ASIPP Controlled Substance Management Questions Flashcards
- A 25-year-old male receiving hydrocodone and diazepam
presents with disorientation. He states that he had
nausea, vomiting, abdominal pain and diarrhea since he
took “too many pain pills”. During this time he becomes
extremely lethargic, with slow respirations. No other
history is available. Your immediate action, in addition to
O2 administration is to administer:
A. Naloxone
B. Diphenoxylate
C. N-acetyl-L-cysteine
D. Prochlorperazine
E. Flumazenil
- Answer: A
Explanation:
CNS depression is hallmark of overdosage with opioids
or benzodiazepines.
Respiratory depression is seen with opioids.
Nausea, vomiting, abdominal pain, and diarrhea are
early signs of the severe liver toxicity caused
by high levels of acetaminophen. Other symptoms of
acetaminophen toxicity include dizziness,
excitement, and disorientation.
A. Naloxone is antagonist of opioids. Symptoms indicate
opioid overdose.
B. Diphenoxylate is an antidiarrheal agent
C. N-acetyl-L-cysteine is the appropriate treatment for
acetaminophen overdose.
D. Prochlorperazine is to treat the nausea and vomiting
caused by radiation therapy, cancer chemotherapy, surgery,
and other conditions
E. Flumazenil is a competitive benzodiazepine receptor
antagonist.
Source: Stern - 2004
2475.Once an opioid treatment is selected, titration upwards
should continue until:
A. A ceiling is reached.
B. Addiction occurs
C. Tolerance occurs
D. A balance between analgesia and side effects is reached.
E. Respiratory depression occurs
- Answer: D
Explanation:
There is no ceiling for opioids (other than the limitations
of agonist/antagonists or APAP). The goal is to prevent
addiction. Tolerance is less likely with long acting opioids.
Respiratory depression is unlikely with stable doses of
opioids. The goal is a balance between pain relief and
intolerable side effects.
Source: Trescot AM, Board Review 2004
2476.
- Answer: D
Explanation:
A. Naltrexone is an antagonist therapy for heroin
addiction
B. Physostigmine is used to treat glaucoma
C. Pralidoxime is used together with another medicine
called atropine to treat poisoning caused by organic
phosphorus pesticides
D. Flumazenil is a competitive antagonist of
benzodiazepines at the GABA receptor.
Repeated administration is necessary because of its
short half-life relative to that of most
benzodiazepines.
E. Naloxone is an opioid antagonist.
2477.A patient on methadone 90 mg daily, stable, with good
relief now presents with a kidney stone. For the present
problem :
A. Continue at 90 mg of methadone daily
B. Stop methadone
C. Continue 90 mg of methadone, but add higher than
normal doses of hydrocodone
D. Continue 90 mg of methadone and add lower doses of
hydrocodone
E. Continue 90 mg of methadone and add usual doses of
hydrocodone
- Answer: E
Source: Laxmaiah Manchikanti, MD
2478.A 29-year-old male uses secobarbital to satisfy his
addiction to barbiturates. During the past week, he is
imprisoned and is not able to obtain the drug. He is
brought to the prison medical ward because of the onset
of severe anxiety, increased sensitivity to light, dizziness,
and generalized tremors. On physical examination, he is
hyperrefl exic. Which of the following agents should he be
given to diminish his withdrawal symptoms?
A. Buspirone
B. Chloral hydrate
C. Chlorpromazine
D. Diazepam
E. Trazodone
- Answer: D
Explanation:
Reference: Hardman, p 564.
A. The anxiolytic effects of buspirone take several days to
develop, obviating its use for acute severe anxiety.
B. Chloral hydrate a sedative, is used in the short-term
treatment of insomnia .
C. Chlorpromazine is used to treat psychotic disorders
and symptoms such as hallucinations, delusions, and
hostility
D. A long-acting benzodiazepine, such as diazepam, is
effective in blocking the secobarbital withdrawal
symptoms.
E. Trazodone is an anti-depressant
Source: Stern - 2004
2479.Which of the following statements regarding controlled
substances prescriptions is FALSE?
A. A controlled substances prescription must be dated as
of and signed on the day it is issued.
B. A controlled substances prescription must contain the full name and address of the patient.
C. A physician who has given his or her staff at least
eight hours of training on the federal laws and
regulations concerning controlled substances prescriptions
has no liability for a controlled substance
prescription completed by a staff member that does not
comply with the federal requirements.
D. A controlled substances prescription must contain the
name of the drug, the strength of the drug, the dosage
form of the drug, quantity of drugs prescribed, and directions
for use.
E. A prescription for a Schedule III, IV, or V drug given
for the purpose of detoxifi cation or maintenance treatment
must include the unique identifi cation number
issued by the Administrator of DEA in addition to the
physician’s DEA number.
- Answer: C
Explanation:
Answer (c) is wrong because, under 21 CFR 1306.05, the
physician is responsible if the prescription does not
conform to applicable laws and regulations.
Reference: 21 CFR 1306.05.
Source: Erin Brisbay McMahon, JD, Sep 2005
2480.A 16-year old patient has terminal cancer and has failed
all treatment. Pain is worsening and he requires higher
doses of opioid analgesics for pain relief. He inquires as
to whether a research program may or may not help. One
of the side effects with the new treatment is worsening of
peripheral neuropathy. At this point, he refuses further
treatment. His parents want you to talk to him and enroll
him in the experimental protocol. Which of the following
is your next course of action?
A. Inform the patient that he can not refuse treatment
B. Begin treatment if the parents provide written consent
C. Respect the patient’s wishes and cancel plans for treatment
D. Avoid further escalation in opioid doses.
E. Discuss the issues with the patient
- Answer: E
Explanation:
The next course of action is to explore the issues with the
patient.
2481.Addiction is defi ned as:
A. Physical dependence and the need to increase the drug to
obtain the same effect.
B. A patient who needs the drug and has good control over
personal behavior.
C. Psychological dependence on the use of controlled substances
for their psychic effects and is characterized by
compulsive use.
D. Slow but progressive deterioration of health in light of
drug use.
E. Loss of effectiveness of the drug to control pain.
- Answer: C
Explanation:
Addiction is a chaotic disturbance in physical and
psychological control factors that involve impulse control,
and often evolves to a patient utilizing the drug to their
detriment, inducing physical harm, and personal disregard
of danger. There is a signifi cant loss of personal control,
and the patient seeks the drug, sometimes at all costs.
Addiction does not necessarily mean a non-functional
individual. We see some levels of addiction, even with our
very straightforward pain control patients, i.e. tobacco use.
Functional alcoholics perform in some segments of
society, and it is not uncommon to be introduced to a
patient with an iatrogenic addiction to a controlled
substance such as benzodiazepine (Xanax?), opioid,
Oxycontin?. It is also not unusual to hear that some of
these patients are very highly respected members of
society, kind and caring, and have had personality changes
that are not appreciated by the individual. This is where
professional and family intervention is necessary.
Source: Hans C. Hansen, MD
2482.According to the 2003 National Survey on Drug Use and
Health (NSDUH), 6.3 million persons age 12 or older
used prescription medications for non-medical reasons.
Which of the following is the most prevalent agent for
non-medical reasons?
A. Pain reliever
B. Tranquilizers
C. Stimulant
D. Sedatives
E. NSAIDs
- Answer: A
Source: Hans C. Hansen, MD
2483.Fluoxetine (Prozac®) is classifi ed as:
A. As an MAO inhibitor (MAOI)
B. As a tricyclic nonselective amine reuptake inhibitor
C. As a heterocyclic nonselective amine reuptake inhibitor
D. As a selective serotonin reuptake inhibitor
E. As an alpha2-adrenergic receptor inhibitor
- Answer: D
Explanation:
Fluoxetine is a highly selective serotonin reuptake
inhibitor (SSRI) acting on the 5-HT transporter. It forms
an active metabolite that is effective for several days.
Selective serotonin reuptake inhibitors are inhibitors of
cytochrome P450 isoenzymes, which is the basis of
potential drug interactions
- Tolerance is:
A. A need to increase drug dosage to obtain the same effect.
B. A rapid immunity to opioids, secondary to cross-reactive
antibodies.
C. The concept of understanding that a drug is necessary,
except in the community.
D. A patient’s ability to take the drug.
E. The physician’s willingness and acceptance to prescribe
the drug.
- Answer: A
Explanation:
Tolerance is the concept of the need to increase dosage of
drug to produce the same level of analgesic capacity that
previously existed. Tolerance may occur at a constant
dose, and tolerance should not be considered within the
defi ned purview of addiction.
Source: Hans C. Hansen, MD
2485.All of the following are true statements regarding
ketamine EXCEPT:
A. Ketamine is a dissociative anesthetic
B. Dissociative anesthesia induced by ketamine emphasizes
that the anesthetized patient is “disconnected”- from
his or her environment
C. Ketamine is one of the most commonly abused drugs
D. Ketamine has been placed in Schedule I of the Federal
Controlled Substances Act.
E. Ketamine induces coma in a dose-dependent manner
- Answer: D
Explanation:
A. Ketamine is a dissociative anesthetic
B. Dissociative anesthesia induced by ketamine
emphasizes that the anesthetized patient is “disconnected”-
from his or her environment
C. Persons who abuse ketamine may use a variety of
routes of administration, and general anesthesia obviously
is not the object of their use. It is the low-dose mental
state that ketamine induces is considered as reinforcing by
substance abusers.
D. Ketamine is a Schedule III drug
E. Ketamine induces coma in a dose-dependent manner.
A minimum of 0.5 mg/kg intravenous is necessary to
induce coma for approximately 1.5 minutes.
A dose of 1 mg/kg induces coma for approximately
5.8 minutes, whereas a dose of 2 mg/kg
induces coma for approximately 10 minutes.
2486.The W.H.O. cancer pain relief ladder is:
A. Poorly validated with anecdotal reports of effectiveness.
B. Emphasizes non-opioid treatment through the fi rst three
steps.
C. Is inappropriate to utilize on a terminally ill patient.
D. Is a simple and effective tool to afford relief with a high
level of confi dence, in an overwhelming majority of
patients.
E. Suggests alternative therapy management in the early
stages.
- Answer: D
Explanation:
The W.H.O. ladder emphasizes Step One: Non-Opioid,
Step Two: Opioid for Mild to Moderate Pain, and Step
Three: Opioids for Moderate to Severe Pain. The ladder is
just that. It increases potency and adjunctive medication
to treat pain, and is highly effective, well-validated,
suggesting 90% of cancer patients receiving relief. 75% of
terminally ill patients also report relief.
Source: Hans C. Hansen, MD
2487.Among the following neuroleptics, the most likely
neuroleptic associated with skeletal muscle rigidity,
tremor at rest, fl at facies, uncontrollable restlessness, and
spastic torticollis is
A. Clozapine
B. Haloperidol
C. Olanzapine
D. Sertindole
E. Ziprasidone
- Answer: B
Explanation:
Reference: Katzung, p 482.
Haloperidol, a butyrophenone is by far the most likely
antipsychotic to produce extrapyramidal toxicities.
Other agents, such as piperazine (an aromatic
phenothiazine), thiothixene ( a thioxanthene), and
pimozide ( a diphenylbutyropiperidine) are comparatively
less likely to produce extrapyramidal toxicity than
haloperidol.
The antagonism of dopamine in the nigrostriatal system
might explain the Parkinson-like effects.
Both haloperidol and pimozide act mainly on D2
receptors, whereas thioridazine and piperazine act on
alpha-adrenergic receptors, and have a less potent but
defi nite effect on D2 receptors.
Source: Stern - 2004
2488.Among the following neuroleptics, the agent most likely associated with constipation, urinary retention, blurred vision, and dry mouth is: A. Chlorpromazine (Thorazine®) B. Clozapine (Clozaril®) C. Olanzapine (Zyprexa®) D. Sertindole (Serdolect®) E. Haloperidol (Haldol®)
- Answer: A
Explanation:
Reference: Katzung, pp 471, 473, 482.
The phenothiazines as a class are the most potent
anticholinergics of the neuroleptics.
Tolerance to their anticholinergic effects occur in most
patients.
Cholinomimetic agents may be used to overcome
symptoms that persist.
Source: Stern - 2004
2489.Drug interactions common to cyclobenzaprine
(Flexeril®) include all of the following except :
A. MAOI agents
B. Barbiturates
C. Tertiary tricyclic antidepressants
D. Zolpidem (Ambien®)
E. Alcohol
- Answer: D
Source: Hansen HC, Board Review 2004
- Gabapentin (Neurontin®) exerts its analgesic affect by:
A. Inhibition of reuptake Serotonin and Norepinephrine
B. Central modulation of the dorsal lateral funiculus at the
dorsal horn intermediary.
C. GABA-A affi nity and activation.
D. The analgesic effect is unknown.
E. NMDA modulation.
- Answer: D
Source: Hansen HC, Board Review 2004
2491.A 36-year-old male with a bipolar disorder is treated
with lithium. Among the following adverse effects, the
side effect attributed to lithium treatment is:
A. Browning of the vision
B. Hypothyroidism
C. Agranulocytosis
D. Neuroleptic malignant syndrome
E. Pseudodepression
- Answer: B
Explanation:
Reference: Katzung, pp 493-494.
A decrease in thyroid function occurs in most patients on
lithium. This effect is usually reversible or not
progressive, but a few patients develop symptoms of
hypothyroidism.
A serum thyroid-stimulating hormone (TSH)
concentration is recommended every 6 to 12 months.
“Browning” of vision, clinically described as pigmentary
retinopathy, occurs with thioridazine. This is due to retinal
deposition of the drug.
Although neurologic adverse effects (e.g., tremor,
choreoathetosis, motor hyperactivity, ataxia, dysarthria,
and aphasia) can occur with lithium, it does not cause the
neuroleptic malignant syndrome associated with antipsychotic
agents. Pseudodepression sometimes occurs in patients on antipsychotics.
This may be related to drug-induced akinesia.
Source: Stern - 2004
2492.N-acetyl benzoquinoneimine is the hepatotoxic metabolite of which drug? A. Sulindac B. Acetaminophen C. Isoniazid D. Indomethacin E. Procainamide
- Answer: B
Explanation:
Reference: Hardman, pp 632-633.
Hepatic necrosis can occur with overdosage of
acetaminophen. The hepatic toxicity is the result of the
biotransformation of acetaminophen to Nacetylbenzoquinoneimine,
which reacts with hepatic
proteins and glutathione. This metabolite depletes
glutathione, stores and produces necrosis. The
administration of N-acetyl-L-cysteine restores hepatic
concentrations of glutathione and reduces the potential
hepatotoxicity. Sulindac is biotransformed to sulindac
sulfi de, the active form of the drug. Both sulindac and its
metabolites are excreted in the urine and in the feces.
Indomethacin undergoes a demethylation reaction and an
N-deacylation reaction. The parent compound and its
metabolites are mainly excerted in the urine. Procainamide
is converted to an active metabolite by an acetylation
reaction. The product that is formed is Nacetylprocainamide
(NAPA). In addition, procainamide is
hydrolyzed by amidases. An N-acetylation reaction occurs
also in the biotransformation of isoniazid. In the liver, the
enzyme N-acetyltransferase converts isoniazid to
acetylisoniazid.
Source: Stern - 2004
2493.The mechanism of action of most benzodiazepines is
by :
A. Activation of GABA receptors
B. Antagonism of glycine receptors in the spinal cord
C. Blockade of the action of glutamic acid
D. Increased GABA-mediated chloride ion conductance
E. Inhibition of GABA aminotransferase
- Answer: D
2494. A drug that is used in the treatment of parkinsonism and will also attenuate reversible extrapyramidal side effects of neuroleptic is A. Amantadine (Symmetrel®) B. Levodopa (Dopar®) C. Pergolide (Permax®) D. Selegiline (Eldepryl®) E. Trihexyphenidyl (Artane®)
- Answer: E
2495.Meprobamate is the active metabolite of which skeletal muscle relaxant? A. Carisoprodol (soma®) B. Cyclobenzaprine (Flexeril®) C. Methocarbamol (Robaxin®) D. Valdecoxib (Bextra®) E. Baclofen®
- Answer: A
Source: Jackson KC. Board Review 2003
2496.The following statements are true regarding opioidinduced
constipation.
A. Treat constipation
B. To obtain a surgical consult to rule out complications
C. To evaluate for drug abuse
D. Start on transdermal fentanyl
E. Start on methadone maintenance program
- Answer: A
Explanation:
A. Constipation is the most frequent side effect of opioid
therapy.
Tolerance does not develop to this side effect.
Therefore, as the dose of opioid increases, so does
the potential for constipation.
Frank bowel obstruction, biliary spasm, and ileus have
occurred with opioid use.
It is crucial to place patients on an active bowel regimen
that includes laxatives, stool softeners,
adequate fl uids and exercise, and cathartics as needed to
prevent the severe constipation that
can occur with opioid use.
B. Surgical complications are unlikely.
C. Constipation is not a symptom of drug abuse.
D. Transdermal fentanyl may be an option if morphine
titration fails. Constipation is similar.
E. Methadone maintenance is not indicated
Source: Manchikanti L, Board Review 2005
2497.What document refl ects the practitioner’s explanation
and the patient’s understanding of the risks, benefi ts,
alternative treatments, and special issues concerning the
use of controlled substances?
A. Narcotic contract
B. History and Physical Evaluation form
C. Pain scale evaluation and update report
D. Informed consent form
E. The approval letter from the patient’s health care benefi t
plan
- Answer: D
Explanation:
Reference: The Federation of State Medical Boards’ Model
Policy for the Use of Controlled Substances for the
Treatment of Pain, (May 2004); Bolen, J Pain Medicine
News (Informed Consent).
Explanation:
A. This is not the best answer. A narcotic contract
(typically called a Controlled Substances Treatment
Agreement) usually contains boundaries for use with high
risk patients. Most often, boundary language includes the
use of urine screens, one physician and one pharmacy for
obtaining controlled substances, a specifi c term for
periodic review, and a discussion of the consequences
should the patient fail to abide by the agreement.
B. This is not the best answer. A History and Physical
Evaluation form is not used to explain the risks and
benefi ts of using controlled substances to treat pain.
Rather, the H&P form is designed to gather information
about the patient’s medical history and treatment past, so
the provider can decide on a course of treatment. Once the
provider and the patient agree upon a treatment plan, the
provider should engage in informed consent with the
patient.
C. This is not the best answer. A pain scale and periodic
evaluation form are used to follow the patient after
treatment begins.
D. This is the best answer. An Informed Consent form is
different from a Narcotic Contract or Treatment
Agreement, because it helps the practitioner establish the
proper interaction between him/her and the patient
concerning the risks, benefi ts, treatment alternatives, and
special issues regarding the use of controlled substances to
treat pain. When a practitioner uses an Informed Consent,
he/she is minimizing legal exposure for negligence
associated with the use of controlled substances to treat
pain. Of course, it is up to the practitioner to follow
accepted current clinical care standards, which include a
proper informed consent process.
E. This is not the best answer. Rarely, if ever, does a letter
from the patient’s health care benefi t plan contain
language relating to informed consent.
Source: Jennifer Bolen, JD, Sep 2005
2498.Which one of the following effects is unlikely to occur during treatment with amitriptyline? A. Alpha adrenoceptor blockade B. Elevation of the seizure threshold C. Mydriasis D. Sedation E. Urinary retention
- Answer: B
Explanation:
Tricyclics modify peripheral sympathetic effects in two
ways; through blockade of norepinephrine reuptake at
neuroeffector junctions and through alpha adrenoceptor
blockade. Sedation and atropine-like side effects are
common with tricyclics, especially amitriptyline. In
contrast to sedative-hypnotics, tricyclics lower the
threshold to seizures.
Source: Katzung & Trevor’s Pharmacology, Examination
and Board Review, 6th Ed., McGraw Hill, New York, 1998
2499.Regarding the clinical use of antidepressant drugs, which
one of the following statements is false.
A. Patients should be advised not to abruptly discontinue
antidepressant medications.
B. In selecting an appropriate drug for treatment of depression,
the past history of patient response to specifi c
drugs is a valuable guide
C. In the treatment of major depressive disorders, sertraline
is usually more effective than fl uoxetine
D. MAO inhibitors are sometimes effective in depressions
with attendant anxiety, phobic features, and hypochondriasis
E. Weight loss often occurs in patients taking SSRIs
- In severe tricyclic antidepressant overdose, it
would NOT be of value to
A. Administer lidocaine (to control cardiac arrhythmias)
B. Institute hemodialysis (to hasten drug elimination)
C. Administer bicarbonate and potassium chloride (to correct
acidosis and hypokalemia)
D. Provide intravenous diazepam (to control seizures)
E. Maintain the rhythm of the heart by electrical pacing
- Answer: E
Explanation:
There is no evidence that any SSRI is more effective than
another in its antidepressant effi cacy. While an individual
patient may respond more favorably to a specifi c drug,
several controlled studies have shown equivalent effective
ness of these agents. However, SSRIs may be more effective
than tricyclic antidepressants in some patients.
Source: Katzung & Trevor’s Pharmacology, Examination
and Board Review, 6th Ed., McGraw Hill, New York, 1998 - Answer: B
Explanation:
Tricyclic antidepressant overdose is a medical emergency.
The “three Cs”- coma, convulsions, and cardiac problems are
the most common causes of death. Widening of the
QRS complex on the ECG is a major diagnostic feature of
cardia toxicity. Arrhythmias resulting from cardiac
conductivity (eg, lidocaine). There is no evidence that
hemodialysis (or hemoperfusion) increases the rate of
elimination of tricyclic antidepressants, presumably
because of their large volume of distribution and their
binding to tissue components.
Source: Katzung & Trevor’s Pharmacology, Examination
and Board Review, 6th Ed., McGraw Hill, New York, 1998
2501.A weak acid drug (A), with a pKa = 6, is given orally.
Assuming that the pH of the stomach equals 3 and the pH
of the blood equals 7, which of the following statements
is true?
A. At equilibrium, there is roughly 1000 times more dissociated
drug than undissociated drug in the stomach
B. At equilibrium, the ratio of dissociated to undissociated
drug in the blood is approximately 10
C. At equilibrium, 10 times more undissociated drug than
dissociated drug is in the blood
D. Drug concentrations on the blood side of the stomach
barrier will never reach the concentration of drug in
the stomach
E. The drug will be more rapidly excreted if the urine is
made acidic
- Answer: B
Explanation:
According to the Henderson-Hasselbalch equation, the pK
equals the pH when the log of the ratio is ionized
(dissociated) and protonated (undissociated) forms is 0
(i.e., their concentrations are equal and have a ratio of 1).
When the pH of a solution (blood) is 7 and the pK of the
acid is 6, at equilibrium, the log of the ratio of
concentrations of ionized form to protonated form is 1
(i.e., there is 10 times more ionized than protonated acid
in the blood). When the pH of a solution (stomach) is 3
and the pK of the acid is 6, the log of the ratio of the
concentrations of the ionized to protonated forms is –3
(i.e., the concentration of the ionized form is 1/1000 that
of the protonated form, meaning that there is 1000 times
more protonated than ionized acid). Drug will accumulate
in the compartment in which it is more highly charged
(ion trapping) – in this case, the blood. Acidifi cation of
the urine will increase the protonation of an acid and
increase reabsorption, thereby slowing renal excretion.
- Which of the following is NOT a true statement with
respect to a Schedule III or IV drug?
A. Schedule III and IV prescriptions may not be fi lled or
refi lled more than six months after the date the original
prescription was issued.
B. Schedule III and IV prescriptions may not be refi lled
more than 10 times after the date of the prescription
unless renewed by the prescribing practitioner.
C. No Schedule III or IV drug may be dispensed without
a written or oral prescription, except when dispensed
directly by a physician or other practitioner to an ultimate
user.
D. A pharmacist may dispense a Schedule III or IV drug
based on a fax to the pharmacy of a written, signed
prescription transmitted by the practitioner or one of
his/her staff.
E. A pharmacist may dispense a Schedule III or IV drug
based on an oral prescription received from the
prescribing practitioner, if the oral authorization is
promptly reduced to writing by the pharmacist.
- Answer: B
Explanation:
Schedule III and IV prescriptions may not be refi lled more
than 5 times after the date of the original prescription
unless renewed by the prescribing practitioner.
Reference: 21 USC 829 (b) - (c).
Source: Erin Brisbay McMahon, JD, Sep 2005
2503.Identify the LEAST important advice in defending drug
charges:
A. Comply with all federal and state laws and regulations
governing prescribing – have and follow a compliance/
risk management program
B. Keep current with and comply with DEA Policy Statements
C. Comply with Kentucky Board of Medical Licensure Policies,
Guidelines, and Newsletters, especially Guidelines
for Use of Controlled Substances in Pain Treatment
D. Keep up with your documentation
E. Check if the patients are paying for visits.
- Answer: E
Source: Erin Brisbay McMahon, JD, Sep 2005
2504. All of the following are chronic pain related psychiatric disorders, EXCEPT: A. Anxiety B. Depression C. Sleep disorders D. Post traumatic stress disorder E. Increased sexual function
- Answer: E
Source: Renee R. Lamm, MD, Sep 2005
- Which of the following statements concerning lithium
is true?
A. Lithium is used to control agitation associated with
schizophrenia
B. Retention of lithium is enhanced by a high-sodium diet
C. Early signs of lithium toxicity may include tremors
D. The onset of lithium action occurs within 24 hours
E. All of the above
- Answer: C
Explanation:
Severe tremors, along with confusion, drowsiness,
vomiting, ataxia and dizziness, are an early sign of lithium
toxicity. Retention of lithium may be enhanced by a lowsodium
diet because sodium competes with lithium for
reuptake in the kidney. The onset of lithium action may
take a week or more; the drug is used to normalize mood
in patients with mania or bipolar disorder.
- If a patient brings unused controlled substances back to
you at your offi ce, you should do which of the following?
A. Dispose of the controlled substances after the patient
leaves your offi ce and write down what you did in the
medical record.
B. Inventory the returned controlled substances and use
them with other patients who cannot afford to pay for
prescriptions for these drugs because they do not have
health insurance.
C. It depends on regulations of State Board of Medical
Licensure
D. Flush the stuff down the toilet.
E. Call a DEA agent to come and get the drugs.
- Answer: C
Explanation:
Reference: 21 C.F.R. § 1307.21 (Disposal of Controlled
Substances).
Explanation:
A. This is not the best answer. You must understand the
federal law in this area and then check to see if you state
requires more of you when it comes to disposing of
controlled substances. If you wait until after the patient
leaves your offi ce to record the disposal or destruction of
the returned controlled substances, you may be in
violation of state licensing board regulations/rules or
guidelines, policy, or position statements, or the
controlled substances act. Further, the patient may try to
argue that he/she returned more medication than what
you wrote down in the medical record. The federal law
states in § 1307.21(a) “[a]ny person in possession of any
controlled substance and desiring or required to dispose
of such substance may request assistance from the Special
Agent in Charge of the Administration in the area in
which the person is located for authority and instructions
to dispose of such substance. The request should be made
as follows: (1) If the person is a registrant, he/she shall list
the controlled substance or substances which he/she
desires to dispose of on DEA Form 41, and submit three
copies of that form to the Special Agent in Charge in his/
her area. Remember, your state guidelines, laws, and
regulations may be stricter and prohibit certain actions or
require more from you in this area.
B. This is not the correct answer. Except in very limited
circumstances which are outside the scope of this question pattern, the law prohibits the reintroduction of controlled
substances in this manner.
C. This is the best answer. Check with your state licensing
board and/or state bureau of narcotics to determine
whether you can dispose of these controlled substances at
your offi ce and, if the board says it is appropriate to do so,
have the patient inventory the controlled substances
returned, write down the amount on a return form, sign
the return form, use a witness to sign the return form, and
then have the patient witnessed as he/she fl ushes the
returned substances down the toilet. Alternatively, but only
if your state allows this option, you may follow the
guidance of 21 C.F.R. § 1307.21, when disposing of
controlled substances.
D. This is not the best answer. While fl ushing returned
drugs down the toilet may seem like an easy option, some
states actually prohibit this action. See the answers to A
and C above for complete guidance.
E. This is not the best answer. While 21 C.F.R. § 1307.21
permits a registrant to contact the Special Agent in Charge
of the nearest DEA offi ce, your state may require you to do
something else. Thus, answer C is the best answer and you
should check with your state licensing board and/or state
bureau of narcotics for guidance on how to dispose of
controlled substances returned by patients. In all cases, you
should document the medical record accurately and
completely.
Source: Jennifer Bolen, JD, Sep 2005
- Which of the following is an action of a non-competitive
antagonist?
A. Alters the mechanism of action of an agonist
B. Alters the potency of an agonist
C. Shifts the dose-response curve of an agonist to the right
D. Decreases the maximum response to an agonist
E. Binds to the same site on the receptor as the agonist
- Answer: D
Explanation:
A noncompetitive antagonist decreases the magnitude of
the response to an agonist but does not alter the agonist’s
potency (i.e., the ED50 remains unchanged). A
competitive antagonist interacts at the agonist binding site.
2508.Drug interactions involving antidepressants do NOT
include
A. Additive impairment of driving ability in patients taking
trazodone when ethanol is ingested
B. Behavioral excitation and hypertension in patients taking
MAO inhibitors with meperidine
C. Elevated plasma levels of lithium if fl uoxetine is administered
D. Increased antihypertensive effects of methyldopa when
tricyclics are administered
E. Prolongation of tricyclic drug half-life in patients with
cimetidine
- Answer: D
Explanation:
Tricyclic drugs block the uptake of guanethidine into
sympathetic nerve endings, thus reversing its benefi cial
effects on blood pressure. While the precise mechanism is
not defi ned, the tricyclics may also block the
antihypertensive effects of clonidine and methyldopa. All
of the other drug interactions have been reported.
Source: Katzung & Trevor’s Pharmacology, Examination
and Board Review, 6th Ed., McGraw Hill, New York, 1998
2509.A substance abuser who decides to abstain checks in
to a county detoxifi cation facility and undergoes a 5
day detoxifi cation program. Assuming the abuser gets
no further treatment or aftercare, his or her chance at
remaining sober is about:
A.
- Answer: A
Explanation:
The rate of continued abstinence after simple
detoxifi cation is about 2 to 3%. Prolonged treatment and
aftercare markedly increase the success rate.
Source: Roger Cicala, MD, Sep 2005
2510.A patient presents for treatment of mechanical and
radicular chronic spine pain resulting from severe
degenerative disease with multilevel stenosis. He has
had a 2 level fusion in the past, undergone multiple
interventional techniques and physical therapy without
benefi t. His radicular pain has improved somewhat
with gabapentin 400 mg QID but he continues to have
severe mechanical back pain. He has a past history of
cocaine and alcohol abuse, but has been clean and sober
for 7 years. When considering chronic opioid therapy in
this patient which of the following is the most correct
statement?
A. Opioid therapy may be appropriate, but the patient must
be advised he has increased risk of relapse or cross addiction.
B. Opioid therapy is not appropriate because of his past history
of substance abuse.
C. The patient is not at increased risk because opioids were
never his drug of choice.
D. Opioid therapy is acceptable, but only short-acting
agents such as hydrocodone or oxycodone should be
used.
E. The physician could be arrested for “aiding and abetting addiction” if he or she prescribes controlled substances
for the patient.
- Answer: A
Explanation:
A. The majority of recovering persons can be
successfully treated with chronic opioid therapy, but they
have some increased risk of addiction.
B. The majority of recovering persons can be
successfully treated with chronic opioid therapy, but they
have some increased risk of addiction.
C. Even though opioids were not the patient’s drug of
choice, cross addiction can and does occur.
D. Short acting agents may be more likely to trigger
addictive disease than long acting agents. They certainly
are no safer.
E. There is no such legal ramifi cation, although a
physician may face licensure issues for prescribing to a
known active addict.
Source: Roger Cicala, MD, Sep 2005
2511. A substance abuser enters and completes a 6 months long term treatment program. His or her chance at remaining sober is about: A. 5% B. 10% C. 30% D. 60% E. 90%
2511. Answer: D Explanation: Long term treatment has the highest success rate for continued abstinence, about 65%. Source: Roger Cicala, MD, Sep 2005
2512.When compared to the general population, the mortality
rate of a prescription drug abuse is about:
A. The same
B. 3 times higher
C. 6 times higher
D. 10 times higher
E. 25 times higher
- Answer: B
Source: Roger Cicala, MD, Sep 2005
2513.You have agreed to see a new patient who comes to
you through a referral from a family physician in a city
approximately 50 miles from your practice. The patient
gives you a referral package that does not contain any
reference to the patient’s recent history with the other
physician. The referral package also does not contain
any reference to the patient’s history of compliance with
the family physician’s treatment plan or instructions
regarding the patient’s use of controlled drugs. The
patient asks you to prescribe controlled substances to
treat his/her pain and reports that he/she is using a high
dosage of a specifi ed Schedule II controlled substance.
The patient claims he/she has run out of medications
and will experience acute withdrawal symptoms if he/she
does not get the medications from you. What should
you do prior to minimize the potential for abuse and
diversion of these drugs by this patient?
A. Prescribe the patient a months’ worth of drugs and see
him/her back in your offi ce after you obtain the medical
records from the previous physician.
B. Call the previous physician and attempt to verify the
patient’s self-report of recent pain treatments and
medications, use an appropriate urine screen to verify
the presence of the drug the patient says he/she has
taken and to determine whether he/she is
C. Attempt to verify the patient’s self-report of recent pain
treatments and medications and perform an appropriate
urine screen.
D. Accept the patient’s self-report and continue with treatment
without verifi cation through the prior provider.
E. Send the patient back to the previous provider for necessary
controlled substances to treat acute withdrawal
symptoms and tell him/her that you will not prescribe
controlled substances until you receive all the necessary
records from the prior provider.
- Answer: B
Explanation:
Reference: Miscellaneous accepted standards of care; the
Federation of State Medical Boards’ Model Policy for the
Use of Controlled Substances for the Treatment of Pain
(May 2004); and www.deadiversion.usdoj.gov; various
Intractable Pain Treatment Acts from states like
California, Tennessee, and Texas.
Explanation:
A. This is not the best answer because a provider has a
responsibility to minimize the potential for abuse and
diversion of controlled substances (DEA Interim Policy
Statement, Nov. 16, 2004). If the patient is not known to
you and you do not have reliable paperwork from which to
make an informed judgment about the patient’s history of
prior pain treatments, including the use of medications
reported, then you should be very cautious about
prescribing medication. Several states have policy
statements cautioning physicians to “control the drug
supply.”
B. This is the best answer. The fact pattern shows that you
have agreed to see this patient and establish a physicianpatient
relationship. For this reason, you must balance
your ethical duty to prevent the patient from experiencing
acute withdrawal symptoms with your legal/regulatory
obligation to minimize the potential for abuse and
diversion of controlled substances. Do what you can to
verify the patient’s self-report. Use an appropriate form of
urine or serum screen, especially if the patient has a
history of substance abuse (him/herself or through a fi rstdegree
family relative). Control the initial supply of
controlled substances to this patient. C. This is not the best answer. You should attempt to
verify the patient’s self-report of recent pain treatments
and medications and perform an appropriate urine screen.
However, you should also control the drug supply and this
answer omits that statement and fails to acknowledge the
ethical duty to prevent or minimize the patient’s acute
withdrawal from controlled substances.
D. This is not the best answer. If you simply accept the
patient’s self-report and continue to treat him/her without
verifying the patient’s past pain treatments and use of
controlled substances, you are likely violating one of your
state’s regulations/rules or guidelines/policies/position
statements on the use of controlled substances for the
treatment of pain. More importantly, you are likely
ignoring accepted standards of care and may place yourself
in a position of prescribing controlled substances outside
the usual course of professional practice.
E. This may appear to be the best answer and it might be
if you had not agreed to see the patient on a referral basis.
In other words, if someone simply drops into your
practice on a Friday afternoon claiming they want you to
treat their pain and that their prior physician
recommended you, then you are right to be very cautious
about taking this patient without having the appropriate
referral material. If you elect to send a patient back to his/
her referring provider (or if they show up at your offi ce on
a self-referral) make sure you contact the referring
provider and/or caution the patient to go to the emergency
room if they believe they are undergoing acute withdrawal
symptoms. No answer is easy in this situation and your
best bet is to document your medical record carefully and
ensure you document your clinical rational for saying “no,”
including any aspect of the patient’s (1) medical history,
(2) behaviors, (3) physical indings, and (4) lab screen or
test results.
Source: Jennifer Bolen, JD, Sep 2005
2514.Which one of the following is characteristic of
cytochrome P-450?
A. Located in the lipophilic environment of mitochondrial
membranes
B. Catalyzes O-, S-, and N-methylation reactions
C. Catalyzes aromatic and aliphatic hydroxylations
D. Catalyzes conjugation reactions
E. Activity is not inducible by drugs
- Answer: C
Explanation:
Cytochrome P-450 catalyzes demethylation, not
methylation or conjugation, reactions. The enzyme is
located in the endoplasmic reticulum, not in
mitochondria. Drugs can induce cytochrome P-450
activity.
2515.All of the following describe psychological components of pain, EXCEPT: A. Catastrophic thinking B. Helplessness C. Compulsive search for a job D. Blame E. Chronic maladaptive coping patterns
- Answer: C
Source: Renee R. Lamm, MD, Sep 2005
2516.Demerol (meperidine) should not be used for chronic pain because: A. it is addictive B. it is ineffective C. the metabolite causes seizures D. the medication is expensive E. all of the above
- Answer: C
Explanation:
All opioids can potentially be abused. Meperidine may be
useful for acute pain, and it is cheap. The metabolite
normeperidine can cause seizures and can accumulate
with chronic dosing, especially in renal failure
Source: Trescot AM, Board Review 2004
2517.What are correct statements about drug interactions of
following statements?
A. Amitriptyline will increase morphine metabolism
B. Morphine will decrease desipramine levels
C. Erythromycin will decrease opioid levels
D. Tricyclic antidepressants will increase methadone levels
E. Propoxyphene will increase propranolol levels
- Answer: E
Explanation:
Propoxyphene will increase carbazepine, doxepin,
metoprolol and propranolol levels, and decrease the
excretion of benzodiazepines, leading to accumulation and
overdose. Amitriptyline will decrease morphine
breakdown, leading to increased blood levels. Morphine
will decrease the breakdown of desipramine, leading to
increased doses. Erythromycin will increase opioid effects,
and methadone will increase TCA levels.
References: Bergendal L, Friberg A, Schaffrath AM, et al,
The clinical relevance of the interaction between
carbamazepine and dextropropoxyphene in elderly
patients in Gothenburg,
Abernethy DR, Greenblatt DJ, Morse DS, et al, Interaction
of propoxyphene with diazepam, alprazolam and
lorazepam. Br J Clin Pharmacol 1985;19:51-7
Source: Andrea M. Trescot, MD
2518.A urine drug test in a patient on hydrocodone was
positive for hydrocodone and hydromorphone. Choose
the correct option.
A. The patient is taking Dilaudid
B. Refuse to write any more opioids
C. Ignore the results as a false positive
D. Counsel the patient regarding taking drugs that have not
been prescribed
E. Avoid the use of SSRIs in this patient
- Answer: E
Explanation:
The hydromorphone is most likely from the 2D6
metabolism of hydrocodone, not from abuse. Discharging
the patient, refusing to write more opioids, or ignoring the
results would be inappropriate. SSRIs, especially
fl uoxetine and paroxetine, will inhibit 2D6 and prevent the
metabolism of hydrocodone to hydromorphone, which
will decrease his analgesia.
Source: Andrea M. Trescot, MD
2519.Benzodiazepines differ from barbiturates in that
benzodiazepines :
A. Facilitate the action of aminobutyric acid (GABA) on
neuronal chloride channels
B. Have anticonvulsant activity
C. May induce physical dependence
D. Have a higher margin of safety than barbiturates
E. All of the above
- Answer: D
Explanation:
Benzodiazepines are much safer than barbiturates because
they cause minimal central nervous system depression.
Both drug classes facilitate the action of aminobutyric acid
(GABA), although by different mechanisms of action.
They are both used to prevent seizures, and both can result
in physical dependence with long-term use.
2520.Methadone in addition to being a μ-receptor agonist has been proposed to also act as a: A. COX-2 inhibitor B. Sodium Channel blocker C. NMDA receptor antagonist D. Delta receptor agonist E. Opiod Antagonist
- Answer: C
Explanation:
One of the two rate limiting steps in prostaglandin
synthesis is the conversion of arachidonic acid
to the prostanoid precursor PGH2 by cycloxygenase
(COX). COX-2 is an isozyme of COX and
mediates responses to infl ammation, infection and
injury.
Methadone is a synthetic opioid derivative which seems
to function both as a μ-receptor agonist
and an NMDA receptor antagonist.
The drug has a tendency to accumulate with repeated
administration.
It is excreted almost exclusively in the feces and can be
given to patients with compromised renal
function, however caution should be used
Methadone is equipotent to morphine after parenteral administration.
Source: Chopra P, 2004
2521.Alkalinization of the urine with sodium bicarbonate is
useful in the treatment of poisoning with
A. Aspirin (acetylsalicylic acid)
B. Amphetamine
C. Morphine
D. Phencyclidine
E. Cocaine
- Answer: A
Explanation:
Reference: Hardman, pp 16-20.
A. Sodium Bicarbonate is excreted principally in the urine
and alkalinizes it.
Increasing urinary pH interferes with the passive renal
tubular reabsorption of organic acids (such
as aspirin and Phenobarbital) by increasing the ionic
form of the drug in the tubular fi ltrate.
This would increase their excretion.
B-E. Excretion of organic bases (such as amphetamine,
cocaine, phencyclidine, and morphine) would be enhanced
by acidifying the urine.
Source: Stern - 2004
2522.True statement(s) with regards to urine drug testing
include:
A. Thin layer chromatography is a relatively new technique,
most sensitive, labor intense, and expensive.
B. Gas chromatography is most sensitive, most reliable,
inexpensive, an old and established technique.
C. Enzyme immunoassay is less sensitive than thin layer
chromatography, more sensitive than gas chromatography,
and has ability to screen multiple drugs at a time.
D. Rapid drug screens are similar to other enzyme immunoassay
tests but may be more expensive or less
expensive.
E. Rapid drug screens are less sensitive than enzyme immunoassay,
gas chromatography, and thin layer chromatography
and highly unreliable, but least expensive.
- Answer: D
Explanation:
Urine Drug Testing
* Thin-layer chromatography (TLC)
- Relatively old technique, testing the migration of a
drug on a plate or fi lm, which is compared to a known
control
* Gas chromatography: liquid and mass spectometry
(CGMS)
- Most sensitive and specifi c tests
- Most reliable
- Labor intensive/costly
- Several days to know results
- Used to confi rm results of other tests
* Enzyme immunoassay
- Easy to perform/highly sensitive
- More sensitive than TLC
- Less expensive than GC/MS
- Common tests
EMIT (enzyme multiplied immunoassay test)
FPIA (fl uorescent polarization immunoassay)
RIA (radioimmunoassay)
- Screen only one drug at a time
- Rapid drug screens
- Similar to other enzyme immunoassay tests
- May be more expensive
2523.Which of the following opioids is vagolytic? A. Morphine B. Meperidine C. Sufentanil D. Nalbuphine E. Alfentanil
- Answer: B
Source: American Board of Anesthesilogy, In-trainnig
examination
2524.Which of the following factors will determine the
number of drug-receptor complexes formed?
A. Effi cacy of the drug
B. Receptor affi nity for the drug
C. Therapeutic index of the drug
D. Half-life of the drug
E. Rate of renal secretion
- Answer: B
Explanation:
Receptor affi nity for the drug will determine the number
of drug-receptor complexes formed. Effi cacy is the ability
of the drug to activate the receptor after binding has
occurred. Therapeutic index (TI) is related to safety of the
drug. Half-life and secretion are properties of elimination
and do not infl uence formation of drug-receptor
complexes.
Source: Laxmaiah Manchikanti, MD
2525.A former heroin addict is maintained on methadone, but
succumbs to temptation and buys an opioid on the street.
He takes it and rapidly goes into withdrawal. Which
opioid did he take?
A. Meperidine
B. Heroin
C. Pentazocine
D. Codeine
E. Propoxyphene
- Answer: C
Explanation:
Reference: Hardman, p 546.
Pentazocine is a mixed agonist-antagonist of opioid
receptors. When a partial agonist, such as pentazocine,
displaces a full agonist, such as methadone, the receptor is
less activated; this leads to withdrawal syndrome in an
opioid-dependent person.
Source: Stern -2004
2526.Concerning the proposed mechanisms of action of
antidepressant drugs, which one of the following
statements is accurate?
A. Bupropion (Wellbutrin®) can effective inhibitor of Nor-
Epinephrine and 5-HT transporters
B. Chronic treatment with an antidepressant often leads to
the up-regulation of adrenoceptor
C. Elevation in amine metabolites in cerebrospinal fl uid is
characteristic of most depressed patient prior to drug
therapy
D. MAO inhibitors used as antidepressants selectively decrease
the metabolism of norepinephrine
E. The acute effect of most tricyclics is to block the neuronal
reuptake of both norepinephrine and serotonin in the CNS
- Answer: E
Explanation:
The mechanism of action of bupropion is unknown, but
the drug does not inhibit amine transporters. Levels of
norepinephrine and serotonin metabolites in the
cerebrospinal fl uid of depressed patients prior to drug
treatment are not higher than normal. Some studies have
reported decreased levels of these metabolites. Downregulation
of adrenoceptor appears to be a common
feature of all mode3s of chronic drug treatment of
depression, including the use of drugs that have no direct
actions o catecholamine receptors. MAO inhibitors used
in depression are nonselective.
Source: Katzung & Trevor’s Pharmacology, Examination
and Board Review, 6th Ed., McGraw Hill, New York, 1998
- The Drug Abuse Warning Network (DAWN) is a network
that:
A. Treats addicted patients
B. Is a self help and support group
C. Collects information on hospital emergency department
admissions for drug-related episodes
D. Is an arm of the Drug Enforcement Agency
E. Monitors physicians’ prescription habits
- Answer: C
Source: Hans C. Hansen, MD
2528.Which of the following opioids is not a good choice in patients with renal failure: A. Fentanyl® B. Sufentanil® C. Morphine® D. Alfentanil® E. Meperidine®
- Answer: E
Explanation:
Ref: Murphy. Chapter 16. Opioids. In: Clinical
Anesthesia, 2nd Edition. Barash, Cullen, Stolling;
Lippincott, 1992, pg 431
Source: Day MR, Board Review 2003
2529.What are the correct statements about drug abuse in
patients receiving opioids?
A. Illicit drug use and abuse of prescription controlled substances
is non-existent in patients receiving long-acting
opioids in appropriate doses.
B. Short-acting opioids show signifi cantly higher use of illicit
drugs and abuse of controlled prescription drugs.
C. Illicit drug use and controlled substance abuse in chronic
non-cancer patients is similar whether they are on
short-acting or long-acting opioids.
D. Patients on long-acting opioids are highly compliant
and functional and therefore not necessary to monitor
them.
E. Patients on short-acting opioids signifi cantly abuse
drugs. Thus, they should be monitored every month
with urine drug testing.
- Answer: C
Explanation:
Source: Manchikanti L - Pain Physician 2005; 8:257-262.
2530.A 28-year-old woman presents with symptoms of major
depression that are unrelated to a general medical
condition, bereavement, or substance abuse. She is
not currently taking any prescription or over-thecounter
medications. Drug treatment is to be initiated
with a selective serotonin reuptake inhibitor. In your
information to the patient, you would NOT tell her that
A. Divided doses may help to reduce nausea and gastrointestinal
distress
B. Muscle cramps and twitches sometimes occur
C. She must inform you if she anticipates using other
medications
D. Taking the drug in the evening will ensure a good night’s
sleep
E. The drug may require 2 weeks or more to become effective
- Answer: D
Explanation:
The SSRIs have CNS-stimulating effects. They may cause
agitation, anxiety, “the jitters”, and insomnia. The evening
is not the best time to take such drugs. Anorexia and
nausea, akathisia, dyskinesias, and dystonic reactions may
occur. Because of the possibility of drug interactions, the
physician needs to be informed of changes in drug
regimens when maintaining a patient on antidepressants.
Source: Katzung & Trevor’s Pharmacology, Examination and Board Review, 6th Ed., McGraw Hill, New York, 1998
2531.Choose the correct statement with regards to the
comparison of effectiveness and safety profi les of longacting
versus short-acting opioids in chronic non-cancer
pain.
A. There was conclusive evidence from high quality randomized
and systematic trials to determine that longacting
opioids as a class were more effective and safer
with no adverse events than short-acting opioids.
B. There was no good-quality data available to assess comparative
effi cacy and adverse event risks in sub-populations
of patients with chronic non-cancer pain.
C. There was insuffi cient evidence from available trials to
determine whether long-acting opioids as a class are
more effective or associated with fewer adverse events
than short-acting opioids.
D. There were approximately 20 randomized trials investigating
long-acting oxycodone versus short-acting oxycodone
showing conclusive evidence that long-acting
oxycodone was superior to short-acting oxycodone.
E. Recent GAO reports, DEA statements, and media attention
and case reports of abuse, addiction, and overdose
from long-acting opioids represent a decreased risk
proportionate to prescribing pattern changes as these
are widely used.
- Answer: C
Source: Chou et al. - J Pain Manage Symptom Manage Vol.
25, No. 5 Nov. 2003, 1026-1048.
2532.Choose the correct statement about effectiveness of
one or more long-acting opioids in reducing pain and
improving functional outcomes.
A. There was insuffi cient evidence to prove that different
long-acting opioids are associated with different effi -
cacy or adverse event rates.
B. OxyContin was shown to be more effective with a lesser
side effect profi le compared to morphine.
C. MS Contin was superior to transdermal fentanyl.
D. The combination of OxyContin, Xanax, and Soma were
superior to all other drugs.
E. The combination of morphine, diazepam, and oxycodone
were superior to MS Contin alone.
- Answer: A
Source: Chou et al. - J Pain Manage Symptom Manage Vol.
25, No. 5 Nov. 2003, 1026-1048.
2533.Which of the following statements applies to a drug
exhibiting a saturated elimination process?
A. Upon multiple dosing, steady-state plasma concentrations
will be reached in approximately 4 to 5 biologic
half-lives
B. The fraction of drug eliminated per unit time is constant
C. The biologic half-life (t1/2) is affected by dose
D. First-order kinetics are operable
E. The rate of drug elimination is dependent on plasma
drug concentration
- Answer: C
Explanation:
The biologic half-life (t1/2) will be affected by dose in a
drug when the elimination process is saturated. In that
case, the drug will accumulate on repeated dosings, and
elimination will be independent of plasma concentration.
The amount (not fraction) of drug eliminated per unit
time will be constant, ad zero-order elimination will be
observed.
2534.When selecting and dosing opioids:
A. There is no ceiling dose for combination analgesics
B. Use long acting opioids for as-needed pain
C. Use short acting opioids for around-the-clock pain
D. There is no ceiling dose for pure agonists
E. Agonist-antagonist opioids are appropriate breakthrough
medications
- Answer: D
Explanation:
There is no specifi c ceiling dose for pure opioid agonists,
though we are becoming aware of the potential for
hyperalgia from at least morphine metabolites.
Combination drugs are limited by the APAP or NSAID
content. Use long acting for baseline pain, and short acting
opioids for “breakthrough” pain. Agonist-antagonists have
very little role in chronic pain management in general,
and specifi cally will trigger withdrawal when used as
breakthrough meds for other agonists.
Source: Andrea M. Trescot, MD
2535.N-methyl-D-aspartate (NMDA) receptors are best
defi ned as:
A. NMDA receptors are calcium-permeable ion channels
that require only glutamate for activation.
B. NMDA receptors are calcium-permeable ion channels that
require only glycine for activation.
C. NMDA receptors are calcium-permeable ion channels
that require both glutamate and glycine for activation.
D. At the molecular level, NMDA receptors are composed
of a single subunit.
E. NMDA receptors have small intracellular C-termini that
interact with a single protein that regulates receptor
phosphorylation.
- Answer: C
Explanation:
A. NMDA receptors require glutamate and glycine for
activation.
B. NMDA receptors require glycine, but also glutamate for
activiation.
C. NMDA receptors are calcium-permeable ion channels
that require both glutamate and glycine for activation.
The amino acid-binding sites on the receptor are
contributed by two different subunits, NR1 and NR2.
Antagonism of
either of these two sites is suffi cient to completely block
the ion fl ocks that normally follows receptor activation.
D. At the molecular level, NMDA receptors are composed
of multiple subunits that co-assemble to form functional
channels.
NR1 subunits exist as a family of 8 splice variants
generated by alternative splice of 1N-terminal
cassette and to intracellular C-terminal cassettes.
The presence of 1 or more of the NR1 and NR2
subunits in a single receptor complex confers
unique biophysical and pharmacologic properties to the
NMDA receptor.
E. NMDA receptors have large intracellular C-termini
that interact with a variety of important proteins that
regulate receptor phosphorylation and clustering to
important signaling complexes.
2536.According to the DSM-IV, which of the following is a
criterion for diagnosing substance ABUSE?
A. Using a substance for a purpose other than that described
in the PDR
B. Substance use in hazardous situations
C. Development of tolerance to the substance
D. Attempts to cut down substance use
E. An episode of withdrawal
- Answer: B
Explanation:
A. Using a substance for purpose other than described
in the PDR has nothing to do with substance abuse.
B. Use of a substance in hazardous situations is one of
the criteria for substance abuse.
C. Development of tolerance to the substance can occur
in any individual who takes the substance, even properly as
prescribed. It MAY indicate substance dependence but is
not a criteria for indicating substance abuse.
D. Attempts to cut down substance use are on of the
criteria for substance dependence, not substance abuse.
E. An episode of withdrawal substance can occur in any
individual who takes the substance in suffi cient quantities,
even properly as prescribed. It MAY indicate substance
dependence but is not a criteria for indicating substance
abuse.
Source: Roger Cicala, MD, Sep 2005
2537. Compared to morphine, butorphanol would be expected to display which one of the following pharmacologic characteristics? A. Kappa receptor antagonist activity B. Analgesic ceiling effect C. No respiratory depression D. Histamine release E. Mu receptor agonist activity
- Answer: B
Explanation:
Butorphanol exhibits opioid kappa receptor agonist and
mu receptor antagonist activity. Respiratory depression
with butorphanol is similar to that produced by equivalent
morphine doses. Histamine release is prominent with
morphine and not butorphanolStoelting RK.
Pharmacology and Physiology in Anesthesia Practice. 3rd
ed. Lippincott-Raven, Philadelphia, 1999.
Evers AS, Maze M. Anesthetic Pharmacology: Physiologic
Principles and Clinical Practice. Churchill Livingstone,
Philadelphia, 2004.
Stoelting RK. Pharmacology and Physiology in Anesthesia
Practice. 3rd ed. Lippincott-Raven, Philadelphia, 1999
Source: James D. Colson, MS, MD
- Which of the following characteristics of buprenorphine
best account for its effectiveness in the treatment of
opioid dependence and detoxifi cation?
A. Sublingual formulation with naloxone
B. High opioid mu-1 receptor affi nity and slow receptor
dissociation
C. Partial kappa receptor agonist activity
D. Low oral bioavailability necessitating parenteral administration
E. High intrinsic activity at the opioid mu receptor
- Answer: B
Explanation:
Buprenorphine has low oral bioavailability, but is well
absorbed sublingually. Naloxone has poor sublingual
bioavailability, but is formulated along with
buprenorphine to prevent misuse when administered IV.
Buprenorphine is a partial agonist at the mu-opiate
receptor and an antagonist at the kappa receptor.
While buprenorphine has high opioid mu receptor affi nity,
it has a low intrinsic activity. Malinoff HL, Barkin RL, Wilson G. Sublingual
buprenorphine is effective in the treatment of chronic pain
syndrome. American Journal of Therapeutics 2005; 12(5):
379-384
http://buprenorphine.sahsa.gove/about.html
Source: James D. Colson, MS, MD
2539.Which of the following is NOT considered the imposition
of discipline:
A. Revocation or suspension.
B. An order that a physician pay the actual costs of the
investigation.
C. A reprimand.
D. An order to obtain 20 hours of Category I continuing
medical education in the area of management of persistent
pain.
E. An order that a physician pay a civil forfeiture or penalty.
- Answer: B
Explanation:
As an order to pay costs is considered merely a costshifting
measure which keeps the cost of licensure down
for physicians who have not committed unprofessional
conduct.
2540.A patient who had called for an early refi ll of opioid
medication is rather agitated and jittery when seen in
the offi ce. She states she had not run out of her opioid
medication but simply thought she needed a higher dose.
All of the following symptoms would suggest opiate
withdrawal EXCEPT :
A. Diarrhea
B. Piloerection
C. Pinpoint pupils
D. Sweating
E. Rhinorrhea
- Answer: C
Explanation:
Pinpoint pupils are a sign of opiate intoxication, dilated
pupils would be more likely in withdrawal. All of the other
symptoms are associated with opiate withdrawal.
Source: Roger Cicala, MD, Sep 2005
- A PET scan is performed on a known substance abuser
who receives their drug of choice during the procedure.
The PET scan would show activation of :
A. Nucleus Accumbens
B. Ventral Tegmental Areas
C. Central Nucleus of the Amygdala
D. All of the above
E. None of the above, they would actually be suppressed
- Answer: D
Explanation:
Areas throughout the mesolimbic system, including all of
the above, the stria terminalis, and portions of the frontal
lobes are all activated during intake of a substance of
abuse.
Source: Roger Cicala, MD, Sep 2005
2542.Neurochemically, ALL substances considered abusable
eventually activate:
A. Cholinergic pathways in the brainstem
B. Adrenergic pathways in the frontal lobes
C. GABA-B receptors diffusely throughout the brain
D. Serotonergic centers in the diencephalon
E. Dopaminergic neurons in the mesolimbic system
- Answer: E
Explanation:
Different substances may activate different primary
receptors in the brain, but dopaminergic neurons in the
mesolimbic system are activated either directly, or
secondarily with all substances of abuse.
Source: Roger Cicala, MD, Sep 2005
2543.Which of the following statements are true?
A. Opioid calculators are very useful and reliable.
B. If a patient complains of breakthrough pain, you should
double the dose of long acting opioid every day until
pain relief.
C. Nerve pain might respond better to anticonvulsants
than opioids
D. Bone pain might respond better to anticonvulsants than
opioids
E. Opioid hyperalgia may be due to M6G accumulation
- Answer: C
Explanation:
Opioid calculators are potentially dangerous to use
secondary to metabolic polymorphism. Long acting
opioids have a long half-life, reaching steady state in
approximately 5 days, so increasing doses too frequently
can lead to overdose. Bone pain probably responds better
to NSAIDs. Hyperalgia may be due to M3G.
Source: Andrea M. Trescot, MD
- According to the DSM-IV, which of the following is NOT
a criterion for diagnosing substance DEPENDENCE?
A. Continued use despite physical or psychological problems
caused by use.
B. Recurrent substance related legal problems
C. Development of tolerance to the substance
D. Attempts to cut down substance use
E. An episode of withdrawal
- Answer: B
Explanation:
Recurrent substance related legal problems are a clear sign
of abuse, but do not in themselves indicate there is
dependence upon the substance.
Source: Roger Cicala, MD, Sep 2005
2545.Which of the following is the most accurate defi nition
of tolerance:
A. The medication stops working after a few months
B. Stopping the medication causes withdrawal symptoms
C. A given dose is less effective, increasing the dose restores
the effect
D. Side effects of a given dose are less severe over time
E. A medication is less effective, changing to a different
medication restores the effect
- Answer: C
Explanation:
A. Tolerance involves reduced effectiveness, not
complete loss of effect
B. Withdrawal can occur without tolerance, nor does
withdrawal always occur when tolerant patients stop the
substance in question.
C. Tolerance indicates less effectiveness of a given dose.
Increasing the dose can restore the effect, up to a point.
D. Many opiate side effects decrease over time, but not
necessarily in parallel with developing tolerance.
E. A different medication may be more effective, but this
does not of itself demonstrate tolerance.
Source: Roger Cicala, MD, Sep 2005
2546.A heroin addict comes to the emergency room in an
anxious and agitated state. He complains of chills, muscle
aches, and diarrhea; he has also been vomiting. His
symptoms include hyperventilation and hyperthermia.
He claims to have had an intravenous “fi x” approximately
12 hours ago. The attending physician notes that pupil
size is greater than normal. What is the most likely cause
of these signs and symptoms?
A. The patient has overdosed with an opioid
B. These are early signs of the toxicity of MPTP, a contaminant
in “street heroin”
C. The signs and symptoms are those of the abstinence syndrome
D. In addition to opioids, the patient has been taking barbiturates
E. The patient has hepatitis B
- Answer: C
Explanation:
Explanation: The signs and symptoms are those of
withdrawal in a patient physically dependent on an opioid
agonist. Such signs and symptoms usually start within 6-
10 hours after the last dose; their intensity depends on the
degree oh physical dependence that has developed. Peak
effects usually occur at 36-48 hours. Mydriasis is a
prominent feature of the abstinence syndrome; other
symptoms include rhinorrhea, lacrimation, piloerection,
muscle jerks, and yawning.
Source: Katzung & Trevor’s Pharmacology, Examination
and Board Review, 6th Ed., McGraw Hill, New York, 1998
2547.Which one of the following drugs is most likely to increase plasma levels of alprazolam, theophylline, and warfarin: A. Desipramine (Pamelor®) B. Fluvoxamine (Luvox®) C. Imipramine (Tofranil®) D. Nefazodone (Serazone®) E. Venlafaxine (Effexor®)
- Answer: B
Explanation:
Fluvoxamine inhibits liver drug-metabolizing enzymes.
Dosages of alprazolam, theophylline, and warfarin must be
reduced if any of these drugs are given concomitantly with
fl uvoxamine. Nefazodone may also decrease the
metabolism of benzodiazepines, and venlafaxine may
inhibit haloperidol metabolism.
Source: Katzung & Trevor’s Pharmacology, Examination
and Board Review, 6th Ed., McGraw Hill, New York, 1998
2548.A patient injured in an auto accident received 80 mg
of meperidine. He subsequently developed a severe
reaction characterized by tachycardia, hypertension,
hyperpyrexia, and seizures. When a questioned, the
uninjured spouse revealed that the patient had been
taking a drug for a psychiatric condition. Which of the
following drugs is most likely to be responsible for this
untoward interaction with meperidine?
A. Alprazolam (Xanax®)
B. Amitriptyline (Elavil®)
C. Lithium
D. Mirtazapine (Norbil®)
E. Phenelzine (Nardil®)
- Answer: E
Explanation:
Concomitant administration of meperidine and MAO
inhibitors has resulted in life-threatening hyperpyrexic
reactions that may culminate in seizures or coma. Such
reactions have even occurred when phenelzine was
administered 14 days after a patient had been treated with
meperidine! Note that concomitant use of SSRIs and
meperidine has resulted in the serotonin syndrome,
another life-threatening drug interaction.
Source: Katzung & Trevor’s Pharmacology, Examination
and Board Review, 6th Ed., McGraw Hill, New York, 1998
2549.Fentanyl patches have been used to provide analgesia. The most dangerous adverse effect of this mode of administration is A. Cutaneous reactions B. Diarrhea C. Hypertension D. Relaxation of skeletal muscle E. Respiratory depression
- Answer: E
Explanation:
The fentanyl transdermal patch releases the drug over 72
hours. The blood levels achieved will often provide
analgesia for postoperative pain but at the same time will
increase arterial PCO2 due to depression of the brain stem
respiratory center. This effect has contributed to severe
respiratory depression with occasional fatalities.
Source: Katzung & Trevor’s Pharmacology, Examination
and Board Review, 6th Ed., McGraw Hill, New York, 1998
2550.A recently bereaved 74-year-old female patient was
treated with benzodiazepine for several weeks after the
death of her husband, but she did not like the daytime
sedation it caused. She has no major medical problems but
appears rather infi rm for her age and has poor eyesight.
Because her depressive symptoms are not abating, you
decide on trial of an antidepressant medication. Which
one of the following drugs would be the most appropriate
choice for this patient?
A. Amitriptyline
B. Mirtazapine
C. Paroxetine
D. Phenelzine
E. Trazodone
- Answer: C
Explanation:
The elderly patient may be especially sensitive to
antidepressant drugs that cause sedation, atropine-like side
effects, or postural hypotension. Paroxetine (or another
SSRI) is the best choice for this patient because it is the
least likely of the drugs listed to exert such actions.
Source: Katzung & Trevor’s Pharmacology, Examination
and Board Review, 6th Ed., McGraw Hill, New York, 1998
2551.Pharmacologic options for pain:
1. opioids work for peripheral, nerve, spinal cord, or brain
pathologies
2. local anesthetics work at the brain level
3. AEDs work at the nerve root and the brain
4. Anti-infl ammatories work at the periphery only.
2551. Answer: A (1, 2, & 3) Explanation: Anti-infl ammatories work on peripheral as well as central tissues. Source: Andrea M. Trescot, MD
2552.According to NIDA household surveys and the National Comorbidity Survey, the prevalence of substance abuse among U. S. adults is about: A. 1% B. 3% C. 7% D. 17% E. 33%
2552. Answer: C Explanation: Most studies indicate the prevalence rate of substance abuse is 6% to 7%. Source: Roger Cicala, MD, Sep 2005
2553.Regarding the use of opioids, which of the following
statements is true?
A. Opioid medications have predictable side effects at certain
doses.
B. Blood level of the drug needed for perceived therapeutic
effect is consistent through the day.
C. If a pain signal is too weak to be perceived, it has no
biophysiologic effect.
D. Complete pain relief is the goal of the use of opioid
medication.
E. Treating pain aggressively early may decrease the risk of
sensitization.
- Answer: E
Explanation:
Opioids are unpredictable, and the blood levels needed for
analgesia vary with level of activity and time of day. Even
when a pain signal is below threshold, there are potential
physiologic effects. Early aggressive treatment is the goal
of preemptive analgesia.
Source: Andrea M. Trescot, MD
2554.The most commonly used illicit drug in America is: A. Oxycontin® B. Cocaine C. Morphine® D. Marijuana E. Alcohol
- Answer: D
Explanation:
You could easily argue that alcohol far exceeds marijuana
in use, based on national data. 120 million Americans, or
50% of the population consume alcohol. The defi nition
would easily move to alcohol as the number one used illicit
drug, if alcohol was uniformly considered “a drug”. It
does have physical dependence, psychic and toxic effects,
but for purposes of terminology and the use of controlled
substances, marijuana will be considered the number one
drug of abuse. Ironically, it is now not a controlled
substance, as the Supreme Court has defi ned no legitimate
medical need for marijuana. Marijuana is properly termed
a drug of abuse, Schedule I. There are 7 thousand new
users per day.
Source: Hans C. Hansen, MD
2555.Adults who have completed four years of college are:
A. Less likely to use an illicit drug
B. More likely to use an illicit drug
C. Adults with four years of college who are alcoholics are
more likely to use an illicit drug.
D. Adults who have not completed high school, are dropouts,
or live in metropolitan areas are more likely to use
illicit drugs.
E. There is no evidence that education has an effect on the
statistical prevalence of illicit drug use.
- Answer: B
Explanation:
It may be surprising, but adults who have completed four
years of college are more likely to experience an illicit
drug, 51.1% of the American population. 38% of those
who did not complete high school have used an illicit
drug. The use is higher in metropolitan than nonmetropolitan
areas.
Source: Hans C. Hansen, MD
- Which of the following is NOT a condition to an oral
refi ll of a Schedule III or IV prescription?
A. The total quantity authorized, including the amount of
the original prescription, does not exceed fi ve refi lls nor
extend beyond six months from the date of the original
prescription.
B. The pharmacist obtaining the oral authorization must
record on the reverse of the original prescription the
date, quantity of refi ll, and the number of additional
refi lls authorized, and must initial the prescription.
C. The quantity of each additional refi ll authorized is equal
to or less than the quantity authorized for the initial fi lling
of the original prescription.
D. The pharmacist must verify that the oral authorization
came from a physician or other practitioner by, for example,
calling the physician back at the number for the
physician listed in the telephone directory.
E. The prescribing practitioner must execute a new and
separate prescription for any additional quantities beyond
the fi ve-refi ll, six-month limitation.
- Answer: A
Explanation:
While a callback requirement might be a good idea, it is
not a condition to an oral authorization for a refi ll of a
Schedule III or IV prescription.
Reference: 21 CFR 1306.22
Source: Erin Brisbay McMahon, JD, Sep 2005
2557.The non-medical use of pain medication has been
followed since 1965. The largest growth of non-medical
use of pain medication since this time has been between:
A. 1986 and 1990
B. 1995 and 2000
C. 2001 and 2002
D. 1965 and 1972
E. 1968 and 1971
- Answer: B
Explanation:
The non-medical use of pain medication experienced its
largest growth between 1995 and 2000, and has somewhat
slowed in the past couple of years.
Source: Hans C. Hansen, MD
2558.With regard to narcotic addiction treatment, which of
the following statements is most accurate?
A. A practitioner who dispenses Schedule II narcotic drugs
for maintenance or detoxifi cation treatment must obtain
a separate registration every fi ve years as a narcotic
treatment program.
B. Registration as a narcotic treatment program allows a
practitioner to administer, dispense, and prescribe,
Schedule II drugs approved by the Food and Drug Administration
for treatment of narcotic addiction.
C. The only Schedule II drugs approved by the Food and
Drug Administration for treatment of narcotic addiction
are Methadone and levo-alpha-acetyl-methadol
(LAAM).
D. Registration as a narcotic treatment program is contingent
on proper registration with the appropriate state
attorney general.
E. To obtain registration as a narcotic treatment program, a
practitioner must have been engaging in narcotic addiction
treatment for at least fi ve years.
- Answer: C
Explanation:
A) Registration is required every year.
B) Schedule II drugs cannot be prescribed for narcotic
addiction.
C) This is correct.
D) Registration as an NTP is contingent on proper
registration with the State Methadone Authority and the
Department of Health and Human Services.
E) This is incorrect; a practitioner must obtain SAMHSA
certifi cation.
Reference: 21 U.S.C. § 823(g).
Source: Erin Brisbay McMahon, JD, Sep 2005
- Is it legal for Internet pharmacies to approach a physician
to write prescriptions based on on-line consultations
with customers/consumer?
A. Yes, this is legal and on-line consultations qualify as a
proper physician-patient relationship.
B. Yes, but the physician must see the patient in person and
establish a valid physician-patient relationship prior to
issuing Internet prescriptions.
C. No, a physician cannot do this under existing law.
D. No, a physician cannot do this unless he/she obtains a
special Internet certifi cation from the DEA.
E. Yes, but the physician must obtain a special Internet certifi
cation from DEA.
- Answer: B
Explanation:
Reference: 21 C.F.R. § 1306.04 (prescriptions) and DEA
Guidance Document on Dispensing and Purchasing
Controlled Substances over the Internet, Fed. Reg. Vol. 66,
No. 82 (April 27, 2001);
http://www.deadiversion.usdoj.gov/fed_regs/notices/2001
/fr0427.htm.
Explanation:
A. This is not the correct answer. A physician may use the
Internet to provide information and to communicate with
the patient, but the Internet communications cannot be
the sole basis for authorizing the prescriptions. If a valid
physician-patient relationship exists, a physician may use
the Internet to communicate with patients. For example, a
physician may use the Internet to receive requests for
treatment. However, all requests for treatment should be
logical based upon the physician’s knowledge of the
patient’s medical history and the presenting complaint.
DEA states that, assuming a valid physician-patient
relationship, it is permissible for a physician to use the
Internet to receive requests for refi lls of prescriptions
from patients. Practitioners should check to see whether
their licensing state places additional requirements on
those who engage in telemedicine.
B. This is the best answer. A physician may use the
Internet to communicate with patients, but the Internet
communications may not form the sole basis for the
physician-patient relationship. The physician must
establish a valid physician-patient relationship with each
patient in accordance with federal and state laws governing
telemedicine. Most states have internet prescribing
policies requiring physicians to obtain a thorough medical
history and conduct an appropriate physical examination
before prescribing any medication for the fi rst time.
C. This is not the correct answer. See explanations above.
D. This is not the correct answer. There is no such Internet
certifi cation from the DEA allowing physicians to
prescribe controlled substances to patients over the
Internet.
E. This is not the correct answer. There is no such Internet
certifi cation from the DEA.
Source: Jennifer Bolen, JD, Sep 2005
- According to the Federal Controlled Substances Act of
1970, a Schedule III drug could be considered to possess
which one of the following characteristics:
A. Lack of accepted safety and indication for medical use
B. Limited, if any, physical or psychological dependence
C. High potential for abuse
D. No withdrawal syndrome noted with abrupt discontinuation
of use
E. Analgesic, anabolic, sedative, and/or hypnotic effects
- Answer: E
Explanation:
Schedule III substances are comprised of drugs possessing
analgesic, anabolic steroid, sedative, and/or hypnotic
properties.
Controlled Substances Act-U.S. Drug Enforcement
Administration (http://www.usdoj.gov/dea/agency/
csa.htm)
Source: James D. Colson, MS, MD
- Which of the following statements concerning an opioid
treatment program (OTP) is false?
A. An OTP must apply to the Substance Abuse and Mental
Health Services Administration for certifi cation.
B. To become certifi ed by the Substance Abuse and Mental
Health Services Administration (SAMHSA), an OTP
must be accredited by a SAMHSA-approved accreditation
body.
C. OTPs must comply with the Federal Law on Confi dentiality
of Substance Abuse Patient Records and with the
HIPAA privacy rule.
D. OTPs must notify the Substance Abuse and Mental
Health Services Administration within sixty days of
any replacement or change in the status of the program
sponsor or medical director.
E. OTPs must be registered by the Drug Enforcement Administration
before administering or dispensing any
opioid agonist treatment medications.
- Answer: D
Explanation:
Answer (d) is wrong; the time limit is 3 weeks.
Reference: 42 CFR 8.11
Source: Erin Brisbay McMahon, JD, Sep 2005
- Compared to a short-acting, immediate release opioid, a
long-acting, sustained release opioid differs in which one
of the following characteristics?
A. Higher level of opioid receptor affi nity and intrinsic
activity
B. Greater degree of tachyphylaxis
C. Faster development of tolerance
D. Protracted withdrawal syndrome following abrupt discontinuation
E. No ceiling effect for analgesia
- Answer: D
Explanation:
Drug properties, such as receptor affi nity, intrinsic activity
or the propensity to develop tolerance or tachyphylaxis
aremore inherent to the drug itself and not specifi cally to
its duration of action or particular formulation. Opioids as
a class do not have a ceiling effect for analgesia. Longacting
opioids tend to have a delayed onset and protracted
course of withdrawal following abrupt discontinuation.
Stoelting RK. Pharmacology and Physiology in Anesthesia
Practice. 3rd ed. Lippincott-Raven, Philadelphia, 1999.
Savage SR. Critical clinical issues in pain and addiction.
Pain Management Rounds 2005; 2(9):
Source: James D. Colson, MS, MD
2563.A patient complains of worsening chronic temporal
headache, despite daily treatment with aspirin,
butalbital, caffeine and ergotamine. MRI of the head was
normal, but MRI of the neck demonstrated spondylosis.
Headache most likely is due to:
A. Migraine
B. Drug rebound phenomenon
C. Cervical spondylosis
D. Pseudo-tumor cerebri
E. Vasodilation due to ergotamine
- Answer: B
Source: Andrea M. Trescot, MD
2564.For the following statements, fi rst decide if each is true or
false and then select the correct pattern from the choices
given.1)Narcotic agonist/antagonist drugs are useful
agents for pain management in many situations.2)The
metabolism of opioid medication is predictable within
ethnic subsets or behavioral subsets of the general
population.3)CYP2D6 extensive metabolizers (normals)
comprise a majority of the patients tested for the
genotype.
A. 1 is True, 2 is True, 3 is True
B. 1 is False, 2 is True, 3 is True
C. 1 is True, 2 is False, 3 is True
D. 1 is False, 2 is True, 3 is False
E. 1 is False, 2 is False, 3 is False
- Answer: E
Explanation:
Agonist/antagonists are rarely useful in chronic pain
(other than buprenorphine.) Opioid metabolism is very
variable, and the (normal)population makes up barely
half of the population.
Source: Andrea M. Trescot, MD
2565.For the following statements, fi rst decide if each
is true or false and then select the correct pattern
from the choices given.1)Codeine is metabolized to
morphine.2)Methadone has no signifi cant drug interacti
ons.3)Hydrocodone is metabolized to hydromorphone.
A. 1 is True, 2 is True, 3 is True
B. 1 is False, 2 is True, 3 is True
C. 1 is True, 2 is False, 3 is True
D. 1 is False, 2 is True, 3 is False
E. 1 is False, 2 is False, 3 is False
- Answer: C
Explanation:
Codeine is metabolized to morphine, and hydrocodone to
hydromorphone, Methadone has multiple drug
interactions.
Source: Andrea M. Trescot, MD
2566.An individual abruptly discontinuing long-term, high
dose use of an opioid drug will likely experience which
one of the following conditions?
A. Opioid-induced hyperalgesia
B. Increased opioid mu receptor affi nity
C. Increased opioid tolerance
D. Loss of physical dependence and addiction
E. Increased sympathetic nervous system activity
- Answer: E
Explanation:
A withdrawal syndrome with symptoms consistent with
increased sympathetic activity will occur following the
abrupt discontinuation of long-term opioid use.
Hyperalgesia is associated with continued use of high dose
opiates. Mu receptor affi nity is an inherent pharmacologic
property of the opioid and would not be expected to
change
with its discontinued use. Tolerance will be expected to
diminish with discontinuation of use, while physical
dependence is a physiologic state in which abrupt
cessation of opioid results in a withdrawal syndrome.
Stoelting RK. Pharmacology and Physiology in Anesthesia
Practice. 3rd ed. Lippincott-Raven, Philadelphia, 1999.
Savage SR. Critical clinical issues in pain and addiction.
Pain Management Rounds 2005; 2(9):
Source: James D. Colson, MS, MD
- Which one of the following statements about pentazocine
(Talwin®) is FALSE?
A. Analgesia is at least equivalent to that of codeine
B. Causes sedation
C. Classifi ed as a mixed agonist-antagonist
D. Full agonist at mu receptors
E. May interfere with the analgesic effects of morphine
- Answer: D
2568. Among persons with a known substance abuse disorder, the substance most commonly abused is: A. Marijuana B. Prescription opiates C. Cocaine D. Benzodiazepines E. Alcohol
- Answer: E
Explanation:
Alcohol accounts for 60% of all cases of substance abuse.
Source: Roger Cicala, MD, Sep 2005
- Regarding low back pain in a primary care practice:
A. Less than 10% of new low back pain patients followed up
with a doctor at 12 months.
B. Less than 10% of new low back pain patients still had low
back pain at 12 months
C. Less than 10% of new low back patients still had diffi culties
with ADLs at 12 months
D. Less than 10% of new low back pain patients still had
pain complaints at 3 months
E. Less than 10% of new low back pain patients followed up
with a doctor at 3 months
- Answer: A
Explanation:
Only 8% of new low back pain patients made a return
appointment after 12 months. 25% still had pain at 12
months, and 50% still had diffi culties with ADLs at 12
months. 79% still had pain at 3 months, and 32% made
follow up at 3 months.
Croft PR, Macfarlane GJ, Papageorgiou AC, et al. Outcome
of low back pain in general practice: a prospective study.
BMJ (1998);316(7141):1356-9
Source: Andrea M. Trescot, MD
2570.Which one of the following drugs has been used in
the management of alcohol withdrawal states and in
maintenance treatment of patients with tonic-clonic
or partial seizure states? Its chronic use may lead to an
increased metabolism of warfarin and phenytoin.
A. Chlordiazepoxide
B. Meprobamate
C. Phenobarbital
D. Triazolam
E. Zolpidem
- Answer: C
Explanation:
Chronic administration of phenobarbital increases the
activity of hepatic drug-metabolizing enzymes, including
cytochrome P450 isozymes. This often increases the rate
of metabolism of drugs administered concomitantly, with decreases in the intensity and duration of their effects.
Source: Katzung & Trevor’s Pharmacology, Examination
and Board Review, 6th Ed., McGraw Hill, New York, 1998
- The greatest risk in a patient on 300 mg of daily Tramadol
(Ultram®) and paroxetine (Paxil®) combination is:
A. Withdrawal
B. Increased depression
C. Seizures
D. Increased pain
E. GI bleeding
- Answer: C
Explanation:
Because tramadol is not only activated by CYP2D6, but
also metabolized for excretion by CYP2D6, the patient is at
risk for accumulation of the drug, leading to seizures.
Source: Andrea M. Trescot, MD
2572.The thalamus:
1. Is a collection of cell bodies that process incoming sensory
signals.
2. Can tell the difference between different receptors.
3. Connects to various areas of the cortex.
4. Is made up of wide dynamic response neurons.
- Answer: B (1 & 2)
Explanation:
The thalamus is a collection of cell bodies in the brain that
process pain signals, and connect to variousareas of the
cortex . It determines the type of interpretation based on
region of signal input (all action potentials look alike) and
is not made up of WDN.
Source: Andrea M. Trescot, MD
2573.A 17-year old who ingests “mushrooms” would present with symptoms best described as: A. Anticholinergic B. Adrenergic C. Cholinergic D. Alpha adrenergic E. Dopaminergic
- Answer: C
Source: Stimmel, B
2574.A known heroin addict underwent emergency surgery
after a motor vehicle injury. He received morphine 10
mg IV, three doses in 2 hours which helped him only 15
minutes. The course of treatment in this patient is:
A. To titrate morphine
B. To obtain a surgical consult to rule out complications
C. To evaluate for drug abuse
D. Start on transdermal fentanyl
E. Start on methadone maintenance program
- Answer: A
- The common belief that most people who misuse, divert,
or assign illicit use to controlled substances are felt to be
unemployed and from the inner city. The following is
true of demographics according to SAMHSA:
A. 75% of illicit drug users were employed full or part time
B. The highest use of illicit controlled substances were
among American Indians and Alaskan natives.
C. Blacks and whites were approximately equal in the use
and misuse of controlled substances.
D. Inner city blacks were of the highest percentage of illicit
drug users.
E. 60% of illicit drug users were on Medicaid
- Answer: A
Explanation:
75% of illicit drug users were employed full or part time,
with American Indian and Alaskan natives at about 12%
of the population of abuse of illicit drug users. Blacks and
whites were essentially equal, with Asians lowest.
Source: Hans C. Hansen, MD
2576.The most commonly used illicit drug is: A. Marijuana B. LSD C. Ecstasy D. Methamphetamine E. OxyContin®
- Answer: A
Explanation:
The most commonly used illicit drug remains marijuana,
with a lifetime use at roughly 20%. It is the most
commonly used illicit drug on a regular basis, 6.2%, 14.6
million Americans. In contrast 1% were cocaine users,
and ectasy is on the decline, from 3.2 million to 2.1 million
users.
Source: Hans C. Hansen, MD
2577.Which of the following opioids is least likely to cause bradycardia in high doses? A. Fentanyl® B. Meperidine® C. Morphine® D. Hydromorphone® E. Oxycodone®
- Answer: B
Source: Day MR, Board Review 2005
2578.Identify evidence-based recommendations of meperidine
use in chronic pain.
A. Given no more frequently than every four hours for 6
months
B. Used in standard doses in the elderly indefi nitely if response
is positive
C. Used in individuals with impaired renal function as meperidine
is shown to have only hepatotoxicity
D. Always used in conjunction with non-steroidal anti-infl
ammatory agents.
E. Reserved for very brief therapy in otherwise healthy patients
who cannot tolerate other opioids
- Answer: E
Source: Stimmel, B
- What is the fi rst step in a patient on 300 mg Tramadol
per day with paroxetine(Paxil®) with inadequate pain
relief ?
A. Change the paroxetine
B. Add a benzodiazepine
C. Increase the tramadol
D. Switch to a more potent opioid
E. Switch to an agonist/antagonist opioid
- Answer: A
Explanation:
It would be tempting to increase the tramadol, since he is
not on the maximum of 400mg/day. However, that would
increase his risk of seizures even more. The simplest
treatment would be to change his antidepressant to one
that was not a CYP2D6 inhibitor, which would then allow
the tramadol to be more active, while at the same time
decreasing the risk of seizures because of excretion of the
drug. Codeine, hydrocodone, and oxycodone are also
metabolized to active forms by CYP2D6, and therefore
would also be less effective in the face of CYP2D6
inhibition. Agonist/antagonist opioids are not usually a
good choice for chronic pain management.
Source: Andrea M. Trescot, MD
- The Golden Crescent and the Golden Triangle refer to:
A. A geographic region of Africa where opium is grown.
B. A geographic region of Asia where marijuana is grown.
C. Various names from heroin.
D. Symbols used in drug traffi cking.
E. A geographic region of Asia where opium is grown.
- Answer: E
Source: Stimmel, B
2581.Adverse effects of opioids that can be used to advantage include: A. Dysphoria B. Respiratory depression C. Decreased GI motility D. Pupil constriction E. Sexual dysfunction
- Answer: C
Explanation:
Decreased GI motility is the deliberate effect of poorly
absorbed opioids such as loperamide (Lomotil). The rest
are usually undesirable effects.
Source: Andrea M. Trescot, MD
- Meperidine
A. Has been used for many years and is appropriate for
chronic use
B. Is metabolized by CYP2D6
C. Is safe to use in elderly patients
D. May cause side effects that cannot be reversed by opioid
antagonists.
E. Becomes more effective over time, because of an active
metabolite
- Answer: D
Explanation:
The seizures from normeperidine cannot be reversed by
naloxone. Although it has been used for many years,
recognition of its poor analgesia, metabolite accumulation,
and abuse potential has lead to gradual condemnation by
the pain community. It is metabolized by glucuronidation,
is not safe in the elderly and does not become more
effective over time.
Source: Andrea M. Trescot, MD
2583. Which of the statements about tolerance is most true in a patient taking repeated daily doses of lysergic acid diethylamide (LSD)? A. No tolerance develops B. Tolerance develops in 3 to 4 days C. Tolerance develops in 2 to 3 weeks. D. Tolerance develops in 2 to 3 months. E. Tolerance develops in 6 months
- Answer: B
Source: Stimmel, B
2584.A physician determines that an emergency situation
exists justifying a Schedule II emergency oral
prescription. Which of the following statements is true?
A. Within 7 days after the oral authorization to the pharmacist,
the physician must deliver to the pharmacist a
written prescription for the emergency quantity prescribed,
and the written prescription must have written
on its face “Authorization for Emergency Dispensing”
and the date of the oral authorization.
B. Within 14 days after the oral authorization to the pharmacist,
the physician must deliver to the pharmacist a
written prescription for the emergency quantity prescribed
and the written prescription must have written
on its face “Authorization for Emergency Dispensing”
and the date of the oral authorization.
C. Within 30 days after the oral authorization to the pharmacist,
the physician must deliver to the pharmacist a
written prescription for the emergency quantity prescribed
and the written prescription must have written
on its face “Authorization for Emergency Dispensing”
and the date of the oral authorization.
D. No further action is required.
E. Within 60 days after the oral authorization to the pharmacist,
the physician must deliver to the pharmacist a
written prescription for the emergency quantity prescribed
and the written prescription must have written
on its face “Authorization for Emergency Dispensing”
and the date of the oral authorization.
- Answer: A
Explanation:
Within 7 days after the oral authorization to the
pharmacist, the physician must deliver to the pharmacist a
written prescription for the emergency quantity
prescribed, and the written prescription must have written
on its face “Authorization for Emergency Dispensing” and
the date of the oral authorization.
Reference: 21 CFR 290.10, 1306.11(d).
Source: Erin Brisbay McMahon, JD, Sep 2005
2585.To avoid criminal investigations into prescribing
patterns for controlled substances, a physician should . . .
Choose the answer that best completes this sentence.
A. Warn patients to fi ll prescriptions at different drugstores.
B. Make sure there is a logical relationship between the
drugs prescribed and the treatment of the condition
allegedly existing.
C. Issue prescriptions to patients known to be selling drugs
to others.
D. Prescribe controlled substances at intervals inconsistent
with legitimate medical treatment.
E. Use street slang when talking about the drugs prescribed
- Answer: B
Explanation:
Answers (a) and (c)-(e) are noted in the DEA’s Interim
Policy Statement as behaviors that lead to criminal
convictions.
Reference: 69 Fed. Reg. 67170.
Source: Erin Brisbay McMahon, JD, Sep 2005
- Which of the following statements is NOT true with
regard to a continuing criminal enterprise?
A. Conviction for being the manager or organizer of a continuing
criminal enterprise results in the person being
sentenced to not less than 20 years and not more than
life imprisonment, a fi ne of $2 million or more, and
forfeiture of assets under 21 USC 853.
B. To be convicted of being the manager or organizer of a
continuing criminal enterprise, one must obtain substantial
income or resources.
C. To be convicted of being the manager or organizer of a
continuing criminal enterprise, at least fi ve other persons
must be involved.
D. To be convicted of being the manager or organizer of a
continuing criminal enterprise, a person must violate a
provision of the Controlled Substances Act, the punishment
for which is a misdemeanor.
E. To be convicted of being the manager or organizer of a
continuing criminal enterprise, a person must engage
in a continuing series of violations of the Controlled
Substances Act.
- Answer: D
Explanation:
Answer (d) is wrong because, to be convicted of being the
manager or organizer of a continuing criminal enterprise,
a person must violate a provision of the Controlled
Substances Act, the punishment for which is a felony.
Reference: 21 U.S.C. § 848.
Source: Erin Brisbay McMahon, JD, Sep 2005
2587.A practitioner intending to dispense and prescribe
Schedule III, IV, or V controlled substances for
maintenance and detoxifi cation treatment must submit
to the Secretary of the Department of Health and Human Services a notifi cation that he or she intends to do so. The
notifi cation must state . . .Which one of the following
would not correctly complete this sentence?
A. That the practitioner has the capacity to refer patients to
whom the practitioner provides narcotic drugs for appropriate
counseling and other ancillary services.
B. If the practitioner is in solo practice, that s/he will not
treat more than thirty patients at any one time with
Schedule III, IV, or V drugs for detoxifi cation or maintenance.
C. If the practitioner is in group practice, that the group
practice will not treat more than sixty patients at any
one time with Schedule III, IV, or V drugs for detoxifi -
cation or maintenance.
D. That the practitioner is a qualifi ed physician, as that term
is defi ned in the federal statutes.
E. If the practitioner is in group practice, the names and
DEA registration numbers for all practitioners in a
group practice.
- Answer: C
Explanation:
Answer (c) should be limited to thirty patients.
Reference: 21 USC 823(g); 21 CFR 1306.07(d).
Source: Erin Brisbay McMahon, JD, Sep 2005
- Axis IV provides important information about which of
the following?
A. Ability to pay for all necessary medical services.
B. Overall satisfaction with scope of ongoing medical services.
C. Desire to serve as a subject in an upcoming clinical trial
for a new medication.
D. Impact of psychosocial and environmental problems
that may impact the patient.
E. Personality disorders
- Answer: D
Source: Cole EB, Board Review 2003
2589.A 15-year-old male high school freshman presents to an
emergency department with a blank stare, belligerence,
psychomotor agitation, horizontal nystagmus, vertical
nystagmus, blood pressure 160/110 mm Hg, ataxia
dysarthria, and diminished responsiveness to pain.
He appears to be hallucinating, and as he is being
interviewed he assaults one of the attendants. The most
likely diagnosis is:
A. Phencyclidine (PCP) intoxication.
B. Atropine intoxication
C. Benzodiazepine intoxication
D. Mescaline intoxication
E. Solvent intoxication
- Answer: A
Source: Stimmel, B
- Under the Drug Addiction Treatment Act of 2000,
practitioners who are qualifi ed physicians may
dispense and prescribe Schedule III, IV, or V controlled
substances specifi cally approved by the Food and Drug
Administration for narcotic addiction treatment to a
narcotic dependent person if the practitioner meets
several requirements.Which one of the following
credentials will NOT make a physician a qualifi ed
physician?
A. The physician holds a subspecialty board certifi cation
in addiction psychiatry from the American Board of
Medical Specialties.
B. The physician holds an addiction certifi cation from the
American Society of Addiction Medicine.
C. The physician holds a subspecialty board certifi cation
in addiction medicine from the American Osteopathic
Association.
D. The physician has completed not less than 8 hours of
training regarding the treatment and management of
opiate-dependent patients.
E. The physician has published a peer-reviewed article on
the treatment of opiate-dependent patients.
- Answer: E
Explanation:
Answer (e) is not one of the credentials that will render a
physician a qualifi ed physician to dispense and prescribe
Schedule III, IV, or V controlled substances specifi cally
approved by the Food and Drug Administration for
narcotic addiction treatment to a narcotic dependent
person.
Reference: 21 USC 823(g)(2)(B)
Source: Erin Brisbay McMahon, JD, Sep 2005
- The US work loss related to pain:
A. Half the workforce report having pain in the last two
weeks.
B. 10% of the work force was absent from work one or more
days per week
C. Abdominal pain was the most common complaint.
D. Half of the workforce lost productive time due to pain
E. An average of 8 hours of work per week is lost because of
pain
- Answer: A
Explanation:
Only 1% of the work force was absent from work,
headaches and low back pain were the most common
complaints, 12% of the workforce lost productive time due
to pain, and an average of 4.6% hours per week are lost
because of pain.
Stewart WF, Ricci JA, et al. Lost Productive Time and Cost
Due to Common Pain Conditions in the US Workforce.
JAMA (2003)290:18, p. 2446.
Source: Andrea M. Trescot, MD
2592.Which of the following statements about the CSA is
true?
A. If a practitioner needs only a small number of dosage
units of a controlled substance for offi ce use , a prescription
order may be issued to permit a pharmacy to
dispense them.
B. The Act prohibits treating a known addict with an
opioid/opiate product for persistent (as opposed to
acute) pain.
C. The defi nes the term “narcotic” as those controlled substances
which are opioids or opiates, whether natural,
synthetic, or semi-synthetic.
D. Cocaine is classifi ed by the Act as a C-I substance.
E. The Act permits DEA Diversion Investigators to inspect
your controlled substances records (inventories, storage
facility, order forms, etc.) at any time during your normal
practice hours.
- Answer: E
Explanation:
Only E is correct. A is expressly prohibited; B is not
discussed in the Act at all, C is incorrect because “narcotic”
is defi ned to include not only the opioids and opiates, but
also cocaine. D is incorrect because medical cocaine is a
C-II substance, and is often used as a topical anesthetic in
sinus surgery.
Source: Arthur Thexton
2593.Which of the following is true about the federal
Controlled Substances Act:
A. It prohibits self-prescribing.
B. It permits DEA Diversion Investigators to inspect patient
records without patient consent, upon written request.
C. It allows most practitioners to prescribe C-I substances
for IRB-approved research
D. It permits a “Do Not Fill Until” instruction on a prescription
order.
E. It prohibits prescribing methadone without a special
registration as a methadone clinic.
- Answer: D
Explanation:
A is not covered at all in the CSA, but is a matter of state
law. B is incorrect because the CSA does not permit this;
the HIPAA rule does this. C is incorrect, in that a special
registration is required to order C-I substances for any
purpose. And, E is incorrect because methadone may be
prescribed for pain relief or for any other medically
appropriate purpose, EXCEPT the treatment of addiction,
without any special registration.
Source: Arthur Thexton
2594. A meperidine (Demerol) dose equivalent to morphine 10 mg every 3 to 4 hours by injection is: A. 100 mg every 3 hours B. 75 mg every 3 hours C. 50 mg every 3hours D. 100 mg every 4 hours E. 75 mg every 4 hours
- Answer: A
Source: Stimmel, B
- A 22 year old weight lifter who has been observed to have
a gradual behavior change marked by aggression and
mood swings may be demonstrating the effects of:
A. Increased protein intake
B. Creatine and chromium nutritional supplements.
C. Prednisone tablets
D. Anabolic steroids
E. Massive doses of vitamins
- Answer: D
Source: Stimmel, B
2596.Identify the statement describing the withdrawal when
chronic opioid use is discontinued?
A. Is of no clinical signifi cance
B. Can be prevented by administering of a benzodiazepine
C. Can be prevented by administering of an amphetamine
D. Is best managed by slowly tapering the opioid dose by no
more than 10% every few days.
E. Can be alleviated by immediately starting on an opioid
agonist-antagonist
- Answer: D
Source: Stimmel, B
2597.While on a maintenance dose of methadone 80 mg per
day, a patient “shoots up” the heroin equivalent of 10 mg.
The most likely effect will be:
A. Euphoria and sedation
B. Sedation only.
C. Neither euphoria nor sedation
D. Lacrimation, piloerection, and abdominal cramps
E. Respiratory distress, chest pain, and tachycardia
- Answer: C
Source: Stimmel, B
2598.When stimulating a receptor:
A. Increased stimulation causes increased amplitude of the
action potential
B. Increased stimulation causes increased fi ring of the action
potential
C. Increased stimulation causes increased voltage of the
action potential
D. Increased stimulation causes increased recruitment of
other receptors
- Answer: B
Explanation:
Increased stimulation causes an increase in action
potentials of the receptor, which is perceived as a stronger
stimulus.
Source: Andrea M. Trescot, MD
2599.A 23-year-old male presents with a history of smoking
“crack cocaine.” He is disoriented, confused, and in a
dissociative state. Physical examination reveals rotary
nystagmus. Pending the results of his urine drug
screen, you would be suspicious that his drug had been
adulterated with:
A. Methamphetamine.
B. LSD
C. Lidocaine
D. Phencyclidine
E. Ketamine.
- Answer: D
Source: Stimmel, B
2600.A patient of yours is brought in for evaluation by his
wife, 3 days after cervical epidural steroid injection with
multiple complaints. On examination he is found to
be disoriented, confused and in a fugue-like state with
nystagmus on upward gaze, tachycardia and elevated
blood pressure. The most likely diagnosis is:
A. Cocaine intoxication
B. Cannabis intoxication
C. Barbiturate intoxication
D. Phencyclidine (PCP) intoxication
E. Epidural abscess
- Answer: D
Source: Stimmel, B
2601.Death from acute intoxication with phencyclidine is most likely to occur as a result of: A. Violence B. Cholinergic crisis. C. Hypertensive crisis. D. Cardiac arrest. E. Status epilepticus.
- Answer: A
Source: Stimmel, B
2602.Supportive management (“talking down”) of most acute
reactions to lysergic acid diethylamide (LSD):
A. Should be accompanied by an injection of diazepam
(Valium).
B. Should be attempted in a hospital or emergency room
setting.
C. Is not indicated for these reactions.
D. Can usually be accomplished without medication or
hospitalization.
E. Should be accompanied by an injection of haloperidol
(Haldol).
- Answer: D
Source: Stimmel, B
2603.Methylenedioxyamphetamine (DMA) and its analog met hylenedioxymethamphetamine (MDMA) are reported to cause all of the following EXCEPT: A. Mild stimulation B. A feeling of well-being. C. Visual illusions or hallucinations. D. Auditory hallucinations. E. Anxiety
- Answer: D
Source: Stimmel, B
2604.Flashbacks can occur:
A. Long after the hallucinogenic intoxication has dissipated.
B. Only in patients with pre-existing psychological problems.
C. As a result of impurities in street psychedelics.
D. Usually a half hour after the drug has been ingested.
E. Only in patients with combined use of hallucinogens and
opioids
- Answer: A
Source: Stimmel, B
- Choose true statements concerning infective endocarditis
in heroin addictions, compared to endocarditis in nonaddicted
patients:
A. The tricuspid valve is affected more often.
B. Mixed fl ora of bacteria and fungi are more prevalent.
C. Staphylococcus aureus is found more often as a causative
organism.
D. Surgical treatment is rarely necessary.
E. Easily identifi ed by an aortic murmur
- Answer: A
Source: Stimmel, B
2606.The states of a patient in which repetitions of the same
dose of a drug has progressively less effect or in which the
dose needs to be increased to obtain the same degree of
pharmacological effect as was caused by the original dose
is defi ned as:
A. Physical dependence
B. Synergistic effect
C. Additive effects
D. Disuse supersensitivity
E. Tolerance
- Answer: E
Source: Stimmel, B
2607.Choose the correct statements describing the risks of malprescribing
A. Never given re-education options
B. Not reportable to databank
C. State Board Investigation or Sanction
D. Usually results in publicity to increase your practice
E. Not liable to civil lawsuits, only criminal liability
2607. Answer: C Explanation: Risks of Malprescribing State Board Investigation or Sanction Often given re-education options May result in databank report Usually results in adverse publicity Attention attracts civil lawsuits Source: Laxmaiah Manchikanti, MD
2608.Methadone metabolism may be signifi cantly altered by the co-administration of all of the following EXCEPT: A. Ciprofl oxin B. Phenytoin C. Oxycodone D. Biaxin E. Rifampin
- Answer: D
Explanation:
Ciprofl oxin inhibits CYP3A4 and may result in withdrawal. Phenytoin lowers methadone concentration
by about half in 3-4 days. Rifampin may cause withdrawal
by interference with CYP3A4. Oxycodone metabolism is
inhibited by methadone and the combination may
increase oxycodone levels or effects.
Reference: Drugs for Pain, Smith 2003, Page 459
Source: Art Jordan, MD, Sep 2005
2609.Federal Control over the use of controlled substances
comes from which one of the following:
A. Balanced budget act of 1997
B. Food and drug Cosmetic Act administered by the F.D.A.
C. Judicial branch of the government
D. Executive branch of the government
E. National Narcotics Bureau (N.N.B.)
2609. Answer: C Explanation: Pain Medicine: A Comprehensie Review, Second Edition; P. Prithvi Raj: Mosby, Page 390 Source: Art Jordan, MD, Sep 2005
2610.Which one of the following is the most frequently abused opiate in the United States? A. Morphine B. Toradol C. Hydrocodone D. Oxycodone E. Fentanyl lollypops
- Answer: C
Explanation:
D.A.W.N. Drug Abuse Warning Network Reports
Hydrocodone is a Schedule II controlled substance only
when prescribed alone. With acetaminophen, it is a
Schedule III. It has an average serum half-life of 3.8 hours.
It is widely used as an antitussive.
Disposition of Toxic Drugs and Chemicals in man. Fifth
Edition. Randall C. Baselt 2000
Drug Enforcement Administration website
Source: Art Jordan, MD, Sep 2005
2611.How often must a practitioner renew his/her DEA registration? A. Every 2 years. B. Every 6 years. C. Every 3 years. D. Every 4 years. E. Every 5 years.
- Answer: C
Explanation:
Reference: 21 U.S.C. § 823; 21 C.F.R. § 1301.01 through
1301.55.
Explanation:
DEA requires practitioners to renew their DEA
registration number every 3 years. This may be done online
through www.deadiversion.usdoj.gov. Moreover,
DEA requires practitioners to request modifi cations of
their DEA registration numbers when they move to a new
medical practice or open another offi ce requiring
additional registration.
Source: Jennifer Bolen, JD, Sep 2005
2612.All of the following statements about Food and Drug Act
are correct, EXCEPT:
A. 1906 - Wiley Act was founded the F. D. A., and centered
on foods and meat packing
B. 1938 - Food, Drugs, and Cosmetics Act mandated premarket
approval of drugs
C. Marijuana Tax Act 1938
D. 1932 - Food, Drugs, and Cosmetics Act required proof
safety
E. 1906 - Wiley Act required concentration standards for all
medications
2612. Answer: D Explanation: Food and Drug Acts * 1906 - Wiley Act - Founded the F. D. A. - Centered on foods and meat packing - Required ingredients and concentration standards for all medications - largely to regulate patent medicines. * 1938 - Food, Drugs, and Cosmetics Act - Mandated premarket approval of drugs - Required proof of safety - Prohibited false therapeutic claims * Marijuana Tax Act 1938 Source: Roger Cicala, MD, Sep 2005
2613.As a DEA registrant you have certain responsibilities,
including (1) proper registration and renewal; (2)
proper record-keeping; and (3) what newly explained
responsibility as stated in the Interim Policy Statement,
published by DEA in the Federal Register on November
16, 2004?
A. A responsibility to report to DEA about the misuse of a
DEA number.
B. A responsibility to seriously consider any sincerely
expressed concerns made by family members about a
patient’s potential abuse of controlled substances.
C. A responsibility to see all patients every thirty days.
D. A responsibility to issue drugs for a legitimate medical
purpose.
E. A responsibility to review patient records every thirty
days.
- Answer: B
Explanation:
Reference: DEA Interim Policy Statement, Fed. Reg. Vol.
69, No. 220, pp. 67170-67172 (Nov. 16, 2004).
Explanation:
A. This is not the correct answer. While a physician must
report to DEA if their DEA number has been
compromised, the Interim Policy Statement does not
discuss this duty.
B. This is the best answer. The Interim Policy Statement
states: “[g]iven the addictive and sometimes deadly nature
of prescription narcotic abuse, the tremendous volume of
such drug abuse in the United States, and the propensity
of many drug addicts to attempt to deceive physicians in
order to obtain controlled substances for the purpose of
abuse, a physician should seriously consider any sincerely
expressed concerns about drug abuse conveyed by family
members and friends.”
C. This is not the best answer because the Interim Policy
Statement did not assign a time frame within which to see
patients and does not say that you must see your patients
every thirty days.
D. This is not the correct answer. To be valid, a physician
must issue a prescription for controlled substances for (1)
a legitimate medical purpose, and (2) within the usual
course of professional practice. This has been the law of
the Controlled Substances Act of 1970 and was not a new
directive from the Interim Policy Statement.
E. This is not the correct answer. The Interim Policy
Statement did not assign a time frame within which a
physician must review patient records.
Source: Jennifer Bolen, JD, Sep 2005
2614.Patients usually develop tolerance to all opioid effects EXCEPT: A. Sedation B. Pruritus C. Constipation D. Pain relief E. Respiratory depression
- Answer: C
Explanation:
Sedation and pruritus (due to direct histamine release)
abate over time. Although tolerance to pain relief can
occur, with long acting narcotics (especially methadone) it
is less likely. Constipation, however, should be expected to
be a problem for the entire length of treatment.
Source: Trescot AM, Board Review 2004
2615.The Controlled Substances Act of 1970 does not give DEA
the authority to do which of the following:
A. Scheduled drugs
B. Regulate medical practice
C. Administer the CSA and create policy related to the
CSA
D. Establish quotas for the manufacture of controlled substances
E. Reschedule drugs depending on their potential for
abuse
- Answer: B
Explanation:
Reference: The Controlled Substances Act of 1970, codifi ed
at 21 U.S.C. § 801 and sections that follow; see also 1994,
Joranson DE, Gilson AM. Chapter 8 - Controlled
substances, medical practice and the law. In: Schwartz HI.
Psychiatric Practice Under Fire: The Infl uence of
Government, the Media and Special Interests on Somatic
Therapies. Washington, DC: American Psychiatric Press,
Inc., 1994:173-194. Explanation:
A. This is not the correct answer. The Controlled
Substances Act of 1970 does give DEA the authority to
schedule drugs according to whether the drug has been
approved by the Food and Drug Administration for
medical use and according to the drug’s potential for
abuse.
B. This is the correct answer. The states, not the federal
government, have the authority to regulate medical
practice. State authority derives from both federal and
state constitutions. States create medical practice acts to
regulate the practice of medicine and protect the public.
The CSA does not give DEA the authority to regulate
medical decisions and it does not permit DEA to change
or
limit indications for which a drug may be prescribed.
Likewise, the CSA does not give DEA the authority to
regulate the quantity or chronicity of prescribing relative
to controlled substances.
C. This is not the correct answer because the Controlled
Substances Act of 1970 does give DEA authority to
administer the CSA and create policy related to the various
provisions of the CSA.
D. This is not the correct answer because the Controlled
Substances Act of 1970 does give DEA authority to
establish manufacturing quotas that drug manufacturers
must follow when producing controlled substances. There
are many facets to DEA’s authority to establish
manufacturing quotes and the important point is that
DEA must ensure that there are suffi cient controlled drugs
available to meet legitimate health care demands.
E. This is not the correct answer because the Controlled
Substances Act of 1970 does give DEA authority to
reschedule drugs into higher or lower schedules,
depending on whether a drug remains approved for
medical use and depending on developments and trends
regarding the trends for the abuse of these drugs.
Source: Jennifer Bolen, JD, Sep 2005
2616.You treat patients who suffer from conditions producing
chronic, non-malignant pain. You prescribe controlled
substances to your patients (1) for a legitimate medical
purpose, and (2) within the usual course of professional
practice. The Federation of State Medical Boards and
many state licensing boards require practitioners to keep
medical records that include which of the following items
in connection with their use of controlled substances to
treat pain?
A. The name of the drug and the amount prescribed.
B. The medical history and physical examination, diagnostic,
therapeutic and laboratory results, evaluations
and consultations, treatment objectives, discussion of
risks and benefi ts, informed consent and treatment
agreements, treatments, medications (including date,
type, dosage and quantity prescribed), instructions and
agreements, and periodic reviews.
C. An inventory of all the drugs prescribed to each patient,
a record of all communications with the patient, and all
office forms.
D. A carbon copy of the prescriptions issued, all contact
information for the patient, and all clinical rationale for
the drugs prescribed.
E. A list of each office visit you have with the patient and a
statement of all treatments rendered.
- Answer: B
Explanation:
Reference: The Federation of State Medical Boards’ May
2004 Model Policy for the Use of Controlled Substances
for the Treatment of Pain, www.fsmb.org.
Explanation:
A. This is not the best answer because it only involves
some of the records state licensing boards require
practitioners to keep when they prescribe controlled
substances for the treatment of pain.
B. This is the best answer. The Federation of State Medical
Boards’ Model Policy for the Use of Controlled Substances
for the Treatment of Pain sets forth the following
categories of medical records that practitioners should
keep when they treat pain. Many states have adopted these
categories in prescribing guidelines and, quite frequently,
in prescribing regulations or rules. - the medical history and physical examination,
- diagnostic, therapeutic and laboratory results,
- evaluations and consultations,
- treatment objectives,
- discussion of risks and benefi ts,
- informed consent,
- treatments,
- medications (including date, type, dosage and
quantity prescribed), - instructions and agreements and
- periodic reviews.
C. This is not the best answer because it only involves
some of the records state licensing boards require
practitioners to keep when they prescribe controlled
substances for the treatment of pain.
D. This is not the best answer because it only involves
some of the records state licensing boards require
practitioners to keep when they prescribe controlled
substances for the treatment of pain.
E. This is not the best answer because it only involves
some of the records state licensing boards require
practitioners to keep when they prescribe controlled
substances for the treatment of pain.
Source: Jennifer Bolen, JD, Sep 2005
2617.Use of which the following opioids by breast-feeding mothers depresses the behavior of the infant more than the equianalgesic dose of morphine: A. Fentanyl® B. Meperidine® C. Nalbuphin® D. Buprenorphine® E. Tramadol®
- Answer: B
Source: Raj, Pain Review 2nd Edition
2618.Which of the following is NOT true about
benzodiazepines when used long term in chronic pain?
A. Decrease REM and slow wave sleep
B. Decrease serotonin levels
C. May produce a dangerous withdrawal syndrome if suddenly
discontinued
D. Have a primary analgesic effect
E. May have a much higher rate of cognitive dysfunction
than opioids
- Answer: D
Explanation:
Benzodiazepines decrease REM and Stage and Stage 4
sleep, resulting in increased fatigue and sleep deprivation.
Some studies have shown a cognitive dysfunction rate as
high as 70% in patients on long term benzodiazepines.
Withdrawal from benzodiazepines may be worse than
opioids. There is no evidence that benzodiazepines have a
primary analgesic effect.
Source: Art Jordan, MD, Sep 2005
2619.Convulsions caused by drug poisoning are most commonly associated with A. Phenobarbital B. Diazepam C. Strychnine D. Chlorpromazine E. Phenytoin
- Answer: C
Reference: Hardman, pp 89-90.
Strychnine acts as a competitive antagonist of glycine, the
predominant postsynaptic inhibitory transmitter in the
brain and spinal cord. The fatal adult dose is 50 to 100mg.
Persons poisoned by strychnine suffer convulsions that
progress to full tetanic convulsions. Because the
diaphragm and thoracic muscles are fully contracted, the
patient cannot breathe. Hypoxia eventually causes
medullary parasysis and death. Control of the convulsions
and respiratory support are the immediate objectives of
the therapy. Diazepam may be preferred to a barbiturate in
controlling the convulsions because it offers less
concomitant respiratory depression. Poisoning caused by
the other drugs listed in the question is not associated with
convulsions but with depression of the CNS.
Source: Stern - 2004
2620.Disadvantages of long-term morphine therapy in a cancer patient are: A. Withdrawal when drug is stopped B. Cognitive dysfunction C. Addiction D. Liver dysfunction E. Constipation
- Answer: E
2621.Under the Controlled Substances Act (CSA), the following drug schedules is thought to have the highest potential for abuse? A. Schedule II B. Schedule III C. Schedule V D. Schedule I E. Schedule IV
- Answer: D
Explanation:
A. Schedule II drugs have a high potential for abuse and a
high rate of psychological or physical dependence.
Narcotic analgesics are schedule II drugs.
Non-narcotic drugs such as amphetamines,
methylphenidate, and pentobarbital are also schedule II.
B. Schedule III drugs have a potential for abuse less than
the drugs or other substances in schedules I and II. Abuse
of the drug or other substance may lead to moderate or
low physical dependence or high psychological
dependence.
C. Schedule V drugs have the lowest potential for abuse of
the drugs under the jurisdiction of the Controlled
Substances Act. Antitussives and antidiarrheal
preparations that contain narcotics in limited quantities
are schedule V drugs.
D. Schedule I is reserved for the most dangerous drugs
without recognized medical value.
E. Schedule IV drugs are thought to have less potential for
abuse than schedule I, II, and III drugs. Examples of
schedule IV drugs are benzodiazepines, phenobarbital,
meprobamate, chloral hydrate, and dextropropoxyphene
(Darvon).
2622.Cocaine, produced from the leaves of Erythroxylon
species,
A. Produces bradycardia and vasodilation
B. Is directly related chemically to opioid analgesics
C. Is metabolized by the microsomal metabolizing system
D. Blocks nerve conduction effectively
E. Blocks norepinephrine receptors directly
- Answer: D
Explanation:
Reference: Hardman, pp 338, 570.
A. Peripherally, cocaine produces sympathomimetic
effects including tachycardia and vasoconstriction.
B. Cocaine is an ester of benzoic acid and is closely related
to the structure of atropine. Death from acute overdose
can be from respiratory depression or cardiac failure.
C. Cocaine is biotransformed by plasma esterases to
inactive products.
D. Cocaine has local anesthetic properties; it can block the
initiation or conduction of a nerve impulse.
E. Cocaine also blocks the reuptake of norepinephrine.
This action produces CNS stimulant effects including
euphoria, excitement, and restlessness.
Source: Stern - 2004
2623.When prescribing sublingual or buccal route of
administration, the best drug (55%) for absorption is
A. Methadone
B. Fentanyl
C. Morphine
D. Buprenorphine
E. Demerol
- Answer: D
Source: Raj P, Pain medicine - A comprehensive Review -
Second Edition
- In order for a prescription to be valid under federal and
state law, it must be issued
A. With the proper date and the physician’s signature.
B. With the proper date, patient information, drug identification and instructions for use, physician signature,
and it must be issued for a legitimate medical purpose
within the usual course of professional practice.
C. To a patient who does not have a criminal history.
D. Only by a licensed physician and not by any mid-level
practitioner.
E. Within three days of seeing the patient.
- Answer: B
Explanation:
Reference: Code of Federal Regulations, 21 C.F.R. §
1306.04 (Prescriptions).
Explanation:
A. This is not the best answer. Prescriptions must meet
both substantive and technical requirements to be valid. As
a technical matter, a prescription must be dated and
signed
on the date it is actually issued to the patient or guardian.
The prescription must contain not only the date and the
properly licensed and registered provider’s signature, but
also information about the patient and the drug
prescribed. However, date and signature alone are not
enough to make a prescription valid and the prescription
must meet the substantive requirements of (1) legitimate
medical purpose, and (2) usual course of professional
practice to be wholly valid.
B. This is the best answer. To be valid, the federal and state
laws and regulations require a prescription be issued for a
legitimate medical purpose within the usual course of
professional practice. State licensing boards often add to
this requirement by requiring physicians and other health
care practitioners to document the medical record to show
compliance with applicable laws and regulations
governing controlled substance prescribing.
C. This is not the correct answer because federal and state
laws do not prohibit a physician from prescribing
controlled substance to a person with a criminal history.
The only caveat to this statement concerns the patient’s
history of substance abuse, as it may call for restrictive
monitoring on the patient’s use of controlled substances or
other restrictions to ensure that the controlled substances
prescribed get used as they are intended – for pain relief.
D. This is not the correct answer because most states allow
physicians to use mid-level practitioners in the treatment
of patients. These working relationships allow for
practitioners to see more patients on a given day. While some state laws may require the physician to sign all
prescriptions, in many cases mid-level practitioners also
have DEA registrations and thus may prescribe controlled
substances for the treatment of pain. Anyone who signs a
controlled substances prescription must be licensed
properly by state authorities and registered with the DEA.
E. This is not the correct answer. Federal and state laws do
not require physicians to issue controlled substances
prescriptions within three days of seeing the patient.
Source: Jennifer Bolen, JD, Sep 2005
- You are a solo practitioner in a pain specialist capacity.
You have a patient who wants to be treated in your offi ce
for opioid addiction and pain. Do you need a separate
registration to provide Narcotic Treatment Services?
A. No, I can issue 72-hour emergency prescriptions as
needed to detoxify a patient.
B. No, I can prescribe methadone to help them detoxify
because I prescribe methadone to treat their pain.
C. No, I have the proper training on the use of Schedule
III-V drugs in the offi ce based treatment of opioid addiction.
D. Yes, I must have a separate registration to provide narcotic
treatment services.
E. Yes, so I can prescribe drugs in Schedule II-V to detoxify
a patient due to opioid addiction.
- Answer: D
Explanation:
Reference: 21 U.S.C. § 823; 21 C.F.R. 1306.07; and
www.deadiversion.usdoj.gov.
Explanation:
A. This is not the correct answer because the 72-hour
exception to the federal law requirement of a separate
registration for detoxifi cation or maintenance treatment
only allows a practitioner to administer or dispense (but
not prescribe) (1) one day’s worth of emergency
medication to the patient at one time, (2) for not more
than a total of 72-hours, and (3) the practitioner may not
extend or renew the 72-hour period. This 72-hour
exception is known as the “three day rule” and it is found
in 21 C.F.R. § 1306.07(b). Thus, if a practitioner is not
separately registered as a narcotic treatment program,
he/she may administer BUT NOT prescribe narcotic drugs
to a patient for the purpose of relieving acute withdrawal
symptoms while arranging for the patient’s referral for
treatment. Congress intended § 1306.07(b) to give
practitioners fl exibility in emergency situations when
confronted with a patient undergoing withdrawal. Thus,
Congress established this exception to “augment, not to
circumvent” the separate registration requirement set
forth in the CSA.
B. This is not the correct answer because no one is legally
permitted to prescribe methadone to detoxify or maintain
a patient for addiction.
C. This is not the correct answer because having only the
training on the use of Schedule III-V controlled substances
to perform the offi ce-based treatment of opioid addiction
is not enough. Practitioners must obtain an “X”
certifi cation from DEA to use Schedule III-V controlled
substances to treat patients in their offi ces for opioid
addiction. Also, you may administer or dispense, but not
prescribe, methadone according to the “three day rule”
described above in answer A.
D. This is the best answer. If a practitioner wants to use
Schedule II narcotic drugs for maintenance and/or
detoxifi cation, federal and state law require the
practitioner to obtain separate registration from the DEA
as a narcotic treatment program pursuant to the Narcotic
Addict Treatment Act of 1974. Signifi cantly, this
registration allows a practitioner to administer or
dispense, but not prescribe, scheduled narcotic drugs that
are approved by the United States Food and Drug
Administration (FDA) for the treatment of narcotic
addiction. Until October 2000, methadone and levo-alphaacetyl-
methadol (LAAM) were the only scheduled
narcotics approved by FDA for use in maintenance and
detoxifi cation treatment. In October 2000, pursuant to the
Drug Abuse Treatment Act of 2000 (DATA 2000),
Congress amended the CSA (21 U.S.C. § 823(g)) to allow
properly registered and trained practitioners to dispense
or prescribe Schedule III-V controlled substances
specifi cally approved by the FDA for the offi ce-based
treatment of opioid addiction.
E. This is not the correct answer. While a separate
registration is required to render narcotic treatment
services, no DEA registration to do so allows any
practitioner to prescribe Schedule II controlled substances
to detoxify or maintain an individual with an addiction. As
stated above in answer D, those properly registered and
trained may prescribe those drugs in Schedules III-V
approved by FDA for the purpose of detoxifi cation from
opioids.
Source: Jennifer Bolen, JD, Sep 2005
- Consequences of undertreatment of pain may include all
of the following EXCEPT:
A. Possible jail time
B. Civil lawsuits
C. Loss or restriction of prescribing abilities
D. No effect of medical license
E. Exclusion from Medicare/Medicaid
2626. Answer: D Explanation: * Possible jail time * Civil Lawsuits * Loss or restriction of prescribing abilities * Loss or restriction of medical license * Exclusion from Medicare/Medicaid * Loss of patients * Loss of your practice Source: Erin Brisbay McMahon, JD, Sep 2005
- In performing urine drug testing, a physician must know
all of the following EXCEPT:
A. The characteristics of testing procedures, since many
drugs are not routinely detected by all UDTs.
B. Although no aberrant behavior is pathognomonic of
abuse or addiction, such behavior should never be
ignored.
C. Reliance on aberrant behavior to trigger a UDT will miss
more than 50% of those individuals using unprescribed
or illicit drugs.
D. Always prescribe “on-demand” for the patient until you
are comfortable with the situation.
E. A history of drug abuse does not preclude treatment
with a controlled substance, when indicated, but does
require a treatment plan with firmly defined boundaries.
- Answer: D
Explanation:
Urine Drug Testing
Know the characteristics of testing procedures, since many
drugs are not routinely detected by all UDTs.
Although no aberrant behavior is pathognomonic of
abuse or addiction, such behavior should never be ignored.
Reliance on aberrant behavior to trigger a UDT will miss
more than 50% of those individuals using unprescribed or
illicit drugs.
Never prescribe “on-demand” for the patient until you are
comfortable with the situation. A history of drug abuse does not preclude treatment with
a controlled substance, when indicated, but does require a
treatment plan with fi rmly defi ned boundaries.
Source: Laxmaiah Manchikanti, MD
- All of the following are signs of controlled substance in
work place, EXCEPT:
A. Progressive deterioration in personal appearance and
hygiene
B. Uncharacteristic deterioration of handwriting and charting
C. Wearing long sleeves when inappropriate
D. Personality change - mood swings, anxiety, depression,
lack of impulse control, suicidal thoughts or gestures
E. Increased personal and professional activities
- Answer: E
Explanation:
Watch for signs:
Progressive deterioration in personal appearance and
hygiene;
Uncharacteristic deterioration of handwriting and
charting;
Wearing long sleeves when inappropriate;
Personality change - mood swings, anxiety, depression,
lack of impulse control, suicidal thoughts or gestures;
Patient and staff complaints about health care provider’s
changing attitude/behavior;
Increasing personal and professional isolation.
Source: Erin Brisbay McMahon, JD, Sep 2005
- The management of phencyclidine toxicity is likely to
include all of the following except:
A. Naloxone for respiratory depression
B. Diazepam for seizures
C. Propranolol for adrenergic crisis
D. Haloperidol for disorganized, disruptive behavior
E. Low-stimulus environment
- Answer: A
Explanation:
Phencyclidine (“angel dust,” “crystal,” “hog”) toxicity
induces organize mental disorders, intoxication, delirium,
delusional mood, and fl ashback disorders with physical
problems related to high blood pressure, muscle rigidity,
ataxia, coma, nystagmus (particularly vertical), and dilated
pupils. Treatment is with IV diazepam as the drug of fi rst
choice. Propranolol can be used for an adrenergic crisis,
and haloperidol is effective for psychotic and disruptive
behavior. Elimination of the drugs is enhanced by
ammonium chloride in the acute stage and later by
ascorbic acid. Environmental stimuli should be kept to a
minimum. The urine is positive for PCP up to seven days,
but there can be false negatives.
Source: Psychiatry specialty Board Review By William M.
Easson, MD and Nicholas L. Rock, MD
- Which of the following is associated with crack (the freebase
form of cocaine)?
A. Flashbacks (recurrences of effects) may occur months
after the last use of the drug
B. It may cause seizures and cardiac arrhythmias
C. It acts by blocking adrenergic receptors
D. It is the salt form of cocaine
E. It is primarily administered intranasally
- Answer: B
Explanation:
Reference: Katzung, p 538.
A. Flashbacks can occur with use of LSD and mescaline
but have not been associated with the use of cocaine.
B. Use of crack cocaine has led to seizures and cardiac
arrhythmias.
C. Some of cocaine’s effects (sympathomimetic) are due to
blockade of norepinephrine reuptake into presynaptic
terminals; it does not block receptors.
D. Crack is the
free-base (nonsalt) form of the alkaloid cocaine. It is called
crack because, when heated, it makes a crackling sound.
E.Heating crack enables a person to smoke it; the drug is
readily absorbed through the lungs and produces an
intense euphoric effect in seconds.
Source: Stern - 2004
2631.What are some of the signs of abuse of controlled
substances by your offi ce workers and co-workers?
A. No extra time is spent near a drug supply
B. Extreme reliability in keep appointments and meeting
deadlines
C. Never volunteer for overtime
D. Only at work when scheduled
E. Absenteeism, frequent disappearances or long unexplained
absences, making improbable excuses and
taking frequent or long trips to the bathroom or to the
stockroom where drugs are kept
- Answer: E
Explanation:
Watch for signs:
Absenteeism, frequent disappearances or long unexplained
absences, making improbable excuses and taking frequent
or long trips to the bathroom or to the stockroom where
drugs are kept;
Excessive amounts of time spent near a drug supply.
Volunteer for overtime and at work when not scheduled;
Unreliability in keeping appointments and meeting
deadlines;_
Source: Erin Brisbay McMahon, JD, Sep 2005
2632.If you move the location of your practice, you are
required to do what regarding your DEA registration?
A. Send a request for modifi cation of registration in writing
to the nearest DEA fi eld offi ce, and obtain approval for
the modifi ed registration prior to the move.
B. Wait until the next renewal date for your controlled substances
registration to notify DEA of the move.
C. Tell only your state drug bureau about the move and
seek a new registration with them that you can use
with DEA.
D. Send DEA a request for a new registration number after
you move.
E. Wait until DEA asks you for updated information about
your registration and current address.
- Answer: A
Explanation:
Reference: 21 U.S.C. § 823; 21 C.F.R. § 1301.11 (separate
registrations) and § 1301.51 (modifi cation of
registration); www.deadiversion.usdoj.gov.
Explanation:
A. This answer is the best answer. If you move your
principal registered location, you must send DEA a request
for modifi cation of registration in writing and obtain
approval for the modifi ed registration prior to the move.
This request for modifi cation should be addressed to the
DEA fi eld offi ce nearest to your currently registered
location. You may obtain an Address Change Request from
DEA’s internet site at www.deadiversion.usdoj.gov. You
must manually sign and fax or mail it to the local DEA
offi ce. The form must include (1) a copy of your current
state medical/professional license for the new address
along with a copy of the practitioner’s corrected state
controlled substance registration, if applicable.
B. This is not the correct answer. You may not wait until
the next renewal date for your controlled substances
registration to notify DEA of the move. If you do so, you
may lose your registration number and you will be
considered in violation of the law.
C. This is not the best answer. You must fi rst get
permission from DEA to modify your registration, and
thus simply telling your state drug bureau is not suffi cient.
You should learn what your state requires from you if you
move principal locations from which you administer,
dispense, and prescribe controlled substances
D. This is not the correct answer. You may not wait until
after you move to send DEA a request for a new registration number. Because you are administering and/
or dispensing controlled substances from your currently
registered location, you must fi rst obtain DEA’s approval
to use the new location to store controlled substances.
E. This is not the correct answer. You may not wait until
DEA asks you for updated information about your
registration and current address. DEA puts the burden on
you, the registrant, to stay current with the paperwork
surrounding the registration of individuals and locations.
Source: Jennifer Bolen, JD, Sep 2005
2633.Which of the following statements is accurate with
administration of psychostimulants in opioid induced
sedation?
A. They are safe in patients with a history of paranoid
disorders
B. They are safe in patients with a history of hypertension
C. They should be given morning and noon so as not to
disturb sleep
D. They are safe in patients with a history of delirium
E. They should be administered only at bedtime
- Answer: C
Explanation:
They are contraindicated in patients with a history of
hallucinations, delirium, or paranoid disorders. They are
relatively contraindicated with a history of substance
abuse or hypertension. Their use may exacerbate the
above.
Examples include methylphenidate, destroamphetamine,
and pemoline.
Reference: Melzack and Wall 2003, page 390
Source: Art Jordan, MD, Sep 2005
- You have a patient that you suspect may be altering
your prescriptions. You want to fax a copy of a Schedule
II prescription to the pharmacist the patient uses to fi ll
prescriptions. Is this legal and what must happen before
the pharmacist dispenses the prescription?
A. No, it is not legal to fax a Schedule II prescription to a
pharmacist.
B. Yes, but only if you have a HIPAA consent from the
patient.
C. Yes, and the patient must present the original prescription
to the pharmacist.
D. No, because faxes apply only to emergency prescriptions
for Schedule II drugs.
E. No, because faxes apply only to hospice and nursing
home situations.
- Answer: C
Explanation:
Reference: 21 C.F.R. § 1306.11(a) (Requirement of a
Prescription), which states “[a] prescription for a
Schedule II controlled substance may be transmitted by
the practitioner or the practitioner’s agent to a pharmacy
via facsimile equipment, provided that the original
written, signed prescription is presented to the pharmacist
for review prior to the actual dispensing of the
controlled substance, except as noted in paragraph (e), (f),
or (g) of this section. The original prescription shall be
maintained in accordance with § 1304.04(h) of the CSA.”
Explanation:
A. This is not the best answer because it states only one of
the two requirements concerning the faxing of
prescriptions. While it is legal to fax a Schedule II
prescription to a pharmacist, the pharmacist may not
dispense the prescription to the patient without the
original prescription.
B. This is not the correct answer because HIPAA consent
has nothing to do with this law regarding the faxing of
Schedule II controlled substances prescriptions to
pharmacists. If you want to discuss the patient’s
prescription with the pharmacist in connection with your
treatment of the patient, you may do so and HIPAA does
not require the patient’s consent for such conversations.
C. This is the best answer because it is legal to fax a
Schedule II prescription to a pharmacist and the patient
must present the original prescription to the pharmacist
prior to dispensation of the prescription. This measure
would prove helpful in determining whether the patient in
question has attempted to alter your prescriptions. Do not
tell the patient that you are faxing a copy of the
prescription to the pharmacist.
D. This is not the correct answer because faxes are not
limited to emergency prescriptions.
E. This is not the correct answer because faxes are not
limited to hospice and nursing home situations. However,
it is important to note that the requirement of the original
prescription does not apply to hospice and nursing home
situations.
Source: Jennifer Bolen, JD, Sep 2005
2635. Which controlled substance produces a toxic metabolite which may cause seizures with accumulation with repeated dosing? A. Pentazocine B. Propoxyphene C. Morphine D. Ketamine E. Meperidine
- Answer: E
Explanation:
A major metabolite of meperidine is to normeperidine.
Accumulation of normeperidine with repeated doses may
cause seizures.
Meperidine should only be used for short term acute pain
management, if at all.
Pentazocine, morphine, and ketamine are not associated
with toxic metabolites at normal repeated dosing.
Reference: Melzack and Wall 2003, Page 381
Source: Art Jordan, MD, Sep 2005
2636.Every practitioner who administers, prescribes, or
dispenses any controlled substance must be registered
with the DEA and must maintain the DEA certifi cate of
registration at the registered location. If a practitioner
has more than one offi ce where controlled substances
are administered and/or dispensed, then the practitioner
must:
A. Register only the principal offi ce location.
B. Register each offi ce location where controlled substances
are administered and/or dispensed.
C. Register only those offi ce locations where controlled
substances are prescribed.
D. Do nothing.
E. Register every location that uses prescription pads.
- Answer: B
Explanation:
Reference: 21 U.S.C. § 823; 21 C.F.R. § 1301.12;
www.deadiversion.usdoj.gov.
Explanation:
A. This is not the correct answer. If a practitioner
administers and/or dispenses controlled substances at
more than one location, he/she must register and post a
DEA registration number at each principal place of
business or professional practice where controlled
substances are stored, administered, or dispense by a
person. Thus, under this hypothetical registering only one
principal offi ce location is insuffi cient.
B. This is the best answer. A separate registration is
required for each principal place of business or
professional practice where controlled substances are
stored, administered or dispensed by a person. If a
practitioner will only be prescribing from an additional
location located within the same state, then an additional
registration is not necessary.
C. This is not the best answer. A practitioner must register
each principal place of business or professional practice
where controlled substances are stored, administered, or
dispensed by a person.
D. This is not the correct answer. Do nothing is not the answer here as a registration is required at all locations
where practitioners administer and/or dispense controlled
substances. This is because the DEA requires registration
of locations that keep controlled substances on the
premises. The practice is different if the only thing kept on
the premises is a prescription pad.
E. This is not the correct answer. Registering a principal
place of business where one administers and/or dispenses
controlled substances is different from registering every
place where the practitioner travels and issues
prescriptions for controlled substances. Practitioners
must register their principal place of business. If a
practitioner has several offi ces, he/she must register
separately those offi ces where he/she administers and/or
dispenses controlled substances. However, he/she is not
required to register every location where he/she uses
prescription pads for controlled substances prescriptions.
Source: Jennifer Bolen, JD, Sep 2005
- What are the basic requirements for prescribing
controlled substances?
A. DEA Registration, state DEA registration (where required),
state medical license allowing the provider
to prescribe controlled substances, and a legitimate
medical purpose within the usual course of professional
practice.
B. DEA Registration, state DEA registration (where required),
and a state medical license allowing the provider
to prescribe controlled substances.
C. DEA Registration and a state medical license.
D. DEA Registration, a state medical license, and evidence
showing that you have had 10 or more hours training in
controlled substance prescribing.
E. State DEA registration and a state medical license.
- Answer: A
Explanation:
Reference: 21 U.S.C. § 829; 21 C.F.R. § 1306.01 through §
1306.26; www.deadiversion.usdoj.gov.
Explanation:
A. This is the best answer. Only practitioners acting in the
usual course of their professional practice may prescribe
controlled substances. Practitioners must be registered
with DEA and licensed to prescribe controlled substances
by the State(s) in which they operate. In addition, if the
state requires a separate state DEA registration number,
practitioners must obtain this registration prior to
applying for a federal DEA registration. Finally, a
prescription must be issued in the usual course of
professional practice and for a legitimate medical purpose
(or authorized research).
B. This is not the correct answer because it omits the
requirement of (1) legitimate medical purpose within (2)
the usual course of professional practice.
C. This is not the correct answer because it omits the
requirement of a state DEA registration number, which
many states require.
D. This is not the correct answer because the federal law
does not contain a training requirement currently. Note,
however, this may change in the near future due to the
growing abuse and diversion of prescription controlled
drugs in the United States. Several states require some
level of training in the use of controlled substances to treat
pain.
E. This is not the correct answer because it omits two
elements: (1) the state DEA registration number (where
required), and (2) legitimate medical purpose within the
usual course of professional practice.
Source: Jennifer Bolen, JD, Sep 2005
2638.You have a patient you have seen for several years. The
patient is stable and has been on the same controlled
substances, including a Schedule II drug, for one year.
The patient has been relatively compliant with your
treatment plan and fully compliant with medication
issues. Identify the federal legal/regulatory material that
prohibits you from issuing this patient multiple schedule
II medications with different fi ll dates or “do not fi ll
before” language on your prescriptions.
A. The Interim Policy Statement of November 16, 2004.
B. The Controlled Substances Act of 1970.
C. The Code of Federal Regulations pertaining to the issuance
of prescriptions.
D. A, B, and C.
E. My state allows this so there is nothing in the federal
legal/regulatory material that prevents me from using
multiple schedule II prescriptions with different fi ll
dates with my patients.
- Answer: D
Explanation:
Reference: DEA Interim Policy Statement, Fed. Reg. Vol.
69, No. 220, pp. 67170-7172 (Nov. 16, 2004).
Explanation:
A. This is not the best answer. Although the Interim Policy
Statement discusses the prohibition against the use of
“multiple schedule II prescriptions with different fi ll
dates,” the Interim Policy Statement refers to the
Controlled Substances Act of 1970’s prohibition against
refi lls of Schedule II controlled substances. Likewise, the
federal law on prescriptions for scheduled drugs is found
in the CFR. For the answer to be correct, you would have
to look to all three levels of federal materials on the subject
matter.
B. This is not the best answer. Although the Controlled
Substances Act of 1970 prohibits refi lls of Schedule II
prescriptions, it is the Interim Policy Statement that
actually discusses the prohibition against the use of
“multiple schedule II prescriptions with different fi ll
dates.” Likewise, the federal law on prescriptions for
scheduled drugs is found in the CFR. For the answer to be
correct, you would have to look to all three levels of federal
materials on the subject matter.
C. This is not the best answer. Although the Code of
Federal Regulations contains references to prescriptions
and the prohibition against refi lls on Schedule II
controlled substances, it is the Interim Policy Statement
that actually discusses the prohibition against the use of
“multiple schedule II prescriptions with different fi ll
dates.” Likewise, the federal law on prescriptions for
scheduled drugs is found in the CSA. For the answer to be
correct, you would have to look to all three levels of federal
materials on the subject matter.
D. This is the best answer. DEA discussed the prohibition
against the use of multiple schedule II prescriptions with
different fi ll dates in the Interim Policy Statement.
However, DEA makes reference to the CSA and the federal
law also involves the Code of Federal Regulations. Thus,
all three levels of federal materials apply.
E. This is not the correct answer. Federal law takes priority
over state law in this area. States may create laws and rules
that are stricter than the federal rule prohibiting the use of
multiple schedule II prescriptions with different fi ll dates,
but states may not permit their providers to use
prescriptions in this format - with “Do not fi ll before”
dates and language.
Source: Jennifer Bolen, JD, Sep 2005
- What are the main types of legal/regulatory material at
the federal level governing record-keeping for the use of
controlled substances for the treatment of pain?
A. Acts and Laws, regulations and rules, and guidelines,
policy or position statements.
B. Laws and regulations.
C. Controlled Substances Act of 1970.
D. DEA Policy Statements.
E. Food and Drug Act.
- Answer: A
Explanation:
Reference: Federal and state materials nationwide; Bolen, J
Pain Medicine News; Bolen, J Journal of Opioid
Management (forthcoming publication 2005). Explanation:
A. This is the best answer. At the federal level there are
three main types of legal/regulatory materials governing
the parameters of and record-keeping for the use of
controlled substances to treat pain: (1) laws, like the
Controlled Substances Act of 1970, (2) regulations
governing the issuance of prescriptions, as found in the
Code of Federal Regulations, and (3) policy statements
and rules, as used by DEA to explain the federal
interpretation or position on the laws and regulations.
B. This is not the best answer. Laws and regulations do
exist at the federal level. However, the DEA uses an
additional level of legal/regulatory material called policy
statements and rules to explain the laws. It is vital for DEA
Registrants to read and understand these policy statements
and rules because they give the registrant a better
understanding of how the DEA applies and interprets the
federal legal/regulatory materials governing recordkeeping
and the use of controlled substances to treat pain.
C. This is not the best answer. Although the Controlled
Substances Act of 1970 is a law, it is just part of the body of
federal materials governing the use of controlled
substances in the United States.
D. This is not the best answer. The DEA policy statements,
such as the Interim Policy Statement of November 16,
2004, are only a part of the body of federal materials
governing the use of controlled substances in the United
States.
E. This is not the best answer. The Food and Drug Act is a
law that, in general, pertains to the development, approval,
and marketing of drugs in the United States. While it
certainly has much to do with the drugs that ultimately get
scheduled under the controlled substances act, it is only
part of the body of federal materials governing the use of
controlled substances in the United States.
Source: Jennifer Bolen, JD, Sep 2005
