Detecting Substance Abuse and Dependence

Symptoms, Red Flags, and Risk Factors

Implementing screening instruments is not the only way to identify drug-using patients. Red
flags may be apparent during the clinical interview and physical exam. A variety of
psychosocial indicators may point to substance abuse or dependence. Look for:
 Agitation, anxiety, anger, irritability, depression, mood swings
 Marital problems (including separation and divorce), abuse or violence, children's
 behavioral problems, family members' anxiety and depression
 Loss of long-standing friendships, spending time with other drug abusers, social
 isolation, loss of interest in regular activities
 Missing work or school, poor performance, frequent job changes or relocations
 Arrests, DUIs, theft, drug dealing
 Large recent debt, borrowing money from friends/relatives, selling possessions
 (presumably for drug money)
 
Some opioids, such as heroin, are commonly injected. Note whether your patient presents
with any physical indications of injection drug use, such as:
 Track marks or scars
 Abscesses, cellulitis, or dermatitis present at injection sites
 Skin necrosis
 Allergic reactions
 Tourniquet pigmentation

In addition to these general indications of drug use, there are some signs and symptoms
particular to opioid use. Note the following, indicative of prolonged opioid use, in your
patients. Also be watchful for patients who are high during office visits.
 Pupillary constriction
 Dry mouth and nose
 Constipation
 Decreased libido and/or sexual dysfunction
 Irregular periods in female patients