PS3.1 | Addiction Psychiatry — Practice Quiz

Correct. Tremors, diaphoresis, and autonomic arousal appearing 6–12 hours after the last drink are hallmarks of uncomplicated (early) alcohol withdrawal. Orientation is preserved at this stage.

Alcohol withdrawal follows a predictable timeline: tremors 6–12 h → seizures 24–48 h → delirium tremens 48–72 h. Recognising the stage guides management urgency.

Delirium tremens (confusion, hallucinations) peaks at 48–72 hours. Seizures typically occur at 24–48 hours. Wernicke presents with the triad of ophthalmoplegia, ataxia, and confusion — not tremors alone at 10 hours.

Correct. Thiamine must be given before (or simultaneously with) IV dextrose in malnourished alcohol-dependent patients. Dextrose alone precipitates acute Wernicke encephalopathy by rapidly depleting the last reserves of thiamine.

In any malnourished or alcohol-dependent patient requiring glucose, always administer IV thiamine 100 mg before IV dextrose to prevent precipitating Wernicke encephalopathy.

Thiamine-before-glucose is a life-saving sequence. Dextrose drives glucose metabolism, consuming the residual thiamine, and can trigger Wernicke encephalopathy. This is a clinical emergency rule.

Correct. Failed attempts to cut down, intense cravings, and withdrawal-like irritability indicate impaired control over use — a core feature of dependence under ICD-11, not merely harmful use.

ICD-11 nicotine (tobacco) dependence requires impaired control + increasing priority given to use + physiological features (tolerance or withdrawal). Harmful use is a lower-severity category that excludes these features.

Harmful use requires evidence of health damage (physical or mental) with NO dependence features. Impaired control, cravings, and failed cessation attempts fulfil ICD-11 dependence criteria.

Correct. A CAGE score of ≥2 (out of 4) is the validated cut-off for a positive screen. A score of 3 indicates very likely alcohol use disorder and warrants detailed assessment and intervention.

CAGE: Cut down, Annoyed, Guilty, Eye-opener. ≥2/4 = positive screen. CAGE is rapid and validated for primary care; AUDIT provides additional severity and domain detail.

The CAGE threshold is ≥2/4 for a positive screen. A score of 3 is clearly positive. CAGE is a screening tool — it does not by itself diagnose ICD-11 dependence, but it does not differentiate harmful use from dependence either.

Correct. Buprenorphine — a partial mu-opioid agonist — is the first-line substitution therapy for opioid use disorder in India under the National Drug Dependence Treatment Centre (NDDTC) programme. The buprenorphine/naloxone combination reduces diversion risk.

Opioid substitution therapy (OST) in India: buprenorphine (partial agonist) or methadone (full agonist, specialist centres). Naloxone reverses overdose; disulfiram/naltrexone are used in alcohol/opioid relapse prevention.

Naloxone alone is an antagonist used for overdose reversal, not substitution. Diazepam treats alcohol/benzodiazepine withdrawal. Disulfiram is an aversion agent for alcohol use disorder.

Correct. The classic triad of delirium tremens — delirium (acute confusion), vivid hallucinations, and autonomic hyperactivity — emerging at 48–72 hours (day 3) after last drink fits perfectly. DTs carry up to 5–15% mortality if untreated.

Delirium tremens: onset 48–72 h, triad of delirium + vivid hallucinations + autonomic storm. Treatment: high-dose IV benzodiazepines (diazepam or lorazepam), IV thiamine, correct electrolytes, HDU/ICU care.

Alcoholic hallucinosis features hallucinations (usually auditory) with clear consciousness and no autonomic instability. Korsakoff psychosis is a chronic amnestic syndrome from thiamine deficiency. Withdrawal seizures are brief GTCS without delirium.

Correct. The classic opioid overdose triad — coma, miosis (pinpoint pupils), and respiratory depression — demands immediate naloxone (opioid antagonist) and airway support. Naloxone 0.4–2 mg IV reverses respiratory depression within 1–2 minutes.

Opioid overdose triad: coma, miosis, respiratory depression. Treatment: naloxone IV (short half-life — repeat doses or infusion may be needed for long-acting opioids) + airway support. Do NOT delay for investigations.

Methadone is a substitution agent for chronic opioid dependence, not acute overdose reversal. Diazepam would worsen respiratory depression. Gastric lavage is irrelevant for IV/insufflated opioid overdose.

Correct. Disulfiram (Antabuse) inhibits aldehyde dehydrogenase, causing acetaldehyde accumulation if alcohol is consumed — manifesting as flushing, nausea, vomiting, and palpitations (disulfiram-ethanol reaction). It works through aversion conditioning.

Relapse-prevention pharmacotherapy: Disulfiram = aversion (aldehyde DH inhibitor); Naltrexone = anti-craving (opioid antagonist); Acamprosate = anti-craving (NMDA/GABA modulator). Disulfiram requires motivation and liver function monitoring.

Naltrexone blocks opioid-mediated reward from alcohol (anti-craving). Acamprosate reduces glutamate-mediated craving. Buprenorphine is for opioid use disorder. Only disulfiram causes a pharmacological aversive reaction to alcohol itself.

Correct. Varenicline (a partial agonist at α4β2 nicotinic acetylcholine receptors) has the highest abstinence rates among approved cessation pharmacotherapies — approximately 2–3× better than placebo and superior to NRT and bupropion in head-to-head trials.

Tobacco cessation pharmacotherapy efficacy order (approximately): varenicline > combination NRT > bupropion > single NRT > placebo. All are superior to unassisted cessation. Combine with behavioural counselling for best results.

NRT (patches, gum) and bupropion SR are effective first-line options but demonstrate lower 12-month abstinence rates than varenicline in most comparative trials. Clonidine is a second-line agent.

Correct. ICD-11 dependence syndrome requires all three: (1) impaired control over initiation, frequency, amount, or cessation; (2) increasing priority given to the substance over other activities; (3) physiological features — tolerance and/or characteristic withdrawal.

ICD-11 dependence vs harmful use: Dependence requires ALL THREE features (control + priority + physiology). Harmful use requires documented health damage WITHOUT the dependence triad. Confusing these categories is a common examination error.

Daily use is not required (intermittent patterns can fulfil criteria). Physical consequences describe harmful use. Legal problems and prior detox are not ICD-11 dependence criteria. Only the triad of impaired control + increasing priority + physiological features satisfies ICD-11.