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PS3.1 | Addiction Psychiatry — Graded Quiz
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A 50-year-old male is admitted to medicine ward following a road traffic accident. He was last known to have consumed alcohol 36 hours ago. Nursing staff report that he is now confused, agitated, and seeing non-existent animals in the room; his pulse is 128 bpm and BP 180/110 mmHg. Which condition has developed?
Correct. Confusion, vivid visual hallucinations, and autonomic hyperactivity (tachycardia, hypertension) arising 36–72 hours after last alcohol intake is the classic presentation of delirium tremens.
Delirium tremens (DTs) peaks at 48–72 hours post-cessation. Triad: delirium + hallucinations + autonomic storm. Mortality up to 15% without treatment. IV benzodiazepines are first-line.
Wernicke encephalopathy presents with ophthalmoplegia, ataxia, and confusion — caused by thiamine deficiency, not withdrawal hyperactivity. Alcoholic hallucinosis features hallucinations in a clear sensorium. Seizures are brief and generalised without sustained delirium.
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A 40-year-old construction worker presents to a primary health centre reporting that he drinks 6–8 units of alcohol daily and has done so for 8 years. He denies any health problems attributable to drinking and has not tried to stop. On examination, he has mild hepatomegaly but is otherwise well. Which ICD-11 diagnosis is most appropriate at this stage?
Correct. ICD-11 harmful use of alcohol requires documented physical or mental health damage (hepatomegaly here) from drinking, WITHOUT fulfilment of the dependence triad (no impaired control, no prioritisation, no tolerance/withdrawal reported).
ICD-11 distinguishes: harmful use (health damage, no dependence) from dependence (control + priority + physiology). Know both categories and their differentiating features for the examination.
Dependence requires ALL THREE: impaired control + increasing priority + physiological features. 'Alcohol use disorder' is DSM-5 terminology, not ICD-11. 'Hazardous use' is a public-health risk concept, not an ICD-11 clinical diagnosis.
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You are conducting a brief alcohol screening in a general medicine outpatient clinic. Using the AUDIT-C (first 3 questions of AUDIT), you identify a patient with a positive screen. The patient then scores 3/4 on CAGE. What is the correct clinical interpretation of the CAGE score?
Correct. The validated cut-off for CAGE is ≥2/4. A score of 3 is a strongly positive screen, indicating a high likelihood of clinically significant alcohol use disorder. It does not by itself establish an ICD-11 diagnosis.
CAGE mnemonic: Cut down (felt need to cut down), Annoyed (people's criticism annoys you), Guilty (felt guilty about drinking), Eye-opener (need a drink in the morning). ≥2/4 = positive screen requiring full assessment.
The CAGE threshold is ≥2/4, not ≥3/4. CAGE does not diagnose by ICD-11 criteria — it screens. CAGE does not distinguish harmful use from dependence; it flags problem drinking broadly.
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A 32-year-old woman with nicotine dependence (20 cigarettes/day) wants pharmacotherapy. She has a history of a seizure disorder managed with sodium valproate. Which cessation agent should be AVOIDED in her case?
Correct. Bupropion SR lowers the seizure threshold and is contraindicated in patients with a history of seizure disorders. NRT and varenicline do not carry this risk.
Bupropion SR contraindications: seizure disorder, anorexia nervosa/bulimia, abrupt alcohol/benzodiazepine withdrawal, MAOIs within 14 days. For patients with epilepsy, use NRT or varenicline.
NRT and varenicline are safe in patients with seizure disorders. Bupropion's dose-dependent proconvulsant effect is its key contraindication — essential to recall when choosing cessation pharmacotherapy.
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A 27-year-old man dependent on injected heroin is enrolled in an opioid substitution therapy (OST) programme in India. He is commenced on buprenorphine. Which statement about buprenorphine's pharmacology is most accurate?
Correct. Buprenorphine is a partial mu-opioid agonist. Its ceiling effect on respiratory depression makes it significantly safer than full agonists (heroin, methadone) in overdose, while still suppressing withdrawal symptoms and craving.
Buprenorphine = partial mu-opioid agonist: activates receptor but less than full agonists + ceiling on respiratory depression + high receptor affinity (will displace other opioids). The buprenorphine/naloxone combination reduces diversion risk.
Methadone is the full mu-opioid agonist used in OST. Naloxone/naltrexone are antagonists. Buprenorphine's partial agonism — producing a plateau on respiratory depression — is the key pharmacological safety feature.
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In India, which of the following psychoactive substances contributes to the highest burden of substance use disorder at the population level, according to national surveys?
Correct. Alcohol accounts for the largest burden of substance use disorder in India by prevalence. The 2019 National Survey on Extent and Pattern of Substance Use reported approximately 57 million people with alcohol use disorders.
India-prevalent substance use (MEMORY AID): Alcohol > tobacco > cannabis > opioids > sedatives. Regional variation exists: opioid use is higher in Punjab/Manipur; heroin and pharmaceuticals both contribute. Tobacco is the leading cause of preventable mortality.
While opioids, cannabis, and sedatives each contribute significant burden, alcohol remains the most prevalent substance use disorder in India and is the leading cause of substance-related treatment seeking.
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A 38-year-old woman presents with alcohol dependence. After detoxification, her treating team wants to add a relapse-prevention agent that reduces craving by modulating the glutamate/GABA balance and is particularly useful in patients with significant protracted withdrawal symptoms. Which drug is most appropriate?
Correct. Acamprosate (calcium acetylhomotaurinate) restores glutamate/GABA dysregulation caused by chronic alcohol use, reducing protracted abstinence symptoms (anxiety, sleep disturbance, mild craving). It is renally cleared and safe in liver disease.
Acamprosate mechanism: NMDA receptor modulation + GABA-A agonism → reduces glutamate hyperexcitability of protracted withdrawal. Excreted unchanged in urine — safe in liver disease but contraindicated in renal failure. Start after full detoxification.
Disulfiram works by aversion (ALDH inhibition). Naltrexone reduces reward-mediated craving via opioid blockade. Topiramate is used off-label. Only acamprosate specifically targets the GABA/glutamate imbalance of protracted withdrawal.
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A rural physician uses the 5As framework for tobacco cessation at a primary care clinic. A patient who smokes 10 cigarettes/day scores 6/10 on the Fagerström Test for Nicotine Dependence (FTND). He is willing to quit. Correctly sequencing the 5As, which step follows 'Ask' and 'Advise'?
Correct. The 5As sequence is: Ask (about tobacco use) → Advise (to quit, clear unambiguous advice) → Assess (willingness to make a quit attempt) → Assist (with counselling and pharmacotherapy) → Arrange (follow-up). 'Assess' follows 'Advise'.
5As framework for tobacco cessation: Ask → Advise → Assess → Assist → Arrange. For unwilling patients, shift to the 5Rs motivational approach (Relevance, Risks, Rewards, Roadblocks, Repetition). FTND ≥4 indicates moderate-to-high dependence, warranting pharmacotherapy.
The validated sequence is Ask → Advise → Assess → Assist → Arrange. Assess (willingness to quit) must come before Assist — pharmacotherapy is only initiated after confirming the patient is ready to make a quit attempt.
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A 45-year-old chronic alcohol user is brought to casualty 18 hours after his last drink with agitation and tremor. On examination: BP 160/95, HR 116, RR 18. He is given IV diazepam 10 mg which partially controls his symptoms. Routine blood tests show: serum sodium 128 mEq/L, potassium 3.1 mEq/L, magnesium 0.6 mg/dL. Which electrolyte abnormality is most likely to worsen his seizure risk?
Correct. Hypomagnesaemia is a well-recognised precipitant of seizures in alcohol withdrawal. Magnesium acts as a physiological NMDA receptor blocker; its depletion facilitates glutamate-driven excitotoxicity and lowers the seizure threshold. Correction of magnesium is part of standard withdrawal management.
Electrolyte management in alcohol withdrawal: always check and correct magnesium (IV MgSO4 if <0.8 mg/dL), potassium, and phosphate. Hypomagnesaemia renders benzodiazepine-refractory withdrawal seizures more likely.
Hyponatraemia and hypokalaemia can both increase seizure risk, but in the specific context of alcohol withdrawal, hypomagnesaemia (common from poor nutrition + renal wasting) is the electrolyte most directly associated with treatment-refractory seizures.
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A 24-year-old college student is evaluated after being found unresponsive at a party. He has miosis, GCS 8/15, RR 8/min, and HR 72/min. Naloxone 0.4 mg IV produces a full reversal within 90 seconds. Which substance is most responsible for this clinical picture?
Correct. The opioid toxidrome — coma/depressed consciousness, miosis (pinpoint pupils), and respiratory depression (bradypnoea) — with complete reversal by naloxone within seconds is pathognomonic of opioid intoxication.
Toxidromes to know: Opioid = miosis + CNS depression + bradypnoea (naloxone reversal). Sympathomimetic (amphetamines) = mydriasis + tachycardia + hyperthermia. Anticholinergic = mydriasis + dry skin + tachycardia. Cholinergic = miosis + bradycardia + SLUDGE.
Alcohol intoxication does not reverse with naloxone. Cannabis causes conjunctival redness, mild euphoria, and tachycardia — not miosis or severe respiratory depression. Amphetamines produce mydriasis (dilated pupils) and sympathomimetic features — the opposite of this picture.
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