{"id":37210,"date":"2026-07-04T07:54:14","date_gmt":"2026-07-04T02:24:14","guid":{"rendered":"https:\/\/atsixty.com\/?p=37210"},"modified":"2026-07-04T07:54:15","modified_gmt":"2026-07-04T02:24:15","slug":"substance-use-disorders-alcohol-opioids-beyond","status":"publish","type":"post","link":"https:\/\/atsixty.com\/index.php\/morning-rounds\/substance-use-disorders-alcohol-opioids-beyond\/","title":{"rendered":"Substance Use Disorders \u2014 Alcohol, Opioids & Beyond"},"content":{"rendered":"\n\n\n\n\nMorning Rounds · Psychiatry · Substance Use Disorders<\/title>\n<link href=\"https:\/\/fonts.googleapis.com\/css2?family=Playfair+Display:ital,wght@0,400;0,600;0,700;1,400;1,600&family=Source+Serif+4:ital,wght@0,300;0,400;0,600;1,400&display=swap\" rel=\"stylesheet\">\n<style>\n#psy06 *,#psy06 *::before,#psy06 *::after{box-sizing:border-box;margin:0;padding:0}\n#psy06{\n --py:#34547A;\n --py-light:#4A6B95;\n --py-pale:#E8EEF5;\n --py-dark:#243C56;\n 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.mr-band-s{background:var(--py-pale);color:var(--py)}\n#psy06 .mr-retry{display:block;margin:18px auto 4px;background:transparent;border:2px solid var(--py);color:var(--py);border-radius:8px;padding:9px 28px;font-family:'Playfair Display',serif;font-size:0.92rem;font-weight:700;cursor:pointer}\n#psy06 .mr-retry:hover{background:var(--py);color:#EEF3FA}\n@media(max-width:480px){#psy06 .mr-title{font-size:1.4rem}#psy06 .mr-num{font-size:1.7rem}#psy06 .mr-stem{font-size:0.9rem}#psy06 .mr-opt-text{font-size:0.86rem}}\n<\/style>\n\n<div id=\"psy06\">\n\n <div class=\"mr-header\">\n <div class=\"mr-eyebrow\">Morning Rounds · Psychiatry Series · Round 06<\/div>\n <div class=\"mr-title\">\n Substance Use Disorders —<br><em>Alcohol, Opioids & Beyond<\/em>\n <\/div>\n <div class=\"mr-subtitle\">Five cases · Withdrawal, Wernicke's, opioid reversal, substitution therapy & cannabis · Trust your instinct<\/div>\n <div class=\"mr-chips\">\n <span class=\"mr-chip\">5 Cases<\/span>\n <span class=\"mr-chip\">+4 \/ −1 scoring<\/span>\n <span class=\"mr-chip\">Options reshuffled<\/span>\n <\/div>\n <\/div>\n\n <div class=\"mr-sentinel\" id=\"psy06-sentinel\"><\/div>\n\n <div class=\"mr-progress\" id=\"psy06-progress\">\n <div class=\"mr-prog-inner\">\n <div class=\"mr-pips\" id=\"psy06-pips\"><\/div>\n <\/div>\n <\/div>\n\n <div class=\"mr-body\">\n <div id=\"psy06-cases\"><\/div>\n <div class=\"mr-submit-wrap\">\n <button class=\"mr-btn\" id=\"psy06-submit\">Submit for Debrief<\/button>\n <\/div>\n <div class=\"mr-score\" id=\"psy06-score\">\n <div class=\"mr-score-in\">\n <div class=\"mr-score-ey\">Round Complete<\/div>\n <div class=\"mr-ring\" id=\"psy06-ring\">\n <div class=\"mr-ring-in\">\n <span class=\"mr-ring-pct\" id=\"psy06-pct\">0%<\/span>\n <span class=\"mr-ring-sub\">net<\/span>\n <\/div>\n <\/div>\n <div class=\"mr-score-title\">Your Debrief<\/div>\n <div class=\"mr-score-net\" id=\"psy06-net\"><\/div>\n <div class=\"mr-verdict\" id=\"psy06-verdict\"><\/div>\n <div class=\"mr-bands\">\n <span class=\"mr-band mr-band-c\" id=\"psy06-ct-c\"><\/span>\n <span class=\"mr-band mr-band-w\" id=\"psy06-ct-w\"><\/span>\n <span class=\"mr-band mr-band-s\" id=\"psy06-ct-s\"><\/span>\n <\/div>\n <button class=\"mr-retry\" id=\"psy06-retry\">↻ New Round<\/button>\n <\/div>\n <\/div>\n <\/div>\n\n<\/div><!-- end #psy06 -->\n\n<script>\n(function () {\n 'use strict';\n\n var NS = 'psy06';\n var TOTAL = 5;\n var MAX = 20;\n var LTRS = ['A','B','C','D'];\n\n var QS = [{\"id\": 1, \"tag\": \"Alcohol Withdrawal: Seizure Risk & Benzodiazepine Protocol\", \"stem\": \"A 45-year-old daily heavy drinker is admitted after his last drink 18 hours ago. He has coarse tremor, diaphoresis, tachycardia, and is agitated. What is the risk if untreated, and what is the first-line pharmacological approach?\", \"correct\": \"Untreated alcohol withdrawal risks seizures and delirium tremens; chlordiazepoxide on a symptom-triggered reducing protocol is first-line.\", \"opts\": [\"Untreated alcohol withdrawal risks seizures and delirium tremens; chlordiazepoxide on a symptom-triggered reducing protocol is first-line.\", \"Alcohol withdrawal is self-limiting within 24 hours; haloperidol is first-line since agitation here reflects an underlying psychotic process.\", \"The main risk is Wernicke's encephalopathy from dehydration alone; IV fluids without any benzodiazepine are the appropriate first-line management here.\", \"Untreated withdrawal risks seizures; however lorazepam is absolutely contraindicated and propranolol is the correct pharmacological first-line.\"], \"exp\": \"Alcohol withdrawal reflects CNS hyperexcitability from upregulated NMDA receptors and downregulated GABA-A receptors after chronic alcohol suppression. Untreated, it can progress to withdrawal seizures (typically 24–48 hours after last drink) and delirium tremens (48–72 hours), which carries significant mortality. Benzodiazepines — chlordiazepoxide or diazepam — are first-line, cross-tolerant with alcohol at GABA-A receptors and given on either a symptom-triggered (CIWA-Ar guided) or fixed reducing schedule.<br><br>Alcohol withdrawal is not reliably self-limiting within 24 hours, and haloperidol lowers seizure threshold — it is not first-line here. The Wernicke's risk is real (from thiamine deficiency, not dehydration) and requires IV thiamine supplementation, but benzodiazepines remain the backbone of withdrawal management, not a supplementary add-on. And lorazepam is actually frequently used in alcohol withdrawal (particularly IV in severe cases) — it is not contraindicated; propranolol addresses autonomic symptoms but doesn't prevent seizures or delirium.\", \"imgId\": null}, {\"id\": 2, \"tag\": \"Wernicke's Encephalopathy: Triad & Thiamine Priority\", \"stem\": \"A chronic alcohol user presents with confusion, ataxia, and bilateral lateral gaze palsies. What is the diagnosis, what must be given immediately, and why must glucose precede thiamine administration be reversed?\", \"correct\": \"Wernicke's encephalopathy — IV thiamine before or alongside glucose, since glucose alone precipitates acute thiamine depletion.\", \"opts\": [\"Wernicke's encephalopathy — IV thiamine before or alongside glucose, since glucose alone precipitates acute thiamine depletion.\", \"Delirium tremens — the triad of confusion, ataxia, and gaze palsy is its defining presentation, treated with benzodiazepines before any thiamine.\", \"Wernicke's encephalopathy — but oral thiamine is equally effective as IV in this setting, so parenteral administration adds no clinical advantage.\", \"Korsakoff's syndrome — confusion and ataxia are its defining features, and thiamine plays no meaningful role in the acute management phase.\"], \"exp\": \"Wernicke's encephalopathy is the acute thiamine-deficiency triad: confusion, ataxia, and ophthalmoplegia (classically lateral gaze palsies or nystagmus). Thiamine (vitamin B1) must be given IV before or alongside glucose — giving glucose first in a thiamine-depleted patient drives the already-deficient cofactor into metabolic pathways, acutely worsening depletion and potentially precipitating or worsening Wernicke's. IV thiamine (Pabrinex) is necessary because gut absorption is unreliable in heavy drinkers.<br><br>Delirium tremens is hyperadrenergic withdrawal, not this triad. Benzodiazepines before thiamine would be the wrong priority here; the neurological emergency is Wernicke's. Oral thiamine has poor and unreliable absorption in this population — IV is the standard. And Korsakoff's syndrome is the chronic amnestic sequela of untreated Wernicke's, not the acute presentation; thiamine is central to preventing its development.\", \"imgId\": null}, {\"id\": 3, \"tag\": \"Opioid Overdose vs. Opioid Withdrawal: Directions of Signs\", \"stem\": \"Patient A has pinpoint pupils, respiratory rate of 6, and is unrousable. Patient B, dependent on heroin, missed his dose 16 hours ago and now has dilated pupils, piloerection, diarrhoea, and cramping. What are the two states, and what drug is used acutely in Patient A?\", \"correct\": \"Patient A: opioid overdose — naloxone IV\/IM is the reversal agent; Patient B: opioid withdrawal, distressing but rarely life-threatening.\", \"opts\": [\"Patient A: opioid overdose — naloxone IV\/IM is the reversal agent; Patient B: opioid withdrawal, distressing but rarely life-threatening.\", \"Patient A: opioid withdrawal; Patient B: opioid overdose — naltrexone is the correct acute reversal agent given IV immediately in overdose.\", \"Both are opioid overdose at different stages; naloxone is given to both, since pupillary dilation in Patient B also reflects opioid toxicity.\", \"Patient A: overdose reversed with methadone; Patient B: withdrawal treated urgently with naloxone to clear residual opioid from receptors.\"], \"exp\": \"Opioid overdose produces the classic triad of miosis (pinpoint pupils), CNS depression, and respiratory depression — the life-threatening element is hypoventilation. Naloxone, a competitive opioid-receptor antagonist, reverses this rapidly (IV or IM; intranasal formulations also exist). Opioid withdrawal produces the opposite autonomic picture: mydriasis, piloerection, lacrimation, diarrhoea, and cramping — highly distressing but not acutely life-threatening in otherwise healthy adults.<br><br>The signs are directionally opposite: overdose = miosis + CNS depression; withdrawal = mydriasis + hyperactivity. Naltrexone is an oral opioid antagonist used for relapse prevention, not acute overdose reversal. Pupillary dilation in withdrawal is a sympathetic rebound sign, not toxicity. And methadone is used for opioid substitution therapy, not acute overdose reversal; naloxone is used in overdose, not withdrawal.\", \"imgId\": null}, {\"id\": 4, \"tag\": \"Opioid Substitution: Methadone vs. Buprenorphine\", \"stem\": \"A patient with heroin use disorder is being considered for opioid substitution therapy. What are the key pharmacological differences between methadone and buprenorphine-naloxone, and what determines which is more appropriate?\", \"correct\": \"Methadone is a full agonist with overdose risk; buprenorphine's partial agonism gives it a respiratory depression ceiling, safer unsupervised.\", \"opts\": [\"Methadone is a full agonist with overdose risk; buprenorphine's partial agonism gives it a respiratory depression ceiling, safer unsupervised.\", \"Both are full opioid agonists with identical overdose risk profiles, so choice between them depends only on patient preference and formulation.\", \"Buprenorphine is a full agonist with higher overdose risk than methadone; methadone's partial agonism limits its respiratory depression ceiling.\", \"Methadone carries no meaningful overdose risk since its long half-life prevents the plasma peaks that drive respiratory depression in misuse.\"], \"exp\": \"Methadone is a full mu-opioid agonist with a long, variable half-life and significant overdose risk, especially during induction; it is typically dispensed daily in supervised settings. Buprenorphine is a partial mu-agonist with a ceiling effect on respiratory depression, making it inherently safer in unsupervised take-home settings; the naloxone component (in Suboxone) deters injection misuse since naloxone is poorly absorbed sublingually but precipitates withdrawal if injected. Choice depends on supervision availability, prior treatment history, and patient stability.<br><br>These drugs are pharmacologically distinct — their agonist profiles and overdose risks differ meaningfully. The partial vs. full agonist distinction is precisely reversed in the third option. And methadone's long half-life actually increases overdose risk during induction, as accumulation is unpredictable — a long half-life does not eliminate peak-related respiratory depression risk.\", \"imgId\": null}, {\"id\": 5, \"tag\": \"Cannabis Use Disorder & Acute Cannabis Intoxication\", \"stem\": \"A 19-year-old presents acutely with paranoia, tachycardia, conjunctival injection, and dry mouth after using cannabis. A friend asks whether cannabis is 'safe because it's not addictive.' What is the diagnosis, and how should the addiction claim be addressed?\", \"correct\": \"Acute cannabis intoxication; cannabis use disorder is a recognised DSM-5 diagnosis, with roughly 9% of users developing dependence over time.\", \"opts\": [\"Acute cannabis intoxication; cannabis use disorder is a recognised DSM-5 diagnosis, with roughly 9% of users developing dependence over time.\", \"Acute cannabis intoxication; cannabis causes no withdrawal syndrome and no physical dependence, so use disorder cannot be formally diagnosed.\", \"Stimulant intoxication, since tachycardia and paranoia are specific to stimulant toxidrome, and cannabis cannot cause these features acutely.\", \"Acute cannabis intoxication; cannabis use disorder exists only in daily users over decades, not in adolescent recreational users by definition.\"], \"exp\": \"Acute cannabis intoxication classically produces euphoria or anxiety\/paranoia, tachycardia, conjunctival injection, dry mouth, and increased appetite. Cannabis use disorder is a DSM-5 diagnosis, and dependence develops in approximately 9% of users who ever try cannabis, rising to around 17% in daily users — the claim that cannabis is non-addictive is factually incorrect. Withdrawal is also recognised: irritability, anxiety, sleep disturbance, and decreased appetite.<br><br>Cannabis does produce a recognised withdrawal syndrome and can cause physical and psychological dependence — DSM-5 formalises this as cannabis use disorder. Tachycardia and paranoia are well-recognised features of cannabis intoxication, not exclusively stimulant toxidrome. And cannabis use disorder is not restricted to decades of daily use — it can develop in adolescent users, among whom the risk of dependence and psychiatric sequelae is actually higher than in adults.\", \"imgId\": null}];\n\n var answers = {};\n var answered = 0;\n var shuffled = {};\n var done = false;\n\n function byId(id) { return document.getElementById(id); }\n function gid(suffix) { return byId(NS + '-' + suffix); }\n\n function shuffleArr(arr) {\n var a = arr.slice(), i, j, tmp;\n for (i = a.length - 1; i > 0; i--) {\n j = Math.floor(Math.random() * (i + 1));\n tmp = a[i]; a[i] = a[j]; a[j] = tmp;\n }\n return a;\n }\n\n function countVal(val) {\n var k, n = 0;\n for (k in answers) {\n if (answers.hasOwnProperty(k) && answers[k] === val) n++;\n }\n return n;\n }\n\n function buildPips() {\n var cont = gid('pips'), i, q, wLine, wPip, line, pip;\n cont.innerHTML = '';\n for (i = 0; i < QS.length; i++) {\n q = QS[i];\n if (i > 0) {\n wLine = document.createElement('div');\n wLine.className = 'mr-pip-wrap';\n line = document.createElement('div');\n line.className = 'mr-pip-line';\n line.id = NS + '-pl' + q.id;\n wLine.appendChild(line);\n cont.appendChild(wLine);\n }\n wPip = document.createElement('div');\n wPip.className = 'mr-pip-wrap';\n pip = document.createElement('div');\n pip.className = 'mr-pip';\n pip.id = NS + '-pip' + q.id;\n pip.textContent = String(q.id);\n wPip.appendChild(pip);\n cont.appendChild(wPip);\n }\n }\n\n function build() {\n var cont, i, q, opts, card, top, numDiv, meta, tag, stem,\n rule, optsDiv, expDiv, lbl, txt, imgDiv, imgSrc, j,\n optEl, ltrSpan, txtSpan;\n\n cont = gid('cases');\n cont.innerHTML = '';\n answers = {}; answered = 0; shuffled = {}; done = false;\n gid('score').style.display = 'none';\n buildPips();\n\n for (i = 0; i < QS.length; i++) {\n q = QS[i];\n opts = shuffleArr(q.opts);\n shuffled[q.id] = opts;\n\n card = document.createElement('div');\n card.className = 'mr-case';\n\n top = document.createElement('div');\n top.className = 'mr-case-top';\n\n numDiv = document.createElement('div');\n numDiv.className = 'mr-num';\n numDiv.textContent = q.id < 10 ? 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