Contingency management — MCQs

A 47-year-old male presents to a psychiatrist for the first time, explaining that he is tired of living his 'double life.' At church, he preaches vehemently against the sin of drinking alcohol, but at home he gets drunk every night. Which of the following ego defenses best explains his behavior?

A 22-year-old man seeks help from a physician for his heroin addiction. He tells the doctor that he started using heroin at the age of 17 and gradually started increasing the dose. He has been trying to quit for the last 6 months after realizing the negative consequences of his addiction but has not succeeded because of the withdrawal symptoms. The physician suggests a drug that can be taken within a supervised rehabilitation program as a substitute for heroin to help alleviate withdrawal symptoms. The drug will then be tapered over time. He is further informed by the physician that this drug is not to be taken by the patient on his own and is not used for emergency reversal of opioid overdose. Which of the following drugs is most likely to have been recommended by the physician?

A 25-year-old man is brought to the emergency department by police for aggressive behavior. The patient is combative and shouts sexually aggressive remarks at the nursing staff. While obtaining the patient’s vitals, it is noted that he has markedly dilated pupils. His temperature is 98.2°F (36.8°C), pulse is 112/min, blood pressure is 130/70 mmHg, respirations are 18/min, and oxygen saturation is 98% on room air. Urine toxicology is obtained and sent off. Physical exam is notable for an energetic patient with dilated pupils and increased sweating. The patient spends the night in the emergency department. In the morning the patient is withdrawn and has a notable depressed affect. He apologizes for his behavior the previous night and states that he is concerned about his problem and wants help. Which of the following is appropriate management of this patient?

A 40-year-old man is brought into the emergency department because he was involved in a bar fight and sustained an injury to the head. The next day, as requested by the patient, the psychiatry team is called to address some of the concerns he has regarding his drinking habits. He admits that he got irate last night at the bar because his driver’s license was recently taken away and his wife had taken his children to live with her parents because of his drinking problem. He drinks 4–6 beers on a weeknight and more on the weekends. He wants to know if there is anything that could help him at this point. Which stage of overcoming his addiction is this patient currently in?

A 33-year-old woman presents with anxiety, poor sleep, and occasional handshaking and sweating for the past 10 months. She says that the best remedy for her symptoms is a “glass of a good cognac” after work. She describes herself as a “moderate drinker”. However, on a more detailed assessment, the patient confesses that she drinks 1–2 drinks per working day and 3–5 drinks on days-off when she is partying. She was once involved in a car accident while being drunk. She works as a financial assistant and describes her job as “demanding”. She is divorced and lives with her 15-year-old daughter. She says that she often hears from her daughter that she should stop drinking. She realizes that the scope of the problem might be larger than she perceives, but she has never tried stopping drinking. She does not feel hopeless, but sometimes she feels guilty because of her behavior. She does not smoke and does not report illicit drugs use. Which of the following medications would be a proper part of the management of this patient?

A 54-year-old male comes to the clinic to initiate care with a new physician. He has no complaints at this time. When taking his history, the patient says his medical history is notable for diabetes and hypertension both of which are well managed on his medications. His medications are metformin and lisinopril. A review of systems is negative. While taking the social history, the patient hesitates when asked about alcohol consumption. Further gentle questioning by the physician leads the patient to admit that he drinks 5-6 beers per night and up to 10-12 drinks per day over the weekend. He says that he has been drinking like this for “years.” He becomes emotional and says that his alcohol is negatively affecting his relationship with his wife and children; however, when asked about efforts to decrease his consumption, the patient says he has not tried in the past and doesn’t think he has “the strength to stop”. Which of the following stages of change most accurately describes this patient’s behavior?

A 30-year-old man with schizophrenia stabilized on clozapine presents to establish care at a new clinic. Records show stable psychiatric symptoms for 2 years. Routine urine drug screen is positive for cocaine. He admits to using cocaine 2-3 times monthly at parties but denies it affects his functioning. He has maintained employment, housing, and medication adherence. He refuses substance use treatment, stating 'it's recreational and under control.' His last clozapine level was therapeutic. Evaluate the management approach balancing psychiatric stability, substance use, and patient autonomy.

A 42-year-old physician presents voluntarily to the state physician health program after colleagues noticed erratic behavior. He admits to diverting fentanyl from the operating room for 18 months, using it to manage work stress. He has no prior substance use history, maintains he can 'handle it,' but acknowledges his medical license and career are at risk. He completed detoxification last week. Evaluate the comprehensive management strategy that addresses medical, professional, and legal considerations.

A 26-year-old pregnant woman at 16 weeks gestation with opioid use disorder requests medication-assisted treatment. She has been using heroin daily for 3 years and is motivated for treatment. She has tried 'quitting cold turkey' previously but relapsed within days. Obstetrics has referred her urgently for addiction medicine consultation. Evaluate the treatment approach that optimizes both maternal and fetal outcomes.

A 50-year-old man with alcohol use disorder presents for the third time in 6 months with alcohol-related pancreatitis. He has completed detoxification twice, attended some AA meetings, but relapsed each time. He has compensated cirrhosis (Child-Pugh A) and is motivated to quit. Lab shows AST 95, ALT 60, GGT 180. He requests 'something that will make me sick if I drink.' Analyze the treatment options and select the most evidence-based pharmacotherapy.