Substance misuse

Question 1

State the formula for working out the amount of unit of alcohol in a drink

Answer 1

ABV x volume (in mls) / 1000

Question 2

Roughly state the definition of dependence syndrome from ICD-10

Answer 2

Cluster of physiological, behavioural, and cognitive phenomena, in which the use of a substance(s) has a much higher priority than other previously important values/behaviours

Question 3

State the diagnostic features of dependence syndrome from ICD-10

Answer 3

Diagnosis if 3 or more have been present during previous year:

• Strong desire to take the substance
• Withdrawal state if reduced/stopped
• Difficulties controlling substance-taking behaviour e.g. stopping
• Evidence of tolerance
• Neglect of alternative pleasures / interests because of psychoactive
  substance use
• Persisting despite being aware of harmful consequences

Question 4

State the name of the alcohol severity questionnaire and when should it be done

Answer 4

SADQ - severity of alcohol dependence questionnaire

Questionnaire should be done prior to detoxification treatment

Question 5

State the 2 drugs that should be used in the process of alcohol withdrawal

Answer 5

1. Chlordiazepoxide (benzodiazepine)
   Helps to reduce withdrawal symptoms
   Has low dependence-forming potential
2. Pabrinex (Thiamine B1 replacement) if risk of Wernicke’s is high

Question 6

State the recommended alcohol limits for men and women

Answer 6

Same for men and women now!

14 units per week - spread over 3 days or more

Question 7

State some symptoms of acute alcohol withdrawal

Answer 7

• Hand tremors
• Sweating
• Tachycardia
• N&V
• Headaches
• Loss of appetite
• Anxiety/depression
• Irritability
• Insomnia

Question 8

State some illicit drugs that can induce a schizophrenic presentation

Answer 8

• LSD
• Ecstasy
• Cocaine
• Alcohol
• Amphetamines

Question 9

List some physical symptoms of opioid withdrawal

Answer 9

Unpleasant but mostly not life threatening

Symptoms can start within 6 hours, peaking at 36-72 hours
- Agitation / anxiety
- Insomnia
- Muscle aches / cramps
- Sweating
- Nausea & vomiting
- Diarrhoea
- Tachycardia
- Hypertension
- Dilated pupils

Question 10

List some physical symptoms of opioid intoxication

Answer 10

• Drowsiness
• Confusion
• Decreased respiratory rate
• Decreased heart rate
• Constricted pupils
• Track marks / abscesses at injection sites

Question 11

Outline management steps for opioid withdrawal (acute on ongoing)

Answer 11

Acute:
- Methadone
- Lofexidine (alpha-2 receptors, reduced noradrenaline release)
- Antiemetics (nausea)
- Loperamide (diarrhea)

Ongoing:
- Detox programmes
- Methadone and buprenorphine
- Relapse can be prevented using Naltrexone once detox is complete

Question 12

Outline management steps for opioid overdose

Answer 12

Naloxone

Question 13

Outline symptoms of alcohol intoxication

Answer 13

• Ataxic gait
• Slurred speech (dysarthria)
• N&V
• Reduced consciousness
• Impaired judgement

Question 14

Outline symptoms of alcohol withdrawal

Answer 14

Potentially life-threatening!

• Anxiety / agitation
• Tremor
• Sweating
• Headache
• N&V
• Clouding of consciousness

Question 15

Outline how to manage acute alcohol intoxication

Answer 15

A-E approach
- Protection of airway if poor level of consciousness
- Cannula and fluids (also take alcohol blood levels)
- Antiemetics if vomiting

Question 16

Outline how to manage acute alcohol withdrawal as well as a long term plan

Answer 16

• Benzodiazepines e.g. Chlordiazepoxide (Librium) or Diazepam
• IV Pabrinex (B vitamins, C vitamins and glucose)

Longer term:
- Referral to Turning Point
- Continue long acting Benzodiazepine
- Continue on Thiamine

Question 17

Outline some specific (characteristic) symptoms of delirium tremens

Answer 17

Life threatening medical emergency
Usually occurs at day 3 of withdrawal (lasting 3 days)

• Classically tactile hallucinations (sensation of crawling)
• Delusions of paranoia
• Visual / auditory hallucinations
• Seizures

Question 18

Outline first line management for delirium tremens

Answer 18

1st line = Oral Lorazepam

(2nd line IV Lorazepam or Haloperidol)

Question 19

Outline the triad of symptoms for Wernicke encephalopathy (plus others)

Answer 19

• Ophthalmoplegia (lateral rectus most often)
• Ataxia
• Confusion

Others:
- Sweating
- Tremor
- Reduced conscious level
- Memory impairment

Question 20

Outline the main management step for Wernicke’s encephalopathy

Answer 20

IV Pabrinex (B vitamins complex)

Longer term:
- Long term oral thiamine supplements
- Alcohol abstinence

Question 21

Outline some causes of acute dystonia and medications that can be used to treat it

Answer 21

Causes:
- Anti-dopaminergic medications / dopamine receptor antagonists e.g. antipsychotics, antiemetics e.g. Metoclopramide

Medication:
- Benzodiazepines
- Anticholinergics

Question 22

List 3 features of Korsakoff psychosis

Answer 22

• Confabulation
• Anterograde amnesia
• Retrograde amnesia

Question 24

State how to manage Clozapine-induced agranulocytosis

Answer 24

• Stop Clozapine
• Start G-CSF (Filgrastim)