Which of the following is a factor that can increase the risk of benzodiazepine withdrawal in a clinical setting?
D. Symptoms associated with the withdrawal of benzodiazepine therapy may reflect one of three phenomena – a recurrence (return of the original symptoms); a rebound (worsening of the original symptoms), or true withdrawal (emergence of new symptoms). These symptoms may include anxiety, dysphoria, irritability, altered sleep–wake cycle, daytime drowsiness, tachycardia, elevated blood pressure, hyperreflexia, muscle tension, agitation/motor restlessness, tremor, myoclonus, muscle and joint pain. Patients may also experience various perceptual disturbances such as hyperacusis, depersonalization, blurred vision, and hallucinations. In severe cases, delirium similar to delirium tremens has been reported. Factors influencing the development of the discontinuance or withdrawal syndrome include the dose of the drug, duration of the drug intake, rapid tapering of the dose and greater psychopathology before initiation and termination of medication, dependent personality traits, and lower education levels.
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Which of the following is NOT a feature of alcoholic hallucinosis?
B. Alcoholic hallucinosis is a condition in which auditory hallucinations are present during clear consciousness in the absence of autonomic overactivity, usually in a person who has been drinking excessively for many years. Initially the hallucinations are simple in nature, but later on become complex voices that are derogatory. These voices are usually second person, but at times are third person. They may also be command hallucinations. Delusions, if present are secondary to the voice. In both ICD-10 and DSM-IV, the disorder is classified as a substance-induced psychotic disorder. The differential diagnosis includes withdrawal symptoms and delirium tremens. In both these conditions the auditory hallucinations are transient and disorganized, and in the latter, consciousness is impaired. Auditory hallucinations of alcoholic hallucinosis are persistent and organized, and occur during clear consciousness. The hallucinations usually respond rapidly to antipsychotic medication. The prognosis is good; usually the condition improves within days or a couple of weeks, provided that the person remains abstinent. Symptoms that last for 6 months generally continue for years. The other differential diagnosis one needs to rule out, especially in the presence of derogatory hallucinations, is major depression with psychotic symptoms.
An 18-year-old boy was brought to the A&E by police after being picked up wandering near Tower Bridge. He was angry, agitated, and suspicious. He was concerned about people trying to ‘get him’. On examination, he showed evidence of stereotyped behaviour, tachycardia, pupillary dilation and elevated blood pressure. Soon after initial evaluation, he developed seizures.
What is the most likely substance that may have led to this presentation?
D. The features described in the clinical scenario are that of amphetamine intoxication. The clinching points are the sympathetic activity due to release of catecholamines and the stereotyped behaviour, which are characteristic of amphetamine use. According to DSM-IV, the diagnostic criteria for intoxication with amphetamine includes behavioural or psychological changes such as euphoria or affective blunting; changes in sociability; hypervigilance; interpersonal sensitivity; anxiety, tension, or anger; stereotyped behaviours; and impaired judgment. Physical symptoms/signs include tachycardia or bradycardia, pupillary dilation, elevated or lowered blood pressure, perspiration or chills with nausea or vomiting. Psychomotor changes include agitation or retardation. Patients may complain of muscular weakness, chest pain; some may develop cardiac arrhythmias and seizures.
Cocaine intake is associated with all of the following phenomena except:
E. Cocaine inhibits the normal reuptake of monoamines from the synaptic cleft by binding to transporter proteins. Its reinforcing effects are primarily due to its actions at the dopamine transporter, producing high levels of dopamine in the synapse. Cocaine also inhibits reuptake of noradrenaline and serotonin. The increase in noradrenaline concentration is important for some of cocaine’s toxic effects. The drug produces increases in adrenocorticotropic hormone (ACTH) and cortisol by stimulating release of hypothalamic corticotropin-releasing hormone (CRH). Acutely, cocaine also stimulates the release of luteinizing hormone and follicle-stimulating hormone (FSH) and suppresses the release of prolactin.
Martin has been admitted to the addictions unit to undergo detoxification from opiates. He has been known to suffer from low blood pressure.
Which of the following would be the best agent to treat his withdrawal symptoms?
A. Buprenorphine is preferable to α2 adrenergic agonists if there are concerns about bradycardia or hypotension. Buprenorphine results in lower severity of withdrawal symptoms than α2 adrenergic agonists. Buprenorphine can be used for short-term opioid withdrawal and has a better outcome than clonidine. Methadone and α2 adrenergic agonists (e.g. clonidine and lofexidine) also have a good evidence base for reducing withdrawal symptoms. If a short duration of treatment is desirable, α2 adrenergic agonists are preferable to methadone. Methadone treatment is more successful if carried out slowly or with a linear dose reduction. Methadone can be used during pregnancy, and there are emerging studies regarding the use of buprenorphine. α2 adrenergic agonists should not be prescribed in pregnancy.
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