Pain 3

Routes of Administration

• Routes of administration include: oral, intravenous, intramuscular, subcutaneous, topical, inhalation and targeted
• Other routes of administration include: portal circulation, rectal, sublingual, intrathecal, transdermal
• Patient-controlled analgesia (PCA) allows patients to self-administer pain medication

Pain & Pain Treatment

• Considerations for pain treatment include identifying the cause, evaluating risk vs benefit, and considering synergy

• Monitoring the efficacy of pain treatment and side effects is crucial

• Adjunct therapies can be utilized for comprehensive pain management

• Analgesia includes synergy treatment

• It has the combination of two or more drugs where their effect is greater than if used on their own

• Lower doses of each drug can be used, creating an effect while lowering the chance of side effects

• Treatment at the peripheral (PNS) level is highly effective if inflammation is present

• NSAIDs and Glucocorticoids can be used for PNS treatment

• Treatment at the central nervous system (CNS) level can be achieved through Opioids and Tylenol (acetaminophen)

Arachidonic Acid Pathway

• Arachidonic acid is converted into prostaglandins via the COX-2 enzyme, leading to inflammatory effects
• Prostaglandins contribute to pain, inflammation, and fever, with limited homeostatic effects
• NSAIDs and/or Glucocorticoids treat the pathophysiologies

Case Study & Questions

• Case Study: A 30-year-old patient with a fractured right arm experiencing acute pain.

• Abdominal injuries could be hard to catch in patients because the abdomen is large and bleeding won’t be obvious

• The use of a strong opioid is recommended for a patient rating their pain as 10/10, especially via IV, IM, or IN routes for fast action.

• Fentanyl 180 mcg, IN, STAT, is significant because In route is fast and it means to administer immediately which is good

• Morphine 5 mg, IV, q2h & advil 500 mg, PO, q4h is given to the pt, morphine is a weak opioid and advil is NSAID

• Two drugs are used for synergy, and to lower the risk of side effects

• The following inquiries are required:

  • "Do they have an allergy?"
  • "Do they have a history of addiction?"

• Assess if treatment helps with pain and a needle is required for morphine

• Assess vital signs as anaphylaxis may manifest with changes

• Should the patient have asthma drugs like Forotemol, Salbutamol and Albuterol are needed

• Hypotension, bradycardia, shallow breathing and low oxygen indicate blood loss

Opioid Side Effects & Prescription Changes

• Educate the pt to stay hydrated.
• A percocet is a weak opioid to wean off of stronger opioids in a shorter time
• Advil is given for anti-inflammation and Tylenol is given for analgesic purposes
• All this treatment helps the pt from down taking fentanyl, a strong opioid

Assessment Findings & Treatment

• Assessment reveals no rash, itchy skin, pale and warm skin, and no diaphoresis; no SOB, no dysphagia, able to speak in sentences; peripheral pulses
• An anti-pruritic or antihistamine addresses pruritus, using a 2nd generation antihistamine to minimize drowsiness

Acetaminophen (Tylenol)

• Centrally acting analgesic, but not anti-inflammatory, with synergy in combined medications(Tramacet)
• The MOA has many theories, but it interferes with PGs but not at the peripheral, and agonizes cannabinoid receptors
• It is antipyretic

Fever (Pyrexia)

• Hypothalamic response to pyrogens, which are exogenous or endogenous
• Exogenous pyrogens include endotoxins from bacteria, while endogenous pyrogens are inflammatory mediators
• The Aim is to destroy pathogens by high temperature
• High temperature increasesbasal metabolic rate (BMR) and causes discomfort
• It is a symptom only, determine the cause/diagnosis

Treatment: Antipyretics

• The goal is Patient comfort, decrease BMR and optimize cellular fx
• Use acetaminophen as a 1st choice with the best efficacy
• It induces hypothalamic-peripheral vasodilation.
• Safe for pediatrics and ObG patients

Acetaminophen in Combination Drugs

• Allergy-related symptom treatment, antihistamines should be used
• Some antitussives drugs have hydrocodone because coughing is at times desirable
• CNS depression of cough reflex with Codeine (opioid); Dextromethorphan
• Adrenergic agonist SNS stimulation decreases nasal secretions
• Drugs: ephedrine, pseudoephedrine

Cough Reflex

• Protective with afferent impulses to medulla is Corticol, modulating
• Involves efferent impulses diaphragm/lungs/intercostals, the Trachea and Effector muscles

Mucus & Phlegm

• Menthol cools nerve endings, and activates inhibitory interneurons to reduce pain

Barriers to Pain Relief:

• Healthcare professionals, patients, and the healthcare system can have barriers.
• Patients: Underreporting of pain
• Fear of creating addiction

Addiction

• A psychological problem which induces 4 C's
• Cravings
• Change in behaviour to to have the substance ASAP
• Compulsion to use
• Loss of Control over use
• Use despite harmful Consequences

Acute vs Chronic Pain

• Acute Pain: <10 days, self-limiting, active SNS responses, protective, treatable
• Chronic Pain: >6 months; C fibres; Neurogenic; inflammation, not self-limiting; absent modulators destructive; causes dysfunctions; needs multimodal treatment

Chronic Pain & Complex Regional Pain Syndrome (CRPS)

• CRPS involves repetitive & altered sympathetic nerve stimulation, chronic inflammation, and a pain cycle.
• Features include allodynia, skin changes, and muscle/joint stiffness

Chronic Pain: Treatment

• Change the patient thought process and behaviour
• Involves, counselling, CNS drugs and physiotherapy
• Decrease excitatory neurotransmitters and the use of
• Antagonist that binds glutamate, and NMDA, and
• Use SSRI's to enhance Serotonin, although there are side effects
• Sedation, decreases pain awareness, also sedation has a lot of side effects

Efficacy Overview:

• Tx of inflammation includes antihistamines, NSAIDs, Glucocorticoids and DMARD for tissue injury
• Tx of pain includes, Acetaminophen, NSAIDs, Glucocorticoid and opioids
• Methotrexate has some anti inflammtory properties and is mainly used for arthritis
• Tx of fever includes, Acetaminophen, NSAIDs and beta 2 adrenergic agonists