Week3Presentation.pptx
DrugsthatAffectPainandAntiinflammatories.docx
March 30, 2022April-1.pdf
March 30, 2022Medications That Treat Pain
Chapter 28-30
NSG 220
1
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”
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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 .
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Types of Pain
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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
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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.
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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
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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
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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)
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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**
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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
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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)
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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
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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
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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)
