Addiction Medicine Certification Addiction Medicine Pharmacotherapy 3 — Questions and Answers
Question 1: Which medication used off-label for alcohol use disorder has evidence for reducing heavy drinking days and works by blocking sodium channels and enhancing GABA activity?
- Gabapentin
- Topiramate (Correct answer)
- Baclofen
- Ondansetron
Correct answer: Topiramate
Topiramate reduces heavy drinking days through multiple mechanisms including sodium channel blockade and GABA enhancement, though it is not FDA-approved for AUD.
Question 2: A pregnant patient with opioid use disorder is seeking treatment. Which approach is recommended by ACOG and ASAM?
- Abrupt opioid detoxification to eliminate fetal exposure
- Medically supervised withdrawal followed by naltrexone
- Maintenance treatment with methadone or buprenorphine (Correct answer)
- Clonidine only to avoid opioid receptor stimulation
Correct answer: Maintenance treatment with methadone or buprenorphine
ACOG and ASAM recommend opioid agonist maintenance therapy (methadone or buprenorphine) during pregnancy because abrupt withdrawal carries high rates of relapse and adverse fetal outcomes.
Question 3: The Suboxone film formulation combines buprenorphine with naloxone in what ratio to deter injection misuse?
- 1:1
- 2:1
- 4:1 (Correct answer)
- 8:1
Correct answer: 4:1
Suboxone contains buprenorphine and naloxone in a 4:1 ratio; sublingual administration minimizes naloxone absorption, but injection would precipitate withdrawal.
Question 4: Which medication is classified as a GABA-B receptor agonist and has evidence for reducing alcohol cravings and withdrawal symptoms, though not FDA-approved for AUD in the US?
- Topiramate
- Gabapentin
- Baclofen (Correct answer)
- Pregabalin
Correct answer: Baclofen
Baclofen is a GABA-B agonist with evidence for AUD and is approved for this indication in France, but it remains off-label in the US with mixed evidence.
Question 5: When initiating buprenorphine in the office setting, a patient should ideally be in mild-to-moderate opioid withdrawal (COWS score ≥8-12) to avoid which complication?
- Respiratory depression
- Hepatotoxicity
- Precipitated withdrawal (Correct answer)
- QT prolongation
Correct answer: Precipitated withdrawal
Buprenorphine's high mu-receptor affinity displaces full agonists; if given while opioids still occupy receptors, it precipitates acute withdrawal.
Question 6: Which of the following is a known risk of varenicline (Chantix) that must be discussed during informed consent for smoking cessation?
- Risk of physical opioid dependence
- Neuropsychiatric symptoms including depression and suicidal ideation (Correct answer)
- QT interval prolongation requiring baseline ECG
- Hepatic failure requiring LFT monitoring
Correct answer: Neuropsychiatric symptoms including depression and suicidal ideation
Varenicline carries a black-box warning (later revised) for neuropsychiatric adverse effects including mood changes, depression, and suicidal ideation, particularly in those with psychiatric history.
Question 7: A patient taking naltrexone for alcohol use disorder requires surgery. Which pain management consideration is most important?
- Naltrexone has no effect on opioid analgesia so no adjustment is needed
- Opioid analgesics will be ineffective or require higher doses; plan non-opioid alternatives (Correct answer)
- Naltrexone should be continued through surgery to prevent alcohol relapse
- Buprenorphine can replace naltrexone for peri-operative analgesia
Correct answer: Opioid analgesics will be ineffective or require higher doses; plan non-opioid alternatives
Naltrexone blocks opioid receptors, making standard opioid analgesics ineffective; the surgical team must plan around this by using regional anesthesia and non-opioid analgesics.
Addiction Medicine Certification Addiction Medicine Pharmacotherapy 3
Which medication used off-label for alcohol use disorder has evidence for reducing heavy drinking days and works by blocking sodium channels and enhancing GABA activity?