V's Study Guide Exam 3 Advanced Pharmacology PDF

Study Guide Exam 3 Advanced Pharmacology 1. Knowledgeable about asthma management (mild intermittent, mild persistent, moderate persistent, acute exacerbations) - - **Short-Acting**: **SABA** as needed. - **Long-Acting**: **Low-dose ICS** (like **budesonide**); **LTRAs** (like **...

Study Guide Exam 3 Advanced Pharmacology 1. Knowledgeable about asthma management (mild intermittent, mild persistent, moderate persistent, acute exacerbations) - - **Short-Acting**: **SABA** as needed. - **Long-Acting**: **Low-dose ICS** (like **budesonide**); **LTRAs** (like **montelukast**) as an alternative. - **Short-Acting**: **SABA** as needed. - **Long-Acting**: **Medium-dose ICS** or **Low-dose ICS + LABA** (like **formoterol**). - **Short-Acting**: **SABA** as needed. - **Long-Acting**: **High-dose ICS + LABA**; add **biologics** like **omalizumab** if needed. - **Short-Acting Focus**: High-dose **SABA** (often nebulized) + **ipratropium**; add **oral steroids** like **prednisone** for severe cases. **[Snapshot]:** - - - - - 2. Short-acting versus long-acting medications used in each classification of asthma - **Short-Acting**: SABA (e.g., **albuterol**) - **Long-Acting**: None - **Short-Acting**: SABA as needed - **Long-Acting**: Low-dose ICS (e.g., **budesonide**) - **Short-Acting**: SABA as needed - **Long-Acting**: Low-dose ICS + LABA (e.g., **formoterol**) or Medium-dose ICS - **Short-Acting**: SABA as needed - **Long-Acting**: High-dose ICS + LABA; add **biologics** if needed - **Short-Acting**: High-dose SABA (nebulized) - **Long-Acting**: Oral steroids (e.g., **prednisone**) 3. Patient education when prescribing asthma medications **Inhaled Corticosteroids (ICS)** - **Daily Use**: ICS should be used every day, even if you feel well, as it helps prevent inflammation over time. - **Not for Immediate Relief**: ICS medications do not provide quick relief for acute asthma attacks. - **Mouth Rinse**: After each use, rinse your mouth with water to prevent oral thrush (a yeast infection in the mouth)​. - **Quick Relief**: SABAs, like albuterol, are \"rescue\" inhalers that provide fast relief during asthma attacks. - **Use as Needed**: Only use SABAs when you have symptoms; overuse can lead to decreased effectiveness and increased side effects like tremors and palpitations​. - **Not for Rescue**: LABAs (like formoterol or salmeterol) should not be used alone or for immediate relief. They are maintenance medications and work over time to prevent symptoms. - **Use with ICS**: LABAs are typically prescribed alongside an ICS to enhance control of persistent asthma​. - **Nightly Dosing**: Medications like montelukast should be taken daily, often in the evening, to help manage chronic asthma symptoms. - **Non-Immediate Relief**: These are preventive medications and should not be used to relieve an acute asthma attack​. - **Proper Inhaler Use**: Demonstrate and check your inhaler technique regularly, as improper use can reduce medication effectiveness. - **Follow Device-Specific Instructions**: Different devices, such as metered-dose inhalers (MDIs) or dry powder inhalers (DPIs), require specific handling. 4. Asthma medication side effects - **Side Effects**: **Tremors, palpitations, nervousness**. - **Side Effects**: **Tremors, palpitations**. - **Warning**: Never use alone---always pair with ICS. - **Side Effects**: **Thrush, hoarseness, sore throat**. - **Long-Term**: Risk of **bone loss, slowed growth, cataracts**. - **Side Effects**: **Headache, belly pain, mood changes**. - **Rare Risk**: **Liver issues** (monitor liver enzymes). - **Side Effects**: **Nausea, vomiting, insomnia, tremors**. - **Serious**: **Arrhythmias, seizures** (narrow therapeutic range). - **Side Effects**: **Injection site pain, headache, muscle pain**. - **Severe**: Risk of **anaphylaxis** (administered in a clinic). 5. Combination of respiratory medication indications - **Indications**: Used for long-term control of moderate to severe persistent asthma and COPD. The combination reduces inflammation (ICS) and improves bronchodilation (LABA). - **Examples**: - **Budesonide + Formoterol (Symbicort)**: Asthma and COPD. - **Fluticasone + Salmeterol (Advair)**: Asthma and COPD. - **Fluticasone + Vilanterol (Breo Ellipta)**: Asthma and COPD​. - **Indications**: Used for quick relief of symptoms in COPD and in acute asthma exacerbations. - **Example**: **Combivent Respimat** (Ipratropium + Albuterol) is commonly used for COPD​. - **Indications**: Primarily indicated for long-term maintenance in COPD to improve lung function and reduce exacerbations. - **Examples**: - **Tiotropium + Olodaterol (Stiolto Respimat)**: COPD. - **Umeclidinium + Vilanterol (Anoro Ellipta)**: COPD​. - **Indications**: Sometimes used in asthma for patients who need additional control of allergic inflammation, particularly in exercise-induced or allergy-related asthma. - **Example**: This combination may include low-dose ICS with a leukotriene receptor antagonist like **Montelukast**​. **[Snapshot]:** - - - - 6. COPD management - **SABA**: Medications like albuterol and levalbuterol are used as needed for quick relief. - **SAMA**: Ipratropium is commonly used as needed to relieve symptoms. - **LABA** and **LAMA**: These are used daily for maintenance to improve lung function and reduce symptoms. Examples include tiotropium (LAMA) and salmeterol (LABA). - **Combination LAMA + LABA**: Often prescribed for moderate to severe COPD, providing enhanced bronchodilation. - Inhaled Corticosteroids, such as fluticasone and budesonide, are added to LABA for patients with a high risk of exacerbations, especially for those with an eosinophilic phenotype. These are typically combined in single inhalers, like Symbicort (budesonide + formoterol). - Roflumilast is used for severe COPD patients with chronic bronchitis and frequent exacerbations. This medication reduces inflammation and can help lower exacerbation rates but may cause side effects like weight loss and GI issues. - Used short-term to manage acute exacerbations of COPD but are not recommended for long-term maintenance due to significant potential side effects. - Recommended for patients with severe hypoxemia (PaO2 ≤ 55 mmHg or SaO2 ≤ 88%), as long-term oxygen use can improve survival in these cases. - **Smoking Cessation**: Essential for all COPD patients to slow disease progression. - **Pulmonary Rehabilitation**: Incorporates exercise training, nutritional guidance, and education to enhance quality of life and physical function. - **Vaccinations**: Influenza and pneumococcal vaccinations are recommended to reduce the risk of respiratory infections. 7. Be able to define asthma and COPD **[Asthma]**: \"Sensitive, tight airways.\" - - - - **[COPD]**: \"Blocked airflow from damage.\" - - - - 8. Understand asthma and COPD guidelines **Asthma Guidelines (GINA Guidelines)** 1. **Stepwise Treatment**: - Asthma management is divided into steps, increasing from Step 1 (mild) to Step 5 (severe) based on symptom severity and frequency. - **Reliever**: As-needed use of a short-acting beta-2 agonist (SABA) for quick symptom relief across all steps. - **Controllers**: - **Step 1**: Consider low-dose inhaled corticosteroids (ICS) as needed. - **Step 2**: Daily low-dose ICS or leukotriene receptor antagonist (LTRA). - **Step 3**: Low-dose ICS combined with a long-acting beta-2 agonist (LABA) or medium-dose ICS. - **Step 4**: Medium/high-dose ICS + LABA, with options for add-ons like tiotropium. - **Step 5**: High-dose ICS + LABA, with additional treatments such as anti-IgE therapy for severe cases. 2. **Inhaler Technique and Adherence**: - Proper inhaler technique and consistent daily use of controllers are emphasized for effective management. Patients are encouraged to rinse their mouths after ICS use to prevent side effects like thrush. 3. **Exacerbation Management**: - Short-term oral corticosteroids are recommended for managing asthma exacerbations, especially in severe cases. **COPD Guidelines (GOLD Guidelines)** 1. **Categorization by Severity**: - COPD treatment is based on disease severity and risk of exacerbations, classified into groups A to D. - **Group A**: Low symptoms, low exacerbation risk; treated with as-needed bronchodilators (SABA or SAMA). - **Group B**: More symptoms but low exacerbation risk; typically managed with a long-acting bronchodilator (LAMA or LABA). - **Group C**: Low symptoms but high exacerbation risk; managed with LAMA or ICS + LABA. - **Group D**: High symptoms and high exacerbation risk; requires combination therapy (ICS + LABA + LAMA) or additional agents like phosphodiesterase-4 (PDE4) inhibitors for chronic bronchitis. 2. **Long-Term Oxygen Therapy**: - Recommended for severe cases with chronic hypoxemia (PaO2 ≤ 55 mmHg or SaO2 ≤ 88%). 3. **Exacerbation Management**: - Exacerbations are managed with short-acting bronchodilators, oral corticosteroids, and sometimes antibiotics if there's evidence of infection. 9. Indications for each respiratory medication **Short-Acting Beta-Agonists (SABAs)** - **Indications**: Quick relief of acute asthma symptoms and bronchospasm in COPD. Used as-needed for immediate symptom control. - **Examples**: Albuterol, Levalbuterol​ - - - - - - - - - - - - - **Indications**: Used in severe COPD with chronic bronchitis to reduce exacerbations. Not indicated for asthma. - **Example**: Roflumilast​ - **Indications**: Asthma, particularly for preventing allergen or exercise-induced bronchoconstriction. Not used in COPD. - **Example**: Cromolyn​ - **Indications**: Severe asthma not controlled by conventional medications, targeting specific inflammatory pathways. - **Examples**: Omalizumab (anti-IgE), Mepolizumab (IL-5 inhibitor)​ - **Indications**: Alternative option for long-term control in asthma and COPD, although less commonly used due to side effects and monitoring requirements. - **Example**: Theophylline tablets​ 10. Smoking cessation medication options and dosing **Nicotine Replacement Therapy (NRT)** - **Indications**: Helps manage nicotine withdrawal symptoms by delivering nicotine in controlled doses. - **Forms and Dosing**: - **Nicotine Patch**: Doses vary by smoking habits (often starting with 21 mg for heavy smokers and tapering down). - **Nicotine Gum/Lozenges**: Typically 2 mg or 4 mg doses, used as needed when cravings occur, with a max number of pieces per day. - **Nicotine Nasal Spray/Inhaler**: Delivers nicotine more rapidly for acute craving control, with dosing tailored to patient needs. **Bupropion SR (Zyban)** - **Indications**: Non-nicotine aid for smoking cessation, often used to reduce cravings and withdrawal symptoms. - **Dosing**: Typically started at 150 mg once daily for 3 days, then increased to 150 mg twice daily. Treatment usually lasts 7-12 weeks. **Varenicline (Chantix)** - **Indications**: Partial agonist for nicotine receptors, reducing craving and withdrawal. - **Dosing**: Starts at 0.5 mg once daily for 3 days, increased to 0.5 mg twice daily for days 4-7, then 1 mg twice daily. Treatment usually lasts 12 weeks, with the option for an additional 12 weeks to enhance abstinence. 11. Smoking cessation education (Know the 5 A's) A blue and white poster with text Description automatically generated 12. Understand oxygen therapy - Oxygen therapy is primarily used to increase oxygen levels in patients with chronic lung diseases, such as COPD, who experience low oxygen saturation. - It has been shown to prolong survival when used for more than 15 hours per day in patients with severe hypoxemia (low blood oxygen levels). - Recommended for patients with: - **PaO₂ ≤ 55 mmHg** or **SaO₂ ≤ 88%** at rest. - **PaO₂ between 56-59 mmHg** if they have additional complications such as: - Pulmonary hypertension (high blood pressure in the lungs). - Right-sided heart failure (cor pulmonale). - Elevated hematocrit (Hct \> 55%) indicating increased RBC count. - **Oxygen Concentrators**: Devices that increase the concentration of oxygen from room air, ideal for home use. - **Portable Oxygen Cylinders**: - **D-cylinder**: Small, portable canister that can be carried. - **E-cylinder**: Larger and typically used with a wheeled cart for easier movement. - Oxygen therapy has minimal impact on improving pulmonary arterial pressure (pressure in the lungs' blood vessels) or quality of life scores, but it is crucial for survival in severe cases of low oxygen levels. 13. Safety considerations with Theophylline - Theophylline has a narrow therapeutic window, with effective blood levels between **5-15 mcg/mL**. Regular monitoring is essential to avoid toxicity, as even slight increases can lead to adverse effects. - Includes **nausea**, **vomiting**, **insomnia**, and **tremors**. Other frequent side effects are **headaches** and **restlessness**. - At higher levels, theophylline toxicity can cause severe reactions, including **arrhythmias** and **seizures**, which may be life-threatening. - Theophylline is metabolized by liver enzymes, particularly **CYP1A2** and **CYP3A4**, making it susceptible to interactions with many drugs. Medications like ciprofloxacin, erythromycin, and fluvoxamine increase theophylline levels, raising toxicity risks. Other drugs, such as phenytoin and rifampin, can decrease its effectiveness by lowering blood levels. - Conditions like **smoking**, **heart failure**, and **liver disease** can alter theophylline levels, requiring dose adjustments. Smokers, for instance, may have lower theophylline levels, while those with liver disease may need lower doses due to slower drug metabolism. - Patients should be instructed to avoid high-caffeine foods and beverages, as caffeine can amplify side effects like nervousness and insomnia. **[Neurology and Pain Management ]** 1. Understand **acetylcholinesterase inhibitors** and side effects Acetylcholinesterase inhibitors (AChE inhibitors) work by blocking the enzyme acetylcholinesterase, which normally breaks down acetylcholine in the synaptic cleft. This leads to increased levels of acetylcholine, enhancing its effects in the nervous system. AChE inhibitors are primarily used in conditions where improved acetylcholine signaling is beneficial, such as in Alzheimer's disease and certain muscle disorders like myasthenia gravis. **Common Side Effects of AChE Inhibitors** 1. **Gastrointestinal Distress**: Increased acetylcholine in the gut can lead to side effects like nausea, vomiting, diarrhea, and abdominal cramps. These effects are due to enhanced parasympathetic activity, which promotes gastrointestinal motility and secretions. 2. **Bradycardia**: Acetylcholine also affects the heart by slowing down the heart rate, which can lead to bradycardia and, in some cases, heart block. 3. **Increased Salivation and Sweating**: Due to heightened cholinergic activity, patients may experience excessive saliva production and sweating, known as cholinergic side effects. 4. **Muscle Cramps and Weakness**: Although AChE inhibitors can help improve muscle strength in conditions like myasthenia gravis, they can also cause muscle cramps or generalized weakness due to overstimulation of muscles. 5. **CNS Effects**: Especially with drugs that cross the blood-brain barrier, such as donepezil, side effects like dizziness, headache, and even confusion can occur. This is due to increased central cholinergic activity, which can affect mood and cognition. 2. Recognize when **anti-seizure medications** can be discontinued Guidelines on discontinuing anti-seizure medications consider several factors: seizure type, control stability, and potential risks. 1. **Duration of Seizure Control**: Generally, a seizure-free period of 2--5 years is recommended before attempting to taper and discontinue anti-seizure medication. 2. **Type of Epilepsy**: Certain types, such as childhood absence epilepsy, may have a better prognosis, allowing for possible discontinuation sooner, while other types may necessitate longer-term therapy. 3. **Normal Neurological Examination**: Patients should ideally have a normal neurological exam and neuroimaging results, which suggest a lower risk of recurrence upon discontinuation. 4. **EEG Findings**: A normal electroencephalogram (EEG) may support discontinuing therapy as it suggests a lower risk of seizure recurrence. 3. Understand the primary mechanism of action of **Dilantin** and potential side effects The primary mechanism of action of **Dilantin (phenytoin)** is blocking sodium (Na⁺) channels associated with depolarization and repolarization, leading to increased membrane stability. By prolonging the inactivation of these Na⁺ channels, phenytoin reduces the sustained high-frequency repetitive firing of action potentials, which is particularly effective in areas prone to epileptic activity​. **Potential side effects** of phenytoin include: - **Gingival hyperplasia** (gum overgrowth) - **Hirsutism** (excessive hair growth) - **Facial coarsening** - **Hyperglycemia** (high blood sugar levels) - **Hematologic effects**, such as anemia - **Osteoporosis** (bone weakening) - **Rash**, including Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) - **Megaloblastic anemia** due to reduced folate - **Teratogenicity** (fetal harm), associated with fetal hydantoin syndrome when taken during pregnancy​. 4. Indications for anticonvulsant medications - **Drug Example**: *Keppra* - **Key Point**: Keppra is for partial seizures. - **Drug Example**: *Lacosamide* - **Key Point**: Lacosamide treats large, whole-body seizures (tonic-clonic). - **Drug Example**: *Lacosamide* - **Key Point**: Lacosamide is also used for muscle-jerk seizures (myoclonic). - **Drug Example**: *Lacosamide (off-label)* - **Key Point**: Lacosamide can help in continuous seizure emergencies. - **Drug Example**: *Gabapentin* - **Key Point**: Gabapentin helps with nerve-related pain. 5. Understand the mechanism of action for seizure medications Anticonvulsant drugs work primarily by targeting specific neural pathways to help control seizures. Here's a breakdown of common mechanisms of action among these drugs: 1. **Inhibiting Sodium (Na⁺) Channels**: Many anticonvulsants work by blocking sodium channels, which helps to stabilize the neuron and prevent excessive firing that could lead to a seizure. Examples include: - **Phenytoin** - **Carbamazepine** - **Lamotrigine** 2. **Increasing Gamma-Aminobutyric Acid (GABA) Activity**: GABA is an inhibitory neurotransmitter, meaning it reduces neuron excitability. Drugs that increase GABA activity help in calming the brain and reducing seizure occurrences. Examples include: - **Benzodiazepines** (such as diazepam) - **Valproic Acid** 3. **Inhibiting Calcium (Ca²⁺) Channels**: Blocking calcium channels can help decrease neurotransmitter release, further stabilizing the neuron. Drugs like **ethosuximide** use this mechanism, especially effective in absence seizures. 4. **Decreasing Glutamate Activity**: Some drugs work by reducing the action of glutamate, an excitatory neurotransmitter. **Perampanel** acts as an antagonist to AMPA glutamate receptors, lowering the chances of excitatory action in neurons. 6. Which class of anticonvulsants cause **hyperammonemia**? - **Drug**: Valproic acid (Depakote) - **Issue**: Can cause high blood ammonia (hyperammonemia) - **Solution**: L-carnitine may be used if symptoms appear 7. **NSAID** Mechanism of action NSAIDs reduce pain and inflammation by blocking both COX-1 and COX-2, but they can irritate the stomach because of the COX-1 blockage. 1. **Main Job**: NSAIDs block an enzyme called **COX** (cyclooxygenase), which is responsible for making chemicals (prostaglandins) that cause pain, inflammation, and fever. 2. **Types of COX**: - **COX-1**: This type protects the stomach lining and helps with blood clotting. - **COX-2**: This type appears when there's injury or inflammation to create pain and swelling. 3. **Effect of Blocking COX**: - By blocking **COX-2**, NSAIDs reduce pain and swelling. - By blocking **COX-1**, NSAIDs can cause side effects like stomach irritation and a higher chance of bleeding. 8. Recognize and treat opioid overdose To recognize and treat an opioid overdose, the key indicators and steps involve: **Recognition** 1. **Symptoms**: Opioid overdose is marked by: - Coma or unresponsiveness - Pinpoint pupils - Respiratory depression or apnea (slow or stopped breathing)​ **Treatment** 2. **Naloxone (Narcan)**: - **Administration**: Use naloxone as an emergency treatment for opioid overdose. - **Dosing**: - Adult: Start with 0.4-2 mg intravenously (IV); doses can be repeated every 2-3 minutes until there is a response. If there is no response after 10 mg, consider other diagnoses. - Pediatric: Dose at 0.01 mg/kg IV​ - **Routes**: Naloxone can be given via intranasal spray, IV, intramuscular (IM), or subcutaneous (SubQ) routes. - **Onset and Duration**: Naloxone's onset is rapid, within 2-3 minutes when administered IV, but it has a short duration of action (30-120 minutes). Re-dosing may be necessary due to the short half-life compared to some opioids​. 3. **Post-Naloxone Care**: - Monitor for signs of withdrawal, which may include nausea, vomiting, sweating, and agitation. - Respiratory support may be required if respiratory depression persists even after naloxone administration​. Naloxone is the main treatment for reversing opioid effects, acting as a competitive antagonist to displace opioids at receptor sites. 9. Indications for **Tylenol** versus **NSAIDs** - **Tylenol (Acetaminophen)**: Primarily used for pain relief and reducing fever (antipyretic) but does not have anti-inflammatory properties. It is commonly chosen for: - Mild to moderate pain - Fever management - Patients needing pain relief who have gastrointestinal issues or are at risk for GI bleeding, as it is gentler on the stomach than NSAIDs - **NSAIDs (Non-Steroidal Anti-Inflammatory Drugs)**: These medications provide pain relief and also possess anti-inflammatory effects, making them suitable for conditions where inflammation is a significant component. NSAIDs are typically indicated for: - Osteoarthritis and rheumatoid arthritis - Acute pain with inflammation, such as sprains and strains - Headaches, migraines, and menstrual cramps - Inflammatory conditions like ankylosing spondylitis and acute gout arthritis​ 10. **Opioid** mechanism of action Opioids primarily act by binding to mu-opioid receptors in the brain and spinal cord, where they function as agonists, leading to pain relief. Their mechanism involves two main effects: 1. **Presynaptic Neuron Effect**: Opioid binding to mu receptors on presynaptic neurons reduces cyclic AMP (cAMP) levels. This reduction **closes** voltage-gated **calcium** **channels**, decreasing calcium influx and, consequently, the release of neurotransmitters involved in pain transmission, such as glutamate and substance P. 2. **Postsynaptic Neuron Effect**: Activation of mu receptors **opens potassium** **channels**, causing potassium to exit the cell. This hyperpolarizes the postsynaptic neuron, making it less likely to fire and transmit pain signals. The overall effect of these actions is a reduction in ascending pain pathways, thus alleviating the perception of pain​. 11. Review **gabapentin** and **pregabalin** **Gabapentin (Neurontin)** - **How it Works**: Boosts GABA and blocks calcium channels (calms down nerve activity). - **Use**: Seizures, shingles pain, and nerve pain (e.g., diabetic neuropathy). - **Starting Dose**: 300 mg, can go up to 3600 mg daily. - **Side Effects**: Think **"SAD"** -- **S**edation, **A**taxia, **D**izziness. **Pregabalin (Lyrica)** - **How it Works**: Similar to gabapentin -- blocks calcium channels to reduce nerve signals. - **Use**: Seizures, nerve pain, fibromyalgia. - **Starting Dose**: 150 mg, up to 600 mg daily. - **Side Effects**: **"SWEDE"** -- **S**edation, **W**eight gain, **E**dema, **D**izziness, **E**yes (blurred vision). 12. **Parkinson** and **Alzheimer** treatment options and important education **Parkinson's Disease** 1. - - - - 2. - - - **Alzheimer's Disease** 1. - - 2. - - - **[Snapshot]:** - **Parkinson's**: \"Dopamine Boost,\" \"Schedule,\" \"Protein.\" - **Alzheimer's**: \"Memory Support,\" \"Daily Dose,\" \"Routine.\" 13. Long-term opioid management safety - **Rule**: Lower the new opioid dose by **25-50%** when switching to account for cross-tolerance. - **Tip**: Adjust doses especially for patients with **liver, kidney, or lung issues**. - **Watch for**: Respiratory depression, especially with dose changes. - **Solution**: **Use Naloxone** if breathing slows, to restore normal breathing and oxygen levels. - **Common issues**: Sedation, confusion, and constipation. - **Pro Tip**: For constipation, **methylnaltrexone** can help without affecting breathing. - **Goal**: Support pain control and reduce dependence. - **Use**: Non-drug options (like **physical therapy**) and non-opioid pain relievers. 14. General understanding of the PDMP (Covered in Live session earlier this term by Dr. Dunlap) - **New prescriptions, refills, new patients**, and **annual visits**. - **Register** by state guidelines; **Check for red flags** in patterns; **Alert providers** and discuss naloxone if needed. - Healthcare providers, **law enforcement, prosecutors, medical examiners, drug courts,** and **workers' compensation** for cases like **fraud** or **Medicaid drug reviews**. - **Kentucky**: Tracks overdose data, requiring hospitals to report overdoses to PDMP. - **Pennsylvania**: Connects patients to care and notifies PDMP for new pain management. - **West Virginia**: Includes **non-fatal overdose data** in its PDMP. - **Missouri**: Last state to adopt PDMP in **January 2023**. - The military has its own PDMP but started **sharing information with civilian PDMPs** in 2019. - **Sharing varies by state**: Some allow bi-directional sharing, others only one-way, or none at all.