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Q1: Diagnosis and definition (2 min)
Examiner: Define substance use disorder. How is it classified by DSM-5, and how does this differ from the older abuse/dependence dichotomy?
Expected answer: SUD is a chronic relapsing brain disease defined in DSM-5 by 2 or more of 11 criteria within a 12-month period — graded mild (2 to 3), moderate (4 to 5), severe (6 or more). DSM-5 replaced the categorical abuse/dependence distinction with a single dimensional continuum, recognising that physiological dependence alone does not equate to a disorder, and that severity matters. ICD-10 retained a dependence syndrome (3+ of 6 features in 12 months: tolerance, withdrawal, salience, impaired control, continued use despite harm, reinstatement after abstinence); ICD-11 aligns more closely with DSM-5.
The 11 DSM-5 criteria fall into four domains: impaired control (larger/longer than intended, failed quit attempts, craving, time spent), social impairment (neglected roles, social problems, activities given up), risky use (hazardous situations, continued use despite harm), and pharmacological indicators (tolerance, withdrawal).
Q2: Alcohol withdrawal management (3 min)
Examiner: A chronic heavy drinker is admitted and develops tremor and agitation 12 hours after his last drink. Walk me through your assessment and management.
Expected answer: I would assess severity with CIWA-Ar (10 items, max 67 — under 8 mild, 8 to 15 moderate, over 15 severe). Management is benzodiazepine-based, ideally symptom-triggered via CIWA-Ar. Chlordiazepoxide is preferred in uncomplicated withdrawal (long-acting, smooth taper; typical regimen 10 to 20 mg QDS day 1, tapering over 5 to 7 days). If there is significant liver disease, switch to lorazepam (or oxazepam, temazepam) — all glucuronide-conjugated only, with no oxidative metabolism, safer in cirrhosis.
Adjuncts every patient gets: IV thiamine 300 to 500 mg TDS for 3 to 5 days BEFORE any glucose (prevents Wernicke — confusion + ataxia + ophthalmoplegia; Korsakoff = anterograde amnesia + confabulation); folic acid 5 mg, replete magnesium, potassium, phosphate; hydration; treat intercurrent infection.
The withdrawal timeline: minor 6 to 12 h, hallucinosis 12 to 48 h, seizures 24 to 48 h, delirium tremens 48 to 72 h (confusion + vivid hallucinations + autonomic storm; mortality 5 percent untreated — ICU, IV benzodiazepine). Always check glucose, sodium, and consider CT/LP if there are atypical features.
Q3: Opioid overdose and MAT (3 min)
Examiner: A patient is brought in with coma, pinpoint pupils and respiratory rate 6. Discuss the immediate management, and then the long-term treatment of opioid use disorder.
Expected answer: This is the opioid overdose triad — coma + pinpoint pupils (under 2 mm) + respiratory depression. Immediate: naloxone 0.4 to 0.8 mg IV/IM/intranasal (intranasal commercial prep is 4 mg per spray), repeat every 2 to 3 minutes up to 10 mg. The goal is adequate respiration, not full alertness — over-resuscitation precipitates withdrawal. Because most opioids outlast naloxone, set up an infusion (0.4 to 0.8 mg/h) and observe at least 6 to 12 hours (24 hours for methadone/fentanyl). Secure airway, recovery position, intubate if GCS 8 or less. Note xylazine ('tranq') is naloxone-unresponsive.
Long-term: medication-assisted treatment (MAT) is the most effective intervention and reduces mortality by over 50 percent. Three options: methadone 60 to 120 mg daily (full agonist; supervised dispensing; ECG for QT prolongation); buprenorphine-naloxone 8 to 24 mg SL daily (partial agonist with ceiling on respiratory depression = safer; induce only at COWS over 12 to avoid precipitated withdrawal; naloxone component deters IV misuse); extended-release naltrexone 380 mg IM monthly (for patients already 7 to 10 days opioid-free). Add CBT, contingency management, motivational interviewing, AA/NA; harm reduction (needle exchange, take-home naloxone, supervised consumption sites).
Q4: Prognosis, complications and special populations (2 min)
Examiner: What are the major complications of substance use disorders, and how do you approach pregnancy?
Expected answer: Complications: acute — overdose (respiratory depression, death), trauma, withdrawal seizures, DTs, Wernicke-Korsakoff; chronic alcohol — cirrhosis, HCC, pancreatitis, cardiomyopathy, neuropathy, cerebellar degeneration, FASD; chronic opioid — HIV/HBV/HCV, right-sided endocarditis, septic emboli, epidural abscess; chronic stimulant — MI, stroke, aortic dissection, psychosis. Psychosocial: unemployment, homelessness, suicide (greatly elevated — assess every patient).
Pregnancy: there is no safe alcohol level (FASD — growth restriction, characteristic facies, neurodevelopmental impairment). For opioid-dependent women, methadone or buprenorphine maintenance is preferred over detoxification (detox risks relapse and fetal distress); do not initiate naltrexone in pregnancy. The neonate develops neonatal abstinence syndrome (NAS) — scored with the modified Finnegan tool, treated with oral morphine or methadone solution, weaning over weeks. Breastfeeding is encouraged on stable methadone/buprenorphine. SUD is a chronic relapsing illness — relapse is a clinical event to manage, not a moral failure; retention in treatment predicts survival.