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Quantum Units Education

Opioid Use Disorder: Pharmacotherapy

Part 3: Pharmacotherapy for Opioid Use Disorder

1. Which of the following can block the effects of exogenously administered opioids?

A. Mu-opioid receptor full agonists

B. Mu-opioid receptor partial agonists

C. Mu-opioid receptor antagonists

D. The effects of exogenously administered opioids can be blocked by mu-opioid receptor full agonists, partial agonists, and antagonists

Chapter 3A: Overview of Pharmacotherapy for Opioid Use Disorder

2. Which of the following is typically used for patients with OUD who have abstained from short-acting opioids for at least 7 to 10 days and long-acting opioids for at least 10 to 14 days?

A. Extended-Release Injectable Naltrexone

B. Methadone

C. Buprenorphine

D. Patients do not need to have a period of abstinence for any of the above medications

3. Naltrexone consideration should be given to its use in situations where adherence can be ensured, such as with observed daily dosing.

A. True

B. False

4. Buprenorphine is more likely than methadone to cause respiratory depression in an accidental overdose due to it not having a ceiling effect on opioid activity.

A. True

B. False

5. Which of the following is recommended for OUD treatment during pregnancy?

A. Methadone only

B. Methadone or buprenorphine

C. Buprenorphine or Extended-Release Injectable Naltrexone

D. Buprenorphine only

6. A review of clinical trials found that, when provided at flexible doses on an outpatient basis, buprenorphine retained patients in treatment longer than methadone.

A. True

B. False

7. Stable patients can continue on their selected OUD medication indefinitely as long as it is beneficial.

A. True

B. False

8. Medically supervised withdrawal using buprenorphine or methadone is appropriate when patients:

A. Prefer it to treatment without medications, after they have been told the risks and benefits of this approach compared with treatment with medication.

B. Wish to start XR-NTX, which is also FDA approved for the treatment of alcohol dependence.

C. Are entering a controlled environment or workplace that disallows opioid agonists.

D. Medially supervised withdrawal using buprenorphine or methadone is appropriate if patients prefer it to treatment without medications, if patients wish to start XR-NTX, or if patients are entering a controlled environment or workplace that disallows opioid agonists.

Chapter 3B: Methadone

9. All of the following apply to methadone, except for:

A. It is a short-acting mu-opioid receptor full agonist.

B. It is a schedule II controlled medication.

C. It is highly plasma-protein bound and binds to proteins within tissues throughout the body.

D. At adequate doses, it reduces opioid craving and withdrawal and blunts or blocks the effects of illicit opioids.

10. The average half-life of methadone is:

A. 8 hours

B. 24 hours

C. 36 hours

D. 59 hours

11. At the start of methadone treatment, methadone can increase CYP3A4 activity and accelerate its own metabolism in some individuals.

A. True

B. False

12. The goal of methadone dosing in the first weeks of treatment is to relieve withdrawal but avoid oversedation and respiratory depression.

A. True

B. False

13. Because of methadone’s half-life, patients will not feel the full effect of the initial dose for _____ or more days even if the daily dose is the same.

A. 2

B. 3

C. 4

D. 5

14. Engage in outpatient medically supervised withdrawal only with patients who:

A. Are physically dependent on benzodiazepines.

B. Inject benzodiazepines.

C. Binge on benzodiazepines.

D. Outpatient medically supervised withdrawal should not be performed for patients on benzodiazepines.

15. The treatment with which of the following has been associated with QTc prolongation?

A. Extended-Release Injectable Naltrexone

B. Methadone

C. Buprenorphine

D. All OUD treatment medications have been associated with QTc prolongation

16. Methadone has fewer clinically significant drug-drug interactions than buprenorphine.

A. True

B. False

17. All of the following may cause a reduction in serum methadone levels, except for:

A. Efavirenz

B. Abacavir

C. Rifampin

D. Ketoconazole

18. Side effects of methadone include all of the following, except for:

A. Constipation

B. Sexual dysfunction or decreased libido

C. Drowsiness

D. Weight loss

19. An alcohol breathalyzer should be used to estimate the patient’s blood alcohol content and methadone should not be provided until the alcohol reading is considerably below the legal level of alcohol intoxication.

A. True

B. False

20. Patients should be warned of the increased risk of overdose during the first _____ of methadone treatment.

A. 24 hours

B. 72 hours

C. 2 weeks

D. Month

21. For patients addicted to prescription opioids, opioid conversion tables should be relied on to determine methadone dosage.

A. True

B. False

22. For patients with opioid tolerance, after the first dose, patients should remain for observation for ____ if possible to see whether the dose is sedating or relieves withdrawal signs.

A. 1 to 2 hours

B. 2 to 4 hours

C. 4 to 6 hours

D. 8 to 12 hours

23. Patients who miss more than ____ dose(s) of methadone treatment must be reassessed, and their next methadone dose should be decreased substantially and built back up gradually.

A. 1

B. 2

C. 3

D. 4

24. What should be done for those in the third trimester of pregnancy, when after being on a stable methadone dose, they report feeling drowsy 2 to 4 hours after dose administration but develop craving or withdrawal symptoms before the next dose is due to be administered?

A. Their dosage should be doubled.

B. Their dosage should be halved.

C. Their dosage should be divided into twice-daily dosing.

D. Their dosage should not be adjusted.

25. Peak:trough ratios above 4:1 may indicate rapid methadone metabolism.

A. True

B. False

26. People with OUD who are not in treatment more frequently use illicit methadone to achieve euphoria than to self-medicate withdrawal symptoms.

A. True

B. False

27. Interim methadone maintenance has been shown to be more effective than a waiting list to facilitate entry into comprehensive methadone treatment and to reduce illicit opioid use.

A. True

B. False

Chapter 3C: Naltrexone

28. Oral naltrexone is not widely used to treat opioid use disorder for all of the following reasons, except for:

A. It has special regulatory requirements.

B. Low rates of patient acceptance.

C. Difficulty in achieving abstinence for the necessary time before initiation of treatment.

D. High rates of medication nonadherence.

29. A Cochrane review concluded that oral naltrexone is superior to placebo and to no medication in treatment retention or illicit opioid use reduction.

A. True

B. False

30. Naltrexone does which of the following?

A. Activates the mu-opioid receptor.

B. Competitively binds to the mu-opioid receptor with strong receptor affinity.

C. Exerts an opioid effect.

D. Alleviates withdrawal symptoms.

31. All of the following are contraindications to receiving XR-NTX, except for:

A. Current pain treatment with opioid analgesics

B. Current acute opioid withdrawal

C. Severe hepatic impairment

D. Renal impairment

32. A negative naloxone challenge guarantees that the patient will not experience precipitated opioid withdrawal upon naltrexone administration.

A. True

B. False

33. Naltrexone use has been occasionally associated with dysphoria, although it is unclear whether this is a side effect of the medication or a manifestation of underlying depression or depressed mood related to OUD.

A. True

B. False

34. Naltrexone is not recommended for OUD treatment in pregnancy.

A. True

B. False

35. A naltrexone medication guide should be dispensed to patients with each injection.

A. True

B. False

36. All of the following are signs that a patient may be ready to discontinue medication, except for:

A. Switching to a new job that requires drug testing.

B. Sustaining illicit drug abstinence over time.

C. Having substantially reduced cravings.

D. Attending counseling or mutual-help groups.

37. When patients stop using naltrexone, they will have no tolerance for opioids, and their risk of overdose is very high if they use again.

A. True

B. False

Chapter 3D: Buprenorphine

38. Peak buprenorphine plasma concentrations occur 12 hours after implant insertion, slowly decrease, and reach steady-state concentrations in about:

A. 24 hours

B. 4 to 6 days

C. 4 weeks

D. 4 to 6 months

39. After providing the first dose of buprenorphine, wait at least _____ to decide whether a second dose is necessary.

A. 30 minutes

B. 2 hours

C. 8 hours

D. 24 hours

40. Both buprenorphine and naloxone are bioavailable in transmucosal products, thereby allowing naloxone to blunt the immediate opioid agonist effects of buprenorphine, when taken:

A. Intranasally or intravenously

B. As prescribed

C. Intranasally, intravenously, and as prescribed

D. Buprenorphine and naloxone are not both bioavailable at the same time

41. Subdermal buprenorphine implants release buprenorphine in steady concentrations over 6 months approximately equivalent to _____ of the buprenorphine sublingual formulations.

A. 16 mg

B. 12 mg

C. 8 mg

D. 4 mg

42. Misuse and diversion of buprenorphine can be discouraged by:

A. Requiring frequent office visits until patients are stable.

B. Testing urine for buprenorphine and norbuprenorphine or buprenorphine glucuronide.

C. Using other methods to ensure adequate adherence to the medication as prescribed, such as developing and adopting a diversion control plan.

D. Misuse and diversion can be discouraged by requiring frequent office visits, testing urine, and adopting a diversion control plan.

43. Patients will develop physical dependence on buprenorphine and should be alerted that they will experience opioid withdrawal if they stop buprenorphine.

A. True

B. False

44. Research has shown that the dose of opioid agonist medication is directly related to the severity of neonatal abstinence syndrome and pregnant women should therefore be on the lowest dose of medication necessary.

A. True

B. False

45. In animal reproductive studies with Sublocade’s excipient, there have been reported fetal adverse reactions.

A. True

B. False

46. Before buprenorphine is prescribed, all of the following laboratory tests should be conducted, except for:

A. Pregnancy test

B. Liver function test

C. Renal function test

D. Hepatitis and HIV tests

47. Prior use of diverted buprenorphine rules out OUD treatment with buprenorphine.

A. True

B. False

48. Unsuccessful treatment experiences with buprenorphine in the past indicated that buprenorphine will be ineffective if tried again.

A. True

B. False

49. Pregnant women should be considered for transmucosal buprenorphine treatment.

A. True

B. False

50. Buprenorphine implants are indicated for patients who have already achieved illicit opioid abstinence and clinical stability while taking transmucosal buprenorphine for at least:

A. 120 days

B. 90 days

C. 60 days

D. 30 days

51. Clinical experience indicates that patients suitable for home induction can:

A. Describe, understand, and rate withdrawal.

B. Understand induction dosing instructions.

C. And will contact their provider about problems.

D. Patients suitable for home induction can describe, understand, and rate withdrawal, understand induction dosing instructions, and will contact their provider about problems.

52. Withdrawal can include all of the following, except:

A. Constipation

B. Running nose

C. Goose bumps

D. Yawning

53. Nicotine causes vasoconstriction, decreasing the surface area of blood vessels that absorb buprenorphine, therefore, patients should be advised to abstain from tobacco before dosing.

A. True

B. False

54. Nearly all patients stabilize on daily doses of 4 mg/1 mg to:

A. 8 mg/2 mg

B. 16 mg/4 mg

C. 20 mg/5 mg

D. 24 mg/6 mg

55. An effective maintenance dose is the lowest dose that can:

A. Eliminate withdrawal

B. Reduce or eliminate opioid cravings

C. Reduce or stop illicit opioid use’s desirable effects

D. An effective maintenance dose is the lowest dose that eliminates withdrawal, reduces or eliminates opioid craving, reduces or stops illicit opioid use’s desirable effects, and is a dose that can be well tolerated

56. Gauge treatment progress and success based on:

A. The patients’ achievement of specific goals that were agreed on in a shared decision-making and treatment planning process.

B. The amount of medication a patient needs.

C. How long treatment is required.

D. Treatment progress and success should be gauged by the amount of medication a patient needs, how long treatment is required, and the achievement of specific goals that were agreed on.

57. It is up to patients to decide whether to taper or eventually discontinue medication.

A. True

B. False

Chapter 3E: Medical Management Strategies for Patients Taking OUD Medications in Office-Based Settings

58. Overdose death with buprenorphine is most often associated with intravenous benzodiazepine and heavy alcohol use.

A. True

B. False

59. Initiation of HIV or hepatitis C virus treatments contraindicate buprenorphine treatment.

A. True

B. False

60. Prescribers of _____ must be able to refer patients for appropriate adjunctive counseling and ancillary services as needed according to federal law.

A. Naltrexone

B. Buprenorphine

C. Both naltrexone and buprenorphine

D. Neither naltrexone nor buprenorphine

61. Some peer recovery support groups consider patients taking methadone and buprenorphine for OUD treatment as not being abstinent from opioids, and groups not accepting of OUD medications are not appropriate for patients taking them.

A. True

B. False

62. All of the following are indications that a patient is ready to come less than weekly for visits, except for:

A. Adherence to appointments and treatment plan.

B. No ongoing drug use that may risk patient safety.

C. Several months of illicit opioid abstinence based on self-report.

D. Absence of significant mediation side effects.

63. Buprenorphine implants are indicated only for patients treated with transmucosal buprenorphine for at least 1 week.

A. True

B. False

64. Ongoing clinical monitoring that includes drug testing of urine or oral fluid specimens is part of good practice.

A. True

B. False

Chapter 3F: Medical Management of Patients Taking OUD Mediations in Hospital Settings

65. Which of the following is the key to effective patient management in general hospital settings?

A. Balancing pharmacotherapy for OUD with other medical concerns.

B. Careful management after discharge.

C. Seamless transfer to opioid treatment.

D. Balancing pharmacotherapy for OUD with other medical concerns, careful management after discharge, and seamless transfer to opioid treatment are all keys to effective patient management in general hospital settings.

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