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Transcript
ASIPP’s Comprehensive Pain Medicine Board Review Course-2007 SECTION 12 Controlled Substance Management Directions: Choose the best answer 2310. The common belief that most people who misuse, divert, or assign illicit use to controlled substances are felt to be unemployed and from the inner city. The following is true of demographics according to SAMHSA: A. 75% of illicit drug users were employed full or part time B. The highest use of illicit controlled substances were among American Indians and Alaskan natives. C. Blacks and whites were approximately equal in the use and misuse of controlled substances. D. Inner city blacks were of the highest percentage of illicit drug users. E. 60% of illicit drug users were on Medicaid 2311. All of the following describe psychological components of pain, EXCEPT: A. Catastrophic thinking B. Helplessness C. Compulsive search for a job D. Blame E. Chronic maladaptive coping patterns 2312. Which one of the following is characteristic of cytochrome P-450? A. Located in the lipophilic environment of mitochondrial membranes B. Catalyzes O-, S-, and N-methylation reactions C. Catalyzes aromatic and aliphatic hydroxylations D. Catalyzes conjugation reactions E. Activity is not inducible by drugs 2313. You have agreed to see a new patient who comes to you through a referral from a family physician in a city approximately 50 miles from your practice. The patient gives you a referral package that does not contain any reference to the patient’s recent history with the other physician. The referral package also does not contain any reference to the patient’s history of compliance with the family physician’s treatment plan or instructions regarding the patient’s use of controlled drugs. The patient asks you to prescribe controlled substances to treat his/her pain and reports that he/she is using a high dosage of a specified Schedule II controlled substance. The patient claims he/she has run out of medications and will experience acute withdrawal symptoms if he/she does not get the medications from you. What should you do prior to minimize the potential for abuse and diversion of these drugs by this patient? A. Prescribe the patient a months’ worth of drugs and see him/her back in your office after you obtain the medical records from the previous physician. B. Call the previous physician and attempt to verify the patient’s self-report of recent pain treatments and medications, use an appropriate urine screen to verify the presence of the drug the patient says he/she has taken and to determine whether he/she is C. Attempt to verify the patient’s self-report of recent pain treatments and medications and perform an appropriate urine screen. D. Accept the patient’s self-report and continue with treatment without verification through the prior provider. E. Send the patient back to the previous provider for necessary controlled substances to treat acute withdrawal symptoms and tell him/her that you will not prescribe controlled substances until you receive all the necessary records from the prior provider. 466 Section 12 • Controlled Substance Management 2314. What document reflects the practitioner’s explanation 2320. Gabapentin (Neurontin®) exerts its analgesic affect by: A. Inhibition of reuptake Serotonin and Norepinephrine and the patient’s understanding of the risks, benefits, B. Central modulation of the dorsal lateral funiculus at the alternative treatments, and special issues concerning the dorsal horn intermediary. use of controlled substances? C. GABA-A affinity and activation. A. Narcotic contract D. The analgesic effect is unknown. B. History and Physical Evaluation form E. NMDA modulation. C. Pain scale evaluation and update report D. Informed consent form E. The approval letter from the patient’s health care benefit 2321. Drug interactions common to cyclobenzaprine (Flexeril®) include all of the following except : plan A. MAOI agents B. Barbiturates 2315. If a patient brings unused controlled substances back to C. Tertiary tricyclic antidepressants you at your office, you should do which of the following? D. Zolpidem (Ambien®) A. Dispose of the controlled substances after the patient E. Alcohol leaves your office and write down what you did in the medical record. B. Inventory the returned controlled substances and use them with other patients who cannot afford to pay for 2322. Among the following neuroleptics, the agent most likely associated with constipation, urinary retention, blurred prescriptions for these drugs because they do not have vision, and dry mouth is: health insurance. A. Chlorpromazine (Thorazine®) C. It depends on regulations of State Board of Medical B. Clozapine (Clozaril®) Licensure C. Olanzapine (Zyprexa®) D. Flush the stuff down the toilet. D. Sertindole (Serdolect®) E. Call a DEA agent to come and get the drugs. E. Haloperidol (Haldol®) 2316. Cocaine intoxication has become a common problem in hospital emergency rooms. Which one of the following 2323. Fluoxetine (Prozac®) is classified as: A. As an MAO inhibitor (MAOI) drugs is not likely to be of any value in the management B. As a tricyclic nonselective amine reuptake inhibitor of cocaine overdose? C. As a heterocyclic nonselective amine reuptake inhibiA. Dantrolene tor B. Diazepam D. As a selective serotonin reuptake inhibitor C. Lidocaine E. As an alpha2-adrenergic receptor inhibitor D. Naltrexone E. Nitroprusside 2324. Among the following neuroleptics, the most likely neuroleptic associated with skeletal muscle rigidity, tremor at rest, flat facies, uncontrollable restlessness, and spastic torticollis is A. Clozapine B. Haloperidol C. Olanzapine D. Sertindole E. Ziprasidone 2318. N-acetyl benzoquinoneimine is the hepatotoxic metabolite of which drug? A. Sulindac 2325. The W.H.O. cancer pain relief ladder is: B. Acetaminophen A. Poorly validated with anecdotal reports of effectiveC. Isoniazid ness. D. Indomethacin B. Emphasizes non-opioid treatment through the first E. Procainamide three steps. C. Is inappropriate to utilize on a terminally ill patient. 2319. A 36-year-old male with a bipolar disorder is treated D. Is a simple and effective tool to afford relief with a high with lithium. Among the following adverse effects, the level of confidence, in an overwhelming majority of side effect attributed to lithium treatment is: patients. A. Browning of the vision E. Suggests alternative therapy management in the early B. Hypothyroidism stages. C. Agranulocytosis D. Neuroleptic malignant syndrome E. Pseudodepression 2317. All of the following are chronic pain related psychiatric disorders, EXCEPT: A. Anxiety B. Depression C. Sleep disorders D. Post traumatic stress disorder E. Increased sexual function ASIPP Section 12 • Controlled Substance Management 467 2326. The concept of substance dependency is categorized as a B. Have anticonvulsant activity risk relationship. The term pseudotolerance is: C. May induce physical dependence A. The need to increase dosage that is not due to tolerance, D. Have a higher margin of safety than barbiturates but to other factors such as disease progression, new E. All of the above disease, increased physical activity, lack of compliance. 2333. Axis IV provides important information about which of B. An expected course in use of controlled substances. the following? C. The first sign of addiction. A. Ability to pay for all necessary medical services. D. An indication to the physician that dosing needs to be B. Overall satisfaction with scope of ongoing medical increased. services. E. A change of medication is necessary to ensure funcC. Desire to serve as a subject in an upcoming clinical trial tional enhancement. for a new medication. D. Impact of psychosocial and environmental problems 2327. When selecting and dosing opioids: that may impact the patient. A. There is no ceiling dose for combination analgesics E. Personality disorders B. Use long acting opioids for as-needed pain C. Use short acting opioids for around-the-clock pain 2334. Which of the following opioids is least likely to cause D. There is no ceiling dose for pure agonists bradycardia in high doses? E. Agonist-antagonist opioids are appropriate breakA. Fentanyl® through medications B. Meperidine® C. Morphine® 2328. Which of the following factors will determine the D. Hydromorphone® number of drug-receptor complexes formed? E. Oxycodone® A. Efficacy of the drug B. Receptor affinity for the drug 2335. What are the correct statements about drug abuse in C. Therapeutic index of the drug patients receiving opioids? D. Half-life of the drug A. Illicit drug use and abuse of prescription controlled E. Rate of renal secretion substances is non-existent in patients receiving longacting opioids in appropriate doses. 2329. Which of the following opioids is not a good choice in B. Short-acting opioids show significantly higher use of ilpatients with renal failure: licit drugs and abuse of controlled prescription drugs. A. Fentanyl® C. Illicit drug use and controlled substance abuse in B. Sufentanil® chronic non-cancer patients is similar whether they C. Morphine® are on short-acting or long-acting opioids. D. Alfentanil® D. Patients on long-acting opioids are highly compliant E. Meperidine® and functional and therefore not necessary to monitor them. 2330. The Drug Abuse Warning Network (DAWN) is a network E. Patients on short-acting opioids significantly abuse that: drugs. Thus, they should be monitored every month A. Treats addicted patients with urine drug testing. B. Is a self help and support group C. Collects information on hospital emergency depart- 2336. Choose the correct statement with regards to the ment admissions for drug-related episodes comparison of effectiveness and safety profiles of longD. Is an arm of the Drug Enforcement Agency acting versus short-acting opioids in chronic non-cancer E. Monitors physicians’ prescription habits pain. A. There was conclusive evidence from high quality ran2331. Which of the following statements concerning lithium domized and systematic trials to determine that longis true? acting opioids as a class were more effective and safer A. Lithium is used to control agitation associated with with no adverse events than short-acting opioids. schizophrenia B. There was no good-quality data available to assess comB. Retention of lithium is enhanced by a high-sodium parative efficacy and adverse event risks in sub-popudiet lations of patients with chronic non-cancer pain. C. Early signs of lithium toxicity may include tremors C. There was insufficient evidence from available trials to D. The onset of lithium action occurs within 24 hours determine whether long-acting opioids as a class are E. All of the above more effective or associated with fewer adverse events than short-acting opioids. 2332. Benzodiazepines differ from barbiturates in that D. There were approximately 20 randomized trials investibenzodiazepines : gating long-acting oxycodone versus short-acting oxyA. Facilitate the action of aminobutyric acid (GABA) on codone showing conclusive evidence that long-acting neuronal chloride channels oxycodone was superior to short-acting oxycodone. ASIPP 468 Section 12 • Controlled Substance Management E. Recent GAO reports, DEA statements, and media attention and case reports of abuse, addiction, and overdose from long-acting opioids represent a decreased risk proportionate to prescribing pattern changes as these are widely used. B. They are safe in patients with a history of hypertension C. They should be given morning and noon so as not to disturb sleep D. They are safe in patients with a history of delirium E. They should be administered only at bedtime 2337. The most commonly used illicit drug is: A. Marijuana B. LSD C. Ecstasy D. Methamphetamine E. OxyContin® 2343. Tolerance is: A. A need to increase drug dosage to obtain the same effect. B. A rapid immunity to opioids, secondary to cross-reactive antibodies. C. The concept of understanding that a drug is necessary, except in the community. D. A patient’s ability to take the drug. E. The physician’s willingness and acceptance to prescribe the drug. 2338. Choose the correct statement about effectiveness of one or more long-acting opioids in reducing pain and improving functional outcomes. A. There was insufficient evidence to prove that different long-acting opioids are associated with different ef- 2344. A weak acid drug (A), with a pKa = 6, is given orally. ficacy or adverse event rates. Assuming that the pH of the stomach equals 3 and the pH B. OxyContin was shown to be more effective with a lesser of the blood equals 7, which of the following statements side effect profile compared to morphine. is true? C. MS Contin was superior to transdermal fentanyl. A. At equilibrium, there is roughly 1000 times more dissoD. The combination of OxyContin, Xanax, and Soma were ciated drug than undissociated drug in the stomach superior to all other drugs. B. At equilibrium, the ratio of dissociated to undissociated E. The combination of morphine, diazepam, and oxycodrug in the blood is approximately 10 done were superior to MS Contin alone. C. At equilibrium, 10 times more undissociated drug than dissociated drug is in the blood 2339. Which controlled substance produces a toxic metabolite D. Drug concentrations on the blood side of the stomach which may cause seizures with accumulation with barrier will never reach the concentration of drug in repeated dosing? the stomach A. Pentazocine E. The drug will be more rapidly excreted if the urine is B. Propoxyphene made acidic C. Morphine D. Ketamine 2345. Identify the LEAST important advice in defending drug E. Meperidine charges: A. Comply with all federal and state laws and regulations 2340. Which of the following is an action of a non-competitive governing prescribing – have and follow a compliance/ antagonist? risk management program A. Alters the mechanism of action of an agonist B. Keep current with and comply with DEA Policy StateB. Alters the potency of an agonist ments C. Shifts the dose-response curve of an agonist to the C. Comply with Kentucky Board of Medical Licensure right Policies, Guidelines, and Newsletters, especially D. Decreases the maximum response to an agonist Guidelines for Use of Controlled Substances in Pain E. Binds to the same site on the receptor as the agonist Treatment D. Keep up with your documentation E. Check if the patients are paying for visits. 2341. When compared to the general population, the mortality rate of a prescription drug abuse is about: 2346. Federal Control over the use of controlled substances is A. The same under the supervision of B. 3 times higher A. Balanced budget act of 1997 C. 6 times higher B. Food and drug Cosmetic Act administered by the D. 10 times higher F.D.A. E. 25 times higher C. Judicial branch of the government D. Executive branch of the government 2342. Which of the following statements is accurate with E. National Narcotics Bureau (N.N.B.) administration of psychostimulants in opioid induced sedation? 2347. Which one of the following is the most frequently abused A. They are safe in patients with a history of paranoid opiate in the United States? disorders A. Morphine B. Toradol ASIPP Section 12 • Controlled Substance Management 469 C. Hydrocodone D. Oxycodone E. Fentanyl lollypops 2352. Which of the following statements applies to a drug exhibiting a saturated elimination process? A. Upon multiple dosing, steady-state plasma concentrations will be reached in approximately 4 to 5 biologic 2348. Which of the following is NOT true about half-lives benzodiazepines when used long term in chronic pain? B. The fraction of drug eliminated per unit time is conA. Decrease REM and slow wave sleep stant B. Decrease serotonin levels C. The biologic half-life (t1/2) is affected by dose C. May produce a dangerous withdrawal syndrome if sudD. First-order kinetics are operable denly discontinued E. The rate of drug elimination is dependent on plasma D. Have a primary analgesic effect drug concentration E. May have a much higher rate of cognitive dysfunction than opioids 2353. According to NIDA household surveys and the National Comorbidity Survey, the prevalence of substance abuse 2349. The most frequent type of drug interaction that occurs among U. S. adults is about: in patients using drugs of the sedative hypnotic class is A. 1% A. Additive CNS depression B. 3% B. Antagonism of sedative or hypnotic actions C. 7% C. Competition for plasma protein binding D. 17% D. Induction of liver drug-metabolizing enzymes E. 33% E. Inhibition of liver drug-metabolizing enzymes 2354. According to the DSM-IV, which of the following is NOT 2350. A patient presents for treatment of mechanical and a criterion for diagnosing substance DEPENDENCE? radicular chronic spine pain resulting from severe A. Continued use despite physical or psychological probdegenerative disease with multilevel stenosis. He has lems caused by use. had a 2 level fusion in the past, undergone multiple B. Recurrent substance related legal problems interventional techniques and physical therapy without C. Development of tolerance to the substance benefit. His radicular pain has improved somewhat D. Attempts to cut down substance use with gabapentin 400 mg QID but he continues to have E. An episode of withdrawal severe mechanical back pain. He has a past history of cocaine and alcohol abuse, but has been clean and sober 2355. A patient complains of worsening chronic temporal for 7 years. When considering chronic opioid therapy in headache, despite daily treatment with aspirin, this patient which of the following is the most correct butalbital, caffeine and ergotamine. MRI of the head was statement? normal, but MRI of the neck demonstrated spondylosis. A. Opioid therapy may be appropriate, but the patient Headache most likely is due to: must be advised he has increased risk of relapse or A. Migraine cross addiction. B. Drug rebound phenomenon B. Opioid therapy is not appropriate because of his past C. Cervical spondylosis history of substance abuse. D. Pseudo-tumor cerebri C. The patient is not at increased risk because opioids were E. Vasodilation due to ergotamine never his drug of choice. D. Opioid therapy is acceptable, but only short-acting 2356. Which one of the following statements about pentazocine agents such as hydrocodone or oxycodone should be (Talwin®) is FALSE? used. A. Analgesia is at least equivalent to that of codeine E. The physician could be arrested for “aiding and abetting B. Causes sedation addiction” if he or she prescribes controlled substances C. Classified as a mixed agonist-antagonist for the patient. D. Full agonist at mu receptors E. May interfere with the analgesic effects of morphine 2351. A substance abuser enters and completes a 6 months long term treatment program. His or her chance at remaining sober is about: 2357. Among persons with a known substance abuse disorder, A. 5% the substance most commonly abused is: B. 10% A. Marijuana C. 30% B. Prescription opiates D. 60% C. Cocaine E. 90% D. Benzodiazepines E. Alcohol ASIPP 470 Section 12 • Controlled Substance Management 2358. Which of the following is the most accurate definition of tolerance: A. The medication stops working after a few months B. Stopping the medication causes withdrawal symptoms C. A given dose is less effective, increasing the dose restores the effect D. Side effects of a given dose are less severe over time E. A medication is less effective, changing to a different medication restores the effect 2359. A patient who had called for an early refill of opioid medication is rather agitated and jittery when seen in the office. She states she had not run out of her opioid medication but simply thought she needed a higher dose. All of the following symptoms would suggest opiate withdrawal EXCEPT : A. Diarrhea B. Piloerection C. Pinpoint pupils D. Sweating E. Rhinorrhea 2360. Adults who have completed four years of college are: A. Less likely to use an illicit drug B. More likely to use an illicit drug C. Adults with four years of college who are alcoholics are more likely to use an illicit drug. D. Adults who have not completed high school, are dropouts, or live in metropolitan areas are more likely to use illicit drugs. E. There is no evidence that education has an effect on the statistical prevalence of illicit drug use. 2361. Neurochemically, ALL substances considered abusable eventually activate: A. Cholinergic pathways in the brainstem B. Adrenergic pathways in the frontal lobes C. GABA-B receptors diffusely throughout the brain D. Serotonergic centers in the diencephalon E. Dopaminergic neurons in the mesolimbic system 2362. Which of the following is NOT a condition to an oral refill of a Schedule III or IV prescription? A. The total quantity authorized, including the amount of the original prescription, does not exceed five refills nor extend beyond six months from the date of the original prescription. B. The pharmacist obtaining the oral authorization must record on the reverse of the original prescription the date, quantity of refill, and the number of additional refills authorized, and must initial the prescription. C. The quantity of each additional refill authorized is equal to or less than the quantity authorized for the initial filling of the original prescription. D. The pharmacist must verify that the oral authorization came from a physician or other practitioner by, for example, calling the physician back at the number for the physician listed in the telephone directory. E. The prescribing practitioner must execute a new and separate prescription for any additional quantities ASIPP beyond the five-refill, six-month limitation. 2363. According to the DSM-IV, which of the following is a criterion for diagnosing substance ABUSE? A. Using a substance for a purpose other than that described in the PDR B. Substance use in hazardous situations C. Development of tolerance to the substance D. Attempts to cut down substance use E. An episode of withdrawal 2364. A heroin addict comes to the emergency room in an anxious and agitated state. He complains of chills, muscle aches, and diarrhea; he has also been vomiting. His symptoms include hyperventilation and hyperthermia. He claims to have had an intravenous “fix” approximately 12 hours ago. The attending physician notes that pupil size is greater than normal. What is the most likely cause of these signs and symptoms? A. The patient has overdosed with an opioid B. These are early signs of the toxicity of MPTP, a contaminant in “street heroin” C. The signs and symptoms are those of the abstinence syndrome D. In addition to opioids, the patient has been taking barbiturates E. The patient has hepatitis B 2365. Which one of the following drugs is most likely to increase plasma levels of alprazolam, theophylline, and warfarin: A. Desipramine (Pamelor®) B. Fluvoxamine (Luvox®) C. Imipramine (Tofranil®) D. Nefazodone (Serazone®) E. Venlafaxine (Effexor®) 2366. A patient injured in an auto accident received 80 mg of meperidine. He subsequently developed a severe reaction characterized by tachycardia, hypertension, hyperpyrexia, and seizures. When a questioned, the uninjured spouse revealed that the patient had been taking a drug for a psychiatric condition. Which of the following drugs is most likely to be responsible for this untoward interaction with meperidine? A. Alprazolam (Xanax®) B. Amitriptyline (Elavil®) C. Lithium D. Mirtazapine (Norbil®) E. Phenelzine (Nardil®) 2367. Fentanyl patches have been used to provide analgesia. The most dangerous adverse effect of this mode of administration is A. Cutaneous reactions B. Diarrhea C. Hypertension D. Relaxation of skeletal muscle E. Respiratory depression Section 12 • Controlled Substance Management 471 2368. A recently bereaved 74-year-old female patient was 2374. A patient complains of inadequate analgesia and treated with benzodiazepine for several weeks after the increases his use of his medication. This behavior may death of her husband, but she did not like the daytime represent: sedation it caused. She has no major medical problems but A. Addiction appears rather infirm for her age and has poor eyesight. B. Drug abuse Because her depressive symptoms are not abating, you C. Tolerance decide on trial of an antidepressant medication. Which D. Drug diversion one of the following drugs would be the most appropriate E. All or any of the above choice for this patient? A. Amitriptyline 2375. Convulsions caused by drug poisoning are most B. Mirtazapine commonly associated with C. Paroxetine A. Phenobarbital D. Phenelzine B. Diazepam E. Trazodone C. Strychnine D. Chlorpromazine 2369. Which of the following statements are true? E. Phenytoin A. Opioid calculators are very useful and reliable. B. If a patient complains of breakthrough pain, you should 2376. Phencyclidine may best be characterized by which of the double the dose of long acting opioid every day until following statements? pain relief. A. It has opioid activity C. Nerve pain might respond better to anticonvulsants B. Its mechanism of action is related to its anticholinergic than opioids properties D. Bone pain might respond better to anticonvulsants C. It can cause significant hallucinogenic activity than opioids D. It causes significant withdrawal symptoms E. Opioid hyperalgia may be due to M6G accumulation E. Treatment of overdose is with an opiate 2370. A PET scan is performed on a known substance abuser 2377. Disadvantages of long-term morphine therapy in a who receives their drug of choice during the procedure. cancer patient are: The PET scan would show activation of : A. Withdrawal when drug is stopped A. Nucleus Accumbens B. Cognitive dysfunction B. Ventral Tegmental Areas C. Addiction C. Central Nucleus of the Amygdala D. Liver dysfunction D. All of the above E. Constipation E. None of the above, they would actually be suppressed 2378. The most commonly used illicit drug in America is: A. Oxycontin® 2371. When prescribing sublingual or buccal route of B. Cocaine administration, the best drug (55%) for absorption is C. Morphine® A. Methadone D. Marijuana B. Fentanyl E. Alcohol C. Morphine D. Buprenorphine 2379. Cocaine, produced from the leaves of Erythroxylon E. Demerol species, A. Produces bradycardia and vasodilation 2372. The management of phencyclidine toxicity is likely to B. Is directly related chemically to opioid analgesics include all of the following except: C. Is metabolized by the microsomal metabolizing system A. Naloxone for respiratory depression D. Blocks nerve conduction effectively B. Diazepam for seizures E. Blocks norepinephrine receptors directly C. Propranolol for adrenergic crisis D. Haloperidol for disorganized, disruptive behavior 2380. Which of the following statements about the CSA is E. Low-stimulus environment true? A. If a practitioner needs only a small number of dosage 2373. Which of the following is associated with crack units of a controlled substance for office use , a pre(the free-base form of cocaine)? scription order may be issued to permit a pharmacy A. Flashbacks (recurrences of effects) may occur months to dispense them. after the last use of the drug B. The Act prohibits treating a known addict with an B. It may cause seizures and cardiac arrhythmias opioid/opiate product for persistent (as opposed to C. It acts by blocking adrenergic receptors acute) pain. D. It is the salt form of cocaine C. The defines the term “narcotic” as those controlled subE. It is primarily administered intranasally stances which are opioids or opiates, whether natural, ASIPP 472 Section 12 • Controlled Substance Management synthetic, or semi-synthetic. D. Cocaine is classified by the Act as a C-I substance. E. The Act permits DEA Diversion Investigators to inspect your controlled substances records (inventories, storage facility, order forms, etc.) at any time during your normal practice hours. 2381. Patients usually develop tolerance to all opioid effects EXCEPT: A. Sedation B. Pruritus C. Constipation D. Pain relief E. Respiratory depression 2382. Which of the following is not an accurate statement regarding personal protective equipment (“PPE”)? A. The PPE does not permit blood or other potentially infectious materials to pass through or reach employee’s work clothes, skin, face, etc. B. PPE must be readily accessible in the workplace or issued to the employee. C. The employer is responsible for laundering PPE. D. The employer is responsible for repairing PPE. E. A physician practice may deduct the cost of an employee’s PPE from his or her paycheck. 2383. Which of the following is NOT an element of an effective compliance program for a physician practice? A. Regular auditing and monitoring B. Education and training on the program for the physicians with an equity interest in the practice C. Education and training for all personnel in the practice D. Written practice standards including a code/standard of conduct E. A response mechanism and corrective action plan 2384. Which of the following characteristics of buprenorphine best account for its effectiveness in the treatment of opioid dependence and detoxification? A. Sublingual formulation with naloxone B. High opioid mu-1 receptor affinity and slow receptor dissociation C. Partial kappa receptor agonist activity D. Low oral bioavailability necessitating parenteral administration E. High intrinsic activity at the opioid mu receptor 2385. Compared to morphine, butorphanol would be expected to display which one of the following pharmacologic characteristics? A. Kappa receptor antagonist activity B. Analgesic ceiling effect C. No respiratory depression D. Histamine release E. Mu receptor agonist activity ASIPP 2386. According to the Federal Controlled Substances Act of 1970, a Schedule III drug could be considered to possess which one of the following characteristics: A. Lack of accepted safety and indication for medical use B. Limited, if any, physical or psychological dependence C. High potential for abuse D. No withdrawal syndrome noted with abrupt discontinuation of use E. Analgesic, anabolic, sedative, and/or hypnotic effects 2387. Compared to a short-acting, immediate release opioid, a long-acting, sustained release opioid differs in which one of the following characteristics? A. Higher level of opioid receptor affinity and intrinsic activity B. Greater degree of tachyphylaxis C. Faster development of tolerance D. Protracted withdrawal syndrome following abrupt discontinuation E. No ceiling effect for analgesia 2388. Under the Controlled Substances Act (CSA), the following drug schedules is thought to have the highest potential for abuse? A. Schedule II B. Schedule III C. Schedule V D. Schedule I E. Schedule IV 2389. A physician determines that an emergency situation exists justifying a Schedule II emergency oral prescription. Which of the following statements is true? A. Within 7 days after the oral authorization to the pharmacist, the physician must deliver to the pharmacist a written prescription for the emergency quantity prescribed, and the written prescription must have written on its face “Authorization for Emergenc B. Within 14 days after the oral authorization to the pharmacist, the physician must deliver to the pharmacist a written prescription for the emergency quantity prescribed and the written prescription must have written on its face “Authorization for Emergenc C. Within 30 days after the oral authorization to the pharmacist, the physician must deliver to the pharmacist a written prescription for the emergency quantity prescribed and the written prescription must have written on its face “Authorization for Emergenc D. No further action is required. E. Within 60 days after the oral authorization to the pharmacist, the physician must deliver to the pharmacist a written prescription for the emergency quantity prescribed and the written prescription must have written on its face “Authorization for Emergenc Section 12 • Controlled Substance Management 473 2390. Choose the most likely effect resulting from treatment 2396. Regarding low back pain in a primary care practice: with 10 mg of diazepam 3 times daily? A. Less than 10% of new low back pain patients followed A. Retrograde amnesia up with a doctor at 12 months. B. Improved performance on tests of psychomotor funcB. Less than 10% of new low back pain patients still had tion low back pain at 12 months C. Alleviation of the symptoms of major depressive disC. Less than 10% of new low back patients still had diforder ficulties with ADLs at 12 months D. Increased porphyrin synthesis D. Less than 10% of new low back pain patients still had E. Agitation and possible hyperreflexia with abrupt dispain complaints at 3 months continuance after chronic use E. Less than 10% of new low back pain patients followed up with a doctor at 3 months 2391. A morbidly obese patient with low back pain complains of not sleeping well and feeling tired during the day. His 2397. Which of the statements about tolerance is most true wife wakes him up several times during the night due to in a patient taking repeated daily doses of lysergic acid his loud snores. Patient wants a prescription for sleep diethylamide (LSD)? medicine. Your next step is: A. No tolerance develops A. Prescribe Clorazepate B. Tolerance develops in 3 to 4 days B. Prescribe Flurazepam C. Tolerance develops in 2 to 3 weeks. C. Prescribe Secobarbital D. Tolerance develops in 2 to 3 months. D. Prescribe Triazolam E. Tolerance develops in 6 months. E. Refer to sleep disorder clinic 2398. A 17-year old who ingests “mushrooms” would present 2392. Choose the accurate statements concerning the with symptoms best described as: Barbiturates and Benzodiazepines: A. Anticholinergic A. Compared with benzodiazepines, barbiturates exhibit a B. Adrenergic flatter dose-response relationship C. Cholinergic B. Respiratory depression caused by barbiturate overdosD. Alpha adrenergic age can be reversed by flumazenil E. Dopaminergic C. An increase in urinary pH will accelerate the elimination of phenobarbital 2399. To avoid criminal investigations into prescribing D. Barbiturates may increase the half-lives of drugs mepatterns for controlled substances, a physician should . . tabolized by the liver .Choose the answer that best completes this sentence. E. Symptoms of the abstinence syndrome are less severe A. Warn patients to fill prescriptions at different drugduring the withdrawal from secobarbital than from stores. phenobarbital B. Make sure there is a logical relationship between the drugs prescribed and the treatment of the condition 2393. What is the first step in a patient on 300 mg Tramadol per allegedly existing. day with paroxetine(Paxil®) with inadequate pain relief ? C. Issue prescriptions to patients known to be selling A. Change the paroxetine drugs to others. B. Add a benzodiazepine D. Prescribe controlled substances at intervals inconsistent C. Increase the tramadol with legitimate medical treatment. D. Switch to a more potent opioid E. Use street slang when talking about the drugs preE. Switch to an agonist/antagonist opioid scribed. 2394. The greatest risk in a patient on 300 mg of daily Tramadol 2400. Which of the following statements is NOT true with (Ultram®) and paroxetine (Paxil®) combination is: regard to a continuing criminal enterprise? A. Withdrawal A. Conviction for being the manager or organizer of a B. Increased depression continuing criminal enterprise results in the person C. Seizures being sentenced to not less than 20 years and not more D. Increased pain than life imprisonment, a fine of $2 million or more, E. GI bleeding and forfeiture of assets under 21 USC 853. B. To be convicted of being the manager or organizer of a 2395. Adverse effects of opioids that can be used to advantage continuing criminal enterprise, one must obtain subinclude: stantial income or resources. A. Dysphoria C. To be convicted of being the manager or organizer of a B. Respiratory depression continuing criminal enterprise, at least five other perC. Decreased GI motility sons must be involved. D. Pupil constriction D. To be convicted of being the manager or organizer of a E. Sexual dysfunction continuing criminal enterprise, a person must violate a provision of the Controlled Substances Act, the pun- ASIPP 474 Section 12 • Controlled Substance Management ishment for which is a misdemeanor. E. To be convicted of being the manager or organizer of a continuing criminal enterprise, a person must engage in a continuing series of violations of the Controlled Substances Act. 2401. A practitioner intending to dispense and prescribe Schedule III, IV, or V controlled substances for maintenance and detoxification treatment must submit to the Secretary of the Department of Health and Human Services a notification that he or she intends to do so. The notification must state . . .Which one of the following would not correctly complete this sentence? A. That the practitioner has the capacity to refer patients to whom the practitioner provides narcotic drugs for appropriate counseling and other ancillary services. B. If the practitioner is in solo practice, that s/he will not treat more than thirty patients at any one time with Schedule III, IV, or V drugs for detoxification or maintenance. C. If the practitioner is in group practice, that the group practice will not treat more than sixty patients at any one time with Schedule III, IV, or V drugs for detoxification or maintenance. D. That the practitioner is a qualified physician, as that term is defined in the federal statutes. E. If the practitioner is in group practice, the names and DEA registration numbers for all practitioners in a group practice. unless renewed by the prescribing practitioner. C. No Schedule III or IV drug may be dispensed without a written or oral prescription, except when dispensed directly by a physician or other practitioner to an ultimate user. D. A pharmacist may dispense a Schedule III or IV drug based on a fax to the pharmacy of a written, signed prescription transmitted by the practitioner or one of his/her staff. E. A pharmacist may dispense a Schedule III or IV drug based on an oral prescription received from the prescribing practitioner, if the oral authorization is promptly reduced to writing by the pharmacist. 2404. Compared with diazepam (Valium®), midazolam(Versed®) A. Is more lipid soluble B. Has a longer elimination half-life C. Has a larger volume of distribution D. Has greater clearance E. Undergoes slower hepatic metabolism 2405. According to the 2003 National Survey on Drug Use and Health (NSDUH), 6.3 million persons age 12 or older used prescription medications for non-medical reasons. Which of the following is the most prevalent agent for non-medical reasons? A. Pain reliever B. Tranquilizers C. Stimulant 2402. Under the Drug Addiction Treatment Act of 2000, D. Sedatives practitioners who are qualified physicians may E. NSAIDs dispense and prescribe Schedule III, IV, or V controlled substances specifically approved by the Food and Drug 2406. Meperidine Administration for narcotic addiction treatment to a A. Has been used for many years and is appropriate for narcotic dependent person if the practitioner meets chronic use several requirements.Which one of the following B. Is metabolized by CYP2D6 credentials will NOT make a physician a qualified C. Is safe to use in elderly patients physician? D. May cause side effects that cannot be reversed by opioid A. The physician holds a subspecialty board certification antagonists. in addiction psychiatry from the American Board of E. Becomes more effective over time, because of an active Medical Specialties. metabolite B. The physician holds an addiction certification from the American Society of Addiction Medicine. 2407. Supportive management (“talking down”) of most acute C. The physician holds a subspecialty board certification reactions to lysergic acid diethylamide (LSD): in addiction medicine from the American Osteopathic A. Should be accompanied by an injection of diazepam Association. (Valium). D. The physician has completed not less than 8 hours of B. Should be attempted in a hospital or emergency room training regarding the treatment and management of setting. opiate-dependent patients. C. Is not indicated for these reactions. E. The physician has published a peer-reviewed article on D. Can usually be accomplished without medication or the treatment of opiate-dependent patients. hospitalization. E. Should be accompanied by an injection of haloperidol 2403. Which of the following is NOT a true statement with (Haldol). respect to a Schedule III or IV drug? A. Schedule III and IV prescriptions may not be filled or 2408. The following statements are true regarding opioidrefilled more than six months after the date the origiinduced constipation. nal prescription was issued. A. Treat constipation B. Schedule III and IV prescriptions may not be refilled B. To obtain a surgical consult to rule out complications more than 10 times after the date of the prescription C. To evaluate for drug abuse ASIPP 475 Section 12 • Controlled Substance Management D. Start on transdermal fentanyl E. Start on methadone maintenance program 2409. Which of the following is true about the federal Controlled Substances Act: A. It prohibits self-prescribing. B. It permits DEA Diversion Investigators to inspect patient records without patient consent, upon written request. C. It allows most practitioners to prescribe C-I substances for IRB-approved research D. It permits a “Do Not Fill Until” instruction on a prescription order. E. It prohibits prescribing methadone without a special registration as a methadone clinic. 2410. A meperidine (Demerol) dose equivalent to morphine 10 mg every 3 to 4 hours by injection is: A. 100 mg every 3 hours B. 75 mg every 3 hours C. 50 mg every 3hours D. 100 mg every 4 hours E. 75 mg every 4 hours 2411. A 22 year old weight lifter who has been observed to have a gradual behavior change marked by aggression and mood swings may be demonstrating the effects of: A. Increased protein intake B. Creatine and chromium nutritional supplements. C. Prednisone tablets D. Anabolic steroids E. Massive doses of vitamins 2412. The states of a patient in which repetitions of the same dose of a drug has progressively less effect or in which the dose needs to be increased to obtain the same degree of pharmacological effect is most likely A. Physical dependence B. Synergistic effect C. Additive effects D. Disuse supersensitivity E. Tolerance A. Phencyclidine (PCP) intoxication. B. Atropine intoxication C. Benzodiazepine intoxication D. Mescaline intoxication E. Solvent intoxication 2415. All of the following statements are sources of confusion in describing chronic pain EXCEPT: A. Pain can be described in terms of its physiological underpinnings and its felt experience B. Patients are ashamed of acknowledging the psychological contributors to their pain. C. Practitioners are uncomfortable with acknowledging psychological contributors D. Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage (IASP). E. Pain is best described if only structural abnormalities are utilized. 2416. Death from acute intoxication with phencyclidine is most likely to occur as a result of: A. Violence B. Cholinergic crisis. C. Hypertensive crisis. D. Cardiac arrest. E. Status epilepticus. 2417. A known heroin addict underwent emergency surgery after a motor vehicle injury. He received morphine 10 mg IV, three doses in 2 hours which helped him only 15 minutes. The course of treatment in this patient is: A. To titrate morphine B. To obtain a surgical consult to rule out complications C. To evaluate for drug abuse D. Start on transdermal fentanyl E. Start on methadone maintenance program 2418. Reported symptoms of Methylenedioxyamphetamine (DMA) and its analog methylenedioxymethamphetam 2413. While on a maintenance dose of methadone 80 mg per ine (MDMA) are reported to cause all of the following day, a patient “shoots up” the heroin equivalent of 10 mg. EXCEPT: The most likely effect will be: A. Mild stimulation A. Euphoria and sedation B. A feeling of well-being. B. Sedation only. C. Visual illusions or hallucinations. C. Neither euphoria nor sedation D. Auditory hallucinations. D. Lacrimation, piloerection, and abdominal cramps E. Anxiety E. Respiratory distress, chest pain, and tachycardia 2419. Flashbacks can occur: A. Long after the hallucinogenic intoxication has dis2414. A 15-year-old male high school freshman presents to an sipated. emergency department with a blank stare, belligerence, B. Only in patients with pre-existing psychological probpsychomotor agitation, horizontal nystagmus, vertical lems. nystagmus, blood pressure 160/110 mm Hg, ataxia C. As a result of impurities in street psychedelics. dysarthria, and diminished responsiveness to pain. D. Usually a half hour after the drug has been ingested. He appears to be hallucinating, and as he is being E. In patients with combined use of hallucinogens and interviewed he assaults one of the attendants. The most opioids likely diagnosis is: ASIPP 476 2420. The following pathology results from infective endocarditis in heroin addicts, compared to endocarditis in non-addicted patients: A. The tricuspid valve is diseased B. Mixed flora of bacteria C. Staphylococcus aureus is found more often as a causative organism. D. Surgical treatment is mandatory E. Easily identified by an aortic murmur 2421. The Golden Crescent and the Golden Triangle refer to: A. A geographic region of Africa where opium is grown. B. A geographic region of Asia where marijuana is grown. C. Various names from heroin. D. Symbols used in drug trafficking. E. A geographic region of Asia where opium is grown. 2422. Identify evidence-based recommendations of meperidine use in chronic pain. A. Given no more frequently than every four hours for 6 months B. Used in standard doses in the elderly indefinitely if response is positive C. Used in individuals with impaired renal function as meperidine is shown to have only hepatotoxicity D. Always used in conjunction with non-steroidal antiinflammatory agents. E. Reserved for very brief therapy in otherwise healthy patients who cannot tolerate other opioids 2423. Identify the statement describing the withdrawal when chronic opioid use is discontinued? A. Is of no clinical significance B. Can be prevented by administering of a benzodiazepine C. Can be prevented by administering of an amphetamine D. Is best managed by slowly tapering the opioid dose by no more than 10% every few days. E. Can be alleviated by immediately starting on an opioid agonist-antagonist 2424. The US work loss related to pain: A. Half the workforce report having pain in the last two weeks. B. 10% of the work force was absent from work one or more days per week C. Abdominal pain was the most common complaint. D. Half of the workforce lost productive time due to pain E. An average of 8 hours of work per week is lost because of pain 2425. A patient of yours is brought in for evaluation by his wife, 3 days after cervical epidural steroid injection with multiple complaints. On examination he is found to be disoriented, confused and in a fugue-like state with nystagmus on upward gaze, tachycardia and elevated ASIPP Section 12 • Controlled Substance Management blood pressure. The most likely diagnosis is: A. Cocaine intoxication B. Cannabis intoxication C. Barbiturate intoxication D. Phencyclidine (PCP) intoxication E. Epidural abscess 2426. What are the main types of legal/regulatory material at the federal level governing record-keeping for the use of controlled substances for the treatment of pain? A. Acts and Laws, regulations and rules, and guidelines, policy or position statements. B. Laws and regulations. C. Controlled Substances Act of 1970. D. DEA Policy Statements. E. Food and Drug Act. 2427. Applied to the skin in a transdermal patch (transdermal therapeutic delivery system), this drug is used to prevent or reduce the occurrence of nausea and vomiting that are associated with motion sickness A. Diphenhydramine B. Chlorpromazine C. Ondansetron D. Dimenhydrinate E. Scopolamine 2428. Use of which the following opioids by breast-feeding mothers depresses the behavior of the infant more than the equianalgesic dose of morphine: A. Fentanyl® B. Meperidine® C. Nalbuphin® D. Buprenorphine® E. Tramadol® 2429. The Controlled Substances Act of 1970 does not give DEA the authority to do which of the following: A. Scheduled drugs B. Regulate medical practice C. Administer the CSA and create policy related to the CSA D. Establish quotas for the manufacture of controlled substances E. Reschedule drugs depending on their potential for abuse 2430. In order for a prescription to be valid under federal and state law, it must be issued A. With the proper date and the physician’s signature. B. With the proper date, patient information, drug identification and instructions for use, physician signature, and it must be issued for a legitimate medical purpose within the usual course of professional practice. C. To a patient who does not have a criminal history. D. Only by a licensed physician and not by any mid-level practitioner. E. Within three days of seeing the patient. Section 12 • Controlled Substance Management 477 2431. As a DEA registrant you have certain responsibilities, D. The Controlled Drug Act. including (1) proper registration and renewal; (2) E. The Controlled Substances Act of 1970. proper record-keeping; and (3) what newly explained responsibility as stated in the Interim Policy Statement, 2436. You have a patient that you suspect may be altering published by DEA in the Federal Register on November your prescriptions. You want to fax a copy of a Schedule 16, 2004? II prescription to the pharmacist the patient uses to fill A. A responsibility to report to DEA about the misuse of prescriptions. Is this legal and what must happen before a DEA number. the pharmacist dispenses the prescription? B. A responsibility to seriously consider any sincerely A. A. No, it is not legal to fax a Schedule II preexpressed concerns made by family members about a scription to a pharmacist. patient’s potential abuse of controlled substances. B. B. Yes, but only if you have a HIPAA consent C. A responsibility to see all patients every thirty days. from the patient. D. A responsibility to issue drugs for a legitimate medical C. C. Yes, and the patient must present the origipurpose. nal prescription to the pharmacist. E. A responsibility to review patient records every thirty D. D. No, because faxes apply only to emergency days. prescriptions for Schedule II drugs. E. E. No, because faxes apply only to hospice and 2432. How often must a practitioner renew his/her DEA nursing home situations. registration? 2437. Demerol (meperidine) should not be used for chronic A. Every 2 years. pain because: B. Every 6 years. A. It is addictive C. Every 3 years. B. It is ineffective D. Every 4 years. C. The metabolite causes seizures E. Every 5 years. D. The medication is expensive E. All of the above 2433. Every practitioner who administers, prescribes, or dispenses any controlled substance must be registered 2438. A former heroin addict is maintained on methadone, but with the DEA and must maintain the DEA certificate of succumbs to temptation and buys an opioid on the street. registration at the registered location. If a practitioner He takes it and rapidly goes into withdrawal. Which has more than one office where controlled substances opioid did he take? are administered and/or dispensed, then the practitioner A. Meperidine must: B. Heroin A. Register only the principal office location. C. Pentazocine B. Register each office location where controlled substancD. Codeine es are administered and/or dispensed. E. Propoxyphene C. Register only those office locations where controlled substances are prescribed. 2439. You are a solo practitioner in a pain specialist capacity. D. Do nothing. You have a patient who wants to be treated in your office E. Register every location that uses prescription pads. for opioid addiction and pain. Do you need a separate registration to provide Narcotic Treatment Services? 2434. If you move the location of your practice, you are A. No, I can issue 72-hour emergency prescriptions as required to do what regarding your DEA registration? needed to detoxify a patient. A. Send a request for modification of registration in writB. No, I can prescribe methadone to help them detoxify ing to the nearest DEA field office, and obtain approval because I prescribe methadone to treat their pain. for the modified registration prior to the move. C. No, I have the proper training on the use of Schedule B. Wait until the next renewal date for your controlled III-V drugs in the office based treatment of opioid substances registration to notify DEA of the move. addiction. C. Tell only your state drug bureau about the move and D. Yes, I must have a separate registration to provide narseek a new registration with them that you can use cotic treatment services. with DEA. E. Yes, so I can prescribe drugs in Schedule II-V to detoxify D. Send DEA a request for a new registration number after a patient due to opioid addiction. you move. E. Wait until DEA asks you for updated information about 2440. Which one of the following effects is unlikely to occur your registration and current address. during treatment with amitriptyline? A. Alpha adrenoceptor blockade 2435. The federal law governing the scheduling of drugs as B. Elevation of the seizure threshold “controlled substances” is called: C. Mydriasis A. The Food, Drug, and Cosmetic Act of 1962. D. Sedation B. The Federal Uniform Controlled Substances Act. E. Urinary retention C. The Code of Federal Regulations. ASIPP 478 Section 12 • Controlled Substance Management 2441. The mechanism of action of most benzodiazepines is by : A. Activation of GABA receptors B. Antagonism of glycine receptors in the spinal cord C. Blockade of the action of glutamic acid D. Increased GABA-mediated chloride ion conductance E. Inhibition of GABA aminotransferase 2442. Concerning the proposed mechanisms of action of antidepressant drugs, which one of the following statements is accurate? A. Bupropion (Wellbutrin®) can effective inhibitor of NorEpinephrine and 5-HT transporters B. Chronic treatment with an antidepressant often leads to the up-regulation of adrenoceptor C. Elevation in amine metabolites in cerebrospinal fluid is characteristic of most depressed patient prior to drug therapy D. MAO inhibitors used as antidepressants selectively decrease the metabolism of norepinephrine E. The acute effect of most tricyclics is to block the neuronal reuptake of both norepinephrine and serotonin in the CNS 2443. A 28-year-old woman presents with symptoms of major depression that are unrelated to a general medical condition, bereavement, or substance abuse. She is not currently taking any prescription or over-thecounter medications. Drug treatment is to be initiated with a selective serotonin reuptake inhibitor. In your information to the patient, you would NOT tell her that A. Divided doses may help to reduce nausea and gastrointestinal distress B. Muscle cramps and twitches sometimes occur C. She must inform you if she anticipates using other medications D. Taking the drug in the evening will ensure a good night’s sleep E. The drug may require 2 weeks or more to become effective 2444. Which one of the following actions of opioid analgesics is mediated via activation of kappa receptors? A. Cerebral vascular dilation B. Decreased uterine tone C. Euphoria D. Sedation E. Psychologic dependence 2445. All of the statements are correct about chronic pain syndromes, EXCEPT: A. Pain that lasts longer than 6 months. B. Varying levels of mental health problems are diagnosed prior to, or concurrent with, onset of pain. C. Impairment in vocational, social, emotional functioning. D. Low rates of health care utilization. E. Frequent issues of secondary gain and addiction to pain medications. ASIPP 2446. A deliberate (dealing) practitioner characteristics include all of the following EXCEPT: A. Practitioner becomes a mercenary B. Sells drugs for money, sex, street drugs, etc. C. Office becomes a pill factory—full of drug seekers D. Prescribes for known addicts who will likely sell drugs to others E. Keeps close contact with DEA 2447. Is it legal for Internet pharmacies to approach a physician to write prescriptions based on on-line consultations with customers/consumer? A. Yes, this is legal and on-line consultations qualify as a proper physician-patient relationship. B. Yes, but the physician must see the patient in person and establish a valid physician-patient relationship prior to issuing Internet prescriptions. C. No, a physician cannot do this under existing law. D. No, a physician cannot do this unless he/she obtains a special Internet certification from the DEA. E. Yes, but the physician must obtain a special Internet certification from DEA. 2448. Correct statements describing the risks of malprescribing include A. Never given re-education options B. Not reportable to databank C. State Board Investigation or Sanction D. Usually results in publicity to increase your practice E. Not liable to civil lawsuits, only criminal liability 2449. You have a patient you have seen for several years. The patient is stable and has been on the same controlled substances, including a Schedule II drug, for one year. The patient has been relatively compliant with your treatment plan and fully compliant with medication issues. Identify the federal legal/regulatory material that prohibits you from issuing this patient multiple schedule II medications with different fill dates or “do not fill before” language on your prescriptions. A. The Interim Policy Statement of November 16, 2004. B. The Controlled Substances Act of 1970. C. The Code of Federal Regulations pertaining to the issuance of prescriptions. D. A, B, and C. E. My state allows this so there is nothing in the federal legal/regulatory material that prevents me from using multiple schedule II prescriptions with different fill dates with my patients. 2450. A drug that is used in the treatment of parkinsonism and will also attenuate reversible extrapyramidal side effects of neuroleptic is A. Amantadine (Symmetrel®) B. Levodopa (Dopar®) C. Pergolide (Permax®) D. Selegiline (Eldepryl®) E. Trihexyphenidyl (Artane®) Section 12 • Controlled Substance Management 2451. Meprobamate is the active metabolite of which skeletal muscle relaxant? A. Carisoprodol (soma®) B. Cyclobenzaprine (Flexeril®) C. Methocarbamol (Robaxin®) D. Valdecoxib (Bextra®) E. Baclofen® 2452. All of the following are true statements regarding ketamine EXCEPT: A. Ketamine is a dissociative anesthetic B. Dissociative anesthesia induced by ketamine emphasizes that the anesthetized patient is “disconnected”from his or her environment C. Ketamine is one of the most commonly abused drugs D. Ketamine has been placed in Schedule I of the Federal Controlled Substances Act. E. Ketamine induces coma in a dose-dependent manner 479 compulsive disorders B. Clonazepam has effectiveness in patients who suffer from phobic anxiety states C. Diazepam is used for chronic management of bipolar affective disorder in patients who are unable to tolerate lithium D. Intravenous buspirone is useful in status epilepticus E. Symptoms of the alcohol withdrawal state may be alleviated by treatment with zaleplon 2456. Choose the correct statement about a duped practitioner. A. Never assumes the best about his patients and is gullible B. Never leaves script pads lying around C. Does not believe in hydrophilic medicine “fell” into the toilet or the sink D. Believes when patients only want specific medications (i.e. OxyContin or Percocet) E. Never co-dependent - always tells patients “No” when they ask for narcotics 2453. You treat patients who suffer from conditions producing chronic, non-malignant pain. You prescribe controlled substances to your patients (1) for a legitimate medical 2457. Your friend’s daughter whom you have known for several years makes an appointment with you. During the visit, purpose, and (2) within the usual course of professional she tells you that she is a heroin addict and requests practice. The Federation of State Medical Boards and a prescription for Hydrocodone. Your options in this many state licensing boards require practitioners to keep situation are as follows: medical records that include which of the following items A. Immediately call her father and give hydrocodone. in connection with their use of controlled substances to B. Immediately tell father and give her Methadone. treat pain? C. Start rapid detoxification in your office. A. The name of the drug and the amount prescribed. D. Provide her with a prescription for Methadone mainB. The medical history and physical examination, diagtenance nostic, therapeutic and laboratory results, evaluations E. Do not tell the father and do not give Hydrocodone. and consultations, treatment objectives, discussion of risks and benefits, informed consent and treatment 2458. Compared with midazolam, diazepam has which of the agreements, treatments, medications (includ following characteristics? C. An inventory of all the drugs prescribed to each patient, A. Greater solubility in water a record of all communications with the patient, and B. Shorter beta half-life all office forms. C. More potent ventilatory depressant effect D. A carbon copy of the prescriptions issued, all contact D. Lower risk for thrombophlebitis information for the patient, and all clinical rationale E. A pharmacologically active metabolite for the drugs prescribed. E. A list of each office visit you have with the patient and a 2459. True statement(s) with regards to urine drug testing statement of all treatments rendered. include: A. Thin layer chromatography is a relatively new tech2454. A registered individual practitioner is not required to nique, most sensitive, labor intense, and expensive. keep records of controlled substances in Schedules II, B. Gas chromatography is most sensitive, most reliable, III, IV, and V which are prescribed in the lawful course of inexpensive, an old and established technique. professionalpractice, unless C. Enzyme immunoassay is less sensitive than thin layer A. He/she prescribes controlled substances in the course of chromatography, more sensitive than gas chromamaintenance or detoxification treatment of a patient. tography, and has ability to screen multiple drugs at B. He/she prescribes controlled substances at more than a time. one practice location. D. Rapid drug screens are similar to other enzyme imC. He/she uses the Internet for all patient contact. munoassay tests but may be more expensive or less D. He/she has been registered for less than three years. expensive. E. He/she uses electronic medical records. E. Rapid drug screens are less sensitive than enzyme immunoassay, gas chromatography, and thin layer 2455. Concerning the clinical uses of benzodiazepines and chromatography and highly unreliable, but least exrelated drugs, which one of the following statements is pensive. accurate? A. Alprazolam is effective in the management of obsessive- ASIPP 480 2460. Which of the following opioids is vagolytic? A. Morphine B. Meperidine C. Sufentanil D. Nalbuphine E. Alfentanil 2461. N-methyl-D-aspartate (NMDA) receptors are best defined as: A. NMDA receptors are calcium-permeable ion channels that require only glutamate for activation. B. NMDA receptors are calcium-permeable ion channels that require only glycine for activation. C. NMDA receptors are calcium-permeable ion channels that require both glutamate and glycine for activation. D. At the molecular level, NMDA receptors are composed of a single subunit. E. NMDA receptors have small intracellular C-termini that interact with a single protein that regulates receptor phosphorylation. 2462. What are correct statements about drug interactions of following statements? A. Amitriptyline will increase morphine metabolism B. Morphine will decrease desipramine levels C. Erythromycin will decrease opioid levels D. Tricyclic antidepressants will increase methadone levels E. Propoxyphene will increase propranolol levels 2463. Methadone in addition to being a µ-receptor agonist has been proposed to also act as a: A. COX-2 inhibitor B. Sodium Channel blocker C. NMDA receptor antagonist D. Delta receptor agonist E. Opiod Antagonist 2464. A patient presents to you with chronic low back pain. He is being treated with OxyContin 40 mg twice a day and hydrocodone 10 mg four times daily. You performed a drug testing. The results of the drug testing were positive for oxycodone, hydromorphone, and hydrocodone. The results indicate the following: A. The patient abusing controlled substances by taking non-prescribed drugs. B. He is non-compliant by not taking the prescribed drugs. C. He is selling drugs D. The results of the drug test show a normal pattern E. The drug test indicates the patient is taking his mother’s hydromorphone 2465. A urine drug test in a patient on hydrocodone was positive for hydrocodone and hydromorphone. Choose the correct option. A. The patient is taking Dilaudid B. Refuse to write any more opioids C. Ignore the results as a false positive ASIPP Section 12 • Controlled Substance Management D. Counsel the patient regarding taking drugs that have not been prescribed E. Avoid the use of SSRIs in this patient 2466. The following statements are true with typical detection times for urine testing of common drugs of abuse. A. Methadone, 2 to 4 days B. Chronic use of marijuana, 1 to 3 days C. Morphine, 15 days D. Cocaine, 15 days E. Benzodiazepines, 15 days 2467. The Schedule I substance among the following drugs is? A. Buprenorphine B. Hydromorphone C. Heroin D. Diazepam E. Morphine 2468. What are the correct statements about long-term use of opioids in chronic non-cancer pain? A. No reliable long term studies (> 8 months) that demonstrate efficacy and safety of long term opioid therapy for chronic pain B. Overall relief with opioids is high (75%) C. Physicians must be liberal when prescribing long term opioids D. Outcomes are not patient-specific E. No risk of adverse events, addiction, diversion, or noncompliance have been noted 2469. With regard to narcotic addiction treatment, which of the following statements is most accurate? A. A practitioner who dispenses Schedule II narcotic drugs for maintenance or detoxification treatment must obtain a separate registration every five years as a narcotic treatment program. B. Registration as a narcotic treatment program allows a practitioner to administer, dispense, and prescribe, Schedule II drugs approved by the Food and Drug Administration for treatment of narcotic addiction. C. The only Schedule II drugs approved by the Food and Drug Administration for treatment of narcotic addiction are Methadone and levo-alpha-acetyl-methadol (LAAM). D. Registration as a narcotic treatment program is contingent on proper registration with the appropriate state attorney general. E. To obtain registration as a narcotic treatment program, a practitioner must have been engaging in narcotic addiction treatment for at least five years. 2470. Which of the following statements concerning an opioid treatment program (OTP) is false? A. An OTP must apply to the Substance Abuse and Mental Health Services Administration for certification. B. To become certified by the Substance Abuse and Mental Health Services Administration (SAMHSA), an OTP must be accredited by a SAMHSA-approved accreditation body. Section 12 • Controlled Substance Management 481 in controlled substance prescribing. C. OTPs must comply with the Federal Law on ConfidenE. State DEA registration and a state medical license. tiality of Substance Abuse Patient Records and with the HIPAA privacy rule. D. OTPs must notify the Substance Abuse and Mental 2475. Which one of the following statements best describes the mechanism of action of benzodiazepines? Health Services Administration within sixty days of A. Benzodiazepines activate GABA B receptors in the any replacement or change in the status of the prospinal cord gram sponsor or medical director. B. Their inhibition of GABA transaminase leads to inE. OTPs must be registered by the Drug Enforcement Adcreased levels of GABA ministration before administering or dispensing any C. Benzodiazepines block glutamate receptors in hieraropioid agonist treatment medications. chical neuronal pathways in the brain D. They increase the frequency of opening of chloride ion 2471. Regarding the use of opioids, which of the following channels that are coupled to GABA A receptors statements is true? E. They are direct-acting GABA receptor agonists in the A. Opioid medications have predictable side effects at CNS certain doses. B. Blood level of the drug needed for perceived therapeutic effect is consistent through the day. C. If a pain signal is too weak to be perceived, it has no 2476. An 82-year-old woman, otherwise healthy for her age, has difficulty sleeping. Triazolam (Halcion®) is prescribed biophysiologic effect. for her at one-half of the conventional adult dose. The D. Complete pain relief is the goal of the use of opioid most likely explanation for the increased sensitivity of medication. elderly patients to a single dose of triazolam and other E. Treating pain aggressively early may decrease the risk of sedative-hypnotic drugs is sensitization. A. Changes in plasma protein binding B. Decreased renal function 2472. All of the statements are correct about Drug Abuse C. Increased cerebral blood flow Prevention and Control Act of 1970 EXCEPT: D. Decreased hepatic metabolism of lipid-soluble drugs A. It is Title 21, Chapter 13 of US Code E. Changes in brain function that accompany the aging B. Established current schedules, registrations, agencies, process enforcement and penalties. C. There has been little change in laws since that time. D. Enforcement since inception has changed significantly. 2477. A 40-year-old patient with liver dysfunction is scheduled for an interventional surgical procedure. Lorazepam ( E. Described schedules of controlled drugs Ativan®) can be used for sedation in this patient without concern for excessive CNS depression because the drug A. 2473. A 29-year-old male uses secobarbital to satisfy his A selective anxiolytic like buspirone addiction to barbiturates. During the past week, he is B. Actively secreted in the renal proximal tubule imprisoned and is not able to obtain the drug. He is C. Conjugated extrahepatically brought to the prison medical ward because of the onset D. Eliminated via the lungs of severe anxiety, increased sensitivity to light, dizziness, E. Reversible by administration of naloxone and generalized tremors. On physical examination, he is hyperreflexic. Which of the following agents should he be 2478. Addiction is defined as: given to diminish his withdrawal symptoms? A. Physical dependence and the need to increase the drug A. Buspirone to obtain the same effect. B. Chloral hydrate B. A patient who needs the drug and has good control over C. Chlorpromazine personal behavior. D. Diazepam C. Psychological dependence on the use of controlled subE. Trazodone stances for their psychic effects and is characterized by compulsive use. 2474. What are the basic requirements for prescribing D. Slow but progressive deterioration of health in light of controlled substances? drug use. A. DEA Registration, state DEA registration (where reE. Loss of effectiveness of the drug to control pain. quired), state medical license allowing the provider to prescribe controlled substances, and a legitimate medical purpose within the usual course of profes- 2479. Alkalinization of the urine with sodium bicarbonate is useful in the treatment of poisoning with sional practice. A. Aspirin (acetylsalicylic acid) B. DEA Registration, state DEA registration (where reB. Amphetamine quired), and a state medical license allowing the proC. Morphine vider to prescribe controlled substances. D. Phencyclidine C. DEA Registration and a state medical license. E. Cocaine D. DEA Registration, a state medical license, and evidence showing that you have had 10 or more hours training ASIPP 482 Section 12 • Controlled Substance Management 2480. Which of the following statements regarding controlled took “too many pain pills”. During this time he becomes substances prescriptions is FALSE? extremely lethargic, with slow respirations. No other A. A controlled substances prescription must be dated as history is available. Your immediate action, in addition to of and signed on the day it is issued. O2 administration is to administer: B. A controlled substances prescription must contain the A. Naloxone full name and address of the patient. B. Diphenoxylate C. A physician who has given his or her staff at least eight C. N-acetyl-L-cysteine hours of training on the federal laws and regulations D. Prochlorperazine concerning controlled substances prescriptions has no E. Flumazenil liability for a controlled substance prescription completed by a staff member that does n 2486. The non-medical use of pain medication has been D. A controlled substances prescription must contain the followed since 1965. The largest growth of non-medical name of the drug, the strength of the drug, the dosage use of pain medication since this time has been between: form of the drug, quantity of drugs prescribed, and A. 1986 and 1990 directions for use. B. 1995 and 2000 E. A prescription for a Schedule III, IV, or V drug given for C. 2001 and 2002 the purpose of detoxification or maintenance treatD. 1965 and 1972 ment must include the unique identification number E. 1968 and 1971 issued by the Administrator of DEA in addition to the physician’s DEA number. 2487. An individual abruptly discontinuing long-term, high dose use of an opioid drug will likely experience which 2481. The second most common opioid of choice for one of the following conditions? intrathecal infusion following morphine is: A. Opioid-induced hyperalgesia A. Fentanyl B. Increased opioid mu receptor affinity B. Sufentanil C. Increased opioid tolerance C. Hydromorphone D. Loss of physical dependence and addiction D. Morphine E. Increased sympathetic nervous system activity E. Mepiridine 2488. A 16-year old patient has terminal cancer and has failed all treatment. Pain is worsening and he requires higher doses of opioid analgesics for pain relief. He inquires as to whether a research program may or may not help. One of the side effects with the new treatment is worsening of peripheral neuropathy. At this point, he refuses further treatment. His parents want you to talk to him and enroll him in the experimental protocol. Which of the following is your next course of action? A. Inform the patient that he can not refuse treatment B. Begin treatment if the parents provide written consent C. Respect the patient’s wishes and cancel plans for treatment 2483. What is the drug of choice to reverse the effect of D. Avoid further escalation in opioid doses. Diazepam® overdose E. Discuss the issues with the patient A. Naltrexone® B. Physostigmine® 2489. A substance abuser who decides to abstain checks in C. Pralidoxime® to a county detoxification facility and undergoes a 5 D. Flumazenil® day detoxification program. Assuming the abuser gets E. Naloxone® no further treatment or aftercare, his or her chance at 2482. A patient on methadone 90 mg daily, stable, with good relief now presents with a kidney stone. For the present problem : A. Continue at 90 mg of methadone daily B. Stop methadone C. Continue 90 mg of methadone, but add higher than normal doses of hydrocodone D. Continue 90 mg of methadone and add lower doses of hydrocodone E. Continue 90 mg of methadone and add usual doses of hydrocodone remaining sober is about: 2484. Once an opioid treatment is selected, titration A. < 5% upwards should continue until: B. 10% A. A ceiling is reached. C. 25% B. Addiction occurs D. 50% C. Tolerance occurs E. 90% D. A balance between analgesia and side effects is reached. E. Respiratory depression occurs 2490. Regarding the clinical use of antidepressant drugs, which one of the following statements is false. 2485. A 25-year-old male receiving hydrocodone and diazepam A. Patients should be advised not to abruptly discontinue presents with disorientation. He states that he had antidepressant medications. nausea, vomiting, abdominal pain and diarrhea since he B. In selecting an appropriate drug for treatment of de- ASIPP Section 12 • Controlled Substance Management 483 pression, the past history of patient response to spe- 2495. In severe tricyclic antidepressant overdose, it would cific drugs is a valuable guide NOT be of value to C. In the treatment of major depressive disorders, sertraA. Administer lidocaine (to control cardiac arrhythmias) line is usually more effective than fluoxetine B. Institute hemodialysis (to hasten drug elimination) D. MAO inhibitors are sometimes effective in depressions C. Administer bicarbonate and potassium chloride (to with attendant anxiety, phobic features, and hypocorrect acidosis and hypokalemia) chondriasis D. Provide intravenous diazepam (to control seizures) E. Weight loss often occurs in patients taking SSRIs E. Maintain the rhythm of the heart by electrical pacing 2491. In performing urine drug testing, a physician must know all of the following EXCEPT: 2496. What are some of the signs of abuse of controlled A. The characteristics of testing procedures, since many substances by your office workers and co-workers? drugs are not routinely detected by all UDTs. A. No extra time is spent near a drug supply B. Although no aberrant behavior is pathognomonic of B. Extreme reliability in keep appointments and meeting abuse or addiction, such behavior should never be deadlines ignored. C. Never volunteer for overtime C. Reliance on aberrant behavior to trigger a UDT will D. Only at work when scheduled miss more than 50% of those individuals using unpreE. Absenteeism, frequent disappearances or long unexscribed or illicit drugs. plained absences, making improbable excuses and D. Always prescribe “on-demand” for the patient until you taking frequent or long trips to the bathroom or to the are comfortable with the situation. stockroom where drugs are kept E. A history of drug abuse does not preclude treatment with a controlled substance, when indicated, but does 2497. All of the following statements about Food and Drug Act require a treatment plan with firmly defined boundarare correct, EXCEPT: ies. A. 1906 - Wiley Act was founded the F. D. A., and centered on foods and meat packing 2492. All of the following are signs of controlled substance in B. 1938 - Food, Drugs, and Cosmetics Act mandated prework place, EXCEPT: market approval of drugs A. Progressive deterioration in personal appearance and C. Marijuana Tax Act 1938 hygiene D. 1932 - Food, Drugs, and Cosmetics Act required proof B. Uncharacteristic deterioration of handwriting and safety charting E. 1906 - Wiley Act required concentration standards for C. Wearing long sleeves when inappropriate all medications D. Personality change - mood swings, anxiety, depression, lack of impulse control, suicidal thoughts or gestures E. Increased personal and professional activities Directions: Each question below contains four suggested responses of which one or more is correct. Select 2493. Drug interactions involving antidepressants do NOT A if 1, 2 and 3 are correct include B if 1 and 3 are correct A. Additive impairment of driving ability in patients takC if 2 and 4 are correct ing trazodone when ethanol is ingested D if 4 is correct B. Behavioral excitation and hypertension in patients takE if All (1, 2, 3 and 4) are correct ing MAO inhibitors with meperidine C. Elevated plasma levels of lithium if fluoxetine is administered D. Increased antihypertensive effects of methyldopa when 2498. If a patient who is on tramadol is given a CYP2D6 tricyclics are administered inhibitor, E. Prolongation of tricyclic drug half-life in patients with 1. The analgesia of tramadol will decrease cimetidine 2. The analgesia of tramadol will increased 3. The excretion of tramadol will decrease 2494. Consequences of undertreatment of pain may include all 4. The excretion of tramadol will increase of the following EXCEPT: A. Possible jail time B. Civil lawsuits C. Loss or restriction of prescribing abilities D. No effect of medical license E. Exclusion from Medicare/Medicaid 2499. Medications that should be avoided with grapefruit include: 1. Those with a low oral bioavailablity 2. Those metabolized by CYP3A4 3. Those with an intestinal transport by p-glycoprotein 4. Those metabolized by CYP2D6 ASIPP 484 2500. Incipient liver failure due to acetaminophen toxicity will most affect the metabolism of: 1. Lidocaine 2. Methadone 3. Codeine 4. Meperidine 2501. Which of the following is a true statement: 1. Tramadol’s first metabolite has less activity than the parent compound 2. Heroin is metabolized to morphine 3. Morphine’s metabolites increase in liver failure. 4. Hydrocodone is metabolized to hydromorphone. 2502. Significant drug-food interactions include: 1. Coffee and tea are more rapidly metabolized in the presence of ciprofloxin. 2. Phenobarbital is useful to treat folate deficiency neuropathy. 3. Smokers have a greater perceived effect of propoxyphene than non- smokers. 4. NSAIDS cause greater renal damage in patients with high dietary fat intake. 2503. As a pain physician, you are evaluating a new patient who recently moved to your area. Consistent with your usual office policy, all new patients get a urine drug test. The patient’s urine is positive for morphine, however his medication list shows no listing for any controlled substances.Which of the following are possible sources for this finding? 1. Morphine use 2. Heroin use 3. Poppy seeds 4. Codeine 2504. Drugs can be altered by: 1. Absorbsion 2. Distribution 3. Metabolism 4. Excretion 2505. A newly immigrated patient from Viet Nam with tuberculosis, neuropathy, and acid reflux disease is being prescribed methadone for pain following spine surgery to stabilize a fracture. The metabolism of methadone has been documented to be affected by: 1. Isoniazid 2. Carbamazepine 3. Cimetidine 4. Ethnicity 2506. Drug clearance from the plasma at a constant amount per unit time and the time for the plasma concentration of a drug to decrease by one-half, best represent which of the following drug properties? 1. Pharmacodynamic profile 2. Bioequivalence 3. Drug potency 4. Metabolism and excretion ASIPP Section 12 • Controlled Substance Management 2507. What are the guidelines of the Federation of State Medical Boards (FSMB), adapted by multiple State Medical Boards? 1. Opioids are used for a legitimate medical purpose 2. Opioids are used for documented abnormalities on MRI 3. Opioids are used in the course of professional practice 4. Opioids are used if another physician has previously written prescriptions for controlled substances for the patient 2508. The following statements are true regarding the paleospinothalamic tract: 1. The paleospinothalamic tract is poor in opioid receptors. 2. The paleospinothalamic tract connects the thalamus to the cortex. 3. The paleospinothalamic tract passes impulses from the 2nd order neurons to the C-fibers. 4. The paleospinothalamic tract connects the thalamus and the reticular activating system. 2509. When choosing an opioid, factors to be considered include: 1. Patient compliance 2. Dosing schedule of concurrent medications 3. Drug interactions 4. Opioid side effects 2510. If a patient has inadequate relief from an opioid, options include: 1. Increase the dose 2. Increase the frequency 3. Add a breakthrough medication 4. Change medications 2511. The following are true statements regarding morphine: 1. Morphine is primarily renally metabolized 2. Morphine is primarily renally excreted 3. Morphine is metabolized by CYP2D6 4. Morphine is metabolized by glucuronidation 2512. The choice of opioid medications is influenced by: 1. Frequency of pain 2. Response to prior opioids 3. Daily activity 4. Cost and insurance plan 2513. Choose the correct statements about codeine and morphine 1. Prescribed morphine cannot account for the presence of codeine. 2. Codeine metabolizes to morphine. 3. Codeine alone is possible due to a small proportion of patients who lack the cytochrome P450 2D6 enzyme necessary to convert codeine to morphine. 4. Morphine metabolizes to codeine Section 12 • Controlled Substance Management 2514. What are the pitfalls of opioid urine drug testing? 1. Tests for opiates are very responsive for morphine and codeine. 2. Urine drug tests do not distinguish between morphine and codeine. 3. UDT’s show a low sensitivity for semisynthetic/ synthetic opioids such as oxycodone. 4. A negative response excludes oxycodone and methadone use. 485 2. Shorter hospital stays. 3. Less total analgesic use. 4. A greater potential for subsequent opiate dependence 2521. What are Federation of State Medical Boards Guidelines for the Treatment of Pain? 1. Use of controlled substances, including opiates may be essential in the treatment of pain 2. Effective pain management is a part of quality medical practice 3. Patients with a history of substance abuse may require monitoring, consultation, referral and extra documentation 4. MD’s should not fear disciplinary action for legitimate medical purposes 2515. What are the correct statements of amphetamine in urine drug testing? 1. Tests for amphetamine/methamphetamine are highly cross-reactive. 2. Very predictive for amphetamine/methamphetamine use. 3. UDT will detect other sympathomimetic amines such 2522. Identify the components of the four cornerstones of as ephedrine and pseudoephedrine good clinical practice in chronic opioid prescribing. 4. Further testing is NOT required. 1. A specific diagnosis that is opioid responsive 2. Verify no evidence of drug abuse 2516. In order to qualify for a waiver under the Drug Abuse 3. Document improved function Treatment Act of 2000 to treat opioid addiction with 4. Manage side effects appropriately scheduled drugs, a physician must meet the following conditions: 1. Hold a current state medical license and valid DEA 2523. True statements with regards to properties of NMDA antagonists and therapeutic use and misuse are as number follows: 2. Hold an addiction certification from the American 1. Phencyclidine or PCP was developed as an intravenous Society of Addiction Medicine anesthetic. 3. Hold a subspecialty board certification in addiction 2. The unique anesthesia produced by phencyclidine was psychiatry from the American Board of Medical Speassociated with rapid emergence. cialties 3. MK-801 (dizocilpine) was developed as an anticonvul4. Complete at least 8 hours of training in the treatment sant and subsequently was used as a brain protective and management of opioid-addicted patients agent. 4. Dextromethorphan is a strong NMDA antagonist, even 2517. Dexmedetomidine and midazolam share the following when taken in very small amounts. pharmacologic properties: 1. Provide a continuum of sedation 2. Preserve respiratory function without potentiating 2524. Which of the following statements about alcohol absorption are valid? opioid-induced respiratory depression 1. Surgical removal of the pylorus allows more rapid 3. Clearance is decreased in hepatic disease absorption of alcohol 4. Selective alpha-2 adrenergic agonist activity 2. Most alcohol is absorbed through the gastric mucosa 3. Secretion of gastric mucus induced by high concentra2518. Epidemiologic risks for work-related low back pain tion of alcohol delays absorption include: 4. The longer the alcohol remains in the blood, the gre1. Prior WC claim taer the effect. 2. Perceived over-education 3. Cumulative compressive back forces 4. Peak hand forces 2525. Mixed opioid agonist-antagonists (nalbuphine, pentazocin) have limited use in cancer patients because: 1. Respiratory depression is a common side effect 2519. Physical dependence is a term defined as: 2. Mixed interaction at the opioid receptor can precipi1. The presence of withdrawal symptoms with abrupt tate withdrawal symptoms. discontinuation of drug. 3. Pruritus is a common side effect. 2. Is synonymous with addiction 4. Effectiveness is limited by a dose-related ceiling effect. 3. Reveals abrupt withdrawal symptoms when antagonist is administered 4. Does not respond to a tapering dose, and requires 2526. In the management of alcohol withdrawal delirium, the clinician may wish to use all of the following : detoxification 1. Chlordiazepoxide 2. Magnesium sulfate 2520. True statements concerning patient controlled analgesia 3. Thiamine include the following: 4. Intravenous glucose 1. Better patient satisfaction with pain control. ASIPP 486 2527. Which of the following include subjective reports of marijuana effects? 1. Increased sexual desire 2. Increased appetite 3. Enhanced tactile sensitivity 4. Increased motivation Section 12 • Controlled Substance Management 2534. The CSA requires the following of practitioners who dispense ONLY manufacturer’s samples of controlled substances to patients. 1. An initial, and then biennial, inventories. 2. A secure locked box for storage of controlled substances. 3. As separate dispensing log, in addition to any records kept in the patients’ charts. 4. Complete records of all controlled substances received, dispensed, or otherwise disposed of. 2528. True statements about heroin are as follows: 1. The chemical name is diacetyl morphine 2. Heroin is more water soluble but less potent than morphine 2535. What are the correct statements about UDT of cocaine? 3. Heroin is metabolized in humans by de-acetylation to 1. Tests for cocaine react principally with cocaine and its 6-mono-acetylmorhpine and morphine primary metabolite, benzoylecgonine. 4. Heroin is classified as Schedule II drug and is widely 2. Tests for cocaine are non-specific in predicting cocaine available for therapeutic purposes in the United use. States. 3. Tests for cocaine have low cross-reactivity with other substances 2529. What is the prevalence of co-existing diseases in drug 4. Cold medicines may test false-positive for cocaine dependence? 1. Alcohol dependence (63%) 2536. Mechanisms of drug interactions include: 2. Any psychiatric disorder (74%) 1. Drug-drug interactions 3. Antisocial personality disorder (44%) 2. Drug allergies 4. Major depression (25%) 3. Drug-food interactions 4. Drug doses 2530. Which of the following statements are true with regards to the Controlled Substances Act of the Comprehensive 2537. “Joe the Doper” is one of your patients. You are Drug Abuse Prevention and Control Act of 1970 ? prescribing oxycodone for a legitimate medical purpose, 1. It is the legal foundation of the government’s fight and his pain is well controlled. Joe had a routine urine against the abuse of drugs and other substances. drug test as part of a federal job interview and the screen 2. It is a consolidation of numerous laws regulating the reported opiates as “none detected”Joe “found religion” manufacture and distribution of narcotics, stimulants, during his last incarceration in jail for cutting the heads depressants, hallucinogens, anabolic steroids and off parking meters and swears that he has been taking the chemicals used in the illicit production of controlled meds and not selling them on the street. Correct options substances. at this time include: 3. All the substances that are regulated under existing 1. Increase his dose of oxycodone and recheck his urine federal law are placed into I of V schedules. 2. Make a note in the chart that you really believe him and 4. Schedule I is reserved for the least dangerous drugs that continue the oxycodone have the highest recognized medical use. 3. Change his pain medication to a fentanyl patch 4. Order GC/MS specifically for oxycodone 2531. A 34-year-old recently married man seeks help from a methadone clinic. Chose all of the true statements 2538. The following MAY legally be prescribed by a physician meeting criteria for acceptance into the program: without a special registration or permission from DEA: 1. He has AIDS 1. Methadone 2. He has no legal charges pending 2. Buprenorphine 3. He has used heroin for 2 years 3. Injectible C-II morphine 4. He has been married to a heroin addict 4. Heroin 2532. Choose all side effects of clonidine (Catapres): 1. Drowsiness 2. Hypotension 3. Dizziness 4. Dry mouth 2539. When changing a patient’s controlled substance medications, a physician may desire a patient to bring in all unused supplies of discontinued controlled substances. Which of the following is true? 1. The physician may refuse to prescribe additional controlled substances until the patient destroys (in a veri2533. If a patient is a “slow metabolizer”, possible responses to fied manner) or surrenders all unused meds. medications might include: 2. Because they are the legal property of the patient, the 1. Increased toxicity physician can do nothing about the patient’s previ2. Decreased effect ously prescribed and dispensed medications. 3. Increased effect 3. The physician may observe the patient destroy the 4. Decreased excretion medications by flushing them down the toilet, unless ASIPP Section 12 • Controlled Substance Management 487 such disposal is prohibited by state law. 2546. Analgesic agents capable of producing tolerance, 4. The physician may take possession of unused medicadependence and withdrawal include: tions, inventory them, and send them to the DEA. 1. Codeine 2. Propoxyphene (Darvon) 2540. Urine screening of patients should be able to detect each 3. Buprenorphine of the following: 4. Pentazocine (Talwin) 1. Cocaine 2. Morphine 3. Alcohol 2547. What is the explanation of a routine urine drug test 4. Barbiturates in a patient receiving codeine with acetaminophen 240 mg/day testing positive for codeine and negative for 2541. The CSA requires the following of practitioners who morphine? administer controlled substances via any modality to 1. The laboratory made a mistake patients directly, before or during procedures in the 2. The morphine was metabolized faster than the codeine office or surgical suite, from physician-owned stock or and was therefore excreted earlier supplies: 3. The morphine was “neutralized” by the specific carrier 1. An initial, and then biennial, inventories agent in the Codeine with acetaminophen 2. A secure locked box for storage of controlled sub4. The patient is one of a small number who lack cystances tochrome P450 2D6 and cannot convert codeine to 3. As separate dispensing log, in addition to any records morphine kept in the patients’ charts. 4. Complete records of all controlled substances received, dispensed, or otherwise disposed of. 2548. Examples of pro-drugs include: 1. Gabapentin 2. Morphine 2542. An intervention on a chemically dependent individual 3. Baclofen should include all of the following: 4. Codeine 1. A clear message 2. Caring for the patient 3. Planning 2549. When a state has different rules than the CSA: 4. Presence of persons important to the patient 1. Federal constitutional supremacy principles dictate that the CSA overrules all state regulations relating to 2543. What are some of the communication issues faced by controlled substances. health care providers in terminal patients? 2. The issue is decided on a case-by-case basis, by the 1. Diagnosis and prognosis courts. 2. Advanced directives and do-not-resuscitate(DNR) 3. State rules govern, as the states traditionally regulate orders medicine and pharmacy. 3. Spiritual needs 4. Whichever rule is more restrictive must be followed, as 4. Symptom Management both have full legal force and effect. 2544. What are the identified problems of screening 2550. Choose the accurate statement(s) below regarding tools of drug abuse? the Drug Enforcement Administration’s proposed rule 1. Developed in psychiatric field allowing issuance of multiple prescriptions for Schedule 2. Rely on subjective reporting of the patients II controlled substances: 3. Not designed to detect prescription opioid abuse 1. A prescription for a Schedule II controlled substance 4. Designed to detect cocaine use cannot be refilled. 2. The physician must write instructions on each prescription (other than the first prescription, if the 2545. What are true statements about painful crises in sicklephysician intends for that prescription to be filled cell disease: immediately) indicating the earliest date on which a 1. The pain is rarely severe. pharmacy may fill the prescription 2. Abdominal crises are frequent. 3. The physician must conclude that providing the pa3. Joint crises are frequent, accompanied by swelling and tient with multiple prescriptions in this manner does discoloration of the affected joint. not create an undue risk of diversion or abuse 4. Analgesics may frequently have to be administered in 4. Multiple prescriptions may be issued authorizing a greater than standard doses due to the development patient to receive a total of up to a 120-day supply of a of tolerance. Schedule II controlled substance. ASIPP 488 Section 12 • Controlled Substance Management 2551. What are the correct statements about urine drug testing 2555. Which of the following are true regarding opioid(UDT)? induced constipation in a patient with cancer pain? 1. A UDT would be positive if the patient took the drug 1. Impaired defecation reflex (true positive) and negative if the drug was not taken 2. Increased colonic motility (true negative). 3. Reduced colonic peristaltic activity 2. Sensitivity of a test is the ability to identify a particular 4. Bulk laxatives most helpful drug. 3. False-positive or False-negative results can occur, so it 2556. What are the clinical recommendations in chronic is imperative to interpret the UDT results carefully. opioid therapy? 4. Specificity is the ability to detect a class of drugs. 1. Daily doses above 180 mg/day of morphine have not been validated 2552. The following statements are accurate for addiction and 2. Dose escalation beyond the stabilization phase may dependence. predict a problem 1. Based on the Controlled Substances Act, the term 3. Opioid rotation may be helpful “addict” means any individual who habitually uses 4. Drug formulation does not influence tolerance any narcotic drug so as to endanger the public health and safety. 2557. What precautions must a physician take in interpretation 2. Based on DSM-IV definition, addiction means malof urine drug testing? adaptive pattern leading to distress or impairment. 1. Consult with laboratory regarding ANY unexpected 3. DSM-IV definition of substance dependence includes results. tolerance, withdrawal, and continued use despite 2. Never use results to strengthen physician-patient relaproblems. tionship and support positive behavior change. 4. Federation of State Medical Board guidelines for the 3. Schedule an appointment to discuss abnormal/ treatment of pain recommend use of controlled subunexpected results with the patient; discuss in a stances in patients with history of substance with no positive, supportive fashion to enhance readiness to additional monitoring, referral, or documentation. change/motivational enhancement therapy (MET) opportunities. 2553. True statements regarding the five schedules of 4. It is not necessary to document results and interpretacontrolled substances, known as Schedules I, II, III, IV, tion and V include all the following: 1. The Schedule I substances have high potential for abuse and the substance has no currently accepted 2558. If a patient is unable to tolerate oxycodone because of medical use in the treatment in the United States. nausea, the likely opioids to be tolerated would be: 2. The Schedule I substances may be changed to a lower 1. Fentanyl schedule if the safety of the drug is demonstrated even 2. Propoxyphene though there is a high potential for abuse and there is 3. Methadone no accepted medical use for medical treatment. 4. Morphine 3. The Schedule II drugs have high potential for abuse and may lead to severe psychological or physical de- 2559. What is the suggested protocol of Ballantyne and Mao pendence. published in New England Journal of Medicine? 4. Schedule V drugs or substances have a high potential 1. Ensure benefit will out weigh risk for abuse and may lead to physical or psychological 2. Evaluate possible addiction and problems with poor dependence. functioning 3. Watch deterioration in function related to lack of mo2554. The following is an accurate statement with regards to tivation to improve function of Controlled Substances Act. 4. Once opioids are started no further monitoring is 1. It creates a closed system of distribution for those aurequired thorized to handle controlled substances. 2. The cornerstone of this system is the licensure of all those authorized by the State Medical Licensure Board 2560. Pain physicians must consider the following in chronic to handle controlled substances. long-term opioid therapy: 3. Only the individuals and practices which dispense di1. Prolonged, high dose therapy may have adverse conrectly to the patients from their clinics are required to sequences maintain a DEA license. 2. The opioid formulation does not reduce development 4. It is required to maintain complete inventory of conof tolerance trolled substances, only if the drugs are administered 3. Abuse potential of long acting and short acting formuby physician, but not if dispensed to the patient. lations are the same 4. Long term opioids produce adverse physiologic changes (immune, hormonal, pain, etc) ASIPP Section 12 • Controlled Substance Management 2561. What are the requirements of continued controlled substance prescribing? 1. Reduction in pain 2. Improvement in functional status 3. Lack of evidence of drug abuse 4. Lack of unmanageable side effects 2562. Which of the following are true about lorazepam: 1. Has a serum half-life of approximately 12 hours 2. Exhibits linear kinetics 3. Is almost completely converted to benzoylecgonine 4. Is frequently used an anti-anxiety agent 489 to the analgesic effects of the maintenance dose of methadone. 2. During opioid maintenance treatment, a cross-tolerance develops to all opioid agonist drugs. 3. The usual maintenance dose of opioid maintenance does not provide any analgesia, and adequate analgesia will require higher doses of opioid agonists given more frequently than in the non-tolerant patient. 4. The usual maintenance dose provides significant analgesia, thus, no opioid agonists are required to provide analgesia for the acute pain. 2568. Which of the following statements about alcohol withdrawal delirium are correct except ? 1. May be precipitated by surgery 2. Withdrawal seizures are most common 24 hours after withdrawal 3. Delirium tremens has peak incidence four days after withdrawal 2564. Which of the following statements about alcoholics are 4. Does not occur while still drinking correct? 1. Suicidal behavior is common after personal loss 2569. When a patient has been taking heavy doses of 2. High incidence of alcohol abuse is patients who combarbiturates for an extended period, early symptoms of mit suicide withdrawal are likely to include: 3. Alcohol tends to worsen depression 1. Weakness 4. Alcoholics who threaten suicide usually do not kill 2. Insomnia themselves 3. Anxiety 4. Tremulousness 2565. Which of the following is a red flag that prosecutors look for when deciding whether to prosecute a case involving 2570. In treatment opioid overdose, which of the following is inappropriate prescribing? effective? 1. A physician issued prescriptions knowing that the pa1. Methadone tient was delivering the drugs to others. 2. L-alpha-acetylmethadol (LAAM) 2. The physician prescribed controlled drugs at intervals 3. Buprenorphine inconsistent with legitimate medical treatment. 4. Naloxone 3. The physician involved used street slang rather than medical terminology for the drugs prescribed. 2571. Physicians should not fear regulatory action from 4. There was no logical relationship between the drugs the Board for ordering, prescribing, dispensing or prescribed and treatment of the condition allegedly administering controlled substances, including opioid existing analgesicsChoose correct statements described in model policy for the use of controlled substances for the 2566. Substance dependence is best characterized by which of treatment of pain by Federation of State Medical Boards: the following statements? 1. For a legitimate medical purpose 1. Substance use is discontinued once there is insight 2. For documented abnormalities/pathology on M.R.I. about the physical or psychological harm that is likely Scan to have been caused or exacerbated by the substance 3. In the course of professional practice use 4. If another physician has previously written prescrip2. Important social, occupational or recreational activitions for controlled substances for the patient ties are decreased because of the use of substances. 3. Symptoms may be due to another general medical 2572. Choose the accurate statement(s) below regarding condition. the purposes for which a prescription for controlled 4. Tolerance and withdrawal are associated with it. substance can be issued: 1. A prescription for a controlled substance must be 2567. A patient presents to you with injury of ankle strain. issued for a legitimate medical purpose in the usual The ankle is swollen and extremely painful. However, course of a physician’s practice. there was no fracture. The patient is also on opioid 2. A prescription for a controlled substance may be issued maintenance treatment with methadone of 120 mg daily. to a physician so that he or she can dispense the drugs True statements with regards to his pain management to patients as medically necessary. including the following: 3. Prescriptions for Schedule III, IV, and V drugs are per1. Opioid maintenance patients develop full tolerance mitted for purposes of detoxification or maintenance 2563. Strategies to reduce aberrant drug behaviors include: 1. Random urine drug screens 2. Narcotic contracts 3. No early refills 4. Opioid rotation ASIPP 490 Section 12 • Controlled Substance Management treatment if the drug is specifically approved by the 2579. Analgesia of six hours or longer in duration can be obtained with all the following drugs: Food and Drug Administration (FDA) for those uses 1. Levo Dromoran and the prescribing physician meets the leg 2. MS Contin 4. Prescriptions for Schedule II drugs for detoxification 3. Methadone or maintenance treatment are permitted. 4. Oxycodone 2573. The transdermal route of fentanyl administration has been used in cancer patients because it offers the 2580. Choose the correct statements about cocaine testing. 1. A patient’s urine may test positive for the cocaine following advantages: metabolite benzoylecgonine after a procedure with 1. Convenience of dosing. cocaine as a topical anesthetic for up to 3 to 4 weeks. 2. Rapid absorption through the skin allows quick titra2. Cocaine, a topical anesthetic, is clinically used in certion. tain trauma, dental, ophthalmoscopic, and otolaryn3. Highly potent opioid for analgesic efficacy. gologic procedures. 4. Low cost. 3. There is structural similarity between other topical anesthetics that end in “caine” (eg, Novocaine, lidocaine) 2574. Methadone blood levels are: and cocaine or benzoylecgonine. 1. Increased by cimetidine 4. A positive UDT result for the cocaine metabolite, in 2. Decreased by butabutal the absence of a medical explanation, should be inter3. Increased by Ciprofloxin preted as due to deliberate use. 4. Decreased by grapefruit juice 2581. What are the reasons for drug testing in patients in your practice? 1. To assess if the patient is taking the medications prescribed 2. To assess if the patient is taking substances/drugs NOT prescribed 3. To assess if the patient is taking licit and illicit drugs 2576. In accordance with the Federal Controlled Substances 4. To assess if the prescribed drugs caused diabetes Act of 1970, which of the following applies towards regulating the use of narcotic drugs for opioid detoxification or maintenance? 1. Practitioner is separately registered with the DEA as a 2582. Drug testing may be performed by any of the following 1. Hair samples narcotic treatment program 2. Saliva testing 2. Practitioner may dispense or prescribe a controlled 3. Serum drug testing drug in schedules III, IV, or V to a narcotic dependent 4. Urine drug screening individual for addiction treatment 3. Practitioner in solo practice will not treat more than 30 patients at any one time with scheduled drugs for 2583. Controlled substance abuse in work place may be detoxification or maintenance identified by the following signs? 4. A narcotic drug can not be dispensed for a period in 1. Work performance alternating between periods of high excess of 180 days for the purposes of detoxification and low productivity and mistakes made due to inattention, poor judgment and bad decisions. 2577. What are the true statements about early history of 2. Confusion, memory loss, and difficulty concentrating Opium? or recalling details and instructions. Ordinary tasks 1. Arabia - (600-900 A. D.) used medicinally. When the require greater effort and consume more time Koran forbade alcohol, Opium and Hashish became 3. Interpersonal relations with colleagues, staff and pathe primary social drugs. tients suffer. 2. Galen - 100 A. D. - ‘great cure-all’ 4. Promptly admits errors or accepts blame for errors or 3. Greece - mixed with wine 100 B. C. oversights 4. Eber’s Papyrus, 1500 B. C. - pain relief 2575. Medical Records should include which of the following: 1. Treatment objectives 2. Instructions and agreements 3. Periodic reviews 4. Financial contracts 2578. What are correct statements of Food and Drug Act 2584. True statements about methadone include the following: Amendments? 1. It is useful as an analgesic 1. Durham-Humphrey 1951 - make OTCs require pre2. It has greater oral efficacy than morphine scriptions. 3. It produces a milder but more protracted withdrawal 2. Boggs Act (1951) syndrome than that associated with morphine 3. Narcotic Control Act (1956) 4. Adverse reactions may include constipation, respira4. Drug Abuse Control Acts of 1956 and 1958 labeled tory depression, and light headedness ‘potential drugs of abuse’ and gave power to DEA precursors to regulate. ASIPP Section 12 • Controlled Substance Management 2585. The following statements are true: 1. All opiates are opioids 2. All opioids are opiates 3. All opioids are narcotics 4. All narcotics are opioids 2586. During cocaine withdrawal, which of the following symptoms can be anticipated? 1. Cardiac arrhythmias 2. Desire for sleep, often with insomnia 3. Delirium 4. Depression 2587. After chronic amphetamine use, abrupt withdrawal is likely to cause which of the following symptoms? 1. Seizures 2. Delirium 3. Formication 4. Sleep disturbance 491 2592. What are the correct statements of Harrison Narcotics Tax Act of 1914? 1. Required physicians to register and keep records of prescribed medications. 2. Created Bureau of Narcotics of Treasury Department (and Federally run Heroin Clinics for addicts). 3. 3,000 physician arrests during 1920s. 4. By 1930 “addict pattern” was male, minority, criminal. But much smaller (?20,000). 2593. What are the steps to avoiding trouble with misuse of controlled substances? 1. Know your state laws and regulations 2. Know your Medical Licensure Board’s guidelines on prescribing controlled substances 3. DEA statement about your state on its website 4. Follow the rules of advocacy groups and organization supporting unrestricted use of controlled substances 2588. Regarding the metabolism of opioids: 1. Some opioids are metabolized by glucuronidation 2. Some opioids are metabolized by the P450 enzyme system 3. M6G is an analgesic metabolite of morphine 4. M3G is an analgesic metabolite of morphine 2594. Which of the following are true regarding nociceptive pain? 1. Alpha 2 antagonists are useful for management. 2. Automatic firing of damaged nerves is a component. 3. Deafferentation can produce a firing of first order neurons. 4. Prostaglandin inhibition may be useful for management. 2589. Patient complains of low back pain, headaches, and depression, She is taking Lortab (hydrocodone) 10/500 six per day, Fioricet (butalbital) six per day, and Paxil (paroxetine) 20mg per day. She complains of inadequate pain relief. Appropriate medication management would include: 1. Counsel patient on the amount of acetaminophen, and change her to lower acetaminophen products 2. Start methadone 10mg six per day 3. Change her antidepressant to a super-selective serotonin reuptake inhibitor 4. Change the butalbital to a triptan 2595. Which of the following is true about state medical regulation: 1. Investigation of physicians is generally the result of complaints received 2. State Boards may obtain copies of patient records without patient consent, upon written request, under HIPAA. 3. State regulations generally prohibit any medical act which is an unreasonable danger to the health, safety or welfare of patient or public. 4. A physician has a right to hire a lawyer at any stage of a medical board investigation or proceeding. 2590. Effects on the respiratory system by opioids include: 1. Equipotent doses of opioids result in equal amounts of respiratory depression 2. Depression of cough is a different mechanism than respiratory depression 3. There is a direct respiratory depression effect on the medulla 4. Respiratory rate decreases decrease first and then CO2 and hypoxia response decreases. 2591. What are the correct statements of urine drug testing? 1. Thin-layer chromatography (TLC) is a relatively old technique, testing the migration of a drug on a plate or film, which is compared to a known control 2. Gas chromatography (CGMS) is most sensitive and specific test, most reliable, and labor intensive/costly 3. Enzyme immunoassay is easy to perform/highly sensitive, more sensitive than TLC, and less expensive than GC/MS 4. Rapid drug screens are not similar to other enzyme immunoassay testsand may be more expensive 2596. A state could, if it chose to do so, do which of the following: 1. Make ordinary negligence in treatment a basis for professional discipline, even without any requirement of intent. 2. Require random periodic audits of physician’s practices, including patient health care records, to ensure quality of care. 3. Generally outlaw any practice which is not accepted by the majority of physicians in the relevant specialty. 4. Authorize state medical boards to impose very short jail terms (less than 30 days). 2597. The ultimate decisions regarding the specific medical treatment to be rendered to a patient in a specific situation are made by: 1. The physician 2. The courts 3. The state legislature 4. The patient ASIPP 492 Section 12 • Controlled Substance Management 2598. What is the level of care - necessary to achieve and maintain abstinence from opioids? 1. Medically managed inpatient treatment 2. Intensive outpatient program 3. Residential treatment program 4. Medically managed phone consultations 2599. What are the perceived barriers to non-opioid management? 1. The opioid model words well from a business standpoint 2. Easy to assemble a multidisciplinary team 3. “Rebound pain” phenomenon after detoxification 4. Multidisciplinary model works well from a business standpoint “legitimate medical reasons”. 2604. What are the correct statements about controlled substance abuse? 1. Almost half a ton of prescription narcotics reached six counties in Eastern Kentucky from 1998-2001, equating to .75 pound for every adult in those counties. 2. On a per capita basis, Eastern Kentucky drugstores, hospitals, and legal outlets receive more prescription painkillers than anywhere else in the United States. 3. Nationally, emergency room visits for hydrocodone overdoses increased 500 percent from 1990-2000 4. OxyContin sells on the street for about $10/pill; Lortab sell for $2/pill and Lorcet for $1/pill 2600. All of the following statements are correct about detoxification EXCEPT: 1. In one year post completion outcome data all patients still had some pain - most had much less 2. In one year post completion outcome data 70% had achieve continuous sobriety 3. In one year post completion outcome data pain was not ever worse without narcotics than it was while taking narcotics 4. In one year post completion outcome data only 20% had continued sobriety 2605. The Drug Abuse Treatment Act of 2000 allows for which of the following for detoxification treatment? 1. The use of schedule III drugs to detoxify chemically dependent patients in an office setting 2. The use of opioids in a substance abuser for legitimate medical reasons to provide analgesia 3. The use of opioids for detoxification in a nonabuser, who is opioid dependent from legitimate pain therapy and desires to discontinue opioid use 4. Practitioners may administer, dispense, or prescribe a controlled drug from any schedule to a narcotic dependent individual for addiction treatment 2601. Choose the correct statement about state board rules physicians do not know: 1. Cannot Rx Schedule II or III for family members 2. Can provide samples of unscheduled drugs for family, but MUST document in a medical record 3. Cannot Rx to anyone (including friends) if you have not documented their H&P and have a current chart on file. 4. Can Rx for yourself 2606. Which of the following statements about U.S. enlisted men who became addicted to opioids in Vietnam are correct? 1. Nearly 90% did not become addicted again within three years of return to the United States 2. Relapse more common in older white soldiers 3. Higher relapse rate in sons of alcoholic parents 4. About 75% of soldiers who used heroin five or more times became drug dependent 2602. Controlled substance is considered a national epidemic in U.S. What are correct statements showing grim national statistics? 1. Opioid abuse increased 85% from 1994-2000 2. Oxycodone abuse increased 166% since 1994 3. Hydrocodone abuse increased 116% since 1994 4. Methadone abuse increased 140% since 1994 2607. Factitious disorders consist of the following: 1. Physical or psychiatric symptoms that are intentionally produced to assume a sick role 2. External incentives are present 3. Most severe form of Münchhausen Syndrome 4. Intentional symptoms with obvious goal 2603. Choose the correct statements describing opioids in patients with substance abuse? 1. Federal Guidelines allow for use of opioids for analgesia in persons with substance abuse disorder for “legitimate medical reasons”. 2. No clear documentation of the pain problem is needed to demonstrate the physician without proper credentials is not attempting to detoxify an opiate abuser. 3. State regulations in certain states do no allow for prescription of opioids in patients with substance abuse and consider prescribing opioids in known substance abusers malprescribing. 4. Federal Guidelines do not allow for use of opioids for analgesia in persons with substance abuse disorder for ASIPP 2608. Which of the following statements best describes a characteristic of the antimigraine agent ergotamine? 1. It promotes vasodilatation 2. It is useful in reducing premature contractions of the uterus 3. It acts as a serotonin (5HT)-receptor antagonist 4. It acts as an alpha-adrenoceptor agonist 2609. Which of the following adverse effects if associated with the use of Neuroleptic agents ? 1. Acute dystonia 2. Gynecomastia 3. Sedation 4. Loss of libido 493 Section 12 • Controlled Substance Management 2610. Which of the following statements about biotransformation are true ? 1. Biotransformation often produces metabolites with less affinity for receptors than the parent drug 2. Biotransformation often produces metabolites with a higher renal clearance than the parent drug 3. Biotransformation often entails multiple enzyme-catalyzed reactions 4. Biotransformation reactions often occur in the liver 2611. What are common side effects leading to discontinuation of opioids? 1. Constipation 2. Nausea 3. Somnolence 4. Hyperactivity 2612. Which of the following sedative medications have analgesic properties: 1. Midazolam® 2. Ketamine® 3. Propofol® 4. Dexmedetomidine® 2613. What are the risks of malprescribing? 1. Legal charges, probably jail time 2. Conviction rate is currently almost 30% 3. Felony conviction will likely prevent or at least severely limit future practice 4. Duped and Dated are highly viable defenses 2614. Mixed opioid agonist-antagonists (nalbuphine, pentazocine) have limited use in cancer patients because: 1. Respiratory depression is a common side effect 2. Interaction at the opioid receptor can precipitate withdrawal symptoms. 3. Pruritus is a common side effect. 4. Effectiveness is limited by a dose-related ceiling effect. 2615. Evidence based medicine was developed in response to public need. What are the accurate statements? 1. Patients and payers call for more accountability 2. Changing patient-physician relationship with financial focus is positive 3. Concern about increasing costs 4. Clinicians (and patients) are good at decision making 2616. Which of the following may cause constipation in the cancer patient? 1. Chronic opioid use for pain. 2. Iron supplementation for anemia. 3. Antacids containing Ca and Al. 4. Drugs with anticholinergic effects. 2617. A COX 2 selective agent may be preferred in the following: 1. History of GI bleed or complicated ulcer 2. Anticoagulant use 3. Oral corticosteroid use 4. Age < 60 2618. The scope of the problem of prescription opioids among physicians is as follows: 1. Up to 20% of prescribed opioids are diverted. 2. 567 physician arrests and sanctions in 2002. 3. No more federal diversion program for malprescribing physicians. 4. State boards may not take any actions. 2619. Goals of pharmacotherapy in opioid addiction include the following: 1. Prevention or reduction of withdrawal symptoms 2. Prevention or reduction of drug craving 3. Restoration to or toward normalcy of any physiologic function disrupted by chronic drug use. 4. To provide addictive drugs to prevent relapse 2620. What are substance induced disorders? 1. Delirium-intoxication or withdrawal 2. Dementia 3. Amnestic disorders 4. Psychotic disorders 2621. Prescriptions for pain relief are receiving special attention by the Drug Enforcement Agency and the Office of Inspector General due to . . . 1. The significant increase in the types of pain prescriptions available today. 2. The significant increase in the number of pain medications prescribed today. 3. Evidence of doctor shopping by persons who obtain pain prescriptions from doctors either for their own abusive use or for illegal resale to others. 4. A lessening of illegal drug trafficking. 2622. If urine tampering is suspected, the following should be included in urine drug testing (UDT) 1. Temperature 2. Creatinine 3. PH 4. Color 2623. What are the true statements about marijuana urine drug testing (UDT)? 1. UDTs provide reasonable reliability 2. Marinol tests positive 3. Protonix may test false-positive 4. Marijuana may be positive 2 years after use. 2624. The “Whizzinator” is which of the following: 1. An electromechanical device for stirring alcoholic drinks 2. A urologic testing device to measure the force of urine flow 3. A suction device for maintaining an erection 4. A commercially available device to thwart urine drug testing ASIPP 494 Section 12 • Controlled Substance Management 2625. The pain management physician is challenged to find 2631. A prominent pain physician in North Carolina is treating non-traditional approaches for pain management. Ms. Lavonia Gotrocks from Indiana. Traveling to see this Effective treatments to be considered in a multimodality physician greatly interferes with her social calendar, and approach include she does not wish to make the trips more than every 1. Myofascial relief and musculoskeletal treatment stratethree months. She is currently taking sustained release gies. oxycodone and hydromorphone.The physician writes her 2. Psychological drug therapy. prescriptions on September 1, and then writes additional 3. Chiropractic care. prescriptions for the same medications and indicates that 4. Naturopathic medicine. they should be filled on October1, and November1. Her next appointment in the office is December 1.Which of 2626. The action of Tramadol is considered: the following responses would include the following 1. A centrally acting synthetic opioid analgesic. 1. This is correctly called “alternate dating” and not cov2. Associated with mu-opioid receptor activity. ered by the “No Refill” rule 3. Inhibition of reuptake of norepinephrine and sero2. Is a recurring tactic among physicians who seek to tonin. avoid detection when dispensing controlled substanc4. Tramadol induced analgesia is totally reversed by es for unlawful (nonmedical) purposes naloxone. 3. Is legal if done for no more than 3 months total (3 prescriptions) 2627. The Federation of State Medical Boards (FSMB) 4. Is tantamount to writing a prescription authorizing encourage practitioners to include the following in the refills of a schedule II controlled substance medical record : 1. Medical history 2. Pain history 2632. What are D.E.A considered “certain recurring 3. Working diagnosis concomitance of condemned behavior” in physician 4. History of allergies to opioids conviction? 1. The physician involved used street slang rather than 2628. Identify the “federal five” drugs or drug classes that must medical terminology for the drugs prescribed be tested for in federal employees and federally regulated 2. The physician warned the patient to fill prescriptions at industries? different drug stores 1. Marijuana 3. There was no logical relationship between the drugs 2. Cocaine prescribed and treatment of the condition allegedly 3. Amphetamine/Methamphetamine existing 4. Methadone 4. The physician issued prescriptions to a patient known to be delivering the drugs to others 2629. Urine Drug Testing (UDT) may be useful in which of the following situations? 2633. An opiate overdose patient may present with all of the 1. To determine if a patient is taking the controlled subfollowing: stances prescribed 1. Increase in respiratory rate 2. To determine the patient’s state of hydration in an ef2. Small pupils fort to regulate the dosage of medication 3. Hypertension 3. To determine if the patient is taking medications and 4. Coma substances which are not prescribed by the physician administering the test 4. To determine the half-life of the drugs prescribed 2634. Based on systematic reviews, what are the correct statements about opioids? 2630. If a physician is aware that a patient is a drug addict or 1. Morphine and oxycodone are not equal has resold prescription narcotics, which of the following 2. Morphine 20 mg/day and oxycodone 30 mg/day are is correct according to the “Interim Policy” equally ineffective . 1. It is merely recommended that the physician engage in 3. Improved functional status was conclusive additional monitoring of the patient’s use of narcotics 4. Opioids did not improve depression 2. The physician, as a D.E.A. registrant, has a responsibility to exercise a much greater degree of oversight to prevent diversion 2635. What are the characteristics of a drug dependent (addict) 3. Should prescribe controlled substances for intervals of practitioner? 1-2 weeks only with frequent urine drug screens 1. Starts by taking controlled drug samples 4. May not dispense controlled substances with the 2. Never asks staff to pick up medications in their names knowledge they will be used to support addiction or 3. Calls in scripts in names of family members or fictibe resold tious patients and picks them up himself 4. Never uses another doctor’s DEA number ASIPP Section 12 • Controlled Substance Management 495 2636. What are the true statements of drug abuse in the United 2642. DSM-IV definition of substance dependence includes some of the following items as part of at least 3 in 12 States? months. 1. In lifetime, 46% of persons aged 12 and older used 1. Larger amounts/longer periods drugs 2. Patient spends large amount of time using/obtaining 2. In past month, 8.3% of persons aged 12 and older used controlled substances drugs 3. Activities given up: social/work/recreation 3. In past year, 14.9% of persons aged 12 and older used 4. Continued use despite problems drugs 4. Prescription opioids are not abused 2643. What are the clinical implications of non-responsiveness to opioids in chronic pain? Choose the correct 2637. Which of the following statements about statements. biotransformation reactions are true? 1. Difficult to distinguish pharmacologic tolerance from 1. They may introduce an active center for further conopioid-induced abnormal pain sensitivity jugations 2. Treating increasing pain with increasing doses may be 2. They almost always yield water-soluble metabolites futile 3. They are often important in activating pro-drugs 3. High dose therapy may have adverse consequences 4. They are all inducible upon repeated drug administra4. Push the dose to highest level or combine 2 opioids tion 2638. Which one of the following results may occur from 2644. What are the advantages of prolonged, high-dose opioid therapy? repeated administration of a drug? 1. No evidence to support high dose therapy (>200 to 300 1. Increased metabolism of the drug mg/day or more) 2. Increased metabolism of other drugs 2. Opioid doses should not be limited in the name of 3. Induction of cytochrome P-450 or glucuronyl transimproving efficacy and safety ferase 3. Anecdotal evidence that pain relief not better 4. Increased metabolism of endogenous compounds 4. There is solid evidence that 3600 mg of oxycodone per day is effective in neuropathic pain 2639. What is the definition of addiction as per the Controlled Substances Act? 1. The term “addict” means any individual who habitu- 2645. What were the physician opioids of choice in 2002? 1. Hydrocodone 40% ally uses any narcotic drug so as to endanger the public 2. Oxycodone 25% morals, health, safety, or welfare 3. Ultram 70% 2. “Addict” is a patient who is taking as per prescription 4. Dilaudid 25% very high opioids in cancer pain 3. Any individual who is so far addicted to the use of narcotic drugs as to have lost the power of self-control 2646. Symptoms of opioid toxicity include which of the with reference to his addiction. following? 4. “Addict” is a patient taking controlled prescription 1. Leg muscle twitching drugs 2. Pulmonary edema 3. Seizures 2640. Definitions of addiction include the following: 4. Hypothermia 1. A primary, chronic neurobiologic disease with genetic, psychosocial and environmental factors effecting its course and presentation 2. Characterized by either impaired control of drug use 2647. What were the physician opioids of choice in the 1990s? 1. Oxycodone 20% or other symptoms 2. Hydrocodone 70% 3. Addiction involves loss of control, craving, compulsive 3. Dilaudid 20% use, and continued use despite consequences 4. Fentanyl class 10% 4. DSM-IV definition defines addiction to involve impaired control of drug use 2648. A hypertensive crisis is most likely to result from the 2641. Morphine is used therapeutically action of drugs from which one of the following drug 1. To suppress the withdrawal syndrome associated with classes: the chronic use of alcohol 1. Tricyclic antidepressants 2. To induce miosis 2. Barbiturates 3. To treat severe constipation 3. Opioids 4. To relieve pain associated with a heart attack 4. Monoamine oxidase (MAO) inhibitors ASIPP 496 2649. Which of the following effects if produced by tricyclic antidepressant drugs? 1. Increase in the antihypertensive effect of guanethidine 2. Hypertensive crisis 3. Increased absorption of an oral dose of levodopa 4. Precipitation of narrow-angle glaucoma 2650. Which of the following effects is associated with benzodiazepines? 1. Paradoxical excitement 2. Ataxia 3. Sedation 4. Amnesia 2651. Which of the following effects is produced by morphine? 1. Relief of dyspnea accompanying pulmonary edema 2. Decreased sensitivity of the respiratory center to carbon dioxide 3. Miosis that can be blocked by atropine 4. Vasodilation of cerebral blood vessels 2652. Which of the following drugs will increase blood levels of oxycodone? 1. Fluoxetine (Prozac®) 2. Sertraline (Zoloft®) 3. Paroxetine (Paxil®) 4. Carbamazepine (Tegretol®) Section 12 • Controlled Substance Management 2. Only aware of a few treatments or medications 3. Prescribes for friends or family without a patient record 4. Well aware of controlled drug categories 2658. The most significant increase in prescriptive medication for illicit use is: 1. THC (tetrahydrocannabinol) 2. Cocaine 3. Benzodiazepines 4. Pain relievers 2659. What are the pitfalls of prescription practices? 1. 4 D’s - Deficient, Duped, Deliberate, Dependent Practitioner 2. Never say “NO” - Family, Friends, Patients 3. Ignore complaints 4. Focus on positive aspects of regulations and reimbursement 2660. Which of the following statements concerning barbiturate is true? 1. Barbiturates can increase bleeding time when administered to patient taking anticoagulants 2. Patients tolerant to the therapeutic actions of barbiturates are also tolerant to the analgesic effect of morphine 3. Barbiturates are used to prevent withdrawal symptoms 2653. DSM-IV definition of substance abuse includes at least associated with heroin dependence one of the following in 12 months: 4. Barbiturates are contraindicated in patients with acute 1. Maladaptive pattern leading to distress or impairment intermittent porphyria 2. Recurrent failure to fill role 3. Recurrent physically hazardous behavior 2661. What are the risks of malprescribing related to practice 4. Recurrent legal problems management? 1. Loss of “Provider Status” 2654. Which of the following have been identified as algogenic 2. Insurers frequently report to Boards substances? 3. Plans may remove providers for “overprescribing” 1. Serotonin 4. Insurers are unable to report any type of national data2. Leukotrienes bank for malprescribing 3. Acetylcholine 4. Histamine 2662. Symptoms of withdrawal from opioids include the following symptoms and signs: 2655. Opioids recommended for lactating patients include 1. Sweating 1. Morphine 2. Restlessness 2. Hydromorphone 3. Irritability 3. Hydrocodone 4. Hot/cold flashes 4. Meperidine 2663. What were the physician drugs of abuse in 2001? 2656. Identify accurate statements of open label studies of 1. Opioids 30% opioids 2. Alcohol 20% to 30% 1. Less then 50% of patients were continued on opioids 3. Benzodiazepines 20% at 2yeras 4. Marijuana 2% 2. Most of patients experiences at least one adverse event 3. No firm conclusions were made about tolerance and 2664. A 16-year-old boy is brought for emergency evaluation addiction after taking some of his mother’s medication in order to 4. Results were made applicable to general public get “high.” He is flushed and his pupils are dilated and only poorly reactive. He complains of dry mouth. He 2657. What are the correct statements about a deficient (dated is restless, confused at times, and may be having visual practitioner)? hallucinations. Which of the following medications is he 1. Too busy to keep up with CME likely to have taken? ASIPP 497 Section 12 • Controlled Substance Management 1. 2. 3. 4. Phenelzine Disulfiram Alprazolam Benztropine 3. Increased blood pressure 4. Diarrhea 2671. In the management of detoxified substance-abusing patients in a therapeutic community, poor prognosis is more likely with: 2665. Chose the correct statements about use of opium in 1. Coexisting severe psychopathology Europe and America: 2. Dropout before three months 1. Paracelsus 1500 called laudanum (opium, cloves, and 3. Continued alcohol use alcohol) the “stone of immortality”. 4. Adjunctive use of antidepressants 2. Thomas Sydenham brought to England about 1700. 3. 1831 Sertuener given Nobel Prize for isolating indi2672. Withdrawal convulsions are likely to occur in patients vidual opiates. who have used chronically which of the following drugs? 4. 1853 - hypodermic syringe invented. The American 1. Secobarbital Civil War and Prussian Wars of 1860-1870 led to wide2. Desipramine spread morphine injection. 3. Lorazepam 4. Phencyclidine 2666. What are the historical aspects of opiate abuse? 1. “Soldier’s Disease” - morphine addiction - reported during American Civil War and Prussian Wars of 2673. A 42 year old physician who suffers from ankylosing spondylosis is referred for pain management. After 2 1860-1870. months of treatment with long-acting opioids he feels 2. 10% of U. S. population used laudanum nonmediciso much better that he plans to return to work as an nally. emergency room physician. Which of the following 3. Widespread laudanum and opiate abuse in U. S. in late would be appropriate actions: 1800s. Sears carried syringe kits in catalogs. Estimated 1. Recommend he have neuropsychologic testing to doc500,000 - 1,000,000 addicted in U. S. ument good mental function while taking opioids. 4. Heroin introduced in 1898 as “non-addicting” mor2. Write a statement that he is capable of returning to the phine. practice of emergency medicine at this time. 3. Insist the physician inform his employer and the hos2667. True statements regarding the Controlled Substances pital of the medications he takes as a requirement to Act in determining the control or removal from schedules continue treatment. of substances include the following: 4. Inform him that legally he cannot return to practicing 1. Drugs actual or relative potential for abuse. medicine while taking opioids. 2. Scientific evidence of its pharmacological effect, if known. 2674. A significant minority of persons with substance abuse 3. Any risks to the public health disorder have and atypical course and will eventually 4. Guarantee by the manufacturer that it will be provided either stop using or be able to return to controlled use. at affordable price to public. Which of the following factors are associated with being able to stop or control use? 2668. When a person taking a medication or abusing a drug 1. Stable premorbid personality develops tolerance, which of the following statements are 2. Developing medical complications of substance abuse valid? 3. Age greater than 40 1. The same dosage of the drug has reduced effect 4. Arrest and incarceration 2. Tolerance develops uniformly to all effects of the drug 3. Physical dependence tends to develop in parallel with 2675. What are the characteristics of simple chronic pain? tolerance 1. Pain lasting longer than 6 months. 4. Withdrawal symptoms are less likely after tolerance 2. Tend to have no more distress or psychopathology than has developed what is expected in the general population. 3. Tend to continue working. 2669. Which of the following statements are correct about 4. Tend to maintain meaningful relationships heroin abuse? 1. The peak incidence is age 25 to 35 2676. Choose the statements reflecting prescription drug use 2. It affects men three times as often as women for non-medical purposes. 3. The majority of heroin abusers are involved in main1. Overall, it is believed that 10% of prescription drugs tenance programs are used for non-medial purposes. 4. Most heroin abusers eventually stop on their own 2. Controlled prescription drugs for non-medical purposes have been reported to be used over 6 million 2670. Symptoms of heroin withdrawal include all of the people over the age of 12 years in the United States. following : 3. Prescription drug abuse and illicit drug abuse may be 1. Twitching movements in the legs significantly higher in chronic pain patients than in 2. Dilated pupils ASIPP 498 Section 12 • Controlled Substance Management normal population. 4. Marijuana use is only second to cocaine. 3. Prescription opiate abuse increases in late 1990s (?or increased awareness?) 4. Heroin resurgence begins late 1880’s. 2677. An otherwise healthy 45 year old patient taking 100 mg of morphine per day for pain associated with rheumatoid 2683. Drugs able to diminish the dose of opioids analgesics arthritis has decided to stop his pain medication 3 days required to relieve pain include the following: prior to seeing you in the office. Which of the following 1. Amphetamines symptoms indicate severe withdrawal that probably 2. Tricyclic antidepressants requires treatment: 3. Non-steroidal anti-inflammatory agents 1. Fever 4. Acetaminophen (Tylenol) 2. Headache 3. Hypertension 2684. Identify reasons for a standard order for Meperidine 75 4. Rhinorrhea mg every four hours to be inappropriate? 1. Effective analgesia lasts only 2.5 to 3 hours. 2678. A patient with esophageal cancer has been taking 2. If a person is also receiving a monoamine oxidase inhydrocodone 10mg 2 TID by mouth with good relief. hibitor, severe toxicity can occur. However, he is admitted to the hospital with esophagitis 3. That dose is equivalent only to 5 to 7.5 mg of morphine. from radiation and is not able to tolerate any medications 4. In the presence of impaired renal function toxicity may by mouth. Options for pain management include: occur. 1. 1 mg/hr morphine IV continuously 2. 50 mg meperidine IM every 6 hours 2685. What are true statements about non-opiate drugs of 3. 0.5mg hydromorphone IV every 4 hours abuse? 4. 25 mcg/hr Fentanyl transdermally 1. Coca products began widespread use in 1880s in patent medicines and ‘soft drinks’. Endorsed by the Surgeon 2679. Those that drink alcohol on a regular basis are General in 1886. recognized to have increased risk when mixed with 2. Amphetamines 1920s, used by military, physicians, controlled substances, particularly sedatives, opioids and widespread public use in 30s. benzodiazepines. Which is true of those that consume 3. Barbiturates and amphetamines began widespread use alcohol, and placed at risk in this population? in 1940s, originally as OTC medications and in patent 1. 120 million Americans use alcohol regularly. medications. 2. 20% of the American population consider themselves 4. Hallucinogens popularized in 1960s. Declined by late alcohol users. 1970s. 3. 16.1 million are heavy, or regular drinkers. 4. 1% of Americans have participated in a binge drinking 2686. Intravenous heroin use causes or is associated with all of episode one month prior to the survey. the following: 1. Affective disorder 2. Liver disease 2680. In obtaining a history during the evaluation of a new 3. Endocarditis patient, which of the following would be considered risk 4. Gall bladder disease factors for possible substance abuse? 1. History of substance abuse in a brother and father. 2687. Upon abrupt discontinuation of L-alpha-acetyl2. History of psychiatric problems in the mother methadol (LAAM) in a tolerant patient, one may observe: 3. History of bipolar illness in the patient 1. Decreased respiratory response to increased carbon 4. Age over 40 years old dioxide. 2. Withdrawal symptoms, which may not appear for up to 3 days. 2681. According to the ASAM, APS, AAPM consensus statement 3. Vomiting, diarrhea, hypertension, skeletal muscular on the use of opioids for the treatment of chronic pain, twitching as severe signs. which of the following characterize addiction? 4. Few symptoms until 72 hours have passed. 1. Impaired control over drug use 2. Continued use despite harm 2688. Highly tolerant opioid users, maintained on their drug 3. Craving in a research setting, will: 4. Compulsive drug use 1. Continue to feel a “rush” when their drug of choice is administered intravenously. 2682. Choose the correct statement of U.S. opiate abuse 2. Continue to use their drug of choice for reasons other patterns: than fear of experiencing withdrawal. 1. Change from morphine to heroin in 50s-60s. Dramatic 3. Continue to experience pleasurable effects from food, increase in numbers 60s-70s. sex, tobacco and other non-opiate drugs. 2. Reduction in opiate abuse during 80s and early 90s 4. Will not use any other drug for medical or recreational (?cocaine effect?) purposes ASIPP Section 12 • Controlled Substance Management 499 2689. The accurate statements about prescription drug abuse 4. Heavy chronic use can lower serum testosterone levels for non-medical purposes include the following: in men 1. Prescription drug abuse, particularly of opioid pain killers, has increased at an alarming rate over the last 2695. Chronic alcoholism is associated with: ten years. 1. Retrobulbar optic neuropathy 2. Non-medical use of narcotic pain relievers, tranquil2. Caudate calcification izers, stimulants, and sedatives ranks second (behind 3. Cerebellar anterior lobe degeneration marijuana) as a category of illicit drug abuse among 4. Acoustic neuroma adults and youth. 3. In 2003, 6.3 million Americans were current abusers 2696. 30 mg of Morphine Sulphate orally is equivalent to: of prescription drugs, with 4.7 million using pain 1. 10mg MSO4 IV relievers. 2. 20mg of oral oxycodone 4. E.R. visits for Benzodiazepine abuse in 2002 were 3. 1.5mg hydromorphone IV 100,000 and for 0pioid abuse in 2002 were 119,000 4. 20mg methadone 2690. Which of the following are principles of medical ethics? 1. Justice 2. Beneficence 3. Autonomy 4. Non-negligence 2697. Delirium is an acute confusional state that results from diffuse organic brain dysfunction. In the cancer patient, the causes include: 1. Opioid toxicity 2. Dehydration 3. Hypoxia 2691. A 29-year old patient whom you had been treating 4. Brain metastases for postlaminectomy syndrome with only time release morphine, 120 mg per day, had a urine drug screen 2698. As per the Controlled Substances Act, a denial, positive for cocaine and benzodiazepines. When this revocation, or suspension of registration may be carried was discussed with the patient, he admitted getting out based on the following grounds. medications from a number of physicians and to 1. The physician has failed to inform change of his office injecting cocaine intravenously, but refused evaluation address. by an addictionologist and was dismissed from your 2. Has been convicted of a felony. practice. 3 days later an emergency room physician calls 3. The physician has reached an agreement with the State because the patient has been admitted following his first Medical Board of Licensure. ever grand mal seizure. Which of the following are likely 4. Has had his state license or registration suspended, causes of the seizure? revoked, or denied. 1. Cocaine overdose 2. Opiate withdrawal 2699. No Schedule II prescription drug may be dispensed 3. Benzodiazepine withdrawal without a written prescription, unless: 4. Cocaine withdrawal 1. A physician calls in a refill. 2. It is dispensed directly by the physician to the ultimate 2692. Which of the following is NOT true regarding penalties user. for an unlawful intentional or knowing distribution or 3. The drug is dispensed to another physician. dispensation of controlled substances? 4. There is an emergency situation which is defined by 1. As little as a one-year sentence may be imposed. regulation; in that case, an oral prescription may be 2. A life sentence may be imposed. allowed. 3. Supervised release will be imposed and will last from 1-5 years. 2700. For purposes of ordering a Schedule II emergency 4. The court has the power to suspend a sentence or grant oral prescription, an emergency situation exists if the probation or parole, no matter what the facts of the prescribing physician determines . . .: case are. 1. That immediate administration of the controlled substance is necessary for proper treatment of the 2693. Sequelae of an acute cocaine overdose include intended ultimate user. 1. Myocardial ischemia and high output cardiac failure 2. That no appropriate alternative treatment is available, 2. Seizure activity including administration of a drug which is not a con3. Tremulousness and hyperthermia trolled substance under schedule II. 4. Blockade of inhibition of epinephrine 3. That it is not reasonably possible for the prescribing physician to provide a written prescription to be pre2694. The characteristics of marijuana include: sented to the person dispensing the substance, prior to 1. It may lower intraocular pressure the dispensing. 2. A sign of acute intoxication is reddening of conjunc4. That the patient complains of extreme and unremittiva ting pain. 3. It has antiemetic properties ASIPP 500 Section 12 • Controlled Substance Management 2701. Identify the suggested requirements to be included in 2706. Findings of illicit drug use based on insurance in an agreement, if the patient is at high risk for medication interventional pain management setting was: abuse or has a history of substance abuse: 1. Third party - 17% 1. Reasons for which drug therapy may be discontinued 2. Medicare with/without third party - 10% (e.g., violation of agreement) 3. Medicare/Medicaid - 24% 2. Requirement for medical interview with members of 4. Medicaid - 39% immediate family 3. Urine/serum medication levels screening when re- 2707. All of the following are symptoms of alcohol withdrawal quested : 4. Periodic reports from a local law enforcement agency 1. Coarse tremor of hands or tongue 2. Generalized tonic-clonic seizures 2702. A fax will serve as the original prescription for a Schedule 3. Tachycardia, sweating, dilated pupils II narcotic substance . . .: 4. Abducent nerve paresis or paralysis 1. That is to be compounded for direct administration to the patient by parenteral, IV, intramuscular injection, 2708. An opioid treatment program must provide which of the subcutaneous or intraspinal infusion. following? 2. For a resident of a long-term care facility. 1. Drug abuse testing services 3. For a patient enrolled in a hospice program licensed 2. Vocational services by the state or certified and/or paid for by Medicare, 3. Educational services if the prescription notes that the patient is a hospice 4. Medical services patient. 4. For any terminally ill patient. 2709. Somatoform disorders include the following: 1. Physical symptoms suggestive but not fully explained 2703. Which of the following is true with respect to a partial by a general medical disorder filling of a Schedule II prescription? 2. Includes: somatization disorder 1. If the remaining portion of the prescription is not or 3. Includes: conversion disorder cannot be filled within 72 hours of the partial filling, 4. Includes: major depression the pharmacist must notify the prescribing physician. 2. A partial filling is allowed for a terminally ill patient, 2710. All states that have guidelines, laws, and/or regulations and the prescribing physician has the sole responsigoverning the use of controlled substances to treat pain bility to make sure the controlled substance is for a set, as a minimum standard, that the physician should ask terminally ill patient. the patient whether he/she has 3. A partial filling is allowed for a terminally ill patient, 1. Ever used prescribed controlled drugs before. and the prescribing physician and the pharmacist both 2. Ever been to a pain doctor before. have the responsibility to make sure the controlled 3. A history of chemical/substance abuse, including alcosubstance is for a terminally ill patient. hol, illicit, and licit drugs. 4. A partial filling is allowed for a terminally ill patient, 4. Had any tests related to his/her pain condition. and the pharmacist has the sole responsibility to make sure the controlled substance is for a terminally ill 2711. What is the impact of psychological factors in treatment patient. of pain with a comorbid substance use disorder? 1. Impedes diagnosis and complicates interventions 2704. Partial filling of a prescription for a controlled substance 2. Pain can mask addiction - switch to legal drugs listed in Schedule III, IV, or V is permissible, if: 3. Promotes regression and may induce hyperalgesia and 1. Each partial filling is recorded in the same manner as extreme tolerance a filling. 4. Positive impact as psychotherapeutic drugs provide 2. The total quantity dispensed in all partial fillings does excellent analgesia not exceed the total quantity prescribed. 3. No dispensing occurs after six months after the date on 2712. What are the Methadone interactions? which the prescription was issued. 1. Cimetidine will increase methadone levels 4. The prescribing practitioner authorizes the partial fill2. Butalbital will decrease methadone levels ing in writing. 3. Ciprofloxin will increase methadone levels 4. Phenytoin will decrease methadone levels 2705. Cocaine abuse is likely to produce symptoms similar to which of the following? 1. Major depression 2. Obsessive compulsive disorder 3. Generalized anxiety disorder 4. Paranoid schizophrenia ASIPP Section 12 • Controlled Substance Management 501 2713. A former drug addict is admitted to the psychiatric ward 2716. Drug testing may be performed by utilizing any of the following technique(s): with depression secondary to chronic back pain. He has 1. Urine drug screening been taking tramadol 6 tablets per day. He was started on 2. Hair samples paroxetine and you were consulted for pain management. 3. Saliva testing He complains that the tramadol is not working, and he is 4. Specific drug analysis of blood noted to become more agitated. Your assessment is: 1. He is drug seeking 2717. After starting a hospital patient on a morphine PCA, you 2. He is withdrawing from illicit medications get a call from the nurse that the patient’s face is itching. 3. His depression is making his pain worse You tell the nurse that: 4. He is on the inappropriate antidepressant 1. This is an allergic reaction, and to stop the medicine 2. This is a histamine release and will likely go away 2714. True statements regarding the Controlled Substances 3. The chart should be marked “allergic to all opioids” Act (CSA) include which of the following? 4. Changing the PCA to hydromorphone will likely stop 1. Methadone is a DEA Schedule II controlled substance the itching that is indicated for the relief of severe pain and detoxification or maintenance of narcotic addiction. 2. A prescription may not be issued for the dispensing 2718. “Opioid rotation” 1. May work because of variable affinity for the µ recepof methadone for detoxification treatment or maintetor nance treatment 2. May work because of differing opioid metabolic path3. To use Schedule II opiates for detoxification from opiways ate addiction, a special registration is required. 3. May work because of avoidance of metabolite antago4. Drug Abuse Treatment Act of 2000 allows physicians nists to use Schedule III agents to detoxify chemical depen4. May work because of differing drug interactions dent patients in an office setting, provided the physician qualifies for and obtains a waiver issued through 2719. Opioids exert their action by: DEA. 1. Inhibiting the release of substance P 2. Activating G proteins 2715. What are the true statements describing history of 3. Inhibiting adenylate cyclase spread of opium? 4. Activating dopaminergic neurons 1. Arabic traders spread use and cultivation to China by 900 A. D. 2. 1644 China outlawed tobacco, opium smoking became 2720. What are the requirements according to the FSMB Policy Guidelines, to prescribe controlled substances within the endemic course of professional practice? 3. 1700 British East India company smuggled opium 1. A physician-patient relationship from India to China for tea (China refused legitimate 2. Diagnosis and documentation of unrelieved pain trade). 3. Compliance with applicable state or federal law 4. 1839 - Because of “rampant addiction” Chinese em4. Urine drug testing (UDT) at least every six months peror destroyed 45,000 pounds of British opium in Canton, beginning the Opium war. ASIPP Answers 2310. Answer: A Explanation: 75% of illicit drug users were employed full or part time, with American Indian and Alaskan natives at about 12% of the population of abuse of illicit drug users. Blacks and whites were essentially equal, with Asians lowest. Source: Hans C. Hansen, MD 2311. Answer: C Source: Renee R. Lamm, MD, Sep 2005 2312. Answer: C Explanation: Cytochrome P-450 catalyzes demethylation, not methylation or conjugation, reactions. The enzyme is located in the endoplasmic reticulum, not in mitochondria. Drugs can induce cytochrome P-450 activity. 2313. Answer: B Reference: Miscellaneous accepted standards of care; the Federation of State Medical Boards’ Model Policy for the Use of Controlled Substances for the Treatment of Pain (May 2004); and www.deadiversion.usdoj.gov; various Intractable Pain Treatment Acts from states like California, Tennessee, and Texas. Explanation: A. This is not the best answer because a provider has a responsibility to minimize the potential for abuse and diversion of controlled substances (DEA Interim Policy Statement, Nov. 16, 2004). If the patient is not known to you and you do not have reliable paperwork from which to make an informed judgment about the patient’s history of prior pain treatments, including the use of medications reported, then you should be very cautious about prescribing medication. Several states have policy statements cautioning physicians to “control the drug supply.” B. This is the best answer. The fact pattern shows that you have agreed to see this patient and establish a physicianpatient relationship. For this reason, you must balance your ethical duty to prevent the patient from experiencing acute withdrawal symptoms with your legal/regulatory obligation to minimize the potential for abuse and diversion of controlled substances. Do what you can to verify the patient’s self-report. Use an appropriate form of urine or serum screen, especially if the patient has a history of substance abuse (him/herself or through a first-degree family relative). Control the initial supply of controlled substances to this patient. C. This is not the best answer. You should attempt to verify the patient’s self-report of recent pain treatments and medications and perform an appropriate urine screen. However, you should also control the drug supply and this answer omits that statement and fails to acknowledge the ethical duty to prevent or minimize the patient’s acute withdrawal from controlled substances. D. This is not the best answer. If you simply accept the patient’s self-report and continue to treat him/her without verifying the patient’s past pain treatments and use of controlled substances, you are likely violating one of your state’s regulations/rules or guidelines/policies/position statements on the use of controlled substances for the treatment of pain. More importantly, you are likely ignoring accepted standards of care and may place yourself in a position of prescribing controlled substances outside the usual course of professional practice. E. This may appear to be the best answer and it might be if you had not agreed to see the patient on a referral basis. In other words, if someone simply drops into your practice on a Friday afternoon claiming they want you to treat their pain and that their prior physician recommended you, then you are right to be very cautious about taking this patient without having the appropriate referral material. If you elect to send a patient back to his/her referring provider (or if they show up at your office on a self-referral) make sure you contact the referring provider and/or caution the patient to go to the emergency room if they believe they are undergoing acute withdrawal symptoms. No answer is easy in this situation and your best bet is to document your medical record carefully and ensure you document your clinical rational for saying “no,” including any aspect of the patient’s (1) medical history, (2) behaviors, (3) physical findings, and (4) lab screen or test results. Source: Jennifer Bolen, JD, Sep 2005 2314. Answer: D Explanation: Reference: The Federation of State Medical Boards’ Model Policy for the Use of Controlled Substances for the Treatment of Pain, (May 2004); Bolen, J Pain Medicine News (Informed Consent). Explanation: A. This is not the best answer. A narcotic contract (typically called a Controlled Substances Treatment Agreement) usually contains boundaries for use with high risk patients. Most often, boundary language includes the use of urine screens, one physician and one pharmacy for obtaining controlled substances, a specific term for periodic review, and a discussion of the consequences should the patient fail to abide by the agreement. B. This is not the best answer. A History and Physical Evaluation form is not used to explain the risks and benefits of using controlled substances to treat pain. Rather, the H&P form is designed to gather information about the patient’s medical history and treatment past, so the provider can decide on a course of treatment. Once the provider and the patient agree upon a treatment plan, the provider should engage in informed consent with the patient. C. This is not the best answer. A pain scale and periodic evaluation form are used to follow the patient after treatment begins. D. This is the best answer. An Informed Consent form is different from a Narcotic Contract or Treatment Agreement, because it helps the practitioner establish the proper interaction between him/her and the patient concerning the risks, benefits, treatment alternatives, and special issues regarding the use of controlled substances to treat pain. When a practitioner uses an Informed Consent, he/she is minimizing legal exposure for negligence associated with the use of controlled substances to treat pain. Of course, it is up to the practitioner to follow accepted current clinical care standards, which include a proper informed consent process. E. This is not the best answer. Rarely, if ever, does a letter from the patient’s health care benefit plan contain language relating to informed consent. Source: Jennifer Bolen, JD, Sep 2005 2315. Answer: C Explanation: Reference: 21 C.F.R. § 1307.21 (Disposal of Controlled Substances). returned more medication than what you wrote down in the medical record. The federal law states in § 1307.21(a) “[a]ny person in possession of any controlled substance and desiring or required to dispose of such substance may request assistance from the Special Agent in Charge of the Administration in the area in which the person is located for authority and instructions to dispose of such substance. The request should be made as follows: (1) If the person is a registrant, he/she shall list the controlled substance or substances which he/she desires to dispose of on DEA Form 41, and submit three copies of that form to the Special Agent in Charge in his/her area. Remember, your state guidelines, laws, and regulations may be stricter and prohibit certain actions or require more from you in this area. B. This is not the correct answer. Except in very limited circumstances which are outside the scope of this question pattern, the law prohibits the reintroduction of controlled substances in this manner. C. This is the best answer. Check with your state licensing board and/or state bureau of narcotics to determine whether you can dispose of these controlled substances at your office and, if the board says it is appropriate to do so, have the patient inventory the controlled substances returned, write down the amount on a return form, sign the return form, use a witness to sign the return form, and then have the patient witnessed as he/she flushes the returned substances down the toilet. Alternatively, but only if your state allows this option, you may follow the guidance of 21 C.F.R. § 1307.21, when disposing of controlled substances. D. This is not the best answer. While flushing returned drugs down the toilet may seem like an easy option, some states actually prohibit this action. See the answers to A and C above for complete guidance. E. This is not the best answer. While 21 C.F.R. § 1307.21 permits a registrant to contact the Special Agent in Charge of the nearest DEA office, your state may require you to do something else. Thus, answer C is the best answer and you should check with your state licensing board and/or state bureau of narcotics for guidance on how to dispose of controlled substances returned by patients. In all cases, you should document the medical record accurately and completely. Explanation: Source: Jennifer Bolen, JD, Sep 2005 A. This is not the best answer. You must understand the federal law in this area and then check to see if you state requires more of you when it comes to disposing of controlled substances. If you wait until after the patient leaves your office to record the disposal or destruction of the returned controlled substances, you may be in violation of state licensing board regulations/rules or guidelines, policy, or position statements, or the controlled substances act. Further, the patient may try to argue that he/she 2316. Answer: D 2317. Answer: E Source: Renee R. Lamm, MD, Sep 2005 2318. Answer: B Explanation: Reference: Hardman, pp 632-633. 504 Section 12 • Controlled Substance Management Hepatic necrosis can occur with overdosage of Cholinomimetic agents may be used to overcome acetaminophen. The hepatic toxicity is the result of the symptoms that persist. biotransformation of acetaminophen to NSource: Stern - 2004 acetylbenzoquinoneimine, which reacts with hepatic proteins and glutathione. This metabolite depletes glutathione, stores and produces necrosis. The 2323. Answer: D administration of N-acetyl-L-cysteine restores hepatic Explanation: concentrations of glutathione and reduces the potential Fluoxetine is a highly selective serotonin reuptake hepatotoxicity. Sulindac is biotransformed to sulindac inhibitor (SSRI) acting on the 5-HT transporter. It forms sulfide, the active form of the drug. Both sulindac and its an active metabolite that is effective for several days. metabolites are excreted in the urine and in the feces. Selective serotonin reuptake inhibitors are inhibitors of Indomethacin undergoes a demethylation reaction and an cytochrome P450 isoenzymes, which is the basis of N-deacylation reaction. The parent compound and its potential drug interactions metabolites are mainly excerted in the urine. Procainamide is converted to an active metabolite by an acetylation 2324. Answer: B reaction. The product that is formed is NExplanation: acetylprocainamide (NAPA). In addition, procainamide is Reference: Katzung, p 482. hydrolyzed by amidases. An N-acetylation reaction occurs Haloperidol, a butyrophenone is by far the most likely also in the biotransformation of isoniazid. In the liver, the antipsychotic to produce extrapyramidal toxicities. enzyme N-acetyltransferase converts isoniazid to Other agents, such as piperazine (an aromatic acetylisoniazid. phenothiazine), thiothixene ( a thioxanthene), and Source: Stern - 2004 pimozide ( a diphenylbutyropiperidine) are comparatively less likely to produce extrapyramidal toxicity than haloperidol. 2319. Answer: B The antagonism of dopamine in the nigrostriatal system Explanation: might explain the Parkinson-like effects. Reference: Katzung, pp 493-494. Both haloperidol and pimozide act mainly on D2 A decrease in thyroid function occurs in most patients on receptors, whereas thioridazine and piperazine act on lithium. This effect is usually reversible or not alpha-adrenergic receptors, and have a less potent but progressive, but a few patients develop symptoms of definite effect on D2 receptors. hypothyroidism. Source: Stern - 2004 A serum thyroid-stimulating hormone (TSH) concentration is recommended every 6 to 12 months. 2325. Answer: D “Browning” of vision, clinically described as pigmentary Explanation: retinopathy, occurs with thioridazine. This is due to retinal The W.H.O. ladder emphasizes Step One: Non-Opioid, deposition of the drug. Step Two: Opioid for Mild to Moderate Pain, and Step Although neurologic adverse effects (e.g., tremor, Three: Opioids for Moderate to Severe Pain. The ladder is choreoathetosis, motor hyperactivity, ataxia, dysarthria, just that. It increases potency and adjunctive medication and aphasia) can occur with lithium, it does not cause the to treat pain, and is highly effective, well-validated, neuroleptic malignant syndrome associated with antisuggesting 90% of cancer patients receiving relief. 75% of psychotic agents. terminally ill patients also report relief. Pseudodepression sometimes occurs in patients on antiSource: Hans C. Hansen, MD psychotics. This may be related to drug-induced akinesia. Source: Stern - 2004 2320. Answer: D Source: Hansen HC, Board Review 2004 2321. Answer: D Source: Hansen HC, Board Review 2004 2322. Answer: A Explanation: Reference: Katzung, pp 471, 473, 482. The phenothiazines as a class are the most potent anticholinergics of the neuroleptics. Tolerance to their anticholinergic effects occur in most patients. ASIPP 2326. Answer: A Explanation: Pseudotolerance is an increase in dosage that is not due to tolerance, but to other factors such as disease progression, new disease, increased physical activity, lack of compliance, change of medication, or drug interaction. It may be a sign of addiction, more importantly defined as a drug that has lost its effectiveness at a fixed dosage. Pseudotolerance should be contrasted to pseudoaddiction. In contrast, of those that believe “pseudoaddiction” is actually a real entity, pseudoaddiction is drug seeking behavior that appears similar to addiction, but is due to unrelieved pain. Haddox, et al. suggested this term in the literature, and it seems to have stuck. Actually pseudoaddiction is an unsophisticated term that is not scientifically relevant. 505 Section 12 • Controlled Substance Management The concept of pseudoaddiction is better defined by real terminology that would be considered a component of tolerance. Plausible scientific explanations of tolerance offered in the literature suggests that mechanisms involving cAMP and protein kinase pathways, with up regulated cellular pathways are important mediators of tolerance. Receptor modulation is also considered a potential mechanism, involving sodium and potassium channels, and, in some instances, endocytosis of opioid receptors. Source: Hans C. Hansen, MD 2327. Answer: D Explanation: There is no specific ceiling dose for pure opioid agonists, though we are becoming aware of the potential for hyperalgia from at least morphine metabolites. Combination drugs are limited by the APAP or NSAID content. Use long acting for baseline pain, and short acting opioids for “breakthrough” pain. Agonist-antagonists have very little role in chronic pain management in general, and specifically will trigger withdrawal when used as breakthrough meds for other agonists. Source: Andrea M. Trescot, MD 2328. Answer: B Explanation: Receptor affinity for the drug will determine the number of drug-receptor complexes formed. Efficacy is the ability of the drug to activate the receptor after binding has occurred. Therapeutic index (TI) is related to safety of the drug. Half-life and secretion are properties of elimination and do not influence formation of drug-receptor complexes. Source: Laxmaiah Manchikanti, MD 2329. Answer: E Explanation: Ref: Murphy. Chapter 16. Opioids. In: Clinical Anesthesia, 2nd Edition. Barash, Cullen, Stolling; Lippincott, 1992, pg 431 Source: Day MR, Board Review 2003 they cause minimal central nervous system depression. Both drug classes facilitate the action of aminobutyric acid (GABA), although by different mechanisms of action. They are both used to prevent seizures, and both can result in physical dependence with long-term use. 2333. Answer: D Source: Cole EB, Board Review 2003 2334. Answer: B Source: Day MR, Board Review 2005 2335. Answer: C Explanation: Source: Manchikanti L - Pain Physician 2005; 8:257-262. 2336. Answer: C Source: Chou et al. - J Pain Manage Symptom Manage Vol. 25, No. 5 Nov. 2003, 1026-1048. 2337. Answer: A Explanation: The most commonly used illicit drug remains marijuana, with a lifetime use at roughly 20%. It is the most commonly used illicit drug on a regular basis, 6.2%, 14.6 million Americans. In contrast 1% were cocaine users, and ectasy is on the decline, from 3.2 million to 2.1 million users. Source: Hans C. Hansen, MD 2338. Answer: A Source: Chou et al. - J Pain Manage Symptom Manage Vol. 25, No. 5 Nov. 2003, 1026-1048. 2339. Answer: E Explanation: A major metabolite of meperidine is to normeperidine. Accumulation of normeperidine with repeated doses may cause seizures. Meperidine should only be used for short term acute pain management, if at all. 2330. Answer: C Source: Hans C. Hansen, MD Pentazocine, morphine, and ketamine are not associated with toxic metabolites at normal repeated dosing. 2331. Answer: C Explanation: Severe tremors, along with confusion, drowsiness, vomiting, ataxia and dizziness, are an early sign of lithium toxicity. Retention of lithium may be enhanced by a lowsodium diet because sodium competes with lithium for reuptake in the kidney. The onset of lithium action may take a week or more; the drug is used to normalize mood in patients with mania or bipolar disorder. Reference: Melzack and Wall 2003, Page 381 Source: Art Jordan, MD, Sep 2005 2340. Answer: D Explanation: A noncompetitive antagonist decreases the magnitude of the response to an agonist but does not alter the agonist’s potency (i.e., the ED50 remains unchanged). A competitive antagonist interacts at the agonist binding site. 2332. Answer: D Explanation: Benzodiazepines are much safer than barbiturates because 2341. Answer: B Source: Roger Cicala, MD, Sep 2005 ASIPP 506 Section 12 • Controlled Substance Management 2342. Answer: C Explanation: They are contraindicated in patients with a history of hallucinations, delirium, or paranoid disorders. They are relatively contraindicated with a history of substance abuse or hypertension. Their use may exacerbate the above. Examples include methylphenidate, destroamphetamine, and pemoline. Reference: Melzack and Wall 2003, page 390 Source: Art Jordan, MD, Sep 2005 2343. Answer: A Explanation: Tolerance is the concept of the need to increase dosage of drug to produce the same level of analgesic capacity that previously existed. Tolerance may occur at a constant dose, and tolerance should not be considered within the defined purview of addiction. Source: Hans C. Hansen, MD Schedule III. It has an average serum half-life of 3.8 hours. It is widely used as an antitussive. Disposition of Toxic Drugs and Chemicals in man. Fifth Edition. Randall C. Baselt 2000 Drug Enforcement Administration website Source: Art Jordan, MD, Sep 2005 2348. Answer: D Explanation: Benzodiazepines decrease REM and Stage and Stage 4 sleep, resulting in increased fatigue and sleep deprivation. Some studies have shown a cognitive dysfunction rate as high as 70% in patients on long term benzodiazepines. Withdrawal from benzodiazepines may be worse than opioids. There is no evidence that benzodiazepines have a primary analgesic effect. Source: Art Jordan, MD, Sep 2005 2349. Answer: A Explanation: While drug interactions based on p;harmacolinetics do occure with sedative-hypnotics, the most common drug interaction is additive CNS depression. Additive effects can be predicted with concomitant use of alchololic beverages, anticonvulsants, opioid analgesics and phenothiazines. Less obvious but equally important is enhanced CNS depression with many antihistamines, antiypertensives, and antidpressants of th etricyclic class. Source: Katzung & Trevor’s Pharmacology, Examination and Board Review, 6th Ed., McGraw Hill, New York, 1998 2344. Answer: B Explanation: According to the Henderson-Hasselbalch equation, the pK equals the pH when the log of the ratio is ionized (dissociated) and protonated (undissociated) forms is 0 (i.e., their concentrations are equal and have a ratio of 1). When the pH of a solution (blood) is 7 and the pK of the acid is 6, at equilibrium, the log of the ratio of concentrations of ionized form to protonated form is 1 (i.e., there is 10 times more ionized than protonated acid 2350. Answer: A in the blood). When the pH of a solution (stomach) is 3 Explanation: and the pK of the acid is 6, the log of the ratio of the A. The majority of recovering persons can be concentrations of the ionized to protonated forms is –3 successfully treated with chronic opioid therapy, but they (i.e., the concentration of the ionized form is 1/1000 that have some increased risk of addiction. of the protonated form, meaning that there is 1000 times B. The majority of recovering persons can be more protonated than ionized acid). Drug will accumulate successfully treated with chronic opioid therapy, but they in the compartment in which it is more highly charged have some increased risk of addiction. (ion trapping) – in this case, the blood. Acidification of C. Even though opioids were not the patient’s drug of the urine will increase the protonation of an acid and choice, cross addiction can and does occur. increase reabsorption, thereby slowing renal excretion. D. Short acting agents may be more likely to trigger addictive disease than long acting agents. They certainly are no safer. 2345. Answer: E E. There is no such legal ramification, although a Source: Erin Brisbay McMahon, JD, Sep 2005 physician may face licensure issues for prescribing to a known active addict. 2346. Answer: C Source: Roger Cicala, MD, Sep 2005 Explanation: Pain Medicine: A Comprehensie Review, Second Edition; 2351. Answer: D P. Prithvi Raj: Mosby, Page 390 Explanation: Source: Art Jordan, MD, Sep 2005 Long term treatment has the highest success rate for continued abstinence, about 65%. 2347. Answer: C Source: Roger Cicala, MD, Sep 2005 Explanation: D.A.W.N. Drug Abuse Warning Network Reports 2352. Answer: C Hydrocodone is a Schedule II controlled substance only Explanation: when prescribed alone. With acetaminophen, it is a ASIPP 507 Section 12 • Controlled Substance Management The biologic half-life (t1/2) will be affected by dose in a drug when the elimination process is saturated. In that case, the drug will accumulate on repeated dosings, and elimination will be independent of plasma concentration. The amount (not fraction) of drug eliminated per unit time will be constant, ad zero-order elimination will be observed. 2353. Answer: C Explanation: Most studies indicate the prevalence rate of substance abuse is 6% to 7%. Source: Roger Cicala, MD, Sep 2005 2354. Answer: B Explanation: Recurrent substance related legal problems are a clear sign of abuse, but do not in themselves indicate there is dependence upon the substance. Source: Roger Cicala, MD, Sep 2005 2355. Answer: B Source: Andrea M. Trescot, MD 2356. Answer: D 2357. Answer: E Explanation: Alcohol accounts for 60% of all cases of substance abuse. Source: Roger Cicala, MD, Sep 2005 2358. Answer: C Explanation: A. Tolerance involves reduced effectiveness, not complete loss of effect B. Withdrawal can occur without tolerance, nor does withdrawal always occur when tolerant patients stop the substance in question. C. Tolerance indicates less effectiveness of a given dose. Increasing the dose can restore the effect, up to a point. D. Many opiate side effects decrease over time, but not necessarily in parallel with developing tolerance. E. A different medication may be more effective, but this does not of itself demonstrate tolerance. Source: Roger Cicala, MD, Sep 2005 2359. Answer: C Explanation: Pinpoint pupils are a sign of opiate intoxication, dilated pupils would be more likely in withdrawal. All of the other symptoms are associated with opiate withdrawal. Source: Roger Cicala, MD, Sep 2005 2360. Answer: B Explanation: It may be surprising, but adults who have completed four years of college are more likely to experience an illicit drug, 51.1% of the American population. 38% of those who did not complete high school have used an illicit drug. The use is higher in metropolitan than nonmetropolitan areas. Source: Hans C. Hansen, MD 2361. Answer: E Explanation: Different substances may activate different primary receptors in the brain, but dopaminergic neurons in the mesolimbic system are activated either directly, or secondarily with all substances of abuse. Source: Roger Cicala, MD, Sep 2005 2362. Answer: A Explanation: While a callback requirement might be a good idea, it is not a condition to an oral authorization for a refill of a Schedule III or IV prescription. Reference: 21 CFR 1306.22 Source: Erin Brisbay McMahon, JD, Sep 2005 2363. Answer: B Explanation: A. Using a substance for purpose other than described in the PDR has nothing to do with substance abuse. B. Use of a substance in hazardous situations is one of the criteria for substance abuse. C. Development of tolerance to the substance can occur in any individual who takes the substance, even properly as prescribed. It MAY indicate substance dependence but is not a criteria for indicating substance abuse. D. Attempts to cut down substance use are on of the criteria for substance dependence, not substance abuse. E. An episode of withdrawal substance can occur in any individual who takes the substance in sufficient quantities, even properly as prescribed. It MAY indicate substance dependence but is not a criteria for indicating substance abuse. Source: Roger Cicala, MD, Sep 2005 2364. Answer: C Explanation: Explanation: The signs and symptoms are those of withdrawal in a patient physically dependent on an opioid agonist. Such signs and symptoms usually start within 610 hours after the last dose; their intensity depends on the degree oh physical dependence that has developed. Peak effects usually occur at 36-48 hours. Mydriasis is a prominent feature of the abstinence syndrome; other symptoms include rhinorrhea, lacrimation, piloerection, muscle jerks, and yawning. Source: Katzung & Trevor’s Pharmacology, Examination and Board Review, 6th Ed., McGraw Hill, New York, 1998 2365. Answer: B Explanation: Fluvoxamine inhibits liver drug-metabolizing enzymes. Dosages of alprazolam, theophylline, and warfarin must be ASIPP 508 Section 12 • Controlled Substance Management reduced if any of these drugs are given concomitantly with fluvoxamine. Nefazodone may also decrease the metabolism of benzodiazepines, and venlafaxine may inhibit haloperidol metabolism. Source: Katzung & Trevor’s Pharmacology, Examination and Board Review, 6th Ed., McGraw Hill, New York, 1998 2366. Answer: E Explanation: Concomitant administration of meperidine and MAO inhibitors has resulted in life-threatening hyperpyrexic reactions that may culminate in seizures or coma. Such reactions have even occurred when phenelzine was administered 14 days after a patient had been treated with meperidine! Note that concomitant use of SSRIs and meperidine has resulted in the serotonin syndrome, another life-threatening drug interaction. Source: Katzung & Trevor’s Pharmacology, Examination and Board Review, 6th Ed., McGraw Hill, New York, 1998 2367. Answer: E Explanation: The fentanyl transdermal patch releases the drug over 72 hours. The blood levels achieved will often provide analgesia for postoperative pain but at the same time will increase arterial PCO2 due to depression of the brain stem respiratory center. This effect has contributed to severe respiratory depression with occasional fatalities. Source: Katzung & Trevor’s Pharmacology, Examination and Board Review, 6th Ed., McGraw Hill, New York, 1998 2368. Answer: C Explanation: The elderly patient may be especially sensitive to antidepressant drugs that cause sedation, atropine-like side effects, or postural hypotension. Paroxetine (or another SSRI) is the best choice for this patient because it is the least likely of the drugs listed to exert such actions. Source: Katzung & Trevor’s Pharmacology, Examination and Board Review, 6th Ed., McGraw Hill, New York, 1998 2369. Answer: C Explanation: Opioid calculators are potentially dangerous to use secondary to metabolic polymorphism. Long acting opioids have a long half-life, reaching steady state in approximately 5 days, so increasing doses too frequently can lead to overdose. Bone pain probably responds better to NSAIDs. Hyperalgia may be due to M3G. Source: Andrea M. Trescot, MD 2370. Answer: D Explanation: Areas throughout the mesolimbic system, including all of the above, the stria terminalis, and portions of the frontal lobes are all activated during intake of a substance of abuse. Source: Roger Cicala, MD, Sep 2005 ASIPP 2371. Answer: D Source: Raj P, Pain medicine - A comprehensive Review Second Edition 2372. Answer: A Explanation: Phencyclidine (“angel dust,” “crystal,” “hog”) toxicity induces organize mental disorders, intoxication, delirium, delusional mood, and flashback disorders with physical problems related to high blood pressure, muscle rigidity, ataxia, coma, nystagmus (particularly vertical), and dilated pupils. Treatment is with IV diazepam as the drug of first choice. Propranolol can be used for an adrenergic crisis, and haloperidol is effective for psychotic and disruptive behavior. Elimination of the drugs is enhanced by ammonium chloride in the acute stage and later by ascorbicacid. Environmental stimuli should be kept to a minimum. The urine is positive for PCP up to seven days, but there can be false negatives. Source: Psychiatry specialty Board Review By William M. Easson, MD and Nicholas L. Rock, MD 2373. Answer: B Explanation: Reference: Katzung, p 538. A. Flashbacks can occur with use of LSD and mescaline but have not been associated with the use of cocaine. B. Use of crack cocaine has led to seizures and cardiac arrhythmias. C. Some of cocaine’s effects (sympathomimetic) are due to blockade of norepinephrine reuptake into presynaptic terminals; it does not block receptors. D. Crack is the free-base (nonsalt) form of the alkaloid cocaine. It is called crack because, when heated, it makes a crackling sound. E.Heating crack enables a person to smoke it; the drug is readily absorbed through the lungs and produces an intense euphoric effect in seconds. Source: Stern - 2004 2374. Answer: E Explanation: If a patient increases the medication despite the knowledge that he will be discharged, this may be addiction. If he increases the medication because it is no longer effective, that may be tolerance. Source: Trescot AM, Board Review 2004 2375. Answer: C Explanation: Reference: Hardman, pp 89-90. Strychnine acts as a competitive antagonist of glycine, the predominant postsynaptic inhibitory transmitter in the brain and spinal cord. The fatal adult dose is 50 to 100mg. Persons poisoned by strychnine suffer convulsions that progress to full tetanic convulsions. Because the diaphragm and thoracic muscles are fully contracted, the patient cannot breathe. Hypoxia eventually causes medullary parasysis and death. Control of the convulsions 509 Section 12 • Controlled Substance Management and respiratory support are the immediate objectives of the therapy. Diazepam may be preferred to a barbiturate in controlling the convulsions because it offers less concomitant respiratory depression. Poisoning caused by the other drugs listed in the question is not associated with convulsions but with depression of the CNS. Source: Stern - 2004 2376. Answer: C Explanation: Reference: Hardman, pp 574-575 A. Phencyclidine has no opioid activity B. Its mechanism of action is amphetamine-like with opioid activity. C. Phencyclidine is a hallucinogenic compound with no opioid activity. Its mechanism of action is amphetaminelike. D. A withdrawal syndrome has not been described for this drug in human subjects. E. In overdose, the treatment of choice for the psychotic activity is the antipsychotic drug haloperidol. Source: Stern - 2004 C. Cocaine is biotransformed by plasma esterases to inactive products. D. Cocaine has local anesthetic properties; it can block the initiation or conduction of a nerve impulse. E. Cocaine also blocks the reuptake of norepinephrine. This action produces CNS stimulant effects including euphoria, excitement, and restlessness. Source: Stern - 2004 2380. Answer: E Explanation: Only E is correct. A is expressly prohibited; B is not discussed in the Act at all, C is incorrect because “narcotic” is defined to include not only the opioids and opiates, but also cocaine. D is incorrect because medical cocaine is a C-II substance, and is often used as a topical anesthetic in sinus surgery. Source: Arthur Thexton 2381. Answer: C Explanation: Sedation and pruritus (due to direct histamine release) abate over time. Although tolerance to pain relief can occur, with long acting narcotics (especially methadone) it is less likely. Constipation, however, should be expected to be a problem for the entire length of treatment. Source: Trescot AM, Board Review 2004 2377. Answer: E 2378. Answer: D Explanation: You could easily argue that alcohol far exceeds marijuana in use, based on national data. 120 million Americans, or 50% of the population consume alcohol. The definition would easily move to alcohol as the number one used illicit drug, if alcohol was uniformly considered “a drug”. It does have physical dependence, psychic and toxic effects, but for purposes of terminology and the use of controlled substances, marijuana will be considered the number one drug of abuse. Ironically, it is now not a controlled substance, as the Supreme Court has defined no legitimate medical need for marijuana. Marijuana is properly termed a drug of abuse, Schedule I. There are 7 thousand new users per day. Source: Hans C. Hansen, MD 2379. Answer: D Explanation: Reference: Hardman, pp 338, 570. A. Peripherally, cocaine produces sympathomimetic effects including tachycardia and vasoconstriction. B. Cocaine is an ester of benzoic acid and is closely related to the structure of atropine. Death from acute overdose can be from respiratory depression or cardiac failure. 2382. Answer: E Explanation: 29 CFR § 1910.1030(d)(3). Source: Erin Brisbay McMahon, JD 2383. Answer: B Explanation: 65 Fed. Reg. 59434 Source: Erin Brisbay McMahon, JD 2384. Answer: B Explanation: Buprenorphine has low oral bioavailability, but is well absorbed sublingually. Naloxone has poor sublingual bioavailability, but is formulated along with buprenorphine to prevent misuse when administered IV. Buprenorphine is a partial agonist at the mu-opiate receptor and an antagonist at the kappa receptor. While buprenorphine has high opioid mu receptor affinity, it has a low intrinsic activity. Malinoff HL, Barkin RL, Wilson G. Sublingual buprenorphine is effective in the treatment of chronic pain syndrome. American Journal of Therapeutics 2005; 12(5): 379-384 http://buprenorphine.sahsa.gove/about.html Source: James D. Colson, MS, MD ASIPP 510 Section 12 • Controlled Substance Management 2385. Answer: B Explanation: Butorphanol exhibits opioid kappa receptor agonist and mu receptor antagonist activity. Respiratory depression with butorphanol is similar to that produced by equivalent morphine doses. Histamine release is prominent with morphine and not butorphanolStoelting RK. Pharmacology and Physiology in Anesthesia Practice. 3rd ed. Lippincott-Raven, Philadelphia, 1999. Evers AS, Maze M. Anesthetic Pharmacology: Physiologic Principles and Clinical Practice. Churchill Livingstone, Philadelphia, 2004. Stoelting RK. Pharmacology and Physiology in Anesthesia Practice. 3rd ed. Lippincott-Raven, Philadelphia, 1999 Source: James D. Colson, MS, MD 2386. Answer: E Explanation: Schedule III substances are comprised of drugs possessing analgesic, anabolic steroid, sedative, and/or hypnotic properties. Controlled Substances Act-U.S. Drug Enforcement Administration (http://www.usdoj.gov/dea/agency/ csa.htm) Source: James D. Colson, MS, MD 2387. Answer: D Explanation: Drug properties, such as receptor affinity, intrinsic activity or the propensity to develop tolerance or tachyphylaxis are more inherent to the drug itself and not specifically to its duration of action or particular formulation. Opioids as a class do not have a ceiling effect for analgesia. Longacting opioids tend to have a delayed onset and protracted course of withdrawal following abrupt discontinuation. Stoelting RK. Pharmacology and Physiology in Anesthesia Practice. 3rd ed. Lippincott-Raven, Philadelphia, 1999. Savage SR. Critical clinical issues in pain and addiction. Pain Management Rounds 2005; 2(9): Source: James D. Colson, MS, MD 2388. Answer: D Explanation: A. Schedule II drugs have a high potential for abuse and a high rate of psychological or physical dependence. Narcotic analgesics are schedule II drugs. Non-narcotic drugs such as amphetamines, methylphenidate, and pentobarbital are also schedule II. B. Schedule III drugs have a potential for abuse less than the drugs or other substances in schedules I and II. Abuse of the drug or other substance may lead to moderate or low physical dependence or high psychological dependence. ASIPP C. Schedule V drugs have the lowest potential for abuse of the drugs under the jurisdiction of the Controlled Substances Act. Antitussives and antidiarrheal preparations that contain narcotics in limited quantities are schedule V drugs. D. Schedule I is reserved for the most dangerous drugs without recognized medical value. E. Schedule IV drugs are thought to have less potential for abuse than schedule I, II, and III drugs. Examples of schedule IV drugs are benzodiazepines, phenobarbital, meprobamate, chloral hydrate, and dextropropoxyphene (Darvon). 2389. Answer: A Explanation: Within 7 days after the oral authorization to the pharmacist, the physician must deliver to the pharmacist a written prescription for the emergency quantity prescribed, and the written prescription must have written on its face “Authorization for Emergency Dispensing” and the date of the oral authorization. Reference: 21 CFR 290.10, 1306.11(d). Source: Erin Brisbay McMahon, JD, Sep 2005 2390. Answer: E Explanation: A. At high doses, benzodiazepines may cause anterograde but not retrograde, amnesia. B. Diazepam use can cause a decrease in psychomotor function. C. Diazepam has no more effectiveness than placebo in the treatment of major depression D. Benzodiazepines do not increase activity of liver drugmetabolizing enzymes or of enzymes involved in porphyrin synthesis. E. With abrupt discontinuance following chronic use, anxiety and agitation may occur, sometimes with hyperreflexia and, rarely, seizures. Source: Katzung & Trevor’s Pharmacology, Examination and Board Review, 6th Ed., McGraw Hill, New York, 1998 2391. Answer: E Explanation: A-D. Benzodiazepines and barbiturates are ontraindicated in breathing-related sleep disorders because they will further compromise ventilation. In the obstructive sleep apnea syndrome (pickwickian syndrome), obesity is a major risk factor. The best prescription you can give this patient is to lose weight. E. Patient probably suffers with sleep apnea syndrome and should be referred to sleep disorder clinic or sleep study. Source: Katzung & Trevor’s Pharmacology, Examination and Board Review, 6th Ed., McGraw Hill, New York, 1998 511 Section 12 • Controlled Substance Management 2392. Answer: C Explanation: A. The dose-response curve for benzodiazepines is flatter than that for barbiturates. B. Flumazenil is an antagonist at Benzodiazepine receptors and is used to reverse CNS depressant effects of benzodiazepines. C. As a weak acid (pKa +=7), phenobarbital will exist mainly in the ionized (nonprotonated) form in the urine at alkaline pH and will not be reabsorbed in the renal tubule. D. Induction of liver drug-metabolizing enzymes occurs with barbiturates and may lead to decreases in half-life of other drugs. E. Withdrawal symptoms from use of the shorter-acting barbiturate secobarbital are more severe than with phenobarbital. Source: Katzung & Trevor’s Pharmacology, Examination and Board Review, 6th Ed., McGraw Hill, New York, 1998 2393. Answer: A Explanation: It would be tempting to increase the tramadol, since he is not on the maximum of 400mg/day. However, that would increase his risk of seizures even more. The simplest treatment would be to change his antidepressant to one that was not a CYP2D6 inhibitor, which would then allow the tramadol to be more active, while at the same time decreasing the risk of seizures because of excretion of the drug. Codeine, hydrocodone, and oxycodone are also metabolized to active forms by CYP2D6, and therefore would also be less effective in the face of CYP2D6 inhibition. Agonist/antagonist opioids are not usually a good choice for chronic pain management. Source: Andrea M. Trescot, MD 2394. Answer: C Explanation: Because tramadol is not only activated by CYP2D6, but also metabolized for excretion by CYP2D6, the patient is at risk for accumulation of the drug, leading to seizures. Source: Andrea M. Trescot, MD 2395. Answer: C Explanation: Decreased GI motility is the deliberate effect of poorly absorbed opioids such as loperamide (Lomotil). The rest are usually undesirable effects. Source: Andrea M. Trescot, MD 2396. Answer: A Explanation: Only 8% of new low back pain patients made a return appointment after 12 months. 25% still had pain at 12 months, and 50% still had difficulties with ADLs at 12 months. 79% still had pain at 3 months, and 32% made follow up at 3 months. Croft PR, Macfarlane GJ, Papageorgiou AC, et al. Outcome of low back pain in general practice: a prospective study. BMJ (1998);316(7141):1356-9 Source: Andrea M. Trescot, MD 2397. Answer: B Source: Stimmel, B 2398. Answer: C Source: Stimmel, B 2399. Answer: B Explanation: Answers (a) and (c)-(e) are noted in the DEA’s Interim Policy Statement as behaviors that lead to criminal convictions. Reference: 69 Fed. Reg. 67170. Source: Erin Brisbay McMahon, JD, Sep 2005 2400. Answer: D Explanation: Answer (d) is wrong because, to be convicted of being the manager or organizer of a continuing criminal enterprise, a person must violate a provision of the Controlled Substances Act, the punishment for which is a felony. Reference: 21 U.S.C. § 848. Source: Erin Brisbay McMahon, JD, Sep 2005 2401. Answer: C Explanation: Answer (c) should be limited to thirty patients. Reference: 21 USC 823(g); 21 CFR 1306.07(d). Source: Erin Brisbay McMahon, JD, Sep 2005 2402. Answer: E Explanation: Answer (e) is not one of the credentials that will render a physician a qualified physician to dispense and prescribe Schedule III, IV, or V controlled substances specifically approved by the Food and Drug Administration for narcotic addiction treatment to a narcotic dependent person. Reference: 21 USC 823(g)(2)(B) Source: Erin Brisbay McMahon, JD, Sep 2005 2403. Answer: B Explanation: Schedule III and IV prescriptions may not be refilled more than 5 times after the date of the original prescription unless renewed by the prescribing practitioner. Reference: 21 USC 829 (b) - (c). Source: Erin Brisbay McMahon, JD, Sep 2005 ASIPP 512 Section 12 • Controlled Substance Management 2404. Answer: D 2405. Answer: A Source: Hans C. Hansen, MD Source: Arthur Thexton 2410. Answer: A Source: Stimmel, B 2411. Answer: D 2406. Answer: D Source: Stimmel, B Explanation: The seizures from normeperidine cannot be reversed by 2412. Answer: E naloxone. Although it has been used for many years, Source: Stimmel, B recognition of its poor analgesia, metabolite accumulation, and abuse potential has lead to gradual condemnation by 2413. Answer: C the pain community. It is metabolized by glucuronidation, Source: Stimmel, B is not safe in the elderly and does not become more effective over time. 2414. Answer: A Source: Andrea M. Trescot, MD Source: Stimmel, B 2407. Answer: D Source: Stimmel, B 2415. Answer: E Source: Murray McAllister, PsyD, LP - Spring 2004 2408. Answer: A Explanation: A. Constipation is the most frequent side effect of opioid therapy. 2416. Answer: A Source: Stimmel, B 2417. Answer: A Tolerance does not develop to this side effect. Therefore, as the dose of opioid increases, so does the potential for constipation. Frank bowel obstruction, biliary spasm, and ileus have occurred with opioid use. 2418. Answer: D Source: Stimmel, B 2419. Answer: A Source: Stimmel, B 2420. Answer: A It is crucial to place patients on an active bowel regimen Source: Stimmel, B that includes laxatives, stool softeners, adequate fluids and exercise, and cathartics as needed to 2421. Answer: E prevent the severe constipation that Source: Stimmel, B can occur with opioid use. 2422. Answer: E B. Surgical complications are unlikely. Source: Stimmel, B C. Constipation is not a symptom of drug abuse. 2423. Answer: D Source: Stimmel, B D. Transdermal fentanyl may be an option if morphine titration fails. Constipation is similar. E. Methadone maintenance is not indicated Source: Manchikanti L, Board Review 2005 2409. Answer: D Explanation: A is not covered at all in the CSA, but is a matter of state law. B is incorrect because the CSA does not permit this; the HIPAA rule does this. C is incorrect, in that a special registration is required to order C-I substances for any purpose. And, E is incorrect because methadone may be prescribed for pain relief or for any other medically appropriate purpose, EXCEPT the treatment of addiction, without any special registration. ASIPP 2424. Answer: A Explanation: Only 1% of the work force was absent from work, headaches and low back pain were the most common complaints, 12% of the workforce lost productive time due to pain, and an average of 4.6% hours per week are lost because of pain. Stewart WF, Ricci JA, et al. Lost Productive Time and Cost Due to Common Pain Conditions in the US Workforce. JAMA (2003)290:18, p. 2446. Source: Andrea M. Trescot, MD 2425. Answer: D Source: Stimmel, B 513 Section 12 • Controlled Substance Management 2426. Answer: A Explanation: Reference: Federal and state materials nationwide; Bolen, J Pain Medicine News; Bolen, J Journal of Opioid Management (forthcoming publication 2005). Explanation: A. This is the best answer. At the federal level there are three main types of legal/regulatory materials governing the parameters of and record-keeping for the use of controlled substances to treat pain: (1) laws, like the Controlled Substances Act of 1970, (2) regulations governing the issuance of prescriptions, as found in the Code of Federal Regulations, and (3) policy statements and rules, as used by DEA to explain the federal interpretation or position on the laws and regulations. B. This is not the best answer. Laws and regulations do exist at the federal level. However, the DEA uses an additional level of legal/regulatory material called policy statements and rules to explain the laws. It is vital for DEA Registrants to read and understand these policy statements and rules because they give the registrant a better understanding of how the DEA applies and interprets the federal legal/regulatory materials governing recordkeeping and the use of controlled substances to treat pain. C. This is not the best answer. Although the Controlled Substances Act of 1970 is a law, it is just part of the body of federal materials governing the use of controlled substances in the United States. D. This is not the best answer. The DEA policy statements, such as the Interim Policy Statement of November 16, 2004, are only a part of the body of federal materials governing the use of controlled substances in the United States. E. This is not the best answer. The Food and Drug Act is a law that, in general, pertains to the development, approval, and marketing of drugs in the United States. While it certainly has much to do with the drugs that ultimately get scheduled under the controlled substances act, it is only part of the body of federal materials governing the use of controlled substances in the United States. Source: Jennifer Bolen, JD, Sep 2005 2427. Answer: E Explanation: Reference: Hardman, p 930. All the drugs listed in the question are used as antiemetics. A. Diphenhydramine and dimenhydrinate are used orally for the active and prophylactic treatment of motion sickness. B. Chlorpromazine is a general antiemetic, used orally, rectally, or by injection for the control of nausea and vomiting that is caused by conditions that are not necessarily defined. C. Ondansetron is indicated in the oral or intravenous route for the prevention of nausea and vomiting caused by cancer chemotherapy. D. Dimenhydrinate is used for prophylaxis and treatment of motion sickness. E. Scopolamine is a transdermal preparation used in the prevention of motion sickness. The drug is incorporated into a bandage-like adhesive unit that is placed behind the ear. The scopolamine delivered in this manner is well absorbed and maintainsan effect for up to 72h. Other drugs that are prepared for transdermal delivery include clonidine (an antihypertensive agent), estradiol (an estrogen), fentanyl ( an opioid analgesic), nicotine (a smoking deterrent), nitroglycerin (an antianginal drug), and testosterone ( an androgen). Source: Stern - 2004 2428. Answer: B Source: Raj, Pain Review 2nd Edition 2429. Answer: B Explanation: Reference: The Controlled Substances Act of 1970, codified at 21 U.S.C. § 801 and sections that follow; see also 1994, Joranson DE, Gilson AM. Chapter 8 - Controlled substances, medical practice and the law. In: Schwartz HI. Psychiatric Practice Under Fire: The Influence of Government, the Media and Special Interests on Somatic Therapies. Washington, DC: American Psychiatric Press, Inc., 1994:173-194. Explanation: A. This is not the correct answer. The Controlled Substances Act of 1970 does give DEA the authority to schedule drugs according to whether the drug has been approved by the Food and Drug Administration for medical use and according to the drug’s potential for abuse. B. This is the correct answer. The states, not the federal government, have the authority to regulate medical practice. State authority derives from both federal and state constitutions. States create medical practice acts to regulate the practice of medicine and protect the public. The CSA does not give DEA the authority to regulate medical decisions and it does not permit DEA to change or limit indications for which a drug may be prescribed. Likewise, the CSA does not give DEA the authority to regulate the quantity or chronicity of prescribing relative to controlled substances. ASIPP 514 Section 12 • Controlled Substance Management C. This is not the correct answer because the Controlled Substances Act of 1970 does give DEA authority to administer the CSA and create policy related to the various provisions of the CSA. D. This is not the correct answer because the Controlled Substances Act of 1970 does give DEA authority to establish manufacturing quotas that drug manufacturers must follow when producing controlled substances. There are many facets to DEA’s authority to establish manufacturing quotes and the important point is that DEA must ensure that there are sufficient controlled drugs available to meet legitimate health care demands. E. This is not the correct answer because the Controlled Substances Act of 1970 does give DEA authority to reschedule drugs into higher or lower schedules, depending on whether a drug remains approved for medical use and depending on developments and trends regarding the trends for the abuse of these drugs. Source: Jennifer Bolen, JD, Sep 2005 D. This is not the correct answer because most states allow physicians to use mid-level practitioners in the treatment of patients. These working relationships allow for practitioners to see more patients on a given day. While some state laws may require the physician to sign all prescriptions, in many cases mid-level practitioners also have DEA registrations and thus may prescribe controlled substances for the treatment of pain. Anyone who signs a controlled substances prescription must be licensed properly by state authorities and registered with the DEA. E. This is not the correct answer. Federal and state laws do not require physicians to issue controlled substances prescriptions within three days of seeing the patient. Source: Jennifer Bolen, JD, Sep 2005 2431. Answer: B Explanation: Reference: DEA Interim Policy Statement, Fed. Reg. Vol. 69, No. 220, pp. 67170-67172 (Nov. 16, 2004). Explanation: 2430. Answer: B Explanation: Reference: Code of Federal Regulations, 21 C.F.R. § 1306.04 (Prescriptions). Explanation: A. This is not the best answer. Prescriptions must meet both substantive and technical requirements to be valid. As a technical matter, a prescription must be dated and signed on the date it is actually issued to the patient or guardian. The prescription must contain not only the date and the properly licensed and registered provider’s signature, but also information about the patient and the drug prescribed. However, date and signature alone are not enough to make a prescription valid and the prescription must meet the substantive requirements of (1) legitimate medical purpose, and (2) usual course of professional practice to be wholly valid. B. This is the best answer. To be valid, the federal and state laws and regulations require a prescription be issued for a legitimate medical purpose within the usual course of professional practice. State licensing boards often add to this requirement by requiring physicians and other health care practitioners to document the medical record to show compliance with applicable laws and regulations governing controlled substance prescribing. A. This is not the correct answer. While a physician must report to DEA if their DEA number has been compromised, the Interim Policy Statement does not discuss this duty. B. This is the best answer. The Interim Policy Statement states: “[g]iven the addictive and sometimes deadly nature of prescription narcotic abuse, the tremendous volume of such drug abuse in the United States, and the propensity of many drug addicts to attempt to deceive physicians in order to obtain controlled substances for the purpose of abuse, a physician should seriously consider any sincerely expressed concerns about drug abuse conveyed by family members and friends.” C. This is not the best answer because the Interim Policy Statement did not assign a time frame within which to see patients and does not say that you must see your patients every thirty days. D. This is not the correct answer. To be valid, a physician must issue a prescription for controlled substances for (1) a legitimate medical purpose, and (2) within the usual course of professional practice. This has been the law of the Controlled Substances Act of 1970 and was not a new directive from the Interim Policy Statement. E. This is not the correct answer. The Interim Policy Statement did not assign a time frame within which a physician must review patient records. Source: Jennifer Bolen, JD, Sep 2005 C. This is not the correct answer because federal and state laws do not prohibit a physician from prescribing controlled substance to a person with a criminal history. 2432. Answer: C The only caveat to this statement concerns the patient’s Explanation: history of substance abuse, as it may call for restrictive Reference: 21 U.S.C. § 823; 21 C.F.R. § 1301.01 through monitoring on the patient’s use of controlled substances or 1301.55. other restrictions to ensure that the controlled substances prescribed get used as they are intended – for pain relief. ASIPP 515 Section 12 • Controlled Substance Management Explanation: DEA requires practitioners to renew their DEA registration number every 3 years. This may be done online through www.deadiversion.usdoj.gov. Moreover, DEA requires practitioners to request modifications of their DEA registration numbers when they move to a new medical practice or open another office requiring additional registration. Source: Jennifer Bolen, JD, Sep 2005 2433. Answer: B Explanation: Reference: 21 U.S.C. § 823; 21 C.F.R. § 1301.12; www.deadiversion.usdoj.gov. Explanation: A. This is not the correct answer. If a practitioner administers and/or dispenses controlled substances at more than one location, he/she must register and post a DEA registration number at each principal place of business or professional practice where controlled substances are stored, administered, or dispense by a person. Thus, under this hypothetical registering only one principal office location is insufficient. B. This is the best answer. A separate registration is required for each principal place of business or professional practice where controlled substances are stored, administered or dispensed by a person. If a practitioner will only be prescribing from an additional location located within the same state, then an additional registration is not necessary. C. This is not the best answer. A practitioner must register each principal place of business or professional practice where controlled substances are stored, administered, or dispensed by a person. D. This is not the correct answer. Do nothing is not the answer here as a registration is required at all locations where practitioners administer and/or dispense controlled substances. This is because the DEA requires registration of locations that keep controlled substances on the premises. The practice is different if the only thing kept on the premises is a prescription pad. E. This is not the correct answer. Registering a principal place of business where one administers and/or dispenses controlled substances is different from registering every place where the practitioner travels and issues prescriptions for controlled substances. Practitioners must register their principal place of business. If a practitioner has several offices, he/she must register separately those offices where he/she administers and/or dispenses controlled substances. However, he/she is not required to register every location where he/she uses prescription pads for controlled substances prescriptions. Source: Jennifer Bolen, JD, Sep 2005 2434. Answer: A Explanation: Reference: 21 U.S.C. § 823; 21 C.F.R. § 1301.11 (separate registrations) and § 1301.51 (modification of registration); www.deadiversion.usdoj.gov. Explanation: A. This answer is the best answer. If you move your principal registered location, you must send DEA a request for modification of registration in writing and obtain approval for the modified registration prior to the move. This request for modification should be addressed to the DEA field office nearest to your currently registered location. You may obtain an Address Change Request from DEA’s internet site at www.deadiversion.usdoj.gov. You must manually sign and fax or mail it to the local DEA office. The form must include (1) a copy of your current state medical/professional license for the new address along with a copy of the practitioner’s corrected state controlled substance registration, if applicable. B. This is not the correct answer. You may not wait until the next renewal date for your controlled substances registration to notify DEA of the move. If you do so, you may lose your registration number and you will be considered in violation of the law. C. This is not the best answer. You must first get permission from DEA to modify your registration, and thus simply telling your state drug bureau is not sufficient. You should learn what your state requires from you if you move principal locations from which you administer, dispense, and prescribe controlled substances D. This is not the correct answer. You may not wait until after you move to send DEA a request for a new registration number. Because you are administering and/ or dispensing controlled substances from your currently registered location, you must first obtain DEA’s approval to use the new location to store controlled substances. E. This is not the correct answer. You may not wait until DEA asks you for updated information about your registration and current address. DEA puts the burden on you, the registrant, to stay current with the paperwork surrounding the registration of individuals and locations. Source: Jennifer Bolen, JD, Sep 2005 2435. Answer: E Explanation: Reference: The Controlled Substances Act of 1970, codified in 21 U.S.C. § 801 and sections that follow. Explanation: A. The Food, Drug, and Cosmetic Act of 1962, establishes the law on drug development, approval for medical use, and marketing in the United States. However, this Act does ASIPP 516 Section 12 • Controlled Substance Management not contain the law governing the scheduling of drugs as controlled substances. B. There is no such federal act. Instead, many states have adopted a Uniform Controlled Substances Act (sometimes referred to as a Uniform Controlled Drugs Act). C. The Code of Federal Regulations explains various components of the Controlled Substances Act of 1970, but the CFR does not contain the law relating to the scheduling of drugs in the United States. D. There is no such federal act. E. The Controlled Substances Act of 1970 contains the law in the United States governing the scheduling of drugs as “controlled substances.” The CSA places controlled substances into five schedules. Schedule I contains drugs with no accepted medical use. Schedule I drugs are available only for scientific research. Schedules II-V contain drugs that have been approved for medical and schedules them according to potential for abuse, with drugs having the highest potential for abuse assigned to Schedule II. Source: Jennifer Bolen, JD, Sep 2005 2436. Answer: C Explanation: Reference: 21 C.F.R. § 1306.11(a) (Requirement of a Prescription), which states “[a] prescription for a Schedule II controlled substance may be transmitted by the practitioner or the practitioner’s agent to a pharmacy via facsimile equipment, provided that the original written, signed prescription is presented to the pharmacist for review prior to the actual dispensing of the controlled substance, except as noted in paragraph (e), (f), or (g) of this section. The original prescription shall be maintained in accordance with § 1304.04(h) of the CSA.” prior to dispensation of the prescription. This measure would prove helpful in determining whether the patient in question has attempted to alter your prescriptions. Do not tell the patient that you are faxing a copy of the prescription to the pharmacist. D. This is not the correct answer because faxes are not limited to emergency prescriptions. E. This is not the correct answer because faxes are not limited to hospice and nursing home situations. However, it is important to note that the requirement of the original prescription does not apply to hospice and nursing home situations. Source: Jennifer Bolen, JD, Sep 2005 2437. Answer: C Explanation: All opioids can potentially be abused. Meperidine may be useful for acute pain, and it is cheap. The metabolite normeperidine can cause seizures and can accumulate with chronic dosing, especially in renal failure Source: Trescot AM, Board Review 2004 2438. Answer: C Explanation: Reference: Hardman, p 546. Pentazocine is a mixed agonist-antagonist of opioid receptors. When a partial agonist, such as pentazocine, displaces a full agonist, such as methadone, the receptor is less activated; this leads to withdrawal syndrome in an opioid-dependent person. Source: Stern -2004 2439. Answer: D Explanation: Reference: 21 U.S.C. § 823; 21 C.F.R. 1306.07; and www.deadiversion.usdoj.gov. Explanation: Explanation: A. This is not the best answer because it states only one of the two requirements concerning the faxing of prescriptions. While it is legal to fax a Schedule II prescription to a pharmacist, the pharmacist may not dispense the prescription to the patient without the original prescription. B. This is not the correct answer because HIPAA consent has nothing to do with this law regarding the faxing of Schedule II controlled substances prescriptions to pharmacists. If you want to discuss the patient’s prescription with the pharmacist in connection with your treatment of the patient, you may do so and HIPAA does not require the patient’s consent for such conversations. C. This is the best answer because it is legal to fax a Schedule II prescription to a pharmacist and the patient must present the original prescription to the pharmacist ASIPP A. This is not the correct answer because the 72-hour exception to the federal law requirement of a separate registration for detoxification or maintenance treatment only allows a practitioner to administer or dispense (but not prescribe) (1) one day’s worth of emergency medication to the patient at one time, (2) for not more than a total of 72-hours, and (3) the practitioner may not extend or renew the 72-hour period. This 72-hour exception is known as the “three day rule” and it is found in 21 C.F.R. § 1306.07(b). Thus, if a practitioner is not separately registered as a narcotic treatment program, he/she may administer BUT NOT prescribe narcotic drugs to a patient for the purpose of relieving acute withdrawal symptoms while arranging for the patient’s referral for treatment. Congress intended § 1306.07(b) to give practitioners flexibility in emergency situations when confronted with a patient undergoing withdrawal. Thus, 517 Section 12 • Controlled Substance Management Congress established this exception to “augment, not to circumvent” the separate registration requirement set forth in the CSA. B. This is not the correct answer because no one is legally permitted to prescribe methadone to detoxify or maintain a patient for addiction. C. This is not the correct answer because having only the training on the use of Schedule III-V controlled substances to perform the office-based treatment of opioid addiction is not enough. Practitioners must obtain an “X” certification from DEA to use Schedule III-V controlled substances to treat patients in their offices for opioid addiction. Also, you may administer or dispense, but not prescribe, methadone according to the “three day rule” described above in answer A. D. This is the best answer. If a practitioner wants to use Schedule II narcotic drugs for maintenance and/or detoxification, federal and state law require the practitioner to obtain separate registration from the DEA as a narcotic treatment program pursuant to the Narcotic Addict Treatment Act of 1974. Significantly, this registration allows a practitioner to administer or dispense, but not prescribe, scheduled narcotic drugs that are approved by the United States Food and Drug Administration (FDA) for the treatment of narcotic addiction. Until October 2000, methadone and levo-alphaacetyl-methadol (LAAM) were the only scheduled narcotics approved by FDA for use in maintenance and detoxification treatment. In October 2000, pursuant to the Drug Abuse Treatment Act of 2000 (DATA 2000), Congress amended the CSA (21 U.S.C. § 823(g)) to allow properly registered and trained practitioners to dispense or prescribe Schedule III-V controlled substances specifically approved by the FDA for the office-based treatment of opioid addiction. E. This is not the correct answer. While a separate registration is required to render narcotic treatment services, no DEA registration to do so allows any practitioner to prescribe Schedule II controlled substances to detoxify or maintain an individual with an addiction. As stated above in answer D, those properly registered and trained may prescribe those drugs in Schedules III-V approved by FDA for the purpose of detoxification from opioids. Source: Jennifer Bolen, JD, Sep 2005 2440. Answer: B Explanation: Tricyclics modify peripheral sympathetic effects in two ways; through blockade of norepinephrine reuptake at neuroeffector junctions and through alpha adrenoceptor blockade. Sedation and atropine-like side effects are common with tricyclics, especially amitriptyline. In contrast to sedative-hypnotics, tricyclics lower the threshold to seizures. Source: Katzung & Trevor’s Pharmacology, Examination and Board Review, 6th Ed., McGraw Hill, New York, 1998 2441. Answer: D 2442. Answer: E Explanation: The mechanism of action of bupropion is unknown, but the drug does not inhibit amine transporters. Levels of norepinephrine and serotonin metabolites in the cerebrospinal fluid of depressed patients prior to drug treatment are not higher than normal. Some studies have reported decreased levels of these metabolites. Downregulation of adrenoceptor appears to be a common feature of all mode3s of chronic drug treatment of depression, including the use of drugs that have no direct actions o catecholamine receptors. MAO inhibitors used in depression are nonselective. Source: Katzung & Trevor’s Pharmacology, Examination and Board Review, 6th Ed., McGraw Hill, New York, 1998 2443. Answer: D Explanation: The SSRIs have CNS-stimulating effects. They may cause agitation, anxiety, “the jitters”, and insomnia. The evening is not the best time to take such drugs. Anorexia and nausea, akathisia, dyskinesias, and dystonic reactions may occur. Because of the possibility of drug interactions, the physician needs to be informed of changes in drug regimens when maintaining a patient on antidepressants. Source: Katzung & Trevor’s Pharmacology, Examination and Board Review, 6th Ed., McGraw Hill, New York, 1998 2444. Answer: D Explanation: Kappa receptor activation does not appear to be responsible for dependence, euphoria, or effects on smooth muscle. Increases in cerebral blood flow and (possibly) increased intracranial pressure result from the respiratory depressant actions of opioid analgesics. The latter effects are due to increased arterial PCO2, which results from mu receptor inhibition of the medullary respiratory center. However, the activation of kappa receptors contributes to analgesia at the spinal level and is probably responsible forsedative actions of the opioids. Source: Katzung & Trevor’s Pharmacology, Examination and Board Review, 6th Ed., McGraw Hill, New York, 1998 2445. Answer: D 2446. Answer: E Explanation: Deliberate (Dealing) Practitioner becomes a mercenary Sells drugs for money, sex, street drugs, etc. Office becomes a pill factory—full of drug seekers ASIPP 518 Section 12 • Controlled Substance Management Prescribes for known addicts who will likely sell drugs to others Source: Roger Cicala, MD, Sep 2005 State Board Investigation or Sanction Often given re-education options May result in databank report 2447. Answer: B Explanation: Reference: 21 C.F.R. § 1306.04 (prescriptions) and DEA Guidance Document on Dispensing and Purchasing Controlled Substances over the Internet, Fed. Reg. Vol. 66, No. 82 (April 27, 2001); http://www.deadiversion.usdoj.gov/fed_regs/notices/2001 /fr0427.htm. Explanation: A. This is not the correct answer. A physician may use the Internet to provide information and to communicate with the patient, but the Internet communications cannot be the sole basis for authorizing the prescriptions. If a valid physician-patient relationship exists, a physician may use the Internet to communicate with patients. For example, a physician may use the Internet to receive requests for treatment. However, all requests for treatment should be logical based upon the physician’s knowledge of the patient’s medical history and the presenting complaint. DEA states that, assuming a valid physician-patient relationship, it is permissible for a physician to use the Internet to receive requests for refills of prescriptions from patients. Practitioners should check to see whether their licensing state places additional requirements on those who engage in telemedicine. B. This is the best answer. A physician may use the Internet to communicate with patients, but the Internet communications may not form the sole basis for the physician-patient relationship. The physician must establish a valid physician-patient relationship with each patient in accordance with federal and state laws governing telemedicine. Most states have internet prescribing policies requiring physicians to obtain a thorough medical history and conduct an appropriate physical examination before prescribing any medication for the first time. C. This is not the correct answer. See explanations above. D. This is not the correct answer. There is no such Internet certification from the DEA allowing physicians to prescribe controlled substances to patients over the Internet. E. This is not the correct answer. There is no such Internet certification from the DEA. Source: Jennifer Bolen, JD, Sep 2005 2448. Answer: C Explanation: Risks of Malprescribing ASIPP Usually results in adverse publicity Attention attracts civil lawsuits Source: Laxmaiah Manchikanti, MD 2449. Answer: D Explanation: Reference: DEA Interim Policy Statement, Fed. Reg. Vol. 69, No. 220, pp. 67170-7172 (Nov. 16, 2004). Explanation: A. This is not the best answer. Although the Interim Policy Statement discusses the prohibition against the use of “multiple schedule II prescriptions with different fill dates,” the Interim Policy Statement refers to the Controlled Substances Act of 1970’s prohibition against refills of Schedule II controlled substances. Likewise, the federal law on prescriptions for scheduled drugs is found in the CFR. For the answer to be correct, you would have to look to all three levels of federal materials on the subject matter. B. This is not the best answer. Although the Controlled Substances Act of 1970 prohibits refills of Schedule II prescriptions, it is the Interim Policy Statement that actually discusses the prohibition against the use of “multiple schedule II prescriptions with different fill dates.” Likewise, the federal law on prescriptions for scheduled drugs is found in the CFR. For the answer to be correct, you would have to look to all three levels of federal materials on the subject matter. C. This is not the best answer. Although the Code of Federal Regulations contains references to prescriptions and the prohibition against refills on Schedule II controlled substances, it is the Interim Policy Statement that actually discusses the prohibition against the use of “multiple schedule II prescriptions with different fill dates.” Likewise, the federal law on prescriptions for scheduled drugs is found in the CSA. For the answer to be correct, you would have to look to all three levels of federal materials on the subject matter. D. This is the best answer. DEA discussed the prohibition against the use of multiple schedule II prescriptions with different fill dates in the Interim Policy Statement. However, DEA makes reference to the CSA and the federal law also involves the Code of Federal Regulations. Thus, all three levels of federal materials apply. E. This is not the correct answer. Federal law takes priority 519 Section 12 • Controlled Substance Management over state law in this area. States may create laws and rules that are stricter than the federal rule prohibiting the use of multiple schedule II prescriptions with different fill dates, but states may not permit their providers to use prescriptions in this format - with “Do not fill before” dates and language. Source: Jennifer Bolen, JD, Sep 2005 2450. Answer: E 2451. Answer: A Source: Jackson KC. Board Review 2003 2452. Answer: D 2453. Answer: B Explanation: Reference: The Federation of State Medical Boards’ May 2004 Model Policy for the Use of Controlled Substances for the Treatment of Pain, www.fsmb.org. Explanation: A. This is not the best answer because it only involves some of the records state licensing boards require practitioners to keep when they prescribe controlled substances for the treatment of pain. B. This is the best answer. The Federation of State Medical Boards’ Model Policy for the Use of Controlled Substances for the Treatment of Pain sets forth the following categories of medical records that practitioners should keep when they treat pain. Many states have adopted these categories in prescribing guidelines and, quite frequently, in prescribing regulations or rules. 1. the medical history and physical examination, 2. diagnostic, therapeutic and laboratory results, 3. evaluations and consultations, 4. treatment objectives, 5. discussion of risks and benefits, 6. informed consent, 7. treatments, 8. medications (including date, type, dosage and quantity prescribed), 9. instructions and agreements and 10. periodic reviews. C. This is not the best answer because it only involves some of the records state licensing boards require practitioners to keep when they prescribe controlled substances for the treatment of pain. some of the records state licensing boards require practitioners to keep when they prescribe controlled substances for the treatment of pain. Source: Jennifer Bolen, JD, Sep 2005 2454. Answer: A Explanation: A. This is the best answer. Unless a practitioner prescribes controlled substances in the course of detoxification or maintenance of opioid addiction, he/she is NOT REQUIRED to keep the records described by the Controlled Substances Act of 1970. However, most states have Uniform Controlled Substances Act, a medical practice act, regulations or rules, and/or guidelines or policy statements (sometimes called position statements) containing recordkeeping requirements for controlled substances. B. This is not the correct answer. The fact that a provider prescribes at more than one location does not change his/her obligation to follow federal and state controlled substances recordkeeping mandates. C. This is not the correct answer. A provider who uses the Internet to interact with patients must do so pursuant to a valid physician patient relationship. Likewise, providers must follow federal and state controlled substances recordkeeping mandates. D. This is not the correct answer. It does not matter how long a provider has been registered with the DEA. As long as a practitioner holds a DEA registration, he/she is responsible for following federal and state controlled substances recordkeeping mandates. E. This is not the correct answer. Using electronic medical records does not excuse a provider from following federal and state controlled substances recordkeeping mandates. Source: Jennifer Bolen, JD, Sep 2005 2455. Answer: B Explanation: Benzodiazepines have no significant therapeutic benefit in the management of obsessive-compulsive disorders. Drugs effective for this condition increase the activity of serotonergic systems in the brain. Clonazepam has been used commonly as an anticonvulsant and also has efficacy in anxiety states, including agoraphobia. Clonazepam (not diazepam) has also been used as a back-up drug in bipolar affective disorder. Source: Katzung & Trevor’s Pharmacology, Examination and Board Review, 6th Ed., McGraw Hill, New York, 1998 D. This is not the best answer because it only involves some of the records state licensing boards require practitioners to keep when they prescribe controlled substances for the treatment of pain. E. This is not the best answer because it only involves ASIPP 520 Section 12 • Controlled Substance Management 2456. Answer: D Explanation: Duped Always assumes the best about his patients and is gullible Leaves script pads lying around Hydrophilic medicine—fell into the toilet or the sink Patients only want specific medications (i.e. OxyContin or Percocet) Co-dependent—cannot tell patients “No” when they ask for narcotics Source: Roger Cicala, MD, Sep 2005 2457. Answer: E 2458. Answer: E Source: American Board of Anesthesilogy, In-trainnig examination 2459. Answer: D Explanation: Urine Drug Testing * Thin-layer chromatography (TLC) - Relatively old technique, testing the migration of a drug on a plate or film, which is compared to a known control * Gas chromatography: liquid and mass spectometry (CGMS) - Most sensitive and specific tests - Most reliable - Labor intensive/costly - Several days to know results - Used to confirm results of other tests * Enzyme immunoassay - Easy to perform/highly sensitive - More sensitive than TLC - Less expensive than GC/MS - Common tests EMIT (enzyme multiplied immunoassay test) FPIA (fluorescent polarization immunoassay) RIA (radioimmunoassay) - Screen only one drug at a time - Rapid drug screens - Similar to other enzyme immunoassay tests - May be more expensive 2460. Answer: B Source: American Board of Anesthesilogy, In-trainnig examination 2461. Answer: C Explanation: ASIPP A. NMDA receptors require glutamate and glycine for activation. B. NMDA receptors require glycine, but also glutamate for activiation. C. NMDA receptors are calcium-permeable ion channels that require both glutamate and glycine for activation. The amino acid-binding sites on the receptor are contributed by two different subunits, NR1 and NR2. Antagonism of either of these two sites is sufficient to completely block the ion flocks that normally follows receptor activation. D. At the molecular level, NMDA receptors are composed of multiple subunits that co-assemble to form functional channels. NR1 subunits exist as a family of 8 splice variants generated by alternative splice of 1N-terminal cassette and to intracellular C-terminal cassettes. The presence of 1 or more of the NR1 and NR2 subunits in a single receptor complex confers unique biophysical and pharmacologic properties to the NMDA receptor. E. NMDA receptors have large intracellular C-termini that interact with a variety of important proteins that regulate receptor phosphorylation and clustering to important signaling complexes. 2462. Answer: E Explanation: Propoxyphene will increase carbazepine, doxepin, metoprolol and propranolol levels, and decrease the excretion of benzodiazepines, leading to accumulation and overdose. Amitriptyline will decrease morphine breakdown, leading to increased blood levels. Morphine will decrease the breakdown of desipramine, leading to increased doses. Erythromycin will increase opioid effects, and methadone will increase TCA levels. References: Bergendal L, Friberg A, Schaffrath AM, et al, The clinical relevance of the interaction between carbamazepine and dextropropoxyphene in elderly patients in Gothenburg, Abernethy DR, Greenblatt DJ, Morse DS, et al, Interaction of propoxyphene with diazepam, alprazolam and lorazepam. Br J Clin Pharmacol 1985;19:51-7 Source: Andrea M. Trescot, MD 2463. Answer: C 2464. Answer: D Source: Manchikanti L, Board Review 2005 521 Section 12 • Controlled Substance Management 2465. Answer: E Explanation: The hydromorphone is most likely from the 2D6 metabolism of hydrocodone, not from abuse. Discharging the patient, refusing to write more opioids, or ignoring the results would be inappropriate. SSRIs, especially fluoxetine and paroxetine, will inhibit 2D6 and prevent the metabolism of hydrocodone to hydromorphone, which will decrease his analgesia. Source: Andrea M. Trescot, MD 2466. Answer: A Explanation: Drug Test Detection Amphetamine or methamphetamine Barbiturates (short-acting) Barbiturates (long-acting) Benzodiazepines Cocaine (benzoylecgonine-cocaine metabolite) Heroin or morphine Marijuana (occasional use) Marijuana (chronic use) Methadone Phencyclidine (occasional use) Phencyclidine (chronic use) 2 to 4 days 2 to 4 days Up to30 days Up to 30 days 1 to 3 days 1 to 3 days 1 to 3 days Up to 30 days 2 to 4 days 2 to 7 days Up to 30 days Source: Manchikanti L, Board Review 2005 2467. Answer: C Explanation: The Controlled Substances Act has divided drugs under its jurisdiction into five schedules. Schedule I drugs have a high potential for abuse and no accepted medical use in the United States. Examples of schedule I drugs include heroin, marijuana, LSD, etc. A. Buprenorphine is Schedule III drug B. Hydromorphone is Schedule II C. Heroin is Schedule II D. Diazepam is Schedule IV E. Morphine is Schedule II Source: Manchikanti L, Board Review 2005 2468. Answer: A Explanation: * No reliable long term studies (> 8 months) that demonstrate efficacy and safety of long term opioid therapy for chronic pain * Overall relief with opioids is modest (35%) * Physicians must be cautious when prescribing long term opioids * Outcomes are patient-specific * Be aware of risk of adverse events - Addiction; diversion; noncompliance - Concomitant psychiatric illness - Accidental overdose; etc * What are your true practice costs? Source: Mark V. Boswell, MD, KSIPP 2005 2469. Answer: C Explanation: A) Registration is required every year. B) Schedule II drugs cannot be prescribed for narcotic addiction. C) This is correct. D) Registration as an NTP is contingent on proper registration with the State Methadone Authority and the Department of Health and Human Services. E) This is incorrect; a practitioner must obtain SAMHSA certification. Reference: 21 U.S.C. § 823(g). Source: Erin Brisbay McMahon, JD, Sep 2005 2470. Answer: D Explanation: Answer (d) is wrong; the time limit is 3 weeks. Reference: 42 CFR 8.11 Source: Erin Brisbay McMahon, JD, Sep 2005 2471. Answer: E Explanation: Opioids are unpredictable, and the blood levels needed for analgesia vary with level of activity and time of day. Even when a pain signal is below threshold, there are potential physiologic effects. Early aggressive treatment is the goal of preemptive analgesia. Source: Andrea M. Trescot, MD 2472. Answer: E Explanation: Drug Abuse Prevention and Control Act of 1970 * Title 21, Chapter 13 of US Code * Established current schedules, registrations, agencies, enforcement and penalties. * Little change in laws since that time, although enforcement varies and case law has modified interpretation. Source: Roger Cicala, MD, Sep 2005 2473. Answer: D Explanation: Reference: Hardman, p 564. ASIPP 522 Section 12 • Controlled Substance Management A. The anxiolytic effects of buspirone take several days to develop, obviating its use for acute severe anxiety. B. Chloral hydrate a sedative, is used in the short-term treatment of insomnia . C. Chlorpromazine is used to treat psychotic disorders and symptoms such as hallucinations, delusions, and hostility D. A long-acting benzodiazepine, such as diazepam, is effective in blocking the secobarbital withdrawal symptoms. E. Trazodone is an anti-depressant Source: Stern - 2004 2474. Answer: A Explanation: Reference: 21 U.S.C. § 829; 21 C.F.R. § 1306.01 through § 1306.26; www.deadiversion.usdoj.gov. Explanation: A. This is the best answer. Only practitioners acting in the usual course of their professional practice may prescribe controlled substances. Practitioners must be registered with DEA and licensed to prescribe controlled substances by the State(s) in which they operate. In addition, if the state requires a separate state DEA registration number, practitioners must obtain this registration prior to applying for a federal DEA registration. Finally, a prescription must be issued in the usual course of professional practice and for a legitimate medical purpose (or authorized research). B. This is not the correct answer because it omits the requirement of (1) legitimate medical purpose within (2) the usual course of professional practice. 2475. Answer: D Explanation: Benzodiazepines are thought to exert most of their CNS effects by increasing the inhibitory effects of GABA. Benzodiazepines interact with specific receptors (BZ receptors) that are components of the GABA A receptorchloride ion channel macromolecular complex to increase the frequency of chloride ion channel opening. Benzodiazepines are not GABA receptor agonists because they do not interact directly with this component of the complex. Source: Katzung & Trevor’s Pharmacology, Examination and Board Review, 6th Ed., McGraw Hill, New York, 1998 2476. Answer: E Explanation: Decreased blood flow to vital organs, including the liver and kidney, occurs during the aging process. These changes may contribute to cumulative effects of sedativehypnotic drugs. However, this does not explain the enhanced sensitivity of the elderly patient to a single dose of central depressant, which appears to be due to changes in brain function that accompany aging. Source: Katzung & Trevor’s Pharmacology, Examination and Board Review, 6th Ed., McGraw Hill, New York, 1998 2477. Answer: C Explanation: The elimination of most benzodiazepines involves their metabolism by liver enzymes, including cytochrome P450 isozymes. In a patient with liver dysfunction, lorazepam, which is metabolized extrahepatically, is less likely to cause excessive CNS depression. Benzodiazepines are not eliminated via the kidneys or lungs. Flumazenil is used to reverse excessive CNS depression caused by benzodiazepines. Source: Katzung & Trevor’s Pharmacology, Examination and Board Review, 6th Ed., McGraw Hill, New York, 1998 2478. Answer: C Explanation: Addiction is a chaotic disturbance in physical and psychological control factors that involve impulse control, and often evolves to a patient utilizing the drug to their D. This is not the correct answer because the federal law detriment, inducing physical harm, and personal disregard does not contain a training requirement currently. Note, of danger. There is a significant loss of personal control, however, this may change in the near future due to the and the patient seeks the drug, sometimes at all costs. growing abuse and diversion of prescription controlled Addiction does not necessarily mean a non-functional drugs in the United States. Several states require some individual. We see some levels of addiction, even with our level of training in the use of controlled substances to treat very straightforward pain control patients, i.e. tobacco use. pain. Functional alcoholics perform in some segments of society, and it is not uncommon to be introduced to a E. This is not the correct answer because it omits two patient with an iatrogenic addiction to a controlled elements: (1) the state DEA registration number (where substance such as benzodiazepine (Xanax?), opioid, required), and (2) legitimate medical purpose within the Oxycontin?. It is also not unusual to hear that some of usual course of professional practice. these patients are very highly respected members of Source: Jennifer Bolen, JD, Sep 2005 society, kind and caring, and have had personality changes that are not appreciated by the individual. This is where professional and family intervention is necessary. C. This is not the correct answer because it omits the requirement of a state DEA registration number, which many states require. ASIPP 523 Section 12 • Controlled Substance Management Source: Hans C. Hansen, MD 2479. Answer: A Explanation: Reference: Hardman, pp 16-20. A. Sodium Bicarbonate is excreted principally in the urine and alkalinizes it. Increasing urinary pH interferes with the passive renal tubular reabsorption of organic acids (such as aspirin and Phenobarbital) by increasing the ionic form of the drug in the tubular filtrate. This would increase their excretion. intolerable side effects. Source: Trescot AM, Board Review 2004 2485. Answer: A 2486. Answer: B Explanation: The non-medical use of pain medication experienced its largest growth between 1995 and 2000, and has somewhat slowed in the past couple of years. Source: Hans C. Hansen, MD B-E. Excretion of organic bases (such as amphetamine, cocaine, phencyclidine, and morphine) would be enhanced 2487. Answer: E by acidifying the urine. Explanation: Source: Stern - 2004 A withdrawal syndrome with symptoms consistent with increased sympathetic activity will occur following the 2480. Answer: C abrupt discontinuation of long-term opioid use. Explanation: Hyperalgesia is associated with continued use of high dose Answer (c) is wrong because, under 21 CFR 1306.05, the opiates. Mu receptor affinity is an inherent pharmacologic physician is responsible if the prescription does not property of the opioid and would not be expected to conform to applicable laws and regulations. change with its discontinued use. Tolerance will be expected to diminish with discontinuation of use, while Reference: 21 CFR 1306.05. physical dependence is a physiologic state in which abrupt Source: Erin Brisbay McMahon, JD, Sep 2005 cessation of opioid results in a withdrawal syndrome. 2481. Answer: C Source: Nader and Candido – Pain Practice. June 2001 2482. Answer: E Source: Laxmaiah Manchikanti, MD 2483. Answer: D Explanation: A. Naltrexone is an antagonist therapy for heroin addiction B. Physostigmine is used to treat glaucoma C. Pralidoxime is used together with another medicine called atropine to treat poisoning caused by organic phosphorus pesticides D. Flumazenil is a competitive antagonist of benzodiazepines at the GABA receptor. Repeated administration is necessary because of its short half-life relative to that of most benzodiazepines. E. Naloxone is an opioid antagonist. 2484. Answer: D Explanation: There is no ceiling for opioids (other than the limitations of agonist/antagonists or APAP). The goal is to prevent addiction. Tolerance is less likely with long acting opioids. Respiratory depression is unlikely with stable doses of opioids. The goal is a balance between pain relief and Stoelting RK. Pharmacology and Physiology in Anesthesia Practice. 3rd ed. Lippincott-Raven, Philadelphia, 1999. Savage SR. Critical clinical issues in pain and addiction. Pain Management Rounds 2005; 2(9): Source: James D. Colson, MS, MD 2488. Answer: E Explanation: The next course of action is to explore the issues with the patient. 2489. Answer: A Explanation: The rate of continued abstinence after simple detoxification is about 2 to 3%. Prolonged treatment and aftercare markedly increase the success rate. Source: Roger Cicala, MD, Sep 2005 2490. Answer: E Explanation: There is no evidence that any SSRI is more effective than another in its antidepressant efficacy. While an individual patient may respond more favorably to a specific drug, several controlled studies have shown equivalent effective ness of these agents. However, SSRIs may be more effective than tricyclic antidepressants in some patients. Source: Katzung & Trevor’s Pharmacology, Examination and Board Review, 6th Ed., McGraw Hill, New York, 1998 2491. Answer: D Explanation: ASIPP 524 Section 12 • Controlled Substance Management Urine Drug Testing Know the characteristics of testing procedures, since many drugs are not routinely detected by all UDTs. Although no aberrant behavior is pathognomonic of abuse or addiction, such behavior should never be ignored. Reliance on aberrant behavior to trigger a UDT will miss more than 50% of those individuals using unprescribed or illicit drugs. Never prescribe “on-demand” for the patient until you are comfortable with the situation. A history of drug abuse does not preclude treatment with a controlled substance, when indicated, but does require a treatment plan with firmly defined boundaries. Source: Laxmaiah Manchikanti, MD 2492. Answer: E Explanation: Watch for signs: Progressive deterioration in personal appearance and hygiene; Uncharacteristic deterioration of handwriting and charting; QRS complex on the ECG is a major diagnostic feature of cardia toxicity. Arrhythmias resulting from cardiac conductivity (eg, lidocaine). There is no evidence that hemodialysis (or hemoperfusion) increases the rate of elimination of tricyclic antidepressants, presumably because of their large volume of distribution and their binding to tissue components. Source: Katzung & Trevor’s Pharmacology, Examination and Board Review, 6th Ed., McGraw Hill, New York, 1998 2496. Answer: E Explanation: Watch for signs: Absenteeism, frequent disappearances or long unexplained absences, making improbable excuses and taking frequent or long trips to the bathroom or to the stockroom where drugs are kept; Excessive amounts of time spent near a drug supply. Volunteer for overtime and at work when not scheduled; Unreliability in keeping appointments and meeting deadlines;_ Source: Erin Brisbay McMahon, JD, Sep 2005 2497. Answer: D Explanation: Food and Drug Acts Wearing long sleeves when inappropriate; Personality change - mood swings, anxiety, depression, lack of impulse control, suicidal thoughts or gestures; Patient and staff complaints about health care provider’s changing attitude/behavior; Increasing personal and professional isolation. Source: Erin Brisbay McMahon, JD, Sep 2005 2493. Answer: D Explanation: Tricyclic drugs block the uptake of guanethidine into sympathetic nerve endings, thus reversing its beneficial effects on blood pressure. While the precise mechanism is not defined, the tricyclics may also block the antihypertensive effects of clonidine and methyldopa. All of the other drug interactions have been reported. Source: Katzung & Trevor’s Pharmacology, Examination and Board Review, 6th Ed., McGraw Hill, New York, 1998 2494. Answer: D 2495. Answer: B Explanation: Tricyclic antidepressant overdose is a medical emergency. The “three Cs”- coma, convulsions, and cardiac problemsare the most common causes of death. Widening of the ASIPP * 1906 - Wiley Act - Founded the F. D. A. - Centered on foods and meat packing - Required ingredients and concentration standards for all medications - largely to regulate patent medicines. * 1938 - Food, Drugs, and Cosmetics Act - Mandated premarket approval of drugs - Required proof of safety - Prohibited false therapeutic claims * Marijuana Tax Act 1938 Source: Roger Cicala, MD, Sep 2005 2498. Answer: B (1 & 3) Explanation: Tramadol is metabolized by CYP2D6 to an active metabolite that has more effect than the parent compound, so that CYP2D6 inhibitors cause the effective analgesia to decrease. However, CYP2D6 is also the enzyme responsible for the excretion of tramadol, so that inhibition leads to decreased excretion and the increased possibility for seizures. Source: Andrea M. Trescot, MD 2499. Answer: A (1,2, & 3) Explanation: Grapefruit inhibits CYP3A4, not 2D6, and has its action by 525 Section 12 • Controlled Substance Management altering liver and intestinal 3A4 as well as inhibiting intestinal transport by p-GP. Medicines with a low bioavailability have the potential for increased absorption. Source: Andrea M. Trescot, MD 2500. Answer: B (1 & 3) Explanation: Lidocaine is highly dependant upon liver excretion, while methadone is not. Codeine is metabolized to morphine, which is highly dependant upon liver excretion (though M3G accumulates in renal insufficiency), while meperidine requires renal excretion. Source: Andrea M. Trescot, MD 2501. Answer: C (2 & 4) Explanation: Tramadol’s M1 metabolite has greater activity. Morphine would have decreased metabolism in liver failure, but the metabolites accumulate in renal failure. Source: Andrea M. Trescot, MD 2502. Answer: D (4 only) Explanation: Caffeine (in coffee and tea) is metabolized by CYP1A2, which is inhibited by ciprofloxin. Phenobarbital will increase the risk of folate deficiency neuropathy. Smokers metabolize propoxyphene faster and therefore have less effect. Source: Andrea M. Trescot, MD 2503. Answer: E (All) Explanation: The opiate immunoassay screens were designed to detect heroin abuse, not adherence to a therapeutic opioid regimen. These assays detect morphine and codeine—heroin is rapidly metabolized to 6monoacetylmorphine (6-MAM) and then to morphine. Performing opiate immunoassays at the federally mandated level of 2000 ng/ml should eliminate nearly all positive results due to morphine from foodstuffs. Only specific detection of 6-MAM by GC/MS is proof of heroin intake. Street heroin may be contaminated with codeine. Remember that codeine may be metabolized to morphine. Hydrocodone can also be produced as a minor metabolite of codeine. J Anal Toxicol 2000;24:530-535 Source: Art Jordan, MD, Sep 2005 2504. Answer: E (All) Explanation: All of these actions can influence the drug-drug interaction. Source: Andrea M. Trescot, MD 2505. Answer: A (1,2, & 3) Explanation: Isoniazid and carbamazepine will increase the metabolism of methadone (leading to decreased levels), while cimetidine will slow down the metabolism (leading to increased levels. While many CYP enzymes show ethnic differences, methadone metabolism has not been documented to have an ethnic variability. Source: Andrea M. Trescot, MD 2506. Answer: D (4 only) Explanation: Drug clearance and plasma half-life are pharmacokinetic, not pharmacodynamic, variables associated with the elimination of drug through renal excretion and/or hepatic metabolism.Bioequivalence compares different formulations of the same drug and is not the same as bioavailability or the fraction of a drug absorbed following administration.Potency is a measure of the amount or dose of drug required for an effect. Evers AS, Maze M. Anesthetic Pharmacology: Physiologic Principles and Clinical Practice. Churchill Livingstone, Philadelphia, 2004. Hardman JG, Limbird LE. Goodman and Gilman’s Pharmacological Basis of Therapeutics. 10th ed. McGrawHill, New York, 2001. Source: James D. Colson, MS, MD 2507. Answer: B (1 & 3) Explanation: A documented abnormality/pathology on MRI may be an incidental finding and not causing pain. You should make your decision based on examination, previous medical records, imaging studies, and careful evaluation. Just because another physician has been dispensing narcotics to a patient, does not necessarily mean it was appropriate or legal. The dispensing/prescribing must be based on a legitimate medical purpose as determined by the current prescribing physician, after careful evaluation and examination. Source: Art Jordan, MD, Sep 2005 2508. Answer: C (2 & 4) Explanation: The paleospinothalamic tract is rich in opioid receptors, connects the thalamus to the cortex and reticular activation system, and passes impulses from the C-fibers to the 2nd order neurons. Source: Andrea M. Trescot, MD 2509. Answer: E (All) Explanation: A patient compliance problem might suggest the choice of a once a day medication or patch. If a patient is on other BID mediations, a BID pain medication might be the best choice. Drug interactions can affect choice of medication, such as when a patient is already on Fiorinal, which will decrease methadone levels. Side effects such as nausea from hydroxylated opioids or constipation that might be lessoned by a patch can also influence medication choice. ASIPP 526 Section 12 • Controlled Substance Management Source: Andrea M. Trescot, MD 2510. Answer: E (All) Explanation: Other options include changing route and adding adjuvant meds. Source: Andrea M. Trescot, MD 2511. Answer: C (2 & 4) Explanation: Morphine is primarily hepatically metabolized by glucuronidation Source: Andrea M. Trescot, MD 2512. Answer: A (1,2, & 3) Source: Andrea M. Trescot, MD 2513. Answer: A (1,2, & 3) 2514. Answer: A (1,2, & 3) Explanation: Urine Drug Test Methods Opioids: Pitfalls Tests for opiates are very responsive for morphine and codeine . Do not distinguish which is present. Show a low sensitivity for semisynthetic/synthetic opioids such as oxycodone. A negative response does not exclude oxycodone, or methadone use. Source: Laxmaiah Manchikanti, MD 2515. Answer: B (1 & 3) Explanation: Urine Drug Test Methods Amphetamines: Low Specificity Tests for amphetamine/methamphetamine are highly cross-reactive. They will detect other sympathomimetic amines such as ephedrine and pseudoephedrine Not very predictive for amphetamine/methamphetamine use. Further testing is required. Source: Laxmaiah Manchikanti, MD 2516. Answer: E (All) Explanation: http://buprenorphine.sahsa.gov/waiver _qualifications 21 U.S.C 823 (g) Source: James D. Colson, MS, MD 2517. Answer: B (1 & 3) Explanation: Only dexmedetomidine preserves respiratory function without potentiating opioid-induced respiratory ASIPP depression. Only dexmedetomidine possesses selective alpha-2 adrenergic agonistic activity, while midazolam works through a GABA2 receptor mechanism. Evers AS, Maze M. Anesthetic Pharmacology: Physiologic Principles and Clinical Practice. Churchill Livingstone, Philadelphia, 2004. Morgan GE, Mikhail MS, Murray MJ. Clinical Anesthesia. 3rd ed. McGraw-Hill, New York, 2002. Source: James D. Colson, MS, MD 2518. Answer: E (All) Explanation: Norman R, Wells R, Neumann P, et al. A comparison of peak vs cumulative physical loading factors for reported low back pain in the automobile industry, Clinical Biomechanics, 13(8): 561-573, 1998. Source: Andrea M. Trescot, MD 2519. Answer: B (1 & 3) Explanation: Physical dependence is an occurrence that follows opioid, benzodiazepine, or other controlled substance use, and sometimes non-controlled substances, such as nicotine and alcohol, particularly revealed when abruptly discontinued. Titration is acceptable, and done slowly, with the caveat that physicians that do not have a special attachment to their DEA certificate do not use methadone as a taper. Opioid antagonist drugs can abruptly throw an individual into withdrawal. Source: Hans C. Hansen, MD 2520. Answer: A (1,2, & 3) Source: Stimmel, B 2521. Answer: E (All) Explanation: Federation of State Medical Boards Guidelines for the Treatment of Pain Use of controlled substances, including opiates may be essential in the treatment of pain Effective pain management is a part of quality medical practice Patients with a history of substance abuse may require monitoring, consultation, referral and extra documentation MD’s should not fear disciplinary action for legitimate medical purposes Source: Laxmaiah Manchikanti, MD 2522. Answer: E (All) Source: Mark V. Boswell, MD, KSIPP 2005 2523. Answer: B (1 & 3) 527 Section 12 • Controlled Substance Management Explanation: 1.Phencyclidine was developed as an intravenous anesthetic. However, the unique anesthesia it produced was complicated by a prolonged emergence delirium, leading to its demise as a clinically useful agent. Phencyclidine also caused symptoms of sensory deprivation, which is an excellent drug model of schizophrenia. 2.The desirable anesthetic properties of phencyclidine were retained in the short-acting arylcyclohexylamine derivative ketamine or Ketalar, which produced a much briefer emergence delirium. The term “dissociative anesthetic” was coined to emphasize the anesthetized patient was “disconnected” from his or her environment. Ketamine subsequently was discovered by the drug abuse community, where it is known as K, Super K, Special K, and Kat Valium. Phencyclidine has been placed in Schedule I of the Federal Controlled Substances Act, and Ketamine in Schedule II. 3.MK-801 was developed as an anticonvulsant and subsequently was used as a brain protective agent. However, it was discarded because of its PCP-like effects. Clinical trials of MK-801 have been extremely limited, and the results are not publicly available. 4.Dextromethorphan is an antitussive agent. When taken in very large amounts, it produces dysphoric mental effects that can be related to its weak NMDA antagonistic properties. 5.Amantadine and a related compound, memantidine, have been shown to be weak NMDA receptor antagonists. 2524. Answer: B (1 & 3) Explanation: Alcohol absorption is slowed by food, but increased by water, especially if carbonated. Alcohol goes directly into the bloodstream from the stomach and it is distributed throughout all tissues of the body. If somach alcohol concentration becomes too high, mucus is secreted and the pyloric valve closes, thereby slowing absorption. Source: Psychiatry specialty Board Review By William M. Easson, MD and Nicholas L. Rock, MD 2525. Answer: C (2 & 4) Source: Reddy Etal. Pain Practice: Dec 2001, march 2002 2526. Answer: E (All) Explanation: The prefered medications for the management of alcohol withdrawal delirium are the benzodiazepines (chlordiazepoxide, diazepam, lorazepam, oxyazepam). Multivitamins, particularly thiamine, B12, and folic acid, should be used. Thiamine IV or IM should be given prior to glucose loading. If seizures develop, using magnesium sulfate. Clonidine, propranolol, chloral hydrate, benzodiazepines, or barbiturates can be used dependin on the total clinical picture. Source: Psychiatry specialty Board Review By William M. Easson, MD and Nicholas L. Rock, MD 2527. Answer: A (1,2, & 3) Source: Stimmel B 2528. Answer: B (1 & 3) Explanation: 1. Diacetyl morphine or heroine was first synthesized in 1874. It was produced in 1989 by the Bayer Company and marketed under the name heroin. Heroin is synthesized from morphine by acetylation at both the 3 and 6 position. 2. Heroin is more water soluble and also more potent than morphine. 3. Heroin is metabolized in humans by de-acetylation to 6-mono-acetylmorphine and then further metabolized to morphine 4. Heroin is classified as Schedule I drug. It is not available for any therapeutic use in the United States. It is prescribed in a few other countries as a pain medication or for use in the management of heroin addiction. 2529. Answer: E (All) Explanation: Reference: Compton, et al. Am J Psychiatry 2001; 160: 890-895. Co-existing Diseases and Drug Dependence Alcohol dependence (63%) Any psychiatric disorder (74%) Antisocial personality disorder (44%) Phobic disorder (41%) Major depression (25%) Source: Mark V. Boswell, MD, KSIPP 2005 2530. Answer: A (1,2, & 3) Explanation: The Controlled Substances Act (CSA), title 2 of the Comprehensive Drug Abuse Prevention and Control Act of 1970 is the legal foundation of the government’s fight against the abuse of drugs and other substances. This law is a consolidation of numerous laws regulating the manufacture and distribution of narcotics, stimulants, depressants, hallucinogens, anabolic steroids, and chemicals used in the illicit production of controlled substances. All the substances that are regulated under existing federal law are placed into I of V schedules. This placement is based upon the substances’ medicinal value, harmfulness, and potential for abuse or addiction. Schedule I is reserved for the most dangerous drugs that have no recognized medical use. Schedule V is the classification used for the least dangerous drugs. The Act also provides a mechanism for substances to be ASIPP 528 Section 12 • Controlled Substance Management controlled, added to a schedule, decontrolled, removed from control, rescheduled, or transferred from one schedule to another. Source: Manchikanti L, Board Review 2005 2531. Answer: A (1,2, & 3) Source: Stimmel, B 2532. Answer: E (All) Source: Stimmel, B 2533. Answer: E (All) Explanation: A slow metabolizer cannot detoxify drugs quickly, leading to increased toxicity and possibly increased effect. If the drug needs to be metabolized for increased effect (such as with a pro-drug), slow metabolizers will have a decreased effect. Since metabolism is necessary for most excretion, slow metabolizers would have decreased excretion. Source: Andrea M. Trescot, MD 2534. Answer: E (All) Source: Arthur Thexton 2535. Answer: B (1 & 3) Explanation: Urine Drug Test Methods Cocaine: Very specific You might also want to order a serum oxycodone level to get an idea of what the doses are achieving. Reference: UDT in Clinical Practice: Purdue Pharma, 2005 Source: Art Jordan, MD, Sep 2005 2538. Answer: A (1,2, & 3) Explanation: There are restrictions on methadone and buprenorphine use ONLY when prescribed to treat addiction; when prescribed for pain or other conditions, they may be prescribed by anyone authorized to prescribe other controlled substances in the same schedule. Source: Arthur Thexton 2539. Answer: B (1 & 3) Source: Arthur Thexton 2540. Answer: E (All) Source: Stimmel, B 2541. Answer: E (All) Source: Arthur Thexton 2542. Answer: E (All) Source: Stimmel, B 2543. Answer: E (All) Source: Reddy Etal. Pain Practice: Dec 2001, march 2002 Tests for cocaine react principally with cocaine and its primary metabolite, benzoylecgonine. 2544. Answer: A (1,2, & 3) Source: Laxmaiah Manchikanti, MD These tests have low cross-reactivity with other substances 2545. Answer: C (2 & 4) Source: Stimmel, B Very specific in predicting cocaine use. Source: Laxmaiah Manchikanti, MD 2546. Answer: E (All) Source: Stimmel, B 2536. Answer: C (2 & 4) Explanation: Drug interactions include drug-drug, drug-food, and drug-condition interactions. Drug allergies influence the choice of medicines, and drug doses are important in drug treatment, but neither are specifically related to drug metabolism. Source: Andrea M. Trescot, MD 2537. Answer: D (4 Only) Explanation: Standard urine opiate immunoassay is designed to detect only morphine and codeine, and will not detect oxycodone. GC/MS (Gas chromatography/mass spectrometry)will specifically detect oxycodone, or other specific substances as you indicate to the lab. 2547. Answer: D (4 Only) Explanation: A small number of patients lack cytochrone P450 2D6 and cannot convert part of the codeine to morphine, a normal metabolite of codeine Source: Art Jordan, MD, Sep 2005 2548. Answer: D (4 only) Explanation: Gabapentin, morphine, and baclofen have their primary action as the parent drug. Morphine’s metabolite, M6G, has analgesic activity, but a pro-drug is a drug whose parent compound has no activity. Codeine, which is a prodrug, has no activity until it is metabolized into morphine. Source: Andrea M. Trescot, MD 2549. Answer: D (4 only) Source: Arthur Thexton 2550. Answer: A (1, 2 & 3) ASIPP 529 Section 12 • Controlled Substance Management Explanation: Explanation: 4 is incorrect. A physician may issue multiple prescriptions authorizing the patient to receive a total of up to a 90-day supply of a Schedule II drug. Source: 71 Fed. Reg. 52,724. Source: Erin Brisbay McMahon, JD 2551. Answer: B (1 & 3) Source: Laxmaiah Manchikanti, MD 2552. Answer: B (1 & 3) Explanation: 1. The term “addict” by CSA means any individual who habitually uses any narcotic drug so as to endanger the public morals, health, safety, or welfare, or who is so far addicted to the use of narcotic drugs as to have lost the power of self-control with reference to his or her addiction. 2. There is no definition for addiction in DSM-IV. DSM-IV defines substance abuse with at least 1 in 12 month period. 3. Maladaptive pattern leading to distress or impairment. Recurrent failure to field role. Recurrent physically undesirous behavior. Recurrent legal problems. Continued use despite social problems. Never met dependence criteria DSM-IV definition for substance dependence is as follows: Tolerance Withdrawal Larger Amounts/Longer periods Efforts or desire to cut down Large amount of time using/obtaining/recovering Activities given up: social/work/recreation Continued use despite problems Need 3 of above in 12 months An alternate definition from the American Society of Addiction Medicine for addiction is as follows: Addiction A primary, chronic neurobiologic disease with genetic, psychosocial and environmental factors effecting its course and presentation Characterized by one or more of the following Impaired control of drug use Compulsive use Craving Continued use despite harm 4. The federation recommends several additional steps in patients with addiciton or abuse Source: Manchikanti L, Board Review 2005 2553. Answer: B (1 & 3) Explanation: 1, 2. Schedule I The drug or other substance has a high potential for abuse. The drug or other substances has no currently accepted medical use in treatment in the United States. There is a lack of accepted safety for use of the drug or other substance under medical supervision. 3. Schedule II The drug or other substance has a high potential for abuse. The drug or other substances has no currently accepted medical use in treatment in the United States or a currently accepted medical use with severe restrictions. Abuse of the drug or other substances may lead to severe psychological or physical dependence. Other Schedule III The drug or other substance has a potential for abuse less than the drugs or other substances in schedules I and II. The drug or other substances has no currently accepted medical use in treatment in the United States. Abuse of the drug or other substance may lead to moderate or low physical dependence or high psychological dependence. Schedule IV The drug or other substance has a low potential for abuse relative to the drugs or other substances in schedule III. The drug or other substance has a currently accepted medical use in treatment in the United States. Abuse of the drug or other substances may lead to limited physical dependence or psychological dependence relative to the drugs or other substances in schedule III. 4. Schedule V The drug or other substance has a low potential for abuse relative to the drugs or other substances in schedule IV. The drug or other substance has a currently accepted medical use in treatment in the United States. Abuse of the drug or other substances may lead to limited physical dependence or psychological dependence relative to the drugs or other substances in schedule IV. Source: Manchikanti L, Board Review 2005 ASIPP 530 Section 12 • Controlled Substance Management 2554. Answer: A (1, 2 & 3) Explanation: 1. The CSA created a closed system of distribution for those authorized to handle controlled substances. 2. The system is the registration of all those authorized by the DEA to handle controlled substances. 3. Only the individuals and practices that dispense directly to the patients from their clinics are required to maintain a DEA license. 4. All individuals and firms that are registered are required to maintain complete and accurate inventories and records of all transactions involving controlled substances, as well as the security for the storage of controlled substances. The attorney general may limit revocation or suspension of a registration to the particular controlled substance. However, the Board of Medical Licensure may also limit this indirectly by means of requesting the limitation by DEA and reaching an agreement with the practitioner. Source: Manchikanti L, Board Review 2005 2555. Answer: A (1,2, & 3) Explanation: Opioids increase colonic motility but reduce peristaltic acitivity; in addition, the defecation reflex is impaired. Bulk laxatives are a poor choice because adequate water intake is required and the bulk can make the stool hard and precipate impaction. Source: Oxford Textbook of Palliative Medicine, 2nd Ed Schedule an appointment to discuss abnormal/unexpected results with the patient; discuss in a positive, supportive fashion to enhance readiness to change/motivational enhancement therapy (MET) opportunities. Use results to strengthen physician-patient relationship and support positive behavior change. Chart results and interpretation. Source: Laxmaiah Manchikanti, MD 2558. Answer: A ( 1, 2, & 3) Explanation: Morphine is in the same class of opioids (phenanthrenes) as oxycodone, but morphine has a 6-OH group (associated with more nausea). Fentanyl, meperidine, propoxyphene, and methadone are completely different classes of opioids Source: Trescot AM, Board Review 2004 2559. Answer: A (1,2, & 3) Explanation: Ballantyne J, Mao J. Opioids for Chronic Pain. NEJM. 2003; 349: 1943-1953 Source: Mark V. Boswell, MD, KSIPP 2005 2560. Answer: E (All) Explanation: * Prolonged, high dose therapy may have adverse consequences * The opioid formulation does not reduce development of tolerance * Abuse potential of long acting and short acting formulations are the same 2556. Answer: E (All) Explanation: Clinical Recommendations * Limit the dose - Daily doses above 180 mg/day of morphine have not been validated - Dose escalation beyond the stabilization phase may predict a problem * Drug formulations - Formulation does not influence tolerance * Long term opioids produce adverse physiologic changes (immune, hormonal, pain, etc) * Opioid rotation may help reduce the need for dose escalation and improve efficacy Source: Mark V. Boswell, MD, KSIPP 2005 2561. Answer: E (All) Explanation: Continued controlled substance prescribing requires: * Diagnosis * Opioid rotation - Concept of incomplete cross-tolerance - Rotation may restore efficacy Source: Mark V. Boswell, MD, KSIPP 2005 2557. Answer: B (1 & 3) Explanation: UDT results: Consult with laboratory regarding ANY unexpected results. ASIPP * Reduction in pain * Improvement in functional status * Lack of evidence of drug abuse * Documented informed consent Source: Mark V. Boswell, MD, KSIPP 2005 2562. Answer: C (2 & 4) 531 Section 12 • Controlled Substance Management Explanation: Half life is 12 hours, as compared to diazepam which is 21-37 hours. Is indicated for short term use of anxiety. The kinetics are linear. It is converted to lorazepam glucuronide (75%) abd NOT to benzoylecgonine, a major metabolite of cocaine. Reference: Disposition of Toxic Drugs and Chemicals in Man. Fifth Edition. Randall C. Baselt. 2000 page 483 Source: Art Jordan, MD, Sep 2005 2563. Answer: A (1,2, & 3) Explanation: 1, 2, & 3. Random drug screens, narcotic contracts, and aggressive refill policies (no early refills) have been felt to help control aberrant drug behaviors. 4. Opioid rotation tries to address the issue of drug tolerance. Source: Trescot A, Board Review 2003 2564. Answer: A (1, 2, & 3) Explanation: Alcoholism is the third largest health problem after heart disease and cancer. In males 25-44 years old, alcohol plays a major role in all four leading causes of death: accidents, homicides, suicides, and alcoholic cirrhosis. The chronic use of alcohol produces psychological, interpersonal, and medical problems, which include violence, absence from work, loss of job, and legal difficulties. Alcohol is a factor associated with at least 50% of traffic fatalities, 50% of homicides, and 25% of suicides. Source: Psychiatry specialty Board Review By William M. Easson, MD and Nicholas L. Rock, MD 2565. Answer: E (All) Explanation: Explanation:All of these are condemned behaviors; the more occurring in combination, the more likely a conviction is. Source: 71 Fed. Reg. 52,724. Source: Erin Brisbay McMahon, JD 2566. Answer: C (2 & 4) Source: Cole EB, Board Review 2003 2567. Answer: A (1,2, & 3) Explanation: Patients being maintained with methadone require special consideration for acute pain management in surgical or trauma situations. 1. Maintenance patients develop full tolerance to the analgesic effects of the maintenance dose of methadone. 2.During opioid maintenance treatment, a cross-tolerance develops to all opioid agonists drugs, accounting for the “blockade effect. Early research has demonstrated that stable opioid maintenance treatment patients could not distinguish 20 mg of intravenous morphine from intravenous saline. 3. The usual maintenance dose does not provide any analgesia, and adequate analgesia will require higher doses of opioid agonists given more frequently than in the nontolerant patient. Methadone has a half-life of 24 to 36 hours, but its analgesic effects range from 4 to 6 hours, which is similar to morphine in both potency and duration. Morphine, Dilaudid, codeine, and other agonist drugs are appropriate for opioid maintenance treatment patients. Mixed agonist-antagonists (pentazocine, butorphanol, nalbuphine) and partial agonists (buprenorphine) must not be used, as they will precipitate an opioid withdrawal syndrome. Meperidine and propoxyphene should be avoided because of the risk of seizures at the higher doses required to produce analgesia in these patients. 4. Maintenance doses of opioids do not provide adequate analgesia in acute pain. 2568. Answer: D (4 Only) Explanation: Alcohol withdrawal delirium (delirium tremens, DT’s) is characterized by confusion, disorientation, fluctuating or clouded consciousness, perceptual disturbances, delusions, vivid hallucinations, agitation, insomnia, mild fever, and marked autonomic arousal. Problems may apepar suddently or two or three days after cessation or redduction of heavy drinking, with a peak at the fourth or fifth day. Symptoms may last four to five weeks, but in the majority of patients, problems subside after three days. About one-third who develop alcohol withdrawal seizures (“rum fits”) go into delirium tremens. The best treatment is to prevent withdrawal by the use of benzodiazepines and a hig-calorie, high carbohydrate diet with supplemental vitamins. Source: Psychiatry specialty Board Review By William M. Easson, MD and Nicholas L. Rock, MD 2569. Answer: E (All) Explanation: Barbiturate withdrawal (especially short acting) usually results in weakness, insomnia, anxiety, tremulousness, abdominal discomfort, nausea and vomiting. With preexisting cardiovascular problems, there may be fatal reactions. Seizures generally precede delirium. Symptoms are more marked with secobarbital an dleast with phenobarbital withdrawal (due to its long half-life). Source: Psychiatry specialty Board Review By William M. Easson, MD and Nicholas L. Rock, MD ASIPP 532 Section 12 • Controlled Substance Management 2570. Answer: D (4 Only) Explanation: In Acute opioid overdose, the drug of choice is naloxone HCI (Narcan), 0.4-2.0 mg, preferably IV, every 2 to 3 minutes, to a maximum dose of 10 mg. Nalocone is an opioid antagonist that blocks opioid receptors. Other opioid antagonists are nalorphine and levellorphane. In an opioid withdrawal procedure, naltrexone HCI (Trexan), clonidine, and methadone may be used as they have longer acting effects. Source: Psychiatry specialty Board Review By William M. Easson, MD and Nicholas L. Rock, MD prescribed) Source: Art Jordan, MD, Sep 2005 2576. Answer: E (All) Explanation: 21 U.S.C 823 (g) Source: James D. Colson, MS, MD 2577. Answer: E (All) Explanation: History of Opium * Eber’s Papyrus, 1500 B. C. - pain relief 2571. Answer: B (1 & 3) Explanation: A documented abnormality/pathology on MRI may be an incidental finding and not causing pain . . . treat the patient, not the MRI. Just because another physician has been dispensing narcotics to a patient, does not necessarily mean it was appropriate or legal. The dispensing/prescribing must be based on a legitimate medical purpose as determined by the current prescribing physician, after careful evaluation and examination. Source: Art Jordan, MD, Sep 2005 2572. Answer: B (1 & 3) Explanation: 2 and 4 are incorrect. A prescription cannot be issued in order for an individual practitioner to obtain controlled substances for supplying the individual practitioner for the purpose of general dispensing to patients. Schedule II drugs cannot be prescribed for narcotic addiction treatment. Reference: 21 USC 823(g); 21 CFR 1306.04 Source: Erin Brisbay McMahon, JD, Sep 2005 * Greece - mixed with wine 100 B. C. * Galen - 100 A. D. - ‘great cure-all’ * Arabia - (600-900 A. D.) used medicinally. When the Koran forbade alcohol, Opium and Hashish became the primary social drugs. Source: Roger Cicala, MD, Sep 2005 2578. Answer: A (1,2, & 3) Explanation: Food and Drug Act Amendments * Durham-Humphrey 1951 - make OTCs require prescriptions. * Boggs Act (1951) * Narcotic Control Act (1956) * Drug Abuse Control Acts of 1965 _and 1968 labelled ‘potential drugs of abuse’ and gave power to DEA precursors to regulate. Source: Roger Cicala, MD, Sep 2005 2573. Answer: B (1 & 3) Source: Reddy Etal. Pain Practice: Dec 2001, march 2002 2579. Answer: A (1,2, & 3) Source: Stimmel, B 2574. Answer: A (1,2, & 3) Explanation: Grapefruit juice will increase methadone levels. Source: Andrea M. Trescot, MD 2580. Answer: C (2 & 4) Explanation: Urine Drug Test Methods: Cocaine 2575. Answer: A (1,2, & 3) Explanation: Financial contracts are not included. ASIPP Cocaine, a topical anesthetic, is clinically used in certain trauma, dental, ophthalmoscopic, and otolaryngologic procedures. In addition, the complete listing includes: A patient’s urine may test positive for the cocaine metabolite benzoylecgonine after such a procedure for up to 2 to 3 days. 1: Medical history and physical examination 2: Diagnostic, therapeutic and laboratory results 3: Evaluations and consultations 4: Discussion of risks and benefits 5: Informed consent 6: Treatments 7: Medications (including date, type, dosage and quantity There is no structural similarity between other topical anesthetics that end in “caine” (eg, Novocaine, lidocaine) and cocaine or benzoylecgonine; therefore, cross-reaction does not occur. A positive UDT result for the cocaine metabolite, in the 533 Section 12 • Controlled Substance Management absence of a medical explanation, should be interpreted as due to deliberate use. Source: Laxmaiah Manchikanti, MD 2581. Answer: A (1,2, & 3) Source: Laxmaiah Manchikanti, MD 2582. Answer: E (All) Explanation: Drug Testing may be performed by any of the following: Urine Drug Screening Specific drug analysis (blood) Hair Samples Saliva Testing Serum Levels Source: Laxmaiah Manchikanti, MD 2583. Answer: B (1 & 3) Explanation: Watch for signs: Work performance alternating between periods of high and low productivity and mistakes made due to inattention, poor judgment and bad decisions; Confusion, memory loss, and difficulty concentrating or recalling details and instructions. Ordinary tasks require greater effort and consume more time; Interpersonal relations with colleagues, staff and patients suffer. Rarely admits errors or accepts blame for errors or oversights; Heavy “wastage” of drugs; Sloppy recordkeeping, suspect ledger entries and drug shortages; Inappropriate prescriptions for large narcotic doses; Insistence on personal administration of injected narcotics to patients; Source: Erin Brisbay McMahon, JD, Sep 2005 2584. Answer: E (All) Explanation: 1. Methadone is an opioid receptor agonist. It is used as an analgesic and to treat opioid abstinence and heroin users (methadone maintenance). 2. Methadone has greater oral efficacy than morphine and a much longer biologic half-life; 3. Methadone produces milder but more protracted abstinence syndrome associated with methadone. 4. Adverse reactions may include constipation, respiratory depression, and light headedness. 2585. Answer: B (1 & 3) Explanation: Opiates are naturally occurring alkaloids such as morphine. Opioids are natural or synthetic compounds that work at the opioid receptor. All opiates are opioids, and all opioids are narcotics. However, not all opioids are opiates. All narcotics are opioids; examples of nonopioid narcotics include marijuana and LSD. Source: Andrea M. Trescot, MD 2586. Answer: C (2 & 4) Explanation: Cocaine withdrawal has no specific physiological signs, but there are physical problems (“crash”) that peak in two to four days. Depression and irritability can persist for weeks. These patients show a desire for sleep, often with insomnia, with disturbed sleep and increased dreaming, general fatigue, and suicidal ideation. Drug-seekingbehavior usually occurs after bein drug-free for a few days. Source: Psychiatry specialty Board Review By William M. Easson, MD and Nicholas L. Rock, MD 2587. Answer: D (4 Only) Explanation: Amphetamines or “speed” are stimulants with reinforcing effects similar to cocaine. Chronic amphetamine use causes tachycardia, elevated BP, pupillary dilation, agitation, elations, and hypervigilance. Adverse side effects include insomnia, fever, headaches, confusion, irritability, hostility, and visual hallucinations. Source: Psychiatry specialty Board Review By William M. Easson, MD and Nicholas L. Rock, MD 2588. Answer: A (1,2, & 3) Explanation: Some opioids, such as morphine, are metabolized by glucuronidation, while other opioids, such as propoxyphene are metabolized by the P450 system. M6G is analgesic while M3G is probably produces hyperalgesia. Reference: Sjogren P, Jensen NH, Jensen TS. Disappearance of morphine-induced hyperalgesia after discontinuing or substituting morphine with other opioid agonists. Pain 1994 Nov;59(2):313-6. Source: Andrea M. Trescot, MD 2589. Answer: B (1 & 3) Explanation: Patient is taking 4950mg acetaminophen per day (Lortab has 500mg per tablet = 3000mg, Fioricet has 325mg per tablet = 1950mg). Toxic acetaminophen levels range from 3 to 4 gm per day. The equivalent dose of methadone would be 10mg TID (hydrocodone 60mg per day = morphine 60mg; decrease dose by 1/2 =30mg, divide by 3 and dose q 8hr would be 10mg q 8hrs). Paroxetine is a potent CYP2D6 inhibitor and will inhibit the metabolism of hydrocodone to hydromorphone, leading to decreased analgesia. Neither escitalopram (Lexapro) or citalopram ASIPP 534 Section 12 • Controlled Substance Management (Celexa), which are considered “super-selective SSRIs”, will inhibit CYP2D6. Butalbital and triptons can cause rebound headaches, and should be changed; prophylactic medications may be needed. Methadone gives good relief of headaches, but butalbital will decrease methadone levels. Source: Andrea M. Trescot, MD 2590. Answer: A (1,2, & 3) Explanation: Equipotent doses of opioids are equipotent on the respiratory system, and there is a direst effect on the medulla. The cough suppression is a different mechanism than the respiratory response. However, respiratory rate will only drop after the CO2 and hypoxia responses have decreased. Source: Andrea M. Trescot, MD 2591. Answer: A (1,2, & 3) 2592. Answer: E (All) Explanation: Harrison Narcotics Tax Act of 1914: * Tax on all opium and coca. * Required physicians to register and keep records of prescribed medications. * Outlaws sale and distribution except prescribed by physician. * Created Bureau of Narcotics of Treasury Department (and Federally run Heroin Clinics for addicts). * The Bureau of Narcotics became the Prohibition Unit after passage of the Volstead Act. After Prohibition ended it became the Federal Narcotics Bureau and later the D. E. A. -does your Medical Licensure Board have guidelines on prescribing controlled substances? -what does DEA say about your state on its website? http://www.dea.gov/pubs/state_factsheets.html Source: Erin Brisbay McMahon, JD, Sep 2005 2594. Answer: D (4 only) Explanation: Nociceptive pain is caused by the activation of nociceptors in the tissues, and is divided into somatic and visceral causes. Deafferentation and automatic firing are characteristics of neuropathic pain, and respond to alpha 2 antagonists. NSAIDs, which block prostaglandins, are often useful in nociceptive pain. Source: Andrea M. Trescot, MD 2595. Answer: E (All) Source: temp 2596. Answer: A (1, 2 & 3) 2597. Answer: D (4 only) 2598. Answer: A (1,2, & 3) Explanation: Level of Care - Necessary to Achieve & Maintain Abstinence * Medically managed inpatient treatment - Medical/surgical hospital - Psychiatric hospital * Medically supervised inpatient treatment * Partial hospitalization Harrison Act Case Law: * Intensive outpatient program * Three physician cases: Webb (1919), Moy (1920), and Behrman (1921). - Behrman: Physicians could not prescribe to ‘habitual users. - Webb and Moy: Must be “in the usual course of practice” to a “legitimate patient”. - 3,000 physician arrests during 1920s. * Residential treatment program Source: Kennison Roy, MD * By 1930 “addict pattern” was male, minority, criminal. But much smaller (?20,000). * Payment issues - The opioid model works well from a business standpoint * 1925 Linder case allowed physicians to prescribe long term or in addicted persons - but few would. Source: Roger Cicala, MD, Sep 2005 * System difficulties - Hard to assemble a multidisciplinary team 2593. Answer: A (1,2, & 3) Explanation: AVOIDING TROUBLE Know your state -what laws and regulations are in place? ASIPP 2599. Answer: B (1 & 3) Explanation: Barriers to Non-Opioid Management * Issues of detoxification - “Rebound pain” phenomenon Source: Kennison Roy, MD 2600. Answer: D (4 Only) Explanation: * Outcome studies are becoming available 535 Section 12 • Controlled Substance Management - One year post completion outcome data: All patients still had some pain - most had much less 70% had achieved continuous sobriety Pain was not ever worse without narcotics than it was while taking narcotics. Source: Kennison Roy, MD 2601. Answer: A (1,2, & 3) Explanation: State Board Rules You Might Not Know Case Study: Eastern Kentucky * Almost half a ton of prescription narcotics reached six counties in Eastern Kentucky from 1998-2001, equating to .75 pound for every adult in those counties. * On a per capita basis, Eastern Kentucky drugstores, hospitals, and legal outlets receive more prescription painkillers than anywhere else in the United States. The Escalating Problem: Hydrocodone Cannot Rx Schedule II or III for family members Can provide samples of unscheduled drugs for family, but MUST document in a medical record Cannot Rx for anyone in sexual relationship, EVER. Cannot Rx for yourself, EVER. Cannot Rx to anyone (including friends) if you have not documented their H&P and have a current chart on file. Source: Laxmaiah Manchikanti, MD 2602. Answer: E (All) Explanation: Source: Manchikanti et al., National All Schedules Prescription Electronic Reporting Act (NASPER): Balancing Substance Abuse and Medical Necessity, Pain Physician 2002 GRIM NATIONAL STATISTICS Opioid abuse increased 85% from 1994-2000 Oxycodone abuse increased 166% since 1994 Hydrocodone abuse increased 116% since 1994 OxyContin suspected in 282 overdose deaths during a 19month period Source: Erin Brisbay McMahon, JD, Sep 2005 2603. Answer: B (1 & 3) Explanation: Federal Guidelines allow for use of opioids for analgesia in persons with substance abuse disorder for “legitimate medical reasons”. Clear documentation of the pain problem is needed to demonstrate the physician without proper credentials is not attempting to detoxify an opiate abuser. State regulations in certain states do no allow for this, and consider prescribing opioids in known substance abusers malprescribing. Source: Laxmaiah Manchikanti, MD 2604. Answer: A (1,2, & 3) Explanation: Source: Linda Johnson, Eastern Kentucky: Painkiller Capital, Lexington Herald-Leader, Jan.19, 2003 and Linda Johnson, Lesser-Known Favorites Cheap, Abundant, Lexington Herald-Leader, Jan.19, 2003. * Nationally, emergency room visits for hydrocodone overdoses increased 500 percent from 1990-2000 * Three Eastern Kentucky counties had enough Lortab, Lorcet, and Vicodin pills in 2001 to provide every adult in those counties with 156 pills * Oxycontin sells on the street for about $40/pill; Lortabs sell for $20/pill and Lorcets for $9/pill Source: Erin Brisbay McMahon, JD, Sep 2005 2605. Answer: A (1,2, & 3) Explanation: Practitioner may administer or dispense directly, but not prescribe, a narcotic drug in any schedule to a narcotic dependent person for the purposes of detoxification or maintenance treatment only if the practitioner is registered as a narcotic treatment program and compliant with DEA regulations21 U.S.C 823 (g) Source: James D. Colson, MS, MD 2606. Answer: E (All) Explanation: U.S. enlisted soldiers addicted to opioids in RVN did not follow the pattern of addicted civilians: on return to U.S.; the great majority no longer used the drug (heroin). Source: Psychiatry specialty Board Review By William M. Easson, MD and Nicholas L. Rock, MD 2607. Answer: B (1 & 3) Source: Renee R. Lamm, MD, Sep 2005 2608. Answer: D (4 Only) Explanation: Ergotamine actions are mediated by agonist actions at both serotonin (5HT)-receptors and ?-adrenoceptor. Ergotamine causes vasoconstriction and is contraindicated during pregnancy. 2609. Answer: E (All) Explanation: Acute dystonia, gynecomastia, sedation and loss of libido may all be seen in patients being treated with neuroleptic agents. 2610. Answer: E (All) Explanation: Biotransformation generally produces metabolites that are more water soluble than the parent drug. The metabolites are less lipophilic and, hence, are poorly reabsorbed in the ASIPP 536 Section 12 • Controlled Substance Management kidney, thus facilitating elimination. 2611. Answer: A (1,2, & 3) Explanation: Side Effects are Common - Opioids are often discontinued because of adverse event: Constipation Nausea Somnolence Vomiting Source: Mark V. Boswell, MD, KSIPP 2005 Up to 20% of prescribed opioids are diverted. 567 physician arrests and sanctions in 2002. No more Federal diversion program for malprescribing physicians. State Boards may react to arrests of physicians, increasing sanctions. Source: Roger Cicala, MD, Sep 2005 2619. Answer: A (1,2, & 3) Explanation: 1. Goals of pharmacotherapy include prevention or reduction of withdrawal symptoms 2612. Answer: C (2 & 4) Explanation: Ref: Frogen and Avram. Chapter 15. Nonopioid Intravenous Anesthetics. In: Clinical Anesthesia, 2nd Edition. Barash, Cullen, Stolling; Lippencott, 1992, pg 388 Source: Day MR, Board Review 2003 2. Goals of pharmacotherapy include prevention or reduction of drug craving 2613. Answer: B (1 & 3) Explanation: Risks of Malprescribing 4. Goals of pharmacotherapy also include prevention of relapse to use of addictive drugs. Legal charges, probably jail time Conviction rate is currently almost 90% Felony conviction will likely prevent or at least severely limit future practice Duped and Dated aren’t viable defense Source: Laxmaiah Manchikanti, MD 2614. Answer: C (2 & 4) Source: Reddy Etal. Pain Practice: Dec 2001, march 2002 2615. Answer: B (1 & 3) Explanation: What is the public need? Patients and payers call for more accountability - Changing patient-physician relationship - Concern about increasing costs Clinicians (and patients) coping with information overload need tools for better decision making - Synthesis of alternative diagnostic and treatment options - Quantification of outcomes Source: Laxmaiah Manchikanti, MD 2616. Answer: E (All) Source: Reddy Etal. Pain Practice: Dec 2001, march 2002 2617. Answer: A (1,2, & 3) Source: Jackson KC. Board Review 2003 2618. Answer: A (1,2, & 3) Explanation: ASIPP 3. Goals of pharmacotherapy include restoration to or toward normalcy of any physiologic function disrupted by chronic drug use. 2620. Answer: E (All) Source: Renee R. Lamm, MD, Sep 2005 2621. Answer: A (1,2, & 3) Explanation: Prescriptions for pain relief are receiving special attention by the DEA and even the OIG because of the significant increase in the types of pain prescriptions available today, the significant increase in the number of prescriptions for these medications, and the evidence of doctor shopping by persons who obtain pain prescriptions from multiple doctors for their own abusive use or for illegal resale to others. Source: U.S. Drug Enforcement Administration News Release, October 23, 2001 (http://www.usdoj.gov/dea/pubs/pressrel/pr102301.html). Source: Erin Brisbay McMahon, JD, Sep 2005 2622. Answer: E (All) Explanation: The temperature should be 90-100 degrees F. within 4 minutes of voiding. The pH should remain with the range of 4.5 to 8.0. The urinary creatinine should be greater than 20 mg/dl; less than 20 mg/dl is considered dilute and less than 5 mg/dl is not consistent with human urine. Color may be a result of substances from food pigments, medications, or disease states. Ideally, the collection room should not contain a basin with running water, to reduce potential for specimen dilution, and blue pigment should be added to the toilet water. 537 Section 12 • Controlled Substance Management Reference: Cook, Caplan et al; The characterization of human urine for specimen validity determination in workplace drug testing: a review. J Anal Toxicol. 2000;24:579-588. Urine Drug Testing in Clinical Practice: Pearls & Pitfalls: Purdue Pharma, 2005 (available free on request) Source: Art Jordan, MD, Sep 2005 2623. Answer: A (1,2, & 3) 2624. Answer: D (4 Only) Explanation: It is important that the physician know that there are many available devices to avoid detection of improper or illegal substances in the urine, including the “Whizzinator”; an artificial penis which contains urine “guaranteed” to be drug free. Source: Art Jordan, MD, Sep 2005 2625. Answer: E (All) Explanation: It is advisable that an allopathic physician stay true to scientific and well-validated approaches when treating pain. Many times the pain management physician is a referral of desperation, and expectations of the patient may be unrealistically high. Alternative therapies such as naturopathic medicine may be trialed, in conjunction with well-established treatment to enhance positive outcome. The patient should understand from the beginning the treatment style, policy and procedures of the clinic, and expectations, particularly if controlled substances are being used. Source: Hans C. Hansen, MD 2626. Answer: A (1,2, & 3) Source: Hansen HC, Board Review 2004 2627. Answer: A (1,2, & 3) Explanation: The Federation of State Medical Boards requires specific documentation in the medical record to define legitimate medical need when controlled substances are used. This includes: medical history, substance or chemical abuse, pain history, appropriate studies, working diagnosis, treatment plan, rationale for treatment selected, patient education, and documentation that the patient and physician understand the treatment goals. The standard medical history course will cover allergies to medications, but not necessarily relevant to the concept of legitimate medical need. For appropriate prescription habitry to be realized, diagnosis, historical features and exam must meet the need for the medication, clearly outlined and understood in the medical record. Source: Hans C. Hansen, MD 2628. Answer: A (1,2, & 3) Explanation: Methadone, is not included in the federal five. The correct federal five are: 1: Marijuana (delta-9-THC acid) 2: Cocaine (benzoylecgonine) 3: Opiates 4: Phencyclidine 5: Amphetamine/methamphetamine Source: Art Jordan, MD, Sep 2005 2629. Answer: B (1 & 3) Explanation: The state of hydration on an isolated sample would be of no use in determining dosage. Likewise, the half life of the medication could not be determined from an isolated urine sample, while only checking for drugs present It is most important that the ordering physician know exactly which drugs are included in the specific test, and which drugs may not be detected. Examples include oxycodone, fentanyl, and methadone which may not be detected in many basic urine drug screens on the market. Source: Art Jordan, MD, Sep 2005 2630. Answer: C (2 & 4) Explanation: Reference: “Interim Policy Statement” November 2004 Source: Art Jordan, MD, Sep 2005 2631. Answer: C (2 & 4) Explanation: “1” was commonly referred to as alternate dating prior to the F.A.Q.’s and was generally accepted by the D.E.A. as a legal but not recommended activity. The F.A.Q.’s actually stated that this action was acceptable, however this was specifically addressed as illegal in the “Interim Policy” statement in November of 2004. Source: Art Jordan, MD, Sep 2005 2632. Answer: E (All) Explanation: Explanation: All of the above answers are listed in the interim policy. In addition, the following are also listed as “certain recurring concomitance of condemned behavior”: 1:An inordinately large quantity of controlled substances was prescribed 2: Large numbers of prescriptions were written 3: No physical examination was given 4: The physician prescribed controlled drugs at intervals inconsistent with legitimate medical treatment 5: The physician wrote more than one prescription on occasions in order to spread them out **You will frequently see some of these behaviors listed as ASIPP 538 Section 12 • Controlled Substance Management “Red Flags” Source: Art Jordan, MD, Sep 2005 2633. Answer: C (2 & 4) Source: Stimmel, B 2634. Answer: C (2 & 4) Explanation: Reference: Kalso E, Edwards JE, Moore A, McQuay JH. Opioids in chronic non-cancer pain: systematic review of efficacy and safety. Pain 2004; 112;372-380. 2639. Answer: B (1 & 3) Source: Laxmaiah Manchikanti, MD 2640. Answer: A (1,2, & 3) Explanation: Addiction: Definitions DSM-IV - None A primary, chronic neurobiologic disease with genetic,psychosocial and environmental factors effecting its course and presentation Morphine and oxycodone equally effective Morphine 20mg/day and oxycodone 30 mg/day not effective All patients in studies were on opioids previously Opioids did not improve depression Improved functional status unclear Source: Mark V. Boswell, MD, KSIPP 2005 2635. Answer: B (1 & 3) Explanation: Drug Dependent (Addict) Uses another doctor’s DEA number 2641. Answer: D (4 Only) Explanation: Morphine is used to relieve the pain associated with myocardial infarction. It can suppress the opioid withdrawal syndrome but not the withdrawal syndrome associated with other classes of central nervous system depressants. Morphine and other opioids induce constipation and can be used to treat diarrhea. Miosis is an adverse effect of morphine. Calls in scripts in names of family members or fictitious patients and picks them up himself Source: Laxmaiah Manchikanti, MD 2642. Answer: E (All) Explanation: SUBSTANCE DEPENDENCE: DSM-IV DEFINITION Starts by taking controlled drug samples Asks staff to pick up medications in their names 2636. Answer: A (1,2, & 3) Explanation: NEED SLIDE 13 Source: Laxmaiah Manchikanti, MD 2637. Answer: A (1,2, & 3) Explanation: Phase II reactions typically yield water-soluble metabolites. Active centers are introduced during phase I, not phase II, biotransformation. Glucuronyl transferase is the only phase II enzyme inducible by drug administration. Prodrugs are often activated by phase I, not phase II, reactions; phase II reactions generally terminate drug action. 2638. Answer: E (All) Explanation: All of the choices are possible consequences of drug administration. Many enzymes involved in drug biotransformation also catalyze the metabolism of endogenous compounds such as steroids. ASIPP Characterized by one or more of the following Impaired control of drug use Compulsive use Craving Continued use despite harm4-Cs Loss of Control Craving Compulsive Use Continued use despite consequences Source: Laxmaiah Manchikanti, MD Need 3 in 12 months Tolerance Withdrawal Larger Amounts/Longer periods Efforts or desire to cut down Large Amount of time using/obtaining/recovering Activities given up: social/work/recreation Continued use despite problems Source: Laxmaiah Manchikanti, MD 2643. Answer: A (1,2, & 3) Explanation: Clinical Implications: * Difficult to distinguish pharmacologic tolerance from opioid-induced abnormal pain sensitivity * Treating increasing pain with increasing doses may be futile * High dose therapy may have adverse consequences Source: Mark V. Boswell, MD, KSIPP 2005 539 Section 12 • Controlled Substance Management 2644. Answer: B (1 & 3) Explanation: Prolonged, High-Dose Opioid Therapy: No evidence to support high dose therapy (> 200 to 300 mg/day or more) Anecdotal evidence that pain relief not better Opioid doses should be limited to improve efficacy and safety Source: Mark V. Boswell, MD, KSIPP 2005 2645. Answer: A (1,2, & 3) Explanation: Physician Opioid of Choice 1990s Hydrocodone 70% Fentanyl class 10% Dilaudid < 5% Oxycodone < 5% Codeine < 5% 2002 Ultram 70% Hydrocodone 40% Oxycodone 25% Fentanyl class < 5% Dilaudid < 5% Source: Roger Cicala, MD, Sep 2005 2646. Answer: C (2 & 4) Explanation: Opioid toxicity or overdose should be suspected in any undiagnosed coma patient or patients with respiratory depression (pulmonary edema), shock (hypothermia), pupillary construction, and needle marks. Grand mal seizures can occur with meperidine overdose. Source: Psychiatry specialty Board Review By William M. Easson, MD and Nicholas L. Rock, MD 2647. Answer: C (2 & 4) Explanation: Physician Opioid of Choice 1990s Hydrocodone 70% Fentanyl class 10% Dilaudid < 5% Oxycodone < 5% Codeine < 5% 2002 Ultram 70% Hydrocodone 40% Oxycodone 25% Fentanyl class < 5% Dilaudid < 5% Source: Roger Cicala, MD, Sep 2005 2648. Answer: D (4 Only) Explanation: Monoamine oxidase (MAO) inhibitors such as tranylcypromine may precipitate a hypertensive crisis when used in the presence of certain foods that contain tyramine, or in the presence of certain sympathomimetic agents. Note also that opioids, particularly meperidine, may also (although rarely) precipitate a hypertensive crisis when used with MAO inhibitors. 2649. Answer: D (4 Only) Explanation: Tricyclic antidepressants can precipitate narrow-angle glaucoma through their muscarinic-cholinoreceptor antagonist activity. They may cause hypotension and may block neuronal uptake of guanethidine and thus decrease its antihypertensive action. They may also decrease the gastrointestinal absorption of levodopa. 2650. Answer: E (All) Explanation: Short-acting benzodiazepines are used as preanesthetic medications because of their anxiolytic, sedative, and amnestic effects. Daytime drowsiness and ataxia are commonly produced by benzodiazepines and may impair judgment and interfere with motor skills. Paradoxical excitement is a rare adverse effect of these drugs. 2651. Answer: E (All) Explanation: Morphine produced all of the above effects. It decreases the sensitivity of the respiratory center to carbon dioxide and directly inhibits the respiratory center, leading to respiratory depression. This effect on respiration may be responsible for morphine’s beneficial effect when used to treat dyspnea and for cerebral vasodilation. Morphine produced miosis by stimulation or the Edinger-Westphal nucleus of the oculomotor nerve; this is mediated by acetylcholine and can be blocked by atropine. 2652. Answer: A (1,2, & 3) Explanation: Carbamazepine is an inducer of 2D6 and will reduce oxycodone levels. Source: Boswell MV, Board Review 2004 2653. Answer: E (All) Explanation: SUBSTANCE ABUSE: DSM-IV DEFINITION At least one in 12 months: Maladaptive pattern leading to distress or impairment Recurrent failure to fill role Recurrent physically hazardous behavior Recurrent legal problems Continued use despite social problems Never met dependence criteria Source: Laxmaiah Manchikanti, MD ASIPP 540 Section 12 • Controlled Substance Management 2654. Answer: E (All) 2655. Answer: A (1,2, & 3) Explanation: Meperidine is contraindicated for lactation because normeperidine collects in the neonate Source: Boswell MV, Board Review 2005 2656. Answer: A (1,2, & 3) Explanation: Open Label Studies 44% on opioids at 2 years 80% of patients experienced at least one adverse event No firm conclusions about tolerance and addiction 4. Poor documentation 5. No policies – No agreements 6. Ignore complaints 7. Focus on negative aspects of regulations and reimbursement 8. Not nice to investigators from Board, DEA!! 9. Reckless disregard to law with prescription pads and regulations 10. Know it all – Do it all Source: Laxmaiah Manchikanti, MD 2660. Answer: D (4 Only) Explanation: Barbiturates induce liver microsomal enzymes that increase porphyrin synthesis and increase the metabolism and inactivation of certain anticoagulants. Barbiturates show cross-dependence with other sedative-hypnotic drugs but not with opioids. Patients in trials were highly selected Results not generally applicable 5% of 1000 screened patients included Source: Mark V. Boswell, MD, KSIPP 2005 2657. Answer: E (All) Explanation: Deficient (Dated Practitioner) Too busy to keep up with CME Unaware of controlled drug categories Only aware of a few treatments or medications Prescribes for friends or family without a patient record 2661. Answer: A (1,2, & 3) Explanation: Risks of Malprescribing Loss of “Provider Status” Insurors frequently report to Boards Insurors frequently report to Boards now Several plans have removed providers for “overprescribing.” Seems more common with more expensive agents (Duh!). Insurors can report to a separate national data bank, not available to public, but available to hospitals and other insurors. Source: Laxmaiah Manchikanti, MD Unaware of symptoms of addiction Remains isolated with peers Only education from reps Source: Laxmaiah Manchikanti, MD 2658. Answer: D (4 Only) Explanation: 2002 and 2003 saw a significant increase in non-medical use of pain relievers. This seems to be a trend over the past decade. Hydrocodone leads at 15 million, followed by oxycodone (Oxycontin? specifically mentioned as a subset of oxycodone), methadone, and tramadol. Source: Hans C. Hansen, MD 2659. Answer: A (1,2, & 3) Explanation: Top 10 Pitfalls 1. 4 D’s – Deficient, Duped, Deliberate, Dependent Practioner 2. Weak heart – pretend addiction doesn’t exist 3. Never say “NO” – Family, Friends, Patients ASIPP 2662. Answer: E (All) Explanation: Symptoms of withdrawal include: Opiate craving Rhinorrhea Anxiety/Dysphoria Sweating Dilated pupils Piloerection Restlessness Yawning Muscle twitching Nervousness Increased respiration Headache Fatigue Irritability Anorexia Fever Cutaneous hypersensitivity Insomnia Tachycardia 541 Section 12 • Controlled Substance Management Hypertension Hot/cold flashes Nausea Vomiting Muscle aches/spasms Abdominal cramps Bone pain Diarrhea 2663. Answer: B (1 & 3) Explanation: Physician Drugs of Abuse 2001 Alcohol 50% to 60% Opioids 30% Benzodiazepines 20% (40% for females) Marijuana 20% Cocaine 10% Amphetamines, Ritalin 10% Source: Roger Cicala, MD, Sep 2005 2664. Answer: D (4 Only) Explanation: Benzotropine (Cogentin) has atropine-like side effects; dilated pupils, dry mouth, urinary retention, restlessness, confusion and toxic psychosis.1. Phenelzine, a MAOI, reacts with tyramine-containing substances causing a “cheese reaction,” which consists of sweating, palpitations, headache, and increased blood pressure resulting in a possible intracerebral hemorrhage.2. Disulfiram (Antabuse), if taken with alcohol, cuases flushing, throbbing, sweating, thirst, respiratory difficulty, nausea, vomiting, tachycardia, hypotension, vertigo, blurred vision, and confusion.3.Alprazolam, a benzodiazepine, causes sedation, impairment of performance, and dependency. Source: Psychiatry specialty Board Review By William M. Easson, MD and Nicholas L. Rock, MD 2665. Answer: E (All) Explanation: Use in Europe and America * Opium knowledge was lost during Dark Ages, reintroduced after Crusades. * Paracelsus 1500 called laudanum (opium, cloves, and alcohol) the “stone of immortality”. * Thomas Sydenham brought to England about 1700. * 1831 Sertuener given Nobel Prize for isolating individual opiates. * 1853 - hypodermic syringe invented. The American Civil War and Prussian Wars of 1860-1870 led to widespread morphine injection. Source: Roger Cicala, MD, Sep 2005 2666. Answer: B (1 & 3) Explanation: Opiate Abuse * “Soldier’s Disease” - morphine addiction - reported during American Civil War and Prussian Wars of 18601870. * Widespread laudanum and opiate abuse in U. S. in late 1800s. Sears carried syringe kits in catalogs. Estimated 500,000 - 1,000,000 addicted in U. S. * 4% of U. S. population used laudanum nonmedicinally. * Laudanum addiction was considered fashionable. Typically described as ‘middle-aged, upper-class white female’. Samuel Taylor Coleridge, Elizabeth Barrett Browning, Thomas De Quincy all quite open about their addiction. * Heroin introduced in 1898 as “non-addicting” morphine. Used as cure for “Morphinism” similar to methadone today. Source: Roger Cicala, MD, Sep 2005 2667. Answer: A (1, 2, & 3) Explanation: Factors determinative of control or removal from schedules by the attorney general are as follows: 1. Its actual or relative potential for abuse. 2. Scientific evidence for its pharmacological effect, if known. The state of current scientific knowledge regarding the drug or other substance. 3. Potential and current pattern of abuse The scope, duration, and significance of abuse. What, if any, risk there is to public health. Its physic or physiological dependence liability. Whether the substance is an immediate precursor of a substance already controlled under this title. 4. Price has no impact. 2668. Answer: B (1 & 3) Explanation: Tolerance occurs when the same dosage of drug has a reduced effect and increased amounts of the drug are needed to achieve the desired effect. Physical dependence, the need to take the drug to prevent withdrawal, tends to develop in parallel with tolerance. Source: Psychiatry specialty Board Review By William M. Easson, MD and Nicholas L. Rock, MD 2669. Answer: C (2 & 4) Explanation: Heroin abusers tend to start in late teens and early 20s (most common 18-25 years old), with the majority in the ASIPP 542 Section 12 • Controlled Substance Management mid-30s. There is a 3:1 male to female ratio. Suicide in abusers is three times greater than in the general population. They also have a 20 times greater death rate, as well as higher rates of hepatitis B and HIV III viral infections. Source: Psychiatry specialty Board Review By William M. Easson, MD and Nicholas L. Rock, MD 2670. Answer: E (All) Explanation: Heroin withdrawal symptoms are similar to a influenzalike syndrome along with anxiety and dysphoria. Physical symptoms include yawning, sweating, rhinorrhea, lacrimation, pupillary dilation, piloerection, hypertension, waves of gooseflesh, twitching movements, deep muscle and joint pains, nausea, diarrhea, vomiting, abdominal pains, fever, and hot and cold flashes. Source: Psychiatry specialty Board Review By William M. Easson, MD and Nicholas L. Rock, MD 2671. Answer: A (1, 2, & 3) Explanation: Therapeutic communities for substance abusers have as their goals a complete change of lifestyle and abstinence from drugs. If the patient’s stay is more than 90 days, there is a long-term decrease in illicit drugs use, antisocial behavior, and arrests, and increased employment. With a 12-month stay, subjects fare even better at five years postprogram follow-up. Source: Psychiatry specialty Board Review By William M. Easson, MD and Nicholas L. Rock, MD 2672. Answer: B (1 & 3) Explanation: Withdrawal convulsions can occur with alcohol, certain benzodiazepines, and barbiturates. Source: Psychiatry specialty Board Review By William M. Easson, MD and Nicholas L. Rock, MD 2673. Answer: B (1 & 3) Explanation: 1. Neuropsychologic testing can document the physician is mentally acute while on chronic opioid therapy. 2. Without adequate documentation of the physician patient’s mental ability and the requirements of the hospital, the pain treatment physician could place him or herself at risk by making such a statement. 3. The pain treatment physician cannot directly inform the interested parties of the patient’s medications, but can cease treating the patient if he or she feels the situation is not acceptable. 4. There is no law in most states that prevents practicing medicine while taking opioids. Source: Roger Cicala, MD, Sep 2005 2674. Answer: B (1 & 3) Explanation: Those who either stop or control drug use after a period of addiction are more likely to be older than age 40, have a ASIPP normal premorbid personality, never be arrested for substance abuse, and to undergo substance abuse treatment / rehabilitation. Developing medical complications from abuse rarely leads to abstinence. Source: Roger Cicala, MD, Sep 2005 2675. Answer: E (All) Explanation: Simple Chronic Pain Pain lasting longer than 6 months. Tend to have no more distress or psychopathology than what is expected in the general population. Tend to continue working. Tend not to become overly reliant on medications, i.e., have various ways to self-manage pain. Tend to maintain meaningful relationships Tend to maintain a sense of meaning and direction to their lives. Source: Murray McAllister, PsyD, LP - Spring 2004 2676. Answer: A (1,2, & 3) Explanation: 1. 10% of prescription drugs are used for non-medical purposes. 2. Over 6 million people over the age of 12 years in the United States have been reported to use controlled prescription drugs for non-medical purposes. 3. Opioid abuse is seen in as high as 18% to 24% of the patients in chronic pain. Illicit drug use is seen in 14% to 32% of chronic pain patients. 4. Marijuana is the most commonly used illicit drug, followed by cocaine. Source: Laxmaiah Manchikanti, MD 2677. Answer: B (1 & 3) Explanation: All of the above are symptoms of opiate withdrawal along with numerous others. Fever, Hypertension, and Tachycardia are considered the most consistent symptoms indicated severe withdrawal reaction. Source: Roger Cicala, MD, Sep 2005 2678. Answer: B (1 & 3) Explanation: The patient’s total dose of hydrocodone is 60mg per day, which is equal to 60mg oral morphine per day. This converts to 20mg IV morphine per day (30mg morphine = 10mg IV), which is divided by 24 to get the hourly dose of 1mg per hour. This is equivalent to 3mg per day of hydromorphone (10mg IV morphine = 1.5mg IV hydromorphone so 20mg IV morphine = 3mg IV hydromorphone), which, divided into 6 doses (q4hrs) = 0.5mg per dose. Meperidine is not appropriate, and fentanyl is too slow an onset for the initial conversion. Source: Andrea M. Trescot, MD 543 Section 12 • Controlled Substance Management 2679. Answer: B (1 & 3) Explanation: Alcohol is a significant problem, particularly when controlled substances are being used, and those that have significant risks associated with them, particularly pharmacokinetically long acting drugs. An example that underscores this issue is that the FDA recently removed Palladone?, a pharmacokinetically long acting hydromorphone preparation from the market. Palladone? has been considered for pain control for a number of years, recently introduced, and to be found an unacceptably high risk when mixing alcohol and this drug. 50% of the American population consider themselves alcohol consumers, and 22% of those participated in a binge drinking episode one month prior to the survey. 16.1 million are heavy drinkers, and at significant risk. Source: Hans C. Hansen, MD 2680. Answer: A (1,2, & 3) Explanation: Personal and family history of substance abuse, personal and family history of psychiatric illness, male gender, age under 40, and nonmarried status are all associated with increased prevalence of substance abuse. Source: Roger Cicala, MD, Sep 2005 2681. Answer: E (All) Explanation: The above are the 4 listed characteristics in the Consensus Statement. Source: Roger Cicala, MD, Sep 2005 2682. Answer: A (1,2, & 3) Explanation: U. S. Opiate Abuse Patterns * Change from morphine to heroin in 50s-60s. Dramatic increase in numbers 60s-70s. * Reduction in opiate abuse during 80s and early 90s (?cocaine effect?) * Prescription opiate abuse increases in late 1990s (?or increased awareness?) * Heroin resurgence begins late 1990s. Source: Roger Cicala, MD, Sep 2005 * Coca products began widespread use in 1880s in patent medicines and ‘soft drinks’. Endorsed by the Surgeon General in 1886. * Amphetamines 1920s, used by military, physicians, widespread public use in 30s. * Barbiturates and amphetamines began widespread use in 1940s, originally as OTC medications and in patent medications. * Marijuana use reported in 1880s. Became popular during prohibition and through the great depression. * Hallucinogens popularized in 1960s. Declined by late 1970s. Source: Roger Cicala, MD, Sep 2005 2686. Answer: A (1,2, & 3) Source: Stimmel, B 2687. Answer: E (All) Source: Stimmel, B 2688. Answer: A (1,2, & 3) Source: Stimmel, B 2689. Answer: E (All) Explanation: Prescription drug abuse, particularly of opioid pain killers, has increased at an alarming rate over the last ten years. Non-medical use of narcotic pain relievers, tranquilizers, stimulants, and sedatives ranks second (behind marijuana) as a category of illicit drug abuse among adults and youth. In 2003, 6.3 million Americans were current abusers of prescription drugs, with 4.7 million using pain relievers. 100,000 E.R. visits for Benzodiazepine abuse in 2002 119,000 E.R. visits for 0pioid abuse in 2002 SAMSHA, 2003 Survey DAWN, 2004 Report Source: Laxmaiah Manchikanti, MD 2690. Answer: A (1, 2, & 3) 2683. Answer: E (All) Source: Stimmel, B 2684. Answer: E (All) Source: Stimmel, B 2685. Answer: E (All) Explanation: Other Drugs of Abuse 2691. Answer: B (1 & 3) Explanation: Seizure can occur with stimulant overdose or benzodiazepine withdrawal. It is not a reported part of the syndrome of opiate withdrawal or of cocaine withdrawal. Given the positive drug screen for benzodiazepines and cocaine, either scenario is possible. Source: Roger Cicala, MD, Sep 2005 ASIPP 544 Section 12 • Controlled Substance Management 2692. Answer: D (4 Only) Explanation: Answer (a) is wrong because the court cannot grant probation, parole, or a suspended sentence if death or serious bodily injury results with respect to a S I or II drug. Reference: 21 USC 841. Source: Erin Brisbay McMahon, JD, Sep 2005 2693. Answer: A (1,2, & 3) Explanation: (Stoelting, Anesthesia and Co-Existing Disease, 3/e, pp 528-529.) Acute cocaine overdose will increase in central catecholamine levels are increased. Cocaine inhibits the reuptake of norepinephrine. Increased circulating norepinephrine levels have numerous effects on the cardiac system, including coronary artery vasospasm, an increase in myocardial oxygen consumption, and an increase in systemic vascular resistance. These effects can cause high-output cardiac failure and cardiac ischemia. Source: Curry S. 2694. Answer: E (All) Explanation: The active ingredient in marijuana is Delta-9tetrahydrocannabinol. In general, marijuana is a CNS stimulant causing tachycardia, giddiness, and , at high doses, visual hallucinations. 1. Potential therapeutic uses include antiemesis in cancer chemotherapy and reduction of intraocular pressure in glaucoma. 2. Acute intoxication is characterized by reddening of the conjunctiva (bloodshot eyes) owing to local vasodilation. 3. Potential therapeutic uses include antiemesis in cancer chemotherapy and reduction of intraocular pressure in glaucoma. 4. Chronic use has been associated with an amotivational syndrome and with a reduction in serum testosterone and sperm count. 2695. Answer: B (1 & 3) Explanation: Chronic alcoholism is associated with retrobulbar optic neuropathy, cerebellar anterior lobe degeneration, encephalopathy (Wernicke’s), subdural hematoma, amnestic disorder (Korsakoff ’s syndrome), dementia, peripheral neuropathy, pancreatitis, esophageal varices, duodenal ulcer, cardiomyopathy, pulmonary infections (especially tuberculosis), cirrhosis, and fetal alcohol syndrome. Source: Psychiatry specialty Board Review By William M. Easson, MD and Nicholas L. Rock, MD 2696. Answer: E (All) ASIPP Explanation: Although equipotent charts may vary, in general, 30mg of oral MSO4 is equivalent to 10mg MSO4 IV, 20mg of oral oxycodone, 1.5mg of IV hydromorphone, or 20mg of methadone. Source: Trescot A, Board Review 2003 2697. Answer: E (All) Source: Reddy Etal. Pain Practice: Dec 2001, march 2002 2698. Answer: C (2 & 4) Explanation: * The attorney general may suspend or revoke a registration to manufacture, distribute, or dispense a controlled substance upon finding that the registrant: - Has materially falsified any application filed. - Has been convicted of a felony. - Has had his state license or registration suspended, revoked, or denied. * Has committed such acts as wound render his registration inconsistent with the public interest. * Has been excluded or directed to be excluded from participation in a program pursuant to Section 1128 (A) of the Social Security Act. 2699. Answer: C (2 & 4) Explanation: Answer (1) is wrong because no Schedule II prescription can be refilled. Answer (3) is wrong because there is no exception for dispensing drugs to another physician. Reference: 21 USC 829(a). Source: Erin Brisbay McMahon, JD, Sep 2005 2700. Answer: A (1,2, & 3) Explanation: Answer (4) is wrong as the physician does not need to determine that the patient is complaining of extreme and unremitting pain before finding that an emergency situation exists. Reference: 21 CFR 290.10, 1306.11(d). Source: Erin Brisbay McMahon, JD, Sep 2005 2701. Answer: B (1 & 3) Explanation: Interviews with family members may be helpful under certain circumstances if clinically indicated and if within legal bounds of privacy, however, this is not listed by the Board. Periodic reports from law enforcement, without patient consent, would be inappropriate and possibly a violation of privacy laws. Source: Art Jordan, MD, Sep 2005 545 Section 12 • Controlled Substance Management 2702. Answer: A (1,2, & 3) Explanation: Answer (4) is wrong because a fax will not serve as the original prescription for a Schedule II controlled substance for any terminally ill patient. Reference: 21 CFR 1306.11. Source: Erin Brisbay McMahon, JD, Sep 2005 2703. Answer: B (1 & 3) Explanation: Answers (2) and (4) are wrong because both the prescribing physician and the pharmacist have the responsibility to make sure the controlled substance is for a terminally ill patient when the partial filling is for a terminally ill patient. Reference: 21 CFR 1306.13. Source: Erin Brisbay McMahon, JD, Sep 2005 2704. Answer: A (1,2, & 3) Explanation: Answer (1) is wrong; that is not a requirement for a partial filling of a prescription for a Schedule III, IV, or V substance. Reference: 21 CFR 1306.23. Source: Erin Brisbay McMahon, JD, Sep 2005 2705. Answer: D (4 Only) Explanation: Cocaine blocks neuronal dopamine, serotonin, and norepinephrine reuptake. With prolonged cocaine use and abuse, a delusional psychosis similar to paranoid schizophrenia may develop. Source: Psychiatry specialty Board Review By William M. Easson, MD and Nicholas L. Rock, MD 2706. Answer: E (All) Source: Laxmaiah Manchikanti, MD 2707. Answer: A (1,2, & 3) Explanation: Alcohol withdrawal occurs when there is a relative drop in blood alcohol levels; therefore, it can develop while still drinking. The patients are likely to show a coarse, fastfrequency generalized tremor that is made worse by motor activity or stress and is easily observed when the hands or tongue are extended. Withdrawal is manifested by autonomic hyperactivity (increased BP, tachycardia, sweating), malaise, vomiting with anxiety, depression, irritability, cognitive changes, and possible seizures. Source: Psychiatry specialty Board Review By William M. Easson, MD and Nicholas L. Rock, MD 2708. Answer: E (All) Explanation: All of the above are required services for an OTP. Refernece: 42 CFR 8.12. Source: Erin Brisbay McMahon, JD, Sep 2005 2709. Answer: A (1,2, & 3) Source: Renee R. Lamm, MD, Sep 2005 2710. Answer: E (All) Explanation: Reference: The Federation of State Medical Boards’ Model Policy for the Use of Controlled Substances for the Treatment of Pain (May 2004); www.fsmb.org. Explanation: The correct answer is E, all of the above, because each of these items plays into the minimum standards related to the taking of a patient history and the performance of a physical examination prior to prescribing controlled substances for the treatment of pain. A provider should not omit any of these questions from his/her interaction with the patient. Many of these questions can be set forth in a general history form. Providers may also develop special forms on substance abuse issues to use with patients prior to prescribing them controlled substances. In all cases, providers should cover these areas and more with their patients. Consult your state materials on the use of controlled substances for the treatment of pain. Source: Jennifer Bolen, JD, Sep 2005 2711. Answer: A (1,2, & 3) Explanation: Reference: Collins and Streltzer 2003, Am J. Addict 12:2, Covington an dKoltz, 2003 Prin of Addict Med Source: Renee R. Lamm, MD, Sep 2005 2712. Answer: E (All) Explanation: Cimetidine, and Ciprofloxin are CYP3A4 inhibitors, and will increase methadone levels. Ciprofloxin can inhibit CYP3A4 by up to 65%. Phenytoin and butalbital will induce the CYP3A4 enzyme and decrease blood levels. Source: Andrea M. Trescot, MD 2713. Answer: D (4 Only) Explanation: The most likely problem is that the paroxetine (Paxil®) (a potent CYP2D6 inhibitor) is preventing the metabolism of tramadol to the active M1 metabolite. He is therefore not drug seeking or withdrawing from illicit drugs, but instead has had his previously working opioid made ineffective by the drug interaction. Source: Andrea M. Trescot, MD 2714. Answer: E (All) 2715. Answer: E (All) Explanation: History of Opium * Arabic traders spread use and cultivation to China by 900 A. D. * 1644 China outlawed tobacco, opium smoking became endemic ASIPP 546 Section 12 • Controlled Substance Management * 1700 British East India company smuggled opium from India to China for tea (China refused legitimate trade). * 1839 - Because of “rampant addiction” Chinese emperor destroyed 45,000 pounds of British opium in Canton, beginning the Opium war. * Britain won the ensuing war, receiving Hong Kong and forcing China to accept opium in trade. * Opium finally outlawed in China by 1913. Source: Roger Cicala, MD, Sep 2005 2716. Answer: E (All) 2717. Answer: C (2 & 4) Explanation: Itching from opioids (usually the naturally occurring such as codeine and morphine) is usually not an antibody/antigen reaction but rather a direct histamine release from the mast cells, as well as a central µ receptor stimulation. Changing to a synthetic opioid such as hydromorphone will usually resolve the problem. In the face of a “true allergy”, there is usually no cross reactivity across classes. Source: Andrea M. Trescot, MD 2718. Answer: E (All) Explanation: Different opioids have different receptor affinity, so that switching from a low affinity opioid like hydrocodone to a high affinity opioid like fentanyl may allow for better analgesia at a lower than equipotent dose. Different metabolic pathways may explain why hydrocodone (a prodrug metabolized by CYP2D6) might not be effective when propoxyphene is, especially in a patient who is CYP2D6 deficient. High doses of morphine can lead to accumulation of M3G which is hyperalgesic; switching to an opioid without this type of antagonist would give better analgesia. Inhibition of one enzyme system (such as 3A4 and methadone) would have no effect on an opioid metabolized by another system (such as 2D6 and hydrocodone). Source: Andrea M. Trescot, MD ASIPP 2719. Answer: E (All) Explanation: Opioid receptors, concentrated in the ventral tegmental and periaqueductal grey areas, presynaptically inhibit the transmission of excitatory pathways: acetylcholine, catecholamine, serotonin, and substance P. Activation of the opioid receptor inhibits adenylate cyclase. All opioid receptors are G protein-linked structures embedded in the plasma membrane of neurons; activation releases a portion of the G protein, which moves in the membrane until it reaches its target (either an enzyme or an ion channel). These targets alter protein phosphorylation and/ or gene transcription. Opioids and endogenous opioids activate presynaptic receptors on GABA neurons, which inhibit the release of GABA in the ventral tegmental area. This allows dopaminergic neurons to fire more vigorously , and the extra dopamine in the nucleus accumbens is intensely pleasurable. Source: Andrea M. Trescot, MD 2720. Answer: A (1,2, & 3) Explanation: Urine drug testing may be helpful, however is not required by law nor in the usual course of professional practice. Source: Art Jordan, MD, Sep 2005
