oh Catherine saved the day okay thank you so much Catherine you're welcome okay Lord we're already starting off with the bang guys this is interesting um I uh I'm trying to see I know here we go the chat that's what I'm looking for okay so here we go um so in the chat someone has asked "Will the beta delta fibers use the symbols or be written out?" Um I'm pretty sure the symbols will be what you see yeah so it'll be the the symbols that you see um let's see someone said "Can you clarify if we need to know the off label medication for pain disorders or only the FDA approved?" Um there won't be just tons and tons of questions specific to the treatment of pain um so really the ones that otherwise were kind of emphasized in the lecture itself would be what you really need to focus on but as far as like going deep down the rabbit hole of like pain management that generally falls outside the scope of I guess primary care psych mental health nurse practitioners role so you really don't need to go too deep into the sticks on that um let's see concerning the brain areas and function can you narrow down that information for us i guess in which aspect are you referring to cuz I think um you know that could apply as far as the brain circuitry for pain anxiety or sleepwake stuff well as a a follow-up question to that I didn't ask that question but uh I know that there's a lot of neurobiology for sleepwake uh I mean you you got there's so many different parts that are from rafi nuclei to uh what is it the tubro uh memor memor sorry the TMC I mean TMN I mean yeah do we need to know all the neurobiology or do we or we just focus on the u the drugs I I I know that each each particular aspect um there's resides a a neuro um transmitter So I was just curious about like why I guess you haven't really ever asked a question about like what neurotransmitter is located in this this part of the brain so I don't know if we're going to see questions like that i mean you haven't never asked anything like that before so I wouldn't start today either don't worry we won't be starting it today either so um I see now I had to scroll all the way down to figure out uh where that the brain and their function part question was coming from and I just hadn't scrolled down far enough but what we're looking at I guess is that very last key point so I'd say that very last key point would be the specificity that you're asking about when you look at sort of like the guess that would be number three and number four like key points three and four where we're talking about you know brain circuitry for pain and anxiety and I guess sleep i don't have that in there but you can just tack on sleep as well those different brain areas that are listed in that last key point are really what we're focusing on so I guess let me just throw this out there do the amydala and the hippocampus seem to have any role in sleep say no i would agree yeah no they don't so then where do those two like brain areas seem to have like the most relevance those are like more related to mood and um you know emotions exactly so like for sure anxiety that's related there for sure and maybe even pain a little bit but not as much yeah okay very good and same with like the parrachial nucleus the perryqueductal gray those really have a major role in sleep or sleep wake well it seems it's been primarily a thamus rafy nuclei yeah so then things like the pineal gland does that seem to have a huge role in anxiety or pain no yeah it's mostly for sleep same with like the tuber nucleus and the VPO so generally knowing where they're related to the course content is all you kind of need to do and then connect the dots on like how that was discussed in that content and you'll be set so uh let me think I think I saw Yeah okay so in the chat someone had said can we talk about some of the surgery for pain and anxiety we can i'd say let's focus it on anxiety though because that's where more of the content is really covered as far as like the actual circuitry goes so with anxiety remember you've got amygdala driven or amydala centered type anxiety right and then you have that cstc type centered anxiety who can tell me the difference between that type of anxiety so I think the amygdala center uh is for like fear panic phobia and then the CSTC is like more like anxiety like that misery or like um obsession kind of yeah you're definitely on the right track there so amydaladriven anxiety is much more of like almost a physical kind of feeling that physical fight orflight panicky type anxiety stuff for sure and we can connect those physical feelings to different brain areas that connect to the amydala so that's where like the locus ceruius comes into play the perryqueductal gray the parabra nuclei those different areas and their connections to the amydala are where we get the different breakdowns of like physical type symptoms that are experienced as fear the CSTC type anxiety is more kind of mental or cognitive so worrying obsessing ruminating that kind of thing and obviously there can be some overlap if you worry about something long enough you can sort of escalate yourself into panicky levels and if you have a panic attack out of nowhere you can become sort of preoccupied about if or when you'll ever have another one but they definitely are different in a lot of ways biologically and even in the treatment to some extent there are some differences so for like real world application this is why when a patient just says,"I have a lot of anxiety," just that statement alone is not likely to help you a whole lot on knowing what to do for them because not every anxiety means you need to throw a benzo at them or another rookie mistake is not every time a person complains of anxiety does someone need to throw propranol at it and think it's going to fix everything because it might fix some types of anxiety but it's not going to do a whole lot for someone who's got a lot of like cognitive worrying or ruminating type anxiety so do yourself the favor and try to get them to be a bit more specific on well how are you aware that you're anxious is it more of like a physical feeling or is it more kind of like a mental type thing like help me understand what you mean when you say that and it'll help you a lot in the long run on doing a good job on treating it so then um do we know based on kind of like understanding the differences between amydala driven and ST cstcdriven anxiety what the different um projections to the amygdala and their physical symptoms are so like maybe let me be more specific so with like the perryqueductal gray and it's projection to the amydala what kind of physical fear symptoms manifest that's the stopping behavior the fight or flighting the exactly and with the locus to the amygdala what kind of symptoms do you see like physical symptoms your autonomic type yeah the cardiovascular stuff yeah exactly like cardiovascular autonomic over arousal type stuff yep and so then that leaves the parrachial nucleus and its projection to the amydala which kind of symptoms do you see there increased respiratory rate yeah respiratory symptoms exactly i remember it is the parab bronchial nucleus absolutely very good so is that a little bit more clear as far as like that key point about the um guess like the biology and all that or the circuitry if you will of uh anxiety is concerned or the pathophysiology if you will okay good it looks like we have a little bit better grasp of that so that's great um okay let's see i'm trying to scroll back up no someone asked earlier about the uh a point of one of your um one of your bullet points related to overdose i don't remember what the question was but I wanted to ask that i'm glad you did because I don't see it but I I was trying to scroll it myself and see so we'll just go to it anyway so with overdose scenarios um I guess thinking about either the Well okay so thinking about the medications that are you know both listed here but just generally that you learned about in these type of things I guess are there any classes of drugs that would be the most concerning as far as overdose goes yeah for these TCAs that's true tricyclic would be a concern although I will just say since that would have been covered more in depth I guess on the previous exam you don't really need to worry about seeing it again as far as like barbituates for sure although we don't really talk about barbituates much in this course because it's just not something you will likely see a ton of you are correct though benzo and barbituates and any other meds or types of meds that might be relevant given the content we're talking about that's covered on the exam oh maybe some of the sleep meds opioids opiates opiates yeah and while we aren't going to obviously talk about opiates to any extent since we're not going to prescribe them certainly would be relevant as far as they are used for pain management and you certainly want to avoid benzo with patients taking opiates right so it is relevant so then what if any are the antidotes to these overdose scenarios since those are the two big classes of meds that are the most concerning if overdosed either individually or especially together naran naan and flamazanil that's right flamazinil for which one it looks like in the chat people are saying benzo that's right narcan for opiates that's true there you go simple as that and I mean while we're already on the topic since that kind of piggybacks nicely into I think the key point that's below the meds but before the brain areas we've already touched a little bit on like a relative contraindication when it comes to using benzo with someone maybe who's taking prescription opiates notice I say relative contraindication doesn't mean like it is a hard and fast absolutely never but it certainly shouldn't be the first thing you do and we've kind of talked about why that's a relative contraindication since that's a high risk for respiratory depression people would have history of abuse uh abuse of alcohol substance abuse sure substance abuse yeah and of course the rational for why that might be a re contraindication would be because why benzos can be abused too they sure can and you know actually that's a good point especially if someone maybe was early in their recovery or maybe not even fully committed to recovery from alcohol use then using a benzo for someone who's also still drinking would be kind of a problem potentially alcohol and benzo do not go well together are there any other kind of either patient populations or maybe clinical bipolar you don't want to give anybody benzo who um is bipolar so for bipolar disorder what would be the concern using benzo i think it would be the misuse of it how they um how one minute they you know they could be okay and next minute they can just go not taking their medication or maybe overdosing on the benzo i'm not sure maybe okay that might be a reach like I guess I was like maybe although I guess would you then also avoid it in a depressed person who might be suicidal i mean I would but I mean yeah I was like I would too i'm like so I'm like I don't know if I would say that but I mean yeah those are valid i hadn't really thought about that but those would be reasonable I guess um let's see someone has said elderly in the chat and what would be the reason why we might want to avoid using benzo and the elderly cognitive impairment absolutely and false gift absolutely so can I ask you this um I found some other information and it was saying that um benzo shouldn't be prescribed in people with sleep apnnea because it could cause acute respiratory failure bronchitis because it could cause respiratory depression COPD because respiratory failure um what else uh let's see chronic fatigue syndrome because it may give them energy and focus and leading on to them overdoing um activities and then crashing out i don't know is that like stuff we need to know uh I mean those would also be things to relatively for sure like the respiratory disorders okay wouldn't be like again these are all relative because of course if someone also has a lot of trouble breathing they might be anxious and though sometimes you know the a prudent use of a low dose and infrequent benzo might help them relax and not freak out see someone in the chat's even kind of commenting on that so it's like so again it's not an outright contraindication but like it might not be the first thing you need to jump to let's put it that way um some other people have mentioned liver failure or liver disease that's interesting and what would be the reasoning there why we might want to avoid using benzo then so benzo are metabolized through the liver they are they are so it can make them a little bit unpredictable then as far as how quickly they might be eliminated or how long it might take for them to reach steady state so that can be kind of a challenge now there are three of them though that if you must use a benzo um are not going to be as troublesome to try to use lot lazipam is that yeah oxazipam and tazipam i don't know have any of you actually seen oxazipam used never never yeah i'm like I don't know if I've ever seen it used maybe maybe from like some old school like dinosaur of a provider or something but I cannot ever think of a time that I've seen it used so yeah so maybe but it's going to be pretty unlikely so then that really leaves like Laorazzipam and Tamazipam is the other ones um does that have anything to do with whether it's lipopilic or less lipopilic somewhat so the reason why those are preferred is they're sort of like the how can I explain this maybe so it's not super complicated well like maybe think about how Valium has like a ton of different metabolites and so some of those metabolites then end up even becoming like other benzo so these are sort of like the final boss as far as that goes to where like they're just the last metabolite of really they don't break down into further metabolites I guess maybe might be the cleanest way to say that and so then that makes them a bit more predictable as far as when you administer it you have a little bit more of a clearer predictability as far as what dose is going to give you what effect and about how long it will last before it's eliminated and that's not the case for meds that are going to be broken down further into different metabolites now the how lipohilic something is will in part influence how quickly it kicks in and I guess while we're talking about benzo um remember that you have different how do I want to say this it's like you've got different I guess intensities potencies is the word I was trying to look for different potencies with benzo right you've got higher potency and then lower potency so then out of those thinking like higher and lower potency what would be the most risky as far as misuse abuse and dependence goes isn't it the I thought the ones that have the shorter halflife have the greatest use for abuse or something like that that's true if it has a short halflife and high potency absolutely that definitely puts you at the highest risk for misuse abuse and dependence cuz think about it if you're going to get addicted to something you want it to hit you hard and fast it's not a there is no long you know like a a slow race to addiction like you want it to be fast and furious and immediate so high potency short acting very high risk for misuse and abuse and dependence so then of the various benzo that you've learned about which would be like pretty concerning Xanax xanax is probably the worst offender there that's true doesn't mean that it shouldn't be something that you should be afraid of using it's just if you are going to prescribe it I suggest you stick with low doses of it um very good and so then anything that's going to be lower potency and long acting less likely to be abused misused or dependent and then you've got the ones that are just kind of intermediate but um the really important concept as far as like what to grasp here is high potency short acting very high risk for misuse abuse and dependence also what type of a benzo would be guess the most problematic for withdrawal for someone who's been using it long term so someone says Xanax and why would Xanax be one i mean the short answer is all benzo you would be concerned if you abruptly stop but like stratifying risk there are some that you're going to be much more worried about for withdrawal than others so someone has said Xanax and do we know why that might be the one is it because it's short acting like it's like the halflife like it's acting in its high potency exactly same reasoning so for the reasons that it's highly abusable misusable and can cause like dependence that is also why it would be the one most concerning for withdrawal or have maybe the highest risk for withdrawal if you abruptly stop it is probably a better way to say that very good um now so we already talked about kind of liver problem stuff and how the lot drugs are like if you must use them those will be the ones to use in people with problematic livers does anyone know why laazzipan would probably be like the preferred option to use is it because it comes like IV I am that is exactly why it has different much more different options for administration yeah as far as I know and someone might know better than I do but I don't think Tamasazipam comes in any other option but oral i've never seen like a Well actually I don't know about that does it come IV now I'm question no I'm thinking of verse JK never mind uh yeah I don't think I've ever seen it other than just oral i've never seen like an IM Tamasipam so uh larazzipam can be given IM IV oral i think there might even be uh like rectal versions that can be administered so there's a lot different options of of administration that you can have with Adavan that you don't have with the other two cool i mean I think that hit just about everything well all the major major highlights of the benzo type stuff anyhow um let's see with the sleepwake meds because that's kind of circling back to some of the remaining key points that I guess we've not touched on yet do you have a decent grasp of like which sleep aids are going to be better to help with just the going to sleep problem versus those which are going to help more with the staying asleep problem so I know Lunesta and ambient can help you stay asleep and I think Sonata will help you go to sleep that's right and that's a really good point what's the biggest difference between Sonata and maybe Ambient and Lunesta cuz they're all in the same family you know known as the Z drugs so they all work the same way but obviously what you just said means there's got to be some kind of a difference between those so what would be kind of like the biggest reason why the sonata helps with going to sleep but the other two help with staying asleep the half life or half life half life is a big part of it that's right that's right and what would be probably the most important teaching elements for anyone that you might give either ambient lunessa or sonata so anywhere that you might prescribe a z drug i'm thinking like there's at least two really big important teaching things to make sure well now there's three so someone said do not drink that's true so that's true would it be the time frame that they take it cuz you can't take it too late because you'll end up waking up and being draw groggy and not able to really function okay yeah that's a good point make sure that you take it and allow there to be enough time to go to sleep although maybe not so much with Sonata since it's got a short half-life but yes not for long-term use sure immediately go to bed absolutely no driving or operating machinery okay these are all great not at all what I'm thinking though that's funny risk of sleepwalking thank you Nicole that's true uh a little bit more than just sleepwalking but that is definitely one way it can manifest complex sleepreated behaviors is what you're looking for complex sleepreated behaviors and that can be like sleepwalking sleep eating driving shopping um there have been some very rare cases where people engage in like sexual activity while asleep weird stuff but complex sleepreated behaviors is definitely one of those things that we must absolutely must not optional must tell our patients about with Zdrugs and if it happens they need to stop taking it and there's one more important thing that I'm thinking that you really need to make sure you know and that you tell your patients about when it comes to Zdrugs they also have a potential for abuse as well that's true they are considered um controlled substances that's a very good point so um now I will say I don't know that I've really seen well let me put it this way i have seen people like misuse sleeping aids like Lunesta and ambient but I've never seen anyone go to rehab because of their Lunesta dependency or ambient abuse interestingly enough um so I guess there might be more of a theoretical than actual risk but that is a very good point fall risk fall risk sure are there any important interactions that might affect these meds besides alcohol i mean that can be dangerous but are there any kind of interactions that you can think of that you'd want to make sure present or benzo and barbituates i believe yeah benzo barbbituates opiates we want to kind of avoid those with sleep aids tricyclics maybe what about with food it either be St john's or delayed it could delay their response action delay the response of those meds so you do not go and eat a whole pasta dinner and then take your Lunesta it will not kick in in time it and that also could be like a contributing factor to why you might feel groggy and hung over the next day or why it feels like I took my pill and it didn't kick in for hours it's because food messes with their absorption so they need to either eat earlier or take that medicine much later especially like highfat meals I should say that in particular will affect the absorption of those meds very good um okay and let's see so then thinking about the sleeping medications uh this kind of is a good point someone had mentioned how they are controlled substances so there is that potential risk for missing use abuse and dependency so then what would we what would maybe be some better options to consider if we have a person who's complaining of trouble sleeping but they have a history of you know maybe alcoholism or opiate dependence or I don't know you know some kind of substance use problem i'm not going to say it right it's the synthetic melatonin but I can't say it right i can't pronounce it right yeah romelion or Rosaram that's a good one now kind of thinking back to that original key point as far as going to sleep and staying asleep which one is Rosaram going to be good for going to sleep going to sleep that's right very very short halflife it's only going to be super helpful with the going to sleep problem excellent someone said Trizone yep that's a good option too is that a good one for going to sleep or staying asleep uh both i think yeah I'd say both but for sure staying asleep yeah it tends to have a longer duration what is probably this is like every board exam loves to ask this kind of a question if it comes to tradone what's like the main major thing to remember to warn about or be monitoring for someone on tradone there might be more than one prisonism i don't priism yeah priapism that's definitely one of them uh and that was the one I was thinking of and then orthostatic hypotension sometimes can be an issue with trazadm very good um let's see are there any other things you can think of for sleep and someone with substance use problems so we said rosaram that's a good one trazadone that's a good one is docipin an option too docipin's another excellent option yes magnesium that's true kind of off label melatonin yeah that would be a good option if someone wants to avoid any kind of prescription drug and is looking for a natural option then sure melatonin is not a bad option either now um we sometimes though will prescribe melatonin for very specific sleepwake problems does anyone remember which ones yeah for sure the falling asleep that's right um and maybe I should ask that question a little bit more precisely does anyone remember like light exposure and melatonin administration and like when you do it and for which problems advance and delayed sleep yeah so like phase advanced and phase delayed so for like the phase delayed what do we mean by that like what's their issue they're night owls they might just fall asleep at normal times yeah they're night owls that's true so when would you give them melatonin and when would you expose them to light so give the melatonin before bed and then expose to light in the morning that's true yep so evening melatonin morning light so then for the phase advanced people what is that what problem is that those are the early birds they are yeah they are the old people that wake up at just the unspeakable hour to start their day um which I don't normally see a ton of people like coming in saying this is a problem it's usually the people that stay up all night that that's the problem but these people that get up at just before the sun does you don't normally have that come in as a clinical issue but it could be i guess so then when do we give melatonin and when do we expose them to light melatonin early morning late in the evening mhm that's right very good very good so can you repeat that you said melatonin in the morning and light and light late late in the evening yep okay because really kind of connecting this to the circuitry piece someone's asked why melatonin in the morning well what does melatonin and light affect as far as thinking about the parts of the brain what is affected by melatonin and light it's the s uh your circadian rhythms right that is true so it is part of the circadian rhythms absolutely what now the SCM with the sending signals to that yes exactly the super kayazmatic nucleus that is what sort of helps set the clock the sleepwake clock exactly and uh so very good and let's see which part of the brain then is sort of like the so the SC is the clock which one is sort of like the sleepwake switch is that the ventrolateral pre well yeah the VPO yes okay it is yes the VPO is what sort of helps with your sleep and then the tuberoma nucleus or the TMN is what sort of helps you with being awake yeah very good trying to see with [Music] um can you clarify the function of the pineal gland yeah who can answer that for us i mean generally that's a really big question let's just focus it to the content that we're learning about for this exam where does the pineal gland fall what does it relate to it releases the melatonin sure does helps regulate the circadian yep that's where melatonin comes from yep very good let's see cuz we've got about about 15 minutes left so we're doing great as far as what we are covering and what is still left to cover um okay so honestly like we've hit on almost everything we haven't really talked about the wakefulness meds but there's not that many to talk about um and we haven't touched a ton about pain someone said "Will there be much about orexin?" There will be at least something about it uh what does our rexin do stabilizes wakefulness it does it does stabilize wakefulness so how do any of the meds that we talk about have anything to do with that the Doras that's true dora the Explorer that's what I call them um that's right the Dora drugs and so how do they help as far as what do they do to the erection they inhibit them from binding right that's right they block orexin because if orrexin stabilizes wakefulness then if we get in its way you're going to be less wakeful which is another way of thinking maybe more asleep but it's a little bit different though because if I want to make you more sleepy I'm going to do things like give you a lot of GABA because GABA directly makes you sleepy so our benzo make you more sleepy our Z drugs make you more sleepy our Dora drugs make you less awake our unisome makes you less awake because we're blocking histamine so there are chemicals that enhance wakefulness so that'd be like orexin and histamine dopamine norepinephrine probably and then there are chemicals I guess that enhance sleepiness GABA specifically very good um and I guess the big thing with sinosi is just remember it's a wakefulness promoting med it's not a controlled substance as far as how it works it's very similar to like how wellbutrin works how seella works how um strata works and how I'm forgetting one oh fetma level yeah that that works it's more of like a norepinephrine and dopamine ri up what drug was this you what what drug are you talking about sosi solar someone said "I think there was a few drugs not mentioned in the lectures if we use the drug book should we be okay?" Um yes uh I'm trying to think which ones i mean there might be like I think there was an extra Dora drug that came out i think Dave Viggo maybe might be actually I just noticed that Dave Viggo is listed on here twice but that's not true one of these is Dave Viggo the other one is Q Vivic i just noticed that yeah it was just the brand new I was like wait a second i'm like why is Dave Vgo on here twice but it is not the same one jk uh so there was a new one um Q Vivic that came out but it's also a Dora drug and you'll know it's a Dora drug cuz they all end in orrexent um so anyways like subversent bombra dairy durexent I'm pretty sure is uh cuivvic and limber reexent is [ __ ] but they all end in orrexent so those are your dora drugs there's not anything majorly distinguishing between those that it's like critical for you to like know other than recognizing that they're part of the door drugs and how the door drugs work um but yes otherwise just generally if it wasn't emphasized heavily in the lecture it would not be fair to you to expect you to know a bunch about it but just generally looking it up in like a drug book or in like installs prescribers guide or in um even cafers you know does a pretty good job of covering things kind of as a broad overview you should be fine uh let's see so as I'm looking at the med list you know you see that we've got amitryptalene listed here and you've got symbalta listed here so these were two drugs that came from the previous exam so one it's not like there's going to be a ton of emphasis on those but where do they relate to the content that we covered for this one that we're talking about or that we're studying for pain exactly right so um I guess what would be like the most important things just to be aware of for either one of those which hope you remember from the previous test well I'm sorry symbalta is contraindicated with liver is contraindicated with liver yep biggest thing with symbalta liver so you don't want to use it in someone with a bad liver it's one of the four drugs that we commonly use in psych that are very potent 2D6 inhibitors so that can be a problem with drug interactions does anyone remember what the others are i thinkine should be should be used somebody with a negro disease to always should be monitored you definitely want to be careful i mean really with most things you want to be careful with liver disease it might affect how high you can go or depending on how severe the liver disease you might not be able to use it at all um yep if it's an einerite can affect blood pressure that's true too i'd say the biggest thing is remember the liver disease um let's see and then seella what role does that play where where does that seem to help what kind of thing does that help with fibromyalgia does help with fibromyalgia and I guess that covers a whole lot of different symptoms uh I guess and what type of symptoms does it help the most with the fibro fog yeah a lot of the cognitive stuff fibro fog fatigue things like that very good i'm sorry can you repeat what was the pharmaceutical name of that drug yeah Sevela is the brand name the generic name is Milnasopran oh okay and so from the previous exam we had levomanosopran which is it comes from seella fetma that's fetma yeah the anti-depressant fetimma comes from seella levomopran what's the main difference between Gabapentin and Lica for pain um I mean they both work very similarly as far as like on those uh those channels um I think probably a big difference would be there's just so much variability and how like readily absorbed gapentin is and I think LA is maybe a little bit more precise in that though um I guess maybe it's more potent is one way to think about it the bentin is harsh on the kidneys and requires higher doses to be effective is not as harsh on the kidneys as and requires very little doses effect yeah but as far as like mechanism goes like it's very very similar yeah and both actually are used off label a lot for anxiety there's actually quite a bit of evidence that LA works very well for like generalized anxiety um yeah yeah i've never successfully gotten it covered for that purpose but theoretically it would be a great option to use um and gabapentin helps a lot with handovers tremors from alcohol joint gabentin is used for so much stuff so much stuff very very very widely used for lots and lots of things off label most of it but although I've never seen it used for seizures even though it is a seizure med I've never seen that at least on its own used as like the primary treatment for a seizure disorder which is very interesting to me it's emotional for pain um and one of the key points with the chronic pain like establishing how that happens do we have to like like go into like the whole like I know like it's really like a hyper sensitivity and then the whole um like descending pathway with the with the the nonadeneric and serotonin output like that whole I don't know if I'm like explaining absolutely not watching videos and I find that listening to me I'm like yeah it's like no my god know uh just generally what you're trying to grasp the concept is as far as like chronic pain goes or and really even neuropathic pain to some extent especially the longer it kind of goes on is whether it be from some kind of like inflammatory process you know due to some other kind of damage or dysfunction to the periphery like you see like with diabetic neuropathy or like posteretic neuralgia or you know like some kind of mechanical damage like osteoarthritis itis or or whatever something like that ends up happening potentially and then along with you know either that damage to the periphery it starts to move more into like this central hijacking kind of thing and that's where it kind of uh will manifest as more chronic widespread pain type things where you get uh hyperalesia or aladinia even and that also kind of connects to those different fibers right because we've got the you know a beta fibers which is your I call it my baseline so that you know is not really pain inducing but it is stimulated by just non-noxxious stimuli but then you've got those C fibers that happen when you've got you know heat or um some other kind of like noxious injury right and um or chemical injury I should say heat or chemical injury and then you've got the other fiber which I always forget i think it's is it delta thank you i'm like I cannot remember what that Greek letter is and then you've got the delta fibers which are the other one that you're just going to have to remember but they are from mechanical so the ones that are more specifically related to pain are those delta and C fibers but then once you start get like that central sensitization that you see with chronic pain even non-noxious stimuli starts to trigger a painful response so like all the pain fibers really get affected there um in the chat someone had asked about the scheduling for lica and gabapentin i think it depends on the state some states categorize gabapentin as a controlled substance and some don't in Texas it's not considered a controlled substance but Lica is but I know in other states gabapentin is classified as a controlled substance so it might depend on your state organization well the current just keep going up and eventually they gradually left in the club and there's no current and if there's no Okay well we've got five minutes left i guess what okay i just said L is mostly twice daily um like every morning at bedtime 12 hours span and then they were bent mostly three times a day and they could go high on the doses up to like 600 millig depending on how the patient is tolerating but once they have something like a back off mhm oh I know but I was like I feel like there is something that I wanted to cover and I didn't i was rocking my brain on what was it um Boobar this is the only time it's even appeared who wants to tell me about Boobar boobar the forgotten antioxidation it is forgotten both in providers thinking to use it and in providers knowing how to use it correctly yeah the PRN I see that so often and it pisses me off every time every time I get so triggered when I see that um and I want to I really want to be like this is why primary care needs to stop trying to dabble in psychiatry but truthfully I've also seen psych providers who clearly just didn't know what they were doing with it do the same thing irritates me so much but yes so help me God if I ever inherit a patient that saw one of you and I see Boobar PRN I will find you don't do it guys it doesn't work oh my god i've never seen anything like that i know well consider yourself blessed but don't worry you will you'll see it and it'll annoy me too maybe I will share this pet peeve with the rest of you because it drives me absolutely insane drives me crazy oh it drives me nuts cuz it does not work so I'm like why well it Let me clarify it does not work when given PRN okay so at that point it's just a placebo effect now maybe you know I don't know maybe for some people it might have like a slight sedating kind of quality to it as far as like a side effect goes so then when they take a PRN maybe because it makes them feel a little tired perhaps it helps all right maybe but that's a big stretch and that's not like how it is supposed to help therapeutically right you think a boost bar as being just like an SSRI exactly it takes time and or daily some people do daily when it's supposed to be at least B at least daily stoppage it has to be twice daily at least very good and another kind of like just side note with boostar that I do see commonly is because it's really only indicated for anxiety people will mistakenly think okay well if I have a patient who has oh I don't know who you know has major depressive disorder and generalized anxiety disorder and let's say I've got them on I don't know we'll say uh 20 milligrams of Prozac that's a very normal starting dose and they say that their depression's a bit better but they're still just super anxious do not add Boostbar to that tiny dose of Prozac thinking that you're saving lives and changing the world because what on earth are you doing you're complicating the regimen unnecessarily for one it's not like boostar is uniquely effective for anxiety it is it is helpful but so is Prozac so like it would make much more sense to just optimize that dose of Prozac before we decide all right we need to add something that needs to be taken twice daily on top of this exceptions might be if you're already on a very decent dose of the Prozac and if you go up they don't tolerate the higher dose well then it might make sense to use a lower dose of the Prozac and add boost bar to it maybe um but just as a general rule of thumb it is always better to optimize if you still have wiggle room than to complicate the regimen by adding more things to it so you want to have a really solid rationale for why you're complicating things if it could otherwise be addressed with a simpler strategy by optimizing that's not obviously going to be on the test that's just a real world tip that I see it's a rookie mistake I see all the time though and yes in pharmarmacology it is a very good adjunct so that's a good point we do remember adjunctive treatment is when we are on an adequate dose of a med for an adequate amount of time so if we are on a tiny dose of a first-line treatment we don't adjunct to it if there was otherwise more room that we could optimize first but yes I would agree it is a very good adjunct medication but as monotherapy that's another rookie mistake I see that drives me nuts monotherapy that doesn't mean that it won't help some people with anxiety but it's not the most potently effective option so unless a person just has not historically tolerated SSRIs or SNRIs like for some reason then I very well might consider using Boost Bar all on its own but it's much it seems to have a much better role when it's added to something else first line so you want to use your first line options first that's why they are called first line um and then boost bar is kind of like a supporting role when it's like we've gotten a decent amount of effect from you know Prozac or Zoloft but there's still just like this ceiling that we're hitting and we're not quite where we want to be but our our first line treatment is doing a good job just not as good as it could be then it makes sense to add boost bar to that but if someone's on you know I don't know 150th of Zoloft and they've had absolutely no relief to their anxiety do not think adding boost bar is going to miraculously make that work it means you probably need to switch them to something besides Zoloft we add adjunctive things when our existing treatment is optimized and there has been some response but not full response awesome well time flies whether we're having fun or not it looks like and I cannot believe it is already after 7:30 i think we did a pretty good job hitting all of the majorly critically important parts and from what it sounds like at least for those present uh I think you all have a pretty good grasp of the content so that's good um so again do not forget do not be that person that doesn't realize the exam is happening but it opens on Tuesday morning at 8:00 a.m central Standard Time closes on Friday morning 8 a.m central Standard Time someone asked in the chat how many questions there's 48 so almost one point per question so I think there's maybe one or two short answer questions but even then I think they're only worth a point each so you're good there and uh best of luck we only have one more to go it's hard to believe one more exam to go you're in the home stretch so until next time H so when I try to leave it say end meeting for all should I click