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
16
Q
- 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 to any type
of national databank for malprescribing
A
- (A) Risks of malprescribing include loss of
“provider” status; insurers frequently report
to the Boards now; several plans have removed
providers for “overprescribing”; and finally
insurers can report to a separate national data
bank, not available to public, but available to
hospitals and other insurers.
17
Q
- Diagnostic and Statistical Manual of Mental
Disorder (Fourth Edition) (DSM-IV) definition
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 fill role
(3) Recurrent physically hazardous behavior
(4) Recurrent legal problems
A
- (E) As per the DSM-IV definition for substance
abuse at least one of the following should hold
true in 12 months:
• Maladaptive pattern leading to distress or
impairment.
• Recurrent failure to fill role.
• Recurrent physically hazardous behavior.
• Recurrent legal problems.
• Continued use despite social problems.
• Never met dependence criteria.
18
Q
- Which of the following is (are) correct statement(
s) regarding amphetamines in UDT?
(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
A
890. (B) UDT method Amphetamines: Low specificity • 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.
19
Q
- Which of the following is (are) the correct statement(
s) about UDT for cocaine?
(1) Tests for cocaine react principally with
cocaine and its primary metabolite, benzoylecgonine
(2) Tests for cocaine are nonspecific in predicting
cocaine use
(3) Tests for cocaine have low cross-reactivity
with other substances
(4) Cold medicines may test false-positive
for cocaine
A
- (B) UDT method
Cocaine: Very specific
• Tests for cocaine react principally with
cocaine and its primary metabolite, benzoylecgonine.
• These tests have low cross-reactivity with
other substances.
• Very specific in predicting cocaine use.
20
Q
- What precautions must a physician take in
interpretation of UDT?
(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
A
- (B) 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.
21
Q
- Which of the following is (are) true about postoperative
pain management in patients receiving
methadone maintenance treatment?
(1) Continue maintenance treatment without
interruption
(2) Immediately stop maintenance treatment
(3) Provide adequate individualized doses
of opioid agonists, which must be titrated
to the desired analgesic effect
(4) If opioids are administered in methadone
maintenance patients, doses should be given less frequently and as needed
A
- (B)
- Continue maintenance treatment without
interruption. - Maintenance treatment must be continued.
- Provide adequate individualized doses of
opioid agonists, which must be titrated to
the desired analgesic effect. - Doses should be given more frequently and
on a fixed schedule rather than as needed.
22
Q
- A38-year-old white male with chronic low back
pain and history of alcoholism, on a total of
200 mg of morphine per day, was admitted to
the emergency room because he was acting
agitated and confused. The emergency room
physician notifies you of his admission. Which
of the following identifies delirium tremens in
differential diagnosis of this patient’s condition?
(1) Clear sensorium
(2) Prominent tremor
(3) Auditory hallucination
(4) Dilated pupils with slow reaction to light
A
- (B)
- There is difficulty sustaining attention, disorganized
thinking, and perceptual disturbances. - Acute alcoholic hallucinosis may start
without a drop in blood alcohol concentration,
and without delirium, tremor, or autonomic
hyperactivity. - Hallucinations are usually auditory and
paranoid and may last more than 10 days. - In delirium tremens, the patient is confused,
with prominent tremor and psychomotor
activity, disturbed vital signs, autonomic
dysfunction with dilated pupils, and a slow
reaction to light. Hallucinations are usually
of the visual type.
23
Q
- Which of the following is (are) true regarding
the five schedules of controlled substances,
known as schedules I, II, III, IV, and V?
(1) Schedule I substances have high potential
for abuse and the substance has no
currently accepted medical use in treatment
in the United States
(2) 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 in treatment
(3) Schedule II drugs have high potential
for abuse and may lead to severe psychologic
or physical dependence
(4) Schedule V drugs or substances have a
high potential for abuse and may lead to
physical or psychologic dependence
A
- (B)
- and 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. - 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 psychologic 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 psychologic 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 psychologic
dependence relative to the drugs or
other substances in schedule III. - 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 psychologic
dependence relative to the drugs or
other substances in schedule IV.
24
Q
- 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 fictitious patients and picks
them up himself
(4) Never uses another doctor’s DEA number
A
- (B) 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 fictitious patients and picks them up
himself.
25
Q
- Which is (are) the true statement(s) about marijuana
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
A
897. (A) UDT methods THC: Marijuana: Moderate specificity • Reasonable reliability • Marinol: positive • Protonix: false-positive
Table
26
Q
- Which of the following is (are) the correct statement(
s) for UDT?
(1) Thin-layer chromatography (TLC) is a
relatively old technique, testing the
migration of a drug on a plate or film,
which is compared to a known control
(2) Gas chromatography (GC) is most sensitive
and specific 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
(4) Rapid drug screens are not similar to
other enzyme immunoassay tests and
may be more expensive
A
898. (A) Thin-layer chromatography (TLC) Relatively old technique, testing the migration of a drug on a plate or film, which is compared to a known control Gas chromatography: liquid and mass spectrometry (CGMS) Most sensitive and specific tests Most reliable Labor intensive/costly Several days to know results Used to confirm results of other tests Enzyme immunoassay Easy to perform/highly sensitive More sensitive than TLC Less expensive than GC Common tests EMIT (enzyme multiplied immunoassay test) FPIA (fluorescent polarization immunoassay) RIA (radioimmunoassay) Screen only one drug at a time Rapid drug screens Similar to other enzyme immunoassay tests May be more expensive
27
Q
899. Drug testing may be performed by any of the following: (1) Hair samples (2) Saliva testing (3) Serum drug testing (4) Urine drug screening
A
899. (E) Drug testing may be performed by any of the following: • Urine drug screening • Specific drug analysis (blood) • Hair samples • Saliva testing • Serum levels
28
Q
- Which of the following is (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 definition, addiction
means maladaptive pattern leading to
distress or impairment
(3) DSM-IV definition of substance dependence
includes tolerance, withdrawal,
and continued use despite problems
(4) Federation of State Medical Board
guidelines for the treatment of pain recommends
use of controlled substances
in patients with history of substance
with no additional monitoring, referral,
or documentation
A
- (B)
- 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. - There is no definition for addiction in
DSM-IV. - DSM-IV defines substance abuse with at
least one of the following in a 12-month
period.
• Maladaptive pattern leading to distress or
impairment
• Recurrent failure to field role
• Recurrent physically undesirous behavior
• Recurrent legal problems
• Continued use despite social problems
• Never met dependence criteria
DSM-IV definition for substance dependence
is as follows (need three of the following in a
12-month period):
• 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
An alternate definition for addiction is from
the American Society of Addiction Medicine. It
says addiction is a primary, chronic neurobiological
disease with genetic, psychosocial and
environmental factors affecting its course and
presentation. Addiction is characterized by one
or more of the following:
• Impaired control of drug use
• Compulsive use
• Craving
• Continued use despite harm - Federation of State Medical Board guidelines
recommends several additional steps
in patients with addiction or abuse.
