Substance Dependence

Question 1

Untreated heroin dependence shows early withdrawal symptoms within __________, with peak symptoms at ____________; symptoms subside substantially after ________ days

Answer 1

8 hours

36–72 hours

5

Question 2

Compared to heroin withdrawal, methadone or buprenorphine withdrawal occurs __________ (earlier/later) with ___________ (longer/shorter)-lasting symptoms

Answer 2

Later

Longer

Question 3

Opioid substitution therapy involves using ___________ and ___________ to substitute heroin or other opioids in dependence

Answer 3

Methadone

Buprenorphine

Question 4

Opioid substitute medication should be commenced with a short period of stabilisation, followed by either a ____________ regimen or by ___________ treatment.

Answer 4

withdrawal

maintenance

Question 5

What is the aim of maintenance treatment in patients who are recovering from opioid addiction?

Answer 5

Enables patients to achieve stability, reduces drug use and crime, and improves health; it should be regularly reviewed to ensure the patient continues to derive benefit

Question 6

Why is enforced withdrawal from opioids ineffective for sustained abstinence?

Answer 6

Increases the risk of patients relapsing and subsequently overdosing because of loss of tolerance

Question 7

Complete withdrawal from opioids usually takes up to ____________ in an inpatient or residential setting, and up to ___________ in a community setting.

Answer 7

4 weeks

12 weeks

Question 8

If abstinence from opioids is not achieved, illicit drug use is resumed, OR the patient cannot tolerate withdrawal, the ___________ regimen should be stopped and ___________ therapy should be resumed at the optimal dose.

Answer 8

withdrawal

maintenance

Question 9

Following successful withdrawal treatment from opioids, further support and monitoring to maintain abstinence should be provided for a period of at least _____________

Answer 9

6 months

*This includes medical, social, and psychological support

Question 10

Patients who miss _________ or more of their regular prescribed dose of opioid maintenance therapy are at risk of overdose because of loss of tolerance.

Answer 10

3 days

Question 11

Patients who miss 3 days or more of their regular prescribed dose of opioid maintenance therapy are at risk of ___________ because of loss of tolerance.

Answer 11

Overdose

Consider reducing the dose in these patients

Question 12

If the patient misses _____ or more days of opioid maintenance therapy, an assessment of illicit drug use is also recommended before restarting substitution therapy

Answer 12

If the patient misses 5 or more days of treatment, an assessment of illicit drug use is also recommended before restarting substitution therapy

*this is particularly important for patients taking buprenorphine because of the risk of precipitated withdrawal

Question 13

If the patient misses 5 or more days of treatment, an assessment of ___________ is also recommended before restarting substitution therapy

Answer 13

illicit drug use

*this is particularly important for patients taking buprenorphine because of the risk of precipitated withdrawal

Question 14

Buprenorphine is preferred by some patients because it is less __________ than methadone hydrochloride

Answer 14

sedating

Question 15

What is the mechanism of action of buprenorphine?

Answer 15

Partial agonist at mu receptors (ie partially activates opiate receptors) to cause a potent analgesic effect on the CNS

Question 16

____________ (buprenorphine/methadone) may be more suitable for employed patients or those undertaking other skilled tasks such as driving

Answer 16

Buprenorphine (less sedating)

Question 17

_____________ (buprenorphine/methadone) is safer than _____________ (buprenorphine/methadone) when used in conjunction with other sedating drugs, and has fewer drug interactions

Answer 17

Buprenorphine

Methadone

Question 18

Dose reductions may be easier than with ______________ (buprenorphine/methadone) because the withdrawal symptoms are milder, and patients generally require fewer adjunctive medications

Answer 18

Methadone

Question 19

There is a lower risk of overdose with _____________ (buprenorphine/methadone)

Answer 19

Methadone

Question 20

Buprenorphine can be given on alternate days in higher doses and it requires a shorter drug-free period than methadone hydrochloride before induction with _____________ for prevention of relapse.

Answer 20

naltrexone hydrochloride

Question 21

What is “precipitated withdrawal” in the context of opioid dependence?

Answer 21

When patients are dependent on high doses of opioids, withdrawal can occur if buprenorphine (a partial agonist) is administered when other opioid agonist drugs are in circulation

Question 22

Precipitated opioid withdrawal, if it occurs, starts within __________ of the first buprenorphine dose and peaks at around _________.

Answer 22

1–3 hours

6 hours

Question 23

Non-opioid adjunctive therapy, such as ______________, may be required if symptoms of precipitated withdrawal are severe.

Answer 23

lofexidine hydrochloride

Question 24

To reduce the risk of precipitated withdrawal, the first dose of buprenorphine should be given when _______________, or ___________ after the last use of heroin (or other short-acting opioid), or ___________ after the last dose of methadone hydrochloride.

Answer 24

the patient is exhibiting signs of withdrawal

6–12 hours

24–48 hours

Question 25

Suboxone is a combination preparation containing _____________ and ____________

Answer 25

Buprenorphine Naloxone

Question 26

Where there is a risk of diversion of opioid substitution medicines, or difficulties with adherence to daily supervised opioid substitution medication, buprenorphine _______________ may be an option.

Answer 26

prolonged-release injection

Question 27

Methadone is a __________(long/short)-acting opioid agonist

Answer 27

Long

Question 28

Methadone is usually administered in a ________-daily dose as an _________ of 1 mg/mL

Answer 28

Once Oral solution

Question 29

Patients with a long history of opioid misuse, those who typically abuse a variety of sedative drugs and alcohol, and those who experience increased anxiety during withdrawal of opioids may prefer ___________ (methadone/buprenorphine) to ____________ (methadone/buprenorphine) because it has a more pronounced sedative effect

Answer 29

Methadone Buprenorphine

Question 30

Methadone hydrochloride is initiated at least ___________ after the last heroin dose

Answer 30

8 hours; provided that there is objective evidence of withdrawal symptoms

Question 31

Because of the ________________ of methadone, a dose that was tolerated on the first day of treatment may become a toxic dose on the third day as cumulative toxicity develops

Answer 31

Long half-life; plasma concentrations progressively rise during initial treatment even if the patient remains on the same daily dose (it takes 3–10 days for plasma concentrations to reach steady-state in patients on a stable dose)

Question 32

Acute withdrawal of opioids should be avoided in pregnancy because it can cause ___________.

Answer 32

fetal death

Question 33

_____________ is recommended during pregnancy because it carries a lower risk to the fetus than continued use of heroin or other illicit drugs

Answer 33

Opioid substitution therapy

Question 34

If a woman who is stabilised on methadone hydrochloride or buprenorphine for treatment of opioid dependence becomes pregnant, what is the recommended management?

Answer 34

Therapy should be continued [buprenorphine is not licensed for use in pregnancy]

Question 35

Many pregnant patients choose a withdrawal regimen but withdrawal during the first trimester should be avoided because it is associated with an increased risk of ______________

Answer 35

spontaneous miscarriage

Question 36

Many pregnant patients choose a withdrawal regimen but withdrawal during the _____________ should be avoided because it is associated with an increased risk of spontaneous miscarriage

Answer 36

first trimester

Question 37

Withdrawal of methadone hydrochloride or buprenorphine should be undertaken gradually during the _____________ trimester, with dose reductions made every _________

Answer 37

second 3-5 days

Question 38

If illicit drug use occurs in a pregnant woman undertaking an opioid withdrawal regimen in the second trimester of pregnancy, what is the recommended management?

Answer 38

The patient should be re-stabilised at the optimal maintenance dose and consideration should be given to stopping the withdrawal regimen

Question 39

Further withdrawal of methadone hydrochloride or buprenorphine in the third trimester _____ (is/is not) not recommended

Answer 39

Is NOT; maternal withdrawal, even if mild, is associated with fetal distress, stillbirth, and risk of neonatal mortality

Question 40

Further withdrawal of methadone hydrochloride or buprenorphine in the third trimester is not recommended because maternal withdrawal, even if mild, is associated with ___________, ___________, and the risk of ____________.

Answer 40

fetal distress stillbirth neonatal mortality

Question 41

Drug metabolism can be ____________ (increased/decreased) in the third trimester; it may be necessary to either __________ (increase/decrease) the dose of methadone hydrochloride or change to twice-daily consumption (or a combination of both strategies) to prevent withdrawal symptoms from developing.

Answer 41

Increased Increase

Question 42

Drug metabolism can be increased in the third trimester; it may be necessary to either increase the dose of methadone hydrochloride or change to twice-daily consumption (or a combination of both strategies) to prevent ____________ symptoms from developing.

Answer 42

withdrawal

Question 43

The neonate should be monitored for ____________ and signs of __________ if the mother is prescribed high doses of opioid substitue.

Answer 43

Respiratory depression Withdrawal

Question 44

Signs of neonatal withdrawal from opioids usually develop ____________ after delivery but symptoms may be delayed for up to ________, so monitoring may be required for several weeks.

Answer 44

24–72 hours 14 days

Question 45

Symptoms of neonatal withdrawal from opioids include…? (6)

Answer 45

1. high-pitched cry 2. rapid breathing 3. hungry but ineffective suckling 4. excessive wakefulness severe, but rare symptoms include: 5. hypertonicity 6. convulsions

Question 46

Can breastfeeding be continued while on opioid substitution therapy?

Answer 46

Yes, but doses of methadone and buprenorphine should be kept as low as possible

Question 47

________________, _______________, or __________ in breast-fed babies of mothers taking opioid substitutes should be reported urgently to a healthcare professional.

Answer 47

Increased sleepiness breathing difficulties limpness

Question 48

In the adjunctive treatment of opioid withdrawal, loperamide may be used for ___________

Answer 48

Control of diarrhea

Question 49

In the adjunctive treatment of opioid withdrawal, _____________ may be used for the control of diarrhea

Answer 49

Loperamide

Question 50

In the adjunctive treatment of opioid withdrawal, mebeverine may be used for ___________

Answer 50

Controlling stomach cramps

Question 51

In the adjunctive treatment of opioid withdrawal, ____________ may be used for controlling stomach cramps

Answer 51

Mebeverine

Question 52

In the adjunctive treatment of opioid withdrawal, paracetamol and NSAIDs may be used for ______________ and __________

Answer 52

Muscular pains headaches

Question 53

In the adjunctive treatment of opioid withdrawal, ______________ and ____________ may be used for muscle pain and headaches

Answer 53

Paracetamol NSAIDs

Question 54

In the adjunctive treatment of opioid withdrawal, metoclopramide or prochlrperazine may be used for ___________ or ___________

Answer 54

Nausea Vomiting

Question 55

In the adjunctive treatment of opioid withdrawal, ______________ or _____________ may be used for nausea or vomiting

Answer 55

Metoclopramide Prochlorperazine

Question 56

Topical ____________ can be helpful for relieving muscle pain associated with methadone hydrochloride withdrawal

Answer 56

rubefacients

Question 57

If a patient is suffering from insomnia associated with opioid withdrawal, short-acting _____________ or ____________ may be prescribed, but because of the potential for abuse, prescriptions should be limited to a short course of a few days only.

Answer 57

benzodiazepines zopiclone

Question 58

Lofexidine hydrochloride may alleviate some of the physical symptoms of opioid withdrawal by attenuating the increase in _______________ that occurs during opioid withdrawal

Answer 58

adrenergic neurotransmission

Question 59

__________________ may alleviate some of the physical symptoms of opioid withdrawal by attenuating the increase in adrenergic neurotransmission that occurs during opioid withdrawal

Answer 59

Lofexidine hydrochloride

Question 60

______________ can be prescribed as an adjuvant to opioid substitution therapy, initiated either at the same time as the opioid substitute or during withdrawal of the opioid substitute

Answer 60

Lofexidine hydrochloride

Question 61

_____________ may be prescribed instead of an opioid substitute in patients who have mild or uncertain dependence (including young people), and those with a short history of illicit drug use

Answer 61

Lofexidine hydrochloride | Can also be used as an adjuvant to opioid substitution therapy

Question 62

Lofexidine hydrochloride may be prescribed instead of an opioid substitute in patients who have ____________ or ___________ dependence (including young people), and those with a _________ history of illicit drug use

Answer 62

mild uncertain short

Question 63

What is the mechanism of action of naloxone?

Answer 63

Opioid antagonist; reverses the effects of opioids including respiratory depression, sedation, and hypotension Can be given to patients in the case of accidental overdose

Question 64

What is the mechanism of action of naltrexone?

Answer 64

Mu-opioid receptor antagonist; blocks opioid effects and precipitates withdrawal symptoms in opioid-dependent subjects Prescribed as an aid to prevent relapse

Question 65

What is the role of naloxone in opioid cessation?

Answer 65

Can be given to patient to be used in case of accidental overdose

Question 66

What is the role of naltrexone in opioid cessation?

Answer 66

Can be given to formerly opioid-dependent patients to block opioid effect in the case of relapse

Question 67

Why is opioid substitution therapy usually inappropriate in younger patients (under 18 yo)?

Answer 67

Drug misuse is more often related to acute intoxication than to dependence; maintenance treatment with opioid substitution therapy is therefore controversial in young people However, it may be useful for older adolescents who have a history of opioid use to undergo a period of stabilisation with buprenorphine or methadone before starting a withdrawal regimen

Question 68

For opioid substitution therapy, in patients taking methadone who want to switch to buprenorphine, the dose of methadone should be reduced to a maximum of ________ daily before starting buprenorphine treatment

Answer 68

30 mg

Question 69

For sublingual tablets of buprenorphine, if the dose of methadone is over 10 mg daily, buprenorphine can be started at a dose of ________ daily and titrated according to requirements

Answer 69

4 mg

Question 70

For sublingual tablets, if the dose of methadone is below 10 mg daily, buprenorphine can be started at a dose of _______ daily

Answer 70

2 mg

Question 71

The MHRA reminds healthcare professionals that opioids co-prescribed with benzodiazepines and benzodiazepine-like drugs can produce additive CNS depressant effects, thereby increasing the risk of ___________, ___________, __________, and _________.

Answer 71

sedation respiratory depression coma death

Question 72

The MHRA reminds healthcare professionals that opioids co-prescribed with ___________ and ___________-like drugs can produce additive CNS depressant effects, thereby increasing the risk of sedation, respiratory depression, coma, and death.

Answer 72

benzodiazepines benzodiazepine

Question 73

Healthcare professionals are advised to discuss with patients that prolonged use of opioids, even at therapeutic doses, may lead to __________ and __________

Answer 73

dependence addiction

Question 74

Healthcare professionals are advised to agree on a treatment strategy and plan for __________ with the patient before starting opioids

Answer 74

end of treatment

Question 75

Healthcare professionals are advised to counsel patients and their carers on the risks of _________ and potentially fatal ____________, as well as signs and symptoms of overdose when taking opioids (eg buprenorphine, methadone)

Answer 75

tolerance unintentional overdose

Question 76

Regarding the use of buprenorphine and methadone, healthcare professionals are advised to provide regular monitoring and support to patients at increased risk, such as those with current or history of ___________ or ____________

Answer 76

substance use disorder (including alcohol misuse) mental health disorders

Question 77

Healthcare professionals are advised to consider _____________ in patients on long-term opioid treatment who present with increased pain sensitivity

Answer 77

hyperalgesia

Question 78

Do not confuse the formulations of buprenorphine______________ which are available in 72-hourly, 96-hourly and 7-day forms

Answer 78

transdermal patches

Question 79

What are the contraindications to prescribing buprenorphine, methadone, and all opioids? (5)

Answer 79

1. Acute respiratory depression 2. Comatose patients 3. Head injury (interfere with pupillary responses vital for neurological assessment) 4. Raised ICP ( “ “ ) 5. Risk of paralytic ileus

Question 80

Prolonged use of opioid analgesics may lead to drug dependence and addiction, even at therapeutic doses. There is an increased risk in individuals with current or history of _______________ or ____________

Answer 80

substance use disorder mental health disorders

Question 81

Opioids cause a dose-dependent increased risk of _____________, consider total opioid dose reduction

Answer 81

central sleep apnoea

Question 82

In the control of pain in terminal illness, the cautions listed _____________ (should/should not) be a deterrent to the use of opioid analgesics

Answer 82

Should not

Question 83

In elderly adults, buprenorphine should not be prescribed without concomitant __________

Answer 83

Laxatives

Question 84

What are the common or very common side effects of buprenorphine?

Answer 84

1. Anxiety 2. Decreased appetite 3. Depression 4. Diarrhea 5. Dyspnea 6. Syncope 7. Tremor Many more…. Arthralgia (in adults); asthenia (in adults); asthma (in adults); behaviour abnormal (in adults); chest pain (in adults); chills (in adults); cough (in adults); dysmenorrhoea (in adults); eye disorders (in adults); fever (in adults); gastrointestinal discomfort (in adults); gastrointestinal disorders (in adults); hypersensitivity; hypotension; increased risk of infection (in adults); insomnia (in adults); lymphadenopathy (in adults); malaise (in adults); migraine (in adults); muscle complaints (in adults); muscle tone increased (in adults); pain (in adults); paraesthesia (in adults); peripheral oedema (in adults); speech disorder (in adults); thinking abnormal (in adults); vasodilation (in adults); withdrawal syndrome neonatal; yawning (in adults); asthenia (in adults); gastrointestinal discomfort (in adults); muscle weakness (in adults); oedema (in adults); sleep disorders (in adults)

Question 85

Neonates breastfed by mothers taking buprenorphine should be monitored for ____________, ____________, and _____________

Answer 85

Drowsiness Adequate weight gain Developmental milestones

Question 86

Can buprenorphine be prescribed in patients with hepatic and/or renal impairment?

Answer 86

Avoid in severe hepatic impairment; dose reduction in mild to moderate impairment Caution and dose reduction in severe renal impairment

Question 87

Documentation of ___________ status is recommended before commencing therapy for opioid dependence.

Answer 87

viral hepatitis

Question 88

What monitoring is required for patients taking buprenorphine as opioid substitution therapy?

Answer 88

Liver function (baseline before commencing therapy AND regular LFTs throughout treatment)

Question 89

Many preparations of Methadone oral solution are licensed for opioid drug addiction only but some are also licensed for ____________ in _____________.

Answer 89

Analgesia severe pain

Question 90

In addition to contraindications associated with opioid use, what is the main contraindication specific to methadone?

Answer 90

Phaeochromocytoma

Question 91

Methadone should be prescribed with caution in patients with _______________ or risk factors for it

Answer 91

QT interval prolongation

Question 92

In addition to preventing opioid relapse, naltrexone is also used in patients with _________-dependence

Answer 92

Alcohol

Question 93

What are the common or very common side effects of naltrexone? (9)

Answer 93

1. Abdominal pain, diarrhea, constipation, vomiting 2. Arthralgia 3. Asthenia 4. Eye disorders 5. Altered mood, anxiety 6. Sexual dysfunction 7. Palpitations, tachycardia, chest pain 8. Sleep disorders, headache 9. Skin reactions, hyperhydrosis

Question 94

Is naltrexone safe to use in breastfeeding?

Answer 94

Avoid due to potential toxicity

Question 95

Is naltrexone safe to use in hepatic and/or renal impairment?

Answer 95

Caution in mild to moderate hepatic impairment (adjust dose); avoid if severe or acute impairment Caution in mild to moderate renal impairment (adjust dose)avoid in severe impairment

Question 96

What pre-treatment screening is required before starting naltrexone?

Answer 96

Test for opioid dependence with naloxone before treatment.

Question 97

What are the monitoring requirements for patients taking naltrexone?

Answer 97

LFTs before and during treatment

Question 98

Patients and carers should be given what additional advice regarding opioid blocking drugs like naltrexone?

Answer 98

Attempts to overcome blockade of opioid receptors by overdosing could result in acute opioid intoxication