Week3Presentation.pptx

Medications That Treat Pain

Chapter 28-30

NSG 220

What we will review:

What is Pain?

Types of Pain

Drugs used to Treat Pain

Adjuvant Analgesics

Non-Opioids

Opioids

Narcotic Agonist

Definitions of the class of medications

Anti-Rheumatic RX-

RX to treat inflammation/pain

Gout (meds)

Clinical Pearls

Pain

Pain- Universally unpleasant emotional and sensory experience that occurs in response to actual or potential tissue trauma or inflammation

5th vital sign that should be assessed in all patients

Influenced by multiple factors

Emotional

Physical

Psychologic status

Subjective: “whatever the client says”

Pain

Can further be classified according to its sources.

Most common:

Somatic Pain- Originates from skeletal muscles, ligaments, and joints

visceral pain –originates from organs and smooth muscles

superficial pain originates from the skin and mucous membranes

deep pain –occurs in tissue below skin level

They may be appropriately treated when the source of the pain is known. For example, visceral and superficial pain usually require opioids for relief, whereas somatic pain including bone pain usually respond better to non opioid analgesics such as non steroidal anti inflammatory drugs .

Types of Pain

Acute pain

Mild to severe

lasting 6 months usually due to injury

↑ pulse rate, ↑ b/p, respirations, ↑ glucose levels (sympathetic nervous system responses)

Chronic pain

Mild to severe

Lasts longer than 6 months

Parasympathetic nervous system responses

May not demonstrate symptoms associated with acute pain symptoms

May lead to depression and decreased functional status

Types of Pain (cont.)

Nociceptive pain- due to an injury or damage to the body tissue

External Injury- hitting part of the body against something or procedure (surgery)

Joints, muscles, skin, bones, tendons

Described as achy, throbbing or sharp

Inflammation- due to an abnormal immune response

Ex: cellulitis

Neuropathic- due to nerve irritation

Shingles/neuropathy (feet/hands-diabetics)

Burning, shooting, pins and needles, sensitive to touch

Radicular- compressed or inflamed spinal nerve

Radiates from the back & hips into the legs (sciatica-sciatic nerve)

Aggravated when walking, sitting and other activities

Types of Drugs that Treat Pain

Definitions

Analgesics- Medications that relieve pain without causing loss of consciousness.

Agonist- drugs that activates opioid brain receptors giving full effect (heroin, methadone, morphine). Initiates a specific response.

Antagonist- drugs that block opioids drugs from attaching/activating opioid receptors (Naloxone/Narcan)

Partial agonist- activates opioid receptors in the brain, but does give have the full effect (buprenorphine, tramadol, pentazocine). They can also block agonist drugs (buprenorphine, butorphanol, nalbuphine, pentazocine) – “antagonist effect”.

Meds have a limited effect "Ceiling”.

Can have a withdrawal effect on patient who are opioid-dependent patients

Agonist/Mixed/Antagonist

Agonist- a full response (initiates a response)

Antagonist – blocks response

Agonist/Antagonist mixture- while under other conditions, behaves as an antagonist- a substance that binds to a receptor but does not activate and can block the activity of other agonists.

Ex: Works to relief pain without the full side effect. Less effect on respirations. Not much of an pain relieving effect.

Agonist-Antagonist Opioids (Pentazocine, Butorphanol, Nalbuphine, Buprenorphine)

MOA: Blocks access of the pure agonist to mu receptors. They also prevent receptor activation, thereby triggering withdrawal. "

Also called a partial agonist or a mixed agonist, binds to a pain receptor and causes a weaker pain response that does a full agonist.

Not a first-line analgesic. Sometimes useful in pan management of OB patients.

Medications have an analgesic effect

Can cause a withdrawal effect if given to people who are physically dependent on pure agonist

NOT A REVERSAL MEDICATION

Advantages:

Low potential for abuse

Have less effect on respiratory depression

Disadvantage

Less powerful analgesic effect

**Buprenorphine- used to treat opioid addiction.

Opioids Morphine, Fentanyl, Hydromorphone, Hydrocodone, Oxycodone, Oxymorphone, Methadone

Advantages

MOA- bind to An opioid pain receptor in the brain and causes an analgesic response. The reduction of pain sensation

Forms: Injectable, patches, tablets, capsules (long and short acting)

Indications:

Used to alleviate moderate to severe pain

Surgical/post-operative pain.

1st line analgesics for immediate post-op settings.

Disadvantages

Constipation

Excessive sedation and respiratory depression*

Some can produce metabolites that can accumulate and produce toxicity (morphine 3-glucuronide)

Screening for appropriateness

Ongoing monitoring via therapeutic relationship with patient and prescriber are required for safe and effective long-term therapy

Can be highly addictive

Tolerance can develop

Non-Opioid(Aspirin, Diclofenac, Ibuprofen, Ketoprofen, Ketorolac, Meloxicam*, Naproxen, Celecoxib)Acetaminophen-antipyretic & analgesic)

Advantage

Versatile with multiple agents, formulation, and routes of administration available

Can be given in combination with opioids

Flexible and useful for a wide variety of mild to moderate nociceptive (injury to tissue)-type pain conditions

Disadvantage

Ineffective neuropathic pain

NSAIDs- caution in pts with CV and/or GI risk factors, bleeding disorders and impaired kidney fx

Not exceed daily maximum daily dose

Acetaminophen- monitor hepatic status

Side Effects

Vary according to the medication type

Opioid Schedule

5 Scheduled Drug Classes

Schedule I*- not seen or administered in the U.S.

Schedule II- high likelihood of abuse; Risk of developing a severe physiological addiction (Percocet, OxyContin, Codeine)

Schedule III- likelihood of abuse is lower than that of schedule one or two (Lortab, Vicodin)

high risk of developing physiological dependence

Moderate to low- risk for developing a physical dependence

Schedule IV- Likelihood of abuse or developing a physiological or physical dependence is lower than Schedule III

Schedule V- likelihood of abuse or developing a physiological or physical dependence is lower than Schedule or IV (Codeine cough medications)

Nursing Implications

Always count this drug**

Witness any waste**

Do not leave medication alone with patient. Watch them take it!

Do not walk around with the RX in your pocket! Return it immediately. __________________________________________

Assess patient first! Assess pain level and administer as ordered (if groggy, lethargic, vitals abnormal, low saturations?)

Reassess patient one after administering.

May need to administer RX before pain to improve pain control (give exactly on schedule, don’t wait until the patient asks**

But do not give before scheduled time (example: PRN 3 hours)

*** Physical dependence is extremely rare when given in hospital for short term therapy.

Narcotic Antagonist (Naloxone*, Relistor, Naloxegol, Alvimopan, Naltrexone)

Action: Opioid antagonist block (or antagonize) opiate-receptor sites. Principal use is the treatment of opioid overdose.

Uses: Reverse the opiate effects of narcotic overdose and respiratory depression

**The drug of choice when there is an uncertainty of type of overdose.

Side Effect:

Return of the symptoms the narcotic was used for.

Watch for ↑ B/P

Tremors

Hyperventilation

Severe diarrhea**

Adjuvant Analgesics(Gabapentin, Venlafaxine, Bupivacaine, Baclofen, Cyclobenzaprine, Ketamine, Duloxetine, Nortriptyline)

Advantages

Drugs that are not primarily identified as a primary analgesic but can have analgesic (pain relieving effects) or complimentary analgesic effect when used in combination with opioids.

help manage concurrent symptoms that exacerbate pain

treat side effects caused by opioids

Useful for neuropathic pain

Disadvantages

Pain relief is limited and less predictable

Pain relief is usually slow

Anti-Rheumatic Drugs (treat cancers & pain)

Rheumatoid Arthritis

Autoimmune, inflammatory immune disease

Joint stiffness, swelling, and pain

Can develop at any age, usually found amongst men and women 60 years and older

Drugs can slow down disease progression

Drug Treatment

Nonsteroidal anti-inflammatory drugs (NSAIDs)

Provide relief but do not slow disease progression

Glucocorticoids

Slow down disease progression

Given short term because they can cause serious toxicity

Disease-modifying antirheumatic drugs (DMARDs)

Reduce joint destruction and slow down disease progression

Recommended to start within 3 months of RA diagnosis

Medications

Methotrexate- interferes with growth of certain cells of the body (quick growing)

Treats inflammatory response (in arthritis)

Category X – contraindicated in pregnancy, can cause miscarriage/teratogenic effects causing deformities/ interrups the grown and division of a fertilized egg.

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Prednisone*

Prednisolone* (*Most common used)

NSAIDS (1st and 2nd generation)

Nursing Implications

Methotrexate should be taken with folic acid to reduce GI and hepatic toxicity.

DMARD- disease modifying anti-rheumatic drug/ antineoplastic (cancer drugs)

Gout

Inflammatory condition caused by elevated levels of uric acid (>6 mg/dL)

High uric acid leads to accumulation in joint spaces

Commonly found in hands and feet (redness, swelling, extreme tenderness to palpitation

Pharmacologic treatment can be used during acute episodes and/or for prophylactic therapy if symptoms occur more than 3 times a year.

Antigout Medications(Colchicine, Allopurinol, Probenecid, Indomethacin, Prednisone)

Therapeutic Goals

Decrease inflammation in joints during acute attacks

Decrease uric acid levels for long-term prevention of flares

Medications

Acute phase

Indomethacin

1st choice for gout flare

Used for short term

Colchicine (take every 1 hour) *

Can be used alone or with NSAID

Decreases inflammation

Take until the symptoms resolve or until they have diarrhea.

Maintenance

Allopurinol (take for a life time)

Chronic

Prevents uric acid formation

Probenecid

Chronic

Lowers uric acid by Increases excretion of uric acid in urine

**Can also be used in the acute phase

Definitions to know:

Acute pain – pain that is sudden in onset, usually subsides when treated, and typically occurs over less than a six months.

Chronic pain- persistent or recurring pain that is often difficult to treat usually more than 6 months.

Adjuvant analgesic drugs –drugs that are indicated for other purposes but also have an analgesic effect. Usually added for combined therapy with a primary drug.

Breakthrough pain- pain that occurs between doses of pain medication.

Patient Controlled Analgesic (PCA)- Narcotic will be on a pump. Examples: Morphine, Dilaudid,

Family members nor the nurse are not allowed to press the button to give the patient a dose.

Routes of Administration

Oral (preferred route of administration)

Rectal

Transdermal (if you put one on, take the other off)

Intraspinal

Intraventricular- delivered via external infusion pump through a catheter to the cerebral ventricles or through a subcutaneous reservoir (intermittent administration).

Intravenous/Subcutaneous- used when unable to administer (oral, rectal, transdermal)

Works fastest

Allow for rapid administration and increasing dosage

IM –least preferred route

Unable to adjust or give repeat doses due to inconsistent absorption from IM sites.

Patient-Controlled Analgesia (PCA)- On demand deliver of medication

Delivered vial IV ipr subQ in which the patient can control the amount of medication administered to them

Clinical Pearls

A large number of anti-inflammatory medications are enteric-coated or extended release. Do not crush or split these medications.

Be careful when administering aspirin to certain patients

children – could develop Reye’s syndrome

Patients due to have surgery- will need to stop medication up to 1 week to reduce risk of bleeding (NSAIDS)

Asthma patients –could develop adverse reactions such as bronchospasms, angioedema and urticaria (NSAIDs)