Substance dependence

Question 1

What serious consequences can occur if alcohol-dependent individuals reduce their intake too abruptly?

Answer 1

Abrupt reduction can lead to alcohol withdrawal syndrome, seizures, delirium tremens, and potentially death.

Question 2

Do patients with mild alcohol dependence usually require assisted alcohol withdrawal?

Answer 2

No, they usually do not require assisted withdrawal.

Question 3

What is the recommended treatment for moderate and severe alcohol dependence?

Answer 3

Moderate - Patients can usually be treated in the community unless they are at high risk of alcohol withdrawal seizures or delirium tremens.

Severe - They should undergo withdrawal in an inpatient setting.

Question 4

Which medications are typically used to manage alcohol withdrawal?

Answer 4

Long-acting benzodiazepines like chlordiazepoxide or diazepam are recommended.

Question 5

What is a fixed-dose reducing regimen in alcohol withdrawal management?

Answer 5

It involves a standard starting dose followed by a gradual reduction to zero, usually over 7–10 days.

Question 6

What is carbamazepine used for in alcohol withdrawal?

Answer 6

It can be used as an alternative treatment for acute alcohol withdrawal.

Question 7

How is benzodiazepine and alcohol dependence treated?

Answer 7

The dose of benzodiazepine should be increased to manage both alcohol and benzodiazepine withdrawal.

Question 8

What is delirium tremens (DTs)?

Answer 8

DTs is a severe form of alcohol withdrawal, characterized by confusion, agitation, hallucinations, and seizures, and requires specialist inpatient care.

Question 9

What is the first-line treatment for delirium tremens?

Answer 9

Lorazepam is used as first-line treatment.

Parenteral lorazepam or haloperidol can be used as adjunctive therapy.

Question 10

What should be offered to harmful drinkers or those with mild alcohol dependence?

Answer 10

Psychological interventions like cognitive behavioral therapy should be offered.

Question 11

What medications can be used in combination with psychological interventions for patients who haven’t responded to therapy alone or who request pharmacological treatment?

Answer 11

Acamprosate calcium or oral naltrexone hydrochloride can be used in combination with psychological intervention.

Question 12

How does acamprosate help in alcohol dependence?

Answer 12

Acamprosate helps reduce the desire to drink by modulating the glutamatergic system and does not cause a physical reaction to alcohol.

Question 13

How does naltrexone assist with alcohol dependence?

Answer 13

Naltrexone works by blocking the euphoric effects of alcohol, reducing the desire to drink.

Question 14

What is disulfiram used for in alcohol dependence?

Answer 14

Disulfiram is used as an aversion therapy, causing an unpleasant reaction to alcohol, acting as a deterrent.

Question 15

What are some symptoms caused by disulfiram when alcohol is consumed?

Answer 15

Flushing, nausea, vomiting, headache, chest pain, palpitations, and difficulty breathing.

Question 16

What is Wernicke’s encephalopathy and what causes it?

Answer 16

It is a serious neurological condition caused by thiamine (vitamin B1) deficiency, often due to chronic alcohol use.

Question 17

What are the symptoms of Wernicke’s encephalopathy?

Answer 17

Altered consciousness, eye movement problems, and balance difficulties.

Question 18

How is Wernicke’s encephalopathy treated?

Answer 18

Parenteral thiamine followed by oral thiamine should be given to patients with suspected Wernicke’s encephalopathy.

Question 19

Should patients with alcohol dependence receive thiamine supplementation?

Answer 19

Yes, prophylactic oral thiamine should be given to those with alcohol dependence who are in withdrawal or undergoing assisted alcohol withdrawal.

Question 20

Why might long-term thiamine supplementation be needed in alcohol-dependent individuals?

Answer 20

Chronic alcohol use impairs thiamine absorption, and liver damage can prevent thiamine activation, so ongoing supplementation may be necessary.

Question 21

Name the stages of nicotine dependence.

Answer 21

1. Precontemplation
2. Contemplation
3. Preparation
4. Action
5. Maintenance
6. Termination

Question 22

What are the main diseases linked to smoking tobacco?

Answer 22

Smoking tobacco is linked to lung cancer, chronic obstructive pulmonary disease (COPD), cardiovascular disease, and complications during pregnancy.

Question 23

What are common withdrawal symptoms associated with smoking cessation?

Answer 23

Nicotine cravings, irritability, depression, restlessness, poor concentration, light-headedness, sleep disturbances, and increased appetite.

Question 24

How can smokeless tobacco use affect health?

Answer 24

Smokeless tobacco is associated with oropharyngeal cancers, cardiovascular disease, and periodontal disease.

Question 25

What is the most effective treatment combination for smoking cessation?

Answer 25

The most effective treatment combination includes varenicline, or a combination of long-acting NRT (transdermal patch) and short-acting NRT (e.g., gum, lozenges).

Question 26

What are the risks of smoking during pregnancy?

Answer 26

Smoking during pregnancy can lead to reduced oxygen supply, low birth weight, preterm birth, and miscarriage or stillbirth.

Question 27

What is the role of varenicline in smoking cessation?

Answer 27

Varenicline helps reduce cravings and has been shown to be effective in helping individuals quit smoking by targeting nicotine receptors in the brain.

Question 28

Why is nicotine replacement therapy (NRT) considered safer than smoking tobacco during pregnancy?

Answer 28

NRT provides a much lower dose of nicotine compared to tobacco smoking and is less addictive, making it safer for pregnant women when combined with behavioral support.

Question 29

How does smoking affect the metabolism of other drugs?

Answer 29

Polycyclic aromatic hydrocarbons in tobacco smoke increase the metabolism of some drugs by inducing hepatic enzymes, often requiring an increase in the dose of those medications.

Question 30

What are the typical withdrawal symptoms of untreated heroin dependence?

Answer 30

Early withdrawal symptoms occur within 8 hours, with peak symptoms at 36–72 hours, and symptoms subside substantially after 5 days.

Question 31

What is the recommended approach for opioid withdrawal after stabilization with methadone or buprenorphine?

Answer 31

A withdrawal regimen should be considered carefully, as enforced withdrawal can increase relapse risk and overdose due to loss of tolerance.

Question 32

How long does opioid withdrawal usually take?

Answer 32

Complete withdrawal usually takes up to 4 weeks in an inpatient setting and up to 12 weeks in a community setting.

Question 33

What should be done if a patient misses 3 or more days of opioid maintenance therapy?

Answer 33

The patient is at risk of overdose due to loss of tolerance, and the dose may need to be reduced. As per the MEP - If you know a patient has missed three days’ prescribed treatment, there is a risk that he or she will have lost tolerance to the drug and the usual dose may cause overdose. In the best interests of the patient, consider contacting the prescriber to discuss appropriate next steps.

Question 34

What is the advantage of buprenorphine over methadone for some patients?

Answer 34

Buprenorphine is less sedating than methadone, making it suitable for employed individuals or those undertaking tasks such as driving. It also has fewer drug interactions and a lower overdose risk.

Question 35

What is the "ceiling effect" of buprenorphine?

Answer 35

Buprenorphine has a ceiling effect, meaning it does not increase its effects beyond a certain dose, reducing the risk of overdose.

Question 36

How should buprenorphine be administered to avoid precipitated withdrawal?

Answer 36

Buprenorphine should be given when the patient shows signs of withdrawal or 6–12 hours after the last use of heroin or 24–48 hours after the last dose of methadone.

Question 37

What are the risks of using naloxone in combination with buprenorphine?

Answer 37

Naloxone in combination with buprenorphine can precipitate withdrawal if the preparation is injected but has no effect when taken sublingually, which helps prevent misuse.

Question 38

Why is methadone used for opioid dependence?

Answer 38

Methadone is a long-acting opioid agonist that is often preferred by patients with a long history of opioid misuse due to its sedative effects, making it easier to tolerate withdrawal.

Question 39

How long must a patient be opioid-free before starting naltrexone after methadone use?

Answer 39

The patient needs to be opioid-free for a minimum of 7-10 days before naltrexone can be safely administered to avoid severe withdrawal symptoms.

Question 40

What is the recommended approach for opioid substitution during pregnancy?

Answer 40

Opioid substitution therapy with methadone or buprenorphine is recommended during pregnancy to reduce risks to the foetus compared to continued illicit drug use. Withdrawal should be avoided during the first and third trimester.

Question 41

What are the risks of opioid withdrawal during pregnancy?

Answer 41

Acute opioid withdrawal during pregnancy can cause foetal death, so gradual withdrawal in the second trimester is recommended, while third-trimester withdrawal is generally not advised due to the risk of foetal distress and stillbirth.

Question 42

What is lofexidine and when is it used?

Answer 42

Lofexidine is an alpha-2 adrenergic agonist used to alleviate physical symptoms of opioid withdrawal, either alongside opioid substitution therapy or as a standalone treatment for mild or uncertain opioid dependence.

Question 43

How can naloxone be used in opioid dependence treatment?

Answer 43

Naloxone is used to reverse opioid overdoses and may be prescribed to opioid-dependent patients as a precaution in case of accidental overdose.