Clinical common sense is required in deciding whether or not to ask about the use of illicit drugs. In many situations, questioning is unnecessary and could damage the patient-doctor relationship. However, illicit drug consumption is rising rapidly and if there is any doubt, it is advisable to approach the subject with tact and firmness. If illicit drugs are being used or have been used, the following should be noted: the type(s) of drug involved; the frequency and duration of use; intravenous use and whether needle-
sharing occurred; whether drug dependence occurred: any physical, mental or social problems arising from drug misuse (as for alcohol history): any treatment interventions.
Inquiries concerning illicit drug use are fraught with even greater difficulty if the patient has been indulging in other illegal activities such as theft to fund the purchase of drugs, How far questioning should be pursued depends upon the urgency of the clinical problem. Information about drug-taking by a young person brought into casualty having collapsed may prove crucial. The past medical history may also include disorders which could be due to intravenous drug misuse while the social history may include interests like attending 'raves' where the use of stimulants is common. The patient may be more forthcoming if there is an established dependence on drugs which are being medically prescribed to control dependence and to reduce harm.
When asking about substance misuse it is necessary to advise the patient that medical confidentiality affords protection but that affirmative responses would need to be recorded in the casenotes. This information need not be conveyed in correspondence if il is not clinically relevant. If a patient refuses to disclose details of drug-taking, this should be noted.
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