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NMSP > Week 6 (Exam 3) > Flashcards

Week 6 (Exam 3) Flashcards

1
Q

Recommended opioids w/ Hepatic insufficiency

A

Fentanyl: totally safe

Codeine, Meperidine, Methadone: totally unsafe

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2
Q

Endocannabinoid transmission process

A

Produced in post-synapse, raising intracellular Ca++
This activates DAG lipase
Cannabinoids go into space, bind CB1Rs pre-synapse
This inhibits Adenylyl cyclase, pre-syn hyperpolarization

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3
Q

Suvorexant MOA

A 
Blocks Orexin (wakefulness) binding
Lemborexant is similar
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4
Q

Preferred obstetric analgesic

A

Meperidine: less effect on fetal respiration and uterine contractions

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5
Q

Genito-pelvic pain penetration disorder

A

persistent or recurring difficulties with 1+ for 6mos:
Vaginal penetration
Vulvovaginal or pelvic pain during sex
Fear or anxiety about pain before or during sex
Tension or tightening of pelvic floor muscles during

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6
Q

Withdrawl symptoms associated with barbiturates, benzos, and EtOH

A

Anxiety, insomnia, delirium, tremors, seizures, death

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7
Q

Female orgasmic disorder

A

delay in or absence of orgasm 70-100% of the time for 6 mos

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8
Q

Cannabinoids

A

Anandamide (partial agonist)

2-Arachidonoylglycerol (2-AG, full agonist)

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9
Q

Splitting

A

People are either pure good or pure evil

Primitive, seen in borderline personality disorder

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10
Q

Lithium metabolism

A

Monovalent Ion
Competes with Na, builds up in Principal cells of CD
Can cause ADH resistance: Polyuria/polydipsia
(picture of nephrogenic DI)

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11
Q

Tourettes

A

multiple motor and vocal tics for more than 1 year

clinical triad of ACD, ADHD, Tourettes

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12
Q

Blocking

A

Temporary inhibition of thinking. Just “stops” momentarily

Neurotic

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13
Q

Black box warning for diazepam / benzos

A

Dont use with opioids: respiratory depression, coma, death

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14
Q

Drugs approved to tx tourettes

A

Haloperidol, Pimozide, Aripirazole

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15
Q

Undoing

A

Hoping to fix or reverse previously unacceptable behavior
Bulemia, intimate partner violence, compulsive behavior, superstition, checking behavior
Neurotic

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16
Q

Whats the difference between 2 and 3-amine SNRIs?

A

2 favors NE over 5-HT
3 favors 5-HT over NE (except clomipramine/amitriptyline)
Other SNRIs favor 5HT

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17
Q

Introjection / identification

A

Unconsciously taking others behaviors or emotions and internalizing them (when aware of it, its imitation)
Neurotic

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18
Q

Most common cause of death in abused children

A

Neglect

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19
Q

Modafinil

A

For Adults Only, tx ADHD

Inhibits DA reuptake

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20
Q

Persistent (chronic) motor or vocal tic disorder

A

One or the other, not both!

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21
Q

Trazodone MOA

A

Heterocyclic / Atypical antidepressant that acts as an SSRI and SARA (serotonin adrenergic receptor antagonist)

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22
Q

Bulemia criteria

A

Binge eating and inappropriate compensatory behaviors at least 2x/week for 3 mos
Body weight can be variable, unlike AN

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23
Q

Cluster A personality disorders

A

Schizotypal (magical/bizarre beliefs, egocentric)
Paranoid
Schizoid (loner by choice, flat affect)

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24
Q

Loperamide

A

u-agonist that cant readily cross BBB
Indicated for acute and chronic diarrhea
Take a lot to get high? risk torsade

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25
Q

Cluster B personality disorders

A

Borderline (impulsive, emotional, self-harm)
Histrionic
Antisocial
Narcissist

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26
Q

Lithium MOA

A

Limits DA (via Gs and Gi) and Glutamate (via NMDA)
Increases GABA release and GABAb receptors
Limits Myoinosital (via IPPase and IMPase)
Limits PKC and MARCKS (anti-manic) and GSK-3
Increases CREB, producing BDNF and Bcl-2 (protect)

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27
Q

Varenicline MOA

A

Nicotinic receptor partial agonist

This is Chantix

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28
Q

Special MOA of Vortioxetine

A

SSRI that is also a 5HT-1b partial agonist
Full agnost to 5HT-1a
Full antagonist to 5HT-1D(3,7)

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29
Q

What two clinical indications are specific for administering Clozapine as an anti-psychotic?

A

Multi-drug resistant disease

Psychosis with anti-suicidal-thoughts/behaviors

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30
Q

Lithium Na/K-drug interations

A

Diuretics (esp thiazides): Na loss, Li reabsorption
ACEi’s (esp Lisinopril): renal eliminated
NSAIDs: alteration of renal perfusion

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31
Q

Why would you want to tirade down from clonidine

A

Risk of Rebound HTN

do it over 1+ weeks depending on dose to discontinue

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32
Q

How do you treat a psychosis patient with poor adherence?

A

Long Acting Injectabe Agents

Risperidone, Olanzapine, Aripiprazole lauroxil (and paliperidone palmitate - fyi)

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33
Q

Non-stimulant ADHD medication MOA

A

Inhibit NE pre-synaptic uptake

Agnoists of CNS a2a adrenergics (guanfacine/clonidine)

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34
Q

Suspicious abuse injuries

A 
Posterior rib fractures
Scapular fracture
Spinous process fracture
Sternal fracture
Metaphyseal lesions
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35
Q

Causes of positive schizophrenia sx

A

Overactive mesolimbic pathway
VTA to Nucleus Accumbens
D2

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36
Q

Carbamazepine indications

A

acute and maintenance treatment of acute mania and mixed episodes (Bipolar I)
Major CYP450 inducer!

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37
Q

Sx of serotonin syndrome

A 
Hyper-reflexia
Clonus
Dilated pupils
Hyperactive bowels
Tremors
Sweating
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38
Q

Nigrostriatal Pathway

A

Fron SN to BG
Stimulates purposeful movement
D2 antagonism induces extrapyramidal sx

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39
Q

forms of methylphenidate rx

A

Tab: dexmethylphenidate (Focalin) and methylphenidate
Liquid: Methylphenidate oral

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40
Q

How does HTN crisis result from an MAOi?

A

MAO-A is necessary for tyramine metabolism in the GI
Tyramine buildup releases catecholamines
Selegiline blocks MAO more as the dose goes up

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41
Q

Dronabinol

A

Synthetic d-9-THC

For anorexia in AIDS patients, Chemo-induced N/V

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42
Q

Main distinction between ASD and Intellectual disability

A

Presence of restricted interests or repetitive behavior

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43
Q

XR amphetamine formulations

A

Adzenys XR-ODT (dl-amphetamine)
3:1 D:L
50-50 IR and XR
No water necessary, ages 6+, q.d. dosing

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44
Q

Therapeutic concentration of Li

A

0.6 - 1.2 mEq/L

Trough at steady state (7-10 days)

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45
Q

Tablet medications for ADHD

A

Dextroamphetamine (AMP/Adderall, Zenzidi)

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46
Q

Considerations for Guanfacine and Conidine

A

Do not crush, chew, or break
Ages 5+, q.d. dosing (H.S. for clonidine)
Non-stimulant treatment of ADHD

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47
Q

Moderate drinking

A

Men: 2 drinks or fewer / day

Women, people over 65: 1 or fewer/day

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48
Q

Special indications for alprazolam and diazepam

A

alprazolam has anti-depressant and anti-panic effects

diazepam has skeletal muscle relaxing effects

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49
Q

Major warnings associated with SSRIs

A 
Serotonin Syndrome (sweat, hyperreflexia, tremors, etc)
Suicidality (esp young people)
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50
Q

What unique side effect is associated with Clozapine?

A

Agranulocytosis

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51
Q

Cariprazine MOA

A

5HT-2a and DA antagonist

Partial DA/5HT-1a Agonist

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52
Q

5HT-2a/DA antagonists for tx psychosis

A

Iloperiodone, Lurasidone (also partial 5HT-1a agonist), Paliperidone (from risperidone), Risperidone, Ziprasidone

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53
Q

reaction formation

A

Taking unconscious threatening wishes or impulses and making them opposite
Neurotic

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54
Q

Opioids + anti-cholinergics

A

increased constipation and urinary retention

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55
Q

Buprenorphine MOA

A

Partial u-opiod receptor agonist

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56
Q

Somatization / Hypochondriasis

A

Transforms negative feelings towards others to self, pain, illness, anxiety
Neurotic

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57
Q

Disulfiram MOA

A

Irreversibly inhibits aldehyde dehydrogenase

Causes extreme sickness if EtOH is consumed

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58
Q

Ego

A

Resolves conflicts

Keeps us grounded to reality

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59
Q

SARA Side effects

A

CNS (sedation): most w/ Trazadone and Mirtazapine
Orthostatic HPTN: most w/ Trazadone
Weight Gain: most w/ Mirtazapine

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60
Q

Mechanism behind Pre-synaptic release of NE and DA when taking Bupropion

A

VMAT2

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61
Q

Considerations of hydrocodone

A

Only available formulated with other drugs like ibuprofen

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62
Q

Enzymes that hydrolyze cannabinoids

A

FAAH: does Anandamide post-synapse

MAG-Lipase does 2-AG presynaptically

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63
Q

Doxepin

A

H1 antagonist, NE/5HT reuptake inhibitor
Causes sedation, maintenance for insomnia
Treatment resistant major unipolar depressive disorder

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64
Q

Why is codeine ineffective in some people?

A

They might lack the CYP2D6 Gene, which metabolizes it to morphine (required for analgesia)

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65
Q

Naltrexone

A

Prevents euphoria from opioids (but not craving)

Reduces craving for alcoholism

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66
Q

Causes of negative and cognitive schizophrenia sx

A

Mesocortical pathway dysfunction

VTA to frontal cortex

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67
Q

Whats the difference between SNRIs and TCAs?

A

TCAs are SNRIs, except they also impact:

Histamine (H1), Muscarinic (cholinergic), and a1 (adrenergic) receptors

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68
Q

Brexanolone

A

GABAa receptor (positive allosteric modulator)
Identical to Allopregnanolone, for Postpartum Depression
Superior efficacy at 60 hours, lasts up to 30 days

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69
Q

Histrionic comorbidities

A

Somatic Sx, Conversion, Depressive

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70
Q

Head injury and opioids

A

they can increase intracranial pressure and make it worse, actually

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71
Q

Female sexual interest / arousal disorder

A

At least 3 of the following for 6 months:

Absent/reduced interest; thoughts; initiation; pleasure; interest in response to cues; sensation during sex

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72
Q

Treatment for binge eating disorder

A

Vyvanse

73
Q

Presentation of Borderline Personality Disorder

A

Pattern of undermining self right before success

State of crisis, unpredictable, splitting

74
Q

Overdose effects that appear as drunken behavior

A

Barbiturates, benzos, EtOH

75
Q

Primitive defense mechanisms

A

Childhood, dreams, psychotic adults
Rearrange external experiences so no need to cope
Projection, Denial, Splitting

76
Q

How to treat splitting and other attachment dangers associated with borderline personality disorder

A

Dialectical Behavioral Therapy

77
Q

Second gen anti-psychotic MOA

A

Block D2 post-synapse AND 5HT2a (more strongly)

78
Q

Buprenorphine MOA

A

partial u agonist and full k antagonist

79
Q

treat opioid withdrawl

A 
Buprenorphine or methadone
Buprenorphine and naloxone 
Clonidine for BP
Diphenhydramine for itching and rhinorrhea
Imodium for diarrhea
80
Q

Side effects of MAOi’s

A

Drug interactions w/ 5HT/NE drugs: 2 week washout period (5 weeks for fluoxetine)
HTN Crisis Risk
Serotonin Syndrome Risk
Orthostatic HPTN, sexual dysfunction, weight gain, etc

81
Q

Atomoxetine

A

24 hour capsule for non-stimulant ADHD medication
Metabolized by CPT 2D6
Ages 6+, q.d. dosing

82
Q

Drugs able to treat irritability and agitation associated with autism

A

Risperidone

Aripiprazole

83
Q

At-Risk drinking

A

Men: more than 14 /week or 4/occasion
Women: more than 7/week or 3/occasion

84
Q

General, constitutional, “other” side effects of Li

A

Tremor, Confusion, Dizziness, Sedation
Thyroid Goiter (hypothyroidism)
Leukocytosis (stimulates M-CSF)
Seizures and Serotonin Syndrome

85
Q

Epipiolex

A

Oral CBD to treat Childhood epilepsies Lennox Gastaut and Dravet

86
Q

Sustained release methylphenidate-based stimulations

A

Methylphenidate-SR, methamphetamine tabs
Methylphenidate transdermal
Methylphenidate HCL, chewable
Methylphenidate XR, liquid

87
Q

Delayed ejaculation

A

Either delayed ejeculation or infrequent or absent ejaculation for 6 mos

88
Q

The 5 R’s of anti-depressants

A 
Response (or partial response)
Remission (sx free)
Relapse (return of sx after remission, before recovery)
Recovery (6-12 months of remission)
Recurrence (return of sx after recovery)
89
Q

Multi-acting receptor-target agents (2nd gen anti-psychotics)

A

Asenapine, Clozapine, Olanzapine, Quetiapine

Lumateperone

90
Q

Nefazodone MOA

A

Heterocyclic / Atypical antidepressant that acts as an SSRI and SARA (serotonin adrenergic receptor antagonist)

91
Q

Etiology of ADHD Executive Function Defect

A

DA/NE deficiency in PFC (Dorsal Anterior Mid-Cingulate Cortex)

92
Q

Indications for the variations of Fentanyl

A

Anesthesia

93
Q

butalbital indications

A

headache pain (half life ~35 hrs)

94
Q

Methylnaltrexone

A

u-antagonist that cannot readily cross BBB

Indicated for opioid-induced constipation

95
Q

Temazepam indications

A

insomnia (along with triazolam)

96
Q

Valproic Acid / Divalproex indications

A

Acute Bipolar I

Therapeutic [serum] 50 - 125 mcg/mL

97
Q

Which antidepressant is the only one used to treat OCD?

A

Fluoxetine

98
Q

Ramilteon MOA

A

Activates MT1 and 2 (melatonin) receptors in Suprachiasmatic nuclei of CNS for sleep disorders
Fluvoxamine inhibits its metabolism
Tasimelteon is similar

99
Q

First generation Anti-Psychotic MOA

A

Primary Block D2 post-synapse

also may block muscarinics, histaminics, a-adrenergics, D2 in nigrostriatal and tuberoinfundibulnar paths

100
Q

Diazepam metabolism

A

CYP3a4 (major)

101
Q

ADHD Dx tools

A

Computerized: TOVA, Conners
Checkists: Vanderbilt, Conners

102
Q

What SSRI has the most drug interactions (CYP450) and what has the least?

A

Most: Fluoxetine
Mid: Citalopram, sertraline vlazodone
Least: Vortioxetine and Escitalopram

103
Q

Binge drinking criteria for men and women

A

4+ drinks in an occasion for women, 5 for men

104
Q

Preferred analgesic for MI

A

Morphine

105
Q

Acamprosate

A

Alcoholism medication

Reduces desire to drink

106
Q

Binge Eating Disorder Criteria

A

1x/week for at least 3 mos, at least 3 of:
Binging when not hungry; eating rapidly; becoming uncomfortably full; eating alone because of it; guilt/depression/disgust after purge

107
Q

Manage a patient on nolly

A

Hypertonic saline
Ice bath
Benzos for psychomotor agitation and shivering
Cyproheptadine for Serotonin Symptom Signs

108
Q

Where are CB2 receptors found?

A

Immune cells, they modulate cytokine release

Anandamide and 2-AG have more CB-1 Affinity

109
Q

Barbiturate MOA

A

Binds GABAa and increases duration of Cl- opening
Hyperpolarizes cell for fewer APs
High doses can directly open Cl in absence of GABA
Inhibit some glutamate receptors

110
Q

Naltrexone MOA

A

u-opioid receptor antagonist (long acting)

111
Q

Drugs for treating acute methanol or ethylene glycol poisoning (2)

A

Ethanol

Fomepizole

112
Q

Barbiturates and sleep

A

Loss of REM. Made up for when discontinued gives sense of restlessness
RAS is particularly targeted by barbiturates

113
Q

Nabilone

A

THC capsule for chemo-induced N/V

114
Q

Bupropion

A

Tx ADHD, may increase risk of seizure

115
Q

Lamotrigine indications

A

Maintenance of Bipolar I and II

116
Q

Special ability of codeine

A

cough suppressant

117
Q

Capsule medications for ADHD

A

Amphetamine Sulfate
Dextroamphetamine XR
Lisdexamfetamine
Amphetamine (mixed)

118
Q

Non-benzo BZ-1 binders

A

Zolepidem
Eszopidone
Zaleplon

119
Q

Isolation of affect

A

voiding emotion from ideas and events.

Neurotic

120
Q

Oxycodone metabolism

A

CYP3A4

121
Q

First generation Anti-Psychotics (6)

A 
-azine's (Chlorprom/Fluphen/Thiorid)
Haloperidol
Loxapine
Molindone
Pimozide
Thiothixene
122
Q

Alcohol Detox order set

A

Benzos, anti-psychotics, fluids (Mg, K), Vitamins (thiamin, folic acid), Restraints if needed

123
Q

Cluster C personality disorders

A

Dependent
Avoidant (fear of rejection)
OCPD (inflexible, rigid, order and detail)

124
Q

Tuberoinfundibular pathway

A

Prolactin Release
Hypothalamus to infundibular region
Inhibited by DA (inhibition increases prolactin)

125
Q

Signs of overdose with Stimulants like blow

A

Agitation, HTN, Tach, seizures, death

126
Q

Toxic ingestion / OD of tricyclics

A

Coma, Cardiotoxicity, Convulsions

127
Q

ED

A

One of the three in almost all occasions for 6 mos:

Difficulty obtaining; difficulty maintaining to completion; decrease in rigidity

128
Q

ADHD first line treatment for 12-18

A

Medication (can add therapy too)

129
Q

ADHD first line treatment for age 6-11

A

medications AND/OR behavior therapy

130
Q

Side effects of NDRI’s (Bupropion)

A

SIEZURES (dose dependent, or those at risk)

Stimulation: agitation, insomnia, HTN/Tach/Tremors, Weight Loss

131
Q

Special MOA of bupropion

A

Heterocyclic / atypical antidepressant that also increases NE and DA pre-synaptic release

132
Q

What are the two u-blocking k-agonizing opioids?

A

Pentazocine

Butorphanol

133
Q

Benzo MOA

A

Increases Cl- channel opening on GABAa
Greater post-synaptic response to released GABA
local hyperpolarization means cell is less likely to fire

134
Q

What unique side effect is associated with Olanzapine?

A

DRESS: drug reaction w/ eosinophilia and systemic sx

135
Q

Midazolam

A

pre-operative sedation (this is versed)
acid is water soluble, then lipid soluble in vivo
associated with respiratory depression and cardiac arrest

136
Q

Criteria for antisocial personality disorder

A

Must be 18 years old with evidence of behavior patterns before 15 years old

137
Q

Risk factors for child maltreatment

A

Fussy, colicky infant
Behavioral problems (esp hyperactive)
Illness, Prematurity, non-biological caregiver

138
Q

Drugs to help gain weight from Anorexia

A

Olanzapine 2.5 - 10mg/day

139
Q

Medications to avoid when treating anorexia

A

Bupropion!! (seizures) (goes for bulimia as well)
TCAs (cardiotoxic)
Anti-psychotics and antidepressants (QT prolongation)

140
Q

Partial DA/5HT-1A receptor agonists for tx psychosis

A

Aripiprazole

Brexpiprazole

141
Q

Special MOA of Vilazodone

A

SSRI that is also a 5HT-1a partial agonist

142
Q

What should you determine in all patients considered for anti-psychotics?

A

Serum glucose, lipids, weight, BP, Waist circumference, FHx of metabolic and CV disease

143
Q

Drugs for treating acute alcohol withdrawal (4)

A

Diazepam (Valium)
Lorazepam
Oxazepam
Thiamine (B1)

144
Q

Premature ejaculation

A

finish within 1 minute almost every time for 6 mos

145
Q

Mirtazapine MOA

A

Heterocyclic/atypical antidepressant that is also an SSRI
Blocks pre-synaptic a2 receptors on NE and 5HT recs
Blocks Post-Synaptic 5HT-2/3 receptors
No SERT/Net Activity
Also H1 blockade (sedation)

146
Q

Sensate focus

A

No intercourse allowed for a while, eventually systematically reintroduce it

147
Q

Intellectualization

A

Focusing on / exaggerating intellectual aspect of a situation to avoid the anxiety part.
e.g. focusing on lab results of a crazy disease
Neurotic

148
Q

Liquid medications for ADHD

A

Amphetamine/Dyanavel XR

Dextroamphetamine Sulfate

149
Q

Rare side effects of ADHD stimulants

A

Priapism, Seizures (may lover convulsive threshold), sudden cardiac death, stroke/MI, leukoderma w/ Daytrana patch

150
Q

Treat extra-pyramidal side effects of first gen anti-psychotics

A

Anticholinergics (benztropine, trihexyphenidyl)

Antihistamines (diphenhydramine)

151
Q

Pimavanserin

A

Inverse 5HT agonist/antagonist

Parkinson’s Psychosis

152
Q

ADHD stimulant MOA

A

Block reuptake and inhibit VMAT
Increase NE, then DA, then 5-HT at increasing dose
D-isomers have more CNS activity

153
Q

DA-assoicated side effects of first gen anti-psychotics

A

Hyperprolactinemia (amenorrhea, galactorrhea, gyno, decreased libido)
Tardive dyskinesia/acute akathisia/dystonia/PD-like

154
Q

Treat stimulant overuse

A

HTN and hyperthermia: Phentolamine

Psychotic sx: Haloperidol

155
Q

Special MOA of selegiline

A

MAO inhibitor that is only selective at low doses. High doses are non-selective (like every other MAOi)
Anti-depressant version comes as a patch

156
Q

Presentation of anti-depressant withdrawl

A

Flu-like, Insomnia, Nausea, imbalance, sensory disturbance, hyperarousal

157
Q

Treat Tardive Dyskinesia associated with first gen anti-psychotics

A

Selective vesicular monoamine Transporter 2 (VMAT2) inhibitors: Valbenazine, Deutetrabenazine

158
Q

Tuberomammilary nucleus

A

Controls general states of metabolism and consciousness

159
Q

Flumazenil

A

Non-Benzo GABAa binder (blocks them)

Black box for seizures, esp. w/ long-term sedation or TCAs

160
Q

Regions of the brain protected by lithium

A

Anterior cingulate cortex
Superior temporal gyrus
Ventral prefrontal cortex
Hippocampus

161
Q

Frotteuristic disorder

A

touching or rubbing against a non-consenting person

162
Q

Diazepam indications

A

alcohol withdrawal, anxiety, muscle spasm, status epileptics

Off-label: chloroquine toxicity, sympathomimetic toxicity, opioid withdrawal, serotonin syndrome, vertigo

163
Q

Side effects of Tricyclics

A

Cardio: Tach, Ortho HPTN, Dysrhythmias
Anti-Cholinergic: Dry mouth, retention, blurred vision
CNS: sedation/fatigue, dizziness/seizures

164
Q

Recommended opioids w/ renal insufficiency

A

Fentanyl: safe
Methadone: kinda safe
Meperidine and Codeine: totally unsafe

165
Q

SERT

A

Does Pre-synaptic Serotonin Reuptake

166
Q

Acamprosate MOA

A

weak NMDA antagonist and GABAa agonist

167
Q

Opioids + MOAIs

A

Hyperpyrexic coma

168
Q

Special MOA of methadone

A

Not only a u and k agonist but also NMDA antagonist

169
Q

Pharmacotherapy for Bulimia

A
  1. Fluoxetine 60mg/day or taper up from 20
  2. SSRIs like Sertraline or Fluvoxamine. High dose
  3. TCAs, Topiramate, Trazodone, MAOIs
170
Q

ADHD First line treatment 4-5 years old

A

Parent and/or teacher administered behavioral therapy

171
Q

Phenobarbital indications

A

tonic-clonic seizures

172
Q

Male Hypoactive Sexual desire disorder

A

Must last 6 months

173
Q

What effects do Mu receptors have that Kappa don’t?

A

Respiratory depression
Euphoria
Physical dependence

174
Q

Methylphenidate MOA

A

Inhibits DA reuptake (doesn’t stimulate its release)

175
Q

What drug do you use to treat alcohol withdrawal if there is a known liver impairment?

A

Lorazepam

176
Q

Neuroleptic Malignant Syndrome

A

Rare Parkinson-like movement disorder with wide-spread muscle contraction
Associated with 2nd gen anti-psychotics
Tx w/ Dantrolene

177
Q

Off label use of Li

A

Reduces risk of suicide and all-cause mortality in patients with mood disorders

178
Q

Drugs for preventing alcohol abuse (3)

A

Acamprosate
Disulfiram
Naltrexone

NMSP (7 decks)

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