MRCPsych Paper B - Addiction

Question 1

Average heroin use per in a day of a typical dependent user

Answer 1

0.25-2.0g/ day

Question 2

Preferred maintenance treatment for opioid use disorder

Answer 2

Buprenorphine

Question 3

3 main types of pharmacotherapy in opioid withdrawal symptom

Answer 3

1. Methadone at tapered doses
2. Buprenorphine
3. a2 adrenergic agonists - lofexidine, clonidine

Question 4

Tolerance to this symptom does not usually develop with long-term opiate use

Answer 4

constipation

Question 5

Intervention with the most consistent evidence base among all psychosocial interventions for cocaine users

Answer 5

Contingency management

Question 6

Most common side effects of benzodiazepines

Answer 6

drowsiness, ataxia, dizziness

Question 7

ICD-11 term that denotes a state in which alcohol has caused damage to a person’s physical and mental health, without meeting the criteria for dependence

Answer 7

Harmful pattern of use

Question 8

Most commonly used illicit opioid in Europe

Answer 8

heroin

Question 9

Acute harmful effects of LSD (2 answers)

Answer 9

Behavioral toxicity, bad trips

Question 10

NICE guidelines: first choice treatment for opioid dependence

Answer 10

Methadone → buprenorphine

Question 11

Most common cause of death in benzodiazepine overdose

Answer 11

respiratory depression

Question 12

LSD can be detected in the urine for up to how many days

Answer 12

4 days

Question 13

Initial treatment period for nicotine replacement therapy

Answer 13

8-12 weeks

Question 14

Kinaesthetic hallucinations are reported incases with

Answer 14

benzodiazepine withdrawal
*patients feel that their limbs are being twisted, pulled, or moved

Question 15

NICE recommendation: atypical antidepressant for smoking cessation

Answer 15

Bupropion
*seizure risk 1:1000

Question 16

Opioid injection practice that is associated with Candida enophthalmitis

Answer 16

using lemon juice to reconstitute

Question 17

Main side effect of varenicline

Answer 17

nausea

Question 18

Most effective smoking cessation pharmacotherapy in the general population

Answer 18

Varenicline

Question 19

Percentage of UK men aged 55-64 that drinks over 14 SD per week

Answer 19

38%

Question 20

Lifetime risk of suicide in those with alcohol dependence drinkers

Answer 20

10-15%

Question 21

Lifetime risk of suicide in those with alcohol problems

Answer 21

4%

Question 22

Cerebellar degeneration has been reported to occur in up to what percentage of alcoholics

Answer 22

33%

Question 23

Most common CNS complication in alcoholics with and without micronutrient deficiencies

Answer 23

Cerebellar degeneration
*damage is irreversible

Question 24

Reducing regime management for alcohol withdrawal: typical duration of chlordiazepoxide to be given

Answer 24

5-7 days
*Chlordiazepoxide 10-20mg QID, reducing gradually over 5-7 days

Question 25

Classic triad of delirium tremens

Answer 25

clouding of consciousness/ confusion vivid hallucinations marked tremors

Question 26

Onset of delirium tremens

Answer 26

72-96 hours after last drink

Question 27

Discrete episodes of anterograde amnesia that occur in association with alcohol intoxication

Answer 27

Alcoholic blackouts/ alcohol induced amnesia/ palimpsest

Question 28

Percentage of alcoholic patients that experience alcoholic hallucinosis with abstinence

Answer 28

5%

Question 29

Medication avoided for outpatient assisted withdrawal from alcohol due to the risk of respiratory depression

Answer 29

Chlormethiazole

Question 30

Edwards & Gross criteria for alcohol dependence

Answer 30

1. Narrowing of the drinking repertoire 2. Salience/ primacy of alcohol-seeking behaviour 3. Increased tolerance 4. Repeated withdrawal symptoms 5. Relief or avoidance of withdrawal symptoms by further drinking 6. Subjective awareness of compulsion to drink 7. Reinstatement after abstinence

Question 31

Mortality rate of delirium tremens

Answer 31

1-15%

Question 32

Alcohol detoxification protocol: patient with liver disease, COPD, and want to avoid over-sedation

Answer 32

Oxazepam *shorter-acting benzodiazepine

Question 33

Opioid receptor antagonist that is effective in blocking the high of alcohol

Answer 33

Naltrexone

Question 34

Common side effect reported by patients for disulfram

Answer 34

halitosis & headache

Question 35

Wernicke encephalopathy: gliosis and small haemorrhages in which brain region

Answer 35

Mamillary bodies *accounts for wakefulness, hypertonia, ocular palsies

Question 36

General finding in the MATCH trial

Answer 36

Matching patients to treatment options does not make a significant impact on outcome *Motivational therapy vs social behaviour and network therapy

Question 37

Alcohol withdrawal symptoms usually subside within how many days after cessation

Answer 37

3-7 days

Question 38

NICE guidelines: inpatient opioid detoxification with buprenorphine lasts for how many days

Answer 38

7-14 days

Question 39

NICE guidelines: inpatient opioid detoxification with methadone lasts for how many days

Answer 39

14-21 days

Question 40

NICE recommendations: most suitable screening tool in primary care settings in detecting hazardous and dependent drinking

Answer 40

Alcohol use disorders identification test (AUDIT)

Question 41

Alcohol withdrawal symptom timeline

Answer 41

Time from last drink: 3-12 hours - mild symptoms 12-18 hours - generalized seizures 24-48 hours - peak symptoms 3-4 days - delirium tremens can last up to 14 days

Question 42

Minimum interval from last drink when starting disulfram

Answer 42

24 hours

Question 43

Time to normalize on abstinence: blood alcohol levels/ breathalyzer

Answer 43

6 hours in blood, 12-24 hours in breath *useful in assessing recent drinking

Question 44

Time to normalize on abstinence: GGT

Answer 44

4 weeks *best used in follow-up

Question 45

Time to normalize on abstinence: MCV

Answer 45

3-6 mos *best used inf follow-up

Question 46

Time to normalize on abstinence: ALT/ AST

Answer 46

4 weeks

Question 47

Time to normalize on abstinence: carbohydrdate-deficient transferrin (CDT)

Answer 47

4 weeks

Question 48

Case: treatment for pregnant woman who is opioid dependent

Answer 48

Methadone

Question 49

Investigations: CBC findings in alcohol use disorder

Answer 49

anaemia, thrombocytopenia, neutropenia, raised MCV (macrocytosis)

Question 50

Opioid overdose triad

Answer 50

unconsciousness, low RR, pin-point pupils (miosis)

Question 51

Case: management of opioid-dependent women

Answer 51

stabilization on substitute methadone

Question 52

Case: which medication to give - pregnant woman + heavy user of heroin + plan on breastfeeding

Answer 52

methadone or buprenorphine

Question 53

Case: highly motivated opioid user who wants to remain abstinent and follow-up appointments + supportive partner

Answer 53

Naltrexone

Question 54

Case: heroin user + unsuccessful trial of methadone and buprenorphine (opioid substitution treatment). Next best treatment option?

Answer 54

injectable diamorphine

Question 55

Case: man being treated for heroin addiction + "running out of methadone" + demanding treatment. What is the best course of action?

Answer 55

Optimise the dose of methadone

Question 56

Case: physically dependent on dihydrocodeine for low back pain + wants to stop and go back to work. What is the best course of action?

Answer 56

Withdraw codeine gradually. *opioids are harmful in the treatment of low back pain. Dont prescribe opioids for long term treatments.

Question 57

Case: Patient keen on stopping heroin + anxious about withdrawal symptoms. Which is best suited to support detoxification?

Answer 57

Methadone *Buprenorphine is a partial agonist therefore a precipitated withdrawal may occur

Question 58

Percentage of schizophrenia that use nicotine

Answer 58

70-80%

Question 59

Case: adult man + unable to cut down due to withdrawal symptoms + low mood, anhedonia, fatigueability. What would be the most appropriate treatment option?

Answer 59

Alcohol detoxification

Question 60

Indications for alcohol detoxification

Answer 60

regular consumption of 15+ units/day AUDIT >20 history of significant withdrawal symptoms

Question 61

Case: 55yo man with opioid dependence + considering pharma maintenance treatment along with psychosocial interventions. What is the most appropriate medication would be?

Answer 61

NICE guidelines: maintenance therapy - methadone & buprenorphine

Question 62

Type of memory that is most affected in Korsakoff syndrome

Answer 62

Episodic memory

Question 63

Case: polysubstance user complaining of frequent urination and hematuria. What is the most likely offending drug?

Answer 63

Ketamine *UTI

Question 64

Signs of advanced opioid withdrawal state

Answer 64

Muscle spasms and twitching

Question 65

Investigation: sensitive marker of alcohol abuse

Answer 65

GGT

Question 66

Investigation: alcohol abuse test that accurately predicts RECENT alcohol use and can be useful in detecting relapse

Answer 66

Carbohydrate deficient transferrin (CDT)

Question 67

Investigation: alcohol abuse test that is more specific but less useful in detecting relapse

Answer 67

MCV *RBC's life span is 120 days. range is too big to assess for relapse

Question 68

Investigation: best alcohol use disorder screening tool in primary care

Answer 68

AUDIT

Question 69

Investigation: part of the routine assessment of patients in follow-up under a supervised detoxification programme

Answer 69

Breathalyser

Question 70

Investigation: most widely used screening tool for alcoholism but does not ask for frequency of alcohol use

Answer 70

CAGE

Question 71

Investigation: brief structured interview for alcohol use disorder for general practice use

Answer 71

AUDIT

Question 72

Investigation: tool for detecting dependent drinkers + focus on lifetime alcohol related problems

Answer 72

Michigan Alcohol Screening Test (MAST)

Question 73

Investigation: shorter version of AUDIT

Answer 73

Fast alcohol screening test (FAST)

Question 74

Case: adult alcoholic + abstinent + motivated

Answer 74

disulfram