Analgesic Drugs

Understanding Pain
Most common symptom prompting people to seek health care Occurs when tissue damage activates free nerve endings of peripheral nerves Cerebral cortex analyzes messages and determines actions Activation of opiate receptors in CNS inhibits pain transmission

Understanding Pain
Pain is a subjective experience People differ in their perceptions, behavior and tolerance of pain Stressors increase pain Diversionary activities tend to decrease pain deep breathing, listening to music, visual imagery, others?

Acute pain can be super-imposed on chronic pain

 Try alternative measures for pain control in addition to drugs Promote circulation and musculoskeletal function Use heat or cold as ordered Relieve pain ASAP Administer analgesic before pain producing activities Use the least amount of the mildest drug likely to be effective

Types of Pain
Acute pain Chronic pain Superficial pain Deep pain

NARCOTICS OPIOIDS
Opioid-any derivative of opium plant or any synthetic drug that imitates natural narcotics Opioid agonists-include opium derivatives and synthetic drugs w/similar properties (Kee p.332) Decrease pain without losing consciousness Opioid antagonists Block effects of opioid agnoists Used to reverse drug reactions-RD, CNS depression Narcan (always keep antagonist nearby)

 Opioid agonists
Any route Inhalation uncommon Absorbed from GI tract Transmucosal / intrathecal fast acting IV provides most rapid and almost immediate Sub Q and IM delayed absorption
Poor circulation can cause further delay

Metabolized extensively in the liver

Administration of meperedine > 48 hours increases risk of neurotoxicity and seizures from buildup

Pharmacodynamics
Reduce pain by binding to opiate receptors in PNS/CNS Stimulation of opiate receptors-mimic effects of endorphins the bodys naturally occurring opiates Cause dilation of blood vessels in head, neck, face could result in increased cranial pressure With the exception of Demerol, suppress cough center to have antitussive effect Adverse / Side effects include constipation, respiratory depression, nausea, vomiting, urinary retention, orthostatic hypotension Morphine relieve dyspna r/t pulmonary edema

 Nursing process
Assess pain before and after administration Monitor for adverse reactions / side effects Monitor for tolerance dependence
Shortened duration of effect

Evaluate respiratory status before each dose

Respiratory depression Restlessness

Mechanisms by Which Opioid Analgesics Work

Reduce the perception of pain sensation Produce sedation Decrease emotional upsets associated with pain

Characteristics of Opioid Analgesics

Most are Schedule II or III drugs Morphine (MSO4) is the prototype May be given PO, IV, IM, SQ, or topically Oral drugs undergo significant first-pass metabolism Metabolized by liver and excreted in urine

 Exert CNS effects Use cautiously in clients with renal or hepatic disease, respiratory depression or increased intracranial pressure Exert depressant effect on GI tract Not recommended for prolonged periods of use except with chronic pain or malignant diseases

Morphine
Naturally occurring opium alkaloid Used to relieve severe pain Maximum analgesia occurs in 10-20 minutes with IV route Controlled released tablets given for chronic pain May be given intrathecally or epidurally Route determines time interval or frequency of administration

Hydromorphone (Dilaudid)
Synthetic derivative of morphine Same actions, uses, adverse effects as morphine More potent on a mg per mg basis More effective orally than morphine Effects last longer than morphine

Meperidine (Demerol)
Synthetic drug similar to morphine Dose of 100mg is equivalent to Morphine 10mg Has shorter duration Has less respiratory depression and little antitussive effect Causes less smooth muscle spasm

Codeine
Naturally occurring opium alkaloid Used for milder pain Acts as an antitussive (found in cough meds) Often combined with acetaminophen Preferred analgesic with head trauma

Oxycodone
Semisynthetic derivative of codeine Used to relieve moderate pain More potent and more likely to produce abuse than codeine Available in combination with acetaminophen

Opioid Antagonists
Reverse or block analgesia, CNS and respiratory depression of opioid agonists Compete with opioids for opioid receptor sites in brain Do not relieve depressant effects of anti-anxiety drugs or antipsychotics Naloxone - oldest, most commonly known Nalmefene - newer with longer duration Naltrexone - used in maintenance of opiate free states in opiate addicts

Client Teaching For Opioid Analgesics

Narcotics may be alternated with a non-narcotic analgesic If pain relief not achieved notify physician Do not drink alcohol or take other drugs that cause drowsiness Do not smoke, cook, drive a car or operate machinery after taking

 Constipation is a common adverse effect Do not crush or chew long acting tablets Decrease dose or omit if adverse effects occur

Use In Older Adults

Use cautiously if debilitated or hepatic, renal or respiratory impairment Start with lower dose and increase gradually Give less often? Give opioid analgesic with short half-life (Oxycodone) Monitor for sedation or confusion Monitor urinary output Assess ability to self-medicate

Characteristics of Withdrawal From Opiates

Generalized body aches Insomnia Lacrimation Rhinorrhea Perspiration Pupil dilation Piloerection Anorexia N/V/D Increased vital signs Abdominal and other muscle cramps

Treatment Of Withdrawal Syndrome

Gradually reduce the opioid over several days Substitute methadone and slowly reduce dose over a longer time Clonidine reduces withdrawal symptoms

NONNARCOTICS SALICYLATES
Salicylates-produce peripheral blood vessel dilation Most common pain reliever Control pain Reduce fever-stimulate hypothalmus Reduce inflammation ASA is oldest nonnarcotic analgesic Bonus effect-inhibits platelet aggregrate Guideline Use lowest dose that produces analgesia Highly protein bound-can interfere w/other drugs Heparin,methotrexate, oral antidiabetic meds, insulin

 Adverse reactions
Hearing loss Diarrhea Thirst Sweating Tinnitus Confusion Dizziness Impaired vision Hyperventilation Reyes syndrome-when given to children (do not use < 12 yrs old)

Common side effects

Gastric distress Bleeding tendencies NVD

Give w/food May crush except enteric coated Hold and notify MD for bleeding Stop ASA 5-7 days before elective surgery Salicylate hypersensitivity
Tinnitus or hearing loss Vertigo Bronchospasm Urticaria Need to avoid prunes, raisins, paprika, licorice

ACETAMINOPHEN
Acetaminophen Antipyretic and analgesic IS NOT ANTI INFLAMMATORY Drug of choice for children with flulike symptoms Risk of liver disease Phenytoin, barbituates, INH, ETOH Rarely cause GI distress-may cause LIVER toxicity Monitor total daily dose (adults 4g max.)

Phenazopyridine hydrochloride
Pyridium-now OTC Dye used in commercial coloringanalgesic effect on urinary tract Relieves pain, burning, itching, urgency,

Teach
Urine orange Stains fabric-contact lenses Notify in ineffective

Anti Inflammatory Drugs

 Anti inflammatory agents

Reduce body temperature Relief of pain Anticoagulant (ASA) Reduce inflammation

ASA oldest NSAIDS- reduce inflammation & pain for arthritic conditions Inhibit enzyme COX

 OTC Ibuprofen, Motrin, Nuprin, Advil, Medipren Naproxen (Aleve) Motrin only available in 200 mg form MD must prescribe higher dose

 Second generation NSAIDS COX-2 inhibitors COX 1 inhibitor Decreased protection of lining of stomach Clotting time decreased-benefit cardiovascular patients

 NSAIDS
Inhibit prostaglandin synthesis
Prostaglandins produced / released in inflammatory disorders

Ankylosing spondylitis Moderate to severe arthritis Osteoarthritis Acute gouty arthritis Dysmenorrhea Migranes Bursitis, tendonitis

 Adverse reactions
Abdominal pain, bleeding Anorexia Diarrhea, nausea Ulcers Liver toxicity Drowsiness Headache Tinnitus Confusion Vertigo Depression Blood in urine, bladder infection, kidney necrosis Sodium & water retention Heart failure Pedal edema

 Nursing implications
CBC, platelet count, PT Monitor hepatic / renal function Bronchospasm Monitor for s/s of bleeding Take w/meals Avoid alcohol

Corticosteroids
prednisone / prednisolone / dexamethasone Suppresses components of inflammatory process at the injured site NOT THE DRUG OF CHOICE FOR ARTHRITIC CONDITIONS USED TO CONTROL FLARE UPS Must taper dose when D/C

DMARDS-disease modifying antirheumatic drugs

Toxic Alter disease process Gold/Gold Salts IM/PO Used for relief of symptoms Immunosuppressive agents-used when antiinflammatories do not work-cytoxan, methotexrate/cancer drugs Antimalarials-when all other tx fails

Antiinflammatory Gout Drugs

gouty arthritis Urinary calculi Gouty nephrophaty

Increase fluid intake Avoid foods rich in purine - organ meats, sardines, salmon, gravy, legumes Avoid alcohol, caffeine, large doses of vitamin C Zyloprim - inhibits final steps of uric acid Colchicine - first drug, inhibits migration of leukocytes to the inflamed site

Propionic Acid Derivatives

Ibuprofen (Motrin) - prototype; ketoprofen (Orudis), naproxen (Naprosyn) Used as anti-inflammatory agents in gout, arthritis, tendonitis Used as analgesic for dysmenorrhea, episiotomy, minor trauma Used as antipyretic

 Better tolerated than ASA but more expensive Similar adverse affects as with ASA May lead to renal impairment Inhibits platelets only while drug molecules in bloodstream Combined with other drugs

Acetic Acid Derivatives

Indomethacin (Indocin) - prototype; Tolmetin (Tolectin), Sulindac (Clinoril) Used to treat moderate to severe rheumatoid arthritis, osteo-arthritis, gouty arthritis, bursitis, pericarditis for antiinflammatory effects Prescription drug Has increased incidence and severity of adverse effects

Client Teaching Guidelines

Take ASA and NSAIDS with full glass of water and food Drink 2-3 quarts of fluid daily with NSAIDS Report signs of bleeding Avoid or minimize alcoholic beverages Do not take more than prescribed amount Do not take more that 3 days for fever or 10 days for pain Read labels of other OTC medications