Drug Use and Dependence ☺️

Question 1

How would you communicate to someone about their substance use and management

Answer 1

Feedback
-discuss risks and their thoughts
Responsibility
-explore whether they are ready to change
Advice
-reduce harm, give options on how to change
Menu
-give options, ask what they've tried
Empathy
-no judgement
Self efficacy
-project motivation that they can do this

Question 2

Presentation of alcohol withdrawal

• 6-12hrs
• 36hrs
• 48-72hrs

Answer 2

6-12hrs - tremor, sweating, high HR, anxiety

36hrs - seizures

48-72hrs - delirium tremens

• coarse tremor
• confusion
• delusions, auditory, visual hallucinations
• high HR
• fever

Question 3

Mechanism of

• chronic alcohol use
• withdrawal

Answer 3

Chronic alcohol consumption

• GABA agonist
• NMDA antagonist

Withdrawal

• decreased GABA input => less NA, D inhibition => ANS activation & hallucinations
• increased NMDA input => memory impairment

Question 4

Risk factors for DT

Answer 4

• Hx of DT, seizures
• past detoxes
• increased AST, GGT
• decreased Cl, Na, K, Mg

Question 5

Alcohol withdrawal management

• pharmacological
• community

Answer 5

1st line - long acting BZ
-chlordiazepoxide/diazepam
If in hepatic failure - lorazepam
-may need flumazenil to reverse resp depression

REDUCING DOSE PROTOCOL
-fixed dosing OR symptom dosing

Care plan in reducing related harm
Medical, psychosocial support
Support in community services

Question 6

Complications of alcohol withdrawal

Answer 6

DT
Sepsis - aspiration pneumonia
Wernicke’s encephalopathy
-confusion, eye instability, unsteadiness
Central pontine myelinolysis
-confusion, hyperreflexia, nausea, gait changes

Question 7

Wernicke’s encephalopathy
-presentation
-management
Relationship with Korsakoff syndrome

Answer 7

THIAMINE DEFICIENCY
Eye instability
Ataxia
Confusion
Pins and needles

PABRINEX
Prophylaxis - 1 pair/day x5
Treatment 
-2–3 pairs TDS x3-5 
-followed by 1 pair/day x3-5

IF UNTREATED => KORSAKOFF SYNDROME
-anteroretrograde amnesia and confabulation

Question 8

Describe the pathophysiology of GHB, GBL use

Minimising harm associated with G use

Answer 8

GHB is a GABA B and GHB receptor agonist
GHB is a GABA precursor

Premeasured dose/limit use
No stimulants
Time doses 
Write G on wrist
Watch out for G dribble and slouch
BBV, sex health clinic check

Question 9

G overdose signs

How would you treat this

Answer 9

N+V, LOC
Sweating
Irregular shallow breathing
Dribble, slouch

Management is mainly supportive

Question 10

G dependence signs
G withdrawal signs
Management of withdrawal

Answer 10

Use alcohol or BZ to manage withdrawal
Wake up at night/every few hours to use
Prioritization of G use

More acute onset, like alcohol withdrawal
-fewer seizures, increased DT

Management
-Baclofen and diazepam

Question 11

Presentation of opioid misuse

Complications

Answer 11

Triad

• CNS depression
• resp depression => T2RF
• pinpoint pupils

Complications

• infection from needle use
• dependence

Question 12

Management of opioid misuse

What are the signs of opioid toxicity
How would you manage this

Answer 12

IV, IM naloxone

Harm reduction
-HIV, HepB,C testing

Opioid detox

• methadone or buprenorphine
• compliance measured with urinalysis
• support from local addiction team