MCQ Quiz-Downers

MCQ Quiz: Downers

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CNS depressants, or “downers,” include a wide range of substances from alcohol and opioids to prescription sedatives like benzodiazepines. While therapeutically essential for managing anxiety, pain, and other conditions, they also carry significant risks of dependence, overdose, and adverse effects. For PharmD students, a deep understanding of their pharmacology, risks, and management is critical for patient safety. This quiz will test your knowledge on these powerful medications and substances.

1. Benzodiazepines, such as alprazolam and diazepam, exert their primary effect by enhancing the activity of which major inhibitory neurotransmitter?

  • Serotonin
  • Dopamine
  • GABA (gamma-aminobutyric acid)
  • Norepinephrine

Answer: GABA (gamma-aminobutyric acid)

2. A patient presents to the emergency department with severe respiratory depression, pinpoint pupils, and unresponsiveness. This clinical presentation is a classic sign of overdose with which class of CNS depressants?

  • Benzodiazepines
  • Barbiturates
  • Alcohol
  • Opioids

Answer: Opioids

3. The most life-threatening adverse effect of combining two or more CNS depressants, such as alcohol and opioids, is:

  • Serotonin syndrome.
  • A hypertensive crisis.
  • Severe respiratory depression.
  • Acute kidney injury.

Answer: Severe respiratory depression.

4. Which medication is a specific reversal agent for benzodiazepine overdose?

  • Naloxone
  • N-acetylcysteine
  • Flumazenil
  • Protamine sulfate

Answer: Flumazenil

5. Naloxone is a competitive antagonist used to rapidly reverse the effects of:

  • Barbiturate overdose.
  • Alcohol intoxication.
  • Opioid overdose.
  • Benzodiazepine overdose.

Answer: Opioid overdose.

6. Alcohol, barbiturates, and benzodiazepines all share a mechanism of action that involves modulation of which receptor complex?

  • NMDA receptor
  • AMPA receptor
  • GABA-A receptor
  • Mu-opioid receptor

Answer: GABA-A receptor

7. Due to their high potential for abuse and risk of fatal overdose, the therapeutic use of which class of CNS depressants has been largely replaced by benzodiazepines and other agents?

  • SSRIs
  • Barbiturates
  • Non-stimulant ADHD medications
  • Antihistamines

Answer: Barbiturates

8. Abrupt discontinuation of a benzodiazepine after long-term use can lead to a potentially life-threatening:

  • Hypertensive crisis.
  • Withdrawal syndrome, including seizures.
  • Serotonin syndrome.
  • Myopathy.

Answer: Withdrawal syndrome, including seizures.

9. In a patient with a history of substance use disorder, which medication class should be used with extreme caution for anxiety due to its abuse potential?

  • SSRIs
  • Buspirone
  • Benzodiazepines
  • Hydroxyzine

Answer: Benzodiazepines

10. In geriatric patients, benzodiazepines are considered potentially inappropriate medications primarily due to an increased risk of:

  • Hypertension and tachycardia.
  • Weight gain.
  • Falls, confusion, and cognitive impairment.
  • Hepatotoxicity.

Answer: Falls, confusion, and cognitive impairment.

11. The primary first-line pharmacotherapy for treating moderate to severe alcohol withdrawal syndrome is:

  • Haloperidol
  • Opioids
  • Benzodiazepines
  • Antidepressants

Answer: Benzodiazepines

12. Common side effects of CNS depressants like benzodiazepines include:

  • Insomnia and anxiety.
  • Drowsiness, dizziness, and ataxia (impaired coordination).
  • Increased appetite and weight gain.
  • Dry mouth and constipation.

Answer: Drowsiness, dizziness, and ataxia (impaired coordination).

13. Most benzodiazepines are classified as which schedule of controlled substances?

  • Schedule II
  • Schedule III
  • Schedule IV
  • Schedule V

Answer: Schedule IV

14. A key counseling point for a patient starting a new sedative-hypnotic for insomnia is:

  • To take the medication in the middle of the night if they wake up.
  • To avoid activities that require mental alertness, such as driving, after taking the medication.
  • That the medication is safe to take with alcohol.
  • To take the medication every morning.

Answer: To avoid activities that require mental alertness, such as driving, after taking the medication.

15. Opioids cause CNS depression but are primarily used for their _______ effects.

  • Anxiolytic
  • Antidepressant
  • Analgesic
  • Antipsychotic

Answer: Analgesic

16. Why is the use of flumazenil for benzodiazepine overdose often controversial and reserved for specific situations?

  • It is not effective.
  • It can precipitate seizures in patients with a physical dependence on benzodiazepines.
  • It is prohibitively expensive.
  • It has a very long half-life.

Answer: It can precipitate seizures in patients with a physical dependence on benzodiazepines.

17. Tolerance to the sedative effects of a CNS depressant often develops more quickly than tolerance to its:

  • Respiratory depressant effects.
  • Anxiolytic effects.
  • Anticonvulsant effects.
  • All of the above are correct.

Answer: Respiratory depressant effects.

18. A first responder finds an individual unconscious and suspects a drug overdose. After ensuring the scene is safe, the immediate next step is to:

  • Administer naloxone.
  • Administer flumazenil.
  • Check for breathing and call for emergency medical services.
  • Obtain a detailed medication history from a family member.

Answer: Check for breathing and call for emergency medical services.

19. Which of the following is a “Z-drug” hypnotic that acts on the GABA-A receptor but is structurally different from benzodiazepines?

  • Lorazepam
  • Diazepam
  • Zolpidem
  • Phenobarbital

Answer: Zolpidem

20. A pharmacist dispensing a new prescription for an opioid to a patient already taking a benzodiazepine has a professional responsibility to:

  • Refuse to fill the opioid prescription.
  • Counsel the patient on the significant risk of additive sedation and respiratory depression.
  • Tell the patient to stop their benzodiazepine immediately.
  • Fill the prescription without comment.

Answer: Counsel the patient on the significant risk of additive sedation and a respiratory depression.

21. The pathophysiology of alcohol withdrawal involves a state of CNS hyperexcitability caused by a sudden lack of ______ agonism and persistent _______ antagonism.

  • Dopamine; Serotonin
  • GABA; Glutamate
  • Serotonin; Dopamine
  • Acetylcholine; Histamine

Answer: GABA; Glutamate

22. Which of the following is a symptom of benzodiazepine withdrawal?

  • Calmness and relaxation.
  • Anxiety, insomnia, and tremors.
  • Improved memory.
  • Bradycardia.

Answer: Anxiety, insomnia, and tremors.

23. The role of the state’s Prescription Drug Monitoring Program (PDMP) is critical for identifying patients who may be:

  • At risk for drug-drug interactions, such as receiving opioids and benzodiazepines from multiple prescribers.
  • Adherent to their therapy.
  • In need of a flu shot.
  • Eligible for MTM services.

Answer: At risk for drug-drug interactions, such as receiving opioids and benzodiazepines from multiple prescribers.

24. The term “sedative” refers to a drug that _____, while a “hypnotic” refers to a drug that _____.

  • Produces sleep; reduces anxiety.
  • Reduces anxiety and exerts a calming effect; produces drowsiness and induces sleep.
  • Is a controlled substance; is not a controlled substance.
  • Is short-acting; is long-acting.

Answer: Reduces anxiety and exerts a calming effect; produces drowsiness and induces sleep.

25. A pharmacist counseling a patient taking a “Z-drug” like zolpidem should warn about the potential for:

  • Increased energy the next day.
  • Complex sleep-related behaviors like sleep-walking or sleep-driving.
  • Improved memory and concentration.
  • Weight loss.

Answer: Complex sleep-related behaviors like sleep-walking or sleep-driving.

26. The main difference in the mechanism of benzodiazepines and barbiturates is that:

  • Barbiturates increase the duration of GABA-A channel opening, while benzodiazepines increase the frequency of opening.
  • Barbiturates increase the frequency of channel opening, while benzodiazepines increase the duration.
  • Benzodiazepines can directly open the GABA-A channel without GABA present.
  • Only benzodiazepines work on the GABA-A receptor.

Answer: Barbiturates increase the duration of GABA-A channel opening, while benzodiazepines increase the frequency of opening.

27. A patient with alcohol-associated liver disease may have impaired metabolism of which class of drugs, increasing their risk of toxicity?

  • Drugs metabolized by the liver, such as many benzodiazepines.
  • Drugs eliminated unchanged by the kidneys.
  • Topical medications.
  • Inhaled medications.

Answer: Drugs metabolized by the liver, such as many benzodiazepines.

28. Why is a long-acting benzodiazepine like diazepam or chlordiazepoxide often used for alcohol withdrawal protocols?

  • It has a lower abuse potential.
  • It provides a smoother, self-tapering effect that helps prevent rebound symptoms and seizures.
  • It has a more rapid onset of action than short-acting agents.
  • It does not cause sedation.

Answer: It provides a smoother, self-tapering effect that helps prevent rebound symptoms and seizures.

29. The term “downer” is a colloquial term for a drug that is a:

  • Central Nervous System (CNS) stimulant.
  • Central Nervous System (CNS) depressant.
  • Non-steroidal anti-inflammatory drug.
  • Monoclonal antibody.

Answer: Central Nervous System (CNS) depressant.

30. A key leadership practice when dealing with a patient with a substance use disorder involving CNS depressants is to:

  • Use a non-judgmental, empathetic, and patient-centered approach.
  • Confront the patient aggressively about their use.
  • Refuse to provide any pharmacy services.
  • Focus only on the dispensing aspect of their care.

Answer: Use a non-judgmental, empathetic, and patient-centered approach.

31. In a first response scenario, it can be difficult to distinguish between CNS depressant overdose and:

  • A stroke.
  • Hypoglycemia.
  • A post-ictal state after a seizure.
  • All of the above.

Answer: All of the above.

32. The “Therapeutic Index” is particularly important for which class of CNS depressants due to their steep dose-response curve and low margin of safety?

  • Benzodiazepines
  • Z-drugs
  • Barbiturates
  • SSRIs

Answer: Barbiturates

33. The primary reason for the decline in the therapeutic use of barbiturates is their:

  • High cost.
  • High lethality in overdose and high potential for dependence.
  • Lack of efficacy as sedatives.
  • Poor oral absorption.

Answer: High lethality in overdose and high potential for dependence.

34. A patient should be counseled that CNS depressants can cause significant impairment, and they should avoid:

  • Driving.
  • Operating heavy machinery.
  • Making important legal or financial decisions while under the influence.
  • All of the above.

Answer: All of the above.

35. A pharmacist performing a “brown bag review” for an elderly patient finds they are taking two different benzodiazepines prescribed by two different doctors. This is a red flag for:

  • A potential therapeutic duplication and increased risk of adverse effects.
  • Excellent coordination of care.
  • A common and safe practice.
  • An effective treatment for insomnia.

Answer: A potential therapeutic duplication and increased risk of adverse effects.

36. The process of tapering a patient off a long-term benzodiazepine should be:

  • Done as quickly as possible, over 1-2 days.
  • A slow and gradual process over weeks to months to minimize withdrawal symptoms.
  • Handled entirely by the patient without a prescriber’s guidance.
  • Accomplished by switching to a short-acting benzodiazepine.

Answer: A slow and gradual process over weeks to months to minimize withdrawal symptoms.

37. Which of the following is a symptom of Delirium Tremens (DTs), the most severe form of alcohol withdrawal?

  • Calmness
  • Bradycardia
  • Visual hallucinations
  • Pinpoint pupils

Answer: Visual hallucinations

38. The pharmacist’s role in dispensing naloxone under a state protocol is a key public health strategy to:

  • Increase opioid abuse.
  • Reduce harm and prevent deaths from opioid overdose.
  • Ensure patient privacy is violated.
  • Increase pharmacy profits from the sale of opioids.

Answer: Reduce harm and prevent deaths from opioid overdose.

39. Muscle relaxants like cyclobenzaprine and carisoprodol have what CNS effect?

  • Stimulant
  • Depressant
  • No effect on the CNS
  • Antipsychotic

Answer: Depressant

40. Why is it important to use a standardized scale like the CIWA-Ar for assessing alcohol withdrawal?

  • It provides an objective way to measure the severity of withdrawal and guide treatment.
  • It is a patient self-assessment tool.
  • It is required for billing purposes only.
  • It helps to diagnose the cause of the patient’s alcohol use disorder.

Answer: It provides an objective way to measure the severity of withdrawal and guide treatment.

41. The use of certain first-generation antihistamines (like diphenhydramine) as OTC sleep aids is due to their:

  • Stimulant properties.
  • Sedating, CNS depressant properties.
  • Analgesic properties.
  • Decongestant properties.

Answer: Sedating, CNS depressant properties.

42. A patient with sleep apnea should use CNS depressants with extreme caution because they can:

  • Improve their breathing during sleep.
  • Worsen airway collapse and exacerbate apneic episodes.
  • Cure sleep apnea.
  • Have no effect on breathing.

Answer: Worsen airway collapse and exacerbate apneic episodes.

43. The legal requirement for a written prescription for a C-II opioid (with some exceptions) is a regulation designed to:

  • Make it more difficult for patients with legitimate pain to get medication.
  • Reduce the potential for forgery and diversion.
  • Increase the workload for physicians.
  • Ensure the pharmacist is able to read the prescription.

Answer: Reduce the potential for forgery and diversion.

44. A patient-centered approach to managing chronic pain in a patient with a history of substance use disorder would prioritize:

  • High-dose opioid therapy.
  • Multimodal therapy with non-opioid and non-pharmacologic strategies.
  • A long-term prescription for a benzodiazepine.
  • A trial of different stimulant medications.

Answer: Multimodal therapy with non-opioid and non-pharmacologic strategies.

45. Which of the following is a key sign of barbiturate toxicity?

  • Tachycardia and hypertension.
  • Agitation and psychosis.
  • Respiratory depression, hypotension, and coma.
  • Dry mouth and urinary retention.

Answer: Respiratory depression, hypotension, and coma.

46. The pharmacist’s professional responsibility when dispensing a CNS depressant extends beyond accuracy to include:

  • Assessing the appropriateness of the therapy.
  • Counseling the patient on risks and safe use.
  • Monitoring for potential misuse or abuse.
  • All of the above.

Answer: All of the above.

47. A “drug-disease” interaction concern with CNS depressants would be prescribing one to a patient with:

  • Hypertension.
  • A history of falls.
  • High cholesterol.
  • GERD.

Answer: A history of falls.

48. Why are many states moving away from allowing prescriptions for “opioid-benzodiazepine” combinations?

  • Due to the extremely high risk of fatal overdose when combined.
  • Due to the high cost of the medications.
  • Due to a lack of efficacy.
  • Due to pressure from pharmaceutical companies.

Answer: Due to the extremely high risk of fatal overdose when combined.

49. The role of mind-body skills in managing anxiety can be to:

  • Provide coping mechanisms that may reduce the need for or dose of CNS depressant medications.
  • Increase the side effects of benzodiazepines.
  • Replace the need for all pharmacotherapy.
  • Make the patient more anxious.

Answer: Provide coping mechanisms that may reduce the need for or dose of CNS depressant medications.

50. The ultimate goal when managing therapy with CNS depressants is to:

  • Use the highest dose for the longest possible duration.
  • Achieve the therapeutic goal with the lowest effective dose for the shortest appropriate duration to minimize risks.
  • Ensure the patient develops a physical dependence.
  • Eliminate all sources of anxiety and pain from the patient’s life.

Answer: Achieve the therapeutic goal with the lowest effective dose for the shortest appropriate duration to minimize risks.

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