NAECB Medication Management 5 — Questions and Answers
Question 1: A patient on buprenorphine/naloxone is prescribed benzodiazepines by a separate provider. What is the most significant risk to communicate?
- Benzodiazepines reduce buprenorphine absorption
- Concurrent use increases risk of respiratory depression and overdose death (Correct answer)
- Naloxone in Suboxone will block benzodiazepine effects
- Buprenorphine doses must be doubled to maintain efficacy
Correct answer: Concurrent use increases risk of respiratory depression and overdose death
Concurrent use of buprenorphine with benzodiazepines or other CNS depressants carries an FDA black box warning for potentially fatal respiratory depression.
Question 2: Which nicotine replacement therapy (NRT) formulation delivers nicotine most rapidly, approximating the speed of cigarette nicotine delivery?
- Nicotine patch (transdermal)
- Nicotine gum (2 mg)
- Nicotine inhaler
- Nicotine nasal spray (Correct answer)
Correct answer: Nicotine nasal spray
Nicotine nasal spray delivers nicotine most rapidly among NRT formulations, reaching peak blood levels within 10-12 minutes, closest to inhaled tobacco.
Question 3: Which of the following best describes the concept of 'precipitated withdrawal' in the context of buprenorphine initiation?
- Gradual onset of withdrawal symptoms over several days
- Sudden severe withdrawal triggered when buprenorphine displaces full opioid agonists (Correct answer)
- Withdrawal that occurs when buprenorphine dose is too low
- Withdrawal symptoms that appear only after buprenorphine is discontinued
Correct answer: Sudden severe withdrawal triggered when buprenorphine displaces full opioid agonists
Precipitated withdrawal occurs when buprenorphine's high receptor affinity displaces full opioid agonists while the patient is still opioid-dependent, triggering acute severe withdrawal.
Question 4: A patient on naltrexone for alcohol use disorder needs emergency surgery. How should the anesthesiologist be informed?
- Naltrexone has no effect on anesthesia requirements
- Higher opioid doses may be required for pain control due to opioid receptor blockade (Correct answer)
- Naltrexone must be continued through surgery to prevent relapse
- Regional anesthesia is absolutely contraindicated with naltrexone
Correct answer: Higher opioid doses may be required for pain control due to opioid receptor blockade
The surgical team must know about naltrexone use because opioid receptor blockade may require higher-than-normal opioid doses for adequate perioperative pain control.
Question 5: What is the primary difference between methadone dispensed through an OTP and methadone prescribed for pain management?
- Methadone for OUD requires a higher dose than for pain
- OTP methadone dispensing is federally regulated with daily clinic visits, while pain prescriptions can be written by any DEA-licensed provider (Correct answer)
- OTP methadone is a different formulation than pain methadone
- Methadone for pain cannot be dispensed in liquid form
Correct answer: OTP methadone dispensing is federally regulated with daily clinic visits, while pain prescriptions can be written by any DEA-licensed provider
Methadone for OUD must be dispensed through a SAMHSA-certified OTP with federal oversight, while methadone for pain can be prescribed by any DEA Schedule II-licensed provider.
Question 6: Which of the following medications used in addiction treatment is available as a monthly extended-release injectable formulation?
- Naltrexone (Vivitrol) (Correct answer)
- Buprenorphine (Brixys ER)
- Acamprosate (Campral)
- Disulfiram (Antabuse)
Correct answer: Naltrexone (Vivitrol)
Naltrexone (Vivitrol) is available as a monthly extended-release intramuscular injection (380 mg), improving adherence by eliminating daily dosing.
Question 7: A patient taking buprenorphine/naloxone reports chewing and swallowing the film instead of dissolving it sublingually. What clinical consequence is most likely?
- Toxicity due to increased buprenorphine absorption
- Reduced buprenorphine bioavailability and inadequate symptom control (Correct answer)
- Activation of naloxone causing precipitated withdrawal
- No clinical difference since absorption is equivalent
Correct answer: Reduced buprenorphine bioavailability and inadequate symptom control
Buprenorphine undergoes extensive first-pass hepatic metabolism when swallowed, resulting in significantly reduced bioavailability compared to sublingual administration.
NAECB Medication Management 5
A patient on buprenorphine/naloxone is prescribed benzodiazepines by a separate provider.
What is the most significant risk to communicate?