60 ABPM Addiction Medicine Board Exam Practice Questions

Low-dose computed tomography (CT) of the chest is the recommended modality for screening of lung cancer. Annual screening is recommended for adults aged 55 to 80 years with a 30 pack-year smoking history who are currently smoking or have smoked in the last 15 years. Low-dose CT of the chest is more sensitive than chest x-ray or sputum analysis in detecting early-stage lung cancers, leading to a decrease in mortality.

Chest ultrasound is not recommended for screening for lung cancer as it has low sensitivity compared to CT scan in detecting neoplastic lesions. Ultrasound of the chest is sometimes used to assess invasion of the chest wall by a tumor.

X-ray of chest is not recommended as a screening modality for lung cancer as it has not shown to decrease mortality rate when compared to screening with a low dose CT of the chest.

Sputum analysis is not recommended for lung cancer screening as it is less sensitive in the detection of early-stage lung cancer when compared to low-dose CT scan.

Contrast-enhanced CT of the chest is not recommended for screening of lung cancer as low-dose, non-contast CT of the chest can detect early lung cancers without the added risk of adverse effects from the use of contrast.

Every 3 years is the correct answer. Nonsmoking women aged 25 to 65 years should undergo cervical cancer screening every 5 years. However, there is an increased risk of cervical cancer in women who smoke, and so smokers should have more frequent screening.

Annually is incorrect. Since disease progression from precancerous lesions to invasive cervical cancer is slow, and some abnormal lesions resolve over time, screening more frequently than 3 years leads to unnecessary procedures like biopsy.

Biannually is incorrect. Screening at this frequency overuses resources without the benefit of an increase in the detection rates of early cervical cancer.

Every 2 years is incorrect. Screening at this frequency overuses resources without increasing detection rates of early cervical cancer.

Nonsmoking women aged 25 to 65 years should undergo cervical cancer screening every 5 years. However, there is an increased risk of cervical cancer in women who smoke, and so smokers should have more frequent screening.

Moderate is the correct answer because the patient has 4 symptoms from the diagnostic criteria of tobacco use disorder. Moderate-severity tobacco use disorder is described as the presence of 4 to 5 symptoms. The symptoms include prolonged use of tobacco, strong cravings, failure to quit, and continued use despite interpersonal problems arising from use.

Minor is incorrect because there is no category with minor severity in the diagnostic criteria of the tobacco use disorder.

Major is incorrect because there is no category with major severity in the diagnostic criteria of the tobacco use disorder.

Mild is incorrect because the patient has 4 symptoms from the diagnostic criteria of tobacco use disorder. Mild severity is described as the presence of 2 to 3 symptoms.

Severe is incorrect because the patient has 4 symptoms from the diagnostic criteria of tobacco use disorder. Severe tobacco use disorder is described as the presence of 6 or more symptoms.

Nortriptyline is the correct answer because it is a tricyclic antidepressant that will not only be beneficial for the treatment of major depressive disorder in this patient but has also been demonstrated to be effective in smoking cessation. Nortriptyline is effective in the treatment of tobacco use disorder in smokers with a history of major depression. It will be most beneficial for the patient to be prescribed one drug that can be effective for the treatment of both disorders.

Venlafaxine is incorrect because although it may be beneficial in the treatment of major depression in this patient, it will not be beneficial in the treatment of tobacco use disorder. Venlafaxine has not shown any significant effect on smoking cessation.

Sertraline is incorrect because it is an antidepressant with no effect on the treatment of tobacco use disorder. The patient needs to be treated for both major depressive disorder and tobacco use disorder. It will be the most beneficial for the patient to be prescribed one drug that can be effective for the treatment of both disorders.

Fluoxetine is incorrect because it will not be beneficial in the concurrent treatment of tobacco use disorder in this patient with major depressive disorder.

Paroxetine is incorrect because it will only benefit the patient in the treatment of major depression without any effect on smoking cessation.

Bupropion is the correct answer – bupropion is contraindicated in patients with eating disorders due to an increased risk of seizures.

Nicotine patches is incorrect; it is not contraindicated in patients with anorexia nervosa and is used as nicotine replacement therapy for smoking cessation.

Clonidine is incorrect; clonidine is used to treat tobacco use disorder as second line of treatment, and is not contraindicated with anorexia nervosa.

Varenicline is incorrect; it is not contraindicated in patients with anorexia nervosa and is a first-line non-nicotine medication for treating tobacco use disorder.

Nicotine gum is incorrect; it is not contraindicated in patients with anorexia nervosa and is used as nicotine replacement therapy for smoking cessation.

Nicotine gum is the correct answer because the patient is currently experiencing tobacco withdrawal and needs immediate relief of symptoms. Nicotine gum can be prescribed to this patient with adjustment of the dose as per her smoking frequency. Nicotine gum will provide similar satisfaction to when a cigarette is smoked without the disadvantages of smoke particulates and chemicals harmful to the health.

Bupropion is incorrect because it will require dose titration for a week before the patient can quit smoking. This will not be beneficial in this patient who is currently experiencing tobacco withdrawal.

Varenicline is incorrect because varenicline requires dose titration for 2 weeks before the patient can quit smoking. This is done to achieve an adequate systemic concentration of the drug and to reduce side effects.

Nortriptyline is incorrect because it is not a first-line of medication in the treatment of patients with tobacco use disorder, especially in patients experiencing withdrawal symptoms. Nortriptyline is prescribed in patients with tobacco use disorder and a history of depression.

Clonidine is incorrect because it is second line of treatment for patients with tobacco use disorder who have failed to respond to first-line medications. It will not be beneficial in this patient with withdrawal symptoms.

Nicotine patch or gum is correct as it replaces nicotine from tobacco to decrease nicotine withdrawal and helps in smoking cessation. The combination of nicotine patch and gum works better. Pharmacologic treatment should be combined with counseling and supportive therapy.

Bupropion is incorrect as this patient has a history of bulimia. It is contraindicated in bulimia as it reduces the threshold for seizures in such patients.

Acamprosate is incorrect as it is used in alcohol use disorder. It has no proven efficacy for smoking cessation.

Lorazepam is incorrect as it is a benzodiazepine receptor agonist with no proven efficacy for smoking cessation.

Sertraline is incorrect as it is a selective serotonin reuptake inhibitor used in the management of the major depressive disorder, among other diseases. It has no proven efficacy for smoking cessation.

Observer bias is correct because this study is compromised by the presence of the observer bias, a type of measurement bias. Observer bias occurs when the evaluation of results is affected by knowledge of a feature of the study participants. In this study, the addiction medicine specialists who interviewed participants in-person categorized more men with the habit of smoking when they were not blinded to the gender of the study participants.

Confounding bias is incorrect because the study describes observer bias rather than confounding bias. Confounding bias occurs when a different variable affects the relationship between the exposure variable and the outcome variable.

Lead-time bias is incorrect because the study described above describes observer bias rather than lead-time bias. Lead-time bias commonly occurs in the setting of screening tests; for example, a screening test may detect disease earlier in its course. This early detection may then be translated into an improvement in the length of survival, which is known as lead-time bias.

Recall bias is incorrect because it is not present in this study. It is also a type of measurement bias. Recall bias occurs when study participants who have a specific condition remember an exposure more or less frequently than study participants who do not have a specific condition. For example, individuals with gastroesophageal reflux disease (GERD) may recall eating spicy foods more frequently than those without GERD.

Selection bias is incorrect because the study described above describes observer bias rather than selection bias. It occurs when the study participants are not selected in a manner that accurately represents the study population.

Type I error is correct because this study determines that there is an association between vaping and liver cirrhosis when there is not a statistically significant difference, given the p-value of 0.3. This is an example of a type I error, which occurs when the null hypothesis is incorrectly rejected.

Beta is incorrect because this is an example of a type I error rather than a type II error. Beta is also known as the type II error. Type II error occurs when a study fails to recognize an effect between an exposure and an outcome when the effect, in fact, exists.

Power is incorrect because this study describes a type I error rather than a type II error. Power is the probability that a study correctly rejects the null hypothesis. It is calculated by subtracting 1 from the Beta or the type II error.

Pygmalion effect is incorrect because it is an effect that occurs when a research investigator conveys his or her desires with regards to the results of the study to the study participants, which leads study participants to knowingly modify their behavior to produce the expected results.

Type II error is incorrect because it occurs when a study fails to recognize an effect between an exposure and an outcome when the effect, in fact, exits.

The future risk of hypertension is the same in patients with or without a smoking history from a young age is correct because, in this proposed cohort study, two populations will be compared, i.e., individuals with no smoking history and individuals with a significant smoking history who started smoking at a young age. The measured variable will be the blood pressure and risk of developing hypertension. Therefore, the null hypothesis should state that there is no significant difference between the two individual populations, and both have the same risk of developing hypertension.

A smoking history will not change the future risk of developing hypertension is incorrect because a statement regarding the presence or absence of causal relation is not appropriate for the null hypothesis.

Smoking is not associated with an increased prevalence of hypertension is incorrect because this null hypothesis would be more appropriate for a cross-sectional study. This study has a cohort study design.

The future risk of hypertension is higher in individuals with a smoking history from a young age than without is incorrect because this statement represents the possible alternate hypothesis.

Early quitting of smoking habits will decrease the future risk of smoking is incorrect because this statement represents a possible interpretation of the results or conclusions that may be drawn from the study.

Diazepam is correct. The case describes a patient with acute stimulant intoxication, which may be characterized by tachycardia, pupillary dilatation, hypertension, sweating, nausea or vomiting, psychomotor agitation, chest pain or cardiac arrhythmias, confusion, seizures, dyskinesias, dystonias or coma. Significant behavioral or psychological changes are commonly seen. In cases where the patient is agitated, confused, or anxious, the preferred treatment is with benzodiazepines (like diazepam) to prevent behavioral injury.

Haloperidol is a typical antipsychotic which can be used as a second-line drug in the treatment of severe agitation, anxiety, or psychosis in patients with stimulant toxicity if benzodiazepines fail to control the symptoms. However, antipsychotics can worsen the sympathomimetic and cardiovascular effects of the stimulant, lower the seizure threshold, increase the risk of hyperthermia, or precipitate extrapyramidal reactions.

Naloxone is an opioid antagonist used to treat acute opioid intoxication. It is not used to treat acute stimulant intoxication.

Phentolamine is an alpha-adrenergic blocker that can be used to control hypertension if sedation with benzodiazepine does not lead to a reduction in blood pressure.

Propranolol is a beta-adrenergic blocker that should be avoided as it can result in vasoconstriction and further worsening of hypertension from unopposed alpha-adrenergic stimulation by the stimulant drug.

Levamisole is the correct answer because it is the most common adulterant used to cut cocaine. Levamisole is found in up to 70% of the cocaine analyzed. Levamisole-induced vasculitis mostly settles when cocaine use is discontinued, and corticosteroids increase the rate of recovery. Levamisole is used to cut cocaine because it adds to the bulk without reducing the purity of the cocaine. Levamisole also potentiates the stimulant effect of cocaine.

Hydroxyzine is incorrect because it is less commonly used to cut cocaine, and it does not cause vasculitis, as seen in this patient.

Phenacetine is incorrect because it does not induce vasculitis, as seen in this patient.

Methylone is incorrect because it does not cause cocaine-induced vasculitis when used as an adulterant.

Lidocaine is incorrect because it does not cause vasculitis, as seen in this patient when used as an adulterant for cocaine.

Phenoxybenzamine is correct because this patient is suffering from cocaine toxicity, as evident by his dilated pupils, agitation, hallucinations, and physical symptoms (elevated blood pressure and heart rate). He currently has a severely elevated blood pressure, which must be controlled. In cocaine toxicity, a patient is under alpha and beta adrenergic-receptor stimulation. If a beta-blockade is initiated first, the patient will have unopposed alpha stimulation, which may lead to further exacerbation of his hypertensive emergency. An alpha-blocker should be started first. Phentolamine is the most commonly used agent for severe cocaine toxicity, but phenoxybenzamine is another alpha blocker that is a good choice.

Haloperidol is incorrect because it is an antipsychotic, which can also be used in emergent situations to calm patients to protect staff and the patients themselves. While haloperidol could be used to relax this patient, his agitation is not the most concerning issue at the moment. His blood pressure constitutes hypertensive urgency and should be treated immediately.

Metoprolol is correct because it is a beta-blocker and should not be used in cocaine toxicity unless an alpha-blocker is already on board.

Naloxone is incorrect because it is an opioid receptor antagonist used in the reversal of life-threatening opioid toxicity. Usually, it should only be used to prevent intubation. In milder cases, the practitioner can wait for the drug to wear off.

Propranolol is incorrect because it is a beta-blocker and should not be used in cocaine toxicity unless an alpha-blocker is already on board.

Lorazepam is correct because chest pain, diaphoresis, agitation, elevated temperature, tachycardia, hypertension, and mydriasis suggest the use of stimulants (e.g., amphetamine, cocaine). Stimulant use is common among long-haul truck drivers who are required to stay awake at night. Patients with symptomatic stimulant intoxication (e.g., amphetamine overdose, cocaine overdose) should be treated with benzodiazepines such as lorazepam. Benzodiazepines sedate the patient, control hypertension, and prevent seizures. In addition, patients who are actively febrile should be cooled externally.

Dantrolene is incorrect because it is not used to treat amphetamine overdose. Instead, it is used to treat neuroleptic malignant syndrome (NMS) or malignant hyperthermia, which can result in increased body temperature, diaphoresis, tachycardia, hypertension, and an altered mental status. However, NMS typically occurs with antipsychotic medications, and malignant hyperthermia occurs following the administration of volatile anesthetics or muscle relaxants such as succinylcholine.

Activated charcoal is incorrect because it is not very useful more than 1-2 hours after the ingestion of a toxic substance. Moreover, activated charcoal requires oral administration, which is generally contraindicated in agitated or drowsy patients due to the risk of aspiration.

Propranolol is incorrect because, in patients with amphetamine or cocaine overdose, there is a surge of catecholamines, which causes vasoconstriction mediated through alpha-receptors. Blockage of beta-receptors by beta-blockers such as propranolol can cause unopposed stimulation of alpha-receptors, and thereby worsen vasoconstriction.

Ketamine is incorrect because it is typically used to sedate patients prior to rapid sequence intubation or as an emergency anesthetic for polytrauma patients with a risk of hypotension. In this patient, intubation is not indicated at this point in time.

Isolate, observe, and reassure the patient is correct. An appropriate initial approach to stimulant intoxication without acute agitation or safety concerns is mostly supportive. Isolating the patient limits external stimuli which can exacerbate anxiety or paranoia.

Lorazepam (a benzodiazepine) can be useful for treating agitated or anxious patients, however, behavioral interventions such as isolation and calm reassurance are first line approaches.

Haloperidol is a typical antipsychotic. Although it is sometimes used in cases of acute agitation and psychosis, it has a number of possible serious adverse effects such as akathisia, acute dystonias, and QTc prolongation. In this case, isolation, observation and reassurance would be the first treatments of choice.

Start cognitive behavioral therapy is incorrect because while it has been shown to reduce methamphetamine use in treatment of stimulant use disorder, cognitive approaches are unlikely to be useful during a period of acute stimulant intoxication.

Apply restraints is not recommended unless acute safety issues are present, and other means of ensuring safety have failed. Physical restraints can exacerbate anxiety and increase the risk of physical injury.

Diazepam is correct as it is a benzodiazepine receptor agonist used as a first-line drug in the management of acute intoxication of cocaine. Cocaine intoxication presents with tactile hallucinations, tachycardia, hypertension, and pupillary dilation, as observed in this patient.

Naloxone is incorrect as it is an opioid receptor antagonist used in opioid intoxication, which presents with respiratory depression and miosis. This patient’s symptoms are consistent with sympathetic stimulation and not opioid overdose.

Flumazenil is incorrect as it is a benzodiazepine receptor antagonist used in the management of benzodiazepine overdose, which presents with sedation, coma, and respiratory depression, unlike this patient’s symptoms of sympathetic stimulation.

Valproic acid is incorrect as it is an anticonvulsant used as a mood stabilizer in the management of alcohol or opioid withdrawal. This patient’s symptoms cannot be managed with this drug.

Methadone is incorrect as it is used in the management of opioid withdrawal. It is an opioid receptor agonist. This patient’s symptoms are consistent with stimulant use and not opioid withdrawal.

Basal ganglia is correct, such use represents the binge-intoxication stage. This stage produces rewarding effects of drugs via the neurocircuitry of the basal ganglia. These effects are experienced as “wellbeing,” “high,” “euphoria,” and relief depending on the degree of tolerance to the rewarding effects of the drug.

Amygdala is incorrect. Changes in the amygdala are implicated in the withdrawal-negative affect stage, manifested by dysphoria, anhedonia, and irritability.

Cerebellum is incorrect as it is involved in balance and movements of the body without any significant effect on a person feeling happy or light hearted due to a drug.

Habenula is incorrect. It is involved in the withdrawal-negative affect stage.

Prefrontal cortex is incorrect as it is involved in the stage of drug craving. This patient does not have any symptoms that might indicate craving.

Cocaine is the correct answer because few systemic drugs can cross-react with cocaine immunoassay to produce a false-positive result. Coco leaf tea and topical anesthetics containing cocaine can interfere with the immunoassay to produce false-positive results.

Marijuana is incorrect because various drugs can interfere with the immunoassay and result in a false positive test. Drugs that cross-react with the marijuana immunoassay include dronabinol, efavirenz, nonsteroidal-anti-inflammatory drugs, pantoprazole, and tolmetin.

Phencyclidine is incorrect because various drugs can cross-react with the immunoassay and result in a false positive test. These drugs include dextromethorphan, diphenhydramine, doxylamine, ibuprofen, imipramine, ketamine, meperidine, mesoridazine, thioridazine, tramadol, and venlafaxine.

Opioids are incorrect because there are a number of drugs that can cross-react with the immunoassay and result in a false positive test. These drugs include dextromethorphan, diphenhydramine, quinine, quinolones, rifampin and verapamil.

Amphetamines is incorrect because a number of different drugs can cross-react with the immunoassay to produce a false-positive result. These drugs include amantadine, benzphetamine, bupropion, chlorpromazine, clobenzorex, desipramine, and dextroamphetamine.

Reduces number of D1 receptors in the striatal pathway is correct. Long-term use of cocaine is associated with certain extrapyramidal symptoms, such as dystonic reactions, akinesia, bradykinesia, akathisia, and pseudoparkinsonism. The factors responsible for this are the reduced density of D1 dopamine receptors in the nigrostriatal pathways and the eventual depletion of dopamine, which occurs with chronic use of cocaine. Both factors increase the risk of neuroleptic-induced dystonic reactions, while the latter factor causes cocaine-induced dystonia.

Increases dopamine in the nigrostriatal area is incorrect. Reduction in the number of D1 receptors in the striatal pathway occurs in response to the increased concentration of dopamine in the synapses in chronic cocaine users. The reduced density of D1 receptors occurs in response to the chronic increase in synaptic dopamine caused by cocaine-induced inhibition of dopamine reuptake.

Reduces number of D2 receptors in the striatal pathway is incorrect. Cocaine only reduces the number of D1 receptors – it does not affect the number of the D2 dopamine receptors directly, though a reduction is seen in many states of dependence.

Reduces metabolism of haloperidol is incorrect. Cocaine does not interfere with the metabolism of haloperidol. Neuroleptics are the main drugs which cause dystonic reactions through this mechanism.

Induces blockade of dopamine receptors in the nigrostriatal pathway is incorrect. Cocaine does not block dopamine receptors in the nigrostriatal pathway.

Benzodiazepines provide sedation which resolves some of the cardiovascular manifestations of cocaine toxicity including hypertension and tachycardia.

High-dose epinephrine may potentiate the effect of cocaine in the bloodstream, exacerbating symptoms.

Phenothiazines are contraindicated in cocaine toxicity, as they may increase QTc interval and seizure risk.

Procainamide exacerbates cocaine effects and may exacerbate symptoms.

Beta-blockers should be used with caution in cocaine toxicity, as they lead to an unopposed alpha-adrenergic activity which may worsen hypertension and cause coronary vasospasms and acute myocardial infarction.

Oxazepam is the correct answer because most of the benzodiazepine immunoassays are designed to detect oxazepam. An immunoassay that is targeted to detect oxazepam commonly will give negative results if the patient is using benzodiazepines like clonazepam, lorazepam, or triazolam, as these are excreted as glucuronide conjugates.

Chlordiazepoxide is incorrect because the most common metabolite that is detected by the immunoassays used for benzodiazepine is oxazepam.

Demoxepam is incorrect because it is not a metabolite that is detected by the benzodiazepine immunoassays commonly used. Oxazepam is the most common metabolite detected by the immunoassays used for benzodiazepines.

Temazepam is incorrect because immunoassays most commonly used for benzodiazepine screening are designed to detect oxazepam.

Desmethyldiazepam is incorrect because oxazepam is the metabolite most commonly detected by the immunoassays used for benzodiazepine screening.

Inhalation is the correct answer because cocaine base, when smoked, is rapidly absorbed via the lungs and reaches the brain within seconds. The onset of action occurs within minutes of smoking.

Intranasal administration is incorrect because cocaine is slowly absorbed through the intranasal mucous membrane. The onset of action occurs 30 to 45 minutes following administration.

Intravenous administration is incorrect because the onset of action is seen within minutes compared to seconds for the inhalational route. Intravenous administration has the second-fastest onset of action after smoking.

Oral administration is incorrect because, similar to the intranasal route, it has a slower onset of action, taking up to 30 to 45 minutes.

Subcutaneous administration is incorrect because cocaine is not administered via the subcutaneous route. However, the onset of action will be slower than the inhalational route.

Cognitive behavioral therapy + selective serotonin reuptake inhibitor is recommended in all mild cases of hands-off paraphilic disorders with low risk of sexual violence like exhibitionism disorder without any risk or rape or child abuse.

Cognitive behavioral therapy alone is recommended in cases of voyeurism, fetishism, frotteurism disorders without any risk of sexual violence.

Selective serotonin reuptake inhibitor (SSRI) is usually recommended as an adjunct to cognitive-behavioral therapy in all mild cases of hands-off paraphilic disorders with low risk of sexual violence as the SSRIs can take 1 to 3 months to show treatment efficacy.

Cognitive behavioral therapy + Cyproterone acetate are recommended in patients with a moderate risk of sexual violence or if there are no satisfactory results from cognitive behavioral therapy and selective serotonin reuptake inhibitors.

Cognitive behavioral therapy + GnRH agonists are recommended in patients with moderately high to high risk of sexual violence and severe paraphilic disorders.

Cyproterone acetate (CPA) is correct. When first administered, the gonadotropin-releasing hormone (GnRH) agonists stimulate the pituitary gland to release luteinizing hormone (LH), which leads to an increase in the levels of testosterone transiently, also referred to as the flare-up effect. However, due to continuous administration of GnRH agonists, rapid desensitization of the GnRH receptors occur. This leads to a decrease in the levels of LH and testosterone within 2 to 4 weeks. In order to prevent the flare-up effect, an antiandrogen is administered one week before and during the first month of starting GnRH agonists.

Fluoxetine is a selective serotonin reuptake inhibitor, which is not indicated as the pretreatment in patients starting treatment with GnRH agonists.

Olanzapine is an antipsychotic drug that is not indicated as the pretreatment in patients starting treatment with GnRH agonists.

Lithium carbonate is not indicated as the pretreatment in patients starting treatment with GnRH agonists.

Carbamazepine is an anticonvulsant that is not indicated as the pretreatment in patients starting treatment with GnRH agonists.

Lisdexamfetamine is the only medication approved by the FDA for the treatment of binge eating disorder. Lisdexamfetamine is a prodrug of dextroamphetamine, a central nervous system stimulant that is used for the treatment of attention-deficit hyperactivity disorder (ADHD). It has shown to be effective in reducing binge eating frequency and thoughts related to binge eating.

Clonidine is used for the treatment of ADHD. However, it is not used for the treatment of binge eating disorder.

Guanfacine is used for the treatment of ADHD. However, it is not used for the treatment of binge eating disorder.

Atomoxetine is used for the treatment of ADHD. However, it is not used for the treatment of binge eating disorder.

Methylphenidate is used for the treatment of ADHD. However, it is not used for the treatment of binge eating disorder.

Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) considered a first-line treatment for binge eating disorder. It is the best choice in this scenario because this care describes a patient who likely has binge eating disorder. SSRIs have been shown to provide modest reductions in weight, although results have been inconsistent.

Acamprosate is not the treatment of choice in this patient with binge eating disorder. Limited data has failed to show a benefit of acamprosate.

Lithium has no role in the treatment of binge eating disorder.

Baclofen has not shown efficacy in the treatment of binge eating disorder.

Lamotrigine has not shown efficacy in the treatment of binge eating disorder.

Cognitive behavioral therapy (CBT) is considered the first-line treatment for binge eating disorder based on the large number of studies showcasing its efficacy.

Dialectical behavior therapy has shown effectiveness in the treatment of patients with binge eating disorder. However, it is not as widely studied and effective when compared to cognitive behavioral therapy (CBT).

Motivational enhancement therapy has been used to treat patients with binge eating disorder, but ognitive behavioral therapy (CBT) is considered first-line treatment for the condition.

Interpersonal psychotherapy (IPT) has a role in the treatment of binge eating disorder and has demonstrated efficacy in these patients. However, IPT does not address symptoms of binge eating disorder.

Family therapy is effective in the treatment of anorexia nervosa in young adolescent patients. Family therapy is not a first-line therapy in patients with binge eating disorder.

Decreased activity of 5HT presynaptic neurons is correct. Studies have shown that serotonin is one of the neurotransmitters involved in the pathophysiology of paraphilic disorders. There is decreased activity of 5HT presynaptic neurons and up-regulation of postsynaptic 5 HT2A receptors in paraphilic disorders, which is the basis for the use of SSRIs in their treatment. Decreased levels of serotonin increases sexual drive and associated behaviors, while increased central serotonergic activity decreases sexual drive and associated behavior. Similarly, there is inhibition of sexual motivation due to increased levels of serotonin levels in the hypothalamus and increased emotional resilience and impulse control due to increased levels of serotonin in the prefrontal cortex. Hence, use of SSRIs may lead to increase in serotonin at synaptic junctions compensating for the decreased activity of serotonin releasing presynaptic neurons in paraphilic disorders.

Normal activity of 5HT presynaptic neurons is incorrect. There is decreased activity of 5HT presynaptic neurons and up-regulation of postsynaptic 5 HT2A receptors in paraphilic disorders.

Decreased activity of 5HT2A postsynaptic neurons is incorrect. There is decreased activity of the 5HT presynaptic neurons and up-regulation of postsynaptic 5 HT2A receptors in paraphilic disorders.

Increased activity of 5HT presynaptic neurons is incorrect, There is decreased activity of 5HT presynaptic neurons and up-regulation of postsynaptic 5 HT2A receptors in paraphilic disorders.

Down-regulation of postsynaptic 5 HT2A receptors is incorrect. There is up-regulation of postsynaptic 5 HT2A receptors due to decreased activity of 5HT presynaptic neurons in paraphilic disorders.

Inform the patient that romantic relationships with current patients are unethical is the correct response. Romantic relationships compromise the physician’s objectivity regarding the patient’s treatment and cloud their judgment, which can hinder their ability to make the best decision for the patient.

Inform the patient that since he no longer requires her service as a physician, she can go out on a date with him is incorrect as the patient is currently undergoing treatment for substance use disorder and requires her as a physician.

Inform him that she will go on a date with him, but he will have to transfer his care to a different physician is incorrect as this is considered poor clinical practice to terminate a patient-physician relationship to start a romantic relationship.

Inform the patient that dating him will never be appropriate even after the termination of the patient-physician relationship is incorrect because a physician can date his/her former patients if a considerable amount of time has passed after the termination of the patient-physician relationship.

Inform the patient that she can go on a date with him as his case is uncomplicated is incorrect. An uncomplicated case does not mean that the patient-physician relationship should be transformed into a romantic one because it can still cloud the judgment of the physician and compromise her clinical practice.

Justice implies treating patients fairly and equitably. This principle is being breached in this situation as the clinician is not treating equitably patients based on their need; rather, he is deciding based on his preference.

Beneficence describes an act by the clinician in the interests of the patient.

Autonomy refers to a patient’s right to make decisions about their own medical care.

Confidentiality (an aspect of patient autonomy) means that a patient is entitled to have their personal health information protected.

Efficiency, in a medical context, may refer to the allocation of possibly scarce medical resources. There is no indication that the physician is making decisions on care based on considerations of efficiency.

30 mL is the correct answer because, according to the mandatory guidelines for workplace drug testing programs published by the Substance Abuse and Mental Health Services Administration (SAMHSA), if the urine volume is less than 30 mL, and the temperature is within the acceptable range, the donor should be asked to provide a second sample after adequate water intake.

10 mL is incorrect because the set limit for the volume of urine specimen according to mandatory federal workplace drug testing guidelines is 30 mL.

15 mL is incorrect because the volume required to proceed with the drug testing according to the guidelines is 30 mL.

20mL is incorrect because the set volume limit for urine specimen is 30 mL according to the testing guidelines.

25 mL is incorrect because the volume required for the urine specimen set by the guidelines is 30 mL.

2 years is the correct answer based on guidelines for workplace drug testing published by the Substance Abuse and Mental Health Services Administration (SAMHSA). A laboratory can be directed to retain records for a longer period of time in certain circumstances.

1 year is incorrect because the records of a given specimen are retained for a minimum of 2 years unless otherwise instructed.

3 years is incorrect because the drug-testing laboratory keeps the records of a given urine specimen for a minimum of 2 years unless otherwise instructed.

4 years is incorrect because the record for a certain urine specimen is kept by the drug-testing laboratory for a minimum of 2 years.

5 years is incorrect because the laboratory retains the records for a certain urine specimen for a minimum of 2 years unless otherwise instructed.

One year is the correct answer. At the end of the year, the positive specimen is discarded if the laboratory does not receive any request to retain the specimen for an additional time period.

Two years is incorrect. Urine specimens that test positive are stored for a minimum of 1 year before being discarded.

Three years is incorrect; positive urine specimens are stored for a minimum of 1 year before being discarded.

Four years is incorrect; positive urine specimens are stored a minimum of 1 year before being discarded.

Five years is incorrect; positive urine specimens are stored a minimum of 1 year before being discarded.

Reflect his concerns about the concept of therapy is correct. When a client develops resistance, counselors are to roll with or adjust to resistance. Using simple reflection to resistance often moves patient toward change.

Give examples of other successful cases is incorrect as this choice is not keeping with motivational interviewing concepts.

Directly challenge doubt is incorrect as this choice is not keeping with motivational interviewing concepts.

Encourage arguments about the purpose of therapy is incorrect as this choice is not keeping with motivational interviewing concepts.

Show evidence based studies as proof of efficacy is incorrect as this choice is not keeping with motivational interviewing concepts.

Unaware of the need for change is correct. Precontemplation is the first of five stages of change described by James O. Prochaska in 1977. In this first stage, the person is not thinking about change or has completely rejected it. This phase can be called the phase of denial, where the individual underestimates the importance of changing their habits, exaggerate the cons of changing their habits, or may not be aware of the mistakes they have made during their use. At this stage, motivational interviewing can play an important role in showing the association between the drug use and different problems or mistakes the individual is facing.

Constantly seeking support is incorrect. Stage 2 of change is contemplation, where the person feels ambivalence and considers the pros and cons of their use to be equal, and hence is reluctant about changing but does consider it.

Thinks the pros and cons of substance use are equal is incorrect. Stage 3 is the preparation stage, where the individual decides to start the changing process.

Has ambivalence incorrect. Stage 4 is action, where most treatment is done.

Takes positive steps towards solving the problem is incorrect. Stage 5 is maintenance. The individual can relapse back from any of these stages into previous ones.

Opioid maintenance treatment in an outpatient setting is correct. A consent is required from the patient or surrogate before commencing opioid maintenance treatment. In an emergency, when a patient may not be able to give consent for diagnosis or treatment, a surrogate is designated to make those decisions on behalf of the patient.

Blood valium levels is incorrect. To diagnose the patient’s condition and initiate appropriate treatment, it is essential to test for valium, alcohol, cocaine, and heroin; therefore, consent may not be necessary.

Testing for blood alcohol levels in the ER is incorrect. To diagnose the patient’s condition and initiate appropriate treatment, it is essential to test for valium, alcohol, cocaine, and heroin; therefore, consent may not be necessary.

Test for cocaine blood levels is incorrect. To diagnose the patient’s condition and initiate appropriate treatment, it is essential to test for valium, alcohol, cocaine, and heroin; therefore, consent may not be necessary.

Blood test for heroin levels is incorrect. To diagnose the patient’s condition and initiate appropriate treatment, it is essential to test for valium, alcohol, cocaine, and heroin; therefore, consent may not be necessary.

Ask the patient how much she wants to know before disclosure is the correct option. Although this patient is young, the principle of autonomy is still applicable. She has the right to know about her disease and the likely course of action. Withholding information from the patient without her consent is unethical. Asking her how much she wants to know before explaining to her in an easy-to-understand manner is the best course of action.

Let the infectious disease physician disclose the diagnosis to the patient is incorrect because the clinician should reveal the test results to the patient and the reason for referral.

Explain to the patient that her parents do not want her to know about her test results is an incorrect option because it will lead to a rift between the patient and her family and be detrimental for the patient.

Refer to another clinician for management of her substance use is incorrect because it is unethical to refer a patient just because a physician disagrees with the patient or his guardians. Counseling the parents and explaining the diagnosis to the patient easily is the best policy in this situation.

Withhold the diagnosis from the patient is incorrect because she should be informed about her diagnosis after her consent.

Acupuncture is based on the principles of traditional Asian medicine that includes inserting thin solid needles into specific documented body points. The needles can be manipulated manually or via an electrical stimulator (electroacupuncture). Acupuncture is inexpensive, simple, has minimal side effects and can be used to treat both objective and subjective signs of withdrawal. The underlying mechanism is thought to be based on the release of endogenous opioids in the brain that interacts with different opioid receptors to ease pain and relieve withdrawal symptoms.

Chinese herbal medicine, like extracts from Corydalis yanhusuo, has been used in the treatment of opioid use disorder. However, since the patient is reluctant to use any drugs, it will not be a suitable mode of therapy in this patient.

Ayurvedic medicine is based on Indian traditional medicine that includes plant-derived medicines as well as the use of meditation and yoga to treat various bodily conditions. However, this has not shown significant evidence in the treatment of opioid use disorder.

Hypnosis has been used in various psychiatric conditions but there is no significant evidence in the treatment of opioid use disorder.

Electromagnetic therapy has not shown significant evidence in the treatment of opioid use disorder.

Request further information about which drugs he has taken recently and in the past is correct. This patient’s presentation is suspicious of drug-seeking behavior and suggests that he is at risk of drug misuse. However, the physician must avoid prejudice and cognitive bias. It is, therefore, appropriate to request further information regarding the patient’s recent and former drug use. The physician tries to guard against misuse while properly assessing and treating the patient’s pain.

Prescribe a short course of oxycodone and schedule a follow-up appointment in one week may be a reasonable step for patients requiring pain management. However, it is not the best next action in a patient with a suspected drug-seeking behavior, as it may enable prescription medication misuse.

Prescribe a long-acting opioid for better pain relief if he is willing to sign a pain contract is incorrect. Although it may be a reasonable consideration for patients undergoing narcotic therapy, especially for chronic pain, the suspected drug-seeking behavior in this patient needs to be addressed first.

Request consent for a urine test to assess current drug use is incorrect because, although this scenario is suspicious for drug-seeking behavior, requesting consent for a urine drug test would likely alienate the patient.

Refer to a substance use counselor for addiction counseling is incorrect because, although this scenario is suspicious for drug-seeking behavior, it is too early in the interaction to determine if the patient does indeed suffer from a substance use problem. Referring to a substance use counselor at this point may result in a loss of rapport.

Administer life-saving measures is correct. Under all circumstances, the clinician must follow the core medical ethics principle of beneficence and provide the patient with life-saving measures without the patient’s consent unless the patient has clearly stated his/her intent to not receive any such measures prior to the presentation. This patient has no such prior verbal or written evidence confirming that she does not require any life-saving measures. Although she is currently a person with a substance use disorder, who is undergoing therapy, all life-saving measures needed should be performed.

Don’t administer any form of medical measures as the patient refuses to stop taking drugs is incorrect because this is against the core medical ethics principle of beneficence, which states that under the circumstances that a patient is unconscious or is experiencing altered mental status, the attending clinician is to act in the best interest of the patient unless stated otherwise by the patient prior to the presentation. This patient has no such prior verbal or written evidence, which confirms that she does not want any life-saving measures.

Administer only supportive measures is incorrect because it is against the core medical ethics principle of beneficence, which states that under the circumstances that a patient is unconscious or is experiencing altered mental status, the attending clinician is to act in the best interest of the patient unless stated otherwise by the patient prior to the presentation.

Administer life-saving measures after informing the patient’s parents/guardians is incorrect because this is against the core medical ethics principle of beneficence, which states that under the circumstances that a patient is unconscious or is experiencing altered mental status, the attending clinician is to act in the best interest of the patient unless stated otherwise by the patient prior to the presentation. The parents may be informed after the patient recovers, and consent has been obtained from the patient regarding this.

Administer some form of medical measures but inform the patient’s parents/guardians is incorrect because this is against the core medical ethics principle of beneficence, which states that under the circumstances that a patient is unconscious or is experiencing altered mental status, the attending clinician is to act in the best interest of the patient unless stated otherwise by the patient prior to the presentation. The parents may be informed after the patient recovers, and consent has been obtained from the patient regarding this.

Autonomy is an ethical principle that refers to the right of patients to make informed decisions about accepting and refusing care (if they have decision-making competence and legal capacity). It also dictates that patient confidentiality is to be maintained at all times. By informing the patient’s parents against the patient’s wishes, the clinician is breaching this principle.

Beneficence is an ethical principle to take actions that serve patient welfare. Although it is an important ethical principle, it is not the main core principle being breached here.

Nonmaleficence is an ethical principle to avoid or minimize harm (e.g., adverse effects of treatment) when acting toward a beneficial outcome. Although it is an important ethical principle, it is not the main core principle being breached here.

Informed consent refers to a decision made by a patient regarding a procedure (i.e., surgery) after being well aware of all of the consequences and associated complications. This principle is not being breached here.

Justice describes treating the patient fairly and equitably. This principle is not being breached in this case.

Naloxone is the correct option because naloxone is a pure opioid antagonist that is used in the treatment of opioid intoxication. Naloxone can be prescribed as chemoprophylaxis via the intranasal route to avoid serious overdose and relevant mortality.

Thiamine is incorrect because there is no role of thiamine in prophylaxis for opioid intoxication.

Flumazenil is incorrect because flumazenil is a selective GABA A receptor antagonist that is used in the treatment of benzodiazepine overdose. It has no role as a chemoprophylactic agent in opioid intoxication.

Metadoxine is incorrect because metadoxine is an ionic complex of a pyridoxine-pyrrolidone molecule that increases the metabolism of alcohol and reduces the duration of intoxication. It has no role as a chemoprophylactic agent in opioid intoxication.

Glucose is incorrect because glucose has no role in the reversal of opioid intoxication and is not prescribed as a chemoprophylactic agent.

Naloxone is correct because this patient has most likely experienced an opioid overdose. Naloxone is a pure competitive antagonist of the opioid receptor. It can quickly reverse the effects of opioids. Opioid overdose presents with respiratory depression and obtundation.

Fomepizole is incorrect because it is used to block the adverse effects of methanol and ethylene glycol. Fomepizole blocks the activity of alcohol dehydrogenase, preventing the formation of toxic metabolites that can cause metabolic acidosis, kidney damage, and vision problems.

Flumazenil is incorrect because it is a competitive antagonist of the GABA receptor and is used to reverse benzodiazepine overdose.

Methadone is incorrect because it is a long-acting opioid used in addiction medicine as substitution therapy. Use in this case would exacerbate opioid overdose/intoxication.

Cyproheptadine is a 5-HT2 receptor antagonist that may be useful in treating serotonin syndrome. This patient likely experienced an opioid overdose.

Naloxone is correct as it is an opioid receptor antagonist with rapid onset of action (2-3 minutes). It rapidly reverses the effects of opioids. This patient’s pinpoint pupils and respiratory depression strongly suggest opioid intoxication.

Naltrexone is incorrect because although it is an opioid receptor antagonist, its mode of action is delayed, i.e., 1-2 hours. It is used in reducing opioid use by reducing its euphoric effect. This patient’s respiratory depression, unconsciousness, and pinpoint pupils are suggestive of an opioid overdose.

Methadone is incorrect as it is used in the management of opioid withdrawal. It is an opioid receptor agonist and is, therefore, contraindicated in the management of opioid intoxication.

Flumazenil is incorrect as it is a benzodiazepine receptor antagonist used in the management of benzodiazepine overdose, which does not typically present with miosis as seen in this patient.

Fomepizole is incorrect as it is used in the management of methanol or ethylene glycol ingestion.

Naloxone is correct as this patient’s clinical picture –including altered mental state, hypotension, hypothermia, hypoxia, and decreased respiratory rate– suggest opioid intoxication as the likely diagnosis. Although this patient does not have miosis, it may be due to the co-ingestion of other drugs that counter miosis in this case. Naloxone rapidly reverses bradypnea in such patients.

External rewarming is incorrect as this patient’s hypoxia and altered state, along with hypotension, suggest opioid intoxication that needs reversal with naloxone first. If hypothermia does not correct by naloxone administration, then external rewarming can be considered.

Diazepam is incorrect as it is a benzodiazepine receptor agonist and can worsen the respiratory depression in this case and is, therefore, avoided.

CT scan of the brain is incorrect as this patient’s presentation is more consistent with opioid intoxication than head injury or stroke. Moreover, the patient is very unstable, and transporting him out of the facility can be detrimental for his health.

Flumazenil is incorrect as it is a benzodiazepine receptor antagonist used in the management of benzodiazepine overdose characterized by altered mental state, slurred speech, and sometimes respiratory depression. This patient’s hypotension, hypoxia, and hypothermia cannot be explained by benzodiazepine intoxication.

Urine is the correct answer because the concentration of the drug metabolites in the urine sample is the amount of drug that has accumulated in the bladder. Since each void volume is approximately 300 ml on average, there is enough volume left to repeat the test rather than obtaining another sample.

Blood is incorrect because the sample volume is usually limited, and it is difficult to retest the same sample.

Sweat is incorrect because there is not enough sample to retest in the majority of the samples taken. However, there is a possibility if specific patches are used.

Breath is incorrect because air exhaled is not collected, but exhaled in a system that instantly provides results, so it will not be possible to retest the sample.

Oral fluid is incorrect because the sample volume is collected in a small amount that is not enough for a retest.

Naloxone is the correct response. The patient’s reported history of use of unspecified pain medications, pinpoint pupils, and respiratory depression suggest opioid intoxication. Naloxone, a competitive opioid receptor antagonist with a rapid onset of action (2-3 minutes), is the treatment of choice for opioid overdose.

Phentolamine is incorrect because it is useful for treating a hypertensive crisis in case of cocaine overdose, while this patient’s condition is suspicious for opioid overdose.

Naltrexone is incorrect because it is not useful for treating acute opioid overdose. It has a longer time to action and longer half-life than naloxone. It is used instead to prevent or reduce chronic opioid use.

Methadone is incorrect; an opioid agonist is contraindicated in patients with opioid overdose.

Fomepizole is incorrect because this patient’s condition is suspicious for opioid overdose. Fomepizole is used to treat ethylene glycol or methanol poisoning.

Selection bias is correct because even though not a single patient opted out of the study, this is still an example of selection bias, as the study population (inpatients) does not necessarily reflect the general population.

Procedure bias is incorrect because the procedure described in this vignette seems to treat each patient the same. Procedure bias occurs when different groups in a study are treated differently.

Observer-expectancy bias is incorrect because it occurs when an investigator’s belief alters the outcome. For example, an investigator’s belief in treatment alters the outcome of treatment (i.e., a psychiatrist might be more likely to record that their patients on SSRIs are happier).

Measurement bias is incorrect because this study had brain activity measured via an MRI scan in each patient. There is no reason to assume that the machine is defective. Measurement bias occurs when information is gathered in a faulty manner.

Confounding variable is incorrect because while it is possible that there is a third variable positively associated with one of the test variables and negatively associated with other variables, resulting in an erroneous negative correlation, such a bias is not as straightforward as the selection bias in this vignette.

Decision-making capacity is correct. Determination of a patient’s decision-making capacity requires the patient’s thought process to demonstrate 1) understanding, 2) appreciation, 3) clear reasoning through new information, and 4) the ability to use the information to make a choice. While this patient has articulated a choice, she cannot recall key information presented to her, which suggests that she does not understand the procedure to which she is consenting and, therefore, currently lacks decision-making capacity.

Patient autonomy refers to the obligation of clinicians to respect patients as individuals and respect their decisions, even if in conflict with the clinician’s recommendation. There is no information provided in this scenario suggesting that the clinician does not respect this patient’s autonomy.

Patient competence is the legal ability of the patient to direct her own care as determined by a court. This patient is discussing her care with a clinician, who is unable to determine legal competence.

Beneficence describes an act by the clinician in the interests of the patient. It may conflict with autonomy. The clinician is acting in the best interest of this patient in this scenario.

Nonmaleficence describes avoidance of causing suffering or injury to the patient. For example, during surgery, even though an incision is given to treat the patient, the surgeon aims to minimize complications to avoid harming the patient. Nonmaleficence is not being compromised in this scenario.

CYP2D6 is the correct response. A single nucleotide polymorphism (SNP) in the CYP2D6 gene may alter enzyme activity and result in the ultrarapid metabolization of codeine to morphine, rendering a person an ultrarapid metabolizer (UM) of the codeine.

CYP2A6 is incorrect because it is involved in the metabolism of nicotine to cotinine by cytochrome P450 enzymes.

CYP3A4 is incorrect because it is involved in N-demethylation of methadone to EDDP (2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine).

CYP1A2 is an incorrect response because it is responsible for metabolizing caffeine into paraxanthine.

CHRNA5 is incorrect because it is associated with nicotine metabolism to cotinine.

St John’s wort is correct because it is an inducer of CYP3A4, a microsomal enzyme responsible for the metabolism of opioids like morphine. When induced, this enzyme can lead to a faster breakdown of morphine and an eventual drop in the drug’s blood levels. This, in turn, can lead to a decreased effectiveness of morphine as an analgesic, which seemed to have happened in this case.

Fluoxetine is incorrect because it is an inhibitor of CYP3A4, a microsomal enzyme responsible for the metabolism of opioids like morphine. When inhibited, it decreases the breakdown of morphine, thus, causing a rise in its levels in the blood. This can result in morphine having more potent effects and even developing toxicity.

Erythromycin is incorrect because it is an inhibitor of CYP3A4, a microsomal enzyme responsible for the metabolism of opioids like morphine. When inhibited, it decreases the breakdown of morphine, thus, causing a rise in its levels in the blood. This can result in morphine having more potent effects and even developing toxicity.

Fluvoxamine is incorrect because it is an inhibitor of CYP3A4, a microsomal enzyme responsible for the metabolism of opioids like morphine. When inhibited, it decreases the breakdown of morphine, thus, causing a rise in its levels in the blood. This can result in morphine having more potent effects and even developing toxicity.

Ketoconazole is incorrect because it is an inhibitor of CYP3A4, a microsomal enzyme responsible for the metabolism of opioids like morphine. When inhibited, it decreases the breakdown of morphine, thus, causing a rise in its levels in the blood. This can result in morphine having more potent effects and even developing toxicity.

Lethal arrhythmia is correct because this patient most likely suffered from sudden sniffing death syndrome given her history of inhaling volatile substances. It is a term that has been used to describe lethal ventricular dysrhythmias and sudden cardiac death associated with hydrocarbon inhalation. Sniffing is a mode of drug administration in which the volatile substance is directly inhaled from containers.

Acute myocardial infarction is incorrect. This patient’s past history is notable for inhaling volatile substances. Acute myocardial infarction in a young adult may raise suspicion for cocaine use and cardiac dysfunction secondary to vasoconstriction of the coronary arteries. However, there is no indication of cocaine use in this case.

Massive stroke is incorrect because although a massive stroke may result in instant death, this patient’s youth and lack of notable risk factors for stroke make this less likely.

Pulmonary embolism may be fatal, but it is relatively uncommon in young people without known risk factors for the condition.

Chronic hepatic failure is incorrect as it would be uncommonly found in a young woman without some history of liver disease previously discovered.

5HT2A receptor is correct because this patient is reporting symptoms consistent with intoxication with LSD. LSD is commonly used for its euphoric effects. Patients experience a heightened perception of sensation with synesthesia (blending of senses; for example, “seeing sounds”). It mainly works through the stimulation of serotonin receptors.

Alpha-adrenergic receptor is incorrect because this patient is presenting with features of intoxication with LSD, which acts primarily on serotonin receptors. Cocaine inhibits the uptake of serotonin, dopamine, and norepinephrine. Norepinephrine results in excess alpha-adrenergic stimulation.

GABAA receptor is incorrect because this patient is presenting with features of intoxication with LSD, which acts on primarily serotonin receptors. Benzodiazepines and alcohol act on GABAA receptors. These agents stimulate the receptor resulting in general depression of the central nervous system. Patients present with reduced arousal, respiratory depression, and hypotension.

NMDA receptor is incorrect because this patient is presenting with features of intoxication with LSD, which acts primarily on serotonin receptors. Phencyclidine (PCP) acts as an antagonist on NMDA receptors, and can result in violent or abnormal behavior.

D1 receptor is incorrect because LSD acts to some extent on central D2, and not D1 receptors. It agonizes these receptors resulting in symptoms such as depersonalization.

Antipsychotics is correct because the scenario describes a patient experiencing a “bad trip” associated with a previous history of hallucinogen overdose. A bad trip is defined as re-experiencing the effects of hallucinogen intoxication that may cause hallucinations, agitation, or even panic attacks. It is also sometimes referred to as a hallucinogen persisting perception disorder. Hallucinogen persisting perception disorder should be differentiated from acute schizophrenic psychosis by the fact that auditory hallucinations are most commonly seen with acute schizophrenic psychosis. Visual and tactile hallucinations characterize the former. Treatment is initially supportive that involves individualized counseling and oral benzodiazepines. Second generation antipsychotics that are 5-HT2A antagonists are used to reverse the psychological effects and hallucinations.

Psilocybin is incorrect because it is a hallucinogen, and has no use in treating this condition.

Antidepressants is incorrect because they have no role in treating hallucinogen persisting perception disorder.

Nicotine lozenges is incorrect because they have no role in treating hallucinogen persisting perception disorder.

Monoamine oxidase inhibitors is incorrect because they have no role in treating hallucinogen persisting perception disorder.

Moderate is the correct answer because according to the DSM-V diagnostic criteria for gambling disorder if an individual meets 6-7 criteria, it is specified as moderate gambling disorder. The six criteria met here are a need to gamble with increasing amounts of money, becoming irritable when trying to stop, unsuccessful efforts to cut back, preoccupation with gambling, gambling when distressed, and lies to conceal the extent of gambling.

Major is incorrect, as it is not a severity specifier in the diagnostic criteria for gambling disorder according to DSM-V.

Minor is incorrect, as it is not a severity specifier in the diagnostic criteria for gambling disorder according to DSM-V.

Mild is incorrect because if an individual meets 4-5 criteria, it will be diagnosed as mild gambling disorder according to DSM-V.

Severe is incorrect because if an individual meets 8-9 criteria, it will be diagnosed as severe gambling disorder according to DSM-V. In severe gambling disorder, the criteria met are often the least exhibited, which include jeopardizing relationships or career opportunities and relying on others to provide money for gambling losses.

Create insight regarding the patient’s addiction is correct as this patient is at the pre-contemplation stage of change and needs to realize the intensity of her drug addiction before further treatment can be initiated.

Cognitive behavioral therapy is incorrect as it targets avoidance with behavioral techniques like relaxation, exposure, and behavior modification. It may be helpful in this case but will not help this patient as she does not have insight into her substance use disorder yet.

Recommend a support group is incorrect as it is suggested at the preparation stage of change. This patient is at the pre-contemplation stage and therefore needs to be properly aware of her disorder.

Twelve-step facilitation therapy (TSF) is incorrect as TSF is recommended for patients who are coming to treatment after incurring significant consequences of substance use disorder. They are unable to control or stop using the drug on their own. This patient is not suitable for this intervention as she does not realize the severity of his disorder.

Supportive psychotherapy is incorrect as it helps in maintaining hope and provides encouragement to a patient reinforcing the coping mechanisms and defenses of an individual. It is most commonly used in the management of psychotic disorders or in patients in crisis. This patient’s substance use disorder cannot be improved with this technique.

Gas chromatography-mass spectrometry is the correct answer because preliminary drug testing is done using immunoassays, following which any positive result is confirmed with chromatographic techniques. The above case described a patient who has most likely used cannabis because his urine sample has tested positive for 11-nor-9- tetrahydrocannabinol-9-carboxylic acid, which is a metabolite of cannabis. The chromatographic analysis is a reliable method for the detection and quantitation of various cannabis metabolites to confirm any false-positive results.

Enzyme-linked immunosorbent assay (ELISA) is incorrect because the initial test for drug testing, including cannabinoids, includes immunoassays while any false-positive results with immunoassays are confirmed with chromatographic techniques.

Fluorescence polarization is incorrect because it is an immunoassay, and positive results with immunoassays are confirmed with chromatographic techniques.

Enzyme-multiplied immunoassay technique (EMIT®) is incorrect because it is an immunoassay that is used as the preliminary analytic technique for the detection of drugs, including cannabinoids. If the initial test is positive, the result is confirmed with chromatographic techniques.

Radioimmunoassay is incorrect because chromatographic techniques are used for the analysis of positive results with preliminary immunoassay.

Marijuana misuse is correct because THC is the cannabinoid present in marijuana. It is metabolized to an active metabolite 11-OH-THC and is rapidly conjugated to 11-nor-9-carboxy-THC in urine.

Alcohol addiction is incorrect because the laboratory reports of such a patient will show decreased platelets, increase in gamma-glutamyl transpeptidase (GGT), or vitamin and folic acid deficiency.

Nicotine overdose is incorrect because the reports of such a patient will show presence of cotinine in urine.

Heroin misuse is incorrect because THC is not present in heroin.

Opioid overdose is incorrect because THC is not present in opioids. Opioids are excreted in urine and bile.

Benzoylecgonine ethyl ester is the correct answer because it is a metabolite of cocaine, which is formed only in the presence of alcohol. It is also known as cocaethylene. Cocaethylene increases the risk of cardiac complications. Cocaine is metabolized into 2 main metabolites, including benzoylecgonine and ecgonine methyl ester. Cocaine metabolism also produces minor metabolites, including meta-hydroxybenzoylecgonine, para-hydroxybenzoylecgonine, and norbenzoylecgonine. Therefore, patients with cocaine use should be screened for concurrent alcohol use to prevent postoperative complications.

Benzoylecgonine is incorrect because it is one of the major metabolites of cocaine, which is formed in the absence of alcohol. Therefore, it cannot be used to detect concurrent alcohol use.

Ecgonine methyl ester is incorrect because it is one of the major metabolites of cocaine, which is formed in the absence of alcohol. Therefore, it cannot be used to detect concurrent alcohol use.

Meta-hydroxybenzoylecgonine is incorrect because it is one of the minor metabolites of cocaine, which is formed in the absence of alcohol. Therefore, it cannot be used to detect concurrent alcohol use.

Para-hydroxybenzoylecgonine is incorrect because it is one of the minor metabolites of cocaine, which is formed in the absence of alcohol. Therefore, it cannot be used to detect concurrent alcohol use.

Habenula is correct as the woman is currently in the withdrawal-negative affect stage as evidenced by her irritability, loss of enjoyment in life, and dissatisfaction with life. This stage is characterised by dysphoria, anhedonia, and irritability. The extended amygdala and habenula are involved in this stage.

Basal ganglia is incorrect as she has already passed the binge-intoxication stage. When someone takes a drug, they enter a state of euphoria regulated by basal ganglia.

Cerebellum is incorrect as it is involved in balance and movements of the body without any effects on these kinds of feelings related to life and withdrawal of drug.

Medulla oblongata is incorrect as it does not have a significant effect on the feelings of a person. In fact, it is mainly involved in regulating some involuntary functions of the body important to life such as breathing and respiration.

Pons is incorrect as it also does not have significant effects on feelings. It is also a part of the brainstem similar to medulla oblongata and is involved in regulating some involuntary function of the body like breathing.

Smoking is the correct answer because smoking significantly increases levels of carbohydrate-deficient-transferrin (CDT) when compared to nonsmokers consuming similar amounts of alcohol. CDT is a transferrin. Chronic alcohol use prevents the glycosylation of transferrin. It is an indirect biomarker of moderate to heavy chronic alcohol use. CDT levels usually return to normal within 2 weeks of drinking cessation.

Height on its own does not affect the level of carbohydrate-deficient transferrin (CDT) rather it is the body mass index (BMI) that significantly affects the levels of CDT. Patients with high BMI have low levels of CDT as compared to patients with low BMI despite consuming similar amounts of alcohol.

Male gender is incorrect. Female gender significantly affects levels of carbohydrate-deficient transferrin (CDT) compared to male gender. Pregnant women have increased levels of CDT as gestation progresses despite no alcohol use. Also, there are decreased levels of CDT in postmenopausal women.

Age does not affect carbohydrate-deficient transferrin (CDT) levels.

Hepatitis B infection is incorrect. Hepatitis C virus infection rather than hepatitis B virus infection significantly decreases levels of CDT when compared to seronegative HCV patients.

Cognitive-behavioral therapy (CBT) is correct as it targets reducing avoidance behaviors and negative thoughts, leading to relapse in patients with addiction. CBT educates recovering addicts to discover associations between their contemplations, emotions, and activities and improves attention to how they may impact rehabilitation and recovery.

Dialectical behavioral therapy is incorrect as it is used in the management of borderline personality disorder targeting suicidal behaviors. This patient with alcohol use disorder cannot benefit from this therapy.

Exposure therapy is incorrect as it is used in the management of specific phobias. It leads to systematic desensitization causing habituation and decreased anxiety over time. It is superior to the pharmacologic management of specific phobias and is not efficacious for alcohol use disorder.

Psychodynamic psychotherapy is incorrect as it builds insight and resolves internal conflicts of an individual. It is used in the management of personality disorders. This person already has an insight into her disorder; therefore, this therapy is not appropriate for this patient.

Supportive psychotherapy is used in high-risk patients leading to decompensation or in low-functioning patients. Patients with addiction cannot benefit from this type of psychotherapy.

Twelve-step facilitation therapy (TSF) is the correct response as TSF is recommended for patients who are coming to treatment after incurring significant consequences of substance use disorder. They are unable to control or stop using the drug on their own and would meet the formal Diagnostic and Statistical Manual of Mental Disorders (DSM-V) criteria for substance use disorder.

Contingency management is incorrect as it uses positive reinforcement to encourage abstinence from drugs. Contingency management focuses on the maximal usage of medical clinic offices and guarantees decreased future hospitalizations. This patient is not a suitable candidate for this intervention.

Motivational enhancement therapy is incorrect as it is a counseling technique that helps the patients resolve their ambivalence about beginning treatment and stopping their drug use. This patient is already motivated to abstain from alcohol and cannot benefit from motivational enhancement therapy.

Support groups is incorrect as this patient, with a recent history of a life-changing event and willingness to quit substance use, is a perfect candidate for the twelve-step facilitation therapy. Support groups may help during the preparation phase of change in an individual, they will not provide adequate treatment in this case.

Psychodynamic psychotherapy is incorrect as it builds insight into the unconscious conflicts of the past and breaks down maladaptive defenses. It is commonly used in the management of personality disorders. This patient’s substance use disorder cannot benefit from this therapy.

Naltrexone is correct. It is the first line medication for this condition. It is not contraindicated in patients with renal disease. However, it needs to be used with caution in patients with liver disease.

Acamprosate is incorrect as naltrexone is preferred over acamprosate in treating alcohol use disorder initially. Acamprosate is used with caution in patients with renal disease.

Bupropion is incorrect as it is used in the management of tobacco use disorder and for treating depression.

Methadone is incorrect. It is used in the management of heroin or opioid use disorder.

Topiramate is incorrect because, although it is used in the management of alcohol use disorder, it is not considered a first line drug. It is used as a third- or fourth-line drug. Moreover, it should be used with caution in patients with renal disease.

Arrhythmias is the correct option as it is the most common cause of death in anorexia nervosa patients. Anorexic patients have electrolyte imbalance that leads to hypokalemia, which results in arrhythmias that cause death. Almost one-third of total deaths in patients with anorexia nervosa are thought to be due to cardiac causes, mostly sudden deaths.

Pneumonitis is incorrect as it is not the most common cause of sudden death in patients with anorexia nervosa.

Liver cirrhosis is incorrect. Although it is commonly seen in patients with alcoholism, the patient was diagnosed with alcohol use disorder 2 years ago, and it takes almost 10 years for alcohol to cause severe liver cirrhosis. Moreover, liver cirrhosis doesn’t cause sudden death.

Renal failure is incorrect as it is not the most likely cause of sudden death in individuals with anorexia nervosa.

Oesophageal tear is incorrect as it is common with hydrocarbon use; it is not seen in alcohol use disorder or anorexia nervosa.

Confounding bias is correct because this study does not control variables that could be related to both exposure (i.e., alcohol) and the outcome (i.e., endocarditis). This distorts the effect that exposure to alcohol has on the outcome of developing endocarditis. For example, one confounding variable is IV drug use as heavy alcohol users may be more likely to utilize IV drugs more accounting for the association between alcohol and endocarditis. Therefore, because alcohol is not the only endocarditis-effecting factor that differs between the 2 groups in the study, confounding is present. Confounding can be addressed by redesigning the study to include a control group and matching participants with similar characteristics in both the exposure group and the control group.

Lead-time bias is incorrect because the study in this example is affected by confounding bias rather than lead-time bias. Lead-time bias occurs when early detection of a disease is confused with an increase in survival. For example, if a new screening test diagnoses breast cancer 3 years earlier than a mammogram, a researcher might conclude that the earlier detection leads to an increase in survival by 3 years in this patient population. In reality, the patients may be dying of the disease at the same time; thus, the screening did not increase the survival of patients.

Length-time bias is incorrect because the study in this example is affected by confounding bias rather than length-time bias. Length-time bias occurs when there is an overestimation of the survival duration of patients due to an excess of patients whose disease is slowly progressive. For example, a screening test may not detect a rapidly progressive disease as well as a slowly progressive disease, which leads to an increase in the estimated survival of the patients with this specific disease (whether or not they have rapidly progressive or slowly progressive disease).

Recall bias is incorrect because the study in this example is affected by confounding bias rather than recall bias. Recall bias is defined as the awareness of a disorder that alters the recall by study participants. For example, a mother of a baby with fetal alcohol syndrome might underreport alcohol consumption.

Selection bias is incorrect because the study in this example is affected by confounding bias rather than selection bias. Selection bias occurs when the conclusion from a study are drawn about a study population that is not representative of the target population being addressed. A specific type of selection bias is Berkson’s bias.

Recommend naltrexone is correct as this is the most suitable option for this patient considering his comorbid conditions.

Recommend disulfiram is incorrect because disulfiram is contraindicated in psychosis, severe coronary occlusion or myocardial disease, recent use of metronidazole and in hypersensitivity to disulfiram.

Recommend baclofen is incorrect because baclofen is a potentially promising medication, however, it is still not fully investigated and not routinely use in clinical practice.

Recommend topiramate is incorrect because topiramate is not an FDA-indicated drug, it it not used routinely, and it also has more side effects compared to other mentioned medications.

Recommend gabapentin is incorrect because gabapentin is a potentially promising medication, however, it is still not fully investigated and not routinely use in clinical practice.

Alcohol use disorder is correct. This patient shows the typical signs of alcohol withdrawal: restlessness, agitation, nausea, headache, tremor, and palpitation that often begins in 6 to 24 hours after cessation of alcohol consumption. Motivational interviewing is indicated to help this patient address alcohol use.

Post traumatic stress disorder is incorrect. This patient does not report signs and symptoms of PTSD.

Antisocial behavior is incorrect. The case presentation does not mention antisocial personality disorder.

Medication adherence is incorrect. Motivational interviewing is known to increase the rates of successful medication adherence in a patient who has a history of failed medicine use or is at particular risk to not use it as prescribed. However, it does not apply to this patient.

Safe driving skills is incorrect. The case presentation does not mention unsafe driving skills.