Chapter 12. Drug Abuse and Addiction Flashcards
1
Q
- In performing urine drug testing (UDT), a
physician must know all of the following,
EXCEPT
(A) the characteristics of the testing procedures,
since many drugs are not routinely
detected by all UDTs
(B) that 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
A
- (D) In performing UDT, 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
firmly defined boundaries.
2
Q
- A 65-year-old man with cancer and multiple
bony metastases complains of increasing requirement
of intrathecal morphine. However, he also
complains of increased nausea associated with
the increased dose. All the workup with regards
to carcinomatous spread failed to show any progression
of the disease. Which of the following
explanations is accurate?
(A) The catheter is no longer in the intrathecal
space and he is not receiving appropriate
dosages
(B) He is addicted to the drugs and requesting
higher doses
(C) He is physically dependent on the drug
and is nauseated because of withdrawal
symptoms
(D) He has developed tolerance to the analgesics
effects of intrathecal morphine
(E) There is significant progression of the
disease, which was unidentified by the
evaluation
A
- (D) The patient is most likely developing tolerance
to the analgesic effects of the intrathecal
morphine while continuing to complain of
the adverse side effect of nausea as the
intrathecal dose is increased. The mechanism
by which tolerance develops is not known.
The development of tolerance can be minimized
by selecting the lowest effective narcotic
dose; placing the catheter as close as
possible to the cord level of the painful areas;
giving multiple, small, divided doses rather
than one or two large, daily boluses; and
using low-dose continuous infusions whenever
possible.
3
Q
- Which of the following is true regarding quality
assurance?
(A) Quality assurance, quality improvement,
and quality management are
interchangeable words
(B) Quality assurance is internally driven,
follows patient care, and has no endpoints
(C) Quality improvement is externally driven,
focused on individuals, and works
toward end points
(D) Total quality of management, quality
management and improvement, and
continuous quality improvement are
synonymous with quality assurance
(E) Aquality improvement program is different
from quality assurance and focuses
on patient care, process, and integrated
analysis
A
(E) Ashort tabular comparison of quality assurance
versus quality improvement is given here:
4
Q
- Which of the following is 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
A
- (A) Ashort tabular description of some common
drugs of abuse and there typical detection time
for urine testing is as follows:
5
Q
- What is the mode of action for cocaine in the
central nervous system?
(A) Increasing the reuptake of norepinephrine
(B) Blocking dopamine receptors
(C) Activating γ-aminobutyric acid (GABA)
receptors
(D) Mediating its effect through dopamine
cells in the ventral tegmentum
(E) Inhibiting acetylcholine esterase in the
central nervous system
A
- (D) Cocaine acts by blocking reuptake of neurotransmitters
(norepinephrine, dopamine, and
serotonin) at the synaptic junctions, resulting in
increased neurotransmitter concentrations. As
norepinephrine is the primary neurotransmitter
of the sympathetic nervous system it causes
sympathetic stimulation and leads to vasoconstriction,
tachycardia, mydriasis, and hyperthermia.
Central nervous system stimulation may appear as increased alertness, energy, and
talkativeness, repetitive behavior, diminished
appetite, and increased libido. Psychologic stimulation
by cocaine produces an intense euphoria
that is often compared to orgasm. Pleasure
and reward sensations in the brain have been
correlated with increased neurotransmission in
the mesolimbic or mesocortical dopaminergic
tracts (or both). Cocaine increases the functional
release of dopamine, which activates the ventral
tegmental–nucleus accumbens pathway, which
seems to be major component of the brain
reward system. Activation of this pathway is
essential for the reinforcing actions of psychomotor
stimulants.
6
Q
878. Which is the accurate statement on federal regulations? (A) They are promulgated by the US Congress, CMS, and Office of Inspector General (OIG) (B) They are promulgated by the Department of Justice (DOJ), Federal Bureau of Investigation (FBI), and OIG (C) Courts may not promulgate any regulations, as it is the duty of the US Congress and Administration (D) They are enforced by the US Congress (E) They are enforced by local Medicare carriers
A
- (A) Federal regulations are
table
7
Q
- A 38-year-old white male with history of low
back pain with radiation into the lower extremity
with disc herniation demonstrated at L4-5
with nerve root compression, and electromyographic
evidence of L5 radiculopathy was
referred for consultation. You have examined
the patient and decided to perform transforaminal
epidural steroid injection at the L5
nerve root. This encounter is appropriately considered
as follows:
(A) It is a consultation as the patient was
referred by another physician for management
(B) It is a consultation as the patient was
referred and your opinion was requested
(C) It is a new office visit since it is a known
problem and the patient was referred to
you for the treatment
(D) It is a consultation as you told the patient
to return to the referring physician after
completion of course of epidurals
(E) It is a consultation, as you do not plan
on billing for another consultation within
the next 3 years
A
879. (C) Consultation • An opinion is requested • Patient is not referred The three R’s • Request for opinion is received • Render the service/opinion • Report back to physician requesting your opinion
8
Q
880. Which of the following is schedule I substance? (A) Buprenorphine (B) Hydromorphone (C) Heroin (D) Cocaine (E) Morphine
A
- (C) The Controlled Substances Act has divided
drugs under its jurisdiction into five 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, lysergic acid diethylamide
(LSD). Hydromorphone, heroin, morphine
are schedule II drugs; buprenorphine is
schedule III drug; and diazepam is schedule
IV drug.
9
Q
- All of the following are accurate statements
with managing opioid-dependent pregnant
patients experiencing withdrawal symptoms
when the drug is discontinued, EXCEPT
(A) methadone frequently is used to treat
acute withdrawal from opioids
(B) current federal regulations restrict the
use of methadone for the treatment of
opioid addiction to specially registered
clinics
(C) methadone may be used by a physician
in a private practice for temporary
maintenance or detoxification when an
addicted patient is admitted to the hospital
for an illness other than opioid
addiction
(D) methadone may never be used by a private
practitioner in an outpatient setting
when administered daily
(E) methadone may be used by a private
practitioner in an outpatient setting
when administered daily for a maximum
of 3 days
A
- (D)
A. Methadone frequently is used to treat
acute withdrawal from opioids.
B. Current federal regulations restrict the use
of methadone for the treatment of opioid
addiction to specially registered clinics.
C Methadone may be used by a physician in
private practice for temporary maintenance
or detoxification when an addicted patient
is admitted to the hospital for an illness
other than opioid addiction. This includes
evaluation for preterm labor, which can be
induced by acute withdrawal.
D. Methadone may also be used by a private
practitioner in an outpatient setting when
administered daily for a maximum of
3 days while a patient awaits admission to
a licensed methadone treatment program.
10
Q
- 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 detoxification in your office
(D) Provide her with a prescription for
methadone maintenance
(E) Do not tell the father and do not give
hydrocodone
A
- (E)
A. A physician has to maintain patient’s confidentiality.
Further, she may be addicted
to not only heroin, but hydrocodone. It is
not certain at this point. She may be receiving
hydrocodone from other sources.
B. A physician has to maintain patient’s confidentiality.
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.
C. Rapid detoxification requires a special
license.
D. Similarly, methadone maintenance treatment
also requires special licensure.
E. The best option is to maintain confidentiality,
protect the patient, and yourself.
11
Q
883. Which of the following is true regarding opioid-induced constipation? (A) Treat constipation (B) Obtain a surgical consult to rule out complication (C) Evaluate for drug abuse (D) Start on transdermal fentanyl (E) Start on methadone-maintenance program
A
- (A)
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 fluids 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.
12
Q
- 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
A
- (B) Risks of malprescribing includes 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.
13
Q
- Which of the following is (are) an accurate
statement(s) 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 requires maintaining complete inventory
of controlled substances, only if the
drugs are administered by physician,
but not if dispensed to the patient
A
- (A)
- The CSA created a closed system of distribution
for those authorized to handle controlled
substances. - The system is the registration of all those
authorized by the DEA to handle controlled
substances. - Only the individuals and practices that dispense
directly to the patients from their clinics
are required to maintain a DEA license. - All individuals and firms 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.
14
Q
- What are the pitfalls of opioid UDT?
(1) Tests for opiates are very responsive for
morphine and codeine
(2) UDTs do not distinguish between morphine
and codeine
(3) UDTs show a low sensitivity for semisynthetic/
synthetic opioids such as oxycodone
(4) A negative response excludes oxycodone
and methadone use
A
- (A) UDT method
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.
15
Q
- What are the pitfalls of prescription practices?
(1) The four D’s—deficient, duped, deliberate,
dependent practitioner
(2) Never say “NO”—family, friends,
patients
(3) Ignore complaints
(4) Focus on positive aspects of regulations
and reimbursement
A
- (A) The top 10 pitfalls of prescription practices
are: - The four D’s—deficient, duped, deliberate,
dependent practitioner - Weak heart—pretend addiction doesn’t
exist - Never say “NO”—family, friends, patients
- Poor documentation
- No policies—no agreements
- Ignore complaints
- Focus on negative aspects of regulations
and reimbursement - Not nice to investigators from the Board
and DEA - Reckless disregard to law with prescription
pads and regulations - Know it all—do it all
