Clinical challenge

Case 1: Loretta Valance

Loretta Valance, aged 34 years is seeing you for a Pap smear. You take the opportunity to update her history, including her alcohol intake. She tells you she drinks 2–3 glasses (about 150 mL each) of red wine most weeknights and usually about one bottle (750 mL) of wine on Saturday nights when she goes out for dinner.

Question 1

Which of the following statements is TRUE regarding Loretta’s alcohol intake?

1. Loretta’s drinking level on weeknights is within acceptable daily limits according to the NHMRC guidelines.
2. Loretta’s drinking level on Saturdays is within acceptable limits according to the NHMRC guidelines regarding a single occasion of drinking.
3. On her typical Saturday nights, Loretta’s risk of injury after drinking a bottle of wine is twice as high as if she had fewer than four standard drinks.
4. At her current level of drinking, Loretta’s lifetime risk of death from an alcohol-related disease is six times higher than if she had two or fewer standard drinks per day.
5. Loretta should restrict her alcohol intake to no more than one standard drink per day if she is considering becoming pregnant in the near future.

Question 2

You discuss safe drinking levels with Loretta. She tells you that she thinks her level of drinking is pretty normal, compared with most of the people she knows, and suggests that the guidelines might be a bit unrealistic. Which of following statements is TRUE regarding alcohol consumption in Australia?

1. The proportion of men who drink at risky levels has increased more sharply than that of women in the past 15 years.
2. A majority of Australians have been adversely affected by someone else’s drinking in the past 12 months.
3. Alcohol is the fourth leading cause of preventable morbidity and mortality.
4. Alcohol-related deaths and hospitalisations have remained at the same level for many years.
5. 5.     Social costs of alcohol use by Australians are up to $15 million per annum.

Question 3

After further discussion, Loretta agrees that she would like to cut back her drinking. Which of the following statements is TRUE regarding interventions that might assist Loretta?

1. A brief period of abstinence from alcohol (eg. 1 month) is unlikely to produce any longstanding benefits.
2. Naltrexone must be prescribed by psychiatrists or addiction specialists.
3. A 5-minute intervention administered by a general practitioner can reduce harmful alcohol consumption by almost one-third.
4. Pharmacotherpeutic agents for long-term alcohol relapse prevention are much less effective than medications for other chronic medical conditions.
5. Mutual aid groups have a limited role in treatment of alcohol disorders.

Question 4

Loretta is a member of your local government and is interested to know whether there is anything she could advocate for in that role to reduce alcohol-related harm in the area. Which of the following is TRUE regarding population health measures to tackle alcohol-related harm?

1. Australia has lenient counter-measures regarding drink driving, compared with other countries.
2. There is no evidence that reduced trading hours of licensed venues affects alcohol-related harms.
3. Raising the price of alcohol has no impact on the incidence of alcohol-related harm.
4. Reducing the number of bottle shops in close proximity has been shown to reduce the incidence of domestic violence.
5. To date, no Australian governments have been able to implement laws restricting alcohol availability due to significant political barriers.

Case 2: Aaron Childs

Aaron Childs is 25 years of age and has developed worsening sleeping difficulties. He works at a pub and often feels ‘wired’ after his shifts, so to help him settle he spends most evenings after work playing the poker machines, often for many hours. Sometimes he also bets on the races and other sports that are showing on the televisions at the pub.

Question 5

Regarding gambling by Australians, which of the following statements is TRUE?

1. Up to 75% of Australians have participated in some form of gambling in the past 12 months.
2. Cumulative gambling losses for Australians were $19 million in 2008/9.
3. Young men such as Aaron are less likely to be problem gamblers than men in other age groups.
4. Approximately 0.1% of the adult population shows problem-gambling behaviour.
5. The average losses for each gambling Australian in 2008/9 were $500.

Question 6

You want to ascertain how significant Aaron’s gambling issues are. Which of the following characteristics would make you suspect Aaron may have a gambling disorder?

1. He does not view his gambling as a problem.
2. His has never tried to stop gambling.
3. He says he enjoys gambling.
4. He spends over $500 per week on gambling.
5. He lies to his wife about his gambling spending.

Question 7

On further questioning, Aaron also reveals that he has lost interest in activities he used to find pleasurable, has lost his appetite and that his mood has been very low for the past few months. Which of the following statements is TRUE with respect to these symptoms?

1. These may be symptoms of gambling disorder.
2. People with problem gambling have the same suicide risk as the general population.
3. Most people with problem gambling have at least one additional mental illness.
4. People with problem gambling have a similar prevalence of other mental illnesses as the general community.
5. Addressing his gambling disorder alone is likely to alleviate these symptoms.

Question 8

You feel that Aaron’s gambling is a clinically significant problem and would like to assist him. Which of the following measures is likely to be helpful for Aaron?

1. Naltrexone
2. Peer-support groups
3. Self-help treatments
4. Cognitive behavioural therapy
5. All of the above.

Case 3: Nick Koutsoukis

Nick Koutsoukis, aged 47 years, is seeing you for a repeat script for olanzapine. He has a history of epilepsy as well as schizophrenia, which is currently stable. Nick has smoked 40 cigarettes per day for the past 25 years.

Question 9

Which of the following statements is TRUE regarding cigarette smoking and people with mental illnesses?

1. 50% of people with mental illnesses smoke.
2. People with mental illnesses have a similar level of nicotine dependence as the general population.
3. People with mental illnesses are generally less motivated to quit smoking.
4. People with mental illnesses require the same degree of support to quit as the general population.
5. Smoking cessation may increase drug levels for many drugs, including olanzapine.

Question 10

Nick is thinking about quitting smoking but has been unsuccessful in previous attempts at going ‘cold turkey’. He would like to know more about nicotine replacement therapy (NRT). Which of the following is TRUE regarding NRT?

1. Nicotine patches are more effective than nicotine gum.
2. Combining a nicotine patch with a fast-acting oral form of NRT is more effective than monotherapy.
3. Patches should not be started before the first day of quitting.
4. Patches should be used at the lowest dose that is tolerable, which may mean that users still experience some withdrawal symptoms.
5. Patches should be used for about 6 weeks.

Question 11

Nick has also heard about a tablet that can help with smoking cessation (you suspect he is referring to varenicline) but he isn’t sure if it is appropriate for him. Which of the following statements regarding varenicline is TRUE?

1. It is a centrally acting nicotinic receptor antagonist that relieves cravings.
2. It has no effect on the rewarding effects of smoking.
3. It has a similar efficacy as NRT.
4. Varenicline should be used with caution in Nick given his history of mental illness as it associated with neuropsychiatric adverse effects.
5. Approximately 30% of users experience nausea.

Question 12

Nick would like to know what other options there are to assist him with smoking cessation. Which of the following is TRUE regarding the options available to Nick?

1. Bupropion is as effective as NRT and would be a suitable option for Nick.
2. Using e-cigarettes would increase the likelihood of his quitting.
3. Cutting down the number of cigarettes he smokes is unlikely to result in his quitting altogether.
4. Cutting down the number of cigarettes he smokes as well as using NRT would increase his chances of quitting by 50%.
5. Behavioural therapy is unlikely to help him to quit.