1. Although opioid poisonings and overdose deaths occur throughout all segments of society, clinicians serving people who are homeless or unstably housed report that these individuals are at especially high risk, which is often exacerbated by their limited access to medication-assisted treatment and to overdose prevention therapy.
A. True B. False2. According to the authors, numerous factors associated with homelessness may increase the risk of developing severe opioid use disorders and make treatment more difficult, including each of the following EXCEPT:
A. Complex and poorly treated comorbidities B. Insufficient resources to meet basic needs and minimal social supports C. Inadequate educational experiences and connections D. Lack of access to specialty care each of the following3. Research and clinical experience suggest that health outcomes and quality of life can be significantly improved with a selective, behavioral-centered approach to the management of opioid use disorders and comorbid conditions.
A. True B. False4. Although research in this area is lacking, in general, the clinical utility of oral naltrexone for the treatment of opioid dependence in homeless/marginal populations has been limited by poor treatment adherence and retention.
A. True B. False5. Which of the following is NOT one of the major recommendations when taking a clinical history of homeless patients with opioid use disorders?
A. Allow patients to tell their story and listen nonjudgmentally, while building confidence as their provider B. When patients begin to describe their physical health and medical history, it is important to gently but frequently interrupt them in order to clarify what they are saying C. Ask patients to talk about their mental health and, for example, any "problems with stress, low energy, difficulty focusing, or mood swings" D. When assessing history of drug use, begin the interview with questions about cigarette use, which are expected in a medical setting and are nonthreatening, and then follow up with questions about personal and family history of alcohol use and drug use6. Diagnostic questions related to trauma/abuse may include questions about physical/sexual abuse, personal injuries and accidents, as well as:
A. Symptoms related to traumatic brain injury (TBI) B. Consequences of legal problems/incarceration C. Environmental factors that threaten health and safety D. Degree of support from community and social supports7. Since a history of substance use related problems may not be initially revealed during assessment, it is imperative to look for physical signs of drug use, including use of prescribed medications, alcohol, and nicotine.
A. True B. False8. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-IV), opioid use disorder is classified as severe if four or more diagnostic criteria have been met.
A. True B. False9. The American Society of Addiction Medicine (ASAM) defines addiction as a primary, chronic disease of brain reward, motivation, memory and related circuitry, where dysfunction in these circuits leads to characteristic biological, psychological, social and:
A. Physical manifestations B. Spiritual manifestations C. Developmental manifestations D. Emotional evaluations10. Major recommendations when caring for opioid dependent patients include working collaboratively with them to develop realistic, attainable, short-term goals for the management of opioid use disorders, determining treatment approach based on patient needs and preferences, and planning for close follow-up by a case manager.
A. True B. False11. While it is common for individuals to begin opioid use with prescription pills from their own prescription or a diverted source, many individuals progress to heroin, as it is usually the least expensive, potent opioid available.
A. True B. False12. For most homeless clients with co-occurring substance use and mental health disorders, the relationship to homelessness is often causal, regardless of financial and family resources.
A. True B. False13. Reviewing fundamental education and self-management concepts with opioid dependent people who are homeless is critical because:
A. Understanding how to minimize risks associated with opioid use and involvement in self-management goal setting are matters of survival for opioid-dependent people who are homeless B. Discussing risks and benefits of available treatment options with patients can build trust, inspire hope, and foster readiness for behavioral change C. Overdose prevention and response education is essential, as the number of deaths from opioid overdose/ poisoning is increasing, particularly in marginalized populations D. All of the above14. Each of the following is a correct statement about the use of naloxone for opioid overdose EXCEPT:
A. Since 1996, laypersons who are at risk for overdose or likely to witness an overdose have been given naloxone "rescue kits" by community-based organizations like needle exchange programs B. The use of rescue kits in naloxone distribution programs in the United States have resulted in nearly 5000 overdose reversals in recent years C. An international review of interventions for homeless persons discussed peers giving naloxone to others they see overdosing as a promising intervention to reduce drug-related deaths D. Recently, naloxone prescription programs have started in several health care settings throughout the United States, targeting people at risk for opioid overdose15. Choice of medication-assisted treatment for opioid use disorders depends on motivation to change current behavior, which is more limited for homeless than for stably housed persons.
A. True B. False16. According to the World Health Organization, the main causes of increased opioid overdose mortality are loss of tolerance and erroneous judgment with respect to dosage when returning to opiate use following a period of abstinence.
A. True B. False17. Which of the following accurately describes the use of buprenorphine for the treatment of opioid dependence?
A. Buprenorphine is an opioid agonist that is available for treatment of opioid use disorders primarily in strictly regulated opioid treatment program settings B. Buprenorphine may be combined with naloxone for use in situations of lower risk of misuse or diversion, such as supervised detoxification C. Buprenorphine is available in office-based settings from specially trained physicians who have received a special DEA certification D. None of the above18. One reason that maintenance treatment is not appropriate for all opioid users is that withdrawal from methadone or buprenorphine is significantly worse than withdrawal from heroin.
A. True B. False19. Since complying with institutional rules may be difficult for patients with opioid use disorders, especially when this co-occurs with cognitive disorders, unstable housing, and psychiatric disorders, flexibility based on patients' needs is recommended.
A. True B. False20. As of June 2013, every state Medicaid program covers buprenorphine/naloxone as an outpatient pharmacy benefit, and since there are no longer significant variations among the states in the range and duration of covered benefits and prior authorization requirements, overall access has improved significantly across the board.
A. True B. False21. Advantages of buprenorphine in OTP for homeless populations include the ability to establish a daily routine for taking medication, decreased worry about losing or having medication stolen, lost, or diverted in other ways, overall advantages of a highly structured program, and:
A. A strong connection to counseling B. Increased availability of such programs C. Connection to others with similar needs and histories D. Dosing requirements are generally tolerable22. Although no specific studies involving naltrexone for people who are homeless are available, naltrexone is likely to be most useful for patients who are highly motivated to achieve abstinence and when a family member or close friend is available to administer and manage the medication.
A. True B. False23. Harm reduction therapy can be particularly beneficial to homeless individuals, as it acknowledges self-defined positive change by relying on collaboration, respect, and interventions that are:
A. Solution-focused B. Client-driven C. Action-oriented D. Stage-based24. One crucial component of harm reduction practice is to locate treatment activities in places where homeless individuals with substance use disorders typically congregate.
A. True B. False25. While peer-run support groups may offer valuable opportunities to help homeless individuals in recovery, 12-step programs, self-help groups, and mutual aid groups such as Narcotics Anonymous (NA) have shown to be more effective for this population.
A. True B. False26. People with severe opioid use disorder/dependence experience acute sensitivity to pain when withdrawing from heroin use, so acupuncture may be useful for homeless clients who are withdrawing because of its low cost and portability as well as its effectiveness in treating the symptomatology of pain syndromes, substance abuse, and HIV.
A. True B. False27. For individuals with opioid use disorders, mortality rates are significantly increased by drug overdoses or lethal drug combinations, as well as by:
A. Accidental misuse of prescribed medication B. High rates of suicide C. Missed diagnoses of serious medical conditions associated with opioid dependence D. Behavioral health comorbidities28. When buprenorphine/naloxone is obtained on the street or from others with a prescription, this is likely an indication that opioid dependence is progressing and becoming more dangerous.
A. True B. False29. For patients receiving office-based treatment for opioid use disorder, frequency of follow-up should be based on risk of diversion/misuse/abuse of medications used for treatment of opioid use disorders or other substances and:
A. Level of support for adherence to treatment program B. Stability of the patient and his/her living situation C. Severity of medical/physical conditions D. None of the above30. Optimal service delivery includes an approach to care that takes into consideration the patient's personal strengths and aspirations, as well as cultural, religious, and spiritual preferences.
A. True B. False31. Which of the following is NOT one of the major recommendations for providing effective outreach and engagement for homeless populations?
A. Use an approach to care planning and coordination that is based on clinical expertise and experience B. Utilize outreach workers in the community to facilitate initial engagement with and provide support to people at risk for opioid overdose C. Provide ongoing opportunities for group therapy to patients with opioid use disorder D. If possible, provide medication-assisted treatment where homeless people live32. In order for homeless people to have a broader range of interventions for the management of opioid use disorders and to adequately address the structural causes of homelessness, services must be integrated through an expert clinical and scientific process.
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