Substance Dependence

Question 1

Without inpatient medical support, alcohol withdrawal in severely dependent patients can lead to what symptoms can occur?

Answer 1

Seizures, delirium tremens, death.

Question 2

How can moderate alcohol dependence often be treated?

Answer 2

In a community setting.

Question 3

Which drugs are commonly used to reduce alcohol withdrawal symptoms?

Answer 3

Long-acting benzodiazepines. Carbamazepine (unlicensed) is sometimes used when benzodiazepines are contraindicated or not tolerated.

Question 4

Patients in alcohol withdrawal with clear agitation or hallucinations or at risk of delirium tremens may be treated with which drugs?

Answer 4

Antipsychotics such as haloperidol or olanzapine (unlicensed).

Question 5

Which drugs are the first line for the prevention of relapse in alcohol dependence?

Answer 5

Acamprosate and naltrexone.

Question 6

If acamprosate and naltrexone are contraindicated or not tolerated, what other drug can be used to prevent relapse in alcohol dependence?

Answer 6

Disulfiram.

Question 7

Nalmefene is licensed for the reduction of alcohol consumption in which patients?

Answer 7

Patients with alcohol dependence who have a high drinking risk.

Question 8

Which treatments are effective aids to smoking cessation?

Answer 8

NRT, bupropion, varenicline.

Question 9

Is nicotine replacement therapy with bupropion and varenicline recommended?

Answer 9

No.

Question 10

When smoking is stopped, what may need to happen to the patient’s other medication? Why?

Answer 10

The doses may need adjusting due to the reduced induction of CYP1A2 by nicotine.

Question 11

Patients on varenicline should be advised to discontinue treatment when which symptoms occur?

Answer 11

Agitation, depressed mood, suicidal thoughts.

Question 12

Which patients should be monitored closely when taking varenicline?

Answer 12

Patients with a history of psychiatric illness.

Question 13

How long after untreated heroin withdrawal do withdrawal symptoms show? After how long do they subside?

Answer 13

After 8 hours, subsiding after 5 days.

Question 14

How long after stopping methadone or buprenorphine treatment do withdrawal symptoms occur, in relation to those of heroin?

Answer 14

Withdrawal occurs later with longer lasting symptoms.

Question 15

Which drugs are used in opioid substitution therapy?

Answer 15

Methadone and buprenorphine.

Question 16

After how many days missed opioid substitution therapy dose are patients at greater risk of overdose? What should be done in these cases?

Answer 16

Three or more days due to reduced tolerance. Consider reducing next dose.

Question 17

Why is buprenorphine often preferred to methadone for opioid substitution therapy? Why is this?

Answer 17

It is less sedating due to it being a partial opioid-receptor agonist.

Question 18

When is methadone usually administered?

Answer 18

Once daily as a methadone 1mg/ml solution.

Question 19

Why should acute withdrawal of opioids be avoided in pregnancy?

Answer 19

It can cause foetal death.

Question 20

Should treatment of opioid replacement therapy be continued during pregnancy? Is buprenorphine licensed in pregnancy?

Answer 20

Yes and no.

Question 21

How should withdrawal of buprenorphine or methadone be handled during the second trimester of pregnancy?

Answer 21

Slowly and gradually.

Question 22

During the first trimester of pregnancy, there is an increased risk of what adverse effect during opioid withdrawal?

Answer 22

Spontaneous miscarriage.

Question 23

During the third trimester of pregnancy, there is an increased risk of what adverse effects during opioid withdrawal?

Answer 23

Foetal distress, stillbirth, increased risk of neonatal mortality. The neonate should be monitored for respiratory distress and signs of withdrawal.

Question 24

How should the dose of methadone be handled in breastfeeding mothers?

Answer 24

It should be kept as low as possible.

Question 25

How should neonates born to opioid dependent mothers be monitored?

Answer 25

Monitored for drowsiness, adequate weight gain and developmental milestones.

Question 26

How should adverse effects in babies to opioid dependent mothers who are breastfeeding be reported?

Answer 26

Urgently.

Question 27

Apart from opioid substitution therapy, what else is methadone licensed for? In what form and strength is this?

Answer 27

Analgesia in severe pain and cough in terminal illness. Methadone linctus 2mg/5ml.

Question 28

Patients with which risk factors for QT interval prolongation should be monitored whilst taking methadone?

Answer 28

Heart or liver disease, electrolyte abnormalities, concomitant treatment with drugs which can prolong the QT interval. Patients requiring 100mg daily should also be monitored.

Question 29

Why does methadone overdose require prolonged monitoring?

Answer 29

Due to the long-acting nature of the opioid.