can reverse an overdose."

👪 The children & the future

Frame help as protective, sensitively.

"Getting you well is good for you and your kids. I may need to involve some support around the family — not to take anything away, but to make sure everyone's okay and you've got help."

🎓 SCA Checkpoint — Step 1TasksRelating to OthersGlobal Skills

Key phrases that score

"I'm not going to stop your tablets suddenly or judge you." — addresses the core fear.

"Are you taking it for the pain, or to stop feeling unwell when it wears off?" — identifies dependence.

"Mixing opioids with alcohol raises the risk of overdose — let me give you naloxone." — harm reduction.

Deductions

Judgmental/moralising tone; threatening to stop the drug abruptly
Not assessing co-use (alcohol/benzodiazepines) / overdose risk / mood / self-harm
Not considering safeguarding (dependent children)
Confusing dependence with addiction; no shared plan

🔴 Red

Judgmental; threatens abrupt stop; no risk/co-use/safeguarding assessment; no harm reduction; patient disengages

🟠 Amber

Non-judgmental; recognises dependence; some risk assessment; withdrawal plan vague; harm reduction/safeguarding partial; ICE partial

🟢 Green

Engages without stigma; identifies dependence; assesses co-use/overdose/mood/safeguarding; harm reduction + naloxone; supported gradual taper; specialist support; ICE all three

Step 2

Triage — Emergency (Overdose/Withdrawal/Risk) · Specialist Drug Service · Primary Care

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Triage by acute risk: overdose, dangerous withdrawal (benzodiazepine/alcohol), or acute mental-health crisis are emergencies; complex/illicit/injecting dependence needs specialist drug services; and straightforward prescribed dependence can be managed in primary care with a supported taper and harm reduction, alongside specialist support.

🔴 Emergency

Same day / 999

Immediate

OverdoseReduced consciousness/respiratory depression → 999 + naloxone
Dangerous withdrawalBenzodiazepine/alcohol seizures/delirium → medical support
Acute suicidality / crisisUrgent mental-health assessment

🟠 Specialist

Drug services

Refer/share care

Illicit/injecting/OSTSpecialist drug service; methadone/buprenorphine; harm reduction
Complex/polydrug/pregnancyMultidisciplinary specialist
Safeguarding concernsSafeguarding + drug service

🟢 Primary care

Supported taper

With support

Prescribed opioid/benzo/gabapentinoid dependenceGradual taper + review (Dawn)
Harm reductionNaloxone, overdose advice, BBV
Treat mood & painAddress the drivers

🎓 SCA Checkpoint — Step 2Tasks

Triage rationale

"You're safe to manage with me and the local drug-support service — there's no emergency right now. We'll reduce the codeine gradually, keep you safe around alcohol and overdose, and get support for your mood and the pain."

Deductions

Missing overdose / dangerous-withdrawal risk
Not involving specialist drug services when indicated

Step 3

Assessment — Mental State & Risk · Physical/Injecting · Substance Map

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"Examination" is a biopsychosocial assessment: mental state and risk, physical examination (especially in injecting/illicit use), and a map of all substances used — building the full picture that a safe plan depends on.

🧠 Mental state & risk

Domain	What to assess
Mood/affect, sleep	Depression/anxiety (Dawn); driver of use.
Risk	Suicide/self-harm; overdose risk; risk to/from others; safeguarding of children.
Intoxication/withdrawal state	Current state guides immediate safety.
Motivation/readiness	Stage of change; goals (harm reduction vs reduction vs abstinence).

🩺 Physical & substances

Check	Why
Injecting sites / complications	Abscess, DVT, endocarditis signs.
Pupils / respiratory rate / consciousness	Intoxication/overdose.
General physical health	Liver (alcohol), nutrition, comorbidity.
Substance map	All drugs incl. alcohol, prescribed & illicit, doses, routes.

🎓 SCA Checkpoint — Step 3TasksGlobal Skills

Demonstrating the formulation

"My assessment: opioid dependence that began with prescribed codeine, now with escalation and withdrawal-driven use, alongside harmful alcohol use and low mood, with two dependent children — current overdose risk raised by the alcohol, no acute suicidality today."

Deductions

No explicit risk formulation
Not mapping all substances/alcohol

Step 4

Investigations — BBV & Bloods · Urine Drug Screen · Baseline for Treatment

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Investigations support safety and treatment: blood-borne virus testing and vaccination (especially if injecting), bloods for alcohol-related and general health, urine drug screening to corroborate the substance picture, and baseline checks before any substitution therapy.

🧪 Bloods & BBV

Test	Why
HIV, hepatitis B & C	Test & vaccinate (hep B); especially if injecting.
FBC, LFTs, U&E	Alcohol-related/general health; baseline.
Pregnancy test	If relevant — changes the whole plan (specialist).
ECG	Before/with methadone (QTc) where applicable.

🔬 Substance & corroboration

Test	Why
Urine drug screen	Corroborate substances; useful in OST initiation/monitoring.
Mental-health/risk tools	Quantify mood/risk.
Records / controlled-drug monitoring	Prescribing pattern, multiple sources.
Alcohol assessment (AUDIT)	Quantify co-dependence.

🎓 SCA Checkpoint — Step 4Tasks

Key reasoning

"I'd like to check some bloods, including for hepatitis and HIV, and your liver given the alcohol — and we'll assess the alcohol properly too, because reducing both safely matters."

Deductions

Not offering BBV testing/vaccination where relevant
Ignoring the alcohol assessment

Step 5

Formulation — Dependence vs Addiction · Drivers · Risks · Goals

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The "diagnosis" is a biopsychosocial formulation: the substance(s) and dependence pattern, the drivers (pain, mood, social), the risks (overdose, co-use, safeguarding), and the agreed goals — with accurate, non-stigmatising language.

Element	Detail
Substance & pattern	Prescribed opioid dependence with escalation, non-prescribed supplementation, withdrawal-driven use; harmful alcohol co-use (Dawn).
Dependence vs addiction	Physical dependence ± features of addiction; use precise, non-judgmental language.
Drivers	Chronic pain (opioids poor for chronic primary pain), low mood, sleep, social stressors.
Risks	Overdose (alcohol co-use), abrupt-withdrawal seizures (alcohol), mental health, safeguarding (children).
Goals	Agreed, realistic — harm reduction, gradual reduction, treating pain/mood; abstinence as one possible goal.

🚩 Treat the person and the drivers, not just the drug

Dawn's formulation is iatrogenic opioid dependence with harmful alcohol co-use and low mood, in a mother of two, with raised overdose risk from the alcohol. The plan is a supported, gradual opioid taper (never abrupt), harm reduction with take-home naloxone and overdose/alcohol advice, treatment of her mood and a non-opioid approach to her chronic pain, safeguarding consideration for the children, and specialist drug-service support — delivered without stigma and with the door kept open.

🎓 SCA Checkpoint — Step 5Tasks

Explaining it plainly

"What you have is dependence on a medicine you were prescribed — your body needs it to avoid feeling unwell. It's common and treatable. We'll reduce it slowly and safely, treat the pain a different way and your low mood, and keep you safe in the meantime."

Deductions

Labelling without addressing the drivers (pain/mood)
Stigmatising language

Step 6

Referral — Emergency · Drug Services/OST · Mental Health · Safeguarding · Pain

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Referral is multi-agency: emergency care for overdose/dangerous withdrawal; specialist drug & alcohol services for substitution/complex cases; mental health for comorbidity/risk; safeguarding for dependents; and pain/physio for the underlying chronic pain.

Referral	Who / when	Urgency
🔴 Emergency	Overdose; dangerous withdrawal; acute suicidality.	Same day / 999
Specialist drug & alcohol service	OST (methadone/buprenorphine), complex/illicit/injecting, detox, shared care, pregnancy.	Soon
Mental health	Comorbid depression/anxiety/PTSD; risk.	By severity
Safeguarding / social care	Dependent children / vulnerable adults.	Per local procedures
Pain service / physiotherapy	Chronic pain management (non-opioid; NG193 chronic primary pain).	Routine

🎓 SCA Checkpoint — Step 6Tasks

Working in partnership

"I'd like to work alongside the local drug-and-alcohol service — they're supportive, not punitive — and get you some help for your mood and a different approach to the back pain. I'll stay your GP throughout."

Deductions

Not involving specialist services for complex/illicit use
Not addressing safeguarding/mental health/pain

Step 7

Management — Supported Taper · Harm Reduction/Naloxone · Treat Drivers · Keep the Door Open

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Management combines a supported, gradual withdrawal (never abrupt), harm reduction (naloxone, overdose/alcohol advice, BBV), treatment of the drivers (mood and the underlying pain with non-opioid approaches), substitution therapy where appropriate (specialist), safeguarding, and an ongoing, non-judgmental therapeutic relationship that treats relapse as part of recovery.

📉 Withdrawal & substitution

Element	Detail
Gradual taper (Dawn)	Shared, flexible reduction schedule; never abrupt; adjust to symptoms; switch online co-codamol to a prescribed, controlled reduction.
Benzodiazepine/alcohol	Never stop abruptly (seizure risk); gradual taper ± medically supported detox.
Opioid substitution (specialist)	Methadone/buprenorphine for illicit opioid dependence; reduces overdose deaths.
Avoid dangerous combinations	Don't co-prescribe opioids + benzodiazepines/gabapentinoids.

🛟 Harm reduction, drivers & support

Element	Detail
Take-home naloxone	Supply & train patient/carers; overdose & alcohol-mixing advice.
BBV & physical health	Test/vaccinate; needle exchange if injecting; treat complications.
Treat the drivers	Mood (treat depression), sleep, and chronic pain (non-opioid, exercise/physio, NG193).
Safeguarding & social	Support the family; safeguarding where indicated; practical/social help.
Keep the door open	Regular review; non-judgmental; relapse = part of recovery; specialist partnership.

🎓 SCA Checkpoint — Step 7TasksRelating to OthersGlobal Skills

A plan that scores

"Here's the plan: we reduce the codeine slowly together — no sudden stops — and I'll give you naloxone and overdose advice, especially around alcohol, which I'd like to help you cut down too. We'll treat your low mood and find a better way to manage the back pain, and work with the drug-support service. I'll keep seeing you, and if there are setbacks we'll just keep going."

Deductions

Abrupt stopping; no harm reduction/naloxone
Ignoring mood/pain drivers; no safeguarding
Punitive stance; door closed on relapse

(Hesitant, ashamed, on edge) "I don't really know how to say this… I think I've got a problem with my painkillers. Please don't just stop them — I can't cope with the pain or how ill I get without them."

Who you are

Dawn Fletcher, 41, two school-age children. You've taken codeine/co-codamol for chronic back pain for years. You now take well above the prescribed dose, buy extra co-codamol online, and get anxious, sweaty and unwell if you run out — taking it more to stop the withdrawal than for the pain. You feel deeply ashamed, fear you're "an addict", and are terrified the doctor will simply stop your tablets and leave you in pain and withdrawal. Your mood is low, you sleep badly, and you drink about a bottle of wine most evenings. You've come, hesitantly, because a friend nearly died of an overdose and it frightened you.

Hidden concerns (reveal if explored)

Fear of being cut off (main): if the doctor reassures you they won't stop the tablets abruptly and won't judge you, you visibly relax and open up.

Shame: you think you're a bad person/mother; compassion helps hugely.

The alcohol: you'll admit the nightly wine if asked non-judgmentally.

The children: you worry about admitting struggles in case they're taken — needs sensitive handling.

Clinical details if asked

Escalating codeine/co-codamol, non-prescribed online supplementation, withdrawal-driven use
~1 bottle of wine/evening; low mood, poor sleep; no current plan to harm yourself but life feels hard
Two dependent children at home; you're the main carer; no injecting; oral use only
Chronic low back pain (the original reason); opioids don't really help it much now
Frightened after a friend's near-fatal overdose; never had naloxone or overdose advice

Reactions at key moments

If judged or told tablets stop now: you become distressed, defensive, and likely to leave/conceal.
On "I won't cut you off, we'll reduce slowly together": relief, tearful, engaged.
On naloxone/overdose advice (esp. with alcohol): you take it seriously after your friend's experience.
On safeguarding mentioned supportively: anxious but reassured it's about help, not removal.
Challenge line: "You're going to take my tablets away and report me, aren't you?"

"You're going to stop my tablets and report me to social services and take my kids, aren't you? That's why I've been too scared to come."

Resolution: Dawn engages if the GP: (1) responds with warmth and non-judgmental, person-first language, explicitly reassuring her they won't stop her medication abruptly or abandon her, and reframing iatrogenic dependence as common and treatable rather than a moral failing; (2) assesses co-use (the nightly alcohol — raising overdose and abrupt-withdrawal seizure risk), mood/self-harm, and the dependent children (safeguarding, framed supportively); (3) plans a supported, gradual taper (never abrupt), provides take-home naloxone and overdose/alcohol advice, and treats the drivers (mood and a non-opioid approach to the back pain); (4) works with specialist drug services and keeps the door open, treating relapse as part of recovery. She disengages if judged, threatened with abrupt stopping, or frightened about her children without support.

🏥

Clinic Quick Reference

Drug Dependence — Clinical Decision Framework

NG215 · supported taper · harm reduction · no abrupt stop

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🚦 1 — Assess & triage

Recognise dependence (escalation, non-prescribed sources, withdrawal-driven use); distinguish from addiction/tolerance. Assess co-use (alcohol/benzodiazepines → overdose & seizure risk), mood/self-harm, BBV/physical, social & safeguarding. Emergencies: overdose (999 + naloxone), dangerous withdrawal (benzo/alcohol seizures), acute suicidality.

💊 2 — Manage

Supported, GRADUAL taper — never abrupt. Harm reduction: take-home naloxone + training, overdose/alcohol advice, BBV testing/vaccination, needle exchange. OST (methadone/buprenorphine) for illicit opioid dependence (specialist). Avoid co-prescribing opioids + benzodiazepines/gabapentinoids. Treat drivers (mood; chronic pain non-opioid, NG193). Safeguarding for dependents. Non-judgmental; relapse = part of recovery; work with specialist services.

🎓

SCA Quick Reference

Drug Dependence — Consultation Playbook

No stigma · don't cut off · taper slowly · naloxone · safeguard

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🎯 The three pivots that pass this case

1 · Engage, don't shame

Non-judgmental, person-first; reassure "I won't cut you off"; dependence ≠ moral failing (often iatrogenic).

2 · Safety & harm reduction

Assess co-use (alcohol/benzos) & overdose; supply naloxone; never stop benzo/alcohol abruptly (seizures).

3 · Supported taper + drivers

Gradual, shared taper; treat mood & pain (non-opioid); safeguarding for children; specialist drug services.

⛔ Don't moralise or threaten to stop the drug abruptly · Don't miss overdose risk (alcohol/benzo co-use) — offer naloxone · Don't withdraw benzodiazepines/alcohol abruptly (seizures) · Don't forget safeguarding (dependent children), mood and the underlying pain · Work with specialist services; relapse is part of recovery

Drug Dependence · GP Clinical Reasoning Framework v2 · NICE NG215 (Medicines associated with dependence/withdrawal) · NICE CG52 (Drug misuse — opioid detoxification) / CG51 · Orange Book (Drug misuse & dependence UK clinical guidelines) · NICE NG193 (chronic primary pain)

Distinguish dependence, addiction and tolerance; much prescribed dependence is iatrogenic · Never stop abruptly — gradual, supported, shared taper (benzodiazepine/alcohol abrupt withdrawal → seizures) · Assess co-use (alcohol/benzodiazepines/gabapentinoids → additive respiratory depression & overdose); offer take-home naloxone & overdose advice · Harm reduction (needle exchange, BBV testing/vaccination) is core; OST (methadone/buprenorphine) saves lives · Screen mental health/self-harm, safeguarding (dependents), and treat the drivers (mood, non-opioid chronic-pain care) · Non-judgmental, person-first; work with specialist drug services; relapse is part of recovery

Teaching clinicians why each step matters — not just what to do · Always consult current NICE NG215 and the Orange Book · Clinical judgement takes precedence over any framework

Drug Dependence

Red Flags — the dangers in dependence

🙇 Reducing shame

🤝 "I won't cut you off"

🛟 Harm reduction first

👪 The children & the future

Same day / 999

Drug services

Supported taper

🚩 Treat the person and the drivers, not just the drug

🎭 Patient actor brief — click to practise

Who you are

Hidden concerns (reveal if explored)

Clinical details if asked

Reactions at key moments