Narcotic analgesics, commonly known as opioids, are potent medications that are indispensable for managing severe pain but also carry significant risks of misuse, dependence, and overdose. As frontline medication experts, pharmacists are critical in ensuring the safe and appropriate use of this high-risk drug class. This quiz for PharmD students will test your knowledge of the pharmacology, therapeutic principles, side effect management, and regulatory responsibilities associated with opioid therapy.
1. What is the primary mechanism of action for opioid analgesics like morphine and oxycodone?
- They block the reuptake of serotonin and norepinephrine.
- They are antagonists at the NMDA receptor.
- They act as agonists at opioid receptors, primarily the mu (µ) receptor, in the central nervous system.
- They inhibit the cyclooxygenase (COX) enzyme.
Answer: They act as agonists at opioid receptors, primarily the mu (µ) receptor, in the central nervous system.
2. A patient presents to the emergency department with pinpoint pupils (miosis), unresponsiveness, and severe respiratory depression. This clinical triad is the hallmark of an overdose with which class of drugs?
- Benzodiazepines
- Stimulants
- Opioids
- Antidepressants
Answer: Opioids
3. What is the first-line antidote for reversing the respiratory depression associated with an opioid overdose?
- Flumazenil
- N-acetylcysteine
- Naloxone
- Sodium bicarbonate
Answer: Naloxone
4. A patient on chronic opioid therapy complains of persistent constipation. This side effect occurs because opioids:
- Increase fluid secretion into the gut.
- Decrease peristalsis in the gastrointestinal tract.
- Are best absorbed with high-fiber foods.
- Stimulate the vagus nerve.
Answer: Decrease peristalsis in the gastrointestinal tract.
5. A key principle of opioid-induced constipation is that, unlike sedation or nausea, tolerance:
- Develops very quickly.
- Rarely develops, often requiring a long-term bowel regimen.
- Is the first side effect to appear.
- Is not a concern.
Answer: Rarely develops, often requiring a long-term bowel regimen.
6. A patient is prescribed codeine for pain but reports no relief. This is likely because codeine is a prodrug that must be metabolized to morphine by which enzyme?
- CYP3A4
- CYP2C19
- CYP1A2
- CYP2D6
Answer: CYP2D6
7. Due to their high potential for abuse and dependence, most strong opioid analgesics like morphine, fentanyl, and oxycodone are classified in which DEA schedule?
- Schedule I
- Schedule II
- Schedule III
- Schedule IV
Answer: Schedule II
8. The concept of “equianalgesic dosing” is used to:
- Calculate a roughly equivalent dose when converting a patient from one opioid to another.
- Determine the price of an opioid.
- Predict the risk of addiction.
- Choose the best opioid for a specific type of pain.
Answer: Calculate a roughly equivalent dose when converting a patient from one opioid to another.
9. When converting from one opioid to another, it is a common safety practice to reduce the calculated equianalgesic dose by 25-50%. This is done to account for:
- The high cost of the new drug.
- Incomplete cross-tolerance between different opioids.
- The patient’s preference.
- A likely drug-food interaction.
Answer: Incomplete cross-tolerance between different opioids.
10. Buprenorphine is unique because it acts as a ________ at the mu-opioid receptor.
- Full agonist
- Partial agonist
- Competitive antagonist
- Inverse agonist
Answer: Partial agonist
11. The combination of an opioid and which other class of CNS depressants is on an FDA “black box warning” due to a profound risk of fatal respiratory depression?
- Statins
- ACE inhibitors
- Benzodiazepines
- Proton pump inhibitors
Answer: Benzodiazepines
12. A pharmacist checks the state’s Prescription Drug Monitoring Program (PDMP) before dispensing an oxycodone prescription. The primary purpose of this is to:
- Verify the patient’s insurance information.
- Check for signs of “doctor shopping” or overlapping controlled substance prescriptions.
- See if the patient has any known allergies.
- Order more medication for the pharmacy.
Answer: Check for signs of “doctor shopping” or overlapping controlled substance prescriptions.
13. “Physical dependence” on an opioid is best demonstrated by:
- The patient’s request for an early refill.
- The occurrence of a withdrawal syndrome upon abrupt discontinuation.
- The patient’s subjective report of pain.
- The development of a rash.
Answer: The occurrence of a withdrawal syndrome upon abrupt discontinuation.
14. Which of the following is a classic sign of opioid withdrawal?
- Miosis (pupil constriction) and constipation.
- Mydriasis (pupil dilation), yawning, and piloerection (“goosebumps”).
- Respiratory depression.
- Calmness and euphoria.
Answer: Mydriasis (pupil dilation), yawning, and piloerection (“goosebumps”).
15. A long-acting or extended-release opioid is most appropriately used for:
- Acute, short-term pain.
- Breakthrough pain.
- The management of chronic, around-the-clock pain in an opioid-tolerant patient.
- A patient who has never taken an opioid before.
Answer: The management of chronic, around-the-clock pain in an opioid-tolerant patient.
16. A pharmacist’s “corresponding responsibility” means they share a legal duty with the prescriber to ensure that a controlled substance prescription is:
- For the cheapest available medication.
- Issued for a legitimate medical purpose.
- Covered by the patient’s insurance.
- Filled within 10 minutes.
Answer: Issued for a legitimate medical purpose.
17. Which of the following is a key counseling point for a patient starting a fentanyl patch?
- The patch can be cut to adjust the dose.
- To apply a heating pad over the patch to enhance pain relief.
- To avoid exposure to heat, as it can cause a rapid, potentially fatal increase in drug absorption.
- The patch should be changed every day.
Answer: To avoid exposure to heat, as it can cause a rapid, potentially fatal increase in drug absorption.
18. Tramadol has a dual mechanism of action that includes weak mu-opioid agonism and:
- Inhibition of serotonin and norepinephrine reuptake.
- Blockade of dopamine receptors.
- Inhibition of the COX-2 enzyme.
- Agonism at the GABA receptor.
Answer: Inhibition of serotonin and norepinephrine reuptake.
19. A patient with a true IgE-mediated allergy to morphine should be cautious with which of the following opioids due to structural similarity?
- Fentanyl
- Methadone
- Oxycodone
- Meperidine
Answer: Oxycodone
20. Methadone is a unique opioid used for pain and opioid use disorder that is well-known for its:
- Short and predictable half-life.
- Long and variable half-life and its risk of QTc prolongation.
- Lack of any drug interactions.
- Low potency.
Answer: Long and variable half-life and its risk of QTc prolongation.
21. A “harm reduction” strategy that pharmacists are increasingly involved in is:
- Refusing to fill all opioid prescriptions.
- Providing education and access to naloxone for patients and caregivers.
- Reporting all patients who use opioids to law enforcement.
- Advocating for stricter penalties for drug use.
Answer: Providing education and access to naloxone for patients and caregivers.
22. A key principle of pain management is that the best approach is often “multimodal,” which means:
- Using only one opioid at the highest tolerated dose.
- Combining different types of analgesics (e.g., an opioid and an NSAID) and non-pharmacologic therapies.
- Using only non-pharmacologic therapies.
- Prescribing medications from only one drug class.
Answer: Combining different types of analgesics (e.g., an opioid and an NSAID) and non-pharmacologic therapies.
23. A patient-controlled analgesia (PCA) pump is a technology that allows:
- Nurses to administer opioid doses whenever they deem necessary.
- A patient to self-administer small, pre-set bolus doses of an opioid for pain.
- A continuous infusion of an opioid without any bolus capability.
- The patient’s family to control the pain medication.
Answer: A patient to self-administer small, pre-set bolus doses of an opioid for pain.
24. The term “breakthrough pain” refers to:
- The pain a patient feels when they first start an opioid.
- A transitory flare of severe pain in a patient who has relatively stable baseline pain.
- The development of opioid tolerance.
- Pain that is completely psychological.
Answer: A transitory flare of severe pain in a patient who has relatively stable baseline pain.
25. A pharmacist providing care with “geriatric sensitivity” would be aware that older adults are:
- Less sensitive to the effects of opioids.
- More sensitive to the sedating and respiratory depressant effects of opioids.
- The ideal candidates for long-term, high-dose opioid therapy.
- Not at risk for opioid-induced constipation.
Answer: More sensitive to the sedating and respiratory depressant effects of opioids.
26. A key part of the “Business Plan” for a new pain management service would include a protocol for:
- The appropriate screening and monitoring of patients on chronic opioid therapy.
- The marketing of the service to attract new patients.
- The financial model for the service.
- All of the above.
Answer: All of the above.
27. The leadership skill of “advocacy” is demonstrated when a pharmacist:
- Convinces an insurance company to cover a non-opioid alternative for a high-risk patient.
- Insists all patients with pain receive an opioid.
- Refuses to counsel any patient on pain medication.
- Only dispenses brand-name opioids.
Answer: Convinces an insurance company to cover a non-opioid alternative for a high-risk patient.
28. A “difficult conversation” for a pharmacist would be:
- Discussing the potential for a substance use disorder with a patient showing red flag behaviors.
- Handing a patient their refill for a blood pressure medication.
- Taking a patient’s insurance information.
- Explaining the pharmacy’s hours.
Answer: Discussing the potential for a substance use disorder with a patient showing red flag behaviors.
29. The use of an “analytics and reporting system” is critical for public health in:
- Tracking prescribing and overdose trends related to opioids at a population level.
- Identifying individual patients who need counseling.
- Managing a single pharmacy’s inventory.
- Writing a patient’s progress note.
Answer: Tracking prescribing and overdose trends related to opioids at a population level.
30. The ultimate goal of using narcotic analgesics is to:
- Cure the underlying cause of the pain.
- Improve the patient’s functional ability and quality of life while minimizing risks.
- Ensure the patient remains on the medication for as long as possible.
- Eliminate all sensation of pain completely, which is often not realistic.
Answer: Improve the patient’s functional ability and quality of life while minimizing risks.
31. Which of the following is NOT a classic side effect of opioids?
- Nausea/vomiting
- Sedation
- Pruritus (itching)
- Diarrhea
Answer: Diarrhea
32. “Tolerance” to an opioid means that:
- The patient no longer experiences any side effects.
- A higher dose is required to produce the same level of analgesia.
- The patient is addicted.
- The drug has a longer half-life.
Answer: A higher dose is required to produce the same level of analgesia.
33. The use of a “pain contract” or “treatment agreement” for chronic opioid therapy is a tool to:
- Guarantee that the patient will be pain-free.
- Establish clear expectations for both the patient and prescriber to promote safe use.
- Prevent the patient from ever stopping the medication.
- Ensure the pharmacy will always have the medication in stock.
Answer: Establish clear expectations for both the patient and prescriber to promote safe use.
34. In which “practice setting” is a pharmacist most likely to manage a PCA pump?
- Community pharmacy
- Hospital/Institutional setting
- Mail-order pharmacy
- A PBM
Answer: Hospital/Institutional setting
35. A “Clinical Decision Support” alert in an EHR should be designed to fire when:
- A prescriber orders an opioid for an opioid-naïve patient at a very high starting dose.
- A prescriber co-prescribes an opioid and a benzodiazepine.
- A patient has a documented history of an opioid use disorder.
- All of the above.
Answer: All of the above.
36. From a “human factors” perspective, the numerous look-alike/sound-alike names and different formulations of opioids can lead to:
- A high risk of medication errors.
- Improved patient safety.
- A more efficient workflow.
- No impact on the medication use process.
Answer: A high risk of medication errors.
37. A pharmacist’s knowledge of “toxicology” is critical for:
- Recognizing and managing an opioid overdose.
- Dosing a common antibiotic.
- Managing a pharmacy’s inventory.
- Counseling on the use of a blood glucose meter.
Answer: Recognizing and managing an opioid overdose.
38. The service of “deprescribing” is relevant to opioids when:
- A patient on long-term therapy for chronic pain has more harm than benefit from the medication.
- An opioid should never be deprescribed.
- A patient has acute post-operative pain.
- A patient is in hospice care.
Answer: A patient on long-term therapy for chronic pain has more harm than benefit from the medication.
39. A “negotiation” may be required when:
- A pharmacist is discussing with a prescriber a safer, non-opioid alternative for a patient’s chronic pain.
- A patient is picking up a routine, non-controlled refill.
- A pharmacist is ringing up a sale.
- A pharmacist is checking in a medication order.
Answer: A pharmacist is discussing with a prescriber a safer, non-opioid alternative for a patient’s chronic pain.
40. The “financials” of the opioid crisis include:
- The high cost to the healthcare system for treating overdoses and substance use disorder.
- The profits generated by pharmaceutical manufacturers.
- The economic impact of lost productivity.
- All of the above.
Answer: All of the above.
41. The use of “human resources” principles is important when:
- A pharmacy employee is suspected of diverting narcotic analgesics.
- The pharmacy is deciding on a new computer system.
- A patient asks about the price of a medication.
- The pharmacy needs to order more vials.
Answer: A pharmacy employee is suspected of diverting narcotic analgesics.
42. Which of the following is NOT an opioid?
- Fentanyl
- Hydromorphone
- Naproxen
- Meperidine
Answer: Naproxen
43. A pharmacist’s understanding of “health disparities” is relevant as:
- Pain is often undertreated in certain racial and ethnic minority populations.
- Access to treatment for opioid use disorder can be unequal.
- The burden of the opioid crisis has not affected all communities equally.
- All of the above.
Answer: All of the above.
44. A key part of the “Introduction to Pharmacy Informatics” is learning how the PDMP works as a tool to:
- Promote the safe use of controlled substances like narcotic analgesics.
- Increase the sales of opioids.
- Make prescribing easier.
- Replace the Electronic Health Record.
Answer: Promote the safe use of controlled substances like narcotic analgesics.
45. An “Electronic Health Record” improves the safety of opioid prescribing by:
- Providing a clear record of a patient’s prescription history.
- Alerting prescribers to potential duplicate therapy or unsafe combinations.
- Allowing for easy tracking of pain scores and functional improvement.
- All of the above.
Answer: All of the above.
46. A “first response” to a patient who has overdosed on an opioid should prioritize:
- Preserving life by supporting breathing and administering naloxone.
- Determining who supplied the drug.
- Counseling the patient on their life choices.
- Taking a detailed medication history.
Answer: Preserving life by supporting breathing and administering naloxone.
47. A pharmacist’s “leadership” is demonstrated by:
- Taking a proactive role in their community’s response to the opioid crisis.
- Ignoring the problem of prescription drug abuse.
- Filling every opioid prescription without question.
- Focusing only on the speed of dispensing.
Answer: Taking a proactive role in their community’s response to the opioid crisis.
48. The “Drug Use and Prevention” course emphasizes that the best approach to the opioid crisis is:
- A multi-faceted strategy including prevention, treatment, harm reduction, and law enforcement.
- A focus on law enforcement only.
- A focus on treatment only.
- A focus on prevention only.
Answer: A multi-faceted strategy including prevention, treatment, harm reduction, and law enforcement.
49. “Opioid-induced hyperalgesia” is a paradoxical phenomenon where:
- A patient becomes more sensitive to pain as a result of long-term opioid use.
- A patient no longer responds to the analgesic effects of an opioid.
- A patient develops an allergic reaction to an opioid.
- A patient experiences euphoria from an opioid.
Answer: A patient becomes more sensitive to pain as a result of long-term opioid use.
50. The ultimate principle for a pharmacist managing narcotic analgesics is to:
- Ensure patients with legitimate pain have access to effective treatment while minimizing the risks of harm, misuse, and diversion.
- Prevent any patient from ever receiving an opioid.
- Fill every prescription as quickly as possible.
- Prioritize the pharmacy’s profits over public health.
Answer: Ensure patients with legitimate pain have access to effective treatment while minimizing the risks of harm, misuse, and diversion.
I am a Registered Pharmacist under the Pharmacy Act, 1948, and the founder of PharmacyFreak.com. I hold a Bachelor of Pharmacy degree from Rungta College of Pharmaceutical Science and Research. With a strong academic foundation and practical knowledge, I am committed to providing accurate, easy-to-understand content to support pharmacy students and professionals. My aim is to make complex pharmaceutical concepts accessible and useful for real-world application.
Mail- Sachin@pharmacyfreak.com