Substance-related disorders

Question 1

What 3 or more features are required, over the course of at least 1 year, to be Dx with substance dependence?

Answer 1

1. Strong desire or compulsion to use substance
2. Difficulty in controlling substance-taking behaviour
3. Withdrawal state if substance not used
4. Evidence of tolerance
5. Neglect of alternative activities
6. Persistent use despite evidence that substance is harmful and having negative consequences

Question 2

What are the obstetric consequences of alcohol?

Answer 2

1) Foetal alcohol syndrome - increased risk of still-birth, growth retardation, developmental delay and facial abnormalities

Question 3

What are the psychiatric consequence of alcohol?

Answer 3

1) Othello syndrome - pathological jealousy that places partners at risk of harm

Question 4

What are the neurological consequences of alcohol?

Answer 4

1) Peripheral neuropathy
2) Seizures
3) Wernicke’s
4) Korsakoff’s
5) Dementia

Question 5

What are the endocrine consequences of alcohol?

Answer 5

1) Testicular atrophy

2) Amenorrhoea/sub-fertility

Question 6

What are the hepatobillary consequences of alcohol?

Answer 6

1) Cirrhosis
2) Fatty liver
3) Alcoholic hepatitis
4) Portal HTN
5) Carcinoma
6) Acute/chronic pancreatitis

Question 7

What are the GI consequences of alcohol?

Answer 7

1) GORD
2) Gastritis
3) Mallord-Weiss tear
4) Oesophageal varices

Question 8

What are the metabolic consequences of alcohol?

Answer 8

1) Hypoglycaemia
2) Hyperuricaemia
3) Osteoporosis

Question 9

What are the cardiovascular consequences of alcohol?

Answer 9

1) HTN
2) Cardiomyopathy
3) Arrhythmia

Question 10

What are the haematological consequences of alcohol?

Answer 10

1) B12 deficiency
2) Folate deficiency
3) Disordered clotted

Question 11

What causes Wernicke’s encephalopathy?

Answer 11

Thiamine (B1) deficiency

Question 12

How does Wernicke’s present?

Answer 12

Classic trial (but only seen in 10%) =

1) Acute confusional state
2) Ocular signs – nystagmus + opthalmoplegia (paralysis of muscles within or surrounding the eye, usually CNVI palsy)
3) Ataxic gait (unsteady/staggering)

Associated 4) peripheral neuropathy and 5) tachycardia

Question 13

How should Wernicke’s be treated?

Answer 13

IV B1 replacement – 2 ampoules over 30 mins, BD for 3-7 days

Question 14

How does Korsakoff’s differ from Wernicke’s?

Answer 14

Both due to B1 deficiency HOWEVER, where Wernicke’s is reversible if treated early, Korsakoff’s is not. Korsakoff’s is defined by an anterograde amnesia - i.e. an inability to lay down new memories. Unlike in Wernicke’s there is no evidence of an acute confusional state

Question 15

What is the CAGE alcohol-use tool?

Answer 15

C - have you ever thought about CUTTING DOWN your alcohol intake?
A - do you ever get ANNOYED when you have been criticised regarding your drinking?
G - do you ever feel GULITY about the amount you drink?
E - ‘EYE-OPENER’ - do you have a drink first-thing in a morning

Question 16

A reducing dose of what is used in alcohol detox?

Answer 16

BZD - chlordiazepoxide

Question 17

In whom might ‘controlled drinking’ be feasible?

Answer 17

<40y/o
Early detection
No psychiatric co-morbidity
Social stability 
Compliance

Question 18

In whom would abstinence be the only option?

Answer 18

>40y/o
Long duration
Dependance evident
Medical/psychiatric problems
Poor social support
Poor compliance

Question 19

What aversive drug might be prescribed for alcohol addiction?

Answer 19

Disulfiram - inhibits alcohol dehydrogenase, results in the accumulation of acetaldehyde on drinking alcohol = unpleasant S/Es and thus acts as a deterrent

Question 20

What anti-craving drugs might be prescribed for alcohol addiction?

Answer 20

Acamprosate - GABA receptor agonist

Naltrexone - opioid receptor antagonist

Question 21

What are the 4 alcohol withdrawal syndromes?

Answer 21

1. Uncomplicated alcohol withdrawal syndrome
2. Alcohol withdrawal syndrome with seizures
3. Alcoholic hallucinosis
4. DT

Question 22

When does uncomplicated alcohol withdrawal syndrome usually occur?

Answer 22

Between 4-12 hours after the last drink. Worst at 48 hours and resolves within 2-5 days

Question 23

Hoes should seizures in alcohol withdrawal syndrome with seizures be treated?

Answer 23

Magnesium sulfate or carbemazepine

Question 24

How is alcoholic hallucinosis distinguished from DT?

Answer 24

AUDITORY hallucinations that occur in CLEAR CONSCIOUSNESS. Visual hallucinations may also occur (as in DT)

Question 25

What type of hallucinations may be experienced by patients with DT?

Answer 25

Formication - ‘lilliputian’ hallucinations - tactile hallucinations of crawling insects/small animals (also seen in cocaine use)

Question 26

Whom is at increased risk of DT?

Answer 26

1. Pre-existing liver damage
2. Severe dependance
3. Co-morbid infection

Question 27

What are the differentials for DT?

Answer 27

1. Head injury
2. Pneumonia
3. Wernicke’s
4. Acute psychotic episode
5. Hepatic encephalopathy

Question 28

Which hallucinogenic is most likely to result in patients becoming violent?

Answer 28

PCP - withdrawal form intoxication can also cause sudden-onset homicidal violence

Question 29

What are the life-threatening complications associated with cocaine intoxication?

Answer 29

1. Coronary artery vasoconstriction ‘ ‘cocaine chest pain’ - which can cause an MI
2. Placental abruption

Question 30

What are some examples of opiates?

Answer 30

Heroin; methadone; codeine; morphine

Question 31

What are the signs of opiate OD?

Answer 31

1. Pinpoint pupils - un-reactive to light
2. Hypotension
3. Bradycardia
4. Severe drowsiness/unconsciousness
5. Respiratory arrest (with pulse)

Question 32

How is an opiate OD managed?

Answer 32

Naloxone - an opiate antagonist - IV

Question 33

What are the consequences of IVDU?

Answer 33

1. Infection - endocarditis; HIV; hepatitis; skin abscess/brain abscess
2. Arrythmia
3. Embolism risk
4. Sclerosis risk - which may lead to limb amputation

Question 34

How should a sedative OD be managed?

Answer 34

Flumazenil