🤔 MEDIUM

This quiz tests how well you understand the management of alcohol withdrawal, opioid toxicity and some basic psychopharmacology of other addictive substances.

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Substance abuse

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Question 1

Stem 1 - question 1 of 4

You are a final year medical student joining the local ambulance service on a night shift. You are called to an alleyway where the police have reported finding a semi-conscious male who they suspect has had an overdose. When you arrive, you find the patient in respiratory depression and with pinprick pupils. A tourniquet, used syringe and bent spoon are found by the patient.

What drug would you administer to reverse the effect of the overdose?
A
Thiamine
B
Declofenac
C
Naloxone
D
Lorazepam
E
Dextrose
Question 1 Explanation: 
Respiratory depression and pinprick pupils are two signs of opioid and opiate overdose. This is managed with naloxone, which competes for the binding opioid binding site, giving the body time to clear the drug from the system. Naloxone maybe given alongside dextrose (glucose), thiamine and flumezanil in a 'coma cocktail' to reverse or help manage some of the common causes of unconsciousness.
Question 2

Stem 1 - question 2

The patient is stabilised and moved to the ambulance. After treatment with the coma cocktail the patient starts to come around and the paramedics decide to transfer the patient to hospital. En route, the patient starts to show signs of opioid withdrawal. Which of the following are possible signs you might observe? Select three answers.
A
Yawning
B
Hyperventilation
C
Sweating
D
Hallucinations
E
Vomiting
Question 2 Explanation: 
Yawning, sweating and vomiting are signs of opioid withdrawal. Other signs and symptoms include diarrhoea, cramps, myalgia and dilated pupils. Hallucinations are more likely to be associated with alcohol withdrawal (delirium tremons).
Question 3

Stem 1 - question 3

Which of the following are used in the management of heroin addiction?
A
Methadone
B
Supervised medicating
C
IV fluids
D
Urine testing
E
Clopidogrel
Question 3 Explanation: 
Methadone is a mu-receptor agonist that is used in the management of heroin addiction. Both methadone and buprenorphine are first line treatments for opioid detoxification (NICE CG52). Random testing, observation of medication, titrating the dose and psychosocial support are all recommended for improving compliance. Clopidogrel is used to prevent clots. While IV drug users have a higher risk of DVT, the use of anti-platelet agents is not included in the management of toxicity.
Question 4

Stem 1 - question 4

Buprenorphine is an alternative to methadone in the first line treatment of opioid toxicity. Which of the following is true of buprenorphine?
A
Buprenorphine is cheaper than methadone
B
Buprenorphine acts faster than methadone
C
Buprenorphine is a full mu-receptor agonist
D
You require a larger dose of buprenorphine compared to methadone
E
Patient is less likely to overdose on buprenorphine
Question 4 Explanation: 
Patients are less likely to suffer side effects from buprenorphine because it is only a partial agonist. Buprenorphine and methadone are equally affective at treating opioid toxicity but methadone is cheaper, although the doses of methadone are larger.
Question 5

Stem 2 - question 1 of 4

A 60 year old alcoholic is admitted to AMU after being found unconscious in his home. During his recovery he becomes highly agitated and reports seeing "pygmies fighting in the corridors".

What is the likely cause of these signs and symptoms?
A
Wernicke's encephalopathy
B
Korsakoff's syndrome
C
Delirium tremens
D
Charles-Bonnet syndrome
E
Paranoid schizophrenia
Question 5 Explanation: 
Delirium tremons is a syndrome of confusion and agitation featuring hallucinations and paranoia following alcohol withdrawal. Wernicke's encephalopathy is a state seen in alcoholics involving confusion, ataxia and eye signs such as double vision, ophthalmoplegia, nystagmus and ptosis. This may precede Korsakoff's syndrome which is characterised by confabulation (making up memories) and antegrade and retrograde memory loss. Charles-Bonnet syndrome is the experience of life-like visual hallucinations in patients who have lost part of their sight.
Question 6

Stem 2 - question 2

What drug would you use to treat the condition described above?
A
Thiamine
B
Naltrexone
C
Lorazepam
D
Nalmefene
E
Ascorbic acid
Question 6 Explanation: 
Lorazepam is a short-acting benzodiazepine used in the treatment of delirium tremens. Alcohol binds to inhibitory GABA-A channels in the CNS. During alcohol withdrawal, there is a loss of alcohol and hence reduced inhibition of nervous signalling which then become over-excited. Lorazepam binds to GABA-A receptors to prevent this excitability and is slowly titrated down over a number of days. Source: https://bnf.nice.org.uk/treatment-summary/alcohol-dependence.html accessed 21 October 2020
Question 7

Stem 2 - question 3

What drug is used to prevent Wernicke-Korsakoff Sydrome?
A
Thiamine
B
Naltrexone
C
Diazepam
D
Nalmefene
E
Ascorbic acid
Question 7 Explanation: 
Thiamine (vitamin B1) is used to prevent Wernicke-Korsakoff Syndrome, a debilitating and permanent side effect of alcohol misuse. Wernicke-Korsakoff Syndrome has the same symptoms as Wernicke's encephalopathy and Korsakoff syndrome, and can be used to refer to Korsakoff's syndrome when it follows Wernicke's encephalpathy. Thiamine may be given with other B vitamins and ascorbic acid, which alcoholic patients may be deficient in. Source: https://bnf.nice.org.uk/treatment-summary/alcohol-dependence.html, accessed 21 October 2020
Question 8

Stem 2 - question 4

The patient is eventually discharged from hospital but begins drinking again. After several months he speaks to his GP about getting help to treat his alcoholism. As part of this treatment, which drug would the patient be prescribed to manage the side effects of withdrawal?
A
Thiamine
B
Naltrexone
C
Diazapam
D
Nalmefene
E
Haloperidol
Question 8 Explanation: 
Doctors should decide whether a patient's alcohol withdrawal should be managed as an inpatient or an outpatient. Patients with a high alcohol dependence or liver problems should be managed as an inpatient. IN both cases, a long-lasting benzodiazepine should be prescribed that is slowly titrated down over several days. Thiamine may be given to help prevent Wernicke's encephalopathy or Korsakoff's syndrome. Haloperidol would not be used in assisted alcohol withdrawal but could be used to treat delirium tremons in acute alcohol withdrawal (unlicensed). Naltrexone or acamprosate calcium can be given to alcoholics after withdrawal to stop them drinking again. Nalmefene is an alternative for use in severe alcoholics. Source: https://bnf.nice.org.uk/treatment-summary/alcohol-dependence.html accessed 21 October 2020 and Clark T, Day E and Fergusson E, Core Clinical Cases in Psychiatry, 2nd Ed, 2017, Taylor and Francis Group.
Question 9
What is cocaine's mechanism of action?
A
Inhibits dopamine re-uptake
B
Monoamine oxidase inhibitor
C
Stimulates NMDA receptor
D
Prevents breakdown of acetylcholine
E
Stimulates release of histamine
Question 9 Explanation: 
Cocaine inhibits dopamine reuptake so more dopamine remains in the synapse to excite the post-synaptic neuron.
Question 10
Which substance in cannabis is responsible for its anxiolytic effects?
A
Nicotinic acid
B
THC
C
5-HT
D
CBD
E
MDMA
Question 10 Explanation: 
Cannabis contains both CBD and THC. THC can induce psychosis and anxiety while CBD can be a sedative, antipsychotic and anxiolytic. Cannabis plants differ in the relative proportions of CBD:THC leading to different risks for psychosis.
Question 11
MDMA is the active ingredient in which drug?
A
Cocaine
B
Heroin
C
Speed
D
Ecstasy
E
Magic mushrooms
Question 11 Explanation: 
MDMA is the active ingredient in ecstasy. Cocaine and heroin are both opioids. The active ingredient in speed is metamphetamine. Psilocybin is the active ingredient in magic mushrooms.
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