Drug and alcohol problems

Question 1

Nicotine withdrawal symptoms

Answer 1

1. Irritability, frustration or anger
2. Anxiety
3. Difficulty concentrating
4. Increased appetite
5. Restlessness
6. Depressed mood
7. Insomnia

Question 2

ALCOHOL ABUSE TREATMENT: ‘Anti-craving’ drugs

Answer 2

The following show a modest effect on assisting abstinence:

*Acamprosate 666 mg (o) tds (if ≤60 kg)

*Naltrexone 50 mg (o) daily (under close supervision) consider a combination of the above 2 drugs

*Disulfiram can be helpful in highly motivated people but its use, as for the above agents, is recommended under specialist advice

Question 3

ALCOHOL ABUSE: Withdrawal symptoms

Answer 3

1. Agitation/anxiety
2. Prominent tremor
3. Sweating
4. Insomnia
5. Seizures (occasionally)
6. Delirium tremens (DTs)

Question 4

ALCOHOL ABUSE: Treatment for acute withdrawal symptoms

Answer 4

Prevents development of DTs

Maintain fluid, electrolytes and nutrition

Diazepam 20 mg (o) every 2 hours (up to 100 mg (o) daily, although 60 mg is usually adequate) titrated against clinical response (taper off after 2 days)

Thiamine 100 mg IM or IV daily for three days, then 300 mg (o) daily for several weeks

Psychotic features add haloperidol 1.5–5 mg (o) bd or 5 mg IM as single dose if necessary

Question 5

Tobacco smoking cesation: Nicotine replacement therapy (NRT)

Answer 5

Should be used in conjunction with an educational support program, has been proved to be effective and is available as chewing gum, inhaler, oral spray, lozenges, sublingual tablets or transdermal patches (the preferred method).

Ideally the nicotine should not be used longer than 3 months. Eight weeks of patch therapy is as effective as longer courses.

NRT should start at the quit date, not while still smoking.

Question 6

Tobacco smoking cesation: Oral Treatment

Answer 6

The RACGP Expert Advisory Group for Supporting Smoking Cessation strongly recommend the use of NRT, varenicline and bupropion with high certainty, and nortriptyline with moderate certainty.

Bupropion (Zyban)
*This oral agent has a similar effectiveness to NRT.
*Adverse effects include insomnia and dry mouth (both common), with serious effects, such as allergic reactions and increased seizure risk.
*It is contraindicated in persons with a history of epilepsy.
*Recommended dose: 150 mg daily for 3 days then bd for 12 weeks.

Varenicline tartrate (Champix)
*Commence with 0.5 mg daily with food for 3 days titrating slowing to 1 mg bd by day 7 until the end of the 12-week course
*It is an effective agent but there are several adverse side effects, especially nausea with a concern about neuropsychiatric effects.
*Avoid in end-stage kidney disease and take care with diabetics.

Nortriptyline
*Start with 25 mg (o), increasing gradually to 75 mg daily, starting 14 days before quit date then continue for 12 weeks

Question 7

ALCOHOL ABUSE: Laboratory investigations

Answer 7

*blood alcohol

*Abnormal liver function tests, serum GGT (typical): elevated in chronic drinkers (returns to normal with cessation of intake)

*MCV: >96 fL

*Carbohydrate-deficient transferrin (quite specific—dependent on an enzyme induced by alcohol)

*HDLs elevated

*LDLs lowered

*Serum uric acid elevated

Question 8

Delirium Tremens: Clinical features

Answer 8

May be precipitated by intercurrent infection or trauma

*1–5 days after Withdrawal (usually 3–4 days)

*Disorientation, agitation

*Clouding of consciousness

*Marked tremor

*Visual hallucinations (e.g. spiders, pink elephants)

*Sweating, tachycardia, pyrexia

*Signs of dehydration

Question 9

Delirium Tremens: Treatment

Answer 9

Same for acute withdrawal symptoms BUT:

Treat any systemic infection

Thiamine (vitamin B1) 300 mg IM or IV daily for 3–5 days, then thiamine 300 mg (o) daily

Haloperidol 0.5–2 mg (o) bd every 2 hours, titrated to clinical response (max. 10 mg/24 hours).

Diazepam and haloperidol may worsen the symptoms of hepatic toxicity.

Chlorpromazine is not recommended because of its potential to lower seizure threshold.

Question 10

Alcohol overdose

Answer 10

Overdose is potentially fatal.

The average lethal blood alcohol concentration is about 0.45–0.5%.

Death from a lower concentration may occur with other sedative drugs.

Alcohol withdrawal may begin at 0.1%.

Treatment of overdose is supportive and symptomatic.

No stimulants should be given.

Overdose may cause hypoglycaemia and metabolic acidosis.

Question 11

Opioid withdrawal

Answer 11

Develop within 12 hours.

Maximum withdrawal symptoms usually occur between 36 and 72 hours and tend to subside after 10 days.

Symptoms:

Anxiety and panic

Irritability

Chills and shivering

Excessive sweating

‘Gooseflesh’ (cold turkey)

Loss of appetite, nausea (possibly vomiting)

Lacrimation/rhinorrhoea

Tiredness/insomnia

Muscle aches and cramps

Abdominal colic

Diarrhoea

A secondary abstinence syndrome is identified at 2–3 months and includes: irritability, depression and insomnia.