Download N677 Controlled Substance and more Exams Neurology in PDF only on Docsity!
N677 Controlled Substance
Section 1: Controlled Substance Schedules (Questions 1–20)
1. Which of the following is a Schedule I controlled substance? A. Codeine B. Heroin C. Amphetamine D. Alprazolam Answer: B. Heroin Rationale: Heroin has no accepted medical use in the US and high abuse potential (Schedule I). Codeine (with exceptions) is Schedule II–V depending on formulation; amphetamine is Schedule II; alprazolam is Schedule IV. 2. A Schedule II drug must have a prescription that is: A. Verbal, followed by written within 7 days B. Electronic or written, no refills C. Oral with unlimited refills D. Written only, can be refilled twice Answer: B. Electronic or written, no refills Rationale: Schedule II requires written or e-prescription (with exceptions in emergencies). No refills permitted. Verbal only allowed in emergencies with written follow-up within 7 days
- but that is not the standard rule. 3. Which schedule has the lowest abuse potential? A. Schedule I B. Schedule II C. Schedule III D. Schedule V Answer: D. Schedule V Rationale: Schedule V drugs (e.g., cough suppressants with codeine) have lowest abuse potential among controlled substances; Schedule I highest. 4. Buprenorphine (alone) is classified as: A. Schedule I B. Schedule II C. Schedule III D. Schedule V
Answer: C. Schedule III Rationale: Buprenorphine has moderate abuse potential and is used for opioid use disorder; it is Schedule III.
5. Which of the following is NOT a Schedule II drug? A. Methadone B. Oxycodone C. Phentermine D. Diazepam Answer: D. Diazepam Rationale: Diazepam (Valium) is Schedule IV. Methadone, oxycodone are Schedule II; phentermine is Schedule IV (some formulations are Schedule III? No, phentermine is Schedule IV – correct: phentermine is Schedule IV). (Adjust: Phentermine is Schedule IV; thus D is correct Answer.) 6. A prescription for methylphenidate (Schedule II) can be refilled: A. Up to 5 times within 6 months B. Once within 30 days C. Zero times D. Unlimited with provider approval Answer: C. Zero times Rationale: No refills for Schedule II. Must obtain new prescription each time. 7. Which schedule allows for a prescription to be oral and refillable up to 5 times within 6 months? A. Schedule II B. Schedule III C. Schedule IV D. Schedules III, IV, and V Answer: D. Schedules III, IV, and V Rationale: Schedules III-V allow oral prescriptions (with limits) and up to 5 refills within 6 months. 8. A medication with accepted medical use, high abuse potential, and severe dependence potential is: A. Schedule I B. Schedule II C. Schedule III D. Schedule IV
B. On the day of prescribing or earlier C. No more than 30 days before dispensing D. No more than 90 days before dispensing Answer: B. On the day of prescribing or earlier Rationale: Must be signed and dated on the day issued. Cannot be postdated or predated beyond typical prescribing practice.
14. Anabolic steroids are classified as: A. Schedule I B. Schedule II C. Schedule III D. Schedule IV Answer: C. Schedule III Rationale: Anabolic steroids (e.g., testosterone derivatives) have moderate abuse potential and are Schedule III. 15. Which is true about Schedule I? A. May be prescribed by a psychiatrist B. Has no currently accepted medical use C. Is available by prescription only D. Includes fentanyl Answer: B. Has no currently accepted medical use Rationale: Schedule I = no accepted medical use, high abuse potential, not prescribable. 16. The maximum refill period for Schedules III-IV is: A. 3 months B. 6 months C. 12 months D. indefinite Answer: B. 6 months Rationale: Refills allowed up to 5 times within 6 months from issue date. 17. Which schedule includes drugs with moderate abuse potential and limited physical dependence? A. II B. III C. IV D. V Answer: B. III Rationale: Schedule III = moderate abuse potential, moderate/low physical dependence, high psychological dependence (e.g., ketamine, Tylenol with codeine).
18. A prescription for alprazolam (Schedule IV) can be called in by a provider. How long does the pharmacist have to obtain written confirmation? A. Not required B. 7 days C. 14 days D. 30 days Answer: A. Not required Rationale: For Schedules III-V, oral prescriptions are valid without written confirmation, though a written prescription may be required by state law. 19. Which of the following is not a controlled substance? A. Gabapentin (in some states) B. Clonazepam C. Diphenhydramine D. Zolpidem Answer: C. Diphenhydramine Rationale: Diphenhydramine (Benadryl) is not federally controlled. Zolpidem = Schedule IV; clonazepam = IV; gabapentin is not federally controlled but some states schedule it. 20. Partial filling of Schedule II for a patient not in LTCF/hospice: A. Not allowed B. Allowed up to 72 hours C. Allowed only for opioids D. Allowed with DEA Form 222 Answer: A. Not allowed Rationale: Partial fill of CII for non-terminal/non-LTCF patients is prohibited unless pharmacy unable to supply full quantity, then remainder must be filled within 72 hours (DEA rule). **Section 2: DEA Regulations & Prescribing (21–40)
- A DEA number consists of how many characters?** A. 7 B. 8 C. 9 D. 10 Answer: C. 9 Rationale: DEA number = 2 letters + 7 numbers (9 total). First letter = registrant type (A,B,F), second = first letter of last name.
C. 7 days D. 30 days Answer: C. 7 days Rationale: Federal rule: written prescription must be provided within 7 days; if not, pharmacist must notify DEA.
27. A nurse practitioner’s DEA registration is linked to their: A. NPI number B. State license number C. State-controlled substance registration D. All of the above Answer: D. All of the above Rationale: DEA registration requires state licensure, NPI, and often state CS registration. 28. Which of the following is not a valid reason for DEA registration denial? A. Prior felony drug conviction B. Prior license suspension C. Prior DUI 10 years ago D. Falsifying application Answer: C. Prior DUI 10 years ago Rationale: Past DUI alone (without drug-related offense) is not automatic denial; drug- related felonies, license actions, or false statements trigger denial. 29. Telehealth prescribing of controlled substances under the Ryan Haight Act generally requires: A. In-person exam prior to prescription B. No exam needed C. Only written consent D. Two providers Answer: A. In-person exam prior to prescription Rationale: Ryan Haight Act mandates at least one in-person evaluation before prescribing controlled substances via telehealth, with public health emergency exceptions. 30. Which DEA form is used to report theft or loss of controlled substances? A. DEA 106 B. DEA 222 C. DEA 224 D. DEA 363 Answer: A. DEA 106 Rationale: DEA Form 106 is for reporting theft or significant loss. Must be submitted within one business day of discovery.
31. A prescriber may write a prescription for a Schedule II for a family member: A. Never B. Only if no other provider available C. Allowed but must document medical necessity D. Only for non-narcotics Answer: C. Allowed but must document medical necessity Rationale: Not prohibited per se but strongly discouraged; must have legitimate medical relationship and documentation; risk of DEA sanctions. 32. A pharmacist refuses to fill a CII prescription due to concerns of diversion. The prescriber: A. Can demand the pharmacist fill it B. Must write a new prescription for another pharmacy C. Can override the refusal with a verbal order D. Has no recourse; the pharmacist is final arbiter Answer: D. Has no recourse; the pharmacist is final arbiter Rationale: Pharmacist has professional responsibility and can refuse to fill; prescriber cannot force fill. 33. Which patient identification is not required for controlled substance dispensing? A. Name B. Address C. Driver’s license number D. Date of birth Answer: C. Driver’s license number Rationale: Name and address required for prescription; DOB recommended but not federally required; DL # not required federally but some states may require. 34. A prescriber may prescribe buprenorphine for opioid use disorder without a separate DEA X-waiver: A. True, since 2023 (MAT Act) B. False, always need waiver C. Only for Schedule III D. Only for hospital inpatients Answer: A. True, since 2023 (MAT Act) Rationale: The MAT Act (2023) eliminated the X-waiver; any DEA-registered prescriber can prescribe buprenorphine for OUD. 35. A Schedule II prescription is valid for how long from the date written? A. 30 days B. 60 days
40. The “M” in a DEA number starting with “M” indicates: A. Mid-level practitioner B. Medical doctor C. Hospital D. Manufacturer Answer: A. Mid-level practitioner Rationale: DEA first letter: A/B = MD/DO; M = mid-level (NP, PA, CNM). **Section 3: Opioid Prescribing & Pain Management (41–60)
- The CDC 2022 clinical practice guideline for prescribing opioids recommends:** A. Avoiding opioids completely for acute pain B. Initiating immediate-release opioids at lowest effective dose for acute pain C. Long-acting opioids for acute pain D. Mandatory urine drug testing before each prescription Answer: B. Initiating immediate-release opioids at lowest effective dose for acute pain Rationale: 2022 guideline emphasizes IR opioids, lowest effective dose, short duration (≤3- 7 days typically). 42. Morphine milligram equivalents (MME) concern: A. Lower MME = higher risk B. ≥50 MME/day increases overdose risk C. ≥90 MME/day is safest D. MME irrelevant for tramadol Answer: B. ≥50 MME/day increases overdose risk Rationale: ≥50 MME/day doubles overdose risk; ≥90 MME/day even higher. 43. The most common cause of death from prescription opioids is: A. Renal failure B. Respiratory depression C. Constipation D. Cardiac arrest Answer: B. Respiratory depression Rationale: Opioid-induced respiratory depression is the primary lethal mechanism. 44. Which patient characteristic increases opioid overdose risk? A. Concomitant benzodiazepine use B. Young age (18-25) C. Female gender D. Prior tobacco use
Answer: A. Concomitant benzodiazepine use Rationale: Benzodiazepines + opioids synergistically depress respiration, greatly increasing fatal overdose risk.
45. The recommended initial prescription duration for acute pain (e.g., dental extraction) is: A. 1-3 days B. 7-10 days C. 2 weeks D. 30 days Answer: A. 1-3 days Rationale: For acute pain not related to major surgery, 3 days or less often sufficient; 7 days maximum per CDC. 46. Naloxone co-prescribing is recommended when: A. Prescribing any opioid B. MME ≥50 or concurrent benzodiazepines or history of overdose C. Only for IV drug users D. For all Schedule II prescriptions Answer: B. MME ≥50 or concurrent benzodiazepines or history of overdose Rationale: CDC recommends naloxone for high-risk scenarios. 47. Which opioid is associated with serotonin syndrome when combined with SSRIs? A. Morphine B. Hydrocodone C. Tramadol D. Fentanyl patch Answer: C. Tramadol Rationale: Tramadol has SNRI properties; high risk of serotonin syndrome with serotonergic drugs (SSRI, SNRI, MAOI). 48. A patient on methadone for OUD (maintenance) develops severe acute pain. Best approach: A. Increase methadone dose B. Add full agonist opioid (e.g., hydromorphone) temporarily C. Only NSAIDs D. Discontinue methadone Answer: B. Add full agonist opioid (e.g., hydromorphone) temporarily Rationale: Methadone maintenance provides baseline tolerance; acute pain requires additional short-acting full agonist opioid.
C. CYP2C
D. CYP1A
Answer: A. CYP2D Rationale: Codeine is prodrug; CYP2D6 converts to active morphine. Poor metabolizers get no effect; ultra-rapid metabolizers at risk for toxicity.
54. “Opioid-induced hyperalgesia” means: A. Increased pain sensitivity due to opioid use B. Tolerance to sedation C. Allergic reaction to opioids D. Withdrawal pain Answer: A. Increased pain sensitivity due to opioid use Rationale: Opioids can paradoxically lower pain threshold, worsening pain over time. 55. A patient on morphine, fentanyl patch, and hydromorphone for breakthrough pain. This is: A. Appropriate multimodal therapy B. High risk but acceptable C. Inappropriate without clear rationale (same class) D. Best practice for cancer pain Answer: C. Inappropriate without clear rationale (same class) Rationale: Multiple full agonist opioids same class – not recommended; should convert to single long-acting plus short-acting breakthrough. 56. The DEA’s “prescription drug monitoring program” (PDMP) is: A. Voluntary for prescribers B. Federally mandated in all states C. State-run database to track controlled substance prescriptions D. Only for Schedule II Answer: C. State-run database to track controlled substance prescriptions Rationale: PDMPs are state-based; federal mandate for prescribers to query varies by state. 57. Which state law requires PDMP check before every Schedule II-V prescription? A. Federal law B. Many states (e.g., New York, Kentucky) C. None D. Only for opioids Answer: B. Many states (e.g., New York, Kentucky) Rationale: Several states mandate PDMP check before every controlled substance prescription; no federal mandate.
58. For cancer pain, the CDC 2022 guidelines: A. Do not apply recommended MME limits B. Apply same limits as chronic non-cancer pain C. Recommend against any opioid D. Recommend only adjuvant therapies Answer: A. Do not apply recommended MME limits Rationale: CDC guidelines exclude cancer pain, sickle cell pain, and palliative care. 59. A patient requests early refill of oxycodone, stating it “fell in the toilet.” Next step: A. Refill immediately B. Verify with PDMP, contact previous pharmacy, consider urine drug screen C. Report to police D. Discharge patient Answer: B. Verify with PDMP, contact previous pharmacy, consider urine drug screen Rationale: Standard of care – assess for diversion, abuse, or legitimate loss; document. 60. Naloxone’s half-life is approximately: A. 30-60 minutes, shorter than most opioids B. 12 hours C. 24 hours D. Matches methadone Answer: A. 30-60 minutes, shorter than most opioids Rationale: Naloxone half-life ~1 hour; may require repeat dosing for long-acting opioids (methadone, extended-release). **Section 4: Benzodiazepines & Non-Opioid CS (61–75)
- Benzodiazepine withdrawal can be fatal due to:** A. Cardiac arrhythmia B. Seizures C. Hyperthermia D. Stroke Answer: B. Seizures Rationale: Severe withdrawal can cause status epilepticus and death. 62. Which benzodiazepine has the longest half-life? A. Alprazolam B. Lorazepam C. Diazepam D. Midazolam
federally since 2018 Farm Bill D. CBD is Schedule V Answer: C. CBD with >0.3% THC remains Schedule I; hemp-derived CBD (0.3% THC) is not controlled federally since 2018 Farm Bill Rationale: 2018 Farm Bill removed hemp (THC ≤0.3%) from CSA; CBD from hemp is not controlled.
68. The most common side effect of stimulants (amphetamine, methylphenidate) is: A. Bradycardia B. Insomnia and decreased appetite C. Hepatotoxicity D. Seizures Answer: B. Insomnia and decreased appetite Rationale: Sympathomimetic effects – insomnia, anorexia, weight loss. 69. Which drug is a Schedule II stimulant used for narcolepsy? A. Modafinil B. Armodafinil C. Amphetamine mixed salts D. Atomoxetine Answer: C. Amphetamine mixed salts Rationale: Amphetamine (Adderall) = Schedule II for narcolepsy, ADHD. Modafinil = Schedule IV. 70. A patient on methylphenidate for ADHD develops chest pain. Next step: A. Continue, it’s normal B. Stop medication, evaluate for cardiac issue (ECG, cardiology) C. Double dose D. Add beta-blocker Answer: B. Stop medication, evaluate for cardiac issue Rationale: Stimulants can cause tachycardia, arrhythmia, or angina; need cardiac evaluation. 71. Flunitrazepam (Rohypnol) is known as “roofie” and is Schedule: A. I in US (no medical use) B. II C. IV D. V Answer: A. I in US (no medical use) Rationale: Flunitrazepam is Schedule I despite being a benzodiazepine used elsewhere.
72. A patient presents with rapid taper of alprazolam 2 mg TID x 1 year. Risk: A. Seizures and delirium B. Hypertension only C. No withdrawal D. Liver failure Answer: A. Seizures and delirium Rationale: Abrupt or rapid benzodiazepine withdrawal can cause life-threatening seizures and delirium. 73. Which medication is NOT typically abused but is controlled? A. Clonidine B. Gabapentin (federal non-controlled but some states schedule it) C. Pregabalin (Schedule V) D. Lamotrigine Answer: D. Lamotrigine Rationale: Lamotrigine is not a controlled substance; pregabalin is Schedule V; gabapentin not federally controlled; clonidine not controlled. (Correction: Question asks “NOT typically abused but is controlled” – Pregabalin is controlled but has abuse potential; perhaps Answer is none – better: Loperamide not controlled but abuse risk. Let’s adjust.) 73 (revised): Which drug is federally controlled but has low abuse potential? A. Pregabalin B. Gabapentin C. Methylphenidate D. Testosterone Answer: A. Pregabalin (Schedule V) still abuse risk but lower than CII. Testosterone CIII has abuse potential. But choose A as correct relative to others. Better: “Schedule V drugs like pregabalin have low abuse potential compared to CII-IV.” 74. A patient taking phentermine for 4 months (off-label long term). Recommended: A. Continue, it’s safe long term B. Discontinue, limited to 12 weeks approved C. Double dose D. Switch to amphetamine Answer: B. Discontinue, limited to 12 weeks approved Rationale: Phentermine only approved for short-term (≤12 weeks); risk of dependence, tolerance, pulmonary hypertension. 75. Z-drugs (zolpidem, eszopiclone) mechanism: A. Dopamine agonist
80. Buprenorphine/naloxone (Suboxone) is preferred over buprenorphine alone due to: A. Less sedation B. Naloxone precipitates withdrawal if injected, thus reducing IV abuse C. Longer half-life D. Better pain relief Answer: B. Naloxone precipitates withdrawal if injected, thus reducing IV abuse Rationale: Naloxone is poorly absorbed sublingually but active IV; deters injection. 81. The most serious risk of buprenorphine induction is: A. Hypotension B. Precipitated withdrawal if patient has full agonist opioids on board C. Hypertension D. Seizures Answer: B. Precipitated withdrawal if patient has full agonist opioids on board Rationale: Buprenorphine has high affinity, displaces full agonists → acute withdrawal. 82. A pregnant patient with opioid use disorder. Recommended treatment: A. Medically supervised withdrawal (detox) B. Methadone or buprenorphine maintenance C. No medication, only counseling D. Naltrexone Answer: B. Methadone or buprenorphine maintenance Rationale: ASAM/ACOG recommends maintenance to improve maternal/fetal outcomes; withdrawal is harmful. 83. Neonatal abstinence syndrome (NAS) is most effectively managed with: A. Morphine or methadone B. Naloxone C. Phenobarbital alone D. Clonidine Answer: A. Morphine or methadone Rationale: Opioid replacement is standard for NAS. 84. A patient on methadone maintenance (80 mg/day) for OUD presents with severe pain. You prescribe: A. Methadone increased to 120 mg B. Full agonist opioid (e.g., hydromorphone) C. NSAIDs only D. Buprenorphine
Answer: B. Full agonist opioid (e.g., hydromorphone) Rationale: Methadone provides tolerance; acute pain requires additional full agonist opioid; buprenorphine could precipitate withdrawal.
85. The CAGE-AID questionnaire screens for: A. Pain B. Substance use disorder C. Depression D. Anxiety Answer: B. Substance use disorder Rationale: CAGE-AID (Adapted to Include Drugs) screens for alcohol/drug problems. 86. For a patient with chronic non-cancer pain and opioid use disorder, best practice: A. Discontinue all opioids B. Buprenorphine for OUD and manage pain with same buprenorphine or combination C. Full agonist opioids indefinitely D. Only non-pharmacologic therapy Answer: B. Buprenorphine for OUD and manage pain with same buprenorphine or combination Rationale: Buprenorphine treats OUD and provides analgesia; can add adjuncts. 87. The most sensitive urine drug test for cocaine is: A. Benzoylecgonine (metabolite) B. Cocaine parent drug C. Cocaethylene D. Etonitazene Answer: A. Benzoylecgonine Rationale: Primary metabolite; detectable 2-4 days (chronic up to 2 weeks). 88. Fentanyl is not detected on standard opioid immunoassays. True or false? A. True; requires specific fentanyl strip B. False; all assays detect fentanyl C. Only in urine D. Only in blood Answer: A. True; requires specific fentanyl strip Rationale: Most routine opioid immunoassays do not detect synthetic fentanyl and analogs. 89. Which drug causes false-positive amphetamine on urine screen? A. Bupropion B. Labetalol C. Trazodone D. All of the above
