CAADC Pharmacology and MAT 5 — Questions and Answers
Question 1: A patient stabilized on buprenorphine/naloxone needs emergency surgery. The anesthesiologist asks about managing pain perioperatively. The MOST accurate guidance is:
- Buprenorphine must be stopped 72 hours before surgery to allow full opioid analgesia
- Buprenorphine's high receptor affinity may reduce effectiveness of full opioid agonists; higher opioid doses or regional anesthesia may be needed (Correct answer)
- Naloxone in the formulation will reverse all analgesia, so it must be discontinued first
- Buprenorphine provides sufficient post-operative analgesia and no supplemental opioids are ever needed
Correct answer: Buprenorphine's high receptor affinity may reduce effectiveness of full opioid agonists; higher opioid doses or regional anesthesia may be needed
Buprenorphine's very high mu-opioid receptor affinity and partial agonism can competitively reduce the analgesic effect of full agonists, requiring higher doses or alternative analgesic strategies perioperatively.
Question 2: Which of the following is a Schedule III controlled substance under the DEA Controlled Substances Act, relevant to MAT prescribing regulations?
- Methadone when used for OUD treatment
- Naltrexone (oral and injectable)
- Buprenorphine products approved for OUD (Correct answer)
- Acamprosate (Campral)
Correct answer: Buprenorphine products approved for OUD
Buprenorphine is classified as a Schedule III controlled substance, which historically allowed office-based prescribing by waivered physicians (DATA 2000); methadone for OUD is Schedule II dispensed only through OTPs.
Question 3: Varenicline (Chantix/Champix) supports smoking cessation primarily by:
- Blocking nicotinic acetylcholine receptors entirely, preventing nicotine from binding
- Acting as a partial agonist at alpha-4 beta-2 nicotinic receptors, reducing withdrawal and blocking nicotine reward (Correct answer)
- Inhibiting monoamine oxidase to increase dopamine availability and reduce craving
- Replacing nicotine with a safer acetylcholine analog to satisfy cravings
Correct answer: Acting as a partial agonist at alpha-4 beta-2 nicotinic receptors, reducing withdrawal and blocking nicotine reward
Varenicline partially stimulates nicotinic receptors to ease withdrawal while simultaneously blocking the receptor so nicotine produces less reward if the patient smokes.
Question 4: A patient with opioid use disorder and chronic hepatitis C asks about starting MAT. Which statement about buprenorphine and liver function is most accurate?
- Buprenorphine is absolutely contraindicated in any hepatic impairment
- Buprenorphine is safe to use with monitoring in mild-to-moderate hepatic impairment; severe impairment requires caution (Correct answer)
- Liver disease does not affect buprenorphine metabolism or dosing considerations
- Buprenorphine must be replaced with methadone in all patients with hepatitis C
Correct answer: Buprenorphine is safe to use with monitoring in mild-to-moderate hepatic impairment; severe impairment requires caution
Buprenorphine is hepatically metabolized via CYP3A4, and while mild-to-moderate impairment can be managed with monitoring, severe hepatic impairment warrants caution and possible dose adjustment.
Question 5: Clonidine is sometimes used off-label during opioid detoxification. Its role is best described as:
- An opioid agonist that cross-tolerates with heroin to ease withdrawal
- An alpha-2 adrenergic agonist that reduces autonomic symptoms of opioid withdrawal such as sweating, anxiety, and hypertension (Correct answer)
- A GABA-A modulator that sedates patients through the acute withdrawal phase
- An NMDA receptor antagonist that prevents sensitization during opioid withdrawal
Correct answer: An alpha-2 adrenergic agonist that reduces autonomic symptoms of opioid withdrawal such as sweating, anxiety, and hypertension
Clonidine reduces the noradrenergic hyperactivity underlying many opioid withdrawal symptoms by stimulating alpha-2 autoreceptors in the locus coeruleus.
Question 6: A counselor notices a MAT patient's urine drug screen is positive for fentanyl but the patient denies use. Which scenario could produce a FALSE POSITIVE for opioids on an immunoassay screen?
- Current prescription for methadone
- Ingestion of large amounts of poppy seeds (morphine/codeine cross-reactivity) (Correct answer)
- Taking naltrexone for alcohol use disorder
- Use of acamprosate within 48 hours of the test
Correct answer: Ingestion of large amounts of poppy seeds (morphine/codeine cross-reactivity)
Poppy seeds contain morphine and codeine, which can cross-react with immunoassay opioid screens and produce a positive result; fentanyl, however, typically requires a specific immunoassay due to structural differences.
Question 7: Under the SAMHSA Opioid Treatment Program (OTP) regulations, which of the following is a requirement for methadone dispensing for OUD?
- Any licensed physician may prescribe methadone for OUD from their private office
- Patients must receive methadone only at a federally certified OTP clinic, with observed dosing initially (Correct answer)
- Methadone for OUD can be dispensed at retail pharmacies with a standard Schedule II prescription
- Telehealth-only OTPs may dispense methadone to any patient without an initial in-person assessment
Correct answer: Patients must receive methadone only at a federally certified OTP clinic, with observed dosing initially
Federal regulations require methadone for OUD to be dispensed through federally certified OTPs, with initial daily observed dosing and take-home doses granted based on time in treatment and compliance.
CAADC Pharmacology and MAT 5
A patient stabilized on buprenorphine/naloxone needs emergency surgery.
The anesthesiologist asks about managing pain perioperatively.
The MOST accurate guidance is: