U. S.

ARMY MEDICAL DEPARTMENT CENTER AND SCHOOL

FORT SAM HOUSTON, TEXAS 78234

PHARMACOLOGY I

SUBCOURSE MD0804

EDITION 100
 DEVELOPMENT

This subcourse is approved for resident and correspondence course instruction. It

reflects the current thought of the Academy of Health Sciences and conforms to printed
Department of the Army doctrine as closely as currently possible. Development and
progress render such doctrine continuously subject to change.

The instructional systems specialist for the revision of this version of the subcourse was:
Mr. John Arreguin; AMEDDC&S, ATTN: MCCS-HCP, 3151 Scott Road, Fort Sam
Houston, TX 78234; DSN 471-8958; john.arreguin@amedd.army.mil.

The subject matter expert responsible for the revision of this version of the subcourse
was: MSG Karen K. Reynolds, MCCS-HCP, Pharmacy Branch, Department of Clinical
Support Services.

ADMINISTRATION

Students who desire credit hours for this correspondence subcourse must meet
eligibility requirements and must enroll through the Nonresident Instruction Branch of
the U.S. Army Medical Department Center and School (AMEDDC&S).

Application for enrollment should be made at the Internet website:

http://www.atrrs.army.mil. You can access the course catalog in the upper right corner.
Enter School Code 555 for medical correspondence courses. Copy down the course
number and title. To apply for enrollment, return to the main ATRRS screen and scroll
down the right side for ATRRS Channels. Click on SELF DEVELOPMENT to open the
application and then follow the on screen instructions.

In general, eligible personnel include enlisted personnel of all components of the U.S.
Army who hold an AMEDD MOS or MOS 18D. Officer personnel, members of other
branches of the Armed Forces, and civilian employees will be considered eligible based
upon their AOC, NEC, AFSC or Job Series which will verify job relevance. Applicants
who wish to be considered for a waiver should submit justification to the Nonresident
Instruction Branch at e-mail address: accp@amedd.army.mil.

For comments or questions regarding enrollment, student records, or shipments,

contact the Nonresident Instruction Branch at DSN 471-5877, commercial (210) 221-
5877, toll-free 1-800-344-2380; fax: 210-221-4012 or DSN 471-4012, e-mail
accp@amedd.army.mil, or write to:

NONRESIDENT INSTRUCTION BRANCH

AMEDDC&S
ATTN: MCCS-HSN
2105 11TH STREET SUITE 4191
FORT SAM HOUSTON TX 78234-5064
 TABLE OF CONTENTS

Lesson Paragraphs Page

INTRODUCTION

1. PROFESSIONAL REFERENCES IN PHARMACY

Section I. General.......................………………..…. 1-1--1-2 1-2
II. Pharmaceutical Journals……………. 1-3--1-4 1-2
III. Pharmaceutical Texts..........………… 1-5--1-6 1-4
IV. Electronic Drug Information Services 1-7 1-8

Exercises.....................................……………………... 1-9

2. ANATOMY, PHYSIOLOGY, AND PATHOLOGY IMPORTANT TO

PHARMACOLOGY
Section I. Principles of Anatomy and Physiology. 2-1--2-3 2-2
II. Cells.......................…………………… 2-4--2-7 2-3
III. Tissue........................………………… 2-8--2-9 2-8
IV. Skin..........................…………………. 2-10--2-15 2-11
V. Nature and Causes of Disease……… 2-16--2-17 2-17
VI. Treatment of Disease and Injury……. 2-18--2-20 2-22

Exercises.....................................……………………… 2-25

3. INTRODUCTION TO PHARMACOLOGY
Section I. Terms and Definitions Important in
Pharmacology……………………… 3-1--3-2 3-3
II. Introduction to Drugs.........…………. 3-3--3-4 3-5
III. Considerations of Drug Therapy…… 3-5--3-6 3-6
IV. Factors Which Influence Drug Action. 3-7--3-15 3-12

Exercises.....................................……………………… 3-21

4. LOCAL ANESTHETIC AGENTS

Section I. Background Information........……….. 4-1--4-6 4-3
II. Local Anesthetics and Their Clinical
Uses.…………………………………. 4-7--4-8 4-6

Exercises.....................................……………………… 4-11

MD0804 i
Lesson Paragraphs Page

5. THE CENTRAL NERVOUS SYSTEM

Section I. Basic Concepts of the Nervous
System................…………………… 5-1--5-2 5-3
II. The Neuron and its "Connections".... 5-3--5-9 5-4
III. The Human Central Nervous System 5-10--5-15 5-9

Exercises.....................................……………………… 5-16

6. AGENTS USED DURING SURGERY

Section I. General Anesthetic Agents.....……… 6-1--6-4 6-2
II. Other Agents Used During Surgery... 6-5--6-10 6-4

Exercises.....................................………………………. 6-6

7. SEDATIVE AND HYPNOTIC AGENTS

Section I. Background....................…………….. 7-1--7-2 7-3
II. Clinically Important Information
Concerning Sedative-Hypnotics.….. 7-3--7-7 7-3
III. Classification of Sedative- Hypnotic
Agents...............………………………. 7-8--7-9 7-7

Exercises.......................................,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, 7-10

8. ANTICONVULSANT AGENTS
Section I. Review of Epilepsy............…………. 8-1--8-3 8-3
II. Anticonvulsant Therapy........……….. 8-4--8-5 8-4

Exercises.....................................……………………… 8-7

9. PSYCHOTHERAPEUTIC AGENTS
Section I. Overview......................………………. 9-1--9-3 9-3
II. Antianxiety Agents……………………. 9-4--9-9 9-5
III. Antidepressant Agents.........………… 9-10--9-14 9-9
IV. Antipsychotic Agents..........………….. 9-15--9-20 9-14

Exercises.....................................……………………… 9-20

MD0804 ii
Lesson Paragraphs Page

10. CENTRAL NERVOUS SYSTEM (CNS) STIMULANTS

Section I. Background....................……………… 10-1--10-3 10-2

II. Cerebral or Psychomotor Agents........ 10-4--10-5 10-3
III. Analeptic Agents (Brain Stem
Stimulants)...................……………… 10-6--10-7 10-5
IV. Convulsants (Spinal Cord
Stimulants)...................……………… 10-8--10-9 10-6

Exercises.....................................……………………….. 10-7

11. NARCOTIC AGENTS

Section I. Background....................……………… 11-1--11-4 11-3
II. Narcotic Agents and Narcotic
Antagonists......... 11-5--11-7 11-5

Exercises.....................................……………………….. 11-9

ANNEX A. DRUG PRONUNCIATION GUIDE.............. A-1

MD0804 iii
 LIST OF FIGURES

Figure Page

2-1 Diagram of a cell membrane............................……………… 2-4

2-2 Diagram of the cell....................................…………………… 2-6
2-3 Pinocytosis...........................................………………………. 2-7
2-4 Phagocytosis...........................................……………………. 2-8
2-5 Epithelial tissue......................................…………………….. 2-9
2-6 Connective tissue......................................………………….. 2-9
2-7 Muscle tissue..........................................…………………… 2-10
2-8 Neuron and neuroglia..................................………………... 2-10
2-9 Structure of the skin (cross section).................…………….. 2-11
3-1 Dissolution of a drug..................................…………………. 3-13
3-2 The ionization of hydrochloric acid....................……………. 3-13
3-3 Illustration of drug transport concepts................…………… 3-15
3-4 Drug distribution within the body......................…………….. 3-16
3-5 The receptor-site theory...............................……………….. 3-19
3-6 A competitive antagonist...............................………………. 3-19
3-7 Relationship between dosage and drug effect.........………. 3-20
4-1 Mechanism of nerve impulse transmission................……… 4-4
5-1 A neuron...............................................……………………… 5-4
5-2 A synapse..............................................…………………….. 5-6
5-3 A neuronmuscular junction..............................……………… 5-7
5-4 The central nervous system (CNS).......................…………. 5-9
5-5 Human brain: A side view, B bottom view...............………. 5-10
5-6 The spinal column......................................…………………. 5-12
5-7 A cross section of the spinal cord.....................……………. 5-13
5-8 The meninges, as seen in side view of the CNS..........…… 5-14

LIST OF TABLES

4-1 An overview of the clinical uses of various local anesthetics 4-7

MD0804 iv
 CORRESPONDENCE COURSE OF THE
U.S. ARMY MEDICAL DEPARTMENT CENTER AND SCHOOL

SUBCOURSE MD08O4

Pharmacology I

INTRODUCTION

A patient who visits a physician or physician extender frequently receives a

prescription for a medication. That prescription is brought to the pharmacy to be filled.
The patient expects professional attention at the pharmacy. Part of that expectation
involves any caution or warning the patient should heed while taking the medication.

In your role you will serve as a source of drug information. Patients and friends
will ask you specific questions concerning the use of prescription and over-the-counter
medications. You must know the trade and generic names of literally hundreds of
medications. Furthermore, you must know the cautions and warnings associated with
many agents.

How are you to know this information about drugs? Certainly you have had
instruction which presented the basics of anatomy, physiology, and pharmacology. This
instruction has given you a sound foundation for learning more in these areas. This
subcourse will present instruction in anatomy, physiology, and pharmacology. The
material in anatomy and physiology is included to refresh your memory or to give you
additional information so you can better understand the pharmacology material.

This subcourse is not intended to be used as an authoritative source of drug

information. As you know, new drugs are constantly being discovered and new uses for
existing drugs are being found through research. Therefore, you must rely upon this
subcourse to review concepts or to learn new information. You are then to use other
sources (see lesson 1 of this subcourse) to gain new information as it is discovered.

Subcourse Components:

This subcourse consists of 11 lessons and an examination. The lessons are:

Lesson 1. Professional References in Pharmacy.

Lesson 2. Anatomy, Physiology, and Pathology Important to Pharmacology.

Lesson 3. Introduction to Pharmacology.

Lesson 4. Local Anesthetic Agents.

MD0804 v
 Lesson 5. The Central Nervous System.

Lesson 6. Agents Used During Surgery.

Lesson 7. Sedative and Hypnotic Agents.

Lesson 8. Anticonvulsant Agents.

Lesson 9. Psychotherapeutic Agents.

Lesson 10. Central Nervous System (CNS) Stimulants.

Lesson 11. Narcotic Agents.

Credit Awarded:

Upon successful completion of this subcourse, you will be awarded 14 credit

hours.

Lesson Materials Furnished:

Lesson materials provided include this booklet, an examination answer sheet,

and an envelope. Answer sheets are not provided for individual lessons in this
subcourse because you are to grade your own lessons. Exercises and solutions for all
lessons are contained in this booklet. You must furnish a #2 pencil.

Procedures for Subcourse Completion:

You are encouraged to complete the subcourse lesson by lesson. When you
have completed all of the lessons to your satisfaction, fill out the examination answer
sheet and mail it to the AMEDDC&S along with the Student Comment Sheet in the
envelope provided. Be sure that your social security number is on all correspondence
sent to the AMEDDC&S. You will be notified by return mail of the examination results.
Your grade on the exam will be your rating for the subcourse.

Study Suggestions:

Here are some suggestions that may be helpful to you in completing this
subcourse:

Read and study each lesson carefully.

Complete the subcourse lesson by lesson. After completing each lesson,

work the exercises at the end of the lesson, marking your answers in this booklet.

MD0804 vi
 After completing each set of lesson exercises, compare your answers with
those on the solution sheet which follows the exercises. If you have answered an
exercise incorrectly, check the reference cited after the answer on the solution sheet to
determine why your response was not the correct one.

As you successfully complete each lesson, go on to the next. When you have
completed all of the lessons, complete the examination. Mark your answers in this
booklet; then transfer your responses to the examination answer sheet using a #2
pencil.

Student Comment Sheet:

Be sure to provide us with your suggestions and criticisms by filling out the
Student Comment Sheet (found at the back of this booklet) and returning it to us with
your examination answer sheet. Please review this comment sheet before studying this
subcourse. In this way, you will help us to improve the quality of this subcourse.

MD0804 vii
 LESSON ASSIGNMENT

LESSON 1 Professional References in Pharmacy.

TEXT ASSIGNMENT Paragraphs 1-1 through 1-6.

LESSON OBJECTIVES After completing this lesson, you should be able to:

1-1. Given a description of a reference used in a

pharmacy and a list of pharmacy references,
select the particular reference being described.

1-2. Given a description of a situation requiring the

use of a pharmacy reference and a list of
pharmacy references, select the reference
most likely to contain the information required
in that situation.

SUGGESTION After studying the assignment, complete the exercises

at the end of this lesson. These exercises will help
you to achieve the lesson objectives.

MD0804 1-1
 LESSON 1

PROFESSIONAL REFERENCES IN PHARMACY

Section I. GENERAL

1-1. CONSIDERATIONS INVOLVED IN SELECTING A REFERENCE

a. At this point, you may already possess a strong background in pharmacology.

However, if you do not take steps to maintain and expand your knowledge in
pharmacology, you will quickly find yourself out-of-date in terms of drugs and drug
therapy. Furthermore, no individual knows everything about every drug used in
medicine. What happens when a drug-related question arises? What sources of drug
information should be readily available in the pharmacy? Which reference should be
consulted to find the answer to a specific question? These questions will be examined
in this lesson.

b. This lesson does not attempt to every available pharmaceutical reference.

Instead, this lesson will focus on some references that are commonly used in the
practical of pharmacy.

c. Some references, by design, are tailored to meet the needs of those persons
who have strong backgrounds in pharmacy, physiology, and/or medicine. Therefore,
you should carefully select references that are written to a level comparable to your
background and experience. An individual who lacks a technical background can
become frustrated when reading a highly technical reference.

1-2. HUMAN SOURCES

Use human sources of information. Most health care professionals are more than
willing to share their knowledge and experience. Carefully identify those professionals
who are willing to instruct you and/or answer your questions. Also, you should be
willing to share your knowledge and experience with others.

Section II. PHARMACEUTICAL JOURNALS

1-3. OVERVIEW

a. Journals serve as excellent sources of drug information. For the most part,
the information contained in journals is up-to-date. Journals reflect the state of the art of
that discipline at that point in time.

MD0804 1-2
 b. Some journals are designed to be read by many members of the medical
community. Other journals are specifically written to meet the needs of the individuals
who are directly involved with the field of pharmacy. Further, some journals are
especially written for pharmacy personnel, who work in hospitals, while others are
designed for those who work in retail.

c. As you know, there are many journals written for people who work in the
medical field. Some journals are designed to be read by the members of many medical
disciplines, while other journals focus on a particular job specialty (that is, nursing,
pharmacy, or medical technology). Many journals are written to meet the needs of
those in pharmacy practice. Some of these journals are especially written for pharmacy
personnel who work in an inpatient setting, while other journals are designed for those
who work in an outpatient environment.

d. To meet your individual needs, you should become familiar with some
frequently used pharmacy journals, the type of information each contains, and the
particular group(s) for whom the journal is written.

e. As you read a journal, do not limit yourself to the main articles. Letters to the
editor, advertisements, and job announcements also provide information, which can be
very helpful. For example, these parts of a journal can provide up-to-date information
on new products, changes in old products, as well as short- and long-term trends in the
state of the art of pharmacy practice.

1-4. SPECIFIC JOURNALS

a. The American Journal of Health-Systems Pharmacists. The American

Journal of Health-Systems Pharmacists (AJHP) is an official publication of the American
Society of Health-Systems Pharmacists. It is published on a twice monthly basis. As
the name implies, this journal is tailored to pharmacy personnel who practice in a
hospital setting. The AJHP can be read and understood by almost all-medical
personnel who have a background in pharmacy. The AJHP contains information on
drug therapy, new and innovative pharmacy practices, and other topics of particular
interest to hospital pharmacy personnel.

b. Hospital Pharmacy. This journal is a monthly publication of the L. B.

Lippincott Company. Although designed for hospital pharmacists, the journal's contents
can be read and understood by medical personnel who have a background in
pharmacy. Hospital Pharmacy contains information on innovative pharmacy procedures
(that is, unit dose), drug therapies, and other topics of general interest. One section,
"Medication Error Reports," provides a constant reminder of the types of medication
errors that occur in a hospital.

c. The American Journal of Intravenous Therapy. The McMahon Publishing

Company on a bimonthly basis publishes this journal. The journal is tailored toward
those persons directly involved with the preparation and/or administration of intravenous

MD0804 1-3
products. Therefore, it is particularly useful to the pharmacy personnel who work in the
unit-dose/sterile product area. Experienced sterile product prepares should be able to
read and understand this journal. Articles in this journal focus on the theoretical and
practical considerations of intravenous therapy.

d. American Pharmacy. This journal is the official publication of the American

Pharmaceutical Society. It is published on a monthly basis. It is especially designed for
pharmacists who work in an outpatient environment, although the journal contains
useful information for all pharmacy personnel. Articles in American Pharmacy cover a
variety of pharmacy-related topics. For example, changes in drug laws, changes in
drug therapies, and perspectives on the various aspects of health-care management
are found in the journal

e. Clinical Pharmacology and Therapeutics. This journal is the official

publication of the American Society for Clinical Pharmacology and Therapeutics and the
American Society for Pharmacology and Experimental Therapeutics. As the name
implies, the journal is designed to communicate up-to-date drug information and
research related to pharmacology to those medical personnel who have an in-depth
background in pharmacology, therapeutics, and the basic sciences.

f. The Journal of Clinical Pharmacology. This journal is the official

publication of the American College of Clinical Pharmacology. This publication is
designed for those medical personnel who have an excellent background in
pharmacology, therapeutics, and the basic sciences. Articles focus on clinical research
pertaining to pharmacology.

Section III. PHARMACEUTICAL TEXTS

1-5. OVERVIEW

As with journals, many texts are available to pharmacy personnel. Some texts
require a certain amount of background knowledge in physiology, anatomy, and/or
pharmacology. It is important for you to recognize your background strengths and
weaknesses before you begin to search for a text to answer a particular question. You
should also be familiar with the subjects discussed in each of these texts. Being able to
identify a text on your knowledge level, which can provide you with the answer you are
seeking, can pay dividends in terms of saved time and reduced frustration.

1-6. SPECIFIC TEXTS

a. The Physicians' Desk Reference. The Physicians' Desk Reference (PDR)

is published on an annual basis by the Medical Economics Company. The drug
manufacturers, whose products are listed in the reference, prepare the information
contained in the PDR. For the most part, the drug monographs in the PDR come

MD0804 1-4
directly from the package inserts for the drugs. The publisher supplies periodic
supplements to the text. The PDR is written primarily for physicians; however, many
medical personnel have the background to use the reference. The PDR is divided into
the following nine areas:

(1) The Manufacturers' Index. This section supplies information (that is,
address and telephone number) on the manufacturers who supplied prescribing
information for the PDR.

(2) The Product Name Index. This section provides an alphabetical listing
of the drug products by trade name and the page number where the drug product
information may be located.

(3) The Product Classification Index. This section of the PDR provides an
alphabetical listing of the drug products by their therapeutic classifications. Page
numbers for locating the drug products are provided for quick reference.

(4) The Generic and Chemical Name Index. In this section, the products
are categorized under generic and chemical name headings according to their principal
components.

(5) The Product Identification Section. This section of the PDR provides a
pictorial display (by manufacturer) of capsules, tablets, and containers. This area can
be used to identify products that one does not immediately recognize by appearance.

(6) The Product Information Section. Manufacturer lists this alphabetical

arrangement of over 2,500 pharmaceuticals. The drug products are fully described in
the following areas: common names, generic compositions, chemical names,
composition, action and uses, administration and dosage, contraindications,
precautions, side effects, supplied, and other information concerning use.

(7) The Diagnostic Product Information Section. The PDR focuses on the
descriptions of diagnostic products. This section of PDR focuses on the descriptions of
diagnostic products. The products are listed alphabetically.

(8) The Poison Control Centers Section. This section contains a list of
poison control centers and their emergency telephone numbers.

(9) The Guide to Management of Drug Overdose Section. This section is

located on the inside back cover of the PDR. The aim of this section is to provide the
physician with useful information on the management of drug overdoses. Of course,
any individual who is suspected to have ingested an overdose of medication should be
taken to the nearest medical treatment facility for prompt attention and treatment.

b. Remington's Pharmaceutical Sciences. Mack Publishing Company

publishes this text. Although written for pharmacists, who work in any pharmacy setting,

MD0804 1-5
the reference can be read, understood, and used by other medical/pharmacy personnel.
Remington's deals with the theory and practice of the art of pharmacy. It provides
essential information about drugs. Furthermore, the text is especially useful as an
information source for the compounding of extemporaneous products.

c. The Pharmacological Basis of Therapeutics. Louis Goodman and Alfred

Gilman wrote this text. This reference is written for medical personnel who have a
strong background in physiology and pharmacology. Indeed, it is not written for a
reader who has a weak or limited background in the sciences. The clinical application
of drug knowledge is the aim of the text. The book is divided into major sections based
upon therapeutic categories. Sections are subdivided into chapters that focus on
specific drug uses. Each chapter has an excellent overview of the therapeutic area and
a discussion of considerations pertinent to the topic being examined.

d. American Medical Association Drug Evaluations. The American Medical

Association (AMA) Department of Drugs prepares this text. The book is written on a
level that can be read and understood by medical personnel who have a good
background in physiology and pharmacology. American Medical Association Drug
Evaluations is divided into sections based upon therapeutic classifications. Each
chapter has an introductory statement that discusses considerations involved with that
therapeutic category. Further, each chapter contains informative monographs on drugs
pertinent to that category. Dosage information is provided under each drug monograph.

e. Drug Interactions. Philip D. Hansten wrote this text. It is written for the
health-care provider who is concerned about drug interactions and/or the effects upon
clinical laboratory tests by specific agents. Section one of the book is divided into
chapters based upon drug interactions of particular therapeutic categories. Section two
deals with the impact of certain medications upon specific clinical laboratory test results.

f. Dorland’s Illustrated Medical Dictionary. W. B. Saunders Company

publishes this reference. This medical dictionary is a useful reference for all medical
personnel. In particular, the dictionary can be used by pharmacy personnel whenever
unfamiliar medical terms are encountered.

g. Handbook of Injectable Drugs. This book was written by Lawrence A.

Trissel. It is especially tailored to meet the needs of pharmacy personnel who are
directly involved with the preparation of intravenous admixtures. The text is easily used;
however, care should be exercised when using the charts provided in the reference.
The drugs listed are limited to injectable products. For each drug, a monograph is
provided which includes information on drug concentration, stability, pH, dosage,
compatibility, and incompatibility.

h. The American Hospital Formulary Service. The American Hospital

Formulary Service (AHFS) is a two-volume collection of drug monographs published by
the American Society of Health-Systems Pharmacists. The AHFS is designed to be
used by all pharmacy personnel. It is divided into sections based upon therapeutic

MD0804 1-6
categories. A general statement pertaining to the therapeutic category is included at the
beginning of each individual section. Individual drug monographs that present
information on drug chemistry, dosage, and preparations follow this general statement.
Information on the drug monographs is kept current by periodic supplements to the
AHFS.

i. The American Drug Index. Norman Billups writes the American Drug Index
(ADI). The book is designed to provide information to all medical personnel in general
and to pharmacy personnel in particular. The monographs contained in the ADI are
listed in alphabetical order. Both trade and generic names are provided. The
monographs in the ADI do not provide information on actions and dosage. Instead,
specific information (that is, manufacturer, amount of each ingredient present in the
dosage form and the use of the drug) is provided for each product listed.

j. Pharmaceutical Calculations. Mitchell J. Stoklosa wrote this reference. It

was designed for use as a calculation text. Although it is not a pharmacology text, it is
useful to rely on such a reference when questions on dosage calculations arise.
Periodic review of calculation concepts is helpful to all pharmacy personnel.

k. Facts and Comparisons. Facts and Comparisons, Inc wrote this reference.
It is designed to be used by most medical personnel in general and by pharmacy
personnel in particular. Facts and Comparisons are organized into twelve main
chapters by drug use. Drugs and/or drug products are listed together in such a way as
to provide rapid comparisons between drugs or products that are similar in use or
content. Individual drug monographs provide comprehensive information on drug
actions, contraindications, warnings and precautions, drug interactions, adverse
reactions, over-dosage, and administration and dosage. The publisher provides
monthly updates of this loose-leaf text. These updates ensure that the most recent
information on new products and developments in drug therapy are available to the
reader. Moreover, the publisher has available a slide-tape presentation which provides
information on the use of the reference.

l. Handbook of Poisoning: Diagnosis and Treatment. This text was written

by Dr. Robert H. Dreisbach and published by Lange Medical Publications. This
reference provides a concise summary of the diagnosis and treatment of many poisons.
The book is divided into chapters that discuss such topics as general considerations
(that is, prevention and management), agricultural poisons, industrial hazards,
household hazards, medicinal poisons, and animal and plant hazards. Information on
first-aid measures is found on the front and back covers of the text.

m. The United States Pharmacopoeia and The National Formulary. The

United States Pharmacopoeia and The National Formulary reference contains
standards and tests for quality, purity, strength, packaging, and labeling of drugs in the
United States. This reference is designed to be used by researchers and pharmacists
who are concerned about the standards that have been established for drugs. The
United States Pharmacopoeia and The National Formulary reference has information

MD0804 1-7
that is useful for personnel who are involved in both inpatient and outpatient pharmacy
practice. Annual supplements to the reference ensure that it contains the latest
information on the state of the art of pharmacy.

n. United States Pharmacopoeia Dispensing Information. The United States

Pharmacopoeia Convention, Inc publishes the United States Pharmacopoeia
Dispensing Information annual publication. This reference is designed to be used by
individuals who dispense drugs and by persons who administer drugs after the drugs
have been prescribed. The following information about a drug is discussed in the text:
category of use, precautions to use, (that is, drug interactions and medical warnings),
drug preparation immediately prior to administration, side effects with an indication of
their significance, guidelines for patient consultation on safe and effective use of the
drug, dosing information, and requirements for packaging and storage. One section,
"Advice for the Patient," provides guidelines for patient use of the drug. These
guidelines are written in lay terms. Bimonthly updates keep the information in the
United States Pharmacopeial Dispensing Information current.

Section IV. ELECTRONIC DRUG INFORMATION SERVICES

1-7. OVERVIEW

As with journals and texts, electronic forms of drug information are now available
to pharmacy personnel. Most of the reference texts discussed previously are available
on CD-ROM for single or network use. Some examples are Facts and Comparisons,
the PDR, and Clinical Pharmacology. The advantages of this form of information
include easy access to information and timely updates (monthly, quarterly,
semiannually). Micromedex is another information system available as a subscription
at most military pharmacies. Micromedex provides drug information monographs, drug
identification (Identidex), poison information (Poisindex), material safety data sheets,
Martindale’s Extra Pharmacopeoia, AfterCare Notes, as well as many other options.
The majority of these systems are user friendly and easy to use with minimal
orientation.

The most current information about drug use, even prior to approval by the Food
and Drug Administration, is available in medical journals. Medical journals are
accessed through on-line searches such as Medline and Grateful Med. Many U.S.
medical teaching institutions and major medical centers offer search capabilities via the
Internet or through their respective medical libraries. The use of on-line information
services often requires a thorough orientation to perform a good search.

Continue with Exercises

MD0804 1-8
EXERCISES, LESSON 1

INSTRUCTIONS: Answer the following exercises by marking the lettered response

that best answers the exercise, by completing the incomplete statement, or by writing
the answer in the space provided at the end of the exercise.

After you have completed all of these exercises, turn to "Solutions to Exercises" at
the end of the lesson and check your answers. For each exercise answered incorrectly,
reread the material referenced with the solution.

1. A friend has brought several capsules for you to identify; however, at first
glance you are unable to name the particular medication. Select, references below, the
reference you would use to identify the capsule.

a. The Physicians' Desk Reference.

b. Dorland's Illustrated Medical Dictionary.

c. The United States Pharmacopoeia and the National Formulary.

d. America Medical Association Drug Evaluations.

2. Select, from the list below, the reference that deals with the theory and
practice of the art of pharmacy. It is especially useful as an information source for the
extemporaneous compounding of products.

a. The Pharmacological Basis of Therapeutics.

b. The United States Pharmacopoeia Dispensing Information.

c. The American Hospital Formulary Service.

d. Remington's Pharmaceutical Sciences.

3. Select, from the list below, the journal that focuses on the sterile
products/unit-dose area of the hospital pharmacy.

a. The American Journal of Health-Systems Pharmacists.

b. Hospital Pharmacy.

c. The American Journal of Intravenous Therapy.

d. American Pharmacy.

MD0804 1-9
 4. Select, from the references below, the journal tailored to meet the needs of
pharmacy personnel whose practice is in a hospital setting. This journal contains
information on drug therapy and new and innovative pharmacy practices.

a. The American Journal of Intravenous Therapy.

b. The American Journal of Health-Systems Pharmacists.

c. The Journal of Clinical Pharmacology.

d. American Pharmacy.

5. Select, from the list below, the journal that primarily contains articles related
to clinical research in pharmacology.

a. The Journal of Clinical Pharmacology.

b. American Pharmacy

c. The Pharmacological Basis of Therapeutics.

d. Hospital Pharmacy.

6. Select, from the list below, the journal that is tailored to meet the needs of
pharmacists who work in an outpatient pharmacy environment.

a. The Journal of Clinical Pharmacology.

b. Clinical Pharmacology and Therapeutics.

c. The Physicians' Desk Reference.

d. American Pharmacy.

MD0804 1-10
 7. You have a question pertaining to the effect upon a particular laboratory test
by a specific medication. From the list below, select the reference most likely to provide
you the information you need.

a. America Medical Association Drug Evaluation.

b. Drug Interactions.

c. Handbook on Injectable Drugs.

d. Remington's Pharmaceutical Sciences.

8. During your reading of a journal article, you encounter the word

"retroinfection." From the references below, select the reference you would use to find
the meaning of that term.

a. Dorland's Illustrated Medical Dictionary.

b. America Medical Association Drug Evaluations.

c. Remington's Pharmaceutical Sciences.

d. Handbook on Injectable Drugs.

9. A friend of yours is concerned about the safety of his children. It seems that
he believes he has many poisonous plants and chemicals in his home. From the list
below, select the reference most likely to give him the information he needs to make a

a. Facts and Comparisons.

b. The American Hospital Formulary Service.

c. Handbook of Poisoning: Diagnosis and Treatment.

d. The American Drug Index.

MD0804 1-11
 10. Select, from the list below, the reference that contains a section, which
provides pharmacy personnel with specific information that should be communicated to
the patient concerning the use of a particular drug.

a. The American Drug Index.

b. Handbook of Poisoning: Diagnosis and Treatment.

c. The Pharmacological Basis of Therapeutics.

d. The United States Pharmacopeia Dispensing Information.

Check Your Answers on Next Page

MD0804 1-12
SOLUTIONS TO EXERCISES, LESSON 1

1. a The Physicians’ Desk Reference. (para 1-6a)

2. d Remington’s Pharmaceutical Sciences. (para 1-6b)

3. c The American Journal of Intravenous Therapy. (para 1-4c)

4. b The American Journal of Health-Systems Pharmacists. (para 1-4a)

5. a The Journal of Clinical Pharmacology. (para 1-4f)

6. d American Pharmacy. (para 1-4d)

7. b Drug Interactions. (para 1-6e)

8. a Dorland's Illustrated Medical Dictionary. (para 1-6f)

9. c Handbook of Poisoning: Diagnosis and Treatment. (para 1-6l)

10. d The United States Pharmacopoeia Dispensing Information. (para 1-6n)

End of Lesson 1

MD0804 1-13
 LESSON ASSIGNMENT

LESSON 2 Anatomy, Physiology, and Pathology Important

to Pharmacology.

TEXT ASSIGNMENT Paragraphs 2-1 through 2-20.

LESSON OBJECTIVES After completing this lesson, you should be able to:

2-1. Given a term pertaining to anatomy, physiology

or pathology and a group of definitions, select
the definition of that term.

2-2. Given the name of a system of the body and a

group of functions, select the function of that
system.

2-3. Given the name of a structural component of a

cell and a group of descriptions, select the
most appropriate description of that structure.

2-4. Given the name of a type of tissue and a group

of descriptions, select the most appropriate
description of that type of tissue.

2-5. Select from a list of functions the function of

the skin.

2-6. Given the name or type of a disease of the skin

and a group of descriptions, select the best
description of that particular disease.

2-7. Given a cause of disease and a group of

statements discussing various causes of
disease, select the statement that best
describes that cause.

SUGGESTION After studying the assignment, complete the exercises

at the end of this lesson. These exercises will help
you to achieve the lesson objectives.

MD0804 2-1
 LESSON 2

ANATOMY, PHYSIOLOGY, AND PATHOLOGY IMPORTANT TO PHARMACOLOGY

Section I. PRINCIPLES OF ANATOMY AND PHYSIOLOGY

2-1. ANATOMY AND PHYSIOLOGY

a. Anatomy is the study of the structure of the body. Often, you may be more
interested in functions of the body. Functions include digestion, respiration, circulation,
and reproduction. Physiology is the study of the functions of the body.

b. The body is a chemical and physical machine. As such, it is subject to certain

laws. These are sometimes called natural laws. Each part of the body is engineered to
do a particular job. These jobs are functions. For each job or body function, there is a
particular structure engineered to do it.

c. In order to read and understand basic concepts in pharmacology, you must

be familiar with certain topics in anatomy, physiology, and pathology. It is not the intent
of this subcourse to discuss these areas in detail. Instead, the content of this lesson
should give you the knowledge required to complete this subcourse. If you want, you
can read texts and references that discuss these areas in detail.

2-2. ORGANIZATION OF THE HUMAN BODY

The human body is organized into cells, tissues, organs, organ systems, and the
total organism.

a. Cells are the smallest living unit of body construction.

b. A tissue is a grouping of like cells working together. Examples are muscle

tissue and nervous tissue.

c. An organ is a structure composed of several different tissues performing a

particular function. Examples include the lungs and the heart.

d. Organ systems are groups of organs, which together perform an overall

function. Examples are the respiratory system and the digestive system.

e. The total organism is the individual human being. You are a total organism.

MD0804 2-2
2-3. SYSTEMS OF THE BODY

A system is a combination of parts or organs, which, in association, perform some

particular function. The systems of the body are as follows:

a. Integumentary. Covers and protects the body from drying, injury, and
infection, and has functions of sensation, temperature regulation, and excretion.

b. Skeletal. Provides a framework for the body, supports the organs, and
furnishes a place of attachment for muscles.

c. Muscular. Provides the force for the motion and propulsion of the body.

d. Respiratory. Absorbs oxygen from the air and gives off the carbon dioxide
produced by the body tissues.

e. Cardiovascular. Functions in the transportation of blood throughout the

body.

f. Lymphatic (System of Vessels and Glands). Returns protein and fluid to

the blood from the various body tissues; also furnishes the body with protective
mechanisms against pathogenic organisms.

g. Gastrointestinal. Digests and absorbs food substances and excretes waste

products.

h. Genitourinary. Excretes and transports urine (urinary), and elaborates and

transports reproductive cells and sex hormones (reproductive).

i. Nervous and Special Senses. Gives the body awareness of its

environment, and enable it to react to that environment.

j. Endocrine. Manufactures hormones, which are active in the control of much

of the body activity and behavior.

Section II. CELLS

2-4. INTRODUCTION

Each of the 100 trillion cells in a human being is a living structure that is capable
of surviving indefinitely. In most instances, the cell can reproduce itself provided its
surrounding fluids remain intact. To understand the function of the various organs and
other structures of the human body, it is essential that you first understand the basic
organization of the cell and the functions of its component parts.

MD0804 2-3
2-5. STRUCTURAL COMPONENTS OF A CELL

The cell was once viewed as a bag of fluid, enzymes, and chemicals. Now, we
understand that the cell is an extremely complex living the entity. With the advent of
electron microscopy in the early 1940's, several distinct cellular structures called
organelles were clearly recognized. A typical animal cell contains several types of
these organelles (Figure 2-1). Each organelle has an important role in the functioning of
the cell. It is important for you to become familiar with these organelles.

a. Cell Membrane. (Animal cells do not have cell walls; they have cell
membranes only. Plant cells have both cell walls and cell membranes.)

(1) Practically all the structures within the cell, as well as the cell itself, are
lined with a porous, elastic membrane. The cell membrane is composed primarily of
lipids (fats) and proteins that are arranged in layers at right angles to each other
(Figure 2-1).

Figure 2-1. Diagram of a cell membrane.

(2) The lipids of the cell wall are composed of two portions: a long
hydrocarbon chain (that is insoluble in water) and a glycerol-phosphate head (that is
soluble in water). The long chains are in the center of the protein and the glycerol-
phosphate group is attached to the end of the protein.

(3) The cell membrane contains many pores. It is through these pores that
lipid-insoluble particles, such as water and urea, pass between the interior and the
exterior of the cell. Diffusion experiments have shown that particles up to approximately
8-Angstrom units in diameter pass through the pores freely.

(4) The main function of the cell membrane is to regulate the flow of
substances into and out of the cell. This regulation of flow is accomplished by the
membrane's selective permeability. That is, only certain substances may pass through

MD0804 2-4
the pores. This is important, since the cell must obtain the nutrients for its growth from
the extracellular fluid (fluid outside the cell) and discard waste products back into the
extracellular fluid.

b. Cytoplasm (Figure 2-2). Cytoplasm is the fluid or semifluid contained inside

the cell membrane, but outside the nucleus. The cytoplasm functions as a medium to
contain many substances, such as fats, glucose, proteins, water, and electrolytes. The
clear portion of the cytoplasm is called hyaloplasm. Located within the cytoplasm are
the organelles that perform highly specialized functions in the cell.

c. Nucleus (Figure 2-2). The nucleus is the control center for the cell. It
controls the reproduction of the cell as well as the chemical reactions that occur within
the cell. The nucleus contains large amounts of deoxyribonucleic acid (DNA). The
DNA is responsible for controlling the characteristics of the protein enzymes of the
cytoplasm, and thus, it controls cytoplasmic activities. The DNA is also responsible for
controlling the hereditary characteristics of individuals.

d. Mitochondria (Figure 2-2). The mitochondria may be called the power

house" of the cell. The mitochondria are the site of cell respiratory activity. The
mitochondria are found in the cytoplasm. They are usually located near energy
requiring structures (that is, nodes of nerves, contracting ligaments of muscles, active
transport mechanisms in membranes and ribosomes). Their numbers depend on the
amount of energy required by the cell to perform its function. Several infoldings of the
inner unit membrane form shelves on which practically all of the oxidative enzymes of
the cell are said to be absorbed. When nutrients and oxygen meet these enzymes, they
combine to form carbon dioxide, water, and energy. The liberated energy is used to
synthesize ATP (adenosine triphosphate). This ATP then diffuses throughout the cell
and releases its energy whenever it is needed for cellular functions.

e. Lysosomes (Figure 2-2). Lysosomes may be called the digestive organs of

the cell. Lysosomes are surrounded by a membrane and contain digestive (hydrolytic)
enzymes. When this membrane ruptures, it releases the digestive enzymes that will
break down particles or molecules located near the ruptured area. For example, they
surround pinocyticle vesicles containing food particles and digest them. If a sufficient
number of lysosomes rupture, the entire cell may be digested. When the lysosomes
function properly, products of digestion can be used by the cell.

f. Nucleoli (Figure 2-2). In the nucleus of many cells, there may be one or
more structures called nucleoli. The nucleoli do not have a limiting membrane, as do
most organelles. These structures are primarily aggregate of loosely bound granules
composed mainly of ribonucleic acid (RNA). Hereditary units called genes are thought
to synthesize and store in the nucleolus. This stored RNA diffuses into the cytoplasm
where it controls cytoplasmic function. Therefore, the main functions of the nucleolus
are the synthesis of RNA and the storage of RNA.

MD0804 2-5
 Figure 2-2. Diagram of the cell.

g. Endoplasmic Reticulum (Figure 2-2). The endoplasmic reticulum is a

network of tubules and vesicles (saclike structures) in the cytoplasm. The inside of the
tubules and vesicles is filled with endoplasmic matrix, a fluid medium, which is different
from the fluid outside the endoplasmic reticulum. In the matrix, there are enzyme
systems. The first function of the endoplasmic reticulum is to use these enzymes to
synthesize various substances (that is, lipids). The endoplasmic reticulum is connected

MD0804 2-6
to the nuclear membrane and, in some cases, it is connected directly through small
openings to the exterior of the cell. A second function of the endoplasmic reticulum is to
transport various substances, through the vast network of tubules, from one part of the
cell to another area of the cell. A third function of the endoplasmic reticulum is to store
various substances within the cell.

h. Ribosomes (Figure 2-2). Ribosomes are small particles that are usually
attached to the endoplasmic reticulum. Ribosomes are the site of protein synthesis and
are referred to as "protein factories" of the cell. Ribosome is composed mainly of
ribonucleic acid (RNA).

2-6. PINOCYTOSIS

Pinocytosis is the engulfing of small particles or fluids by the cell. That is, when
these substances meet the cell membrane, they cause the membrane to form a
channel. At the end of this channel, small vesicles form. These vesicles contain the
substance and some extracellular fluid. The vesicle then breaks away from the rest of
the membrane and migrates toward the center of the cell. Figure 2-3 illustrates the
process of pinocytosis.

1. Particles contact cell

membrane.

2. Vesicle (saclike structure) is

formed.

3. Vesicle containing the

particles passes into the cell.

Figure 2-3. Pinocytosis.

MD0804 2-7
2-7. PHAGOCYTOSIS

Phagocytosis is the engulfing of solid particles by a cell. For example, bacteria

could be surrounded and ingested by a cell. The mechanism of phagocytosis is similar
to that of pinocytosis. However, in phagocytosis, the cell acts to surround the particle
with the cell membrane and form a vesicle (sac) containing the particle and cytoplasm.
Then, the vesicle breaks away from the cell wall and moves toward the center of the
cell. Figure 2-4 illustrates phagocytosis.

Figure 2-4. Phagocytosis.

Section III. TISSUE

2-8. DEFINITION OF TISSUE

A tissue is composed of a group of cells, which are the same or similar in nature.
For example, liver cells are bound together into a tissue called liver, and bone cells are
bound together with a large amount of lime salts to form bony tissue. The various
tissues of the body have different characteristics because the cells that make up these
tissues are different both in structure and in function.

2-9. TYPES OF TISSUE

There are four primary tissues as follows: epithelial, connective, muscular, and
nervous.

a. Epithelial (Figure 2-5). This tissue covers the outer surface of the body and
forms the lining of the intestinal and respiratory systems. A special form called
endothelium lines the heart and blood vessels. As serous membranes, it lines the
cavities of the abdomen, the chest, and the heart, and covers the organs that lie in
these cavities. Epithelial tissue forms the glands and parts of the sense organs.
According to its location, this tissue has different functions. As the skin, it protects
underlying structures; in the small intestine, it absorbs; in the lungs, it is a highly
permeable membrane; in glands, it secretes; and in the kidneys and liver, it both
secretes and excretes. There are three types of epithelial tissue based on the shape of
the cells. These are squamous (flat), cuboidal, and columnar. These cells are further

MD0804 2-8
designated as simple if they are arranged in a single layer, or stratified if arranged in
layers.

Figure 2-5. Epithelial tissue.

b. Connective (Figure 2-6). This tissue is widely distributed throughout the

body. It binds other tissues together and supports them, forms the framework of the
body, and repairs other tissues by replacing dead cells. Principal types of connective
tissue are osseous (bony), cartilaginous, fibrous, elastic, and fatty. Areolar tissue,
which lies under the skin and serves to fill many of the sharp corners and small spaces
of the body, is a mixed type composed of fibrous, elastic, and fatty connective tissue.

Figure 2-6. Connective tissue.

MD0804 2-9
 c. Muscular (Figure 2-7). This tissue is of three kinds: voluntary (striated),
involuntary (smooth), and cardiac.

Figure 2-7. Muscle tissue.

d. Nervous (Figure 2-8). This tissue is made up of nerve cells (neurons) and
supporting structure of nervous tissue (neuroglia).

Figure 2-8. Neuron and neuroglia.

MD0804 2-10
 Section IV. SKIN

2-10. DESCRIPTION OF SKIN

The skin is a tough, elastic structure covering the entire body (Figure 2-9). It is
made up of two principal layers, the epidermis or cuticle and the dermis or true skin.
The epidermis, which overlies the dermis, is itself composed of a superficial layer and
an inner layer. The superficial or horny layer consists of dead cells that are constantly
being worn off. These are replaced from the living cells that form the inner layer. The
dermis is the thicker part of the skin, and consists of connective tissue containing blood
vessels, nerve endings, sweat glands, sebaceous glands, and hair follicles. The dermis
is held in place by a layer of areolar connective tissue.

Figure 2-9. Structure of the skin (cross section).

2-11. FUNCTIONS OF THE SKIN

a. Protection. The skin protects underlying structures by acting as a

mechanical barrier. When the skin is broken, bacteria may invade the body through the
opening.

b. Regulation of Body Temperature. The skin regulates the body temperature

by controlling heat loss in two ways:

(1) The blood vessels in the skin change in size; they dilate and bring warm
blood to the surface to increase heat loss, and they constrict to decrease heat loss.

MD0804 2-11
 (2) The skin produces sweat which, when it evaporates, cools the body
surface.

c. Sensory Perception. The skin acts as an organ of perception. It contains

sensory nerve endings which are specialized to detect heat, cold) pressure (touch), and
pain.

d. Excretion. The excretion of waste products through the skin is a function of

the sweat glands that open by a duct onto the skin surface. The opening is called a
pore. These glands are distributed in large numbers over the body and secrete an
average of a quart of perspiration each day; although, the amount varies considerably,
depending on the temperature and humidity of the atmosphere, and the amount of
exercise performed by the individual. Perspiration is continuous, but it may be so slow
and the sweat may evaporate so quickly that it is imperceptible. Sweat consists chiefly
of water (99 percent), with small quantities of salts and organic materials which are
waste products. Skin also secretes a thick substance, sebum. This material is the
product of the sebaceous glands, and its purpose is to lubricate the skin and keep it soft
and pliable.

e. Absorption. Although not one of its normal functions, the skin is capable of
absorbing water and other substances. Physicians take advantage of this fact by
prescribing local application of certain drugs.

2-12. APPENDAGES OF THE SKIN

The appendages of the skin include the glands (sweat and sebaceous), the hair,
and the nails. Each hair consists of a shaft (the portion projecting from the surface) and
a root (the part implanted in the skin); each hair root is implanted in an involution of the
epidermis called the hair follicle. A fingernail or toenail grows from a nail bed. If the bed
is destroyed, the nail will no longer grow.

2-13. DISEASES OF THE SKIN

a. General. Diseases of the skin make up a large portion of the physician's

practice, whether in civilian life or in the Army. A specialist in diseases of the skin is
called a dermatologist. Descriptive terms used in dermatology are:

(1) Bulla--large blister filled with serous fluid.

(2) Excoriation--superficial discontinuity or scratch.

(3) Induration--hardness.

(4) Lesion--any localized abnormality.

(5) Macula--small, flat discoloration or freckle.

MD0804 2-12
 (6) Papule--small, elevated lesion.

(7) Pruritis--intense itching.

(8) Pustule--vesicle containing pus.

(9) Squamous--scaly.

(10) Vesicle--small blister.

b. Virus Infections. Virus infections of the skin include the follows:

(1) Verruca vulparis. Verruca vulparis is the common wart.

(2) Herpes simplex. This is often called a fever blister, or cold sore.

(3) Herpes zoster. Herpes zoster is a painful infection commonly known as

shingles.

c. Bacterial Infections. Bacterial infections of the skin include the following:

(1) Furuncle (also called "boil.") This is an acute, inflammatory lesion

produced by the infection of a hair follicle or a skin gland by staphylococci bacteria. The
lesion begins as a pustule. As the pustule enlarges, the skin becomes reddened, tense,
and shiny. Pain and tenderness develop. The furuncle rapidly matures (comes to a
head), and usually ruptures spontaneously, discharging pus. The treatment is heat, and
incision and drainage. Under certain circumstances, antibiotics, such as penicillin, are
indicated.

(2) Carbuncle. A lesion that resembles the furuncle, since it has the same
cause and early course, but carbuncles are larger, and produce fever and leukocytosis
(elevated white cell count in the blood). When a carbuncle ruptures, pus is discharged
through several openings in the skin. The treatment consists of surgical drainage of the
carbuncle and penicillin.

(3) Cellulitis. An acute, deep-spreading inflammation of the skin and

subcutaneous tissues. Streptococcic infections tend to spread more than
staphylococcic infections, because they produce an enzyme which breaks down the
wall the body tries to form around the infection. The skin becomes red, tender, and
swollen. The patient has fever. The infection may spread through lymph vessels,
producing red streaks on the skin. It may enter the bloodstream and be carried through
the body (septicemia or blood poisoning).

d. Fungal Infections. Fungal infections are among the most common of all
diseases. In order for the fungi to produce skin infection, certain favorable conditions

MD0804 2-13
are required. Some of these conditions are: lack of cleanliness; excessive moisture,
usually due to perspiration; and irritation of the skin, usually because of tight clothing.

(1) Dermatophvtosis pedis. Dermatophvtosis pedis (also called tinea pedis

and athlete's foot) may be recognized by the presence of superficial fissures between
and toes, and vesicles on the sides and beneath under the toes. If secondary bacterial
infection occurs, pustules appear, and ulceration may result.

(2) Dermatophvtosis (tinea) corporis, capitis, and cruris. These fungous

infections are commonly called ringworm. Dermatophytosis (or tinea) cruris is also
called "jock itch." The diagnosis of ringworm is made by the presence of a few (usually
not over two or three) circular, ring-like, red, scaling lesions, clearing at the center, with
advancing vesicular margins. Tinea cruris is distinguished by its location on the upper
surface of the thighs. Excessive perspiration and friction from clothing are important
contributing factors. Therefore, an important part of the treatment consists of exposing
the involved parts to the air as much as possible.

e. Arthropod Infestations and Infections. The arthropods are many-celled

animals with outer skeletons but without backbones, and include such organisms as
crayfish, spiders, mites, ticks, centipedes, and insects (lice, mosquitoes).

(1) Pediculosis. Pediculosis is an infestation of the skin with lice.

(a) Diagnosis of louse infestation. Lice have a habit of living in the

clothes and bedding of patients and coming out only at the night to feed. This fact must
be taken into account when examining a patient suspected of being infested. The small
louse bites may be quite difficult to locate in the absence of the louse, although the
patient has usually scratched the skin in the area very vigorously, leaving scratch
marks.
(b) Treatment. Pediculosis is treat by application of gamma benzene
hexachloride (Lindane).

(2) Scabies. Scabies is a disease caused by a very small mite that burrows
into the skin. The infection often begins between the fingers, and spreads to the body,
especially the lower abdomen, buttocks, and genitalia. The mite causes much itching
(especially at night), and there is abrasion of the skin from scratching. Secondary
infection by bacteria may occur, with the formation of pustules. The abrasions and
pustules often obscure the typical lesions of scabies, which are threadlike, twisted
lesions with a small raised area at one end. All washable clothing should be thoroughly
laundered, and other clothing dry-cleaned.

f. Allergic Conditions. In allergic conditions, the patient is sensitive to certain

foreign substances that may contact his skin, or be introduced into his body in the food
he eats or the air he breathes. A first contact is necessary to produce the sensitization,
following which the patient reacts to contact with the foreign substances in an abnormal
manner. Some substances can provoke an allergic reaction in anyone contacting them.

MD0804 2-14
Others appear to produce allergy only in certain individuals who have a constitutional or
inherited predisposition to allergy.

(1) Urticaria. Urticaria (commonly called hives) is an allergic condition which

results in the formation of wheals (rounded or irregular shaped, transitory elevations of
the skin). Urticaria is usually caused by eating a substance to which the patient has
been sensitized, but may also be caused by a local allergen such as poison ivy; or it
might have a psychogenic origin. It is usually associated with much itching and may
cover the whole body. Often it is difficult to determine the cause, and the disease may
constantly reoccur.

(2) Contact dermatitis. Contact dermatitis (dermatitis venenata) is due to

sensitization of the skin by direct contact with a sensitizing substance. The
development depends on how much of the substance is contacted, and how often. Why
sensitivity occurs is not known. At the beginning, the skin is reddened in the contacted
area, then raised lesions appear, and then blisters. The lesions may spread over the
body. The vesicles may become infected by bacteria, and pustules appear. There is
marked itching. The patient may carry the sensitizing substance to other skin areas by
his hands. The sensitizing substance may be almost anything. Examples include:
poison ivy, medicines, clothes, and soaps. A painstaking and thorough search is
necessary to find and remove the allergen. Treatment includes removal of the allergen,
mild bland applications, and antihistaminics in some cases.

h. Other Conditions.

(1) Psoriasis. Psoriasis is a chronic, recurrent disease of the skin,

characterized by reddish, rounded lesions that are covered by silvery scales. When a
scale is removed, it leaves a small bleeding point. The disease tends to begin on the
elbows, knees, or scalp, and to spread over the whole body.

(2) Acne vulgaris. Acne vulgaris is a chronic inflammation of the

sebaceous glands (oil glands) of the skin, which usually develops during adolescence.
Lesions develop rapidly and in crops, located mostly on the face, sometimes on the
sternal region, the shoulders, and the back. The lesions may cause considerable
scarring on healing. Treatment includes good personal hygiene to help prevent
secondary infections, dietary measures, antibiotics, and various skin lotions.

2-14. SIGNS AND SYMPTOMS OF SKIN DISEASE

a. Pruritis (Itching). The most common, most annoying, and least specific
symptom encountered in dermatologic conditions is pruritis. Among the causes of
itching may be included infectious agents, allergic conditions, neuroses, parasitic
infestations, dryness of the skin, anoxia of the skin, and chronic irritation of the skin.
The actual pathological change responsible for this symptom takes place in minute
nerve endings in the skin. The exact change is not known, but these endings become

MD0804 2-15
increasingly sensitive to the various causative agents, and itching will appear more
easily.

b. Pain. Pain is not seen very often in skin disorders, although there may be a
burning sensation associated with indurating lesions.

c. Edema. Edema is the collection of fluid in the tissues of the dermis. This is
usually localized at least to a particular area of the body. When individual lesions take
the form of a small area of swelling with associated pruritis, the eruption is called
urticaria. The edema may be extensive, involving either the face or part of an extremity.
When the edema involves the face, the eyes may be forced shut by the swollen tissues.
Edema is seen in numerous systemic disorders, but there are usually enough other
symptoms of the underlying disease to prevent confusion with a skin reaction to an
allergen.

d. Scales. The upper layer of the epidermis may accelerate the production of
keratinized (horny) cells, and these will begin to flake off following minimal trauma.
These flakes of dry, dead tissue are called scales. Many lesions show scaling as the
disease kills additional layers of the epidermis. Occasionally the scales may take
characteristic shapes because of plugging pores in the skin.

e. Weeping. Weeping is the oozing of fluid from the surface of a lesion. This
occurs whenever sufficient layers of epidermis have been destroyed and removed so
that the capillary beds of the dermis are near the surface. Weeping is serious
because of its tendency to macerate (soften) the lesions and the surrounding skin. As
the healthy tissue breaks down, the disease spreads more easily. Weeping is
frequently seen in body creases and must be guarded against. The use of powders to
dry weeping lesions is the first step in the successful therapy of such conditions.

f. Scaling and Weeping. There may be a combination of scaling and weeping.

This will result in the formation of a crust over the lesion. Any blood, pus, or other
exudate from the lesion may add to this crust. The raw surface of the lesion will be
protected by this crust, but the fluid collecting under it will be an excellent growth
medium for bacteria, thus adding infection to the existing problems. Crusts may be a
cause of itching, and frequently they will be ripped off by the patient, either on purpose
or accidentally while scratching.

g. Fissures. Fissures are small cracks in the skin. These are very common
and occur when there is an excessive drying of the skin. The corners of the mouth are
common sites for this condition. Fissure may also be seen in areas of lichenification
(places where the tissue has become thickened from continuous irritation). Fissures are
open portals of entry for bacteria.

h. Fever. Fever is usually seen in infectious diseases, but it may also be

present in cases of allergy. This is not a common concern to the dermatologist,
because disease limited to the skin will not cause fever.

MD0804 2-16
2-15. TREATMENT

a. Symptomatic. Many forms of treatment are available for disorders of the

skin. Frequently, treatment is instituted merely to relieve the distressing symptoms and
may have no effect on the course of the disease. The antipruritic (anti-itch) medications
are of this type. Both lotions and powders are used and are effective in a fair
percentage of cases. Systemic antipruritics are not very effective but are of some use
in systemic diseases that have itching at some stage. Antihistamines are used primarily
in allergic reactions, and they are extremely effective in relieving the itching as well as in
suppressing the skin lesions.

b. Drugs.

(1) Antibiotics. Antibiotics may be used topically when there is an infection

in the skin, either primary or secondary. The infection should always be present before
the antibiotic is used. The prophylactic (preventive) use of topical antibiotics is
dangerous because these drugs have a higher than usual incidence of sensitivity
reactions when used in this manner.

(2) Steroids. The numerous synthetic steroid preparations have been of

great assistance to the dermatologist. Many diseases will be controlled by steroids after
all other means of treatment have failed. Steroids usually are given systemically, and
they may cause serious consequences; therefore, steroids are normally used only after
other means of therapy have failed. The topical use of steroids, however, is effective
and safe because negligible quantities are absorbed, even through raw lesions.

(3) Antipyretics. Aspirin and acetaminophen are the most effective agents
available for reducing temperatures.

Section V. NATURE AND CAUSES OF DISEASE

2-16. DEFINITION OF DISEASE

Disease can be defined as a derangement of the normal functioning of one or

more of the body processes. This interference with the normal body functions either
prevents them from taking place, or causes them to act in an abnormal manner. For
example, a tumor may obstruct the flow of intestinal contents, or bacteria may cause
irritation or inflammation. In the following text, consideration will be given to those
factors which are responsible for interference with the normal body functions, in other
words, the etiology (causes) of disease.

MD0804 2-17
2-17. CAUSES OF DISEASE

There are nine major causes of disease (a through i below). Frequently a disease
may be produced by a combination of these causes, or the same disease may be
caused by different factors in different patients, or the cause may be unknown (j below).

a. Prenatal Influences. By this is meant those factors which may operate

before birth to produce disease in the offspring; factors may be manifested at birth
(congenital disease) or may not become obvious until later in life.

(1) Heredity. Among prenatal factors, one influence is heredity. A disease

may be genetically transmitted from a parent to offspring. The parents who transmit the
disease to their offspring may or may not have the disease themselves. Examples of
some hereditary diseases are hemophilia and congenital dislocation of the hip.

(2) Congenital influence. Diseases affecting the mother while she is

pregnant with the baby may adversely affect the offspring. For example, some diseases
may be transmitted directly to the baby via the bloodstream, as is often seen in the case
of syphilis in the mother. Alternatively, the pregnant woman may have a disease such
as German measles, which interferes with the normal development of the child in the
uterus (in utero), although, the child does not acquire the disease. Malnutrition in the
mother could result in a poorly nourished baby, which could also interfere with the
normal development of the child.

(3) Mechanical. Purely mechanical factors are also felt to be responsible for
some abnormalities present at birth. Abnormal positioning of the baby in utero is felt to
be occasionally responsible for wryneck; torsion or twisting of the umbilical cord would
limit the blood and food supply to the baby, and dire results could occur. Any defect or
disease present at the time of birth is called a congenital disease or condition. Injuries
or effects sustained during the process of being born may be included here.

b. Parasites. Parasites are organisms that live on or within the body of the man
or any other living organism, and at the expense of the one parasitized. Parasites may
live on the surface of the skin (ectoparasites), or they may enter the body through the
skin, the respiratory tract, the gastrointestinal tract, or the genitourinary tract where they
may enter the bloodstream and be carried to distant parts of the body. If they live inside
the body, but outside the cells, they are called extracellular endoparasites; if they enter
the body's cells, they are called intracellular endoparasites. They all cause disease by
interfering with the tissue and organ functions; they accomplish this by elaborating
toxins, or poisons; by causing inflammation, or irritation; by producing enzymes which
destroy tissue; and by causing mechanical blockage of function.

(1) Viruses. These are the smallest agents known to produce disease;
whether they are living organisms or complex chemical compounds is not known. They
are known to be intracellular endoparasites that cause such common diseases in man

MD0804 2-18
as poliomyelitis, common cold, influenza, measles, mumps, chickenpox, smallpox,
hepatitis, encephalitis, warts, rabies, yellow fever, and lymphogranuloma venereum.

(2) Rickettsiae. These organisms are larger than viruses, but are still very
small intracellular endoparasites. These organisms are transmitted to man by mites,
ticks, fleas or lice, and they produce Rocky Mountain spotted fever, typhus (epidemic
and endemic), scrub typhus (tsutsugamushi fever), Q fever, and Rickettsialpox.

(3) Bacteria. Bacteria are minute, one-celled, organisms that may occur
alone or in large groups called colonies. Significant bacteria can be divided by their
shape into three main groups.

(a) Cocci. Cocci are round, one-celled bacteria. The primary

members of this group are staphylococci, which group themselves in clusters;
streptococci, which arrange themselves in chains; and diplococci, which arrange
themselves in pairs. All are pyogenic (produce pus).

(b) Bacilli. Bacilli are rod-shaped; however, they vary from straight to
irregular-curved and branched shapes. They cause such common diseases as typhoid
fever, diphtheria, tuberculosis, and leprosy.

(c) Spirochetes. Spirochetes are spiral-shaped and can move or twist.

Spirilla and Treponema pallidum are examples. The latter causes syphilis.

(4) Fungi. These extracellular endoparasites or ectoparasites are larger and

higher in the scale of plant life than are the bacteria. They include the yeast and molds,
and produce infections of the skin such as ringworm, and infections of the mucous
membranes such as thrush. Some attack internal organs, especially the lungs and
central nervous system, very often with disastrous results.

(5) Protozoa. These are one-celled animal parasites (either extracellular or

intracellular) that cause such common diseases as malaria and amoebic dysentery.

(6) Metazoa. These many-celled, larger animals include the helminthes

(worms) such as the ascaris, the hookworm, the pinworm, the tapeworms, and the
flukes, as well as the arthropods (mites, lice, and so forth.).

c. Intoxicants. Intoxication is the process of taking any chemical substance

that causes disease or injury into the body. Many substances are very useful in small
amounts, and do not cause intoxication; but the same substances may be very toxic in
larger amounts, and result in severe illness or death.

MD0804 2-19
 d. Trauma. Trauma may be defined as injury sustained by the body as the
result of a physical agent or force. The physical agents that may produce trauma or
injury of the body are:

(1) Light. In excessive amounts, light can cause temporary blindness.

(2) Heat. Excessive heat can cause burns of the body, heat cramps, heat
exhaustion, or heatstroke.

(3) Cold. Cold is absence or deficiency of heat. Exposure to low

temperatures can result in frostbite and other cold injury.

(4) Electricity. One can sustain burns, electric shock, or both when exposed
to this agent.

(5) Ionizing radiation. Excessive exposure to x-rays or to radioactive

elements can produce burns, radiation sickness, malignancies, cataracts of the eye,
and genetic changes.

(6) Mechanical forces. These agents produce contusions, abrasions,

lacerations, fractures, sprains, and strains.

(7) Sound. Exposure to excessive noise can cause temporary or permanent

deafness to certain wavelengths.

e. Circulatory Disturbances. Any interference with the blood flow to a portion

of the body results in a circulatory disturbance.

(1) Ischemia. A decrease in the normal diameter of an artery supplying a

portion of the body results in a decrease in the amount of blood that flows to the part.
The area becomes more pale and colder than normal, and is said to be ischemic.

(2) Thrombosis. Whenever a vessel wall becomes diseased, the blood

tends to collect at the diseased or injured site and form a thrombus (clot). The presence
of an intravascular blood clot is called thrombosis.

(3) Embolism. Portions of a thrombus may break loose, and then travel
freely in the bloodstream until stopped by a vessel too small for the particle to pass
through; or foreign particles, such as air bubbles or fat globules, may be introduced into
the bloodstream and travel freely until stopped by a smaller vessel. These foreign
particles are known as emboli. The process of obstruction or occlusion of a blood vessel
by a transported foreign material is known as embolism.

(4) Gangrene. When an extremity or portion thereof loses its arterial blood
supply as the result of thrombosis, embolism, trauma, or from any other cause, a

MD0804 2-20
massive area of the tissue dies, and is said to have undergone gangrene, or to have
become gangrenous.

(5) Infarction. Death of the tissue of an organ or portion thereof as the result
of the loss of its blood supply is known as infarction. The necrotic (dead) area itself is
called an infarct.

(6) Hemorrhage. This is the loss of blood.

f. Neuropsychiatric Disturbances.

(1) Organic disorders. Injury or disease of the nervous system tissue may
result in the loss of the nerve supply to a particular part of the body. Therefore,
because of loss of enervation, secondary changes in the tissue occur, such as atrophy.
In addition, the normal functions may become paralyzed, and there may be loss of
sensation and other changes.

(2) Functional disorders. Disturbances of the mind or psyche may produce

neuroses, psychoses, or character and behavior disorders. Such disturbances may or
may not be inherited; the environment, childhood experiences, and many other factors
have a bearing on the production of psychiatric disturbances.

g. Mechanical Disturbances. Certain static mechanical abnormalities may

result in disease within the body. For example, volvulus or twisting of the intestine on
itself, torsion of the spermatic cord, strangulation of a hernia, and intussusception, are
all often on a purely mechanical basis.

h. Disorders of Metabolism, Growth, or Nutrition. Metabolism has to do with

the total chemical cycle of converting substances into forms that are usable to the body.
Metabolism occurs in two phases.

(1) Anabolism. In anabolism, foodstuffs are broke down (digested) and

reconverted into compounds which can be utilized as energy, or as building blocks for
new tissue cells and substances. In anabolism, living tissue is manufactured from
nonliving substances. This results in growth or replenishment.

(2) Catabolism. Catabolism is the breaking down of the body’s complex

substances by wear, tear, and age into waste products of simpler composition for
elimination. Metabolism and growth then are dependent on the body’s receiving
enough of the proper foodstuffs in order to supply its needs, in other words, on proper
nutrition. Metabolism and growth are further regulated by the vitamins and hormones.
The hormones are supplied by the ductless glands of the body (the pituitary, thyroid,
parathyroid, pancreas, adrenals, and gonads), and any disorder of these glands will
profoundly disturb growth and metabolism. The vitamins are supplied by the diet; if the
diet or nutrition is unsatisfactory, disturbances in growth and metabolism can result also.
Therefore, metabolism, growth, and nutrition are closely related to one another.

MD0804 2-21
 i. Neoplasms. Normally, the body grows by multiplication of its cells. At first,
in the embryo, these cells are all alike or undifferentiated. However, as they multiply,
they come under the influence of certain factors and take on different forms and
different functions to make up the different tissues, organs, and systems of the body
(that is, they become differentiated). This growth and differentiation is a slow,
methodical, controlled process. However, some cells may not differentiate entirely, but
for some unknown reasons, retain varying degrees of undifferentiation, break free of
their growth control, and form a new growth (neoplasm) or tumor. Tumors cause
disease by interfering with the function of normal cells, tissues, and organs. They may
cause pressure on an organ so that its normal cells are destroyed or its blood supply is
shut off. A tumor may fill the cavity of an organ so that the organ wall cannot contract
properly. The tumor may also use up the nutritive materials taken into the body so that
there is not enough for the normal tissues. Tumors are of two types: benign and
malignant.

(1) Benign. These are more slowly growing, the cells are more
differentiated, the tumor is well separated from the surrounding tissues by its capsule,
and can usually be completely removed surgically.

(2) Malignant. These are more rapidly growing with very little growth
control, and the cells are more primitive or undifferentiated. The cells of the tumor
infiltrate or grow between the normal tissue cells, and are much more difficult to remove
surgically. Because of this, the malignant tumor tends to recur and tends to
metastasize or spread via the blood and the lymph vessels. The common term for
malignant tumors is cancer. The medical profession speaks of carcinoma when the
malignant tumor arises from tissue that covers the surface of the body, lines a hollow
structure, or forms glands, and sarcoma when the malignant tumor arises from any
other tissue in the body such as fatty, muscular, bony, or fibrous tissue.

j. Idiopathic (Unknown) Causes. There are many diseases of known etiology.

The affected organ and effective treatment are often known, however, the cause and
the mechanism through which the disease disrupts the body’s functions remain
unknown.

Section VI. TREATMENT OF DISEASE AND INJURY

2-18. INTRODUCTION

Patients who have disease or injury must be properly diagnosed and treated. The
physician is responsible for these functions; however, the physician may delegate the
accomplishment of some of the treatments to other members of the Army Medical
Department (that is, physicians' assistants and physical therapists). In general, all types
of treatment may be classified as either preventive or corrective.

MD0804 2-22
2-19. PREVENTIVE TREATMENT

Preventive treatment includes all measures used to prevent disease.

a. Preventive procedures include sanitary measures such as cleanliness, proper

waste disposal, inspection of food and food handlers, isolation diseased individuals,
aseptic surgical technique, and the use insecticides of and rodenticides to control
vectors of disease.

b. Another preventive measure is immunization. Active immunity is the result of

a direct introduction into the individual's body of an antigenic preparation (frequently
bacteria or viruses) so that an individual produces his own antibodies that defend him
against the particular antigen introduced. Passive immunity is produced by injecting
serum-containing antibodies into an individual. This blood serum may be from animals
or humans in which the antibodies were produced by an active immunity process.

c. A third preventive measure consists of preventive psychiatry and mental

health work, in which the individual or his environment is manipulated in a manner to
prevent excessive mental stress.

2-20. CORRECTIVE/SYMPTOMATIC TREATMENT

People who have some disease or condition want to receive prompt medical
treatment. Many people believe that the use of prescribed medications is the only way
to ensure that a disease or condition will be cured or improved. The use of drugs does
have an important role in the treatment of disease; however, other treatment methods
are available. For example, rest, radiotherapy, and physical therapy are very useful in
the treatment of certain conditions. In many cases, various treatment methods are used
to benefit the patient.

a. Rest prevents overwork of a diseased organ and includes more than freedom
from physical work; a patient must have mental rest also.

b. Diet is of extreme importance both in the prevention of disease and in medical

care. An adequate intake of proteins, carbohydrates, fats, vitamins, and minerals is
necessary in the treatment of all patients. Patients with fever generally require
increased amounts of all dietary constituents. Patients with certain diseases require
diets in which the various dietary constituents are carefully controlled. One example of
a special diet of this type is that for diabetes mellitus, in which the amounts of protein,
fat, and carbohydrates must be individually regulated.

c. Nursing care is another essential part of medical care. In addition to doing

technical procedures such as administering drugs, nursing service personnel watch for
the appearance of changes in the patient's condition. Frequently the personalities of
such personnel will be an important factor in promoting the patient's morale, securing
his cooperation, and fostering in him a desire to get well.

MD0804 2-23
 d. Drugs are substances used in the treatment of disease. They are used to
relieve the unpleasant effects of disease and to eradicate the disease. Drugs may be
administered externally and internally.

e. Radiotherapy is the use of x-rays, radium, and radioactive isotopes in the

treatment of disease.

f. Occupational therapy is treatment that provides a patient with activity to keep

his mind and body occupied. It is also used to help the patient regain muscular
coordination and control of specific parts of the body.

g. Physical therapy is the treatment of disease by physical means. Various

agents used in physical therapy are light, heat, cold, electricity, water, massage, and
exercise.

h. Psychotherapy is treatment by various means, which may include the use of

drugs, to lessen or rectify abnormal mental conditions. Surgery performed for the same
purpose is called psychosurgery.

i. Surgery is the treatment of disease by manual operation or corrective

apparatus. It includes the removal of diseased tissue or organs and the repair of injured
structures.

Continue with Exercises

MD0804 2-24
EXERCISES, LESSON 2

INSTRUCTIONS: Answer the following exercises by marking the lettered response

that best answers the exercise, by completing the incomplete statement, or by writing
the answer in the space provided at the end of the exercise.

After you have completed all of these exercises, turn to "Solutions to Exercises" at
the end of the lesson and check your answers. For each exercise answered incorrectly,
reread the material referenced with the solution.

1. From the definition below, select the definition of the term anatomy.

a. The study of the functions of the body.

b. The study of the chemical substances in the body.

c. The study of the structures of the body.

d. The study of the systems of the body.

2. From the definitions below, select the definition of the term tissue.

a. A grouping of like cells working together.

b. The smallest living unit of body construction.

c. A group of organs working together.

d. A group of cells that have nothing in common.

3. From the functions below, select the function of the lymphatic system.

a. Protects the body from drying.

b. Returns proteins and fluid from the various body tissues to the blood.

c. Manufactures hormones.

d. Provides nutrients to the various limbs of the body.

MD0804 2-25
 4. From the descriptions below, select the best description of the cytoplasm.

a. Organelles that perform highly specialized functions in the cell.

b. A jelly-like substance that coats the outside of the cell membrane.

c. The part of the cell which manufactures RNA and DNA.

d. The fluid or semifluid contained inside the cell membrane, but outside
the nucleus.

5. From the descriptions below, select the best description of the mitochondria.

a. The organelle of the cell responsible for producing DNA.

b. The site of cell respiratory activity.

c. The part of the cell which is responsible for producing RNA.

d. The organelle responsible for monitoring the flow of water into the cell.

6. From the definitions below, select the definition of pinocytosis.

a. A vesicle which engulfs and destroys the cell.

b. The organelle responsible for producing extracellular fluid.

c. The production of fluids by the cell.

d. The engulfing of small particles or fluids by the cell.

7. From the descriptions below, select the description of connective tissue.

a. The tissue that binds other tissues together and supports other tissues.

b. The tissue that covers the outer layer of the body.

c. The tissue that forms the glands and the sense organs of the body.

d. The tissue that covers the organs in the abdomen.

MD0804 2-26
 8. From the list of function below, select the function of the skin.

a. Controls the size of the patient.

b. Produces chemicals for body growth.

c. Prevents perspiration on hot days.

d. Detects heat, cold, pressure, and pain.

9. Select, from the group of descriptions below, the best description of

pediculosis.

a. An infestation of the skin with fungus.

b. An infection of the skin with bacteria.

c. An infestation of the skin with lice.

d. An infection of the skin with ringworm.

10. Select, from the group of descriptions below, the best description of scabies.

a. A disease caused by a very small mite, which burrows into the skin.

b. A disease caused by small bacteria, which includes the skin.

c. A disease characterized by itching and fungal growth.

d. A disease characterized by the growth of bacteria on the skin.

11. Select, from the descriptions below, the best description of a furuncle.

a. An acute inflammatory lesion produced by the infection of a hair follicle

or skin gland by streptococci bacteria.

b. An acute, inflammatory lesion produced by the infection of a hair follicle

or skin gland by staphylococci bacteria.

c. An acute lesion produced by an infection of a hair follicle by fungal

organisms.

d. An acute, inflammatory lesion produced by the infection of a hair follicle

by allergens.

MD0804 2-27
 12. Select, from the definitions below, the meaning of the term pruritis.

a. A chronic, recurrent disease characterized by reddish, rounded lesions.

b. A chronic inflammation of the sebaceous glands of the skin.

c. A parasitic infestation of the skin caused by lice.

d. Itching.

13. Select, from the descriptions below, a description of edema.

a. A collection of fluid in the tissues, resulting in swelling.

b. A raised area of the skin characterized by cellulitis.

c. A collection of protein in injured tissues resulting in bleeding.

d. A collection of raised swellings on the skin characterized by itching and

discoloration.

14. From the definitions below, select the definition of the term disease.

a. A condition characterized by functioning of certain glands.

b. A derangement of the normal functioning of one or more body

processes.

c. A dysfunction of the body caused by lack of exercise.

d. A dysfunction of the systems of the body characterized by lowered blood

sugar.

15. Select, from the descriptions below, the description of physical therapy.

a. The use of drugs to treat disease of mental origin.

b. The treatment of disease by the administration of antibodies.

c. The treatment of disease by such methods of heat, light, and cold.

d. The treatment of disease by the removal of diseased organs or tissues.

Check Your Answers on Next Page

MD0804 2-28
SOLUTIONS TO EXERCISES, LESSON 2

1. c The study of the structure of the body. (para 2-1)

2. a A grouping of cells working together. (para 2-2b)

3. b Returns protein and fluid from the various body tissues to the blood.
(para 2-3f)

4. d The fluid or semifluid contained inside the cell membrane, but outside the
nucleus. (para 2-5b)

5. b The site of cell respiratory activity. (para 2-5d)

6. d The engulfing of small particles or fluids by the cell. (para 2-6)

7. a The tissue that binds other tissues together and supports other tissues.
(para 2-9b)

8. d Detects heats, colds, pressure, and pain. (para 2-11c)

9. c An infestation of the skin with lice. (para 2-13e(1))

10. a A disease caused by a very small mite which burrows into the skin.
(para 2-13e(2))

11. b An acute, inflammatory lesion produced by the infection of a hair follicle or

skin gland by staphylococci bacteria. (para 2-13c(1))

12. d Itching. (para 2-14a)

13. a A collection of fluid in the tissues resulting in swelling. (para 2-14c)

14. b A derangement of the normal functioning of one or more body processes.

(para 2-16)

15. c The treatment of disease by such methods of heat, light, and cold.
(para 2-20g)

End of Lesson 2

MD0804 2-29
 LESSON ASSIGNMENT

LESSON 3 Introduction to Pharmacology.

TEXT ASSIGNMENT Paragraphs 3-1--3-15.

LESSON OBJECTIVES After completing this lesson, you should be able to:

3-1. Given a pharmacological term and

several definitions, select the definition of
that term.

3-2. Given a source of drugs and a list of

names of drugs, select the drug that is
derived from that source of drugs.

3-3. From a group of statements, select the

use(s) of drugs.

3-4. Given a factor that influences drug

dosage and a group of statements, select
the statement that best describes how
that factor influences drug dosage.

3-5. Given a particular route of administration

and several statements, select the
statement that best describes that route
of administration.

3-6. Given a type of adverse reaction to a

drug and several statements, select the
statement that best describes that type of
adverse reaction.

3-7. Given a factor that influences drug

action and a group of statements, select
the statement that best describes how
that factor influences drug action.

3-8. Given one of the following factors that

influence drug absorption: water
solubility, fat solubility, and transport
mechanisms, and several statements,
select the statement that best describes
how that factor influences drug absorption.

MD0804 3-1
 3-9. From a group of statements, select the
statement that best contrasts passive
transport with active transport.

3-10. Given a group of statements, select the

statement that best describes the
Receptor Site Theory of the mechanism
of drug action.

3-11. Given a group of statements, select the

statement that best contrasts competitive
antagonists with physiological
antagonists.

3-12. From a group of statements, select the

statement that best describes the
importance of structure activity
relationships.

SUGGESTIONS After completing the assignment, complete the

exercises at the end of this lesson. These exercises
will help you to achieve the lesson objectives.

MD0804 3-2
 LESSON 3

INTRODUCTION TO PHARMACOLOGY

Section I. TERMS AND DEFINITIONS IMPORTANT IN PHARMACOLOGY

3-1. GENERAL

a. It is important for you to be familiar with some terms and definitions frequently
used in the study of drugs. Although the terms and definitions presented here are
basic, they will provide you with a sound background for gaining additional knowledge,
and understanding as you read the text of this subcourse.

b. The terms and definitions provided in this section do not include all the
medical terms used in this subcourse. Whenever possible, the meaning of a fairly
difficult and unfamiliar term will be written in parentheses ( ) after that term. In the event
you encounter a term you do not understand, you should use a quality medical
dictionary (that is, Dorland's Illustrated Medical Dictionary) to learn the meaning of that
term.

c. No attempt is made in this subcourse to address the pronunciation of terms

and drug names. If you desire assistance in this area, you should seek the services of
someone who works with drugs on a frequent basis. "Pharmacists, pharmacy
technicians, nurses, physicians, and other medical personnel are well-qualified to help
you to learn the pronunciation of drug names."

3-2. TERMS AND DEFINITIONS

a. Drug. A drug may be broadly defined as any substance or group of

substances, which affects living tissue. However, the term may be specifically defined
as any substance used to prevent, diagnose, or treat disease or to prevent pregnancy.

b. Pharmacology. Pharmacology is the study of the actions and effects of

drugs on living systems and their therapeutic uses.

c. Bioavailability. Bioavailability refers to the amount of drug that is available

to the target tissue after the drug has been administered. In other words, it is the
amount of the drug available to produce the desired effect.

d. Pharmacognosy. Pharmacognosy is the study of the characteristics of

natural drugs.

MD0804 3-3
 e. Toxicology. Toxicology is the science of poisons. Toxicology includes the
origin, chemical properties, toxic actions, detection, and proper antidotal therapy of
poisons.

f. Posology. Posology is the science of dosage. It deals with the amount of

drug necessary to produce a desired physiological, therapeutic, or prophylactic effect.

(1) Usual recommended dose. The usual recommended dose is the

amount of drug that will ordinarily produce the effect for which the drug is intended. In
addition to the usual recommended dose, the usual dosage range is indicated for many
drugs in the United States pharmacopoeia/National Formulary. The usual dose range
provides a guide in deciding whether the prescriber should be consulted about the
correctness of the prescribed dose.

(2) Minimum dose. The minimum dose is considered the smallest dose of
drug that produces the therapeutic effect.

(3) Maximum dose. The maximum dose is considered the largest dose of
a drug that can be safely administered.

(4) Toxic dose. The toxic dose of a drug is considered the amount of a
drug that will produce noxious (harmful) effects.

(5) Lethal dose. The lethal dose of a drug is the amount of substance that
will cause death. You will often see the term "LD50" in association with lethal dose.
LD50 means that 5O percent (or 1/2) of the animals given that amount of drug died.
The LD50 of a drug should be used as a guide, rather than an absolute number.

(6) Single dose. The single dose of a drug is the amount of that
substance to be taken at one time.

(7) Daily dose. The daily dose of a drug is the amount of that substance
to be taken in a 24-hour period. The daily dose of a drug is into several individual
doses.

(8) Maintenance dose. The maintenance dose of a drug is the amount of

that substance taken to maintain or continue a desired therapeutic effect. Some drugs
must be taken on a daily basis in order to maintain the desired therapeutic effect. For
example, drugs used to treat high blood pressure often must be take daily to maintain a
lowered blood pressure.

(9) Loading dose. The first dose given of a drug to achieve maintenance
drug levels quickly. Drugs that are given only one or two times a day may take two or
three days to reach a maximum effect. To overcome this time, a loading dose is given
to achieve the levels associated with the maximum effect more quickly. Loading doses
are often used in very sick patients.

MD0804 3-4
 Section II. INTRODUCTION TO DRUGS

3-3. SOURCES OF DRUGS

Drugs today are obtained from several sources. Some sources of drugs are
discussed below. Some drugs are listed under the sources. The specific drugs
mentioned are not the only drugs obtained from that source.

a. Plants. For thousands of years, plants have served as sources of drugs.

Ephedrine, a drug used to treat nasal congestion, was used by the Chinese long before
western man visited the Orient. Belladonna (or Deadly Nightshade), the source of
atropine and scopolamine was used in the Middle Ages. Its name means "beautiful
woman" in Italian. A solution obtained by soaking the belladonna plant in water caused
the pupils of the eye to dilate and appear black. These were symbols of beauty at the
time. Belladonna was a favorite poison. Opium, a product obtained from the poppy
plant, is mentioned in early Greek mythology as a sleep producer.

b. Animals. Animals provide us with large supplies of natural products like

hormones. Insulin, used in the treatment of diabetes mellitus, used to be obtained from
the pancreas of pork, beef, and even fish. Heparin, a potent anticoagulant, is obtained
from the intestinal and lung mucosa of beef and hogs.

c. Minerals. Minerals, such as iron and iodine, are essential for normal growth
and development. An old remedy for pallor (a very pale complexion) was the water
used to cool horseshoes in the blacksmith shop. This water contained small amounts of
iron in solution.

d. Microorganisms. You are probably aware of the fact that microbes can
cause disease and/or death. Fortunately, some microorganisms can be used to
produce antibiotics. These antibiotics can be used to kill or stop the growth of other
microbes. Furthermore, chemically treated or killed microorganisms can be used to
produce vaccines.

e. Synthetics. Most drugs today are synthetically made. Examples of

synthetically produced drugs are aspirin and the sulfa drugs.

3-4. USES FOR DRUGS

Drugs have many uses. In today’s society, the legitimate--and not so legitimate--
use of drugs is wide seen. Listed and briefly discussed below are the major uses and
some representative examples of drugs:

a. To Maintain Health. Vitamins and minerals are used and abused in the
pursuit of good health.

MD0804 3-5
 b. To Reverse a Disease Process. Antibiotics and chemotherapeutic
(anticancer) agents are commonly used in medicine today. Ideally we would like these
agents to cure the patient.

c. To Relieve Symptoms. Drugs that act to relieve symptoms do not cure the
patient. Instead, they help to make the patient more comfortable in order for the patient
to work or function. Since only symptoms are being relieved, the body is expected to
remedy the problem.

d. To Prevent Disease. Vaccines and toxoids are used to prevent disease. In

the 1950's, many parents kept their children at home in fear of the dreaded polio
disease. Today, the only time most parents think of polio is when they take their
children for their periodic (and necessary) vaccinations for this still-present threat.
Further, any military veteran can quickly testify to the fact that vaccinations are an
essential part of the introduction to military life.

e. To Prevent Pregnancy. The old saying that an ounce of prevention is better

and cheaper than a pound of cure is most applicable here. The birth control "pill" or oral
contraceptives and spermacidal agents in the form of creams, jellies, and suppositories
are the drugs currently being used to prevent pregnancy.

Section III. CONSIDERATIONS OF DRUG THERAPY

3-5. FACTORS WHICH INFLUENCE DRUG DOSAGE EFFECTS

Many factors influence how a dose of a particular drug will affect a patient. Since
not all patients are the same size, weight, age, and sex, it would be wise to consider
how these factors might influence how much drug a person should receive and the
effect(s) that drug might have on the patient. The usual recommended adult dose of
medication, as found in standard references, is based on the assumption that the
patient is a "normal" adult. Such a "normal" (or average) adult is said to be 5 feet 9
inches (173 centimeters) tall and weigh 154 pounds (70 kilograms). However, many
people do not fit into this category. Therefore, the following factors should be
considered when patients receive drugs:

a. Weight. Obese (overweight) patients may require more medication than thin
patients may because the drug has more tissue to which it can go. The dosage of many
drugs is calculated on a weight basis. For example, a person might be prescribed a
drug that has a dosage of 5 milligrams of drug per pound of patient body weight.

b. Surface Area. A person's height and weight are related to the total surface
area of his body. The "normal" (average) adult has a body surface area of
approximately 1.73 square meters. A nomogram (see Subcourse MD08O2,
Pharmaceutical Calculations) is used to determine the surface area of a patient. The

MD0804 3-6
dosage of certain drugs (for example, the anticancer drugs) is determined by the
patient's body surface area.

c. Age. As a rule, the very young and the elderly require less than the normal
adult dose of most medications. Part of this requirement for less medication is due to
the altered metabolism of the drug. Since body enzyme systems greatly influence drug
metabolism, considering the differences in these enzyme systems based upon age is
important. In the infant, some enzyme systems are not yet fully developed. On the
other hand, the enzyme systems of the elderly may not function as well as in the past.
Although several formulas are available for calculating a child's dose of medication, the
two most accepted methods are those based upon the patient's weight (that is,
milligrams per kilogram of body weight) or body surface area (that is, milligrams per
square meter of surface area).

d. Sex. Physiological differences between the sexes may influence the dose or
the requirement for drugs. Since females have proportionately more fat tissue than
males, drugs, which have a high affinity (likeness) for fat, may require larger doses in
females. Moreover, estrogen and testosterone, two sex hormones, can affect the
patient’s rate of metabolism which can, in turn, influence the rate at which a drug is
metabolized, absorbed, or excreted from the body. The requirement for iron is much
higher in the female than in the male, because of the loss of blood in each menstrual
cycle.

e. Genetic Factors. Various racial and ethnic groups have differences in some
metabolic and enzyme systems which can affect the utilization of drugs.

f. Physical Condition of the Patient. The physical condition of the patient

influences how a particular drug might act. Consequently, the weak or debilitated
patient might require smaller doses of some medications. Patients who are in extreme
pain may require larger doses of analgesic agents than those patients who are in less
pain.

g. Psychological Condition of the Patient. The patient’s attitude about his

disease or treatment can influence the effectiveness of a drug. It has been shown that
patients receiving placebo tablets (tablets that contain no active ingredient) sometimes
have the same side effects as the patients who were taking tablets of the same
appearance that did contain the drug. In some cases, both types of patients (those
taking the placebo and those taking the drug) recovered at the same time.

h. Tolerance. The therapeutic effects of some drugs are lessened in individuals

after the drugs have been used for long periods. Thus, an individual who has used
such a drug for a long time needs larger doses of the drug than he did when he first
began to take it in order to obtain the same effect. This effect is called tolerance.
Persons who use opium, heroin, cocaine, amphetamines, and barbiturates develop a
tolerance to these substances. Cross-tolerance occurs when the use of one drug

MD0804 3-7
causes a tolerance to another drug. Alcoholics, barbiturate addicts, and narcotic
addicts develop a cross-tolerance to sedatives and anesthetics.

i. Time of Administration. The time when a drug is administered is important.

Some orally administered medications should be taken before meals (that is, on an
empty stomach) to increase the amount of drug absorbed into the system. Other oral
medications (that is, those that cause irritation to the gastrointestinal tract) should be
taken after meals on a full stomach.

j. Drug Interaction.

The interaction between two or more drugs may influence the overall
effectiveness of each of the drugs.

(1) Synergism. Synergism is the joint action of drugs. That is, their
combined effects are greater than the sum of their independent effects. Concurrent
administration (giving both drugs at the same time) of synergists may require that the
dose of each drug be lowered. In the case of synergism, 1 + 1 = 2 1/2. Synergism may
be beneficial or harmful. Beneficial effects may be obtained when combining two
potentially toxic drugs to achieve the desired therapeutic effect without causing harm to
the patient. Harmful effects may occur when alcohol and some depressants are
combined.

(2) Additive. In an additive drug interaction, the combined effects are equal
to the sum of the independent effects of the drugs. In the case of the additive effect,
1 + 1 = 2.

(3) Antagonism. Antagonism is the canceling effect of one drug upon

another. A sedative administered with a stimulant may antagonize or cancel the effects
of the stimulant. Of course, the degree of antagonism varies from complete cancellation
of the effect to varying degrees of reduced effectiveness.

k. Routes of Administration. Drugs may be given to patients using a variety of

methods. Some drugs are only effective if they are given in a particular dosage form.
Other drugs are administered in forms that enhance or decrease their effect or localize
the drug effects.

(1) Oral. Most drugs available today can be administered by mouth (orally).
Drugs can be orally administered in the form of tablets, capsules, powders, solutions, or
suspensions. Drugs administered by the oral route are usually taken for their systemic
effect. These medications must pass through the stomach and be absorbed in the
intestinal tract. Orally administered medications are usually easy to take and are
usually less expensive than other dosage forms.

(2) Sublingual/buccal. The sublingual/buccal route of administration is

closely related to the oral route; however, in the sublingual/buccal route the dosage

MD0804 3-8
form is not swallowed. The tablet is to be dissolved under the tongue (sublingual) or in
the pouch of the cheek (buccal). The drugs administered in this manner are rapidly
absorbed and have the advantage of bypassing the gastrointestinal tract. Nitroglycerin,
for heart patients, in tablet form is more likely the most frequently administered
sublingual drug.

(3) Rectal. Drugs administered by the rectal route may have a local effect
(as for hemorrhoids) or a systemic effect (as in the prevention of nausea and vomiting).
The rectal route is convenient to use in pediatric patients (children) or in patients who
are unconscious or vomiting. The amount of drug absorbed in the rectal route is usually
less than if the drug were administered orally. The absorption of drugs administered
rectally is unpredictable and can vary among patients.

(4) Vaginal/urethral. Drugs administered using the vaginal/urethral route are

used for their local effect. That is, they are usually given to treat an infection or other
pathological condition. Drugs administered in this route should not be irritating since
systemic absorption may occur.

(5) Inhalation. Drugs administered by inhalation have either may a local or

systemic effect. Anesthetics, like nitrous oxide, are inhaled and exert their effect after
absorption into the circulatory system. Sprays for nasal congestion have their effect on
the tissue in the nose and do not necessarily enter the general circulation.

(6) Topical. The topical route is probably the oldest route of administration.
Topical medications are applied directly upon the skin. As long as the skin is intact (not
broken or cut), drugs applied in this manner exert a local effect. The base (vehicle)
used to carry the ingredients in the local preparation can influence the action of the
drug. For example, dimethylsulfoxide (DMSO) will readily penetrate the skin and carry
the active ingredient along with it.

(7) Parenteral. The term parenteral literally means to avoid the gut
(gastrointestinal tract). Thus, parenterals are injectable drugs that enter the body
directly and are not required to be absorbed in the gastrointestinal tract before they
show their effect. Parenteral routes of administration usually have a more rapid onset of
action (show their effects more quickly) than other routes of administration. Parenteral
products must be sterile (free from living microbes). The parenteral route of
administration does have its disadvantages: it hurts, it is not a convenient route, and
once administered the injected drug cannot be retrieved.

(a) Intravenous (IV). The injection of a drug directly into the patient's
veins is the most rapid route of administration. This type of parenteral route results in
the most rapid onset of action.

(b) Intraarterial. In this parenteral route, the drug is injected directly

into the patient's arteries. This route is not frequently used.

MD0804 3-9
 (c) Intrathecal. The intrathecal route involves the administration of a
drug directly into the spine (subarachnoid space) as in spinal anesthesia. The
intrathecal route is used because the blood-brain barrier often precludes or slows the
entrance of drugs into the central nervous system.

(d) Intramuscular (IM). The intramuscular route is used when drugs

are injected deeply into muscle tissue. If the drug is in aqueous (water) solution,
absorption is rapid. However, if the drug is in an oily liquid or in the form of a
suspension, it can prolong the release of the drug.

(e) Intradermal (ID). In this route, the drug is injected into the (top few
layers) of the skin. Ideally, the drug is placed within the dermis. The intradermal route
is used almost exclusively for diagnostic agents.

(f) Subcutaneous (Sub-Q/SC). This route involves the injection of the

drug under the skin into the fatty layer, but not into the muscle. Absorption of the drug
is rapid. Insulin is normally administered subcutaneously.

3-6. TYPES OF ADVERSE REACTIONS TO DRUGS

A patient will sometimes have an adverse reaction to a drug. Adverse reactions

can have a direct toxic effect on various systems of the body or the adverse reactions
can occur in the form of milder side effects.

a. Direct Toxicity.

(1) In general terms, toxicity refers to the poison-like effects certain

substances can produce in the body. Fortunately, most drugs do not produce toxic
effects in most patients. However, when some drugs are administered to a patient over
prolonged periods or when some drugs are given in high dosages, direct toxic effects
can result. Direct toxicity may involve one or more of the body's systems. Certain parts
of the body (that is, bone marrow) produce red and white blood cells. If a toxic
accumulation of a substance affects these parts of the body, blood dyscrasias (the
formation of malformed or destroyed white or red blood cells) may occur.

(2) The liver has as one of its main functions the detoxification of chemical
substances when they are absorbed. If these substances damage the liver significantly,
its ability to detoxify them if greatly affected. Of course, if these substances are not
detoxified, the concentration of the substance in the body (that is, blood stream)
constantly increases. Thus, hepatotoxicity (the destruction of the cells of the liver) can
result in the accumulation of toxic products to the point that other body systems are
affected.

(3) The kidneys are responsible for eliminating water-soluble toxic products
(that is, waste products from cellular respiration) from the bloodstream. If nephrotoxicity

MD0804 3-10
(damage to the kidneys) results, the accumulation of these toxic products can result in
death.

(4) Toxic effects may not be limited to the person who is taking the drug. In
the past, it has been demonstrated that some drugs will cross the placental barrier and
enter the circulatory system of the fetus. Some drugs can exert serious effects on the
developing fetus. For example, the fetus may abort or be born with any number of
mental or physical defects. Since few mothers are willing to subject themselves and
their unborn children to drug testing, the effects of most drugs on the fetus are
unknown. Most of what is known about teratogenicity, fetal malformations, has been
learned either from experimental studies with animals or from the unfortunate
experiences of some mothers. The fetus is particularly susceptible to the adverse
effects of medications during the first three months after conception (the first trimester).
Unfortunately, many women do not realize they are pregnant until they are well into their
first trimester.

b. Allergic Reactions. A few individuals may be allergic, or hypersensitive, to a

drug. This allergy may arise because of a prior contact with a particular substance
called an allergen (it may even be the drug itself). This acquiring of an allergy is called
sensitization. You should understand that the symptoms of an allergy are not related to
the ordinary effects of the drug. Allergic reactions to a drug may range from a mildly
irritated skin rash to anaphylaxis (a fatal shock). It has been shown that penicillin, a
widely prescribed antibiotic, produces varying types of allergic reactions in from 1 to 10
percent of the patients who are administered the drug.

c. Side Effects. Most drugs do not produce only one single effect. Instead,
they may produce several physiological responses at the same time. For example,
antihistamines, drugs frequently used for their anti-allergic action tend to produce
drowsiness. In this case, drowsiness is a side effect of the antihistamines. With some
drugs, the side effects are so worrisome and inconvenient that the patient may stop
taking the medication.

d. Drug Dependence. All drugs have the potential of producing dependence,

the need to have that drug. There are two major types of dependence: psychological
and physiological.

(1) Psychological dependence may occur after a patient has been taking a
medication for a long time. With psychological dependence, the patient becomes so
convinced that he needs the drug (in order to continue to lead an improved life) that he
will go to great lengths to ensure that he receives the medication. Patients habituated
to amphetamines may demonstrate this type of dependence. Psychological
dependence is very difficult to treat.

(2) With physiological dependence, the patient's body develops a real need
for the drug over a long period. Since there is a physiological need for the drug, the
body reacts by going through withdrawal symptoms (that is, tremors, nausea, vomiting,

MD0804 3-11
and convulsions) if the drug is suddenly withheld. The patient habituated to narcotics
and barbiturates have physiological dependence.

Section IV. FACTORS WHICH INFLUENCE DRUG ACTION

3-7. INTRODUCTION TO PHARMACOKINETICS

Pharmacokinetics deals with the absorption, distribution, metabolism

(biotransformation), and excretion of drugs. Any time a drug is administered, these
factors will directly affect the amount of drug that will arrive at the site where the drug
acts. The amount of drug at the site of action will determine both the intensity of drug
action and the length of time the drug will show its effect(s).

3-8. ABSORPTION OF DRUGS

Absorption involves the uptake of the drug by the body. Three factors affect the
absorption of a drug: its water solubility, its fat solubility, and the transport mechanisms
of the body. It is imperative that you understand that all drugs must be in solution
before they can be absorbed.

3-9. FACTORS WHICH AFFECT ABSORPTION

a. Water Solubility. All body fluids are water based. Therefore, a drug must be
soluble in water in order to be absorbed. Dissolution of the drug in aqueous (water)
solution is dependent 6n the pH of the solution and the disintegration of the drug.

(1) Disintegration. Disintegration (Figure 3-1) increases the surface area of

a drug. The speed at which a dosage form disintegrates is dependent upon the type of
solid dosage form and the manufacturing process used to make that dosage form. The
solid dosage form could be a tablet, suppository, capsule, powder, or suspension. Take
a tablet for example. The manufacturer may add starch to the tablet in order to make it
swell when it is added to water. The tablet may be a sublingual tablet that is made to
rapidly dissolve in the mouth. On the other hand, the manufacturer may compress the
contents of the tablet under great pressure so that it will slowly dissolve. Further, an
enteric coating may be applied to the tablet so that it will dissolve in the intestine. In the
case of some capsules, "tiny time capsules" systematically dissolve during a period and
prolong the effect of the drug.

MD0804 3-12
 Figure 3-1. Dissolution of a drug.

(2) pH. The relative acidity or basicity of the fluids into which a drug is
placed will affect how rapidly the drug will dissolve. The pH of the stomach can be as
low as 1.0 (very acidic), the pH of the small intestine can range from 6.9 to 7.4 (slightly
acidic to slightly basic), while the pH of the plasma is approximately 7 4 (slightly basic).
Weakly acidic drugs (that is, aspirin) are more soluble in a basic or alkaline solution like
the small intestine (pH above 7.4). Weakly basic drugs, such as tetracycline
hydrochloride, are more soluble in an acidic solution like the stomach (pH below 7.0).

(3) Ionization. Ionization is the process whereby a substance breaks down

into positively and negatively charged particles (Figure 3-2).

(a) For example, when hydrochloric acid ionizes, it forms hydrogen

ions (H+) and chloride ions (Cl-).

Figure 3-2. The ionization of hydrochloric acid.

(b) Equilibrium is established based on the chemical nature of each

drug. That is, a certain percentage of the drug ionizes, while the rest remains as the
compound. In summary, dosage forms must go into solution. A solid dosage form must
disintegrate and dissolve before it can be absorbed. A suspension dosage form has
already been partially dissolved; the drug particles must dissolve before absorption can
occur. A solution dosage form contains a drug that has already been dissolved; thus,
no disintegration or dissolution is required before absorption can occur.

b. Fat Solubility. In the last area, the topic of water solubility was discussed.
For instance, a drug is in solution. What other factors must it overcome in order to be
absorbed? One is fat solubility. Almost without exception, all body membranes are lipid
(fatty) in nature. Membranes separate even the various water compartments of the
body. These membranes are selectively permeable. That is, these membranes will
only allow certain materials to pass through them. In particular, the membranes favor

MD0804 3-13
the absorption of unionized particles (particles which have neither a positive nor a
negative charge).

c. Transport Mechanisms. The body either in an active or in a passive way

can absorb drugs.

(1) Passive transport. Passive transport (diffusion) follows a concentration

gradient. That is, if there is a high concentration of a substance on one side of the
barrier and a low concentration of that substance on the other side of the barrier, nature
tries to balance the two concentrations so that one is equal to the other. The two
concentrations can be equalized in one of two ways. One way is for the liquid
containing the substance to move from the side with fewer particles to the side with
more particles. This process, called osmosis, will ultimately result in the two sides
having the same concentration. The second option is for the drug particles to move
from the side of higher concentration to the side of the lower concentration. This
process, called diffusion, will also ultimately result in the two sides having the same
concentration. Most drugs are absorbed in this manner of diffusion. With diffusion, the
drug particles move from the side of higher concentration through the cell membrane
into the side of lower concentration.

(2) Active transport.

(a) A ride in a roller coaster would give you a background to

understand this section on active transport. You have probably observed that a roller
coaster car does not have an engine. Common sense would tell you that the car does
not need an engine to go down the hills, but up those hills--that is a different story. You
have probably observed that a mechanism exists for pulling the car up the hill.

(b) Active transport works in much the same way. Proteins (in the
cells) make up the linings of the cells. Some of these proteins have a particular affinity
(attraction) for a selected drug. When the drug molecule meets the cell wall, the protein
called a "carrier molecule" attaches itself to the drug, carries it across the cell
membrane, and releases the drug on the other side. The drug then enters the
circulation and is distributed throughout the body. Active transport can move against a
concentration gradient to move a substance to a place of higher concentration. Vitamin
B-12 is an example. Very little of this vitamin can pass through the intestinal wall of the
gut by diffusion; however, a carrier molecule, often called "intrinsic factor" transports the
vitamin across the gut. Once in circulation, the vitamin is stored in the liver. The
concentration of drug in the liver is several hundred times higher than in circulation.
Therefore1 if a drug is unionized, water soluble, and fat-soluble, it may pass through the
cells of the gut if taken orally. Once in circulation, the drug must pass through the fatty
layer of the individual cell in order to have an effect. So, even injected medications
have some of the same problems as oral medications.

(3) Illustration of concepts. Perhaps some insight can be gained about this
whole topic of drug transport mechanisms if a diagram depicting the concepts is shown
and discussed. Figure 3-3 is provided for this purpose. In the figure, several concepts
are illustrated:

MD0804 3-14
 A--Drug A is an undissolved drug. It is not in solution and it cannot be
absorbed.

B--B is a molecule of a drug in solution. It is unionized and can be

absorbed.

C--C is a molecule of a drug attached to a "carrier molecule" at the cell

wall.

D--D is an ion of a drug. It cannot be absorbed since the fatty layer

repels it.

E--E is a molecule of a drug. It is in circulation and will be carried away.

F--F is a molecule of the drug that is being released into circulation by a

carrier molecule.

Figure 3-3. Illustration of drug transport concepts.

NOTE: Passive transport or diffusion has absorbed Molecule B. Once it has been
absorbed, the circulating blood will carry it away. Consequently, the concentration of
the drug will always remain higher in the gut and diffusion will continue. As the
unionized particles are absorbed, the ionized particles will attach to each other to form
more unionized drug. This occurs because the drug has equilibrium established

MD0804 3-15
between the ionized and unionized form; as the unionized form is removed, the balance
shifts make up for the loss. Molecules C and F are being moved by active transport.
They must also be unionized and fat soluble; however, their transport does not rely on
differences in concentration. This transport process also accounts for the absorption of
a drug by the individual cells within the body.

3-10. DISTRIBUTION OF DRUGS

a. Once the drug is absorbed, it enters the circulation and is carried throughout
the body. The location in the body where the drug goes varies from drug to drug. The
drug may be stored in bone or fat, bound to the proteins in the blood plasma, or
circulate freely as the unbound drug. The drug will find its way into many organs.
Finally, some of the drug will reach the target tissue where it can cause the effect for
which it was administered. An equilibrium will be established between the circulating
unbound drug and each area of the body.

b. The distribution of a drug in the body happens in a very systematic manner.

Figure 3-4 demonstrates the concept of distribution.

Figure 3-4. Drug distribution within the body.

Assume that 100 micrograms (100 mcg) of a drug have been absorbed and is
distributed based on the percentages noted in Figure 3-4. Of the 100 micrograms
absorbed, only two micrograms of the drug will arrive at the target tissue to give the
desired pharmacological effect. If two micrograms is enough drugs to produce the
desired pharmacological effect, the desired effect will be obtained. However, if the
amount of drug required to produce the effect is four micrograms, the desired
pharmacological effect will not be obtained. The dose of the drug can be increased so
that 200 milligrams of the drug can be absorbed, thus providing the amount of drug
needed to give the desired pharmacological effect. However, doubling the dose may
present problems. Doubling the dose would also double the amount of drug in the other
areas of the body. Perhaps this increased dosage may produce some response by
another body organ. For example, the patient may become nauseous, vomit, lose his

MD0804 3-16
hair, or go into convulsions. These are side effects of the drug. Thus, it is important to
remember that the whole body must be taken into account when a drug is administered.
If the problem of the side effects cannot be resolved, the drug may not be released for
use.

NOTE: Another areas of concern in the distribution of drugs are those that crosses the
placental barrier. Drugs may actively or passively cross the placental barrier and enter
the fetal circulation. The enzyme systems of the developing fetus may not be able to
adequately metabolize the drug. Toxic effects can result. At this time, it is virtually
impossible to predict whether a drug will pass the placental barrier.

3-11. METABOLISM (BIOTRANSFORMATION)

The process of drug absorption and distribution is dynamic. That is, it is

continually changing. Even as the drug is being distributed, the individual cells of the
body begin to chemically change or alter the drug. This metabolic process of changing
the drug is called metabolism or biotransformation. While many cells of the body will be
involved in this process, the liver is the organ primarily responsible for this
biotransformation. The liver changes drugs to make them more water-soluble so that
they may be more easily excreted from the body. During the process of metabolism, a
drug may be rendered inactive, converted from an inactive form to an active one, or be
made more toxic. The liver may oxidize, reduce, hydrolyze, or conjugate (bind with a
protein) the drug. The kidney will also play an active role in conjugating drugs.

3-12. BIOAVAILABILITY

a. The term bioavailability was defined in the first portion of this subcourse. In
Figure 3-4, all 100 micrograms of the drug was available to the system, since it was
absorbed. The amount of drug originally administered to the patient was not stated.
That amount of administered drug could have ranged from 100 micrograms to 1000
milligrams or more. From the reading, you should have noted that absorption is not an
easy process, and that any number of things can interfere with the process.

b. The controversy concerning generic drugs deserves consideration at this

point. For example, switching a patient from one generic brand of ampicillin to another
brand of ampicillin could cause some problems for some patients. Thus, one
company's generic brand of a drug might not be able to be absorbed as quickly as
another company's generic brand of the same drug. With other drugs and some
patients the switch from one company's drug to another company's drug is of little
consequence.

c. Drugs that present the most problems in terms of bioavailability are oral
solids. That is because oral solids must disintegrate, dissolve, be water soluble, be fat
soluble, unionize, and pass through the drastic pH changes from the stomach to the
small intestine.

MD0804 3-17
3-13. EXCRETION

a. Excretion is the process of eliminating a drug or its metabolites from the body.
The major organ of excretion is the kidney. Secondary routes of excretion are hepatic
(liver), through the bile into the feces, lungs, saliva, sweat, and breast milk.

b. The inability of a patient to excrete drugs and other waste can be life
threatening. The elimination of drugs through sweat, saliva, and the lungs is of minor
interest in this subcourse. Of course, the excretion of drugs in breast milk is of concern
to mothers who breast-feed their infants. As a rule, drugs that are weakly basic are
more likely to be excreted in breast milk, because the milk is slightly acidic; therefore,
the basic drugs are more soluble in breast milk.

c. Patients who have limited liver and kidney function usually require lower
doses of medication. This is because more of the drug tends to stay in the body.

3-14. MECHANISMS OF DRUG ACTION

a. Receptor Site Theory. A drug that finally enters a cell may produce an
effect. It is able to produce this effect by a variety of complex biochemical processes.
Most of the processes can be simplified into one explanation of the mechanism of drug
action known as the receptor-site or "lock and key" theory. This theory states that a
drug (the key) combines with a receptor-site (the lock) to produce a pharmacological
effect. Drugs that will fit into the receptor-site are said to have an "affinity" for that
receptor-site. Only drugs that fit into the receptor-site will produce a pharmacological
response. Figure 3-5 visually represents the receptor-site theory.

b. Chemical Structure Activity Relationship. As a review, drug molecules

have specific chemical structures. The chemical structure of a drug will determine if a
drug molecule (the key) will fit into the receptor-site (the lock) and produce a
pharmacological effect. For example, whether the hydroxyl (OH-) group is on the left or
right side of the molecule or is at a 520 angle with the molecule can determine whether
the "key" will fit the "lock." This is referred to as chemical structure activity relationship.
From this, we can say that drugs that are similar in composition and chemical structure
may have similar effects. The chemical structure of a drug can be altered with no effect
upon the pharmacological effect the drug produces. However, the change in the
chemical structure of the drug molecule can increase or decrease its side effects.
Further, the modification of a drug molecule can influence its pharmacological actions.
Therefore, the modification of a drug's molecular structure can result in the formation of
a drug that can produce a desired pharmacological effect with a significantly lower dose
and with an accompanying decrease in undesired side effects.

MD0804 3-18
 Figure 3-5. The receptor-site theory.

c. Antagonists. Antagonists are drugs that will or reverse block the action of
other drugs. There are two types of antagonists: competitive and physiological.

(1) Competitive antagonists. Competitive antagonists combine with the

receptor-site and prevent another drug from combining with the receptor-site. A
competitive antagonist does not displace a drug at the receptor-site. Figure 3-6
illustrates the concept of a competitive antagonist.

Figure 3-6. A competitive antagonist.

(2) Physiological antagonists. Physiological antagonists reverse the action

of the drug by acting on a different receptor-site to cause a different physiological effect.

3-15. DRUG EFFICACY

a. Drug efficacy refers to the effectiveness of a drug. Drug efficacy is measured

by the clinical response of the patient. A drug is considered to have a high degree of
efficacy, if it achieves desired clinical results.

b. Laboratory tests may be used to determine the amount of drug that has been
absorbed. The amount of drug absorbed may be used to predict a patient's response.
However, since people respond differently to the same dose of the same drug, merely

MD0804 3-19
knowing the amount of drug absorbed does not always indicate the response of an
individual patient.

c. A general rule is that as the dose of a drug is increased, a greater effect is

seen in the patient until a maximum desired effect is reached. If more drug is
administered after the maximum point is reached, the side effects will normally increase.
Figure 3-7 illustrates this principle.

Figure 3-7. Relationship between dosage and drug effect.

Continue with Exercises

MD0804 3-20
EXERCISES, LESSON 3

INSTRUCTIONS: Answer the following exercises by marking the lettered response that
best answers the question, by completing the incomplete statement, or by writing the
answer in the space provided at the end of the exercise.

After you have completed all of these exercises, turn to "Solutions to Exercises" at
the end of the lesson and check your answers. For each exercise answered incorrectly,
reread the material referenced with the solution.

1. From the definitions below, select the definition of the term drug.

a. A substance that is used to cure all diseases.

b. A substance used to prevent, diagnose, or treat disease or to prevent

pregnancy.

c. A substance that can only be purchased at a drugstore.

d. A substance that occurs naturally and cannot cause any toxic reactions.

2. From the definitions below, select the definition of the term toxicology.

a. The science of chemicals.

b. The science of drugs.

c. The science of poisons.

d. The science of dosage.

3. Select the drug that is derived from an animal source.

a. Belladonna.

b. Heparin.

c. Iron.

d. Aspirin.

MD0804 3-21
 4. Select the statement that best describes a use of drugs.

a. To produce anxiety or tension.

b. To relieve the symptoms of a disease or condition.

c. To cure diabetes.

d. Both a and b.

e. Both b and c.

5. Select the statement that best describes how the physical condition of a
patient might influence the amount of drug required to obtain a specific effect.

a. Debilitated patients always require the same amount of drug as a healthy

person.

b. The physical condition of a patient never influences the required dose of

a drug.

c. The weak patient might require smaller doses of a drug to achieve an

effect.

d. Patients in extreme pain usually require smaller doses of analgesic

agents rather than patients who are in less pain.

6. Select the statement that best describes drug dependence.

a. Drug dependence occurs whenever a patient takes a particular drug for a

long period.

b. Drug dependence is said to occur when the patient has either a

physiological or psychological need for a drug.

c. Drug dependence occurs when a patient's body requires a drug, but

cannot tolerate its harmful effects.

d. Drug dependence can only occur with certain types of drugs (like
narcotics).

MD0804 3-22
 7. Select, from the list below, the definition of the term synergism.

a. Synergism occurs when one drug lives off another drug.

b. Synergism occurs when the combined effect of two drugs is greater than
the sum of their independent effects.

c. Synergism occurs when the combined effects of two drugs are equal to
the sum of the independent effects of the drugs.

d. Synergism occurs when one drug's effects cancel the effects of another
drug.

8. Select the route of administration in which the dosage form is placed in the
mouth but not swallowed.

a. Parenteral.

b. Rectal.

c. Sublingual/Buccal.

d. Oral.

9. Select the statement that best describes the sublingual/buccal route of

administration.

a. In this route of administration, the drug is swallowed and very quickly

absorbed by the patient.

b. In this route of administration, the drugs are absorbed only after being
taken into the gastrointestinal tract.

c. In this route of administration, the drug is absorbed without passing

through the gastrointestinal tract.

d. In this route of administration, the drug is applied directly to the skin.

MD0804 3-23
 10. From the statements below, select the statement that best describes how fat
solubility influences drug absorption.

a. Since all body fluids are fat based, a drug must be soluble in fat in order
to be absorbed and demonstrate its effect.

b. Since body membranes are lipids in nature, a drug that will pass through
lipid material will be absorbed much more quickly than ionized drug particles.

c. The body cannot absorb a fat-soluble drug, because it is unionized.

d. All fat-soluble drugs must be converted into water-soluble substances

before they can be absorbed.

11. From the list below, select the definition of the term metabolism.

a. The chemical process of producing a drug.

b. The metabolic process of changing a drug.

c. The process of transforming a living life form.

d. The modification of complex substances to make them powerless.

12. From the list below, select the definition of the term excretion.

a. The process of placing a drug or its metabolites into the body.

b. The process of metabolically changing a drug or its metabolites.

c. The process of eliminating a drug or its metabolites from the body.

d. The process of concentrating a drug and removing it from the patient's

gastrointestinal tract.

MD0804 3-24
 13. From the descriptions below, select the description that best describes the
Receptor-Site Theory of the mechanism of drug action.

a. A drug (the lock) combines with a receptor-site (the key) to produce a

pharmacological effect.

b. A drug (the key) combines with a receptor-site (the lock) to produce a

pharmacological effect.

c. A drug (the receptor-site) combines with cell components (the lock) to

produce a pharmacological effect.

d. A drug (the lock) combines with a receptor-site in the intestine to produce

an essential effect.

14. Select the statement that best contrasts passive transport with active
transport.

a. Active transport occurs when molecules of the drug move from an area of
high concentration to an area of low concentration, while passive transport occurs when
a "carrier molecule" carries a drug molecule across a cell membrane.

b. Passive transport occurs in comatose patients whose cells are unable to

actively absorb drugs through the normal processes.

c. Passive transport occurs when molecules of a drug move from an area of

high concentration to an area of low concentration, while active transport occurs when a
"carrier molecule" carries a drug molecule across a cell membrane.

d. Passive transport occurs when a "carrier molecule" carries drug

molecules from an area of low concentration to an area of high concentration, while
passive transport involves the movement of blood plasma from a low concentration to a
high concentration.

MD0804 3-25
 15. From a group below, select the description that best describes the importance
of structure activity relationships.

a. Drugs that are similar in composition and structure may have similar
effects.

b. Drugs that are not similar are ineffective.

c. Drugs that are active generally have similar structures.

d. Drugs that are similar in effect generally have the same trade name.

16. Select the statement that best contrasts competitive antagonist with
physiological antagonists.

a. Competitive antagonists combine with the receptor-site and prevent

another drug from combining with the receptor-site, while physiological antagonists
reverse the action of a drug by acting on a different receptor-site to cause different
physiological reaction.

b. Competitive antagonists produce pharmacological effects by producing a

physiological effect different from the drug, while physiological antagonists
physiologically compete for a spot on the receptor-site.

c. Competitive antagonists combine with the receptor-site and remove the

drug from the site, while physiological antagonists physically compete for the receptor-
site.

d. Physiological antagonists physically remove drug molecules from the

receptor-site, while competitive antagonists compete for the receptor-site.

Check Your Answers on Next Page

MD0804 3-26
SOLUTIONS TO EXERCISES, LESSON 3

1. b A substance used to prevent, diagnose, or treat disease or to prevent

pregnancy. (para 3-2a)

2. c The science of poisons. (para 3-2e)

3. b Heparin. (para 3-3b)

4. b To relieve the symptoms of a disease or condition. (para 3-4c)

5. c The weak patient may require smaller doses of a drug to achieve an effect.
(para 3-5f)

6. b Drug dependence is said to occur when the patient has either a physiological or
psychological need for a drug. (para 3-6)

7. b Synergism occurs when the combined effect of two drugs is greater than the
sum of their independent effects. (para 3-5j(1))

8. c Sublingual/Buccal. (para 3-5k(2))

9. c In this route of administration the drug is absorbed without passing through the
gastrointestinal tract. (para 3-5k(2))

10. b Since body membranes are lipid in nature, a drug that will pass through lipid
material will be absorbed much more quickly than ionized drug particles.
(para 3-9b)

11. b The metabolic process of changing a drug. (para 3-11)

12. c The process of eliminating a drug or its metabolites from the body.
(para 3-13a)

13. b A drug (the key) combines with a receptor-site (the lock) to produce a
pharmacological effect. (para 3-14a)

14. c Passive transport occurs when molecules of a drug move from an area of high
concentration to an area of low concentration, while active transport occurs
when a “carrier molecule” carries a drug molecule across a cell membrane.
(para 3-9c(1) and (2))

MD0804 3-27
15. a Drugs that are similar in composition and structure may have similar effects.
(para 3-14b)

16. a Competitive antagonists combine with the receptor-site and prevent another
drug from combining with the receptor-site, while physiological antagonists
reverse the action of a drug by acting on a different receptor-site to cause a
different physiological reaction. (para 3-14c(1) and (2))

End of Lesson 3

MD0804 3-28
 LESSON ASSIGNMENT

LESSON 4 Local Anesthetic Agents.

TEXT ASSIGNMENT Paragraphs 4-1--4-8.

LESSON OBJECTIVES After completing this lesson, you should be able to:

4-1. Given one of the following terms: local

anesthetic, local infiltration, topical block,
surface anesthesia, nerve block, peridural, and
spinal anesthesia, and a group of statements,
select the meaning of that term.

4-2. From a group of statements, select the

statement that best describes the mechanism
of action for local anesthetics.

4-3. Given a group of statements, select the

statement that best describes why
vasoconstrictors are used in conjunction with
local anesthetics.

4-4. From a group of statements, select the caution

and warning associated with the use of a local
anesthetic combined with a vasoconstrictor.

4-5. Given a group of statements, select the

statement that best describes why
hyaluronidase (Wydase®) is used in
conjunction with local anesthetics.

4-6. Given a group of statements, select the

statement that describes a caution and warning
associated with the use of local anesthetics.

4-7. From a list of toxicities, select the toxicity

associated with the use of local anesthetics.

4-8. Given the trade name of a local anesthetic

agent and a list of generic names, match the
trade name of the agent with its generic name.

MD0804 4-1
 4-9. Given the trade and/or generic name of a local
anesthetic agent and a group of possible uses
or cautions and warnings, select the clinical
use or caution and warning associated with
that agent.

SUGGESTION After completing the assignment, complete the

exercises at the end of this lesson. These exercises
will help you to achieve the lesson objectives.

MD0804 4-2
 LESSON 4

LOCAL ANESTHETIC AGENTS

Section I. BACKGROUND INFORMATION

4-1. BACKGROUND INFORMATION

In order to understand what a local anesthetic is and how it is used, you need to
study/review the following definitions:

a. Local Anesthetic. A local anesthetic is an agent that interrupts pain

impulses in a specific region of the body without a loss of patient consciousness.
Normally, the process is completely reversible--the agent does not produce any residual
effect on the nerve fiber.

b. Local Infiltration (Local Anesthesia). Local infiltration occurs when the

nerve endings in the skin and subcutaneous tissues are blocked by direct contact with a
local anesthetic, which is injected into the tissue. Local infiltration is used primarily for
surgical procedures involving a small area of tissue (for example, suturing a cut).

c. Topical Block. A topical block is accomplished by applying the anesthetic

agent to mucous membrane surfaces and in that way blocking the nerve terminals in the
mucosa. This technique is often used during examination procedures involving the
respiratory tract. The anesthetic agent is rapidly absorbed into the bloodstream. For
topical application (that is, to the skin), the local anesthetic is always used without
epinephrine. The topical block easily anesthetizes the surface of the cornea (of the eye)
and the oral mucosa.

d. Surface Anesthesia. This type of anesthesia is accomplished by the

application of a local anesthetic to skin or mucous membranes. Surface anesthesia is
used to relieve itching, burning, and surface pain (for example, as seen in minor
sunburns).

e. Nerve Block. In this type of anesthesia, a local anesthetic is injected around

a nerve that leads to the operative site. Usually more concentrated forms of local
anesthetic solutions are used for this type of anesthesia.

f. Peridural Anesthesia. This type of anesthesia is accomplished by injecting

a local anesthetic into the peridural space. The peridural space is one of the coverings
of the spinal cord.

g. Spinal Anesthesia. In spinal anesthesia, the local anesthetic is injected into

the subarachnoid space of the spinal cord.

MD0804 4-3
4-2. MECHANISM OF ACTION OF THE LOCAL ANESTHETICS

a. The nerve fiber is a long cylinder surrounded by a semipermeable (allows

only some substances to pass) membrane. This membrane is made up of proteins and
lipids (fats). Some of the proteins apparently act as channels, or pores, for the passage
of sodium and potassium ions through the membrane.

b. The movement of nerve impulses along a nerve fiber is associated with a

change in the permeability of the membrane. The pores widen, and sodium ions (Na+)
move to the inside of the fiber. At the same time, potassium ions (K+) diffuse out
through other pores (see Figure 4-1). The entire process is called depolarization.
Immediately after the nerve impulse has passed, the pores again become smaller.
Sodium ions (Na+) are now "pumped" out of the fiber. At the same time, potassium ions
are actively transported into the fiber. The nerve membrane is then ready to conduct
another impulse.

Figure 4-1. Mechanism of nerve impulse transmission.

c. Local anesthetics block depolarization of the nerve membrane. That is, to

make the conduction of the nerve impulse impossible.

d. The local anesthetic effect lasts as long as the agent maintains a certain
critical concentration in the nerve membrane. There is a potential problem: the local
concentration needed to prevent conduction of the nerve impulse is much greater than
the tolerable blood level. TO AVOID A SYSTEMIC TOXIC REACTION TO THE LOCAL
ANESTHETIC, THE SMALLEST AMOUNT OF THE MOST DILUTE SOLUTION THAT
WILL EFFECTIVELY BLOCK THE PAIN SHOULD BE ADMINISTERED.

4-3. THE USE OF VASOCONSTRICTORS IN CONJUNCTION NITH LOCAL

ANESTHETICS

a. Indications. Vasoconstrictors (like epinephrine) are sometimes used in

conjunction with local anesthetics. Vasoconstrictors are used to prolong the duration of
action of local anesthetics. Vasoconstrictors also help to control bleeding.
Furthermore, the vasoconstrictor delays the absorption of the local anesthetic by
reducing the blood flow to the affected area. This results in a reduction of the toxic
effects of the local anesthetic, since the rate of absorption keeps pace with the rate the

MD0804 4-4
local anesthetic is metabolized by the body. Vasoconstrictors are of no value in
delaying the absorption of the local anesthetic from mucous membranes (that is, topical
blocks).

b. Cautions and Warnings of the Combination.

(1) It should be recognized that the injection of epinephrine-containing

solutions in or around fingers, toes, and the penis is not recommended.

(2) Freshly prepared combinations of vasoconstrictors and local anesthetics

are more effective than commercially premixed epinephrine-containing local anesthetic
solutions. This is because a very low pH is required to stabilize the epinephrine in these
mixtures. In general, the content of one part epinephrine to 200,000 parts of the local
anesthetic agent (is optimum) will minimize the side effects inherent with epinephrine.
Great care must be taken in calculating this dilution. Small, precisely calibrated
syringes should be used in the mixing process. It should be noted that the standard
solution of epinephrine supplied is a 1:1000 (1 to 1000) concentration in each glass
ampule. This means that 1 milliliter of the 1:1000 epinephrine solution contains 1
milligram of epinephrine. In preparing a 1:200,000 dilution, epinephrine should be
added to a local anesthetic solution on a ratio of 0.1 milliliter-20 milliliters of local
anesthetic solution. This does not apply to subarachnoid injections, in which a higher
concentration of epinephrine is required.

4-4. ANOTHER AGENT WHICH CAN AFFECT THE ACTIONS OF LOCAL

ANESTHETICS

Hyaluronidase (Wydase®) is sometimes used in conjunction with local

anesthetics. Hyaluronidase is an enzyme that breaks down the material that binds cells
together. Thus, when hyaluronidase is combined with local anesthetic, greater
infiltration (movement) of the local anesthetic in the tissues is made possible.

4-5. CAUTIONS AND WARNINGS ASSOCIATED WITH LOCAL ANESTHETICS

a. Precautions should be taken against the danger of confusing the various

agents with one another or mistaking different concentrations of the same drug.

b. In order to avoid intravascular (into the veins) injection, aspiration in several

planes with the plunger of the syringe should always be done before injecting the
anesthetic solution into the tissues.

c. The instillation of local anesthetic agents into the trachea and bronchi leads to
immediate absorption, which soon reach blood levels comparable to those reached by
straight intravenous injection.

d. A previously punctured vial of local anesthetic solution should never be re-

autoclaved.

MD0804 4-5
 e. Discolored local anesthetic solutions should be immediately thrown away.

4-6. TOXICITIES OF LOCAL ANESTHETICS

Essentially all systemic toxic reactions associated with local anesthetics are the
result of over-dosage leading to high blood levels of the agent given. Therefore, to
avoid a systemic toxic reaction to a local anesthetic, the smallest amount of the most
dilute solution that effectively blocks pain should be administered.

a. Hypersensitivity. Some patients are hypersensitive (allergic) to some local

anesthetics. Although such allergies are very rare, a careful patient history should be
taken in an attempt to identify the presence of an allergy. There are two basic types of
local anesthetics (the amide type and the ester type). A patient who is allergic to one
type may or may not be allergic to the other type.

b. Central Nervous System Toxicities. Local anesthetics, if absorbed

systematically in excessive amounts, can cause central nervous system (CNS)
excitement or, if absorbed in even higher amounts, can cause CNS depression.

(1) Excitement. Tremors, shivering, and convulsions characterize the

CNS excitement.

(2) Depression. The CNS depression is characterized by respiratory

depression and, if enough drug is absorbed, respiratory arrest.

c. Cardiovascular Toxicities. Local anesthetics if absorbed systematically in

excessive amounts can cause depression of the cardiovascular system. Hypotension
and a certain type of abnormal heartbeat (atrioventricular block) characterize such
depression. These may ultimately result in both cardiac and respiratory arrest.

Section II. LOCAL ANESTHETICS AND THEIR CLINICAL USES

4-7. EXAMPLES OF LOCAL ANESTHETICS

The local anesthetics you may encounter in a hospital or fields setting are
described below. The discussion does not cover every fact known about the use of a
particular drug. Therefore, you are encouraged to read references or to ask
knowledgeable personnel your specific questions concerning points not presented in
this subcourse.

MD0804 4-6
 a. Lidocaine Hydrochloride (Xylocaine®).

(1) Clinical uses. Lidocaine is used as a local anesthetic for infiltrations,

nerve blocks, spinal anesthesia, topical anesthesia, and for caudal and epidural
anesthesia. It has a rapid onset of action and its effects last from 75 to 150
minutes. It has also been used as a cardiac depressant (anti arrhythmic).

NOTE: Refer to Table 4-1 for an overview of the clinical uses of various local
anesthetics.

Epidural and
Nerve Block
Ophthalmic

Infiltration
Topical

Topical

Caudal
Spinal
1. Cocaine X X

2. Procaine X X X

3. Chloroprocaine X X X

4. Tetracaine X X X

5. Proparacaine X

6. Benzocaine X

7. Lidocaine X X X X X

8. Mepivacaine X X X

9. Prilocaine X X X

10. Bupivacaine X X X

11. Bupivacaine X X X

12. Dichlorotetra-
X
fluorethane *

13. Ethyl chloride * X

*Surface anesthetics for application to the skin.

Table 4-1. An overview of the clinical uses of various local anesthetics.

MD0804 4-7
 (2) Forms available. Lidocaine is available in injection form (various
percentage concentrations), jelly form, and in cream form.

b. Mepivacaine (Carbocaine®).

(1) Clinical uses. Mepivacaine is pharmacologically and chemically related

to lidocaine. It is used for infiltration, nerve block, peridural, and regional anesthesia.
The duration of action for this drug is from 2 to 2 1/2 hours.

(2) Forms available. Mepivacaine is available in injection form.

c. Prilocaine (Citanes®).

(1) Clinical uses. Prilocaine is pharmacologically similar to both lidocaine

and mepivacaine. It is used for infiltration, nerve block, peridural, and regional
anesthesia. This drug is less toxic than lidocaine because it is metabolized and
excreted faster than lidocaine.

(2) Forms available. Prilocaine is available in injection form.

d. Bipivacaine (Marcaine®).

(1) Clinical uses. Bipivacaine is pharmacologically related to lidocaine. It is

used for infiltration, nerve block, and epidural anesthesia.

(2) Forms available. Procaine is available in injection form.

e. Dibucaine (Nupercainal®, Nupercaine®).

(1) Clinical uses. Dibucaine is used for spinal and topical anesthesia. It is
the most potent local anesthetic. It is one of the most toxic and longest-acting local
anesthetics.

(2) Forms available. Dibucaine is available in cream, spray, suppository,

ointment, and injection forms.

f. Procaine (Novocaine®).

(1) Clinical uses. Procaine is used for infiltration, nerve block, and spinal
anesthesia. Procaine is not applied topically. Its duration of action is approximately 1
hour. It is a fairly safe local anesthetic to use since it is metabolized quickly.

(2) Forms available. Procaine is available in injection form.

MD0804 4-8
 g. Chloroprocaine (Nesacaine®, Nesacaine-C®).

(1) Clinical uses. Chloroprocaine is pharmacologically similar to procaine.

Chloroprocaine is used for infiltration, nerve block, caudal, and epidural anesthesia.

(2) Forms available. Chloroprocaine is available in injection form.

h. Tetracaine (Pontocaine®).

(1) Clinical uses. Tetracaine is used for topical, nerve block, infiltration,
spinal, and caudal anesthesia. Its onset of action is 15 minutes.

(2) Forms available. Pontocaine is available in injection, cream, ointment,

and injectable forms.

i. Proparacaine (Alcaine®, Ophthetic®).

(1) Clinical uses. Proparacaine is used primarily to produce anesthesia

when applied to the eye. It has a rapid onset of action (20 seconds) and its duration of
action is approximately 15 minutes.

(2) Forms available. Proparacaine is supplied in solution form.

j. Benzocaine (Americaine®).

(1) Clinical uses. Bezocaine is used for topical anesthesia of the mucous
membranes and skin. It is used in many over-the-counter spray preparations for the
treatment of sunburn and itching.

(2) Forms available. Benzocaine is available in solution, ointment, and

spray forms.

k. Cocaine.

(1) Clinical uses. Cocaine is applied to produce local anesthesia with

intensive vasoconstriction on mucous membranes. It is applied to procedure
anesthesia in the nose, throat, ear, and in bronchoscopy (a procedure in which an
instrument is used to inspect the bronchi).

(2) Forms available. Cocaine is supplied in the form of a white powder.

Cocaine solution must be compounded. It is a Schedule II controlled substance.

MD0804 4-9
4-8. LOCAL ANESTHETICS USED FOR TOPICAL APPLICATION ONLY

a. Dichlorotetrafluorethane (Freon®)

(1) Clinical uses. Dichlorotetrafluorethane is a nonflammable and non-

explosive agent for topical anesthesia of the skin. It is especially useful for localized
minor surgical procedures. This agent should not be sprayed on the skin for a period
that exceeds 45 seconds.

(2) Forms available. Dichlorotetrafluorethane is available in a spray form.

b. Ethyl Chloride.

(1) Clinical uses. This agent is used for topical anesthesia of the skin.

(2) Forms available. Ethyl chloride is available in a spray form.

Continue with Exercises

MD0804 4-10
EXERCISES, LESSON 4

INSTRUCTIONS: Answer the following exercises by marking the lettered response that
best answers the question, by completing the incomplete statement, or by writing the
answer in the space provided at the end of the exercise.

After you have completed all of these exercises, turn to "Solutions to Exercises" at
the end of the lesson and check your answers. For each exercise answered incorrectly,
reread the material referenced with the solution.

1. Which of the following statements best defines the term local infiltration?

a. A type of anesthesia achieved by applying the anesthetic agent to the

surface of mucous membranes to block nerve transmissions.

b. A type of anesthesia achieved when the nerve endings in the skin and
subcutaneous tissues are blocked by direct contact with a local anesthetic that is
injected into the tissue.

c. A type of anesthesia accomplished by injecting a nerve that leads to the

operative site.

d. A type of anesthesia accomplished by injecting a local anesthetic into

the peridural space.

2. Which of the following statements best describes the mechanism of action of

local anesthetics?

a. Local anesthetics destroy the nerve tissue so that electrical impulses

cannot be carried.

b. Local anesthetics greatly increase the number of electrical impulses

being transmitted so that pain cannot be felt in that particular area.

c. Local anesthetics block depolarization of the nerve membrane so that

the conduction of the nerve impulse is impossible.

d. Local anesthetics remove both potassium and sodium ions from the
nerve tissue so that polarity in the nerve cannot be accomplished; therefore, the
impulses are not allowed to move past a certain point in the tissue.

MD0804 4-11
 3. Why is hyaluronidase (Wydase®) used in conjunction with local anesthetics?

a. Hyaluronidase concentrates the local anesthetic in a particular area in

order that its effects might be prolonged.

b. Hyaluronidase neutralizes the local anesthetic so that undesired adverse

effects are greatly reduced.

c. Hyaluronidase is an enzyme that acts to tenderize the tissue and make

the nerves more sensitive to the effects of the local anesthetic.

d. Hyaluronidase increases the movement of the local anesthetic through

the tissue.

4. Select the caution(s) and warning(s) associated with the use of local
anesthetics.

a. When a local anesthetic is to be injected, the plunger should be

aspirated in several planes to ensure the drug is not being injected into a vein.

b. Discolored solutions of local anesthetic should be thrown away.

c. A previously used vial of local anesthetic solution should never be

reautoclaved.

d. All the above.

5. Select the toxicity(ies) associated with the use of local anesthetics.

a. Large amounts of systemically absorbed local anesthetics can cause

depression of the cardiovascular system.

b. Local anesthetics, even when given in small amounts, cause tremors,

shivering, and convulsions.

c. Local anesthetics cause respiratory depression.

d. Local anesthetics tend to produce hypersensitive reactions in most

people.

MD0804 4-12
INSTRUCTIONS: In Exercises 6-9, match the trade and generic names of the local
anesthetics.

6. Tetracaine ______________________________ a. Americaine®

7. Mepivacaine ____________________________ b. Freon®

8. Dichlorotetrafluorethane ___________________ c. Pontocaine®

9. Benzocaine _____________________________ d. Carbocaine®

10. Select the clinical use of ethyl chloride.

a. Used to produce anesthesia when applied to the eye.

b. Used for topical anesthesia of the skin.

c. Used for infiltration and caudal anesthesia.

d. Used to produce anesthesia in mucous membranes procedures.

11. What is the clinical use of proparacaine?

a. Used to produce topical anesthesia on the skin.

b. Used to produce both anesthesia and vasoconstriction when applied to

certain tissues.

c. Used in nerve block, spinal, and caudal anesthesia.

d. Used to produce anesthesia in the eye.

12. What is the clinical use of bupivacaine (Marcaine®)?

a. Used to produce anesthesia when applied to the eye.

b. Used to produce infiltration, nerve block, and epidural anesthesia.

c. Used to produce anesthesia when applied to the skin or mucous

membranes.

d. Used to produce anesthesia in a localized area when applied topically

(that is, bronchoscopy).

MD0804 4-13
 13. Select the caution and warning associated with the use of procaine
(Novocaine®).

a. The drug should not be applied topically.

b. The drug should not be used for infiltration anesthesia.

c. The drug should not be used to produce spinal anesthesia.

d. The drug should not be used to produce nerve block anesthesia.

Check Your Answers on Next Page

MD0804 4-14
SOLUTIONS TO EXERCISES, LESSON 4

1. b A type of anesthesia achieved when the nerve endings in the skin and
subcutaneous tissues are blocked by direct contact with a local anesthetic
that is injected into the tissue. (para 4-1b)

2. c Local anesthetics block depolarization of the nerve membrane so that the

conduction of the nerve impulse is impossible. (para 4-2)

3. d Hyaluronidase increases the movement of the local anesthetic through the

tissue. (para 4-4)

4. d All of the above. (para 4-5b, d, and e)

5. a Large amounts of systemically absorbed local anesthetics can cause

depression of the cardiovascular system. (para 4-6c)

6. c Pontocaine®. (para 4-7h)

7. d Carbocaine®. (para 4-7b)

8. b Freon®. (para 4-8a)

9. a Americaine®. (para 4-7j)

10. b Used for topical anesthesia of the skin. (para 4-8b)

11. d Used to produce anesthesia in the eye. (para 4-7i)

12. b Used to produce infiltration, nerve block, and epidural anesthesia.

(para 4-7d)

13. a The drug should not be applied topically. (para 4-7f)

End of Lesson 4

MD0804 4-15
 LESSON ASSIGNMENT

LESSON 5 The Central Nervous System.

TEXT ASSIGNMENT Paragraphs 5-1--5-15.

LESSON OBJECTIVES After completing this lesson, you should be able to:

5-1. Given a list of types of tissue, select the two

types of nervous tissues.

5-2. From a list of functions, select the function(s)

for which nervous tissues are specialized.

5-3. Given one of the following terms: neuron,

dendrite, or axon, and a group of definitions,
select the definition of that term.

5-4. Given the shape, diameter, or function of a

type of neuron and a list of types of neurons,
select the type of neuron described.

5-5. Given a group of statements, select the

statement that best describes the
neuromuscular junction.

5-6. Given a group of statements, select the

statement that best describes the function of a
neurotransmitter.

5-7. From a list of chemical substances, select the

substance(s) which is/are neurotransmitter(s).

5-8. Given a list of names, select the names of the

three major divisions of the human nervous
system.

5-9. Given a list of names, select the names of the

two major subdivisions of the central nervous
system.

5-10. From a list of functions, select the function(s) of

the cerebrospinal fluid.

MD0804 5-1
 5-11. Given the name of one of the major
subdivisions of the human brain and a list of
functions, select the function(s) of that part.

5-12. Given a list of functions, select the function of

the meninges surrounding the brain and spinal
cord.

SUGGESTION After completing the assignment, complete the

exercises at the end of this lesson. These exercises
will help you to achieve the lesson objectives.

MD0804 5-2
 LESSON 5

THE CENTRAL NERVOUS SYSTEM

Section I. BASIC CONCEPTS OF THE NERVOUS SYSTEM

5-1. TYPES OF NERVOUS TISSUES

There are two types of nervous tissues--the neurons (nerve cells) and glia
(neuroglia). The neuron is the basic structural unit of the nervous system. The glia are
cells of supporting tissue for the nervous system. There are several different types of
glia, but their general function is support (physical, nutritive, and so forth.).

5-2. SPECIALIZATION

Nervous tissues are specialized to:

a. Receive stimuli. Cells receiving stimuli are said to be "irritable" (as are all
living cells somewhat).

b. Transmit information.

c. “Store” information.

MD0804 5-3
 Section II. THE NEURON AND ITS "CONNECTIONS"

5-3. DEFINITION OF A NEURON

A neuron (Figure 5-1) is a nerve cell body and all of its branches.

Figure 5-1. A neuron.

5-4. TYPES OF NEURON BRANCHES

There are two types of neuron branches--dendrites and axons.

a. Dendrite. A dendrite is a neuron process that carries impulses toward the

cell body. Each neuron may have one or more dendrites. Dendrites receive information
and transmit (carry) it to the cell body.

b. Axon. An axon is a neuron branch that transmits information from the cell
body to the next unit. Each neuron has only one axon.

MD0804 5-4
 c. Information Transmission. Information is carried as electrical impulses
along the length of the neuron.

d. Coverings. Some neuron processes have a covering that is a series of

Schwann cells, interrupted by nodes (thin spots). This gives the neuron branch the
appearance of links of sausages. The Schwann cells produce a lipid (fatty) material
called myelin. This myelin acts as an electrical insulator during the transmission of
impulses.

5-5. TYPES OF NEURONS

Neurons may be identified according to shape, diameter of their branches, or

function.

a. According to Shape. A pole is the point where a neuron branch meets the
cell body. To determine the type according to shape, count the number of poles.

(1) Multipolar neurons. Multipolar neurons have more than two poles (one
axon and two or more dendrites).

(2) Bipolar neurons. Bipolar neurons have two poles (one axon and one
dendrite).

(3) Unipolar neurons. Unipolar neurons have a single process that

branches into a T-shape. One arm is an axon; the other is a dendrite.

b. According to Diameter (Thickness) of Branches. Neurons may be rated

according to the thickness of myelin surrounding the axon. In order of decreasing
thickness, they are rated A (thickest), B, and C (thinnest). The thickness affects the rate
at which impulses are transmitted. The thickest carry the impulses the fastest. The
thinnest carry the impulses the slowest.

c. According to Function.

(1) Sensorv neurons. In sensory neurons, impulses are transmitted from

receptor organs (for pain, vision, hearing, and so forth) to the central nervous system
(CNS). Sensory neurons are also known as afferent neurons.

(2) Motor neurons. In motor neurons, impulses are transmitted from the
central nervous system to muscles and glands (effector organs). Motor neurons may be
called efferent neurons.

(3) Interneurons. Interneurons transmit information from one neuron to

another. Interneurons connect sensory neurons with motor neurons.

MD0804 5-5
 (4) Others. There are other, more specialized types of neurons found in the
body (for example, central nervous system).

5-6. NEURON "CONNECTIONS"

A neuron may "connect" either with another neuron or with a muscle fiber. A
phrase used to describe such "connections" is "continuity without contact." Neurons do
not actually touch. There is just enough space to prevent the electrical transmission
from crossing from the first neuron to the next. This space is called the synaptic cleft.
Information is transferred across the synaptic cleft by chemicals called
neurotransmitters. Neurotransmitters are manufactured and stored on only one side of
the cleft. Because of this, information flows in only one direction across the cleft.

a. The Synapse. A synapse (Figure 5-2) is a “connection” between two

neurons.

Figure 5-2. A synapse.

(1) First neuron. An axon terminates in tiny branches. At the end of each
branch is found a terminal knob. Synaptic vesicles (bundles of neurotransmitters) are
located within each terminal knob. That portion of the terminal knob that faces the
synaptic cleft is thickened and is called the presynaptic membrane. This is the
membrane through that neurotransmitters pass to enter the synaptic cleft.

(2) Synaptic cleft. The synaptic cleft is the space between the terminal knob
of the first neuron and the dendrite or cell body of the second neuron.

(3) Second neuron. The terminal knob of the first neuron lies near a site on
a dendrite or the cell body of the second neuron. The membrane at this site on the
second neuron is known as the postsynaptic membrane. Within the second neuron is a
chemical that inactivates the used neurotransmitter.

b. The Neuromuscular Junction. A neuromuscular junction (Figure 5-3) is a

"connection" between the terminal of a motor neuron and a muscle fiber. The

MD0804 5-6
neuromuscular junction has an organization identical to a synapse. However, the knob
is much larger. The postsynaptic membrane is also larger and has foldings to increase
its surface area.

Figure 5-3. A neuromuscular junction.

(1) Motor neuron. The axon of a motor neuron ends as it reaches a skeletal
muscle fiber. At this point, it has a terminal knob. Within this knob are synaptic vesicles
(bundles of neurotransmitters). The presynaptic membrane lines the surface of the
terminal knob and lies close to the muscle fiber.

(2) Synaptic cleft. The synaptic cleft is a space between the terminal knob
of the motor neuron and the membrane of the muscle fiber.

(3) Muscle fiber. The terminal knob of the motor neuron protrudes into the
surface of the muscle fiber. The membrane lining the synaptic space has foldings and
is called the postsynaptic membrane. Beneath the postsynaptic membrane is a
chemical that inactivates the used neurotransmitter.

5-7. PROCESS OF NEUROTRANSMISSION

a. The dendrites receive the impulse and transfer it to the nucleus. The nucleus
will then cause a change in the permeability of the membrane surrounding the axon.
Potassium, which is normally present in high concentrations within the axon, will diffuse
out. Sodium, which is usually present in high concentrations outside the axon, will rush

MD0804 5-7
into the axon. This exchange of potassium and sodium is called depolarization. As
these electrolytes change positions, an electrical charge is set up and the impulses will
travel down the axon until it reaches the terminal bulbs. When the impulse reaches the
terminal bulbs, it will cause a release of neurotransmitters stored there into the synaptic
cleft. Once in the synaptic cleft, the neurotransmitters will diffuse across the synapse to
the dendrite of the postsynaptic neuron causing it to depolarize (see Figure 5-4).

b. Once the postsynaptic neuron has depolarized, the neurotransmitters must be

removed from the synaptic cleft to prevent further depolarization. This is accomplished
by two means. The neurotransmitter is either reabsorbed into the terminal bulb or an
enzyme destroys it. This process ends the impulse.

c. Before the neuron can depolarize again, the electrolyte sodium and
potassium must resume their original positions. The sodium pump theory states that
before the neuron can depolarize again the sodium is pumped out and the potassium is
pumped back in (repolarized).

5-8. NEUROTRANSMITTERS

A neurotransmitter is a chemical substance that aids in the transmission of an

impulse across the synapse. An impulse will cause the release of a neurotransmitter,
which is synthesized and stored in terminal bulbs of the axon. The neurotransmitter will
diffuse across the synaptic cleft and Initiate an impulse in the postsynaptic nerve. The
neurotransmitter reacts with a receptor-site on the postsynaptic nerve initiating an
impulse. The neurotransmitter must be removed from the synaptic cleft to stop the
impulse.

a. Acetylcholine. Acetylcholine (Ach) is destroyed by acetylcholinesterase

(AchE) in the synaptic cleft.

b. Norepinephrine. Norepinephrine (NE) is removed from the synaptic cleft by:

(1) Reabsorption (reuptake) into the terminal knob.

(2) Destroyed by catechol-o-methyl transferase (COMT).

(3) Destroyed by monoamine oxidase (MAO).

(4) Dilution by diffusion out of the junctional cleft.

5-9. THE ALL OR NONE LAW

This law states that if a stimulus is strong enough to cause a nerve impulse, it will
cause the entire fiber to depolarize and not just part of it.

MD0804 5-8
 Section III. THE HUMAN CENTRAL NERVOUS SYSTEM

5-10. GENERAL COMMENTS

The human nervous system is divided into three major divisions: the central
nervous system (CNS), the autonomic nervous system (ANS), and the peripheral
nervous system (PNS). The central nervous system is composed of the brain and
spinal cord. Both the peripheral nervous system and the autonomic nervous system
carry information to and from the central nervous system. The central nervous system
is so named because of its anatomical location along the central axis of the body and
because it is central in function. If we use a computer analogy to understand that it is
central in function, the CNS would be the central processing unit and the other two parts
of the nervous system would supply inputs and transmit outputs. Figure 5-4 shows the
central nervous system.

a. Major Subdivisions of the Central Nervous System. The major

subdivisions of the central nervous system are the brain and spinal cord.

Figure 5-4. The central nervous system (CNS).

b. Coverings of the Central Nervous System. Bone and fibrous tissues cover
the parts of the central nervous system. These coverings help to protect the delicate
tissue of the CNS.

MD0804 5-9
 c. Cerebrospinal Fluid. The cerebrospinal fluid (CSF) is a liquid that is thought
to serve as a cushion and circulatory vehicle within the central nervous system.

5-11. THE HUMAN BRAIN

The human brain has three major subdivisions: brainstem, cerebellum, and the
cerebrum. The central nervous system is first formed as a simple tube like structure in
the embryo. The concentration of nervous tissues at one end of the human embryo to
produce the brain and head is referred to as cephalization. When the embryo is about
four weeks old, it is possible to identify the early forms of the brainstem, cerebellum,
and the cerebrum, as well as the spinal cord. As development continues, the brain is
located within the cranium in the cranial cavity. See Figure 5-5 for illustrations of the
adult brain.

Figure 5-5. Human brain: A side view, B bottom view.

MD0804 5-10
 a. The Brainstem. The term brainstem refers to that part of the brain that would
remain after the removal of the cerebrum and the cerebellum. The brainstem is the
basal portion (portion of the base) of the brain. The brainstem can be divided as
follows:

FOREBRAINSTEM thalamus

MIDBRAINSTEM corpora quadrigemina

HINDBRAINSTEM pons
medulla

(1) The brainstem is continuous with the spinal cord. Together, the
brainstem and the spinal cord are sometimes known as the neuraxis.

(2) The brainstem provides major relays and controls for passing
information up or down the neuraxis.

(3) The 12 pairs of cranial nerves connect at the sides of the brainstem.

b. Cerebellum. The cerebellum is the spherical mass of nervous tissue

attached to and covering the hindbrainstem. It has a narrow central part called the
vermis and right and left cerebellar hemispheres.

(1) Peduncles. The peduncles is a stemlike connecting part. The

cerebellum is connected to the brainstem with three pairs of peduncles.

(2) General shape and construction. A cross section of the cerebellum

reveals that the outer cortex is composed of gray matter (cell bodies of neurons), with
many folds and sulci (shallow grooves). More centrally located is the white matter
(myelinated processes of neurons).

(3) Function. The cerebellum is the primary coordinator/integrator of motor

actions of the body.

c. Cerebrum. The cerebrum consists of two very much-enlarged hemispheres

connected to each other by a special structure called the corpus callosum. Each
cerebral hemisphere is connected to the brainstem by a cerebral peduncle. The surface
of each cerebral hemisphere is subdivided into areas known as lobes. Each lobe is
named according to the cranial bone under which it lies: frontal, parietal, occipital, and
temporal.

(1) The cerebral cortex is the gray outer layer of each hemisphere. Deeper
within the cerebral hemispheres the tissue is white. The "gray matter" represents cell
bodies of neurons. The "white matter" represents the axons.

MD0804 5-11
 (2) The areas of the cortex are associated with groups of related functions.

(a) For example, centers of speech and hearing are located along the
lateral sulcus, at the side of each hemisphere.

(b) Vision is centered at the rear in the area known as the occipital
lobe.

(c) Sensory and motor functions are located along the central sulcus,
which separates the frontal and parental lobes of each hemisphere. The motor areas
are located along the front side of the central sulcus, in the frontal lobe. The sensory
areas are located along the rear side of the central sulcus in the parietal lobe.

d. Ventricles. Within the brain, there are interconnected hollow spaces filled
with cerebrospinal fluid (CSF). These hollow spaces are known as ventricles. The right
and left lateral ventricles are found in the cerebral hemispheres. The third ventricle is
located in the forebrainstem. The fourth ventricle is in the hindbrainstem. The fourth
ventricle is continuous with the narrow central canal of the spinal cord.

5-12. THE HUMAN SPINAL CORD

a. Location and Extent. Referring to Figure 5-6, you can see that the typical
vertebra has a large opening called the vertebral (or spinal) foramen. Together, these
foramina form the vertebral (spinal) canal for the entire vertebral column. The spinal
cord, located within the spinal canal, is continuous with the brainstem. The spinal cord
travels the length from the foramen magnum at the base of the skull to the junction of
the first and second lumbar vertebrae.

Figure 5-6. The spinal column.

MD0804 5-12
 (1) Enlargements. The spinal cord has two enlargements. One is the
cervical enlargement, associated with nerves for the upper members. The other is the
lumbosacral enlargement, associated with nerves for the lower members.

(2) Spinal nerves. A nerve is a bundle of neuron branches that carry

impulses to and from the CNS. Those nerves arising from the spinal cord are spinal
nerves. There are 31 pairs of spinal nerves.

b. A Cross Section of the Spinal Cord (Figure 5-7). The spinal cord is a
continuous structure that runs through the vertebral canal down to the lumbar region of
the column. It is composed of a mass of a central gray matter (cell bodies of neurons)
surrounded by peripheral white matter (myelinated branches of neurons). The gray and
white matter are thus considered columns of material. However, in cross section, this
effect of columns is lost.

Figure 5-7. A cross section of the spinal cord.

MD0804 5-13
5-13. COVERINGS OF THE CENTRAL NERVOUS SYSTEM

The coverings of the central nervous center (CNS) are skeletal and fibrous.

a. Skeletal Coverings.

(1) Brain. The bones of the cranium form a spherical case around the brain.
The cranial cavity is the space enclosed by the bones of the cranium.

(2) Spinal cord. The vertebrae, with the vertebral foramina, form a
cylindrical case around the spinal cord. The overall skeletal structure is the vertebral
column (spine). The vertebral (spinal) canal is the space enclosed by the foramina of
the vertebrae.

b. Meninges (Fibrous Membranes). The brain and spinal cord have three
different membranes called meninges surrounding them (Figure 5-8). These coverings
provide protection.

(1) Dura mater. The dura mater is a tough outer covering for the CNS.
Beneath the dura mater is the subdural space, which contains a thin film of fluid.

Figure 5-8. The meninges, as seen in side view of the CNS.

(2) Arachnoid mater. To the inner side of the dura mater and subdural
space is a fine membranous layer called the arachnoid mater. It has fine spider-web
type threads that extend inward through the subarachnoid space to the pia mater. The
subarachnoid space is filled with cerebrospinal fluid (CSF).

ARACHNOID = Spiderlike

MD0804 5-14
 (3) Pia mater. The pia mater is a delicate membrane applied directly to the
surface of the brain and the spinal cord. It carries a network of blood vessels to supply
the nervous tissues of the CNS.

5-14. BLOOD SUPPLY TO THE CNS

a. Blood Supply of the Brain. The paired internal carotid arteries and the
paired vertebral arteries supply blood rich in oxygen to the brain. Branches of these
arteries join to form a circle under the base of the brain. This is called the cerebral
circle (of Willis). From this circle, numerous branches supply specific areas of the brain.

(1) A single branch is often the only supply to that particular part of the
brain. Such an artery is called an end artery. If it fails to supply blood to that specific
area, the area will die (as in a stroke).

(2) The veins and venous sinuses of the brain drain into the paired internal
jugular veins. These veins carry blood back toward the heart.

b. Blood Supply of the Spinal Cord. The blood supply of the spinal cord is by
way of combination of three longitudinal arteries running along its length and reinforced
by segmental arteries from the sides.

5-15. CEREBROSPINAL FLUID

A clear fluid called cerebrospinal fluid (CSF) is found in the cavities of the central
nervous system. Cerebrospinal fluid is found in the ventricles of the brain, the
subarachnoid space, and the central canal of the spinal cord. Cerebrospinal fluid and
its associated structures make up the circulatory system for the CNS.

a. Choroid Plexuses. Choroid plexuses are special collections of arterial

capillaries found in the roofs of the third and fourth ventricles of the brain. The choroid
plexuses continuously produce CSF from the plasma of the blood.

b. Path of the Cerebrospinal Fluid Flow. Blood flows through the arterial
capillaries of the choroid plexuses. As the choroid plexuses produce CSF, it flows into
all four ventricles. Cerebrospinal fluid from the lateral ventricles flows into the third
ventricle, through the cerebral aqueduct then into the fourth ventricle. By passing
through three small holes in the roof of the fourth ventricle, CSF enters the
subarachnoid space. From the subarachnoid space, the CSF is transported through the
arachnoid villi (granulations) into the venous sinuses. Thus, the CSF is formed from
arterial blood and returned to the venous blood.

Continue with Exercises

MD0804 5-15
EXERCISES, LESSON 5

INSTRUCTIONS: Answer the following exercises by marking the lettered response that
best answers the exercise, by completing the incomplete statement, or by writing the
answer in the space provided at the end of the exercise.

After you have completed all of these exercises, turn to "Solutions to Exercises" at
the end of the lesson and check your answers. For each exercise answered incorrectly,
reread the material referenced with the solution.

1. Which of the following is/are a type of nervous tissue?

a. Neurons.

b. Axons.

c. Dendrites.

d. Glia.

2. Select the function(s) for which nervous tissues are specialized.

a. To transmit information.

b. To "store" information.

c. To receive stimuli.

d. All the above.

3. A neuron is defined as ___________________________.

a. A process that carries impulses toward the cell body.

b. A branch that transmits information from the cell body to the next unit.

c. A nerve cell body and all of its branches.

d. A nerve process that has two or more poles.

MD0804 5-16
 4. A dendrite is defined as _________________________.

a. A neuron process that carries impulses toward the cell body.

b. A neuron branch that transmits information from the cell body to the next
unit.

c. A neuron that has two poles.

d. A nerve cell body and all of its branches.

5. From the statement below, select the type of neuron that is being described:

In this type of neuron, impulses are transmitted from the central nervous
system to muscles and glands.

a. Sensory neurons.

b. Interneurons.

c. Afferent neurons.

d. Motor neurons.

6. Which of the following statements best describe the neuromuscular junctions?

a. A connection between two neurons.

b. A connection that relays information from muscle tissue to the brain.

c. A connection between the terminal knob of a motor neuron and a muscle

fiber.

d. A connection which joins two neurons.

7. Which of the following substances is a neurotransmitter?

a. Sodium chloride.
b. Norepinephrine.
c. Acetylcholinesterase.
d. Catechol-o-methyl transferase (COMT).

MD0804 5-17
 8. Select the names of the three major subdivisions of the human nervous
system.

a. The central nervous system, brain, and spinal cord.

b. The autonomic nervous system, the peripheral nervous system, and the
central nervous system.

c. The peripheral nervous system, the brain, and the spinal cord.

d. The autonomic nervous system, the peripheral nervous system, and the
codaptive nervous system.

9. What is the function of the meninges surrounding the brain and spinal cord?

a. They carry nervous impulses into the brain and spinal cord.

b. They prevent nerve impulses from injuring delicate tissue.

c. They direct nerve impulses to the proper places in the brain.

d. They provide protection for the brain and spinal cord.

10. What is the function of the cerebrum of the human brain?

a. It serves as the primary coordinator/integrator of motor actions in the

body.

b. It serves as the center of speech, hearing, and vision.

c. It provides major relays and controls for passing information up or down

the neuraxis.

d. It protects the cerebellum.

Check Your Answers on Next Page

MD0804 5-18
SOLUTIONS TO EXERCISES, LESSON 5

1. a Neurons. (para 5-1)

d Glia.

2. d All the above. (para 5-2a, b, and c)

3. c A nerve cell body and all of its branches. (para 5-3)

4. a A neuron process that carries impulses toward the cell body. (para 5-4a)

5. d Motor neurons. (para 5-5c(2))

6. c A connection between the terminal knob of a motor neuron and a muscle

fiber. (para 5-6b)

7. b Norepinephrine. (para 5-8b)

8. b The autonomic nervous system, the peripheral nervous system, and the
central nervous system. (para 5-10)

9. d They provide protection for the brain and spinal cord. (para 5-13b)

10. b It serves as the center of speech, hearing, and vision. (para 5-11c(2))

End of Lesson 5

MD0804 5-19
 LESSON ASSIGNMENT

LESSON 6 Agents Used During Surgery.

TEXT ASSIGNMENT Paragraphs 6-1--6-10.

LESSON OBJECTIVES After completing this lesson, you should be able to:

6-1. Given a group of definitions, select the definition

of the term general anesthetic.

6-2. Given a list, select the types of general

anesthetic.

6-3. Given a type of medication used during surgery

and a list of drugs, select the drug that belongs
to that category of general anesthetics.

6-4. Given the name of an agent used during

surgery and a list of uses, side effects, and/or
cautions and warnings, select the use, side
effect, or caution and warning associated with
that agent.

SUGGESTION After studying the assignment, complete the exercises

at the end of this lesson. These exercises will help
you to achieve the lesson objectives.

MD0804 6-1
 LESSON 6

AGENTS USED DURING SURGERY

Section I. GENERAL ANESTHETIC AGENTS

6-1. INTRODUCTION

a. Have you ever undergone surgery? If you have, you can readily appreciate
the importance of drugs used during surgery. This group of agents is widely used. The
agents within the group differ widely in their uses and indications. This lesson will focus
on this group of drugs with the intent of giving you a background in this important area.

b. In days gone by, various substances (that is, whiskey) were used to "put the
patient to sleep" during surgery. As surgical procedures became increasingly
sophisticated, the need for better anesthetic agents became more apparent. Today,
general anesthetic agents comprise an important group of pharmacological agents.
Their use promotes patient welfare. This section of the subcourse will discuss this
important group of agents.

6-2. DEFINITION

A general anesthetic is an agent that depresses the central nervous system

reversibly, producing loss of consciousness, analgesia, and muscle relaxation, with
minimal depression of the patient's vital functions. That is, a general anesthetic agent
places the patient in a state of anesthesia in which his muscles are relaxed and he feels
no pain. Later, after the procedure has been completed, the patient can regain
consciousness and recuperate.

6-3. MECHANISM OF ACTION OF GENERAL ANESTHETICS

It is known that the general anesthetic agents depress the central nervous
system. Precisely how this depression occurs is unknown. Several theories attempt to
explain this depression. One-theory states the agents affect lipid (fat) structures in the
brain in order to produce the central nervous system depression. If you desire a
detailed discussion of the various theories, you should consult a pharmacology text.

6-4. TYPES OF GENERAL ANESTHETIC AGENTS

There are two broad types of general anesthetics: The inhalation agents and the
intravenous agents. It is not the purpose of this subcourse to provide a complete listing
or a detailed discussion of the agents that are presented. If you desire additional
information on these agents, you should consult a pharmacology text.

MD0804 6-2
 a. Inhalation Agents. Inhalation anesthetic agents are gases or volatile liquids.
These substances are often mixed with oxygen and the patient is allowed to breathe the
mixture. After a period, a sufficient level of the anesthetic agent is obtained in the blood
and anesthesia is produced. In general, anesthesia can be well controlled with these
agents because the concentration of the agent in the blood can be increased or
decreased easily by either increasing or decreasing the concentration of the agent in
the air the patient is breathing. It is relatively uncommon for a patient to have an allergic
reaction to one of the inhalation general anesthetic agents. However, the side effects of
some of these agents can be quite serious. There is rapid recovery for the patient when
this type of agent is used. That is, when the patient is no longer allowed to breathe the
agent, the depression of the central nervous system quickly disappears.

(1) Nitrous oxide. Nitrous oxide is a gas supplied in blue metal cylinders.
Nitrous oxide is commonly referred to as laughing gas. Although nitrous oxide is a safe
general anesthetic, it is relatively weak in terms of producing anesthesia and muscle
relaxation. Consequently, nitrous oxide is often used in conjunction with other agents.
Nitrous oxide is often used in dental surgery and in obstetrical practice during delivery.

(2) Halothane (Fluothane®). Halothane is a volatile liquid inhalation

anesthetic. It is one of the most widely used general anesthetics. Since halothane
does not produce potent analgesia and muscle relaxation, other agents are sometimes
administered with halothane on an as-needed basis. Halothane has popularity because
it is nonexplosive, rapid acting, pleasant smelling, and is compatible with other drugs.

(3) Enflurane (Erthrane®. Enflurane is a volatile liquid inhalation

anesthetic with many of the properties of halothane. It produces greater muscle
relaxation than halothane, but like halothane, it is a poor analgesic.

b. Intravenous Agents. Intravenous general anesthetics are sterile solutions

intended to be administered into the patient's circulatory system. Intravenous
anesthetic agents do produce loss of consciousness; however, most of these agents
lack the ability to produce complete analgesia. In general, the level of anesthesia is
more difficult to control with intravenous anesthetics than with inhalation anesthetics.

(1) Thiopental sodium (Pentothal®) Thiopental sodium is an ultrashort

acting barbiturate. That is, this agent acts very quickly to produce anesthesia.
Sometimes this agent is used alone for minor surgical procedures. In other cases, the
drug is used to initiate anesthesia. Then, other anesthetic agents are used to maintain
the anesthesia. Thiopental sodium is a NOTE Q item. That is, it is a controlled
substance.

(2) Fentanyl (Sublimaze®) and droperidol (Innovar®). This agent is an

intravenously administered product, which combines the narcotic analgesic effect of
fentanyl with the sedative and antiemetic effects of droperidol. This agent produces a
semiconscious state in the patient, and it is used in types of surgery in which the
surgeon needs the cooperation of the patient. Innovar is usually used in combination

MD0804 6-3
with nitrous oxide because of its slow induction. Innovar may also be used for various
diagnostic procedures. This product is a controlled substance (Note R item).

(3) Ketamine (Ketalar®) is a nonbarbiturate anesthetic that can be

administered either intravenously or intramuscularly. Ketamine produces a dissociative
type anesthesia in which the patient becomes detached mentally from the environment.
Ketamine may be used for induction anesthesia or for diagnostic or minor surgical
procedures in children.

Section II. OTHER AGENTS USED DURING SURGERY

6-5. INTRODUCTION

No single anesthetic agent is capable of producing the deep levels of analgesia

and skeletal muscle relaxation required during all types of surgery. Consequently, other
drugs that have certain desired effects are administered along with the general
anesthetic being used. Five major categories of these agents will be presented in this
subcourse. They are analgesic agents, drying agents, skeletal muscle relaxants,
sedative and hypnotic agents, and antianxiety agents.

6-6. ANALGESIC AGENTS

Analgesic agents relieve pain. Although a general anesthetic agent will produce
unconsciousness, the patient might still be able to feel some pain. In these cases, a
preanesthetic medication might be administered to the patient in order to relieve the
pain. A variety of analgesic agents are available to achieve this purpose. Following are
some commonly used agents:

a. Meperidine (Demerol®).

b. Morphine.

c. Nubain®.

d. Stadol®.

MD0804 6-4
6-7. DRYING AGENTS

It is sometimes advantageous during an operation to have the patient's mucous

membranes (that is, nose, throat) dry. Drying agents are administered for just this
reason. You are probably familiar with the use of drying agents in certain over-the-
counter cold medications. Following are two commonly used drying medications:

a. Atropine sulfate.

b. Glycopyrrolate (Robinul®).

6-8. NEUROMUSCULAR BLOCKING AGENTS

In some types of surgery (for example, abdominal surgery) it is highly

advantageous to have the patient's skeletal muscles (for example, abdominal surgery)
in a state of relaxation. Most general anesthetic agents do not produce a sufficient level
of skeletal muscle relaxation. Therefore, neuromuscular blocking agents are
administered to achieve the desired muscle relaxation effects. Two commonly used
neuromuscular blocking agents:

a. Vecuronium (Norcuron®).

b. Succinylcholine (Anectine®).

6-9. SEDATIVE AND HYPNOTIC AGENTS

To ensure a good night's sleep prior to a surgical procedure, patients are

sometimes administered either a sedative or a hypnotic agent. Agents commonly used
for this purpose are:

a. Pentobarbital (Nembutal®).

b. Secobarbital (Seconal®).

6-10. ANTIANXIETY AGENTS

As one might expect, some patients are highly anxious about upcoming surgical
procedures. Such increased anxiety interferes with the functioning of the patient
(interferes with rest and decreases appetite). Anti-anxiety agents help to control this
anxiety. Diazepam (Valium®) is sometimes used to control anxiety.

Continue with Exercises

MD0804 6-5
EXERCISES, LESSON 6

INSTRUCTIONS: Answer the following exercises by marking the lettered response that
best answers the exercise, by completing the incomplete statement, or by writing the
answer in the space provided at the end of the exercise.

After you have completed all of these exercises, turn to "Solutions to Exercises" at
the end of the lesson and check your answers. For each exercise answered incorrectly,
reread the material referenced with the solution.

1. From the definitions below, select the definition of the term general
anesthetic.

a. An agent that depresses the central nervous system irreversibly to

produce a loss of consciousness, analgesia) and muscle relaxation.

b. An agent that stimulates the central nervous system, thus making it

possible for a physician to perform various types of surgeries.

c. An agent used to produce localized analgesia in a patient.

d. An agent that depresses the central nervous system reversibly to

produce a loss of consciousness, analgesia, and muscle relaxation.

2. From the list below, select the type(s) of general anesthetic.

a. Local.

b. Intravenous.

c. Induction.

d. Clinical.

3. From the list below, select the agent that is classified as an inhalation
anesthetic agent.

a. Thiopental sodium (Pentothal®).

b. Enflurane (Ethrane®).

c. Glycopyrrolate (Robinal®).

d. Succinylcholine (Anectine®).

MD0804 6-6
 4. From the list below, select the agent classified as an intravenous anesthetic
agent.

a. Fentanyl (Sublimaze®) and droperidol (Innovar®).

b. Glycopyrrolate (Robinal®).

c. Meperidine hydrochloride (Demerol®).

d. Succinylcholine (Anectine®).

5. From the list of uses below, select the use of glycopyolate (Robinal®)

a. Intravenous anesthetic agent.

b. Skeletal muscle relaxant.

c. Drying agent.

d. Inhalation anesthetic agent.

6. From the list of uses below, select the use of succinylcholine (Anectine®).

a. An antianxiety agent used the night before surgery.

b. A sedative used the day before surgery.

c. An analgesic agent used after surgery.

d. A neuromuscular blocking agent used during surgery.

7. From the list of uses below, select the use of meperidine hydrochloride
(Demerol®).

a. An agent often used as a preanesthetic analgesic.

b. An analgesic used to produce unconsciousness.

c. An analgesic agent used for its ability to dry the patient's mouth.

d. An analgesic agent used to stimulate a patient's breathing during surgery.

MD0804 6-7
 8. From the list below, select the use of ketamine (Ketalar®).

a. An inhalation anesthetic used to induce anesthesia for diagnostic

purposes.

b. An intravenous anesthetic used to perform major surgery in adults over

the age of 60.

c. An intravenous anesthetic used to perform minor surgical procedures in

children.

d. An inhalation anesthetic agent used because of its ability to produce

analgesia.

9. From the group below, select the use of the agent fentanyl (Sublimaze®) and
droperidol (Innovar®).

a. An agent that is used because it produces a dissociative type of

anesthesia.

b. An agent used because the patient easily inhales it.

c. An agent used when the surgeon needs the cooperation of the patient
because it produces a semiconscious state in the patient.

d. An agent used during surgery because it produces a drying effect in the

patient's mucous membranes.

10. From the group below, select the use of the agent diazepam (Valium®).

a. A drying agent used to reduce saliva product in comatose patients.

b. An analgesic agent administered after surgery.

c. An antianxiety agent used to reduce a patient's apprehension before

surgery.

d. A nonbarbiturate anesthetic used before surgery.

Check Your Answers on Next Page

MD0804 6-8
SOLUTIONS TO EXERCISES, LESSON 6

1. d An agent that depresses the central nervous system reversibly to produce a

loss of consciousness, analgesia, and muscle relaxation. (para 6-2)

2. b Intravenous. (para 6-4b)

3. b Enflurane (Ethrane®). (para 6-4a(3))

4. a Fentanyl (Sublimaze®) and droperidol (Innovar®). (para 6-4b(2))

5. c Drying agent. (para 6-7)

6. d A neuromuscular blocking agent used during surgery. (para 6-8)

7. a An agent used as a preanesthetic analgesic. (para 6-6)

8. c An intravenous agent used to perform minor surgical procedures in children.

(para 6-4b(3))

9. c An agent used when the surgeon needs the cooperation of the patient
because it produces a semiconscious state in the patient. (para 6-4b(2))

10. c Antianxiety agent used to reduce a patient's apprehension before surgery.

(para 6-10)

End of Lesson 6

MD0804 6-9
 LESSON ASSIGNMENT

LESSON 7 Sedative and Hypnotic Agents.

TEXT ASSIGNMENT Paragraphs 7-1--7-9.

LESSON OBJECTIVES After completing this lesson, you should be

able to:

7-1. Given a group of statements, select the best

definition of a sedative-hypnotic.

7-2. From a group of statements, select the

statement that best describes the mechanism
of action of sedative-hypnotics.

7-3. Given a list of possible effects, select the

effect(s) produced by sedative-hypnotics.

7-4. Given an effect produced by the sedative-

hypnotics and a group of statements, select the
statement that best describes that effect.

7-5. From a list of possible clinical uses, select the

clinical use(s) of the sedative-hypnotics.

7-6. From a list of adverse reactions, select the

adverse effect(s) associated with sedative-
hypnotics.

7-7. From a list of cautions and warnings, select the

caution(s) and warning(s) associated with the
sedative-hypnotics.

7-8. Given a group of statements and two types of

barbiturates (for example, ultra short-acting
and short-acting), select the statement which
best differentiates between the two types.

7-9. Given the trade name of a sedative-hypnotic

agent and a list of generic names, match the
trade name with its generic name.

MD0804 7-1
 7-10. Given the trade or generic name of a sedative-
hypnotic agent and a group of possible clinical
uses or side effects, select the use(s) or side
effect(s) associated with that agent.

SUGGESTION After studying the assignment, complete the exercises

at the end of this lesson. These exercises will help
you to achieve the lesson objectives.

MD0804 7-2
 LESSON 7

SEDATIVE AND HYPNOTIC AGENTS

Section I. BACKGROUND

7-1. INTRODUCTION

Sedative and hypnotic agents form an important class of drugs that are widely
used in modern medical practice. The names of many of the agents should be fairly
familiar to you since these drugs are so widely used in hospitals and dispensed to
patients on an outpatient basis. You probably know that most sedative-hypnotic agents
are controlled because of their abuse/misuse potential. The barbiturates have been
regarded as the prototypes of this class of drugs because of their extensive use over
the past 80 years. Because of their potential for addiction, physical dependence, and
side effects, the barbiturates have been replaced by the benzodiazepines (for example,
Valium®). The benzodiazepines are currently the most important sedative hypnotics
because of their efficacy and safety.

7-2. DEFINITION OF SEDATIVE-HYPNOTIC

A sedative-hypnotic agent is a substance, which, if given in progressively larger

doses, produces calm (sedation), sleep (hypnosis), general anesthesia, and ultimately
death (because of medullary depression). Sedative-hypnotic agents are commonly
used for symptomatic relief of anxiety and for the induction of sleep. Sedatives may be
also referred to as anti-anxiety agents.

Section II. CLINICALLY IMPORTANT INFORMATION

CONCERNING SEDATIVE-HYPNOTICS

7-3. INTRODUCTION

Sedative-hypnotic agents are an important group of drugs, which are often

prescribed to a variety of patients. You should be familiar with the effects and the
clinical uses of these drugs.

7-4. THE PHARMACOLOGICAL ACTIONS OF SEDATIVE-HYPNOTIC AGENTS

a. Mechanism of Action. Sedatives and hypnotics selectively depress the

reticular activating system (RAS), the mechanism responsible for keeping us awake.

MD0804 7-3
 b. Effects Produced by Sedative-Hypnotic Agents.

(1) Sedation. To sedate means to calm; therefore, sedation refers to the act
of producing calm in a patient. You can also think of sedation as referring to a
decreased responsiveness to a constant level of stimulation. Small doses (small
amounts) of a sedative-hypnotic drug administered to a patient will produce sedation.

(2) Disinhibition. Disinhibition refers to actions a person may perform while

under the effects of a drug that he would not perform if he were not taking the drug.
This effect may be seen as euphoria, (feeling of well being or elation) in some patients
and is a potential source of abuse of these agents. Disinhibition is presumed because
of depression of a higher cortical (brain) center, which results in a resultant release of
lower brain centers from constant inhibitory influence. Larger doses of a sedative-
hypnotic agent will produce this effect.

(3) Relief of anxiety. This particular effect probably cannot be separated

from the sedative and euphoriant effects produced by the sedative-hypnotic agents.

(4) Sleep. Sedative-hypnotic induced sleep differs in several ways from

normal sleep. If a sufficiently large dose of any sedative-hypnotic agent is administered
to a patient, sleep will result; however, the dose of a particular agent required to
produce sleep will vary with the physiologic and psychologic state of the individual and
the environmental situation in which the drug is given.

(5) Anesthesia. State III of general anesthesia (surgical anesthesia--

unconsciousness and paralysis of reflexes) can be induced in humans with large doses
of sedative-hypnotic agents. Short- and ultra short-acting barbiturates are the only
drugs used as anesthetic agents from this class.

(6) Analgesia. Patients who have been deeply anesthetized with

barbiturates are totally unresponsive to pain.

(7) Anticonvulsant activity. All the barbiturates commonly used in clinical

practice are capable of inhibiting convulsions. Phenobarbital and other long-acting
drugs are selectively more effective at lower therapeutic doses in the treatment of
epilepsy.

(8) Cardiovascular and respiratory effects. Sedative-hypnotic agents are

respiratory depressants that depress the respiratory system. Sedative-hypnotic agents
do not, when administered orally, produce significant cardiovascular effects.

(9) Dependence. Both psychic and physical dependence has been reported
with both the barbiturate and nonbarbiturate sedative-hypnotic agents. Dependence
usually occurs when sedative-hypnotics are given over a long period in large doses.
Therefore, continued administration of these agents is usually necessary to prevent a
withdrawal state in the patient.

MD0804 7-4
7-5. CLINICAL USES OF SEDATIVE-HYPNOTIC AGENTS

Sedative-hypnotic agents are used to treat a variety of conditions. These include:

a. Relief of Anxiety. Sedative-hypnotics are effectively used to temporarily

relieve anxiety associated with threatening or fearful situations (for example, anxiety
that typically occurs before a surgical procedure).

b. Treatment of Depression. Depression is the most common manifestation of

anxiety. Treatment of depression with sedative-hypnotic agents may be effective. It
should be noted that major (psychotic) depressions might be intensified with sedative-
hypnotics.

c. Induction of Sleep (Hypnosis). Short-acting sedative-hypnotics are

generally used because of less hangover or persistent effects. When used to produce
sleep, sedative-hypnotics should not be administered continuously and should only be
part of an overall plan of management and counseling.

d. Anticonvulsant Therapy. Some sedative-hypnotics (for example,

phenobarbital) have been successfully used in the treatment of various types of
convulsive disorders.

e. Skeletal Muscle Relaxation. Some sedative-hypnotics have been used to

produce muscle relaxation in patients. However, the effectiveness of sedative-
hypnotics for this use may be related more to their sedative properties than to their
ability to produce true muscle relaxation.

f. Anesthesia. The ultra short-acting barbiturates (for example, thiopental) are

used for surgical procedures of short duration.

7-6. ADVERSE EFFECTS OF SEDATIVE HYPNOTICS

Sedative-hypnotics, although safe when taken as directed, are not without their
side effects. You should be familiar with the side effects produced by these agents:

a. Drowsiness. As you might anticipate, all of the sedative-hypnotic agents will

cause drowsiness if a large enough dose is given to the patient. Furthermore, because
of individual reactions to drugs, some patients will be made drowsy even by small doses
of these agents. Patients who are prescribed sedative-hypnotics should be told not to
drink alcoholic beverages while taking the drug since the alcohol could intensify the
drowsiness effect.

b. Impaired Performance and Judgment. These agents interfere with a

person 5 ability to think and to perform certain "hands-on" tasks. Sedative-hypnotic
agents are equivalent to alcohol in their effects on distorting judgment and minor motor
skills.

MD0804 7-5
 c. Hangover Effect. When a patient arises from a night's sleep after having
taken a bedtime dose of a sedative-hypnotic, the patient may complain of feeling dizzy,
lethargic, or exhausted. This is referred to as the "hangover effect." This effect is more
prevalent with the long-acting sedative-hypnotics.

d. Chronic Toxicity.

(1) Drug abuse. The relief of anxiety and the euphoria provided by these
drugs has led to the compulsive misuse of every member of this group. Because of
their rapid onset of action and intense effect, the short-or intermediate-acting sedative-
hypnotics are more apt to be misused than are the other types of sedative-hypnotics.
These agents do not cause chronic organic toxicity.

(2) Withdrawal state. A patient who has been taking therapeutic doses of a
sedative-hypnotic may find that he has a disturbed pattern of sleep with restlessness
and nightmares when he suddenly stops taking the drug. Discontinuing larger doses of
sedative-hypnotics may produce a hyperexcitable state in the patient characterized by
weakness, tremor, anxiety, elevated blood pressure, and elevated pulse rate. The
sudden withdrawal of even larger doses may produce convulsions or toxic psychosis
with agitation, confusion, and hallucinations.

e. Acute Toxicity. The amount of a particular sedative-hypnotic required to

produce death in a patient depends upon a variety of factors. An extremely large dose
of a sedative-hypnotic will produce a state of prolonged, deep anesthesia. If the stage
of severe medullary depression is reached, circulatory shock occurs. In case of acute
toxicity, it is necessary for the patient to be immediately taken to the nearest medical
treatment facility for emergency treatment.

7-7. CAUTIONS AND WARNINGS ASSOCIATED WITH THE USE OF SEDATIVE-

HYPNOTICS

a. Ambulatory patients (those patients able to walk) should be warned to avoid

activities that require mental alertness, judgment, and physical coordination while taking
sedative-hypnotics.

b. Alcohol should not be consumed with sedative-hypnotic agents. This is

because both the alcohol and the sedative-hypnotic would both act to depress the
central nervous system.

c. Caution should be observed when these drugs are given to patients who have
impaired liver function, since the sedative-hypnotics are broken down in the liver.

d. Sedative-hypnotic agents are probably best prescribed and taken only on an

irregular basis when needed. Some physicians believe that a short (that is, week long)
course of scheduled sedative-hypnotic therapy is the most desirable. The aim is not to

MD0804 7-6
offer the patient the opportunity to become physically or psychologically dependent
upon the drugs.

Section III. CLASSIFICATION OF SEDATIVE-HYPNOTIC AGENTS

NOTE: The agents in this section are classified according to their duration of action
and whether they are barbiturates or nonbarbiturates.

7-8. BARBITURATE SEDATIVES AND HYPNOTICS

a. Ultra Short-Acting Barbiturates.

(1) Basic information. Ultra short-acting barbiturates usually have a duration

of action of 15 to 30 minutes. They are administered intravenously in order to induce
anesthesia because of their high degree in lipid (fatty) materials. Ultra short-acting
barbiturates are used to counteract the convulsions associated with some chemical
substances (for example, tetanus toxin) or by the overdosage of certain drugs.

(2) Examples of ultra short-acting barbiturates.

(a) Methohexital (Brevital®).

(b) Thiopental (Pentothal®).

b. Short-Acting Barbiturates.

(1) Basic information. Short-acting barbiturates usually have a duration of

action that lasts from 2 hours to 4 hours. Short-acting barbiturates are effective
treatment--when taken by mouth--for the initial and short-term treatment of insomnia.
These agents are widely used intramuscularly (IM) for preanesthetic sedation in order to
calm the patient and to reduce anxiety often found in patients about to undergo surgery.
Pentobarbital and secobarbital (see below) may be used for short-term daytime
sedation in patients who suffer from anxiety.

(2) Examples of short-acting barbiturates.

(a) Pentobarbital (Nembutal®).

(b) Secobarbital (Seconal®).

MD0804 7-7
 c. Intermediate-Acting Barbiturates.

(1) Basic information. Intermediate-acting barbiturates have a duration of

action that lasts from 4 hours to 6 hours. These agents are mainly use for the initial and
short-term treatment of insomnia.

(2) Example of intermediate-acting barbiturate. Amobarbital (Amytal®).

d. Long-Acting Barbiturates.

(1) Basic information. Long-acting barbiturates have a duration of action

that lasts from 6 hours to 8 hours. These agents are used orally to maintain daylong
sedation in anxiety-tension states. Furthermore, long-acting barbiturates are useful in
the treatment of various convulsive disorders.

(2) Examples of long-acting barbiturates.

(a) Phenobarbital.

(b) Mephobarbital (Mebaral®).

7-9. NONBARBITURATE SEDATIVES AND HYPNOTICS

a. Short-Acting Agents.

(1) Background information. Short-acting nonbarbiturate sedative-hypnotics

are generally used orally in the initial and short-term treatment of insomnia.

(2) Examples of short-acting nonbarbiturate sedative-hypnotics.

(a) Chloral hydrate (Noctec®). Drug interactions may occur between

chloral hydrate and anticoagulants, furosemide, alcohol, or other drugs that are CNS
depressants.
(b) Triazolam (Halcion®). Triazolam is rapidly absorbed through the
oral route and is as effective as the barbiturates in inducing sleep. It is excreted in
breast milk and should not be administered to nursing mothers.

b. Intermediate-Acting Agents.

(1) Background information. Intermediate-acting nonbarbiturate agents are

administered orally to effectively control moderate to severe daytime anxiety and
tension in patients who have neuroses and mild depressive states.

(2) Examples of intermediate-acting nonbarbiturates.

MD0804 7-8
 (a) Diazepam (Valium®). Diazepam may be useful in the treatment of
alcohol withdrawal symptoms (for example, delirium tremens, agitation, and so forth.)
This agent produces skeletal muscle relaxant effects in humans and has been used with
limited success in various neurologic and musculoskeletal disorders. Diazepam may be
administered parenterally as a preanesthetic medication to reduce anxiety and to calm
the patient. Diazepam is also administered intravenously in the treatment of status
epilepticus. It is available in tablet form (2, 5, and 10 milligrams) and in injection form
(5 milligrams per milliliter in 2 and 10 milliliter containers). Diazepam is a Note Q
controlled substance in the military.

(b) Meprobamate (Equanil®, Miltown®). Meprobamate can produce

skeletal muscle relaxant effects in humans; therefore, it has been used with some
success in the treatment of various neurologic and musculoskeletal disorders. It
appears to be less effective than diazepam in the treatment of anxiety and tension. The
most common side effect associated with the agent is drowsiness. It is supplied in
tablet and suspension forms. Meprobamate is a Note Q controlled item in the military.

(c) Other examples of nonbarbiturates used in the treatment of anxiety

disorders include Lorazepam (Ativan®), Alprazolam (Xanax®), and Buspirone (Buspar®).
Lorazepam is used primarily as an antianxiety agent, but is useful for treating insomnia
due to stress and anxiety. Lorazepam is also used as a preanesthetic medication to
produce sedation and decrease the patient's ability to recall events related to the day of
surgery.
(d) Temazepam (Restoril®). Temazepam is administered in a nightly
dose of 15 to 30 mg. It is an effective inducer of sleep with a good safety profile.
Animal studies indicate a potential for Temazepam to cause teratogenic effects.
Therefore, it should not be administered during pregnancy.

c. Long-Acting Nonbarbiturate Agents.

(1) Background information. These agents depress the central nervous

system. Patients taking these drugs should be cautioned against performing hazardous
activities while under their effects.

(2) Examples of long-acting nonbarbiturate agents.

(a) Chlordiazepoxide hydrochloride (Librium®). Chlordiazepoxide is

orally administered as an antianxiety agent. It is also effective when administered
parenterally in the treatment of alcohol withdrawal. Side effects associated with the
agent include drowsiness, ataxia, and lethargy.

(b) Oxazepam (Serax®). Oxazepam is generally less effective than

either diazepam or chlordiazepoxide in the treatment of tension and anxiety.
Drowsiness is the most common side effect associated with this agent.

Continue with Exercises

MD0804 7-9
EXERCISES, LESSON 7

INSTRUCTIONS: Answer the following exercises by marking the lettered response that
best answers the exercise, by completing the incomplete statement, or by writing the
answer in the space provided at the end of the exercise.

After you have completed all of the exercises, turn to "Solutions to Exercises" at
the end of the lesson and check your answers. For each exercise answered incorrectly,
reread the material referenced with the solution.

1. Which statement best describes the mechanism of action of sedative-

hypnotics?

a. They inhibit the flow of potassium and sodium ions across the
semipermeable membranes of the nerves.

b. They inhibit the depolarization of the nerve fibers and thus produce calm
or sleep.

c. They depress the reticular activating system (RAS).

d. They inhibit the transmission of electrical impulses from the brain by

interfering with the passage of certain ions through the nerve fibers.

2. Select the effect(s) produced by the sedative-hypnotics.

a. Relief of anxiety.

b. Disinhibition.

c. Analgesia.

d. All the above.

MD0804 7-10
 3. Which of the following statements best describes the analgesia produced by
sedative-hypnotics?

a. Patients who have been given extremely large doses of barbiturates are
unresponsive to pain.

b. Patients who are administered intravenous doses of sedative-hypnotics

are unable to feel any painful stimuli.

c. Patients who are given sedative-hypnotics seem to be more tolerant of

pain than those patients who are not given these drugs.

d. Patients who are given any amount of sedative-hypnotics are unable to

feel pain, but they are also unable to maintain consciousness for long periods.

4. Select the clinical use(s) associated with the sedative-hypnotics.

a. To induce sleep.

b. To treat minimal brain dysfunction (MBD).

c. To treat pain.

d. All the above.

5. Select the adverse effect(s) associated with the use of sedative-hypnotic

agents.

a. Drowsiness.

b. Hangover.

c. Impaired judgment.

d. All the above.

MD0804 7-11
 6. Select the caution(s) and warning(s) associated with the use of sedative-
hypnotics.

a. Caution should be observed when giving these drugs to patients who

have impaired liver function.

b. These agents should not be prescribed to those persons who are likely to
become dependent upon them.

c. Sedative-hypnotics should be taken on a continuous and regular basis to

ensure desired therapeutic effects.

d. All the above.

INSTRUCTIONS: Match the generic name of the drug with its corresponding trade
name. (Exercise items 7 through 10.)

7. Pentobarbital _______________ a. Librium®

8. Oxazepam _______________ b. Nembutal®

9. Chlordiazepoxide _______________ c. Serax®

10. Triazolam _______________ d. Halcion®

11. Select the clinical use(s) of diazepam (Valium®).

a. A treatment for minimal brain dysfunction (MBD).

b. An anoretic for the suppression of appetite.

c. A preanesthetic medication used to calm the patient.

d. A drug used for induction of sleep.

MD0804 7-12
 12. Select the clinical use(s) of chlordiazepoxide.

a. Antianxiety agent.

b. Sleep inducer.

c. Skeletal muscle constrictor.

d. All the above.

13. What is the most common side effect associated with oxazepam (Serax®)?

a. Ataxia.

b. Lethargy.

c. Drowsiness.

d. Blurred vision.

14. What is the duration of action for ultra-short acting barbiturates?

a. 6 to 8 hours.

b. 4 to 6 hours.

c. 2 to 4 hours.

d. 15 to 30 minutes.

Check Your Answers on Next Page

MD0804 7-13
SOLUTIONS TO EXERCISES, LESSON 7

1. c They depress the reticular activating system (RAS).

(para 7-4a)

2. d All the above. (para 7-4b(2), (3), and (4))

3. a Patients who have been given extremely large doses of barbiturates are
unresponsive to pain. (para 7-4b(6))

4. a To induce sleep. (para 7-5a)

5. d All the above. (para 7-6)

6. a Caution should be observed when prescribing these drugs to patients who

have impaired liver function. (para 7-7c)

7. b Nembutal®. (para 7-8b(2))

8. c Serax®. (para 7-9c(2)(b))

9. a Librium®. (para 7-9c(2)(a))

10. d Halcion®. (para 7-9a(2)(b))

11. c A preanesthetic medication used to calm the patient.

(para 7-9b(2)(a))

12. a Antianxiety agent. (para 7-9c(2)(a))

13. c Drowsiness. (para 7-9c(2)(b))

14. d 15 to 30 minutes. (para 7-8a(1))

End of Lesson 7

MD0804 7-14
 LESSON ASSIGNMENT

LESSON 8 Anticonvulsant Agents.

TEXT ASSIGNMENT Paragraphs 8-1--8-5.

LESSON OBJECTIVES After completing this lesson, you should be able to:

8-1. Given one of the following terms: epilepsy or

convulsions, and a group of statements, select
the meaning of that term.

8-2. Given a group of statements, select the

statement that best differentiates between
clonic and tonic convulsions.

8-3. Give the name of a type of epilepsy and a

group of descriptions, select the best
description of that type of epilepsy.

8-4. From a group of potential causes, select the

cause(s) of epilepsy in either a child or an
adult.

8-5. Given a group of statements, select the

statement that best describes the mechanism
of action for anticonvulsants.

8-6. Given the trade name of an anticonvulsant

agent and a group of generic names, match
the trade name with its generic name.

8-7. Given a trade or generic name of an

anticonvulsant agent and a group of
statements, select the statement that best
describes the clinical use(s) or adverse
reaction(s) associated with that agent.

8-8. Given a trade or generic name of an

anticonvulsant agent, a description of a
situation involving the dispensing of that agent,
and a group of statements describing cautions
and/or warnings to the patient, select the
statement that should be made to the patient
receiving that medication.

MD0804 8-1
SUGGESTION After completing the assignment, complete the
exercises at the end of this lesson. These exercises
will help you to achieve the lesson objectives.

MD0804 8-2
 LESSON 8

ANTICONVULSANT AGENTS

Section I. REVIEW OF EPILEPSY

8-1. BASIC DEFINITIONS

Before studying about anticonvulsants, you should review/study the definitions

that relate to the topic:

a. Epilepsy. Epilepsy is a chronic convulsive disorder of cerebral function.

Epilepsy is characterized by recurrent attacks of motor, sensory, psychic, or autonomic
nature. The attacks may involve changes in the state of patient consciousness and are
usually sudden in onset and brief.

b. Convulsion. A convulsion is a violent involuntary contraction or series of

contractions of the voluntary muscles. There are two types of convulsions.

(1) Clonic convulsions. A clonic convulsion has alternating periods of

contraction and relaxation of the voluntary muscles.

(2) Tonic convulsions. A tonic convulsion is a state of sustained contraction

of voluntary muscles.

8-2. TYPES OF EPILEPSY

There are four types of epilepsy. Certain signs and symptoms characterize each
type.

a. Grand Mal. Grand Mal is the most common type of epilepsy. In this type of
epilepsy, the person often experiences an aura (this can consist of certain sounds, fear
discomfort) immediately before a seizure. Then the patient loss consciousness and has
tonic-clonic convulsions. The seizures generally last from 2 to 5 minutes.

b. Petit Mal. This type of epilepsy is most frequently found in children. Brief
periods of blank spells or loss of speech characterizes petit mal. During the seizures,
which usually last from 1 to 30 seconds, the person stops what he is doing and after the
seizure resumes what he was doing before the seizure. Many persons are not aware
that they have had a seizure.

c. Jacksonian (Focal). This type of epilepsy is rare. It is usually associated

with an organic lesion of a certain part of the brain (cerebral cortex). Jacksonian

MD0804 8-3
epilepsy is characterized by focal or local clonic type convulsions of localized muscle
groups (for example, thumb, big toe, and so forth). The seizures normally last from
1-2 minutes.

d. Psychomotor. Psychomotor epilepsy is rare. Psychomotor epilepsy is

characterized by periods of abnormal types of behavior (for example, extensive chewing
or swallowing). The localized seizures may advance to generalized convulsions with
resultant loss of consciousness.

8-3. CAUSES OF EPILEPSY

a. In Children. Epilepsy that occurs in infancy usually results from

developmental defects, metabolic diseases, or injuries sustained during birth.

b. In Adults. Epilepsy that begins in adulthood usually is caused by trauma (an

accident), cerebrovascular accident (a "stroke"), tumors, or diseases associated with
the brain.

Section II. ANTICONVULSANT THERAPY

8-4. MECHANISM OF ACTION OF ANTICONVULSANTS

The mode and the site of action anticonvulsants are not known for sure.
However, it is believed that the anticonvulsants suppress seizures by depressing the
cerebral (motor) cortex of the brain, thereby raising the threshold of the central nervous
system (CNS) to convulsive stimuli. Therefore, the person is less likely to undergo
seizures.

8-5. SPECIFIC ANTICONVULSANT DRUGS

a. Phenobarbital.

(1) Clinical uses. Phenobarbital is orally administered in the treatment of

grand mal epilepsy. It is less effective in the treatment of petit mal and psychomotor
epilepsy. The injectable from of the drug is used to treat other types of convulsions.

(2) Adverse effects. The most common adverse effects associated with
phenobarbital are related to sedation and disinhibition (see lesson 7 of this subcourse).
These include dizziness, drowsiness, ataxia (lack of muscular coordination), and
nystagmus (a rapid involuntary movement of the eyeball). Furthermore, as discussed in
lesson 7 of this subcourse, persons taking phenobarital can experience withdrawal
symptoms when they suddenly stop taking the drug. Epileptic patients are unusually
susceptible to the hyperexcitable state induced by too rapid reduction of dosage or too
rapid withdrawal of phenobarbital.

MD0804 8-4
 (3) Cautions and warnings. Patients who take phenobarbital should be
warned about drowsiness. Patients who take phenobarbital should not drink alcohol
while taking phenobarbital. Dosage of the drug should be reduced by small amounts in
order to avoid hastening convulsions. Lastly, phenobarbital may stimulate the activity of
a number of enzyme systems and affect the metabolism of various drugs (for example,
anticoagulants, phenytoin).

b. Phenytoin (Dilantin).

(1) Clinical uses. Phenytoin is used alone or in combination with

phenobarbital in the treatment of grand mal and psychomotor epilepsy. It is also used
in the treatment of other types of convulsions.

(2) Adverse effects. Adverse effects associated with phenytoin include

ataxia (lack of muscular coordination, staggering walk), nystagmus (a rapid, involuntary
movement of the eyeball), and slurred speech. Drowsiness and fatigue may
accompany these adverse effects in some patients by tremors and nervousness and in
others.

(3) Caution and warning. Drug interactions can occur between phenytoin
and alcohol, barbiturates, folic acid, coumarin-type anticoagulants, disulfirams, the
sulfonamides, and sympathomimetic agents. Phenytoin should be used cautiously with
patients who are alcoholics or who have blood dyscrasias.

c. Ethosuximide (Zarontin®).

(1) Clinic use. Ethosuxamide is the drug of first choice for the treatment of
petit mal epilepsy.

(2) Adverse effects. Drowsiness, ataxia, and gastrointestinal irritation are

adverse effects associated with the use of ethosuxamide.

(3) Caution and warning. Ethosuxamide should be used cautiously with

patients who have blood dyscrasias or liver or kidney impairment.

d. Clonazepam (Klonopin®).

(1) Clinical uses. Clonazepam is used in the treatment of grand mal

epilepsy. It is the alternate drug for the treatment of petit mal in patients who fail to
respond to ethosuxamide (Zarontin®) therapy.

(2) Adverse effects. The primary side effect associated with clonazepam is
central nervous system depression. Drowsiness is frequently seen in patients who take
this medication.

MD0804 8-5
 e. Diazepam (Valium®), lorazepam (Ativan®).

(1) Clinical uses. Diazepam or lorazepam are drugs of first choice for the
treatment of status epilepticus (a particular type of convulsive disorder) when it is given
intravenously.

(2) Adverse effects. Drowsiness, fatigue, and ataxia are the most common
adverse effects seen with diazepam.

NOTE: Midazolam (Versed®) may be used as a continuous infusion for the treatment of
status epilepticus in patients that fail diazepam or lorazepam.

Continue with Exercises

MD0804 8-6
EXERCISES, LESSON 8

INSTRUCTIONS: Answer the following exercises by marking the lettered response that
best answers the exercise, by completing the incomplete statement, or by writing the
answer in the space provided at the end of the exercise.

After you have completed all of these exercises, turn to “Solutions to Exercises” at
the end of the lesson and check your answers. For each exercise answered incorrectly,
reread the material referenced with the solution.

1. Which of the following statements best describes epilepsy?

a. A mental condition that can be transmitted from one person to another.

b. A chronic convulsive disorder of brain function.

c. A chronic mental condition that is always characterized by violent

contractions of the involuntary muscles.

d. A condition that harms the brain in such a way that the person cannot
live a normal life.

2. Which of the following statements best describes grand mal epilepsy?

a. A type of epilepsy characterized by brief periods of blank spells or loss

speech.

b. A type of epilepsy characterized by focal or local clonic type convulsions

of localized muscle groups (for example, thumb, big toe, and so forth).

c. A type of epilepsy characterized by seizures which generally last from 2

to 5 minutes.

d. A rare type of epilepsy characterized by periods of abnormal behavior

(for example, extensive chewing).

3. Which of the following cause epilepsy in adults?

a. Tumors.
b. Trauma.
c. Cerebrovascular accident.
d. All the above.

MD0804 8-7
 4. The anticonvulsants act by _________________.

a. Depressing the cerebral cortex of the brain, thereby lowering the

threshold of the CNS to convulsive stimuli.

b. Stimulating the cerebral cortex of the brain, thereby raising the threshold
of the CNS to convulsive stimuli.

c. Depressing the cerebral cortex of the brain, thereby raising the threshold
of the CNS to convulsive stimuli.

d. Depressing the cerebral cortex of the brain, thereby deadening the part
of the brain that is responsible for the seizures.

INSTRUCTIONS: For exercises 5 through 8, match the generic name with its
corresponding trade name.

5. Clonazepam _______________ a. Zarontin®

6. Diazepam ________________ b. Klonopin®

7. Phenytoin ________________ c. Valium®

8. Ethosuximide _______________ d. Dilantin®

9. Phenobarbital is orally administered in the treatment of ______________.

a. Grand mal epilepsy.

b. Petit mal epilepsy.

c. Jackson epilepsy.

d. Psychomotor epilepsy.

MD0804 8-8
 10. Patients who take phenobarbital should be cautioned not to_________.

a. Take aspirin with the drug.

b. Take the drug with meals.

c. Take the medication immediately after a seizure.

d. Take the medication with alcohol.

11. Which adverse effect(s) is/are associated with the use of ethosuximide?

a. Dizziness.

b. Ataxia.

c. Nystagmus.

d. All the above.

12. Which adverse effect(s) is/are associated with the use of phenytoin.

a. Nystagmus.

b. Ataxia.

c. Slurred speech.

d. All the above.

Check Your Answers on Next Page

MD0804 8-9
SOLUTIONS TO EXERCISES, LESSON 8

1. b A chronic convulsive disorder of brain function.

(para 8-1a)

2. c A type of epilepsy characterized by seizures, which generally last from 2 to 5,

minutes. (para 8-2a)

3. d All the above. (para 8-3b)

4. c Depressing the cerebral cortex of the brain, thereby raising the threshold of
the CNS to convulsive stimuli. (para 8-4)

5. b Klonopin®. (para 8-5d)

6. c Valium®. (para 8-5e)

7. d Dilantin®. (para 8-5b)

8. a Zarontin®. (para 8-5c)

9. a Grand mal epilepsy. (para 8-5a)

10. d Take the medication with alcohol. (para 8-5a(3))

11. b Ataxia. (para 8-5c(2))

12. d All the above. (para 8-5b(2))

End of Lesson 8

MD0804 8-10
 LESSON ASSIGNMENT

LESSON 9 Psychotherapeutic Agents.

TEXT ASSIGNMENT Paragraphs 9-1--9-20.

LESSON OBJECTIVES After completing this lesson, you should be able to:

9-1. Given a group of statements and one of the

four classes of functional mental disorders,
select the best description of that class of
mental disorders.

9-2. From a group of statements, select the

statement that best differentiates between fear
and anxiety.

9-3. Given one of the following terms: fear, anxiety,

antianxiety agent, depression, antidepressant,
antipsychotic agent, or tranquilizer and a group
of definitions, select the correct definition of
that term.

9-4. Given one of the following categories of drugs:

antianxiety agents, antidepressant agents, and
antipsychotic agents and a group of statements
that describe uses, advantages,
disadvantages, adverse effects, or precautions
and warnings select the statement that best
describes the use(s) advantage(s),
disadvantage(s), adverse effect(s), or
caution(s) and warning(s) associated with that
category of drug.

9-5. Given a group of statements, select the

statement that best describes the advantages
of antianxiety agents over drugs that were
previously used to calm or sedate patients.

9-6. Given the generic and/or trade name of a

psychotherapeutic agent and a group of uses,
adverse effects, or cautions and warnings,
select the use(s), adverse effects, or cautions
and warnings associated with that agent.

MD0804 9-1
SUGGESTION After completing the assignment, complete the
exercises at the end of this lesson. These exercises
will help you to achieve the lesson objectives.

MD0804 9-2
 LESSON 9

PSYCHOTHERAPEUTIC AGENTS

Section I. OVERVIEW

9-1. INTRODUCTION

Stress, anxiety, and depression are frequently used words in today’s world. Every
living person has problems of one type or another. Some people seem to cope quite
well with stress most of the time, while other persons need assistance to make
adjustments to life. The wise use of psychotherapeutic agents has become an integral
part of assisting others to adjust to certain situations. Of course, psychologists and
psychiatrists combine other treatment means with the wise use of drugs in their efforts
to help others.

9-2. THE FOUR MAJOR CLASSES OF FUNCTIONAL MENTAL DISORDERS

Later in this lesson, certain drugs and their uses will be discussed. In order for
you to understand the use of some of the drugs, you must be aware of the four major
classes of functional mental disorders.

NOTE: Reality testing is an ego function that consists of an individual’s ability to

recognize and interpret the surrounding world (that is, what’s going on?). The ability to
recognize and interpret the surrounding world allows an individual to meet the demands
of life and make survival judgments.

a. Neuroses (Neurotic Disorders). Neuroses are a group of conditions

characterized by the development of anxiety because of unresolved unconscious
conflicts. The neurotic person is anxious, but he does not know the cause of his
anxiety. These conditions tend to become chronic. Reality testing is maintained. That
Is, the neurotic remains in touch with reality.

b. Psychoses (Psychotic Disorders). Psychoses are a group of disorders with

more or less severe disturbances of thought, mood, and/or behavior. Psychoses are
usually chronic, but short episodes of psychosis do sometimes occur. Reality testing is
always lost in one or more important respects. That is, a psychotic is not entirely in
touch with his environment.

c. Personality Disorders. Personality disorders are types of mental disorders

characterized by lifelong maladaptive patterns of adjustment to life. These types of
disorders tend to be chronic. Personality disorders are usually recognized by
adolescence. Reality testing is usually preserved.

MD0804 9-3
 d. Transient Situational Disturbances (Adjustment Disorders). Transient
situational disturbances (TSD) are temporary emotional disorders of any severity, which
occur as reactions to overwhelming environmental stress. Reality testing may or may
not be impaired during the acute phase of these disorders.

9-3. TERMINOLOGY ASSOCIATED WITH PSYCHOTHERAPEUTIC AGENTS

Before discussing the various psychotherapeutic agents, some terms and their
definitions will be presented. These terms will be used later in the discussion of the
psychotherapeutic agents.

a. Fear. Fear is a feeling of apprehension caused by a real object in the

environment. For example, a person who is unexpectedly confronted with a rattlesnake
would probably display fear of the snake. If you closely observed such a surprised
person, you would see such signs as increased blood pressure, increased respiratory
rate, and increased heart rate. These physiological responses are mediated by the
sympathetic nervous system.

b. Anxiety. Anxiety is a feeling of apprehension that has no specific object.

Most people have experienced the feeling of anxiety that occurs during test-taking time.
Anxiety has both positive and negative components. On the positive side, anxiety
motivates you to study for the exam rather than to go to the movies. On the negative
side, anxiety can interfere with performance on the examination (that is, "black outs"
during a pencil and paper test). Interestingly enough, a person who is frightened (that
is, with a snake) or is anxious (as with a test) will display the same body signs such as
increased blood pressure, increased heart rate, and increased respiratory rate.

c. Antianxiety Agent. An antianxiety agent is a drug that is used to calm a

patient. Although the drug reduces the subjective feeling of anxiety, it will have no
effect on the cause of the anxiety.

d. Depression. Depression is a disturbance of mood manifested by decreased

self-esteem, decreased vitality, and increased sadness.

e. Antidepressant. An antidepressant is a drug that will, after a period, cause

an improvement in a depressed patient’s mood.

f. Antipsychotic Agent. An antipsychotic agent is a drug that will reduce

specific symptoms (that is, hallucinations, delusions) in patients experiencing a
psychosis.

g. Tranquilizer. The term tranquilizer refers to a wide-variety of drugs that

produce a calming change in patient attitude and behavior. At one time, these drugs
were categorized into two major categories: the major tranquilizers and the minor
tranquilizers. The major tranquilizers are now generally referred to as antipsychotic
agents and the minor tranquilizers are referred to as antianxiety agents.

MD0804 9-4
 Section II. ANTIANXIETY AGENTS

9-4. INTRODUCTION TO ANTIANXIETY AGENTS

It is not unusual for a person to experience stress and anxiety. Most people can
deal with the minor stresses of life without using antianxiety agents. However, when the
degree of anxiety increases to the point of causing social and/or economic impairment,
the attending physician may decide to prescribe an antianxiety agent. It should be
remembered that the antianxiety agent will calm the patient, but the drug cannot remove
the cause of anxiety. Often the antianxiety therapy is combined with counseling or
therapy to help the patient deal with the stress and anxiety.

9-5. INDICATIONS FOR ANTIANXIETY AGENTS

Antianxiety agents are indicated in patients to control moderate to severe degrees

of anxiety. Antianxiety agents are also extremely useful in treating patients when
periods of overwhelming stress occur.

9-6. USES OF ANTIANXIETY AGENTS

Antianxiety agents are used in a variety of situations. Listed below are some of
those situations.

a. Control Moderate to Severe Stress and Anxiety in Neurotic and

Depressed Patients. Some neurotic and depressed patients are prescribed antianxiety
agents to reduce the amount of subjective anxiety; thus enabling them to more
productively participate in counseling or therapy.

b. Control Stress and Anxiety in Previously Normal Persons in Periods of

Overwhelming Stress. In most cases, normal individuals are able to cope with the
stress and anxiety of life. However, when unusual circumstances of extreme stress
arise, physicians sometimes prescribe antianxiety agents to assist people during these
periods. Antianxiety agents should not be prescribed for dealing with the stresses of
everyday life (Food and Drug Administration ruling).

c. Treat Withdrawal Symptoms in Alcoholism. These agents are very

effective in the treatment of delirium tremens associated with the withdrawal of alcohol
from alcoholics.

d. Treat Psychotic Patients in Periods of Acute Agitation. Sometimes

patients who have certain psychotic conditions undergo periods of acute agitation.
Antianxiety agents are used to calm these types of patients during these periods. Thus,
the patients become much more manageable. Generally speaking, antipsychotic drugs
are more effective when used for this particular purpose.

MD0804 9-5
 e. Decrease Preoperative and Postoperative Apprehension. Patients who
will undergo or have undergone surgery frequently have periods of apprehension.
Antianxiety agents have been used to reduce this type of stress and tension.

9-7. ADVANTAGES OF THE USE OF ANTIANXIETY AGENTS

Anti-anxiety agents have two main advantages over drugs that were previously
used to calm or sedate patients:

a. Antianxiety Agents Do Not Cause Excessive Loss of Alertness.

Barbiturates were frequently used to calm patients. Unfortunately, the barbiturates
sometimes calmed the patients to an undesirable degree. Although the antianxiety
agents produce some degree of sedation during the initial days of therapy, this sedation
is usually short-lived.

b. Overdosage of Antianxiety Agents Rarely Results in Death to the

Patient. As previously stated, the barbiturates were previously used to calm patients.
Unfortunately, overdose of barbiturates can frequently result in coma, respiratory
depression, and death. Antianxiety agents, on the other hand, are somewhat safe in
terms of the amount of drug required to produce coma, respiratory depression, and
death. This factor makes the wise use of antianxiety agents in special circumstances
useful in the treatment of extremely anxious patients who are entertaining thoughts
about suicide.

9-8. DISADVANTAGES OF THE USE OF ANTIANXIETY AGENTS

Although the antianxiety agents do have many advantages over previously used
drugs, they are not free from potentially harmful effects. The discussion below focuses
on two major disadvantages of the group of drugs classified as antianxiety agents.

a. Drowsiness. Antianxiety agents, especially during the first few days of

therapy, produce drowsiness in many patients. Further, many patients who take
antianxiety drugs experience loss of judgment and a loss of mental powers.
Consequently, patients who are on antianxiety therapy should be cautioned not to
operate machinery.

b. Drug Interaction Effects. The antianxiety agents can interact with central
nervous system depressants to produce a further degree of depression to the central
nervous system. Thus, patients who are on antianxiety therapy should be cautioned
against drinking alcohol or taking other central nervous system depressants.

9-9. EXAMPLES OF ANTIANXIETY AGENTS

This area of the subcourse is designed to provide you with a brief overview of
some commonly prescribed antianxiety agents. If you desire further information about

MD0804 9-6
the agents discussed below, you should consult a reference (for example, AMA Drug
Evaluations) which is well written and easy to understand.

a. Chlordiazepoxide Hydrochloride (Librium®).

(1) Uses. Chlordiazepoxide hydrochloride is widely used as an antianxiety

agent to help people deal with stress. Further, it is used preoperatively to reduce
patient apprehension. As an antianxiety agent, it has less anticonvulsant activity, and it
produces less drowsiness than diazepam, another antianxiety drug.

(2) Adverse effects. Chlordiazepoxide is likely to produce such adverse

effects as drowsiness and lethargy. These adverse effects are more likely to occur in
older patients.

(3) Cautions and warnings. Patients taking chlordiazepoxide should be

cautioned not to take a central nervous system depressant like alcohol since the
additive effect might produce depression of the central nervous system. Furthermore,
patients taking chlordiazepoxide should be cautioned against operating machinery (for
example, driving an automobile).

b. Diazepam (Valium®).

(1) Uses. Diazepam is widely used for the treatment of anxiety and tension.
Further, it is used in the treatment of muscle spasms.

(2) Adverse effects. Diazepam produces such adverse effects as

drowsiness, fatigue, and ataxia (lack of coordination). Physical dependence can
develop over a period with resultant withdrawal symptoms to include seizures.

(3) Cautions and warnings. An individual taking diazepam should be

cautioned against taking central nervous system depressants (that is, alcohol) and
operating machinery.

c. Lorazepam (Ativan®).

(1) Uses. Lorazepam is primarily used in the treatment of anxiety.

(2) Adverse effects. Lorazepam produces such adverse effects as

drowsiness, fatigue, and ataxia (lack of coordination). Physical dependence can
develop over a period of time with resultant withdrawal symptoms to include seizures.

(3) Cautions and warnings. An individual taking lorazepam should be

cautioned against taking central nervous system depressants (that is, alcohol) and
operating machinery.

MD0804 9-7
 d. Alprazolam (Xanax®).

(1) Uses. Alprazolam is primarily used in the treatment of anxiety and has
been useful in the management of panic attacks.

(2) Adverse effects. Alprazoam produces such adverse effects as

drowsiness, fatigue, and ataxia (lack of coordination). Physical dependence can
develop over a period with resultant withdrawal symptoms to include seizures.

(3) Cautions and warnings. An individual taking alprazolam should be

cautioned against taking central nervous system depressants (that is, alcohol) and
operating machinery.

e. Hydroxyzine Hydrochloride (Atarax®) or Hydroxyzine Pamoate

(Vistaril®).

(1) Uses. Hydroxyzine has the following three primary uses:

(a) Antianxiety agent. The drug is used to treat anxiety, tension, and
agitation.
(b) Antiemetic agent. Because hydroxyzine does have some
antiemetic (antinausea and vomiting) properties, it is used in its injectable form
(hydroxyzine pamoate) to manage postoperative nausea and vomiting.

(c) Antipruritic agent. Hydroxyzine has been used because of its

antipruritic (anti-itch) properties.

NOTE: Atarax® is sometimes used as a sedative.

(2) Adverse effects. There is an extremely low incidence of adverse

reactions with this drug. Some drowsiness may occur during the initial days of therapy;
however, this drowsiness is short-lived.

(3) Cautions and warnings. An individual taking hydroxyzine should be

cautioned against drinking alcohol and taking other central nervous system depressants
because of the additive effect that may be produced. Furthermore, persons taking this
drug should be cautioned against operating machinery (for example, driving an
automobile).

f. Buspirone (Buspar®).

(1) Uses. Buspirone is used in the management of anxiety or the short term
relief of symptoms of anxiety. It is unrelated to the benzodiazepines and therefore lacks
the sedative and addictive properties of these agents.

MD0804 9-8
 (2) Adverse effects. The most common adverse effects include dizziness,
nausea, and headache.

(3) Cautions and warnings. Although buspirone does not produce

significant drowsiness, patients should be cautioned about driving or operating
machinery until they are certain that this drug does not affect them adversely.

NOTE: Antidepressants, which are discussed in the next section, are becoming the
agents of choice for anxiety disorders.

Section III. ANTIDEPRESSANT AGENTS

9-10. INTRODUCTION TO ANTIDEPRESSANT AGENTS

Depression is a frequently occurring psychiatric disorder. Patients with medical

and surgical conditions frequently have signs and symptoms associated with
depression. People who are depressed usually have low moods, decreased physical
activity and mental alertness, decreased appetite, abnormal sleep patterns, and morbid
preoccupations. Depression can be of rapid or slow onset. For example, a soldier who
has been denied leave might display several signs of depression. This type of
depression could be of rapid onset.

9-11. INDICATIONS FOR ANTIDEPRESSANT AGENTS

a. Most people undergo changes in mood. You can probably remember when
you have been "up" (that is, right before a three-day weekend) and when you have been
"down" (that is, right after a three-day weekend). Physicians have found antidepressant
agents to be useful in the treatment of depression, which is not time limited and causes
the patient social and economic difficulties.

b. Depression can be caused by chemical imbalances in the body, by stress,

and by situations in the environment. It has been found that psychotherapy, reduction
of stress, and improvement in the environment can be successful in treating some types
of depression. However, in depression that results from chemical imbalances in the
body, these types of treatment have not proven to be very effective.

9-12. EFFECTS OF ANTIDEPRESSANT AGENTS

Antidepressant agents elevate mood, increase physical activity and mental

alertness, improve appetite and sleep patterns, and reduce morbid preoccupations.
These effects are not seen immediately upon beginning antidepressant therapy.
Instead, one to four weeks may pass before the patient shows any signs of
improvement in the depression. This period is called the therapeutic lag period.

MD0804 9-9
9-13. PRECAUTIONS ASSOCIATED WITH THE USE OF ANTIDEPRESSANT
AGENTS

Although the antidepressant agents are safe for patient use, there are some
precautions associated with their use:

a. Antidepressants should be used cautiously with patients who are hyperactive

or agitated.

b. Antidepressants should be used cautiously with the elderly, with patients

who have glaucoma, and with patients who have hypertension (high blood pressure).

c. Antidepressants may interact with other types of drugs. For example,

references should be consulted to determine if any interaction could occur between a
particular antidepressant and a drug a patient is taking to control high blood pressure,
since some antidepressants partially block the action of some antihypertensive drugs.
In addition, the action of some drugs (that is, the barbiturates) is increased in duration
when they are administered to patients who are taking certain antidepressant agents.

9-14. SPECIFIC ANTIDEPRESSANT AGENTS

Immediately following is a discussion of several antidepressant agents. By no

means is the listing below complete in terms of the number of agents available to the
physician. Further, no attempt has been made to provide an in-depth discussion of
each individual agent. If you desire additional information about any of the agents
discussed below, you should consult a pharmacology reference (for example, AMA
Drug Evaluations).

a. Fluoxetine (Prozac®).

(1) Uses. Fluoxetine belongs to a class of antidepressants called Selective

Serotonin Reuptake Inhibitors (SSRIs). SSRIs are usually regarded as the treatment of
choice for depression due to fewer side effects and a better safety profile than older
agents. Fluoxetine is used to treat depression and anxiety disorders. The Serafem®
product is approved for premenstrual dysphoric disorder (PMDD).

(2) Adverse effects. Fluoxetine may produce the following adverse effects:

(a) Miscellaneous effects (that is, sexual dysfunction).

(b) Central nervous system effects (for example, agitation and

insomnia).

(c) Gastrointestinal effects (that is, nausea and diarrhea).

MD0804 9-10
 (3) Cautions and warnings.

(a) Do not overlap with other antidepressants or monoamine oxidase

inhibitors.

(b) The drug may produce drowsiness.

(c) The patient should not consume any alcohol while taking the drug.

NOTE: Other SSRIs include sertraline (Zoloft®), paroxetine (Paxil®), citalopram

(Celexa®), and fluvoxamine (Luvox®).

b. Imipramine Hydrochloride (Tofranil®).

(1) Uses. Imipramine is used to treat depression; however, it can

paradoxically aggravate the anxiety sometimes associated with depression. Imipramine
also produces an anticholinergic effect and is therefore approved by the Food and Drug
Administration (FDA) for the treatment of enuresis (bedwetting) in children.

(2) Adverse effects. Imipramine may produce the following adverse

effects:

(a) Cardiovascular effects (that is, orthostatic hypotension).

(b) Central nervous system effects (for example, confusion and

anxiety).

(c) Gastrointestinal effects (that is, nausea and vomiting).

(d) Anticholinergic effects (for example, dry mouth and constipation).

(3) Cautions and warnings.

(a) Abruptly taking the drug away from the patient after long-term
therapy may produce withdrawal symptoms.

(b) The drug may produce drowsiness.

(c) The patient should not consume any alcohol while taking the drug.

(d) The drug should be used with caution in patients with glaucoma or
urinary retention because of its anticholinergic effects.

MD0804 9-11
 c. Desipramine (Norpramin®).

(1) Uses. Desipramine is used to treat depression. It has also been used
in facilitating withdrawal from cocaine.

(2) Adverse effects. Desipramine is closely related to imipramine but has

only minimal cardiovascular, CNS, GI, and anticholinergic effects.

(3) Cautions and warnings.

(a) Abruptly taking the drug away from the patient after long-term
therapy may produce withdrawal symptoms.

(b) The drug may produce drowsiness.

(c) The patient should not consume any alcohol while taking the drug.

(d) The drug should be used with caution in patients with glaucoma or
urinary retention because of its anticholinergic effects.

d. Amitriptyline Hydrochloride (Elavil®).

(1) Uses. Amitriptyline is used in the treatment of depression and

neuropathic pain syndromes.

(2) Adverse effects. Amitriptyline tends to cause confusion in elderly

patients. In addition, it has other adverse effects that are similar to those produced by
imipramine hydrochloride.

(3) Cautions and warnings.

(a) Abruptly taking the drug away from the patient after long-term
therapy may produce withdrawal symptoms.

(b) The drug may produce drowsiness.

(c) The patient should not consume any alcohol while taking the drug.

(d) The drug should be used with caution in patients who have
glaucoma or urinary retention due to its anticholinergic effects.

(4) Precautions. Amitriptyline can be cardiotoxic to some individuals.

MD0804 9-12
 d. Nortriptyline Hydrochloride (Aventyl®).

(1) Uses. Nortriptyline is used in the treatment of depression and

neuropathic pain disorders.

(2) Adverse effects. The adverse effects produced by nortriptyline are the
same as those produced by imipramine hydrochloride (see para 9-14b).

(3) Cautions and warnings. The adverse effects produced by nortriptyline

are the same as those produced by imipramine hydrochloride (see para 9-14b).

e. Trazodone (Desyrel®).

(1) Uses. Trazodone is used in the treatment of depression. It is unrelated

to any of the antidepressants discussed thus far.

(2) Adverse effects. The adverse effects produced by trazodone include

skin rash, chest pain, drowsiness, tachycardia, vivid dreams/nightmares, and muscle
aches.

(3) Cautions and warnings. Trazodone may produce drowsiness and may
cause irregular heartbeat. The patient should observe caution when driving or
performing other tasks requiring alertness. Alcohol and other depressant drugs should
be avoided while taking trazodone.

f. Nefazodone Hydrochloride (Serzone®).

(1) Uses. Nefazodone hydrochloride is an oral antidepressant that is totally

unrelated to the other available antidepressants.

(2) Adverse effects. The adverse effects of nefazodone hydrochloride are

similar to selective serotonin reuptake inhibitors.

(3) Contraindications.

(a) The drug is contraindicated in patients who are taking other

monoamine oxidase (MAO) inhibitors, and those having hypersensitivity to nefazodone
or other phenylpiperazine antidepressants.

(b) The drug is contraindicated on patients who are taking

nonsedating antihistimines (that is, Terfenadine and Astemizole).

(4) Cautions and warnings. Patients taking nefazodone hydrocloride

should be cautioned against the following:

(a) The drug may produce drowsiness.

MD0804 9-13
 (b) The patient should not consume any alcohol while taking the drug.

(c) Patients with cardiovascular or cerebrovascular disease that could

be exacerbated by hypotension should use with caution.

(d) The potential for a fatal outcome is significantly increased by the

concurrent use of alprazolam and triazolam.

Section IV. ANTIPSYCHOTIC AGENTS

9-15. INTRODUCTION TO ANTIPSYCHOTIC AGENTS

The general term psychoses encompass a wide variety of conditions. Each

specific condition has particular signs and/or symptoms that assist the psychiatrist in
making a diagnosis. Some psychotic conditions require long-term hospitalization, while
others can be managed on an outpatient basis. Many psychotic patients show marked
disorganization of thought patterns and behavior with either increased or decreased
psychomotor activity. Antipsychotic agents help psychotic patients better organize their
thoughts and coordinate their motor activities. In some cases, the use of antipsychotic
agents can mean the difference between hospitalization and home-care.

9-16. INDICATIONS FOR USE OF ANTIPSYCHOTIC AGENTS

In order for an antipsychotic agent to be wisely used to treat a psychotic patient,

the attending psychiatrist must carefully examine the patient and diagnose the specific
condition. Proper diagnosis is the key word for beginning drug therapy for the psychotic
patient.

9-17. USES OF ANTIPSYCHOTIC AGENTS

a. The antipsychotic agents are used to treat various conditions of psychosis.

When used in this manner, they help reduce the patient’s fear, panic, and hostility. With
this help, the patient is better able to organize life and more realistically respond to the
environment.

b. Some antipsychotic agents are used as adjuncts in anesthesia to control

nausea and vomiting.

c. The state of psychotic hyperarousal is the first group of symptoms to

respond to antipsychotic medication. Delusions and hallucinations resolve more
gradually over a period.

MD0804 9-14
9-18. ADVERSE EFFECTS ASSOCIATED WITH ANTIPSYCHOTIC AGENTS

As with most drugs, the antipsychotic agents produce some adverse effects.
Discussed below are some of those reactions:

a. Extrapyramidal Reactions. Extrapyramidal reactions are manifested by a

parkinson-like syndrome. That is, the patient has tremors, muscular rigidity, postural
abnormalities, pill-rolling movements with the fingers, and hypersalivation. Fortunately,
these symptoms may be relieved or lessened, or the reactions may be prevented before
they occur by the administration of diphenhydramine (Benadryl).

b. Drowsiness, Dizziness, and Fatigue. Although a sedative-effect is

produced by many of the antipsychotic agents, this effect is short-lived because
tolerance develops after one to three days.

c. Orthostatic Hypotension. Orthostatic hypotension (low blood pressure) is

an adverse reaction produced by some of the antipsychotic agents. Patients
experiencing this problem are at risk of fainting and injuring themselves.

d. Anticholinergic Effects.

9-19. DOSAGE PRINCIPLE ASSOCIATED WITH THE ANTIPSYCHOTIC AGENTS

You should be familiar with a dosage principle associated with the antipsychotic
agents. This principle is: "High dosage-low potency/low dosage-high potency."

a. High Dosage/Low Potency. Initially when treating a psychotic patient, a

psychiatrist might choose to select a drug that can be given in a high dosage (large
amount of drug) because of its low potency. This allows the psychiatrist some freedom
in dosage-especially if the patient is uncontrollable--without potential harm to the
patient. High dosage/low potency drugs usually have a high incidence of anticholinergic
side effects, but low incidence of extrapyramidal side effects.

b. Low Dosage/High Potency. After a patient has been on one antipsychotic

agent and has been stabilized, the psychiatrist may choose to use another agent that
can be given in smaller amounts (low dosage) because of its high potency. Usually,
more potent drugs are easier to administer (that is, in tablet form). Low dosage/high
potency drugs usually have a low incidence of anticholinergic side effects, but high
incidence of extrapyramidal side effects

MD0804 9-15
9-20. SPECIFIC ANTIPSYCHOTIC AGENTS

a. Chlorpromazine (Thorazine®).

(1) Uses. Chlorpromazine is a phenothiazine drug (a particular class of

drugs) used in the treatment of acute and chronic psychoses. It is also used as a pre-
or postoperative agent in the prevention of nausea and vomiting.

(2) Adverse effects. Chlorpromazine produces three major adverse effects:

(a) Extrapyramidal reactions. These reactions are frequently seen in

both young and elderly patients who are taking large doses of the drug.

(b) Drowsiness.

(c) Orthostatic hypotension. Orthostatic hypotension is most likely to

occur when the patient has been administered the drug intravenously. This can be
prevented by having the patient remain reclined for at least one hour after the
administration of the drug.

(d) Dryness of the mouth.

(3) Cautions and warnings. Chlorpromazine should not be prescribed to

patients who have liver disease or glaucoma. Furthermore, patients taking the drug
should be cautioned not to drink alcoholic beverages.

b. Fluphenazine Hydrochloride (Prolixin®, Permitil®).

(1) Use. Fluphenazine hydrochloride is used in the treatment of psychotic

disorders.

(2) Adverse effects.

(a) Extrapyramidal reactions.

(b) Drowsiness or lethargy.

(c) Hypertension (increased blood pressure).

(3) Cautions and warnings. Abrupt withdrawal of the drug may result in
nausea and vomiting, gastritis, and dizziness.

MD0804 9-16
 c. Thioridazine Hydrochloride (Mellaril®).

(1) Use. This is a phenothiazine used to treat acute and chronic types of
psychosis. Thioridazine is safe in treating psychotic patients who also have liver
disease.

(2) Adverse effects. Thioridazine produces the following adverse effects:

(a) Sedation and lethargy.

(b) Gastric irritation.

d. Perphenazine (Trilafon®).

(1) Uses. Perphenazine is used in the management of psychotic disorders.

(2) Adverse effects. Perphenazine, like chlorpromazine, can produce

extrapyramidal reactions, orthostatic hypotension, drowsiness, and dry mouth
(drowsiness and orthostatic hypotension are less than that seen with chlorpromazine).

(3) Cautions and warnings. Perphenazine may cause drowsiness.

Patients should avoid alcohol and other CNS depressants while taking this drug.

e. Trifluoperazine Hydrochloride (Stelazine®).

(1) Use. This phenothiazine is used in the treatment of various types of

acute and chronic psychoses. This drug is used primarily in the maintenance treatment
of psychotic patients.

(2) Adverse effects. Two adverse effects are produced by this drug:

(a) Drowsiness may occur with the use of this drug.

(b) Extrapyramidal reactions may occur with the use of this drug.

(3) Cautions and warnings. The following cautions and warnings are
associated with trifluoperazine:

(a) The use of alcohol with this agent should be avoided

because of the possible interaction between the two substances.

(b) Since the drug can produce sedation, the patient should be
cautioned against operating vehicles while under the effects of this drug.

MD0804 9-17
 f. Haloperidol (Haldol®).

(1) Use. This drug is used in the treatment of acute and chronic psychosis.
In its parenteral (injectable) form (10 milligrams per milliliter of solution), haloperidol is a
potent antipsychotic medication which is well suited for emergency room use.
Haloperidol can be safely prescribed to patients who have liver disease.

NOTE: Haloperidol is considered the gold standard for antipsychotics.

(2) Adverse effects. Two adverse effects are seen with this drug:

(a) Extrapyramidal reactions.

(b) Depression, anxiety, and/or dizziness.

g. Lithium Carbonate (Eskalith®, Lithane®).

(1) Use. Lithium carbonate is used in the treatment of manic-depressive

psychosis. After initial administration, approximately 7 to 10 days are required before
the effects of the drug can be observed in the patient.

(2) Adverse effects. The following are some of the adverse effects
associated with lithium carbonate:

IMPORTANT NOTE: The level of lithium carbonate in the bloodstream of the patient is
very significant. The severity of the toxic symptoms tends to increase as the level of the
drug in the patient’s blood increases.

(a) Nausea, vomiting, cramps diarrhea.

(b) Drowsiness and muscular weakness.

(c) Tremors.

(d) Height loss or weight gain.

(3) Cautions and warnings. Cautions and warnings associated with the use
of this agent are:

(a) Patients who are administered lithium carbonate should be kept

under close medical supervision at all times. This is necessary because the amount of
drug required to produce the desired effects is very close to the amount of drug that will
produce toxic effects.

MD0804 9-18
 (b) Blood levels of lithium carbonate should always be performed at
regular intervals to ensure that the appropriate therapeutic levels of the drug are
maintained.

(c) Lithium carbonate should not be administered to patients who are

taking diuretics (that is, some antihypertensive medications), because diuretics tend to
cause an accumulation of the drug, and toxic levels of the drug could rapidly occur.

(d) The efficacy (clinical effectiveness) of lithium carbonate in the

treatment of the depressive phase of manic depressive illness remains controversial.
The drug is the most effective treatment for true bipolar illness, particularly in the control
of manic episodes. The drug is not effective in established depressed episodes. It may
prevent reoccurrence of both manic and depressive episodes.

(e) Drowsiness. Patients taking the drug should be cautioned against

operating heavy machinery (for example, driving an automobile).

h. Risperidone (Risperdal®).

(1) Use. This drug belongs to the class of antipsychotics called “atypical”.
They are used for treatment resistance in older agents and reduce the likelihood of
extrapyramidal side effects. They may be used as first line agents.

(2) Adverse effects. Adverse effects seen with this drug are:

(a) Extrapyramidal reactions.

(b) Orthostatic hypotension.

NOTE: Other atypical antipsychotics include Olazapine (Zyprexa®), Clozapine

(Clozaril®), and Quetiapine (Seroquel®).

Continue with Exercises

MD0804 9-19
EXERCISES, LESSON 9

INSTRUCTIONS: Answer the following exercises by marking the lettered response that
best answers the exercise, by completing the incomplete statement, or by writing the
answer in the space provided at the end of the exercise.

After you have completed all of these exercises, turn to "Solutions to Exercises" at the
end of the lesson and check your answers. For each exercise answered incorrectly,
reread the material referenced with the solution.

1. Select the best description of personality disorders.

a. Types of conditions characterized by the development of anxiety because of

unresolved unconscious conflicts.

b. Temporary emotional disorders that occur as reactions to overwhelming

environmental stress.

c. Types of mental disorders characterized by lifelong maladaptive patterns of

adjustment to life.

d. A group of disorders with more or less severe disturbances of thought, mood,

and/or behavior.

2. From the statements below, select the statement that best differentiates between
fear and anxiety.

a. Fear is a feeling of apprehension caused by a real object in the environment,

while anxiety is a feeling of apprehension that has no specific object in the environment.

b. Fear and anxiety produce entirely different physiological reactions.

c. Fear cannot be controlled, while anxiety can be controlled without the use of
drugs.

d. Fear is a feeling of apprehension that has no specific object in the environment,

while anxiety is a feeling of apprehension caused by a real object in the environment.

MD0804 9-20
3. Select the correct definition of the term antianxiety agent.

a. A drug used to improve the depressed mood of a patient.

b. A drug used to calm a patient.

c. A drug which will reduce certain symptoms such as hallucinations and

delusions.

d. A drug which will remove a patient’s fear.

4. Select the statement that best describes the use(s) of antidepressant agents.

a. The treatment of depression that results because of chemical imbalances in the

body.

b. The treatment of depression that is not a result of chemical imbalances in the

body.

c. The treatment of patients who are experiencing periods of overwhelming stress.

d. The treatment of acute and chronic psychoses.

5. Select the statement that best describes the adverse effects associated with
antipsychotic agents.

a. Antipsychotic agents are noted for the lack of adverse effects they produce.

b. Antipsychotic agents can cause severe stimulation in many patients.

c. Antipsychotic agents produce orthostatic hypertension.

d. Antipsychotic agents can produce reactions that consist of tremors, muscular

rigidity, and hypersalivation.

MD0804 9-21
6. Select the statement that best describes the disadvantage(s) of antianxiety agents.

a. Antianxiety agents can produce drowsiness in patients and can interact with
central nervous system (CNS) depressants to produce a greater degree of CNS
depression.

b. Antianxiety agents produce an excessive loss of alertness.

c. Because of their side effects, overdosage of antianxiety agents frequently

results in death.

d. Antianxiety agents produce tremors, muscular rigidity, and hypersalivation in

many patients.

7. From the statements below, select the statement which best describes the
advantage(s) of antianxiety agents over drugs which were previously used to calm or
sedate patients.

a. Antianxiety agents do not cause excessive loss of alertness.

b. Antianxiety agents can be safely taken while driving or operating machinery.

c. Overdosage of antianxiety agents rarely results in death to the patient.

d. Both a and c.

e. Both b and c.

8. Select the use of hydroxyzine hydrochloride (Atarax®).

a. Antidiarrheal agent.

b. Antianxiety agent.

c. Antipsychotic agent.

d. Antipyretic agent.

MD0804 9-22
9. Select the statement that best describes an adverse reaction associated with
haloperidol (Haldol®).

a. This drug may cause extrapyramidal reactions.

b. This drug may produce hypotension.

c. This drug may produce overstimulation.

d. This drug may produce withdrawal.

10. Select the statement which best describes the use(s) associated with
chlorpromazine (Thorazine®):

a. The drug is used to treat acute and chronic types of psychosis.

b. The drug is used as an antiemetic to prevent pre- or postoperative nausea and

vomiting.

c. The drug is used as an antianxiety agent.

d. a and b.

e. b and c.

Check Your Answers on Next Page

MD0804 9-23
SOLUTIONS TO EXERCISES, LESSON 9

1. c Types of mental disorders characterized by lifelong maladaptive patterns of

adjustment to life. (para 9-2c)

2. a Fear is a feeling of apprehension caused by a real object in the environment,

while anxiety is a feeling of apprehension which has no specific object in the
environment. (para 9-3a, b)

3. b A drug used to calm a patient. (para 9-3c)

4. b The treatment of depression that is not a result of chemical imbalances in the

body. (para 9-11b)

5. d Antipsychotic agents can produce reactions that consist of tremors, muscular

rigidity, and hypersalivation. (para 9-18a)

6. a Anxiety agents can produce drowsiness in patients and can interact with central
nervous system (CNS) depressants to produce a greater degree of CNS
depression. (para 9-8a, b)

7. e Both b and c. (para 9-7a, b)

8. b Antianxiety agent. (para 9-9e)

9. a This drug may cause extrapyramidal reactions. (para 9-20f)

10. d Both a and b. (para 9-20a)

End of Lesson 9

MD0804 9-24
 LESSON ASSIGNMENT

LESSON 10 Central Nervous System Stimulants.

TEXT ASSIGNMENT Paragraphs 10-1--10-9.

LESSON OBJECTIVES After completing this lesson, you should be able to:

10-1. Given several categories, select the

category(ies) of central nervous system
(CNS) stimulants.

10-2. Given a group of possible effects, select the

pharmacological effect associated with
xanthine derivatives.

10-3. Given the trade name of a CNS stimulant and

a group of generic names, match the trade
name with its generic name.

10-4. Given the trade or generic name of a CNS

stimulant and a group of possible clinical
uses, side effects, or cautions and warnings,
select the clinical use, side effect, or caution
and warning associated with that agent.

SUGGESTION After completing the assignment, complete the

exercises at the end of this lesson. These exercises
will help you to achieve the lesson objectives.

MD0804 10-1
 LESSON 10

CENTRAL NERVOUS SYSTEM STIMULANTS

Section I. BACKGROUND

10-1. INTRODUCTION TO THE CENTRAL NERVOUS SYSTEM

a. Many people are familiar with the class of drugs known as CNS stimulants.
Unfortunately, most people are aware of these agents because of the abuse/misuse
associated with these drugs. The central nervous system stimulants do have a variety
of medically approved uses. This subcourse lesson will focus on those uses.

b. This lesson will introduce you to the topic of CNS stimulants, how they act,
their approved uses, and drugs representative of the drug class. Much has been written
on CNS stimulants. If you wish to learn more about these agents, you should obtain an
appropriate reference (see the lesson on reference selection, lesson 1 of this
subcourse).

10-2. OTHER DRUGS WHICH ACT UPON THE CENTRAL NERVOUS SYSTEM

This lesson will focus on drugs that stimulate the central nervous system. There
are, as you know, many classes of drugs that have other effects on the central nervous
system. These drug classes include sedative and hypnotic agents (lesson 7),
antianxiety agents (lesson 9), and anti-psychotic agents (lesson 9), centrally acting
skeletal muscle relaxants (SC MD0805), and anticonvulsants (lesson 8). You should be
familiar with the types of responses produced by these agents because, as you know,
patients take a variety of medications. Some combinations of medications may not be
desirable.

10-3. CLASSIFICATION OF CENTRAL NERVOUS SYSTEM (STIMULANTS)

a. Central nervous system stimulants excite the nerve cells of the central
nervous system. These agents are classified according to their main site of action and
their primary pharmacological effects. Following are the three categories of agents:

(1) Cerebral of psychomotor agents.

(2) Analeptics (brain stem stimulants).

(3) Convulsants (spinal cord stimulants).

MD0804 10-2
 b. As you might anticipate, when increasingly larger doses of a drug are
administered to the patient, the effects produced by the drug cause stimulation of more
than one area.

c. Some central nervous system stimulants produce high levels of stimulation

at other sites in the body (for example, the heart). In some cases, the usefulness of
several CNS agents is limited because of the stimulation they produce in body organs.

Section II. CEREBRAL OR PSYCHOMOTOR AGENTS

10-4. INTRODUCTION

A variety of agents are classified as cerebral or psychomotor central nervous

system agents. These drugs have one characteristic in common: they primarily
stimulate the cerebral cortex of the brain.

10-5. CLASSES OF CEREBRAL OR PSYCHOMOTOR CENTRAL NERVOUS

SYSTEM STIMULANTS

a. The Xanthine Derivatives. The xanthine derivatives have several

pharmacological effects. One, they directly relax the smooth muscle of the bronchi and
pulmonary blood vessels. By such dilation of the bronchi, more oxygen can be drawn
into the lungs. Two, they stimulate the central nervous system and produce diuresis
(they increase the production of urine) by direct action on the kidney. There are several
examples of xanthine derivatives:

(1) Caffeine. Caffeine is found in coffee, tea, and in kola nuts (used to
make some soft drinks). Caffeine is a stimulant that has been long used as a morning
"picker-upper" for workers and students. Caffeine is found in some headache remedies
products promoted to prevent drowsiness, and in some products designed to suppress
appetite (in these preparations caffeine acts to stimulate the person). Although caffeine
does have some desirable qualities (that is, small doses of the drug can promote better
performance on tasks like typing and thinking), it is possible for a person to develop a
psychological dependence on the drug. Withdrawal of the drug results in some persons'
having mild withdrawal symptoms (for example, headaches).

(2) Aminophylline (Theophylline ethylenediamine). This drug is used in

the treatment of bronchial asthma. It is given intravenously to provide rapid relief of
pulmonary edema and dyspnea seen in the acute congestive heart failure patient
because it increases cardiac output, slightly increases venous pressure, and relaxes the
bronchial muscle. Side effects associated with the oral administration of this agent
include nausea, vomiting, and nervousness. The patient should be informed to take this
medication with food. The medication is supplied in 100 and 200-milligram tablets, 250

MD0804 10-3
and 500-milligram suppositories, and in injectable form (25 milligrams per milliliter in a
10-milliliter ampule).

(3) Theophylline (Theo-dur®, Elixophyllin®). This xanthine derivative is

used for the symptomatic relief of asthma because of its bronchial dilation effect.
Theolair is but only one of many anhydrous theophylline products in use today. The
side effects usually associated with the use of the drug are nausea, vomiting, and
nervousness. The patient should be told to take theophylline with food. The drug is
usually administered in a dosage of 3 to 5 milligrams per kilogram of body weight. It is
supplied in various dosage forms (elixir, tablets, capsules, and sprinkles).

b. The Amphetamines. Many health care professionals are concerned about

the abuse/misuse of the amphetamines. These Schedule II medications certainly have
been abused in the past. Today, physicians and pharmacists cooperate to ensure
these drugs are wisely used for medically acceptable purposes. Amphetamines act
pharmacologically to produce two primary effects. One, they increase an individual's
state of alertness. Two, they elevate a person's mood. Now, several agents will be
discussed. The particular use(s) for each agent will be presented.

(1) Methylphenidate (Ritalin®). Methylphenidate (Ritalin®) is used to treat

attention deficit hyperactivity disorder (ADHD), formerly known as minimal brain
dysfunction, and narcolepsy. Observed abnormalities in ADHD include impulsiveness,
short attention span, purposeless hyperactivity, emotional overreactivity, coordination
and learning deficits, distractibility, and deficits in the perception of space, form,
movement, and time. Since the first clinical sign seen with ADHD is purposeless
hyperactivity, the terms hyperkinetic and hyperkinesia are sometimes used in place of
attention deficit hyperactivity disorder (ADHD). Narcolepsy can be defined as an
inability to stay awake. The most common side effect associated with this agent is
nervousness. Methylphenidate is a Schedule II drug (Note R). The usual dosage of
methylphenidate is 20 to 30 milligrams daily in divided doses. It is supplied in the form
of 5 milligram, 10 milligram, and 20-milligram tablets.

(2) Dextroamphetamine sulfate (Dexedrine®). Dextroamphetamine was

once prescribed as an anoretic (an appetite depressant) for many years. Recently, it
has been found that dextroamphetamine's inhibitory effect on the appetite lasts only for
four or five weeks. This finding, coupled with its increased abuse, has drastically
reduced the quantity of the prescriptions for this drug. This agent is not used in the
military for the inhibition of appetite. It is used only for the treatment of attention deficity
hyperactivity disorder (ADHD) and narcolepsy. Most military and civilian physicians
believe that exercise and the restriction of food (caloric) intake is the method of choice
for weight reduction. The most common side effects associated with
dextroamphetamine are nervousness and headaches. This drug has a very high abuse
potential. It is controlled as a Schedule II (Note R) item. Dextroamphetamine is
supplied in 5-milligram tablets, 10- and 15-milligram capsules.

MD0804 10-4
 (3) Methamphetamine hydrochloride (Desoxyn®). This drug is similar to
dextroamphetamine in terms of its ability to suppress the appetite. However, its abuse
potential is such that it is rarely used any longer for this purpose.

c. Other Agents. Many other drugs produce pharmacological effects similar

to those produced by the amphetamines. These are most often used for their ability to
suppress the patient's appetite. Sometimes you will find these medications combined
with other drugs (for example, a sedative or an antianxiety agent) in order to counteract
the stimulation they produce.

(1) Pemoline (Cylert®). This drug is used in the treatment of ADHD. It is

usually prescribed in a graduated dose - beginning with a 37.5-milligram daily dose. It
is then gradually increased at 1-week intervals of 18.75 milligrams until a desired clinical
response is observed. The most common side effect seen with this agent is insomnia.
Pemoline appears to have a lower abuse potential than methylphenidate; pemoline is
classified as a Note Q drug. The drug is supplied in the form of 18.75, 37.5, and 75
milligram tablets.

(2) Diethylpropion hydrochloride (Tenuate®). Diethylpropion hydrochloride

is used as an appetite suppressant. It is less effective in this use than the
amphetamines. It produces such side effects as dryness of the mouth, nausea, and
headaches. It is available in both 25-milligram tablets and 75-milligram (timed-release)
tablets. Diethylpropion is a Note Q drug.

(3) Phendimetrazine tartrate (Prelu-2®). This drug is used as an appetite

suppressant. Long-term use of the drug, especially in large doses, may produce
psychic dependence. It produces such side effects as nervousness, excitement,
euphoria, and dryness of the mouth. It is supplied in 35-mIlligram tablets and capsules
and 105-milligram (timed-release) capsules. Phendimetrazine is a Note Q drug.

Section III. ANALEPTIC AGENTS (BRAIN STEM STIMULANTS)

10-6. INTRODUCTION

a. Analeptic agents are drugs that produce two primary effects. One, they
stimulate the nerve cells of the body's respiratory center when it has been depressed by
some condition (for example, illness or drugs). Two, they stimulate nerve cell centers
responsible for keeping a person conscious.

b. Analeptic agents are not commonly used today because of the stimulation
they produce in doses sufficient to produce their analeptic effect. These agents can
produce such undesirable effects as convulsions, respiratory problems, or vomiting.

MD0804 10-5
10-7. EXAMPLE OF AN ANALEPTIC AGENT

Doxapram (Dopram®) is an analeptic agent used for postanesthetic arousal and

drug-induced central nervous system depression. It has the ability to arouse the patient
after surgery without reducing the analgesia produced by opiates (for example,
morphine). Thus, it is used to hasten recovery time. The faster the patient becomes
aware of his or her surroundings, the faster nursing personnel are relieved of intensive
care responsibilities. Doxapram is also used to stimulate respiration and hasten arousal
in patients who have mild to moderate respiratory and central nervous system
depression because of overdose. The most common side effects associated with this
drug are headaches, nausea, and vomiting. The usual dose of the drug is 0.5 to 2.0
milligrams per kilogram of body weight. It is supplied as an injectable containing 20
milligrams per milliliter of solution.

Section IV. CONVULSANTS (SPINAL CORD STIMULANTS)

10-8. INTRODUCTION

Some chemical substances can so stimulate the motor areas of the central
nervous system that a person's muscles begin to powerfully convulse (begin
uncontrollable violent contractions). Some natural and manmade chemicals are
capable of producing such reactions. For example, tetanospasmin, a chemical
produced by the bacteria Clostridium tetani, is such a natural agent. Strychnine, a
poison, once was used as a respiratory stimulant; however, its medicinal use has been
stopped because of its toxicity.

10-9. THERAPEUTIC USE OF CONVULSANTS

Drugs in this classification have little clinical usefulness. Some drugs in this
class have been used in the treatment of some types of psychotic agents.

Continue with Exercises

MD0804 10-6
EXERCISES, LESSON 10

INSTRUCTIONS: Answer the following exercises by marking the lettered response that
best answers the exercise, by completing the incomplete statement, or by writing the
answer in the space provided at the end of the exercise. After you have completed all
of the exercises, turn to "Solutions to Exercises" at the end of the lesson and check your
answers. For each exercise answered incorrectly, reread the material referenced with
the solution.

1. Select the category(ies) of central nervous system stimulants.

a. Cerebral agents.

b. Convulsants.

c. Analeptics.

d. All the above.

2. Select the pharmacological effect(s) associated with xanthine derivatives.

a. Bronchoconstriction.

b. Smooth muscle relaxation.

c. Enuresis.

d. All the above.

Match the generic names below with their corresponding trade names.

3. Diethylpropion hydrochloride_______________ a. Dopram®

4. Methyl phenidate b. Aminophylline®

5. Theophylline ethylenediamine c. Ritalin®

6. Theophylline d. Desoxyn®

7. Methamphetamine hydrochloride___________ e. Elixophylline®

8. Doxapram f. Cylert®

9. Pemoline g. Tenuate®

MD0804 10-7
 10. What is the clinical use of diethylpropion hydrochloride?

a. Used in the treatment of attention deficit hyperactivity disorder (ADHD).

b. Used to suppress a patient's appetite.

c. Used to treat a patient's anxiety.

d. Used to stimulate a patient's respiratory system.

11. Long-term use of phendimetrazine tartrate (Prelu-2®) may produce

_________________.

a. Nausea or vomiting.

b. Decreased metabolic rate.

c. Psychic dependence.

d. Insomnia.

12. What is the clinical use of dextroamphetamine sulfate (Dexedrine®)?

a. To suppress a patient's appetite.

b. To increase a patient's ability to concentrate.

c. To treat narcolepsy.

d. To stimulate respiration.

13. When taking Aminophylline orally, the patient should be cautioned

_____________________________.

a. Not to take the medication with alcohol.

b. Take the medication with food.

c. Discontinue the medication immediately if any slight nervousness is

detected.

d. Not to drive while taking the medication.

Check Your Answers on Next Page

MD0804 10-8
SOLUTIONS TO EXERCISES, LESSON 10

1. d All the above. (para 10-3a)

2. b Smooth muscle relaxation. (para 10-5a)

3. g Tenuate®. (para 10-5c(2))

4. c Ritalin®. (para 10-5b(1))

5. b Aminophylline. (para 10-5a(2))

6. e Elixophylline®. (para 10-5a(3))

7. d Desoxyn®. (para 10-5b(3))

8. a Dopram®. (para 10-7)

9. f Cylert®. (para 10-5c(1))

10. b Used to suppress a patient's appetite. (para 10-5c(2))

11. c Psychic dependence. (para 10-5c(3))

12. c To treat narcolepsy. (para 10-5b(2))

13. b Take the medication with food. (para 10-5a(2))

End of Lesson 10

MD0804 10-9
 LESSON ASSIGNMENT

LESSON 11 Narcotic Agents.

LESSON ASSIGNMENT Paragraphs 11-1--11-7

LESSON OBJECTIVES After completing this lesson, you should be able to:

11-1. Given a group of definitions, select the

definition of analgesia.

11-2. Given a group of pharmacological effects,

select those that are produced by narcotic
agents.

11-3. Given a group of definitions, select the

meaning of the following terms: dysphoria,
euphoria, tolerance, and miosis.

11-4. Given a general pharmacological effect

produced by the narcotics and a group of
statements, select the term that best describes
that effect.

11-5. Given several statements, select the statement

that best contrasts psychological and
physiological dependence.

11-6. Given a group of side effects, select those side

effects associated with the narcotic agents.

11-7. Given the trade and/or generic name of a

specific narcotic agent, and a list of uses,
side effects, or cautions and warnings, select
the use, side effect, or caution and warning
associated with that agent.

11-8. Given a group of cautions, select the caution

associated with the use of narcotic agents.

11-9. Given the name naloxone (Narcan®) and a

group of uses/indications, select the
use/indication associated with the drug.

MD0804 11-1
SUGGESTION After studying the assignment, complete the
exercises at the end of this lesson. These exercises
will help you to achieve the lesson objectives.

MD0804 11-2
 LESSON 11

NARCOTIC AGENTS

Section I. BACKGROUND

11-1. GENERAL COMMENTS

Most people have legally used narcotic agents. Conditions characterized by a

degree of discomfort (that is, pain, diarrhea, or cough), often are treated with
medications that have narcotics as the active ingredient. It is very important for all
medical personnel to be familiar with narcotic agents.

11-2. HISTORY OF NARCOTIC AGENTS

a. There is evidence that the opium poppy was used in Sumeria as early as
4000 B.C., and it is mentioned in the medical records of ancient Greece and Rome.
During the Dark Ages, it passed to the Arabs, who took it to China about 900 A.D. It
was either smoked or taken orally.

b. Opium was first used injectably around 1800; the U.S. Civil War saw the first
widespread use in this manner. Because of a lack of knowledge and caution, a
condition called “Soldier’s Disease” was described--addiction. This coupled with the
large influx of Chinese laborers who smoked, and the ready availability of opium caused
a great deal of concern. There were no packaging or distribution laws; indeed, a
children’s formulation was marketed called “Mrs. Winslow’s Soothing Syrup.” This
concern was an important factor in motivation for the Pure Food and Drug Act of 1906.

c. In 1805, a German Pharmacist’s assistant isolated a pure alkaloid (a basic

substance found usually in plant parts) from opium that he called morphine. It was
subsequently found that opium contains two general categories of alkaloids; narcotics
(phenanthrene) such as morphine and codeine, and nonnarcotics (benzylisoquinoline)

11-3. PHARMACOLOGICAL EFFECTS OF THE NARCOTICS

Narcotics produce pharmacological effects when administered to a patient.

Some of these effects are desirable, while others are undesirable. Always remember
that the legitimate use of these agents is implied in our discussion.

a. Analgesic Effect. Analgesia means relief of pain without the loss of

consciousness. Analgesia is the most common use of narcotics. Although the exact
mechanism of action by which narcotics act is unknown, it is thought that analgesia is
obtained by the action of these agents on the cerebral cortex. The relief of pain is
enhanced because narcotics raise a patient's pain threshold and thus produce a

MD0804 11-3
calming and soothing effect. Narcotic agents have particular application in the relief of
continuous, dull pain. Consequently, these drugs are widely used in patients who are
terminally ill.

b. Antitussive Effect. An antitussive agent acts to control or prevent cough.

Some narcotics will depress the cough center of the brain and produce this antitussive
effect. In general, the antitussive dose of a narcotic is lower than the analgesic dose of
that same drug. Before progressing, it should be noted that a narcotic is not indicated
for all types of coughs. Indeed, sometimes it is useful for a patient to cough in order to
remove substances from the lungs.

c. Mood Alteration Effect. Some narcotics will produce a mood alteration in

patients. The types of mood changes can be classified in two categories.

(1) Dysphoria. Dysphoria is a mood alteration characterized by feelings of

anxiety, fidgetiness, or being ill at ease.

(2) Euphoria. Euphoria is characterized by an exaggerated feeling of well-

being.

d. Gastrointestinal Effect. Narcotics produce some significant effects upon the

gastrointestinal system (that is, stomach and intestines). Some narcotics are used
specifically for their effect upon this system of the body.

(1) Decrease gastrointestinal motility. Narcotics decrease the peristaltic

(wavelike) movements of the gastrointestinal tract. Consequently, they may cause
constipation. This effect of narcotics is the basis of their being used to treat diarrhea.
When used to treat diarrhea, the agents are referred to as antidiarrheals.

(2) Stimulate the chemoreceptor trigger zone. The chemoreceptor trigger

zone (CTZ) is located at the base of the brain. When stimulated, the CTZ produces
nausea and vomiting. Like many other categories of drugs, narcotics can stimulate the
chemoreceptor trigger zone and cause nausea and vomiting.

e. Respiratory System Effect. Narcotics cause respiratory system depression

because they reduce the sensitivity of the medullary centers to carbon dioxide in the
blood. This depression of the respiratory system usually occurs at higher narcotic
doses.

11-4. SIDE EFFECTS OF NARCOTICS

Side effects are frequently seen with the use of narcotics. Some of these side
effects are characteristics of the narcotic agents.

MD0804 11-4
 a. Dependence. Dependence is a side effect of narcotics, which has caused
much concern among many health-care professionals. There are two types of
dependence.

(1) Psychological. Psychological dependence is produced when the drug

causes an emotional or mental desire to repeat the use of the drug. Consequently, the
individual taking the drug has a craving for the pleasurable mental effects produced by
the drug (that is, euphoria, and so forth).

(2) Physiological (physical). Physical dependence is produced by prolonged

use of a drug whose pharmacological action causes the body to adapt to its presence.
When the drug is withdrawn after the person has become physically dependent, the
body of the individual reacts in a hyperexcited way. You have probably read about or
seen heroin (narcotic) addicts who are undergoing withdrawal. These episodes of
withdrawal are characterized by stimulation of the central nervous system.

b. Tolerance. Tolerance is the body’s ability to adapt to the presence of a

foreign chemical substance (drug). This results in the requirement for progressively
larger doses of the drug in order to obtain the same effect in the patient. It should be
noted that tolerance is frequently seen in patients who abuse narcotics. Tolerance is
not of great concern in narcotic therapy of short duration. However, for those
chronically ill patients who are on long-term narcotic therapy, increased doses of the
narcotic agents might be indicated to maintain the desired level of analgesia.

c. Drowsiness. Drowsiness is another side effect of narcotics. For this reason,

individuals who are receiving narcotics should seriously examine their activities that is,
driving) for safety purposes.

d. Miosis. Miosis (constricted pupils) is an effect commonly known as “pinpoint”

pupils. Miosis is commonly seen in patients who are taking narcotic agents.

Section II. NARCOTIC AGENTS AND NARCOTIC ANTAGONISTS

11-5. SPECIFIC NARCOTIC AGENTS

a. Morphine. Morphine is the basis of the narcotic effect of opium and is the
standard by which other analgesics are judged. It is used in moderate to severe pain, is
the analgesic of choice for myocardial infarction, and is used to treat acute pulmonary
edema. Morphine is most frequently given IM or SC, 10-15 mg every 4 hours, or IV,
where 4-10 mg are diluted and given slowly over 4-5 minutes. It is used less frequently
by the oral route (1/15--1/6 the effectiveness of parenteral administration) in a dose of 8-
20 mg every 4 hours. The most common side effects associated with morphine are
drowsiness, nausea, and vomiting. Morphine is supplied as an injection containing 8,
10, and 15 milligrams per milliliter; in tablets of 10, 15, and 30 milligrams; and as an oral

MD0804 11-5
solution containing 10-milligrams per 5-milliliters. Morphine in all forms is a Note R
substance.

b. Codeine. Codeine is the second naturally occurring narcotic. Its use is very
widespread; in some states it can be sold without prescription in combination products if
its concentration is weak enough (ETH & codeine, Robitussin AC®). For our purposes,
however, when codeine is dispensed as a single agent, it is Note R, when in
combination, it is Note Q. Codeine is used as an antitussive, 5-15 mg every 4-6 hours,
and as an analgesic in mild to moderate pain, 30-60mg every 4-6 hours. Its most
common side effects include drowsiness, nausea/vomiting, and constipation; patients
must be cautioned about the drowsiness and the additive effect seen with concurrent
use of alcohol. Codeine is available as an injection of 15, 30, and 60 mg/ml, and in 15
and 30 mg tablets. A powder form for compounding is also available.

c. Hydromorphone (Dilaudid®). Hydromorphone (Dilaudid®) is a drug that was

obtained by chemical modification of morphine, used as an analgesic in moderate to
severe pain. It is frequently used in pain associated with cancer. Its usual dose is 2 mg
every 4 to 6 hours. Its major side effects are nausea and vomiting, dizziness, and
constipation. Although the manufacturer states that drowsiness occurs infrequently,
patients should be made aware of this possibility; also alcohol may intensify its effects.
Dilaudid® is a Note R drug and is supplied in tablet or injectable form, both in 1, 2, 3,
and 4 mg strengths.

d. Meperidine (Demerol®). Meperidine was the first synthetically produced

narcotic. It is one of the first widely used agents for moderate to severe pain. Usual
doses of this agent (50-150 mg every 3-4 hours) produce some drowsiness, nausea,
and vomiting. Patients who are prescribed meperidine should be cautioned that
drowsiness might occur. Further, they should be advised that alcohol might intensify
this drowsiness. Meperidine is a Note R drug, which is available as an injection (25, 50,
75, and 100 mg/ml), a tablet (50 or 100 mg tablets), and in a syrup (50 mg/5ml).

e. Fentanyl (Sublimaze®, Duragesic®, Oralet®, Actiq®). Fentanyl is a

synthetic agent with actions similar to morphine, but on a weight basis, Sublimaze® is
80-100 times more potent. It is used as an analgesic component in general anesthesia
or conscious sedation and given intramuscularly (IM) or intravenously (IV). The dosage
is dependent upon its intended role during anesthesia, and ranges from 0.025 to 0.1
mg. Respiratory depression is the side effect of concern for this agent. Fentanyl is
unique in that it is available as an injection (Sublimaze®), in a topical patch formulation
(Duragesic®), a lozenge (Fentanyl Oralet®) and a lozenge on a stick (“lollipop”) (Actiq®)
formulation. The latter three formulations are prescribed primarily for severe pain
conditions. Fentanyl is handled as a Note R product.

f. Methadone (Dolophine®). Methadone (Dolophine®) is a synthetic agent that

has been used as an analgesic for moderate to severe pain, and to treat withdrawal
symptoms of narcotics in a dose-tapering fashion. The usual dose for analgesia is 2.5-
10 mg every 4 hours, and common side effects include drowsiness and

MD0804 11-6
nausea/vomiting. The effects of methadone may be intensified by alcohol, and the
patient also should be cautioned about drowsiness. The injection, 10 mg/ml, and the
tablets, 5 and 10 mg, are all Note R.

g. Percodan®. Percodan® is a popular semisynthetic narcotic intended for the

relief of moderate pain that contains two salts of oxycodone, combined with aspirin. It
is, of course, a fixed combination and is given in a usual dose of one tablet every 6
hours. In addition to the side effects of drowsiness and nausea/vomiting, pruritis is also
a fairly frequent complaint. Patient cautionary statements regarding drowsiness and
alcohol apply to this agent. It is a Note R product even though it is a combination.
Percodan® is available in tablet form, and a half-strength product called Percodan-
Demi® is also produced.

NOTE: Combination products of acetaminophen with oxycodone are Tylox® and

Percocet®.

h. Combination Products. Codeine is combined with aspirin or acetaminophen

(Tylenol®) to produce products that are used to treat mild to moderate pain. Common
side effects of these combination products include nausea, vomiting, and drowsiness.
Patients who are taking these products should be cautioned about the drowsiness.
Further, patients should be warned against taking these with alcohol. These
combination products are handled as Note Q items.

(1) Empirin® with codeine. Empirin® with codeine is a combination of aspirin

and codeine. The usual dosage of these products is from one to two tablets every four
hours. The various products are numbered based upon the amount of codeine
contained in each product as noted below:

(a) Empirin® with Codeine #2 - 15 mg of codeine per tablet.

(b) Empirin® with Codeine #3 - 30 mg of codeine per tablet (most

widely used of these products).

(c) Empirin® with Codeine #4 - 60 mg of codeine per tablet.

(2) Tylenol® with codeine. Tylenol® with codeine is a combination

acetaminophen with codeine. The usual dosage of these products is from one to two
tablets every four hours. As with Empirin® with codeine, the products are numbered
based upon the amount of codeine contained in each tablet as noted below:

(a) Tylenol® with Codeine #1 - 7.5 mg of codeine per tablet.

(b) Tylenol® with Codeine #2 - 15 mg of codeine per tablet.

(c) Tylenol® with Codeine #3 - 30 mg of codeine per tablet (most

widely used of these products).

MD0804 11-7
 (d) Tylenol® with Codeine #4 - 60 mg of codeine per tablet.

11-6. CAUTIONS OF NARCOTIC USE

a. Narcotics should not be used in patients experiencing any form of respiratory

depression (that is, asthma).

b. Narcotics cause an increase in intracranial pressure (pressure within the

skull). Therefore, they should not be used in the presence of head injuries.

c. Narcotics should be used cautiously in combination with other drugs that

depress the central nervous system.

11-7. NARCOTIC ANTAGONISM

a. Explanation. As previously mentioned, narcotics depress the respiratory

system. Sometimes it is necessary to reverse this respiratory depression (that is,
overdose of narcotics) in order to save a patient’s life.

b. Naloxone (Narcan®). Naloxone (Narcan®) is the only true narcotic antagonist

in that it does not possess agonist or morphine-like properties and, most importantly, it
has no respiratory depressant action in therapeutic doses. Because it does not depress
respiration, naloxone is the drug of choice in the treatment of respiratory depression of
unknown causes, but which is suspected of being produced by a narcotic. Narcan® is
given in a usual dose of 0.4 mg IM, SC, or IV, and may produce some nausea and
vomiting. It is not a controlled substance, and is available as an injection, 0.4 mg/ml or
0.2 mg/ml for pediatric use.

c. Indications/Uses. Naloxone (Narcan®) is indicated/used to reverse

respiratory depression caused by natural and synthetic narcotics, pentazocine
(Talwin®), and propoxyphene (Darvon®). It is not effective against the respiratory
depression caused by the barbiturates or benzodiazepines. Naloxone is a competitive
antagonist.

Continue with Exercises

MD0804 11-8
EXERCISES, LESSON 11

INSTRUCTIONS: Answer the following exercises by marking the lettered response that
best answers the exercise, by completing the incomplete statement, or by writing the
answer in the space provided at the end of the exercise.

After you have completed all of the exercises, turn to “Solutions to Exercises” at
the end of the lesson and check your answers. For each exercise answered incorrectly,
reread the material referenced with the solution.

1. From the group of definitions below, select the meaning of the term analgesia.

a. The decrease in a patient’s pain threshold.

b. The relief of pain with loss of consciousness.

c. The relief of pain without the loss of consciousness.

d. The loss of consciousness with no effect on pain level.

2. From the group of pharmacological effects below, select the response that
contains those produced by narcotic agents.

(1) Relief of pain. (6) Depress respiratory rate.

(2) Antitussive. (7) Increase blood pressure.

(3) Antipyretic. (8) Increase respiratory rate.

(4) Decrease gastrointestinal (9) Decrease clotting time.

motility.
(10) Produce loss of
(5) Produce diarrhea. consciousness.

a. (1), (2), (3), (6) and (10).

b. (1), (2), (4) and (6).

c. (1), (2) and (5).

d. (1), (2), (4), (5), (6), (7) and (10).

MD0804 11-9
 3. From the group of definitions below, select the meaning of the term euphoria.

a. A mood alteration characterized by feelings of anxiety.

b. A mood alteration characterized by feelings of being ill at ease.

c. A mood alteration effect characterized by analgesia.

d. A mood alteration characterized by exaggerated feelings of well-being.

4. Narcotic agents produce an effect on a patient’s respiratory system. From the

list of descriptions below, select the best description of the specific effect produced by
the narcotic agents.

a. Narcotic agents stimulate a patient’s respiratory system.

b. Narcotic agents depress a patient’s respiratory system.

c. Narcotic agents decrease the levels of carbon dioxide in the blood.

d. Narcotic agents depress the respiratory rate only in small doses.

5. Narcotic agents produce an effect on a patient’s gastrointestinal system.

From the list of descriptions below, select the best description of that specific effect.

a. Narcotic agents stimulate the patient’s CTZ to produce nausea and

vomiting.

b. Narcotic agents stimulate the patient’s CTZ to produce diarrhea.

c. Narcotic agents stimulate the patient’s CTZ to produce constipation.

d. Narcotic agents stimulate the patient’s CTZ to produce peristalsis.

MD0804 11-10
 6. From the group of side effects below, select the response that contains the
side effects associated with the narcotic agents.

(1) Independence. (4) Miosis.

(2) Mitosis. (5) Dependence.

(3) Tolerance. (6) Drowsiness.

a. (1), (2), (3), (6).

b. (1), (3), (5), (6).

c. (3), (4), (5), (6).

d. (1), (2), (5), (6).

7. From the definitions below, select the best definition of the term tolerance.

a. The ability of the body to adapt to the presence of foreign substances that
result in the requirement for progressively larger doses of the drug to obtain the same
effect.

b. The ability of the body to adapt to the presence of foreign substances that
result in the requirement for progressively smaller doses of the drug to obtain the same
effect.

c. The ability of the body to adapt to the presence of foreign substances that
result in the requirement for changing the route of administration of the drug.

d. The ability of the body to adapt to the presence of foreign substances that
result in the requirement for changing the dosage form of the drug.

8. From the list of uses below, select the use of codeine.

a. Antitussive.

b. Antiemetic.

c. Antipyretic.

d. Sedative.

MD0804 11-11
 9. From the list of uses below, select the use of hydromorphone (Dilaudid®).

a. Analgesic for moderate to severe pain.

b. Analgesic for mild to moderate pain.

c. Antidiarrheal in severe diarrhea.

d. Emetic in poisoning.

10. From the list of cautions and warnings, select the caution and warning
associated with the use of meperidine hydrochloride (Demerol®).

a. The patient should be cautioned against taking aspirin with meperidine.

b. The patient should be warned that alcohol can intensify the drowsiness
caused by meperidine.

c. The patient should be warned against not taking the drug on a regular
basis.

d. The patient should be cautioned against exercise when taking the drug.

11. From the list of uses below, select the use associated with Methadone
(Dolophine®).

a. An agent used to treat withdrawal symptoms associated with narcotic

antagonists.

b. An agent used in the treatment of mild to moderate pain.

c. An agent used in the treatment of alcohol withdrawal symptoms.

d. An agent used in the treatment of the withdrawal symptoms associated

with narcotic agents.

MD0804 11-12
 12. From the group of cautions below, select the caution associated with the use
of narcotic agents.

a. Narcotics should not be administered to patients over the age of 65.

b. Narcotics should not be administered intravenously.

c. Narcotics should be used cautiously with drugs that depress the central
nervous system.

d. Narcotics should not be used by cardiac patients.

13. Select the use of Naloxone (Narcan®) from the list of uses below.

a. Narcotic.

b. Narcotic analgesic.

c. Narcotic suppressant.

d. Narcotic antagonist

Check Your Answers on Next Page

MD0804 11-13
SOLUTIONS TO EXERCISES, LESSON 11

1. c The relief of pain without the loss of consciousness. (para 11-3a)

2. b (1), (2), (4), and (6). (para 11-3a, b, d(1), and e)

3. d A mood alteration characterized by exaggerated feelings of well

being. (para 11-3c(2))

4. b Narcotic agents depress a patient's respiratory system.

(para 11-3e)

5. a Narcotic agents stimulate the patient's CTZ to produce nausea and

vomiting. (para 11-3d(2))

6. c (3), (4), (5), and (6). (para 11-4a, b, c, and d)

7. a The ability of the body to adapt to the presence of foreign

substances which results in the requirement for progressively larger
doses of the drug to obtain the same effect. (para 11-4b)

8. a Antitussive. (para 11-5b)

9. a Analgesic for moderate to severe pain. (para 11-5c)

10. b The patient should be warned that alcohol can intensify the
drowsiness caused by meperidine. (para 11-5d)

11. d An agent used in the treatment of the withdrawal symptoms associated

with narcotic agents. (para 11-5f)

12. c Narcotics should be used cautiously with drugs which depress the
central nervous system. (para 11-6c)

13. d Narcotic antagonist. (para 11-7b)

End of Lesson 11

MD0804 11-14
 ANNEX

DRUG PRONUNCIATION GUIDE

This Drug Pronunciation Guide was developed to help you to learn how the trade and
generic names of commonly prescribed medications are frequently pronounced. Not all
the drugs in the guide are discussed in this subcourse. Remember, it is not enough to
be able to know the uses, indications, cautions and warnings, and contraindications for
a drug--you must also know how to pronounce that drug’s name.

Trade Name Generic Name

Actifed (Ak’-ti-fed) Triprolidine (Tri-pro’-li-deen) and

Pseudoephedrine (Soo-do-e-fed’-rin)
Adapin (Ad’-a-pin) Doxepin (Dok’-se-pin)
Sinequan (Sin’-a-kwan) " "
Afrin (Af’-rin) Oxymetazoline (Ok-see-met-az’-o-leen)
Aldactazide (Al-dak’-ta-zide) Spironolactone (Spi-ro-no-lak’-tone) and
Hydrochlorothiazide
(Hy-dro-klor-thi‘-a-zide)
Aldactone (Al-dak’-tone) Spironolactone (Spi-ro-no-lak’-tone)
Aldomet (Al‘-do-met) Methyldopa (Meth-il-do’-pah)
Alupent (Al‘-u-pent) Metaproterenol (Met-a-pro-ter’-eh-nol)
Amoxil (Am-ok’-sil) Amoxicillin (Ah-moks’-i-sil-in)
Amphojel (Am’-fo-jel) Aluminum (Al-loo’-mi-num)
Hydroxide (Hy-drok’-side)
Ampicillin (Amp’-I-sil-in) Same
Antepar (Ab’-te-par) Piperazine (Pi-per’-ah-zeen)
Anturane (An’-tu-rain) Sulfinpyrazone (Sul-fin-pie’-ra-zone)
Anusol (An’-u-sol) Pramoxine (Pram-ok’-seen)
Apresoline (A-press’-o-leen) Hydralazine (Hy-dral’-ah-zeen)
Aralen (Ar’-a-len) Chloroquine (Klor’-o-kwin)
Aristocort (A-ris’-to-cort) Triamcinolone (Tri-am-sin’-o-lone)
Artane (Ar’-tane) Trihexyphenidyl(Tri-hek-see-fen’-i-dil)
A.S.A. Aspirin (As’-per-in)
Atromid S (A’-tro-mid) Clofibrate (Klo-fi’-brate)
Avlosulfon (Av-lo-sul’-fon) Dapsone (Dap’-sone)
Azolid (Az’-o-lid) Phenylbutazone (Fen-il-bute’-a-zone)

Bactrim (Bak’-trim) Sulfamethoxazole

(Sul-fah-meth-oks’-ah-zole) and
Trimethoprim (Tri-meth’-o-prim)
Bellergal (Bel‘-er-gal) Ergotamine (Er-got’-a-meen),
Phenobarbital (Feen-o-bar’-bi-tal) and
Belladonna (Bel-la-don’-na) Alkaloids
Benadryl (Ben’-a-dril) Diphenhydramine (Di-fen-hy’-dra-meen)

MD0804 A-1
Trade Name Generic Name

Bendectin (Ben-dek’-tin) Doxylamine (Dok-sil‘-a-meen)

Benemid (Ben’-eh-mid) Probenecid (Pro-ben’-eh-sid)
Bonine (Bo’-neen) Meclizine (Mek’-li-zeen)

Cafergot (Kaf’-er-got) Ergotamine (Er-got’-a-meen) and

Caffeine (Kaf’-feen)
Calamine (Kal’-a-mine) Same
Catapres (Kat’-a-press) Clonidine (Klo’-ni-deen)
CeeNu (See’-new) Lomustine (Lo-mus’-teen)
Chlor-Trimeton (Klo-tri ‘-meh-ton) Chlorpheniramine (Klor-fen-it’-a-meen)
Clomid (Klo’-mid) Clomiphene (Klo’-mi-feen)
Clonopin (Klo-o-pin) Clonazepam (Klo-na’-ze-pam)
Codeine (Ko’-deen) Same
Cogentin (Ko-jen’-tin) Benztropine (Benz’-tro-peen)
Colace (Ko’-lace) Dioctyl(Di-ok’-til) Sodium (So’-dee-um)
Sulfosuccinate (Sul-fo-suk’-si-nate)
Colchicine (Kol’-chi-seen) Same
Compazine (Kom’-pa-zeen) Prochiorperazine (Pro-klor-per’-a-zeen)
Cordran (Kor’-dran) Flurandrenolide (Floor-an-dren’-o-lide)
Coumadin (Koo’-mah-din) Warfarin (War’-fah-rin)
CP Cloroquine (Klor’-o-kwin) and
Primaquine (Prim’-a-kwin)
Cyclogyl (Si‘-klo-jel) Cyclopentolate (Si-klo-pen’-to-late)
Cytomel (Si‘-to-mel) Liothyronine (Li-o-thy-ro-neen)
Cytoxan (Si-tok’-san) Cyclophosphamide (Si-klo-fos’-fa-mide)

Dalmane (Dal ‘-mane) Flurazepam (Floor-az’-e-pam)

Darvocet (Dar’-vo-set) Propoxyphene (Pro-pok’-se-feen) and
Acetaminopen (As-et-am’-ino-fen)
Darvon (Dar’-von) Propoxyphene (Pro-pok-se-feen)
Decadron (Dek’-a-dron) Dexamethasone (Dek-sa-meth’-ah-
sone)
Deltasone (Del ‘-ta-sone) Prednisone (Pred’-ni-sone)
Demerol (Dem’-er-ol) Meperidine (Meh-pair’-i-deen)
Dexedrine (Deks ‘-eh-dreen) Dextroamphetamine
(Deks-tro-am-fet'-a-meen)
Diabinese (Di-ab’-i-nees) Chlorpropamide (Klor-prop’-a-mide)
Diethylstilbestrol (Di-eth-il-stil-bes'-trol) Same
Dilantin (Di-lan’-tin) Phenytoin (Fen’-i-toin)
Dilaudid (Di-law’-did) Hydromorphone (Hy-dro-more’ -fon)
Dimetane (Di‘-meh-tane) Brompheniramine (Brom-fen-ir’-a-meen)

MD0804 A-2
Trade Name Generic Name

Dimetapp (Di‘-meh-tap) Brompheniramine (Brom-fen-ir’-a-meen)

Phenylephrine (Fen-il-ef’-rin) and
Phenylpropanolamine
(Fen-il-pro-pan-ol‘-a-meen)
Disophrol (Dice’-o-frol) Dexbrompheniramine
(Deks-brom-fen-ir‘-a-meen) and
Pseudoephedrine (Soo-do-e-fed‘-rin)
Dolophine (Dol‘-o-feen) Methadone (Meth’-a-done)
Domeboro (Dome-bor’-o) Aluminum (Ah-loo’-mi-num)
Acetate (As‘-e-tate)
Donnatal (Don’-na-tal) Belladonna (Bel-la-don’-na)
Alkaloids (Al’-ka-loids) and
Phenobarbital (Feen-o-barb’-i-tal)
Doxidan (Dok’-si-dan) Danthron (Dan’-thron) and Dicctyl
(Di-ok’-til) Calcium (Kal‘-see-um)
Sulfosuccinate (Sul-fo-suk’-si-nate)
Drixoral (Driks’-or-al) Dexbrompheniramine
(Deks-brom-fen-ir’-a-meen) and
Pseudoephedrine (Soo-do-e-fed‘-rin)
Dulcolax (Dul’-ko-laks) Bisacodyl (Bis-a’-ko-dil)
Dyazine (Di’-a-zide) Triamterene (Tri-am’-ter-een) and
Hydrochlorothiazide
(Hy-dro-klor-o-thi‘-a-zide)
Dymelor (Die’-meh-lor) Acetohexamide (As-e-to-heks’-a-mide)
Dyrenium (Die-ren’-i-um) Triamterene (Tri-am’-ter-een)

Efudex (Ef'-u-deks) Fluorouracil (Floo-ro-ur’-ah-sil)

Elavil (El’-ah-vil) Amitriptyline (Am-i-trip’-til-een)
Elixir Terpin (Ter’-pin) Hydrate Same
Empirin (Em’-per-in) Codeine (Ko’-deen) and
Aspirin (As’-per-in)
E-Mycin (E-mie’-sin) Erythromycin (E-rith-ro-mie’-sin)
Equanil (Ek’-wa-nil) Meprobamate (Me-pro-bam’-ate)
Ergomar (Er’-go-mar) Ergotamine (Er-got’-a-meen)
Ergotrate (Er’-go-trate) Ergonovine (Er-go-no’-veen)
Erythrocin (Er-eeth’-ro-sin) Erythromycin (Er-eeth-ro-my’-sin)
Stearate (Stare’-rate)
Esidrix (Es’-i-driks) Hyrochlorothiazide
(Hy-dro-klor-o-thi‘-a-zide)
Feosol (Fe’-o-sol) Ferrous (Fer’-rus) Sulfate (Sul’-fate)
Fergon (Fer’-gon) Ferrous (Fer’-rus)
Gluconate (Glu'-con-ate)

MD0804 A-3
Trade Name Generic Name

Fiorinal (Fee-or’-i-nal) Butalbi tal (Bu-tal‘-bi-tal), Apririn,

Phenacetin (Fen-ass’-eh-tin), and
Caffeine (Kaf’-feen)
Flagyl (Fla’-jil) Metronidazole (Me-tro-ni‘-dah-zole)
Flexeril (Flek’-sa-ril) Cyclobenzaprine (Si-klo-benz’-a-preen)
Fulvicin (Ful’-vi-sin) Griseofulvin (Griz-e-o-ful’-vin)

Guantanol (Gan’-ta-nol) Suiphamethoxazole

(Sul-fah-meth-oks’-ah-zole)
Gantrisin (Gan’-tri-sin) Sulfisoxazole (Sul-fi-sok’-sah-zole)
Gelusil (Jel’-u-sil) Aluminum (Ah-loo’-mi-num) Hydroxide
(Hy-drok’-side) and Magnesium
(Mag-nee’-zee-um) Hydroxide
Grifulvin (Gri-ful’-vin) Griseofulvin (Griz-e-o-ful’-vin)
Gynergen (Jin’-er-jen) Ergotamine (Er-got’-a-meen)

Haldol (Hal‘-dol) Haloperidol (Hal-o-pair’-i-dol)

Halotestin (Hal-o-tes’-tin) Fluoxymesterone
(Floo-ok-see-mes-teh-rone)
Hexadrol (Hek’-sa-drol) Dexamethasone (Dek-sa-meth’-a-sone)
Hydrodiuril (Hy-dro-di‘-ur-il) Hydroclorothiazide
(Hy-dro-kior-thi'-a-zide)
Hygroton (Hy-grow’-ton) Chiorthalidone (Kior-thal‘-i-done)

Ilosone (I’-low-sone) Erythromycin (Er-ith-ro-mi’-sin)

Estolate (Es’-to-late)
Inderal (In’-der-al) Propranolol (Pro-pran’-o-lol)
Indocin (In‘-do-sin) Indomethacin (In-do-meth‘-a-sin)
INH Isoniazid (I-so-ni’-a-zid)
Insulin (In’-sul-in) Same
Intal Cromolyn (Kro’-mo-lin)
Ismelin (Is’-meh-lin) Guanethidine (Gwan-eth’-i-dine)
Isopto-Atropine (I-sop-to-at’-ro-peen) Atropine (At’-ro-peen)
Isopto-Carpine (I-sop-to-car’-peen) Pilocarpine (Pile-o-car’-peen)
Isordil (I’-sor-dil) Isosorbide (I-so-sor’-bide)

Keflex (Kef’-lex) Cephalexin (Sef-ah-lek’-sin)

Lanoxin (Lan-ok’-sin) Digoxin (Di-jok’-sin)
Larodopa (Lar-o-do’-pa) Levodopa (Le-o-do’-pa)
Larotid (Lar’-o-tid) Amoxicillin (Ah-moks’-i-sil-in)
Lasix (La’-siks) Furosemide (Fu-ro’-se-mide)
Leukeran (Lu’-ker-an) Chlorambucil (Klor-ram’-bu-sil)
Librium (Lib’-ree-um) Chlordiazepoxide
(Klor-die-az-eh-pok’-side)

MD0804 A-4
Trade Name Generic Name

Lidex (Lie’-deks) Fluocinoide (Floo-o-sin’-o-nide)

Lomotil (Lo’-mo-til) Diphenoxylate (Die-fen-ok’-si-late)
Lopressor (Lo’-pres-sor) Metoprolol (Met-o-pro’-lol)
Lotrimin (Lo’-tri-min) Chlotrimazole (Klo-trim’-ah-zole)

Maalox (May’-loks) Aluminum (Ah-loo’-mi-num) and

Magnesium (Mag-nee’-zee-um)
Hydroxides
Macrodanton (Ma-kro-dan’-tin) Nitrofurantoin (Ni-tro-fur-an’-toin)
Mandelamine (Man-del‘-a-meen) Methenamine (Meth-en’-a-meen)
Mandelate (Man‘-deh-late)
Medihaler-Iso (Med-i-hail-er-I’-so) Isoproterenol (I-so-pro-ter’-en-ol)
Mellaril (Mel’-la-ril) Thioridazine (Thi-o-rid’-a-zeen)
Metamucil (Met-a-mu’-sil) Psyllium (Sil‘-e-um)
Metaprel (Meh‘-ta-prel) Metaproterenol (Meh‘-ta-pro-ter’-eh-nol)
Methotrexate (Meth-o-treks‘-ate) Amethopterin (Ah-meth-op’-ter-in)
Milk of Magnesia Same
Minipress (Min’-i-press) Prazosin (Pra’-zo-sin)
Minocin (Min’-o-sin) Minocycline (Mi-no-si’-kleen)
Monistat (Mon’-i-stat) Miconazole (Mi-kon’-ah-zole)
Motrin (Mo’-trin) Ibuprofen (I-bu’-pro-fen)
Myambutol (My-am’-bu-tol) Ethambutol (Eth-am’-bu-tol)
Mycostatin (My-co-stat’-in) Nystatin (Ny-stat’-in)
Mylanta (My-lan’-ta) Aluminum (Ah-loo’-mi-num) and
Magnesium (Mag-nee’-zee-um)
Hydroxides and Simethicone
(Si-meth‘-i-kone)
Myleran (My-ler-an) Busulfan (Bu-sul‘-fan)
Mylicon (My’-li-kon) Simethicone (Si-meth’-i-kone)
Mysoline (My’-so-leen) Primidone (Pri’-mi-done)

Nalfon (Nal‘-fon) Fenoprofen (Fen-o-pro’-fen)

Naprosyn (Na’-pro-sin) Naproxen (Na-prok’-sen)
Nembutal (Nem’-bu-tal) Pentobarbital (Pen-to-barb’-i-tal)
Neosynephrine (Nee-o-sin-eh’-frin) Phenylephrine (Fen-il-eh’-frin)
Nitrobid (Ni’-tro-bid) Nitroglycerin (Ni-tro-gli’-ser-in)
Nitrol (Ni’-trol) “ "
Nitrostat (Ni-tro-stat) “ "
Noctec (Nok’-tek) Chloral Hydrate (Klor’-al- Hy’-drate)
Norfiex (Nor’-fleks) Orphenadrine Citrate (Or-fen’-a-dreen)
Norpace (Nor’-pace) Disopyramide (Di-so-peer’-a-mide)

MD0804 A-5
Trade Name Generic Name

Novahistine (No-va-his’-teen) Expectorant Guaifenesin (Gwi-fen’-eh-sin),

Phenylpropanolamine
(Fen-il-pro-pan-ol’-a-meen), and
Codeine (Ko’-deen)
NTG Nitroclycerin (Ni-tro-gli‘-ser-in)
Nupercainal (New-per-kain’-al) Dibucaine (Die’-bu-kain)

Oretic (O-ret’-ik) Hydrochiorothiazide

(Hy-dro-kior-thi‘-a-zide)
Orinase (Or’-in-ase) Tolbutamide (Tol-bu’-tah-mide)
Ornade (Or’-nade) Chlorpheniramine (Klor-fen-ir’-a-meen),
Triprolidine (Tri-pro-li-deen) and
Pseudoephedrine (Su-do-eh-fed’-rin)

Parafon Forte (Pair’-a-fon For’-tay) Chlorzoxazone (Klor-zok‘-sa-zone)

Percodan (Per’-ko-dan) Oxycodone (Ok-si-ko’-done)
Periactin (Per-ee-ak’-tin) Cyproheptadine (Si-pro-hep’-tah-deen)
Persantine (Per-san’-teen) Dipyridamole (Di-pi-rid’-ah-mole)
Phenobarbital (Feen-o-barb’-it-al) Same
Phenylpropanolamine Same
(Fen-il-pro-pan-ol‘-a-meen)
Pitocin (Pi-tow’-sin) Oxytocin (Ok-see-tow’-sin)
Pontocaine (Pon’-to-kain) Tetracaine (Teh’-tra-kain)
Povan (Po’-van) Pyrvinium (Pire-vin’-ee-um)
Premarin (Prem’-ar-in) Conjugated (Kon’-joo-gay-ted)
Estrogens (Es-tro-jens)
Presamine (Press’-a-meen) Imipramine (Im-ip’-rah-meen)
Primaquine (Pri‘-mah-kwin) Same
Probanthine (Pro-ban’-theen) Propantheline (Pro-pan’-the-leen)
Pronestyl (Pro-nes’-til) Procainamide (Pro-kain’-a-mide)
Prophylthiouracil (Pro-pil-thi-o-u’-rah-sil) Same
Prostaphlin (Pro-staff’-lin) Oxacillin (Oks’-ah-sil-in)
Provera (Pro-ver’-ah) Medroxyprogesterone
(Med-rok-see-pro-jes’-ter-one)
Pyridium (Pie-rid’-ee-um) Phenazopyridine
(Fen-ahs-o-per’-i-deen)

Quinidine (Kwin’-i-deen) Same

Quinine (Kwie’-nine) Same

Reserpine (Ree-ser’-peen) Same

Retin A (Reh’-tin A) Tretinoin (Tret’-i-noin)
Rifadin (Rie-fad’-in) Rifampin (Rie-fam’-pin)
Riopan (Rie’-o-pan) Magaidrate (Mag’-al-drate)

MD0804 A-6
Trade Name Generic Name

Rimactane (Rim-act’-ane) Rifampin (Rie-fam’-pin)

Ritalin (Rit’-a-lin) Methylphenidate (Meth-il-fen’-i-date)
Robaxin (Ro-bak’-sin) Methocarbamol (Meth-o-kar’-ba-mol)
Robitussin (Row-i-tus’-sin) Guaifenesin (Gwie-fen’-eh-sin)
Robitussin DM Guiafenesin and Dextromethorphan
(Dek-tro-meh-or’-fan)

Sansert (San’-sert) Methysergide (Meth-ee-ser’-jide)

Seconal (Sek’-o-nal) Secobarbital (Sek-o-bar’-bi-tal)
Selsun (Sel’-sun) Selenium (Se-leh’-nee-um)
Septra (Sep’-tra) Sulfamethoxazole
(Sul-fah-meth-oks’-a-zole) and
Trimethroprim (Tri-meth’-o-prim)
Serax (See’-raks) Oxazepam (Oks-az’-eh-pam)
Silvadene (Sil’-va-deen) Silver Sulfadiazine (Sul-fa-die’-a-zeen)
Sinemet (Si‘-ne-met) Levodopa (Le-vo-do’-pa)
Sinequan (Sin’-a-kwan) Doxepin (Dok’-seh-pin)
Sorbitrate (Sor’-bi-trate) Isosorbide (I-so-sor’-bide)
Stelazine (Stel‘-a-zeen) Trifluoperazine(Tri-floo-o-per’-a-zeen)
Sudafed (Soo’-da-fed) Pseudophedrine (Soo-do-eh-feh’-drin)
Sulamyd (Sul‘-a-mid) Sulfacetamide (Sul-fah-set’-a-mide)
Sulfamylon (Sul-fa-mie’-lon) Mafenide (Maf’-eh-nide)
Sultrin (Sul’-trin) Sulfathiazole (Sul-fah-thi‘-ah-zole)
Sulfacetamide (Sul-fah-set’-ah-mide)
and Sulfabenzamide
(Sul-fah-benz’-ah-mide)
Surfak (Sur’-fak) Dioctyl (Di-ok’-til) Calcium (Kal’-see-um)
Sulfosuccinate (Sul-fo-suk’-si-nate)
Synalar (Sine’-a-lar) Fluocinolone (Floo-o-sin’-o-lone)
Synthroid (Sin’-throid) Levothyroxine (Lee-vo-thi-rok’-sin)

Tace (Tace) Chlorotrianisene (Klor-o-tri-an‘-I-seen)

Tagamet (Tag’-a-met) Cimetidine (Si-met’-i-deen)
Talwin (Tal‘-win) Pentazocine (Pen-taz’-o-seen)
Tandearil (Tan’-da-ril) Oxyphenbutazone
(Ok-see-fen-bute’-a-zone)
Tegretol (Teg’-reh-tol) Carbamazepine (Kar-ba-maz’-eh-peen)
Tessalon (Tess’-a-lon) Benzonatate (Benz-on’-a-tate)
Tetracycline (Tet-ra-si‘-kleen)
Thorazine (Thor’-a-zeen) Chlorpromazine (Klor-pro’-ma-zeen)
Thyroid (Thy’-roid) Same
Tigan (Tie’-gan) Trimethobenzamide (Tri-meth-o-benz’-
a-mide)
Timoptic (Tim-op’-tic) Timilol (Tim’-o-lol)

MD0804 A-7
Trade Name Generic Name

Tinactin (Tin-act’-in) Tolnaftate (Tol-naf’-tate)

Titralac (Ti’-tra-lak) Calcium (Kal-see-um) Carbonate
(Kar’-bon-ate) and Glycine (Gly’-seen)
Tofranil (Toe’-fra-nil) Imipramine (I-mip’-rah-meen)
Tolectin (Tow-lek’-tin) Tolmetin (Tol-met’-in)
Triavil (Tri’-a-vil) Perphenazine (Per-fen’-a-zeen) and
Amitriptlyline (Am-i-trip’-ti-leen)
Trilafon (Try’-la-fon) Perphenazine (Per-fen-a-zeen)
Tylenol (Tie’-leh-nol) Acetaminophen (As-et-am’-ino-fen)
Tylenol #3 Acetaminophen and Codeine (Ko’-deen)

Unipen (U’-ni-pen) Nafcillin (Naf-sil-lin)

Urecholine (Ur-eh-ko’-leen) Bethanecol (Beth-an’-eh-kol)

Valisone (Val‘-i-sone) Betamethasone (Beh-tah-meth’-a-sone)

Valium (Val’-ee-um) Diazepam (Die-aze-eh-pam)
Vermox (Ver’-moks) Mebendazole (Meh-ben’-dah-zole)
Vibramycin (Vie-bra-my’-sin) Doxycycline (Doks-see-si‘-kleen)

Xylocaine (Zie’-low-kain) Lidocaine (Lie-do-kain)

Zarontin (Zar-on’-tin) Ethosuximide (Eh-tho-suks’-a-mide)

Zyloprim (Zie’-low-prim) Allopurinol (Al-lo-pure'-in-ol)

MD0804 A-8
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SUBCOURSE MD0804 Pharmacology I EDITION 100

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