Substance use among lawyers is a common way to self-medicate stress, anxiety, and depression and to fuel overwork. To facilitate an understanding of how substances of abuse work in the brain, it is helpful to grasp the basics of neurotransmission. Information travels through the brain via chains of neurons. This information is an electrical impulse while in the brain cell, but to travel across the gap between neurons, the information uses chemicals called neurotransmitters. The site of action for self-medicating substances is at that gap, which is called a synapse. Different substances cause various changes in the brain by influencing the synapses of those lawyers who use them. These drugs are divided by substances that stimulate and can fuel overwork (caffeine, nicotine, amphetamine, cocaine) and sedatives that can calm stress and anxiety (alcohol, cannabis, opioids). Some lawyers use prescribed antidepressant medications. All of them impact the brain at the gap between brain cells, the synapse, where communication involves neurotransmitters and their receptors.

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.

This chapter outlines the scale of the problem of substance misuse in the context of psychiatric intensive care units (PICUs) and related services. Further, it discusses relevant health inequalities and how these impact on the issue. It also reviews the characteristics of dually diagnosed patients and illustrates how substance use commonly presents in clinical practice in PICUs, low secure units (LSUs) and locked rehabilitation units (LRUs).

This chapter describes clinical situations that arise in the general hospital requiring intensive psychiatric care, the use of rapid tranquilisation (RT) and the legal aspects of management. It discusses challenges of delivering psychiatric care in general hospitals, including organisational barriers, environmental difficulties, lack of access to occupational/psychological interventions and managing psychiatric conditions alongside complex medical care, including in the critical care setting. It highlights staff factors affecting good psychiatric treatment, including lack of knowledge about psychiatric conditions and low confidence in providing treatment to mental health patients. The chapter also describes how mental health liaison teams work in the general hospitals.

Substance misuse is already widespread in UK schools, The greater freedoms of university make undergraduates particularly vulnerable to starting or increasing. Legal and medical agencies focus more on forensic consequences of established addiction. University drug use is not only recreational but may be motivated by improved performance or appearance. It is not clear whether the UK actively pursues eradication of non-medicinal drugs or prefers arrangements for safer consumption. Most universities officially ban drug use, but some student unions are permitted to provide facilities to enhance safer consumption. Lessons can be learned from the benefits and challenges of the UK smoking ‘ban’ and the history of alcohol ‘prohibition’. Drug use prevention and management need more rigorous research to discover what works and what doesn’t. Universities are ideally placed to conduct this. Meanwhile regulations need regular review by students, staff and authorities in collaboration. There is paucity of NHS treatment options for substance misuse. Confidential group-based support such as that provided by 12-step groups may provide particular advantages for students living away from home. Students and staff with drug-related concerns can also access advice from University Counselling Services and University Mental Health Advisors.

substances other than alcohol (see Chapter 8). The purpose is to introduce the reader to the wide variety of substances that are abused by explaining why people may use them, why the use can be harmful and broadly how this is managed. Liaison psychiatry is the bridge between inpatient care and community care and this complex relationship is demonstrated herein when discussing the management of these cases that require the input of a variety of clinicians. The substances detailed are further subdivided to cover background information, acute intoxication, toxicity, withdrawal states and other management advice. ‘Top tips’ are included where appropriate, which are practical considerations to make based on day-to-day experience working in the field.

Violence and aggression remain common reasons for admission to psychiatric wards, and violence and aggression commonly occur in inpatient psychiatric units. Furthermore, exposure to violence and aggression has a deleterious impact on patient and staff safety, treatment outcomes, staff morale and performance, and on the therapeutic environment. The chapter begins with a discussion of clinical governance and of factors that contribute to violence. The importance of service user and carer involvement is emphasised, as is the need to create a safe and therapeutic ward environment. Sexual safety and comorbid substance misuse is mentioned. Principles of managing acutely disturbed behaviour and the prediction of violence in inpatient settings are summarised. Readers are also reminded of issues pertaining to observation, de-escalation, seclusion and restraint. The extra care area, therapeutic interventions, meaningful activity and the role of psychologists on acute wards to reduce the risk of violence and restricted practices are discussed. The chapter concludes with considerations regarding pursuing criminal proceedings against violent perpetrators and inpatient care in the context of COVID-19.

Outcomes for children living in families with parental substance misuse and mental health issues can include poor school outcomes, early substance use, early involvement with the justice system and mental health problems. This chapter will discuss how families require acknowledgement and support for these and related problems such as ongoing stressors, including parenting difficulties, financial adversity and limited social connectedness. We know that outcomes for children raised in families with parental substance misuse or mental illness can be poor, with compromised outcomes from early infancy to adulthood well documented. These include impaired cognitive development and educational attainment, adolescent substance misuse and antisocial behavior, and mental health issues (Kuppens et al., 2020). In order to improve outcomes for children, families need to be provided with a therapeutic support plan that takes into a consideration the interplay between substance misuse and mental illness and other risk factors, such as intergenerational trauma, domestic violence, and socioeconomic disadvantage.

Any role for spirituality in addressing the serious clinical and public health problems related to substance misuse and addiction might seem antiquated at best, and clinical malpractice at worst. Yet, from a phenomenological perspective, addiction often penetrates and pervades the core of conscious thought and behaviour, undermining personal values and meaning and purpose in life – factors that many people associate with a diminished sense of personal spirituality. Research on spiritual/religious identity and practices has shown that these both protect against the onset of substance misuse and help millions each year to recover from it. This chapter reviews the interplay of morality, spirituality/religion and substance misuse, suggests why addiction in particular is so prone to spiritual pathology, and describes why spirituality/religion have played such prominent roles in successful remission and stable recovery. Spiritually oriented treatment approaches to addiction are reviewed along with their implications for practice and research.

This chapter introduces the intersections between mental health care and drug and alcohol care. It addresses the implications for holistic health care needs related to dual drug and alcohol use, and concurrent mental health conditions. It tells the contemporary, real-life story of a person who developed an episode of psychosis following consumption of premixed alcohol and caffeine drinks. The chapter also describes change models applied to substance use and recovery, such as motivational interviewing and stages of change readiness. Both common and less common drugs and their misuse affect the physical, social, cognitive and mental health dimensions of people with mental health conditions. Reflective exercises guide readers to consider how they will be able to promote mental health and well-being and minimise drug-related harm to individuals and communities in a practice context.

This chapter introduces the intersections between mental health care and drug and alcohol care. It addresses the implications for holistic health care needs related to dual drug and alcohol use, and concurrent mental health conditions. It tells the contemporary, real-life story of a person who developed an episode of psychosis following consumption of premixed alcohol and caffeine drinks. The chapter also describes change models applied to substance use and recovery, such as motivational interviewing and stages of change readiness. Both common and less common drugs and their misuse affect the physical, social, cognitive and mental health dimensions of people with mental health conditions. Reflective exercises guide readers to consider how they will be able to promote mental health and well-being and minimise drug-related harm to individuals and communities in a practice context.

Substance use and misuse remain a feature of everyday life in the UK today. It is a cause of death and disability and a marker of deprivation and inequality. The health, social and criminal justice systems currently in place are not able to provide the flexible response in which the public can have confidence and to which they can adhere. While much of the debate has centred on younger people, including children and adolescents, attention has recently turned to older people who are misusing cannabis and heroin as well as over-the-counter and medically prescribed medications. The remarkable contributions of neuroscience over the half-century of 1960–2010 have demonstrated the biological basis of substance misuse, which can become a chronic medical condition, much like diabetes and hypertension. There is exciting potential for the development of new pharmaceutical agents for the treatment of substance misuse. An aspiration we have is towards a new public understanding of addiction through education so that people can make informed choices based on realistic policies.