Substance misuse

Question 1

slurred speech, ataxia, aggression, blackouts, hallucinations, memory impairment, impaired judgment, coma

Dx?

Answer 1

Alcohol intoxication

Question 2

Tremor, tachycardia, hypertension, malaise,
nausea, seizures, delirium tremens (DTs), agitation

Dx?

Answer 2

Alcohol withdrawal

Question 3

Treatments of alcohol?

Answer 3

((↓ Cravings)):
Naltrexone (μ-opioid receptor blocker).
Can start while patient is still drinking.

((Aversion منفّر)):
Disulfiram (acetaldehyde dehydrogenase inhibitor): Produces an unpleasant response (eg, flushing, nausea, vertigo, palpitations) when EtOH is consumed!!

((Withdrawal)):
■ Stabilize vital signs; correct electrolyte abnormalities.
■ Thiamine (administer before: glucose, to prevent Wernicke encephalopathy), glucose, and folic acid.
■ Start medium-length benzodiazepine taper (e.g. lorazepam, diazepam, chlordiazepoxide).
■ Add haloperidol for hallucinations and psychotic symptoms.

Question 4

Interactions with alcohol, amnesia, ataxia, somnolence, mild respiratory depression

Dx?

Answer 4

Benzodiazepines Intoxication

Avoid using for insomnia in the elderly; can cause paradoxical agitation even in relatively low doses

Question 5

Rebound anxiety, seizures, tremor, insomnia,
hypertension, tachycardia, death

Dx?

Answer 5

Benzodiazepine withdrawal

Question 6

Euphoria
Hypervigilance
Grandiosity
Paranoia

Tachycardia
Pupillary dilation

Dx?

Answer 6

cocaine/amphetamine intoxication

Question 7

Depression
Fatigue
Excess Sleep
Increased appetite
Unpleasant dreams (nightmares)

Dx?

Answer 7

Amphetamines/Cocaine Withdrawal

Question 8

Treatment of Amphetamines/Cocaine?

Answer 8

((Antipsychotics))

Benzodiazepines
Desipramine (tricyclic)

Bromocriptine
Amantadine

Amphetamine and cocaine addicts suffer from what schizophrenics suffer chronically; hyperactive dopamine. That’s why they are given as a treatment antipsychotics.

Question 9

Why do we give Bromocriptine and Amantadine for Amphetamines/Cocaine?

Answer 9

These are anti-parkinsonian agents
which increase dopamine.

These drugs are used for two reasons:

(a) To help people through withdrawal reactions.

(b) Low levels of Bromocriptine are prophylactic in helping people not
going back to drugs again.

Question 10

Restlessness
Insomnia

Excitement
Agitation

Diuresis
GI disturbances

Dx?

Answer 10

Caffeine Intoxication

Question 11

Headache
Fatigue

Drowsiness

Nausea
Repeated vomiting

usually it lasts 1-4 days

Dx?

Answer 11

Caffeine Withdrawal

Question 12

Impaired motor coordination
Anxiety

Slow reaction time
Impaired judgement
Conjunctival injection (red eyes)
Increased apetite

Dx?

Answer 12

Cannabis Intoxication

(Marijuana, hashish, THC, pot, reefer)

[Note that cannabis has no withdrawal effects, but they can affect respiratory system, associated with Amotivational syndrome!]

Question 13

What is the treatment of Cannabis intoxication?

Answer 13

1. Support

2. Foster Abstinence

Question 14

Pupillary constriction
Constipation

Drowsiness
Slurred speech

Respiratory depression
Bradycardia

Comma Death

Dx?

Answer 14

Opiates Intoxication

Heroin, morphine, codeine, oxycodone, percoset , meperidine, horse, smack, H, Junk, china, white, sag

Question 15

Pupillary dilation
Yawning
Flu like symptoms
Runny Nose
Fever

Muscle aches

Nausea and vomiting

Insomnia

Dx?

Answer 15

Opiate withdrawal

It lasts usually anything between 7 and 10 days

Question 16

What is treatment of opiate addiction?

Answer 16

Naloxine (90 min half life)
Naltrexone (24 half life)

Naloxone and naltrexone are opioid receptor antagonists and reverse the effects of opioids; may require redosing because of short half-life

Clonidine (palliative)

Methadone (also LAMM)
More addicting than heroin
Substitutes addiction (withdrawal 7 to 10 weeks)

Buprenorphine

• Opioid partial agonist
• Sufficient agonism to all stopping use of heroin or methadone
• Taken sublingually
• Half life 1-3 days
• Use in combination with naloxone

Question 17

Irritability

“Depressed Mood”
Depressed Heart Rate

Increased Appetite

Insomnia
Anxiety

Dx?

Answer 17

Nicotine Withdrawal

Question 18

Treatment of Nicotine addiction?

Answer 18

Extremely difficult to quit smoking.
1 trial success, less than 10%.

Usually multiple attempts to quit.

Aids: Nicotine Patch; nicotine gum; behavioural techniques.

Medications:

• Bupropion (Antidepressant)
• Verenicline (binds to Nic receptors)
• Bromocriptine (DA on the NAC)

Question 19

Nystagmus
Unsteady gait
Crushing around nose and mouth
Lack of coordination (due to cerebellar interference

Belligerence/slight confrontational
Impaired judgement
Lethargy

Dx?

Answer 19

Inhalants intoxication

Glue, paint thinner, shoe polish, turpentine, cleaners, market pens

They are not considered addictive and has no withdrawal effects

Treatment:
Counselling
Psychoeducation

Question 20

Hallucinations
Illusions
Lack of coordination (perceptual distort the world around you

Tremors

Anxiety
Ideas of Reference
Depersonalisation
Pupillary dilation

Synesthesias (perceptual confusions: hearing something that is seen; tasting something that is heard)

Dx?

Answer 20

Hallucinogens Intoxication

[LSD, mescaline, peyote, mushrooms]

Treatment:
Supportive Counselling “talking down”
Antipsychotics
Benzodiazepines