Substance intoxication, withdrawal and use disorders in youth — formative SAQs

SAQ 1 (10 marks)

A 16-year-old boy is brought by his mother after a six-month slide in school marks, withdrawal from his usual sport, and a new peer group. He is irritable and guarded in the interview. Taken alone, he admits daily cannabis use, smoking from age 13, failed efforts to cut down, and episodes of driving after using. He describes irritability, insomnia and loss of appetite when he runs out. His CRAFFT screen is positive on five items. He has low mood but no current suicidal plan. [2] [3]

1. Give the most likely diagnosis with the DSM-5 criteria that support it, and separate intoxication, withdrawal and the use disorder in this case. (3) [1]
2. Outline your screening, assessment and the framework you use to stratify him. (3) [2] [3]
3. Describe the stepped-care treatment plan, naming the first-line evidence-based interventions. (4) [4] [5]

Model answer — SAQ 1

(1) Diagnosis and the three states (3). The picture fits a cannabis use disorder, at least moderate. He meets multiple DSM-5 criteria across the clusters: impaired control (failed efforts to cut down, craving implied), social impairment (school decline, withdrawal from sport, new risky peer group), risky use (driving after using), and pharmacological change (tolerance implied and a withdrawal syndrome of irritability, insomnia and appetite loss on cessation). The three states are separable: he is not acutely intoxicated in clinic; he describes a cannabis withdrawal syndrome; and he meets criteria for the use disorder itself, which is the diagnosis. A urine drug screen is not required to make the diagnosis. [1]

(2) Screening and stratification (3). Screen every adolescent with a validated tool — CRAFFT for alcohol and other drugs, with two or more positive items signalling a likely problem (he scores five), or S2BI by past-year frequency. Confirm with a structured, confidential, multi-informant HEEADSSS interview: every substance, age of onset, route, frequency, consequences and attempts to stop, plus a mental state, self-harm, safeguarding and pregnancy assessment. The framework is SBIRT: screen, brief intervention, referral to treatment — and stratify by severity into brief intervention, specialist youth AOD input, or multidisciplinary care. [2] [3]

(3) Stepped care (4). His severity warrants specialist youth alcohol-and-other-drug input. First-line treatment is evidence-based psychosocial: motivational interviewing, cognitive behavioural therapy, family-based therapy and contingency management — the Cannabis Youth Treatment study (Dennis) and the Waldron review establish these as effective in adolescents. Address cannabis withdrawal with sleep, mood and craving management. Treat the comorbid low mood actively and reassess suicide risk at every visit. Build a relapse-prevention plan with a clearly named clinician for follow-up, and counsel openly on the cannabis-and-psychosis and educational-harm risks of early, heavy use. [4] [5]

SAQ 2 (10 marks)

A 17-year-old presents to the emergency department drowsy with a respiratory rate of 8 per minute, pin-point pupils and track marks on her arms. She is known to youth services for opioid use. In a separate scenario her boyfriend describes that she has abruptly stopped a long benzodiazepine binge and is now tremulous, agitated and sweating. [3] [6]

1. Detail the immediate management of her opioid intoxication and the follow-up that must not be missed. (4) [3]
2. Describe the management of her alcohol-or-benzodiazepine withdrawal and why it is treated as an emergency. (3) [3]
3. Outline the buprenorphine pathway for her opioid use disorder once stabilised. (3) [6]

Model answer — SAQ 2

(1) Opioid intoxication (4). This is opioid intoxication with life-threatening respiratory depression. Manage the airway and give naloxone titrated to respiratory effort — do not wait for a tox screen. Because naloxone is shorter-acting than most opioids, observe for re-sedation and repeat or infuse as needed. Check glucose to exclude hypoglycaemia, and assess for co-ingestants. Once stable, take the safeguarding and exploitation history, offer blood-borne-virus testing, provide take-home naloxone and overdose-prevention education, and arrange assertive follow-up into opioid use disorder treatment — the resuscitation is the gateway to the recovery plan, never the endpoint. [3]

(2) Withdrawal as an emergency (3). Alcohol and benzodiazepine withdrawal can produce seizures and delirium tremens and can be fatal, so it is treated as a medical emergency. Manage with a symptom-triggered benzodiazepine taper (such as diazepam), give thiamine to prevent Wernicke encephalopathy, correct fluid and electrolytes, and monitor closely. Opioid withdrawal, by contrast, is intensely distressing but rarely fatal on its own and is managed with symptom relief, clonidine and, where appropriate and supervised, buprenorphine. [3]

(3) Buprenorphine pathway (3). Confirm opioid use disorder on DSM-5 criteria after medical stabilisation and exclude acute intoxication. Engage with motivational interviewing and explain medication-assisted treatment as evidence-based, not a substitute addiction. Initiate buprenorphine during early withdrawal to avoid precipitated withdrawal, supervise the first dose, stabilise on a maintenance dose alongside psychosocial therapy, and address comorbidity, housing, education and family. The Marsch trial showed that a longer buprenorphine taper outperformed short detoxification in adolescents and young adults; agree a maintenance duration tailored to the individual and provide naloxone and overdose-prevention education throughout. [6]