Table 2

 Common features in neurological patients with drug misuse

*Clinical “red flags” for drug misuse.
1. In the UK, the vast majority of drug addicts seen by neurologists will be seen as ward referrals, not as outpatients
2. *Patients are usually young, and often remarkably so for the type of pathology (for example, stroke)
3. *Drug addicts usually present very late, with severe neurological deficits, often waiting for an extraordinary time before seeking medical attention
4. *The history from the patient or from relatives/friends is often inconsistent and unreliable, and may sound either incredible or misleading
5. Drug misuse is usually not volunteered though generally (but not inevitably) admitted on direct questioning
6. *Looking at previous A&E notes is often a good source for the clue to drug misuse
7. *Once drug addicts are mobile, or even sometimes before, they will often abscond from the ward and/or hospital for periods. The nursing staff are the best ones to question, since they are usually the first to notice this, and the altered behaviour before and after these periods, let alone the nature of the “friends” who come to visit them
8. If in doubt, request a urinary drug screen, as early as possible after admission
9. Multiple pathologies are possible, and it is important not to jump to the rare ones, since in my experience the common and mundane are more likely (see below)
10. Always remember the possibility of infective endocarditis: it can produce or mimic so much, and is devastating if missed
11. Management is frequently complicated by poor compliance and/or by poor follow up attendance
12. Be prepared for an up-hill struggle, not only with the patient but also with other health care staff who you will have to rely on to help get investigations done promptly