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Managing Chronic Pain in Substance Abusing Clients

Introduction

1. Which of the following describes aberrant drug-related behaviors that resemble those of patients with addiction but that actually result from inadequate treatment of pain?

A. Addiction B. Pseudoaddiction C. Physical dependence D. Substance use disorder

2. The disease of addiction results when normal neural processes are altered into dysfunctional patterns. This primarily occurs in all of the following, except:

A. The brain's parasympathetic system. B. The brain's memory system. C. The brain's reward system. D. The brain's stress system.

3. Which of the following is a commonality between chronic pain and addiction?

A. Both are neurobiological conditions with evidence of disordered CNS function. B. Both are mediated by genetics and environment. C. Both may have serious harmful consequences if untreated. D. All of the above.

4. Chronic pain often results from a process of neural sensitization following injury or illness in which:

A. Thresholds are lowered. B. Responses are amplified. C. Spontaneous neural discharges occur. D. All of the above.

5. Continual pain can trigger emotional responses, including sleeplessness, anxiety, and depressive symptoms, which in turn produce more pain.

A. True B. False

6. Feelings of reward emerge from the core of the limbic system after neurons in the ventral tegmental area release which neurotransmitter into the nucleus accumbens?

A. Acetylcholine B. Dopamine C. Serotonin D. Oxytocin

7. Which of the following is a negative reinforcer for taking heroin?

A. Going to jail B. Euphoria C. Pain reduction D. Both (A) and (C)

Patient Assessment

8. An assessment of pain and function in patients with SUD histories may be complicated by which of the following factors?

A. Some patients with histories of SUDs may overreport their pain experience if they are afraid that they will be under medicated or that their symptoms will not be taken seriously. B. Some patients with histories of SUDs may underreport their pain experience if they are afraid they will be prescribed medications that will cause them to relapse. C. Some patients may exaggerate pain and disability levels to get opioids for reasons other than pain control. D. All of the above.

9. When initiating a conversation about alcohol and drug use, nurses should do all of the following, except:

A. Approach the topic matter-of-factly, handling it as part of the overall medical history. B. Incorporate questions about drug and alcohol use into a general behavioral health inventory including discussion of other lifestyle behaviors, such as diet and exercise. C. Ask about alcohol and caffeine use; questions about use of these substances provide opportunities to move to assessment of other substances, beginning with nicotine, the most commonly abused substance. D. Assure patients that honest answers to questions of substance use are necessary to developing a treatment plan and that their responses will remain confidential.

10. A good prescreening question is, "When did you last have a drink of beer, wine, or liquor?"

A. True B. False

11. If a patient reports drinking within the past year, the nurse should ask questions to determine all of the following, except:

A. The type of alcohol consumed. B. The frequency alcohol is consumed. C. The quantity of alcohol consumed. D. Evidence of binge drinking.

12. Although a patient's former drug of choice is the one that is most likely to lead to cravings and relapse, a person with a history of an SUD involving any drug is susceptible to developing a cross-addiction with opioids.

A. True B. False

13. Patients who have CNCP and comorbid depression tend to:

A. Have high pain scores. B. Adhere less to treatment plans than patients who are not depressed. C. Respond less well to pain treatment, unless depression is addressed. D. All of the above.

14. Which of the following can result from prolonged exposure to opioids and present as depression?

A. Sleep apnea B. Hypothyroidism C. Hypogonadism D. All of the above

Chronic Pain Management

15. Benzodiazepines should be first-line medications in the treatment of CNCP in patients who have comorbid SUD.

A. True B. False

16. All of the following attributes regarding cannabinoids are true, except for:

A. Cannabinoids are anti-inflammatory. B. Cannabinoids decrease levels of endogenous opioids. C. Cannabinoids inhibit glutamatergic transmission. D. Cannabinoids antagonize the N-methyl-D-aspartate glutamate receptor.

17. Psychiatric comorbidity is of special significance because untreated psychopathology is associated with poor pain treatment outcomes.

A. True B. False

18. Effective options for anxiety associated with chronic pain include all of the following, except:

A. Antihistamines B. Selective serotonin reuptake inhibitors C. Serotonin-norepinephrine reuptake inhibitors D. Tricyclic antidepressants

19. Serotonin syndrome is a potential adverse effect of opioids and some medications used to treat depression. It can cause agitation, confusion, fever, and seizures, and it can be lethal if undetected or untreated.

A. True B. False

20. Patients who take which of the following are at increased risk of serotonin syndrome?

A. St. John's Wort B. SSRIs C. HIV medication D. All of the above

21. Opioids are an important treatment for many patients with CNCP and are often a sufficient treatment on their own.

A. True B. False

22. The route of administration may influence addiction risk, so medications that are injected or easily convertible to forms that can be injected, smoked, or snorted are often avoided in patients who have SUDs.

A. True B. False

23. Although no schedule can be applied to everyone, a general guide is that, if low doses of opioids are initiated for severe pain, they should be titrated slowly to avoid them wearing off too quickly.

A. True B. False

24. Several studies have shown that opioids eliminate chronic pain, so efforts should be made to achieve a zero pain level for patients.

A. True B. False

25. Many addiction treatment programs are unwilling to admit patients who are taking opioid pain medications, interpreting their prescription opioid use as a sign of active addiction.

A. True B. False

26. The majority of deaths secondary to methadone occur in the first 14 days of use because:

A. The initial dose is too high. B. It is titrated too quickly. C. It interacts with other drugs or medication. D. All of the above.

27. It is critical that patients starting methadone receive a thorough education in the dangers of inadvertent overdose, including:

A. That a dose that seems initially inadequate can be toxic a few days later because of accumulation. B. To keep the medication out of reach so that they cannot take a dose when sedated. C. The extreme danger if a child or nontolerant adult ingests their medication. D. All of the above.

28. Patients taking naltrexone should only be prescribed outpatient opioids for a short period of time.

A. True B. False

29. Tolerance can be characterized as increased sensitivity to pain resulting from opioid use.

A. True B. False

Managing Addiction Risk in Patients Treated With Opioids

30. All of the following substances are recommended for testing during routine screening, except for:

A. Benzodiazepines B. Opioids C. Antidepressants D. Amphetamines

31. Which of the following suggest aberrant drug-related behavior?

A. Insisting that higher doses are needed. B. Being more interested in opioids than in other medications or in any other aspect of treatment. C. Repeatedly losing medications or prescriptions or seeking early refills. D. All of the above.

32. All members of the treatment team should be alert to the patient who:

A. Has attempted to alter or forge prescriptions. B. Strongly prefers brand name drugs or drugs with high street value. C. Cannot produce the remainder of a partially used prescription when asked for a pill or patch count. D. All of the above.

33. Which of the following is the best reason for the patient to discontinue opioid therapy?

A. Opioids are no longer effective. B. The pain has resolved. C. The patient loses control over the medication. D. The patient is diverting the medication.

34. For patients whose active addiction necessitates discontinuation of opioid therapy, referral for specialized addiction treatment is crucial.

A. True B. False

Patient Education and Treatment Agreements

35. General content areas for patient education include information about:

A. The patient's responsibility for keeping track of medications and not losing them or giving them to others. B. Any medication interactions. C. Under what conditions the patient should immediately call the clinician or go to the emergency department. D. All of the above.

36. A useful treatment agreement should be revised as the patient's needs and circumstances change.

A. True B. False


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