Welcome to the ZSA Facts for Action series

This page provides key information to explain what substance misuse is and will help build your understanding of its complexity as a risk factor to suicide. 


  1. What is substance misuse?
  2. Why is substance misuse important to consider in the context of suicide prevalence?
  3. Prevalence of substance misuse
  4. ZSA Suicide Prevention Resource Map - key takeaways
  5. Predisposing factors of substance misuse
  6. Life course of substance misuse
  7. Consequences of substance misuse
  8. Impact of COVID-19
  9. National guidelines for practice
  10. Key approaches
  11. ZSA Suicide Prevention Resource Map - related indicators
  12. Case studies
  13. References

What is substance misuse?

Substance misuse is formally defined as the continued use (misuse) of any mind-altering substance at a level which is harmful and/or problematic, that severely affects a person’s physical and mental health, ability to function in social situations and carry out everyday responsibilities (Drug Wise, 2021[1]).

Over a period of time, continued misuse of a substance can lead to dependency. Substance use disorder refers to the clinical DSM-IV diagnosis in which ‘there is a persistent use of drugs despite substantial harm and adverse consequences’ (Goldstein et al., 2015[2]).

Physical dependency

Physical dependence to a substance is when your body physically relies on use of a substance and can be involves a presence of withdrawal symptoms when the drug is not taken (The Department of Health, 2004[3]).

Psychological dependency

Psychological dependence to a substance is when it becomes central to a person's thoughts and emotions and involves a strong urge to use the drug, despite being aware of its harmful effects (The Department of Health, 2004 [3]).

Alcohol dependence is the most common form of substance misuse, but any drug, including heroin, cocaine, crack and cannabis, comes into this category, as does the misuse of glue and aerosols.

Types of substances


Alcohol is a legal depressant substance that is easily accessible within the UK. Alcohol misuse is characterised as harmful drinking which is a pattern of consumption that increases the risk of harm for themselves and/or others (NICE, 2019[4]). This is defined as excess daily consumption (more than 4 drinks per day for men or more than 3 units per day for women), or excess total consumption (more than 14 drinks per week for men or more than 7 drinks per week for women). This is above the NHS’ 14 units a week recommendation guide (NHS, 2021[5]).

Individuals that misuse alcohol in a harmful way can become alcohol dependent, which NICE (2011[6]) defines as characterised by craving, tolerance, a preoccupation with alcohol and continued drinking in spite of harmful consequences. Alcohol dependence is the most serious form of alcohol use, and is diagnosed in the DSM-5 as an alcohol use disorder.


A stimulant is a class of drug that elevates a person’s mood, intensifies feelings of wellbeing and increases energy and alertness (NHS Foundation Trust, 2021[7]). Legal examples of stimulants include caffeine and coffee. Illegal stimulant substances include amphetamine sulphate (speed), methamphetamine hydrochloride (crystal meth), MDMA (ecstasy) and cocaine.


An analgesic or painkiller work by mimicking the effects of the body’s natural painkillers (endorphins) by blocking the pain signals sent from the nerves to the brain (Drug Wise, 2021[8]).

They are distinct from anaesthetics, which temporarily affect, and in some instances completely eliminate, sensation. Illegal opioid drugs include heroin, and often people that misuse opioid pain receivers switch to heroin as it has the same effects.


Psychoactive drugs are substances that, when taken in or administered into one's system, affect mental processes, e.g. perception, consciousness, cognition or mood and emotions (WHO, 2021[9]). Cannabis is a type of psychoactive drug, which has hallucinogenic, depressant and stimulant effects.


Hallucinogens are substances that when taken in or administered into one's system, affect mental processes, e.g. perception, consciousness, cognition or mood and emotions (Nichols, 2016[10]). This substance can cause hallucinations, and can cause users to feel out of control or disconnected from their body or environment. Examples include LSD (D-lysergic acid diethylamide), Psilocybin (magic mushrooms), DMT (N,N-dimethyltryptamine), PCP and Ketamine.


Although other substances that are misused can be inhaled, the term inhalant refers to the various substances that people typically take only by inhaling. (National Institute on Drug Abuse, 2020[11]).

Legal highs

Drugs containing one or more chemical substances that produce similar effects to drugs like cocaine, cannabis and ecstasy – are known as 'legal highs', which mimic the effects of illegal drugs (Frank, 2021[12]).

Prescription drugs

Prescription drug abuse is the use of a prescription medication in a way not intended by the prescribing doctor. National Institute for Health and Care Excellence (NICE, 2020[13]) updated their guidelines on the treatment of chronic primary pain, recognising that prescription medication contributes to addiction. The new guidelines state that GPs should not prescribe opioids or other medicines like paracetamol to patients because they could be ‘harmful’ and cause addiction.

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Why is substance misuse important to consider in suicide prevalence?

People that misuse substances are more likely to complete suicide than the general population, with substance use being a significant risk factor for suicidal ideation, attempted suicide and completed suicide (Bronisch & Wittchen, 1994[14]).

In the UK, self-poisoning is the second most common means of suicide, and opiates and opioids are still the main type of drug taken in fatal overdoses (NICE, 2019[15]). Risk of suicide for people who misuse alcohol is 8 times greater than those who don’t misuse as alcohol reduces inhibitions enough for people to act on suicidal thoughts, which increases impulsivity, changes mood, deepens depression and increases the likelihood of self harm (Samaritans, 2021[16]; NICE, 2019 [15]). There is also a strong link between alcohol misuse and self harm, with alcohol acting as a method of self harm but can also be a consequence of alcohol misuse.  Research over a 10-year time period found that alcohol was consumed in 58.7% of self-harm incidents (Ness et al., 2015[17]).

Substance misuse increases the risk of suicide even more for people with common mental health problems such as depression or anxiety, or serious mental illnesses such as bipolar disorder, schizophrenia, severe depression and personality disorders. Additionally, people with substance misuse dependency are at an increased risk of co-morbid mental illness and suicide, with 56% of people that are in contact with mental health services and die by suicide have a history of alcohol or drug misuse (National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, 2016[18]).

The National Confidential Inquiry into Suicide and Safety in Mental Health (2018[19]) collected data on the types of opiates or opioids that were involved in death by self-poisoning in people in England who had been in contact with mental health services in the previous 12 months.

  • The most common was heroin or morphine (40%, 113 people), followed by codeine (19%, 53 people), tramadol (17%, 48 people) and methadone (11%, 31 people)
  • In 61% of deaths from self-poisoning with heroin or morphine (where the source of the drug was known), the drug was not prescribed for the person.
  • For other opiates (where the source of the drug was known), the drug was not prescribed for the person in 27% of cases for methadone, 29% for codeine, 12% for tramadol and 32% for paracetamol/opiate compounds.

This illustrates that it is vital that substance misuse is considered within suicide prevention work within the wider community. It also highlights the importance for mental health services to provide effective treatment interventions which include a focus on addressing substance misuse needs in addition to mental health needs.

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Prevalence of substance misuse


Alcohol misuse is a significant public health issue across the UK, and although the amount of alcohol consumed per person in the UK has fallen dramatically, there is an increase in numbers of people who drink at harmful levels. For example, binge drinkers make up 4% of the population in the UK, but consume 30% of the alcohol sold in the UK (Alcohol Change, 2021[20]). This is likely to result in increased hospital admissions for alcohol and more people developing alcohol use disorders.

Within England, research finds that 24% of people regularly drink over the weekly recommended guidelines of 14 units and 27% of people misuse alcohol by binge drinking on their heaviest drinking days. Overall it is estimate that 586,780 people in England are dependent on alcohol [20].

NHS Digital publishes an annual report on alcohol statistics in England, which highlights information relating to alcohol use. The latest publication from NHS Digital (2020[21]) shows that in the year 2018/19:

  • The proportion of men and women usually drinking over 14 units in a week varied across age groups and was most common among men and women aged 55 to 64, with men (38%) being more likely to drink at higher risk levels than women (19%).
  • The proportion of adults who were non-drinkers was highest in most deprived areas (29%)  compared with 10% in the least deprived areas.

  • London has the highest proportion of non-drinkers (28%), whereas East of England had the highest proportion (9%)
  • The proportion of men who drank more than 8 units in a day dropped from 24% in 2006 to 19% in 2018, with a gradual decline since 2009.
  • There were 5,698 alcohol specific deaths, which include deaths from certain types of disease such as alcoholic liver disease. This is 2% lower than 2017 and 7% higher compared to 2008.
  • There was 358,000 admissions to hospital where the main reason was due to drinking alcohol, 6% higher than 2017/18. This was highest in the most deprived areas.

Drug use

The UK has the most people in Europe that use opioids and cocaine (Gov UK, 2021[22]). In particular, drug use in England has been on the rise since 2011, with 9.4% of people reporting that they used drugs.

The Office for National Statistics releases publications which capture the misuse of drugs in England and Wales. The latest publication from ONS (2020[23]) shows that in the year 2020:

  • 3.4% of adults aged 16 to 59 years had taken a Class A drug in the last year (approximately 1.1 million people) compared to 7.4% of adults aged 16 to 24 years (approximately 467,000 people)
  • 2.1% of adults aged 16 to 59 years and 4.3% of adults aged 16 to 24 years were classed as “frequent” drug users
  • An estimated 1 in 11 adults aged 16 to 59 years had taken a drug in the last year (9.4%; 3.2 million people)
  • Around 1 in 5 adults aged 16 to 24 years had taken a drug in the last year (21%; approximately 1.3 million people)
  • An estimated 1% of 60 to 74 year olds had taken a drug in the last year.

This data shows that alcohol misuse is most prevalent within the older adult population (55 to 65), particularly in men and for those living in the least deprived areas. Drug misuse is more common in the younger population (16 to 24).

A large population survey conducted in 2019-20 identified that there were 14,291 young people (aged 12-17) in contact with alcohol and drug services, however, due to the societal norm of misusing substances at a young age, the figure for substance misuse in young adults is likely to be much higher (GOV UK, 2021[24]).

Males in the younger population are more likely to misuse substances than females, with substance misuse services being made up of 67% of males (Addaction, 2021[25]). As substance misuse is a significant risk factor for the completion of suicide, these group differences should be considered in suicide prevention work.

Socioeconomic position

In the UK, there is a strong relationship between socioeconomic position and drug misuse, compared to the general population, with drug misuse being a response to and a driver of poverty and deprivation. For example, deaths from drug misuse poisonings have increased substantially over the last seven years with those in the most deprived areas disproportionately affected (Office for National Statistics, 2020 [23].

One factor which contributes to this is that people in more deprived areas have less access to care and treatment of substance misuse, which is indicated by a lower age of first use, increased harmful use and a fast progression to dependence (Public Health England, 2016[26]).

In relation to alcohol, there is consistent evidence indicating an ‘alcohol harm paradox’ which is when individuals in higher socioeconomic status groups are more likely to report that they exceed recommended drinking limits, but those in lower socioeconomic status groups experience more alcohol-related harm (Bloomfield, 2020[27]). Additionally, although a significant number of people from lower socio-economic do not drink, the small population that do, drink in harmful ways which drives alcohol harm seen in this group (Drink Aware, 2020[28]). 


People that identify as LGBTQ+ are at a higher risk of misusing substances than the general population, in which they often face social stigma, discrimination, and also face a greater risk of harassment and violence (National Institute of Health, 2021[29]). As a result of this, the LGBTQ+ are at an increased risk for mental illness, substance misuse and suicide (Lea & Reynolds, 2014[30]).

A health report by Stonewall (2017[31]) was carried out to highlight mental health, alcohol use and drug use amongst LGBT people and found that:

  • One in six LGBT people (16 per cent) said they drank alcohol almost every day over the last year.
  • Frequency of alcohol consumption increases with age
  •  A third of LGBT people aged 65+ (33 per cent) say they drink almost every day, compared to just seven per cent of LGBT people aged 18-24.
  • One in eight LGBT people aged 18-24 (13 per cent) take drugs at least once a month.

Ethnic minority groups

In general, research has  found that substance misuse is lower within ethnic minority populations than within the white population. Literature reviews identify the rates of abstention from substances are higher amongst ethnic minority communities however there are large barriers to support, resulting from shame and stigma within communities and cultural attitudes towards substance misuse, as limited access or provision of substance misuse services (Gleeson, 2019[32]) This may explain why people from a ethnic minority background are under-represented in alcohol and drug treatment services [32]. This highlights the need to develop services in collaboration with local communities are needed so that people from ethnic minority backgrounds have appropriate support to meet their needs and to feel less isolated from their communities.

Mental health conditions

Substance misuse in people with mental health conditions or serious mental illness is a common occurrence, as substances are often used as an accessible coping mechanism to manage stress. In particular, alcohol has been identified as a common response to mental health problems, with 86% of people using alcohol treatment services have a co-morbid mental health problem (Public Health England, 2017[33]).

For more information, visit our Facts for Action series on Common Mental Health Disorders.


Homelessness has a significant relationship with substance misuse, with those who misuse substances being 7 times more likely to be homeless (Crisis, 2021[34]). One driving factor is that there is high prevalence of mental illness amongst those who are homeless, with 80% of homeless people in England reporting that they have mental health issues (Mental Health Foundation, 2014[35]). Substance misuse can occur through the use of drugs and alcohol as an accessible coping mechanism to manage distressing thoughts and feelings. It can also contribute to becoming homeless and securing temporary or permanent accommodation. Over the period between 2010 to 2021, homelessness has been reported to have increased by 165% (Crisis, 2021[36]). Suicides by people who are homeless have also been found to have increased by 30.2% from 2018 to 2019 (Office for National Statistics, 2020[37]). Homelessness and substance misuse as interconnected factors which link to the heightened risk of suicide need to be considered in suicide prevention and broader support strategies for this group of people.

Armed Forces

Research has identified that substance misuse among UK military personal and retired-veterans is significant, in particular, high levels of alcohol consumption and harmful drinking have been reported (Forces in Mind, 2013[38]). Veterans are also at a high risk for having mental health problems, such as posttraumatic stress disorder (PTSD), with 28.6% reporting PTSD and 57.5% reporting another mental health diagnosis (Ashwick & Murphy, 2018[39]). Alcohol use is common within this group, with research finding that 67% of men and 49% of female veterans were identified with an alcohol misuse problem compared to the general population, whereas only 5.2% reported that they misused drugs. Therefore alcohol misuse alongside mental health problems both need to be addressed in order to help prevent armed forces personnel, both current and retired, from dying by suicide.

Chronic pain

Individuals with chronic pain are more likely to have a problem with specific substances as a way of managing their physical pain and associated psychological stress. This includes cannabis or prescription medication such as opioids, with the prescription of opioids may result in problem drug use. For example, in the UK, 1.4 million people use recreational cannabis for symptomatic relief of an underlying debilitating chronic pain (The British Pain Society, 2019[40]). In comparison, the prevalence of prescribed opioids is high in this group, with 1.25 to 1.38 million people with chronic pain receiving long-term opioid medication (Bedson, Chen & Hayward, 2016[41]). As death by self-poisoning is the second most common means of suicide, with opiates and opioids are the main type of drug taken in fatal overdoses (NICE, 2019[42]), substance misuse and the risk of suicide needs to be considered in supporting and treating this group of people.


A recent report by Public Health England has highlighted the extent of substance misuse within prisons; over 53,193 adults in prison settings were using drug and alcohol treatment services during 2018/19 (Public Health England, 2019[43]). In a recent annual review of drug use in prisons, it was reported that psychoactive substances was the most prevalent drug found in prisons, and were present in 51% of prisoners, overtaking cannabis, opiates and buprenorphine by a large margin (Ministry of Justice, 2019[44]).

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ZSA Suicide Prevention Resource Map – key takeaways

Our ZSA Suicide Prevention Resource map developed with the NHS Benchmarking Network includes a number of metrics which provide a picture of the overall situation for substance misuse across England and shows wide variation in the number of people referred to and accessing services for treatment.

This data shows that across Local Authorities, there is a higher prevalence for opiates and crack use in the North West, North East and the Midlands in comparison to the national prevalence across England as a whole. Additionally, there is a higher prevalence for the number of alcohol dependent adults in the North West and North East.

The data below relates to data from 2016-2021 and is sourced from the NHS Benchmarking Project for substance misuse unless stated otherwise*.

  • Number of people aged 15 to 64 using opiates or crack per 1,000 populations (2016/17) varies from 3 in Rutland to 31 in Middlesbrough, with a median average of 12.
  • Number of alcohol dependent adults per 1,000 populations (2018/19) varies from 6 in Wokingham to 35 in Blackpool to, with a median average of 1.
  • The proportion of people referred for drug treatment waiting more than 3 weeks (2020/21) varies from 0.1% in Birmingham to in 28.3% in Devon, with a median average of 0.3%.
  • The proportion of people referred for alcohol treatment waiting more than 3 weeks (2020/21) varies from 0.1% in Hertfordshire to 41.9%% in Bristol, with a median average of 0.5%
  • An admission due to alcohol for all ages per 100,000 populations (2019/20) varies from 331 in Redbridge to 2,590 in Southampton, with a median average of 637.
  • Admission episodes for mental and behavioural disorders due to use of alcohol per 100,000 populations (2018/19) varies from to 157 in Rutland to 1,675 in Southampton, with a median average of 423. Note that the data completeness for this indicator is low.
  • Successful completion of drug treatment for opiate users (2019) varies from 1.6% in Newcastle upon Tyne to 12.2% in Wokingham, with a median average of 5.8%. Note that the data completeness for this indicator is low.
  • Successful completion of drug treatment for non-opiate users (2019) varies from 11,9% in North East Lincolnshire to 66.8% in Trafford, with a median average of 33.8%. Note that the data completeness for this indicator is low.
  • Successful completion of alcohol treatment in (2019) varies from 17% in Rotherham to 56% in Calderdale, with a median average of 38.8%. Note that the data completeness for this indicator is low.

*All data from NHS Benchmarking Network projects is subject to change dependent upon permissions being receiving from provider organisations to have their data included in the map.  The information reported reflects the data available as at 30/08/2022.

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Predisposing factors of substance misuse

There is no single cause of substance misuse, but in fact, it is a combination of biological, social and physical factors. Biological factors play an important role in the onset by leaving people vulnerable to develop behaviours that lead to misusing substances or substance use disorders. Examples of biological factors include genetics, brain changes and brain chemistry (Volko et al., 2015[45]); however, social and environmental factors have been widely noted that they are a key contributor to the onset of substance misuse. There are many different social and environmental factors; therefore we will include the key factors in this FFA, such as Adverse Childhood Experiences, parental substance misuse, mental health, social environments such as living in poverty, and being in prison. 

Other factors include:

  • Chronic pain
  • Domestic violence
  • Homelessness
  • Peer pressure
  • Violence in the community
  • Lack of economic opportunity
  • Low income
  • Low self esteem
  • Lack of support or barriers to treatment
  • Family dysfunction
  • Life stressors such as bereavement, divorce, moving house, job loss, etFFA.jpg

Figure 1 – The Conceptual framework of alcohol misuse (Public Health England, 2016[46]).

Adverse childhood experiences

Adverse childhood experiences, otherwise known as ACEs, are defined as traumatic events that occur in childhood, which involve violence, abuse, neglect and environmental factors which undermine children’s sense of safety, such as substance misuse, mental health and parental separation (Centres for Disease Control and Prevention, 2021[47]). When children are exposed to chronic stressful events, their neurodevelopment can be disrupted. As a result, the child’s cognitive functioning and/or ability to cope with negative or disruptive emotions may be impaired, therefore they may adopt unhealthy coping mechanisms such as substance misuse (Addaction, 2021 [25]). Some people misuse substances to address the traumatic stress they experienced as a child – including self-medicating to escape from invasive memories, or make traumatic relationships more tolerable. For example, adults who had experienced four or more adversities in their childhood, were two times more likely to misuse alcohol and eleven times more likely to have gone on to use crack cocaine or heroin (Bellis et al., 2014[48]).

Parental substance misuse

Although parental substance misuse is deemed as an Adverse Childhood Experience, it is important to highlight the influence of this factor on children developing a substance misuse problem in later life. A child who has a parent that misuses substances is more likely to develop behavioural, emotional and cognitive problems (NSPCC, 2021[49]) which increases the likelihood of them misusing substances in adulthood. Research has found that children with parents that have parental alcohol misuse are two times more likely to develop a substance misuse and are at a higher risk of suicide (National Association for Children of Alcoholics, 2021[50]).

Mental health

Individuals with poor mental health are at a high risk of misusing substances in harmful ways; individuals with common mental disorders, such as depression and anxiety, and Severe Mental Illnesses (SMIs) such as schizophrenia, bipolar disorder, severe depression and personality disorders may use alcohol or drugs as a method of self medication. This is a common occurrence as substances are often used as an accessible coping mechanism to manage distress. This is supported by research finding that the prevalence of substance misuse among people with SMIs is over 50% (Hunt et al., 2019[51]).


Deprivation and social exclusion are likely to make a significant contribution to drive the rates of drug use. Deprivation relates to poor housing, or lack of access to affordable housing and is another contributory factor in drug misuse include educational disadvantage, criminal involvement, unemployment and low income.

As discussed previously, alcohol is both a determinant and an outcome of socioeconomic inequality. Lower socioeconomic status is associated with higher morbidity and mortality for alcohol-attributable causes, despite lower socioeconomic groups usually reporting lower average levels of alcohol consumption (Collins, 2016[52]).

Deprived areas have experienced significant cuts to treatment budgets and less accessibility to treatment services; therefore this identifies how social inequalities drives substance misuse harms and may contribute to the risk of suicide in this population (Alcohol Change UK, 2021 [20]). Targeted policies and interventions are needed for this group, to not only reduce the inequalities in substance misuse, but as a suicide prevention intervention.

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Life course of substance misuse

Young adults

Substance misuse is most likely to develop in teenage and early adult years, represents a “period of physical, emotion, social and psychological development” (Care Quality Commission, 2017[53]) therefore this can interfere with developmental processes occurring in the brain, leading to more substance misuse.

Early adulthood is a key to social development, and young adults are faced with certain challenges in this period, leading to experimentation of drugs and alcohol, which can lead to harmful misuse. There are many social factors that influence young substance misuse, such as Adverse Childhood Events, peer pressure, or mental health issues.

Significant proportions had multiple other problems or vulnerabilities for substance misuse, such as:

  • Anti-social behaviour (32%)
  • Having a mental health problem (37%)
  • Being affected by their home environment, such as domestic violence (21%)
  • Affected by others substance misuse (22%)
  • Being involved in social services (10%) or being a child in need (10%)

For more information, visit our Facts for Action series on Children and Young People


The experience of substance misuse varies, and some people may experiment at a young age and not go on to developing substance misuse disorders in adulthood. Substance misuse during these years creates the potential for a variety of long-term negative effects with 90% of people with addictions started using substances in their teen years (Partnership to End Addiction, 2021[54]).

Men are more likely than women to misuse substances such as alcohol and heroin, which further increases the risk of males completing suicide (National Institute on Drug Abuse, 2020[55]). Additionally, men are more likely to disengage in treatment leaving them more likely to relapse.  

On the other hand, there is a variation in the substances used between males and females, which highlight the need for specifically tailored treatment programmes. Compared to males, females are more vulnerable to key phases of substance misuse that develop into a disordered use, from being vulnerable to initiation, bingeing and relapse (Anker & Carroll, 2010[56]). Research has highlighted that female hormone levels are associated with certain drug use, with higher oestrogen levels being associated with the use of positive enhancement drugs such as cocaine or amphetamine (Moran-Santa, Flanagan & Brady, 2014[57]).

Older adults

The number of older people in the UK is rising alongside the disproportionate rise in the number of older people who use substances, particularly alcohol and prescription drugs. In particular, 1 in 5 men over the age of 65 years and one in 10 women over the age of 65 are drinking above ‘safe recommended limits’ for adults (Roa, Schofield & Ashworth, 2015[58]). Inappropriate prescribing of prescription drugs to older people means that in 20% of older people, opioids and benzodiazepines are misused by this population (Royal College of Psychiatrists, 2018[59]).

Psychosocial factors such as social isolation, retirement, life events, death and pain have a strong association with substance misuse in older adults. However, these factors increase the risk of early mortality from substance misuse or suicide (Rassool, 2012[60]).

The nature of different substances influences life course experiences. For example, harmful substance misuse can lead to early mortality, through overdoses, suicides or health morbidity such as cancer, strokes or mental health conditions [55].

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Consequences of substance misuse

The psychological health harms can be wide-ranging depending on the composition of the substance itself, the method of consumption, and frequency of use. Consequences of problematic substance use can be of a physical, psychological, and social for both them and those around them (Nutt et al., 2010[61]).

Social inequalities

People that misuse substances face a range of social inequalities. Research has identified that people that misuse drugs are most likely to live in areas of high deprivation and poverty (Jones & Sumnall, 2016[62]). On the other hand, alcohol consumption is lower in areas of higher deprivation, but alcohol harm is increased.

People that with a history of substance misuse face stigma and discrimination in society with public perception that it is a choice. For example, those that have substance use addictions are often seen as dangerous or are to blame (Yang et al., 2017[63]). As a result, this leads to social exclusion in many ways, such as creating barriers to access employment, medical appointments and housing opportunities (UK Drug Policy Commission, 2010[64]).

Studies have found that people with substance use disorders are significantly less likely to be in employment than other adults of working age and face significant challenges in making the transition to work. Individual factors include low self esteem, lack of education or physical health problems, as well as  societal factors including discrimination from employers to take on individuals with drug misuse or criminal convictions (Bault, Hay, McKell & Carroll, 2010[65]).Stigma around older adults and substance misuse also exist, with older adults being reported to have often been ignored and deemed non-essential, with this group facing social inequalities as a result (Royal College of Psychiatrists, 2018 [59]).


It is well known that there is a strong relationship between substance use and crime (Ministry of Justice, 2020[66]) with cultures within prison enabling drug use . Psychoactive substance misuse is prevalent amongst vulnerable groups, who may use it to cope with living in prison  (Ralphs, Gray & Norton, 2017[67]) to cope with boredom, or to self-medicate for their mental health.

Health access inequalities

Life expectancy

Substance misuse leads to physical health inequalities, with a reduction of life expectancy between 9 and 24 years compared to the general population for drugs and alcohol (Chang et al., 2010[68]). Health conditions include:

  • Injecting drugs such as heroin – this is associated with Hepatitis B through use of needles
  • Alcohol – associated with liver disease, liver failure and cancer
  • Opiates – associated with strokes and cognitive impairment
  • Cocaine – associated with kidney or liver failure and/or heart problems

People with substance misuse also experience co-morbidity with mental health disorders, which reduces life expectancy due people with mental health dying on average 15-20 years than the general population (Public Health England, 2018[69]). For example, Two-thirds of these premature deaths are caused by chronic physical conditions such as coronary heart disease, type 2 diabetes and respiratory disease.

Mental health

Substance misuse increases the likelihood of mental health issues, with co-morbidities between substance misuse and mental health being very common. However, the misuse of substances may exacerbate symptoms of mental health, as chemical interactions can trigger initial symptoms of those with a predisposition for the condition (Sacks, Ries & Ziedonis, 2005[70]). One example is the use of cocaine, which is commonly associated with an increased risk of symptoms of psychosis, which users tend to become paranoid, anxious, agitated and experience hallucinations (UK Rehab, 2021[71])

Access to treatment

People living with substance misuse often experience a barrier in accessing appropriate treatment and evidence from service users identifies that people with co-morbid substance misuse and mental health are often unable to access the care that they need from mental health and addiction services (Public Health England, 2017 [26]). More than one in five (22%) of 189 drug treatment services in England say that access to mental health services deteriorated over the 12 months to September 2014 (Drugscope, 2015[72]). This has long term consequences on recovery and can contribute to the mortality rate in this population from dying by suicide.

The result of not having adequate provision in place is that people fall through the gaps between services, leaving their needs unmet (Turning Point, 2016[73]). The barriers of treatment in the community means that A & E staff are often the ones treating people with co-existing issues who have reached a crisis point, with 7027 admissions for drug-related mental and behavioural disorders in 2019/20 (NHS, 2020 [21]). This identifies a need for better care for people with substance misuse and/or mental health.

For more information, visit out Facts for Action series on Substance Misuse Services.

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Impact of COVID-19

The link between substance misuse and mental health has been exacerbated by the COVID-19 pandemic. Although a necessary measure to mitigate the devastating effects of COVID-19 on public health, evidence indicates that periods of self-isolation have influenced acute and prolonged negative mental health consequences, which in turn, has increased the likelihood of substance misuse (The Health Foundation, 2020[74]).

During a time when support from family, friends and professions is limited, alcohol use is an accessible way of coping with distressing feelings. Around one in five people (21%) reported drinking more frequently since the lockdown, suggesting that around 8.6 million UK adults drank more frequently (Alcohol Change, 2020[75]). More than half of adults and over two thirds of young people said that their mental health has gotten worse during the period of lockdown restrictions, with a third using alcohol or illegal drugs, with 18–24 year olds using this coping strategy more than over-25s (Mind, 2020[76]).

Research has found that substance misuse is significant for those with pre-existing mental health conditions such as schizophrenia and bipolar, being found to be related to non-adherence to treatment and poorer outcomes (Margolese et al., 2004[77]; Verdoux et al., 2005[78]).

In people with pre-existing substance misuse disorders, the challenges of the lockdown contributed to increased alcohol intake and relapse of those with alcohol use disorders, with support groups such as Alcoholics Anonymous reporting that they had a 300% surge of enquiries within the lockdown (BBC, 2020[79]).

Primary impact

There has been a direct impact on substance misuse as a result of the COVID-19 lockdown in the UK, with COVID specific stress factors influencing drinking behaviours in groups of people. For example, research has identified that people that were essential workers and having children at home drink larger quantities during quarantine (Sallie et al., 2020[80]). Worsened mental health across the general population, particularly for vulnerable groups such as people with pre-existing mental health illnesses, physical health conditions and those that live in deprived areas were highlighted as key risk groups (Understanding Society, 2020[81]).. Loneliness and isolation was found to be a key contributory theme (Samaritans, 2020[82]). Research conducted by the Centre for Mental Health during the COVID-19 pandemic found that there was a surge in alcohol use in order to cope with increased stress (Centre for Mental Health, 2020[83]; Jackson et al., 2020[84]).

Secondary impact

There were also secondary impacts of the COVID-19 lockdown, meaning that people went through economic adversities, loss of jobs and housing problems, leading to increased substance misuse to cope with this stress. One group of people found to increase their alcohol use were those furloughed from work, with 1 in 3 furloughed workers found to have consumed more alcohol during lockdown, with more than a quarter identifying that they drank harmfully on days they usually wouldn’t (Drink Aware, 2020[85]).

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National guidelines for practice

NHS Long Term Plan

The NHS Implementation Plan[86] (2019/21) and NHS Long Term Plan[87] (2023/24) New and integrated primary and community services should remove thresholds to ensure people can access the care, treatment and support at the earliest point of need, so that they can live as well as possible in their communities. They set out that the NHS will:

  • New and integrated models of primary and community mental health care will support adults and older adults with severe mental illnesses. A new community-based offer will include access to psychological therapies, improved physical health care, employment support, personalised and trauma-informed care, medicines management and support for self-harm and coexisting substance use
  • Improved support for self-harm and coexisting substance use

National Institute for Health and Care Excellence

The National Institute for Health and Care Excellence (NICE) use the best available evidence to develop recommendations and guidelines that guide decisions in health, public health and social care. These guidelines can also be directly relevant to the assessment and treatment of substance misuse.

Drug misuse guidelines:

Alcohol misuse guidelines:

British Psychological Society

The British Psychological Society (BPS) provides a series of guidelines to help clinicians work in a psychologically informed way.  As part of this, the BPS works alongside NICE in developing guidelines for the treatment of substance misuse.

BPS (2016[88]) recommends that:

  • The priority for children and young people deemed to be at risk of developing substance misuse problems is to build skills, bolster self-esteem and foster resilience.
  • An evidenced-based response needs to be accompanied by the identification of treatment and geographical coverage gaps, support for current practitioners, commissioning of senior roles, and funding to support training routes that directly address this need.

Other guidelines:

For more recommended guidelines, visit our Facts for Action Series on Substance Misuse Services.

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Key approaches

Approaches to substance misuse have been developed that move away from solely focusing on treating substance misuse with medical and psychological interventions.

Prevention approach

One approach that is advocated is the prevention approach, which puts emphasis of early prevention of substance misuse in children and young adults, so that it does not progress into disordered use in adulthood. The BPS [88] recommends that due to the complex and varied pathways to substance misuse, treatment needs to be multi-modal, diverse and follows an evidence based-preventative approach.

Recovery Approach  

The recovery approach focuses on the factors contributing to the development of substance misuse and how these factors can delay recovery. One way this the recovery approach addresses issues faced by people that misuse substances is to improve pathways to employment, in which there is a mutually enforcing relationship between employment and recovery (Local Government Association, 2018[89). For example, schemes such as ‘giving something back into work’ enable people with substance misuse issues to gain employment skills through:

  • Confidence building
  • Development of CV’s
  • Building interpersonal skills
  • Building interviewing skills

Another aspect to the recovery is a community approach, which works with residents in communities to focus on key factors that contribute to harmful substance misuse in different areas. This approach encapsulates drug and alcohol use in communities that capture the needs for both adults and young people.

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ZSA Suicide Prevention Resource Map – related indicators

Direct indicators

Risk factors

Indirect indicators

Waiting times

Admissions relating to alcohol use


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Case studies

Examples of excellent practice in line with national guidance and key approaches for substance misuse are included here.

Alcohol and mental health services

Birmingham and Solihull Mental Health Foundation Trust: COMPASS programme


The COMPASS programme in Birmingham provides a service to people who experience severe mental health problems and use drugs and/or alcohol problematically. The team also provides training and clinical input to mental health teams to promote a model of integrated treatment. This service works directly with service users and provides cognitive behavioural interventions, relapse prevention with a focus on mental health and building skills and coping mechanisms for both mental health and substance misuse.


  • Integration of outreach, early intervention services and homeless mental health team has increased the successful engagement and retention of service users in treatment.

For more information, visit the Birmingham and Solihull Mental Health Foundation: COMPASS webpage.

Turning Point: support link


Turning Point support link programme provides intensive community support to people who are experiencing mental health and substance use difficulties and who may also have a history of offending behaviour. Turning Point offer services such as practical support, emotional support, out of hours telephone line, supporting service users link into community services, encourging the development of life skills and offering work experience.


  • Reduction in self-harm incidences
  • Reduced hospital admissions
  • Increased confidence and self-esteem amongst
    service users
  • Interest in self-development through interaction
    with mainstream community activities.

For more information, visit the Turning Point webpage.

Examples of recovery approach 

Tower Hamlet: substance misuse strategy 


This strategy aims to reduce drug and alcohol related harms to individuals, families and communities in Tower Hamlets and to enable more residents to recover from problematic substance misuse. This sets out its community approach into three different priorities through early intervention and prevention, effective evidence based treatment and recovery support, and reducing drug and alcohol related crime. (See Figure 2). 


  • Reduction in the number of drug-related deaths from 5.6 per 100,000 population to 3.5 per 100,000 or 26 deaths in 2016-18
  • Increased the successful completion rates of non-opiate and alcohol service users between April 2016 and April 2019
  • Improved identification and support to children in families with substance misuse problems
  • Launched Chat Health – anonymous drug, alcohol and sexual health support for local young people
  • Improved the treatment provision for young people by integrating sexual health and substance misuse services

For more information, visit the Tower Hamlet Partnership Substance Misuse Strategy (2020) webpage.

Figure 2 - The  integrated community approach 


To be built from: Local Government Association. (2018). Working together: Helping to support and transform the lives of people affected by drug and alcohol problems. Available at: https://www.local.gov.uk/

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Content reviewed and updated 30/08/22