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Substance Misuse (DA)

  • Substance misuse represents a significant and growing challenge in general practice(1), affecting individuals, families, and communities. GPs are often the first point of contact for patients struggling with substance use, whether it presents directly or is uncovered through associated physical, psychological, or social issues. Substance misuse can contribute to a wide range of health problems including liver disease, mental illness and injury and is often closely linked with trauma, deprivation, and marginalisation. 

    General practice plays a crucial role in early identification, brief intervention, harm reduction, and ongoing support for recovery. Building trust, using non-judgemental communication, and understanding the stages of change are essential skills in engaging patients and supporting behaviour change. GPs also collaborate closely with addiction services, mental health teams, and social supports to deliver holistic, patient-centred care. Addressing drug and alcohol misuse effectively requires not only clinical knowledge but a compassionate, person-centred approach that recognises the broader determinants of health and the potential for positive change at any stage. 

    • DA1. Recognise and manage substance misuse, abuse and dependency by understanding the potential physical and psychological dependency of substances, individual risk factors for substance misuse and applying screening tools in everyday practice.
    • DA2. Manage alcohol and drug withdrawal and detoxification safely, acknowledging the limitations of community detox, recognising when hospital referral is necessary, and ensuring appropriate patient support.
    • DA3. Manage abstinence-maintenance (naltrexone, acamprosate, disulfiram) and harm reduction (naltrexone) medications for alcohol use disorder based on their mechanisms, indications, and clinical considerations.
    • DA4. Recognise common prescription medications prone to misuse.
    • DA5. Develop strategies for responsible prescribing and deprescribing of potentially addictive medications (e.g., limiting duration, screening for addiction risk factors, guideline-based approach).
    • DA6. Manage opioid dependence by understanding the benefits of opioid substitution therapy, recognising and managing acute opioid overdose, accessing appropriate treatment options, and providing comprehensive care for patients in recovery.
    • DA7. Identify and manage the secondary complications and infective risks arising from drug use including blood borne infections and organ damage.
    • DA8. Demonstrate a patient-centred, non-judgmental approach to addiction management, addressing barriers to access, promoting recovery, and respecting patient autonomy.
    • DA9. Support individuals with addictions by connecting them with appropriate community resources and fostering hope and belief in their recovery journey.
    • DA10. Develop methods to build trusting relationships with patients, utilising motivational interviewing techniques, and addressing harmful behaviours in a compassionate and supportive manner.
    • DA11. Manage challenging behaviours while maintaining professional boundaries and protecting the doctor-patient relationship, displaying respect for all patients regardless of background or choices.
    • DA12. Assess potential harm to at-risk children and adults related to substance misuse and liaise with social services when concerns arise.
    • DA13. Reflect on trauma informed care, the impact of Adverse Childhood Experiences (ACEs) and ongoing adult trauma on long-term health and well-being, recognising their role in addiction vulnerability.
    • DA14. Coordinate care for individuals with addictions by collaborating with other healthcare professionals and addressing social determinants of health that impact addiction and recovery.
    • DA15. Consider the vulnerability to addiction among medical professionals, fostering strategies to prevent harmful behaviours and reflecting on how to address addiction in oneself or a colleague.
    • DA16. Reflect on the legal implications of substance abuse, including driving under the influence and medico-legal responsibilities in addiction care.
    • DA17. Stay informed about current government policies on drug and alcohol treatment, integrating policy guidance into clinical practice.

    For each problem or disease, consider the following areas within the general context of primary care:  

    • The natural history of the condition, including whether acute or chronic
    • The incidence and prevalence, including in different demographic groups
    • Typical and atypical presentations
    • Recognition of normal variations throughout life
    • Risk factors, including lifestyle, socio-economic and genetic factors
    • Diagnostic features and differential diagnosis
    • Recognition of ‘alarm’ or ‘red flag’ features
    • Appropriate and relevant investigations
    • Interpretation of test results
    • Management, including initial and continuing care, chronic disease monitoring and emergency care
    • Patient and carer information and education
    • Prognosis

    Signs, Symptoms & Presentations

    • Accidents or injuries while under the influence of drugs or alcohol
    • Drug Induced Psychosis
    • Social Withdrawal
    • Self-Neglect
    • Intoxication
    • Malnourishment
    • Overdose
    • Poor Oral Hygiene
    • Withdrawal

    Common and Important Conditions

    • Alcoholic Liver Disease
    • Anabolic Steroid Use
    • Benzodiazepine Addiction
    • Cannabis Use
    • Cocaine Use
    • Fetal Alcohol Spectrum Disorder
    • Prescribing and use of Naloxone for opioid overdose
    • Prescribing opioid substitution therapy - Methadone and Buprenorphine
    • Misuse of prescribed and over the counter medicines
    • Opiate use
    • Polysubstance misuse

  • Wherever possible learning resources included here are peer reviewed and externally maintained. This is to ensure that trainees have access to quality assured information that is kept up to date.

    Self-Directed 

    Blended Learning Resources (Education Platform)

    Addiction Medicine

    Workplace Based Learning

    Workplace-based learning offers an ideal scenario for identifying and managing substance misuse. In general practice, trainees encounter patients at various stages of substance use; from occasional risky drinking to dependence and withdrawal, often alongside mental health, social, or physical health issues. Supervised consultations, case-based discussions, and reflective practice help develop clinical skills in brief intervention, motivational interviewing, harm reduction, and safe prescribing, particularly around medications like benzodiazepines, opioids, and methadone. Collaboration with addiction services, pharmacists, and mental health teams allows trainees to understand local pathways and multidisciplinary approaches, while also reinforcing the importance of non-judgemental, person-centred care.

    Day Release

    Day release sessions provide an important opportunity to explore substance misuse in a supportive, interactive learning environment. These sessions can include case-based discussions, role play, and peer reflection to build skills in recognising substance misuse, conducting brief interventions, and using motivational interviewing techniques. Trainees can also explore the physical, psychological, and social impacts of substance use, as well as ethical issues, stigma, and safeguarding concerns. Guest speakers; such as addiction specialists, service users, or community support workers, can offer valuable perspectives and highlight local services. Day release teaching helps trainees gain confidence in addressing substance misuse with empathy and clinical effectiveness in primary care.

    Registrar Tutorials

    Registrar tutorials provide a focused space to explore the complexities of substance misuse in general practice. These sessions are ideal for discussing real cases and refining practical approaches to screening, brief intervention, and harm reduction. Tutorials can cover topics such as managing withdrawal, safe prescribing (including opioids and benzodiazepines), dual diagnosis, and referral pathways to addiction services. They also offer a valuable opportunity to practise communication skills, such as motivational interviewing, and to reflect on personal attitudes and challenges when working with patients affected by substance misuse. Exploring the broader social determinants of addiction and strategies for long-term support can further enrich understanding and improve clinical confidence.

  • Entrustable Professional Activities (EPAs) underpin workplace-based assessment in this curriculum. Each EPA represents an integrated clinical task that General Practitioners must perform safely and independently, assessed through direct or indirect observation in real clinical settings.

    The curriculum and EPA framework are closely aligned: the curriculum defines the required knowledge, skills, and professional behaviours, while EPAs assess their application in practice. Together, they create a coherent approach to developing and demonstrating readiness for independent clinical work.

    The examples show how specific activities within general practice & chapters of the curriculum align with particular EPAs.

     EPA 12: Manage the mental health needs of adults including older people

    A patient presenting with hazardous drinking and withdrawal symptoms provides an opportunity to demonstrate EPA 12. If the GP Trainer observes the consultation, a PIP-C can be used to assess screening for dependence, risk assessment for withdrawal severity, and safety planning. A succinct case entry could be: “assessment of alcohol dependence and withdrawal risk.” Reflection should explore trauma-informed approaches, motivational interviewing, and strategies to build trust while maintaining professional boundaries.

    Core Knowledge Test (CKT)

    • Management of alcohol misuse

    • Management of opiate addiction

    • Approach to benzodiazepine tapering

    Clinical Competency Test (CCT)

    • A patient attending with a history of alcohol misuse.
    • A patient attending for review of their codeine prescription.
    • A patient attending to discuss cessation of cannabis use. 

    Disclaimer: The examples provided within this section are intended to be indicative only and are included to illustrate how elements of the curriculum may be assessed in the Clinical Competency Test (CCT).

    Examination questions in the CCT test the ability of candidates to integrate knowledge, skills, and professional behaviours across multiple curriculum areas to address the challenges posed by the question.

    The indicative content should therefore be used solely as a general guide as to some of the topics that may be introduced. Actual examination questions will assess a greater depth and complexity of understanding than the illustrative examples provided.

    Please note that a number of CCT questions will require candidates to undertake a physical examination of the simulated patient. In some circumstances, for example in the case of an intimate examination, candidates may be required to display their examination skills through use of a manikin or other device.

  • 1.    McNeely J, McLeman B, Gardner T, Nesin N, Amarendran V, Farkas S, et al. Implementation of substance use screening in rural federally-qualified health center clinics identified high rates of unhealthy alcohol and cannabis use among adult primary care patients. Addiction Science & Clinical Practice. 2023 Sept 20;18(1):56.