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Caring for Homeless Patients with Opioid Use Disorders: Clinical Guidelines

Introduction

1. Many correctional facilities oppose pharmaceutical treatment of opiate dependence as a matter of policy, preferring abstinence-only programs for incarcerated individuals.

A. True

B. False


2. Barriers to effective treatment and management of opioid use disorders include which of the following?

A. Poor understanding of addiction treatment and recovery by medical practitioners.

B. The unwarranted assumption that substance abuse treatment for homeless people is unsuccessful.

C. Lack of authorization for nurse practitioners and physician assistants to prescribe opioid agonist medication.

D. All of the above.


3. Practitioners with expertise in homeless health care, primary care, addiction medicine, psychiatry, harm reduction, and overdose prevention recommend which of the following as an intervention to promote successful treatment of homeless patients with opioid use disorders?

A. A harm reduction / low-threshold model of care.

B. Explicit overdose prevention and management training and naloxone rescue kit access.

C. Integration of primary care with mental health and addiction services provided by a multidisciplinary clinical team.

D. All of the above.


Recommendations for the Care of Homeless Patients with Opioid Use Disorders

4. Which of the following is important for developing a successful plan to address opioid use disorders?

A. Developing a therapeutic relationship.

B. Getting an accurate history.

C. Both (A) and (B).

D. None of the above.


5. When getting a medical history, healthcare providers should not ask specifically about individual or family history of conditions associated with opioid use disorders.

A. True

B. False


6. Due to concerns regarding EKG QTc intervals and methadone treatment, healthcare providers of patients known to have opioid use disorders should obtain thorough cardiac histories, including syncope, congestive heart failure, arrythmias, and cardiac surgery.

A. True

B. False


7. All of the following are strongly associated with opioid use disorder, and may be exacerbated by personal or witnessed overdose experience, except for:

A. Mood swings

B. PTSD

C. Depression

D. Anxiety


8. Which of the following questions is designed to assess the possibility of drug-induced psychosis?

A. What happens when you stop taking the drug or can’t obtain the usual drug or amount?

B. Have you or a family member ever had any odd experiences after taking a prescribed or nonprescribed drug?

C. What are positive and negative effects of drug use?

D. Is a health care provider coordinating all of your prescribed medications?


9. It is important to remember that conditions related to _____ are among the most common causes of morbidity and mortality in substance users.

A. HIV infection

B. Hepatitis B or C

C. Cigarette smoking

D. Liver failure


10. Which of the following baseline laboratory evaluations should only be performed with a patient’s permission?

A. Urine toxicology

B. Complete blood count

C. Liver function tests

D. Lipid profile


11. TB testing is recommended every _____ for homeless patients because of their higher risk for contact with active tuberculosis and unpredictable follow-up.

A. 3 months

B. 6 months

C. 9 months

D. 12 months


12. Which of the following terms may apply to some patients who “self treat” underlying mental health disorders?

A. Addiction

B. Pseudoaddiction

C. Physical dependence

D. Tolerance


Plan & Management: Plan of Care

13. Many homeless patients have obtained buprenorphine on the street and are familiar with its use prior to presentation at primary care clinics.

A. True

B. False


14. Which of the following should be included in a patient-centered goal?

A. Management of opioid use disorders.

B. A personalized overdose risk reduction plan as a potential victim or witness of drug overdose / poisoning.

C. Flexibility to allow patients time to meet basic needs and legal / employment obligations.

D. All of the above.


15. All of the following apply for patients considering MAT who don’t want to discontinue heroin use, except for:

A. Methadone and buprenorphine may ‘block’ the effects of heroin.

B. Overdose is still a danger even when using methadone or buprenorphine.

C. Using buprenorphine immediately after using heroin can help to avoid withdrawal.

D. When heroin effects wear off, if the correct dose of opioid agonist medication is taken, patients should feel alert and not in withdrawal.


16. A history of unsuccessful treatment is a contraindication to further treatment.

A. True

B. False


17. In general, people are more highly motivated to move away from a negative consequence than toward a positive goal.

A. True

B. False


Plan & Management: Education, Self-Management

18. Which of the following is harm reduction?

A. Overdose prevention

B. Avoidance of exposure to bloodborne diseases

C. Recognizing signs and symptoms of relapse

D. All of the above


19. The healthcare worker should help patients understand that opioid use disorder is a chronic disease that may never go away but can go into remission with appropriate treatment and ongoing attention to personal health.

A. True

B. False


20. When providing educational materials, the healthcare worker should presume that because their patients are homeless, they cannot read or understand written information.

A. True

B. False


21. Naloxone rescue kits should be available in locked areas of clinics and shelters, and all staff should be trained to use them to revive individuals experiencing opioid overdose.

A. True

B. False


22. Naloxone rescue kits should be provided to patients who meet which of the following criteria?

A. Taking high doses of opioids for long-term management of chronic pain.

B. Receiving rotating opioid medication regimens.

C. Discharged from emergency medical care following opioid intoxication or poisoning.

D. Any of the above.


23. Concepts such as ‘loss of control’ and ‘compulsion to use’ enable the healthcare provider to distinguish severe substance use disorder from less harmful substance use.

A. True

B. False


24. Which of the following guides any intervention for patients with opioid use disorders, including further education and support?

A. Assessment of level of readiness to change.

B. Motivational enhancement techniques.

C. Unique legal and regulatory issues.

D. Restrictions on MAT utilization.


25. Which of the following is useful to help patients explore and resolve ambivalence about behavioral change?

A. 12-Step participation

B. Motivational interviewing

C. Harm reduction therapy

D. Medication-assisted treatment


26. Which of the following is not one of the six elements critical to a brief intervention to change substance abuse behavior?

A. Feedback is given to the individual about personal risk or impairment.

B. Advice to change is given by the provider.

C. Screening, evaluating, and assessing.

D. Empathic style is used in counseling.


Plan & Management: Treatment, Management

27. Medication-assisted treatment should be offered to any patient with an opioid use disorder.

A. True

B. False


28. Successful treatment of opioid use disorders has been demonstrated to:

A. Reduce HIV incidence

B. Lower hepatitis B & C risk

C. Minimize involvement with the criminal justice system

D. All of the above


29. Instability and lack of social support are conditions of homelessness known to correlate with treatment failure.

A. True

B. False


30. With case management support provided by the treatment program, medication-assisted treatment with buprenorphine is just as effective for people who are homeless as for those who are housed.

A. True

B. False


31. Lack of stable housing is a contraindication to medication-assisted treatment.

A. True

B. False


32. Social support is associated with which of the following?

A. Lower rates of mental health problems, such as depression and suicidal ideation.

B. Fewer physical illness symptoms.

C. Less risky drug and sexual behavior among homeless individuals.

D. All of the above.


33. All of the following are true with regard to treatment for opioid use disorder, except for:

A. Treatment can decrease overdose risk.

B. Treatment can reduce tolerance and significantly increase the risk of fatal overdose for patients who cycle between abstinence and opioid use.

C. Detox of opioid agonist treatment is associated with a lower fatal overdose rate than heroin use.

D. Overdose risk increases for persons utilizing alcohol or other prescribed / nonprescribed medications / drugs.


34. Methadone and buprenorphine have powerful analgesic effects but only when not used in split doses.

A. True

B. False


35. Low levels of _____ have been linked to high use of opioid analgesic medication by patients in chronic pain.

A. Vitamin D

B. Calcium

C. Vitamin K

D. All of the above


36. If office-based maintenance treatment is indicated for opioid-dependent pregnant women who are homeless, buprenorphine/naloxone should be used, not buprenorphine alone.

A. True

B. False


37. Healthcare providers may need to educate staff in residential programs and halfway houses that medication-assisted treatment with methadone or buprenorphine is not equivalent to the use of illicit substances.

A. True

B. False


38. Considerations in selecting a medication-assisted treatment setting should include whether or not the patient:

A. Needs detoxification

B. Is a candidate for maintenance treatment

C. Requires opioid analgesia

D. Any or all of the above


39. Which of the following can only be administered to fully detoxified patients?

A. Naltrexone

B. Methadone

C. Buprenorphine

D. All of the above


40. When prescribed by a qualified physician, _____ is the only opioid currently approved for the treatment of opioid dependence in an office-based setting.

A. Hydrocodone

B. Buprenorphine

C. Benzodiazepine

D. All of the above


41. Relapse to opioid abuse occurs in more than _____% without long-term use of methadone or buprenorphine, regardless of what other kinds of treatment patients are receiving.

A. 80

B. 60

C. 40

D. 20


42. Use of buprenorphine or methadone is substituting one addiction for another.

A. True

B. False


43. Lack of access to / interest in / compliance with counseling is often a serious barrier to medication-assisted treatment for opioid use disorders.

A. True

B. False


44. Buprenorphine acts as a blocker to other opioids and may interfere with analgesic effects of other opioid analgesics needed for pain management.

A. True

B. False


45. It is practically impossible to overdose on buprenorphine alone or buprenorphine combined with other opioids.

A. True

B. False


46. The goal of the induction phase is to find the minimum dose of buprenorphine at which all of the following occur, except for:

A. The patient discontinues or markedly diminishes use of other opioids.

B. The patient experiences only mild withdrawal symptoms.

C. The patient experiences minimal or no side effects.

D. The patient experiences no uncontrollable cravings for drugs of abuse.


47. Health Care for the Homeless providers report beginning patients on the minimum daily dose of _____ mg, but increasing the dosage if they experience any cravings whatsoever, to avoid relapse.

A. 4

B. 8

C. 12

D. 16


48. The most important requirement of the preliminary steps before buprenorphine therapy can be started is:

A. History and physical

B. Labs

C. Documentation of opioid dependence

D. Full detoxification


49. MAT with _____ is the least expensive alternative for medication-assisted maintenance treatment.

A. Naltrexone

B. Methadone

C. Buprenorphine

D. Buprenorphine / Naltrexone


50. All of the following are true with regard to naltrexone, except for:

A. Naltrexone treatment compliance and retention rates are high leading to its clinical effectiveness.

B. Naltrexone is an FDA approved alternative to opioid agonist treatment for patients with opioid dependence.

C. Naltrexone is a long acting opioid antagonist available in both oral and injectable formulations.

D. Naltrexone does not produce euphoria and is not addicting.


51. Patients with opioid dependence must be fully withdrawn from all opioids for up to _____ before beginning naltrexone treatment.

A. 2 - 3 days

B. 4 - 5 days

C. 7 - 10 days

D. 12 - 14 days


52. Because naltrexone is an antagonist, it cannot be stopped abruptly without withdrawal symptoms.

A. True

B. False


53. When taken in combination with opioid agonists / partial agonists (methadone / buprenorphine), benzodiazepines are associated with possible long-term worsening of depression and anxiety disorders and can result in excessive sedation / lethal drug overdose.

A. True

B. False


54. Which of the following pertains to respecting personal space?

A. Remain 3 - 4 feet from the client.

B. Stand in front of or slightly turned from the client.

C. Avoid challenging gestures, stances, and facial expressions.

D. All of the above.


55. Employment as a treatment outcome:

A. Assists in social reintegration.

B. Helps prevent relapse.

C. Promotes economic self sufficiency.

D. All of the above.


Plan & Management: Associated Problems, Complications

56. Buprenorphine / naloxone obtained on the street or from others with a prescription is commonly used to get high, rather than to prevent withdrawal or control withdrawal symptoms.

A. True

B. False


57. Cognitive impairments seen in homeless patients are often associated with all of the following, except for:

A. Pain

B. Traumatic brain injury

C. Mental illness

D. Developmental disabilities


Plan & Management: Follow-Up

58. Each of the following should be assessed at each visit, except for:

A. The patient’s response to treatment.

B. Functional improvement.

C. Mental health and substance use.

D. All of the above should be assessed at each visit.


Model of Care: Outreach and Engagement

59. It is essential to go through appropriate government channels in instituting treatment programs at unconventional sites to avoid losing prescribing authorization / medical licensure.

A. True

B. False


60. Which of the following is a “don’t” for outreach strategies?

A. Wear casual clothing, not suits.

B. Take cell phone for safety.

C. Take calls, text, or use PDA / computer while listening to people experiencing homelessness.

D. None of the above.


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