Substance Misuse

Question 1

What are the causes of substance abuse?

Answer 1

Individual factors(age, gender, family)
External factors (culture, price, availability, advertising)
Impulsivity; novelty seeking behaviours
Inherited vulnerability

Question 2

When should drug addiction be suspected?

Answer 2

Arrests for theft, to buy drugs
Odd transient behaviour e.g. visual hallucinations, elation, mania
Unexplained nasal discharge (cocaine sniffing, opiate withdrawal)
Withdrawal symptoms (red eyes, shaking)
Injection stigmata (marked veins, abscesses, hepatitis, HIV)
Repeated requests for analgesics - only opiates acceptable or sedatives

Question 3

What is the clinical presentation of substance misuse?

Answer 3

Acute intoxication (disturbance in level of consciousness, cognition, perception, affect, behaviour)
Harmful use (damage to mental/physical health/social functioning)
Dependence syndrome (substance taking takes priority over everything else)

Question 4

What is methadone maintenance?

Answer 4

Used as a gateway to abstinence from opiates. Methadone is free (eliminating need for crime to fund opiate use) and orally taken (no injection-related issues). Safer alternative to both the addict and society.

Question 5

What is daily observed methadone dosing?

Answer 5

Methadone initially prescribed in daily instalments and the consumption of it supervised for at least the first 3 months and until the patient has gained stability.

Question 6

What is dependence syndrome?

Answer 6

The strong, sometimes overpowering, desire to take a substance. Requires 3+ of the following:

• strong desire/sense of compulsion to take the substance (craving)
• difficulty in controlling substance use (onset, termination, level of use)
• physiological withdrawal state when reducing/ceasing the substance
• tolerance (increased doses to produce the original effect)
• progressive neglect of alternative pleasures or interests
• persisting use despite clear evidence of harmful consequences

Question 7

What is Wernicke’s encephalopathy?

Answer 7

Resulting from thiamine (vitamin B1) deficiency usually related to alcohol abuse.

Question 8

What are the classical triad of symptoms of Wernicke’s encephalopathy?

Answer 8

Confusion
Wide-based gait ataxia
Ophthalmoplegia (nystagmus, conjugate gaze and bilateral lateral rectus palsies)

Question 9

What are the other symptoms of Wernicke’s encephalopathy?

Answer 9

Clouding of consciousness
Memory disturbance
Peripheral neuropathy
Hypotension
Hypothermia
Ptosis

Question 10

What causes Wernicke’s encephalopathy?

Answer 10

Chronic alcohol consumption decreases nutritional thiamine intake
Also decreases absorption from GI tract and utilisation by cells
Other causes: brain tumour, malabsorption, prolonged vomiting, chemotherapy

Question 11

What is the treatment for Wernicke’s encephalopathy?

Answer 11

This is a medical emergency
High-dose IV/IM thiamine over 1 week
Then oral supplementation until no longer at risk

Question 12

What is the prognosis for Wernicke’s encephalopathy?

Answer 12

Failure to treat appropriately - results in death in 20%

85% remaining left with Korsakoff’s syndrome

Question 13

What is Korsakoff’s syndrome?

Answer 13

Hypothalamic damage and cerebral atrophy due to thiamine deficiency

Question 14

What are the symptoms/signs of Korsakoff’s syndrome?

Answer 14

Inability to acquire new memories
Confabulation
Lack of insight
Apathy

Question 15

What is the treatment for Korsakoff’s syndrome?

Answer 15

1/4 of cases are reversible
1/4 will require long-term institutional care
Even if successful, recovery is slow and often incomplete