Hemoglobin electrophoresis/1 This causes the red cells to be highly sensitive to 11 mentax 15mg lowest price. Hgb A: 40% Hgb S: 35% Hgb F: 5% leukocytes and platelets cheap mentax 15mg overnight delivery, as well as in red cells purchase 15mg mentax mastercard. Hgb A: 60% Hgb S: 40% Hgb A2: 2% is characterized by recurrent, episodic intravascular C. Hgb A: 80% Hgb S: 10% Hgb A2: 10% Hematology/Evaluate laboratory data to recognize health and disease/Special tests/Electrophoresis/2 12. Sickle cell disease Hematology/Apply knowledge of fundamental biological characteristics/Anemia/Hemoglobinopathy/1 1. In the Special tests/2 classic Donath–Landsteiner test, hemolysis is demonstrated in a sample placed at 4°C that is 16. Anti-P During intravascular hemolysis, the red cells rupture, releasing hemoglobin directly into the bloodstream. Hematology/Apply knowledge of fundamental Haptoglobin is a protein that binds to free Hgb. As haptoglobin is depleted, intravascular hemolysis except: unbound hemoglobin dimers appear in the plasma A. Beyond this Hematology/Correlate clinical and laboratory data/ level, free hemoglobin appears in the urine Anemia/Hemolytic/2 (hemoglobinuria). Increased levels of plasma C3 hemolytic anemia and result in an increased osmotic B. Te morphological classification of anemias is Answers to Questions 20–25 based on which of the following? Reticulocyte count the mechanism; and clinically, based upon an assessment of symptoms. C Aplastic anemia has many causes, such as chemical, drug, or radiation poisoning; congenital aplasia; 21. D Microangiopathic hemolytic anemia is a condition characterized by: resulting from shear stress to the erythrocytes. Bizarre multinucleated erythroblasts strands are laid down within the microcirculation, B. D Chloramphenicol is the drug most often implicated biological characteristics/Anemia/Characteristics/2 in acquired aplastic anemia. Penicillin, tetracycline, and characterized by: sulfonamides have been implicated in a small A. Which antibiotic(s) is (are) most often implicated in the development of aplastic anemia? Chloramphenicol Hematology/Correlate clinical and laboratory data/ Aplastic anemia/1 25. Which of the following conditions may produce Answers to Questions 26–30 spherocytes in a peripheral smear? Second, they are produced when the Hematology/Evaluate laboratory data to recognize cell surface-to-volume ratio is decreased, as seen in health and disease states/Morphology/2 hereditary spherocytosis. In addition to a the spleen, the antibodies and portions of the red decreased Hgb and decreased Hct values, what cell membrane are removed by macrophages. D Reticulocytes are polychromatophilic macrocytes, Hematology/Correlate clinical laboratory data/ and the presence of reticulocytes indicates red cell Inclusions/1 regeneration. Reticulocytosis usually indicates: response to anemia is to deliver red cells prematurely A. Bite cells Hematology/Evaluate laboratory data to recognize health and disease states/Red cell membrane/2 1. Storage iron is usually best determined by: thalassemia major would most likely be: A. Decreased after incubation at 37°C Hematology/Apply knowledge of basic laboratory Hematology/Correlate clinical and laboratory data/ procedures/Iron/1 Microscopic morphology/Osmotic fragility/1 Answers to Questions 1–6 2. All of the following are characteristic findings in a patient with iron deficiency anemia except: 1. Microcytic, hypochromic red cell morphology target cells are present and have increased surface B. The serum iron and Hematology/Correlate clinical and laboratory data/ ferritin levels are decreased. D In iron deficiency anemia, the serum iron and ferritin anemia of chronic infection by: levels are decreased and the total iron-binding A. Which anemia has red cell morphology similar to classified as microcytic, hypochromic anemias. Decreased plasma iron, decreased % saturation, associated with iron deficiency anemia. All of the following are associated with Answers to Questions 7–12 sideroblastic anemia except: A. What is the basic hematological defect seen in of the β-chain, resulting in severely depressed or patients with thalassemia major? D Patients with thalassemia major are unable to biological characteristics/Hemoglobinopathy/1 synthesize the β-chain; hence, little or no Hgb A is produced. Which of the following is the primary Hgb in synthesized and lead to variable elevations of Hgb F patients with thalassemia major? This Hgb is elevated in β-thalassemia minor is the morphological classification of this anemia? B Thirty to fifty percent of the individuals with the Hematology/Evaluate laboratory data to recognize anemia of chronic inflammation demonstrate a health and disease states/Hemoglobinopathy/ microcytic hypochromic blood picture with Characteristics/3 decreased serum iron. In which of the following conditions is Hgb A2 be delivered to the nucleated red cells in the bone elevated? Which of the following parameters may be similar for the anemia of inflammation and iron deficiency anemia? Pappenheimer bodies Hematology/Correlate laboratory data to recognize health and disease states/2 1. Which morphological classification is Answers to Questions 1–5 characteristic of megaloblastic anemia? Which anemia is characterized by a lack of and the macrocytosis in the peripheral blood. Pernicious anemia ineffective erythropoiesis and therefore a decrease Hematology/Evaluate laboratory data to recognize in the reticulocyte count. All of the following are characteristics of B12 deficiency will improve the hematological megaloblastic anemia except: abnormalities; however, the neurological problems A. Macrocytic erythrocyte indices of erythroid precursor cells prior to their release from Hematology/Correlate clinical and laboratory data/ the bone marrow. A patient with a vitamin B12 anemia is given a them more liable to intramedullary destruction. Toxicity of the liver and kidneys Hematology/Select course of action/Anemia/Terapy/3 5. A 50-year-old patient is suffering from pernicious Answers to Questions 6–10 anemia. Anemias/2 Consequently, the red cells are larger or more macrocytic than normal red cells. Which of the following may be seen in the peripheral blood smear of a patient with 8. Hematology/Apply principles of basic laboratory procedures/Microscopic morphology/Differentials/2 9. Which of the following are most characteristic of the red cell indices associated with megaloblastic anemias? Increased red blood cell count Hematology/Correlate clinical and laboratory data/ Megaloblastic anemia/2 1. Which of the following is an unusual complication Answers to Questions 1–5 that may occur in infectious mononucleosis? Which of the following is contained in the primary 1-year-old child is 61% compared to the mean granules of the neutrophil? What is the typical range of relative lymphocyte percentage in the peripheral blood smear of a 1-year-old child? Qualitative and quantitative neutrophil changes Answers to Questions 6–10 noted in response to infection include all of the following except: 6. A Neutropenia is defined as an absolute decrease in the absolute neutrophil counts?

Blood Products Transfusion of blood products exposes the recipient to a number of risks buy generic mentax 15mg on line, minimized by stringent blood bank protocols buy mentax 15mg visa, but it is indicated for a number of reasons discussed in this section buy generic mentax 15 mg line. Risks include febrile reactions, allergic reactions, hemolytic reactions, and infectious com- plications. Hemolytic reactions may be severe and potentially fatal if the amount of infused blood is large. Thus, any suspicion of a possible transfusion reaction must result in an immediate cessation of blood product infusion and in further workup to delineate the type of reaction. A significant degree of public anxiety is directed at the possibility of blood-borne infection. Realistically, the risk of transmitting various blood-borne infections is low with current antigen screening. Whole blood is available, but component blood products allow treatment for specific deficiencies without volume overload. Compo- nent therapy also avoids the use of scarce blood fractions that might not be needed in the specific circumstance. Posttransfu- sion hemoglobin and hematocrit levels that do not increase appropri- ately may indicate ongoing, possibly occult, blood loss. In a critically ill patient, a hematocrit of about 30% to 35% is desired for optimal oxygen-carrying capacity and oxygen delivery. Fresh frozen plasma contains clotting factors, fibrinogen, and other plasma proteins. Surgical Bleeding and Hemostasis 147 trates are given when thrombocytopenia exists in the setting of bleed- ing or when platelet dysfunction exists even in the presence of a normal platelet count (in patients with renal failure or post–cardiopulmonary bypass). Each “pack” in the 10-pack consists of 1cc of cryoprecipitate diluted with some saline. Hematologic consultation can greatly assist in the manage- ment of these complex patients. Therefore, empiric calcium supplementa- tion with 1g of calcium gluconate or 1g of calcium chloride is indicated in patients with large-volume transfusions or with low calcium levels. Case Management and Conclusion Upon hearing the nurse’s concerns regarding the incisional bleeding of the patient in our case, you immediately go to the patient’s bedside to assess her. You find the above-stated vital signs, including a respira- tory rate of 25, oxygen saturation of 95%, and a large puddle of bright blood in her bed. You first talk with her and establish her level of con- sciousness and airway/breathing. The groin incision is continuously draining blood during this time period; a pressure dressing is placed. However, over the next 30 minutes, the patient soaks the pressure dressing, has had minimal urine output, and has a blood pressure of 110/60. You also tell him that you think this is surgical bleeding and that the patient needs to return to the operating room for a repair. Summary An understanding of the processes of hemostasis and thrombosis is necessary for every surgical procedure. There are a large number of biochemical events that occur in response to endothelial injury that result in the formation of a fibrin clot. Clinical bleeding may result from a defect or deficiency in any of these events or from technical error. An understanding of the specific history and physiology of a particular patient and of the intraoperative details is necessary to diagnose the etiology of postoperative bleeding. In the case discussed in this chapter, because of the large amount of bright red blood, the attending surgeon is concerned about a technical error that mandates a second trip to the operating room. The treating physician must be aware of the risks, benefits, and indications of the various treatments for postoperative bleeding. Clinical manifestations and therapy of inherited coag- ulation factor deficiencies. To consider the four fundamental moral principles of bioethics in developing an approach to the practice of surgery. To develop an approach to resolving ethical dilem- mas encountered in the practice of surgery. To be aware of personal beliefs that inform the surgeon’s personal approach to providing care for patients. Case You are a medical student in the second week of your required surgery clerkship. Before admission, he was remarkably healthy and independent, with no chronic or acute disease. Recently, they successfully treated a 94-year-old in similar circumstances who had a complete recovery. Braun alive until the birth of his first great-grandchild, expected in several weeks. On admission, the patient stated that he has a living will, but it has not been provided for the medical record. The core issues to be addressed are: • Who is responsible for determining this patient’s resuscitation status? Introduction The curriculum of medical students in their surgical clerkship focuses on pathophysiology and the mechanics of treatment. At first, bioethics seems a peripheral issue, outside the core curriculum of required clin- ical clerkships. Of necessity, students must focus on mastering the basics of medicine and on acquiring the techniques and skills that will allow them to function as physicians. The subtlety of the daily practice of bioethics is not always apparent to the novice practitioner. Out- standing physicians incorporate bioethics into their practice flawlessly, making it a regular part of their daily work by being aware of how bioethics is part of routine care. For others, the awareness of the ele- mental contribution of bioethics to the routine practice of medicine may come only when its absence has resulted in a crisis. By analogy, human genomics can illustrate the role of bioethics in the practice of surgery. Components of the genome provide the code maintaining basic physiologic processes. The complex conversion from this code to the normal processes of the human body may continue seamlessly and unabated for years. Mutations are monitored and usually well contained by the body’s immunologic surveillance. When mutations develop that cannot be contained, the system breaks down, and this may result in disability or death. In a similar way, bioethical principles guide the process of medical decision making. Truth telling, informed consent, autonomy, profes- sionalism, competence, and confidentiality are bioethical principles that are inherent in every physician–patient interaction. For the skilled physician, these principles are applied effortlessly and provide the foundation for interacting with colleagues, applying biomedical science at the bedside, and maintaining the academic mission of the medical school. Occasional, minor lapses in the application of bioethics may have little impact, but repeated or egregious lapses in the practice of bioethics may result in a breakdown of the system or a crisis that is not resolved easily. The physician must attempt to understand the patient’s values and to determine issues relevant to the patient when making decisions about the patient’s healthcare. Failure to take these steps may adversely affect patient outcome and can harm the physician–patient relationship, possibly leading to legal actions against the physician. The core objective of this chapter is to show the relevance of bioethics to the practice of surgery. Although the application of ethical principles acquired during the career of a skilled physician cannot be conveyed in a brief chapter, basic principles of bioethics are presented so that the student can recognize and respond when challenged with bioethical dilemmas in the clinics and on the ward. Bioethical Principles and Clinical Decision Making 151 Frame the question Identify the principles involved Principle 1: Autonomy Assessment of decisional capacity of patient Capable Incapacitated Identify surrogate Principle 2: Plan Beneficence Principle 3: Principle 4: Nonmaleficence Justice Algorithm 9. Surgeons regularly may encounter the following bioethical situations: • Informed consent and patient autonomy, e.

The V is the principal determinant of the d statement about drug clearance is true? It is directly related to half-life between the amount of drug eliminated per hour D discount 15 mg mentax with visa. For drugs following linear Chemistry/Apply knowledge of fundamental biological kinetics buy 15mg mentax visa, clearance equals the elimination rate divided characteristics/Terapeutic drug monitoring/2 by the drug concentration in blood generic mentax 15 mg on line. Which statement about steady-state drug levels (in milligrams per hour) and f are known, the dose per is true? Clearance is inversely amount excreted related to the drug’s half-life and is accomplished B. Constant intravenous infusion will give the same distribution and elimination rates are constant. Peak and trough levels are the dose-response curve characteristics of intermittent dosing regimens. The Chemistry/Apply knowledge of fundamental biological steady state is reached when drug in the next dose is characteristics/Terapeutic drug monitoring/2 sufficient only to replace the drug eliminated since the last dose. If too small a peak–trough difference is seen for a drug half-lives because blood levels will have reached drug given orally, then: 97% of steady state. Dose interval should be increased concentration of the drug, and increasing the dose D. Dose per day and time between doses should be will increase the peak concentration of the drug, decreased resulting in a greater peak–trough difference. The Chemistry/Select course of action/Terapeutic drug peak–trough ratio is usually adjusted to 2 with the monitoring/3 dose interval set to equal the drug half-life. If the peak level is appropriate but the trough level fall within the therapeutic range. Decreasing the dosing per day interval will raise the trough level so that it is B. Not be changed, but dose per day increased level is affected by the drug clearance rate. Be shortened, but dose per day not changed clearance increases, then trough level decreases. If the steady-state drug level is too high, the best Answers to Questions 14–19 course of action is to: A. Decrease the dose and decrease the dose interval The appropriate dose can be calculated if the D. For example, the initial dose is calculated by multiplying the desired Chemistry/Select course of action/Terapeutic drug peak blood drug concentration by the Vd. When should blood samples for trough drug levels concentration obtained in the dosing interval. A The peak concentration of a drug is the highest Chemistry/Apply knowledge to recognize sources of concentration obtained in the dosing interval. For error/Sample collection and handling/1 oral drugs, the time of peak concentration is dependent upon their rates of absorption and 16. Blood sample collection time for peak drug levels: elimination and is determined by serial blood A. Peak levels for oral drugs are usually absorption drawn 1–2 hours after administration of the dose. Is independent of drug formulation For drugs given intravenously, peak levels are C. Is independent of the route of administration measured immediately after the infusion is D. D Therapeutic drug monitoring is necessary for drugs Chemistry/Apply knowledge to recognize sources of that have a narrow therapeutic index. Individual error/Sample collection and handling/2 differences alter pharmacokinetics, causing lack of 17. Which could account for drug toxicity following a correlation between dose and drug blood level. Decreased renal clearance caused by kidney disease food, genetic factors, exercise, smoking, pregnancy, B. Discontinuance or administration of another drug metabolism of other drugs, protein binding, and C. A Most drugs given orally distribute uniformly through Chemistry/Apply knowledge of fundamental biological the tissues reaching rapid equilibrium, so both blood characteristics/Terapeutic drug monitoring/2 and tissues can be viewed as a single compartment. Select the elimination model that best describes Elimination according to Michaelis–Menton kinetics most oral drugs. One compartment, linear first-order elimination hepatic enzyme system becomes saturated, reducing B. The second consists of tissues for Chemistry/Apply knowledge of fundamental biological which distribution of drug is time dependent. In characteristics/Terapeutic drug monitoring/2 determining the loading dose, the desired serum concentration should be multiplied by the volume 19. Drugs rapidly infused intravenously usually follow of the central compartment to avoid toxic levels. Michaelis–Menton or concentration-dependent elimination Chemistry/Apply knowledge of fundamental biological characteristics/Terapeutic drug monitoring/2 298 Chapter 5 | Clinical Chemistry 20. Which fact must be considered when evaluating a Answers to Questions 20–23 patient who displays signs of drug toxicity? A Altered drug pharmacokinetics may result in toxicity may need to be measured as well as parent drug even when the dose of drug is within the accepted B. Two common causes of this are therapeutic limits, the concentration of free drug the presence of unmeasured metabolites that are cannot be toxic physiologically active, and the presence of a higher C. If the drug has a wide therapeutic index, then it than expected concentration of free drug. A drug level cannot be toxic if the trough is binding protein or factors that shift the equilibrium within the published therapeutic range favoring more unbound drug can result in toxicity when the total drug concentration is within the Chemistry/Apply knowledge of fundamental biological therapeutic range. Some drugs with a wide characteristics/Terapeutic drug monitoring/2 therapeutic index are potentially toxic because they 21. When a therapeutic drug is suspected of causing may be ingested in great excess with little or no initial toxicity, which specimen is the most appropriate toxicity. Gastric fluid at the time of symptoms function because the drug half-life is extended. B When a drug is suspected of toxicity, the peak blood monitoring/3 sample (sample after absorption and distribution are 22. For a drug that follows first-order pharmacokinetics, complete) should be obtained because it is most adjustment of dosage to achieve the desired blood likely to exceed the therapeutic limit. New dose = × desired concentration concentration at drug concentration is within the therapeutic range, steady state toxicity is less likely, but cannot be ruled out. New dose = × concentration at steady state desired metabolites, and abnormal response to the drug are concentration causes of drug toxicity that may occur when the concentration at steady state blood drug level is within the published therapeutic C. New dose = × desired current dose concentration meaning the clearance of drug is linearly related to the drug dose. The dose of such drugs can be Chemistry/Apply knowledge of fundamental biological adjusted by multiplying the ratio of the current characteristics/Terapeutic drug monitoring/2 dose to blood concentration by the desired drug 23. For which drug group are both peak and trough concentration, provided the blood concentration is measurements usually required? Most drugs falling in the Chemistry/Select course of action/Terapeutic drug other classes have a narrow peak–trough difference monitoring/2 but are highly toxic when blood levels exceed the therapeutic range. A drug is identified by comparing its Rf value characteristic R,f which is the ratio of the distance and staining to standards migrated by the drug to the solvent. Testing must be performed using a urine sample sample must match the Rf of the drug standard. Antibody conjugated to a drug the sample for a limited amount of reagent antibodies. Enzyme conjugated to an antibody When antibody binds to the enzyme–drug conjugate, C. Antibody bound to a solid phase activity is directly proportional to sample drug Chemistry/Apply principles of special procedures/ concentration because the quantity of unbound Biochemical theory and principles/2 drug–enzyme conjugate will be highest when drug is 26. Te enzyme used is glucose-6-phosphate the low calibrator (drug concentration equal to dehydrogenase U. Te enzyme donor and acceptor molecules are Administration minimum for a positive test) is used fragments of β-galactosidase as the cutoff.

Drug abuse treatment retention and pro- 48th Annual Scientific Meeting buy discount mentax 15mg on-line, the cess effects on follow-up outcomes buy 15mg mentax overnight delivery. Drug and Committee on Problems of Drug Dependence buy cheap mentax 15mg online, Alcohol Dependence 47(3):227ñ235, 1997b. Drug tizing fasciitis in an intravenous drug user and Alcohol Dependence 8(3):189ñ199, 1981. A Family Like methadone treatment: The case for positive Yours: Breaking the Patterns of Drug Abuse. Community Mental Substance Abuse and Mental Health Services Health Journal 37(6):469ñ479, 2001. Journal of Pediatrics 89(5):842ñ846, Developing Treatment Programs for People 1976. W ith Co-Occurring Substance Abuse and Substance Abuse and Mental Health Services Mental Disorders. From the Drug Abuse W arning Network, Substance Abuse and Mental Health Services 2001. Drug and Alcohol methadone maintenance patients is associated Dependence 45:105ñ113, 1997a. In: The hepatitis C virus infection: Host, viral and Medical Review Officerís Manual: Medical environmental factors. The impact of drug and alcohol Correlates of hepatitis C virus infections use on hepatitis C treatment outcomes. Intravenous and oral l-alpha- care to methadone clinic patients: Referral vs acetylmethadol: Pharmacodynamics and on-site care. Clinical phar- Linguistically Appropriate Services in Health macology of buprenorphine: Ceiling effects at Care. Improving treatment engagement Journal of Clinical Psychiatry and outcomes for cocaine-using methadone 49(Suppl. Drug and Alcohol Dependence of buprenorphine and norbuprenorphine in 52(3):183ñ192, 1998. Slaying the Dragon: The History Classification of Mental and Behavioural of Addiction Treatment and Recovery in Disorders: Clinical Descriptions and America. Patterns of service maintenance treatment in New South W ales, use and treatment involvement of methadone Australia 1990ñ1995. Methadone distribution and excretion into Journal of Psychoactive Drugs 33(1):67ñ73, breast milk of clients in a methadone mainte- 2001. High- Can you trust patient self-reports of drug use dose methadone and the need for drug during treatment? Integrating psychosocial services tality rates following methadone treatment with pharmacotherapies in the treatment of discharge. Nonuse of alcohol or any illicit drugs, as well as nonabuse of medications normally obtained by prescription or over the counter. Combination of the physical dependence on, behavioral manifestations of the use of, and subjective sense of need and craving for a psychoactive substance, leading to compulsive use of the substance either for its positive effects or to avoid negative effects associated with abstinence from that substance. Opioid analgesics are a class of compounds that bind to 283 specific receptors in the central nervous diazepam, chlordiazepoxide, clonazepam, system to block the perception of pain or alprazolam, lorazepam). Methods deter- tives, as well as a number of synthetic com- mined, often by a consensus of experts, to pounds. Chronic administration or abuse be optimal for defined therapeutic situa- of opioid analgesics may lead to addiction. Such guidelines usually are based on both an analysis of published research antagonist. Identifying evidence of opioid cise nature and extent of a patientís sub- and other psychoactive substance use and stance use disorder and other medical, measuring the levels of substances or medi- mental health, and social problems as a cations in the body by examining patient basis for treatment planning. Assessment blood specimens for the presence and con- usually begins during program admission centrations of identifiable drugs and their and continues throughout treatment. Severity of disease often is assessed or maintenance treatment of opioid addic- further in terms of physiologic dependence, tion and marketed under the trade names SubutexÆ and SuboxoneÆ (the latter also organ system damage, and psychosocial morbidity. Legal process that per- to measure patient progress and to track mits individuals to be confined against their patients through treatment. These determinations are used to assistance or referral to other experts and establish short- and long-term treatment services as needed. Rules estab- substance-free lifestyle and encourage lished by Federal and State agencies to abstinence from alcohol and other limit disclosure of information about a psychoactive substances. Urgent, seemingly overpowering Programs must notify patients of their desire to use a substance, which often is rights to confidentiality, provide a written associated with tension, anxiety, or other summary of these rights, and establish dysphoric, depressive, or negative affective written procedures regulating access to and states. Use of preestab- and practices of persons from a given lished, mutually agreed-on privileges (e. It includes the holding of loss of privileges) to motivate improvements knowledge, skills, and attitudes that allow in treatment outcomes. Much evidence supports a linear stance and/or administration of an antago- relationship among the amount of medica- nist. Examination of an individual term incorrectly suggests that opioid treat- to determine the presence or absence of ment medications are toxic. Compare medi- illicit or nonprescribed drugs or alcohol or cally supervised withdrawal. Release from or discontinuation of treatment medication effectively prevents enrollment in treatment when maximum withdrawal symptoms or craving. Duration benefit has been achieved or when a patient of action can be affected by many factors, is deemed no longer suitable for treatment. Sale or other unauthorized distri- bution of a controlled substance, usually -E- for a purpose other than the prescribed and legitimate treatment of a medical or eligibility. Federal opioid duration of action of a substance or 286 Appendix C medication and can be influenced by intensity of treatm ent. Frequency and patient factors such as absorption rate, method of delivery for therapeutic services. Activity that increases can range from monitoring multidisci- the likelihood that a recovering patient in plinary staff members to direct manage- substance abuse treatment will relapse to ment of cases, depending on the severity of substance use or contract a substance patientsí problems. Treatment of tion) in which addiction professionals and opioid addiction and related complications clinicians provide therapeutic services to that requires patient residency for some clients who live at home or in special resi- period in a hospital setting or outpatient dences. Treatment is delivered in two to treatment in a hospital-linked facility to five regularly scheduled sessions per week ensure that necessary services and levels of totaling 6 to 24 hours per week. The process of providing care macotherapy, usually during the acute to a patient or taking action to modify a phase of treatment, in which steady-state symptom, an effect, or a behavior. Types of -M - intervention can include crisis interven- tion, brief intervention, and long-term m aintenance dosage. Medication sons related to program operations, safety, used for ongoing treatment of opioid or treatment complianceófor example, addiction. An opioid ago- incident to withdrawal from the continuous nist medication derived from methadone or sustained use of opioid drugs. Type of fully or do not show an acceptable response addiction treatment, usually provided in to other addiction treatments. Program offering treatment services, including medical and the benefits of peer support to people who psychosocial services. Facility established as part Twelve-Step programs are one type of of, but geographically separate from, an mutual-help program. The most frequently used opioid displaces opioids from these receptors and agonist medication. Methadone is a synthet- can precipitate withdrawal, but it does not ic opioid that binds to mu opiate receptors activate the mu receptors, nor does it cause and produces a range of mu agonist effects the euphoria and other effects associated similar to those of short-acting opioids such with opioid drugs. Some pro- Dispensing of methadone at stable dosage grams use naloxone to evaluate an individ- levels for more than 21 days in the super- ualís level of opioid dependence. W ithdrawal comprehensive maintenance services (with symptoms evoked by naloxoneís antagonist medication and counseling in one or several interaction with opioids confirm an individ- mobile units) to more limited care, usually ualís current dependence. Other substances com- drawal from opioids to prevent drug monly used by people addicted to opioids relapse in selected, well-motivated patients. Some drugsóin particular, high-dose barbituratesóused in Glossary 289 -O- opioid agonist. Areas on cell surfaces in that normally are bound by opioid psy- the central nervous system that are activat- choactive substances and that blocks the ed by opioid molecules to produce the activity of opioids at these receptors with- effects associated with opioid use, such as out producing the physiologic activity pro- euphoria and analgesia. Drug that binds to, Mu and kappa opiate receptor groups prin- but incompletely activates, opiate receptors cipally are involved in this activity. Natural derivative of opium or syn- nist but, at increasing doses, does not pro- thetic psychoactive substance that has duce as great an agonist effect as do effects similar to morphine or is capable of increased doses of a full agonist.

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