The use of alcohol and illicit substances has increased greatly in this country over the past decade (Department of Health et al, 2007; Home Office, 2008). Substance misusers are also overrepresented in general hospital populations. One review concludes that in the UK alcohol plays a direct or contributory role in 7–40% of all acute, non-A'E, hospital admissions, the highest proportion (25–40%) in acute, unselected, medical admissions and the lowest (7%) in general, surgical admissions. Alcohol misuse is also probably responsible for at least 10% of all A'E attendances, and for a much greater proportion of cases involving trauma (Royal College of Physicians, 2001). One study found that of people treated for head injuries in A'E, 51% were intoxicated by alcohol, and that alcohol was associated with a significantly increased length of stay (Williams et al, 1994).

Drug misusers are less prevalent in hospitals as they are in the community, but treatment poses significant problems. Unsuspected alcohol and drug misuse may present in a myriad of ways. Detection is very important, particularly now that adequate alcohol and drug treatment services have at last been funded and provided throughout most of the UK. Surprisingly, many doctors take the view that little can be done to help substance misusers. In fact, this is definitely untrue. Effective methods of treatment are now well established, and indeed treatment of drug and alcohol misuse are among the most cost-effective of all interventions (Raistrick et al, 2006; Connock et al, 2007). The Royal College of Physicians (2001) has proposed systems that should be in place in all general hospitals to tackle alcohol misuse (Box 7.1). These same recommendations should also apply to drug misuse.

Substance misuse and the elderly

Substance misuse problems among the elderly often go undetected, even though for some years it has been recognised that up to 30% of older patients admitted to general medical wards and 50% of older psychiatric in-patients may be heavy alcohol users, and across all ages there is a strong association between illicit drug use and alcohol dependence.