Addiction Medicine Certification Pharmacology & Medication Management 3 — Questions and Answers
Question 1: Extended-release naltrexone (Vivitrol) for opioid use disorder is administered as:
- A daily oral tablet of 50mg
- A monthly intramuscular injection of 380mg (Correct answer)
- A weekly subcutaneous injection of 100mg
- A twice-daily sublingual film
Correct answer: A monthly intramuscular injection of 380mg
Vivitrol is administered as a 380mg IM gluteal injection once monthly, which improves adherence by eliminating the need for daily dosing.
Question 2: A patient on buprenorphine/naloxone reports using fentanyl, and urine drug screening is negative for buprenorphine. The most likely explanation is:
- The patient is metabolizing buprenorphine unusually rapidly
- The patient is not taking the buprenorphine as prescribed (diversion) (Correct answer)
- Fentanyl cross-reacts with buprenorphine assays causing a false negative
- The buprenorphine formulation has degraded and lost potency
Correct answer: The patient is not taking the buprenorphine as prescribed (diversion)
Absence of buprenorphine in urine combined with ongoing illicit drug use strongly suggests the patient is not taking (and likely diverting) the prescribed medication.
Question 3: Which drug-drug interaction is most clinically significant for a patient on methadone maintenance who is started on rifampin for tuberculosis?
- Rifampin inhibits CYP3A4, increasing methadone levels and risk of overdose
- Rifampin induces CYP3A4, significantly decreasing methadone levels and precipitating withdrawal (Correct answer)
- Rifampin competitively binds mu-opioid receptors, reducing methadone efficacy
- Rifampin increases methadone's QTc prolonging effects
Correct answer: Rifampin induces CYP3A4, significantly decreasing methadone levels and precipitating withdrawal
Rifampin is a potent CYP3A4 inducer that dramatically lowers methadone plasma levels, often precipitating opioid withdrawal and requiring substantial methadone dose increases.
Question 4: For a pregnant patient with opioid use disorder, which treatment approach is recommended by ACOG and SAMHSA?
- Medically supervised withdrawal (detoxification) is preferred to avoid neonatal opioid withdrawal syndrome
- Buprenorphine or methadone maintenance is recommended as the standard of care (Correct answer)
- Naltrexone is the safest option because it prevents the fetus from being exposed to opioids
- Opioid agonist therapy should be avoided after the first trimester
Correct answer: Buprenorphine or methadone maintenance is recommended as the standard of care
ACOG and SAMHSA recommend opioid agonist therapy (buprenorphine or methadone) as the standard of care in pregnancy because it is associated with better outcomes than withdrawal or no treatment.
Question 5: A patient with alcohol use disorder has a history of alcohol withdrawal seizures. Which medication best prevents recurrence of seizures during withdrawal?
- Haloperidol
- Carbamazepine alone (without benzodiazepines)
- Benzodiazepines (e.g., chlordiazepoxide or diazepam) (Correct answer)
- Phenobarbital alone (without benzodiazepines)
Correct answer: Benzodiazepines (e.g., chlordiazepoxide or diazepam)
Benzodiazepines are the first-line agents for preventing alcohol withdrawal seizures due to their cross-tolerance with alcohol at GABA-A receptors.
Question 6: Which statement correctly describes the ceiling effect of buprenorphine?
- Respiratory depression increases linearly with dose, similar to full opioid agonists
- Above a certain dose, respiratory depression plateaus, reducing overdose risk compared to full agonists (Correct answer)
- The analgesic effect has no ceiling but respiratory depression does
- The ceiling effect means buprenorphine cannot treat pain at any dose
Correct answer: Above a certain dose, respiratory depression plateaus, reducing overdose risk compared to full agonists
Buprenorphine's partial agonist activity produces a ceiling on respiratory depression at higher doses, which makes it significantly safer in overdose compared to full opioid agonists.
Question 7: Varenicline (Chantix) reduces smoking by which primary mechanism?
- Blocking nicotinic acetylcholine receptors completely to prevent nicotine binding
- Acting as a partial agonist at alpha4beta2 nicotinic receptors, reducing cravings and attenuating reward (Correct answer)
- Inhibiting monoamine oxidase to increase dopamine availability
- Blocking dopamine reuptake in the nucleus accumbens
Correct answer: Acting as a partial agonist at alpha4beta2 nicotinic receptors, reducing cravings and attenuating reward
Varenicline is a partial agonist at alpha4beta2 nicotinic acetylcholine receptors, providing enough stimulation to reduce withdrawal cravings while blocking nicotine's rewarding effects.
Addiction Medicine Certification Pharmacology & Medication Management 3
Extended-release naltrexone (Vivitrol) for opioid use disorder is administered as: