GPAtlas🧭 When to suspect
Suspect or actively ask about drug use whenever a patient presents with new or unexplained mental health symptoms – anxiety, low mood, paranoia or psychosis – or with physical harms that drug use can drive, such as blood-borne viruses, recurrent skin and soft-tissue infection, cardiovascular events in a young person, or specific syndromes like ketamine-induced bladder pain or cannabinoid hyperemesis.
It is just as important to read the social footprint: deprivation, contact with the criminal justice system, relationship breakdown, and especially any safeguarding concern for children or vulnerable adults in the household. Drug use is often the unspoken contributor. A high index of suspicion, an open question, and a non-judgemental manner uncover far more than a screening test. Remember that novel psychoactive substances ("legal highs") are widely used and frequently evade standard urine assays, so the history always outranks the screen.
| Substance group | What should raise suspicion |
|---|---|
| Opioids (heroin, diverted methadone, fentanyl/nitazenes) | Overdose (pinpoint pupils, reduced consciousness, slow breathing), injecting harms, blood-borne viruses, recurrent withdrawal. |
| Stimulants (cocaine, amphetamine, MDMA/ecstasy) | Chest pain or arrhythmia in a young person, agitation, paranoia or psychosis, hyperthermia, dilated pupils. |
| Cannabis | Anxiety or psychosis, and cyclical vomiting with abdominal pain relieved by hot showers (cannabinoid hyperemesis). |
| Ketamine | Crampy lower-abdominal and bladder pain, frequency and urgency mimicking recurrent UTI (ketamine uropathy). |
| Nitrous oxide ("nos", "balloons") | Paraesthesiae, unsteady gait and falls from functional vitamin B12 deficiency and cord damage. |
| Benzodiazepines (incl. synthetic) | Sedation or disinhibition without alcohol on the breath; dangerous withdrawal; fatal overdose risk combined with opioids. |
| GHB / GBL | Rapid deep sedation with abrupt recovery; dependence carries a severe, potentially life-threatening withdrawal. |
| Anabolic steroids & image/performance-enhancing drugs | Body-image preoccupation, injecting harms, mood disturbance and cardiovascular effects. |
Source: NICE · UK Clinical Guidelines on Drug Misuse (Orange Book)
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