Substance Use

December 2016

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Clinical Challenge

Volume 45, No.12, December 2016 Pages 931-932

Questions for this month’s clinical challenge are based on articles in this issue. The clinical challenge is endorsed by the RACGP Quality Improvement and Continuing Professional Development (QI&CPD) program and has been allocated four Category 2 points (Activity ID: 69787). Answers to this clinical challenge are available immediately following successful completion online at http://gplearning.racgp.org.au. Clinical challenge quizzes may be completed at any time throughout the 2014–16 triennium; therefore, the previous months’ answers are not published.

Each of the questions or incomplete statements below is followed by four or five suggested answers or completions. Select the most appropriate statement as your answer.

Case 1

John, a plumber aged 35 years, has seen you for a variety of minor injuries and illnesses over the years. He presents today with symptoms of an upper respiratory tract infection that he has had for the past two days and he asks for a medical certificate for time off from work. As part of your assessment, he reveals for the first time that he has been using cannabis regularly for the past year and is concerned he has become dependent on it.

Question 1

Which one of the following has the highest prevalence of cannabis use disorder?

  1. Males

  2. Tobacco smoker

  3. People aged 18–45 years

  4. People aged 46–60 years 

You discuss John’s concerns further and he asks what are the most common harms caused by cannabis dependence

Question 2

Which one of the following is NOT a documented harm from cannabis use? 

  1. Poor academic achievement

  2. Suicide

  3. Short-term memory impairment

  4. Decreased cardiovascular risk

  5. Psychosis

John remains concerned about his cannabis use as he reveals that it is causing financial problems and conflict in his relationships with his parents and his girlfriend. 

Question 3

Which one of the following has the best evidence for formal treatment of cannabis use?

  1. Abstinence

  2. Cognitive behaviour therapy

  3. Detox adapted from alcohol withdrawal guidelines

  4. Low-dose selective serotonin-reuptake inhibitor

Case 2

You are interested in setting up a protocol for screening new patients for common conditions who present to your general practice. You are considering including alcohol screening and whether to screen everyone or a select group of patients.

Question 4

In which one of the following age cohorts in years is the prevalence of chronic alcohol use highest?

  1. 15–18

  2. 19–30

  3. 31–44

  4. 45–64

  5. 65–80

You decide to establish a protocol for the treatment of alcohol abuse in the clinic. 

Question 5

Which one of the following treatments is NOT included in the Department of Health guidelines for chronic alcohol abuse?

  1. Limited use of diazepam

  2. Referral to drug and alcohol services

  3. Monitoring health effects of alcohol abuse

  4. Advice about self-help groups

  5. Monitored and tapered alcohol consumption

Case 3

Lucy, 34 years of age, is a patient you have seen several times over the past two years. She has chronic pelvic pain syndrome and has ongoing review with her gynaecologist. She also attends other practices for short notice health concerns and pain relief prescriptions. On review today, you assess her use of opioid analgesics.

Question 6

Which of the following statements regarding blood oxygen level–dependent (BOLD) imaging is most correct?

  1. Psychotropics

  2. Analgesics and sedatives

  3. Antidepressants

  4. Antibiotics

Question 7

Which one of the following is NOT a recommended strategy for GPs to reduce or manage prescription drug abuse?

  1. Develop a practice policy on reviewing patients on drugs of dependence.

  2. Learn how to respond to inappropriate requests for drugs of addiction.

  3. Using the 24-hour prescription shopping information.

  4. Have a blanket policy to not prescribe drugs of dependence.

Lucy returns several weeks later to tell you she is moving interstate. She understands your explanation of the risks associated with prescribing drugs of dependence and wants to avoid any difficulty during her move.

Question 8

Which one of the following options is most appropriate in completing a clinic handover of Lucy?

  1. A phone call to the clinic Lucy will be attending.

  2. A larger supply of medication to give Lucy longer to find a new clinic and explain her medical conditions.

  3. A referral letter with details about Lucy’s condition, management and treatment plan.

  4. A printout of Lucy’s current medication list for Lucy to carry.

As you compile Lucy’s handover documentation you become aware that she is receiving different forms of opioids from the variety of clinics she attends. After some discussion, she agrees to having these medications rationalised into one single formulation. 

Question 9

Which one of the following options should also be used to best manage Lucy’s pain?

  1. Use of dose equivalence calculator and selection of two opioid agents

  2. Rapid cessation of opioids and introduction of psychological therapy

  3. Continuing with current medications

  4. Development of a pain management plan

Question 10

Grinzi suggests an approach for prescribers when reviewing potentially inappropriate medications that involves deciding if existing pharmacotherapy should be continued. The key consideration when reviewing continuation of pharmacotherapy is to ensure the prescription is:

  1. needed and used appropriately by the patient

  2. rational, defensible, confirmed and within the GP’s professional comfort

  3. recommended by a specialist

  4. affordable and effective for the patient.

Correspondence afp@racgp.org.au

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