Substance Use Disorders — MCQs

A person was addicted to alcohol for 10 years. He sustained an injury to his toe, and the wound was not healing. He was admitted to the hospital, where he was restless in bed, attempting to catch imaginary insects. He referred to the doctor as his brother and complained of uncontrollable fear of being murdered and insomnia. What is the likely diagnosis?

Substance Use Disorders Indian Medical PG Practice Questions and MCQs

Question 71: Which drugs are used in the maintenance treatment of substance dependence?

A. Naloxone
B. Acamprosate
C. Disulfiram (Correct Answer)
D. Clonidine

Explanation: **Explanation:** The goal of **maintenance treatment** in substance dependence is to prevent relapse and support long-term abstinence after the initial detoxification phase. **Why Disulfiram is Correct:** Disulfiram is a classic **aversion therapy** agent used for the maintenance of alcohol abstinence. It works by irreversibly inhibiting the enzyme **Aldehyde Dehydrogenase**. When a patient consumes alcohol while on Disulfiram, acetaldehyde accumulates in the body, leading to the highly unpleasant **Disulfiram-Ethanol Reaction (DER)** characterized by flushing, tachycardia, nausea, and palpitations. This psychological deterrent helps maintain sobriety. **Analysis of Incorrect Options:** * **A. Naloxone:** This is a short-acting opioid antagonist used exclusively for the **emergency reversal of acute opioid overdose**. It is not used for maintenance because of its very short half-life and lack of oral bioavailability. (Note: *Naltrexone* is used for maintenance). * **B. Acamprosate:** While Acamprosate is indeed used for alcohol maintenance (to reduce cravings), in the context of standard NEET-PG questions, Disulfiram is often highlighted as the prototypical "deterrent" maintenance drug. However, if this were a multiple-choice question where "all of the above" wasn't an option, Disulfiram remains a historically classic answer for maintenance. * **D. Clonidine:** This is an alpha-2 agonist used to manage the **autonomic symptoms of acute opioid withdrawal** (e.g., hypertension, sweating). It has no role in long-term maintenance treatment. **High-Yield Clinical Pearls for NEET-PG:** * **Disulfiram:** Must not be administered until the patient has been abstinent from alcohol for at least 12 hours. * **Acamprosate:** Preferred in patients with liver disease (excreted renally). * **Naltrexone:** First-line for reducing "reward" and cravings in both Alcohol and Opioid Use Disorders. * **Methadone/Buprenorphine:** Gold standard for opioid substitution maintenance therapy.

Question 72: Which drug's long-term use effects can closely mimic schizophrenia?

A. Alcohol
B. Amphetamines (Correct Answer)
C. Opioids
D. MDMA

Explanation: **Explanation:** The correct answer is **Amphetamines**. **Why Amphetamines?** Chronic use of amphetamines leads to a condition known as **Amphetamine-Induced Psychosis**, which is clinically indistinguishable from the positive symptoms of schizophrenia. The underlying mechanism is the **Dopamine Hypothesis**: amphetamines trigger a massive release of dopamine and block its reuptake in the mesolimbic pathway. This results in symptoms such as paranoid delusions, auditory and visual hallucinations, and disorganized behavior. Unlike other drug-induced states, amphetamine psychosis can persist for weeks even after cessation of the drug. **Analysis of Incorrect Options:** * **Alcohol:** Long-term use is associated with Wernicke-Korsakoff syndrome (memory deficits) or Alcohol Hallucinosis. While hallucinosis involves auditory hallucinations, it occurs in a clear sensorium and lacks the complex delusional system seen in schizophrenia. * **Opioids:** Chronic use typically leads to sedation, miosis, and physical dependence. Withdrawal causes autonomic hyperactivity, but it does not mimic the chronic psychotic features of schizophrenia. * **MDMA (Ecstasy):** While it has hallucinogenic properties due to serotonin release, its long-term effects are primarily related to mood disturbances (depression), cognitive impairment, and neurotoxicity rather than a chronic schizophreniform presentation. **Clinical Pearls for NEET-PG:** * **Formication (Magnan’s Sign):** A classic symptom of stimulant (cocaine/amphetamine) use where the patient feels "bugs crawling under the skin." * **Differential:** To distinguish from schizophrenia, look for **sympathomimetic signs** (tachycardia, mydriasis, hypertension) which are present in amphetamine use but absent in schizophrenia. * **Treatment:** Antipsychotics (D2 blockers) are the treatment of choice for the acute psychotic episode.

Question 73: The CAGE questionnaire is used to screen for:

A. Alcohol abuse (Correct Answer)
B. Depression
C. Suicidal intention
D. Coma

Explanation: **Explanation:** The **CAGE questionnaire** is a globally recognized, four-item clinical screening tool used to identify potential **alcohol use disorder (alcohol abuse or dependence)**. It is highly favored in busy clinical settings due to its brevity and high sensitivity. The acronym **CAGE** stands for: * **C: Cut down** – Have you ever felt you should cut down on your drinking? * **A: Annoyed** – Have people annoyed you by criticizing your drinking? * **G: Guilty** – Have you ever felt bad or guilty about your drinking? * **E: Eye-opener** – Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover? A score of **2 or more** is considered clinically significant, indicating a high probability of alcohol abuse. **Analysis of Incorrect Options:** * **B. Depression:** Screened using tools like the **PHQ-9** (Patient Health Questionnaire) or the **Beck Depression Inventory (BDI)**. * **C. Suicidal Intention:** Assessed using scales like the **SAD PERSONS scale** or the Columbia-Suicide Severity Rating Scale (C-SSRS). * **D. Coma:** Evaluated using the **Glasgow Coma Scale (GCS)** to determine the level of consciousness. **High-Yield Clinical Pearls for NEET-PG:** * **Sensitivity:** The CAGE questionnaire is more sensitive for detecting dependence than heavy drinking. * **T-ACE & AUDIT:** Other important screening tools for alcohol include the **AUDIT** (Alcohol Use Disorders Identification Test), which is the gold standard for detecting early hazardous drinking, and **T-ACE**, specifically designed for pregnant women. * **Most sensitive question:** The "Eye-opener" question is often considered the most specific indicator of physical dependence.

Question 74: Paranoid delusions are associated with the use of which substance?

A. Cocaine (Correct Answer)
B. Heroin
C. Cannabis
D. GHB

Explanation: **Explanation:** **Cocaine (Option A)** is a potent central nervous system stimulant that acts by inhibiting the reuptake of dopamine, norepinephrine, and serotonin. The resulting surge in synaptic dopamine, particularly in the mesolimbic pathway, is strongly associated with the development of **Cocaine-Induced Psychosis**. This condition is classically characterized by **paranoid delusions** (e.g., being followed by police) and tactile hallucinations, such as **formication** (the sensation of insects crawling under the skin, also known as "Cocaine bugs"). **Why other options are incorrect:** * **Heroin (Option B):** As an opioid, it primarily causes CNS depression, euphoria, and miosis. While withdrawal can cause agitation, it does not typically present with paranoid delusions. * **Cannabis (Option C):** While cannabis can cause acute anxiety or "cannabis-induced psychosis," it is more frequently associated with amotivational syndrome and perceptual distortions. In the context of standard NEET-PG questions, cocaine is the classic association for acute paranoid states. * **GHB (Option D):** Gamma-Hydroxybutyrate is a CNS depressant often used as a "date rape drug." It typically causes sedation, bradycardia, and respiratory depression rather than psychosis. **High-Yield Clinical Pearls for NEET-PG:** * **Magnan’s Symptom:** Another name for formication (tactile hallucinations) specifically seen in cocaine use. * **Physical Signs:** Look for sympathetic overactivity—mydriasis (dilated pupils), tachycardia, hypertension, and tremors. * **Chronic Use:** May lead to perforation of the nasal septum due to vasoconstriction. * **Treatment:** Acute cocaine-induced paranoia is generally managed with benzodiazepines and, if severe, antipsychotics.

Question 75: A person with a 20-year history of daily alcohol consumption and physical dependence is to be treated. Which drug should NOT be administered to this individual?

A. Disulfiram (Correct Answer)
B. Acamprosate
C. Naltrexone
D. Chlordiazepoxide

Explanation: ### Explanation The correct answer is **Disulfiram**. **Why Disulfiram is contraindicated in this scenario:** The patient has a 20-year history of daily alcohol consumption and **physical dependence**. In such cases, the immediate clinical priority is the management of **Alcohol Withdrawal Syndrome (AWS)**. Disulfiram is an alcohol-sensitizing agent that inhibits the enzyme *aldehyde dehydrogenase*, leading to the accumulation of acetaldehyde if alcohol is consumed. Administering Disulfiram to a person currently dependent or likely to have alcohol still in their system can trigger a severe, potentially fatal **Disulfiram-Ethanol Reaction (DER)**. Furthermore, Disulfiram is used for **maintenance of abstinence** (relapse prevention) and has no role in the acute detoxification phase. It should only be started after the patient has been abstinent for at least 12–24 hours and has cleared the withdrawal phase. **Analysis of Incorrect Options:** * **Chlordiazepoxide:** This is a long-acting benzodiazepine and the **drug of choice** for managing acute alcohol withdrawal symptoms and preventing seizures/delirium tremens. * **Acamprosate:** An NMDA receptor antagonist used for maintaining abstinence. It is safe to start even if the patient is not yet fully abstinent and is preferred in patients with liver disease. * **Naltrexone:** An opioid antagonist that reduces alcohol cravings and the "reward" of drinking. It can be initiated while the patient is still drinking. **NEET-PG High-Yield Pearls:** * **Gold Standard for Withdrawal:** Benzodiazepines (Chlordiazepoxide or Diazepam). If liver failure is present, use **LOT** (Lorazepam, Oxazepam, Temazepam). * **Disulfiram Mechanism:** Irreversible inhibition of Aldehyde Dehydrogenase. * **Wernicke’s Encephalopathy:** Always administer **Thiamine before Glucose** in chronic alcoholics to prevent precipitating Wernicke’s. * **First-line for Cravings:** Naltrexone or Acamprosate.

Question 76: An addict develops delusions, misperceiving hallucinations of sight and hearing, and the sensation of "grains of sand" creeping under the skin. What substance is the patient likely addicted to?

A. Heroin
B. Methadone
C. Cocaine (Correct Answer)
D. Amphetamines

Explanation: **Explanation:** The clinical presentation described is characteristic of **Cocaine intoxication** (specifically "Cocaine Psychosis"). The hallmark symptom mentioned—the sensation of "grains of sand" or insects creeping under the skin—is known as **Formication** (also called **Cocaine Bugs** or **Magnan’s symptom**). This is a type of tactile hallucination. When combined with delusions and visual/auditory hallucinations, it points strongly toward stimulant-induced psychosis. **Analysis of Options:** * **Cocaine (Correct):** Cocaine increases synaptic dopamine by blocking reuptake. High doses lead to sympathetic overactivity and psychosis. Formication is a classic, high-yield association with chronic cocaine use. * **Heroin & Methadone (Incorrect):** These are opioids. Acute intoxication typically presents with CNS depression, pinpoint pupils, and respiratory depression. Withdrawal causes "gooseflesh" (piloerection) and lacrimation, but not tactile hallucinations or "grains of sand" sensations. * **Amphetamines (Incorrect):** While amphetamines can cause a very similar paranoid psychosis, **Magnan’s symptom** (tactile hallucinations of insects/sand) is classically and more frequently associated with Cocaine in medical examinations. **High-Yield Clinical Pearls for NEET-PG:** * **Magnan’s Symptom:** Tactile hallucinations specific to cocaine. * **Cocaine vs. Amphetamine:** Cocaine has a shorter half-life and is associated with local anesthetic properties; Amphetamine psychosis lasts longer. * **Physical Sign:** Look for **mydriasis** (dilated pupils) and perforated nasal septum in chronic snorters. * **Treatment:** Benzodiazepines are the first-line treatment for agitation and hypertension in cocaine toxicity; avoid beta-blockers due to risk of unopposed alpha-adrenergic stimulation.

Question 77: A 36-year-old female, a chronic alcoholic, reports auditory hallucinations, specifically hearing voices commanding her to do things, and also experiences difficulty falling asleep. What is the most likely diagnosis?

A. Delirium tremens
B. Depression
C. Alcoholic hallucinosis (Correct Answer)
D. Wernicke's encephalopathy

Explanation: ### Explanation **Correct Option: C. Alcoholic hallucinosis** Alcoholic hallucinosis is a distinct clinical entity characterized by vivid auditory hallucinations (often accusatory or commanding) that occur in a state of **clear consciousness** (sensorium is clear). It typically develops within 12–24 hours of abstinence or reduction in intake in chronic alcoholics. Unlike delirium tremens, the patient remains oriented to time, place, and person. Difficulty falling asleep (insomnia) is a common associated withdrawal symptom. **Why other options are incorrect:** * **A. Delirium tremens:** This is a medical emergency characterized by **clouding of consciousness** (disorientation), autonomic hyperactivity (tachycardia, hypertension, sweating), and global confusion. While hallucinations occur, the lack of disorientation in the question points away from DT. * **B. Depression:** While chronic alcoholics often have comorbid mood disorders, the acute presentation of commanding auditory hallucinations is more characteristic of a primary psychotic or withdrawal-related phenomenon rather than simple depression. * **D. Wernicke's encephalopathy:** This is caused by Thiamine (B1) deficiency and is defined by the classic triad of **Ataxia, Ophthalmoplegia (nystagmus), and Confusion**. It does not typically present with isolated auditory hallucinations. **High-Yield Clinical Pearls for NEET-PG:** * **Alcoholic Hallucinosis vs. DT:** The key differentiator is the **level of consciousness**. Hallucinosis = Clear sensorium; Delirium Tremens = Clouded sensorium. * **Hallucination Type:** In alcoholic hallucinosis, auditory hallucinations are most common. In Delirium Tremens, visual hallucinations (e.g., seeing small animals/insects) are more frequent. * **Timeline:** Hallucinosis (12–24 hours) usually precedes Delirium Tremens (48–72 hours). * **Treatment:** Benzodiazepines (e.g., Lorazepam, Chlordiazepoxide) are the mainstay for managing alcohol withdrawal symptoms.

Question 78: Oniomania is a psychological disorder characterized by an uncontrollable impulse to:

A. Shop (Correct Answer)
B. Use cellular phones excessively
C. Use the internet excessively
D. Self-mutilate

Explanation: **Explanation:** **Oniomania**, commonly known as **Compulsive Buying Disorder (CBD)**, is characterized by an obsession with shopping and buying behavior that causes adverse consequences. It is currently classified under "Impulse Control Disorders Not Otherwise Specified" (ICD-10) or often discussed alongside Behavioral Addictions. The term is derived from the Greek words *onios* (for sale) and *mania* (insanity). Patients experience an irresistible urge to purchase items, often followed by a sense of relief or euphoria, which is subsequently replaced by guilt or financial distress. **Analysis of Options:** * **Option A (Correct):** Oniomania specifically refers to the uncontrollable impulse to **shop**. It shares a common neurobiological pathway with substance use disorders, involving the dopaminergic reward system. * **Option B (Incorrect):** Excessive cellular phone use is termed **Nomophobia** (No Mobile Phone Phobia) or simply problematic smartphone use; it is not Oniomania. * **Option C (Incorrect):** Excessive internet use is classified as **Internet Addiction Disorder** or Problematic Internet Use (PIU). * **Option D (Incorrect):** The impulse to self-mutilate is often a symptom of **Borderline Personality Disorder** or "Non-Suicidal Self-Injury" (NSSI), not a "mania." **High-Yield Clinical Pearls for NEET-PG:** * **Kleptomania:** Irresistible urge to steal items not needed for personal use or monetary value. * **Pyromania:** Deliberate and purposeful fire-setting. * **Trichotillomania:** Recurrent pulling out of one's hair. * **Treatment:** Cognitive Behavioral Therapy (CBT) is the mainstay. SSRIs (like Fluoxetine) are often used to manage comorbid anxiety or depression.

Question 79: What is the recommended treatment for the management of delirium tremens?

A. Diazepam (Correct Answer)
B. Phenobarbital
C. Chlorpromazine
D. Haloperidol

Explanation: **Explanation:** **Delirium Tremens (DT)** is the most severe form of alcohol withdrawal, characterized by altered sensorium, autonomic hyperactivity, and hallucinations. **Why Diazepam is Correct:** The mainstay of treatment for alcohol withdrawal and DT is **Benzodiazepines (BZDs)**. Alcohol is a CNS depressant that enhances GABAergic tone; abrupt cessation leads to GABA underactivity and NMDA overactivity. Diazepam, a long-acting BZD, acts as a cross-tolerant substitute for alcohol, stimulating GABA-A receptors to restore inhibitory tone, prevent seizures, and stabilize vital signs. It is preferred due to its rapid onset and long-acting metabolites (e.g., desmethyldiazepam), which provide a "self-tapering" effect. **Why Other Options are Incorrect:** * **Phenobarbital:** While effective for refractory withdrawal, it has a narrow therapeutic index and carries a higher risk of respiratory depression compared to BZDs. It is not the first-line agent. * **Chlorpromazine:** Antipsychotics like phenothiazines are **contraindicated** as monotherapy because they significantly lower the seizure threshold, increasing the risk of withdrawal seizures. * **Haloperidol:** It may be used as an *adjunct* for severe agitation or hallucinations but never as monotherapy, as it does not treat the underlying autonomic instability or prevent seizures. **High-Yield Clinical Pearls for NEET-PG:** * **Drug of Choice (DOC):** Chlordiazepoxide or Diazepam (Long-acting). * **Liver Failure/Elderly:** Use **LOT** (Lorazepam, Oxazepam, Temazepam) as they undergo direct glucuronidation and do not have active metabolites. * **Timing:** DT typically occurs **48–96 hours** after the last drink. * **Wernicke’s Prophylaxis:** Always administer **Thiamine** before intravenous glucose to prevent precipitating Wernicke’s Encephalopathy.

Question 80: A person was addicted to alcohol for 10 years. He sustained an injury to his toe, and the wound was not healing. He was admitted to the hospital, where he was restless in bed, attempting to catch imaginary insects. He referred to the doctor as his brother and complained of uncontrollable fear of being murdered and insomnia. What is the likely diagnosis?

A. Alcoholic seizures/rum fits
B. Korsakoff's psychosis
C. Delirium tremens (Correct Answer)
D. Alcoholic hallucinosis

Explanation: **Explanation:** The clinical presentation describes a classic case of **Delirium Tremens (DT)**, the most severe form of alcohol withdrawal. The patient was hospitalized (leading to forced abstinence), and subsequently developed a triad of **clouding of consciousness** (disorientation—referring to the doctor as his brother), **visual hallucinations** (zoopsia—catching imaginary insects), and **autonomic hyperactivity** (restlessness, insomnia, and intense fear/paranoia). **Why the other options are incorrect:** * **Alcoholic Seizures (Rum Fits):** These typically occur within 6–48 hours of abstinence and present as generalized tonic-clonic seizures. They do not involve prolonged delirium or complex hallucinations. * **Korsakoff’s Psychosis:** This is a chronic amnestic disorder caused by Thiamine (B1) deficiency. It is characterized by profound anterograde amnesia and **confabulation**, without the acute autonomic arousal or visual hallucinations seen here. * **Alcoholic Hallucinosis:** This occurs in a **clear sensorium** (the patient is oriented). While hallucinations are present (usually auditory), the patient does not exhibit the clouding of consciousness or global confusion seen in this case. **High-Yield NEET-PG Pearls:** * **Timeline:** DT typically starts **48–72 hours** after the last drink. * **Hallucinations:** Visual hallucinations of small animals or insects are termed **"Zoopsia."** * **Treatment:** The drug of choice for DT is **Benzodiazepines** (e.g., Chlordiazepoxide or Diazepam). If liver failure is present, use **LOT** (Lorazepam, Oxazepam, Temazepam). * **Mortality:** Untreated DT has a mortality rate of up to 20%, usually due to cardiovascular collapse or hyperthermia.

Practice by Chapter

Neurobiology of Addiction

Practice Questions

Alcohol Use Disorder

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Opioid Use Disorder

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Cannabis Use Disorder

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Stimulant Use Disorders

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Sedative, Hypnotic, and Anxiolytic Use Disorders

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Tobacco Use Disorder

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Hallucinogen-Related Disorders

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Substance Withdrawal Syndromes

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Pharmacotherapy for Substance Use Disorders

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Psychosocial Interventions

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Dual Diagnosis Management

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