Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

► Med Notes 2 > ASIPP Controlled Substance Management Questions > Flashcards

ASIPP Controlled Substance Management Questions Flashcards

1
Q
  1. 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
A
  1. 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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

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

A
  1. 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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

2476.

A
  1. 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.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

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

A
  1. Answer: E

Source: Laxmaiah Manchikanti, MD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

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

A
  1. 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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

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.

A
  1. 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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

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

A
  1. Answer: E
    Explanation:
    The next course of action is to explore the issues with the
    patient.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

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.

A
  1. 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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

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

A
  1. Answer: A

Source: Hans C. Hansen, MD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

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

A
  1. 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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q
  1. 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.
A
  1. 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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

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

A
  1. 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.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

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.

A
  1. 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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

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

A
  1. 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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q 
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®)
A
  1. 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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

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

A
  1. Answer: D

Source: Hansen HC, Board Review 2004

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q
  1. 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.
A
  1. Answer: D

Source: Hansen HC, Board Review 2004

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

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

A
  1. 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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q 
2492.N-acetyl benzoquinoneimine is the hepatotoxic
metabolite of which drug?
A. Sulindac
B. Acetaminophen
C. Isoniazid
D. Indomethacin
E. Procainamide
A
  1. 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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

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

A
  1. Answer: D
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q 
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®)
A
  1. Answer: E
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q 
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®
A
  1. Answer: A

Source: Jackson KC. Board Review 2003

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

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

A
  1. 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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

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

A
  1. 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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
``` 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 ```
2498. 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
26
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 2500. 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
2499. 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 2500. 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
27
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
2501. 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.
28
2502. 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.
2502. 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
29
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.
2503. Answer: E | Source: Erin Brisbay McMahon, JD, Sep 2005
30
``` 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 ```
2504. Answer: E | Source: Renee R. Lamm, MD, Sep 2005
31
2505. 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
2505. 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.
32
2506. 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.
2506. 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
33
2507. 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
2507. 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.
34
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
2508. 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
35
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.
2509. 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
36
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.
2510. 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
37
``` 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 ```
38
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
2512. Answer: B | Source: Roger Cicala, MD, Sep 2005
39
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.
2513. 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
40
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
2514. 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.
41
``` 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 ```
2515. Answer: C | Source: Renee R. Lamm, MD, Sep 2005
42
``` 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 ```
2516. 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
43
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
2517. 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
44
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
2518. 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
45
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
2519. 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.
46
``` 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 ```
2520. 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
47
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
2521. 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
48
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.
2522. 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
49
``` 2523.Which of the following opioids is vagolytic? A. Morphine B. Meperidine C. Sufentanil D. Nalbuphine E. Alfentanil ```
2523. Answer: B Source: American Board of Anesthesilogy, In-trainnig examination
50
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
2524. 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
51
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
2525. 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
52
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
2526. 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
53
2527. 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
2527. Answer: C | Source: Hans C. Hansen, MD
54
``` 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® ```
2528. 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
55
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.
2529. Answer: C Explanation: Source: Manchikanti L - Pain Physician 2005; 8:257-262.
56
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
2530. 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
57
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.
2531. Answer: C Source: Chou et al. - J Pain Manage Symptom Manage Vol. 25, No. 5 Nov. 2003, 1026-1048.
58
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.
2532. Answer: A Source: Chou et al. - J Pain Manage Symptom Manage Vol. 25, No. 5 Nov. 2003, 1026-1048.
59
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
2533. 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.
60
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
2534. 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
61
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.
2535. 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.
62
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
2536. 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
63
``` 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 ```
2537. 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
64
2538. 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
2538. 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
65
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.
2539. 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.
66
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
2540. 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
67
2541. 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
2541. 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
68
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
2542. 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
69
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
2543. 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
70
2544. 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
2544. 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
71
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
2545. 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
72
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
2546. 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
73
``` 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®) ```
2547. 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
74
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®)
2548. 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
75
``` 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 ```
2549. 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
76
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
2550. 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
77
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 ```
78
``` 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 ```
79
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.
2553. 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
80
``` 2554.The most commonly used illicit drug in America is: A. Oxycontin® B. Cocaine C. Morphine® D. Marijuana E. Alcohol ```
2554. 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
81
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.
2555. 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
82
2556. 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.
2556. 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
83
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
2557. 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
84
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.
2558. 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
85
2559. 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.
2559. 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
86
2560. 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
2560. 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
87
2561. 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.
2561. 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
88
2562. 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
2562. 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
89
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
2563. Answer: B | Source: Andrea M. Trescot, MD
90
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
2564. 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
91
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
2565. Answer: C Explanation: Codeine is metabolized to morphine, and hydrocodone to hydromorphone, Methadone has multiple drug interactions. Source: Andrea M. Trescot, MD
92
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
2566. 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
93
2567. 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
2567. Answer: D
94
``` 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 ```
2568. Answer: E Explanation: Alcohol accounts for 60% of all cases of substance abuse. Source: Roger Cicala, MD, Sep 2005
95
2569. 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
2569. 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
96
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
2570. 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
97
2571. 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
2571. 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
98
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.
2572. 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
99
``` 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 ```
2573. Answer: C | Source: Stimmel, B
100
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
2574. Answer: A
101
2575. 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
2575. 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
102
``` 2576.The most commonly used illicit drug is: A. Marijuana B. LSD C. Ecstasy D. Methamphetamine E. OxyContin® ```
2576. 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
103
``` 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® ```
2577. Answer: B | Source: Day MR, Board Review 2005
104
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
2578. Answer: E | Source: Stimmel, B
105
2579. 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
2579. 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
106
2580. 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.
2580. Answer: E | Source: Stimmel, B
107
``` 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 ```
2581. 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
108
2582. 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
2582. 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
109
``` 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 ```
2583. Answer: B | Source: Stimmel, B
110
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.
2584. 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
111
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
2585. 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
112
2586. 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.
2586. 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
113
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.
2587. 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
114
2588. 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
2588. Answer: D | Source: Cole EB, Board Review 2003
115
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
2589. Answer: A | Source: Stimmel, B
116
2590. 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.
2590. 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
117
2591. 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
2591. 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
118
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.
2592. 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
119
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.
2593. 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
120
``` 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 ```
2594. Answer: A | Source: Stimmel, B
121
2595. 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
2595. Answer: D | Source: Stimmel, B
122
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
2596. Answer: D | Source: Stimmel, B
123
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
2597. Answer: C | Source: Stimmel, B
124
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
2598. 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
125
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.
2599. Answer: D | Source: Stimmel, B
126
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
2600. Answer: D | Source: Stimmel, B
127
``` 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. ```
2601. Answer: A | Source: Stimmel, B
128
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).
2602. Answer: D | Source: Stimmel, B
129
``` 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 ```
2603. Answer: D | Source: Stimmel, B
130
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
2604. Answer: A | Source: Stimmel, B
131
2605. 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
2605. Answer: A | Source: Stimmel, B
132
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
2606. Answer: E | Source: Stimmel, B
133
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 ```
134
``` 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 ```
2608. 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
135
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 ```
136
``` 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 ```
2610. 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
137
``` 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. ```
2611. 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
138
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 ```
139
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.
2613. 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
140
``` 2614.Patients usually develop tolerance to all opioid effects EXCEPT: A. Sedation B. Pruritus C. Constipation D. Pain relief E. Respiratory depression ```
2614. 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
141
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
2615. 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
142
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.
2616. 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. 1. the medical history and physical examination, 2. diagnostic, therapeutic and laboratory results, 3. evaluations and consultations, 4. treatment objectives, 5. discussion of risks and benefi ts, 6. informed consent, 7. treatments, 8. medications (including date, type, dosage and quantity prescribed), 9. instructions and agreements and 10. 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
143
``` 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® ```
2617. Answer: B | Source: Raj, Pain Review 2nd Edition
144
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
2618. 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
145
``` 2619.Convulsions caused by drug poisoning are most commonly associated with A. Phenobarbital B. Diazepam C. Strychnine D. Chlorpromazine E. Phenytoin ```
2619. 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
146
``` 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 ```
2620. Answer: E
147
``` 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 ```
2621. 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).
148
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
2622. 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
149
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
2623. Answer: D Source: Raj P, Pain medicine - A comprehensive Review - Second Edition
150
2624. 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.
2624. 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
151
2625. 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.
2625. 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
152
2626. 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 ```
153
2627. 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.
2627. 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
154
2628. 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
2628. 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
155
2629. 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
2629. 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
156
2630. 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
2630. 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
157
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
2631. 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
158
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.
2632. 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
159
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
2633. 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
160
2634. 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.
2634. 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
161
``` 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 ```
2635. 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
162
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.
2636. 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
163
2637. 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.
2637. 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
164
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.
2638. 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
165
2639. 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.
2639. 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
166
2640.A registered individual practitioner is not required to keep records of controlled substances in Schedules II, III, IV, and V which are prescribed in the lawful course of professionalpractice, unless A. He/she prescribes controlled substances in the course of maintenance or detoxifi cation treatment of a patient. B. He/she prescribes controlled substances at more than one practice location. C. He/she uses the Internet for all patient contact. D. He/she has been registered for less than three years. E. He/she uses electronic medical records.
2640. Answer: A Explanation: A. This is the best answer. Unless a practitioner prescribes controlled substances in the course of detoxifi cation or maintenance of opioid addiction, he/she is NOT REQUIRED to keep the records described by the Controlled Substances Act of 1970. However, most states have Uniform Controlled Substances Act, a medical practice act, regulations or rules, and/or guidelines or policy statements (sometimes called position statements) containing recordkeeping requirements for controlled substances. B. This is not the correct answer. The fact that a provider prescribes at more than one location does not change his/her obligation to follow federal and state controlled substances recordkeeping mandates. C. This is not the correct answer. A provider who uses the Internet to interact with patients must do so pursuant to a valid physician patient relationship. Likewise, providers must follow federal and state controlled substances recordkeeping mandates. D. This is not the correct answer. It does not matter how long a provider has been registered with the DEA. As long as a practitioner holds a DEA registration, he/she is responsible for following federal and state controlled substances recordkeeping mandates. E. This is not the correct answer. Using electronic medical records does not excuse a provider from following federal and state controlled substances recordkeeping mandates. Source: Jennifer Bolen, JD, Sep 2005
167
2641.All of the statements are correct about Drug Abuse Prevention and Control Act of 1970 EXCEPT: A. It is Title 21, Chapter 13 of US Code B. Established current schedules, registrations, agencies, enforcement and penalties. C. There has been little change in laws since that time. D. Enforcement since inception has changed signifi cantly. E. Described schedules of controlled drugs
2641. Answer: E Explanation: Drug Abuse Prevention and Control Act of 1970 * Title 21, Chapter 13 of US Code * Established current schedules, registrations, agencies, enforcement and penalties. * Little change in laws since that time, although enforcement varies and case law has modifi ed interpretation. Source: Roger Cicala, MD, Sep 2005
168
2642. Phencyclidine may best be characterized by which of the following statements? A. It has opioid activity B. Its mechanism of action is related to its anticholinergic properties C. It can cause signifi cant hallucinogenic activity D. It causes signifi cant withdrawal symptoms E. Treatment of overdose is with an opiate
2642. Answer: C Explanation: Reference: Hardman, pp 574-575 A. Phencyclidine has no opioid activity B. Its mechanism of action is amphetamine-like with opioid activity. C. Phencyclidine is a hallucinogenic compound with no opioid activity. Its mechanism of action is amphetaminelike. D. A withdrawal syndrome has not been described for this drug in human subjects. E. In overdose, the treatment of choice for the psychotic activity is the antipsychotic drug haloperidol. Source: Stern - 2004
169
2643.The federal law governing the scheduling of drugs as “controlled substances” is called: A. The Food, Drug, and Cosmetic Act of 1962. B. The Federal Uniform Controlled Substances Act. C. The Code of Federal Regulations. D. The Controlled Drug Act. E. The Controlled Substances Act of 1970.
2643. Answer: E Explanation: Reference: The Controlled Substances Act of 1970, codifi ed in 21 U.S.C. § 801 and sections that follow. Explanation: A. The Food, Drug, and Cosmetic Act of 1962, establishes the law on drug development, approval for medical use, and marketing in the United States. However, this Act does not contain the law governing the scheduling of drugs as controlled substances. B. There is no such federal act. Instead, many states have adopted a Uniform Controlled Substances Act (sometimes referred to as a Uniform Controlled Drugs Act). C. The Code of Federal Regulations explains various components of the Controlled Substances Act of 1970, but the CFR does not contain the law relating to the scheduling of drugs in the United States. D. There is no such federal act. E. The Controlled Substances Act of 1970 contains the law in the United States governing the scheduling of drugs as “controlled substances.” The CSA places controlled substances into fi ve schedules. Schedule I contains drugs with no accepted medical use. Schedule I drugs are available only for scientifi c research. Schedules II-V contain drugs that have been approved for medical and schedules them according to potential for abuse, with drugs having the highest potential for abuse assigned to Schedule II. Source: Jennifer Bolen, JD, Sep 2005
170
2644.A deliberate (dealing) practitioner characteristics include all of the following EXCEPT: A. Practitioner becomes a mercenary B. Sells drugs for money, sex, street drugs, etc. C. Offi ce becomes a pill factory—full of drug seekers D. Prescribes for known addicts who will likely sell drugs to others E. Keeps close contact with DEA
2644. Answer: E Explanation: Deliberate (Dealing) Practitioner becomes a mercenary Sells drugs for money, sex, street drugs, etc. Offi ce becomes a pill factory—full of drug seekers Prescribes for known addicts who will likely sell drugs to others Source: Roger Cicala, MD, Sep 2005
171
2645.Which one of the following statements best describes the mechanism of action of benzodiazepines? A. Benzodiazepines activate GABA B receptors in the spinal cord B. Their inhibition of GABA transaminase leads to increased levels of GABA C. Benzodiazepines block glutamate receptors in hierarchical neuronal pathways in the brain D. They increase the frequency of opening of chloride ion channels that are coupled to GABA A receptors E. They are direct-acting GABA receptor agonists in the CNS
2645. Answer: D Explanation: Benzodiazepines are thought to exert most of their CNS effects by increasing the inhibitory effects of GABA. Benzodiazepines interact with specifi c receptors (BZ receptors) that are components of the GABA A receptorchloride ion channel macromolecular complex to increase the frequency of chloride ion channel opening. Benzodiazepines are not GABA receptor agonists because they do not interact directly with this component of the complex. Source: Katzung & Trevor’s Pharmacology, Examination and Board Review, 6th Ed., McGraw Hill, New York, 1998
172
2646.Concerning the clinical uses of benzodiazepines and related drugs, which one of the following statements is accurate? A. Alprazolam is effective in the management of obsessivecompulsive disorders B. Clonazepam has effectiveness in patients who suffer from phobic anxiety states C. Diazepam is used for chronic management of bipolar affective disorder in patients who are unable to tolerate lithium D. Intravenous buspirone is useful in status epilepticus E. Symptoms of the alcohol withdrawal state may be alleviated by treatment with zaleplon
2646. Answer: B Explanation: Benzodiazepines have no signifi cant therapeutic benefi t in the management of obsessive-compulsive disorders. Drugs effective for this condition increase the activity of serotonergic systems in the brain. Clonazepam has been used commonly as an anticonvulsant and also has effi cacy in anxiety states, including agoraphobia. Clonazepam (not diazepam) has also been used as a back-up drug in bipolar affective disorder. Source: Katzung & Trevor’s Pharmacology, Examination and Board Review, 6th Ed., McGraw Hill, New York, 1998
173
2647.Choose the accurate statements concerning the Barbiturates and Benzodiazepines: A. Compared with benzodiazepines, barbiturates exhibit a fl atter dose-response relationship B. Respiratory depression caused by barbiturate overdosage can be reversed by fl umazenil C. An increase in urinary pH will accelerate the elimination of phenobarbital D. Barbiturates may increase the half-lives of drugs metabolized by the liver E. Symptoms of the abstinence syndrome are less severe during the withdrawal from secobarbital than from phenobarbital
2647. Answer: C Explanation: A. The dose-response curve for benzodiazepines is fl atter than that for barbiturates. B. Flumazenil is an antagonist at Benzodiazepine receptors and is used to reverse CNS depressant effects of benzodiazepines. C. As a weak acid (pKa +=7), phenobarbital will exist mainly in the ionized (nonprotonated) form in the urine at alkaline pH and will not be reabsorbed in the renal tubule. D. Induction of liver drug-metabolizing enzymes occurs with barbiturates and may lead to decreases in half-life of other drugs. E. Withdrawal symptoms from use of the shorter-acting barbiturate secobarbital are more severe than with phenobarbital. Source: Katzung & Trevor’s Pharmacology, Examination and Board Review, 6th Ed., McGraw Hill, New York, 1998
174
2648. A morbidly obese patient with low back pain complains of not sleeping well and feeling tired during the day. His wife wakes him up several times during the night due to his loud snores. Patient wants a prescription for sleep medicine. Your next step is: A. Prescribe Clorazepate B. Prescribe Flurazepam C. Prescribe Secobarbital D. Prescribe Triazolam E. Refer to sleep disorder clinic
2648. Answer: E Explanation: A-D. Benzodiazepines and barbiturates are contraindicated in breathing-related sleep disorders because they will further compromise ventilation. In the obstructive sleep apnea syndrome (pickwickian syndrome), obesity is a major risk factor. The best prescription you can give this patient is to lose weight. E. Patient probably suffers with sleep apnea syndrome and should be referred to sleep disorder clinic or sleep study. Source: Katzung & Trevor’s Pharmacology, Examination and Board Review, 6th Ed., McGraw Hill, New York, 1998
175
2649. Choose the most likely effect resulting from treatment with 10 mg of diazepam 3 times daily? A. Retrograde amnesia B. Improved performance on tests of psychomotor function C. Alleviation of the symptoms of major depressive disorder D. Increased porphyrin synthesis E. Agitation and possible hyperreflexia with abrupt discontinuance after chronic use
2649. Answer: E Explanation: A. At high doses, benzodiazepines may cause anterograde but not retrograde, amnesia. B. Diazepam use can cause a decrease in psychomotor function. C. Diazepam has no more effectiveness than placebo in the treatment of major depression D. Benzodiazepines do not increase activity of liver drugmetabolizing enzymes or of enzymes involved in porphyrin synthesis. E. With abrupt discontinuance following chronic use, anxiety and agitation may occur, sometimes with hyperrefl exia and, rarely, seizures. Source: Katzung & Trevor’s Pharmacology, Examination and Board Review, 6th Ed., McGraw Hill, New York, 1998
176
2650. All of the following statements are sources of confusion in describing chronic pain EXCEPT: A. Pain can be described in terms of its physiological underpinnings and its felt experience B. Patients are ashamed of acknowledging the psychological contributors to their pain. C. Practitioners are uncomfortable with acknowledging psychological contributors D. Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage (IASP). E. Pain is best described if only structural abnormalities are utilized.
2650. Answer: E | Source: Murray McAllister, PsyD, LP - Spring 2004
177
2651. Applied to the skin in a transdermal patch (transdermal therapeutic delivery system), this drug is used to prevent or reduce the occurrence of nausea and vomiting that are associated with motion sickness A. Diphenhydramine B. Chlorpromazine C. Ondansetron D. Dimenhydrinate E. Scopolamine
2651. Answer: E Explanation: Reference: Hardman, p 930. All the drugs listed in the question are used as antiemetics. A. Diphenhydramine and dimenhydrinate are used orally for the active and prophylactic treatment of motion sickness. B. Chlorpromazine is a general antiemetic, used orally, rectally, or by injection for the control of nausea and vomiting that is caused by conditions that are not necessarily defi ned. C. Ondansetron is indicated in the oral or intravenous route for the prevention of nausea and vomiting caused by cancer chemotherapy. D. Dimenhydrinate is used for prophylaxis and treatment of motion sickness. E. Scopolamine is a transdermal preparation used in the prevention of motion sickness. The drug is incorporated into a bandage-like adhesive unit that is placed behind the ear. The scopolamine delivered in this manner is well absorbed and maintains an effect for up to 72h. Other drugs that are prepared for transdermal delivery include clonidine (an antihypertensive agent), estradiol (an estrogen), fentanyl ( an opioid analgesic), nicotine (a smoking deterrent), nitroglycerin (an antianginal drug), and testosterone ( an androgen). Source: Stern - 2004
178
2652. What are the correct statements about long-term use of opioids in chronic non-cancer pain? A. No reliable long term studies (> 8 months) that demonstrate effi cacy and safety of long term opioid therapy for chronic pain B. Overall relief with opioids is high (75%) C. Physicians must be liberal when prescribing long term opioids D. Outcomes are not patient-specifi c E. No risk of adverse events, addiction, diversion, or noncompliance have been noted
2652. Answer: A Explanation: * No reliable long term studies (> 8 months) that demonstrate effi cacy and safety of long term opioid therapy for chronic pain * Overall relief with opioids is modest (35%) * Physicians must be cautious when prescribing long term opioids * Outcomes are patient-specifi c * Be aware of risk of adverse events - Addiction; diversion; noncompliance - Concomitant psychiatric illness - Accidental overdose; etc * What are your true practice costs? Source: Mark V. Boswell, MD, KSIPP 2005
179
2653. Compared with midazolam, diazepam has which of the following characteristics? A. Greater solubility in water B. Shorter beta half-life C. More potent ventilatory depressant effect D. Lower risk for thrombophlebitis E. A pharmacologically active metabolite
2653. Answer: E Source: American Board of Anesthesilogy, In-trainnig examination
180
``` 2654.The second most common opioid of choice for intrathecal infusion following morphine is: A. fentanyl B. sufentanil C. hydromorphone D. morphine E. mepiridine ```
2654. Answer: C | Source: Nader and Candido – Pain Practice. June 2001
181
``` 2655.A patient complains of inadequate analgesia and increases his use of his medication. This behavior may represent: A. Addiction B. Drug abuse C. Tolerance D. Drug diversion E. All or any of the above ```
2655. Answer: E Explanation: If a patient increases the medication despite the knowledge that he will be discharged, this may be addiction. If he increases the medication because it is no longer effective, that may be tolerance. Source: Trescot AM, Board Review 2004
182
2656. An 82-year-old woman, otherwise healthy for her age, has diffi culty sleeping. Triazolam (Halcion®) is prescribed for her at one-half of the conventional adult dose. The most likely explanation for the increased sensitivity of elderly patients to a single dose of triazolam and other sedative-hypnotic drugs is A. Changes in plasma protein binding B. Decreased renal function C. Increased cerebral blood fl ow D. Decreased hepatic metabolism of lipid-soluble drugs E. Changes in brain function that accompany the aging process
2656. Answer: E Explanation: Decreased blood fl ow to vital organs, including the liver and kidney, occurs during the aging process. These changes may contribute to cumulative effects of sedativehypnotic drugs. However, this does not explain the enhanced sensitivity of the elderly patient to a single dose of central depressant, which appears to be due to changes in brain function that accompany aging. Source: Katzung & Trevor’s Pharmacology, Examination and Board Review, 6th Ed., McGraw Hill, New York, 1998
183
2657.Choose the correct statement about a duped practitioner. A. Never assumes the best about his patients and is gullible B. Never leaves script pads lying around C. Does not believe in hydrophilic medicine “fell” into the toilet or the sink D. Believes when patients only want specifi c medications (i.e. OxyContin or Percocet) E. Never co-dependent - always tells patients “No” when they ask for narcotics
2657. Answer: D Explanation: Duped Always assumes the best about his patients and is gullible Leaves script pads lying around Hydrophilic medicine—fell into the toilet or the sink Patients only want specifi c medications (i.e. OxyContin or Percocet) Co-dependent—cannot tell patients “No” when they ask for narcotics Source: Roger Cicala, MD, Sep 2005
184
``` 2658. The Schedule I substance among the following drugs is? A. Buprenorphine B. Hydromorphone C. Heroin D. Diazepam E. Morphine ```
2658. Answer: C Explanation: The Controlled Substances Act has divided drugs under its jurisdiction into fi ve schedules. Schedule I drugs have a high potential for abuse and no accepted medical use in the United States. Examples of schedule I drugs include heroin, marijuana, LSD, etc. A. Buprenorphine is Schedule III drug B. Hydromorphone is Schedule II C. Heroin is Schedule II D. Diazepam is Schedule IV E. Morphine is Schedule II Source: Manchikanti L, Board Review 2005
185
2659. Your friend’s daughter whom you have known for several years makes an appointment with you. During the visit, she tells you that she is a heroin addict and requests a prescription for Hydrocodone. Your options in this situation are as follows: A. Immediately call her father and give hydrocodone. B. Immediately tell father and give her Methadone. C. Start rapid detoxifi cation in your offi ce. D. Provide her with a prescription for Methadone maintenance E. Do not tell the father and do not give Hydrocodone.
2659. Answer: E Explanation: A. A physician has to maintain patient confi dentiality. Further, she may be addicted to not only heroin, but Hydrocodone. It is not certain at this point. She may be receiving methadone from other sources. B. A physician has to maintain patient confi dentiality. Further, she may be addicted to not only heroin, but Hydrocodone. It is not certain at this point. She may be receiving methadone from other sources. D. Methadone maintenance treatment requires special licensure. C. Similarly, rapid detoxifi cation also requires a special license. E. The best option is to maintain confi dentiality, protect the patient, and yourself. Source: Manchikanti L, Board Review 2005
186
2660. The following statements are true with typical detection times for urine testing of common drugs of abuse. A. Methadone, 2 to 4 days B. Chronic use of marijuana, 1 to 3 days C. Morphine, 15 days D. Cocaine, 15 days E. Benzodiazepines, 15 days
2660. Answer: A | Explanation:
187
2661. A patient presents to you with chronic low back pain. He is being treated with OxyContin 40 mg twice a day and hydrocodone 10 mg four times daily. You performed a drug testing. The results of the drug testing were positive for oxycodone, hydromorphone, and hydrocodone. The results indicate the following: A. The patient abusing controlled substances by taking non-prescribed drugs. B. He is non-compliant by not taking the prescribed drugs. C. He is selling drugs D. The results of the drug test show a normal pattern E. The drug test indicates the patient is taking his mother’s hydromorphone
2661. Answer: D | Source: Manchikanti L, Board Review 2005
188
2662. What are the correct statements about a defi cient (dated practitioner) ? 1. Too busy to keep up with CME 2. Only aware of a few treatments or medications 3. Prescribes for friends or family without a patient record 4. Well aware of controlled drug categories
``` 2662. Answer: E (All) Explanation: Defi cient (Dated Practitioner) Too busy to keep up with CME Unaware of controlled drug categories Only aware of a few treatments or medications Prescribes for friends or family without a patient record Unaware of symptoms of addiction Remains isolated with peers Only education from reps Source: Laxmaiah Manchikanti, MD ```
189
2663. True statements concerning patient controlled analgesia include the following: 1. Better patient satisfaction with pain control. 2. Shorter hospital stays. 3. Less total analgesic use. 4. A greater potential for subsequent opiate dependence
2663. Answer: A (1,2, & 3) | Source: Stimmel, B
190
2664. What were the physician opioids of choice in the 1990s? 1. Oxycodone 20% 2. Hydrocodone 70% 3. Dilaudid 20% 4. Fentanyl class 10%
``` 2664. Answer: C (2 & 4) Explanation: Physician Opioid of Choice 1990s Hydrocodone 70% Fentanyl class 10% Dilaudid ```
191
2665. What were the physician opioids of choice in 2002? 1. Hydrocodone 40% 2. Oxycodone 25% 3. Ultram 70% 4. Dilaudid 25%
``` 2665. Answer: A (1,2, & 3) Explanation: Physician Opioid of Choice 1990s Hydrocodone 70% Fentanyl class 10% Dilaudid ```
192
2666. Choose all side effects of clonidine (Catapres): 1. Drowsiness 2. Hypotension 3. Dizziness 4. Dry mouth
2666. Answer: E (All) | Source: Stimmel, B
193
2667. What are the advantages of prolonged, high-dose opioid therapy? 1. No evidence to support high dose therapy (>200 to 300 mg/day or more) 2. Opioid doses should not be limited in the name of improving effi cacy and safety 3. Anecdotal evidence that pain relief not better 4. There is solid evidence that 3600 mg of oxycodone per day is effective in neuropathic pain
2667. Answer: B (1 & 3) Explanation: Prolonged, High-Dose Opioid Therapy: No evidence to support high dose therapy (> 200 to 300 mg/day or more) Anecdotal evidence that pain relief not better Opioid doses should be limited to improve effi cacy and safety Source: Mark V. Boswell, MD, KSIPP 2005
194
``` 2668. Analgesia of six hours or longer in duration can be obtained with all the following drugs: 1. Levo Dromoran 2. MS Contin 3. Methadone 4. Oxycodone ```
2668. Answer: A (1,2, & 3) | Source: Stimmel, B
195
2669. Opioids recommended for lactating patients include 1. Morphine 2. Hydromorphone 3. Hydrocodone 4. Meperidine
``` 2669. Answer: A (1,2, & 3) Explanation: Meperidine is contraindicated for lactation because normeperidine collects in the neonate Source: Boswell MV, Board Review 2005 ```
196
2670. What were the physician drugs of abuse in 2001? 1. Opioids 30% 2. Alcohol 20% to 30% 3. Benzodiazepines 20% 4. Marijuana 2% 2671. What are the pitfalls of prescription practices? 1. 4 D’s - Defi cient, Duped, Deliberate, Dependent Practitioner 2. Never say “NO” - Family, Friends, Patients 3. Ignore complaints 4. Focus on positive aspects of regulations and reimbursement
``` 2670. Answer: B (1 & 3) Explanation: Physician Drugs of Abuse 2001 Alcohol 50% to 60% Opioids 30% Benzodiazepines 20% (40% for females) Marijuana 20% Cocaine 10% Amphetamines, Ritalin 10% Source: Roger Cicala, MD, Sep 2005 ``` 2671. Answer: A (1,2, & 3) Explanation: Top 10 Pitfalls 1. 4 D’s – Defi cient, Duped, Deliberate, Dependent Practioner 2. Weak heart – pretend addiction doesn’t exist 3. Never say “NO” – Family, Friends, Patients 4. Poor documentation 5. No policies – No agreements 6. Ignore complaints 7. Focus on negative aspects of regulations and reimbursement 8. Not nice to investigators from Board, DEA!! 9. Reckless disregard to law with prescription pads and regulations 10. Know it all – Do it all Source: Laxmaiah Manchikanti, MD
197
2672. What are the clinical implications of non-responsiveness to opioids in chronic pain? Choose the correct statements. 1. Diffi cult to distinguish pharmacologic tolerance from opioid-induced abnormal pain sensitivity 2. Treating increasing pain with increasing doses may be futile 3. High dose therapy may have adverse consequences 4. Push the dose to highest level or combine 2 opioids
2672. Answer: A (1,2, & 3) Explanation: Clinical Implications: * Difficult to distinguish pharmacologic tolerance from opioid-induced abnormal pain sensitivity * Treating increasing pain with increasing doses may be futile * High dose therapy may have adverse consequences Source: Mark V. Boswell, MD, KSIPP 2005
198
``` 2673. Which of the following include subjective reports of marijuana effects? 1. Increased sexual desire 2. Increased appetite 3. Enhanced tactile sensitivity 4. Increased motivation ```
2673. Answer: A (1,2, & 3) | Source: Stimmel B
199
``` 2674. The most signifi cant increase in prescriptive medication for illicit use is: 1. THC (tetrahydrocannabinol) 2. Cocaine 3. Benzodiazepines 4. Pain relievers ```
2674. Answer: D (4 Only) Explanation: 2002 and 2003 saw a signifi cant increase in non-medical use of pain relievers. This seems to be a trend over the past decade. Hydrocodone leads at 15 million, followed by oxycodone (Oxycontin? specifi cally mentioned as a subset of oxycodone), methadone, and tramadol. Source: Hans C. Hansen, MD
200
2675. A 34-year-old recently married man seeks help from a methadone clinic. Chose all of the true statements meeting criteria for acceptance into the program: 1. He has AIDS 2. He has no legal charges pending 3. He has used heroin for 2 years 4. He has been married to a heroin addict
2675. Answer: A (1,2, & 3) | Source: Stimmel, B
201
2676. What are the risks of malprescribing related to practice management? 1. Loss of “Provider Status” 2. Insurers frequently report to Boards 3. Plans may remove providers for “overprescribing” 4. Insurers are unable to report any type of national databank for malprescribing
2676. Answer: A (1,2, & 3) Explanation: Risks of Malprescribing Loss of “Provider Status” Insurors frequently report to Boards Insurors frequently report to Boards now Several plans have removed providers for “overprescribing.” Seems more common with more expensive agents (Duh!). Insurors can report to a separate national data bank, not available to public, but available to hospitals and other insurors. Source: Laxmaiah Manchikanti, MD
202
2677. A 16-year-old boy is brought for emergency evaluation after taking some of his mother’s medication in order to get “high.” He is fl ushed and his pupils are dilated and only poorly reactive. He complains of dry mouth. He is restless, confused at times, and may be having visual hallucinations. Which of the following medications is he likely to have taken? 1. Phenelzine 2. Disulfi ram 3. Alprazolam 4. Benztropine
2677. Answer: D (4 Only) Explanation: Benzotropine (Cogentin) has atropine-like side effects; dilated pupils, dry mouth, urinary retention, restlessness, confusion and toxic psychosis.1. Phenelzine, a MAOI, reacts with tyramine-containing substances causing a “cheese reaction,” which consists of sweating, palpitations, headache, and increased blood pressure resulting in a possible intracerebral hemorrhage.2. Disulfi ram (Antabuse), if taken with alcohol, cuases fl ushing, throbbing, sweating, thirst, respiratory diffi culty, nausea, vomiting, tachycardia, hypotension, vertigo, blurred vision, and confusion.3.Alprazolam, a benzodiazepine, causes sedation, impairment of performance, and dependency. Source: Psychiatry specialty Board Review By William M. Easson, MD and Nicholas L. Rock, MD
203
``` 2678. Cocaine abuse is likely to produce symptoms similar to which of the following? 1. Major depression 2. Obsessive compulsive disorder 3. Generalized anxiety disorder 4. Paranoid schizophrenia ```
2678. Answer: D (4 Only) Explanation: Cocaine blocks neuronal dopamine, serotonin, and norepinephrine reuptake. With prolonged cocaine use and abuse, a delusional psychosis similar to paranoid schizophrenia may develop. Source: Psychiatry specialty Board Review By William M. Easson, MD and Nicholas L. Rock, MD
204
2679. Drugs can be altered by: 1. Absorbsion 2. Distribution 3. Metabolism 4. Excretion
``` 2679. Answer: E (All) Explanation: All of these actions can infl uence the drug-drug interaction. Source: Andrea M. Trescot, MD ```
205
2680. “Opioid rotation” 1. May work because of variable affi nity for the μ receptor 2. May work because of differing opioid metabolic pathways 3. May work because of avoidance of metabolite antagonists 4. May work because of differing drug interactions
2680. Answer: E (All) Explanation: Different opioids have different receptor affi nity, so that switching from a low affi nity opioid like hydrocodone to a high affi nity opioid like fentanyl may allow for better analgesia at a lower than equipotent dose. Different metabolic pathways may explain why hydrocodone (a prodrug metabolized by CYP2D6) might not be effective when propoxyphene is, especially in a patient who is CYP2D6 defi cient. High doses of morphine can lead to accumulation of M3G which is hyperalgesic; switching to an opioid without this type of antagonist would give better analgesia. Inhibition of one enzyme system (such as 3A4 and methadone) would have no effect on an opioid metabolized by another system (such as 2D6 and hydrocodone). Source: Andrea M. Trescot, MD
206
2681. What are the risks of malprescribing? 1. Legal charges, probably jail time 2. Conviction rate is currently almost 30% 3. Felony conviction will likely prevent or at least severely limit future practice 4. Duped and Dated are highly viable defenses
``` 2681. Answer: B (1 & 3) Explanation: Risks of Malprescribing Legal charges, probably jail time Conviction rate is currently almost 90% Felony conviction will likely prevent or at least severely limit future practice Duped and Dated aren’t viable defense Source: Laxmaiah Manchikanti, MD ```
207
2682. The scope of the problem of prescription opioids among physicians is as follows: 1. Up to 20% of prescribed opioids are diverted. 2. 567 physician arrests and sanctions in 2002. 3. No more federal diversion program for malprescribing physicians. 4. State boards may not take any actions.
2682. Answer: A (1,2, & 3) Explanation: Up to 20% of prescribed opioids are diverted. 567 physician arrests and sanctions in 2002. No more Federal diversion program for malprescribing physicians. State Boards may react to arrests of physicians, increasing sanctions. Source: Roger Cicala, MD, Sep 2005
208
2683. Drugs able to diminish the dose of opioids analgesics required to relieve pain include the following: 1. Amphetamines 2. Tricyclic antidepressants 3. Non-steroidal anti-infl ammatory agents 4. Acetaminophen (Tylenol)
2683. Answer: E (All) | Source: Stimmel, B
209
2684. Identify reasons for a standard order for Meperidine 75 mg every four hours to be inappropriate? 1. Effective analgesia lasts only 2.5 to 3 hours. 2. If a person is also receiving a monoamine oxidase inhibitor, severe toxicity can occur. 3. That dose is equivalent only to 5 to 7.5 mg of morphine. 4. In the presence of impaired renal function toxicity may occur.
2684. Answer: E (All) | Source: Stimmel, B
210
``` 2685. Which of the following have been identifi ed as algogenic substances? 1. Serotonin 2. Leukotrienes 3. Acetylcholine 4. Histamine ```
2685. Answer: E (All)
211
2686.Findings of illicit drug use based on insurance in interventional pain management setting was: 1. Third party - 17% 2. Medicare with/without third party - 10% 3. Medicare/Medicaid - 24% 4. Medicaid - 39%
2686. Answer: E (All) | Source: Laxmaiah Manchikanti, MD
212
``` 2687. Which of the following drugs will increase blood levels of oxycodone? 1. Fluoxetine (Prozac®) 2. Sertraline (Zoloft®) 3. Paroxetine (Paxil®) 4. Carbamazepine (Tegretol®) ```
``` 2687. Answer: A (1,2, & 3) Explanation: Carbamazepine is an inducer of 2D6 and will reduce oxycodone levels. Source: Boswell MV, Board Review 2004 ```
213
``` 2688. An opiate overdose patient may present with all of the following: 1. Increase in respiratory rate 2. Small pupils 3. Hypertension 4. Coma ```
2688. Answer: C (2 & 4) | Source: Stimmel, B
214
``` 2689. Intravenous heroin use causes or is associated with all of the following: 1. Affective disorder 2. Liver disease 3. Endocarditis 4. Gall bladder disease ```
2689. Answer: A (1,2, & 3) | Source: Stimmel, B
215
2690. Opioids exert their action by: 1. Inhibiting the release of substance P 2. Activating G proteins 3. Inhibiting adenylate cyclase 4. Activating dopaminergic neurons
2690. Answer: E (All) Explanation: Opioid receptors, concentrated in the ventral tegmental and periaqueductal grey areas, presynaptically inhibit the transmission of excitatory pathways: acetylcholine, catecholamine, serotonin, and substance P. Activation of the opioid receptor inhibits adenylate cyclase. All opioid receptors are G protein-linked structures embedded in the plasma membrane of neurons; activation releases a portion of the G protein, which moves in the membrane until it reaches its target (either an enzyme or an ion channel). These targets alter protein phosphorylation and/ or gene transcription. Opioids and endogenous opioids activate presynaptic receptors on GABA neurons, which inhibit the release of GABA in the ventral tegmental area. This allows dopaminergic neurons to fi re more vigorously, and the extra dopamine in the nucleus accumbens is intensely pleasurable. Source: Andrea M. Trescot, MD
216
2691. After starting a hospital patient on a morphine PCA, you get a call from the nurse that the patient’s face is itching. You tell the nurse that: 1. This is an allergic reaction, and to stop the medicine 2. This is a histamine release and will likely go away 3. The chart should be marked “allergic to all opioids” 4. Changing the PCA to hydromorphone will likely stop the itching
2691. Answer: C (2 & 4) Explanation: Itching from opioids (usually the naturally occurring such as codeine and morphine) is usually not an antibody/antigen reaction but rather a direct histamine release from the mast cells, as well as a central μ receptor stimulation. Changing to a synthetic opioid such as hydromorphone will usually resolve the problem. In the face of a “true allergy”, there is usually no cross reactivity across classes. Source: Andrea M. Trescot, MD
217
``` 2692. All of the following are symptoms of alcohol withdrawal : 1. Coarse tremor of hands or tongue 2. Generalized tonic-clonic seizures 3. Tachycardia, sweating, dilated pupils 4. Abducent nerve paresis or paralysis ```
2692. Answer: A (1,2, & 3) Explanation: Alcohol withdrawal occurs when there is a relative drop in blood alcohol levels; therefore, it can develop while still drinking. The patients are likely to show a coarse, fastfrequency generalized tremor that is made worse by motor activity or stress and is easily observed when the hands or tongue are extended. Withdrawal is manifested by autonomic hyperactivity (increased BP, tachycardia, sweating), malaise, vomiting with anxiety, depression, irritability, cognitive changes, and possible seizures. Source: Psychiatry specialty Board Review By William M. Easson, MD and Nicholas L. Rock, MD
218
2693.Those that drink alcohol on a regular basis are recognized to have increased risk when mixed with controlled substances, particularly sedatives, opioids and benzodiazepines. Which is true of those that consume alcohol, and placed at risk in this population? 1. 120 million Americans use alcohol regularly. 2. 20% of the American population consider themselves alcohol users. 3. 16.1 million are heavy, or regular drinkers. 4. 1% of Americans have participated in a binge drinking episode one month prior to the survey.
2693. Answer: B (1 & 3) Explanation: Alcohol is a signifi cant problem, particularly when controlled substances are being used, and those that have signifi cant risks associated with them, particularly pharmacokinetically long acting drugs. An example that underscores this issue is that the FDA recently removed Palladone?, a pharmacokinetically long acting hydromorphone preparation from the market. Palladone? has been considered for pain control for a number of years, recently introduced, and to be found an unacceptably high risk when mixing alcohol and this drug. 50% of the American population consider themselves alcohol consumers, and 22% of those participated in a binge drinking episode one month prior to the survey. 16.1 million are heavy drinkers, and at signifi cant risk. Source: Hans C. Hansen, MD
219
2694. What are the characteristics of a drug dependent (addict) practitioner? 1. Starts by taking controlled drug samples 2. Never asks staff to pick up medications in their names 3. Calls in scripts in names of family members or fi ctitious patients and picks them up himself 4. Never uses another doctor’s DEA number
``` 2694. Answer: B (1 & 3) Explanation: Drug Dependent (Addict) Starts by taking controlled drug samples Asks staff to pick up medications in their names Uses another doctor’s DEA number Calls in scripts in names of family members or fi ctitious patients and picks them up himself Source: Laxmaiah Manchikanti, MD ```
220
2695.Upon abrupt discontinuation of L-alpha-acetylmethadol (LAAM) in a tolerant patient, one may observe: 1. Decreased respiratory response to increased carbon dioxide. 2. Withdrawal symptoms, which may not appear for up to 3 days. 3. Vomiting, diarrhea, hypertension, skeletal muscular twitching as severe signs. 4. Few symptoms until 72 hours have passed.
2695. Answer: E (All) | Source: Stimmel, B
221
2696. Highly tolerant opioid users, maintained on their drug in a research setting, will: 1. Continue to feel a “rush” when their drug of choice is administered intravenously. 2. Continue to use their drug of choice for reasons other than fear of experiencing withdrawal. 3. Continue to experience pleasurable effects from food, sex, tobacco and other non-opiate drugs. 4. Will not use any other drug for medical or recreational purposes
2696. Answer: A (1,2, & 3) | Source: Stimmel, B
222
2697. A former drug addict is admitted to the psychiatric ward with depression secondary to chronic back pain. He has been taking tramadol 6 tablets per day. He was started on paroxetine and you were consulted for pain management. He complains that the tramadol is not working, and he is noted to become more agitated. Your assessment is: 1. He is drug seeking 2. He is withdrawing from illicit medications 3. His depression is making his pain worse 4. He is on the inappropriate antidepressant
2697. Answer: D (4 Only) Explanation: The most likely problem is that the paroxetine (Paxil®) (a potent CYP2D6 inhibitor) is preventing the metabolism of tramadol to the active M1 metabolite. He is therefore not drug seeking or withdrawing from illicit drugs, but instead has had his previously working opioid made ineffective by the drug interaction. Source: Andrea M. Trescot, MD
223
2698. What are the Methadone interactions? 1. Cimetidine will increase methadone levels 2. Butalbital will decrease methadone levels 3. Ciprofl oxin will increase methadone levels 4. Phenytoin will decrease methadone levels
2698. Answer: E (All) Explanation: Cimetidine, and Ciprofl oxin are CYP3A4 inhibitors, and will increase methadone levels. Ciprofl oxin can inhibit CYP3A4 by up to 65%. Phenytoin and butalbital will induce the CYP3A4 enzyme and decrease blood levels. Source: Andrea M. Trescot, MD
224
2699. A patient with esophageal cancer has been taking hydrocodone 10mg 2 TID by mouth with good relief. However, he is admitted to the hospital with esophagitis from radiation and is not able to tolerate any medications by mouth. Options for pain management include: 1. 1 mg/hr morphine IV continuously 2. 50 mg meperidine IM every 6 hours 3. 0.5mg hydromorphone IV every 4 hours 4. 25 mcg/hr Fentanyl transdermally
2699. Answer: B (1 & 3) Explanation: The patient’s total dose of hydrocodone is 60mg per day, which is equal to 60mg oral morphine per day. This converts to 20mg IV morphine per day (30mg morphine = 10mg IV), which is divided by 24 to get the hourly dose of 1mg per hour. This is equivalent to 3mg per day of hydromorphone (10mg IV morphine = 1.5mg IV hydromorphone so 20mg IV morphine = 3mg IV hydromorphone), which, divided into 6 doses (q4hrs) = 0.5mg per dose. Meperidine is not appropriate, and fentanyl is too slow an onset for the initial conversion. Source: Andrea M. Trescot, MD
225
2700. In the management of alcohol withdrawal delirium, the clinician may wish to use all of the following : 1. Chlordiazepoxide 2. Magnesium sulfate 3. Thiamine 4. Intravenous glucose
2700. Answer: E (All) Explanation: The prefered medications for the management of alcohol withdrawal delirium are the benzodiazepines (chlordiazepoxide, diazepam, lorazepam, oxyazepam). Multivitamins, particularly thiamine, B12, and folic acid, should be used. Thiamine IV or IM should be given prior to glucose loading. If seizures develop, using magnesium sulfate. Clonidine, propranolol, chloral hydrate, benzodiazepines, or barbiturates can be used depending on the total clinical picture. Source: Psychiatry specialty Board Review By William M. Easson, MD and Nicholas L. Rock, MD
226
2701. Which of the following are principles of medical ethics? 1. Justice 2. Benefi cence 3. Autonomy 4. Non-negligence
2701. Answer: A (1, 2, & 3)
227
2702. Which of the following statements about alcoholics are correct? 1. Suicidal behavior is common after personal loss 2. High incidence of alcohol abuse is patients who commit suicide 3. Alcohol tends to worsen depression 4. Alcoholics who threaten suicide usually do not kill themselves
2702. Answer: A (1, 2, & 3) Explanation: Alcoholism is the third largest health problem after heart disease and cancer. In males 25-44 years old, alcohol plays a major role in all four leading causes of death: accidents, homicides, suicides, and alcoholic cirrhosis. The chronic use of alcohol produces psychological, interpersonal, and medical problems, which include violence, absence from work, loss of job, and legal diffi culties. Alcohol is a factor associated with at least 50% of traffi c fatalities, 50% of homicides, and 25% of suicides. Source: Psychiatry specialty Board Review By William M. Easson, MD and Nicholas L. Rock, MD
228
2703.True statements regarding the Controlled Substances Act (CSA) include which of the following? 1. Methadone is a DEA Schedule II controlled substance that is indicated for the relief of severe pain and detoxifi cation or maintenance of narcotic addiction. 2. A prescription may not be issued for the dispensing of methadone for detoxifi cation treatment or maintenance treatment 3. To use Schedule II opiates for detoxifi cation from opiate addiction, a special registration is required. 4. Drug Abuse Treatment Act of 2000 allows physicians to use Schedule III agents to detoxify chemical dependent patients in an offi ce setting, provided the physician qualifi es for and obtains a waiver issued through DEA.
2703. Answer: E (All)
229
2704.True statements regarding the Controlled Substances Act in determining the control or removal from schedules of substances include the following: 1. Drugs actual or relative potential for abuse. 2. Scientific evidence of its pharmacological effect, if known. 3. Any risks to the public health 4. Guarantee by the manufacturer that it will be provided at affordable price to public.
2704. Answer: A (1, 2, & 3) Explanation: Factors determinative of control or removal from schedules by the attorney general are as follows: 1. Its actual or relative potential for abuse. 2. Scientifi c evidence for its pharmacological effect, if known. The state of current scientifi c knowledge regarding the drug or other substance. 3. Potential and current pattern of abuse The scope, duration, and signifi cance of abuse. What, if any, risk there is to public health. Its physic or physiological dependence liability. Whether the substance is an immediate precursor of a substance already controlled under this title. 4. Price has no impact.
230
2705.True statements about methadone include the following: 1. It is useful as an analgesic 2. It has greater oral effi cacy than morphine 3. It produces a milder but more protracted withdrawal syndrome than that associated with morphine 4. Adverse reactions may include constipation, respiratory depression, and light headedness
2705. Answer: E (All) Explanation: 1. Methadone is an opioid receptor agonist. It is used as an analgesic and to treat opioid abstinence and heroin users (methadone maintenance). 2. Methadone has greater oral effi cacy than morphine and a much longer biologic half-life; 3. Methadone produces milder but more protracted abstinence syndrome associated with methadone. 4. Adverse reactions may include constipation, respiratory depression, and light headedness.
231
``` 2706. Drug testing may be performed by utilizing any of the following technique(s): 1. Urine drug screening 2. Hair samples 3. Saliva testing 4. Specifi c drug analysis of blood ```
2706. Answer: E (All)
232
2707.The transdermal route of fentanyl administration has been used in cancer patients because it offers the following advantages: 1. Convenience of dosing. 2. Rapid absorption through the skin allows quick titration. 3. Highly potent opioid for analgesic effi cacy. 4. Low cost.
2707. Answer: B (1 & 3) | Source: Reddy Etal. Pain Practice: Dec 2001, march 2002
233
``` 2708.During cocaine withdrawal, which of the following symptoms can be anticipated? 1. Cardiac arrhythmias 2. Desire for sleep, often with insomnia 3. Delirium 4. Depression ```
2708. Answer: C (2 & 4) Explanation: Cocaine withdrawal has no specifi c physiological signs, but there are physical problems (“crash”) that peak in two to four days. Depression and irritability can persist for weeks. These patients show a desire for sleep, often with insomnia, with disturbed sleep and increased dreaming, general fatigue, and suicidal ideation. Drug-seekingbehavior usually occurs after bein drug-free for a few days. Source: Psychiatry specialty Board Review By William M. Easson, MD and Nicholas L. Rock, MD
234
2709.After chronic amphetamine use, abrupt withdrawal is likely to cause which of the following symptoms? 1. Seizures 2. Delirium 3. Formication 4. Sleep disturbance
2709. Answer: D (4 Only) Explanation: Amphetamines or “speed” are stimulants with reinforcing effects similar to cocaine. Chronic amphetamine use causes tachycardia, elevated BP, pupillary dilation, agitation, elations, and hypervigilance. Adverse side effects include insomnia, fever, headaches, confusion, irritability, hostility, and visual hallucinations. Source: Psychiatry specialty Board Review By William M. Easson, MD and Nicholas L. Rock, MD
235
2710. The following statements are accurate for addiction and dependence. 1. Based on the Controlled Substances Act, the term “addict” means any individual who habitually uses any narcotic drug so as to endanger the public health and safety. 2. Based on DSM-IV defi nition, addiction means maladaptive pattern leading to distress or impairment. 3. DSM-IV defi nition of substance dependence includes tolerance, withdrawal, and continued use despite problems. 4. Federation of State Medical Board guidelines for the treatment of pain recommend use of controlled substances in patients with history of substance with no additional monitoring, referral, or documentation.
2710. Answer: B (1 & 3) Explanation: 1. The term “addict” by CSA means any individual who habitually uses any narcotic drug so as to endanger the public morals, health, safety, or welfare, or who is so far addicted to the use of narcotic drugs as to have lost the power of self-control with reference to his or her addiction. 2. There is no defi nition for addiction in DSM-IV. DSM-IV defi nes substance abuse with at least 1 in 12 month period. 3. Maladaptive pattern leading to distress or impairment. Recurrent failure to fi eld role. Recurrent physically undesirous behavior. Recurrent legal problems. Continued use despite social problems. Never met dependence criteria DSM-IV defi nition for substance dependence is as follows: Tolerance Withdrawal Larger Amounts/Longer periods Efforts or desire to cut down Large amount of time using/obtaining/recovering Activities given up: social/work/recreation Continued use despite problems Need 3 of above in 12 months An alternate defi nition from the American Society of Addiction Medicine for addiction is as follows: Addiction A primary, chronic neurobiologic disease with genetic, psychosocial and environmental factors effecting its course and presentation Characterized by one or more of the following Impaired control of drug use Compulsive use Craving Continued use despite harm 4. The federation recommends several additional steps in patients with addiciton or abuse Source: Manchikanti L, Board Review 2005
236
2711. Choose the accurate statement(s) below regarding the purposes for which a prescription for controlled substance can be issued: 1. A prescription for a controlled substance must be issued for a legitimate medical purpose in the usual course of a physician’s practice. 2. A prescription for a controlled substance may be issued to a physician so that he or she can dispense the drugs to patients as medically necessary. 3. Prescriptions for Schedule III, IV, and V drugs are permitted for purposes of detoxifi cation or maintenance treatment if the drug is specifi cally approved by the Food and Drug Administration (FDA) for those uses and the prescribing physician meets the legal requirements for prescribing such drugs for such uses. 4. Prescriptions for Schedule II drugs for detoxifi cation or maintenance treatment are permitted
2711. Answer: B (1 & 3) Explanation: 2 and 4 are incorrect. A prescription cannot be issued in order for an individual practitioner to obtain controlled substances for supplying the individual practitioner for the purpose of general dispensing to patients. Schedule II drugs cannot be prescribed for narcotic addiction treatment. Reference: 21 USC 823(g); 21 CFR 1306.04 Source: Erin Brisbay McMahon, JD, Sep 2005
237
2712.True statements regarding the fi ve schedules of controlled substances, known as Schedules I, II, III, IV, and V include all the following: 1. The Schedule I substances have high potential for abuse and the substance has no currently accepted medical use in the treatment in the United States. 2. The Schedule I substances may be changed to a lower schedule if the safety of the drug is demonstrated even though there is a high potential for abuse and there is no accepted medical use for medical treatment. 3. The Schedule II drugs have high potential for abuse and may lead to severe psychological or physical dependence. 4. Schedule V drugs or substances have a high potential for abuse and may lead to physical or psychological dependence.
2712. Answer: B (1 & 3) Explanation: 1, 2. Schedule I The drug or other substance has a high potential for abuse. The drug or other substances has no currently accepted medical use in treatment in the United States. There is a lack of accepted safety for use of the drug or other substance under medical supervision. 3. Schedule II The drug or other substance has a high potential for abuse. The drug or other substances has no currently accepted medical use in treatment in the United States or a currently accepted medical use with severe restrictions. Abuse of the drug or other substances may lead to severe psychological or physical dependence. Other Schedule III The drug or other substance has a potential for abuse less than the drugs or other substances in schedules I and II. The drug or other substances has no currently accepted medical use in treatment in the United States. Abuse of the drug or other substance may lead to moderate or low physical dependence or high psychological dependence. Schedule IV The drug or other substance has a low potential for abuse relative to the drugs or other substances in schedule III. The drug or other substance has a currently accepted medical use in treatment in the United States. Abuse of the drug or other substances may lead to limited physical dependence or psychological dependence relative to the drugs or other substances in schedule III. 4. Schedule V The drug or other substance has a low potential for abuse relative to the drugs or other substances in schedule IV. The drug or other substance has a currently accepted medical use in treatment in the United States. Abuse of the drug or other substances may lead to limited physical dependence or psychological dependence relative to the drugs or other substances in schedule IV. Source: Manchikanti L, Board Review 2005
238
2713. Examples of pro-drugs include: 1. Gabapentin 2. Morphine 3. Baclofen 4. Codeine
2713. Answer: D (4 only) Explanation: Gabapentin, morphine, and baclofen have their primary action as the parent drug. Morphine’s metabolite, M6G, has analgesic activity, but a pro-drug is a drug whose parent compound has no activity. Codeine, which is a prodrug, has no activity until it is metabolized into morphine. Source: Andrea M. Trescot, MD
239
2714. The following is an accurate statement with regards to function of Controlled Substances Act. 1. It creates a closed system of distribution for those authorized to handle controlled substances. 2. The cornerstone of this system is the licensure of all those authorized by the State Medical Licensure Board to handle controlled substances. 3. Only the individuals and practices which dispense directly to the patients from their clinics are required to maintain a DEA license. 4. It is required to maintain complete inventory of controlled substances, only if the drugs are administered by physician, but not if dispensed to the patient
2714. Answer: A (1, 2 & 3) Explanation: 1. The CSA created a closed system of distribution for those authorized to handle controlled substances. 2. The system is the registration of all those authorized by the DEA to handle controlled substances. 3. Only the individuals and practices that dispense directly to the patients from their clinics are required to maintain a DEA license. 4. All individuals and fi rms that are registered are required to maintain complete and accurate inventories and records of all transactions involving controlled substances, as well as the security for the storage of controlled substances. The attorney general may limit revocation or suspension of a registration to the particular controlled substance. However, the Board of Medical Licensure may also limit this indirectly by means of requesting the limitation by DEA and reaching an agreement with the practitioner. Source: Manchikanti L, Board Review 2005
240
``` 2715. If a patient has inadequate relief from an opioid, options include: 1. increase the dose 2. increase the frequency 3. add a breakthrough medication 4. change medications ```
``` 2715. Answer: E (All) Explanation: Other options include changing route and adding adjuvant meds. Source: Andrea M. Trescot, MD ```
241
2716. Mixed opioid agonist-antagonists (nalbuphine, pentazocin) have limited use in cancer patients because: 1. Respiratory depression is a common side effect 2. Mixed interaction at the opioid receptor can precipitate withdrawal symptoms. 3. Pruritus is a common side effect. 4. Effectiveness is limited by a dose-related ceiling effect.
2716. Answer: C (2 & 4) | Source: Reddy Etal. Pain Practice: Dec 2001, march 2002
242
2717. In accordance with the Federal Controlled Substances Act of 1970, which of the following applies towards regulating the use of narcotic drugs for opioid detoxifi cation or maintenance? 1. Practitioner is separately registered with the DEA as a narcotic treatment program 2. Practitioner may dispense or prescribe a controlled drug in schedules III, IV, or V to a narcotic dependent individual for addiction treatment 3. Practitioner in solo practice will not treat more than 30 patients at any one time with scheduled drugs for detoxifi cation or maintenance 4. A narcotic drug can not be dispensed for a period in excess of 180 days for the purposes of detoxifi cation
2717. Answer: E (All) Explanation: 21 U.S.C 823 (g) Source: James D. Colson, MS, MD
243
2718.In order to qualify for a waiver under the Drug Abuse Treatment Act of 2000 to treat opioid addiction with scheduled drugs, a physician must meet the following conditions: 1. Hold a current state medical license and valid DEA number 2. Hold an addiction certifi cation from the American Society of Addiction Medicine 3. Hold a subspecialty board certifi cation in addiction psychiatry from the American Board of Medical Specialties 4. Complete at least 8 hours of training in the treatment and management of opioid-addicted patients
``` 2718. Answer: E (All) Explanation: http://buprenorphine.sahsa.gov/waiver _qualifi cations 21 U.S.C 823 (g) Source: James D. Colson, MS, MD ```
244
2719. Dexmedetomidine and midazolam share the following pharmacologic properties: 1. Provide a continuum of sedation 2. Preserve respiratory function without potentiating opioid- induced respiratory depression 3. Clearance is decreased in hepatic disease 4. Selective alpha-2 adrenergic agonist activity
2719. Answer: B (1 & 3) Explanation: Only dexmedetomidine preserves respiratory function without potentiating opioid-induced respiratory depression. Only dexmedetomidine possesses selective alpha-2 adrenergic agonistic activity, while midazolam works through a GABA2 receptor mechanism. Evers AS, Maze M. Anesthetic Pharmacology: Physiologic Principles and Clinical Practice. Churchill Livingstone, Philadelphia, 2004. Morgan GE, Mikhail MS, Murray MJ. Clinical Anesthesia. 3rd ed. McGraw-Hill, New York, 2002. Source: James D. Colson, MS, MD
245
2720. Drug clearance from the plasma at a constant amount per unit time and the time for the plasma concentration of a drug to decrease by one-half, best represent which of the following drug properties? 1. Pharmacodynamic profi le 2. Bioequivalence 3. Drug potency 4. Metabolism and excretion
2720. Answer: D (4 only) Explanation: Drug clearance and plasma half-life are pharmacokinetic, not pharmacodynamic, variables associated with the elimination of drug through renal excretion and/or hepatic metabolism. Bioequivalence compares different formulations of the same drug and is not the same as bioavailability or the fraction of a drug absorbed following administration. Potency is a measure of the amount or dose of drug required for an effect. Evers AS, Maze M. Anesthetic Pharmacology: Physiologic Principles and Clinical Practice. Churchill Livingstone, Philadelphia, 2004. Hardman JG, Limbird LE. Goodman and Gilman’s Pharmacological Basis of Therapeutics. 10th ed. McGraw- Hill, New York, 2001. Source: James D. Colson, MS, MD
246
2721. The Drug Abuse Treatment Act of 2000 allows for which of the following for detoxifi cation treatment? 1. The use of schedule III drugs to detoxify chemically dependent patients in an offi ce setting 2. The use of opioids in a substance abuser for legitimate medical reasons to provide analgesia 3. The use of opioids for detoxifi cation in a nonabuser, who is opioid dependent from legitimate pain therapy and desires to discontinue opioid use 4. Practitioners may administer, dispense, or prescribe a controlled drug from any schedule to a narcotic dependent individual for addiction treatment
2721. Answer: A (1,2, & 3) Explanation: Practitioner may administer or dispense directly, but not prescribe, a narcotic drug in any schedule to a narcotic dependent person for the purposes of detoxifi cation or maintenance treatment only if the practitioner is registered as a narcotic treatment program and compliant with DEA regulations 21 U.S.C 823 (g) Source: James D. Colson, MS, MD
247
2722. Which of the following statements about alcohol absorption are valid? 1. Surgical removal of the pylorus allows more rapid absorption of alcohol 2. Most alcohol is absorbed through the gastric mucosa 3. Secretion of gastric mucus induced by high concentration of alcohol delays absorption 4. The longer the alcohol remains in the blood, the gretaer the effect.
2722. Answer: B (1 & 3) Explanation: Alcohol absorption is slowed by food, but increased by water, especially if carbonated. Alcohol goes directly into the bloodstream from the stomach and it is distributed throughout all tissues of the body. If somach alcohol concentration becomes too high, mucus is secreted and the pyloric valve closes, thereby slowing absorption. Source: Psychiatry specialty Board Review By William M. Easson, MD and Nicholas L. Rock, MD
248
2723. True statements with regards to properties of NMDA antagonists and therapeutic use and misuse are as follows: 1. Phencyclidine or PCP was developed as an intravenous anesthetic. 2. The unique anesthesia produced by phencyclidine was associated with rapid emergence. 3. MK-801 (dizocilpine) was developed as an anticonvulsant and subsequently was used as a brain protective agent. 4. Dextromethorphan is a strong NMDA antagonist, even when taken in very small amounts.
2723. Answer: B (1 & 3) Explanation: 1.Phencyclidine was developed as an intravenous anesthetic. However, the unique anesthesia it produced was complicated by a prolonged emergence delirium, leading to its demise as a clinically useful agent. Phencyclidine also caused symptoms of sensory deprivation, which is an excellent drug model of schizophrenia. 2.The desirable anesthetic properties of phencyclidine were retained in the short-acting arylcyclohexylamine derivative ketamine or Ketalar, which produced a much briefer emergence delirium. The term “dissociative anesthetic” was coined to emphasize the anesthetized patient was “disconnected” from his or her environment. Ketamine subsequently was discovered by the drug abuse community, where it is known as K, Super K, Special K, and Kat Valium. Phencyclidine has been placed in Schedule I of the Federal Controlled Substances Act, and Ketamine in Schedule II. 3.MK-801 was developed as an anticonvulsant and subsequently was used as a brain protective agent. However, it was discarded because of its PCP-like effects. Clinical trials of MK-801 have been extremely limited, and the results are not publicly available. 4.Dextromethorphan is an antitussive agent. When taken in very large amounts, it produces dysphoric mental effects that can be related to its weak NMDA antagonistic properties. 5.Amantadine and a related compound, memantidine, have been shown to be weak NMDA receptor antagonists.
249
2724. True statements about heroin are as follows: 1. The chemical name is diacetyl morphine 2. Heroin is more water soluble but less potent than morphine 3. Heroin is metabolized in humans by de-acetylation to 6-mono-acetylmorhpine and morphine 4. Heroin is classifi ed as Schedule II drug and is widely available for therapeutic purposes in the United States.
2724. Answer: B (1 & 3) Explanation: 1. Diacetyl morphine or heroine was fi rst synthesized in 1874. It was produced in 1989 by the Bayer Company and marketed under the name heroin. Heroin is synthesized from morphine by acetylation at both the 3 and 6 position. 2. Heroin is more water soluble and also more potent than morphine. 3. Heroin is metabolized in humans by de-acetylation to 6-mono-acetylmorphine and then further metabolized to morphine 4. Heroin is classifi ed as Schedule I drug. It is not available for any therapeutic use in the United States. It is prescribed in a few other countries as a pain medication or for use in the management of heroin addiction.
250
2725. Which of the following are true regarding nociceptive pain? 1. Alpha 2 antagonists are useful for management. 2. Automatic fi ring of damaged nerves is a component. 3. Deafferentation can produce a fi ring of fi rst order neurons. 4. Prostaglandin inhibition may be useful for management.
2725. Answer: D (4 only) Explanation: Nociceptive pain is caused by the activation of nociceptors in the tissues, and is divided into somatic and visceral causes. Deafferentation and automatic fi ring are characteristics of neuropathic pain, and respond to alpha 2 antagonists. NSAIDs, which block prostaglandins, are often useful in nociceptive pain. Source: Andrea M. Trescot, MD
251
2726. Which of the following is true about state medical regulation: 1. Investigation of physicians is generally the result of complaints received 2. State Boards may obtain copies of patient records without patient consent, upon written request, under HIPAA. 3. State regulations generally prohibit any medical act which is an unreasonable danger to the health, safety or welfare of patient or public. 4. A physician has a right to hire a lawyer at any stage of a medical board investigation or proceeding.
2726. Answer: E (All) | Source: temp
252
2727. A state could, if it chose to do so, do which of the following: 1. Make ordinary negligence in treatment a basis for professional discipline, even without any requirement of intent. 2. Require random periodic audits of physician’s practices, including patient health care records, to ensure quality of care. 3. Generally outlaw any practice which is not accepted by the majority of physicians in the relevant specialty. 4. Authorize state medical boards to impose very short jail terms (less than 30 days).
2727. Answer: A (1, 2 & 3)
253
2728. Methadone blood levels are: 1. increased by cimetidine 2. decreased by butabutal 3. increased by Ciprofl oxin 4. decreased by grapefruit juice
2728. Answer: A (1,2, & 3) Explanation: Grapefruit juice will increase methadone levels. Source: Andrea M. Trescot, MD
254
2729.As per the Controlled Substances Act, a denial, revocation, or suspension of registration may be carried out based on the following grounds. 1. The physician has failed to inform change of his offi ce address. 2. Has been convicted of a felony. 3. The physician has reached an agreement with the State Medical Board of Licensure. 4. Has had his state license or registration suspended, revoked, or denied.
2729. Answer: C (2 & 4) Explanation: * The attorney general may suspend or revoke a registration to manufacture, distribute, or dispense a controlled substance upon fi nding that the registrant: - Has materially falsifi ed any application fi led. - Has been convicted of a felony. - Has had his state license or registration suspended, revoked, or denied. * Has committed such acts as wound render his registration inconsistent with the public interest. * Has been excluded or directed to be excluded from participation in a program pursuant to Section 1128 (A) of the Social Security Act.
255
2730. An intervention on a chemically dependent individual should include all of the following: 1. A clear message 2. Caring for the patient 3. Planning 4. Presence of persons important to the patient
2730. Answer: E (All) | Source: Stimmel, B
256
2731. If a patient is unable to tolerate oxycodone because of nausea, the likely opioids to be tolerated would be: 1. Fentanyl 2. Propoxyphene 3. Methadone 4. Morphine
2731. Answer: A ( 1, 2, & 3) Explanation: Morphine is in the same class of opioids (phenanthrenes) as oxycodone, but morphine has a 6-OH group (associated with more nausea). Fentanyl, meperidine, propoxyphene, and methadone are completely different classes of opioids Source: Trescot AM, Board Review 2004
257
2732.Which of the following are true regarding opioidinduced constipation in a patient with cancer pain? 1. Impaired defecation refl ex 2. Increased colonic motility 3. Reduced colonic peristaltic activity 4. Bulk laxatives most helpful
2732. Answer: A (1,2, & 3) Explanation: Opioids increase colonic motility but reduce peristaltic acitivity; in addition, the defecation refl ex is impaired. Bulk laxatives are a poor choice because adequate water intake is required and the bulk can make the stool hard and precipate impaction. Source: Oxford Textbook of Palliative Medicine, 2nd Ed
258
``` 2733. Analgesic agents capable of producing tolerance, dependence and withdrawal include: 1. Codeine 2. Propoxyphene (Darvon) 3. Buprenorphine 4. Pentazocine (Talwin) ```
2733. Answer: E (All) | Source: Stimmel, B
259
2734. What are true statements about painful crises in sicklecell disease: 1. The pain is rarely severe. 2. Abdominal crises are frequent. 3. Joint crises are frequent, accompanied by swelling and discoloration of the affected joint. 4. Analgesics may frequently have to be administered in greater than standard doses due to the development of tolerance
2734. Answer: C (2 & 4) | Source: Stimmel, B
260
2735. The ultimate decisions regarding the specifi c medical treatment to be rendered to a patient in a specifi c situation are made by: 1. The physician 2. The courts 3. The state legislature 4. The patient
2735. Answer: D (4 only)
261
2736.The CSA requires the following of practitioners who dispense ONLY manufacturer’s samples of controlled substances to patients. 1. An initial, and then biennial, inventories. 2. A secure locked box for storage of controlled substances. 3. As separate dispensing log, in addition to any records kept in the patients’ charts. 4. Complete records of all controlled substances received, dispensed, or otherwise disposed of.
2736. Answer: E (All) | Source: Arthur Thexton
262
2737. The CSA requires the following of practitioners who administer controlled substances via any modality to patients directly, before or during procedures in the offi ce or surgical suite, from physician-owned stock or supplies: 1. An initial, and then biennial, inventories 2. A secure locked box for storage of controlled substances 3. As separate dispensing log, in addition to any records kept in the patients’ charts. 4. Complete records of all controlled substances received, dispensed, or otherwise disposed of.
2737. Answer: E (All) | Source: Arthur Thexton
263
2738. When a state has different rules than the CSA: 1. Federal constitutional supremacy principles dictate that the CSA overrules all state regulations relating to controlled substances. 2. The issue is decided on a case-by-case basis, by the courts. 3. State rules govern, as the states traditionally regulate medicine and pharmacy. 4. Whichever rule is more restrictive must be followed, as both have full legal force and effect.
2738. Answer: D (4 only) | Source: Arthur Thexton
264
2739.When changing a patient’s controlled substance medications, a physician may desire a patient to bring in all unused supplies of discontinued controlled substances. Which of the following is true? 1. The physician may refuse to prescribe additional controlled substances until the patient destroys (in a verifi ed manner) or surrenders all unused meds. 2. Because they are the legal property of the patient, the physician can do nothing about the patient’s previously prescribed and dispensed medications. 3. The physician may observe the patient destroy the medications by fl ushing them down the toilet, unless such disposal is prohibited by state law. 4. The physician may take possession of unused medications, inventory them, and send them to the DEA.
2739. Answer: B (1 & 3) | Source: Arthur Thexton
265
2740. The following MAY legally be prescribed by a physician without a special registration or permission from DEA: 1. methadone 2. buprenorphine 3. injectible C-II morphine 4. heroin
2740. Answer: A (1,2, & 3) Explanation: There are restrictions on methadone and buprenorphine use ONLY when prescribed to treat addiction; when prescribed for pain or other conditions, they may be prescribed by anyone authorized to prescribe other controlled substances in the same schedule. Source: Arthur Thexton
266
2741. Mechanisms of drug interactions include: 1. Drug-drug interactions 2. Drug allergies 3. Drug-food interactions 4. Drug doses
2741. Answer: C (2 & 4) Explanation: Drug interactions include drug-drug, drug-food, and drug-condition interactions. Drug allergies infl uence the choice of medicines, and drug doses are important in drug treatment, but neither are specifi cally related to drug metabolism. Source: Andrea M. Trescot, MD
267
2742. The choice of opioid medications is infl uenced by: 1. Frequency of pain 2. Response to prior opioids 3. Daily activity 4. Cost and insurance plan
2742. Answer: E (All) | Source: Andrea M. Trescot, MD
268
``` 2743. If a patient is a “slow metabolizer”, possible responses to medications might include: 1. Increased toxicity 2. Decreased effect 3. Increased effect 4. Decreased excretion ```
2743. Answer: E (All) Explanation: A slow metabolizer cannot detoxify drugs quickly, leading to increased toxicity and possibly increased effect. If the drug needs to be metabolized for increased effect (such as with a pro-drug), slow metabolizers will have a decreased effect. Since metabolism is necessary for most excretion, slow metabolizers would have decreased excretion. Source: Andrea M. Trescot, MD
269
2744. The following are true statements regarding morphine: 1. Morphine is primarily renally metabolized 2. Morphine is primarily renally excreted 3. Morphine is metabolized by CYP2D6 4. Morphine is metabolized by glucuronidation
``` 2744. Answer: C (2 & 4) Explanation: Morphine is primarily hepatically metabolized by glucuronidation Source: Andrea M. Trescot, MD ```
270
2745. Which of the following is a true statement: 1. Tramadol’s fi rst metabolite has less activity than the parent compound 2. Heroin is metabolized to morphine 3. Morphine’s metabolites increase in liver failure. 4. Hydrocodone is metabolized to hydromorphone.
``` 2745. Answer: C (2 & 4) Explanation: Tramadol’s M1 metabolite has greater activity. Morphine would have decreased metabolism in liver failure, but the metabolites accumulate in renal failure. Source: Andrea M. Trescot, MD ```
271
2746.Medications that should be avoided with grapefruit include: 1. those with a low oral bioavailablity 2. those metabolized by CYP3A4 3. those with an intestinal transport by p-glycoprotein 4. those metabolized by CYP2D6
2746. Answer: A (1,2, & 3) Explanation: Grapefruit inhibits CYP3A4, not 2D6, and has its action by altering liver and intestinal 3A4 as well as inhibiting intestinal transport by p-GP. Medicines with a low bioavailability have the potential for increased absorption. Source: Andrea M. Trescot, MD
272
2747.If a patient who is on tramadol is given a CYP2D6 inhibitor, 1. the analgesia of tramadol will decrease 2. the analgesia of tramadol will increased 3. the excretion of tramadol will decrease 4. the excretion of tramadol will increase
2747. Answer: B (1 & 3) Explanation: Tramadol is metabolized by CYP2D6 to an active metabolite that has more effect than the parent compound, so that CYP2D6 inhibitors cause the effective analgesia to decrease. However, CYP2D6 is also the enzyme responsible for the excretion of tramadol, so that inhibition leads to decreased excretion and the increased possibility for seizures. Source: Andrea M. Trescot, MD
273
2748.A newly immigrated patient from Viet Nam with tuberculosis, neuropathy, and acid refl ux disease is being prescribed methadone for pain following spine surgery to stabilize a fracture. The metabolism of methadone has been documented to be affected by: 1. Isoniazid 2. Carbamazepine 3. Cimetidine 4. Ethnicity
2748. Answer: A (1,2, & 3) Explanation: Isoniazid and carbamazepine will increase the metabolism of methadone (leading to decreased levels), while cimetidine will slow down the metabolism (leading to increased levels. While many CYP enzymes show ethnic differences, methadone metabolism has not been documented to have an ethnic variability. Source: Andrea M. Trescot, MD
274
``` 2749. Incipient liver failure due to acetaminophen toxicity will most affect the metabolism of: 1. Lidocaine 2. Methadone 3. Codeine 4. Meperidine ```
2749. Answer: B (1 & 3) Explanation: Lidocaine is highly dependant upon liver excretion, while methadone is not. Codeine is metabolized to morphine, which is highly dependant upon liver excretion (though M3G accumulates in renal insuffi ciency), while meperidine requires renal excretion. Source: Andrea M. Trescot, MD
275
2750. Signifi cant drug-food interactions include: 1. Coffee and tea are more rapidly metabolized in the presence of ciprofl oxin. 2. Phenobarbital is useful to treat folate defi ciency neuropathy. 3. Smokers have a greater perceived effect of propoxyphene than non- smokers. 4. NSAIDS cause greater renal damage in patients with high dietary fat intake.
2750. Answer: D (4 only) Explanation: Caffeine (in coffee and tea) is metabolized by CYP1A2, which is inhibited by ciprofl oxin. Phenobarbital will increase the risk of folate defi ciency neuropathy. Smokers metabolize propoxyphene faster and therefore have less effect. Source: Andrea M. Trescot, MD
276
2751. Studies have shown: 1. Daily pain is present in one third of the population over 65 years old 2. Moderate to severe non-cancer pain is present in 9% of the US population. 3. One-thirds of chronic pain patients have been living with pain for more than 5 years. 4. Only 15% of primary care physicians enjoy taking care of pain patients.
2751. Answer: C (2 & 4) Explanation: 55% of American adults over 65 have pain daily. The Arthritis Foundation, “Pain In America: Highlights from a Gallup Survey,” 2000 9% of the US population suffers from moderate to severe pain, and 2/3rds have suffered for more than 5 years. Roper Starch Worldwide, Inc., “Chronic Pain In America: Roadblocks To Relief,” Jan. 1999 Only 15% of PCPs enjoy pain patients Potter M, Schafer S, et al. Opioids for chronic nonmalignant pain: attitudes and practices of primary care physicians. J Fam Pract 2001;50(2):145-51 Source: Andrea M. Trescot, MD
277
``` 2752.Epidemiologic risks for work-related low back pain include: 1. Prior WC claim 2. Perceived over-education 3. Cumulative compressive back forces 4. Peak hand forces ```
2752. Answer: E (All) Explanation: Norman R, Wells R, Neumann P, et al. A comparison of peak vs cumulative physical loading factors for reported low back pain in the automobile industry, Clinical Biomechanics, 13(8): 561-573, 1998. Source: Andrea M. Trescot, MD
278
2753. Regarding cancer pain: 1. There are 1 million cancer patients world-wide 2. 10% of cancer patients in active treatment report pain 3. Half of advanced cancer patients complain of pain 4. More than one-third of oncology outpatients complain of pain that interferes with ADLs
2753. Answer: D (4 only) Explanation: There are 17million cancer patients world-wide. 30 to 40% of cancer patients in active treatment report pain.70 to 90% of advanced cancer patients complain of pain. 36% of oncology outpatients complain of pain that interferes with ADLs Grond S, Sech D, et al Assessment of cancer pain: a prospective evaluation in 2266 cancer patients referred to a pain service. Pain (1996), 64, 107-114. Source: Andrea M. Trescot, MD
279
2754.The following statements are true regarding the paleospinothalamic tract: 1. The paleospinothalamic tract is poor in opioid receptors. 2. The paleospinothalamic tract connects the thalamus to the cortex. 3. The paleospinothalamic tract passes impulses from the 2nd order neurons to the C-fi bers. 4. The paleospinothalamic tract connects the thalamus and the reticular activating system.
2754. Answer: C (2 & 4) Explanation: The paleospinothalamic tract is rich in opioid receptors, connects the thalamus to the cortex and reticular activation system, and passes impulses from the C-fi bers to the 2nd order neurons. Source: Andrea M. Trescot, MD
280
2755. What are the important aspects of chronic pain? 1. Management is inexpensive 2. Multiple regions are involved 3. Low economic impact 4. Persistent pain in 30% - 70% of patients after initial attack
2755. Answer: C (2 & 4) Explanation: Chronic Pain Multiple region involvement Costly Chronic, persistent pain 30% - 70% after initial attack High economic impact Patient suffering - dysfunction, immunosuppression, depression Health care - extensive costly non-productive workups and treatments - $145 billion per year just for low back Societal - disability, loss of revenues Source: Laxmaiah Manchikanti, MD
281
2756.When choosing an opioid, factors to be considered include: 1. patient compliance 2. dosing schedule of concurrent medications 3. drug interactions 4. opioid side effects
2756. Answer: E (All) Explanation: A patient compliance problem might suggest the choice of a once a day medication or patch. If a patient is on other BID mediations, a BID pain medication might be the best choice. Drug interactions can affect choice of medication, such as when a patient is already on Fiorinal, which will decrease methadone levels. Side effects such as nausea from hydroxylated opioids or constipation that might be lessoned by a patch can also infl uence medication choice. Source: Andrea M. Trescot, MD
282
``` 2757. Urine screening of patients should be able to detect each of the following: 1. Cocaine 2. Morphine 3. Alcohol 4. Barbiturates ```
2757. Answer: E (All) | Source: Stimmel, B
283
2758. What are the clinical recommendations in chronic opioid therapy? 1. Daily doses above 180 mg/day of morphine have not been validated 2. Dose escalation beyond the stabilization phase may predict a problem 3. Opioid rotation may be helpful 4. Drug formulation does not infl uence tolerance
``` 2758. Answer: E (All) Explanation: Clinical Recommendations * Limit the dose - Daily doses above 180 mg/day of morphine have not been validated - Dose escalation beyond the stabilization phase may predict a problem * Drug formulations - Formulation does not infl uence tolerance * Opioid rotation - Concept of incomplete cross-tolerance - Rotation may restore effi cacy Source: Mark V. Boswell, MD, KSIPP 2005 ```
284
2759. Which one of the following results may occur from repeated administration of a drug? 1. Increased metabolism of the drug 2. Increased metabolism of other drugs 3. Induction of cytochrome P-450 or glucuronyl transferase 4. Increased metabolism of endogenous compounds
2759. Answer: E (All) Explanation: All of the choices are possible consequences of drug administration. Many enzymes involved in drug biotransformation also catalyze the metabolism of endogenous compounds such as steroids.
285
``` 2760.Symptoms of opioid toxicity include which of the following? 1. Leg muscle twitching 2. Pulmonary edema 3. Seizures 4. Hypothermia ```
2760. Answer: C (2 & 4) Explanation: Opioid toxicity or overdose should be suspected in any undiagnosed coma patient or patients with respiratory depression (pulmonary edema), shock (hypothermia), pupillary construction, and needle marks. Grand mal seizures can occur with meperidine overdose. Source: Psychiatry specialty Board Review By William M. Easson, MD and Nicholas L. Rock, MD
286
2761. Choose the correct statements about cocaine testing. 1. A patient’s urine may test positive for the cocaine metabolite benzoylecgonine after a procedure with cocaine as a topical anesthetic for up to 3 to 4 weeks. 2. Cocaine, a topical anesthetic, is clinically used in certain trauma, dental, ophthalmoscopic, and otolaryngologic procedures. 3. There is structural similarity between other topical anesthetics that end in “caine” (eg, Novocaine, lidocaine) and cocaine or benzoylecgonine. 4. A positive UDT result for the cocaine metabolite, in the absence of a medical explanation, should be interpreted as due to deliberate use.
2761. Answer: C (2 & 4) Explanation: Urine Drug Test Methods: Cocaine Cocaine, a topical anesthetic, is clinically used in certain trauma, dental, ophthalmoscopic, and otolaryngologic procedures. A patient’s urine may test positive for the cocaine metabolite benzoylecgonine after such a procedure for up to 2 to 3 days. There is no structural similarity between other topical anesthetics that end in “caine” (eg, Novocaine, lidocaine) and cocaine or benzoylecgonine; therefore, cross-reaction does not occur. A positive UDT result for the cocaine metabolite, in the absence of a medical explanation, should be interpreted as due to deliberate use. Source: Laxmaiah Manchikanti, MD
287
2762. Which of the following are true about lorazepam: 1. Has a serum half-life of approximately 12 hours 2. Exhibits linear kinetics 3. Is almost completely converted to benzoylecgonine 4. Is frequently used an anti-anxiety agent
2762. Answer: C (2 & 4) Explanation: Half life is 12 hours, as compared to diazepam which is 21-37 hours. Is indicated for short term use of anxiety. The kinetics are linear. It is converted to lorazepam glucuronide (75%) abd NOT to benzoylecgonine, a major metabolite of cocaine. Reference: Disposition of Toxic Drugs and Chemicals in Man. Fifth Edition. Randall C. Baselt. 2000 page 483 Source: Art Jordan, MD, Sep 2005
288
2763.What are the correct statements of amphetamine in urine drug testing? 1. Tests for amphetamine/methamphetamine are highly cross-reactive. 2. Very predictive for amphetamine/methamphetamine use. 3. UDT will detect other sympathomimetic amines such as ephedrine and pseudoephedrine 4. Further testing is NOT required.
``` 2763. Answer: B (1 & 3) Explanation: Urine Drug Test Methods Amphetamines: Low Specifi city Tests for amphetamine/methamphetamine are highly cross-reactive. They will detect other sympathomimetic amines such as ephedrine and pseudoephedrine Not very predictive for amphetamine/methamphetamine use. Further testing is required. Source: Laxmaiah Manchikanti, MD ```
289
2764. What are the pitfalls of opioid urine drug testing? 1. Tests for opiates are very responsive for morphine and codeine. 2. Urine drug tests do not distinguish between morphine and codeine. 3. UDT’s show a low sensitivity for semisynthetic/synthetic opioids such as oxycodone. 4. A negative response excludes oxycodone and methadone use.
``` 2764. Answer: A (1,2, & 3) Explanation: Urine Drug Test Methods Opioids: Pitfalls Tests for opiates are very responsive for morphine and codeine Do not distinguish which is present. Show a low sensitivity for semisynthetic/synthetic opioids such as oxycodone. A negative response does not exclude oxycodone, or methadone use. Source: Laxmaiah Manchikanti, MD ```
290
2765. Defi nitions of addiction include the following: 1. A primary, chronic neurobiologic disease with genetic, psychosocial and environmental factors effecting its course and presentation 2. Characterized by either impaired control of drug use or other symptoms 3. Addiction involves loss of control, craving, compulsive use, and continued use despite consequences 4. DSM-IV defi nition defi nes addiction to involve impaired control of drug use
``` 2765. Answer: A (1,2, & 3) Explanation: Addiction: Defi nitions DSM-IV - None A primary, chronic neurobiologic disease with genetic,psychosocial and environmental factors effecting its course and presentation Characterized by one or more of the following Impaired control of drug use Compulsive use Craving Continued use despite harm 4-Cs Loss of Control Craving Compulsive Use Continued use despite consequences Source: Laxmaiah Manchikanti, MD ```
291
2766.Choose the correct statements about codeine and morphine 1. Prescribed morphine cannot account for the presence of codeine. 2. Codeine metabolizes to morphine. 3. Codeine alone is possible due to a small proportion of patients who lack the cytochrome P450 2D6 enzyme necessary to convert codeine to morphine. 4. Morphine metabolizes to codeine
2766. Answer: A (1,2, & 3) Explanation: Urine Drug Testing Opioid Results: Codeine and Morphine Codeine is metabolized to morphine, so both substances may occur in urine following codeine use: A prescription for codeine may explain the presence of both drugs in the urine. A prescription for codeine does not normally explain the presence of only morphine. This is most consistent with: Use of morphine or heroin. Prescribed morphine cannot account for the presence of codeine. Codeine metabolizes to morphine, but the reverse does not occur. Codeine alone is possible due to a small proportion of patients who lack the cytochrome P450 2D6 enzyme necessary to convert codeine to morphine. Source: Laxmaiah Manchikanti, MD
292
2767. Withdrawal convulsions are likely to occur in patients who have used chronically which of the following drugs? 1. Secobarbital 2. Desipramine 3. Lorazepam 4. Phencyclidine
2767. Answer: B (1 & 3) Explanation: Withdrawal convulsions can occur with alcohol, certain benzodiazepines, and barbiturates. Source: Psychiatry specialty Board Review By William M. Easson, MD and Nicholas L. Rock, MD
293
2768.Which of the following statements about biotransformation reactions are true? 1. They may introduce an active center for further conjugations 2. They almost always yield water-soluble metabolites 3. They are often important in activating pro-drugs 4. They are all inducible upon repeated drug administration
2768. Answer: A (1,2, & 3) Explanation: Phase II reactions typically yield water-soluble metabolites. Active centers are introduced during phase I, not phase II, biotransformation. Glucuronyl transferase is the only phase II enzyme inducible by drug administration. Prodrugs are often activated by phase I, not phase II, reactions; phase II reactions generally terminate drug action.
294
2769.What are the guidelines of the Federation of State Medical Boards (FSMB), adapted by multiple State Medical Boards? 1. Opioids are used for a legitimate medical purpose 2. Opioids are used for documented abnormalities on MRI 3. Opioids are used in the course of professional practice 4. Opioids are used if another physician has previously written prescriptions for controlled substances for the patient
2769. Answer: B (1 & 3) Explanation: A documented abnormality/pathology on MRI may be an incidental fi nding and not causing pain. You should make your decision based on examination, previous medical records, imaging studies, and careful evaluation. Just because another physician has been dispensing narcotics to a patient, does not necessarily mean it was appropriate or legal. The dispensing/prescribing must be based on a legitimate medical purpose as determined by the current prescribing physician, after careful evaluation and examination. Source: Art Jordan, MD, Sep 2005
295
2770. What are the requirements according to the FSMB Policy Guidelines, to prescribe controlled substances within the course of professional practice? 1. A physician-patient relationship 2. Diagnosis and documentation of unrelieved pain 3. Compliance with applicable state or federal law 4. Urine drug testing (UDT) at least every six months 2771. The accurate statements about prescription drug abuse for non-medical purposes include the following: 1. Prescription drug abuse, particularly of opioid pain killers, has increased at an alarming rate over the last ten years. 2. Non-medical use of narcotic pain relievers, tranquilizers, stimulants, and sedatives ranks second (behind marijuana) as a category of illicit drug abuse among adults and youth. 3. In 2003, 6.3 million Americans were current abusers of prescription drugs, with 4.7 million using pain relievers. 4. E.R. visits for Benzodiazepine abuse in 2002 were 100,000 and for 0pioid abuse in 2002 were 119,000
2770. Answer: A (1,2, & 3) Explanation: Urine drug testing may be helpful, however is not required by law nor in the usual course of professional practice. Source: Art Jordan, MD, Sep 2005
296
2772. What are the true statements of drug abuse in the United States? 1. In lifetime, 46% of persons aged 12 and older used drugs 2. In past month, 8.3% of persons aged 12 and older used drugs 3. In past year, 14.9% of persons aged 12 and older used drugs 4. Prescription opioids are not abused
2772. Answer: A (1,2, & 3) Explanation: NEED SLIDE 13 Source: Laxmaiah Manchikanti, MD
297
``` 2773.Which of the following effects is associated with benzodiazepines? 1. Paradoxical excitement 2. Ataxia 3. Sedation 4. Amnesia ```
2773. Answer: E (All) Explanation: Short-acting benzodiazepines are used as preanesthetic medications because of their anxiolytic, sedative, and amnestic effects. Daytime drowsiness and ataxia are commonly produced by benzodiazepines and may impair judgment and interfere with motor skills. Paradoxical excitement is a rare adverse effect of these drugs.
298
2774. Morphine is used therapeutically 1. To suppress the withdrawal syndrome associated with the chronic use of alcohol 2. To induce miosis 3. To treat severe constipation 4. To relieve pain associated with a heart attack
2774. Answer: D (4 Only) Explanation: Morphine is used to relieve the pain associated with myocardial infarction. It can suppress the opioid withdrawal syndrome but not the withdrawal syndrome associated with other classes of central nervous system depressants. Morphine and other opioids induce constipation and can be used to treat diarrhea. Miosis is an adverse effect of morphine.
299
2775. Medical Records should include which of the following: 1. Treatment objectives 2. Instructions and agreements 3. Periodic reviews 4. Financial contracts
2775. Answer: A (1,2, & 3) Explanation: Financial contracts are not included. In addition, the complete listing includes: 1: Medical history and physical examination 2: Diagnostic, therapeutic and laboratory results 3: Evaluations and consultations 4: Discussion of risks and benefi ts 5: Informed consent 6: Treatments 7: Medications (including date, type, dosage and quantity prescribed) Source: Art Jordan, MD, Sep 2005
300
2776.For purposes of ordering a Schedule II emergency oral prescription, an emergency situation exists if the prescribing physician determines . . .: 1. That immediate administration of the controlled substance is necessary for proper treatment of the intended ultimate user. 2. That no appropriate alternative treatment is available, including administration of a drug which is not a controlled substance under schedule II. 3. That it is not reasonably possible for the prescribing physician to provide a written prescription to be presented to the person dispensing the substance, prior to the dispensing. 4. That the patient complains of extreme and unremitting pain.
2776. Answer: A (1,2, & 3) Explanation: Answer (4) is wrong as the physician does not need to determine that the patient is complaining of extreme and unremitting pain before fi nding that an emergency situation exists. Reference: 21 CFR 290.10, 1306.11(d). Source: Erin Brisbay McMahon, JD, Sep 2005
301
2777.Which of the following statements concerning barbiturate is true? 1. Barbiturates can increase bleeding time when administered to patient taking anticoagulants 2. Patients tolerant to the therapeutic actions of barbiturates are also tolerant to the analgesic effect of morphine 3. Barbiturates are used to prevent withdrawal symptoms associated with heroin dependence 4. Barbiturates are contraindicated in patients with acute intermittent porphyria
2777. Answer: D (4 Only) Explanation: Barbiturates induce liver microsomal enzymes that increase porphyrin synthesis and increase the metabolism and inactivation of certain anticoagulants. Barbiturates show cross-dependence with other sedative-hypnotic drugs but not with opioids
302
2778. Which one of the following conditions may be produced by frequent administration of high-dose chlorpromazine (Thorazine®) ? 1. Lens opacities 2. Skin pigmentation 3. Obstructive jaundice 4. Tardive dyskinesia
2778. Answer: E (All) Explanation: Chlorpromazine is associated with all of these adverse effects. Because of its numerous adverse effects, some authorities consider it to be an obsolete antipsychotic agent.
303
2779.Which of the following effects is produced by morphine? 1. Relief of dyspnea accompanying pulmonary edema 2. Decreased sensitivity of the respiratory center to carbon dioxide 3. Miosis that can be blocked by atropine 4. Vasodilation of cerebral blood vessels
2779. Answer: E (All) Explanation: Morphine produced all of the above effects. It decreases the sensitivity of the respiratory center to carbon dioxide and directly inhibits the respiratory center, leading to respiratory depression. This effect on respiration may be responsible for morphine’s benefi cial effect when used to treat dyspnea and for cerebral vasodilation. Morphine produced miosis by stimulation or the Edinger-Westphal nucleus of the oculomotor nerve; this is mediated by acetylcholine and can be blocked by atropine.
304
2780. What precautions must a physician take in interpretation of urine drug testing? 1. Consult with laboratory regarding ANY unexpected results. 2. Never use results to strengthen physician-patient relationship and support positive behavior change. 3. Schedule an appointment to discuss abnormal/ unexpected results with the patient; discuss in a positive, supportive fashion to enhance readiness to change/motivational enhancement therapy (MET) opportunities. 4. It is not necessary to document results and interpretation
2780. Answer: B (1 & 3) Explanation: UDT results: Consult with laboratory regarding ANY unexpected results. Schedule an appointment to discuss abnormal/unexpected results with the patient; discuss in a positive, supportive fashion to enhance readiness to change/motivational enhancement therapy (MET) opportunities. Use results to strengthen physician-patient relationship and support positive behavior change. Chart results and interpretation. Source: Laxmaiah Manchikanti, MD
305
2781. Which of the following effects if produced by tricyclic antidepressant drugs? 1. Increase in the antihypertensive effect of guanethidine 2. Hypertensive crisis 3. Increased absorption of an oral dose of levodopa 4. Precipitation of narrow-angle glaucoma 2782. What are the correct statements about UDT of cocaine? 1. Tests for cocaine react principally with cocaine and its primary metabolite, benzoylecgonine. 2. Tests for cocaine are non-specifi c in predicting cocaine use. 3. Tests for cocaine have low cross-reactivity with other substances 4. Cold medicines may test false-positive for cocaine
2781. Answer: D (4 Only) Explanation: Tricyclic antidepressants can precipitate narrow-angle glaucoma through their muscarinic-cholinoreceptor antagonist activity. They may cause hypotension and may block neuronal uptake of guanethidine and thus decrease its antihypertensive action. They may also decrease the gastrointestinal absorption of levodopa. 2782. Answer: B (1 & 3) Explanation: Urine Drug Test Methods Cocaine: Very specifi c Tests for cocaine react principally with cocaine and its primary metabolite, benzoylecgonine. These tests have low cross-reactivity with other substances Very specifi c in predicting cocaine use. Source: Laxmaiah Manchikanti, MD
306
2783. According to the guidelines of the F.S.M.B.:If the patient is at high risk for medication abuse or has a history of substance abuse, the physician should consider the use of a written agreement between physician and outlining patient responsibilities. This agreement should include which of the following: 1. Reasons for which drug therapy may be discontinued (e.g., violation of agreement) 2. Requirement for medical interview with members of immediate family 3. Urine/serum medication levels screening when requested 4. Periodic reports from a local law enforcement agency
2783. Answer: B (1 & 3) Explanation: Interviews with family members may be helpful under certain circumstances if clinically indicated and if within legal bounds of privacy, however, this is not listed by the Board. Periodic reports from law enforcement, without patient consent, would be inappropriate and possibly a violation of privacy laws. Source: Art Jordan, MD, Sep 2005
307
2784. A triangle of delivery exists between the following: 1. Pharmacists 2. The Physician 3. Drug Enforcement Administration 4. Federation of State Medical Boards
2784. Answer: A (1,2, & 3) Explanation: The physician initiates a prescription based on legitimate medical need. Once legitimate medical need of a controlled substance is established, the patient moves the prescription to a pharmacist, who is charged with dispensing. The third side of the triangle is the Drug Enforcement Administration, which monitors availability. The DEA’s responsibility is not to defi ne legitimate medical need, or to establish appropriate usage guidelines, but to ensure availability of drug. Source: Hans C. Hansen, MD
308
2785. Which of the following statements about the symptoms of barbiturate withdrawal are correct? 1. Develops more quickly with secobarbital then phenobarbital abusers 2. Cardiovascular collapse may be fatal 3. Abdominal discomfort, nausea, and vomiting 4. Seizures generally precede delirium
2785. Answer: E (All) Explanation: Barbiturate withdrawal (especially short acting) usually results in weakness, insomnia, anxiety, tremulousness, abdominal discomfort, nausea and vomiting. With preexisting cardiovascular problems, there may be fatal reactions. Seizures generally precede delirium. Symptoms are more marked with secobarbital an dleast with phenobarbital withdrawal (due to its long half-life). Source: Psychiatry specialty Board Review By William M. Easson, MD and Nicholas L. Rock, MD
309
2786. When a person taking a medication or abusing a drug develops tolerance, which of the following statements are valid? 1. The same dosage of the drug has reduced effect 2. Tolerance develops uniformly to all effects of the drug 3. Physical dependence tends to develop in parallel with tolerance 4. Withdrawal symptoms are less likely after tolerance has developed
2786. Answer: B (1 & 3) Explanation: Tolerance occurs when the same dosage of drug has a reduced effect and increased amounts of the drug are needed to achieve the desired effect. Physical dependence, the need to take the drug to prevent withdrawal, tends to develop in parallel with tolerance. Source: Psychiatry specialty Board Review By William M. Easson, MD and Nicholas L. Rock, MD
310
2787.Which of the following statements are correct about heroin abuse? 1. The peak incidence is age 25 to 35 2. It affects men three times as often as women 3. The majority of heroin abusers are involved in maintenance programs 4. Most heroin abusers eventually stop on their own
2787. Answer: C (2 & 4) Explanation: Heroin abusers tend to start in late teens and early 20s (most common 18-25 years old), with the majority in the mid-30s. There is a 3:1 male to female ratio. Suicide in abusers is three times greater than in the general population. They also have a 20 times greater death rate, as well as higher rates of hepatitis B and HIV III viral infections. Source: Psychiatry specialty Board Review By William M. Easson, MD and Nicholas L. Rock, MD
311
``` 2788.Symptoms of heroin withdrawal include all of the following : 1. Twitching movements in the legs 2. Dilated pupils 3. Increased blood pressure 4. Diarrhea ```
2788. Answer: E (All) Explanation: Heroin withdrawal symptoms are similar to a infl uenzalike syndrome along with anxiety and dysphoria. Physical symptoms include yawning, sweating, rhinorrhea, lacrimation, pupillary dilation, piloerection, hypertension, waves of goosefl esh, twitching movements, deep muscle and joint pains, nausea, diarrhea, vomiting, abdominal pains, fever, and hot and cold fl ashes. Source: Psychiatry specialty Board Review By William M. Easson, MD and Nicholas L. Rock, MD
312
2789.In the management of detoxifi ed substance-abusing patients in a therapeutic community, poor prognosis is more likely with: 1. Coexisting severe psychopathology 2. Dropout before three months 3. Continued alcohol use 4. Adjunctive use of antidepressants
2789. Answer: A (1, 2, & 3) Explanation: Therapeutic communities for substance abusers have as their goals a complete change of lifestyle and abstinence from drugs. If the patient’s stay is more than 90 days, there is a long-term decrease in illicit drugs use, antisocial behavior, and arrests, and increased employment. With a 12-month stay, subjects fare even better at fi ve years postprogram follow-up. Source: Psychiatry specialty Board Review By William M. Easson, MD and Nicholas L. Rock, MD
313
2790.DSM-IV defi nition of substance dependence includes some of the following items as part of at least 3 in 12 months. 1. Larger amounts/longer periods 2. Patient spends large amount of time using/obtaining controlled substances 3. Activities given up: social/work/recreation 4. Continued use despite problems
``` 2790. Answer: E (All) Explanation: SUBSTANCE DEPENDENCE: DSM-IV DEFINITION Need 3 in 12 months Tolerance Withdrawal Larger Amounts/Longer periods Efforts or desire to cut down Large Amount of time using/obtaining/recovering Activities given up: social/work/recreation Continued use despite problems Source: Laxmaiah Manchikanti, MD ```
314
2791.Physicians should not fear regulatory action from the Board for ordering, prescribing, dispensing or administering controlled substances, including opioid analgesicsChoose correct statements described in model policy for the use of controlled substances for the treatment of pain by Federation of State Medical Boards: 1. For a legitimate medical purpose 2. For documented abnormalities/pathology on M.R.I. Scan 3. In the course of professional practice 4. If another physician has previously written prescriptions for controlled substances for the patient
2791. Answer: B (1 & 3) Explanation: A documented abnormality/pathology on MRI may be an incidental fi nding and not causing pain . . . treat the patient, not the MRI. Just because another physician has been dispensing narcotics to a patient, does not necessarily mean it was appropriate or legal. The dispensing/prescribing must be based on a legitimate medical purpose as determined by the current prescribing physician, after careful evaluation and examination. Source: Art Jordan, MD, Sep 2005
315
2792. As a pain physician, you are evaluating a new patient who recently moved to your area. Consistent with your usual offi ce policy, all new patients get a urine drug test. The patient’s urine is positive for morphine, however his medication list shows no listing for any controlled substances.Which of the following are possible sources for this fi nding? 1. Morphine use 2. Heroin use 3. Poppy seeds 4. Codeine
2792. Answer: E (All) Explanation: The opiate immunoassay screens were designed to detect heroin abuse, not adherence to a therapeutic opioid regimen. These assays detect morphine and codeine—heroin is rapidly metabolized to 6- monoacetylmorphine (6-MAM) and then to morphine. Performing opiate immunoassays at the federally mandated level of 2000 ng/ml should eliminate nearly all positive results due to morphine from foodstuffs. Only specifi c detection of 6-MAM by GC/MS is proof of heroin intake. Street heroin may be contaminated with codeine. Remember that codeine may be metabolized to morphine. Hydrocodone can also be produced as a minor metabolite of codeine. J Anal Toxicol 2000;24:530-535 Source: Art Jordan, MD, Sep 2005
316
2793. A signifi cant minority of persons with substance abuse disorder have and atypical course and will eventually either stop using or be able to return to controlled use. Which of the following factors are associated with being able to stop or control use? 1. Stable premorbid personality 2. Developing medical complications of substance abuse 3. Age greater than 40 4. Arrest and incarceration
2793. Answer: B (1 & 3) Explanation: Those who either stop or control drug use after a period of addiction are more likely to be older than age 40, have a normal premorbid personality, never be arrested for substance abuse, and to undergo substance abuse treatment / rehabilitation. Developing medical complications from abuse rarely leads to abstinence. Source: Roger Cicala, MD, Sep 2005
317
2794.A 29-year old patient whom you had been treating for postlaminectomy syndrome with only time release morphine, 120 mg per day, had a urine drug screen positive for cocaine and benzodiazepines. When this was discussed with the patient, he admitted getting medications from a number of physicians and to injecting cocaine intravenously, but refused evaluation by an addictionologist and was dismissed from your practice. 3 days later an emergency room physician calls because the patient has been admitted following his fi rst ever grand mal seizure. Which of the following are likely causes of the seizure? 1. Cocaine overdose 2. Opiate withdrawal 3. Benzodiazepine withdrawal 4. Cocaine withdrawal
2794. Answer: B (1 & 3) Explanation: Seizure can occur with stimulant overdose or benzodiazepine withdrawal. It is not a reported part of the syndrome of opiate withdrawal or of cocaine withdrawal. Given the positive drug screen for benzodiazepines and cocaine, either scenario is possible. Source: Roger Cicala, MD, Sep 2005
318
2795. An otherwise healthy 45 year old patient taking 100 mg of morphine per day for pain associated with rheumatoid arthritis has decided to stop his pain medication 3 days prior to seeing you in the offi ce. Which of the following symptoms indicate severe withdrawal that probably requires treatment: 1. Fever 2. Headache 3. Hypertension 4. Rhinorrhea
2795. Answer: B (1 & 3) Explanation: All of the above are symptoms of opiate withdrawal along with numerous others. Fever, Hypertension, and Tachycardia are considered the most consistent symptoms indicated severe withdrawal reaction. Source: Roger Cicala, MD, Sep 2005
319
2796.In obtaining a history during the evaluation of a new patient, which of the following would be considered risk factors for possible substance abuse? 1. History of substance abuse in a brother and father. 2. History of psychiatric problems in the mother 3. History of bipolar illness in the patient 4. Age over 40 years old
2796. Answer: A (1,2, & 3) Explanation: Personal and family history of substance abuse, personal and family history of psychiatric illness, male gender, age under 40, and nonmarried status are all associated with increased prevalence of substance abuse. Source: Roger Cicala, MD, Sep 2005
320
2797. According to the ASAM, APS, AAPM consensus statement on the use of opioids for the treatment of chronic pain, which of the following characterize addiction? 1. Impaired control over drug use 2. Continued use despite harm 3. Craving 4. Compulsive drug use
``` 2797. Answer: E (All) Explanation: The above are the 4 listed characteristics in the Consensus Statement. Source: Roger Cicala, MD, Sep 2005 ```
321
2798. What is the defi nition of addiction as per the Controlled Substances Act? 1. The term “addict” means any individual who habitually uses any narcotic drug so as to endanger the public morals, health, safety, or welfare 2. “Addict” is a patient who is taking as per prescription very high opioids in cancer pain 3. Any individual who is so far addicted to the use of narcotic drugs as to have lost the power of self-control with reference to his addiction. 4. “Addict” is a patient taking controlled prescription drugs
2798. Answer: B (1 & 3) | Source: Laxmaiah Manchikanti, MD
322
``` 2799. If urine tampering is suspected, the following should be included in urine drug testing (UDT) 1. Temperature 2. Creatinine 3. PH 4. Color ```
2799. Answer: E (All) Explanation: The temperature should be 90-100 degrees F. within 4 minutes of voiding. The pH should remain with the range of 4.5 to 8.0. The urinary creatinine should be greater than 20 mg/dl; less than 20 mg/dl is considered dilute and less than 5 mg/dl is not consistent with human urine. Color may be a result of substances from food pigments, medications, or disease states. Ideally, the collection room should not contain a basin with running water, to reduce potential for specimen dilution, and blue pigment should be added to the toilet water. Reference: Cook, Caplan et al; The characterization of human urine for specimen validity determination in workplace drug testing: a review. J Anal Toxicol. 2000;24:579-588. Urine Drug Testing in Clinical Practice: Pearls & Pitfalls: Purdue Pharma, 2005 (available free on request) Source: Art Jordan, MD, Sep 2005
323
2800. Identify the “federal fi ve” drugs or drug classes that must be tested for in federal employees and federally regulated industries? 1. Marijuana 2. Cocaine 3.Amphetamine/Methamphetamine 4. Methadone
``` 2800. Answer: A (1,2, & 3) Explanation: Methadone, is not included in the federal fi ve. The correct federal fi ve are: 1: Marijuana (delta-9-THC acid) 2: Cocaine (benzoylecgonine) 3: Opiates 4: Phencyclidine 5: Amphetamine/methamphetamine Source: Art Jordan, MD, Sep 2005 ```
324
2801. “Joe the Doper” is one of your patients. You are prescribing oxycodone for a legitimate medical purpose, and his pain is well controlled. Joe had a routine urine drug test as part of a federal job interview and the screen reported opiates as “none detected”Joe “found religion” during his last incarceration in jail for cutting the heads off parking meters and swears that he has been taking the meds and not selling them on the street. Correct options at this time include: 1. Increase his dose of oxycodone and recheck his urine 2. Make a note in the chart that you really believe him and continue the oxycodone 3. Change his pain medication to a fentanyl patch 4. Order GC/MS specifi cally for oxycodone
2801. Answer: D (4 Only) Explanation: Standard urine opiate immunoassay is designed to detect only morphine and codeine, and will not detect oxycodone. GC/MS (Gas chromatography/mass spectrometry)will specifi cally detect oxycodone, or other specifi c substances as you indicate to the lab. You might also want to order a serum oxycodone level to get an idea of what the doses are achieving. Reference: UDT in Clinical Practice: Purdue Pharma, 2005 Source: Art Jordan, MD, Sep 2005
325
2802. What are the identifi ed problems of screening tools of drug abuse? 1. Developed in psychiatric fi eld 2. Rely on subjective reporting of the patients 3. Not designed to detect prescription opioid abuse 4. Designed to detect cocaine use
2802. Answer: A (1,2, & 3) | Source: Laxmaiah Manchikanti, MD
326
2803. What is the explanation of a routine urine drug test in a patient receiving codeine with acetaminophen 240 mg/day testing positive for codeine and negative for morphine? 1. The laboratory made a mistake 2. The morphine was metabolized faster than the codeine and was therefore excreted earlier 3. The morphine was “neutralized” by the specifi c carrier agent in the Codeine with acetaminophen 4. The patient is one of a small number who lack cytochrome P450 2D6 and cannot convert codeine to morphine
2803. Answer: D (4 Only) Explanation: A small number of patients lack cytochrone P450 2D6 and cannot convert part of the codeine to morphine, a normal metabolite of codeine Source: Art Jordan, MD, Sep 2005
327
``` 2804. What is the prevalence of co-existing diseases in drug dependence? 1. Alcohol dependence (63%) 2. Any psychiatric disorder (74%) 3. Antisocial personality disorder (44%) 4. Major depression (25%) ```
``` 2804. Answer: E (All) Explanation: Reference: Compton, et al. Am J Psychiatry 2001; 160: 890-895. Co-existing Diseases and Drug Dependence Alcohol dependence (63%) Any psychiatric disorder (74%) Antisocial personality disorder (44%) Phobic disorder (41%) Major depression (25%) Source: Mark V. Boswell, MD, KSIPP 2005 ```
328
2805.Identify the components of the four cornerstones of good clinical practice in chronic opioid prescribing. 1. A specifi c diagnosis that is opioid responsive 2. Verify no evidence of drug abuse 3. Document improved function 4. Manage side effects appropriately
2805. Answer: E (All) | Source: Mark V. Boswell, MD, KSIPP 2005
329
2806. What are the characteristics of simple chronic pain? 1. Pain lasting longer than 6 months. 2. Tend to have no more distress or psychopathology than what is expected in the general population. 3. Tend to continue working. 4. Tend to maintain meaningful relationships
2806. Answer: E (All) Explanation: Simple Chronic Pain Pain lasting longer than 6 months. Tend to have no more distress or psychopathology than what is expected in the general population. Tend to continue working. Tend not to become overly reliant on medications, i.e., have various ways to self-manage pain. Tend to maintain meaningful relationships Tend to maintain a sense of meaning and direction to their lives. Source: Murray McAllister, PsyD, LP - Spring 2004
330
2807. What are the true statements about marijuana urine drug testing (UDT)? 1. UDTs provide reasonable reliability 2. Marinol tests positive 3. Protonix may test false-positive 4. Marijuana may be positive 2 years after use.
2807. Answer: A (1,2, & 3)
331
2808. Somatoform disorders include the following: 1. Physical symptoms suggestive but not fully explained by a general medical disorder 2. Includes: somatization disorder 3. Includes: conversion disorder 4. Includes: major depression
2808. Answer: A (1,2, & 3) | Source: Renee R. Lamm, MD, Sep 2005
332
2809. DSM-IV defi nition of substance abuse includes at least one of the following in 12 months: 1. Maladaptive pattern leading to distress or impairment 2. Recurrent failure to fi ll role 3. Recurrent physically hazardous behavior 4. Recurrent legal problems
``` 2809. Answer: E (All) Explanation: SUBSTANCE ABUSE: DSM-IV DEFINITION At least one in 12 months: Maladaptive pattern leading to distress or impairment Recurrent failure to fi ll role Recurrent physically hazardous behavior Recurrent legal problems Continued use despite social problems Never met dependence criteria Source: Laxmaiah Manchikanti, MD ```
333
2810.Identify accurate statements of open label studies of opioids 1. Less then 50% of patients were continued on opioids at 2 yeras 2. Most of patients experiences at least one adverse event 3. No fi rm conclusions were made about tolerance and addiction 4. Results were made applicable to general public
``` 2810. Answer: A (1,2, & 3) Explanation: Open Label Studies 44% on opioids at 2 years 80% of patients experienced at least one adverse event No fi rm conclusions about tolerance and addiction Patients in trials were highly selected Results not generally applicable 5% of 1000 screened patients included Source: Mark V. Boswell, MD, KSIPP 2005 ```
334
``` 2811. What are common side effects leading to discontinuation of opioids? 1. Constipation 2. Nausea 3. Somnolence 4. Hyperactivity ```
``` 2811. Answer: A (1,2, & 3) Explanation: Side Effects are Common - Opioids are often discontinued because of adverse event: Constipation Nausea Somnolence Vomiting Source: Mark V. Boswell, MD, KSIPP 2005 ```
335
2812.Based on systematic reviews, what are the correct statements about opioids? 1. Morphine and oxycodone are not equal 2. Morphine 20 mg/day and oxycodone 30 mg/day are equally ineffective . 3. Improved functional status was conclusive 4. Opioids did not improve depression
2812. Answer: C (2 & 4) Explanation: Reference: Kalso E, Edwards JE, Moore A, McQuay JH. Opioids in chronic non-cancer pain: systematic review of effi cacy and safety. Pain 2004; 112;372-380. Morphine and oxycodone equally effective Morphine 20mg/day and oxycodone 30 mg/day not effective All patients in studies were on opioids previously Opioids did not improve depression Improved functional status unclear Source: Mark V. Boswell, MD, KSIPP 2005
336
2813.Identify the suggested requirements to be included in an agreement, if the patient is at high risk for medication abuse or has a history of substance abuse: 1. Reasons for which drug therapy may be discontinued (e.g., violation of agreement) 2. Requirement for medical interview with members of immediate family 3. Urine/serum medication levels screening when requested 4. Periodic reports from a local law enforcement agency
2813. Answer: B (1 & 3) Explanation: Interviews with family members may be helpful under certain circumstances if clinically indicated and if within legal bounds of privacy, however, this is not listed by the Board. Periodic reports from law enforcement, without patient consent, would be inappropriate and possibly a violation of privacy laws. Source: Art Jordan, MD, Sep 2005
337
2814. What are substance induced disorders? 1. Delirium-intoxication or withdrawal 2. Dementia 3. Amnestic disorders 4. Psychotic disorders
2814. Answer: E (All) | Source: Renee R. Lamm, MD, Sep 2005
338
2815. A 42 year old physician who suffers from ankylosing spondylosis is referred for pain management. After 2 months of treatment with long-acting opioids he feels so much better that he plans to return to work as an emergency room physician. Which of the following would be appropriate actions: 1. Recommend he have neuropsychologic testing to document good mental function while taking opioids. 2. Write a statement that he is capable of returning to the practice of emergency medicine at this time. 3. Insist the physician inform his employer and the hospital of the medications he takes as a requirement to continue treatment. 4. Inform him that legally he cannot return to practicing medicine while taking opioids.
2815. Answer: B (1 & 3) Explanation: 1. Neuropsychologic testing can document the physician is mentally acute while on chronic opioid therapy. 2. Without adequate documentation of the physician patient’s mental ability and the requirements of the hospital, the pain treatment physician could place him or herself at risk by making such a statement. 3. The pain treatment physician cannot directly inform the interested parties of the patient’s medications, but can cease treating the patient if he or she feels the situation is not acceptable. 4. There is no law in most states that prevents practicing medicine while taking opioids. Source: Roger Cicala, MD, Sep 2005
339
2816.Factitious disorders consist of the following: 1. Physical or psychiatric symptoms that are intentionally produced to assume a sick role 2. External incentives are present 3. Most severe form of Münchhausen Syndrome 4. Intentional symptoms with obvious goal
2816. Answer: B (1 & 3) | Source: Renee R. Lamm, MD, Sep 2005
340
2817. The “Whizzinator” is which of the following: 1. An electromechanical device for stirring alcoholic drinks 2. A urologic testing device to measure the force of urine fl ow 3. A suction device for maintaining an erection 4. A commercially available device to thwart urine drug testing
2817. Answer: D (4 Only) Explanation: It is important that the physician know that there are many available devices to avoid detection of improper or illegal substances in the urine, including the “Whizzinator”; an artifi cial penis which contains urine “guaranteed” to be drug free. Source: Art Jordan, MD, Sep 2005
341
2818. What are D.E.A considered “certain recurring concomitance of condemned behavior” in physician conviction? 1. The physician involved used street slang rather than medical terminology for the drugs prescribed 2. The physician warned the patient to fi ll prescriptions at different drug stores 3. There was no logical relationship between the drugs prescribed and treatment of the condition allegedly existing 4. The physician issued prescriptions to a patient known to be delivering the drugs to others
2818. Answer: E (All) Explanation: Explanation: All of the above answers are listed in the interim policy. In addition, the following are also listed as “certain recurring concomitance of condemned behavior”: 1:An inordinately large quantity of controlled substances was prescribed 2: Large numbers of prescriptions were written 3: No physical examination was given 4: The physician prescribed controlled drugs at intervals inconsistent with legitimate medical treatment 5: The physician wrote more than one prescription on occasions in order to spread them out **You will frequently see some of these behaviors listed as “Red Flags” Source: Art Jordan, MD, Sep 2005
342
2819. A prominent pain physician in North Carolina is treating Ms. Lavonia Gotrocks from Indiana. Traveling to see this physician greatly interferes with her social calendar, and she does not wish to make the trips more than every three months. She is currently taking sustained release oxycodone and hydromorphone.The physician writes her prescriptions on September 1, and then writes additional prescriptions for the same medications and indicates that they should be fi lled on October1, and November1. Her next appointment in the offi ce is December 1.Which of the following responses is/are correct? 1. This is correctly called “alternate dating” and not covered by the “No Refi ll” rule 2. Is a recurring tactic among physicians who seek to avoid detection when dispensing controlled substances for unlawful (nonmedical) purposes 3. Is legal if done for no more than 3 months total (3 prescriptions) 4. Is tantamount to writing a prescription authorizing refi lls of a schedule II controlled substance
2819. Answer: C (2 & 4) Explanation: “1” was commonly referred to as alternate dating prior to the F.A.Q.’s and was generally accepted by the D.E.A. as a legal but not recommended activity. The F.A.Q.’s actually stated that this action was acceptable, however this was specifi cally addressed as illegal in the “Interim Policy” statement in November of 2004. Source: Art Jordan, MD, Sep 2005
343
2820. What is the impact of psychological factors in treatment of pain with a comorbid substance use disorder? 1. Impedes diagnosis and complicates interventions 2. Pain can mask addiction - switch to legal drugs 3. Promotes regression and may induce hyperalgesia and extreme tolerance 4. Positive impact as psychotherapeutic drugs provide excellent analgesia
2820. Answer: A (1,2, & 3) Explanation: Reference: Collins and Streltzer 2003, Am J. Addict 12:2, Covington an dKoltz, 2003 Prin of Addict Med Source: Renee R. Lamm, MD, Sep 2005
344
2821. If a physician is aware that a patient is a drug addict and/or has resold prescription narcotics, which of the following is correct according to the “Interim Policy” 1. It is merely recommended that the physician engage in additional monitoring of the patient’s use of narcotics 2. The physician, as a D.E.A. registrant, has a responsibility to exercise a much greater degree of oversight to prevent diversion 3. Should prescribe controlled substances for intervals of 1-2 weeks only with frequent urine drug screens 4. May not dispense controlled substances with the knowledge they will be used to support addiction or be resold
2821. Answer: C (2 & 4) Explanation: Reference: “Interim Policy Statement” November 2004 Source: Art Jordan, MD, Sep 2005
345
2822. Urine Drug Testing (UDT) may be useful in which of the following situations? 1. To determine if a patient is taking the controlled substances prescribed 2. To determine the patient’s state of hydration in an effort to regulate the dosage of medication 3. To determine if the patient is taking medications and substances which are not prescribed by the physician administering the test 4. To determine the half-life of the drugs prescribed
2822. Answer: B (1 & 3) Explanation: The state of hydration on an isolated sample would be of no use in determining dosage. Likewise, the half life of the medication could not be determined from an isolated urine sample, while only checking for drugs present It is most important that the ordering physician know exactly which drugs are included in the specifi c test, and which drugs may not be detected. Examples include oxycodone, fentanyl, and methadone which may not be detected in many basic urine drug screens on the market. Source: Art Jordan, MD, Sep 2005
346
2823. A hypertensive crisis is most likely to result from the action of drugs from which one of the following drug classes: 1. Tricyclic antidepressants 2. Barbiturates 3. Opioids 4. Monoamine oxidase (MAO) inhibitors
2823. Answer: D (4 Only) Explanation: Monoamine oxidase (MAO) inhibitors such as tranylcypromine may precipitate a hypertensive crisis when used in the presence of certain foods that contain tyramine, or in the presence of certain sympathomimetic agents. Note also that opioids, particularly meperidine, may also (although rarely) precipitate a hypertensive crisis when used with MAO inhibitors.
347
2824. Which of the following statements about U.S. enlisted men who became addicted to opioids in Vietnam are correct? 1. Nearly 90% did not become addicted again within three years of return to the United States 2. Relapse more common in older white soldiers 3. Higher relapse rate in sons of alcoholic parents 4. About 75% of soldiers who used heroin fi ve or more times became drug dependent
2824. Answer: E (All) Explanation: U.S. enlisted soldiers addicted to opioids in RVN did not follow the pattern of addicted civilians: on return to U.S.; the great majority no longer used the drug (heroin). Source: Psychiatry specialty Board Review By William M. Easson, MD and Nicholas L. Rock, MD
348
2825.What are the true statements about early history of Opium? 1. Arabia - (600-900 A. D.) used medicinally. When the Koran forbade alcohol, Opium and Hashish became the primary social drugs. 2. Galen - 100 A. D. - ‘great cure-all’ 3. Greece - mixed with wine 100 B. C. 4. Eber’s Papyrus, 1500 B. C. - pain relief
2825. Answer: E (All) Explanation: History of Opium * Eber’s Papyrus, 1500 B. C. - pain relief * Greece - mixed with wine 100 B. C. * Galen - 100 A. D. - ‘great cure-all’ * Arabia - (600-900 A. D.) used medicinally. When the Koran forbade alcohol, Opium and Hashish became the primary social drugs. Source: Roger Cicala, MD, Sep 2005
349
2826. Strategies to reduce aberrant drug behaviors include: 1. Random urine drug screens 2. Narcotic contracts 3. No early refi lls 4. Opioid rotation
2826. Answer: A (1,2, & 3) Explanation: 1, 2, & 3. Random drug screens, narcotic contracts, and aggressive refi ll policies (no early refi lls) have been felt to help control aberrant drug behaviors. 4. Opioid rotation tries to address the issue of drug tolerance. Source: Trescot A, Board Review 2003
350
2827. The characteristics of marijuana include: 1. It may lower intraocular pressure 2. A sign of acute intoxication is reddening of conjunctiva 3. It has antiemetic properties 4. Heavy chronic use can lower serum testosterone levels in men
2827. Answer: E (All) Explanation: The active ingredient in marijuana is Delta-9- tetrahydrocannabinol. In general, marijuana is a CNS stimulant causing tachycardia, giddiness, and , at high doses, visual hallucinations. 1. Potential therapeutic uses include antiemesis in cancer chemotherapy and reduction of intraocular pressure in glaucoma. 2. Acute intoxication is characterized by reddening of the conjunctiva (bloodshot eyes) owing to local vasodilation. 3. Potential therapeutic uses include antiemesis in cancer chemotherapy and reduction of intraocular pressure in glaucoma. 4. Chronic use has been associated with an amotivational syndrome and with a reduction in serum testosterone and sperm count
351
2828. Sequelae of an acute cocaine overdose include 1. Myocardial ischemia and high output cardiac failure 2. Seizure activity 3. Tremulousness and hyperthermia 4. Blockade of inhibition of epinephrine
2828. Answer: A (1,2, & 3) Explanation: (Stoelting, Anesthesia and Co-Existing Disease, 3/e, pp 528-529.) Acute cocaine overdose will increase in central catecholamine levels are increased. Cocaine inhibits the reuptake of norepinephrine. Increased circulating norepinephrine levels have numerous effects on the cardiac system, including coronary artery vasospasm, an increase in myocardial oxygen consumption, and an increase in systemic vascular resistance. These effects can cause high-output cardiac failure and cardiac ischemia. Source: Curry S.
352
``` 2829.Symptoms of withdrawal from opioids include the following symptoms and signs: 1. Sweating 2. Restlessness 3. Irritability 4. Hot/cold fl ashes ```
2829. Answer: E (All)
353
2830. Goals of pharmacotherapy in opioid addiction include the following: 1. Prevention or reduction of withdrawal symptoms 2. Prevention or reduction of drug craving 3. Restoration to or toward normalcy of any physiologic function disrupted by chronic drug use. 4. To provide addictive drugs to prevent relapse
2830. Answer: A (1,2, & 3) Explanation: 1. Goals of pharmacotherapy include prevention or reduction of withdrawal symptoms 2. Goals of pharmacotherapy include prevention or reduction of drug craving 3. Goals of pharmacotherapy include restoration to or toward normalcy of any physiologic function disrupted by chronic drug use. 4. Goals of pharmacotherapy also include prevention of relapse to use of addictive drugs.
354
2831. What are the correct statements of Harrison Narcotics Tax Act of 1914? 1. Required physicians to register and keep records of prescribed medications. 2. Created Bureau of Narcotics of Treasury Department (and Federally run Heroin Clinics for addicts). 3. 3,000 physician arrests during 1920s. 4. By 1930 “addict pattern” was male, minority, criminal. But much smaller (?20,000).
2831. Answer: E (All) Explanation: Harrison Narcotics Tax Act of 1914: * Tax on all opium and coca. * Required physicians to register and keep records of prescribed medications. * Outlaws sale and distribution except prescribed by physician. * Created Bureau of Narcotics of Treasury Department (and Federally run Heroin Clinics for addicts). * The Bureau of Narcotics became the Prohibition Unit after passage of the Volstead Act. After Prohibition ended it became the Federal Narcotics Bureau and later the D. E. A. Harrison Act Case Law: * Three physician cases: Webb (1919), Moy (1920), and Behrman (1921). - Behrman: Physicians could not prescribe to ‘habitual users. - Webb and Moy: Must be “in the usual course of practice” to a “legitimate patient”. - 3,000 physician arrests during 1920s. * By 1930 “addict pattern” was male, minority, criminal. But much smaller (?20,000). * 1925 Linder case allowed physicians to prescribe long term or in addicted persons - but few would. Source: Roger Cicala, MD, Sep 2005
355
``` 2832. What are the requirements of continued controlled substance prescribing? 1. Reduction in pain 2. Improvement in functional status 3. Lack of evidence of drug abuse 4. Lack of unmanageable side effects ```
``` 2832. Answer: E (All) Explanation: Continued controlled substance prescribing requires: * Diagnosis * Reduction in pain * Improvement in functional status * Lack of evidence of drug abuse * Documented informed consent Source: Mark V. Boswell, MD, KSIPP 2005 ```
356
2833. Which of the following statements about alcohol withdrawal delirium are correct except ? 1. May be precipitated by surgery 2. Withdrawal seizures are most common 24 hours after withdrawal 3. Delirium tremens has peak incidence four days after withdrawal 4. Does not occur while still drinking
2833. Answer: D (4 Only) Explanation: Alcohol withdrawal delirium (delirium tremens, DT’s) is characterized by confusion, disorientation, fl uctuating or clouded consciousness, perceptual disturbances, delusions, vivid hallucinations, agitation, insomnia, mild fever, and marked autonomic arousal. Problems may apepar suddently or two or three days after cessation or redduction of heavy drinking, with a peak at the fourth or fi fth day. Symptoms may last four to fi ve weeks, but in the majority of patients, problems subside after three days. About one-third who develop alcohol withdrawal seizures (“rum fi ts”) go into delirium tremens. The best treatment is to prevent withdrawal by the use of benzodiazepines and a hig-calorie, high carbohydrate diet with supplemental vitamins. Source: Psychiatry specialty Board Review By William M. Easson, MD and Nicholas L. Rock, MD
357
2834. What are the true statements describing history of spread of opium? 1. Arabic traders spread use and cultivation to China by 900 A. D. 2. 1644 China outlawed tobacco, opium smoking became endemic 3. 1700 British East India company smuggled opium from India to China for tea (China refused legitimate trade). 4. 1839 - Because of “rampant addiction” Chinese emperor destroyed 45,000 pounds of British opium in Canton, beginning the Opium war
2834. Answer: E (All) Explanation: History of Opium * Arabic traders spread use and cultivation to China by 900 A. D. * 1644 China outlawed tobacco, opium smoking became endemic * 1700 British East India company smuggled opium from India to China for tea (China refused legitimate trade). * 1839 - Because of “rampant addiction” Chinese emperor destroyed 45,000 pounds of British opium in Canton, beginning the Opium war. * Britain won the ensuing war, receiving Hong Kong and forcing China to accept opium in trade. * Opium fi nally outlawed in China by 1913. Source: Roger Cicala, MD, Sep 2005
358
2835.Chose the correct statements about use of opium in Europe and America: 1. Paracelsus 1500 called laudanum (opium, cloves, and alcohol) the “stone of immortality”. 2. Thomas Sydenham brought to England about 1700. 3. 1831 Sertuener given Nobel Prize for isolating individual opiates. 4. 1853 - hypodermic syringe invented. The American Civil War and Prussian Wars of 1860-1870 led to widespread morphine injection.
2835. Answer: E (All) Explanation: Use in Europe and America * Opium knowledge was lost during Dark Ages, reintroduced after Crusades. * Paracelsus 1500 called laudanum (opium, cloves, and alcohol) the “stone of immortality”. * Thomas Sydenham brought to England about 1700. * 1831 Sertuener given Nobel Prize for isolating individual opiates. * 1853 - hypodermic syringe invented. The American Civil War and Prussian Wars of 1860-1870 led to widespread morphine injection. Source: Roger Cicala, MD, Sep 2005
359
2836. What are the historical aspects of opiate abuse? 1. “Soldier’s Disease” - morphine addiction - reported during American Civil War and Prussian Wars of 1860- 1870. 2. 10% of U. S. population used laudanum nonmedicinally. 3. Widespread laudanum and opiate abuse in U. S. in late 1800s. Sears carried syringe kits in catalogs. Estimated 500,000 - 1,000,000 addicted in U. S. 4. Heroin introduced in 1898 as “non-addicting” morphine.
2836. Answer: B (1 & 3) Explanation: Opiate Abuse * “Soldier’s Disease” - morphine addiction - reported during American Civil War and Prussian Wars of 1860- 1870. * Widespread laudanum and opiate abuse in U. S. in late 1800s. Sears carried syringe kits in catalogs. Estimated 500,000 - 1,000,000 addicted in U. S. * 4% of U. S. population used laudanum nonmedicinally. * Laudanum addiction was considered fashionable. Typically described as ‘middle-aged, upper-class white female’. Samuel Taylor Coleridge, Elizabeth Barrett Browning, Thomas De Quincy all quite open about their addiction. * Heroin introduced in 1898 as “non-addicting” morphine. Used as cure for “Morphinism” similar to methadone today. Source: Roger Cicala, MD, Sep 2005
360
2837.Choose the correct statement of U.S. opiate abuse patterns: 1. Change from morphine to heroin in 50s-60s. Dramatic increase in numbers 60s-70s. 2. Reduction in opiate abuse during 80s and early 90s (?cocaine effect?) 3. Prescription opiate abuse increases in late 1990s (?or increased awareness?) 4. Heroin resurgence begins late 1880’s.
2837. Answer: A (1,2, & 3) Explanation: U. S. Opiate Abuse Patterns * Change from morphine to heroin in 50s-60s. Dramatic increase in numbers 60s-70s. * Reduction in opiate abuse during 80s and early 90s (?cocaine effect?) * Prescription opiate abuse increases in late 1990s (?or increased awareness?) * Heroin resurgence begins late 1990s. Source: Roger Cicala, MD, Sep 2005
361
2838. What are true statements about non-opiate drugs of abuse? 1. Coca products began widespread use in 1880s in patent medicines and ‘soft drinks’. Endorsed by the Surgeon General in 1886. 2. Amphetamines 1920s, used by military, physicians, widespread public use in 30s. 3. Barbiturates and amphetamines began widespread use in 1940s, originally as OTC medications and in patent medications. 4. Hallucinogens popularized in 1960s. Declined by late 1970s.
2838. Answer: E (All) Explanation: Other Drugs of Abuse * Coca products began widespread use in 1880s in patent medicines and ‘soft drinks’. Endorsed by the Surgeon General in 1886. * Amphetamines 1920s, used by military, physicians, widespread public use in 30s. * Barbiturates and amphetamines began widespread use in 1940s, originally as OTC medications and in patent medications. * Marijuana use reported in 1880s. Became popular during prohibition and through the great depression. * Hallucinogens popularized in 1960s. Declined by late 1970s. Source: Roger Cicala, MD, Sep 2005
362
2839. Prescriptions for pain relief are receiving special attention by the Drug Enforcement Agency and the Offi ce of Inspector General due to . . . 1. The signifi cant increase in the types of pain prescriptions available today. 2. The signifi cant increase in the number of pain medications prescribed today. 3. Evidence of doctor shopping by persons who obtain pain prescriptions from doctors either for their own abusive use or for illegal resale to others. 4. A lessening of illegal drug traffi cking.
2839. Answer: A (1,2, & 3) Explanation: Prescriptions for pain relief are receiving special attention by the DEA and even the OIG because of the signifi cant increase in the types of pain prescriptions available today, the signifi cant increase in the number of prescriptions for these medications, and the evidence of doctor shopping by persons who obtain pain prescriptions from multiple doctors for their own abusive use or for illegal resale to others. Source: U.S. Drug Enforcement Administration News Release, October 23, 2001 (http://www.usdoj.gov/dea/pubs/pressrel/pr102301.html). Source: Erin Brisbay McMahon, JD, Sep 2005
363
2840. Choose the statements reflecting prescription drug use for non-medical purposes. 1. Overall, it is believed that 10% of prescription drugs are used for non-medial purposes. 2. Controlled prescription drugs for non-medical purposes have been reported to be used over 6 million people over the age of 12 years in the United States. 3. Prescription drug abuse and illicit drug abuse may be signifi cantly higher in chronic pain patients than in normal population. 4. Marijuana use is only second to cocaine.
2840. Answer: A (1,2, & 3) Explanation: 1. 10% of prescription drugs are used for non-medical purposes. 2. Over 6 million people over the age of 12 years in the United States have been reported to use controlled prescription drugs for non-medical purposes. 3. Opioid abuse is seen in as high as 18% to 24% of the patients in chronic pain. Illicit drug use is seen in 14% to 32% of chronic pain patients. 4. Marijuana is the most commonly used illicit drug, followed by cocaine. Source: Laxmaiah Manchikanti, MD
364
2841. Delirium is an acute confusional state that results from diffuse organic brain dysfunction. In the cancer patient, the causes include: 1. Opioid toxicity 2. Dehydration 3. Hypoxia 4. Brain metastases
2841. Answer: E (All) | Source: Reddy Etal. Pain Practice: Dec 2001, march 2002
365
2842. Which of the following is NOT true regarding penalties for an unlawful intentional or knowing distribution or dispensation of controlled substances? 1. As little as a one-year sentence may be imposed. 2. A life sentence may be imposed. 3. Supervised release will be imposed and will last from 1-5 years. 4. The court has the power to suspend a sentence or grant probation or parole, no matter what the facts of the case are
2842. Answer: D (4 Only) Explanation: Answer (a) is wrong because the court cannot grant probation, parole, or a suspended sentence if death or serious bodily injury results with respect to a S I or II drug. Reference: 21 USC 841. Source: Erin Brisbay McMahon, JD, Sep 2005
366
2843. What is the suggested protocol of Ballantyne and Mao published in New England Journal of Medicine? 1. Ensure benefi t will out weigh risk 2. Evaluate possible addiction and problems with poor functioning 3. Watch deterioration in function related to lack of motivation to improve 4. Once opioids are started no further monitoring is required
``` 2843. Answer: A (1,2, & 3) Explanation: Ballantyne J, Mao J. Opioids for Chronic Pain. NEJM. 2003; 349: 1943-1953 Source: Mark V. Boswell, MD, KSIPP 2005 ```
367
2844. Partial fi lling of a prescription for a controlled substance listed in Schedule III, IV, or V is permissible, if: 1. Each partial fi lling is recorded in the same manner as a fi lling. 2. The total quantity dispensed in all partial fi llings does not exceed the total quantity prescribed. 3. No dispensing occurs after six months after the date on which the prescription was issued. 4. The prescribing practitioner authorizes the partial fi lling in writing.
2844. Answer: A (1,2, & 3) Explanation: Answer (1) is wrong; that is not a requirement for a partial fi lling of a prescription for a Schedule III, IV, or V substance. Reference: 21 CFR 1306.23. Source: Erin Brisbay McMahon, JD, Sep 2005
368
2845. Which of the following is true with respect to a partial fi lling of a Schedule II prescription? 1. If the remaining portion of the prescription is not or cannot be fi lled within 72 hours of the partial fi lling, the pharmacist must notify the prescribing physician. 2. A partial fi lling is allowed for a terminally ill patient, and the prescribing physician has the sole responsibility to make sure the controlled substance is for a terminally ill patient. 3. A partial fi lling is allowed for a terminally ill patient, and the prescribing physician and the pharmacist both have the responsibility to make sure the controlled substance is for a terminally ill patient. 4. A partial fi lling is allowed for a terminally ill patient, and the pharmacist has the sole responsibility to make sure the controlled substance is for a terminally ill patient.
2845. Answer: B (1 & 3) Explanation: Answers (2) and (4) are wrong because both the prescribing physician and the pharmacist have the responsibility to make sure the controlled substance is for a terminally ill patient when the partial fi lling is for a terminally ill patient. Reference: 21 CFR 1306.13. Source: Erin Brisbay McMahon, JD, Sep 2005
369
2846. A fax will serve as the original prescription for a Schedule II narcotic substance . . .: 1. That is to be compounded for direct administration to the patient by parenteral, IV, intramuscular injection, subcutaneous or intraspinal infusion. 2. For a resident of a long-term care facility. 3. For a patient enrolled in a hospice program licensed by the state or certifi ed and/or paid for by Medicare, if the prescription notes that the patient is a hospice patient. 4. For any terminally ill patient.
2846. Answer: A (1,2, & 3) Explanation: Answer (4) is wrong because a fax will not serve as the original prescription for a Schedule II controlled substance for any terminally ill patient. Reference: 21 CFR 1306.11. Source: Erin Brisbay McMahon, JD, Sep 2005
370
2847. Pain physicians must consider the following in chronic long-term opioid therapy: 1. Prolonged, high dose therapy may have adverse consequences 2. The opioid formulation does not reduce development of tolerance 3. Abuse potential of long acting and short acting formulations are the same 4. Long term opioids produce adverse physiologic changes (immune, hormonal, pain, etc)
2847. Answer: E (All) Explanation: * Prolonged, high dose therapy may have adverse consequences * The opioid formulation does not reduce development of tolerance * Abuse potential of long acting and short acting formulations are the same * Long term opioids produce adverse physiologic changes (immune, hormonal, pain, etc) * Opioid rotation may help reduce the need for dose escalation and improve effi cacy Source: Mark V. Boswell, MD, KSIPP 2005
371
2848. Substance dependence is best characterized by which of the following statements? 1. Substance use is discontinued once there is insight about the physical or psychological harm that is likely to have been caused or exacerbated by the substance use 2. Important social, occupational or recreational activities are decreased because of the use of substances. 3. Symptoms may be due to another general medical condition. 4. Tolerance and withdrawal are associated with it.
2848. Answer: C (2 & 4) | Source: Cole EB, Board Review 2003
372
2849.No Schedule II prescription drug may be dispensed without a written prescription, unless: 1. A physician calls in a refi ll. 2. It is dispensed directly by the physician to the ultimate user. 3. The drug is dispensed to another physician. 4. There is an emergency situation which is defi ned by regulation; in that case, an oral prescription may be allowed.
2849. Answer: C (2 & 4) Explanation: Answer (1) is wrong because no Schedule II prescription can be refi lled. Answer (3) is wrong because there is no exception for dispensing drugs to another physician. Reference: 21 USC 829(a). Source: Erin Brisbay McMahon, JD, Sep 2005
373
2850. A patient presents to you with injury of ankle strain. The ankle is swollen and extremely painful. However, there was no fracture. The patient is also on opioid maintenance treatment with methadone of 120 mg daily. True statements with regards to his pain management including the following: 1. Opioid maintenance patients develop full tolerance to the analgesic effects of the maintenance dose of methadone. 2. During opioid maintenance treatment, a cross-tolerance develops to all opioid agonist drugs. 3. The usual maintenance dose of opioid maintenance does not provide any analgesia, and adequate analgesia will require higher doses of opioid agonists given more frequently than in the non-tolerant patient. 4. The usual maintenance dose provides signifi cant analgesia, thus, no opioid agonists are required to provide analgesia for the acute pain.
2850. Answer: A (1,2, & 3) Explanation: Patients being maintained with methadone require special consideration for acute pain management in surgical or trauma situations. 1. Maintenance patients develop full tolerance to the analgesic effects of the maintenance dose of methadone. 2.During opioid maintenance treatment, a cross-tolerance develops to all opioid agonists drugs, accounting for the “blockade effect. Early research has demonstrated that stable opioid maintenance treatment patients could not distinguish 20 mg of intravenous morphine from intravenous saline. 3. The usual maintenance dose does not provide any analgesia, and adequate analgesia will require higher doses of opioid agonists given more frequently than in the nontolerant patient. Methadone has a half-life of 24 to 36 hours, but its analgesic effects range from 4 to 6 hours, which is similar to morphine in both potency and duration. Morphine, Dilaudid, codeine, and other agonist drugs are appropriate for opioid maintenance treatment patients. Mixed agonist-antagonists (pentazocine, butorphanol, nalbuphine) and partial agonists (buprenorphine) must not be used, as they will precipitate an opioid withdrawal syndrome. Meperidine and propoxyphene should be avoided because of the risk of seizures at the higher doses required to produce analgesia in these patients. 4. Maintenance doses of opioids do not provide adequate analgesia in acute pain.
374
``` 2851.Examples of the phenanthrene class of opioid include all except: 1. Morphine 2. Fentanyl 3. Codeine 4. Meperidine ```
``` 2851. Answer: B (1 & 3) Explanation: Morphine and codeine are phenanthrenes. Fentanyl and meperidine are phenylpiperidines. Source: Trescot A, Board Review 2003 ```
375
2852. 30 mg of Morphine Sulphate orally is equivalent to: 1. 10mg MSO4 IV 2. 20mg of oral oxycodone 3. 1.5mg hydromorphone IV 4. 20mg methadone
2852. Answer: E (All) Explanation: Although equipotent charts may vary, in general, 30mg of oral MSO4 is equivalent to 10mg MSO4 IV, 20mg of oral oxycodone, 1.5mg of IV hydromorphone, or 20mg of methadone. Source: Trescot A, Board Review 2003
376
2853. Chronic alcoholism is associated with: 1. Retrobulbar optic neuropathy 2. Caudate calcifi cation 3. Cerebellar anterior lobe degeneration 4. Acoustic neuroma
2853. Answer: B (1 & 3) Explanation: Chronic alcoholism is associated with retrobulbar optic neuropathy, cerebellar anterior lobe degeneration, encephalopathy (Wernicke’s), subdural hematoma, amnestic disorder (Korsakoff ’s syndrome), dementia, peripheral neuropathy, pancreatitis, esophageal varices, duodenal ulcer, cardiomyopathy, pulmonary infections (especially tuberculosis), cirrhosis, and fetal alcohol syndrome. Source: Psychiatry specialty Board Review By William M. Easson, MD and Nicholas L. Rock, MD
377
``` 2854. In treatment opioid overdose, which of the following is effective? 1. Methadone 2. L-alpha-acetylmethadol (LAAM) 3. Buprenorphine 4. Naloxone ```
2854. Answer: D (4 Only) Explanation: In Acute opioid overdose, the drug of choice is naloxone HCI (Narcan), 0.4-2.0 mg, preferably IV, every 2 to 3 minutes, to a maximum dose of 10 mg. Nalocone is an opioid antagonist that blocks opioid receptors. Other opioid antagonists are nalorphine and levellorphane. In an opioid withdrawal procedure, naltrexone HCI (Trexan), clonidine, and methadone may be used as they have longer acting effects. Source: Psychiatry specialty Board Review By William M. Easson, MD and Nicholas L. Rock, MD
378
2855.When a patient has been taking heavy doses of barbiturates for an extended period, early symptoms of withdrawal are likely to include: 1. Weakness 2. Insomnia 3. Anxiety 4. Tremulousness
2855. Answer: E (All) Explanation: Barbiturate withdrawal (especially short acting) usually results in weakness, insomnia, anxiety, tremulousness, abdominal discomfort, nausea and vomiting. With preexisting cardiovascular problems, there may be fatal reactions. Seizures generally precede delirium. Symptoms are more marked with secobarbital an dleast with phenobarbital withdrawal (due to its long half-life). Source: Psychiatry specialty Board Review By William M. Easson, MD and Nicholas L. Rock, MD
379
2856. Physical dependence is a term defi ned as: 1. The presence of withdrawal symptoms with abrupt discontinuation of drug. 2. Is synonymous with addiction 3. Reveals abrupt withdrawal symptoms when antagonist is administered 4. Does not respond to a tapering dose, and requires detoxifi cation
2856. Answer: B (1 & 3) Explanation: Physical dependence is an occurrence that follows opioid, benzodiazepine, or other controlled substance use, and sometimes non-controlled substances, such as nicotine and alcohol, particularly revealed when abruptly discontinued. Titration is acceptable, and done slowly, with the caveat that physicians that do not have a special attachment to their DEA certifi cate do not use methadone as a taper. Opioid antagonist drugs can abruptly throw an individual into withdrawal. Source: Hans C. Hansen, MD
380
2857. All states that have guidelines, laws, and/or regulations governing the use of controlled substances to treat pain set, as a minimum standard, that the physician should ask the patient whether he/she has 1. Ever used prescribed controlled drugs before. 2. Ever been to a pain doctor before. 3. A history of chemical/substance abuse, including alcohol, illicit, and licit drugs. 4. Had any tests related to his/her pain condition.
2857. Answer: E (All) Explanation: Reference: The Federation of State Medical Boards’ Model Policy for the Use of Controlled Substances for the Treatment of Pain (May 2004); www.fsmb.org. Explanation: The correct answer is E, all of the above, because each of these items plays into the minimum standards related to the taking of a patient history and the performance of a physical examination prior to prescribing controlled substances for the treatment of pain. A provider should not omit any of these questions from his/her interaction with the patient. Many of these questions can be set forth in a general history form. Providers may also develop special forms on substance abuse issues to use with patients prior to prescribing them controlled substances. In all cases, providers should cover these areas and more with their patients. Consult your state materials on the use of controlled substances for the treatment of pain. Source: Jennifer Bolen, JD, Sep 2005
381
2858. What are the correct statements of urine drug testing? 1. Thin-layer chromatography (TLC) is a relatively old technique, testing the migration of a drug on a plate or fi lm, which is compared to a known control 2. Gas chromatography (CGMS) is most sensitive and specifi c test, most reliable, and labor intensive/costly 3. Enzyme immunoassay is easy to perform/highly sensitive, more sensitive than TLC, and less expensive than GC/MS 4. Rapid drug screens are not similar to other enzyme immunoassay testsand may be more expensive
2858. Answer: A (1,2, & 3) Explanation: 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 Source: Laxmaiah Manchikanti, MD
382
``` 2859. Which of the following may cause constipation in the cancer patient? 1. Chronic opioid use for pain. 2. Iron supplementation for anemia. 3. Antacids containing Ca and Al. 4. Drugs with anticholinergic effects. ```
2859. Answer: E (All) | Source: Reddy Etal. Pain Practice: Dec 2001, march 2002
383
2860. Evidence based medicine was developed in response to public need. What are the accurate statements? 1. Patients and payers call for more accountability 2. Changing patient-physician relationship with fi nancial focus is positive 3. Concern about increasing costs 4. Clinicians (and patients) are good at decision making
2860. Answer: B (1 & 3) Explanation: What is the public need? Patients and payers call for more accountability - Changing patient-physician relationship - Concern about increasing costs Clinicians (and patients) coping with information overload need tools for better decision making - Synthesis of alternative diagnostic and treatment options - Quantifi cation of outcomes Source: Laxmaiah Manchikanti, MD
384
2861.Mixed opioid agonist-antagonists (nalbuphine, pentazocine) have limited use in cancer patients because: 1. Respiratory depression is a common side effect 2. Interaction at the opioid receptor can precipitate withdrawal symptoms. 3. Pruritus is a common side effect. 4. Effectiveness is limited by a dose-related ceiling effect.
2861. Answer: C (2 & 4) | Source: Reddy Etal. Pain Practice: Dec 2001, march 2002
385
``` 2862.Which of the following sedative medications have analgesic properties: 1. Midazolam® 2. Ketamine® 3. Propofol® 4. Dexmedetomidine® ```
2862. Answer: C (2 & 4) Explanation: Ref: Frogen and Avram. Chapter 15. Nonopioid Intravenous Anesthetics. In: Clinical Anesthesia, 2nd Edition. Barash, Cullen, Stolling; Lippencott, 1992, pg 388 Source: Day MR, Board Review 2003
386
2863. What are the steps to avoiding trouble with misuse of controlled substances? 1. Know your state laws and regulations 2. Know your Medical Licensure Board’s guidelines on prescribing controlled substances 3. DEA statement about your state on its website 4. Follow the rules of advocacy groups and organization supporting unrestricted use of controlled substances
2863. Answer: A (1,2, & 3) Explanation: AVOIDING TROUBLE Know your state -what laws and regulations are in place? -does your Medical Licensure Board have guidelines on prescribing controlled substances? -what does DEA say about your state on its website? http://www.dea.gov/pubs/state_factsheets.html Source: Erin Brisbay McMahon, JD, Sep 2005
387
2864. What are some of the communication issues faced by health care providers in terminal patients? 1. Diagnosis and prognosis 2. Advanced directives and do-not-resuscitate(DNR) orders 3. Spiritual needs 4. Symptom Management
2864. Answer: E (All) | Source: Reddy Etal. Pain Practice: Dec 2001, march 2002
388
2865. Patient complains of low back pain, headaches, and depression, She is taking Lortab (hydrocodone) 10/500 six per day, Fioricet (butalbital) six per day, and Paxil (paroxetine) 20mg per day. She complains of inadequate pain relief. Appropriate medication management would include: 1. Counsel patient on the amount of acetaminophen, and change her to lower acetaminophen products 2. Start methadone 10mg six per day 3. Change her antidepressant to a super-selective serotonin reuptake inhibitor 4. Change the butalbital to a triptan
2865. Answer: B (1 & 3) Explanation: Patient is taking 4950mg acetaminophen per day (Lortab has 500mg per tablet = 3000mg, Fioricet has 325mg per tablet = 1950mg). Toxic acetaminophen levels range from 3 to 4 gm per day. The equivalent dose of methadone would be 10mg TID (hydrocodone 60mg per day = morphine 60mg; decrease dose by 1/2 =30mg, divide by 3 and dose q 8hr would be 10mg q 8hrs). Paroxetine is a potent CYP2D6 inhibitor and will inhibit the metabolism of hydrocodone to hydromorphone, leading to decreased analgesia. Neither escitalopram (Lexapro) or citalopram (Celexa), which are considered “super-selective SSRIs”, will inhibit CYP2D6. Butalbital and triptons can cause rebound headaches, and should be changed; prophylactic medications may be needed. Methadone gives good relief of headaches, but butalbital will decrease methadone levels. Source: Andrea M. Trescot, MD
389
2866. Drug testing may be performed by any of the following 1. Hair samples 2. Saliva testing 3. Serum drug testing 4. Urine drug screening
``` 2866. Answer: E (All) Explanation: Drug Testing may be performed by any of the following: Urine Drug Screening Specifi c drug analysis (blood) Hair Samples Saliva Testing Serum Levels Source: Laxmaiah Manchikanti, MD ```
390
2867. Regarding the metabolism of opioids: 1. Some opioids are metabolized by glucuronidation 2. Some opioids are metabolized by the P450 enzyme system 3. M6G is an analgesic metabolite of morphine 4. M3G is an analgesic metabolite of morphine
2867. Answer: A (1,2, & 3) Explanation: Some opioids, such as morphine, are metabolized by glucuronidation, while other opioids, such as propoxyphene are metabolized by the P450 system. M6G is analgesic while M3G is probably produces hyperalgesia. Reference: Sjogren P, Jensen NH, Jensen TS. Disappearance of morphine-induced hyperalgesia after discontinuing or substituting morphine with other opioid agonists. Pain 1994 Nov;59(2):313-6. Source: Andrea M. Trescot, MD
391
2868. The following statements are true: 1. All opiates are opioids 2. All opioids are opiates 3. All opioids are narcotics 4. All narcotics are opioids
2868. Answer: B (1 & 3) Explanation: Opiates are naturally occurring alkaloids such as morphine. Opioids are natural or synthetic compounds that work at the opioid receptor. All opiates are opioids, and all opioids are narcotics. However, not all opioids are opiates. All narcotics are opioids; examples of nonopioid narcotics include marijuana and LSD. Source: Andrea M. Trescot, MD
392
2869. What are the correct statements about urine drug testing (UDT)? 1. A UDT would be positive if the patient took the drug (true positive) and negative if the drug was not taken (true negative). 2. Sensitivity of a test is the ability to identify a particular drug. 3. False-positive or False-negative results can occur, so it is imperative to interpret the UDT results carefully. 4. Specificity is the ability to detect a class of drugs.
2869. Answer: B (1 & 3) | Source: Laxmaiah Manchikanti, MD
393
2870. Which of the following statements about biotransformation are true ? 1. Biotransformation often produces metabolites with less affi nity for receptors than the parent drug 2. Biotransformation often produces metabolites with a higher renal clearance than the parent drug 3. Biotransformation often entails multiple enzyme-catalyzed reactions 4. Biotransformation reactions often occur in the liver
2870. Answer: E (All) Explanation: Biotransformation generally produces metabolites that are more water soluble than the parent drug. The metabolites are less lipophilic and, hence, are poorly reabsorbed in the kidney, thus facilitating elimination.
394
``` 2871. Which of the following adverse effects if associated with the use of Neuroleptic agents ? 1. Acute dystonia 2. Gynecomastia 3. Sedation 4. Loss of libido ```
2871. Answer: E (All) Explanation: Acute dystonia, gynecomastia, sedation and loss of libido may all be seen in patients being treated with neuroleptic agents.
395
2872. Which of the following statements best describes a characteristic of the antimigraine agent ergotamine? 1. It promotes vasodilatation 2. It is useful in reducing premature contractions of the uterus 3. It acts as a serotonin (5HT)-receptor antagonist 4. It acts as an alpha-adrenoceptor agonist
2872. Answer: D (4 Only) Explanation: Ergotamine actions are mediated by agonist actions at both serotonin (5HT)-receptors and ?-adrenoceptor. Ergotamine causes vasoconstriction and is contraindicated during pregnancy.
396
2873. Effects on the respiratory system by opioids include: 1. Equipotent doses of opioids result in equal amounts of respiratory depression 2. Depression of cough is a different mechanism than respiratory depression 3. There is a direct respiratory depression effect on the medulla 4. Respiratory rate decreases decrease fi rst and then CO2 and hypoxia response decreases.
2873. Answer: A (1,2, & 3) Explanation: Equipotent doses of opioids are equipotent on the respiratory system, and there is a direst effect on the medulla. The cough suppression is a different mechanism than the respiratory response. However, respiratory rate will only drop after the CO2 and hypoxia responses have decreased. Source: Andrea M. Trescot, MD
397
2874. Choose the correct statement about state board rules physicians do not know: 1. Cannot Rx Schedule II or III for family members 2. Can provide samples of unscheduled drugs for family, but MUST document in a medical record 3. Cannot Rx to anyone (including friends) if you have not documented their H&P and have a current chart on fi le. 4. Can Rx for yourself
2874. Answer: A (1,2, & 3) Explanation: State Board Rules You Might Not Know Cannot Rx Schedule II or III for family members Can provide samples of unscheduled drugs for family, but MUST document in a medical record Cannot Rx for anyone in sexual relationship, EVER. Cannot Rx for yourself, EVER. Cannot Rx to anyone (including friends) if you have not documented their H&P and have a current chart on fi le. Source: Laxmaiah Manchikanti, MD
398
2875. Which of the following statements are true with regards to the Controlled Substances Act of the Comprehensive Drug Abuse Prevention and Control Act of 1970 ? 1. It is the legal foundation of the government’s fi ght against the abuse of drugs and other substances. 2. It is a consolidation of numerous laws regulating the manufacture and distribution of narcotics, stimulants, depressants, hallucinogens, anabolic steroids and chemicals used in the illicit production of controlled substances. 3. All the substances that are regulated under existing federal law are placed into I of V schedules. 4. Schedule I is reserved for the least dangerous drugs that have the highest recognized medical use.
2875. Answer: A (1,2, & 3) Explanation: The Controlled Substances Act (CSA), title 2 of the Comprehensive Drug Abuse Prevention and Control Act of 1970 is the legal foundation of the government’s fi ght against the abuse of drugs and other substances. This law is a consolidation of numerous laws regulating the manufacture and distribution of narcotics, stimulants, depressants, hallucinogens, anabolic steroids, and chemicals used in the illicit production of controlled substances. All the substances that are regulated under existing federal law are placed into I of V schedules. This placement is based upon the substances’ medicinal value, harmfulness, and potential for abuse or addiction. Schedule I is reserved for the most dangerous drugs that have no recognized medical use. Schedule V is the classifi cation used for the least dangerous drugs. The Act also provides a mechanism for substances to be controlled, added to a schedule, decontrolled, removed from control, rescheduled, or transferred from one schedule to another. Source: Manchikanti L, Board Review 2005
399
2876. What are correct statements of Food and Drug Act Amendments? 1. Durham-Humphrey 1951 - make OTCs require prescriptions. 2. Boggs Act (1951) 3. Narcotic Control Act (1956) 4. Drug Abuse Control Acts of 1956 and 1958 labeled ‘potential drugs of abuse’ and gave power to DEA precursors to regulate.
2876. Answer: A (1,2, & 3) Explanation: Food and Drug Act Amendments * Durham-Humphrey 1951 - make OTCs require prescriptions. * Boggs Act (1951) * Narcotic Control Act (1956) * Drug Abuse Control Acts of 1965 _and 1968 labelled ‘potential drugs of abuse’ and gave power to DEA precursors to regulate. Source: Roger Cicala, MD, Sep 2005
400
``` 2877.What is the level of care - necessary to achieve and maintain abstinence from opioids? 1. Medically managed inpatient treatment 2. Intensive outpatient program 3. Residential treatment program 4. Medically managed phone consultations ```
``` 2877. Answer: A (1,2, & 3) Explanation: Level of Care - Necessary to Achieve & Maintain Abstinence * Medically managed inpatient treatment - Medical/surgical hospital - Psychiatric hospital * Medically supervised inpatient treatment * Partial hospitalization * Intensive outpatient program * Residential treatment program Source: Kennison Roy, MD ```
401
2878.What are the perceived barriers to non-opioid management? 1. The opioid model words well from a business standpoint 2. Easy to assemble a multidisciplinary team 3. “Rebound pain” phenomenon after detoxifi cation 4. Multidisciplinary model works well from a business standpoint
``` 2878. Answer: B (1 & 3) Explanation: Barriers to Non-Opioid Management * Payment issues - The opioid model works well from a business standpoint * System diffi culties - Hard to assemble a multidisciplinary team * Issues of detoxifi cation - “Rebound pain” phenomenon Source: Kennison Roy, MD ```
402
2879.The Federation of State Medical Boards (FSMB) encourage practitioners to include the following in the medical record : 1. Medical history 2. Pain history 3. Working diagnosis 4. History of allergies to opioids
2879. Answer: A (1,2, & 3) Explanation: The Federation of State Medical Boards requires specifi c documentation in the medical record to defi ne legitimate medical need when controlled substances are used. This includes: medical history, substance or chemical abuse, pain history, appropriate studies, working diagnosis, treatment plan, rationale for treatment selected, patient education, and documentation that the patient and physician understand the treatment goals. The standard medical history course will cover allergies to medications, but not necessarily relevant to the concept of legitimate medical need. For appropriate prescription habitry to be realized, diagnosis, historical features and exam must meet the need for the medication, clearly outlined and understood in the medical record. Source: Hans C. Hansen, MD
403
2880. The action of Tramadol is considered: 1. A centrally acting synthetic opioid analgesic. 2. Associated with mu-opioid receptor activity. 3. Inhibition of reuptake of norepinephrine and serotonin. 4. Tramadol induced analgesia is totally reversed by naloxone.
2880. Answer: A (1,2, & 3) | Source: Hansen HC, Board Review 2004
404
2881.A COX 2 selective agent may be preferred in the following: 1. History of GI bleed or complicated ulcer 2. Anticoagulant use 3. Oral corticosteroid use 4. Age
2881. Answer: A (1,2, & 3) | Source: Jackson KC. Board Review 2003
405
2882.All of the following statements are correct about detoxifi cation EXCEPT: 1. In one year post completion outcome data all patients still had some pain - most had much less 2. In one year post completion outcome data 70% had achieve continuous sobriety 3. In one year post completion outcome data pain was not ever worse without narcotics than it was while taking narcotics 4. In one year post completion outcome data only 20% had continued sobriety
``` 2882. Answer: D (4 Only) Explanation: * Outcome studies are becoming available - One year post completion outcome data: All patients still had some pain - most had much less 70% had achieved continuous sobriety Pain was not ever worse without narcotics than it was while taking narcotics. Source: Kennison Roy, MD ```
406
2883.Controlled substance abuse in work place may be identifi ed by the following signs? 1. Work performance alternating between periods of high and low productivity and mistakes made due to inattention, poor judgment and bad decisions. 2. Confusion, memory loss, and diffi culty concentrating or recalling details and instructions. Ordinary tasks require greater effort and consume more time 3. Interpersonal relations with colleagues, staff and patients suffer. 4. Promptly admits errors or accepts blame for errors or oversights
2883. Answer: B (1 & 3) Explanation: Watch for signs: Work performance alternating between periods of high and low productivity and mistakes made due to inattention, poor judgment and bad decisions; Confusion, memory loss, and diffi culty concentrating or recalling details and instructions. Ordinary tasks require greater effort and consume more time; Interpersonal relations with colleagues, staff and patients suffer. Rarely admits errors or accepts blame for errors or oversights; Heavy “wastage” of drugs; Sloppy recordkeeping, suspect ledger entries and drug shortages; Inappropriate prescriptions for large narcotic doses; Insistence on personal administration of injected narcotics to patients; Source: Erin Brisbay McMahon, JD, Sep 2005
407
2884. Controlled substance is considered a national epidemic in U.S. What are correct statements showing grim national statistics? 1. Opioid abuse increased 85% from 1994-2000 2. Oxycodone abuse increased 166% since 1994 3. Hydrocodone abuse increased 116% since 1994 4. Methadone abuse increased 140% since 1994
2884. Answer: E (All) Explanation: Source: Manchikanti et al., National All Schedules Prescription Electronic Reporting Act (NASPER): Balancing Substance Abuse and Medical Necessity, Pain Physician 2002 GRIM NATIONAL STATISTICS Opioid abuse increased 85% from 1994-2000 Oxycodone abuse increased 166% since 1994 Hydrocodone abuse increased 116% since 1994 OxyContin suspected in 282 overdose deaths during a 19- month period Source: Erin Brisbay McMahon, JD, Sep 2005
408
2885.Choose the correct statements describing opioids in patients with substance abuse? 1. Federal Guidelines allow for use of opioids for analgesia in persons with substance abuse disorder for “legitimate medical reasons”. 2. No clear documentation of the pain problem is needed to demonstrate the physician without proper credentials is not attempting to detoxify an opiate abuser. 3. State regulations in certain states do no allow for prescription of opioids in patients with substance abuse and consider prescribing opioids in known substance abusers malprescribing. 4. Federal Guidelines do not allow for use of opioids for analgesia in persons with substance abuse disorder for “legitimate medical reasons”.
2885. Answer: B (1 & 3) Explanation: Federal Guidelines allow for use of opioids for analgesia in persons with substance abuse disorder for “legitimate medical reasons”. Clear documentation of the pain problem is needed to demonstrate the physician without proper credentials is not attempting to detoxify an opiate abuser. State regulations in certain states do no allow for this, and consider prescribing opioids in known substance abusers malprescribing. Source: Laxmaiah Manchikanti, MD
409
2886.What are the correct statements about controlled substance abuse? 1. Almost half a ton of prescription narcotics reached six counties in Eastern Kentucky from 1998-2001, equating to .75 pound for every adult in those counties. 2. On a per capita basis, Eastern Kentucky drugstores, hospitals, and legal outlets receive more prescription painkillers than anywhere else in the United States. 3. Nationally, emergency room visits for hydrocodone overdoses increased 500 percent from 1990-2000 4. OxyContin sells on the street for about $10/pill; Lortab sell for $2/pill and Lorcet for $1/pill
2886. Answer: A (1,2, & 3) Explanation: Source: Linda Johnson, Eastern Kentucky: Painkiller Capital, Lexington Herald-Leader, Jan.19, 2003 and Linda Johnson, Lesser-Known Favorites Cheap, Abundant, Lexington Herald-Leader, Jan.19, 2003. Case Study: Eastern Kentucky * Almost half a ton of prescription narcotics reached six counties in Eastern Kentucky from 1998-2001, equating to .75 pound for every adult in those counties. * On a per capita basis, Eastern Kentucky drugstores, hospitals, and legal outlets receive more prescription painkillers than anywhere else in the United States. The Escalating Problem: Hydrocodone * Nationally, emergency room visits for hydrocodone overdoses increased 500 percent from 1990-2000 * Three Eastern Kentucky counties had enough Lortab, Lorcet, and Vicodin pills in 2001 to provide every adult in those counties with 156 pills * Oxycontin sells on the street for about $40/pill; Lortabs sell for $20/pill and Lorcets for $9/pill Source: Erin Brisbay McMahon, JD, Sep 2005
410
2887. What are Federation of State Medical Boards Guidelines for the Treatment of Pain? 1. Use of controlled substances, including opiates may be essential in the treatment of pain 2. Effective pain management is a part of quality medical practice 3. Patients with a history of substance abuse may require monitoring, consultation, referral and extra documentation 4. MD’s should not fear disciplinary action for legitimate medical purposes
2887. Answer: E (All) Explanation: Federation of State Medical Boards Guidelines for the Treatment of Pain Use of controlled substances, including opiates may be essential in the treatment of pain Effective pain management is a part of quality medical practice Patients with a history of substance abuse may require monitoring, consultation, referral and extra documentation MD’s should not fear disciplinary action for legitimate medical purposes Source: Laxmaiah Manchikanti, MD
411
2888. What are the reasons for drug testing in patients in your practice? 1. To assess if the patient is taking the medications prescribed 2. To assess if the patient is taking substances/drugs NOT prescribed 3. To assess if the patient is taking licit and illicit drugs 4. To assess if the prescribed drugs caused diabetes
2888. Answer: A (1,2, & 3) | Source: Laxmaiah Manchikanti, MD
412
``` 2889. An opioid treatment program must provide which of the following? 1. Drug abuse testing services 2. Vocational services 3. Educational services 4. Medical services ```
2889. Answer: E (All) Explanation: All of the above are required services for an OTP. Refernece: 42 CFR 8.12. Source: Erin Brisbay McMahon, JD, Sep 2005
413
2890. The pain management physician is challenged to find non-traditional approaches for pain management. Effective treatments to be considered in a multimodality approach include 1. Myofascial relief and musculoskeletal treatment strategies. 2. Psychological drug therapy. 3. Chiropractic care. 4. Naturopathic medicine.
2890. Answer: E (All) Explanation: It is advisable that an allopathic physician stay true to scientifi c and well-validated approaches when treating pain. Many times the pain management physician is a referral of desperation, and expectations of the patient may be unrealistically high. Alternative therapies such as naturopathic medicine may be trialed, in conjunction with well-established treatment to enhance positive outcome. The patient should understand from the beginning the treatment style, policy and procedures of the clinic, and expectations, particularly if controlled substances are being used. Source: Hans C. Hansen, MD

► Med Notes 2 (34 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions