9. Alcohol and substance misuse

Question 1

Which medications are affected by stopping smoking?

Answer 1

• Warfarin - increased INR
• Olanzapine - increased level
• Flecainide - increased level
• Clozapine - Reduce dose to 75% gradually over a week. Monitor levels 1 week later
• Aminophylline, theophylline - increased level

Question 2

How should you manage those who want to stop smoking?

Answer 2

• refer to local smoking cessation service or self referal
• These services offer:
  -behavioural support
• advice about NRT
• can prescribe NRT (combo of both is best)
• advise withdrawal symptoms improve after 3or 4 days
• Smokefree national helpline/website
• If pt cannot attend local cessation servie - prescribe NRT or bupropion with advice.
• Follow up after 2 weeks

all nicotine products are licenced for use by pregnant and breastfeeding women. Review after 1 week.

Question 3

What is hazardous drinking?

Answer 3

• Drinking >14 units of alcohol a week, but less than 35 units a week for women.
• Drinking >14 units of alcohol a week, but less than 50 units a week for men.

Person is at increasing risk of harm

Question 4

What is Alcohol Use Disorder?

Answer 4

AUD includes both:
* Harmful (higher-risk) drinking — alcohol consumption causing health problems directly related to alcohol.
* Alcohol dependence — craving, tolerance, a preoccupation with alcohol, and continued drinking in spite of harmful consequences.

Question 5

What are the features of acute alcohol withdrawal?

Answer 5

• symptoms start at 6-12 hours: tremor, sweating, tachycardia, anxiety
• peak incidence of seizures at 36 hours
• peak incidence of delirium tremens is at 48-72 hours: coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia

Admit for medically assisted withdrawal (chlordiazepoxide)

Question 6

What are the features of Wernicke’s encephalopathy?

Answer 6

• Ataxia
• Opthalmoplegia, Nystagmus
• Acute confusion

admit to Treat with IV thiamine

Question 7

When should a person be referred for specialist (non-emergency) treatment for alcohol?

Answer 7

• Features of alcohol dependence, particularly if moderate or severe.
• Failed to benefit from structured brief advice and an extended brief intervention, and wishes to receive further help.
• Signs of severe alcohol-related impairment, or has a related comorbidity.

Question 8

What is the Primary care management for people misusing alcohol?

Answer 8

• a session of structured brief advice on alcohol consumption — e.g FRAMES (MI) principles
• extended brief intervention if not responded to structured brief advice (by specialist GP - MI).
• a psychological intervention for harmful drinkers and people with mild dependence. (CBT, Social network and environment-based therapies, behavioural couples therapy)
• prophylactic oral thiamine (B1) for harmful or dependent drinkers.
• Arranging a follow-up.
• If dependent on alcohol: must notify DVLA by law - will have to surrender license for a period. Doctor may have to inform DVLA if they continue to drive.
• Give info on: AA groups, websites.
• Shared care: acamprosate maintenance

Question 9

What are the contraindications for acamprosate?

Answer 9

• renal impairment if serum-creatinine is greater than 120 micromol/ L.
• Pregnant women (unless the benefit outweighs the potential risk).
• Women who are breastfeeding.

should be supervised monthly for 6 months. can stop after 6 months or continue if pt prefers.

Question 10

What is the CAGE questionnaire designed to screen for?

Answer 10

• detects alcohol dependence
• it is insensitive to harmful or hazardous drinking