AKT- Addiction Medicine

James Doherty, aged 45, presents requesting diazepam. He reports feeling anxious and not sleeping well after being recently laid off from work. He has a history of generalised anxiety disorder and was previously prescribed diazepam for short-term use two years ago. He denies suicidal ideation, hallucinations, or current alcohol use. He drinks socially on weekends. There is no history of psychosis or bipolar disorder.

On examination he appears anxious but cooperative. Vital signs are within normal limits.

What is the MOST appropriate next step in management?

David Muir, aged 62, presents for a routine check-up. He has a 40 pack-year smoking history and drinks a six-pack of beer daily. He denies withdrawal symptoms or blackout episodes. Blood pressure is 145/88 mmHg. His liver function tests show mildly elevated GGT and ALT.

He is not ready to quit alcohol but is willing to discuss his drinking.

What is the MOST appropriate screening tool to assess the severity of David’s alcohol use?

Layla Nguyen, aged 28, presents at 10 weeks’ gestation requesting support for methamphetamine cessation. She has been using methamphetamine twice weekly for the past year and has attempted to quit unsuccessfully in the past. She is currently living in a stable home and expresses motivation to stop due to the pregnancy. She denies use of other substances.

Her vital signs are normal and fetal viability is confirmed on ultrasound.

What is the MOST appropriate next step in management?

Mohammed El-Amin, aged 35, presents requesting help quitting smoking. He has made two previous quit attempts using nicotine patches but relapsed due to stress. He smokes 20 cigarettes per day. He is open to trying medication this time and prefers a non-nicotine option.

Past history includes mild depression which resolved two years ago. No current medications.

What is the MOST appropriate pharmacological option to support smoking cessation?

Jacinta Waters, aged 33, presents with her partner who is concerned about her increasing time spent gambling online. She admits to gambling several hours most days and has lied about the amount of money lost. She says she finds it hard to stop once she starts. No alcohol or drug use. No current suicidal ideation. She works as a retail assistant and has mounting credit card debt.

What is the MOST appropriate initial management step?

Thomas Hegarty, aged 47, presents requesting a refill of oxycodone which was previously prescribed after a workplace back injury 6 months ago. He reports persistent lower back pain and says that only oxycodone helps. He is vague about the number of tablets used and does not have a pain management plan. He denies alcohol or other drug use. His mood is low but denies suicidal ideation. Examination reveals no neurological deficit and normal gait.

What is the MOST appropriate next step in his management?

Angela Russo, aged 31, presents seeking help for heroin use. She has been using daily for the past year, mainly via injection. She has had several non-fatal overdoses, and her partner recently died from an overdose. She is motivated to stop and asks about starting treatment today. She has not used heroin today and has moderate cravings. Physical examination is normal. She lives in a supported housing program.

What is the MOST appropriate next step in her management?

Brendan King, aged 56, presents to discuss his long-term use of codeine. He started using over-the-counter preparations years ago for migraines, but has continued taking Nurofen Plus daily. He now takes 12 tablets per day. He reports fatigue and abdominal pain. He admits to multiple unsuccessful attempts to stop.

Investigations show microcytic anaemia and mildly elevated liver enzymes.

What is the MOST appropriate management plan?

Samantha Elliott, aged 22, is brought in by her parents who are concerned about her excessive use of cannabis. She dropped out of university last year and spends most days in her room, smoking cannabis and playing video games. She becomes irritable if she doesn’t smoke and has had several episodes of paranoia. She denies suicidal ideation. Her urine drug screen is positive for cannabis only.

What is the MOST appropriate first-line intervention?

Graham Daniels, aged 39, presents for review of his alcohol dependence. He has had multiple previous detox admissions and has resumed drinking after each. He drinks approximately 12 standard drinks daily. He has early morning shakes and drinks to relieve them. He has previously tried acamprosate and naltrexone without success. He is now interested in trying something else and asks about options.

He is not currently drinking due to recent detox in hospital. He is living in supported accommodation and has a case worker.

What is the MOST appropriate pharmacological treatment to offer?

Christine Petrou, aged 49, presents requesting help to stop using diazepam, which she has taken daily for over 3 years. She originally began taking it for insomnia during a stressful divorce. She currently takes 10 mg at night. She reports poor concentration, daytime sedation, and fears she may be dependent. She has no current substance use and is otherwise healthy. She is motivated to reduce her use.

What is the MOST appropriate first step in managing her benzodiazepine dependence?

Zane Hopwood, aged 25, presents seeking help to reduce his use of MDMA. He reports using pills or powder most weekends over the past year. He describes feeling “flat” during the week and relies on stimulants to feel social. He is otherwise physically well. No history of psychosis or depression. He is working full-time in hospitality. He asks about medications to help stop using.

What is the MOST appropriate initial management approach?

Nina Barbour, aged 42, presents with difficulty sleeping and low mood. She has a history of alcohol dependence and has been abstinent for 6 months with support from a rehabilitation program. She is attending weekly counselling. She asks if she can try melatonin or a “sleeping tablet” to help her maintain her abstinence by improving sleep.

What is the MOST appropriate option?

Jason Karam, aged 34, presents to follow up a positive urine drug screen. He is on a workplace random testing program and tested positive for THC. He says he last used “a few joints” on the weekend. He works in a safety-sensitive role and his employment is at risk. He denies dependence or daily use, and says he only uses socially once or twice a month.

What is the MOST appropriate initial management?

Eileen Tunks, aged 67, presents for opioid dependence treatment. She was started on oxycodone for chronic osteoarthritis 2 years ago and is now taking over 80 mg/day. She reports drowsiness, constipation, and no longer finds pain relief. She is worried she’s addicted and wants help. She is otherwise healthy and lives alone.

What is the MOST appropriate management option?

Kevin Zhou, aged 39, presents seeking assistance with quitting alcohol. He drinks 8–10 standard drinks daily and has noticed morning tremors, sweating, and nausea. He last drank yesterday evening. He has no previous withdrawal seizures or hospitalisations. Vitals today are HR 96 bpm, BP 140/88 mmHg, RR 18. He appears anxious but oriented and alert. CIWA-Ar score is 10.

What is the MOST appropriate next step in management?

Lachlan Smythe, aged 20, is brought in by his parents. They report he has become increasingly withdrawn, with poor hygiene and erratic sleep. He admits to regular cannabis use and occasional LSD. He believes the TV is sending him messages. He denies alcohol use and has no medical history. Examination reveals a flat affect and disorganised thought processes.

What is the MOST likely diagnosis?

Vera Lang, aged 60, is a long-term smoker of 30 cigarettes per day. She has tried nicotine patches and lozenges previously but relapsed each time. She has COPD and is keen to quit before her next spirometry review. She is open to tablets if needed. There is no history of mental illness or recent cardiovascular events.

What is the MOST appropriate pharmacological option?

Rajiv Nair, aged 48, presents requesting Suboxone after moving interstate. He reports being on buprenorphine-naloxone 8 mg daily for opioid dependence. He has a prescription summary and states he has not used heroin for over a year. He has been unable to access a prescriber locally and is now in mild withdrawal. You are not a prescriber for medication-assisted treatment of opioid dependence (MATOD).

What is the MOST appropriate next step?

Aleesha Morris, aged 36, presents with severe insomnia and anxiety. She has been taking over-the-counter codeine-containing analgesics nightly to “help her sleep” for 18 months. She now takes 10–12 tablets of paracetamol/codeine nightly. She denies other substance use. She has not seen a GP in several years. You suspect medication overuse and dependency.

What is the MOST appropriate initial investigation?

Matilda Clegg, aged 29, is 8 weeks postpartum and presents with worsening mood, fatigue, and anxiety. She has a history of postnatal depression with her first child. She admits to drinking 4–6 standard drinks nightly to ‘calm her nerves’ since the baby was born. She is not breastfeeding. She wants help but feels ashamed.

What is the MOST appropriate next step in management?

Peter Zahos, aged 67, is a retired accountant with a history of hypertension and osteoarthritis. His daughter brings him in concerned that he has been increasingly forgetful and sleepy during the day. He admits to taking over-the-counter sleep aids including diphenhydramine and also uses codeine regularly for back pain. He denies alcohol use. Mini-Mental State Examination score is 25/30.

What is the MOST likely contributor to his symptoms?

Callum Ngata, aged 30, presents after losing his licence due to drink driving. He admits he had a problem with alcohol and has since cut back significantly, now drinking only once a week. He is seeking a letter of support to regain his driver’s licence. You confirm he has been attending counselling and has negative urine drug screens for 3 months.

What is the MOST appropriate course of action?

Kylie Tremayne, aged 24, presents after being caught shoplifting while under the influence of inhalants. She reports occasional use of paint thinners for a ‘buzz’, mostly when stressed or bored. She is unemployed and has limited social support. She denies other substance use or psychosis. Examination is normal except for mild unsteadiness and poor dentition.

What is the MOST appropriate next step in management?

Naomi Roth, aged 38, presents requesting help with quitting methamphetamine. She has used daily for the last 6 months and reports paranoid thoughts and sleep disruption. She has no history of violence or suicidal ideation. She is keen to engage in treatment. Physical examination is normal, but she appears tense and speaks rapidly.

What is the MOST appropriate initial management plan?

Joel Barrett, aged 46, presents for review following discharge from hospital where he was treated for alcohol-related pancreatitis. He has a long history of heavy drinking and is interested in relapse prevention. He has no contraindications to pharmacotherapy and is currently abstinent. He asks about the best medication to help him stay off alcohol.

What is the MOST appropriate pharmacological treatment option?

Pauline Werner, aged 55, has been using over-the-counter codeine for many years to manage chronic tension headaches. She now takes more than 20 tablets of paracetamol/codeine per day. She reports nausea, fatigue, and upper abdominal pain. Bloods show ALT 250 U/L, AST 198 U/L, GGT 140 U/L, and INR 1.3.

What is the MOST appropriate next step in management?

Declan Parry, aged 50, is on a stable methadone program for opioid use disorder. He presents with increasing fatigue and mild jaundice. He reports injecting methadone and sharing injecting equipment until 12 months ago. Blood tests reveal elevated ALT, positive HCV antibody and RNA.

What is the MOST appropriate next step in his management?

Kirsten Mallory, aged 32, presents with severe dental caries and weight loss. She admits to injecting methamphetamine daily and has recently lost her job. She has no history of psychosis or seizures but appears restless and avoids eye contact. She is open to treatment and expresses concern about her appearance and health.

What is the MOST important immediate intervention?

Barry O’Donnell, aged 44, presents stating he wants to quit smoking. He smokes 25 cigarettes per day and has moderate COPD. He has previously tried nicotine gum and patches without success. He has a history of depression but is not currently taking any medication. He is interested in trying something new.

What is the MOST appropriate pharmacological aid to recommend?

Isobel Tran, aged 27, presents with low mood, insomnia, and reduced appetite. She recently stopped using cocaine after regular weekend use over the past year. She denies suicidal ideation. She has no significant medical history and is not taking any medications. She asks for help managing her symptoms and preventing relapse.

What is the MOST appropriate initial management approach?

Jared Mulvey, aged 59, has COPD and a long-standing alcohol use disorder. He presents with worsening dyspnoea and weight loss. He continues to drink 6–8 standard drinks daily and has had multiple brief interventions in the past. He is now open to considering a structured approach but is hesitant to go to hospital.

What is the MOST appropriate next step in management?

Lauren Young, aged 19, presents with her mother, who is concerned about Lauren’s increasing use of nitrous oxide. Lauren reports using it daily over the past two months and admits to tingling in her hands and difficulty walking. She denies other substance use. Examination reveals an ataxic gait and decreased vibration sense in the lower limbs.

What is the MOST appropriate initial investigation?

Michael Salim, aged 34, is on buprenorphine-naloxone 16 mg daily for opioid dependence. He presents with worsening anxiety and insomnia over the past two weeks. He denies substance relapse and is attending regular follow-ups. He asks if he should increase his Suboxone dose to help with sleep.

What is the MOST appropriate next step in management?

Ayesha Khan, aged 44, presents with a history of chronic pain and escalating opioid use. She reports low mood and feels her medications are ‘barely working’. She is taking oxycodone modified-release 40 mg twice daily, in addition to paracetamol and ibuprofen. She is open to trying alternative treatments and wants to reduce her reliance on opioids.

What is the MOST appropriate next step in management?

George Athanasiou, aged 72, presents with increasing confusion and unsteady gait. His daughter reports that he has been drinking heavily for years but recently cut back. On examination, he is disoriented, with a wide-based gait and horizontal nystagmus. He is afebrile and haemodynamically stable. Blood glucose is normal. No focal neurological deficits are found.

What is the MOST likely diagnosis?

Stephanie Vu, aged 24, presents for follow-up 3 months after commencing naltrexone for alcohol use disorder. She reports reduced cravings and fewer binge episodes. She asks if she can stop the medication now that she is doing better. She remains abstinent for the past month and is attending counselling.

What is the MOST appropriate response?

Bruno Rossi, aged 38, is brought in by ambulance after collapsing at a party. Friends report he had taken MDMA and possibly GHB. On arrival, he is drowsy but rousable, BP 90/60 mmHg, HR 58 bpm, RR 10, SpO₂ 94% on room air. Pupils are normal and reactive. No focal neurological signs.

What is the MOST appropriate immediate management?

Nerida Collins, aged 61, has severe COPD and presents requesting help to quit smoking. She has made multiple quit attempts in the past using NRTs. She is concerned about weight gain and withdrawal symptoms. She is currently smoking 20 cigarettes per day and is motivated to try medication.

What is the MOST appropriate initial pharmacological option?

Taylor Wu, aged 26, presents with poor appetite, social withdrawal, and poor concentration. He has been using cannabis daily for 4 years but has recently stopped. He describes vivid dreams and irritability. He is concerned these symptoms will last forever.

What is the MOST appropriate response to Taylor’s concern?

Hamish O’Donnell, aged 52, presents to your practice after release from prison where he served a 12-month sentence for drug-related offences. He has a long history of heroin dependence but reports being abstinent for the last 6 months. He is interested in preventing relapse and wants to stay off opioids. He is not currently on any pharmacotherapy.

What is the MOST appropriate pharmacological option to support relapse prevention?

Felicity Martin, aged 48, has a history of alcohol use disorder and presents requesting help with persistent cravings despite abstinence for 4 weeks. She has previously relapsed after periods of abstinence. She is attending counselling weekly and has supportive family. She is not currently taking any medications and denies current withdrawal symptoms.

What is the MOST appropriate pharmacological option for her?

Leo Ferenc, aged 36, presents with concerns about his partner’s prescription opioid use. She was prescribed oxycodone after surgery 6 months ago and has continued to use it daily despite the pain resolving. Leo reports she becomes irritable if she misses a dose and has begun borrowing money to buy extras. He asks what to do.

What is the MOST appropriate advice to give Leo?

Alvin Chong, aged 41, presents for follow-up 2 weeks after starting varenicline for smoking cessation. He reports vivid dreams and mild nausea, but no suicidal ideation or mood changes. He has reduced from 20 to 3 cigarettes per day. He is unsure whether to continue the medication.

What is the MOST appropriate advice?

Melanie Giles, aged 30, presents requesting a script for diazepam to help manage anxiety. She recently stopped heavy cannabis use and has been experiencing restlessness and poor sleep. She is not on any medications and is attending weekly counselling. She denies suicidal ideation or other substance use.

What is the MOST appropriate management strategy?

Craig Donovan, aged 45, presents reporting difficulty with concentration and low mood since stopping daily methamphetamine use two weeks ago. He used daily for over a year. He is not suicidal and is attending counselling weekly. He asks if there is any medication that could help him feel better or speed up recovery.

What is the MOST appropriate next step?

Deborah Singh, aged 57, presents for a repeat prescription of temazepam. She has been using 10 mg nightly for the past 6 years. She reports that she cannot sleep without it but feels drowsy and forgetful during the day. She has not tried any other sleep strategies. She is otherwise healthy and lives alone.

What is the MOST appropriate management?

Luke Chow, aged 33, presents for help with quitting e-cigarettes. He started vaping 4 years ago to quit smoking cigarettes but now uses a nicotine vape every hour. He becomes anxious and irritable if he doesn’t use it and often wakes at night to vape. He has no other substance use or medical issues.

What is the MOST appropriate management option?

Sasha Perera, aged 29, is brought in by her partner after taking what she thought was ecstasy at a music festival. She is agitated, tachycardic, and hyperthermic (39.2°C). She is disoriented and restless. Pupils are dilated, and she is clenching her jaw. Friends report she took two tablets 2 hours ago.

What is the MOST appropriate immediate management step?

Jeremy Tasker, aged 70, is a retired teacher who has recently been diagnosed with mild cognitive impairment. His daughter reports he drinks a bottle of wine every evening and often forgets conversations. He has no history of withdrawal symptoms or liver disease. He is willing to cut back on drinking but feels it helps him relax.

What is the MOST appropriate next step?