Concomitant use of benzodiazepines is common amongst people who use drugs and these guidelines give pragmatic guidance for the hospital management of problematic benzodiazepine use and dependency.

Benzodiazepine withdrawal can cause potentially life-threatening seizures as well as additional symptoms including anxiety, tremor, insomnia, nausea and vomiting. Benzodiazepines obtained illicitly may contain varying concentrations of the active drug, therefore patients should be assessed and treated based on symptoms.

Small doses of diazepam (5-10mg) should be prescribed in the “once-only” section of the prescription and medication administration record and patients re-assessed at regular intervals. If they are not drowsy or intoxicated, then this may be repeated 6 hourly or according to a personalised detox regimen. Seek advice from Drug Liaison Nurses.

Cocaine is a stimulant which increases levels of several neurotransmitters and exerts sodium and potassium blocking effects. As a result, multiple body systems are affected and intoxication may present in a multitude of ways. Cocaine use in Lothian is widespread and along with the traditional powder form, which is usually snorted; crack cocaine is also being used, which is usually smoked and has a faster, stronger onset of action. Both forms of cocaine can also be injected and injection sites should be examined if the patient reports a history of intravenous drug use.

The management of patients with cocaine toxicity is complex. Please refer to TOXBASE and if appropriate discuss with the on-call toxicologist.

• Gabapentinoids (gabapentin and pregabalin) are prescribed for treatment of neuropathic pain, epilepsy and generalised anxiety disorder (pregabalin).
• They are widely misused and are increasingly implicated in drug-related deaths. This has led to their reclassification as controlled drugs in April 2019.
• Patients may present sedated or in some cases, euphoric effects may be noted.
• Abrupt cessation may precipitate withdrawal effects and for this reason doses should be gradually reduced.
• Symptoms of withdrawal may include insomnia, headaches, nausea, anxiety and hyperhidrosis.

Please be mindful if prescribing during admission (misuse potential and also the potentiating effect gabapentinoids have on opiates and methadone).

• New Psychoactive Substances (NPS) represent a diverse group of drugs that can be classified according to their pharmacological activity.
• There have been nearly 500 different compounds identified, however only a handful are found to be in circulation.
• Such drugs may or may not be detected by toxicology testing and the utilisation of such testing will neither confirm nor exclude their use.
• The mainstay of treatment is supportive, with the use of sedation in agitated individuals, and monitoring of blood glucose.

• These represent the most diverse group of compounds, and are the most commonly consumed products, predominantly by smoking.
• They are sold in packets with names such as “Spice” and “Black Mamba” being the most well known.
• They act as full agonists of the endogenous cannabinoid receptors in the brain and can vary greatly in potency.
• Clinical features associated with their use are nausea, vomiting and an induced dissociative state.
• Case reports in the literature have identified acute ischaemic stroke and acute kidney injury following daily consumption.
• The synthetic cannabinoids appear to be a significant trigger in the development of acute mental health presentations.

• There has been an increase in the number of potent novel benzodiazepines on the market, many of which have not undergone formal pharmacological testing.
• Local toxicology and drug-related death reports show etizolam and alprazolam (Xanax) being commonly used, although users may believe they are taking diazepam. They may or may not be identified during toxicology testing and patients often use them to “self-medicate” when consuming stimulants.

• These chemicals represent the synthetic analogues of natural stimulant cathinones found in the Khat plant.
• They act as stimulants similar to amphetamines, but have varying activities on the neurotransmitters, with some more potent at inducing serotonin toxicity.

Most stimulants are sold as alternatives to cocaine or amphetamines. They predominantly act on dopaminergic and adrenergic systems in the body.

Sold on blotters like LSD, these compounds have a prolonged duration of action, with much greater potency. Unlike LSD, they may have intensive vasoconstrictive properties and case reports have identified acute digital ischemia with their use.

Primary problematic alcohol use is not covered by these guidelines, please refer to the CIWA-based Treatment Protocol for Acute Alcohol Withdrawal and contact the Alcohol Liaison Nurse for further advice.

Alcohol withdrawal CIWA algorithm Jul 2020 (scot.nhs.uk)