CASAC - Credentialed Alcoholism and Substance Abuse Counselor Pharmacology and Co-Occurring Disorders 1 — Questions and Answers
Question 1: Methadone, when used as medication-assisted treatment for opioid use disorder, differs from buprenorphine in a clinically significant way. Which of the following statements accurately describes a key distinction?
- Methadone is a partial opioid agonist, while buprenorphine is a full opioid agonist
- Methadone for OUD must be dispensed through a federally certified Opioid Treatment Program (OTP), while buprenorphine can be prescribed in office-based settings (Correct answer)
- Methadone carries no risk of overdose, making it safer than buprenorphine for outpatient use
- Methadone requires naloxone co-formulation to prevent misuse
Correct answer: Methadone for OUD must be dispensed through a federally certified Opioid Treatment Program (OTP), while buprenorphine can be prescribed in office-based settings
Methadone for OUD is a Schedule II controlled substance that can only be dispensed through federally certified OTPs due to its high overdose potential and abuse liability. Buprenorphine, by contrast, can be prescribed by qualified physicians in office-based settings under the DATA 2000 waiver, significantly expanding access to MAT.
Question 2: A client with co-occurring generalized anxiety disorder and alcohol use disorder is being assessed for pharmacological treatment of their anxiety. Which of the following medications would generally be considered the most appropriate first-line choice, given the risk profile in this population?
- A benzodiazepine such as lorazepam, because of its rapid anxiolytic onset
- An SSRI such as sertraline, because it is non-addictive and effective for anxiety with a co-occurring SUD (Correct answer)
- Alcohol itself can serve as a self-medication bridge while waiting for other treatments to take effect
- Barbiturates, because they have less abuse potential than benzodiazepines
Correct answer: An SSRI such as sertraline, because it is non-addictive and effective for anxiety with a co-occurring SUD
SSRIs are the preferred first-line pharmacological treatment for anxiety disorders in patients with co-occurring substance use disorders because they are non-habit-forming and have demonstrated efficacy without reinforcing addictive patterns. Benzodiazepines are generally avoided in this population due to their cross-tolerance with alcohol and high abuse potential.
Question 3: Acamprosate (Campral) is an FDA-approved medication for alcohol use disorder. Which of the following best describes its primary mechanism of action?
- It blocks alcohol metabolism at the acetaldehyde stage, producing a severe aversive reaction when alcohol is consumed
- It binds to opioid receptors to reduce the rewarding effects of alcohol
- It modulates glutamate and GABA neurotransmission to reduce protracted withdrawal symptoms and cravings (Correct answer)
- It acts as a dopamine reuptake inhibitor to normalize reward pathways disrupted by chronic alcohol use
Correct answer: It modulates glutamate and GABA neurotransmission to reduce protracted withdrawal symptoms and cravings
Acamprosate works by stabilizing the glutamate/GABA imbalance that develops after prolonged alcohol use, thereby reducing the neurological hyperexcitability that drives protracted withdrawal symptoms such as anxiety, insomnia, and cravings. Unlike disulfiram, it does not cause an aversive reaction, and unlike naltrexone, it does not act on opioid receptors.
Question 4: A client with a history of psychotic disorder reports daily cannabis use and states it helps them feel relaxed. Which of the following represents the most clinically important concern the counselor should communicate to this client?
- Cannabis is a benign natural substance with no documented psychiatric risks when used in moderation
- THC can exacerbate psychotic symptoms, trigger relapses in schizophrenia, and reduce the efficacy of antipsychotic medications (Correct answer)
- Cannabis is recommended as a harm reduction substitute for clients who use stimulants
- The primary concern with cannabis in this population is respiratory damage, not psychiatric effects
Correct answer: THC can exacerbate psychotic symptoms, trigger relapses in schizophrenia, and reduce the efficacy of antipsychotic medications
Research consistently shows that THC, the primary psychoactive compound in cannabis, can precipitate or worsen psychotic episodes and is associated with earlier onset and more severe course of schizophrenia. Regular cannabis use also interferes with antipsychotic treatment and significantly worsens long-term outcomes for individuals with psychotic disorders.
Question 5: A client with co-occurring ADHD and stimulant use disorder is being evaluated for ADHD pharmacotherapy. Which medication class would raise the greatest concern for misuse and diversion in this population?
- Atomoxetine (Strattera), a non-stimulant selective norepinephrine reuptake inhibitor
- Amphetamine salts (Adderall), a Schedule II stimulant with high abuse potential (Correct answer)
- Bupropion (Wellbutrin), an atypical antidepressant sometimes used off-label for ADHD
- Guanfacine (Intuniv), an alpha-2 adrenergic agonist approved for ADHD
Correct answer: Amphetamine salts (Adderall), a Schedule II stimulant with high abuse potential
Amphetamine-based medications such as Adderall are Schedule II controlled substances with significant abuse and diversion potential, making them particularly risky for individuals with a history of stimulant use disorder. Non-stimulant alternatives such as atomoxetine, bupropion, or guanfacine are generally preferred in this co-occurring population to avoid reinforcing the addiction cycle.
Question 6: A client being treated with buprenorphine/naloxone (Suboxone) for opioid use disorder begins taking a benzodiazepine prescribed by another provider without informing their MAT physician. What is the primary pharmacological danger of this combination?
- The naloxone component of Suboxone will immediately reverse the benzodiazepine, causing acute withdrawal
- Combined CNS depression from both substances significantly increases the risk of respiratory depression and overdose death (Correct answer)
- Benzodiazepines accelerate buprenorphine metabolism, triggering opioid withdrawal symptoms
- This combination causes a disulfiram-like reaction including flushing, nausea, and tachycardia
Correct answer: Combined CNS depression from both substances significantly increases the risk of respiratory depression and overdose death
Both buprenorphine and benzodiazepines cause central nervous system and respiratory depression. When combined, their sedative effects are additive or synergistic, substantially elevating the risk of fatal respiratory depression even though buprenorphine alone has a ceiling effect on respiratory depression. This combination accounts for a significant proportion of buprenorphine-related overdose deaths.
CASAC - Credentialed Alcoholism and Substance Abuse Counselor Pharmacology and Co-Occurring Disorders 1
Methadone, when used as medication-assisted treatment for opioid use disorder, differs from buprenorphine in a clinically significant way.
Which of the following statements accurately describes a key distinction?