Substance misuse

Question 1

1) What does substance misuse describe?

2) What 4 categories can substance misuse be divided into?

Answer 1

1) a pattern of substance use causing physical, mental, social or occupational dysfunction.
2) Intoxication, harmful use, dependency and withdrawal

Question 2

1) What is intoxication?
2) What is harmful use?
3) What is dependency?
4) What is withdrawal?

Answer 2

1) A transient state of emotional and behavioural change following drug use. It is dose dependent and time limited.
2) A pattern of use likely to cause physical or psychological damage.
3) A cluster of physiological, behavioural and cognitive symptoms in which the use of a substance takes on a much higher priority than other behaviours that once had greater value.
4) A transient state occurring while re-adjusting to lower levels of the drug in the body.

Question 3

1) Who tend to be the heaviest alcohol drinkers?
2) Who has alcohol misuse increased in over the past decade?
3) Give the male: female ratios for alcohol disorders and for substance misuse disorders.
4) Substance misuse is highly co-morbid with what?

Answer 3

1) Young males (late teens to early twenties)
2) Women.
3) Alcohol disorders - 2:1, substance misuse disorders - 4:1.
4) Mental illnesses.

Question 4

Name the 4 main theories of dependence.

Answer 4

1) Learning theories: Classical and Operant.
2) Social learning theory (vicarious learning)
3) Neurobiological models.

Question 5

Describe the theory of classical conditioning.

Answer 5

Pavlov’s experiment showed that by presenting the natural stimulus for salivation (food) together with the sound of a bell, dogs are conditioned to salivate to the bell alone.

Essentially, in substance misuse, cravings become conditioned to cues, so the cue itself can trigger a craving.

This can cause drug-seeking behaviour.

Question 6

Describe the theory of operant conditioning.

Answer 6

Operant conditioning depends on repetitive behaviours having predictable outcomes.

Behaviours that are rewarded are repeated (positive reinforcement).

Behaviours are also repeated if they relieve unpleasant experiences (negative reinforcement).

Question 7

1) What does operant conditioning depend on?

Answer 7

1) It depends on repetitive behaviours having predictable outcomes.

Question 8

Name 8 features of dependency.

Answer 8

1) Tolerance
2) Compulsion
3) Withdrawal
4) Problems controlling use
5) Continued use despite harm
6) Salience (primacy)
7) Reinstatement after abstinence
8) Narrowing of the repertoire

Question 9

1) What is tolerance?
2) What is compulsion?
3) Describe withdrawal.
4) What is salience?

Answer 9

1) When larger doses are required to gain the same effect as previously.
2) A strong desire to use the substance.
3) Physiological withdrawal state when the substance is stopped/ decreased (withdrawal syndrome/ substance use to prevent or relieve withdrawal symptoms).
4) When obtaining and using the substance becomes so important that other interests are neglected.

Question 10

1) What is social learning theory?

2) All drugs of abuse affect what pathway in the brain?

Answer 10

1) Learning through copying the behaviours of others; substance misuse can result from peer pressure.
2) The ‘dopaminergic’ pathway.

Question 11

1) Where does the dopaminergic pathway start?
2) Where does the dopaminergic pathway project onto?
3) Which area of the brain has a role in motivation and planning?
4) What is central to the sensation of pleasure?

Answer 11

1) The ventral tegmental area.
2) The prefrontal cortex and the limbic system (the ‘emotional’ brain).
3) The prefrontal cortex.
4) Dopamine release in the nucleus accumbent is central to the sensation of pleasure.

Question 12

1) How do cocaine and amphetamine cause a pleasurable sensation?
2) Which neurotransmitterd do alcohol and opiates increase?

Answer 12

1) They block dopamine reuptake, increasing synaptic dopamine levels.
2) They increase dopamine and affect other neurotransmitters as well.

Question 13

List 4 aetiologies for alcohol misuse.

Answer 13

1) Genetics
2) Occupation
3) Social background
4) Psychiatric illness

Question 14

1) What percentage of the predisposition to alcohol dependence is inherited?
2) What do adoption studies show about the risk of alcohol dependence?
3) How is ethanol metabolised?
4) What causes the ‘flush reaction’?
5) Give 3 symptoms of the ‘flush reaction’.

Answer 14

1) 25-50% of the predisposition to alcohol dependence is inherited.
2) Adopted-out sons of alcohol dependent fathers have a 4 fold risk of alcohol dependence.
3) It is metabolised to acetaldehyde which is then broken down by aldehyde dehydrogenase.
4) In certain populations (for example, East Asian) a less effective version of the aldehyde dehydrogenase enzyme. Therefore, acetaldehyde accumulates causing ‘the flush reaction’.
5) Flushing, palpitations and nausea.

Question 15

1) What happens with the aldehyde dehydrogenase enzyme in East Asian populations?
2) Which occupations is alcohol misuse associated with?
3) What 2 factors combine to increase the risk of alcohol misuse with regards to occupation?
4) There is often a history of what in patients misusing alcohol?
5) What 4 psychiatric illnesses are associated with substance misuse?

Answer 15

1) A less effective variation of the enzyme occurs.
2) Publicans, journalists, doctors, the armed forces and the entertainment industry.
3) Stressful work and sanctioned drinking combine to increase the risk of alcohol misuse.
4) A difficult childhood with parental separation. There is often poor educational achievement and there may be evidence of juvenile delinquency.
5) Personality disorders, mania, depression and anxiety disorders (particularly social phobia).

Question 16

1) What are the 2 clinical presentations alcohol misuse?
2) What does alcohol intoxication cause initially?
3) At higher levels, what might alcohol intoxication cause?
4) What can make people take risks and behave irresponsibly when intoxicated?
5) Give 5 clinical signs of alcohol intoxication.

Answer 16

1) Intoxication and withdrawal.
2) Relaxation and euphoria.
3) People may become irritable, aggressive, weepy, morose and disinhibited.
4) Impulsivity and poor judgement.
5) Slurred speech, ataxic gait, increasing sedation, confusion and coma.

Question 17

1) Give 6 typical symptoms of alcohol withdrawal.
2) Give 4 other signs/ symptoms of alcohol withdrawal.
3) How does alcohol act upon brain excitability?
4) What causes seizures to occur during withdrawal in people who are dependent drinkers?
5) In severe cases of alcohol withdrawal, what can occur?

Answer 17

1) Headache, nausea, retching, vomiting, tremor and sweating are all typical.
2) Insomnia, anxiety, agitation, tachycardia and hypotension.
3) Alcohol is a CNS depressant, stimulating the GABA inhibitory system to reduce brain excitability.
4) When dependent drinkers suddenly stop drinking, neural pathways become hyper-excitable and seizures can occur.
5) Delirium Tremens.

Question 18

1) What is the normal onset for delirium tremens during alcohol withdrawal?
2) How long can delirium tremens last?
3) What is the mortality rate of delirium tremens?
4) What does urgent management of delirium tremens consist of?

Answer 18

1) About 48 hours into abstinence.
2) 3-4 days.
3) 5% but rises to 30% if complications occur (e.g. sepsis)
4) Involves a reducing benzodiazepine regime and parenteral thiamine. Should also manage potentially fatal dehydration and electrolyte abnormalities.

Question 19

List 6 signs/ symptoms delirium tremens.

Answer 19

1) Confusion
2) Hallucinations (especially visual - animals and people)
3) Affective changes (extreme fear and hilarity may alternate)
4) Gross tremor, especially of hands
5) Autonomic disturbance: sweating, tachycardia, hypertension, dilated pupils and fever.
6) Delusions.

Question 20

List 7 categories of physical complications of alcohol dependency.

Answer 20

1) Liver
2) GI: pancreatitis, oesophageal varices, gastritis and peptic ulceration.
3) Neurological: peripheral neuropathy, seizures and dementia.
4) Cancers: Bowel, breast, oesophageal and liver.
5) Cardiovascular: HTN snd cardiomyopathy.
6) Head injuries/ accidents: while intoxicated, there is an increased risk of subdural haematoma.
7) Foetal alcohol syndrome

Question 21

Give 5 psychological complications of alcohol dependency.

Answer 21

1) Depression/ anxiety/ self-harm/ suicide are increased.
2) Amnesia (blackouts) due to intoxication.
3) Cognitive impairment may occur (alcoholic dementia or Korsakoff’s syndrome)
4) Alcoholic hallucinosis
5) Morbid jealousy: the overvalued idea or delusion that a partner is unfaithful.

Question 22

1) Give 3 symptoms of alcoholic hepatitis.
2) In what percentage of alcohol dependent people does liver cirrhosis occur?
3) Give 2 main complications of liver cirrhosis.
4) What is alcoholic hallucinosis?

Answer 22

1) Malaise, hepatomegaly and ascites.
2) 10-20%
3) Ascites and hepatic encephalopathy
4) The experience of auditory hallucinations in clear consciousness while drinking alcohol.

Question 23

1) In alcoholic hallucinosis, what is the usual content of hallucinations?
3) What 3 factors are associated with morbid jealousy.

Answer 23

1) Hallucinations often have persecutory pr derogatory content.
2) Alcohol dependency, impotence and violence.

Question 24

1) What causes Wernicke’s encephalopathy?
2) Describe the clinical presentation of Wernicke’s encephalopathy.
3) What may Wernicke’s encephalopathy progress to if left untreated?
4) How do you treat Wernicke’s encephalopathy?

Answer 24

1) Acute thiamine (B1) deficiency.
2) Presents classically with the triad of confusion, ataxia and opthalmoplegia.
3) Korsakoff’s syndrome
4) Treat urgently with parenteral thiamine.

Question 25

1) What does Korsakoff’s syndrome consist of?
2) What may patients do to fill in their memory in Korsakoff’s syndrome?
3) Give 5 social consequences of alcohol dependency.
4) What 3 things are children at an increased risk of with parents who are alcohol dependent.

Answer 25

1) Irreversible anterograde amnesia (and some retrograde amnesia)
2) Confabulate.
3) Unemployment, poor attendance and performance at work, domestic violence, separation and divorce.
4) Neglect, abuse and conduct disorder.

Question 26

1) When is substance misuse more likely than another psychiatric illness?
2) Give the 2 categories of differential diagnoses for substance misuse.
3) In a severely intoxicated patient, which organic differential diagnoses do you need to be particularly aware of?
4) What is the classification is somebody has a severe substance misuse problems and a severe mental illness?

Answer 26

1) A substance misuse disorder is more likely if there is a clear temporal relationship between substance misuse and presentation.
2) Organic causes and psychiatric illness.
3) Head injuries and subdural haematoma from falls.
4) This is called a dual diagnosis.

Question 27

What 4 psychiatric conditions should you consider as differentials for a patient with suspected substance misuse.

Answer 27

1) Depression/ mania.
2) Functional psychosis
3) Anxiety disorder
4) Personality disorder

Question 28

State 3 investigations you might conduct for a patient with suspected substance misuse.

Answer 28

1) FBC
2) LFTs
3) Additional investigations (ECG for chest pain, UDS if you suspect drug misuse, hepatitis screening if IV drug use).

Question 29

1) What type of anaemia does alcohol misuse cause and why?
2) Which LFT shows increased levels with recent heavy alcohol use?
3) Name a screening tool that can be used to assess and identify potential alcohol misuse?
4) What might raised transaminases suggest?

Answer 29

1) Macrocytic anaemia (raised MCV) due to B12 deficiency.
2) Gamma-GT rises with recent heavy alcohol use.
3) The AUDIT (developed by the WHO)
4) They suggest hepatocellular damage.

Question 30

What are the 4 main stages in management of alcohol dependency?

Answer 30

1) Assessment and preparation
2) Detoxification
3) Relapse prevention
4) Rehabilitation

Question 31

1) What 2 characteristics need to be assessed in alcohol dependent patients as they are important in stopping drinking?
2) What model describes the movement from ambivalence about alcohol dependency to abstinence?

3)

Answer 31

1) Readiness and motivation to change are assessed as they are important factors in stopping drinking.
2) The stages of change model.

Question 32

Name the 6 stages in the ‘stages of change model’.

Answer 32

1) Pre-contemplation
2) Contemplation
3) Preparation
4) Action
5) Maintenance
6) Relapse

Question 33

1) What is pre-contemplation?
2) Describe the contemplation stage in the stages of change model.
3) What is preparation?

Answer 33

1) The patient doesn’t see a problem or what to change. They may be in denial or unaware of the risks.
2) The patient recognises the problem but doesn’t want to change yet. They may become ‘stuck’ at this stage due to ambivalence, but this is a good time to work with them because openness to discussing the pros and cons of change.
3) The person is willing to change and is planning to do this soon.

Question 34

1) What is action in the stages of change model?
2) Describe what maintenance means in the stages of change model.
3) Describe what relapse means in the stages of change model.

Answer 34

1) When change becomes a reality; the person is actively cutting down or has stopped drinking.
2) The person is able to remain abstinent (or keep to their agreed low level of use). It is often the hardest part as lifelong abstinence is difficult.
3) Relapse is a common problem and is part of the overall learning process rather than a sign of failure. Understanding the triggers for relapse aids the next attempt at abstinence.

Question 35

What 3 other things can the stages of change model help to identify?

Answer 35

It can help by identifying the kind of support needed, setting realistic goals and meeting the expectations of both therapist and patient.

Question 36

1) What is the form of counselling that can be especially useful for patients who are ambivalent about their alcohol dependency?
2) What does detoxification allow?
3) What are the 2 types of detoxification?

Answer 36

1) Motivational interviewing.
2) Metabolism and excretion of the substance whilst minimising discomfort.
3) Planned and unplanned.

Question 37

1) How does motivational interviewing work?
2) What is motivational interviewing based upon?
3) What is meant by ‘planned’ detoxification?
4) What is meant by ‘unplanned’ detoxification?

Answer 37

1) By helping the individual to recognise the gap between where they are now and where they want to be.
2) It is based upon a supportive but challenging therapeutic relationship.
3) Detoxification following a period of preparation.
4) Detoxification in an emergency situation where the process starts unexpectedly (e.g. after emergency admission to hospital).

Question 38

1) Name 2 drugs which might be required during the detox process of a patient with alcohol dependency.
2) When might community detoxification be used?
3) What does community detoxification consist of?

Answer 38

1) Long acting benzodiazepines (chlordiazepoxide) and thiamine (B1).
2) In uncomplicated dependency.
3) Using a fixed dose-reducing regime of benzodiazepines over 5-7 days.

Question 39

1) Why might benzodiazepines be required during the detox process of a patient with alcohol dependency?
2) Thiamine is prescribed as prophylaxis against what during detoxification of a patient with alcohol dependency?
3) Why is thiamine best given parenterally?

Answer 39

1) To replace the alcohol and prevent withdrawal symptoms, including seizures and delirium tremens. They are gradually withdrawn and stopped.
2) Wernicke’s encephalopathy.
3) Because it is poorly absorbed in the gut.

Question 40

Give 3 reasons as to why inpatient detoxification might be needed.

Answer 40

1) Hx of withdrawal fits.
2) Co-morbid medical or psychiatric illness.
3) If the patient lacks someone at home to support and observe them.

Question 41

What does a symptoms led assessment allow for during the alcohol detoxification process?

Answer 41

Allows medication to be given according to observed withdrawal symptoms. After 24 hours the total dosage given is calculated, guiding the reducing regime prescribed.

Question 42

1) Name the 2 classifications of relapse prevention during alcohol dependency.
2) Which 3 psychological therapies can be used for alcohol relapse prevention?

Answer 42

1) Psychological and medical.

2) CBT, problem solving therapies and group therapy.

Question 43

1) What do CBT and problem solving therapies identify?
2) What does group therapy allow for during relapse prevention?
3) What is acamprosate and where does it act?
4) What does disulfiram do?

Answer 43

1) Causes of use, so that ways can be found to prevent relapse.
2) Allows experiences and solutions to be shared.
3) An anti-craving drug, thought to act in the midbrain.
4) Mimics the ‘flush’ reaction to alcohol, making drinking an unpleasant experience.

Question 44

1) What is the overall aim of rehabilitation in a patient who suffered from alcohol dependency?
2) What 3 things can organisations such as alcoholics anonymous provide?

Answer 44

1) To initiate a complete restructuring of the person’s life.
2) Can provide essential additional counselling, support and health information.

Question 45

Give 3 factors that are involved in rehabilitation of patients who suffered with alcohol dependency.

Answer 45

1) Relapse prevention.
2) Skills-based groups.
3) Help to access training courses/ find employment.

Question 46

1) The aetiology of drug misuse shares many of the social risk factors of what?
2) Describe the genetic element of drug aetiology.
3) How long after use can a urine drug screen detect the presence of amphetamine/ heroin?

Answer 46

1) Alcohol misuse.
2) It is possibly mediated through risk-taking or self medication of anxious personality traits.
3) 2 days.

Question 47

How long after use can a urine drug screen detect:

1) Cocaine
2) Methadone
3) Cannabis

Answer 47

1) 5-7 days.
2) 7 days.
3) Up to 1 month.

Question 48

1) What is the most notorious opiate?
2) Name 4 other opiate drugs.
3) Briefly describe the mechanism of action of Heroin.

Answer 48

1) Heroin.
2) Morphine, pethidine, codeine, dihydrocodeine.
3) Heroin is a mu opiate agonist, stimulating brain and spinal cord receptors that are normally acted upon by endogenous endorphins.

Question 49

1) How is Heroin initially used?
2) How is Heroin used when a person’s tolerance begins to build?
3) How might IV drug use cause a DVT?

Answer 49

1) It is initially smoked.
2) People often progress to IV injection as tolerance builds.
3) Repeated injection into femoral veins damages the valves, slowing venous return and facilitating blood clotting in the legs.

Question 50

1) If venous access is difficult for Heroin users, what other administration method may be used?
2) Name the 2 classifications of clinical presentation of a person using Opiates.

Answer 50

1) Subcutaneous injection or intramuscular injection. Pure heroin can be snorted, dihydrocodeine and codeine tablets can be swallowed.
2) Intoxication and withdrawal.

Question 51

Name 4 local complications of IV drug use.

Answer 51

1) Abscess formation: injected particles form a nidus of infection under the skin.
2) Cellulitis
3) DVT
4) Emboli: these may cause gangrene, requiring amputation.

Question 52

Name 4 systemic complications of IV drug use.

Answer 52

1) Septicaemia: either from direct injection of bacteria or spread from abscesses or cellulitis.
2) Infective endocarditis: injected organisms settle on the mitral valve.
3) Blood-borne infections: Hep B and C, HIV and syphilis can be injected.
4) Increased risk of overdose: there is less dose-titration than in smoking.

Question 53

1) Describe what IV heroin use produces.
2) Give 2 signs of IV heroin use.
3) Name 2 ways that patients can die from using IV heroin.
4) Name the ‘classic’ sign of opiate intoxication.
5) Give 3 side effects of non-IV use of Heroin.

Answer 53

1) An intense rush or buzz, with feelings of euphoria, warmth and well-being. Sedation and analgesia follow. Some people may vomit or feel dizzy (especially if the first time).
2) Bradycardia and respiratory depression.
3) Respiratory failure or aspiration of vomit during overdose.
4) Pintpoint pupils.
5) Milder effects: constipation, anorexia and decreased libido.

Question 54

1) What is the antidote for opiate overdose?
2) How long after IV Heroin use does withdrawal typically begin?
3) When does withdrawal following IV Heroin use peak?
4) Give 4 things that occur during opiate withdrawal.

Answer 54

1) Naloxone.
2) Around 6 hours after injection.
3) 36-48 hours after injection.
4) Dysphoria, nausea, insomnia and agitation.

Question 55

What occurs as effects on opiate receptors are reversed?

Answer 55

As effects on opiate receptors are reversed , everything ‘runs’:

• Diarrhoea
• Vomiting
• Lacrimation
• Rhinorrhoea

The person feels feverish with abdominal cramps and aching joints and muscles.

Piloerection causes goose flesh, patients yawn irresistibly and their pupils dilate.

Question 56

Name 2 methods of management of opiate misuse which are different to principles in management of alcohol dependency.

Answer 56

1) Harm reduction

2) Substitute prescribing

Question 57

1) What is harm reduction?
2) What is essential in the process of harm reduction?
3) How can intravenous opiate use be made safer?
4) Name 3 other methods that can be used for harm reduction in injecting drug users and sex-workers.

Answer 57

1) A pragmatic approach to drug use, assessing and minimising risk, rather than insisting on abstinence.
2) Information and advice on improving the safety of drug use are essential.
3) By providing sterile needles via needle exchanges.
4) Vaccination and testing for blood-borne viruses, free condoms and accessible sexual health services.

Question 58

1) What is substitute prescribing?
2) Name 2 oral preparations that can be used to replace injectable opiates.
3) Describe the regime in which these drugs are prescribed.
4) What class of drug is Methadone?
5) What class of drug is buprenorphine and how does it work?

Answer 58

1) The deliberate prescribing of drugs in a controlled manner to reduce the use of illicit drugs or the harm associated with them.
2) Methadone (liquid) and Buprenorphine (sublingual tablet).
3) Initially taken in a supervised environment and doses are gradually titrated until the patient does not experience withdrawal symptoms.
4) Methadone is a full agonist at opiate receptors with a longer half life than heroin (so withdrawal is longer but milder).
5) Buprenorphine is a partial agonist at mu receptors, blocking the euphoric effects of heroin whilst preventing withdrawal symptoms.

Question 59

1) How is a patient weaned off of Methadone/ Buprenorphine?
2) Name 3 drugs which are adjunctive in the opiate detoxification process.
3) What might be necessary in a person who thrives on a substitute prescribing regime by deteriorate when detoxification is commended?

Answer 59

1) Slowly weaned off methadone or buprenorphine over weeks or months.
2) Anti-diarrhoeals (loperamide), anti-emetics (metoclopramide) and non-opiate pain killers.
3) Long-term methadone maintenance can reduce harm by helping the patient to gain stability (e.g. maintain employment).

Question 60

1) What is Naltrexone?

2) When does Naltrexone tend to be used?

Answer 60

1) An opiate antagonist that blocks opiate receptors and thus the euphoric effects of opiates.
2) Naltrexone can be given to people who have completed an opiate detoxification as a relapse prevention agent.

Question 61

1) How is cannabis usually taken?
2) What do the effects of cannabis depend on?
3) What is caused by perceptual distortion that occurs when cannabis is taken?
4) What do people often seek when they have taken cannabis?
5) What commonly occurs when cannabis is taken with alcohol?

Answer 61

1) It is usually smoked with tobacco as spliffs or joints or as a bong.
2) Expectation and the original mood state which tends to be enhanced by the drug.
3) Time slows down and aesthetic appreciation is enhanced.
4) Sweet foods due to the ‘munchies’ (hunger pangs).
5) Nausea and vomiting (greening).

Question 62

1) Give 3 signs of cannabis use.
2) What is early heavy use of cannabis particularly likely to precipitate?
3) Give 2 features of chronic heavy cannabis use.
4) What is the psychoactive agent in cannabis?

Answer 62

1) Injected conjunctivae (bloodshot eyes), tachycardia and dry mouth can occur.
2) It is particularly likely to precipitate psychosis, potentially leading to schizophrenia in vulnerable people.
3) Lethargy and poor motivation are recognised features of chronic heavy use.
4) delta-9-tetrahydrocannabinol.

Question 63

1) What type of course do drug and alcohol disorders tend to follow?
2) Give 3 poor prognostic factors for achieving abstinence.
3) Describe the prognostic pattern for total abstinence in comparison to controlled drinking.
4) What 2 factors need to be taken into account when risk assessing a patient with drug or alcohol dependency?

Answer 63

1) Drug and alcohol disorders tend to follow a relapsing and remitting course.
2) IV drug use, chaotic use and poly drug use are poor prognostic factors.
3) Abstinence from alcohol is associated with a better outcome than ‘controlled drinking’ (drinking within healthy limits) which is very difficult to sustain once dependency has developed.
4) Loss of judgement and increased impulsivity can increase the risk of these patients to themselves and to others.