TEXT A: Identifying opioid dependence
The International Classification of Disease, Tenth Edition [ICD-IO] is a coding system created by the World Health Organization (WHO) to catalogue and name diseases, conditions, signs and symptoms. The ICD-IO includes criteria to identify dependence. According to the ICD-IO, opioid dependence is defined by the presence of three or more of the following features at any one time in the preceding year:
• a strong desire or sense of compulsion to take opioids
• difficulties in controlling opioid use
• a physiological withdrawal state
• tolerance of opioids
• progressive neglect of alternative interests or pleasures because of opioid use
• persisting with opioid use despite clear evidence of overtly harmful consequences.
There are other definitions of opioid dependence or ‘use disorder’ (e.g., the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, [DSM-5]), but the central features are the same. Loss of control over use, continuing use despite harm, craving, compulsive use, physical tolerance and dependence remain key in identifying problems.

TEXT B: WHY NOT JUST PRESCRIBE CODEINE OR ANOTHER OPIOID?
Now that analgesics containing codeine are no longer available OTC (over the counter), patients may request a prescription for codeine. It is important for GPs to explain that there is a lack of evidence demonstrating the long-term analgesic efficacy of codeine in treating chronic non-cancer pain. Long-term use of opioids has not been associated with sustained improvement in function or quality of life, and there are increasing concerns about the risk of harm.
GPs should explain that the risks associated with opioids include tolerance leading to dose escalation, overdose, falls, accidents and death. It should be emphasised that OTC codeine-containing analgesics were only intended for short-term use (one to three days) and that longer-term pain management requires a more detailed assessment of the patient’s medical condition as well as clinical management.
New trials have shown that for acute pain, nonopioid combinations can be as effective as combination analgesics containing opioids such as codeine and oxycodone. If pain isn’t managed with nonopioid medications then consider referring the patient to a pain specialist or pain clinic. Patient resources for pain management are freely available online to all clinicians at websites such as:
• Pain Management Network in NSW – www.aci.health.nsw.gov.au/networks/pain-management
• Australian and New Zealand College of Anaesthetists Faculty of Pain Medicine -www. m.anzca.edu.au

TEXT C

Medication	Regulatory requirements	Requires off-label use	Strength of evidence	Advantages	Disadvantages	Notes on dosage
Buprenorphine- naloxone (sublingual)	Permit before treatment; patient registered as drug dependent in some jurisdictions	Indicated for opioid dependence (off-label for pain)	Multiple well- conducted RCTs demonstrate efficacy and safety	A large evidence base (e.g. Cochrane reviews) shows it is the most effective option for opioid taper16	More restrictive than other options (regulatory requirements and supervised dosing) Indicated only for opioid dependence, not for chronic pain in the absence of opioid dependence	See sample withdrawal regimen (Box 8) or refer to state and national guidelines
Tramadol (oral)	Only those that apply to S4 medications	Yes (indicated for pain not opioid dependence)	Low – a small number of RCTs demonstrate efficacy and safety	A small number of studies examined a one-week tramadol taper, with outcomes comparable with those of other opioid tapers and superior to clonidine	May produce serotonergic side effects, known drug interactions, use with caution in the elderly Use is off label Risk of seizures, even at usual doses Variable metabolism through CYP P450, similar to codeine	100 to 300 mg sustained- release formulation twice a day for one-week Supervised dosing and daily dispensing may be indicated

Buprenorphine (transdermal patch)	Permit before treatment if patient is drug dependent	Yes (indicated for pain not opioid dependence)	None – no RCTs or published cases	Good safety profile	Dose likely to be insufficient for patients with clear evidence of opioid dependence	5, 10 or 20 mcg weekly patches are available A single patch should be sufficient for taper from oral codeine
Symptomatic medications	Only those relating to S4/OTC medications	No (if use is consistent with product indication)	Moderate to high – well- conducted RCTs demonstrate efficacy; however, poorer outcomes than buprenorphine or tramadol15	Fewer prescribing restrictions Relatively safe in outpatient setting	Shown to be less effective than buprenorphine and tramadol Multiple medications can be confusing Caution using sedative medications in outpatient setting Clonidine can cause severe hypotension	See Table 1

TEXT D Preparation for tapering
As soon as a valid indication for tapering of opioid analgesics is established, it is important to have a
conversation with the patient to explain the process and develop a treatment agreement. This agreement
could include:
• time frame for the agreement
• objectives of the taper
• frequency of dose reduction
• requirement for obtaining the prescriptions from a designated clinician
• scheduled appointments for regular review
• anticipated effects of the taper
• consent for urine drug screening
• possible consequences of failure to comply.
Before starting tapering, it needs to be clearly emphasised to the patient that reducing the dose of opioid
analgesia will not necessarily equate to increased pain and that it will, in effect, lead to improved mood
and functioning as well as a reduction in pain intensity. The prescriber should establish a therapeutic
alliance with the patient and develop a shared and specific goal.

PART A -For 1-7, decide which text (A, B, C or D) the information comes from.
1. What GPs should say to patients requesting codeine?
2. basic indications of an opioid problem?
3. different medications used for weaning patients off opioids?
4. decisions to make before beginning treatment of dependence?
5. defining features of a use disorder?
6. the development of a common goal for both prescriber and patient?
7. sources of further information on pain management?

Questions 8-14. Answer each of the questions, 8-14, with a word or short phrase from one of the texts.
8. What will reduced doses of opioids lead to a reduction of?
9. What is the most effective medication for tapering opioid dependence?
10. How long should over the counter codeine analgesics be used for?
11. When should doctors consider referring a patient to a pain expert or clinic?
12. What might a patient give permission to before starting treatment?
13. What might be increasingly neglected as a result of opioid use?
14. How many Buprenorphine patches are needed to taper from codeine tablets?

Questions 15-20
 The use of Buprenorphine-naxolone requires a (15)…….. before treatment.
 The use of symptomatic medications for the treatment of opioid dependence has been found to have (16)…….. than tramadol.
 Different definitions of opioid dependence share the same (17)………
 Once it is decided that opioid taper is a suitable treatment the doctor and patient should create a (18)………
 Recent research indicates that (19)…….. can work as well as combination analgesics including codeine and oxycodone.
 The ICD-10 defines a patient as dependent if they have (20)…….. key symptoms simultaneously.

PART B
1. The purpose of the memo about IV solution bags is to remind health practitioners
A. of the procedures to follow when using them.
B. of the hazards associated with faulty ones.
C. why they shouldn’t be reused.
Memo to staff – Intravenous solution bags: IV fluids are administered via a plastic IV solution bag which collapses on itself as it empties. When a bag is disconnected by removing the giving set spike, air can enter the bag. If it is then reconnected to an IV-line, air can potentially enter the patient’s vein and cause an air embolism. For this reason, partially used IV bags must never be re-spiked. All IV bags are designed for single use only – for use in one patient and on one occasion only. All registered large volume injections, including IV bags, are required to have this warning (or words to the same effect) clearly displayed on the labelling. In addition to the potential risk of introducing an air embolus, re-spiking can also result in contamination of the fluid, which may lead to infection and bacteraemia.

2. What do we learn about the use of TENS machines?
a. Evidence for their efficacy is unconfirmed.
b. They are recommended in certain circumstances.
c. More research is needed on their possible side effects
Update on TENS machines: The Association of Chartered Physiotherapists in Women’s Health has an expert panel which could not find any reports suggesting that negative effects are produced when TENS has been used during pregnancy. However, in clinical practice, TENS is not the first treatment of choice for women presenting with musculoskeletal pain during pregnancy. The initial treatment should be aimed at correcting any joint or muscle dysfunction, and a rehabilitation programme should be devised. However, if pain remains a significant factor, then TENS is preferable to the use of strong medication that could cross the placental barrier and affect the foetus. No negative effects have been reported following the use of this modality during any of the stages of pregnancy. Therefore, TENS is preferable for the relief of pain.

3. If surgical instruments have been used on a patient suspected of having prion disease, they
A. must be routinely destroyed as they cannot be reused.
B. may be used on other patients provided the condition has been ruled out.
C. should be decontaminated in a particular way before use with other patients.
Guidelines: Invasive clinical procedures in patients with suspected prion disease: It is essential that patients suspected of suffering from prion disease are identified prior to any surgical procedure. Failure to do so may result in exposure of individuals on whom any surgical equipment is subsequently used. Prions are inherently resistant to commonly used disinfectants and methods of sterilisation. This means that there is a possibility of transmission of prion disease to other patients, even after apparently effective methods of decontamination or sterilisation have been used. For this reason, it may be necessary to destroy instruments after use on such a patient, or to quarantine the instrument until the diagnosis is either confirmed, or an alternative diagnosis is established. In any case, the instruments can be used for the same patient on another occasion if necessary.

4. The email suggests that POCT devices
A. should only be used in certain locations.
B. must be checked regularly by trained staff.
C. can produce results that may be misinterpreted.
To: All Staff. Subject: Management of Point of Care Testing (POCT) Devices: Due to several recent incidents associated with POCT devices, staff are requested to read the following advice from the manufacturer of the devices. The risks associated with the use of POCT devices arise from Management of Point of Care Testing Devices Version 4 January 2014, the inherent characteristics of the devices themselves and from the interpretation of the results they provide. They can be prone to user errors arising from unfamiliarity with equipment more usually found in the laboratory. User training and competence is therefore crucial.

5. It’s permissible to locate a baby’s identification band somewhere other than the ankles when
a. the baby is being moved due to an emergency.
b. the bands may interfere with treatment.
c. the baby is in an incubator.
Identification bands for babies: The identification bands should be located on the baby’s ankles with correct identification details unless the baby is extremely premature and/or immediate vascular access is required.
If for any reason the bands need to be removed, they should be relocated to the wrists or if this is not possible, fixed visibly to the inside of the incubator. Any ill-fitting or missing labels should be replaced at first check. Identity bands must be applied to the baby’s ankles at the earliest opportunity as condition allows and definitely in the event of fire evacuation or transportation.

6. What is the memo doing?
a. providing an update on the success of new guidelines
b. reminding staff of the need to follow new guidelines
c. announcing the introduction of new guidelines
Memo: Administration of antibiotics: After a thorough analysis and review, our peri-operative services, in conjunction with the Departments of Surgery and Anaesthesia, decided to change the protocols for the administration of pre-operative antibiotics and established a series of best practice guidelines. This has resulted in a significant improvement in the number of patients receiving antibiotics within the recommended 60 minutes of their incision. A preliminary review of the total hip and knee replacements performed in May indicates that 88.9% of patients received their antibiotics on time.

PART C. TEXT 1: Detecting Carbon Monoxide Poisoning
Carbon Monoxide (CO) poisoning is the single most common source of poisoning injury treated in US hospital emergency departments. While its presentation is not uncommon, the diverse symptoms that manifest themselves do not lead most clinicians to consider carboxyhemoglobinemia when attempting a diagnosis. The symptoms can be mistaken for those of many other illnesses including food poisoning, influenza, migraine headache, or substance abuse.
What’s more, in an attempt to find the causative agent for the symptoms, many unnecessary, and sometimes resource-intensive, diagnostics may be ordered, to no avail. For example, because the symptoms of CO poisoning may mimic an intracranial bleed, the time needed to obtain a negative result may hold up a proper diagnosis as well as needlessly increasing healthcare costs. Of even greater concern, however, is that during such delays patients may find that their symptoms abate and their health improves as the hidden culprit, CO, is flushed from the blood during the normal ventilation patterns.
Indeed, multiple reports have shown patients being discharged and returned to the very environment where exposure to CO took place. Take the case of a 67-year-old man who sought medical help after three days of lightheadedness, vertigo, stabbing chest pain, cough, chills and headache. He was admitted, evaluated and discharged with a diagnosis of viral syndrome. Ten days later, he returned to the Emergency Department with vertigo, palpitations and nausea but was sent home for outpatient follow-up. Four days later, he presented again with diarrhea and severe chest pain, collapsing to the floor. This time, he was admitted to the Coronary Care Unit with acute myocardial infarction. Among the results of a routine arterial blood gas analysis there, it was found that his carboxyhemoglobin (COHb) levels were 15.6%. A COHb level then obtained on his wife was 18.1%. A rusted furnace was found to be the source.
There are two main types of CO poisoning: acute, which is caused by brief exposure to a high level of carbon monoxide, and chronic or subacute, which results from long exposure to a low level of CO. Patients with acute CO poisoning are more likely to present with more serious symptoms, such as cardiopulmonary problems, confusion, syncope, coma, and seizure. Chronic poisoning is generally associated with the less severe symptoms. Low-level exposure can exacerbate angina and chronic obstructive pulmonary disease, and patients with coronary artery disease are at risk for ischemia and myocardial infarction even at low levels of CO.
Patients that present with low COHb levels correlate well with mild symptoms of CO poisoning, as do cases that register levels of 50-70%, which are generally fatal. However, intermediate levels show little correlation with symptoms or with prognosis. One thing that is certain about COHb levels is that smokers present with higher levels than do non-smokers. The COHb level in non-smokers is approximately one to two percent. In patients who smoke, a baseline level of nearly five percent is considered normal, although it can be as high as 13 percent. Although COHb concentrations between 11 percent and 30 percent can produce symptoms, it is important to consider the patient’s smoking status.
Regardless of the method of detection used in emergency department care, several other variables make assessing the severity of the CO poisoning difficult. The length of time since CO exposure is one such factor. The half-life of CO is four to six hours when the patient is breathing room air, and 40-60 minutes when the patient is breathing 100 percent oxygen. If a patient is given oxygen during their transport to the emergency department, it will be difficult to know when the COHb level hit its highest point. In addition, COHb levels may not fully correlate with the clinical condition of CO-poisoned patients because the COHb level in the blood is not an absolute index of compromised oxygen delivery at the tissue level. Furthermore, levels may not match up to specific signs and symptoms: patients with moderate levels will not necessarily appear sicker than patients with lower levels.
In hospitals, the most common means of measuring CO exposure has traditionally been through the use of a laboratory CO-Oximeter. A blood sample, under a physician order, is drawn from either venous or arterial vessel and injected into the device. Using a method called spectrophotometric blood gas analysis, this then measures the invasive blood sample. Because the CO-Oximeter can only yield a single, discrete reading for each aliquot of blood sampled, the reported value is a non-continuous snapshot of the patient’s condition at the particular moment that the sample was collected. It does, however, represent a stepin the right direction. One study found that in hospitals lacking such a device, the average time it took to receive results of a blood sample sent to another facility was over fifteen hours, compared to a ten-minute turnaround in CO- Oximeter equipped hospitals.

1. In the first paragraph, what reason for the misdiagnosis of CO poisoning is highlighted?
A. the limited experience physicians have of it
B. the wide variety of symptoms associated with it
C. the relative infrequency with which it is presented
D. the way it is concealed by pre-existing conditions
2. In the second paragraph, the writer stresses the danger of delays in diagnosis leading to
A. the inefficient use of scarce resources.
B. certain symptoms being misinterpreted.
C. a deterioration in the patient’s condition.
D. the evidence of poisoning disappearing.
3. The 67-year-old man’s CO poisoning was only successfully diagnosed as a result of
A. attending an outpatient clinic.
B. his wife being similarly affected.
C. undergoing tests as an inpatient.
D. his suggesting the probable cause.
4. In the fourth paragraph, confusion is given as a symptom of
A. short-term exposure to high levels of CO.
B. repeated exposure to varying levels of CO.
C. a relatively low overall level of exposure to CO.
D. sustained exposure to CO over an extended period.
5. In the fifth paragraph, what point is made about COHb levels?
A. They fail to detect CO poisoning in habitual smokers.
B. They are a generally reliable indicator of CO poisoning.
C. They correlate very well with extreme levels of CO poisoning.
D. They are most useful in determining intermediate levels of CO poisoning.
6. The phrase ‘one such factor’ in the sixth paragraph refers to
A. a type of care.
B. a cause of difficulty.
C. a method of detection.
D. a way of making an assessment.
7. One result of administering oxygen to CO poisoned patients in transit is that
A. it becomes harder to ascertain when the COHb level peaked.
B. it may lead to changes in the type of symptoms observed.
C. it could artificially inflate the COHb level in the short term.
D. it affects the ability to assess the effects at tissue level.
8. What reservation about the CO-Oximeter does the writer express?
A. It does not always give an immediate result.
B. Its use needs to be approved by a physician.
C. It requires a skilled analyst to interpret the readings.
D. It does not show variations in the patient’s condition

PART C. Text 2: ADHD

The American Psychiatric Association (APA) recognised Attention Deficit Hyperactivity Disorder (ADHD) as a childhood disorder in the 1960s, but it wasn’t until 1978 that the condition was formally recognised as afflicting adults. In recent years, the USA has seen a 40% rise in diagnoses of ADHD in children. It could be that the disorder is becoming more prevalent, or, as seems more plausible, doctors are making the diagnosis more frequently. The issue is complicated by the lack of any recognised neurological markers for ADHD. The APA relies instead on a set of behavioural patterns for diagnosis. It specifi es that patients under 17 must display at least six symptoms of inattention and/or hyperactivity; adults need only display five.

ADHD can be a controversial condition. Dr Russell Barkley, Professor of Psychiatry at the University of Massachusetts insists; ‘the science is overwhelming: it’s a real disorder, which can be managed, in many cases, by using stimulant medication in combination with other treatments’. Dr Richard Saul, a behavioural neurologist with fi ve decades of experience, disagrees; ‘Many of us have difficulty with organization or details, a tendency to lose things, or to be forgetful or distracted. Under such subjective criteria, the entire population could potentially qualify. Although some patients might need stimulants to function well in daily life, the lumping together of many vague and subjective symptoms could be causing a national phenomenon of misdiagnosis and over-prescription of stimulants.’

A recent study found children in foster care three times more likely than others to be diagnosed with ADHD. Researchers also found that children with ADHD in foster care were more likely to have another disorder, such as depression or anxiety. This finding certainly reveals the need for medical and behavioural services for these children, but it could also prove the non-specific nature of the symptoms of ADHD: anxiety and depression, or an altered state, can easily be mistaken for manifestations of ADHD.

ADHD, the thinking goes, begins in childhood. In fact, in order to be diagnosed with it as an adult, a patient must demonstrate that they had traits of the condition in childhood. However, studies from the UK and Brazil, published in JAMA Psychiatry, are fuelling questions about the origins and trajectory of ADHD, suggesting not only that it can begin in adulthood, but that there may be two distinct syndromes: adult-onset ADHD and childhood ADHD. They echo earlier research from New Zealand. However, an editorial by Dr Stephen Faraone in JAMA Psychiatry highlights potential flaws in the findings. Among them, underestimating the persistence of ADHD into adulthood and overestimating the prevalence of adult-onset ADHD. In Dr Faraone’s words, ‘the researchers found a group of people who had sub-threshold ADHD in their youth. There may have been signs that things weren’t right, but not enough to go to a doctor. Perhaps these were smart kids with particularly supportive parents or teachers who helped them cope with attention problems. Such intellectual and social scaffolding would help in early life, but when the scaffolding is removed, full ADHD could develop’.

Until this century, adult ADHD was a seldom-diagnosed disorder. Nowadays however, it’s common in mainstream medicine in the USA, a paradigm shift apparently driven by two factors: reworked – many say less stringent – diagnostic criteria, introduced by the APA in 2013, and marketing by manufacturers of ADHD medications. Some have suggested that this new, broader defi nition of ADHD was fuelled, at least in part, to broaden the market for medication. In many instances, the evidence proffered to expand the defi nitions came from studies funded in whole or part by manufacturers. And as the criteria for the condition loosened, reports emerged about clinicians involved in diagnosing ADHD receiving money from drug-makers.

This brings us to the issue of the addictive nature of ADHD medication. As Dr Saul asserts, ‘addiction to stimulant medication isn’t rare; it’s common. Just observe the many patients periodically seeking an increased dosage as their powers of concentration diminish. This is because the body stops producing the appropriate levels of neurotransmitters that ADHD drugs replace − a trademark of addictive substances.’ Much has been written about the staggering increase in opioid overdoses and abuse of prescription painkillers in the USA, but the abuse of drugs used to treat ADHD is no less a threat. While opioids are more lethal than prescription stimulants, there are parallels between the opioid epidemic and the increase in problems tied to stimulants. In the former, users switch from prescription narcotics to heroin and illicit fentanyl. With ADHD drugs, patients are switching from legally prescribed stimulants to illicit ones such as methamphetamine and cocaine. The medication is particularly prone to abuse because people feel it improves their lives. These drugs are antidepressants, aid weight-loss and improve confidence, and can be abused by students seeking to improve their focus or academic performance. So, more work needs to be done before we can settle the questions surrounding the diagnosis and treatment of ADHD.

Text 2: Questions 9-16

9. In the first paragraph, the writer questions whether
A. adult ADHD should have been recognised as a disorder at an earlier date.
B. ADHD should be diagnosed in the same way for children and adults.
C. ADHD can actually be indicated by neurological markers.
D. cases of ADHD have genuinely increased in the USA.
10. What does Dr Saul object to?
A. the suggestion that people need stimulants to cope with everyday life
B. the implication that everyone has some symptoms of ADHD
C. the grouping of imprecise symptoms into a mental disorder
D. the treatment for ADHD suggested by Dr Barkley
11. The writer regards the study of children in foster care as significant because it
A. highlights the difficulty of distinguishing ADHD from other conditions.
B. focuses on children known to have complex mental disorders.
C. suggests a link between ADHD and a child’s upbringing.
D. draws attention to the poor care given to such children.
12. In the fourth paragraph, the word ‘They’ refers to
A. syndromes.
B. questions.
C. studies.
D. origins.
13. Dr Faraone suggests that the group of patients diagnosed with adult-onset ADHD
A. had teachers or parents who recognised the symptoms of ADHD.
B. should have consulted a doctor at a younger age.
C. had mild undiagnosed ADHD in childhood.
D. were specially chosen by the researchers.
14. In the fifth paragraph, it is suggested that drug companies have
A. been overly aggressive in their marketing of ADHD medication.
B. influenced research that led to the reworking of ADHD diagnostic criteria.
C. attempted to change the rules about incentives for doctors who diagnose ADHD.
D. encouraged the APA to rush through changes to the criteria for diagnosing ADHD.
15. In the final paragraph, the word ‘trademark’ refers to
A. a physiological reaction.
B. a substitute medication.
C. a need for research.
D. a common request.
16. In the final paragraph, what does the writer imply about addiction to ADHD medication?
A. It is unlikely to turn into a problem on the scale of that caused by opioid abuse.
B. The effects are more marked in certain sectors of the population.
C. Insufficient attention seems to have been paid to it.
D. The reasons for it are not yet fully understood.

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