Box 461 Features in the clinical presentation that may suggest a history of substance misuse

• Current intoxication/withdrawal.

• Patient has assertive personality, often demanding immediate action.

• Patient may show unusual knowledge of controlled substances.

• Patient gives medical history with textbook symptoms or gives evasive or vague answers to questions regarding medical history.

• Patient reluctant or unwilling to provide reference information. May have no General Practitioner.

• Patient will often request a specific controlled drug and is reluctant to try a different drug.

• Patient generally has no interest in diagnosis, fails to keep appointments for further diagnostic tests, or refuses to see another practitioner for consultation.

• Cutaneous signs of drug abuse-skin tracks and related scars on the neck, axilla, groin, neck, forearm, wrist, foot and ankle. Such marks are usually multiple, hyper-pigmented and linear. New lesions may be inflamed. Shows signs of "pop" scars from subcutaneous injections.

The British Pain Society. Pain and substance misuse: improving the patient experience. A consensus document for consultation, 2006, The British Pain Society.

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