NAECB Medication Management 3 — Questions and Answers
Question 1: A patient taking naltrexone for alcohol use disorder experiences an accidental opioid overdose. Which intervention is most appropriate?
- Administer standard naloxone doses; effects will be normal
- Higher doses of naloxone may be needed to overcome naltrexone blockade (Correct answer)
- Opioid overdose cannot occur in patients on naltrexone
- Intubation and mechanical ventilation are contraindicated
Correct answer: Higher doses of naloxone may be needed to overcome naltrexone blockade
Naltrexone occupies opioid receptors, so higher or repeated naloxone doses may be required to reverse an opioid overdose in patients taking naltrexone.
Question 2: Which of the following best describes the COWS (Clinical Opiate Withdrawal Scale) score range indicating severe opioid withdrawal?
- Score of 5-12
- Score of 13-24
- Score of 25-36
- Score of 37 or more (Correct answer)
Correct answer: Score of 37 or more
A COWS score of 37 or more indicates severe opioid withdrawal, while scores of 13-24 indicate moderate withdrawal.
Question 3: A pregnant patient with opioid use disorder presents for treatment. Which medication is considered the gold standard for this population?
- Naltrexone extended-release injectable
- Buprenorphine monoproduct (Subutex)
- Methadone through an OTP program (Correct answer)
- Rapid detoxification under anesthesia
Correct answer: Methadone through an OTP program
Methadone through an Opioid Treatment Program (OTP) has the most evidence and is considered the gold standard for pregnant patients with OUD, though buprenorphine is also accepted.
Question 4: Which medication interaction requires close monitoring when a patient on methadone maintenance is prescribed rifampin for tuberculosis?
- Rifampin increases methadone levels causing toxicity
- Rifampin decreases methadone levels potentially causing withdrawal (Correct answer)
- No significant interaction exists between rifampin and methadone
- Rifampin converts methadone to an active toxic metabolite
Correct answer: Rifampin decreases methadone levels potentially causing withdrawal
Rifampin is a potent CYP3A4 inducer that significantly decreases methadone plasma levels, which can precipitate opioid withdrawal in patients on maintenance therapy.
Question 5: A patient on buprenorphine/naloxone reports the film is not dissolving properly under the tongue. What is the most likely cause?
- The dose is too high for sublingual absorption
- The patient is not allowing sufficient dissolution time (Correct answer)
- Buprenorphine requires swallowing for full absorption
- The naloxone component inhibits sublingual absorption
Correct answer: The patient is not allowing sufficient dissolution time
Buprenorphine/naloxone films require 5-10 minutes of sublingual dissolution without eating, drinking, or swallowing for proper bioavailability.
Question 6: What is the primary rationale for adding naloxone to buprenorphine in the Suboxone formulation?
- To enhance the euphoric effect of buprenorphine
- To deter misuse via injection by precipitating withdrawal (Correct answer)
- To treat opioid overdose if it occurs during maintenance
- To increase the bioavailability of buprenorphine
Correct answer: To deter misuse via injection by precipitating withdrawal
Naloxone is added to deter intravenous misuse; when injected, naloxone becomes bioavailable and precipitates withdrawal, but is minimally absorbed sublingually.
Question 7: Which patient scenario represents an appropriate candidate for extended-release injectable naltrexone (Vivitrol)?
- Patient actively using opioids who refuses detoxification
- Patient fully detoxified from opioids for at least 7-10 days with strong motivation (Correct answer)
- Patient with active hepatitis C requiring antiviral therapy
- Patient in early opioid withdrawal seeking rapid relief
Correct answer: Patient fully detoxified from opioids for at least 7-10 days with strong motivation
Extended-release naltrexone is indicated for patients who have completed detoxification (opioid-free for at least 7-10 days) and are highly motivated to maintain abstinence.
NAECB Medication Management 3
A patient taking naltrexone for alcohol use disorder experiences an accidental opioid overdose.
Which intervention is most appropriate?