Opioid use disorder US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Opioid use disorder. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Opioid use disorder US Medical PG Question 1: A 32-year-old man is brought to the emergency department because he was found stumbling in the street heedless of oncoming traffic. On arrival, he is found to be sluggish and has slow and sometimes incoherent speech. He is also drowsy and falls asleep several times during questioning. Chart review shows that he has previously been admitted after getting a severe cut during a bar fight. Otherwise, he is known to be intermittently homeless and has poorly managed diabetes. Serum testing reveals the presence of a substance that increases the duration of opening for an important channel. Which of the following symptoms may be seen if the most likely substance in this patient is abruptly discontinued?
- A. Tremors
- B. Insomnia
- C. Delayed delirium
- D. Piloerection
- E. Seizures (Correct Answer)
Opioid use disorder Explanation: ***Seizures***
- This patient presents with symptoms of **central nervous system (CNS) depression** (sluggish, incoherent speech, drowsiness) and a history suggestive of **substance abuse** (homelessness, bar fight).
- The key clue is that the substance **increases the duration of opening** of the GABA-A receptor channel, which specifically describes **barbiturates** (benzodiazepines increase the **frequency** of opening, not duration).
- Abrupt discontinuation of barbiturates can lead to life-threatening **withdrawal seizures** due to CNS hyperexcitability when GABAergic inhibition is suddenly removed [1].
- This is the most critical and potentially fatal complication of barbiturate withdrawal.
*Tremors*
- While **tremors** can occur during withdrawal from CNS depressants, they are a less severe symptom compared to seizures.
- Tremors are common in withdrawal syndromes but do not represent the most life-threatening risk in acute barbiturate withdrawal.
*Insomnia*
- **Insomnia** is a common symptom of withdrawal from CNS depressants due to rebound CNS hyperactivity [1].
- However, compared to seizures, insomnia is not life-threatening and is a less critical feature of barbiturate withdrawal.
*Delayed delirium*
- **Delirium** can occur during severe withdrawal, particularly **delirium tremens** in alcohol withdrawal.
- While delirium may develop, the most immediate and severe risk for barbiturate withdrawal is seizures, which can occur within hours to days of cessation.
*Piloerection*
- **Piloerection** (goosebumps) is a classic symptom of **opioid withdrawal**, resulting from sympathetic nervous system activation.
- This symptom is **not** characteristic of withdrawal from barbiturates or other GABAergic substances, making it an incorrect choice.
Opioid use disorder US Medical PG Question 2: A 25-year-old woman comes into her family doctor’s clinic confused as to how she failed her work-required urine drug test. The patient has no significant past medical history and takes no medications. She states that she does not smoke and denies ever using any alcohol or recreational drugs. The patient’s social history reveals a recent change in her diet. For the past 2-weeks, she was experimenting with a ketogenic diet and using poppy seed bagels as her only source of carbohydrates. Her vital signs and physical examination are within normal limits. Which of the following physical exam findings might be present had this patient really been abusing the class of drug for which she most likely tested positive?
- A. Tachypnea
- B. Myalgia
- C. Anhidrosis
- D. Conjunctival injection
- E. Miosis (Correct Answer)
Opioid use disorder Explanation: ***Miosis***
- Poppy seeds can cause a false positive for **opiates** (morphine/codeine) on urine drug screens. Acute opiate intoxication typically causes **miosis** (pinpoint pupils) due to parasympathetic stimulation.
- Other signs of acute opiate intoxication include **respiratory depression** and **CNS depression**.
*Tachypnea*
- **Tachypnea** (increased respiratory rate) is not a typical sign of acute opiate intoxication; rather, **bradypnea** or **respiratory depression** is characteristic.
- Tachypnea is more commonly seen with stimulant abuse, anxiety, or metabolic acidosis.
*Myalgia*
- **Myalgia** (muscle pain) is a common symptom of **opiate withdrawal**, not acute intoxication.
- During acute opiate use, patients more commonly experience analgesia.
*Anhidrosis*
- The class of drugs involved here is **opiates**, which typically cause **diaphoresis** (sweating), not anhidrosis (absence of sweating).
- Anhidrosis can be a symptom of certain neurological conditions or anticholinergic toxicity.
*Conjunctival injection*
- **Conjunctival injection** (red eyes) is more commonly associated with **cannabis use**.
- Opiate intoxication typically causes **miosis** and sometimes mild conjunctival changes but not prominent injection.
Opioid use disorder US Medical PG Question 3: A 22-year-old man seeks help from a physician for his heroin addiction. He tells the doctor that he started using heroin at the age of 17 and gradually started increasing the dose. He has been trying to quit for the last 6 months after realizing the negative consequences of his addiction but has not succeeded because of the withdrawal symptoms. The physician suggests a drug that can be taken within a supervised rehabilitation program as a substitute for heroin to help alleviate withdrawal symptoms. The drug will then be tapered over time. He is further informed by the physician that this drug is not to be taken by the patient on his own and is not used for emergency reversal of opioid overdose. Which of the following drugs is most likely to have been recommended by the physician?
- A. Clonidine
- B. Naltrexone
- C. Methadone (Correct Answer)
- D. Naloxone
- E. Codeine
Opioid use disorder Explanation: **Methadone**
- **Methadone** is a long-acting opioid agonist used in **medically supervised settings** for opioid addiction treatment, acting as a substitute to alleviate withdrawal symptoms and cravings.
- Its long half-life allows for **once-daily dosing**, making it suitable for gradual tapering and preventing acute withdrawal, but it is **not used for emergency reversal** of opioid overdose due to its slow onset and prolonged effects.
*Clonidine*
- **Clonidine** is an alpha-2 adrenergic agonist used to manage **autonomic symptoms of opioid withdrawal** (e.g., sweating, anxiety, muscle aches) but does not directly address opioid cravings or act as an opioid substitute.
- It works by **reducing sympathetic nervous system activity** and can cause sedation and hypotension, but it's not the primary opioid substitution therapy.
*Naltrexone*
- **Naltrexone** is an **opioid receptor antagonist** used to prevent relapse by blocking the euphoric effects of opioids, but it is not used to treat acute withdrawal symptoms.
- It should only be administered after **opioid detoxification is complete**, as giving it to someone with opioids in their system can precipitate severe, acute withdrawal.
*Naloxone*
- **Naloxone** is a pure **opioid receptor antagonist** used primarily to **rapidly reverse opioid overdose** by displacing opioids from their receptors in emergency situations.
- Due to its **short half-life** and immediate action, it is not suitable for the sustained management of withdrawal symptoms or as a substitute for opioids in addiction treatment programs.
*Codeine*
- **Codeine** is an opioid analgesic and antitussive that has a **high potential for abuse and dependence** itself, making it unsuitable as a substitute treatment for heroin addiction.
- Although it can alleviate pain and cough, using codeine in this context would essentially be **substituting one opioid addiction for another**, which is contrary to the goals of addiction treatment.
Opioid use disorder US Medical PG Question 4: A 25-year-old man is brought to the emergency department by police for abnormal behavior in a mini-market. The patient was found passed out in the aisle, and police were unable to arouse him. The patient has a past medical history of alcohol abuse and is not currently taking any medications according to his medical records. His temperature is 99.5°F (37.5°C), blood pressure is 120/87 mmHg, pulse is 50/min, respirations are 5/min, and oxygen saturation is 93% on room air. On physical exam, the patient is minimally responsive. He responds to painful stimuli by retracting his limbs and groaning, but otherwise does not answer questions or obey commands. Which of the following is most likely to be found in this patient?
- A. Visual hallucinations
- B. Conjunctival hyperemia
- C. Hyperactive bowel sounds
- D. Mydriasis
- E. Miosis (Correct Answer)
Opioid use disorder Explanation: ***Miosis***
- The patient's presentation with **respiratory depression**, **bradycardia**, **miosis** (pinpoint pupils), and **depressed mental status** is highly suggestive of **opioid overdose**.
- **Miosis** is a classic and nearly pathognomonic sign of opioid toxicity due to opioid-induced parasympathetic stimulation.
*Visual hallucinations*
- **Visual hallucinations** are more commonly associated with conditions like **alcohol withdrawal** (delirium tremens), stimulant intoxication, or certain psychiatric disorders.
- They are not a typical feature of acute opioid overdose, which primarily causes central nervous system depression.
*Conjunctival hyperemia*
- **Conjunctival hyperemia** (red eyes) is frequently observed with **cannabis intoxication** or certain inhalant exposures.
- This sign is not characteristic of an opioid overdose; rather, pupils are typically constricted.
*Hyperactive bowel sounds*
- **Hyperactive bowel sounds** can be seen in conditions causing increased gastrointestinal motility, such as **gastroenteritis** or early stages of bowel obstruction.
- Opioids typically cause **decreased gastrointestinal motility**, leading to **constipation** and often diminished or absent bowel sounds, not hyperactive ones.
*Mydriasis*
- **Mydriasis** (dilated pupils) is typically associated with sympathomimetic toxicity (e.g., **cocaine**, **amphetamine**), anticholinergic poisoning (e.g., **atropine**), or severe anoxia.
- In direct contrast, opioids cause **miosis**.
Opioid use disorder US Medical PG Question 5: A 28-year-old woman comes to the physician because of an 8-hour history of painful leg cramping, a runny nose, and chills. She has also had diarrhea and abdominal pain. She appears irritable and yawns frequently. Her pulse is 115/min. Examination shows cool, damp skin with piloerection. The pupils are 7 mm in diameter and equal in size. Bowel sounds are hyperactive. Deep tendon reflexes are 3+ bilaterally. Withdrawal from which of the following substances is most likely the cause of this patient's symptoms?
- A. Barbiturate
- B. Heroin (Correct Answer)
- C. Gamma-hydroxybutyric acid
- D. Cocaine
- E. Alcohol
Opioid use disorder Explanation: ***Heroin***
- The constellation of symptoms including **painful muscle cramps**, **runny nose**, **chills**, **diarrhea**, **abdominal pain**, **irritability**, **frequent yawning**, **tachycardia**, **cool and damp skin with piloerection** ("goosebumps"), **dilated pupils**, **hyperactive bowel sounds**, and **hyperreflexia** is highly characteristic of **opioid withdrawal**.
- **Heroin** is a potent opioid, and its withdrawal syndrome presents with these classic signs of autonomic hyperactivity and generalized discomfort.
*Barbiturate*
- **Barbiturate withdrawal** can cause anxiety, seizures, and delirium, but it typically presents with **CNS hyperexcitability** (tremors, seizures, hallucinations) rather than the pronounced autonomic symptoms and pain described.
- While some symptoms like anxiety and tachycardia might overlap, the specific combination of **piloerection**, **dilated pupils**, and **hyperactive bowels** points away from barbiturate withdrawal.
*Gamma-hydroxybutyric acid*
- **GHB withdrawal** can manifest as anxiety, insomnia, tremors, and psychosis, but it does not typically cause the prominent **gastrointestinal distress**, **piloerection**, and **rhinorrhoea** seen in this patient.
- It’s more associated with **seizures** and **delirium tremens-like symptoms** in severe cases.
*Cocaine*
- **Cocaine withdrawal** is often characterized by **dysphoria**, fatigue, increased appetite, and psychomotor retardation, reflecting a **"crash"** after stimulant use.
- It does not typically involve the autonomic hyperactivity signs like **rhinorrhoea**, **piloerection**, or **dilated pupils** described, and the prominent physical symptoms (cramping, diarrhea) are absent.
*Alcohol*
- **Alcohol withdrawal** can cause tremors, anxiety, tachycardia, and seizures, and in severe cases, delirium tremens; however, **piloerection**, **dilated pupils**, and pronounced **gastrointestinal symptoms** (diarrhea, abdominal pain) as the primary presentation are less typical.
- The time course and specific cluster of symptoms strongly favor opioid withdrawal over alcohol withdrawal.
Opioid use disorder US Medical PG Question 6: A 36-year-old man presents to a psychiatrist for management of nicotine dependence. He has been a heavy smoker for the past 20 years. He has unsuccessfully attempted to quit smoking many times. He has seen multiple physicians for nicotine dependence. They prescribed nicotine replacement therapy and varenicline. He has also taken two antidepressants and participated in talk therapy. He asks the psychiatrist whether there are other alternatives. The psychiatrist explains that nicotine replacement therapy, non-nicotine pharmacotherapy, and talk therapy are the best options for the management of nicotine dependence. He tells the patient he can take a second-line medication for non-nicotine pharmacotherapy because the first-line medication failed. Which of the following medications would the psychiatrist most likely use to manage this patient’s nicotine dependence?
- A. Topiramate
- B. Methadone
- C. Clonidine (Correct Answer)
- D. Buprenorphine
- E. Lorazepam
Opioid use disorder Explanation: ***Clonidine***
- **Clonidine** is a **second-line agent** for smoking cessation, particularly effective for managing **withdrawal symptoms** like anxiety, irritability, and restlessness.
- It works as an **alpha-2 adrenergic agonist**, reducing sympathetic outflow and alleviating the somatic symptoms of nicotine withdrawal.
*Topiramate*
- **Topiramate** is an anticonvulsant sometimes used off-label for **alcohol dependence** or **weight management**; it is not a primary or secondary treatment for nicotine dependence.
- Its mechanism of action involves GABAergic and glutamatergic modulation, which is not directly targeted at nicotine withdrawal.
*Methadone*
- **Methadone** is an **opioid agonist** primarily used in the treatment of **opioid use disorder** to prevent withdrawal symptoms and reduce cravings.
- It has no established role in the direct management of nicotine dependence or smoking cessation.
*Buprenorphine*
- **Buprenorphine** is a **partial opioid agonist** used in the treatment of **opioid use disorder**, often combined with naloxone.
- Similar to methadone, it is not indicated for the treatment of nicotine dependence.
*Lorazepam*
- **Lorazepam** is a **benzodiazepine** used to treat **anxiety, insomnia**, and **seizures** due to its sedative and anxiolytic properties.
- While it could help with anxiety associated with nicotine withdrawal, it is not a direct treatment for nicotine dependence and carries risks of dependence itself.
Opioid use disorder US Medical PG Question 7: A 22-year-old man is brought to the emergency department by his roommate 20 minutes after being discovered unconscious at home. On arrival, he is unresponsive to painful stimuli. His pulse is 65/min, respirations are 8/min, and blood pressure is 110/70 mm Hg. Pulse oximetry shows an oxygen saturation of 75%. Despite appropriate lifesaving measures, he dies. The physician suspects that he overdosed. If the suspicion is correct, statistically, the most likely cause of death is overdose with which of the following groups of drugs?
- A. Benzodiazepines
- B. Opioid analgesics (Correct Answer)
- C. Acetaminophen
- D. Antidepressants
- E. Amphetamines
Opioid use disorder Explanation: ***Opioid analgesics***
- The patient's presentation with **unresponsiveness**, **respiratory depression** (respirations 8/min, SpO2 75%), and **bradycardia** is highly characteristic of severe opioid overdose.
- Opioids suppress the **respiratory drive** through their action on mu-opioid receptors in the brainstem, leading to hypoventilation, hypoxemia, and ultimately death if untreated.
- **Statistically**, opioids are the leading cause of fatal drug overdoses in the United States.
*Benzodiazepines*
- While benzodiazepine overdose can cause significant **CNS depression** and unresponsiveness, it is less likely to cause such profound and rapid respiratory depression as the sole agent, particularly with a relatively preserved blood pressure.
- Benzodiazepines primarily enhance the effect of **GABA**, leading to sedation and anxiolysis, but typically have a wider therapeutic index for respiratory depression compared to opioids.
*Acetaminophen*
- Acetaminophen overdose primarily causes **hepatotoxicity** (liver damage), which develops over 24-72 hours, not immediate death from respiratory depression.
- Acute overdose symptoms may initially be mild or absent, with liver failure manifesting hours to days later, which does not fit the rapid demise in this case.
*Antidepressants*
- Overdoses with antidepressants, especially **tricyclic antidepressants (TCAs)**, can cause cardiac arrhythmias, seizures, and CNS depression.
- However, the primary cause of death is typically from **cardiac toxicity** or intractable seizures, not the profound respiratory depression seen here.
*Amphetamines*
- Amphetamine overdose is characterized by **CNS stimulation**, including agitation, hyperthermia, tachycardia, hypertension, and seizures, with respiratory failure often secondary to status epilepticus or cardiovascular collapse.
- This presentation is the opposite of the patient's severe CNS and respiratory depression.
Opioid use disorder US Medical PG Question 8: A middle-aged homeless man is found lying unresponsive on the streets by the police and is rushed to the emergency department. His vital signs include: blood pressure 110/80 mm Hg, pulse rate 100/min, and respirations 10/min and shallow. On physical examination, his extremities are cold and clammy. Pupils are constricted and non-reactive. His blood glucose is 55 mg/dL. IV access is established immediately with the administration of dextrose and naloxone. In half an hour, the patient is fully conscious, alert and responsive. He denies any medical illnesses, hospitalizations, or surgeries in the past. Physical examination reveals injection track marks along both arms. He admits to the use of cocaine and heroin. He smokes cigarettes and consumes alcohol. His vital signs are now stable. A urine sample is sent for toxicology screening. Which of the following was the most likely cause of this patient’s respiratory depression?
- A. Opioid intoxication (Correct Answer)
- B. Alcohol intoxication
- C. Cocaine abuse
- D. Hallucinogen toxicity
- E. Hypoglycemia
Opioid use disorder Explanation: ***Opioid intoxication***
- The patient's presentation with **respiratory depression** (respirations 10/min), **constricted pupils**, and rapid improvement after **naloxone administration** strongly indicates opioid overdose.
- The presence of **injection track marks** and admitted **heroin use** further supports opioid intoxication as the primary cause.
*Alcohol intoxication*
- While alcohol can cause respiratory depression and altered mental status, it typically presents with **dilated pupils** or normal pupils, not pinpoint pupils.
- The rapid reversal with **naloxone** would not occur in pure alcohol intoxication.
*Cocaine abuse*
- Cocaine is a **stimulant** and typically causes **tachycardia**, **hypertension**, **mydriasis (dilated pupils)**, and potentially agitation or seizures, rather than respiratory depression and constricted pupils.
- It would not respond to naloxone.
*Hallucinogen toxicity*
- Hallucinogens (e.g., LSD, PCP) primarily affect perception, mood, and thought, causing **psychosis**, **hallucinations**, and **agitation**, not severe respiratory depression or constricted pupils.
- Their effects are not reversed by naloxone.
*Hypoglycemia*
- Although the patient had a blood glucose of 55 mg/dL (mild hypoglycemia), the primary cause of respiratory depression was reversed by **naloxone**, not solely by dextrose.
- While hypoglycemia can cause altered mental status, it does not typically cause **pinpoint pupils** or such profound respiratory depression that is immediately reversed by an opioid antagonist.
Opioid use disorder US Medical PG Question 9: A 40-year-old woman with a recent history of carcinoma of the breast status post mastectomy and adjuvant chemotherapy one week ago presents for follow-up. She reports adequate pain control managed with the analgesic drug she was prescribed. Past medical history is significant for hepatitis C and major depressive disorder. The patient denies any history of smoking or alcohol use but says she is currently using intravenous heroin and has been for the past 10 years. However, she reports that she has been using much less heroin since she started taking the pain medication, which is confirmed by the toxicology screen. Which of the following is the primary mechanism of action of the analgesic drug she was most likely prescribed?
- A. Pure antagonist at opioid receptors
- B. Pure agonist at the µ-opioid receptor (Correct Answer)
- C. Inhibits prostaglandin synthesis
- D. Mixed agonist-antagonist at opioid receptors
- E. Central action via blockade of serotonin reuptake
Opioid use disorder Explanation: ***Pure agonist at the µ-opioid receptor***
- Opioid analgesics, commonly prescribed for **post-mastectomy pain** and cancer-related pain, primarily exert their effects by acting as **pure agonists at the µ-opioid receptor**.
- This activation leads to profound **analgesia** by modulating pain perception and emotional response to pain in the central nervous system.
*Pure antagonist at opioid receptors*
- A **pure antagonist** would block opioid receptors and **reverse** the effects of opioid agonists, not provide analgesia.
- Such drugs are used to treat **opioid overdose** (e.g., naloxone) or to manage addiction by preventing opioid effects.
*Inhibits prostaglandin synthesis*
- This is the mechanism of action for **NSAIDs** (non-steroidal anti-inflammatory drugs), which primarily treat **mild to moderate pain** and inflammation.
- NSAIDs are generally insufficient for severe **post-surgical** or **cancer pain** of the magnitude experienced by this patient.
*Mixed agonist-antagonist at opioid receptors*
- Mixed agonist-antagonists provide analgesia by acting as agonists at some opioid receptors while acting as antagonists at others (e.g., **buprenorphine**).
- While they can provide pain relief, their use in acute severe pain is often limited, and they can sometimes **precipitate withdrawal** in patients chronically using full opioid agonists.
*Central action via blockade of serotonin reuptake*
- This is the primary mechanism of action for **antidepressants** (SSRIs) and some drugs used for **neuropathic pain** (e.g., tramadol with additional opioid action).
- While some antidepressants have analgesic properties, this mechanism alone is not typically the primary one for the potent pain relief needed post-mastectomy, which usually requires an **opioid**.
Opioid use disorder US Medical PG Question 10: A 30-year-old man presents to his family physician admitting to using heroin. He says he started using about 6-months ago when his back pain medication ran out. At first, he says he would borrow his wife’s Percocet but, eventually, that ran out and he had to find a different source. Since then, he has been having more and more issues related to his heroin use, and it has started to affect his work and home life. He is concerned that, if he continues like this, he might end up in real trouble. He denies sharing needles and is sincerely interested in quitting. He recalls trying to quit last month but recounts how horrible the withdrawal symptoms were. Because of this and the strong cravings, he relapsed shortly after his initial attempt. Methadone maintenance therapy is prescribed. Which of the following would most likely be the most important benefit of this new treatment plan in this patient?
- A. Decreases methadone dependence
- B. Euphoria without the side effects
- C. Prevention of withdrawal symptoms and reduced cravings (Correct Answer)
- D. Reduced risk of hepatitis B and C transmission
- E. Improved interpersonal relationships
Opioid use disorder Explanation: ***Prevention of withdrawal symptoms and reduced cravings***
- **Methadone maintenance therapy** is a long-acting μ-opioid receptor agonist that prevents withdrawal symptoms and reduces cravings—this is the **primary therapeutic benefit** and mechanism of action.
- By providing a stable, long-acting opioid, methadone eliminates the cycle of withdrawal and drug-seeking behavior that characterizes heroin addiction.
- This patient's previous quit attempt failed specifically due to **"horrible withdrawal symptoms"** and **strong cravings**, making this the most directly relevant benefit for his situation.
- All other benefits of methadone maintenance (improved functioning, better relationships, reduced risk behaviors) are **secondary consequences** that stem from this primary pharmacological effect.
- Evidence-based guidelines consistently identify withdrawal prevention and craving reduction as the core therapeutic goals of opioid agonist therapy.
*Improved interpersonal relationships*
- While this is an important **downstream benefit** of successful methadone maintenance, it is an indirect consequence rather than the primary therapeutic effect.
- Improved relationships result FROM the stabilization achieved through withdrawal prevention and craving reduction, not as a direct pharmacological action.
- Though clinically meaningful, this represents a **psychosocial outcome** rather than the most important direct benefit of the medication itself.
*Decreases methadone dependence*
- This is **incorrect**—methadone itself is an opioid agonist and patients on maintenance therapy develop **physical dependence** on methadone.
- The goal is to substitute unstable illicit opioid use (heroin) with stable, medically supervised opioid therapy (methadone), not to eliminate opioid dependence immediately.
- Methadone maintenance is harm reduction, not abstinence-based treatment initially.
*Euphoria without the side effects*
- Methadone is **not intended to produce euphoria**—it is administered at stable doses to maintain normal functioning without intoxication.
- Its slow onset and long duration of action when taken orally minimize the "rush" or euphoric effects associated with rapid-acting opioids like heroin.
- The goal is stabilization and normal functioning, not achieving a "high."
*Reduced risk of hepatitis B and C transmission*
- This is a valuable **harm reduction benefit**, particularly for those who inject drugs and share needles.
- However, this patient specifically **denies sharing needles**, making this less relevant to his individual case.
- More importantly, this is a secondary benefit that occurs as a result of reduced injection drug use, which itself results from the primary effect of withdrawal prevention and craving reduction.
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