Opioid Analgesics: Nursing Considerations

Non-Opioid Analgesics

• Aspirin and Ibuprofen are prototypes
• COX-1 and COX-2 inhibitors suppress inflammation, relieve mild to medium pain, reduce fever, relieve dysmenorrhea, and inhibit platelet aggregation
• Aspirin is used for inflammation suppression, analgesia for mild to moderate pain (osteoarthritis/rheumatoid arthritis), fever reduction, dysmenorrhea (moderate to severe menstrual pain), and inhibition of platelet aggregation.
• Complications include gastric upset, heartburn, nausea, gastric ulceration, bleeding (less with non-aspirin NSAIDs), kidney dysfunction
• Salicylism (aspirin) occurs if a client takes in more aspirin than they excrete
• Reyes syndrome (aspirin) occurs from giving aspirin to a child with a viral infection.
• NSAIDs are contraindicated if teratogenic, hypersensitive to aspirin or other NSAIDs, have peptic ulcer disease, bleeding disorders (hemophilia, vitamin K deficiency), children or adolescents with chicken pox or influenza
• Non-aspirin NSAIDs should not be given with perioperative use prior to coronary artery bypass grafting
• Aspirin should be discontinued within 1 week before any elective surgery
• Interactions: Anticoagulants, glucocorticoids, and alcohol increase the risk of bleeding.
• Ibuprofen decreases the antiplatelet effect of low-dose aspirin
• ACE inhibitors and angiotensin receptor blockers increase the risk of kidney failure
• Antihypertensive effects of ACE inhibitors decrease the risk of increased lithium carbonate and methotrexate toxicity
• Clients should swallow enteric-coated or sustained-release forms whole; do not crush or chew them.
• Discontinue 1 week before scheduled surgery.
• Monitor for initial and continued therapeutic effects.
• Nurses should administer PO
• Evaluation of Medical Effectiveness: reduced fever, client reports a lower level of pain, and inflammation has decreased
• Other first-generation NSAIDs: Naproxen, indomethacin, ketorolac, meloxicam, and diclofenac
• Clients should take with food, milk, or 8oz of water to minimize gastrointestinal effects and avoid alcohol while taking
• Clients should report gastric irritation, manifestations of bleeding, prolonged bleeding, changes in output, weight gain, or manifestations of fluid retention (edema or bloating), ringing or buzzing in the ears, sweating, headache, and dizziness.
• Do not give aspirin or NSAIDs to children under 19 with a viral infection such as chickenpox or influenza, instead use acetaminophen
• Instruct client to report chest pain, heaviness, shortness of breath, sudden and severe headache, numbness, weakness, visual disturbances, or confusion
• Take aspirin once daily to reduce the risk of heart attack and stroke if prescribed
• Salicylism will present with tinnitus, sweating, headache, dizziness, and respiratory alkalosis in aspirin toxicity when a client takes in more aspirin than they excrete

Ketoralac

• Unique administration principles.

Celecoxib

• Unique type of NSAID that has a unique, life-threatening adverse effect and contraindication
• This medication can cause thromboembolic events, monitor for manifestations of myocardial infarction and cerebrovascular accident
• Administer celecoxib 2 hours before or after magnesium or aluminum-based antacids

Acetaminophen

• Its effects are limited to CNS, has no anti-inflammatory or anticoagulant effects, and does not affect the gastric mucosa or platelets, which will decrease the risk for gastric ulcers and cardiovascular events
• Rare complications, but acute toxicity can happen
• Pregnancy risk category B for oral and rectal, C for IV use
• Contraindicated in anemia, immunosuppression, hepatic or kidney disease
• Alcohol increases the clients risk of liver damage
• Acetaminophen slows the metabolism of warfarin, increasing the risk of bleeding
• Administration of Acetaminophen should be oral or rectal, for a maximum of 4g a day
• Acetylcysteine is the acetaminophen antidote, use via duodenal tube to prevent emesis and subsequent aspiration
• Clients should read medication labels carefully to determine proper doses, and take only one product at a time that contains acetaminophen
• Acetaminophen toxicity can result in liver damage with manifestations of nausea, vomiting, diarrhea, sweating, and abdominal discomfort, progressing to hepatic failure, coma, and death.

Opioid Agonists and Antagonists

• Morphine is an opioid agonist
• Analgesic for moderate to severe pain, pre-op sedation, anxiety reduction, cough suppression (codeine), and reduction of bowel motility relief of diarrhea
• Complications: respiratory depression, dizziness/lightheaded or drowsy, constipation, nausea/vomiting, orthostatic hypotension, urinary retention, cough suppression, and potential for misuse and tolerance/cross-tolerance
• Have naloxone present in the client's room in case it is needed
• Take vitals before administering and continue to monitor closely throughout the treatment
• Caution with pregnant women, renal failure, increased cranial pressure, biliary colic, biliary surgery, and preterm labor.
• Opioid agonists increase CNS depressant effects when interacting with barbiturates, phenobarbital, benzodiazepines, and alcohol
• Anticholinergic effects increase, causing constipation and urinary retention when given with anticholinergic agents such as antihistamines and tricyclic antidepressants
• Other antihypertensive medications and St. John's wort can increase hypotensive effects and sedation, respectfully
• PO, IM, IV, subcutaneous, rectally, or epidurally; when ordered intravenously, give slowly over 4 to 5 minutes
• Ask the client to rate pain and wait 30-60 minutes after giving it orally
• Expect cough suppressing and resolution of diarrhea
• Clients should only take as needed and on a short‐term basis
• Do not take before driving or any activity requiring mental alertness, and sit or lie down immediately if feeling lightheaded
• Increase fluid and fiber intake as well as activity and exercise to prevent or treat constipation
• Other opioid agonists: Fentanyl, meperidine, methadone, codeine, oxycodone, hydromorphone
• Avoid taking with other CNS depressants, alcohol, anticholinergic agents, antihistamines, and tricyclic antidepressants to minimize the risk of adverse effects.
• Closely monitor pump settings (dose, lockout, interval, 4-hr limit) and inform the client about safeguards to reduce the risk of excessive doses when using a patient-controlled analgesia (PCA) pump

Fentanyl

• Unique routes of administration
• Transdermal patches will take several hours (up to 24 hours) to achieve the desired therapeutic effect.

Naloxone

• Interferes with the action of opioids by competing for opioid receptors and has no effect in the absence of opioids
• Temporarily reverses euphoria and respiratory depression
• Complications: tachycardia, tachypnea, and abstinence syndrome
• Have oxygen and resuscitation equipment ready
• Caution in pregnancy (can cause withdrawal syndrome in a client who has opioid dependence), lactation (safety not established), clients with physical dependency, brain tumor, seizure disorder, opioid dependence, and respiratory depression due to nonopioid meds
• Reverses effects of opioid agonists
• IV, IM, subcutaneous only, never ORAL
• Rapid infusion can cause hypertension, tachycardia, nausea, and vomiting
• Half-life of opioid analgesic can exceed the naloxone half-life (60 to 90 min); give until crisis has passed
• Evaluation of Medical Effectiveness: respirations return to regular, client is without shortness of breath, and respiratory rate is 12 to 20/min in adults and 30 to 60/min in newborns

Adjuvant Medications for Pain

• Ibuprofen is used with another primary pain medication, to increase relief while reducing the dosage of opioid agonists
• Reduced opioid dosages can result in reduced adverse effects, and targeting the pain stimulus using different types of pain medications can provide improved pain reduction
• Used to treat inflammation and fever and relieve mild to moderate pain and dysmenorrhea
• Complications: bone marrow suppression, Gl distress (presenting as abdominal pain, ulceration, nausea, vomiting, diarrhea, or constipation), and MI or stroke
• Avoid after 30 weeks of gestation and use cautiously with lactation
• Contraindicated with clients who have a history of bronchospasms with aspirin or other NSAIDs and those who have severe kidney/hepatic disease
• Use caution with clients with bleeding, GI, or cardiac disorders and in older adults
• NSAIDs can reduce the effectiveness of antihypertensives, furosemide, thiazide diuretics, and oral antidiabetic medications
• Increases GI effects when taken with aspirin, corticosteroids, alcohol, and tobacco
• NSAIDs can increase levels of oral anticoagulants and lithium
• Increases risk of bleeding with the use of other NSAIDs, thrombolytics, antiplatelets, anticoagulants, and salicylates
• Nursing Administrations: Oral or IV
• Ask client for self-report of pain, create a pain management plan for clients, and provide older clients with careful monitoring for adverse effects and adverse medication interactions
• Teach clients that pain medications should be given on a fixed schedule around the clock, and not as needed

Miscellaneous Pain Medications

• Sumatriptan is a migraine-specific medication that narrows the blood vessels around the brain and reduces substances that trigger headaches, pain, nausea, and sensitivity to light and sounds
• Complications: chest pressure (heavy arms or chest tightness), coronary artery vasospasms/angina, and dizziness or vertigo
• Contraindications/precautions: pregnancy, lactation, reproductive precautions
• Concurrent use of MAOIs can lead to MAOI toxicity and ergotamine or another triptan can cause vasospastic reactions
• Selective serotonin reuptake inhibitors (SSRIs) taken with triptans can cause serotonin syndrome
• Oral, subcutaneous, inhalation, transdermal
• Evaluation of effectiveness: a reduction in intensity of migraines and termination of migraine headaches
• Educate clients to recognize early signs of a migraine/headache and take as directed, inform of potential side effects and when to seek medical attention, and advise against using sumatriptan with other migraine medications without consulting a provider

Lidocaine

• Decreases pain by blocking the conduction of pain impulses in a circumscribed area without loss of consciousness for dental procedures, minor surgical procedures, labor and delivery, diagnostic procedures, and regional anesthesia
• Complications: CNS excitation and seizures followed by respiratory depression, leading to unconsciousness and hypotension cardiosuppression, bradycardia, heart block, reduced contractile force, and cardiac arrest
• Contraindicated in patients with a known hypersensitivity to local anesthetics
• Use cautiously in patients with severe liver disease, heart block, or a history of malignant hyperthermia
• Can interact with other medications that affect heart rhythm, such as beta-blockers and antiarrhythmics
• Parenteral (injection) with monitoring for signs of adverse effects
• Numbs and relieves pain at the affected site with no excessive redness, swelling, or irritation
• Clients should avoid activities requiring alertness until the effects of lidocaine have worn off
• Avoid hot food or drinks if applied in the mouth

EMLA administration

• Topical cream for anesthesia before procedures, applied to intact skin 1 hr before routine procedures/superficial puncture and 2 hrs before more extensive/deep puncture procedures
• Apply to the smallest surface area needed to minimize systemic absorption
• Prior to the procedure, remove the dressing and clean the skin with aseptic solution; can be applied at home before coming to the facility