Detecting Substance Abuse and Dependence: Red Flags, and Risk Factors

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