Substance use and withdrawal

33 NEET-PG practice questions on Substance use and withdrawal, part of Psychiatry. The first 25 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

1. Question 1 · Easy

   In the CAGE questionnaire for alcohol use, what does the letter E ask about?

   1. AEpisodes of memory blackout
   2. BEmergency visits after drinking
   3. CA morning drink to steady the nerves
   4. DExcess money spent on buying alcohol

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   Answer: C · A morning drink to steady the nerves

   CAGE asks four questions: feeling the need to Cut down, being Annoyed by criticism of drinking, feeling Guilty about drinking, and needing an Eye-opener drink in the morning. Two or more 'yes' answers suggest clinically significant alcohol use and call for fuller assessment. It is quick to use in OPDs and primary care. It screens for a problem but does not measure the amount drunk.

   • A: Blackouts are not one of the four CAGE items.
   • B: Emergency visits are not a CAGE item.
   • D: Money spent is not a CAGE item.

2. Question 2 · Hard

   A 55-year-old man with alcoholic cirrhosis (albumin 2.6 g/dL, INR 1.8) is admitted in alcohol withdrawal and had one seizure 20 hours after his last drink. The resident's plan: 1. Phenytoin to prevent further withdrawal seizures. 2. Lorazepam rather than chlordiazepoxide. 3. IV thiamine before glucose-containing fluids. 4. Benzodiazepine doses guided by CIWA-Ar scores. Which parts of the plan are correct?

   1. A1, 3 and 4 only
   2. B1, 2 and 3 only
   3. C2 and 4 only
   4. D2, 3 and 4 only

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   Answer: D · 2, 3 and 4 only

   Steps 2, 3 and 4 are correct. In liver failure lorazepam (or oxazepam) is preferred because it is only glucuronidated and has no active metabolites, whereas chlordiazepoxide and diazepam accumulate. Thiamine is given before glucose to prevent Wernicke encephalopathy, and symptom-triggered dosing by CIWA-Ar avoids over-sedation. Step 1 is wrong: phenytoin does not prevent alcohol withdrawal seizures, which respond to benzodiazepines.

   • A: Includes phenytoin and omits lorazepam, which is preferred in cirrhosis.
   • B: Includes phenytoin and omits CIWA-Ar symptom-triggered dosing.
   • C: Omits thiamine before glucose, which prevents Wernicke encephalopathy.

3. Question 3 · Hard

   A 31-year-old man on a methadone programme is brought to casualty unresponsive, with pinpoint pupils and a respiratory rate of 6/min, after taking extra doses. IV naloxone 0.4 mg wakes him within two minutes and he wants to leave. What is the next best step?

   1. ADischarge him once he is fully awake and oriented
   2. BObserve and continue naloxone as needed for hours
   3. CGive oral naltrexone and discharge him
   4. DGive IV flumazenil to prevent relapse

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   Answer: B · Observe and continue naloxone as needed for hours

   Naloxone acts for only about 30 to 90 minutes, whereas methadone has a long half-life, so respiratory depression often returns after naloxone wears off. He must be kept under observation with repeated boluses or a naloxone infusion titrated to breathing, for many hours. Discharge after a single dose risks death at home. Naltrexone would precipitate prolonged withdrawal in a methadone-dependent patient.

   • A: Early discharge is dangerous: methadone outlasts naloxone and sedation recurs.
   • C: Naltrexone precipitates prolonged withdrawal and is not an overdose treatment.
   • D: Flumazenil reverses benzodiazepines, not opioids.

4. Question 4 · Hard

   A 23-year-old woman at 14 weeks of pregnancy has had hyperemesis gravidarum for six weeks and has been on IV dextrose saline for ten days. She now has confusion, horizontal nystagmus, diplopia and an unsteady gait. Serum sodium is 136 mmol/L and glucose 98 mg/dL. What is the next best step?

   1. AMRI brain before any treatment
   2. BIV thiamine in high doses at once
   3. CHypertonic saline infusion
   4. DOral vitamin B complex tablets

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   Answer: B · IV thiamine in high doses at once

   Prolonged vomiting with glucose-containing fluids and no vitamin supplements can precipitate Wernicke encephalopathy, because glucose metabolism uses up the little thiamine left. Confusion, nystagmus with ophthalmoplegia and ataxia need immediate high-dose parenteral thiamine, without waiting for imaging. Thiamine should be given to every woman with prolonged hyperemesis before or with dextrose. Untreated, it risks permanent memory loss and fetal loss.

   • A: MRI may show changes but treatment must not be delayed for it.
   • C: Her sodium is normal; this is not hyponatraemia or osmotic demyelination.
   • D: Oral absorption is unreliable with vomiting and too slow for an emergency.

5. Question 5 · Medium

   A medical officer at a PHC screens a 38-year-old truck driver for alcohol problems. He answers yes to feeling he should cut down and to feeling guilty about his drinking. Consider these statements: 1. Two positive CAGE answers suggest clinically significant alcohol use. 2. AUDIT is a four-item questionnaire derived from CAGE. 3. CAGE estimates the quantity of alcohol drunk per week. 4. A raised GGT and MCV support chronic heavy drinking. Which statements are correct?

   1. A1, 3 and 4 only
   2. B1, 2 and 4 only
   3. C1 and 4 only
   4. D1 and 3 only

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   Answer: C · 1 and 4 only

   Statements 1 and 4 are correct. Two or more 'yes' answers on CAGE, as here, suggest a clinically significant problem that needs fuller assessment; raised GGT and macrocytosis are supportive markers of chronic heavy drinking. AUDIT is not derived from CAGE: it is a separate 10-item WHO tool covering consumption, dependence and harm. CAGE does not measure quantity, which is why AUDIT or a drinking history is used for that.

   • A: Includes statement 3; CAGE does not estimate quantity.
   • B: Includes statement 2; AUDIT is a separate 10-item WHO tool, not a four-item CAGE variant.
   • D: Includes statement 3 and omits statement 4 about GGT and MCV.

6. Question 6 · Easy

   A 48-year-old daily-wage worker who has drunk arrack heavily for 20 years is brought to casualty confused. He has nystagmus, bilateral lateral rectus palsy and a broad-based unsteady gait. Deficiency of which vitamin is responsible?

   1. ANiacin
   2. BCobalamin
   3. CPyridoxine
   4. DThiamine

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7. Question 7 · Medium

   A 36-year-old man on disulfiram after alcohol detoxification drinks two pegs at a wedding. Within 20 minutes he has facial flushing, throbbing headache, vomiting, palpitations and a fall in blood pressure. Accumulation of which substance causes these symptoms?

   1. AAcetaldehyde
   2. BAcetic acid
   3. CEthanol
   4. DMethanol

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8. Question 8 · Medium

   A 44-year-old man admitted with a fractured femur is calm on admission. On the third day he becomes disoriented, picks at the bedsheet, sees insects crawling on the wall, sweats profusely and has temperature 38.4 C, pulse 128/min and coarse tremor. His wife says he drinks daily. What is the most likely diagnosis?

   1. AAlcoholic hallucinosis
   2. BFat embolism syndrome
   3. CWernicke encephalopathy
   4. DDelirium tremens

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9. Question 9 · Medium

   A 50-year-old man with chronic alcohol use is admitted with confusion and ataxia. Wernicke encephalopathy is suspected and thiamine is started. To confirm thiamine deficiency, the laboratory measures the activity of which red cell enzyme before and after adding thiamine pyrophosphate?

   1. AAspartate aminotransferase
   2. BGlutathione reductase
   3. CTransketolase
   4. DPyruvate kinase

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10. Question 10 · Medium

    A 39-year-old autorickshaw driver cut down his heavy drinking two days ago. He is fully oriented and has no tremor, but he hears several men discussing him and threatening to beat him, and he has barricaded his room. Vitals are normal. What is the most likely diagnosis?

    1. APathological jealousy
    2. BAlcoholic hallucinosis
    3. CDelirium tremens
    4. DKorsakoff syndrome

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11. Question 11 · Medium

    A 33-year-old man on opioid substitution is switched from buprenorphine alone to a sublingual tablet of buprenorphine combined with naloxone. Why is naloxone added?

    1. ATo deter crushing and injecting the tablet
    2. BTo reduce constipation from buprenorphine
    3. CTo prolong the action of buprenorphine
    4. DTo treat overdose if he drinks alcohol

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12. Question 12 · Medium

    A 25-year-old man in a de-addiction centre in Amritsar is 18 hours from his last dose of heroin. He has yawning, watering eyes, running nose, dilated pupils, gooseflesh, abdominal cramps and diarrhoea. He refuses opioid substitution. Which drug best relieves his autonomic symptoms?

    1. AClonidine
    2. BNaloxone
    3. CAtropine
    4. DHaloperidol

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13. Question 13 · Easy

    A 52-year-old man who drinks a litre of whisky a day is admitted for elective hernia surgery. Twelve hours after his last drink he becomes tremulous, sweaty and anxious, with pulse 112/min. Liver function is normal. Which drug is preferred to treat his withdrawal?

    1. AHaloperidol
    2. BDisulfiram
    3. CChlordiazepoxide
    4. DPhenytoin

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14. Question 14 · Medium

    A 58-year-old man with 30 years of heavy drinking was treated for Wernicke encephalopathy last year. He is alert and attentive but cannot remember anything from a few minutes ago, and when asked what he did yesterday he describes a trip to the market that never happened. Damage to which structures most characteristically underlies this?

    1. APrimary visual cortex
    2. BCerebellar vermis alone
    3. CMammillary bodies and medial thalamus
    4. DCaudate nuclei and putamina on both sides

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15. Question 15 · Medium

    A 29-year-old man who injects heroin is enrolled at an opioid substitution therapy centre. His first dose of sublingual buprenorphine is given four hours after his last injection. Within an hour he has severe sweating, cramps, vomiting and diarrhoea. What explains this reaction?

    1. AA high-affinity partial agonist displacing a full agonist
    2. BAn allergic reaction to buprenorphine
    3. CRapid liver metabolism of buprenorphine
    4. DA full agonist adding to residual heroin

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16. Question 16 · Medium

    A 47-year-old man with alcohol dependence and compensated cirrhosis (bilirubin 2.1 mg/dL, ascites controlled) has completed detoxification and wants a drug to reduce craving. His creatinine is normal. Which drug is most suitable?

    1. ADisulfiram
    2. BChlordiazepoxide
    3. CAcamprosate
    4. DNaltrexone

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17. Question 17 · Easy

    Locked in police custody for 30 hours, a man who injects heroin daily now has yawning, a running nose, watery eyes, dilated pupils, goosebumps, abdominal cramps and diarrhoea. He is fully oriented, with no tremor or hallucinations. What is he most likely experiencing?

    1. ACannabis intoxication
    2. BOpioid withdrawal
    3. CAmphetamine intoxication
    4. DAlcohol withdrawal

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18. Question 18 · Medium

    ABG and electrolytes of a street child from a railway platform in Delhi, brought with weakness after sniffing glue daily for months: pH 7.28, HCO3 14 mmol/L, PaCO2 30 mmHg, Na 138, Cl 116 and K 2.5 mmol/L; urine pH 6.8. Which acid-base disorder do these show?

    1. AHigh anion gap metabolic acidosis
    2. BProximal RTA with bicarbonate wasting
    3. CNormal anion gap acidosis, distal RTA type
    4. DPrimary respiratory alkalosis

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19. Question 19 · Easy

    Liver tests of a man who says he drinks 'only socially' show GGT 210 U/L (normal under 50) and an MCV of 104 fL. Which blood marker is the most specific for sustained heavy drinking?

    1. ACarbohydrate-deficient transferrin
    2. BGamma-glutamyl transferase
    3. CMean corpuscular volume
    4. DAlanine aminotransferase

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20. Question 20 · Medium

    Ascites, jaundice and spider naevi are found in a man admitted for an elective hernia repair, who drank about 300 mL of spirits daily until 2 days ago. He now has tremor, sweating and anxiety, pulse 112/min, and is oriented. INR is 1.9 and albumin 2.6 g/dL. Which benzodiazepine is preferred for his withdrawal?

    1. ADiazepam
    2. BChlordiazepoxide
    3. CLorazepam
    4. DAlprazolam

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21. Question 21 · Hard

    Three men from the same village reach the district hospital a day after drinking illicit country liquor; one is already blind. This patient has blurred vision, abdominal pain and deep sighing breathing, and the optic discs are hyperaemic. Results: pH 7.08, HCO3 7 mmol/L, Na 138 and Cl 102 mmol/L; glucose 90 mg/dL and BUN 14 mg/dL; measured serum osmolality 330 mOsm/kg. No ethanol is detected, and the other two men are drowsy with similar results. Besides IV bicarbonate and supportive care, which step is most appropriate?

    1. AIV naloxone infusion
    2. BIV thiamine and dextrose only
    3. CN-acetylcysteine infusion
    4. DFomepizole or ethanol, with haemodialysis

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22. Question 22 · Medium

    At a screening camp run by a PHC, a lorry cleaner scores 17 on the WHO AUDIT questionnaire. He has no tremor on waking and has never had withdrawal symptoms. Under the WHO AUDIT risk zones, which intervention does this score call for?

    1. ASimple advice on safe drinking
    2. BBrief counselling and monitoring
    3. CReferral for dependence treatment
    4. DNo intervention is needed

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23. Question 23 · Medium

    A courier who has used large amounts of cocaine for weeks keeps scratching his forearms raw, saying insects are crawling under his skin; he brings a matchbox of 'bugs' that turn out to be skin flakes. What is this experience called?

    1. AHypnagogic hallucination
    2. BReflex hallucination
    3. CFormication (Magnan sign)
    4. DLilliputian hallucination

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24. Question 24 · Medium

    Every few weeks for a year, a daily cannabis user from Goa has had bouts of severe nausea and vomiting lasting 2-3 days, which he relieves by taking long hot showers many times a day. Endoscopy, abdominal ultrasound and blood tests are normal between bouts. Which management is most effective in preventing these episodes?

    1. ADaily ondansetron
    2. BA proton pump inhibitor
    3. CStopping cannabis use
    4. DDomperidone before meals

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25. Question 25 · Medium

    Consider these statements on methadone maintenance for opioid dependence: 1. Methadone is a long-acting full agonist at mu-opioid receptors. 2. It can prolong the QT interval, so an ECG is advised at higher doses. 3. Rifampicin raises methadone levels and can cause overdose. 4. Doses are taken under supervision in the early weeks. Which statements are correct?

    1. A1 and 3 only
    2. B1, 2 and 4
    3. C1, 2 and 3
    4. D2, 3 and 4

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