Substance dependence

Also called Drug addiction, Opioid dependence, Drug misuse

A treatable health condition, not a character defect. Overdose deaths in the UK are at record levels, and naloxone reverses them.

What it is

Drug-related deaths in the UK are at the highest levels since records began, and the great majority involve opioids.

Dependence is a health condition. The brain adapts to a substance, tolerance rises, and stopping causes withdrawal. Once that has happened, continued use is driven by avoiding withdrawal and by changes in reward and impulse circuitry, not by ongoing choice in any meaningful sense.

Treatment works. Opioid substitution treatment with methadone or buprenorphine substantially reduces overdose deaths, crime and blood-borne virus transmission. It is one of the best-evidenced interventions in medicine and one of the most stigmatised.

The single most useful practical fact in this entry: naloxone reverses an opioid overdose within minutes, it is free, anybody can carry it, and it cannot harm somebody who is not overdosing.

Signs you might notice

Tolerance rising, and withdrawal when stopping.

Life reorganising around obtaining and using.

Continued use despite clear harm.

Injecting marks, abscesses, and infections.

Overdose: pinpoint pupils, unresponsiveness, slow or absent breathing, blue lips.

The highest overdose risk is after a period of abstinence, because tolerance falls: after prison, after detox, after hospital. This is when people die.

How it can affect day-to-day life

The stigma is a clinical problem, not a social one. People avoid healthcare, hide use from prescribers, and are treated dismissively in emergencies.

Poly-drug use, particularly opioids with benzodiazepines or alcohol, is what most overdose deaths involve.

Housing, mental health and substance use travel together, and services that address only one usually fail.

Supporting someone well

Get naloxone and learn to use it. Free from drug services, and every family member and support worker of somebody using opioids should carry it.

Know the post-abstinence risk and talk about it explicitly before a prison release or a detox discharge.

Never leave somebody who has taken drugs to sleep it off. Recovery position, and call 999.

Support treatment rather than requiring abstinence as the price of support. Harm reduction saves lives; ultimatums do not.

Treat the mental health and the substance use together, and challenge services that will not take somebody because of the other condition.

Do not advise abrupt withdrawal from alcohol or benzodiazepines. Both can cause fatal withdrawal seizures. See alcohol dependence.

Where to get help

Every area has a free, confidential drug service. No GP referral needed. Find it through the NHS service finder or FRANK.

Talk to FRANK: 0300 123 6600, any time.

Overdose is a 999 call. Say the person is not breathing properly, give naloxone if available, and stay with them.