Substance Misuse

Question 1

What is considered to be ‘high risk’ drinking?

Answer 1

> 35 units per week regularly

increased risk is from 15 units +

Question 2

Does heroin have a long or short half-life? What is the significance of this?

Answer 2

Heroin has a short half-life which means it causes a quick high but doesn’t stay in the system for that long which leads to cravings

Question 3

What volume of pure alcohol = 1 unit?

Answer 3

10ml pure ethanol = 1 unit

Question 4

How are alcohol units worked out?

Answer 4

(% x volume ) / 10

The % is expressed as a decimal e.g 40% = 0.4
The volume is in mls

Question 5

What different drink quantities = 1 unit? (how much beer/ wine etc…)

Answer 5

1 single measure of spirits

1/2 a pint of beer

1/2 a small glass of wine

Question 6

What are the recommended alcohol guidelines?

Answer 6

<14 units a week spread over 3 days or more

Question 7

What are some of the physical consequences of alcohol consumption?

Answer 7

Gastritis

Peptic ulcers

Mallory-Weiss tear

Oesophageal varices

Cirrhosis

Question 8

What factors are suggestive of alcohol dependence syndrome?

Answer 8

Tolerance

Withdrawal

Strong desire/ compulsion to drink

Difficulty with control

Neglect of other pleasures and interests

Persistence of use despite evidence of harm

Question 9

What effect does alcoholism have on MCV?

Answer 9

Alcoholism is the most common cause of raised MCV

Question 10

What are some of the detection tools which are used for alcoholism?

Answer 10

AUDIT

CAGE

TWEK

FAST

Question 11

Which alcohol detection tool is used to detect hazardous drinkers?

Answer 11

AUDIT

Question 12

Which alcohol detection tool is used to screen for alcohol abuse and DEPENDENCE?

Answer 12

CAGE

Question 13

Which alcohol detection tool is used to screen for alcohol problems in pregnant women?

Answer 13

TWEK

Question 14

Which alcohol detection tool is best for A&E testing?

Answer 14

FAST

Question 15

Which toxicology parameter is a useful indicator of liver injury?

Answer 15

GGT

Question 16

How does alcohol affect NMDA ion channels?

Answer 16

Alcohol inhibits the action of excitatory NMDA glutamate controlled channels

Chronic alcohol use leads to up regulation of these receptors

Question 17

How does alcohol affect GABA channels?

Answer 17

Alcohol potentiates the actions of GABA controlled ion channels

Chronic alcohol use leads to down regulation of these receptors

Question 18

How does alcohol withdrawal affect glutamate and GABA activity?

Answer 18

Alcohol withdrawal leads to excess glutamate activity and reduced GABA activity

*CNS excitability and neurotoxicity

Question 19

Which receptors does chronic alcohol use upregulate and downregulate?

Answer 19

Chronic alcohol use causes up regulation of NMDA glutamate channels and down regulation of GABA channels.

Question 20

When do withdrawal symptoms peak?

Answer 20

At 24-48 hours

Question 21

What are some of the symptoms of withdrawal?

Answer 21

Restlessness

Tremor

Sweating

Anxiety

N&V

Loss of appetite

Insomnia

Question 22

What happens to HR and BP in withdrawal?

Answer 22

Tachycardia

Systolic hypotension

Question 23

How does delirium tremens present?

Answer 23

Acute confusion, disorientation and agitation

Visual hallucinations

Paranoia

Question 24

How is alcohol withdrawal managed?

Answer 24

Benzodiazepines (gradually reduce over 7 days or more)

Thiamine

Antiemetics, analgesia, hydration

Question 25

What can be done as relapse prevention for alcoholics?

Answer 25

CBT Family and couple therapy 12 step facilitation therapy e.g AA Medications

Question 26

What medications can be used for relapse prevention for alcoholics?

Answer 26

Disulfiram Acamprostate Naltrexone

Question 27

Disulfiram can be used as relapse prevention from drinking, how does it work?

Answer 27

Inhibits acetaldehyde dehydrogenase causing an accumulation of acetaldehyde if alcohol is ingested - this is unpleasant for the patient so deters them from drinking

Question 28

Acamprosate can be used as relapse prevention from drinking, how does it work?

Answer 28

Acts centrally on glutamate and GABA systems to reduce cravings

Question 29

Naltrexone is first line for relapse prevention in alcoholics, how does it work?

Answer 29

Naltrexone is an opioid antagonist which reduces the rewards from alcohol

Question 30

Where does heroin come from?

Answer 30

Heroin = diamorphine / diacetylmorphine Poppy seeds!

Question 31

What are the different ways in which heroin can be taken?

Answer 31

IV Smoking Suppository Insufflation (snorting) Ingestion

Question 32

How does drug testing for heroin work? What is the metabolic pathway for heroin breakdown and what compound are you trying to detect?

Answer 32

The metabolic pathway = Diacetylmorphine (heroin) - 6 mono acetyl morphine - morphine If 6 mono-acetyl morphine is detected, the patient has taken heroin If morphine only is detected, don't know if the patient has taken morphine or heroin

Question 33

What are some of the signs you would expect to see on examination in a patient who has taken heroin?

Answer 33

Reduced consciousness Low respiratory rate (respiratory depression) Hypotension and bradycardia Pupillary constriction

Question 34

Why does heroin cause euphoria?

Answer 34

Injecting heroin causes a release of histamine which is what is though to cause the feeling of euphoria

Question 35

Why do patients who take heroin often have poor dentition?

Answer 35

Poor self care Heroin has an analgesic effect so often aren't aware of pain from dental problems such as abscesses

Question 36

When do withdrawal symptoms from heroin typically occur?

Answer 36

After 6-8 hours

Question 37

How often do regular heroin users tend to inject?

Answer 37

3x per day

Question 38

What are some of the withdrawal symptoms from heroin?

Answer 38

Agitation Diarrhoea N&V Joint pains Yawning Runny nose and watery eyes

Question 39

What are some of the physical signs of heroin withdrawal that may be seen on examination?

Answer 39

Piloerection (hairs stand one end) and goosebumps Tachycardia Hypertension Dilated pupils

Question 40

Is heroin withdrawal dangerous?

Answer 40

No unlike alcohol withdrawal it is just very unpleasant

Question 41

What are some of the complications of IV drug use?

Answer 41

Infections (local - cellulitis, abscess, necrotising fasciitis and distant - infective endocarditis and systemic - Hep and HIV) DVT/ PE

Question 42

Which drug is used to reverse the effects of opioid overdose?

Answer 42

Naloxone

Question 43

Heroin causes psychosis and delirium. T/F

Answer 43

No! Heroin doesn't cause psychosis or delirium Drug-induced psychosis is most often due to cannabis

Question 44

What drugs are used for opiate substitution therapy?

Answer 44

Methadone Buprenorphine

Question 45

How do methadone and buprenorphine differ? (opiate substitution options)

Answer 45

Methadone is a long acting full agonist and is usually in liquid form Buprenorphine is a long acting partial agonist which is usually taken as a tablet dissolved under the tongue

Question 46

Which is usually the preferred management of opiate addiction?

Answer 46

Opiate substitution therapy Opiate detoxification has a higher risk of overdose

Question 47

Why is opiate detoxification associated with overdose?

Answer 47

Patients are no longer tolerant but still psychologically dependent so if they take the same dose of heroin as before they may overdose

Question 48

What psychological interventions are options for opiate addiction?

Answer 48

CBT Behavioural couples therapy

Question 49

What is the triad of wernicke's encephalopathy?

Answer 49

Confusion Ataxia Nystagmus

Question 50

Wernicke's can progress to Korsakoffs syndrome. What does this involve?

Answer 50

Inability to make new memories Confabulation to fill in the gaps

Question 51

What are lilliputian hallucinations and when do they occur?

Answer 51

Seeing little people/ animals Occur in delirium tremens