Nursing 200 Analgesics 2024 PDF

Pain & Inflammation: Non-opioid and Opioid Analgesics NURSING 200 ‹#›  ANALGESICS A GROUP OF MEDICATIONS THAT RELIEVE PAIN WITHOUT CAUSING LOSS OF CONSCIOUSNESS. ALSO KNOWN AS “PAINKILLERS” INCLUDES OPIOID AND NON- OPIOID AGENTS. ‹#› ...

Pain & Inflammation: Non-opioid and Opioid Analgesics NURSING 200 ‹#›  ANALGESICS A GROUP OF MEDICATIONS THAT RELIEVE PAIN WITHOUT CAUSING LOSS OF CONSCIOUSNESS. ALSO KNOWN AS “PAINKILLERS” INCLUDES OPIOID AND NON- OPIOID AGENTS. ‹#›  What is PAIN? PHYSICAL PSYCHOLOGICAL involves actual sensation of represents emotional response pain (various nerve paths and to pain brain) Very subjective; varies widely referred to as pain threshold- among persons, it is greatly level of stimulus needed to molded by the person’s age, sex, produce the sensation of pain culture, previous experience Genetically influenced - µ (mu) with pain, anxiety level opioid receptor gene; when referred to as pain tolerance- individual has a high number of amount of pain a person can µ receptors, pain sensitivity is endure without it interfering reduced with normal function ‹#› Visual Pain Scale ‹#›  Conditions that Alter Pain Threshold LOWERED THRESHOLD RAISED THRESHOLD (more likely to be experienced) (less likely to be experienced) anger diversion anxiety empathy depression rest discomfort sympathy fear medications (analgesics, anti- isolation anxiety agents, and chronic pain antidepressants) sleeplessness and tiredness ‹#› ‹#›  SOURCES OF PAIN Somatic Pain Visceral Pain originates from originates from skeletal muscles, organs or smooth ligaments or joints muscles usually responds usually requires better to non- opioids for relief opioid medications (NSAID’s for example) ‹#› ‹#› Undertreatment of Pain Up to 75% of patients have unrelieved pain. Reasons for undertreatment Sociocultural variables Patient inability or willingness to describe pain Lack of regular assessment Health care team attitudes Inaccurate knowledge concerning addiction/tolerance Effects of unrelieved pain Increased HR, RR, B/P Increased stress response Urinary retention Hyperglycemia etc. ‹#› WHO ladder for treatment of pain ‹#› NON-OPIOID ANALGESICS Less potent than opioid analgesics Used to treat mild to moderate pain Effective for the dull, throbbing pain of headaches, dysmenorrhea, inflammation, minor abrasions, muscular aches and pain, and mild to moderate arthritis ‹#›  Acetaminophen Action Inhibits prostaglandin synthesis Uses Relieves pain, discomfort, fever Side effects Rash Low incidence of GI distress Toxic effects/overdose Hepatotoxicity Thrombocytopenia ‹#› How much acetaminophen is safe? ‹#› Class/ Prototype- Administration Cons Adverse/Side Therapeutic Effects Subclass generic iderations Effects Can be given orally, rectally, and IV Assess pain prior to and after administration Administer with a full Skin reddening Nonopioid glass of water Blisters Relief of mild pain and analgesic acetaminophen Maximum dose over Rash fever Antipyretic 24-hour period: Hepatic failure -4000 mg for adults, (liver damage) -3200 mg for geriatric patients -2000 mg for patients with chronic alcoholism ‹#› Acetylcysteine Antidote for acetaminophen poisoning Converts toxic metabolites in the liver to a nontoxic form ‹#› NSAIDs Action: Inhibitition of cycloxygenase 1st generation NSAIDS Aspirin (ASA) Ibuprofen (Motrin, Advil) Naproxen (Aleve) Ketorlac Inhibit COX-1 and COX-2 Indomethacin Diclofenac Meloxicam 2nd generation NSAID Celecoxib } Inhibit COX-2 ONLY Inhibition of COX-1 causes kidney damage and decreased platelet aggregation Inhibition of COX-2 causes decreased inflammation, fever and pain. Does not cause decreased platelet aggregation. ‹#› COX-1 and COX-2 Inhibitors Uses of COX-1 and COX-2 Inhibitors. ‹#› Class/ Prototype Adverse/Side Administration Considerations Therapeutic Effects Subclass -generic Effects Given parenterally and orally Assess pain prior to and after administration May take with food or milk if Headache stomach upset occurs GI bleed Nonopioi Stay well hydrated to prevent renal Constipation d failure Dyspepsia analgesic To relieve mild pain and to ibuprofen Assess patient for signs of GI Nausea NSAID reduce fever bleed Vomiting Antipyreti Assess for skin rash Steven-Johnson c Monitor BUN, serum creatinine, syndrome CBC, and liver function test Renal failure Do not administer to patients who are allergic to aspirin or other NSAIDs ‹#› Class/Subcla Prototype- Administration Considerations Therapeutic Effects Adverse/Side Effects ss generic Given orally, parenterally and as an ophthalmic solution Assess pain prior to and after administration Therapy should always be given initially by the IM or IV route; then Drowsiness use the oral route as a Headache continuation of parenteral therapy GI bleed Stay well hydrated to prevent Abnormal taste Nonopioid To relieve moderate renal failure Dyspepsia analgesic ketorolac pain short term (not to Assess patient for signs of GI Nausea NSAID exceed 5 days) bleed Steven-Johnson Assess for skin rash syndrome Monitor BUN, serum creatinine, Edema CBC, and liver function tests Renal failure Do not administer before any major surgery Do not administer to patients who are allergic to aspirin or other NSAIDs ‹#› Mrs. Emily Johnson Age: 68 Gender: Female Medical History: Hypertension, peptic ulcer disease, chronic kidney disease (Stage 3), osteoarthritis Current Medications: Lisinopril (ACE inhibitor), Omeprazole (Proton pump inhibitor), Acetaminophen (as needed for pain) Presenting Complaint: Mrs. Emily Johnson presents with complaints of worsening joint pain in her knees and hips. She has a history of osteoarthritis, and her pain has been increasing over the past few months. She is finding it difficult to perform her daily activities and is seeking relief from her discomfort.  Salicylates Aspirin (acetylsalicylic acid) (ASA) Action Antiinflammatory, antiplatelet, antipyretic effects Therapeutic serum salicylate level 15 to 30 mg/dL Greater than 30 mg/dl ‹#›  Salicylates (Cont.) Interactions Drugs Increased bleeding with anticoagulants Hypoglycemia with oral antidiabetics Increased gastric ulcer risk with glucocorticoids Labs Increase PT, bleeding time, INR, uric acid Decrease potassium, cholesterol, T₃ and T₄ levels Foods containing salicylates Prunes, raisins, licorice, certain spices ‹#›  Salicylates (Cont.) Caution Do not take with other NSAIDs. Avoid during pregnancy Do not give to children with flu or virus symptoms (Reye syndrome). Side effects/adverse reactions Tinnitus, hearing loss Dizziness, confusion, drowsiness GI distress, peptic ulcer Thrombocytopenia, leukopenia, agranulocytosis Hepatotoxicity ‹#›  Salicylates ty vi iti ns Tinnitus, dizziness, bronchospasm se (Cont.) er yp H m Tinnitus, dizziness, is l ) headache, confusion, y ic ild l sweating, drowsiness, Sa (m thirst, nausea, vomiting, diarrhea re e v e at Convulsions, e yl ng cardiovascular collapse, S lic ni coma sa oiso p ‹#› Class/ Prototype- Administration Considerations Therapeutic Effects Adverse/Side Effects Subclass generic Give orally Assess pain prior to and after administration Children under 12 years: do not use unless directed by a provider Take with a full glass of water and sit upright for 15-30 minutes after administration Nonopioid Take with food if the patient Treatment of mild pain and analgesic GI upset reports that aspirin upsets their fever (NSAID) aspirin GI bleeding stomach Reduces the risk of heart Antipyreti Tinnitus Do not crush, chew, break, or attack and stroke c open an enteric-coated or delayed-release pill; it should be swallowed whole The chewable tablet form must be chewed before swallowing Should be stopped 7 days prior to surgery due to the risk of postoperative bleeding ‹#› Reye’s Syndrome Danger ‹#› Oxicams Indicated for long- term arthritic conditions Can cause gastric problems like ulceration and Piroxicam, epigastric distress Meloxicam Well-tolerated Should not be taken with aspirin or other NSAIDs Full clinical response in 1 to 2 weeks ‹#›  Selective COX-2 Inhibitors Action Selectively inhibits COX-2 enzyme without inhibition of COX-1 Use Decrease inflammation and pain Drug agents Celecoxib Similar agents Nabumetone ‹#›  Selective COX-2 Inhibitors (Cont.) Avoid in pregnancy Caution/Contra Teratogenic in 3rd trimester indicated Alcohol use disorder Headache, dizziness, sinusitis GI distress Side effects Peripheral edema Greater incidence of GI distress, ulceration NSAIDs in Reduced dose decreases risk of side effects. older adults Class/Subclas Prototype Administration Considerations Therapeutic Effects Adverse/Side Effects s -generic Hypertension Peripheral edema Increased liver enzymes Abdominal pain, dyspepsia, gastroesophageal reflux disease, vomiting, and May be given with or without food diarrhea May sprinkle capsules on applesauce Cardiovascular thrombotic and ingest immediately with water NSAIDs To decrease pain and events Monitor patients for signs and symptoms COX-2 celecoxib inflammation caused by GI bleeding, ulceration and of Steven-Johnson syndrome inhibitor arthritis or spondylitis perforation Monitor for signs and symptoms of GI Hepatotoxicity bleed, hypertension, and heart failure Hypertension Monitor liver enzymes Heart failure and edema Renal toxicity and hyperkalemia Anaphylactic reactions Serious skin reactions Hematologic toxicity ‹#›  OPIOID ANALGESICS Opium obtained from the unripe seeds of the opium poppy Opium has been used for many hundreds of years for pain relief Brought to the U.S. by opium-smoking immigrants Was unrestricted until the early 20th century ‹#› Common Opioid Analgesics Generic Name Trade Name(s) Route Adult Dosage codeine/acetaminophen Tylenol #3 PO 30 mg/300 mg Transdermal Duragesic 12 mcg-100mcg/hr0.5-1 mcg/kg fentanyl IM Sublimaze 0.5-1 mcg/kg IV 5 mg/300mg or 325 mg10 Lortab Norco PO PO hydrocodone/acetaminophen mg/320mg or 325 mg Vicodin PO PO Rectal 4-8 mg3 mg hydromorphone Dilaudid SubQ, IM & IV 1.5 mg (may be increased) Duramorph, MS Contin, Oramorph SR, & PO & Rectal 30 mg (may be increased)4-10 mg morphine Roxanol-T SubQ, IM, & IV (may be increased) Oxycodone Oxy IR, Oxycontin & Oxy-FAST Percocet & 5 mg-10 mg (may be increased)5 PO PO oxycodone/acetaminophen Roxicet mg/325 mg ‹#›  Opioid Analgesics: Mechanisms of Action Can be agonists, partial agonists, or antagonists……. AGONIST: binds to a receptor and causes a response PARTIAL AGONIST: binds to a receptor and causes only limited action ANTAGONIST: binds to a receptor and causes no response; competes for binding sites with agonist Opioid Analgesics: Therapeutic Uses Main use is to relieve moderate to severe pain Many have an affinity (attraction to) for the CNS. Suppress the medullary cough center and therefore, result in cough suppression Often combined with drugs from other chemical categories. NSAID’s approach pain from another mechanism and are commonly used with opioids for their synergistic effect ‹#› Therapeutic Uses (Cont.) Strong opioid analgesics such as fentanyl (Sublimaze), sufentanil (Sufenta), and alfentanil (Alfenta) are commonly used in combination with anesthetics during surgery. Practice of using a combination of drugs rather than a single agent to produce anesthesia is known as balanced anesthesia ‹#› Side Effects Central Nervous System: sedation, disorientation, euphoria, light- headedness, dysphoria, lowered seizure threshold, tremors Cardiovascular: hypotension, palpitations, flushing Respiratory: respiratory depression, aggravation of asthma GI: nausea, vomiting, constipation, and biliary tract spasm Other: itching, rash, wheal formation, urinary retention ‹#›  Respiratory Depression One of the most serious side effects of the opioids; it is strongly related to the degree of sedation Despite careful titration, sometimes a patient may experience respiratory compromise May require assisted ventilation May require an opioid reversal agent such as naloxone (Narcan) to reverse the respiratory depression. *A reversal agent, such as Narcan (narcotic antagonist) will also reverse pain control ‹#› You must monitor the VITAL SIGNS! Always monitor the V/S before, during, and after giving opioid analgesics. Withhold the medication if respirations are < 12 breaths/minute or if there are any changes in the level of consciousness ‹#› Release the Histamine! All opioids cause histamine release (natural opioids release more than synthetics). Believed to be responsible for many of the unwanted side effects: itching, pruritis, rash hemodynamic changes flushing Many patients will refer to these histamine mediated reactions as “allergic reactions”, but “true” anaphylaxis is rare ‹#› G.I. Side Effects Opioids irritate the gastrointestinal tract, so GI effects are common they stimulate the chemoreceptor trigger zone, causing: nausea vomiting they slow peristalsis and increase water absorption, causing: CONSTIPATION (more pronounced in non-ambulatory patients) ‹#› Psychological Dependence AKA “addiction” A pattern of compulsive drug use characterized by a continuous craving for an opioid and the need to use it for effects other than pain relief (i.e. euphoria). ‹#›  Physical Dependence The physiologic adaptation of the body to the effects of an opioid. Opioid tolerance: the patient requires larger and larger doses of the opioid agent to maintain the same level of analgesia Opioid tolerance and physical dependence are expected in patients undergoing long-term opioid treatment. Do not confuse this with psychological dependence. ‹#›  Opioid Abstinence Syndrome A physiologic response seen when an opioid agent is abruptly discontinued, or an opioid antagonist (such as Narcan) is administered. Manifestations: anxiety, irritability, chills, hot flashes, joint pain, lacrimation, rhinorrhea, diaphoresis, nausea, vomiting, abdominal cramping, diarrhea. Appearance of the syndrome indicates physical dependence on opioids, but DOES NOT imply psychological dependence (addiction). ‹#›  Opioid INTERACTIONS Additive effects are seen, and you increase the risk of respiratory depression, when opioids are combined with: alcohol antihistamines barbiturates benzodiazepines MAO inhibitors phenothiazines other CNS depressants ‹#›  Opioid Agonists Morphine Codeine C-II scheduled substance C-II scheduled substance may be given by a variety of routes similar to morphine, but less depending on pt. condition effective as an analgesic indicated for severe pain widely used as an antitussive HIGHLY CONSTIPATING (assess indicated for mild to moderate bowel function routinely) pain use with extreme caution in patients may also be used as a treatment with head injuries Do not confuse with meperidine for control of diarrhea (an (Demerol) or hydromorphone unlabeled use), since it is (Dilaudid) constipating variety of routes Hydromorphone A semisynthetic opioid similar to morphine Analgesic effect is approximately six times more potent than morphine with fewer hypnotic effects and less GI distress. Side effects and adverse reactions Contraindications ‹#›  More Opioid Agonists Fentanyl Meperidine C-II scheduled substance- VERY C-II, synthetic opioid POTENT analgesic widely used indicated for moderate to severe for moderate or severe pain pain and as an adjunct to general may cause fatal reaction in patien anesthetics receiving MAO inhibitors variety of routes, including variety of routes transdermal (Duragesic patch), do not confuse with morphine or where it is effective for treatment of hydromorphone (Dilaudid) chronic pain (such as cancer) repiratory depression may last longer than analgesic effects ‹#› https://www.nflis.deadiversion.usdoj.gov/nflisdata/docs/NFLISDrug_2021AnnualReport.pdf ‹#› ‹#›  Partial Opioid Agonists Partial Agonist- a substance that binds to a receptor and causes effects similar to, but less INCLUDES: pronounced than, those of a buprenorphine (Subutex, pure agonist Suboxone) AKA agonist/antagonists butorphanol (Stadol) potent analgesia, but misuse dezocine (Dalgan) potential and addiction nalbuphine (Nubain) liability are low pentazocine (Talwin) antagonist action can produce withdrawal in opioid dependent pts ‹#›  Opioid Antagonists Naloxone (Narcan) a pure antagonist, no agonist properties drug of choice for complete or partial reversal of opioid induced respiratory depression also indicated in diagnosis of suspected acute opioid overdose can precipitate withdrawal in patients who are physically dependent on opioids ‹#›  Opioid Antagonists (Cont.) Naloxone (Narcan) Side effects Tremors, sweating Hypertension, tachycardia, excitement Nausea, vomiting Reversal of analgesia Dysrhythmias Elevated PTT, bleeding Nursing interventions Monitor vital signs and bleeding continuously  Prototyp Class/Su Adverse/Side e- Administration Considerations Therapeutic Effects bclass Effects generic Given parenterally and inhaledAssess for reversal of opioid AgitationTremors effect Drowsiness Opioid Blocks the effects of Assess for hypertension Sweating antagonis naloxone opioid CNS and Assess for return of pain Decreased t respiratory depression Naloxone has a shorter duration of respirations action than opioids, and repeated Hypertension doses are usually necessary Combination Drugs Hydrocodone and ibuprofen (Vicoprofen) Hydrocodone and acetaminophen (Lortab, Vicodin) Oxycodone and acetaminophen (Percocet) Oxycodone and aspirin (Percodan) Acetaminophen and codeine (Tylenol #__) ‹#›  Transdermal Opioid Analgesics Provide a continuous “around-the-clock” pain control that is helpful to patients who suffer from chronic pain Fentanyl (Duragesic) Fentanyl is more potent than morphine. Exercise caution when prescribing fentanyl for patients who weigh less than 110 pounds. Analgesics in Special Populations Children Older adults Cognitively impaired individuals Oncology patients Individuals with a history of substance abuse ‹#› Adjuvant Therapies Adjuvant therapy is usually used along with a nonopioid and opioid. Examples of adjuvant analgesics include anticonvulsants, antidepressants, corticosteroids, antidysrhythmics, and local anesthetics.