Problems relating to alcohol or drugs occur across a spectrum of levels of consumption and may be physical, psychological or social in nature. At one extreme, there is a small but significant proportion of people who develop dependence and may require both intensive and extensive support. However, on a population level, huge reductions in the harm caused by psychoactive substances could be made if everyone was encouraged to use a bit less. All health and social care professionals should be able to screen for potential alcohol use disorders, deliver brief advice and refer on to specialist services where appropriate. They should also have an awareness of the common illicit drugs and the potential problems these drugs are associated with. The evidence base for treatment of substance use disorders has developed over the past 30 years, and clinicians should be positive and optimistic that meaningful change in behaviour can be achieved. Prompt referral to the right level of support and treatment may prevent future problems. Recovery support services play a crucial part in sustaining any gains made in treatment, and many people recover without using professionally directed treatment at all. It is estimated that approximately 10 per cent of the population of the USA is in remission from a substance use disorder of any severity.

Alcohol and drug misuse are no longer confined to younger people, as the baby boomer cohort of older people shows the fastest rise in rates of mortality from drugs and from alcohol. This chapter provides an overview of substance misuse in older people, starting with its terminological, epidemiological, and pharmacological aspects. It goes on to detail clinical aspects that include screening, diagnosis, and presentations such as alcohol withdrawal, self-harm, drug intoxication, overdose, drug withdrawal, and psychosis.

Particular attention is paid to age-related syndromes such as alcohol-related brain damage – amnestic syndrome and alcohol-related dementia. The chapter also considers the relevance of comorbid physical disorders that can affect a range of pathologies and dysfunctions, particularly in gastro-intestinal, respiratory, cardiovascular, and neurological systems.

The organisation of care is also discussed, in order to highlight the importance of multi-agency working to provide a range of interventions that include liaison old age psychiatry and hepatology. The chapter goes on to cover medico-legal aspects as well as substance misuse and driving. It concludes with a section on discharge planning, emphasising the role of multidisciplinary teams in harm reduction – as well that of carers, non-statutory organisations, medical, and mental health services.

Social media are changing the way people are exposed to products with addictive potential – including gambling. This chapter provides a brief overview of the way digital technologies like social media are changing the gambling landscape and their relationship with gambling harm. Traditional approaches to gambling harm reduction have largely failed to recognize and address many of the systemic factors that shape the environment in which gambling harm occurs, such as promotion of gambling. Greater regulatory attention is needed to prevent social media from contributing to harm, especially among vulnerable groups such as minors and people experiencing gambling problems.

Harm reduction refers to a set of strategies aimed to limit the negative consequences associated with drug use, but without requiring complete abstinence. Some harm-reduction strategies aim to reduce the risk of overdose, such as the use of naloxone rescue kits, fentanyl testing strips, and implementation of Good Samaritan laws. Other strategies lower the risk of overdose but also the likelihood of contracting infectious diseases such as HIV and hepatitis. Syringe services programs, also referred to as needle exchange programs, and supervised consumption facilities all fall under this category. Medications for opioid use disorder (MOUD), which include methadone, buprenorphine, and naltrexone, have been proven to lower the risk of overdose, improve the likelihood of maintaining sobriety, and therefore lower rates of disease transmission. Finally, harm reduction is utilized in criminal justice system through the use of drug decriminalization, police diversion programs, and drug treatment courts.

In this chapter, Valeria Catalani, a research student, interviews Dave Croslands, a former professional bodybuilder who is now actively involved in the harm reduction sector, providing online support and educational services to the bodybuilding community. In the course of the interview he describes in detail his journey with the use of performance-enhancing drugs (PEDs), from his initial teenage experiences, when no information about PEDs was available, to his later, more informed years. His aim is not to stop people using PEDs, but to educate them about responsible consumption and usage. He emphasizes his belief that knowledge will reduce the harm and severe side effects caused by using PEDs. He also explains why he does not think that bodybuilding or indeed other sports disciplines can ever be separated from performance-enhancing practices.

Among the image- and performance-enhancing drugs (IPEDs), anabolic-androgenic steroids (AAS) are now a global public health issue. Once confined to sporting arenas and competitive bodybuilding, they have now reached an increasingly image-conscious general population. In addition to the well-documented evidence of physical harm caused by AAS, there is emerging evidence that in sustained high doses they affect the structure and functioning of the brain. For some of the newer drugs the potential long-term impact is unknown. The risks to health are compounded by polypharmacy, high levels of injecting, and variable product content and contamination resulting from the illicit market. Responses to the issue (i.e., the level and implementation of regulations, education and preventive activities, and treatment and harm reduction) vary. However, there are few data to inform the development of effective interventions, and there is a clear need to develop the evidence base, which requires effective engagement with drug-using populations.

Community-based harm reduction for alcohol use disorder (AUD) entails a compassionate stance and pragmatic strategies that minimize alcohol-related harm and enhance quality of life. Community-based harm reduction approaches aim to meet people where they are both in their communities and with respect to their motivation for change. Harm reduction approaches do not require or prioritize abstinence or alcohol use reduction as the sole or most desirable recovery pathway. To date, community-based harm reduction approaches have been applied and investigated primarily within marginalized populations, particularly people experiencing homelessness and AUD. Randomized controlled trials have established efficacy for the low-barrier, non-abstinence-based Housing First approach and for community-based harm-reduction treatment. Managed alcohol programs and meaningful activities programming have shown promising findings in nonrandomized trials and warrant further study. The chapter concludes with reflections on key themes undergirding work in community-based harm reduction and how it has positively affected individuals and communities.

This chapter starts by describing the key features of drug use disorders and how to assess them, including using objective tests of substance use. The principles of medical treatment are described, incorporating harm reduction strategies, medically assisted withdrawal, agonist therapies and relapse prevention. Opiates are used as a case study to consider the theory and practicalities of each approach, before describing how to integrate psychosocial interventions into an integrated approach to treatment. Stimulants and cannabis are then considered, before a review of the overarching concept of recovery and its application in recovery-orientated systems of care.

This chapter considers the assessment and diagnosis of alcohol use disorders, including the use of screening and a comprehensive assessment process, incorporating an evaluation of substance use and dependence alongside psychological and social wellbeing. A spectrum of treatment approaches are then described, beginning with strategies for managing the intoxicated patient and reducing the harms of alcohol consumption. The importance of preparation and planning for successful medically assisted withdrawal or detoxification is emphasised. Psychosocial interventions form the core of treatment of alcohol use disorders, delivered alongside pharmacotherapies for relapse prevention. Comorbid mental health disorders are considered, before reviewing the importance of patient-reported outcome measures in establishing the outcome of effective treatment for alcohol use disorders.

Services providing treatment for drug and alcohol users have developed considerably in the last 30 years. They are now provided in all areas of the UK and there are clear standards which govern how they should be provided and what they should provide. Over that period of development the outcomes services have been trying to achieve have changed. Initially, it was harm reduction and prevention of blood-borne viruses, then prevention of crime and most recently abstinence. Services for substance misusers are different from other services in that they are subject to a considerable amount of control from politicians and policy makers. Furthermore, services have had to change as drug and alcohol problems have changed. They have ebbed and flowed as funding sources have changed. Despite that they have been able to provide effective evidence-based treatment to many. This chapter explores the history of service provision, how treatment models have been developed and why and what elements of service provision are considered best practice.