QuestionSBA
QuestionChoice
This is a reasonable differential as the signs and symptoms of alcohol and opiate withdrawal are very similar, however, dilated pupils are more commonly associated with opiate withdrawal than alcohol
32680
c
Alcohol withdrawal
QuestionChoice
This patient may well be anxious as they have just been arrested, and anxiety can account for some of the symptoms described but would not account for the shivering or the dilated pupils
32679
b
Anxiety attack
QuestionChoice
Drug abuse can lead to drug-induced psychosis. However, this is not the clinical picture here
32681
d
Acute psychosis
QuestionChoice
Drug and alcohol abuse (particularly cocaine use) can raise the risk of myocardial infarction; however, this is not the most likely diagnosis
32682
e
Acute myocardial infarction
QuestionChoice
This patient is showing some of the classic signs and symptoms of early opiate withdrawal. Treatment in the first instance should be supportive, and patients may require fluid resuscitation to replace fluids lost through sweating and diarrhoea. Should they wish it, the patient can have withdrawal management with either buprenorphine or methadone; however, this should be managed by an experienced professional
32678
a
Opiate withdrawal
QuestionComment
Pinpoint pupils = opiate misuse/overdose, withdrawal causes dilation. 
25387
QuestionComment
basic
59837
User
subscriber
Viral Sclerosis
User
subscriber
Impatient patient
Concept
Chapter

# Substance misuse

### Definition
- According to ICD-10, mental and behavioural disorders secondary to substance misuse may be categorised as follows: 
	- Acute intoxication
	- Harmful use (damage to health, either physical or mental)
	- Dependence syndrome
	- Withdrawal state
	- Withdrawal state with delirium
	- Psychotic disorder
	- Amnesic syndrome
	- Residual and late-onset psychotic disorder
 
# Opiate Intoxication and Withdrawal 
- This includes heroin, and they exert their effects through acting on the opioid receptors
- Features are:
	- Drowsiness
	- Confusion
	- Decreased respiratory rate
	- Decreased heart rate
	- Constricted pupils
	- Track marks (needle marks) if the intravenous route has been used; abscesses at injection sites; veins thrombosed and damaged causing difficulties with intravenous access (causing difficulty in 
- Opiate withdrawal is a common issue that may be encountered within general medicine due to the prevalence of opiate abuse. Withdrawal from heroin can begin as early as 6 hours after the last dose, with symptoms peaking at 36-72 hours. Unlike alcohol withdrawal, it is unpleasant but not especially dangerous or life-threatening.
- Features include: 
	- Agitation
	- Anxiety and irritability 
	- Muscle aches or cramps
	- Chills
	- Runny eyes
	- Runny nose
	- Sweating
	- Hypersalivation
	- Yawning
	- Insomnia
	- Gastrointestinal disturbance such as abdominal cramps, nausea, diarrhoea and vomiting
	- Dilated pupils
	- Piloerection 
	- Increased heart rate and blood pressure
- Drugs used in the management of opiate abuse include:
	- **During withdrawal** the following drugs may be used to help with symptoms:
		- Methadone: beware, may cause prolonged QTc
		- Lofexidine (alpha 2 receptor agonist)
		- Loperamide (for diarrhea) 
		- Anti-emetics (for nausea)
		- Benzodiazepines (for agitation)
		--> NICE advises against prescribing opiates during opiate withdrawal, but prefers symptomatic management or use of lofexidine. 
	- **Detox programmes** use methadone and buprenorphine (the latter is a partial agonist of the opiate receptor, so can trigger withdrawal) 
	- **Relapse** can be prevented using neltrexone once detox is complete.
	- **Overdose**  can be managed with naloxone 

# Alcohol Intoxication, Withdrawal, and Wernicke-Korsakoff Syndrome 
- Alcohol abuse is common. Features of intoxication include:
	- Ataxic gait
	- Nausea and vomiting
	- Reduced GCS
	- Dysarthria
	- Impaired judgement 
- Alcohol withdrawal is a potentially life-threatening syndrome with characteristic features. Onset is usually 12 hours after the last drink:
	- Nausea and vomiting
	- Tremor
	- Sweating
	- Anxiety
	- Agitation
	- Headache
	- Clouding of consciousness 
		- These features are summarised by the 'CIWA' score - Clinical Institute Withdrawal Assessment for Alcohol - which could be used to monitor for signs of alcohol withdrawal, and to guide management.
		- Prevention and treatment of alcohol withdrawal is with short acting benzodiazepines such as chlordiazepoxide (Librium) and oxazepam (latter if there is evidence of liver injury.)
		- Supportive treatment includes fluids, anti-emetics, and Pabrinex (to prevent Wernicke-Korsakoff's syndrome.)
		- Referral to local drug and alcohol liaison teams should be offered.
	- Delirium tremens is a life threatening medical emergency, and usually occurs at day 3 of withdrawal, and lasts 3 days, characterised by paranoid delusions, visual/auditory and classically haptic (tactile) hallucinations (sensation of crawling e.g. formication), and seizures. Once delirium tremens starts, NICE recommends oral lorazepam as first line, and if the oral route cannot be used for whatever reason, parenteral lorazepam or haloperidol. 
- Wernicke-Korsakoff Syndrome:
	-  A syndrome associated with chronic alcohol abuse that occurs due to B1 (thiamine) deficiency, resulting in mammillary body atrophy. It is not exclusive to alcohol abuse, however, with any individual with severe nutritional deficiency at risk. 
	- It may be precipitated by a period of excess vomiting (which may reduce nutrition further) and giving a glucose load prior to provision of B vitamins in a hypoglycaemic, malnourished patient. 
	- Wernicke's encephalopathy - a reversible presentation (treaed with high dose intravenous thiamine, e.g. Pabrinex), characterised by a classical tetrad of: 
		- Confusion
		- Ataxia
		- Ophthalmoplegia: classically of the lacteral rectus, but can also be an internuclear ophthalmoplegia or upward-gaze defects 
		- Nystagmus 
		- Less classical features include urinary incontinence and hypothermia due to autonomic neuropathy, making normal pressure hydrocephalus a key differential. 
	- Korsakoff's psychosis - this is an irreversible manifestation of untreated Wernicke's encephalopathy. It is characterised by:
		- Retrograde amnesia
		- Anterograde amnesia
		- Confabulation 

# Cannabis Intoxication
- This includes marijuana, and they exert their effects through acting on the cannabinoid receptors
- Features are:
	- Drowsiness
	- Impaired memory
	- Slowed reflexes 
	- Slowed motor skills 
	- Conjunctival injection 
	- Increased appetite
	- Paranoia and psychotic symptoms (contrast with cannabinoid associated schizophrenia, which has a more insidious onset, over many years)
	- Tachycardia
	- Dry mouth 

# LSD (Lysergic Acid Dethylamide) Intoxication
- LSD, a psychedelic drug, acts at the dopamine receptors primarily.
- Features include: 
	- Labile mood
	- Hallucinations
	- Increased blood pressure
	- Increased heart rate
	- Increased temperature
	- Sweating
	- Insomnia
	- Dry mouth

# Stimulant Intoxication
- These include cocaine, methamphetamine, or MDMA (ecstasy) 
	- MDMA induces rapid serotonin and dopamine release, and directly binds to the 5HT2 receptor
	- Cocaine prevents reuptake of dopamine, noradrenaline, and seroton, resulting in increased levels of free serotonin and dopamine
	- Methamphetamine acts at the sigma receptors, which induces dopamine release 
	- Stimulants such as cocaine or methamphetamine can, in low doses, produce a feeling of increased concentration and focus. Cocaine acts at dopamine receptors. Methamphetamine acts at TAAR1 (Trace Amine-Associated Receptor 1) receptors. Both increase the available amount of dopamine in the brain, producing the associated pleasurable effects of the drugs.
- Features include:
	- Euphoria
	- Hypertensive crises
	- Increased heart rate
	- Dilated pupils
	- Increased temperature
	- Rhabdomyolysis 
	- Seizures
	- Agitation 
	- Arrythmias 
	- Psychosis  
	- Excessive thirst and SIADH, resulting in water overload and hyponatraemia, especially with MDMA, and associated complications from this.
	- Ischaemic events (cardiac, pulmonary, bowel, CNS) with cocaine due to vasospasm  
- Deaths can occur due to hyperpyrexia and hypertension, so cooling, use of antihypertensives such as nitroprusside or GTN, and benzodiazepines, is the mainstay of management. 
- Withdrawal syndromes are not a typical feature of stimulant abuse.



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Substance misuse
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Psychiatry
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Opiate withdrawal presents with symptoms such as tremors, sweating, dilated pupils, and gastrointestinal disturbances.
The police bring a 32-year-old male to the Emergency Department after being injured whilst resisting arrest for theft. On review, he has only minor injuries, but you notice that he is starting to shiver, sweat, retch and has a tremor. His pupils are dilated.

What is the most likely diagnosis?
a