MCQ Quiz: Tobacco Management and Drug Testing

Effective management of Substance Use Disorders requires a broad skill set, including expertise in both therapeutic interventions and clinical monitoring. Tobacco management and clinical drug testing are two fundamental areas where pharmacists play a pivotal role. As detailed in the Patient Care VII curriculum, mastering tobacco cessation strategies—from behavioral counseling like the 5 A’s to the pharmacology of NRT, varenicline, and bupropion—is a core competency. Equally important is understanding the principles of drug testing, a tool used to monitor adherence and guide therapy in a non-punitive manner. This quiz will test your knowledge on these essential management topics, preparing you for the practical and ethical challenges of caring for patients with SUDs.

Tobacco Management

1. The 5 A’s model for treating tobacco use and dependence begins with which crucial first step?

• a) Assess
• b) Advise
• c) Ask
• d) Assist Answer: c) Ask

2. Which non-nicotine prescription medication used for smoking cessation carries a contraindication in patients with a history of seizures?

• a) Varenicline
• b) Nicotine gum
• c) Bupropion SR
• d) Nicotine patch Answer: c) Bupropion SR

3. What is the mechanism of action for varenicline (Chantix) in tobacco management?

• a) It is a full agonist at the nicotinic acetylcholine receptor.
• b) It is a partial agonist at the α4β2 nicotinic acetylcholine receptor.
• c) It inhibits the reuptake of dopamine and norepinephrine.
• d) It blocks the metabolism of nicotine. Answer: b) It is a partial agonist at the α4β2 nicotinic acetylcholine receptor.

4. A key counseling point for the nicotine patch is to:

• a) Apply it to the same spot every day to improve absorption.
• b) Remove the patch at bedtime to reduce the risk of vivid dreams or insomnia.
• c) Cut the patch in half if side effects occur.
• d) Chew the patch for faster relief of cravings. Answer: b) Remove the patch at bedtime to reduce the risk of vivid dreams or insomnia.

5. Combination therapy for tobacco cessation typically involves which pairing?

• a) Two different nicotine patches
• b) A long-acting NRT (patch) plus a short-acting NRT (e.g., gum, lozenge) for breakthrough cravings.
• c) Varenicline plus bupropion.
• d) Nicotine gum plus nicotine lozenges. Answer: b) A long-acting NRT (patch) plus a short-acting NRT (e.g., gum, lozenge) for breakthrough cravings.

6. When counseling a patient on using nicotine gum, the “chew and park” technique is recommended to:

• a) Make the gum last longer.
• b) Prevent the release of nicotine.
• c) Allow for proper buccal absorption of nicotine and prevent GI side effects.
• d) Improve the flavor of the gum. Answer: c) Allow for proper buccal absorption of nicotine and prevent GI side effects.

7. A patient who smokes their first cigarette within 30 minutes of waking up is considered to have a high level of nicotine dependence. This assessment helps in dosing which therapy?

• a) Bupropion SR
• b) Varenicline
• c) Nicotine replacement therapy (NRT)
• d) Motivational Interviewing Answer: c) Nicotine replacement therapy (NRT)

8. Bupropion’s effectiveness in tobacco management is related to its ability to inhibit the reuptake of which neurotransmitters?

• a) Serotonin and GABA
• b) Dopamine and norepinephrine
• c) Acetylcholine and glutamate
• d) Only serotonin Answer: b) Dopamine and norepinephrine

9. The final “A” in the 5 A’s model, “Arrange,” involves:

• a) Arranging for the patient to be admitted to the hospital.
• b) Arranging the pharmacy shelves to promote NRT products.
• c) Arranging for follow-up contact to monitor progress and provide support.
• d) Arranging payment plans for the medication. Answer: c) Arranging for follow-up contact to monitor progress and provide support.

10. What is a common, transient side effect of varenicline that can be managed by taking the medication with food and a full glass of water?

• a) Hypertension
• b) Sedation
• c) Nausea
• d) Weight gain Answer: c) Nausea

11. The Interprofessional Tobacco Awareness and Cessation Training (ATTAC-IT) program, as mentioned in the curriculum, emphasizes what aspect of tobacco management?

• a) The sole responsibility of the pharmacist.
• b) A collaborative, team-based approach to helping patients quit.
• c) The use of pharmacotherapy only, without counseling.
• d) A focus on punishing patients who fail to quit. Answer: b) A collaborative, team-based approach to helping patients quit.

12. The nicotine inhaler should be used with frequent, shallow puffs for up to 20 minutes because:

• a) The nicotine is absorbed in the lungs like a cigarette.
• b) The nicotine is primarily absorbed through the buccal mucosa, not the lungs.
• c) Deep inhalation causes bronchospasm.
• d) The device will break if puffed too hard. Answer: b) The nicotine is primarily absorbed through the buccal mucosa, not the lungs.

13. When is the ideal time to set a “quit date” when starting varenicline?

• a) The same day the patient starts the medication.
• b) One week after starting the medication.
• c) One month after starting the medication.
• d) The patient should quit before starting the medication. Answer: b) One week after starting the medication.

14. Motivational Interviewing is a counseling technique used in smoking cessation to:

• a) Confront the patient about their unhealthy habits.
• b) Explore and resolve the patient’s ambivalence about quitting.
• c) Provide a list of reasons why the patient must quit immediately.
• d) Teach the patient how to use NRT products. Answer: b) Explore and resolve the patient’s ambivalence about quitting.

15. What is the primary advantage of NRT over smoking cigarettes?

• a) It is significantly cheaper.
• b) It provides the “hit” of nicotine faster than a cigarette.
• c) It delivers nicotine without the thousands of carcinogens and toxic chemicals found in tobacco smoke.
• d) It is more addictive than smoking. Answer: c) It delivers nicotine without the thousands of carcinogens and toxic chemicals found in tobacco smoke.

16. The “Assess” step in the 5 A’s model involves evaluating a patient’s:

• a) Ability to pay for medication.
• b) Family history of tobacco use.
• c) Willingness to make a quit attempt.
• d) Knowledge of tobacco pharmacology. Answer: c) Willingness to make a quit attempt.

17. What is the recommended duration of treatment for most smoking cessation pharmacotherapies?

• a) 1 week
• b) 4 weeks
• c) Up to 12 weeks
• d) For the rest of the patient’s life Answer: c) Up to 12 weeks

18. A patient using the nicotine patch complains of skin irritation. What is the best management advice?

• a) Discontinue the patch immediately.
• b) Apply the patch to the exact same spot to build skin tolerance.
• c) Rotate the application site daily and consider applying over-the-counter hydrocortisone cream if irritation persists.
• d) Apply a heating pad over the patch to increase absorption. Answer: c) Rotate the application site daily and consider applying over-the-counter hydrocortisone cream if irritation persists.

19. A patient’s insurance plan will not cover varenicline. As part of the “Assist” step, the pharmacist can help by:

• a) Telling the patient they cannot quit without it.
• b) Recommending they buy it from an online international pharmacy.
• c) Discussing more affordable options like NRT or bupropion and investigating patient assistance programs.
• d) Telling the patient to pay cash regardless of the cost. Answer: c) Discussing more affordable options like NRT or bupropion and investigating patient assistance programs.

20. The partial agonist action of varenicline helps manage tobacco use by:

• a) Causing a severe aversive reaction to nicotine.
• b) Stimulating dopamine release to reduce cravings while blocking nicotine from cigarettes from binding to the receptor.
• c) Only blocking the effects of nicotine with no stimulation.
• d) Making the patient feel sedated and sleepy. Answer: b) Stimulating dopamine release to reduce cravings while blocking nicotine from cigarettes from binding to the receptor.

21. The starting dose of the nicotine patch is determined by:

• a) The patient’s weight.
• b) The number of cigarettes the patient smokes per day.
• c) The patient’s age.
• d) The patient’s gender. Answer: b) The number of cigarettes the patient smokes per day.

22. Which smoking cessation product provides the fastest delivery of nicotine, making it suitable for acute, severe cravings?

• a) Nicotine patch
• b) Nicotine lozenge
• c) Nicotine nasal spray
• d) Bupropion SR Answer: c) Nicotine nasal spray

23. The goal of tobacco management should be framed to the patient as:

• a) An easy process that requires little effort.
• b) A process that may require multiple attempts, and the pharmacist is there to provide support.
• c) A one-time event where success or failure is final.
• d) A test of the patient’s willpower. Answer: b) A process that may require multiple attempts, and the pharmacist is there to provide support.

24. The management of tobacco use is considered a crucial “Health/Wellness” topic in the Patient Care curriculum because it is:

• a) The leading cause of preventable death and disease in the United States.
• b) Only relevant for patients with lung cancer.
• c) A minor health concern.
• d) Unrelated to other chronic diseases. Answer: a) The leading cause of preventable death and disease in the United States.

25. A patient taking bupropion for smoking cessation should be advised that the medication should be:

• a) Started on their quit date.
• b) Started 1-2 weeks before their quit date.
• c) Taken only when they have a craving.
• d) Crushed to achieve a faster effect. Answer: b) Started 1-2 weeks before their quit date.

Drug Testing

26. In the management of SUDs, the primary clinical purpose of a urine drug test (UDT) is to:

• a) Serve as a basis for punishing the patient.
• b) Provide objective data to monitor treatment adherence and detect non-prescribed substance use.
• c) Fulfill a legal requirement for insurance billing.
• d) Determine the patient’s exact level of intoxication. Answer: b) Provide objective data to monitor treatment adherence and detect non-prescribed substance use.

27. A UDT that uses an immunoassay is considered a:

• a) Confirmatory test
• b) Screening test
• c) Genetic test
• d) Saliva test Answer: b) Screening test

28. If an initial immunoassay drug screen is positive, what is the appropriate next step to confirm the result and identify the specific substance?

• a) Repeat the immunoassay test immediately.
• b) Send the sample for a more specific test like gas chromatography-mass spectrometry (GC-MS).
• c) Assume the patient is guilty and discharge them from the clinic.
• d) Ask the patient to provide a hair sample instead. Answer: b) Send the sample for a more specific test like gas chromatography-mass spectrometry (GC-MS).

29. The “detection window” for a substance in urine refers to the:

• a) Time it takes for the test results to come back from the lab.
• b) The period of time after use during which the substance or its metabolites can be detected.
• c) The specific concentration needed for a positive result.
• d) The part of the test strip where the result appears. Answer: b) The period of time after use during which the substance or its metabolites can be detected.

30. Which of the following substances generally has the longest detection window in a urine drug test for a chronic user?

• a) Cocaine
• b) Amphetamine
• c) Alcohol
• d) Cannabis (THC) Answer: d) Cannabis (THC)

31. A patient testing positive for “opiates” on a UDT after eating a poppy seed bagel is an example of a:

• a) True positive
• b) False positive
• c) True negative
• d) False negative Answer: b) False positive

32. A patient is prescribed buprenorphine for OUD. A standard opiate immunoassay screen will likely be:

• a) Positive for buprenorphine.
• b) Negative, because buprenorphine is a synthetic opioid that does not typically trigger a standard opiate screen.
• c) Positive for heroin.
• d) Positive for methadone. Answer: b) Negative, because buprenorphine is a synthetic opioid that does not typically trigger a standard opiate screen.

33. The results of a drug test should be discussed with a patient in what manner?

• a) In a punitive and accusatory tone.
• b) In a non-judgmental, collaborative way to guide their treatment plan.
• c) In the public waiting area of the pharmacy.
• d) The results should not be discussed with the patient. Answer: b) In a non-judgmental, collaborative way to guide their treatment plan.

34. A confirmatory test like GC-MS is able to distinguish between heroin use and codeine use by detecting:

• a) Only morphine.
• b) The specific parent drug and its unique metabolites (e.g., 6-monoacetylmorphine for heroin).
• c) The presence of any opioid.
• d) The cut-off level of the immunoassay. Answer: b) The specific parent drug and its unique metabolites (e.g., 6-monoacetylmorphine for heroin).

35. A UDT result shows a positive for amphetamines. Which of the following over-the-counter medications could be a potential cause of a false positive?

• a) Acetaminophen
• b) Pseudoephedrine
• c) Diphenhydramine
• d) Calcium carbonate Answer: b) Pseudoephedrine

36. A patient is prescribed oxycodone for chronic pain. A UDT result comes back negative for oxycodone. This may indicate:

• a) The patient is taking their medication exactly as prescribed.
• b) The patient is diverting their medication or is non-adherent.
• c) The patient has developed tolerance.
• d) The test is invalid. Answer: b) The patient is diverting their medication or is non-adherent.

37. At-home drug tests, as discussed in the Patient Care VII curriculum, have what primary limitation compared to laboratory testing?

• a) They are more expensive.
• b) They are generally less accurate and are not confirmed, and the results can be easily misinterpreted.
• c) They take several weeks to provide a result.
• d) They can only detect cannabis. Answer: b) They are generally less accurate and are not confirmed, and the results can be easily misinterpreted.

38. The “cut-off level” for a drug test is the:

• a) Maximum concentration the test can detect.
• b) The concentration at which the test is considered positive.
• c) The therapeutic level of the drug in the blood.
• d) The toxic level of the drug. Answer: b) The concentration at which the test is considered positive.

39. Hair testing for drugs of abuse offers what main advantage over urine testing?

• a) It is less expensive.
• b) It provides a much longer detection window (months).
• c) It detects drug use within the last 24 hours.
• d) It is less invasive. Answer: b) It provides a much longer detection window (months).

40. A patient prescribed benzodiazepines for anxiety has a UDT positive for cocaine. The best first step in managing this finding is to:

• a) Immediately discharge the patient from the practice.
• b) Increase their benzodiazepine dose.
• c) Have a non-confrontational conversation with the patient about the result and assess for a co-occurring SUD.
• d) Ignore the result as it is not relevant. Answer: c) Have a non-confrontational conversation with the patient about the result and assess for a co-occurring SUD.

41. Which of the following can cause a false negative on a UDT?

• a) A very dilute urine sample (e.g., from excessive water intake).
• b) Ingesting poppy seeds.
• c) Taking pseudoephedrine.
• d) Testing the sample after the detection window has passed. Answer: d) Testing the sample after the detection window has passed.

42. The detection of ethyl glucuronide (EtG) in the urine is used as a biomarker for recent use of:

• a) Opioids
• b) Cannabis
• c) Alcohol
• d) Cocaine Answer: c) Alcohol

43. A pharmacist’s role regarding at-home drug tests is to:

• a) Recommend them as a definitive way to diagnose an SUD.
• b) Counsel customers on their proper use, limitations, and the importance of confirmatory testing.
• c) Refuse to sell them.
• d) Interpret the results as 100% accurate. Answer: b) Counsel customers on their proper use, limitations, and the importance of confirmatory testing.

44. If a drug test is part of a contingency management program, a negative test result (indicating abstinence) would be:

• a) Punished
• b) Ignored
• c) Rewarded with a small incentive
• d) A reason to stop testing Answer: c) Rewarded with a small incentive

45. What is a primary challenge of interpreting saliva-based drug tests?

• a) They have a very long detection window.
• b) They have a very short detection window, typically only hours to a couple of days.
• c) The sample is very difficult to collect.
• d) They are prone to contamination from food. Answer: b) They have a very short detection window, typically only hours to a couple of days.

46. A patient prescribed methadone for OUD would be expected to test positive for methadone, but a standard opiate screen may be:

• a) Positive for heroin
• b) Positive for codeine
• c) Negative
• d) Inconclusive Answer: c) Negative

47. Point-of-care UDT cups used in clinics provide:

• a) Confirmed, quantitative results.
• b) Rapid, qualitative screening results.
• c) A longer detection window than lab tests.
• d) A measure of blood alcohol content. Answer: b) Rapid, qualitative screening results.

48. What is an ethical consideration for drug testing in a clinical setting?

• a) Testing patients without their knowledge or consent.
• b) Ensuring results are used to improve patient care and not solely for punitive reasons.
• c) Sharing test results with the patient’s employer without a release.
• d) Using the cheapest, least accurate test available to save money. Answer: b) Ensuring results are used to improve patient care and not solely for punitive reasons.

49. A patient taking sertraline might have a false positive on an immunoassay screen for which substance?

• a) Opioids
• b) Benzodiazepines
• c) Cannabis
• d) Amphetamines Answer: b) Benzodiazepines

50. The overall goal of incorporating drug testing into the management of SUD is to:

• a) Create a reason to distrust the patient.
• b) Provide an objective tool that supports the therapeutic relationship and helps guide treatment decisions.
• c) Increase pharmacy revenue from testing supplies.
• d) Replace the need for patient counseling. Answer: b) Provide an objective tool that supports the therapeutic relationship and helps guide treatment decisions.