CASAC Pharmacology & Co-Occurring Disorders 4 — Questions and Answers
Question 1: A client with opioid use disorder on buprenorphine also has hepatic impairment. Which concern is MOST clinically relevant?
- Buprenorphine is renally cleared so liver disease is irrelevant
- Buprenorphine is hepatically metabolized via CYP3A4; severe impairment may increase plasma levels (Correct answer)
- Hepatic impairment accelerates buprenorphine metabolism, requiring higher doses
- Naloxone in the combination formulation is toxic to damaged liver cells
Correct answer: Buprenorphine is hepatically metabolized via CYP3A4; severe impairment may increase plasma levels
Buprenorphine is primarily metabolized by CYP3A4 in the liver; severe hepatic impairment reduces clearance, leading to potential drug accumulation and toxicity.
Question 2: Which of the following best describes the 'kindling' phenomenon relevant to alcohol use disorder?
- The progressive worsening of withdrawal severity with each repeated episode of detoxification (Correct answer)
- The process by which alcohol sensitizes the brain's reward pathways over time
- A pharmacological interaction between alcohol and benzodiazepines
- The way early trauma 'kindles' susceptibility to addiction
Correct answer: The progressive worsening of withdrawal severity with each repeated episode of detoxification
Kindling refers to the neurobiological process whereby each successive alcohol withdrawal episode becomes more severe, increasing seizure risk with repeated detoxifications.
Question 3: A client with schizophrenia and alcohol use disorder is prescribed quetiapine. The counselor should be aware that quetiapine:
- Has no misuse potential and is safe to prescribe without monitoring
- Has sedating properties that may be misused and should be monitored in SUD populations (Correct answer)
- Is contraindicated when alcohol has been used within the past 30 days
- Eliminates cravings for alcohol by blocking dopamine reward pathways directly
Correct answer: Has sedating properties that may be misused and should be monitored in SUD populations
Quetiapine's sedating properties have led to its misuse in SUD populations, where it may be sought for sleep or 'high,' requiring careful monitoring.
Question 4: Extended-release naltrexone (Vivitrol) is administered by injection monthly. What is the PRIMARY advantage of this formulation over oral naltrexone?
- It is more effective at reducing opioid receptor sensitivity
- It eliminates the need for hepatic monitoring
- It removes the daily adherence barrier, bypassing the decision to take a pill each day (Correct answer)
- It has fewer side effects than oral formulations
Correct answer: It removes the daily adherence barrier, bypassing the decision to take a pill each day
Monthly injectable naltrexone removes daily decision-making about taking medication, which is critical given that relapse motivation can override pill-taking compliance.
Question 5: Which substance class is most likely to cause a life-threatening withdrawal syndrome without appropriate medical management?
- Opioids and cannabis
- Alcohol and benzodiazepines (Correct answer)
- Stimulants and hallucinogens
- Cannabis and inhalants
Correct answer: Alcohol and benzodiazepines
Alcohol and benzodiazepine withdrawal can cause seizures, delirium tremens, and death due to CNS hyperexcitability; opioid withdrawal, while severe, is rarely fatal in otherwise healthy adults.
Question 6: A client with generalized anxiety disorder and benzodiazepine use disorder is stabilized and seeking alternatives. Which medication class is FDA-approved and non-addictive for GAD?
- Z-drugs (zolpidem, eszopiclone)
- SSRIs/SNRIs and buspirone (Correct answer)
- Beta-blockers and hydroxyzine only
- Low-dose antipsychotics
Correct answer: SSRIs/SNRIs and buspirone
SSRIs, SNRIs, and buspirone are FDA-approved for GAD and carry no addiction liability, making them preferred for patients with co-occurring SUD.
Question 7: When treating co-occurring depression and opioid use disorder, buprenorphine itself may have antidepressant properties. This is hypothesized to be due to:
- Buprenorphine's serotonin reuptake inhibition similar to SSRIs
- Partial mu agonism and kappa opioid antagonism, which may reduce dysphoria (Correct answer)
- Blockade of NMDA receptors, similar to ketamine's mechanism
- Upregulation of endorphin production in the limbic system
Correct answer: Partial mu agonism and kappa opioid antagonism, which may reduce dysphoria
Buprenorphine's kappa opioid receptor antagonism is believed to reduce dysphoria and depression, distinguishing its mood effects from full mu agonists.
CASAC Pharmacology & Co-Occurring Disorders 4
A client with opioid use disorder on buprenorphine also has hepatic impairment.
Which concern is MOST clinically relevant?