A 45-year-old with alcohol use disorder reports persistent sad mood and anhedonia after 3 weeks
of abstinence. What is the best next step?
a) Start fluoxetine immediately
b) Continue abstinence monitoring; symptoms may be protracted withdrawal
c) Order a brain MRI
d) Prescribe lorazepam daily
Protracted withdrawal can cause mood symptoms lasting weeks to months; ongoing support and
monitoring are first-line.
A patient on methadone 80 mg daily presents with acute confusion and pinpoint pupils. What
medication should you suspect as the cause?
a) Bupropion
b) Another opioid, such as heroin, leading to opioid toxicity
c) Cocaine
d) Amphetamine
Pinpoint pupils and CNS depression with methadone suggest additional opioid use; consider
overdose and give naloxone.
A 30-year-old with opioid use disorder on buprenorphine/naloxone reports precipitated
withdrawal 1 hour after starting the medication. What was the most likely error?
a) Dose was too low
b) First dose given too soon after last full opioid agonist use
c) Naloxone caused the withdrawal
d) Patient is allergic to buprenorphine
Buprenorphine displaces full agonists at mu receptors; wait for moderate withdrawal (COWS
≥12) to avoid precipitated withdrawal.
,A college student drinks 15 beers each weekend but none during the week. Which DSM-5
criterion supports mild alcohol use disorder?
a) Tolerance only
b) Recurrent use in hazardous situations, like driving after drinking
c) Withdrawal symptoms on weekdays
d) Giving up activities
*One criterion (e.g., hazardous use) meets mild AUD if 2-3 criteria total; but this scenario
implies at least two criteria after further history.*
A patient on naltrexone for alcohol use disorder complains of nausea and headache. What is the
most appropriate management?
a) Discontinue naltrexone permanently
b) Reduce dose or take with food; symptoms often transient
c) Add metoclopramide
d) Switch to disulfiram immediately
Naltrexone side effects are common initially; dose adjustment and administration with meals
improve tolerability.
A 22-year-old with cannabis use disorder and daily use reports vomiting and abdominal pain for
2 months, relieved by hot showers. What is the likely diagnosis?
a) Cyclic vomiting syndrome
b) Cannabinoid hyperemesis syndrome
c) Gastroenteritis
d) Peptic ulcer disease
Compulsive hot bathing with chronic cannabis use and vomiting suggests cannabinoid
hyperemesis; cessation resolves symptoms.
,A patient on disulfiram develops flushing, nausea, and dyspnea 30 minutes after eating at a
restaurant. What is the most likely cause?
a) Serotonin syndrome
b) Hidden alcohol in food (e.g., sauce, vinegar)
c) Anaphylaxis to shellfish
d) Disulfiram-induced hepatitis
Disulfiram blocks acetaldehyde dehydrogenase; even small amounts of alcohol (sauces,
marinades) trigger acetaldehyde reaction.
A 55-year-old with alcoholic liver disease and ascites has a daily alcohol use of 8 drinks. What is
the first-line medication for alcohol relapse prevention in this setting?
a) Naltrexone
b) Acamprosate
c) Disulfiram
d) Topiramate
Acamprosate is hepatically safe and effective in maintaining abstinence even with liver disease;
naltrexone carries hepatotoxicity risk.
A patient on buprenorphine for OUD requires surgery. Which statement about perioperative pain
management is correct?
a) Stop buprenorphine 72 hours before surgery
b) Continue buprenorphine and use high-dose opioids or regional anesthesia
c) Switch to methadone only after surgery
d) Avoid all opioids due to blockade
Continued buprenorphine provides baseline coverage; additional mu agonists can overcome
partial blockade with higher doses under monitoring.
A 28-year-old injects heroin daily and tests positive for hepatitis C. What is the most effective
harm reduction intervention to prevent transmission to others?
, a) Provide condoms
b) Prescribe buprenorphine to reduce injection frequency
c) Vaccinate for hepatitis A and B
d) Offer once-daily directly observed therapy
Medication for opioid use disorder (MOUD) dramatically reduces injection episodes and thus
HCV transmission risk.
A pregnant woman at 20 weeks gestation with opioid use disorder asks about methadone vs
buprenorphine. Which statement is accurate for neonatal outcomes?
a) Methadone causes less neonatal abstinence syndrome (NAS)
b) Buprenorphine is associated with shorter NAS duration and lower severity
c) Both are contraindicated in pregnancy
d) Neither medication reduces NAS
Buprenorphine leads to milder NAS than methadone, though both are safe; methadone is more
studied for treatment retention.
A patient on high-dose stimulants for ADHD is found to have a cocaine-positive urine screen.
What is the best clinical approach?
a) Discontinue all stimulants immediately
b) Verify with confirmatory testing (GC-MS) to rule out false positive
c) Assume the patient is selling the prescription
d) Switch to non-stimulant atomoxetine
Prescription stimulants can cross-react with cocaine immunoassays; confirmatory testing
distinguishes therapeutic from illicit use.
A 40-year-old with benzodiazepine use disorder taking clonazepam 4 mg daily wants to taper.
What is the appropriate outpatient conversion for a diazepam taper?
a) 10 mg diazepam daily
b) 40 mg diazepam daily (10 mg per 1 mg clonazepam)
of abstinence. What is the best next step?
a) Start fluoxetine immediately
b) Continue abstinence monitoring; symptoms may be protracted withdrawal
c) Order a brain MRI
d) Prescribe lorazepam daily
Protracted withdrawal can cause mood symptoms lasting weeks to months; ongoing support and
monitoring are first-line.
A patient on methadone 80 mg daily presents with acute confusion and pinpoint pupils. What
medication should you suspect as the cause?
a) Bupropion
b) Another opioid, such as heroin, leading to opioid toxicity
c) Cocaine
d) Amphetamine
Pinpoint pupils and CNS depression with methadone suggest additional opioid use; consider
overdose and give naloxone.
A 30-year-old with opioid use disorder on buprenorphine/naloxone reports precipitated
withdrawal 1 hour after starting the medication. What was the most likely error?
a) Dose was too low
b) First dose given too soon after last full opioid agonist use
c) Naloxone caused the withdrawal
d) Patient is allergic to buprenorphine
Buprenorphine displaces full agonists at mu receptors; wait for moderate withdrawal (COWS
≥12) to avoid precipitated withdrawal.
,A college student drinks 15 beers each weekend but none during the week. Which DSM-5
criterion supports mild alcohol use disorder?
a) Tolerance only
b) Recurrent use in hazardous situations, like driving after drinking
c) Withdrawal symptoms on weekdays
d) Giving up activities
*One criterion (e.g., hazardous use) meets mild AUD if 2-3 criteria total; but this scenario
implies at least two criteria after further history.*
A patient on naltrexone for alcohol use disorder complains of nausea and headache. What is the
most appropriate management?
a) Discontinue naltrexone permanently
b) Reduce dose or take with food; symptoms often transient
c) Add metoclopramide
d) Switch to disulfiram immediately
Naltrexone side effects are common initially; dose adjustment and administration with meals
improve tolerability.
A 22-year-old with cannabis use disorder and daily use reports vomiting and abdominal pain for
2 months, relieved by hot showers. What is the likely diagnosis?
a) Cyclic vomiting syndrome
b) Cannabinoid hyperemesis syndrome
c) Gastroenteritis
d) Peptic ulcer disease
Compulsive hot bathing with chronic cannabis use and vomiting suggests cannabinoid
hyperemesis; cessation resolves symptoms.
,A patient on disulfiram develops flushing, nausea, and dyspnea 30 minutes after eating at a
restaurant. What is the most likely cause?
a) Serotonin syndrome
b) Hidden alcohol in food (e.g., sauce, vinegar)
c) Anaphylaxis to shellfish
d) Disulfiram-induced hepatitis
Disulfiram blocks acetaldehyde dehydrogenase; even small amounts of alcohol (sauces,
marinades) trigger acetaldehyde reaction.
A 55-year-old with alcoholic liver disease and ascites has a daily alcohol use of 8 drinks. What is
the first-line medication for alcohol relapse prevention in this setting?
a) Naltrexone
b) Acamprosate
c) Disulfiram
d) Topiramate
Acamprosate is hepatically safe and effective in maintaining abstinence even with liver disease;
naltrexone carries hepatotoxicity risk.
A patient on buprenorphine for OUD requires surgery. Which statement about perioperative pain
management is correct?
a) Stop buprenorphine 72 hours before surgery
b) Continue buprenorphine and use high-dose opioids or regional anesthesia
c) Switch to methadone only after surgery
d) Avoid all opioids due to blockade
Continued buprenorphine provides baseline coverage; additional mu agonists can overcome
partial blockade with higher doses under monitoring.
A 28-year-old injects heroin daily and tests positive for hepatitis C. What is the most effective
harm reduction intervention to prevent transmission to others?
, a) Provide condoms
b) Prescribe buprenorphine to reduce injection frequency
c) Vaccinate for hepatitis A and B
d) Offer once-daily directly observed therapy
Medication for opioid use disorder (MOUD) dramatically reduces injection episodes and thus
HCV transmission risk.
A pregnant woman at 20 weeks gestation with opioid use disorder asks about methadone vs
buprenorphine. Which statement is accurate for neonatal outcomes?
a) Methadone causes less neonatal abstinence syndrome (NAS)
b) Buprenorphine is associated with shorter NAS duration and lower severity
c) Both are contraindicated in pregnancy
d) Neither medication reduces NAS
Buprenorphine leads to milder NAS than methadone, though both are safe; methadone is more
studied for treatment retention.
A patient on high-dose stimulants for ADHD is found to have a cocaine-positive urine screen.
What is the best clinical approach?
a) Discontinue all stimulants immediately
b) Verify with confirmatory testing (GC-MS) to rule out false positive
c) Assume the patient is selling the prescription
d) Switch to non-stimulant atomoxetine
Prescription stimulants can cross-react with cocaine immunoassays; confirmatory testing
distinguishes therapeutic from illicit use.
A 40-year-old with benzodiazepine use disorder taking clonazepam 4 mg daily wants to taper.
What is the appropriate outpatient conversion for a diazepam taper?
a) 10 mg diazepam daily
b) 40 mg diazepam daily (10 mg per 1 mg clonazepam)
