ADM Pharmacotherapy & Medication-Assisted Treatment 3 — Questions and Answers
Question 1: A patient with OUD on buprenorphine/naloxone reports they are selling part of their medication. Which formulation change addresses diversion most directly?
- Switch to oral naltrexone tablets taken at home
- Transition to extended-release injectable buprenorphine (Sublocade) (Correct answer)
- Increase the naloxone ratio in the sublingual film
- Add daily observed dosing of sublingual film
Correct answer: Transition to extended-release injectable buprenorphine (Sublocade)
Sublocade is a subcutaneous depot formulation that eliminates diversion potential because the medication is injected by a healthcare provider and cannot be removed or transferred.
Question 2: Which QTc threshold on ECG is the standard trigger for clinical concern when a patient on methadone maintenance is being monitored?
- QTc > 400 ms
- QTc > 450 ms
- QTc > 500 ms (Correct answer)
- QTc > 550 ms
Correct answer: QTc > 500 ms
A QTc exceeding 500 ms is considered a threshold requiring dose reduction, medication review, or cardiology consultation due to increased risk of torsades de pointes.
Question 3: Varenicline's superior efficacy over nicotine replacement therapy in smoking cessation is primarily due to its action as a:
- Full nicotinic acetylcholine receptor antagonist blocking all reward
- Partial agonist at alpha4beta2 nicotinic receptors, reducing craving while blunting smoking reward (Correct answer)
- Monoamine oxidase inhibitor increasing dopamine in reward pathways
- Selective serotonin reuptake inhibitor reducing anxiety-driven smoking
Correct answer: Partial agonist at alpha4beta2 nicotinic receptors, reducing craving while blunting smoking reward
Varenicline's partial agonism provides enough dopamine stimulation to reduce withdrawal and craving while competitively blocking nicotine from producing the full rewarding effect.
Question 4: Low-dose naltrexone (LDN, ~1.5–4.5 mg/day) is being studied for conditions such as fibromyalgia. Its proposed mechanism at these doses differs from standard dosing by:
- Providing partial mu-opioid agonism instead of antagonism
- Transiently blocking opioid receptors, triggering a rebound upregulation of endogenous opioids (Correct answer)
- Inhibiting toll-like receptor 4 (TLR4) on microglia to reduce neuroinflammation only
- Increasing endorphin production through hypothalamic-pituitary stimulation
Correct answer: Transiently blocking opioid receptors, triggering a rebound upregulation of endogenous opioids
At low doses, naltrexone briefly occupies opioid receptors, causing a compensatory upregulation of endogenous opioids and endorphins upon receptor release.
Question 5: Which laboratory finding would prompt immediate dose reduction of naltrexone in a patient on extended-release injectable naltrexone?
- ALT/AST greater than 3–5 times the upper limit of normal (Correct answer)
- Serum creatinine above 1.5 mg/dL
- Complete blood count showing mild anemia (Hgb 11 g/dL)
- Urine drug screen positive for cannabis
Correct answer: ALT/AST greater than 3–5 times the upper limit of normal
Naltrexone carries a black box warning for hepatotoxicity; elevations of liver enzymes 3–5 times the upper limit of normal warrant dose reduction or discontinuation.
Question 6: A patient with severe alcohol use disorder and concurrent major depression is being considered for pharmacotherapy. Which agent addresses both conditions with the strongest evidence?
- Disulfiram, which reduces drinking and improves mood through aversion
- Naltrexone, which reduces alcohol craving and has antidepressant properties in some trials (Correct answer)
- Acamprosate, which is FDA-approved for both AUD and MDD comorbidity
- Gabapentin, which reduces alcohol use and has robust antidepressant trial data
Correct answer: Naltrexone, which reduces alcohol craving and has antidepressant properties in some trials
Naltrexone reduces heavy drinking days and has shown mood-stabilizing properties in some studies, making it a reasonable choice in comorbid AUD and depression.
Question 7: The Suboxone film formulation contains buprenorphine and naloxone in which ratio?
- 1:1
- 2:1
- 4:1 (Correct answer)
- 8:1
Correct answer: 4:1
Suboxone contains buprenorphine and naloxone in a 4:1 ratio (e.g., 8 mg buprenorphine / 2 mg naloxone) designed to deter injection misuse.
ADM Pharmacotherapy & Medication-Assisted Treatment 3
A patient with OUD on buprenorphine/naloxone reports they are selling part of their medication.
Which formulation change addresses diversion most directly?