PCSS
A 35 year old man with opioid use disorder is being treated with 16mg of buprenorphine daily. He is abstinent from opioids, which has been confirmed by negative urine toxicology results, however his urines are intermittently positive for benzodiazepines and he notes drinking alcohol two days per week. Further history, corroborated by his wife, indicates that he drinks 2-4 beers, 2-3 days a week and feels intoxicated. He says he wants to stop drinking altogether and has tried, however hasn't been able to quit, as he experiences cravings after a day or two. The drinking worries his wife, but otherwise his marriage, work and their social activities have not been affected by it. He's had no health problems associated with drinking and no history of tolerance or alcohol withdrawal when he does not drink for a few days. What is the most appropriate DSM-5 diagnosis?
mild
faster
*Amphetamines and nicotine increase Dopamine____________than cocaine and morphine
Under DATA 2000 and the Comprehensive Addiction and Recovery Act (CARA) of 2016, a DATA waiver physician may request to manage 275 patients with opioid use disorder (OUD) after how many years of initially obtaining his/her waiver
2 years
Under CARA 2016, in order to obtain a DATA-waiver, a nurse practitioner or a physician assistant must complete
24 hours
Approximately what percent of Americans with a substance use disorder also have a mental health disorder?
45%
receiving treatment for both
8.3% with co-occurring serious mental illness and SUD are ___________________
Which one of the following is required for implementing office-based buprenorphine
A DATA2000-waivered prescriber
Which of the following best describes SMM?
A combined pharmacologic and counseling treatment approach
Which of the following is an example of person-first, medically appropriate terminology?
A person with a substance use disorder
AUDIT Score
A score of 8 or more is considered to indicate harmful drinking.
Office-based practice of managing Opioid Use Disorder (OUD) differs from OTP-based management because
A. Office-based practice may prescribe buprenorphine products for OUD.
functional areas of the brain that are disrupted when an individual is chronically exposed to substances of abuse?
Ability to feel pleasure Memory and learning Motivation Stability of Emotion
The spirit of Motivational Interviewing is characterized by which of the following?
Acceptance, partnership, evocation, compassion
Which of the following statements is TRUE regarding screening and brief intervention for adolescents according to the American Academy of Pediatrics (AAP) Hint: 1 sister 2 brother intervention adolescent screening methord
Adolescents who report "weekly or more" use of any substance on the S2BI screening tool should be offered a referral to a professional who can conduct a substance use disorder evaluation and offer treatment recommendations hint:
What is the most common substance use disorder in the United States?
Alcohol
Federal regulation allows buprenorphine to be prescribed in a clinic or office by the following prescribers
All of the above
When this patient attends her first Narcotics Anonymous (NA) group meeting on the inpatient unit, she immediately gets up and leaves (with the aid of two younger patients). She states, "I cannot relate to those youngsters and their street language." When treating the elderly with Substance Use Disorder it is important to consider which of the following factors
All of the above
Which of the following statements is TRUE about alcohol and adolescent alcohol use?
Almost 50% of all alcohol consumed by underage drinkers is in the context of a binge.
Which structure of the brain plays a key role in the processing of emotions, such as fear
Amygdala
Hub and spoke models for integrating buprenorphine in primary care require which of the following key components
An opioid treatment program
How can one recognize when and older patient is misusing prescribed medications
Any symptoms in an older adult should be considered a medication side effect until proven otherwise.
Which of the following approaches should be used to engage patients in conversations surrounding problematic substance use to strengthen the brief intervention or referral to treatment?
Assess patiente under standing of situation, ask open ended questions, acknowledge patients experience, reflect on intentions Ask open-ended questions, affirm the patient's experiences, reflect statements made by patient, and summarize intermittently and at conclusion
Which of the following is true regarding behavioral addictions?
Behavior addiction may respond well to cognitive therapy
What factors influence stigma?
Behavior and attitude
In someone prescribed opioids for chronic pain, which of the following characterizes opioid use disorder
Behaviors indicating compulsive use
Which of the following patients would require a higher level of care (i.e. inpatient admission) for concurrent treatment of substance use and psychiatric comorbidity
Borderline personality disorder, history of suicide attempt by asphyxiation, currently suicidal with a plan to hang herself, using intranasal cocaine 2-3 times per week while drinking alcohol with friends
Behavioral addictions are similar to substance use disorders in all of the following ways except:
Both have higher prevelance in adults
Adolescents are particularly vulnerable to substance use and addiction due to
Brain development
Which of the following is true regarding the evidence for use of medication treatment for youth with opioid use disorder
Buprenorphine has been studied in teens with opioid use disorder and found to be effective.
Which prescribing practice is NOT allowed under CARA 2016?
Buprenorphine prescription called into pharmacy by DATA-waived physician
Which of the following has the lowest risk of being injected to get high
Buprenorphine/naloxone combination product
A 28 year man on buprenorphine 24 mg per day for treatment of opioid use disorder, is abstinent from opioids, but continues to use cocaine. What is the most appropriate first step in treatment of the cocaine use
CBT for Relapse Prevention
On further discussion, John says "I know I need to stop with these pills, and I really do want to be a better husband and provider." This statement is an example of
Change talk
Please select the term which should not be used from the list below:
Clean
This patient's primary care physician prescribed clonazepam for a presumed diagnosis of anxiety NOS. Which of the following is NOT a barrier to treatment of Substance Use Disorder in the elderly
Comorbid medical conditions may obscure substance use problems in the elderly
Which of the following statements is true considering the epidemiology and presentation of substance use disorders in women
Deaths from prescription painkiller overdoses among women have increased more than among men.
DARN questions
Desire Ability Reason Need
Which of the following medications blocks the metabolism of alcohol leading to an accumulation of acetaldehyde and its unpleasant side effects?
Disulfiram
neurotransmitters are affected by alcohol
Dopamine Endogenous Opioids GABA Glutamate
Which statement best defines "salience attribution"?
Drug associated cues more strongly grab ones attention compared to other cues
Which of the following was found by the World Health Organization to be the number one most stigmatized condition?
Drug use disorder
The 4 processes of Motivational Interviewing are:
Engage focus evoke plan
Two metabolites that can be monitored in urine to test for alcohol (ethanol) exposure within 3 - 5 days include Hint: Ethyl by gluose biscut or " ethyl by sefed nw yetetehaew
Ethyl glucuronide and ethyl sulfate
Medication management for the treatment of opioid use disorder includes the following
Evaluation of medication safety and effectiveness
Twelve-Step Facilitation (TSF) is best characterized as:
Evidence based manual guided psychotherapy
If a person taking disulfiram relapses and consumes alcohol, what symptoms may occur?
Flushing N/V
Which of the following best describes the ordering of the core elements of the initial SMM session
Rapport, Assessment, Diagnosis, Treatment plan, motivational advice
Which of the following describes a clinical concern about detoxification from opioids during pregnancy
Relapse to opioid use is a significant risk
Which of the following treatment settings would be appropriate for a patient with low likelihood of withdrawal, need for constant supervision to support change, and unable to stop using?
Residential
A patient ran out of his opioid medication early and told his healthcare provider that he took extra doses to control his pain. This is the first time he has run out of medications early. Which of the following is the most appropriate step for the provider to consider?
Rule out presence of opioid use disorder, provide additional patient education and encourage communication
Which of the following best describes the empirical evidence in support of SMM for opioid use disorder
SMM is comparable to SMM plus drug counseling
A consistent predictor of compliance with 12-Step meetings is:
Severity of alcohol use disorder
Which of the following is TRUE regarding neonatal abstinence syndrome (NAS)
The incidence of NAS has doubled in the past decade
A 30 year old woman with a 5 year history of opioid use disorder, mainly heroin use, is started on buprenorphine 16 mg per day. She reports abstaining from opioids most days, using only about one day per week, when feeling stressed. Most of her urine tests (3 out of 4) are negative for opioids. She says she has been receiving a prescription for alprazolam, 1 mg TID, from another physician for anxiety and insomnia, which she says has been helpful to her, and asks for a refill. Which of the following is a "red flag" for benzodiazepine misuse or diversion
The patient complains insistently about anxiety and insomnia
What is the most common reason people with a substance use disorder who believe they need treatment do not receive treatment?
They are not ready to stop using
Which of the following types of patients cannot be treated with SMM hint: if you fail to meet minimum req't then we can not treat you.
Those who cannot minimally adhere to the SMM protocol
Which medication is approved only for the treatment of pain?
Transdermal buprenorphine (Butrans®)
SBIRT
acronym that stands for screening, brief intervention, and referral to treatment.
Efficacy data studies have shown that Buprenorphine
all of the above
the emotion center of the brain.
amygdala
orbitofrontal cortex (OFC)
assigns motivation value and the AC is involved in inhibitory control of behaviors.
SUD Diagnosis (DSM-5)
at least two of the eleven criteria listed below occurring in a 12-month period: Impaired Control: · Larger amounts/longer period of time · Persistent desire, cannot cut down or control use · Significant time spent to obtain, use, recover · Cravings Social Impairment: · Failure to meet obligations · Continued use despite social or interpersonal problems · Reduction in important activities Risky Use: · Use is physically hazardous · Continued use despite knowledge of substance use disorder Pharmacological Criteria: · Tolerance · Withdrawal
The 35 year old man with opioid use disorder (described above), treated with buprenorphine, 16mg per day, is abstinent from opioids, using 4 mg per day of alprazolam, is motivated to try to quit benzodiazepines and agrees to a substitution and taper strategy. Which of the following medications, at the total daily dose indicated, would be the most equivalent starting dose for a taper.
chlordiazepoxide 100 mg
Substance use disorder has many characteristics that are similar to other chronic illnesses. For example,
genetics accounts for roughly half of a person's risk of developing the disease.
Two years of abstinence
however, allows a near full return of DATs to normal levels.
Opioid overdose deaths are correlated with:
increases in opioid prescribing
Dopamine
is responsible for controlling behavior and regulates an area of the lower brain—the amygdala.
Stigma's effect on patient care
it erodes the notion that SUD is a valid and treatable chronic condition. This in turn reduces the individual's willingness to seek care.
What cluster of blood test results would be consistent with chronic, heavy alcohol use ; Hint: You have to give magnesium to drunk people, and "there RBC will also drink and swell so high MCV, and liver got hit like online meded SGOT is specific to alcoholics
levated MCV, elevated SGOT, low magnesium
A 75 year old Caucasian female has been feeling anxious and has been complaining to her husband of 50 years for help to address it. She has a history of Anxiety NOS and is prescribed clonazepam by her primary care physician. Her husband is a retired professor at an Ivy League University and has a complex medical history including chronic pain from peripheral neuropathy treated with extended-release oxycodone 40 mg by mouth every twelve hours. She presents to the emergency room after she: became confused, was unable to eat her dinner, and fell into a light sleep at the dinner table while out to dinner with her husband. Upon arrival to the emergency room she required intubation and was given naloxone IV. Her urine toxicology screen was positive for opioids and benzodiazepines. Her breathalyzer was 0.04g/dl. She is stabilized and admitted and detoxified (weaned off of her opioid pain medications with little problem). She is maintained on her clonazepam and transferred to the psychiatry inpatient unit. The psychiatry intern interviews the woman when she is transferred to the inpatient unit. The intern asks, "Where did you get the pain medications?" The patients most likely response is:
Free from a friend or relative (in this case the patient's husband) who received them from one doctor
Which of the following is classified in the DSM-5 under "Substance Related and Addictive Disorders?
Gambling addiction
Which of the following is not included in the definition of addiction as defined by the American Society of Addiction Medicine?
Hardships
Which of the following has been shown to increase the risk for developing a behavioral addiction?
Having a substance use disorder
Substance use disorder shares many features with other chronic illnesses, including:
Heritability, influence of the environment and behavior and response to appropriate tx
Which of the following treatment settings would be appropriate for a patient with low risk of withdrawal, no active medical issues, mild psychiatric issues, needing a highly structured environment to promote change, with moderately high relapse potential, and a small social support network?
Inpatient
A clinician is working with a patient to develop a treatment plan that includes an opioid medication. The patient is a 36-year-old man with low back pain. What should the clinician keep in mind
It is important to set functional goals that are measurable and achievable
Which of the following is true about the utilization of SBIRT?
It is to be administered universally
ohn is a 33 year-old male with a history of asthma, chronic back pain, and depression. He is attending his annual checkup after having not been seen by a doctor in over 5 years. On his screening form he indicates a use of prescription pain medications for non-medical reasons. Which of the following is a MI-consistent way to open up a conversation about his drug use
John, you noted on your screening form that you've been using pain medications. Would it be ok if we spent a few minutes talking about it?
Full opioid agonists produce increasing mu opioid receptor specific activity until maximum opioid agonist effects are achieved and no further effects can be produced, even by giving more medication. An example of a full opioid agonist is
Methadone
Which of the following is a full opioid receptor agonist that exerts effects on the mu receptor at increasing doses with no ceiling effect?
Methadone
Which of the following describes a reasonable monitoring strategy for a patient taking an opioid medication for pain management
Monitoring can be tailored according to the patient's risk, but all patients should be monitored
Which of the following statements is TRUE about college drinking
Most date rape incidents with college students involve alcohol consumption.
Which of the following medications prescribed to treat opioid use disorder works by binding and blocking the opioid receptor but has no intrinsic activity on the receptor? hint: it is full antagonist that fully bind to opioid receptor but has not effect
Naltrexone
Which of the following is a possible concern about the use of naltrexone in pregnant women
Naltrexone may complicate pain management during delivery and post delivery
Which of the following is a generally accepted theory to explain addiction?
Neurobiological
What are considered low risk drinking limits for an adult woman?
No more than three drinks in any given day
In which structure of the human brain are D2 receptors most often found?
Nucleus accumbens
John describes his opioid use causing problems with his wife because he is spending close to $200 every week to buy pills. "It's just something I do to relax and chill out, I don't know if it's a huge deal, it's not like I'm shooting up heroin or smoking crack. I'll stop at some point, and certainly if we're trying to start a family." Which of the following responses is an example of reflective listening
On the one hand you like how these pills make you feel and you're not sure if it's a big deal, and on the other hand these pills are costing you a fortune and causing problems with your wife.
In the nurse care manager model, care managers increase primary clinic capacity for treating patients with opioid use disorder by hint: at Jane st, we asked Nurse case manager who "knows hwo every patient admited, treated and discharged"; asked her to send us all red flags of addiction so our capacity grows.
Partnering with prescriber to manage patients
Which of the following statements about nicotine replacement therapy (NRT) is true?
Patients may combine more than one form of NRT
Which of the following is a non-stigmatizing way to refer to a patient in Standard Medical Management (SMM) treatment
Person with an Opioid Use Disorder
Which of the following is an example of an advantage that buprenorphine has over methadone hint: dr Llewalyn said "to avoid NAS neonatal apgar 1 or respiratory depression due to opiod MEPERIDINE NOW SUBSITTUED WITH NEUBAIN which is like BUPRENORPHIN partial agonist hence no NAS resp depression
Prenatal buprenorphine exposure results in less neonatal abstinence syndrome severity relative to methadone
A 35 year old man with opioid use disorder is being treated with 16mg of buprenorphine daily. He is abstinent from opioids, which has been confirmed by negative urine toxicology results, however his urines are intermittently positive for benzodiazepines and he notes drinking alcohol two days per week. When asked about his benzodiazepine use the patient says he has been buying xanax (alprazolam) 2mg pills "sticks" from dealers who previously sold him heroin. At first he was taking one half pill per day at bedtime, to help with sleep and anxiety. However, the effect gradually diminished and his use has increased over the past several months to 2 pills per day. He denies any impairment in his marriage, work or social life from the alprazolam. He wants to quit because he is spending a lot of time seeking out dealers, and experiences heroin cravings when meeting with them. He has tried to quit and cannot, experiencing cravings for alprazolam. On occasions when he has not used alprazolam for several days, he experiences sweating, shaking, worsened anxiety and insomnia. What is the most appropriate DSM-5 diagnosis
mod
Which of the following is a more detailed screening tool for adults used to detect problematic substance use that may require either brief intervention or referral to treatment?
swift
Serotonin is secreted primarily in
the GI tract and also in the Raphe nuclei of the brain stem.
SBIRT decreases
the extent of drug and alcohol use, and reduces emergency department visits, injury hospitalizations, and motor vehicle crashes, ultimately, reducing healthcare costs can detect a spectrum of substance use
Dopamine is secreted by
the nucleus accumbens and pre-frontal cortex
D2 receptors
the receptors associated with the brain's reward system
People who use buprenorphine without a prescription most often use it for the following reason
to get high
