MCQ Quiz: Substance Use Disorders and Clinical Toxicology

Substance Use Disorders (SUDs) and clinical toxicology represent two of the most challenging and impactful areas in modern healthcare. The pharmacist’s role has evolved significantly, moving to the forefront of addiction management, harm reduction, and emergency overdose response. A deep understanding of the pharmacology of abused substances, the principles of addiction treatment, and the management of toxicological emergencies is essential for any practicing pharmacist. This quiz covers key concepts from the Patient Care VII: Brain and Behavior module, focusing on the etiology of SUDs, management of specific disorders like opioid and alcohol use disorder, and the assessment and treatment of clinical toxicology emergencies.

1. Which neurotransmitter is most commonly associated with the brain’s reward pathway and is central to the neurobiology of addiction?

• a) Acetylcholine
• b) Serotonin
• c) Dopamine
• d) GABA Answer: c) Dopamine

2. A patient presents to the emergency department with respiratory depression, pinpoint pupils (miosis), and altered mental status. These signs are characteristic of which toxidrome?

• a) Anticholinergic
• b) Cholinergic
• c) Sympathomimetic
• d) Opioid Answer: d) Opioid

3. What is the primary mechanism of action of naloxone in reversing an opioid overdose?

• a) It is a partial agonist at the mu-opioid receptor.
• b) It is a competitive antagonist at the mu-opioid receptor.
• c) It inhibits the reuptake of dopamine.
• d) It increases the metabolism of opioids. Answer: b) It is a competitive antagonist at the mu-opioid receptor.

4. A patient with alcohol use disorder is being started on naltrexone. What is its mechanism of action for this indication?

• a) It causes a severe disulfiram-like reaction when alcohol is consumed.
• b) It blocks mu-opioid receptors, which reduces the rewarding effects of alcohol.
• c) It restores the balance between GABA and glutamate neurotransmission.
• d) It inhibits the metabolism of alcohol, leading to higher blood levels. Answer: b) It blocks mu-opioid receptors, which reduces the rewarding effects of alcohol.

5. Which medication used for Alcohol Use Disorder works by inhibiting aldehyde dehydrogenase, leading to the accumulation of acetaldehyde if alcohol is ingested?

• a) Naltrexone
• b) Acamprosate
• c) Disulfiram
• d) Topiramate Answer: c) Disulfiram

6. Benzodiazepines are the standard of care for managing acute alcohol withdrawal to prevent which life-threatening complication?

• a) Hypertensive crisis
• b) Serotonin syndrome
• c) Seizures and delirium tremens
• d) Acute liver failure Answer: c) Seizures and delirium tremens

7. A patient presents with agitation, tachycardia, hypertension, mydriasis (dilated pupils), and diaphoresis. This presentation is most consistent with an overdose of:

• a) Diazepam
• b) Morphine
• c) Cocaine
• d) Amitriptyline Answer: c) Cocaine

8. What is the specific antidote for benzodiazepine overdose?

• a) Naloxone
• b) Flumazenil
• c) N-acetylcysteine
• d) Atropine Answer: b) Flumazenil

9. Buprenorphine is a key medication for Opioid Use Disorder (OUD). What is its unique mechanism of action?

• a) A full opioid agonist, similar to methadone.
• b) A pure opioid antagonist.
• c) A partial agonist at the mu-opioid receptor and antagonist at the kappa-opioid receptor.
• d) A selective serotonin reuptake inhibitor. Answer: c) A partial agonist at the mu-opioid receptor and antagonist at the kappa-opioid receptor.

10. Why must a patient be in a state of mild to moderate withdrawal before initiating buprenorphine?

• a) To ensure the medication is absorbed properly.
• b) To prevent precipitated withdrawal due to buprenorphine’s partial agonist activity displacing full agonists.
• c) To confirm the diagnosis of opioid use disorder.
• d) To reduce the risk of cardiovascular side effects. Answer: b) To prevent precipitated withdrawal due to buprenorphine’s partial agonist activity displacing full agonists.

11. Which of the following is NOT part of the “5 A’s” model for tobacco cessation counseling?

• a) Ask
• b) Advise
• c) Assert
• d) Arrange Answer: c) Assert

12. Varenicline (Chantix) aids in smoking cessation by what mechanism?

• a) Acting as a partial agonist at the α4β2 nicotinic acetylcholine receptor.
• b) Inhibiting the metabolism of nicotine.
• c) Blocking dopamine receptors in the nucleus accumbens.
• d) Providing a steady stream of nicotine to the body. Answer: a) Acting as a partial agonist at the α4β2 nicotinic acetylcholine receptor.

13. N-acetylcysteine (NAC) is the antidote for an overdose of which common over-the-counter medication?

• a) Ibuprofen
• b) Diphenhydramine
• c) Loperamide
• d) Acetaminophen Answer: d) Acetaminophen

14. A patient presenting with the anticholinergic toxidrome (“mad as a hatter, blind as a bat, red as a beet, hot as a hare, dry as a bone”) likely overdosed on:

• a) A beta-blocker
• b) An organophosphate insecticide
• c) An excess of diphenhydramine
• d) A calcium channel blocker Answer: c) An excess of diphenhydramine

15. In the management of a toxicology emergency, what is the primary goal of gastric lavage?

• a) To enhance the elimination of the toxin.
• b) To neutralize the toxin in the stomach.
• c) To physically remove the unabsorbed toxin from the stomach.
• d) To bind the toxin and prevent absorption. Answer: c) To physically remove the unabsorbed toxin from the stomach.

16. Which of the following is considered a “red flag” for potential controlled substance diversion or misuse by a pharmacist?

• a) A patient who has been on a stable dose of oxycodone for years from the same prescriber.
• b) A patient presenting a prescription from a known “pill mill” or a prescriber located hundreds of miles away.
• c) A patient requesting a 90-day supply of a maintenance medication.
• d) A patient asking for counseling on their new medication. Answer: b) A patient presenting a prescription from a known “pill mill” or a prescriber located hundreds of miles away.

17. What is the primary role of the Professionals Resource Network (PRN) in Florida, as mentioned in the curriculum?

• a) To prosecute healthcare professionals who divert medications.
• b) To provide support and monitoring for healthcare professionals with impairing conditions like SUD.
• c) To set the prices for controlled substances.
• d) To lobby for less strict pharmacy regulations. Answer: b) To provide support and monitoring for healthcare professionals with impairing conditions like SUD.

18. What is the mechanism of action of acamprosate in treating Alcohol Use Disorder?

• a) It inhibits aldehyde dehydrogenase.
• b) It is a mu-opioid receptor antagonist.
• c) It is thought to modulate glutamate and GABA neurotransmission, reducing withdrawal symptoms.
• d) It is a selective serotonin reuptake inhibitor. Answer: c) It is thought to modulate glutamate and GABA neurotransmission, reducing withdrawal symptoms.

19. Activated charcoal is most effective when administered within what timeframe after ingestion of a toxin?

• a) 12 hours
• b) 6 hours
• c) 24 hours
• d) 1-2 hours Answer: d) 1-2 hours

20. Which of the following substances is NOT well-adsorbed by activated charcoal?

• a) Aspirin
• b) Amitriptyline
• c) Iron
• d) Phenobarbital Answer: c) Iron

21. Methadone helps treat Opioid Use Disorder by being a:

• a) Long-acting full mu-opioid agonist that reduces cravings and withdrawal.
• b) Partial mu-opioid agonist.
• c) Mu-opioid antagonist that blocks the effects of other opioids.
• d) Norepinephrine reuptake inhibitor. Answer: a) Long-acting full mu-opioid agonist that reduces cravings and withdrawal.

22. “Harm reduction” is a public health strategy that aims to:

• a) Eliminate all drug use in society.
• b) Punish individuals who use illicit substances.
• c) Reduce the negative consequences associated with drug use, such as providing naloxone kits and clean syringes.
• d) Focus solely on abstinence-only programs. Answer: c) Reduce the negative consequences associated with drug use, such as providing naloxone kits and clean syringes.

23. A patient on a high dose of methadone for OUD is started on a potent CYP3A4 inducer like carbamazepine. What is the likely clinical consequence?

• a) Increased methadone levels, leading to risk of overdose.
• b) Decreased methadone levels, leading to withdrawal symptoms and cravings.
• c) No significant interaction.
• d) Development of serotonin syndrome. Answer: b) Decreased methadone levels, leading to withdrawal symptoms and cravings.

24. The “ceiling effect” for respiratory depression is a key pharmacological feature of which OUD medication?

• a) Methadone
• b) Fentanyl
• c) Oxycodone
• d) Buprenorphine Answer: d) Buprenorphine

25. A patient with a tricyclic antidepressant (TCA) overdose may present with what characteristic finding on an electrocardiogram (ECG)?

• a) ST-segment elevation
• b) Widening of the QRS complex
• c) A shortened PR interval
• d) Atrial fibrillation Answer: b) Widening of the QRS complex

26. What is the primary treatment for a widened QRS complex and ventricular dysrhythmias in a TCA overdose?

• a) Sodium bicarbonate
• b) Calcium gluconate
• c) Naloxone
• d) Flumazenil Answer: a) Sodium bicarbonate

27. The primary psychoactive component in cannabis is:

• a) Cannabidiol (CBD)
• b) Tetrahydrocannabinol (THC)
• c) Nabilone
• d) Dronabinol Answer: b) Tetrahydrocannabinol (THC)

28. Chronic, high-dose use of which substance can lead to gingival hyperplasia, ataxia, and nystagmus?

• a) Cocaine
• b) Heroin
• c) Phenytoin
• d) Methamphetamine Answer: c) Phenytoin

29. What is a key counseling point for a patient using a nicotine patch?

• a) Cut the patch in half if the dose is too high.
• b) Apply the patch to the same site every day to increase absorption.
• c) Remove the old patch before applying a new one to a different, clean, dry skin site.
• d) The patch can be removed at night to get better sleep and put back on in the morning. Answer: c) Remove the old patch before applying a new one to a different, clean, dry skin site.

30. The “Clinical Opiate Withdrawal Scale” (COWS) is a tool used to:

• a) Diagnose opioid use disorder.
• b) Objectively measure the severity of opioid withdrawal.
• c) Predict the risk of future overdose.
• d) Determine the appropriate dose of naloxone. Answer: b) Objectively measure the severity of opioid withdrawal.

31. In the pharmacology of ethanol, which two neurotransmitter systems are most acutely affected?

• a) Dopamine and Serotonin
• b) Acetylcholine and Norepinephrine
• c) Histamine and Orexin
• d) GABA (enhanced) and Glutamate (inhibited) Answer: d) GABA (enhanced) and Glutamate (inhibited)

32. The legal and ethical principle of “corresponding responsibility” means that the pharmacist shares responsibility with the prescriber for the:

• a) Cost of the medication.
• b) Legitimate medical purpose of a controlled substance prescription.
• c) Patient’s insurance coverage.
• d) Choice of pharmacy the patient uses. Answer: b) Legitimate medical purpose of a controlled substance prescription.

33. In the management of a sympathomimetic overdose (e.g., cocaine, amphetamines), why are beta-blockers generally avoided for treating hypertension?

• a) They are not effective at lowering blood pressure.
• b) They can lead to unopposed alpha-adrenergic stimulation, paradoxically worsening hypertension.
• c) They have too many drug interactions with stimulants.
• d) They are too sedating for this patient population. Answer: b) They can lead to unopposed alpha-adrenergic stimulation, paradoxically worsening hypertension.

34. The primary initial treatment for agitation and seizures in most toxicological emergencies is the administration of:

• a) Haloperidol
• b) Benzodiazepines
• c) Phenytoin
• d) Propofol Answer: b) Benzodiazepines

35. An osmolar gap, calculated from a basic metabolic panel, can suggest the presence of which toxic alcohols?

• a) Ethanol and Isopropanol
• b) Methanol and Ethylene Glycol
• c) Acetaminophen and Salicylates
• d) Benzodiazepines and Opioids Answer: b) Methanol and Ethylene Glycol

36. Fomepizole is the antidote for methanol or ethylene glycol poisoning. It works by inhibiting:

• a) Aldehyde dehydrogenase
• b) Alcohol dehydrogenase
• c) CYP2E1
• d) Monoamine oxidase Answer: b) Alcohol dehydrogenase

37. Which medication for Tobacco Use Disorder is also an antidepressant and carries a black box warning for serious neuropsychiatric events?

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

38. The term “tolerance” in the context of substance use refers to:

• a) A state of psychological dependence on a substance.
• b) A diminished response to a drug after repeated administration, leading to the need for higher doses to achieve the same effect.
• c) The physical symptoms that occur when a substance is discontinued.
• d) The ability to use a substance without any negative consequences. Answer: b) A diminished response to a drug after repeated administration, leading to the need for higher doses to achieve the same effect.

39. What is the primary difference in the federal regulation between methadone and buprenorphine for OUD treatment?

• a) Buprenorphine can only be dispensed from federally licensed opioid treatment programs (OTPs).
• b) Methadone can be prescribed by any physician, while buprenorphine requires a special waiver.
• c) Methadone for OUD can only be dispensed from OTPs, while buprenorphine can be prescribed from office-based settings by waivered providers.
• d) There is no difference in their regulation. Answer: c) Methadone for OUD can only be dispensed from OTPs, while buprenorphine can be prescribed from office-based settings by waivered providers.

40. A patient experiences bradycardia, bronchospasm, and excessive salivation (SLUDGE syndrome). This is consistent with which toxidrome?

• a) Anticholinergic
• b) Sympathomimetic
• c) Cholinergic
• d) Opioid Answer: c) Cholinergic

41. What is the antidote for a cholinergic crisis, such as one caused by organophosphate poisoning?

• a) Pralidoxime and Atropine
• b) Physostigmine
• c) Naloxone
• d) Sodium bicarbonate Answer: a) Pralidoxime and Atropine

42. Which of the following is an example of a long-acting injectable formulation used to treat SUD?

• a) Naltrexone for intramuscular injection
• b) Immediate-release morphine
• c) Transdermal fentanyl
• d) Oral methadone solution Answer: a) Naltrexone for intramuscular injection

43. A “drug-drug-gene” interaction, as mentioned in the curriculum, could occur in a patient with:

• a) A CYP2D6 poor metabolizer status taking a CYP2D6 inhibitor and a substrate.
• b) Normal genetics and no interacting medications.
• c) An allergy to penicillin.
• d) A preference for brand-name drugs. Answer: a) A CYP2D6 poor metabolizer status taking a CYP2D6 inhibitor and a substrate.

44. What is the primary goal of urine drug testing in the management of SUDs?

• a) To punish patients who have a positive result.
• b) To provide objective data to monitor adherence and detect non-prescribed substance use, as a tool to guide therapy.
• c) To report patients to law enforcement.
• d) To determine if a patient is employed. Answer: b) To provide objective data to monitor adherence and detect non-prescribed substance use, as a tool to guide therapy.

45. Which over-the-counter pain reliever can cause a severe anion gap metabolic acidosis and tinnitus in overdose?

• a) Acetaminophen
• b) Ibuprofen
• c) Naproxen
• d) Aspirin (salicylates) Answer: d) Aspirin (salicylates)

46. The use of whole bowel irrigation with polyethylene glycol is a decontamination method considered for ingestion of:

• a) Sustained-release products or drugs not adsorbed by charcoal, like iron.
• b) A single, small tablet of a non-toxic substance.
• c) Any liquid medication.
• d) Any medication taken more than 12 hours ago. Answer: a) Sustained-release products or drugs not adsorbed by charcoal, like iron.

47. A key component of counseling a patient who is being co-prescribed an opioid and a benzodiazepine is to warn them of the increased risk of:

• a) Liver failure
• b) Serotonin syndrome
• c) Severe respiratory depression
• d) Kidney damage Answer: c) Severe respiratory depression

48. In the management of a digoxin overdose, what is the specific antidote?

• a) Intravenous lipid emulsion
• b) Digoxin immune Fab (DigiFab)
• c) Glucagon
• d) High-dose insulin euglycemia therapy Answer: b) Digoxin immune Fab (DigiFab)

49. The term “withdrawal” refers to:

• a) The act of taking a drug out of its packaging.
• b) A predictable set of signs and symptoms that results from the abrupt removal of, or dose reduction of, a substance upon which the body is physically dependent.
• c) A patient’s desire to stop using a substance.
• d) The process of checking a prescription for accuracy. Answer: b) A predictable set of signs and symptoms that results from the abrupt removal of, or dose reduction of, a substance upon which the body is physically dependent.

50. What is a primary role for a pharmacist in managing a toxicology patient after they have been stabilized in the emergency department?

• a) Administering activated charcoal 24 hours after ingestion.
• b) Providing poison prevention education upon discharge.
• c) Determining the legal consequences for the patient.
• d) There is no role for the pharmacist after the acute phase. Answer: b) Providing poison prevention education upon discharge.