ADM Treatment Protocols & Procedures 3 — Questions and Answers
Question 1: A patient on methadone maintenance therapy for OUD is hospitalized for surgery. What is the best approach to methadone dosing perioperatively?
- Continue the established methadone dose throughout hospitalization and add short-acting opioids for pain as needed (Correct answer)
- Discontinue methadone 48 hours before surgery to reduce opioid burden
- Switch to buprenorphine immediately before surgery
- Hold all opioids postoperatively to avoid reinforcing addiction
Correct answer: Continue the established methadone dose throughout hospitalization and add short-acting opioids for pain as needed
Methadone should be continued at the maintenance dose perioperatively, as discontinuation risks withdrawal and relapse; additional opioids for pain are titrated separately.
Question 2: The CIWA-Ar scale is used to assess severity of which type of withdrawal?
- Alcohol withdrawal (Correct answer)
- Opioid withdrawal
- Benzodiazepine withdrawal
- Nicotine withdrawal
Correct answer: Alcohol withdrawal
The Clinical Institute Withdrawal Assessment for Alcohol Revised (CIWA-Ar) is the standard tool for monitoring alcohol withdrawal severity and guiding benzodiazepine dosing.
Question 3: A 45-year-old patient with severe alcohol use disorder is treated with diazepam using a symptom-triggered protocol. What is the primary advantage of symptom-triggered over fixed-schedule dosing?
- Reduces total benzodiazepine dose administered and shortens detox duration (Correct answer)
- Eliminates the need for CIWA-Ar monitoring
- Prevents all alcohol withdrawal seizures more reliably
- Avoids the need for IV access
Correct answer: Reduces total benzodiazepine dose administered and shortens detox duration
Symptom-triggered dosing administers benzodiazepines only when CIWA-Ar scores indicate need, resulting in lower total doses and faster treatment.
Question 4: Acamprosate is thought to reduce alcohol cravings primarily by which mechanism?
- Modulating glutamate (NMDA) and GABA-B receptor activity to restore neurological balance (Correct answer)
- Blocking mu-opioid receptors in the reward pathway
- Inhibiting aldehyde dehydrogenase to create aversive reactions
- Increasing dopamine in the nucleus accumbens
Correct answer: Modulating glutamate (NMDA) and GABA-B receptor activity to restore neurological balance
Acamprosate restores the glutamate/GABA balance disrupted by chronic alcohol use, reducing the dysphoric state that drives craving.
Question 5: Which opioid use disorder treatment protocol is sometimes called 'low-dose' or 'Bernese' buprenorphine induction and is used for patients currently taking fentanyl?
- Microdosing induction, where buprenorphine is initiated in small doses without requiring full withdrawal first (Correct answer)
- Rapid induction under anesthesia using high-dose buprenorphine
- Standard induction requiring COWS ≥12 before first dose
- High-dose buprenorphine taper over 7 days
Correct answer: Microdosing induction, where buprenorphine is initiated in small doses without requiring full withdrawal first
The Bernese method uses incremental microdoses of buprenorphine while the patient continues their opioid, gradually transitioning without precipitated withdrawal.
Question 6: A pregnant patient with opioid use disorder presents at 14 weeks gestation. Which treatment approach is recommended per ACOG and ASAM guidelines?
- Methadone or buprenorphine maintenance; medically supervised withdrawal is not recommended due to high relapse risk (Correct answer)
- Medically supervised detox in the second trimester followed by naltrexone
- Abstinence-only with psychosocial support; no medications in pregnancy
- Immediate inpatient opioid detox to prevent neonatal opioid withdrawal syndrome
Correct answer: Methadone or buprenorphine maintenance; medically supervised withdrawal is not recommended due to high relapse risk
MOUD with methadone or buprenorphine is the standard of care in pregnancy; withdrawal/detox is associated with high relapse rates and fetal harm.
Question 7: Varenicline (Chantix) for tobacco use disorder works primarily by which mechanism?
- Partial agonism at alpha-4 beta-2 nicotinic acetylcholine receptors, reducing withdrawal and blocking nicotine reward (Correct answer)
- Full antagonism at all nicotinic receptors to prevent nicotine binding
- Inhibiting dopamine reuptake to reduce craving
- Activating mu-opioid receptors to substitute for nicotine's rewarding effects
Correct answer: Partial agonism at alpha-4 beta-2 nicotinic acetylcholine receptors, reducing withdrawal and blocking nicotine reward
Varenicline is a partial agonist at α4β2 receptors, providing enough stimulation to ease withdrawal while blocking nicotine's additional reinforcement.
ADM Treatment Protocols & Procedures 3
A patient on methadone maintenance therapy for OUD is hospitalized for surgery.
What is the best approach to methadone dosing perioperatively?