Week 3 Flashcards
How is nociceptive pain normally terminated?
By the healing and repair process
What is the key locus in the endogenous pain suppressant neural system (modulation)
Mesencehapilic Periacqueductal gray: enkephalin containing neurons.
It’s a multisynpatic pathway descending to dorsal horn of cord
What is another term for the endogenous opioid peptides?
Endorphins
Enkephalin is made out of ___ amino acids (___ and ___). Enkephalin binds to which to receptors?
5 amino acids
Methionine and leucine
Mu and delta
B-endorphin is made out of __ amino acids and binds to which two receptors?
91 amino acids
Binds to mu and delta
Other than affecting the pain pathway, what else do endorphins play a role in?
Stress
GI function
Endocrine systems
Affect the reward pathway (increase dopamine release through mesolimbic system)
Dynorphins A and B is made out of ___ amino acids and binds to which receptors? What i unique about dynorphins?
17 amino acids
Primarily K (kappa) receptors
Dynorphins are unique because they are dysphoric. This means that although it can block pain, it causes an unpleasant feeling, so there is no addiction potential
Endogenous opioid peptides (endorphins) play a key role in ___ feedback and other physiological processes
Inhibitory.
Negative feedback
Drugs that enhance the action of __ and __ in the CNS have antinociceptive effects
NE
5HT (serotonin)
Opioid analgesics act in ___ and ___
PAG (periaqueductal gray)
Dorsal horn
In the dorsal horn, opioid ___ the release of pain transmitters
Inhibit.
How can you pass out from intense pain?
Intense pain will pull blood from the brain to get the blood to the site of pain.
Neuropathic pain sensations may be __ or ___ but occur without the activation of ___ by actual or potential tissue damage.
Continuous
Periodic
Nociceptors
How can neuropathic pain occur?
May result from abnormal activity in nociceptive fibers that have been damaged, but after injury has healed
Or from abnormal activity in central pain pathways (solely occurs in brain without any input signal)
True or false.. neuropathic pain has a protective function and terminates with healing.
Both statements are false.
Name 5 examples of neuropathic pain
Phantom limb
Shingles
Fibromyalgia (9 points of pain)
Diabetes neuropathies
Trigeminal neuralgia
Where do diabetes neuropathies typically occur? Why? Describe the onset of the neuropathic pain.
Typically occurs in the extremities (feet) due to clogging of the microcirculation.
First their feet go numb. Then within weeks to months, they feel pain.
Describe the relationship of shingles with neuropathic pain.
Shingles lesions may cause neuropathic pain that doesn’t go away even after the lesion has healed.
If you treat shingles early and aggressively with antivirals you may avoid this.
What is another name for trigeminal neuralgia?
Tic douloureux
True or false… neuropathic pain may be resolved by NSAIDs or opioids.
NSAIDs do not resolve pain
Opioids inconsistently may resolve pain
True or false… some antidepressants, anticonvulsants, and corticosteroids cause some reduction of neuropathic pain.
True
Name one antidepressant that is used to treat neuropathic pain
Cymbalta
Name two anticonvulsants that may be used to treat neuropathic pain
Lyrica (specifically for fibromyalgia)
Gapapentin
What is a diagnostic tool to determine if the pt is experiencing neuropathic pain?
Functional MRI
Name 4 possible mechanisms for neuropathic pain
The peripheral sensitization process may persist rather than subside
Damaged nociceptive nerves may fire spontaneously
Prolonged input from hyperexcitable nociceptive fibers (learned)
Decreased activity of endogenous pain-suppressant neural system
What is the role of placebo with pain management?
Most likely caused by release of endorphins
Endogenous analgesia elicited by suggestion
Name 4 pain medications that act in the brain
Opioid narcotics
Glutamate
GABA
Antidepressants (5HT/NE)
Name two pain medications that act on descending modulation
Serotonin drugs
Neuropeptides
Name three pain medications that act on the dorsal horn of the spinal cord
Local anesthetic
Opioids
NSAIDs
Name two pain medications that act on nerves
Local anesthetic (can be used to locate area of neuropathic pain so it can be surgically treated)
Opioids
Name 5 pain medications that act in the tissues
Local anesthetic
NSAIDs
COX 1/2 inhibitors
Acetaminophen
Capsaicin
Where does arachidonic acid come from?
Membrane phospholipids
Which causes a higher incidence of stroke and heart attacks, COX-1 inhibitors or COX-2 inhibitors?
COX-2 inhibitors
This is because COX-2 inhibitors interfere with vasodilation
(COX-1 inhibition shouldnt cause cardiovascular problems)
What pain medications may cause stomach ulcers?
NSAIDs
COX-2 selective inhibitors do not
What pain medications may cause hepatic damage?
Acetaminophen
You should be careful with this drug when given to heavy alcohol drinkers and those with hepatitis.
What pain medication can cause bleeding-anticlotting?
COX-1 inhibitors
Aspirin (salicylates)
What pain medicaiton can cause cardiovascular problems?
COX-2 inhibitors
What pain medication can cause dependence/addiction?
Opioids
True or false… acetaminophen is an NSAID
False
True or false.. salicylates are NSAIDs
True
Salicylates inhibit COX-1 and COX-2
What dose of salicylates is recommended for the following…
Analgesia
Antiinflammation
Antipyretic (anti fever)
Analgesia - 600mg
Antiinflammation - 1gm
Antipyretic - 300-600mg
How long do salicylates typically last? What other drugs are often combined with it?
4 hours
Used for mild to moderate somatic pain
Often combined with caffeine, acetaminophen, or opioid
Name 4 side effects associated with salicylates
GI irritation and erosion
Reye’s syndrome in children (colds/flu)
Anti-clotting (last up to 1-2 weeks) (acetylation of the platelets is what prevents clotting, platelets need to be replenished)
Ringing in ears (tinnitus) - high dose
What is the dose for analgesia for ibuprofen?
400mg
What is the dose for anti-inflammation for ibuprofen?
800mg
What is the dose for antipyretic for ibuprofen? How long does it typically last?
400mg
4 hours
True or false… ibuprfen is used for mild to moderate pain relief and is often a little better than aspirin
True
What are the three main side effects of ibuprofen?
GI ulcers (less than aspirin)
Anti-clotting (less than aspirin)
Cardiovascular effects
Name two ibuprofen-like NSAIDs
Ketoprofen (orudis)
Naproxen (Naprosyn)
Ketoprofen is ___ potent than ibuprofen. What is a typical dose per capsule?
More
Lower doses (50mg/capsule)
Naproxen (naprosyn and aleve) have ___-lasting and ___-acting effects than ibuprofen
Longer lasting (about 8 hours)
Slower acting (takes about an hour. Ibuprofen is about 15 minutes)
(It’s a slow releasing drug making it longer for onset but longer lasting)
Celebrex is a __-selective antagonist, given by prescription only. It has ___ potency compared to ibuprofen. It lacks ___ and ___ action. And it has been linked with ___ side effects.
COX-2
The same
Lacks GI and anti-clotting action
Cardiovascular
Name three other NSAID agents that aren’t ibuprofen related.
Indomethacin
Meloxicam
Diflunisal (dolobid)
What is indomethacin?
Potent (between ibuprofen and opioid)
Nonselective NSAID
Used to treat severe rheumatoid arthritis and gout.
Not commonly used due to side effects
Meloxicam preferentially inhibits ___ over ___, meaning less ___ side effects but more ___ side effects.
COX-2
COX-1
GI
CV
Which NSAID agent is related to salicylates and is supposed to be good for bone pain because it concentrates in bony tissue?
Diflunisal (dolobid)
True or false… acetaminophen is an NSAID
False. It does not inhibit COX-1 or COX-2. But it may inhibit a COX-3 enzyme and/or serotonin
The chemical structure of acetaminophen looks similar to ___
Aspirin
Which drug is not a COX-1 or COX-2 inhibitor, has better analgesia for children than adults, has antipyretic properties, and seems to have a sedative effect in children?
Acetaminophen (Tylenol)
True or false… acetaminophen has better analgesia properties than aspirin.
False, its not quite as good.
True or false… acetaminophen does not cause GI problems, clotting effects, Reye’s syndrome, and it has little anti-inflammatory effects
True
What is one side effect associated with acetaminophen?
Acetaminophen is a liver toxin at high doses
Patients with compromised livers should not use.
What are some analgesic features of NSAIDs?
Lessens somatic pain (most dental pain, most headaches besides migraines, most muscle and joint pains, most earaches)
Used for mild - moderate pain (has a plateau)
Part of the analgesia relates to their anti-inflammatory action
What are six contraindications for the use of NSAIDs?
Anticoagulants
Ulcers
Hemophiliac
Already taking high doses of medication
Child/adolescent
History of allergies
What patients are likely to be taking anticoagulants, in which NSAIDs are contraindicated?
Coumadin
Joint replacement
Heart attack/stroke
Major surgery
Atrial fibrillation
What are some signs that a patient might have GI ulcers, in which NSAIDs are contraindicated?
Frequent upset stomach
Bleeding in stools
Takes antacids
Takes H2 blockers
What are three therapeutic uses of opioid narcotics?
Analgesia (somatic and visceral, mild to severe)
Antitussive (anti-coughing, because it blocks the “coughing” part in the brain.)
Antidiarrheal (slows down movement in intestines, can cause constipation as a side-effect)
What is the general rule for determining the potency of opioids based on their names?
Morph - stronger
Cod - weaker
Oxo - stronger
Hydro - weaker
What is the most potent opioid?
Fentanyl - you can die from taking this
What are the two most commonly prescribed opioid brands by dentists? What is their scientific name and dose?
1 = lortab
Hydrocodone + acetaminophen (30mg)
Name four other narcotic analgesics
Meperidine (Demerol)
Pentazocine (talwin)
Methadone
Buprenorphine
Meperidine is a narcotic used to treat __ pain
Moderate
What is unique about pentazocine?
Has a mixed agonist/antagonist action. Discourages abuse
It binds kappa (instead of mu or delta) causing dysphoria. At low dose it is an agonist and an analgesic. At high dose it is an antagonist which shuts it off and pushes the patient into withdrawal. Addicts dont like this drug.
What methadone?
A narcotic analgesic
Moderate to strong
Used to treat opioid addiction and as an analgesic
What is buprenophine?
Moderate analgesic
Mixed agonist antagonist. Used to treat opioid addiction.
Not a kappa agonist like pentazocine (doesn’t cause dysphoria)
What are some major opioid agonist (mu receptors) side effects?
Respiratory depression/decreased pulmonary reflex (patient must be reminded to breathe)
Severe Constipation/slow bowel movement
Sedation/additive or synergistic with other CNS depressants (alcohol, sleep aids, etc.)
Euphoria/dependence/addiction
How many deaths per year occur due to opioid overdose in utah?
200 deaths
What is the treatment for opioid overdose?
Inject the mu antagonist - naloxone (It will reverse in a matter of seconds)
This, however, may precipitate withdrawals
What is another name for naloxone?
Narcan
Name 5 contraindications for the use of opioids?
History of substance abuse
Severe constipation or upset stomach
Respiratory problems
Use of other CNS depressants
History of allergies
True or false.. the use of NSAIDs prior to dental procedure might reduce inflammatory process and associated pain
True
What are three helpful NSAID combinations?
NSAID + acetaminophen
NSAID + caffeine
NSAID + narcotics.
(Note that if you use opioids if NSAIDs are not sufficient. Start low (use combinations), go slow (prescribe few)
What is the first line treatment for managing neuropathic pain?
Gabapentin (antiseizure - lyrica)
Duloxetine (antidepressant)
Nortriptyline (antidepressant)
What is the next-line of treatment for managing neuropathic pain?
Tramadol (ultram) - “non-opioid”?
Other pharmacological treatments include opioid narcotics (usually not effective for long-term treatment
In ordered to diagnose a mental disorder, pts must meet the criteria of ___ and to meet Medicaid requirements for dental care
DSM-5
The DSM-V organizes each psychiatric diagnosis into ___ axes relating to different aspects of disorder or disability
5
What is axis 1 on DSM-V?
All psychological diagnostic categories except mental retardation and personality disorder
Examples include: depression, anxiety disorders, bipolar, ADHD, autism spectrum, anorexia nervosa, bulimia nervosa, schizophrenia, drug dependence
What is axis 2 of DSM5?
Personality disorders and mental retardation
Examples include: paranoid personality disorder, schizoid personality disorder, etc, intellectual disabilities
What is axis 3 of dsm5?
General medical condition; acute medical conditions, and physical disorders.
Mental health conditions are due to an underlying medical condition (such as schizophrenia with huntingtons disease)
Examples include: brain injuries and other medical/physical disorders (Alzheimer’s)
What is axis 4 of DSM5?
Psychosocial and environmental factors contributing to the disorder (stress)
Mental health problem is released to environment. Address the stressor to treat the mental health problem
What is axis 5 of DSM5?
Global assessment of functioning or children’s global assessment scale for children and teens under the age of 18
What are 6 things that are part of the assessment of a mental status examination ?
Mood
Affect
Thought
Appearance
Cognitive function
Dental problems
What are the two things you look for when assessing the mood of a pt?
Type
Severity
What is affect?
The expression of mood. (How they carry themselves, facial expressions, tone of voice)
What are the three things aspects involved with thought? Describe them.
Thought process (organization of thoughts and problem solving. Consistency (are their thoughts sequential?)
Thought content (relevance to the topic. Insightfulness)
Perception (ability to understand. Ability to interpret)
How does the pts appearance help you assess their mental status?
Relevance of dress to the occasion (indicates awareness of the environment)
Hygiene (indicates their care for social norms and motivation)
What are the three aspects to cognitive function? Describe them.
Define: executive skills which include decision making, planning, and implementation. This includes how they process information
Cause: organic vs inorganic
Assessment: orientation, concentration, memory, use of knowledge, abstraction (ability to extrapolate), judgement (difference in responses due to circumstances), insight (creativity).
Other than the mental status examination, what are two other ways to assess mental health?
EEG (electroencephalogram) - identifies epilepsy. Measures neuranol activity on the surface. They identify abnormal wave forms. EEGs are measureing the surface of frontal cortex or sensory cortex
Brain imaging (CT, MRI, PET)
Describe the differences between CT, MRI, and PET.
CT - anatomical, not functional. Shows actual tissue alteration, not neuronal chemistry
MRI - gives a functional read based on oxygen consumption. 2D-glucose (an abnormal form of glucose) is used to see where the metabolism takes place.
PET - positron emission tomography. Use ligands that are radioactively labeled that bind to transporters. This tells you about different specific systems (DA, SER, etc.) this tells us what neurotransmitters are affected.
True or false… psychotic disorders are a symptom, not a diagnosis
True
What is the most common psychotic disorder?
Schizophrenia
____ is a symptom of schizophrenia but not all psychosis pts have ___
Psychosis
Schizophrenia
What is psychosis?
Different sensory input or different interpretation of sensory input.
They may react to a helicopter with a machine gun when its not actually there
How much money a year is spent on schizophrenia?
About 40 billion
What are the symptoms of schizophrenia?
Episodic (periods of functioning and non-functioning)
Incoherent
No pre-pulse inhibitor - jump every time you scare them with no accommodation
Shorter life expectancy (by 20-30years)
Anhadonic - no pleasure or rewards. Life sucks. Antipsychotic drugs make this worse.
Personal appearance issues (poor hygiene)
Flat affect
Difficulty filtering
Who typically have their first episodes of schizophrenia first, males or females?
Males. Females have a later onset
What are the DSM5 requirements to be diagnosed with schizophrenia?
Symptoms must persist for over 6 months
Have active psychosis
(Remember that schizophrenia is very variable from pt to pt)
What are 4 subtypes of scizhophrnia? Briefly describe them.
Disorganized type - blunted affect. No delusions. Bizarre behaviors.
Catatonic type - rigid (dont change positions when you move them, like gumbi). Bizarre postures
Paranoid type - positive symptoms. Very reactive. Paranoid delusions and interpret things in a threatening way. Aggressive
Residual - withdrawal. No communication. Occur later on
What is the easiest and most difficult subtype of schizophrenia to treat?
Easiest - paranoid
Hardest - residual
True or false.. often times different subtypes of schizophrenia end up as the residual type
True
True or false… schizophrenia may go away over time
False. It is incurable.
Pt becomes residual subtype with time
Life expectancy goes down 20-30 years due to diseases and/or suicide
What is the best prognosis for schizophrenia?
Rapid onset
Underlying explanation (stress or disease)
Positive symptoms (instead of negative) Older (over 30(
Female
No genetic history
What are some possible physical findings associated with schizophrenia?
Enlarged ventricles
Changes in the corpus colosum (connects left and right hemispheres)
Describe the neurochemical you with schizophrenia
It is a DA related phenomenon (too much stimulation of D2 (antagonist) on postsynaptic neurons)
Seratonin and glutamate play roles
Nicotine may be involved
Why are a lot of schizophrenics chain smokers?
The nicotine helps clear their mind. Clears the fog so they can think clearly
True or false.. schizophrenia is entirely genetic.
False.. it is genetic and environmental.
What is a potential environmental link that may cause schizophrenia later in life?
Influenza infections early in life
What is the mechanism of the drugs that treat schizophrenia?
All block D2 receptors but also have other effects that likely contribute - correlates with antipsychotic actions.
What are atypical antipsychotics?
Antipsychotics that block seratonin receptors in addition to D2 receptors
What are the clinical benefits of atypical antipsychotics?
Reduce psychotic symptoms generally; enable distinction between reality, delusions, and hallucinations.
Enhance cognition and executive functioning.
Alleviate depression. (Other antipsychotics make depression worse)
Effects on D2/5HT1 also account for many of the side effects known as ____. What are the two types? Describe them.
Extrapyramidal side effects
Tardive dyskinesia - once you have it its permanent, even after quitting the drugs
Parkinson’s like tremors (because DA activity is decreased)
In addition to the extrapyramidal side effects of D2/5HT2 drugs, what are some other side effects?
Psychological - (sleepiness, restlessness, disrupt endocrine, can also cause pseudo-depression)
Weight gain
Phenothiazines are older drugs and are the __ expensive. They have more ___ and ___ side effects due to a higher ___ effect. They have less ___ side effects.
Least expensive
Sedation and weight gain side effects
Higher anticholinergic effect
Less extrapyramidal side effects
Name two phenothiazine drugs
Chlorpromazine
Thioridazine
Butyrophenones have ___ extrapyramidal side effects. Lacks ___ action and associated side effects.
High
Lacks anticholinergic action
What is a widely used, inexpensive, typical antipsychotic drug that is considered a butyrophenone? Describe this drug.
Haloperidol (haldol)
Has extrapyramidal side effects
Really good for younger patients with positive symptoms
Has D2 and 5HT2A activity.
Shuts down DA synthesis.
Atypical antipsychotic drugs, besides being a D2 antagonism, they are also good __ antagonists. They have ___ extrapyramidal side effects. They are most effectivve in treating the ___ symptoms of schizophrenia
5HT2A
Little
Negative (such as withdrawal, less communication) -best for residual schizophrenia
Name two atypical antipsychotic drugs
Clozapine
Quetiapine
What atypical antipsychotic drug can cause serious agranulocytosis in 1-2% of pts.
Clozapine
Need to test blood to check. Agranulocytosis is deadly
Quetiapine (seroquel) and olanzepine (zyprexa) are ____ drugs that are newer and have fewer side effects
Atypical antipsychotic
Other than the 4 subtypes of schizophrenia, name two other sczhicophrenia types and describe them.
Acute psychotic disorder - temporary. Caused by some kind of stressor (situation dependent). May have hallucinations or delusions.
Schizoaffective - can be schizodepressive or schizomania.
How do you diagnose schizomania?
You must give them drugs for schizophrenia and mania. If symptoms only go away when you give them both medications, they have it.
Up to __% of the population have mood disorders. This includes depression and mania. Mania typically occurs with depression (bipolar)
5%
What are minor affective disorders? Name two of them.
Disorders are disruptive but pt remains functional. Seeing a counselor is helpful and some drugs are helpful
Depression-dysthymia
Cyclothymia
What is depression dysthymia?
Person has a diminished mood for over 2 years (in order to diagnose it)
This is when something goes wrong and cant be corrected. They can function but their mood is lower.
Anyhdronia - gloomy
Doesn’t respond well to drugs
F:M 2:1
In order to be diagnosed with cyclothymia, you must have symptoms for over __ years. This is basically minor __. Behavioral management is good treatment, pt remains fairly functional. The F:M ratio is ____
2
Bipolar
1:1
Major depression is a ___ mood disorder . These pts are nonfunctional and vegetative. Some cases are a single episode, some cases are episodic. F:M ratio is ___
Major
F:M 2:1
Name and describe two subtypes of major depression.
Post partum - more likely to appear in the second or third child (usually not the 1st) Lasts 1-4 weeks after birth. Can be severe.
SADS (seasonal affective disorder syndrome). - due to less sunlight in winter months.
The pharmacological treatment of major depression usually has a ___ onset. It is effective in about ___ of pts. If one drug doesn’t work it sometimes helpful to try a different category of antidepressant if patient isn’t responding.
Delayed
70%
MAOIs are the first modern antidepressants. What is their mechanism and some major side effects?
Mechanism: block the metabolizing enzyme for monoamines (likely increases 5HT, DA, NE
Side effects: may interact with cheese and beer (tyramine) to cause strong sympathomimetic effect.
Weight gain
Alter autonomic system activity
Orthostatic hypotension
Some act as stimulants (like amphetamines)
Mat interact with OTC cold decongestants
True or false… you should be careful giving epinepthrine to patients who are on MAOIs
True
Name two examples of MAOIs
Phenelzine (MAO A and MAO B inhibitor)
Selegelin - MAO B inhibitor (also used to treat parkinsons)
Tricyclics antidepressants have a ___ half life. They act by blocking the uptake of __ and varying affinity for the ___ transporter. Side effects include xerostomia (an ___ effect), ___ ___, ___, and H1 blockade, prescribe for hypnotic effect or as an antihistamine for itching.
Long
NE
5HT
Anticholenergic
Orthostatic hypotension
Withdrawal
Name three examples of tricyclic antidepressants.
Amytripytline
Desipramine
Doxepin
Monoamine uptake blockers are used to treat depression. Blocks ___, ___, and ___. It is __ tolerated, has a mixture of selectivity, and has ___ withdrawal. (SSRIs are considered monoamine uptake blockers).
5HT, NE, DA
Better tolerated because of less side effects
Minimal
Monoamine uptake blockers are very popular. However, some side effects include __ upset, ___ dysfunction, ___ in adolescents, and ___. It has a ___ margin of safety. It has ___ anticholinergic activity.
GI upset (could be used to treat IBS)
Sexual
Depression
Wide
No anticholinergic activity
True or false… SSRIs have no anticholinergic activity
True (they are monoamine uptake inhibitors)
Name two Monoamine uptake blocker drugs.
Fluoxetine (Prozac)
Sertraline (Zoloft)
These drugs are NE or mixed transport blockers.
Fluoxetine (Prozac) and sertraline (Zoloft) have more ___ side effects due to ___. It is a moderate CNS ___.
Cardiovascular due to increased NE/sympathetic activity
Stimulant
Venlafaxine (Effexor) and duloxetine (cymbalta) are ___ drugs. Duloxetine can also be used to treat ___
Monoamine uptake blocker
Neuropathic pain
Are bipolar patients more likely to commit suicide in their manic or depressive state?
Manic
What is the difference between cyclothymia and major manic depressive?
Cyclothymia is mild bipolar
Major manic depressive - can cause compromised function. Pts have poor decision making abilities, tremendous impulsivity, unrealistic. Cycling takes weeks to months
Lithium carbonate is a mood stabilizer for bipolar. It has a ___ onset. Works by altering ____. It is often combined with an ___. It is a very potent mood stabilizer but has many side effects.
Slow
2nd messenger system such as those involving adenylyl cyclase and G proteins.
Antidepressant
Lithium carbonate has many side effects. Name them.
Tremors
Potential kidney damage
Major weight gain *
Edema
High rate of compliance problems
Requires monitoring blood levels because it has a narrow therapeutic window.
Other than lithium carbonate, what other types of drugs can be used to treat bipolar? Name three specific kinds.
Antiepileptic agents
- lamotrigene (lamictal)*
- valproic acid
- carbamazepine
Antiepileptic agents (for the treatment of bipolar), in comparison to lithium carbonate, have __ side effects, ___ compliance, ___ expensive, sometimes less potent, although many exceptions. Usually for maintenance after lithium start.
Less
Better
More
What is the most favored antiepileptic drug for treating bipolar?
Lamotrigene (lamicatal)
If a pt is taking this drug, they most likely have bipolar, not epilepsy
What is the catecholamine theory?
Due to an imbalance of DA, NE, or 5HT**
The different drugs rattle everything in the brain around, then the brain tries to put it back together after and heals in the process.
