Psychiatry — Substance Use Disorders, NMC MBBS licence examination syllabus (Nepal Medical Council).
Substance use: the diagnosis nobody asks about
Alcohol appears in every specialty, and is recorded in almost none of them.
Substance use is unusual among major diagnoses in that the main barrier to detecting it is not diagnostic difficulty. It is that the question does not get asked. Patients under-report, doctors under-enquire, and the result is a condition that contributes to liver disease, trauma, depression, hypertension, seizures and family breakdown while appearing in the notes as none of those things.
The clinical skill here, therefore, is largely conversational. Asking routinely, asking without visible judgement, and knowing what to do with the answer are worth more in practice than any amount of detail about neurotransmitters.
🩺 Where this lives: Alcohol withdrawal is a genuine medical emergency, and it is most often precipitated by admission to hospital. A dependent drinker admitted with a fracture, a chest infection or for surgery stops drinking abruptly — not by choice, but because nobody asked and nobody planned for it. Two days later they are confused, hallucinating and febrile, and the deterioration is attributed to sepsis or delirium of unknown cause. Asking about alcohol on arrival is not a social nicety; it prevents a life-threatening complication.
💡 A note on scope and numbers. This chapter gives no doses, no withdrawal regimens and no "safe limits" in units — recommended limits differ between countries, have been revised downward over time, and Nepal's guidance is national. It also gives no prevalence figures, which come from survey data rather than memory. Acute withdrawal management, Wernicke's encephalopathy and the thiamine-before-glucose rule are covered in the Delirium and Risk Assessment chapter; alcoholic liver disease in the Chronic Liver Disease chapter; opioid overdose reversal in the Poisoning chapter.
What dependence is
Dependence is not defined by quantity. It is a syndrome describing the relationship between a person and a substance: compulsion, loss of control, tolerance, withdrawal, neglect of other activities, and — most tellingly — continued use despite clear evidence of harm. That last feature is what distinguishes it from a heavy but controlled pattern of drinking, and it is also what makes moralising so useless: a person who continues drinking after losing their liver, job and family is not demonstrating a lack of willpower so much as the defining feature of the illness.
TWO TERMS THAT ARE NOT THE SAME
HARMFUL USE Damage is actually occurring — physical,
mental or social — as a result of the
substance. It says nothing about compulsion.
DEPENDENCE The syndrome above: compulsion, impaired
control, tolerance, withdrawal, neglect,
persistence despite harm.
A person can be SERIOUSLY HARMED WITHOUT BEING DEPENDENT.
A binge drinker who is never dependent may still die in a
road traffic accident or of an alcoholic hepatitis. This
matters because interventions differ: hazardous and harmful
drinking respond well to BRIEF INTERVENTION, whereas
dependence usually needs structured treatment and planned
withdrawal.
AND NOTE THE OVERLAP WITH MENTAL ILLNESS. Alcohol both
causes and is used to treat low mood, anxiety and
insomnia — so the direction of causation is often
genuinely unclear and does not need to be settled before
helping. Depression that persists after several weeks of
abstinence is more likely to be independent. See the
Depression and Anxiety chapter.
Asking, and the brief intervention
💡 Exam angle: the brief intervention is examined because it is one of the best-evidenced short interventions available in general practice, and because it is cheap. Its components are feedback about the person's own use, clear advice, a menu of options, an empathic manner, and support for the patient's belief that change is possible. It takes minutes, is effective for hazardous and harmful drinking, and requires no specialist referral — which makes it exactly the sort of thing a licensing examination expects a new doctor to be able to do.
The clinical footprint
The breadth here is the point. Alcohol contributes to liver disease, pancreatitis, cardiomyopathy, hypertension, several cancers, neuropathy, seizures, depression, suicide, trauma, domestic violence, poverty and fetal harm. A doctor who thinks of it only in a liver clinic will miss it everywhere else — which is why the practical rule is to consider alcohol in any unexplained presentation, particularly recurrent injury, unexplained hypertension, unexplained abnormal liver tests or treatment-resistant low mood.
Withdrawal
WHY WITHDRAWAL IS DANGEROUS
Chronic alcohol suppresses central nervous system activity,
and the brain compensates by becoming more excitable.
Remove the alcohol suddenly and that compensation is
unopposed — so the nervous system is left in a state of
excess excitation.
THE SEQUENCE, ROUGHLY:
EARLY tremor, sweating, anxiety, nausea,
tachycardia, craving
THEN SEIZURES — alcohol withdrawal is a recognised
cause of a first seizure in an adult
LATER DELIRIUM TREMENS — confusion, vivid
hallucinations, tremor, fever, autonomic
instability. Carries significant mortality if
untreated.
THE PRACTICAL POINT FOR A HOSPITAL DOCTOR:
The commonest trigger for severe withdrawal is UNPLANNED
ABSTINENCE ON ADMISSION. Someone admitted for anything at
all stops drinking abruptly because nobody asked. Ask
about alcohol on arrival, anticipate withdrawal, and treat
it by protocol before it becomes delirium tremens.
Management, thiamine and Wernicke's encephalopathy are
covered in the Delirium and Risk Assessment chapter.
Regimens come from your local protocol.
Tobacco, opioids and harm reduction
💡 Exam angle: harm reduction is worth understanding as a principle rather than a policy. If a person cannot or will not stop today, there is still a great deal that reduces the damage today — clean injecting equipment, hepatitis B vaccination, testing for blood-borne viruses, overdose awareness, and simply remaining in contact with services. Abstinence is a goal, not a precondition for receiving care. A question offering "refuse further treatment until the patient stops using" is describing an ethical and clinical error.
Clinical reasoning: four presentations
🔍 Case 1 — confusion on day two
PresentationA man admitted after a fall becomes tremulous and anxious on day one, then on day two is confused, sweating, febrile and describing insects on the walls. Sepsis is assumed and antibiotics are escalated. No alcohol history was taken on admission.
The missing questionWhat does he normally drink?
ReasoningThis time course — tremor and anxiety, then confusion with vivid hallucinations and autonomic instability — is delirium tremens, precipitated by unplanned abstinence on admission.
AnswerTreat withdrawal per protocol with thiamine, while still excluding infection and other causes of delirium — the two can coexist. See the Delirium chapter for management.
🔍 Case 2 — harmed but not dependent
PresentationA 26-year-old attends after his second injury this year sustained while drinking heavily at weekends. He drinks nothing during the week, has no morning symptoms, no tolerance and no difficulty abstaining. He is told he is "not an alcoholic" and no further advice is given.
ErrorTreating absence of dependence as absence of a problem.
ReasoningHe has harmful use without dependence. Injury is a real and potentially fatal harm, and this pattern responds well to brief intervention — arguably better than dependence does.
AnswerDeliver a brief intervention: feedback, clear advice, options, empathy. This is precisely the group in which it works best.
🔍 Case 3 — low mood and a nightly drink
PresentationA woman with several months of low mood, poor sleep and fatigue drinks most evenings to help her sleep. An antidepressant is started without discussing the alcohol.
Key pointAlcohol is both a cause and a consequence of low mood.
ReasoningAlcohol worsens mood and disrupts sleep architecture, so it perpetuates exactly the symptoms it is being used to treat. Treating the depression without addressing the drinking treats half the problem.
AnswerAddress both. Discuss the alcohol explicitly and offer support, and reassess mood after a period of reduced use — depression persisting after several weeks of abstinence is more likely to be independent.
🔍 Case 4 — still injecting
PresentationA man who injects drugs attends with a skin abscess. He says he is not ready to stop. A clinician suggests deferring hepatitis B vaccination and blood-borne virus testing until he commits to abstinence.
ErrorMaking care conditional on abstinence.
ReasoningHarm reduction means reducing damage now, whatever happens about stopping later. Vaccination, testing, clean equipment and overdose awareness all reduce risk immediately, and withholding them removes the only contact he has with services.
AnswerDrain the abscess, vaccinate, offer testing for HIV and hepatitis B and C, provide harm reduction advice, and keep the door open. Abstinence is a goal, not a precondition.
Commonly confused
Confusion
The distinction
Why it matters
Quantity vs dependence
Dependence is a syndrome, not an amount
Heavy drinkers may not be dependent, and vice versa.
Harmful use vs dependence
Damage occurring versus the syndrome
Brief intervention suits one; structured treatment the other.
Not dependent vs no problem
Injury and organ damage occur without dependence
The group most helped by brief advice.
Delirium tremens vs sepsis
Time course from admission; tremor first
Both may be present — treat for both.
Planned vs unplanned abstinence
Admission causes abrupt cessation
The commonest trigger for severe withdrawal.
Depression causing vs caused by alcohol
Reassess after a period of abstinence
Treating one alone treats half the problem.
Abstinence vs harm reduction
Damage can be reduced today regardless
Care is never conditional on stopping.
Rapid revision
MUST-KNOW FACTS
1. The main barrier to diagnosis is that the question is not asked.
2. DEPENDENCE is a syndrome, NOT defined by quantity.
3. Features: compulsion, impaired control, TOLERANCE, WITHDRAWAL, neglect.
4. And the key one: CONTINUING DESPITE CLEAR HARM.
5. HARMFUL USE means damage is occurring — without necessarily dependence.
6. Someone can be seriously harmed without being dependent.
7. Ask everyone, routinely, WITHOUT JUDGEMENT.
8. A disapproving manner guarantees a false answer.
9. Validated screening questionnaires outperform clinical impression.
10. BRIEF INTERVENTION works and takes minutes.
11. Components: feedback, advice, options, empathy, self-efficacy.
12. Brief intervention suits HAZARDOUS and HARMFUL drinking best.
13. Dependence usually needs structured treatment and planned withdrawal.
14. Alcohol harms: liver, pancreas, heart, hypertension, cancers, neuropathy.
15. Psychiatric: depression, anxiety, insomnia, RAISED SUICIDE RISK.
16. Social: trauma, road injury, DOMESTIC VIOLENCE, poverty, family harm.
17. Alcohol in pregnancy causes FETAL ALCOHOL SPECTRUM DISORDER.
18. Consider alcohol in ANY unexplained presentation.
19. WITHDRAWAL: chronic suppression leaves an over-excitable nervous system.
20. Early withdrawal: tremor, sweating, anxiety, nausea, tachycardia.
21. Then SEIZURES — a recognised cause of first seizure in an adult.
22. Later DELIRIUM TREMENS: confusion, vivid hallucinations, fever, autonomic instability.
23. Delirium tremens carries significant mortality if untreated.
24. UNPLANNED ABSTINENCE ON ADMISSION is the commonest trigger.
25. ASK ABOUT ALCOHOL ON ARRIVAL and anticipate withdrawal.
26. Withdrawal and infection can COEXIST — treat for both.
27. Management, thiamine and Wernicke's: see the Delirium chapter.
28. TOBACCO is the largest preventable cause of death worldwide.
29. Ask and advise about tobacco at every opportunity.
30. Injecting drug use risks HIV and hepatitis B and C.
31. HARM REDUCTION: reduce damage today regardless of abstinence.
32. Abstinence is a GOAL, not a precondition for care.
💡 Exam angle: three threads recur. Dependence as a syndrome rather than a quantity; withdrawal precipitated by admission and mistaken for something else; and harm reduction as care that does not wait for abstinence. All three are as much about attitude as knowledge, which is exactly why they are examined.
Syllabus points
Why the diagnosis is missed
Dependence as a syndrome, not a quantity
Harmful use versus dependence
Taking a substance history
The brief intervention and its evidence
Medical harms of alcohol
Psychiatric harms and suicide risk
Social harms and fetal alcohol effects
Why withdrawal is dangerous
The withdrawal time course
Unplanned abstinence on admission
Tobacco and injecting drug use
Harm reduction as a principle
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