Alcohol + Opioid Abuse

Question 1

What is the recommended weekly alcohol limit?

Answer 1

14 units

Question 2

How many units in a bottle of wine?

Answer 2

9

Question 3

How many units in a 250ml glass of wine?

Answer 3

3

Question 4

How many units in a pint of 4% beer?

Answer 4

2.3

Question 5

How is drinking over 14 units per week classified?

Answer 5

Hazardous drinking
Harmful drinking
Alcohol dependence

Question 6

How is hazardous drinking defined?

Answer 6

> 14 but < 35 units per week for women

> 14 but < 50 units per week for men

Question 7

How is harmful drinking defined?

Answer 7

> 35 units for women

> 50 units for men

Question 8

How is alcohol dependence defined?

Answer 8

A strong desire to drink alcohol and difficulties controlling its use

Question 9

How is alcohol use disorder defined?

Answer 9

Maladaptive pattern of substance use leading to clinically significant impairment or distress
Features of tolerance + withdrawal

Question 10

Which screening tool can be used to assess alcohol harm?

Answer 10

Alcohol use disorders identification test (AUDIT)

- 10 questions

Question 11

How is the AUDIT score interpreted?

Answer 11

Score 0-7 –> lower risk drinking
Score 8-14 –> hazardous drinking
Score 15-19 –> harmful drinking
Score 20+ –> possible dependence

Question 12

What should be done for a lower risk drinking score?

Answer 12

Reinforce current drinking practices

Question 13

What should be done for a hazardous drinking score?

Answer 13

Deliver brief intervention

Question 14

What should be done for a harmful drinking score?

Answer 14

Deliver brief intervention
Deliver motivational enhancement therapy sessions
Consider prescribing options

Question 15

What should be done for a possible dependence score?

Answer 15

Comprehensive assessment

Question 16

What does the Brief Intervention involve?

Answer 16

FRAMES:

Feedback - review problems experienced because of alcohol
Responsibility - patient responsible for change
Advice - reduction of abstinence
Menu - options for changing behaviour
Empathy
Self-efficacy - encourage optimism about change

Question 17

Which psychosocial interventions may help prevent relapse?

Answer 17

CBT
Motivational enhancement therapy
12 Step Facilitation Therapy (AA)
Family and couple therapy

Question 18

What pharmacological treatment is available for alcohol detox?

Answer 18

Chlordiazepoxide

–> medical assisted detoxification

Question 19

What are the features of alcohol withdrawal syndrome?

Answer 19

Tremor, sweating, nausea, retching
Increased HR, BP + temp
Anxiety, agitation
Insomnia, nightmares
Hallucinations
Withdrawal seizures (0-48 hours)
Delirium tremens (48-72 hours)

Question 20

What are the features of delirium tremens?

Answer 20

Coarse tremor
Confusion
Delusions
Hallucinations

Question 21

Which features may occur in a complicated alcohol withdrawal?

Answer 21

Seizures
Hallucinosis
Delirium tremens
Wernicke-Korsakoff syndrome

Question 22

What pharmacological treatments are available for alcohol relapse prevention?

Answer 22

(to be started after successful withdrawal)

• Acamprosate
• Naltrexone
• Disulfiram

Question 23

How does disulfiram work?

Answer 23

Causes an unpleasant reaction when taken with alcohol –> psychological deterrent

Question 24

How is problem drug use defined?

Answer 24

Problematic use of opiates and/or illicit use of benzodiazepines
Routine and prolonged use

Question 25

What are the effects of heroin on the body?

Answer 25

Euphoria
Analgesia 
Respiratory depression
Constipation
Reduced conscious level
Hypotension + bradycardia
Pupillary constriction
Tolerance with repeated use

Question 26

What are the features of heroin withdrawal?

Answer 26

Typically within 6-8 hours
Dysphoria and cravings
Agitation
Tachycardia and hypertension
Piloerection
Diarrhoea, nausea + vomiting
Dilated pupils
Joint pains
Yawning
Rhinorrhoea + lacrimation

Question 27

What are the options for opioid replacement therapy?

Answer 27

Methadone
Buprenorphine
- can be given with naloxone (Suboxone)

Question 28

What is the pharmacological difference between methadone + buprenorphine?

Answer 28

Methadone - pure opioid agonist

Buprenorphine - partial opioid agonist (less potent) with a very high affinity for opioid receptors

Question 29

What are the advantages of buprenorphine compared to methadone?

Answer 29

Safer (less risk of overdose)
Less sedative (clear head)
More likely to block effect of using other drugs on top
Longer effect
Quicker titration
Easier to detox from
Less stigma

Question 30

What are the disadvantages of buprenorphine compared to methadone?

Answer 30

Not indicated for patients taking high doses of opioids
Can be misused
Risk of induced withdrawal
Is less sedative

Question 31

What is the starting dose for methadone?

Answer 31

10-30mgs

Question 32

What is the usually effective dose for methadone?

Answer 32

60-120mgs

Question 33

Which features would indicate the patient is on the right maintenance dose of opioid replacement?

Answer 33

Patient stops using and is not experiencing craving

Question 34

If a patient is on more than 100ml of methadone, what monitoring is required?

Answer 34

ECG - increased risk of QTc prolongation/arrhythmia

Question 35

How many days of methadone prescription can be missed before the pharmacist has to contact the prescriber? Why?

Answer 35

If medication not collected for 3 days

–> may lose tolerance and be at risk of overdosing