Pharmacotherapy & Medication-Assisted Treatment Flashcards

A patient on methadone maintenance develops acute bacterial endocarditis. The infectious disease team proposes adding fluconazole. The primary pharmacokinetic concern is:

Answer: Fluconazole inhibits CYP3A4 and CYP2C19, increasing methadone plasma levels and QTc risk

Fluconazole inhibits CYP3A4 and CYP2C19, reducing methadone clearance and raising plasma levels, which can prolong the QTc interval.

Which statement best describes the ceiling effect of buprenorphine?

Answer: Above a certain dose, increasing buprenorphine produces minimal additional analgesia and respiratory depression plateaus

As a partial agonist, buprenorphine's dose-response curve plateaus at high doses, limiting maximum respiratory depression — a key safety advantage over full agonists.

Neonatal opioid withdrawal syndrome (NOWS) severity is best predicted by which factor?

Answer: Gestational age at birth and breastfeeding status combined

Earlier gestational age and lack of breastfeeding are among the strongest predictors of NOWS severity and duration, more so than maternal opioid type or dose alone.

A patient requests buprenorphine/naloxone but has a history of poorly controlled seizures. Which additional consideration is most relevant?

Answer: Certain antiepileptic drugs (e.g., carbamazepine) induce CYP3A4 and may significantly reduce buprenorphine levels

Enzyme-inducing antiepileptics like carbamazepine and phenytoin accelerate buprenorphine metabolism via CYP3A4, potentially requiring higher buprenorphine doses.

For patients with OUD who cannot tolerate or access buprenorphine or methadone, which medication is an FDA-approved alternative for MAT?

Answer: Naltrexone (oral or extended-release injectable)

Naltrexone (oral tablets or XR-NTX injection) is FDA-approved for OUD as an opioid antagonist-based MAT option for abstinence-motivated patients.

A clinician wants to prescribe buprenorphine/naloxone in an office-based setting. Under the 2023 Mainstreaming Addiction Treatment (MAT) Act, what is required?

Answer: No additional DEA registration beyond a standard DEA controlled substance license for Schedule III medications

The 2023 MAT Act eliminated the X-waiver requirement; any DEA-licensed practitioner authorized to prescribe Schedule III substances can now prescribe buprenorphine for OUD.

Which clinical scenario represents an appropriate use of methadone over buprenorphine for OUD treatment?

Answer: A patient with severe OUD who previously failed buprenorphine and requires structured daily observed dosing

Methadone in an OTP setting is appropriate for patients with severe OUD, prior treatment failures, or those who benefit from daily supervised dispensing and wraparound services.