Each of the following statements about cannabis use is true, except:
Correct Answer A:
Cannabis or marijuana used regularly can lead to dependence and withdrawal. Persistent use despite psychological and physical impairment as well as developing tolerance are hallmarks of such. The delirium seen with cannabis is similar to what is seen with the hallucinogens and psychomimetics and can last up to 10 days. Decreased libido, ataxia, increased reaction time, perceptual distortion, and restlessness are also associated with cannabis usage. Anxiety is common during acute intoxication, especially for inexperienced users, and is often provoked by paranoid thoughts. Although there are approximately 60 active substances in cannabis, THC is thought to be the key chemical responsible for the psychoactive effect.
A 31 year old man comes to the office because he is concerned about his relationship with his young son. The father says that they always have been very close, but recently he has not had much energy to spend quality time with his son. He does not understand why he has had this change in behavior. He says he feels well, and to his knowledge, is healthy. He says that he works daily in a job he likes and has had no occupational problems. History and physical examination lead you to suspect substance abuse.
Abuse of which of the following substances would most likely explain his behavior?
Correct Answer C:
The cardinal symptom reported by this patient is fatigue (lack of energy). Of the substances listed, marijuana is most likely to produce that symptom. The characteristic signs of abuse of this drug are fatigue, lethargy, and somnolence.
Amphetamine is a stimulant that acts via indirect release of catecholamines (epinephrine and norepinephrine) from adrenergic nerve terminals. It is associated with excess energy and with prolonged use, psychosis. Cocaine is also a stimulant. It acts via inhibition of catecholamine (dopamine and norepinephrine) synaptic reuptake and therefore prolongs the availability of these transmitters in the synaptic cleft. Cocaine usage is associated with a profound sense of euphoria, energy and mania. Phencyclidine also known as PCP is a hallucinogen. The symptoms of abuse of this drug are clear and relate to hallucinations and delusions.
Which one of the following is characteristic of drug-seeking behavior in patients who abuse prescription drugs?
Drug-seeking behaviour in patients who abuse prescription drugs includes insistence on brand-name drugs claiming a high tolerance to pain medications, over reporting symptoms, and insistence on a prescription for a controlled drug at the first visit.
Which one of the following historical features is specifically required for the diagnosis of adult attention deficit/hyperactivity disorder (ADHD)?
Correct Answer D:
Of the criteria listed, the feature most critical to the diagnosis of adult attention-deficit/hyperactivity disorder (ADHD) is the presence of symptoms since childhood. An extended, consistent pattern of ADHD symptoms, dating back to childhood, should be uncovered during history taking. The recent onset of symptoms or sporadic episodes of symptoms should raise concern about the appropriateness of the diagnosis of ADHD.
The other features listed are seen with ADHD, but are also seen with other psychiatric disorders. Difficulty maintaining attention and focus is seen with major depression, bipolar disorder, and substance abuse. Affective lability occurs with bipolar disorder, substance abuse, and personality disorders (e.g., borderline and antisocial personality). Impulsivity and hyperactivity are characteristic of personality disorders and bipolar disorder.
A 10 year old male comes in for follow-up of his attention-deficit/hyperactivity disorder (ADHD). At the time of his last visit 1 month ago he was taking methylphenidate (Ritalin) once daily each morning. At that time his mother reported that he did extremely well in class during the morning, but by the end of the day he was having problems with inattentiveness. This carried over into difficulties concentrating on homework after school. These problems were affecting his grades and causing distress to him and his mother. The child expressed a desire not to have to take medicine during the school day. You switched his medicine at that visit to a long acting form of methylphenidate (Concerta).
At this visit the mother reports that her son is now doing well through the entire school day and is able to get his homework done. However, she notes that his appetite at dinner has decreased and that he has lost 2 lb. She also reports that it is somewhat more difficult for him to fall asleep.
What is the most appropriate management at this point?
Correct Answer B:
Anorexia with mild weight loss and difficulty falling asleep are common side effects of amphetamine treatment for ADHD. In most patients these side effects are tolerable and transient. While alternative drugs such as antidepressants can be substituted, these usually do not work as well and have their own potential side effects.
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