8. Substance dependence

Question 1

Alcohol dependence

Answer 1

A strong and uncontrollable desire to drink alcohol

Question 2

Alcohol dependence withdrawal treatment

Answer 2

Moderate- severe alcohol dependence
Long acting benzodiazepine - Chlordiazepoxide OR diazepam - helps to control withdrawal symptoms

If a patient has an alcohol withdrawal seziure: fast-acting benzodiazepine e.g Lorezepam

Delirium tremens involves hallucinations, sympathetic overdrive and progress to cardiovascular collapse
MEDICAL EMERGENCY
1st line: Oral lorezepam
If patient declines, or symptoms persist: parenteral lorezepam OR haloperidol

Question 3

For alcohol dependence

Answer 3

1st line: Acamprosate OR Naltrexone

AND

Psychological therapy

To reduce consumption: Nalmefene

Question 4

Wernicke’s encephalopathy treatment

Answer 4

Thiamine

Question 5

Wernicke’s encephalopathy

Answer 5

Degenerative brain disorder caused by the lack of vitamin B1 - thiamine

Question 6

Most effective approach for smoking cessation

Answer 6

Abrupt quitting + Cessation aids + Behavioural support

Question 7

Smoking cessation treatment

Answer 7

* Varenicline OR Long + short acting NRT*

• Varenicline, the partial agonist helps to stimulate nicotine receptors but blocks rewarding effects.
  Can make patient feel dizzy, sleepy
• Long-acting NRT: 16hour patch or 24 hour patch (if they experience strong cravings on waking)
  Patches may cause skin irritation
• Short-acting NRT: Gum, lozenge, nasal and oral spray, sublingual tablet
  nasal sprays may cause throat irritation

* Bupropion (SNRI) - risk of serotonin syndrome when taken with serotonergic drugs
nausea, vomtiing, diarrhoea, increased heart rate, agitation

May also cause worsening of depression, suicidal behaiviour, behaiviour changes. Patients should be alerted of this

Without tar, carbon monozide and harmful chemical present in tobacco smoke, NRT’s are better

Question 8

Opioid dependence treatment

Answer 8

Opioid substitutes:

Methadone or Buprenorphine

Question 9

Methadone dose and side effects

Answer 9

Methadone dose: OD

Side effect:
- More sedating than buprenorphine, can be preferred if patient abuses sedating drugs or alcohol, or has anxiety during withdrawal
- QT interval prolongation

Has a long half-life

Question 10

Buprenorphine dose and side effects

Answer 10

Dose: OD

Side effects:
Precipitate withdrawal reactions (as it also blocks opiod receptors)

Less sedating than methadone, so preferred if a patient has a job or drives

Question 11

Methadone drug interactions

Answer 11

Interacts with drugs that also prolong the QT interval:
Interacts with drugs that also prolong QT interval: antipsychotic, anti-arrhythmic drug, citalopram, escitalopram, Clarithromycin and erythromycin, domperdone, hydroxyzine, quinolone, onadestron