# Opioids, Alcohol and Drug Dependence for NEET PG Pharmacology: Naloxone, Withdrawal, Buprenorphine, Delirium Tremens, Disulfiram Source: https://tracknation.in/story/opioids-alcohol-and-drug-dependence-for-neet-pg-pharmacology-naloxone-withdrawal-buprenorphine-delirium-tremens-disulfiram (TrackNation — free UPSC notes with PYQs) > NEET PG Pharmacology: opioid overdose (pinpoint pupils, respiratory depression) and naloxone, opioid withdrawal signs, tramadol and fentanyl-patch warnings, methadone, buprenorphine and naltrexone, the alcohol withdrawal timeline and its treatment under India's ICMR workflow, disulfiram, acamprosate, and fomepizole for methanol, with a diagram, hooks, vignette MCQs and cards. ## Start Here 🎯 **Exam priority: High.** *Expect an unconscious patient with pinpoint pupils, a methadone overdose that relapses after naloxone, a withdrawal picture, delirium tremens on day 3 after admission, or a disulfiram question.* CBME mapping: **PH 2.7** (opioids) and **PH 3.7–3.9** (alcohol and drug dependence). ## Opioid Toxicity and Withdrawal | **** | **Opioid toxicity** | **Opioid withdrawal** | | Pupils | Miotic (pinpoint) | Mydriasis | | Key signs | Respiratory depression → apnoea; drowsiness | Piloerection, lacrimation, rhinorrhoea, yawning | | Treatment | Naloxone + respiratory support; watch for recurrence with long-acting opioids | Methadone or buprenorphine; clonidine as support | - Death in overdose is mainly from hypoxia due to **respiratory depression**. - **Naloxone's half-life is shorter than that of long-acting opioids** (methadone, extended-release morphine), so breathing can fail again within hours — keep observing and repeat doses as needed. - Complete reversal in a dependent patient can **precipitate acute withdrawal**. - Morphine commonly causes flushing and itching (mast-cell effects). ## Opioid Analgesic Warnings - **Tramadol**: life-threatening breathing depression and death in children, some after tonsillectomy, including ultra-rapid metabolisers; serotonin syndrome (even alone); seizures at recommended doses. - **Fentanyl patch**: only for **opioid-tolerant** patients (for example, ≥ 60 mg morphine a day for a week or more). External heat (heating pads, hot baths, saunas) increases absorption and has caused fatal overdose. - Extended-release morphine carries a boxed warning for addiction, abuse and misuse. ## Treating Dependence For opioid use disorder, **maintenance treatment** (buprenorphine, methadone or long-acting naltrexone) is the standard of care, better than supervised withdrawal alone. | **Drug** | **Use** | **Must know (source)** | | Methadone | Opioid use disorder (full agonist) | QT prolongation and torsades (boxed) | | Buprenorphine (± naloxone) | Opioid use disorder (partial agonist) | First line with methadone (MSD) | | Naltrexone | Opioid or alcohol dependence (antagonist) | Needs opioid-free 7–10 days, else precipitates withdrawal | | Disulfiram | Alcohol dependence (ICMR: 250 mg daily) | Never when intoxicated or without the patient's knowledge; motivated, consenting patient, family supervision; reaction: flushing, headache, vomiting, low BP, arrhythmias | | Acamprosate | Alcohol dependence | Contraindicated if creatinine clearance ≤ 30 mL/min | | Fomepizole | Methanol or ethylene glycol poisoning | Competitive inhibitor of alcohol dehydrogenase; methanol → formic acid (acidosis, visual loss, blindness); ethylene glycol → glycolate and oxalate (acidosis, kidney damage) | ## Alcohol: Dependence and Withdrawal (ICMR) *Alcohol withdrawal timeline from the MSD Manual: mild symptoms from about 6 h, seizures 6–48 h, hallucinosis 12–24 h, delirium tremens 48–72 h. Drawn by TrackNation.* - **Dependence** (ICMR): at least **3 of 6** criteria for at least a month — compulsion, poor control, withdrawal, tolerance, preoccupation, use despite harm. **Binge**: 5 drinks in 2 hours (men), 4 (women). - **Withdrawal treatment**: diazepam 20–40 mg a day in divided doses, titrated, then reduced by 10–20% a day over 7–10 days; **thiamine 100 mg** daily. With significant liver damage use **lorazepam** (2 mg ≈ diazepam 5 mg). Withdrawal seizures, hallucinations or delirium tremens need inpatient care. - Long-term harm includes **Wernicke encephalopathy** and Korsakoff psychosis. - **Relapse prevention**: disulfiram 250 mg daily in a motivated patient with written consent and family supervision. ## Traps the Examiner Sets - Pinpoint pupils = opioid toxicity; dilated pupils + yawning + piloerection = withdrawal. - Naloxone wears off before methadone — observe and repeat. - Naltrexone needs 7–10 opioid-free days; buprenorphine is a partial agonist. - Methadone: QT prolongation. - Delirium tremens peaks at 48–72 hours, not on day 1; hallucinosis (clear consciousness) comes earlier. - Liver disease: lorazepam rather than diazepam for withdrawal. - Disulfiram never without the patient's knowledge; fomepizole for methanol. ## Memory Hooks & Shortcuts *Shortcuts to lock in this article's numbers and lists. Each one only re-packages facts proven above.* - 🧠 **Pinpoint = Poisoned, Pupils wide = Withdrawal** — miosis in opioid toxicity; mydriasis in withdrawal - 🧠 **Naloxone Nips out early** — short half-life: repeat after long-acting opioid overdose - 🧠 **6 – 12 – 48 – 72** — mild withdrawal ~6 h, hallucinosis 12–24 h, seizures to 48 h, DTs 48–72 h - 🧠 **Liver bad? Lorazepam** — use lorazepam rather than diazepam in significant liver disease - 🧠 **Naltrexone needs a Clean ten** — 7–10 opioid-free days before naltrexone - 🧠 **Disulfiram: Disclose, never Disguise** — never given without the patient's knowledge - 🧠 **Fomepizole Fights methanol** — alcohol dehydrogenase inhibitor for methanol and ethylene glycol ## Rapid-Revision Cards - Miosis + respiratory depression; naloxone + ventilation. - Shorter than methadone/ER morphine: recurrence; repeat. - Mydriasis, piloerection, lacrimation/rhinorrhoea, yawning. - Can precipitate withdrawal. - Mast-cell flushing and itching. - Child deaths (ultra-rapid metabolisers, post-tonsillectomy); serotonin syndrome; seizures. - Opioid-tolerant only; heat ↑ absorption. - Full agonist; QT prolongation. - Partial agonist; first line for OUD. - Antagonist; 7–10 opioid-free days first. - Maintenance therapy, not withdrawal alone. - From ~6 h: tremor, sweating, headache. - 6–48 h. - 12–24 h; clear consciousness. - 48–72 h; confusion, autonomic instability. - Diazepam 20–40 mg/day, taper 10–20%/day over 7–10 days + thiamine 100 mg. - Lorazepam (2 mg ≈ diazepam 5 mg). - ≥ 3 of 6 criteria for ≥ 1 month. - 5 drinks/2 h (men); 4 (women). - 250 mg OD; never secretly or when intoxicated. - Flushing, headache, vomiting, hypotension, arrhythmia. - Avoid if CrCl ≤ 30. - ADH inhibitor; methanol, ethylene glycol. ## Sources *Facts in this article were checked against these documents.* - MSD Manual Professional Edition: Opioid Toxicity and Withdrawal; Opioid Use Disorder; Alcohol Toxicity and Withdrawal — Merck & Co. (MSD Manuals), 2025–2026 (link) - Standard Treatment Workflow: Management of Alcohol Use Disorders — Indian Council of Medical Research / Department of Health Research, MoHFW, October 2019 (link) - Prescribing labels: morphine sulfate ER, tramadol, fentanyl transdermal, naloxone injection, naltrexone, buprenorphine and naloxone sublingual, methadone, disulfiram, acamprosate, fomepizole — DailyMed, US National Library of Medicine, current labels, accessed November 2026 (link) - Competency Based Undergraduate Curriculum, Pharmacology (PH 2.7, PH 3.7–3.9) — National Medical Commission, 2024 ## Test Yourself: Practice Questions Twenty-three questions in NEET PG style, most of them clinical vignettes. ## Practice Questions (NEET PG pattern) *Original questions written in the style of the exam: +4 for a correct answer, −1 for a wrong one. Every answer was checked against the sources listed above. NEET PG papers are not published by NBEMS, so these are not past-paper questions.* **Q1.** A young man is brought unconscious with slow shallow breathing and pinpoint pupils. The first drug to give is - (a) flumazenil - (b) naloxone, with respiratory support - (c) physostigmine - (d) atropine **Answer: (b)** — Opioid overdose: miotic pupils and respiratory depression; treat with naloxone and ventilatory support. **Q2.** A woman who took a large methadone overdose wakes after naloxone, then becomes apnoeic again 2 hours later. The reason is - (a) an allergic reaction to naloxone - (b) naloxone is a partial agonist - (c) naloxone's half-life is shorter than methadone's - (d) methadone induces naloxone metabolism **Answer: (c)** — Respiratory depression can recur within hours after a long-acting opioid; observe and repeat naloxone. **Q3.** A heroin user is given a large IV dose of naloxone and develops yawning, rhinorrhoea, piloerection and agitation. This is - (a) anaphylaxis - (b) naloxone toxicity - (c) precipitated opioid withdrawal - (d) serotonin syndrome **Answer: (c)** — Complete reversal in a dependent patient can precipitate acute withdrawal. **Q4.** Which sign distinguishes opioid withdrawal from opioid toxicity? - (a) Respiratory depression - (b) Constipation - (c) Mydriasis - (d) Drowsiness **Answer: (c)** — Withdrawal: mydriasis, piloerection, lacrimation/rhinorrhoea, yawning; toxicity: miosis and respiratory depression. **Q5.** A 5-year-old given tramadol after tonsillectomy dies of respiratory depression. A recognised risk factor is - (a) ultra-rapid metabolism of tramadol - (b) pseudocholinesterase deficiency - (c) slow acetylation - (d) G6PD deficiency **Answer: (a)** — Tramadol label: deaths in children, some after tonsillectomy, including an ultra-rapid metaboliser. **Q6.** A patient on an SSRI is prescribed tramadol for pain. The labelled risks include - (a) serotonin syndrome and seizures - (b) hyperkalaemia - (c) agranulocytosis - (d) hypoglycaemia only **Answer: (a)** — Tramadol can cause serotonin syndrome (even alone, more with serotonergic drugs) and seizures at recommended doses. **Q7.** A fentanyl patch is prescribed to an opioid-naive patient after surgery. This is wrong because the patch is - (a) only for children - (b) only for opioid-tolerant patients with severe persistent pain - (c) too weak for post-operative pain - (d) contraindicated with paracetamol **Answer: (b)** — Fentanyl transdermal is for opioid-tolerant patients (e.g. ≥ 60 mg oral morphine/day for ≥ 1 week). **Q8.** A cancer patient on a fentanyl patch uses a heating pad over it and becomes deeply sedated. The mechanism is - (a) tolerance - (b) enzyme induction - (c) heat increased fentanyl absorption - (d) heat inactivated fentanyl **Answer: (c)** — External heat increases fentanyl absorption and has caused fatal overdose. **Q9.** A man on methadone maintenance has a prolonged QTc. The relevant boxed warning is - (a) SJS - (b) hepatic failure - (c) agranulocytosis - (d) life-threatening QT prolongation **Answer: (d)** — Methadone: QTc prolongation and torsades de pointes. **Q10.** Buprenorphine differs from methadone because buprenorphine is - (a) a full opioid agonist - (b) a benzodiazepine - (c) a partial opioid agonist - (d) an opioid antagonist **Answer: (c)** — Buprenorphine (partial agonist) and methadone (full agonist) are both first-line for opioid use disorder. **Q11.** A patient dependent on heroin wants naltrexone to prevent relapse. Before starting, he must be - (a) opioid-free for at least 7–10 days - (b) started on disulfiram - (c) on methadone at full dose - (d) given naloxone daily **Answer: (a)** — An opioid-free interval of 7–10 days (short-acting opioids) is needed, or naltrexone precipitates withdrawal. **Q12.** For a patient with opioid use disorder, MSD describes the standard of care as - (a) supervised withdrawal alone - (b) naloxone daily - (c) benzodiazepines - (d) maintenance treatment with buprenorphine, methadone or long-acting naltrexone **Answer: (d)** — Maintenance drug treatment is the standard of care over supervised withdrawal alone. **Q13.** A man admitted for surgery becomes confused, sweaty and tremulous with fluctuating BP on his third hospital day; he drank heavily until admission. The likely diagnosis is - (a) delirium tremens - (b) opioid withdrawal - (c) Wernicke encephalopathy only - (d) alcoholic hallucinosis **Answer: (a)** — Delirium tremens usually begins 48–72 hours after the last drink, with confusion and autonomic instability. **Q14.** Twenty hours after stopping drinking, a man hears accusing voices but is fully oriented with stable vital signs. This is - (a) delirium tremens - (b) Korsakoff psychosis - (c) schizophrenia - (d) alcoholic hallucinosis **Answer: (d)** — Hallucinosis: hallucinations without impaired consciousness, usually within 12–24 hours. **Q15.** Alcohol withdrawal seizures generally occur - (a) only with delirium tremens - (b) within 1 hour - (c) 6–48 hours after the last drink - (d) after 1 week **Answer: (c)** — Seizures generally occur 6–48 hours after cessation. **Q16.** Under the ICMR workflow, uncomplicated alcohol withdrawal is treated with - (a) disulfiram - (b) naltrexone - (c) haloperidol alone - (d) diazepam 20–40 mg a day in divided doses, tapered over 7–10 days, plus thiamine 100 mg daily **Answer: (d)** — Diazepam titrated to severity, reduced 10–20% a day over 7–10 days, with thiamine 100 mg OD. **Q17.** A man in alcohol withdrawal has significant liver dysfunction. The ICMR choice of benzodiazepine is - (a) diazepam - (b) no benzodiazepine - (c) chlordiazepoxide only - (d) lorazepam **Answer: (d)** — Significant liver dysfunction: lorazepam (2 mg ≈ diazepam 5 mg). **Q18.** Alcohol dependence (ICMR) requires - (a) a raised GGT - (b) at least 3 of 6 criteria present for at least a month - (c) any drinking above 2 units a day - (d) one episode of intoxication **Answer: (b)** — Three of six criteria for at least one month. **Q19.** A wife asks the doctor to give her husband disulfiram secretly in his food. The correct response is - (a) agree if he is intoxicated - (b) give naltrexone secretly instead - (c) refuse: disulfiram must never be given without the patient's full knowledge - (d) agree, at a low dose **Answer: (c)** — Boxed warning: never when intoxicated or without the patient's full knowledge; ICMR requires a motivated patient's written consent. **Q20.** A patient on disulfiram drinks a small amount of alcohol. Expect - (a) no reaction - (b) sedation only - (c) hypertensive crisis with bradycardia - (d) flushing, headache, vomiting, fall in BP and arrhythmias **Answer: (d)** — ICMR warns of an unpleasant, potentially serious reaction even with small amounts. **Q21.** Acamprosate is contraindicated when - (a) creatinine clearance is ≤ 30 mL/min - (b) the patient has hypertension - (c) liver enzymes are mildly raised - (d) the patient smokes **Answer: (a)** — Contraindicated in severe renal impairment. **Q22.** A man drinks illicit liquor and develops visual disturbance and metabolic acidosis; methanol is suspected. A specific antidote is - (a) naloxone - (b) fomepizole - (c) flumazenil - (d) N-acetylcysteine **Answer: (b)** — Methanol is converted by alcohol dehydrogenase to formic acid, which causes the acidosis and visual damage; fomepizole blocks alcohol dehydrogenase. **Q23.** A supportive drug used for opioid withdrawal symptoms (besides methadone or buprenorphine) is - (a) clonidine - (b) disulfiram - (c) naloxone - (d) flumazenil **Answer: (a)** — MSD lists clonidine among supportive medications for withdrawal. ### Active Recall From memory: contrast opioid toxicity and withdrawal and explain naloxone's pitfalls; give the warnings for tramadol, fentanyl patches and methadone; compare buprenorphine, methadone and naltrexone; draw the alcohol withdrawal timeline and give the ICMR treatment; and state the rules for disulfiram and the antidote for methanol.