Pain/Tx/Abuse Drugs

Which statement is most accurate? A. Anyone taking drugs, either oral or IV, that was made by a high school dropout in a motor home parked in the woods, is exposing himself or herself to serious and permanent harm B. Cocaine purchased on the street does not result in cardiovascular events C. Manufacturers of illicit drugs such as methamphetamine always follow FDA approved "good manufacturing" procedures D. Methylenedioxymethamphetamine (MDMA) is non-toxic E. The purity and source of illicit drugs is always very consistent due to the integrity and reliability of the manufacturers

A. Serious neuro-toxicity can be produced by administrations of chemicals of unknown origin

Acute ethanol consumption A. Increases GABA mediated ion conductance B. Increases NMDA mediated ion conductance C. Increases smooth muscle tone D. Increases vasopressin secretion E. Reduces esophageal reflux

A. Acute ethanol will increase GABA (inhibitory) and decrease NMDA (excitatory) mediated neuronal conductance.

Ethanol is metabolized into acetaldehyde by which enzyme A. Alcohol dehydrogenase B. Aldehyde dehydrogenase C. Monoamine oxidase D. Tyrosine Hydroxylase E. Glutathione Transferase

A. Alcohol dehydrogenase

A 47-year-old woman presents to you with fibromyalgia. Which of the following medications might be most useful in treating this type of chronic pain state? A. Amitriptyline B. Codeine C. Haloperidol D. Lidocaine E. Morphine

A. Amitriptyline Tricyclic antidepressants have shown some effectiveness in the treatment of chronic pain states. Morphine could be used to reduce symptoms but is less desirable due to addiction potential and effects on cognition.

Liver toxicity produced by chronic ethanol consumption is promoted by which process listed below? A. An increase in the ratio of NADH to NAD+ B. An decrease in triglyceride synthesis from free fatty acids C. An increase in serum glucose D. Metabolic alkalosis E. Inhibition of fibroblast function

A. An increase in the metabolic cofactor NAD (nicotine adenine dinucleotide). Both the enzymes in alcohol metabolism, alcohol dehydrogenase and aldehyde dehydrogenase require NAD+. Because gram quantities of ethanol are metabolized and the metabolism requires NAD+ accept an hydrogen ion from either ethanol or acetaldehyde to oxidize these compounds the oxidative/reduction potential of the liver is altered. Over time the excess NADH appears to contribute to a cascade of metabolic events that leads to fatty liver disease, cirrhosis and liver failure.

A 26-year-old male with a 2-pack per day cigarette habit wants to quit smoking but is having trouble. He is prescribed a drug that may decrease the desire to smoke. Which drug was used? A. Bupropion B. Cocaine C. Diazepam D. Naloxone E. Stanozolol

A. Bupropion

A 65-year-old woman has episodes of sudden, repeated, lightning bursts of pain involving the upper part of the left side of his face. The pain is excruciating, with each burst lasting a few seconds. These symptoms are consistent with trigeminal neuralgia. Which of the following is the treatment of choice for this disorder? A. Carbamazepine B. Ibuprofen C. Lidocaine D. Morphine E. Phenobarbital

A. Carbamazepine is the most common drug used to reduce pain associated with trigeminal neuralgia.

A 25-year-old man has been abusing amphetamine for several months. He as received his supply of amphetamine from the same individual. On a recent business trip he travels out of town and buys a supply of amphetamine from a new dealer. After taking the first dose of amphetamine from this new dealer he loses consciousness and dies. His death is most likely the result of A. Cardiac arrest B. CNS depression C. Hypovolemic shock D. Kidney failure E. Liver failure

A. Cardiac arrest Amphetamine increases the extrasynaptic release of catecholamines. In the periphery the release of norepinephrine can lead to serious cardiovascular complications like stroke and arrhythmias. In the CNS the release of dopamine in the nucleus accumbens is likely to underlie its abuse potential.

A 53-year-old male requires a short surgical procedure to remove a metal plate from his ankle from a previous injury. His anesthesiologist decides to use infiltration anesthesia with bupivacaine. What is a significant toxicity associated with large doses of this drug? A. Cardiovascular collapse. B. Vasoconstriction/local ischemia C. Tachycardia D. Psychosis E. Methemoglobenimia

A. Cardiovascular collapse. Bupivicaine is a long-duration anesthetic that is associated with cardiovascular issues.

A 53-year-old male requires a short surgical procedure to remove a metal plate from his ankle from a previous injury. His anesthesiologist decides to use infiltration anesthesia with lidocaine. What is a significant toxicity associated with large doses of this drug? A. Central nervous system excitation. B. Vasoconstriction/local ischemia C. Tachycardia D. Psychosis E. Methemoglobenimia

A. Central nervous system excitation. High doses of lidocaine are associated with inhibition of inhibitory cortical neurons which can reduce seizure threshold.

A 26-year-old woman, with a history of continual heroin use, is brought to the emergency room. She is agitated, yawning, is nauseous, has muscle aches and is sweating profusely. Her last dose of heroin was 12 hours ago. What is the most appropriate non-addicting treatment for this patient's symptoms? A. Clonidine B. Diazepam C. Methadone D. Naloxone E. Phenobarbital

A. Clonidine This patient is suffering from opioid withdrawal. This withdrawal state was produced by chronic exposure to heroin resulting in neuronal compensatory adaptions so the brain can function at a more normal set point. Besides decreases in opioid receptor function, one of the adaptive mechanisms is to increase catecholaminergic activity in the brain. When a user stops taking heroin the elevated and now un-abated catecholaminergic activity can causes symptoms of agitation, yawning, sweating, etc. These symptoms can be partially alleviated by reducing release of norepinephrine with clonidine. Clonidine is a alph-2 adrenergic receptor agonist. Alpha-2 receptors are located on the presynaptic neuron and when activated decreases the influx of calcium and the subsequent release of neurotransmitters.

A 35-year-old women is undergoing surgical procedure to remove her gall-bladder. She is given an inhaled anesthetic and the muscle relaxant succinylcholine. Shortly after administration of these drugs she becomes hypertensive, acidotic, and hyperthermic. She should be administered which of the following drugs to treat her malignant hyperthermia? A. Dantrolene B. Diazepam C. Etomidate D. Halothane E. Phenobarbital

A. Dantrolene In a small population of people who have a genetic mutation in calcium transporters in the sarcoplasmic reticulum they can exhibit symptoms of malignant hyperthermia when exposed to inhaled anesthetics or succinylcholine. The treatment among other things is to administer dantrolene, which blocks the ryanodine calcium channels in the SR--preventing excess intracellular calcium in muscle

Which drug listed below should have the most rapid onset and recovery? Anesthetic Blood Gas partition coefficient : 1 MAC (% gas) A Desflurane 0.42 : 7 B Sevoflurane 0.69 : 2 C Isoflurane 1.4 : 1.40 D Halothane 2.3 : 0.7597

A. Desflurane The lease water soluble drug will fill the "blood compartment" the fastest and pass to the brain at the quickest rate. This concept centers on the amount of free gas available to pass into the brain.

A 22-year-old college student applies a cream containing lidocaine to her legs prior to driving a laser-hair-removal salon. Unfortunately she does not make it to the salon. She is found in her car by paramedics and presents with episodes of myoclonic jerking. She is transported to the emergency department and presents with consistent tonic-clonic seizures. Which of the following drugs if given promptly could stop this woman's seizures and prevent permanent neurotoxicity? A. Diazepam B. Flumazenil C. Physostigmine D. Propranolol E. Valproic Acid

A. Diazepam. What? Huh? Why this question. All emergent seizure activity (drug-induced or not) is treated first with a benzodiazepine. Fair game for any discussion of all drugs that reduce seizure threshold. TTherapeutic Drug Monitoring Issue: Volume 22(3), June 2000, pp 320-322 MECHANISMS OF EPILEPTOGENICITY Lidocaine is metabolized by the microsomal enzyme system in the liver (16), and less than 10% of lidocaine is excreted unchanged in urine (17). Lidocaine is converted by oxidative N-de-ethylation to monoethylglycinexilidide (MEGX), part of which is then hydrolyzed to 2,6-glycine xylidide (GX) (18). The resulting MEGX and, to a lesser extent GX, can lower seizure threshold (19,20) and potentiate lidocaine-induced seizures. Lidocaine is eliminated in a biphasic mode with an early rapid fall in concentration followed by a later slower decrease in plasma concentration. The average half-life of the drug ranges from 8-17 minutes for the early rapid fall and from 87-108 minutes for the slow phase (16). The fast phase corresponds to the clearance from the intravascular space, the second phase corresponds to the equilibration in the peripheral compartment. The mechanisms mediating the proconvulsant properties of lidocaine are only incompletely understood, and almost nothing is known about the proconvulsant effects of MEGX and GX. At serum levels below 5 µg/mL, lidocaine abolishes cortically induced facilitation of motoneurons (11), and this may account for its anticonvulsant properties. At higher levels, lidocaine produces a selective blockade of inhibitory cortical synapses and neurons (15,21). Lidocaine inhibits the inhibitory action of cerebellar neurons on vestibular nuclei (22) and reduces the inhibitory effect of darkness on the excitation of visual cortex induced by stimulation of the optic nerve (23). Intravenous administration of supratherapeutic doses of lidocaine inhibits L-glutamate-induced transcallosal inhibition of contralateral neurons in cats (24). The inhibition of inhibitory pathways does not seem to involve a direct effect of lidocaine on GABA or its receptor sites (24). High levels of lidocaine seem to release excitatory activity and ultimately lead to convulsions. Lidocaine-induced seizures differ from seizures induced by other proconvulsants such as pentylenetratazol, which are inhibited by increased serotoninergic drugs (25,26). Pretreatment with 5-hydroxytriptophan in cats increases the susceptibility to lidocaine-induced seizures (26). Moreover, the duration of lidocaine-induced seizures, which normally lasts a few seconds to 1-2 minutes, was significantly increased, status epilepticus developing in two of seven animals (26). The role played by lidocaine versus its metabolites in the causation of seizures in individual patients is not always clear. Circumstantial evidence suggests that the rapid metabolism of lidocaine and the potentiating effects of MEGX and GX on seizures is clinically relevant for some patients (9,15,19,27). Patients with lidocaine-induced central nervous system toxicity usually have levels of lidocaine greater than 5 µg/mL and low levels of its metabolites (27). Conversely, there are individuals with signs and symptoms of toxicity, especially with extended infusions of lidocaine, who have low lidocaine levels but very high levels of MEGX (27).

With regard to schedule (levels) of controlled substances, which statement is most accurate? A. Drugs are scheduled (1-5) based on a political assessment of their abuse potential B. Drugs are scheduled (1-5) based on their therapeutic usefulness C. Licensed physicians can write an unlimited refill prescription for anabolic steroids D. Schedule 2 drugs are usually available "over the counter" E. Schedule 2 drugs (strong opioid agonist and stimulants like methamphetamine) can be ordered by a licensed physician by phone

A. Drugs are scheduled (1-5) based on a political assessment of their abuse potential

CNS acting drugs, which can decrease seizure activity, cause hypnosis, sedation and general anesthesia, most likely produce their desired effects by increasing the activity of what type of neurons? A. GABA (gamma-amino-butyric-acid) neurons B. Glutaminergic neurons C. Histaminergic neurons D. Noradrenergic neurons E. Serotonergic neurons

A. GABA (gamma-amino-butyric-acid) neurons

A 26-year-old man is brought to the emergency department after using cocaine for the first time. He is delirious, combative, sweating profusely, thrashing wildly, and screaming threats while being restrained. His blood pressure is 210/115 mm Hg, and his heart rate is 110 BPM. Which of the following is most appropriate for sedating the above patient prior to treating his symptoms? A. Lorazepam B. Flumazenil C. Ethanol D. Naloxone E. Phenobarbitol

A. Lorazepam

Which of the following drugs is a full agonist at opioid receptors, has excellent oral bioavailability, analgesic activity equivalent to that of morphine, and a longer duration of action, and milder withdrawal signs on abrupt discontinuance than morphine? A. Fentanyl B. Hydromorphone C. Methadone D. Nalbuphine

A. Methadone. Methadone has less first pass effect as compared to the other strong-mu agonist. Nalbuphine is a kappa agonist but a mu antagonist. Methadone also has a long half life.

A 63-year-old man, diagnosed with prostatic carcinoma is undergoing radiation treatment as an outpatient because the tumor has metastasized to the bone. He has pain in his right hip and backache when he moves about. The pain has been managed with a fixed combination of oxycodone and acetaminophen taken orally. Despite increasing doses of the analgesic combination, the pain is getting worse. If you decide to continue oral medication for the increasing pain, the best choice for this patient would be: A. Pentazocine B. Morphine C. Buprenorphine D. Propoxyphene E. Codeine plus aspirin

A. Morphine Yes, morphine. It has a high first pass effect so more will be needed as compared to IV. Pentazocine and Buprenorphine are mixed agonist-antoagonist and may produce withdrawal symptoms. Codeine has weak analgesic efficacy as compared to morphine. Propoxyphene has extremely low analgesic efficacy as compared to morphine.

Which statement regarding illicit drug use is most correct? A. Serious neurotoxicity may result from drugs manufactured in someone's garage B. MDMA has no serious long-term effects C. The integrity of an illicit drug salesman or manufacturer can always be trusted D. Illicit drugs manufacturers follow Good Manufacturing Practices E. Drugs manufactured in a motor home are always pure

A. Serious neurotoxicity may result from drugs manufactured in someone's garage. Remember the MPTP story: http://www.cdc.gov/mmwr/preview/mmwrhtml/00000360.htm

Minimum Alveolar Concentration (MAC) A. is an estimation of inhaled anesthetic potency B. of 1 for an inhaled anesthetic will produce general anesthesia in 99% of patients C. of 1 requires more inhaled methoxyflurane as compared nitrous oxide D. represents the blood solubility of an inhaled anesthetic E. represents the speed of onset of inhaled anesthetics

A. is an estimation of inhaled anesthetic potency

A 50-year-old man has consumed 0.5-1 pint of whisky per day for the last 6 years. Which statement is true regarding this patient? A. Adequate nutrition should protect against liver cirrhosis B. Following detoxification, disulfiram could be used to increase the aversive effects of ethanol consumption C. Vitamin A use decreases symptoms of Wernicke-Korsakoff syndrome D. Naltrexone could be used to initially detoxify this patient E. Chronic ethanol consumption is associated with decreased activity of microsomal ethanol-oxidizing system activity

B. Disulfiram inhibits acetaldehyde dehydrogenase, which leads to the accumulation of acetaldehyde. This compound produces flushing, nausea and vomiting. In theory, a person who relapses and drinks would get sick and thus prevent them from the temptation of drinking again. Wernicke-Korsakoff is treated with vitamin B1 (thiamine). Naltrexone is a opioid antagonist used to decrease the desire to drink.

A 26-year-old man is brought to the emergency department in a delirious, combative state after smoking "freebase" cocaine. He is sweating profusely, has elevated heart rate and blood pressure. Cocaine produces these effects by which mechanism listed below? A. Blockade of acetylcholine uptake into neurons B. Blockade of catecholamine neurotransmitter uptake into neurons C. Blockade of serotonergic neurotransmitter uptake into neurons D. Inhibition of monoamine oxidase E. Inhibition of GABA receptor activation

B. Blockade of catecholamine neurotransmitter uptake into neurons

A 26-year-old male dies of a fatal arrhythmia while playing basketball after taking a drug that blocks catecholamine uptake into neurons. A. Bupropion B. Cocaine C. Diazepam D. Naloxone E. Stanozolol

B. Cocaine Cocaine in the periphery blocks the reuptake of norepinephrine and can lead to increased sympathomimetic effects on the heart and vasculature including stroke and arrhythmias. In the CNS, it blocks the reuptake of dopamine in areas like the nucleus accumbens that is the most likely explanation for its high addiction potential.

After recovery from chronic alcohol abuse a patient is placed on a mandatory course of a drug that inhibits aldehyde dehydrogenase in the hopes that when she does drink again she will experience excessive vomiting, nausea and headache, which theoretically should prevent her from drinking too much. Which drug was she placed on? A. Acamprosate B. Disulfiram C. Fomepizole D. Naltrexone E. Thiamine

B. Disulfiram This is a drug that inhibits aldehyde dehydrogenase. When patient drink the acetaldehyde builds up producing unwanted affects by the patient.

Which of the following best describes endogenous opioids? a. Endogenous opioids are small molecules produced inside small clear synaptic vesicles B. Endogenous opioids are released in response to stress and pain. C. Endogenous opioids are found only in the CNS D. Endogenous opioids activate inhibitory GABA-a chloride channels E. Endogenous opioids bind to receptors that produce membrane depolarization.

B. Endogenous opioids are released in response to stress and pain. Opioid-Analgesics work because they mimic signaling neuropeptides released from endogenous pain-modulatory-pathways. These opioid-peptides are: 1) Enkephalins 2) Endorphins and 3) Dynorphins. Opioid peptide neurotransmission starts when neurons synthesize large precursor peptides that are subsequently cleaved by tissue-specific-endopeptidases into small peptide neurotransmitters that are packaged into large dense core vesicles and released along with the classic small translucent vesicles upon depolarization of the presynaptic neuron. For example, prepro-opiomelanocortin (POMC) is cleaved into the active signaling peptides: met-enkephalin, b-endorphin, adrenocorticotropic hormone (ACTH), b-lipoprotein, and melanocyte stimulating hormone (MSH). The relative cleavage pattern depends on the tissue. Prepropenkaphalin is cleaved into several copies met-enkephalin and leu-enkephalin. Preprodynorphin is cleaved into dynorphin A and B, neoendorphins (a and b).

A 21-year-old college student has his first drink of alcohol (ethanol) and is now experiencing nausea, facial flushing, dizziness and a headache. He is most likely having these symptoms due to a build up of acetaldehyde caused by a deficiency in which enzyme listed below? A. Alcohol dehydrogenase B. Aldehyde dehydrogenase C. CYP 2E1 D. CYP 3A4 E. Thiokinase

B. Ethanol is metabolized by alcohol dehydrogenase to acetaldehyde. Acetaldehyde in turn is metabolized by acetaldehyde dehydrogenase into the product acetate. Loss or inhibition of the second enzyme in the metabolism of ethanol (acetaldehyde dehydrogenase) leads to the build up of acetaldehyde, which produces the symptoms described.

Use the table to answer the following question. Blood Gas partition coefficient (BGPC) %=(% inspired gas to produce MAC of 1) Desflurane BGPC (0.42), % (7) Sevoflurane BGPC (0.69), % (2) Isoflurane BGPC (1.4), %(1.4) Halothane BGPC (2.3), %(.75) Which statement is correct? A. Desflurane is the most potent drug listed B. Halothane is the most potent drug listed C. Halothane has the fastest onset of action D. Isoflurane is more efficacious as compared to sevoflurane E. Sevoflurane is more potent than isoflurane

B. Halothane is the most potent drug listed. This question centered on rate of onset vs. potency. For inhaled anesthetics potency relates to lipid solubility (refer to Meyer-Overton hypothesis). The term MAC or minimum alveolar concentration is a term the represents potency. It is a similar concept to ED50 for a quantal dose response curve. It represents the concentration of inspired anesthetic that will produce general anesthesia in 50% of the patients who inspire the concentration given. For inhaled anesthetics the potency relates to lipid solubility. All inhaled anesthetics (except for nitrous oxide) have similar efficacy. Onset of action depends on solubility in blood (or water) or blood gas partition coefficient. Drugs that are more soluble in the blood take longer to saturate this compartment and therefore have a slower rate of onset.

A 43-year-old male, is injured in an auto accident, brought to the emergency room, and is now experiencing intense pain. During a brief history the patient reveals that he is currently taking a monoamine oxidase inhibitor to treat his depression. Which of the following medications would you most likely administer to this patient to treat his pain? A. Meperidine B. Hydromorphone C. Diphenoxylate D. Ibuprofen E. Codeine

B. Hydromorphone Intense pain indicates the use of an opioid with high analgesic efficacy. The Choices are meperidine and hydromorphone. Meperidine is also associated with effects on serotonin uptake and should be avoided in this patient.

A 25-year-old male patient with a dental abscess from a serious bacterial infection needs to have the area anesthetized with lidocaine to allow debridement of the infected tissue. However, lidocaine injection by the dentist fails to produce local anesthesia. Lidocaine is a weak base and infected tissue with high metabolic activity tends to have a lower pH than normal tissue. Which answer below is the most likely explanation of the loss of effect in this patient? A. Lidocaine effectiveness requires epinephrine to reduce systemic spread B. Lidocaine's lipid solubility is reduced in infected tissue C. Lidocaine is more rapidly metabolized in the myofascial tissue D. Lidocaine only inhibits large type A motor neurons E. Lidocaine's water solubility is reduced in infected tissue

B. Lidocaine is a weak base. Weak bases become charged under acidic conditions (review HH equation again). Lidocaine must pass through the lipid membrane to block the open sodium channels from the inside. Bacterial metabolic activity produces hydrogen ions that protonate lidocaine and prevent permeability across lipid membranes.

What is the most plausible explanation for the ability of local anesthetics to preferentially stop conduction in neurons with high firing frequency? A. Local anesthetics can enter the cytoplasm more readily in these neurons B. Local anesthetics bind preferentially to open and inactivated Na+ channels C. High firing frequency neurons are located in the center of axon bundles D. High firing frequency neurons are usually myelinated E. High firing frequency neurons are usually larger in diameter

B. Local anesthetics bind preferentially to open and inactivated Na+ channels

A 47-year-old alcoholic has undergone repeated stays at various drug-detoxification centers. He currently is not addicted to any other drug types. His doctor now prescribes an opioid-receptor-antagonist to reduce his psychological dependence of ethanol and reduce incidence of relapse. Which drug was used? A. Fomepizole B. Naltrexone C. Methadone D. Phenobarbital E. Thiamine

B. Naltrexone, is a relatively long-acting opioid (Mu) receptor antagonist useful in some people to reduce the desire to drink.

A 46-year-old male is transported to the ER after having a bad mountain-bike accident. He is suffering from head injury trauma and has symptoms of elevated intracranial pressure. His cerebrovascular injury will have to be addressed surgically. Which drug would be most likely use for induction or maintenance of general anesthesia in this patient? A. Halothane B. Propofol C. Midazolam D. Sevoflurane E. Ketamine

B. Propofol

The general anesthetic, thiopental, has a short duration of action (minutes) because A. flumazenil is used to reverse its action B. it redistributes from the brain to other tissue C. it is rapidly metabolized by enzymes in the liver D. it is rapidly released via exhalation E. tolerance develops in minutes

B. Thiopental is a lipid soluble barbiturate that passes rapidly into the highly vascularized brain. After this first pass through the brain the lipid soluble drug passes into other lipids rich tissue (muscle, fat, organ tissue). This redistribution out of the brain reduces the amount in brain and terminates the CNS effects.

In regard to the schedules (levels) of controlled substances, which statement regarding Schedule five drugs is most accurate? A. Generally, schedule five drugs have abuse but not addiction potential B. This group has the lowest potential for abuse and addiction of the scheduled substances. C. This group has the highest level of abuse and addiction potential. D. This group is for experimental purposes only

B. This group has the lowest potential for abuse and addiction of the scheduled substances.

The minimum alveolar concentration (MAC) of an inhaled anesthetic represents the concentration of inhaled drug that produces general anesthesia in A. 10% of the population B. 25% of the population C. 50% of the population D. 75% of the population E. 100% of the population

C. 50% of the population. This is the definition of MAC

Which statement is true? A. Alcohol dehydrogenase is specific for the metabolism of ethanol B. Ethanol is metabolized mostly in the gut C. Ethanol is metabolized at a constant amount per hour D. Metabolites of ethanol are inert E. The metabolic rate of ethanol increases with increased ethanol serum levels

C. After saturation a constant amount of ethanol is metabolized per hour. This is the definition of zero order kinetics. Aspirin, phenytoin, and ethanol are the more common drugs that under go zero order kinetics. In the case of ethanol the rate limiting co-factor NAD+ is used up rapidly. This cofactor is necessary to accept proton from both ethanol and acetaldehyde during their conversion to products.

A 26-year-old man is brought to the emergency department after using cocaine for the first time. He is delirious, combative, sweating profusely, thrashing wildly, and screaming threats while being restrained. His blood pressure is 210/115 mm Hg, and his heart rate is 110 BPM. Many of these cocaine-induced symptoms are produced by cocaine A. Acting as a false neurotransmitter in noradrenergic nerves B. Blocking the release of norepinephrine from sympathetic nerve terminals C. Blocking the reuptake of norepinephrine into sympathetic nerve terminals D. Blocking the uptake of norepinephrine into storage vesicles E. Inhibiting tyrosine hydroxylase thus blocking the synthesis of catecholamines

C. Blocking the reuptake of norepinephrine into sympathetic nerve terminals

A 26-year-old male is brought to the emergency room after digesting a small peace (tab) of paper while at a party a few hours earlier. He now presents with organized visual and auditory distortion of perspective, is thrashing wildly, and is screaming threats while being restrained. This patient would most likely be sedated with A. Bupropion B. Cocaine C. Diazepam D. Naloxone E. Stanozolol

C. Diazepam This patient has probably ingested a hallucinogen, like LSD, and is having a "bad trip". Sedatives like benzodiazepines can be used to calm patient.

Which of the following medication is used (except when injecting into distal appendages like, fingers, toes, nose, ears, and the penis) to reduce the systemic toxicity and increase the duration of action of lidocaine? A. Acetylcholine B. Clonidine C. Epinephrine D. Morphine E. Succinylcholine

C. Epinephrine

A 45-year-old auto mechanic, residing in Rivertucky, CA, drinks a glass of ethylene glycol that was temporarily stored in a Gatorade bottle by his co-worker. He is taken to the hospital where intravenous sodium bicarbonate and supportive therapy is given. Which additional drug should be administered to this patient? A. Acamprosate B. Disulfiram C. Fomepizole D. Naltrexone E. Thiamine

C. Fomepizole Ethylene glycol is metabolized by alcohol dehydrogenase into oxalic acid, which forms crystals in the renal tubules resulting in loss of renal function. To prevent the formation of these crystals alcohol dehydrogenase is inhibited with fomepizole.

A 54-year-old male diabetic patient is complaining of an unusual burning and tingling pain that is triggered by light touch. His physician determines that this patient's advanced diabetes is causing nerve damage, which in turn is causing his neuropathic pain. Which medication listed below is useful in treating this type of pain? A. Aspirin B. Atracurium C. Gabapentin D. Phenobarbital E. Succinylcholine

C. Gabapentin

Which of the following is true regarding the inhaled anesthetic? A. They can increases mean arterial pressure B. They can decrease cerebral blood flow C. Hyperventilation increases rate of onset D. Hyperventilation reduces rate of recovery E. Increasing pulmonary blood flow increases onset of action

C. Inhaled anesthetics are systemic drugs applied through the lungs. The lungs function as the "application device" Therefore, increasing the ventilatory rate allows for more drug to be presented to the blood "compartment". The same concept applies to removing the drug--the faster the ventilatory rate the faster the onset and offset. Increasing pulmonary blood flow dilutes the amount of anesthetic presented to the blood "compartment" by increasing the volume of blood.

A 25-year-old combative patient is preventing intubation prior to surgery and is administered an intravenous anesthetic. After administration of this agent the patient is disoriented and is having visual and auditory hallucinations. Which drug was used? A. Dantrolene B. Etomidate C. Ketamine D. Nitrous Oxide E. Thiopental

C. Ketamine Ketamine is a dissociative anesthetic that works by inhibiting NMDA receptors. It therefore, has less medullary effects and can produce hallucinations once the patient is awake

Why is methadone used as a replacement therapy for heroin detoxification? A. Methadone is an opioid antagonist B. Methadone is less addicting C. Methadone is a longer-acting drug with shallower CNS effects D. Methadone is not associated with respiratory depression E. Methadone is a partial opioid agonist

C. Methadone is a longer-acting drug with shallower CNS effects Methadone like heroin is a "strong" mu-opioid receptor agonist. It therefore, will have very similar effects for pain and analgesia as heroin. It also can produce addiction. The principle difference is in its kinetic profile. Because it has a relatively long half life its effects can "self-taper". Consequently, the peak high's and lows are not as realized as with heroin. It also keeps the patient from seeking drugs illegally. Note: this type of therapy is controversial.

Which opioid receptor is correctly matched with its function? Receptor: Function A. Mu: Diarrhea B. Mu: Dysphoria C. Mu: Sedation D. Kappa: Respiratory depression E. Kappa: Psychological dependence

C. Mu: Sedation

24-year-old man was climbing on the cliffs at Fort Funston. The man fell from the cliffs and dislocated his hip, which resulted in a great amount of pain. He will need emergency surgery but is extremely agitated and uncooperative. The patient was given an I.M. ketamine prior to surgery. Which toxicity listed below is associated with ketamine upon recovery from anesthesia? A. Cardiovascular depression B. Hepatotoxicity C. Perceptual illusions D. Malignant Hyperthermia E. Nephrotoxicity

C. Perceptual illusions

Choose the best statement from those below: A. Schedule 1drugs are most commonly prescribed by physicians B. Schedule 4 and 5 drugs require a triplicate prescription in California C. Schedule 5 drugs have a very low abuse or addiction potential

C. Schedule 5 drugs have a very low abuse or addiction potential

Cocaine, heroine, ethanol, chocolate, and sex can all produce a similar effect on central "reward" neural pathways. Which of the following best describes this similar effect? A. They all are central nervous system depressants B. They all are central nervous system stimulants C. They all can stimulate dopamine release at the nucleus accumbens D. The all can stimulate dopamine release in the prefrontal cortex E. They all can stimulate serotonin release at the nucleus accumbens

C. They all can stimulate dopamine release at the nucleus accumbens

The political theory of "gateway drugs" is based on the concept that drugs that produce psychological dependence such as cocaine, heroine, and ethanol all produce a similar effect on central "reward" neural pathways. Which of the following best describes this similar effect? A. They all activate nicotinic acetylcholine receptors B. They all can stimulate dopamine release at the nucleus accumbens C. They all can stimulate serotonin release at the nucleus accumbens D. The all can stimulate dopamine release in the prefrontal cortex E. They all can stimulate opioid interneurons in the ventral tegmental area

C. They all can stimulate dopamine release at the nucleus accumbens

A middle-aged homeless man is brought to the ER. He states he drank a large amount of a clear liquid his friend gave him. He is combative, complains of flickering white spots before his eyes and he has the odor of formaldehyde on his breadth. This patient should be treated with which of the following? A. Acamprosate B. Disulfiram C. Ethanol D. Flumazenil E. Naltrexone

C. This patient has symptoms of methanol poisoning. Saturating alcohol dehydrogenase with ethanol will prevent the conversion of methanol to formaldehyde. This question represents a clinical scenario in which Zero order (saturable) kinetics is used clinically to achieve a therapeutic endpoint.

Use the following bulleted items to determine which statement (A-E) is most correct. * For enflurane a MAC value of one is achieved when 1.7% of inspired alveolar-gas-air mixture is enflurane. * For sevoflurane a MAC value of one is achieved when 2% of inspired alveolar-gas-air mixture is sevoflurane. A. Enflurane will saturate the blood at a faster rate than sevoflurane B. Enflurane is more efficacious as compared to sevoflurane C. Enflurane at 1 MAC will produce complete analgesia in 50/100 patients D. Sevoflurane is more potent than enflurane E. Sevoflurane is most likely more lipid-soluble as compared to enflurane

C. by definition

Use the following table to answer the following two questions. Anesthetic Blood Gas partition coefficient : 1 MAC (% gas) A Desflurane 0.42 : 7 B Sevoflurane 0.69 : 2 C Isoflurane 1.4 : 1.40 D Halothane 2.3 : 0.7597 Which statement is correct? A. Desflurane is the most potent drug listed B. Isoflurane is more efficacious as compared to sevoflurane C. Sevoflurane at 1 MAC will produce complete analgesia in 50/100 patients D. Sevoflurane is more potent than isoflurane E. MAC are the same for the young and the elderly

C. by definition 1 MAC is the concentration of inspired gas that produces loss of movement to a surgical incision in 50% of the patient population

A 32-year-old woman prior to surgery is injected close to her intercostals nerve with a mixture of lidocaine and epinephrine at a ratio of 100,000:1, respectively. Epinephrine is used in a mixture with lidocaine in this situation to: A. Facilitate the ability of lidocaine to cross the lipid bilayer B. Stimulate local wound repair C. Retard the systemic absorption of lidocaine D. Increase the metabolism of lidocaine E. To make the solution of lidocaine more basic

C. epinephrine has two useful characteristics. 1--activation of alpha-1 receptors on the smooth muscle of blood vessels produces vasoconstriction and the subsequent reduction in systemic absorption and metabolism of lidocaine. 2--alpha-2 adrenergic receptors when activated on pre-synaptic nociceptive neurons reduces release of excitatory neurotransmission to the brain.

A 44-year-old patient requires local anesthesia before surgery. Bupivacaine is repeatedly injected into the intercostal area. After these injections the patient loses normal sinus rhythm and now presents with complete AV nodal block. Adding what drug along with bupivacaine prior to injection could have reduced this toxicity? A. Diazepam B. Diltiazem C. Epinephrine D. Lidocaine E. Propranolol

C. epinephrine. Bupivicaine is associated with cardiotoxicity. A mechanism to reduce systemic absorption of bupivicaine is to constrict the blood vessels to decrease blood flow to areas injected.

The principal explanation for the higher sensitivity of small-C-sympathetic-afferents neurons to lidocaine nerve block compared to A-α motor neurons is that A. Small-C-sensory neurons are located in the center of nerve bundles B. Small-C-sensory neurons are myelinated C. Small-C-sensory neurons have a high firing frequency D. Small-C-sensory neurons have more sodium channels E. Sodium channels in small C-sensory neurons spend more time in the closed state

C. higher firing frequency in physiologic terms indicates that more sodium channels (the channels producing firing) exist in the open state more often. Lidocaine binds preferentially to open sodium channels.

Chronic ethanol consumption will most likely produce which adaptive response listed below? A. Decreases catecholaminergic activity in the CNS B. Decreases the gene expression of cytochrome P450 enzymes C. Decreases the metabolism of acute ethanol consumption D. Increases the number of NMDA-glutaminergic receptors on neuronal membranes E. Increases the number of GABA-A, chloride channels

D. The brain adapts to the constant presence of ethanol by producing the opposite to the acute effects of ethanol. In this case increases in the excitatory tone of the brain would allow the brain to function more normal when exposed to alcohol.

A middle-aged homeless man is brought to the ER. He states he drank a large amount of a clear liquid his friend gave him. He is combative, complains of flickering white spots before his eyes and he has the odor of formaldehyde on his breadth. This patient should be treated with which of the following? A. Acamprosate B. Disulfiram C. Flumazenil D. Fomepizole E. Naltrexone

D. Fomepizole, This patient has the classic symptoms of methanol poisoning. Methanol is converted to formaldehyde by alcohol dehydrogenase. Fomepizole is an inhibitor of alcohol dehydrogenase which prevents the conversion of methanol in to the more toxic fomraldehyde. The other treatment for this patient would be to administer ethanol in order to saturate the capacity of alcohol dehydrogenase with ethanol. Note: The other major symptom of both ethylene glycol and methanol poisoning is an elevated anion and osmolar gap. The mnemonic for things that cause an elevated anion gap is : MUDPILES (methanol, uremia, diabetic ketoacidosis, propylene glycol, isoniazid, lactic acidosis, ethylene glycol, salicylate

A 26-year-old woman, with a history of heroin use, is brought to the emergency room. She is unresponsive, has a shallow respiratory rate (5-6/min), and constricted pupils. The most likely treatment choice is A. Bupropion B. Cocaine C. Diazepam D. Naloxone E. Stanozolol

D. Naloxone. Students should recognize the signs of acute opioid intoxication. The management of this patient is repeated treatment of naloxone, which is a mu-opioid receptor antagonist. Naloxone has a short half-life compared to heroin.

A 53-year-old male requires a short dental procedure while traveling in Europe. He is given a local anesthetic before the procedure. Shortly after administration of the drug he becomes short of breadth suggesting signs of methemoglobinemia. Which drug was most likely used? A. Cocaine B. Lidocaine C. Ropivacaine D. Prilocaine B. Bupivacaine

D. Prilocaine Local anesthetics with strong oxidizing potential (e.g. prilocaine and its metabolite ortho-toludine and benzocaine) can produce methemoglobinemia

A 50-year-old man has consumed 0.5-1 pint of whisky per day for the last 6 years. Abrupt cessation of ethanol consumption produced tremors, delusion, visual hallucinations and inevitably resulted in seizure activity. The reason for these symptoms are most likely explained because chronic ethanol consumption A. Decreased catecholaminergic tone B. Decreased the number of NMDA receptors C. Induced expression of metabolic enzymes D. Produced adaptive increases NMDA receptors and decreases GABA activity E. Produced increases in the ability of GABA ergic neurons to conduct chloride ions

D. Produced adaptive increases NMDA receptors and decreases GABA activity.

Which statement is the most correct regarding methoxyflurane A. Increasing pulmonary blood flow speeds Methoxyflurane's rate of onset B. Methoxyflurane has the fastest onset of all inhaled anesthetics C. Methoxyflurane is the least potent of inhaled anesthetics D. Rate of anesthesia is increased by an increasing ventilation rate E. Rate of onset is directly related to the drug's potency

D. Rate of anesthesia is increased by an increasing ventilation rate

Local anesthetics produce their effects by A. Blockade of NMDA channels B. Inactivation of voltage gated potassium channels independent C. State dependent blockade of voltage gated calcium channels D. State dependent blockade of voltage gated sodium channels E. Sate dependent inhibition of GABA-A channels

D. State dependent blockade of voltage gated sodium channels. Local anesthetics pass through the lipid membrane and block the sodium channels from the intracellular side of the the open sodium channel.

Which of the following is a sodium channel blocker used for very short procedures in combination with epinephrine because of its short duration of action? a. Lidocaine b. Bupivacaine c. Ropivacaine d. Chlorprocaine e. Cocaine

D. chlorprocaine Esters (one i) are metabolized by esterase's in the blood and tend to have a shorter duration of action

A 47-year-old man is brought to the operating room with a blown pupil and signs of increased intracranial pressure. He needs emergency surgery. Which is the best drug to use for the induction of anesthesia because it has the least cardiovascular and cerebral vascular effects? A. Flumazenil B. Isoflurane C. Ketamine D. Midazolam E. Thiopental

E. Barbiturates, of the drugs listed, have the least amount of vascular effects.

Which statement is the most correct regarding halothane? A. Halothane can produce uterine muscle contraction B. Halothane is a potent mutagen C. Halothane is contraindicated in pediatric surgery D. Halothane is the safest anesthetic to use in patients with cerebral hemorrhage E. Halothane may sensitize myocardium to catecholamines resulting in arrhythmias

E. Halothane may sensitize myocardium to catecholamines resulting in arrhythmias

Which best describes the metabolism of ethanol? A. Alcohol metabolism occurs primarily in the gut wall B. Aldehyde dehydrogenase converts ethanol into acetaldehyde C. Ethanol is metabolized primarily by the mixed enzyme oxidizing system D. Metabolism of ethanol involves first order kinetics E. Metabolism of ethanol involves zero order kinetics

E. Metabolism of ethanol involves zero order kinetics Most of the metabolism of ethanol occurs in the liver by alcohol dehydrogenase, which converts ethanol into acetaldehyde. Only at high doses ethanol metabolized by the MEOS system. Consuming more than one drink saturates the capacity of the alcohol dehydrogenase and acetaldehyde dehydrogenase to breakdown ethanol. The rate limiting cofactor NAD+ is used up with more than one drink per hour. Therefore, once this capacity is saturated ethanol follows zero order kinetics.

A 35-year-old man is taking a drug to "get-big" (increase muscle mass) and now presents to you at an infertility clinic because he and his wife cannot conceive. A. Bupropion B. Cocaine C. Diazepam D. Naloxone E. Stanozolol

E. Stanozolol Stanozolol is an anabolic steroid used by body builders to develop muscle mass. It is a derivative of dihydrotestosterone.

Lipid soluble barbiturate used as an inductive agent for general anesthesia with a duration-of-action shorter than its metabolic-half-life A. Dantrolene B. Etomidate C. Ketamine D. Nitrous Oxide E. Thiopental

E. Thiopental The duration of thiopental depends on how long it stays in the brain tissue before it is redistributed to other tissue in the body.

A 26-year-old male with a 2-pack per day cigarette habit wants to quit smoking but is having trouble. He is prescribed a drug that reduces symptoms of nicotine withdrawal and shows effects on smoking cessation. Which drug was used? A. Clonidine B. Diazepam C. Methadone D. Naloxone E. Varenicline

E. Varenicline This drug is a partial agonist to nicotinic Ach receptors found in the ventral tegmental areas. Its primary use for smoking cessation. Note: Black Box warning—may increase suicidality.

Which statement is correct regarding the sensitivity to nerve block produced by injection of bupivacaine? A. Axons in the center of nerve bundles are blocked first before axons on the nerve bundle periphery B. Lidocaine preferentially binds to sodium channels in the closed state C. Heavily myelinated, large diameter, and low firing frequency Type A motor neurons are the most sensitive D. Lightly myelinated, relatively small diameter Type B preganglionic autonomic nerve fibers are not blocked E. Very small diameter, unmyelinated, high firing frequency Type C pain fibers are very sensitive to block

E. Very small diameter, unmyelinated, high firing frequency Type C pain fibers are very sensitive to block

A 55-year-old homeless woman is brought to the emergency department by paramedics. She was found wondering the streets. Her medical records indicate that she is a chronic alcoholic and has been admitted to the hospital for several alcohol related accidents over the last few years. She now presents with ophthalmoplegia, ataxia, profound disorientation, is indifferent, and inattentive. You suspect alcohol-induced Wernicke's disease. This patient requires prompt administration, either intravenously or intramuscularly, of which pharmacologic therapy prevent coma and possibly death. A. Acamprosate B. Disulfiram C. Fomepizole D. Naltrexone E. Thiamine

E. Wernicke's syndrome is produced in chronic alcoholics by malnutrition and the loss of absorption of vitamin B1. Therefore, prompt replacement in the ER setting is part of the management of this patient. The classic triad of this disease is opthalmoplegia, ataxia, and confusion.

Schedule I controlled substances are generally prescribed only by specialists. True False

False, schedule one drugs cannot be prescribed and are only used for experimental purposes. This list includes; opioids like heroin; hallucinogens like LSD, peyote, psilocybe mushrooms; marijuana; depressants like methaqualone; and stimulants like cathinone and methamphetamine.

Which drug is matched correctly with the description? Drug Description Bupropion :most common nicotine replacement therapy Clonidine :reduces symptoms of nicotine withdrawal Nicoderm (Transdermal Patch) :comparable peak nicotine levels to smoked cigarette nicotine levels Nicotrol NS (nasal spray) :least likely to produce mucosal irritation Nortriptyline smoking cessation drug with little side effects

Nicotrol NS (nasal spray) :least likely to produce mucosal irritation

An example of a schedule I controlled substance is LSD. True False

True, schedule one drugs cannot be prescribed and are only used for experimental purposes. This list includes, opioids like heroin, hallucinogens like LSD, peyote, psilocybe mushrooms, marijuana, depressants like methaqualone, and stimulants like cathinone and methamphetamine.

Which is the most likely mechanism that produces death in a heroin overdose? a. Acute respiratory depression b. Cerebral hemorrhage c. Cardiac arrest d. Liver failure e. Hyperthermia

a. acute respiratory depression

How do opioid-analgesics stimulate efferent -glutaminergic-neurons to reduce nociceptive -afferent-signals going to the brain? a. by directly activating glutaminergic neurons b. by inhibiting GABA-inhibitory neurons that synapse onto glutaminergic neurons c. by binding to mu-opioid receptors on glutaminergic neurons d. by binding to kappa-opioid receptors on glutaminergic neurons e. by activating enkephalinergic inhibitory neurons

b. by inhibiting GABA-inhibitory neurons that synapse onto glutaminergic neurons. By inhibiting the gaba-inhibitory neuron's influence on descending neurons the "break" is removed and the neuron is able to reach threshold more readily. When this neuron is activated there is a subsequent activation of enkephalinergic inter-neurons that reduced noceciption.

All opioid receptors are or do which of the following? a. ion channels b. coupled to either Gi or Go c. decrease potassium conductance d. increase calcium conductance e. depolarize neurons when activated

b. coupled to either Gi or Go

Which local anesthetic does not require epinephrine to produce vasoconstriction? a Bupivacaine b Lidocaine c Cocaine d Procaine e Tetracaine

c Cocaine cocaine can block sodium channels and prevent the re-uptake of norepinephrine that can in-turn activate vasoconstriction

A 54-year-old man decides to quit using heroin. He has been a heroin addict off and on for several years. He has been using heroin fairly consistently for the past several months. His last injection of heroin was 10 hours ago. What symptoms is he likely to experience at this time? a. constipation b. bradychardia c. autonomic excess d. hypoglycemia e. muscle paralysis

c. autonomic excess Clinical Aspects of Opioid Abuse Opioids with strong abuse potential include, heroin, morphine, oxycodone, fentanyl and meperidine. These drugs share common features of fast onset, short duration, and they are strong mu agonist. Symptoms of opioid withdrawal begin in 8-10 hours after the last use and can last for 7-10 days. Common symptoms include: Autonomic symptoms (appear first)-- lacrimation, rhinorrhea, yawning, and sweating. Next, restless sleep followed by weakness, chills, gooseflesh ("cold turkey"), nausea and vomiting, muscle aches, and involuntary movement ('kicking the habit"). This autonomic excess is likely to be produced by over excitation of the locus ceruleus (LC), a norepinephrine producing nuclei. Chronic opioid administration decreases LC function. Adaptive increasing in the LC-noradrenergic-pathways produce catecholamine excess upon abrupt cessation of opioid influence. These symptoms are followed by hyperpnea, hyperthermia and hypertension. A secondary phase last for 26-30 weeks may ensue with symptoms of hypotension, bradycardia, hypothermia, mydriasis and decreased responsiveness of the respiratory center to carbon dioxide

Which receptor is correctly matched to the physiologic response produced? Receptor : Physiologic response a. kappa : respiratory depression b. kappa : diarrhea c. kappa : euphoria c. mu : constipation d. mu : dysphoria

c. mu : constipation both kappa and mu agonist work on the enteric nervous system to slow GI function. Constipation is a common problem observed while using opioids. Tolerance development for constipation is minimal.

Which of the following would be an appropriate clinical use of morphine? a. to treat constipation b. to produce pupillary dilation when used topically c. to treat severe pain in a heroin addict d. to produce euphoria e. to stimulate gall-bladder secretions

c. to treat severe pain in a heroin addict. pain must be managed. Best to use a high efficacy opioid for severe pain management. Morphine Hydromorphone Oxymorphone Meperidine Fentanyl Methadone Oxycodone Hydrocodone

Morphine activation of presynaptic opioid receptors decreases nociceptive afferent activity by which mechanism of action listed below? a. Activation of adenylyl cyclase b. Activation of GABA-A chloride channels c. Activation of voltage gated sodium channels d. Inhibition neurotransmitter release by decreasing calcium influx e. Decreasing potassium efflux from neuronal cell membranes

d. Inhibition of neurotransmitter release by decreasing calcium influx. Opioid receptors are GPCR receptors coupled to Gi or Go. The activation of these G proteins causes neuronal inhibition by decreasing production of cAMP and the subsequent activation of PKA. PKA when activated in neurons phosphorylates VG-Ca-channels. When phosphorylated in this fashion the channels open more allowing more calcium entry. Intracellular-calcium levels- increases result in docking and fusion of synaptic vesicles with the plasma membrane. Thus, the slowing of this process decreases neurotransmitter release.

Which of the following is correctly ranked with respect to nerve fiber or ion channel sensitivity to blockade by lidocaine? Least sensitive:Most sensitive a. Channels in the open state: Channels in the closed state b. Neurons with high firing rates: Neurons with low firing rates c. Large Diameter neurons: Small diameter neurons d. Type C fibers: Type A fibers e. Unmyelinated nerves: myelinated nerves

d. type c fibers more sensitive than type A fibers

A 48-year-old patient presents to the emergency room with respiratory, truncal rigidity, and pin point pupils after overdosing on his pain medication. Which of the following drugs would most likely be administered to this patient? a. Diazepam b. Fomepizole c. Flumazenil d. Methadone e. Naloxone

e. Naloxone Naloxone (narcan) is a mu opioid receptor antagonist with a short half life that when given repeatedly can reverse the effects of heroin use or opioid overdose.