Clinical Topic 7: Substance Misuse

Question 1

What is the triad of Wernicke’s syndrome? What is it caused by?

Answer 1

Confusion
Ataxia
Opthalmoplegia

Caused by thiamine (Vitamin B1) deficiency

Question 2

What is the CAGE questionnaire used for? What do the questions comprise of? What score should be looked out for?

Answer 2

Used to assess alcohol misuse

• Have you ever thought to Cut down?
• Have you ever felt Annoyed at people’s ideas you should quit?
• Do you feel Guilty about your alcohol intake?
• Do you drink alcohol as an Eye-opener?

Score 2 of 4 -> possible alcohol misuse

Question 3

What is the AUDIT questionnaire used for? What score should be looked out for?

Answer 3

Used to assess alcohol misuse

20/40 -> consider detox

Question 4

For patients with acute alcohol withdrawal, what is first line and second line medication?

Answer 4

• First line: Chlordiazepoxide

- Second line: Carbamazepine

Question 5

What is the mechanism of action for Disulfaram (Antabuse)?

Answer 5

Inhibits ALDH (Acetylaldehyde Dehydrogenase) resulting in accumulation of acetaldehyde, which leads to hangover like symptoms

Question 6

What is the mechanism of action of Chlordiazepoxide?

Answer 6

Benzodiazepine, potentiates GABA

Question 7

What is the treatment for Wernicke’s encephalopathy?

Answer 7

Mg and Thiamine supplements; oral or IV (Pabrinex)

Question 8

In the management of patients with Alcohol Dependence, why is it not recommended to stop alcohol suddenly?

Answer 8

Risk of delirium tremens - fatal in 20% of cases

Question 9

How is Delirium tremens treated? What if they have liver failure?

Answer 9

Benzodiazepines i.e. Chlordiazepoxide

If they have liver failure -> Lorazepam

Question 10

What is CIWA-Ar used for?

Answer 10

Clinical Institute Withdrawal Assessment for Alcohol. Used to guide management of alcohol withdrawal treatment

Question 11

If untreated, what can Wernicke’s lead to? What are the symptoms?

Answer 11

Korsakoff’s syndrome, with symptoms of memory loss and confabulation

Question 12

What medications can be used to MAINTAIN alcohol abstinence? What are their MoAs?

Answer 12

Disulfiram - Aldehyde dehydrogenase inhibitor
Acamprosate - GABA modulator
Naltrexone - Opiod receptor antagonist

Question 13

Seizures in alcohol withdrawal may be shown from what point after not drinking?

Answer 13

36 hours

Question 14

Delirium tremens in alcohol withdrawal may be shown from what point after not drinking?

Answer 14

48-72 hours

Question 15

What four tests could be performed to support / refute a diagnosis of Alcohol Dependence?

Answer 15

• GGT levels (elevated)
• MCV (elevated)
• Alcohol Blood Content (elevated)
• CT scan in patients with alcohol associated falls

Question 16

What illicit substances cause Miosis (constriction) of the eyes?

Answer 16

Opiates i.e. herion

Question 17

What illicit substances cause Mydriasis (dilatation) of the eyes?

Answer 17

Cocaine, Methamphetamines, Amphetamines, LSD

Question 18

What illicit substance causes bladder dysfunction?

Answer 18

Ketamine

Question 19

How do you treat Paracetamol overdose?

Answer 19

Activated charcoal (if < 1 hour)
N-acetylcysteine

Question 20

How do you treat Opiate overdose?

Answer 20

Naloxone

Question 21

How do you treat Benzodiazepine overdose?

Answer 21

Flumazenil

Question 22

How do you treat Tricyclic antidepressant overdose?

Answer 22

IV bicarbonate

Question 23

A heroin user is referred to the local drugs unit for community based detoxification. Which heroin substitutes is he most likely to be offered?

Answer 23

Methadone

Buprenorphine