Substance misuse

Question 1

Harmful use of a substance

Answer 1

A quantity or pattern of substance use that actually causes adverse consequences, without dependence

Question 2

The 4Ls of harmful substance use

Answer 2

Love - difficulties with interpersonal relationships (impotence, domestic violence)

Livelihood - problems meeting work or educational obligations (absenteeism)

Liver - impact on physical health or safety

Law - legal difficulties e.g. disorderly conduct, stealing to fund habit

Question 3

Hazardous use of a substance

Answer 3

A quantity or pattern of substance use that places the user at risk of adverse consequences, without dependence

Question 4

Substance dependence

Answer 4

A syndrome that incorporates physiological, psychological and behavioural elements.

Question 5

Dependence syndrome (ICD-10) (6)

Answer 5

Three or more of the following have been present together at some time over the previous year:

1. A strong desire or compulsion to take the substance
2. Difficulties in controlling substance-taking behaviour (onset, termination, levels of use)
3. Physiological withdrawal state when substance use has reduced or ceased; or continued use to relieve or avoid withdrawal symptoms
4. Signs of tolerance: increased quantities required to produce the same effect
5. Neglect of other interests and activities due to time spent acquiring and taking substance, or recovering from its effects
6. Persistence with substance use despite clear awareness of harmful consequences (physical or mental)

Question 6

Physiological dependence

Answer 6

When a person exhibits signs of tolerance and/or withdrawal

Question 7

Substance intoxication

Answer 7

A transient, substance-specific condition that occurs following the use of a psychoactive substance. Symptoms include disturbances of consciousness, perception, mood, behaviour and physiological function

Question 8

Substance withdrawal

Answer 8

A substance-specific syndrome that occurs on reduction or cessation of a psychoactive substance that has usually been used repeatedly, in high doses, for a prolonged period

Question 9

How to calculate units of alcohol

Answer 9

Alcohol by volume (in %) x volume (in litres)

e.g. ABV x vol = units

Question 10

Safe daily alcohol limits for men and women

Answer 10

Men: 3-4 units/day (

Question 11

What are the potential life-threatening risks associated with acute alcohol intoxication? (5)

Answer 11

Respiratory depression
Aspiration of vomit
Hypoglycaemia
Hypothermia
Trauma

Question 12

Physical complications of excessive alcohol use - nervous system (7)

Answer 12

Intoxication or withdrawal delirium (delirium tremens)
Withdrawal seizures
Cerebellar degeneration
Haemorrhagic stroke
Peripheral and optic neuropathy
Wernicke-Korsakoff syndrome
Alcohol-related cognitive impairment

Question 13

Physical complications of excessive alcohol use - gastroenterological system (4)

Answer 13

Alcoholic liver disease (fatty liver, alcoholic hepatitis, alcoholic cirrhosis)
Acute and chronic pancreatitis
Peptic ulceration and gastritis
Cancers: oropharynx, larynx, oesophagus, liver

Question 14

Physical complications of excessive alcohol use - Cardiovascular system (4)

Answer 14

Hypertension
Arrhythmias
Ischaemic heart disease (in heavy drinkers)
Alcoholic cardiomyopathy

Question 15

Physical complications of excessive alcohol use - immune system (1)

Answer 15

Increased risk of infections (especially meningitis and pneumonia)

Question 16

Physical complications of excessive alcohol use - haematological system (4)

Answer 16

Red cell macrocytosis
Anaemia
Neutropenia
Thrombocytopenia

Question 17

Physical complications of excessive alcohol use - musculoskeletal system (2)

Answer 17

Acute and chronic myopathy

Osteoporosis

Question 18

Physical complications of excessive alcohol use - reproductive system (3)

Answer 18

IUGR
Foetal alcohol syndrome
Impotence, erectile dysfunction

Question 19

Physical complications of excessive alcohol use - metabolic and endocrine system (5)

Answer 19

Hypoglycaemia
Hyperlipidaemia/ hypertriglycerididaemia
Hyperuricaemia
Hypomagnesaemia, hypophosphataemia, hyponatraemia
Alcohol-induced pseudo-Cushing’s syndrome

Question 20

Alcohol dependence syndrome (Edwards & Gross)

Answer 20

1. Narrowing of repertoire
2. Increased salience of drinking
3. Increased tolerance to alcohol
4. Withdrawal symptoms
5. Relief or avoidance of withdrawal symptoms by further drinking
6. Subjective awareness of the compulsion to drink
7. Rapid reinstatement after abstinence

Question 21

Clinical features of uncomplicated alcohol withdrawal syndrome (9)

Answer 21

• Symptoms develop 4–12 hours after drinking cessation
• Tremulousness (‘the shakes’)
• Sweating
• Nausea and vomiting
• Mood disturbance (anxiety, depression, ‘feeling edgy’)
• Sensitivity to sound (hyperacusis)
• Autonomic hyperactivity (tachycardia, hypertension, mydriasis, pyrexia)
• Sleep disturbance
• Psychomotor agitation

Question 22

Clinical features of alcohol withdrawal with perceptual disturbances

Answer 22

As for uncomplicated alcohol withdrawal syndrome (9)

Plus illusions or hallucinations (typically visual, auditory or tactile)

Question 23

Clinical features of alcohol withdrawal seizures (4)

Answer 23

• Develop 6–48 hours after drinking cessation
• Occurs in 5–15% of all alcohol-dependant drinkers
• Generalized and tonic–clonic
• Predisposing factors: previous history of withdrawal fits, concurrent epilepsy, low potassium or magnesium

Question 24

Clinical features of delirium tremens (8)

Answer 24

• Develops 1–7 days after drinking cessation, mean 48 hours
• Altered consciousness and marked cognitive impairment
• Vivid hallucinations and illusions in any sensory modality (patients often interact or are horrified by them; Lilliputian
visual hallucinations, miniature humans/animals; formication, sensation of insects crawling on the skin)
• Marked tremor
• Autonomic arousal (heavy sweating, raised pulse and blood pressure, fever)
• Paranoid delusions (often associated with intense fear)
• Mortality: 5–15% from cardiovascular collapse, hypo-/hyperthermia, infection
• Predisposing factors: physical illness (hepatitis, pancreatitis, pneumonia)

Question 25

Blackouts

Answer 25

Episodes of anterograde amnesia during acute alcohol intoxication. Memory loss may be patchy, or for a discrete block of time during which nothing can be remembered. Common - experienced by 2/3rd of dependent drinkers and 1/3rd of young men in the general population

Question 26

Wernicke-Korsakoff syndrome

Answer 26

Due to thiamine (vitamin B1) deficiency Wernicke's encephalopathy occurs during acute brain damage due to thiamine deficiency: -Triad of delirium, ophthalmoplegia (nystagmus, 6th nerve palsy or conjugate gaze palsy) and ataxia Korsakoff's psychosis is chronic state that emerges after untreated Wernicke's: -Extensive anterograde and retrograde amnesia, frontal lobe dysfunction and psychotic symptoms in the absence of delirium

Question 27

Treatment for Wernicke's encephalopathy

Answer 27

Parenteral thiamine (Pabrinex)

Question 28

The lifetime risk of suicide in problem drinkers

Answer 28

3-4% (60-120x greater than the normal population) Due to alcohol-related psychiatric disorders (mainly low mood), comorbid alcohol misuse with other psychiatric and personality disorders, or through impaired judgement or disinhibition secondary to alcohol

Question 29

Psychological and physical effects of opiates

Answer 29

Heroin, dihydrocodeine, methadone, buprenorphine Psychological: Euphoria, drowsiness, apathy, personality change Physical: Miosis, conjunctival injection, nausea, pruritus, constipation, bradycardia, respiratory depression, coma

Question 30

Psychological and physical effects of sedatives

Answer 30

Temazapam, diazepam, GHB, rohypnol Psychological: Drowsiness, disinhibition, confusion, poor concentration, reduced anxiety, feeling of well- being Physical: Miosis, hypotension, withdrawal seizures, impaired coordination, respiratory depression

Question 31

Psychological and physical effects of stimulants

Answer 31

Amphetamine, cocaine, crack cocaine, MDMA, mephedrone, legal highs Psychological: Alertness, hyperactivity, euphoria, irritability, aggression, paranoid ideas, hallucinations (especially cocaine – formication), psychosis Physical: Mydriasis, tremor, hypertension, tachycardia, arrhythmias, perspiration, fever (especially Ecstasy), convulsions, perforated nasal septum (cocaine)

Question 32

Psychological and physical effects of hallucinogens

Answer 32

LSD, magic mushrooms Psychological: Marked perceptual disturbances including chronic flashbacks, paranoid ideas, suicidal and homicidal ideas, psychosis Physical: Mydriasis, conjunctival injection, hypertension, tachycardia, perspiration, fever, loss of appetite, weakness, tremors

Question 33

Psychological and physical effects of cannabinoids

Answer 33

Cannabis, hashish, hash oil Psychological: Euphoria, relaxation, altered perception, psychosis Physical: Impaired coordination and reaction time, conjunctival injection, nystagmus, dry mouth

Question 34

Psychological and physical effects of dissociative anaesthetics (ketamine)

Answer 34

Psychological: Hallucinations, paranoid ideas, thought disorganisation, aggression Physical: Mydriasis, tachycardia, hypertension

Question 35

Psychological and physical effects of inhalants

Answer 35

Aerosols, glue, lighter fluid, petrol Psychological: Disinhibition, stimulation, euphoria, clouded consciousness, hallucinations, psychosis Physical: Headache, nausea, slurred speech, loss of motor coordination, muscle weakness, damage to brain/bone marrow/liver/kidneys/myocardium, sudden death

Question 36

Three diagnostic relationships between substance use and psychiatric symptoms

Answer 36

1. Primary psychiatric disorder, with the patient coincidentally using drugs (or to obtain relief from symptoms) 2. Symptoms are entirely due to the direct effect of the substance 3. Psychiatric symptoms are due to a combination of the above (somebody might have a predisposing vulnerability to schizophrenia then starts smoking cannabis)

Question 37

Features suggesting a substance-related psychiatric disorder (4)

Answer 37

- The symptoms are known to be associated with the drug in question - There is a temporal relationship (hours or days) between the use of the drug and the development of symptoms - There is complete recovery from all psychiatric symptoms after termination of the suspected drug use - There is absence of evidence to suggest an alternative explanation for psychiatric symptoms (e.g. a family or personal history)

Question 38

What 4 key topics must you address when taking a substance misuse history

Answer 38

- All substances used - Pattern of use (times, methods) - Features of dependence - Consequences of substance use (relationships, employment, physical health, criminality)

Question 39

CAGE questionnaire

Answer 39

Tool to screen for alcohol dependence. Positive if answer yes to 2 or more 1. Cut down - have you ever thought you should? 2. Annoyed - do others annoy you by criticising your drinking? 3. Guilty - have you ever felt guilty about your drinking? 4. Eye-Opener - have you ever needed one?

Question 40

AUDIT

Answer 40

Alcohol Use Disorders Identification Test | 10-item screening questionnaire for problem drinking, takes 3 mins