SUBSTANCE MISUSE

Question 1

Describe the cycle of change model.

Answer 1

1. Pre-Contemplation
   - No intention of changing behavior
2. Contemplation
   - Is aware a problem exists
   - BUT has no commitment to action
3. Preparation/Determination
   - has an INTENTION on taking action to address the problem
4. Action
   - They are ACTIVELY modifying their behavior
5. Maintenance
   - New behavior replaces the old one
6. Relapse
   - Back to old behavior

Question 2

What are the three types of therapies to aid in stopping smoking?

Answer 2

1. NRT
2. Bupropion (Zyban)
3. Varencicline (Champix)

Question 3

Which drugs may be effected when someone stops smoking?

Answer 3

1. Theophylline
   - Smoking decreases theophylline concentration
2. Cinacalcet
3. Ropinorole
4. Clozapine
5. Olanzapine
6. Chlorpromazine
7. Haloperidol

Need dose reductions

Question 4

Champix MOA

Answer 4

Nicotine receptor blockers. Won’t feel anything from smoking and the receptors are blocked

Question 5

What is the MHRA warning of champix?

Answer 5

Discontinue treatment and seek prompt medical advice if they develop:
1. Agitation
2. Depressed mood
3. Suicidal thought
So caution in those with a history of psychiatric illness (should be monitored closely)

Question 6

Champix - avoid in

Answer 6

epilepsy, CVD and psychiatric illness

Question 7

Bupropion - avoid in

Answer 7

1. Acute alcohol withdrawal
2. Acute benzo withdrawal
3. Bipolar
4. HISTORY OF SEIZURES
   - Can cause seizures

Question 8

Bupropion - SE

Answer 8

• SS
• depression = refer

Question 9

NRT

Answer 9

• Patch (16H patch if pregnant/ experience nightmares)
  +
• short term reliever (lozenges, gum, sublingual tabs, inhalator, nasal spray, and oral spray)

Best effects when use together

Question 10

NRT patch and reliever

Answer 10

Patch acts as long term basal fix and short term acts as quick fix

Question 11

Which drugs are used as opioid substitution therapy?

Answer 11

1. Buprenorphine
2. Methadone

Question 12

What are the advantages of
Buprenorphine over methadone?

Answer 12

1. Less sedating than methadone
   - so preferred in employed patients or people who perform skilled tasks e.g. drive
2. Fewer drug-drug interactions
3. Dose reduction is easier with buprenorphine than with methadone
4. Milder withdrawal symptoms
5. Lower risk of overdose

Question 13

What are the
disadvantages of Buprenorphine?

Answer 13

1. Increased risk of precipitating withdrawal
   - especially if taken with opioid
   - reduce the risk by starting the dose 6-12 hours after the last use of heroin
   OR 24 - 48 hours after the last use of Methadone

Question 14

What are the advantages of Methadone over buprenorphine?

Answer 14

More sedative effect:
* Probably preferable for those who typically abuse a variety of sedative drugs and alcohol
* And those who suffer from increased anxiety during withdrawal periods from opioids

Question 15

Opioid dependence - Rx

Answer 15

• FP10MDA
• Maximum supply of 14 days
• SUPERVISED consumption is not a LEGAL requirement. It’s GOOD PRACTICE

Question 16

Methadone - SE

Answer 16

QT

Question 17

Methadone SF vs S

Answer 17

o If its prescribed as SF must give SF
o S can cause more local irritation if pt decides to inject it. Injecting with substance high in sugar would hurt
o SF won’t hurt
o If pt is at high risk of abusing it, then go for S so it hurts them

Question 18

When should methadone be first initiated after the last heroin use?

Answer 18

Initiated at least 8 hours after last heroin use
- provided there is objective evidence of withdrawal symptoms

Question 19

What should you be aware of with regard to titrating the dose of methadone?

Answer 19

A dose on the first day may be toxic on the third day
- because of long-half life, plasma concentrations progressively rise during initiation
- It may take 3-10 days for the plasma concentration to reach a steady state
- titration to a stable dose may take several weeks

Question 20

How do you manage opioid substitution in pregnancy?

Answer 20

• Continue Methadone or
  Buprenorphine (unlicensed)
• Safer than acute withdrawal of opioids
• Safer than illicit drugs

Question 21

Neonate should be monitored for

Answer 21

respiratory depression
- high-pitch,
- rapid breathing
- hungry but ineffective suckling
- excessive wakefulness

Question 22

Can you give opioids during breastfeeding?

Answer 22

• Methadone or Buprenorphine doses MUST be kept to low
• Mother should report
  URGENTLY any symptoms her baby gets:
  1. Increased sleepiness (sedation)
  2. Breathing difficulties
  3. Limpness

Question 23

What other treatments may be given to opioid dependence?

Answer 23

1. Loperamide - for diarrhea
2. Mebeverine - For controlling stomach cramps
3. NSAIDs and paracetamol - for muscular pains and aches
4. Metoclopramide or prochloperazine - N+V
5. Topical rubefacients - muscular aches when withdrawal from methadone
6. Short-acting Benzo or Z-drugs - for insomnia
7. Lofexidine - For opioid withdrawal symptoms
8. Naltrexone - to prevent relapse
9. Naloxone - for overdose

Question 24

What are the signs of opioid withdrawal?

Answer 24

1. Muscle aches
2. Restlessness
3. Anxiety
4. Lacrimaion (eye tearing up)
5. Excessive sweating
6. Inability to sleep
7. Abdominal cramping DNV

Question 25

If someone has strong alcohol dependence and abruptly stops it, what can happen?

Answer 25

- Seizures - Delirium tremens - Death Therefore these people may need assistance in withdrawing alcohol acutely

Question 27

Alcohol withdrawal symptoms: seizures of moderate AWS treatment

Answer 27

1. Long-acting benzodiazepine E.g. Chlordiazepoxide or diazepam 2. Carbamazepine 3. Clomethiazole

Question 28

Chlordiazepoxide or diazepam treatment regimes

Answer 28

- First line - Fixed-dose reducing regimen (in primary care or inpatient) or - Symptom triggered regimen (tailoring the drug regimen according to the severity of the withdrawal)

Question 29

clomethiazole

Answer 29

- ONLY IN an INPATIENT setting - should NOT be prescribed if the patient is liable to drink again - if the patient has cirrhosis and drinks alcohol whilst on clomethiazole, risk of FATAl respiratory depression

Question 30

What is delirium tremens?

Answer 30

* agitation, confusion, paranoia * visual and auditory hallucinations

Question 31

Delirium tremens: first line

Answer 31

1. Oral lorazepam 2. Parenteral lorazepam or haloperidol

Question 32

How do you manage Alcohol dependence?

Answer 32

1. Psychological - e.g. СВТ 2. Pharmacological - if the patient has not responded well to psychological - OR has specifically requested pharmacological

Question 33

Which pharmacological treatments are used in alcohol dependence?

Answer 33

1. Acamprostate calcium 2. Oral Naltrexone 3. Disulfiram 4. Namefene

Question 34

What should patients be counseled on whilst on Disulfiram?

Answer 34

THEY HAVE TO NOT DRINK Also avoid exposure to small amounts of alcohol in: 1. Perfumes 2. Aerosol sprays 3. Low-alcohol or non-alcohol beer and whines

Question 35

Why should they NOT drink whilst on disulfiram?

Answer 35

Risk of getting Disulfiram-like reactions: 1. Flushing 2. Throbbing headache 3. Nausea 4. Palpitations and tachycardia 5. Arrythmias 6. HYPOtension 7. Respiratory depression 8. Coma

Question 36

Wernicke’s encephalopathy treatment

Answer 36

1. Thiamine 2. Pabrinex