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Chapter 20 Drugs Used for Pain Management Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 20-1 Lesson 20.1 Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 20-2 Objectives Differentiate among the properties of opiate agonists, opiate partial agonists, and opiate antagonists. Describe the monitoring parameters necessary for patients receiving opiate agonists. Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 20-3 Objectives (cont.) Cite the common adverse effects of opiate agonists. Compare the analgesic effectiveness of opiate partial agonists when they are administered before or after opiate agonists. Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 20-4 Pain An unpleasant sensation that is part of a larger situation is a pain experience Three terms apply Pain perception—also called nociception Pain threshold—where pain is first perceived Pain tolerance—person’s ability to endure pain Pain described in more than one way Acute pain—short-term, as from injury Chronic pain—slower onset, lasts longer than 3 months beyond the healing process Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 20-5 Pain (cont.) Pain classified by pathophysiology Nociceptive—dull and aching Somatic—originates from skin, bones, or muscles Visceral—originates from abdominal or thoracic areas Neuropathic—results from nerve injury; stabbing and burning Idiopathic—nonspecific and of unknown origin Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 20-6 Pain Management Analgesics relieve pain; can be classified according to neurologic mechanisms Opiate agonists—for severe acute pain Opiate partial agonists—for unrelieved or moderate acute pain Opiate antagonists—reverse adverse effects of opiate agonists Salicylates—for mild acute pain Nonsteroidal antiinflammatory drugs (NSAIDs)— for mild acute pain Miscellaneous Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 20-7 Nonanalgesic Therapy for Pain Management When injury occurs, the body releases chemicals that contribute to pain Drugs used to block these chemicals include Antihistamines Prostaglandin inhibitors (NSAIDs) Antidepressants (TCAs and SSRIs) Substance P antagonists (capsaicin) Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 20-8 Pain Assessment Considered fifth vital sign To be assessed with vital signs and before and after interventions Pain assessment tools Various tools for nonverbal patients, infants, and children Scale of 0 to 10 (0 is no pain, 10 is intense) Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 20-9 Pain Assessment (cont.) Patient’s perception of pain Believe pain experience Note onset, location depth, quality, duration, and severity Nonverbal behavior Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 20-10 Nonpharmacologic Pain Management Nonpharmacologic strategies enhance effects of medications General comfort measures: backrubs, repositioning, heat/cold applications Relaxation techniques Diversional activities Decreased environmental stimulation Visualization Biofeedback Meditation Transcutaneous electrical nerve stimulation (TENS) unit Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 20-11 Medication Encourage patient to request pain medication before pain escalates Identify when last dose of pain medication was administered Pain scale assessment used with pain relief range orders Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 20-12 Patient-Controlled Analgesia (PCA) Syringe pump contains opiate agonist (usually morphine) connected to IV pump, IV catheter Patient self-administers small dose of analgesic Pump limits amount and frequency of dose Provide patient/family teaching Record amount used and degree of pain relief Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 20-13 Audience Response Question 1 The nurse is educating a postoperative patient about the use of a patient-controlled analgesia (PCA) pump. Which statement by the patient indicates a need for further teaching? A. B. C. D. “I’m afraid I’ll give myself too much medicine and become addicted to it.” “I can only receive the medication every 10 minutes.” “I’ll let the nurse know if my pain doesn’t improve.” “I’ll be sure to push the button to give myself pain medicine before I get up into a chair.” Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 20-14 Drug Class: Opiate Agonists Actions Act on same sites in the brain as morphine to stimulate analgesic effects Block the pain sensation Uses Relieve acute or chronic moderate/severe pain Can be used preoperatively or to supplement anesthesia Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 20-15 Drug Class: Opiate Agonists (cont.) Drugs Morphine and morphine-like derivatives; codeine, hydrocodone, oxycodone, meperidine-like derivatives; methadone-like derivatives; other opiate agonists Common adverse effects Lightheadedness, dizziness, sedation, sweating, confusion, disorientation; orthostatic hypotension, nausea, vomiting, constipation Serious adverse effects Respiratory depression; urinary retention; excessive use or abuse, increased effect with CNS depressants Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 20-16 Monitoring Parameters for Opiate Agonists Premedication assessment and planning Appropriate pain assessments Therapeutic goals Pain at rest less than 3 on pain scale Pain with movement less than 5 on pain scale Able to have at least 6 hours of sleep without interruption by pain Able to work at hobby for 1 hour Observe for vital signs and mental status changes, especially respiratory rate. Hold medication if respirations are below 12/min for adult; consult with health care provider Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 20-17 Audience Response Question 2 Which common adverse effect may be seen with use of opiate agonists? A. B. C. D. Appetite stimulation Orthostatic hypotension Mood elevation Increased respirations Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 20-18 Drug Class: Opiate Partial Agonists Actions Effective analgesic without prior administration of opiate agonists Pharmacologic action depends on whether an opiate has been previously administered Subject to ceiling effect Prolonged use leads to tolerance Uses Short-term relief (up to 3 weeks) of moderate to severe pain associated with cancer, burns, renal colic; preoperative analgesia, and obstetric and surgical analgesia Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 20-19 Drug Class: Opiate Partial Agonists (cont.) Drugs Buprenorphine (Buprenex, Subutex) Butorphanol (Stadol) Nalbuphine (Nubain) Pentazocine (Talwin) Common adverse effects Clamminess, dizziness, sedation, sweating; nausea, vomiting, dry mouth, constipation Serious adverse effects Confusion, disorientation, hallucinations; respiratory depression; excessive use or abuse Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 20-20 Drug Class: Opiate Antagonists Drugs Naloxone (Narcan) Naltrexone (Revia) Action Reverse respiratory depression, sedation, hypotension associated with opiate agonists and opiate partial agonists Uses Treat respiratory depression from excessive doses of opiate agonists or opiate partial agonists; drug of choice Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 20-21 Audience Response Question 3 After receiving a dose of morphine for postoperative pain, a patient becomes unresponsive, with a respiratory rate of 10/minute, with shallow breathing. The nurse should anticipate administering which medication? A. B. C. D. Naloxone Nalbuphine Meperidine Pentazocine Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 20-22 Education for Patients Discharged with Analgesics When to call health care provider Report poor pain control Adverse effects that occur Common adverse effects Light-headedness, dizziness, sedation, nausea, sweating; confusion, disorientation; orthostatic hypotension; constipation Encourage using the smallest dose that relieves pain Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 20-23 Lesson 20.2 Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 20-24 Objectives Describe the three pharmacologic effects of salicylates. List the common and serious adverse effects and drug interactions associated with salicylates. Explain why synthetic nonopiate analgesics are not used for inflammatory disorders. Identify the substances listed in Table 20-4 that are the active ingredients in commonly prescribed analgesic combination products. Identify products that contain aspirin and compare the analgesic properties of agents available in different strengths. Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 20-25 Drug Class: Salicylates Actions Inhibit prostaglandin synthesis Three pharmacologic effects: analgesic, antipyretic, antiinflammatory Aspirin has unique property of inhibiting platelet aggregation and clotting Uses Discomfort, pain, inflammation, or fever associated with bacterial and viral infections; drug of choice Headaches, muscle aches, rheumatoid arthritis Reduce risk of myocardial infarction, TIA, stroke Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 20-26 Audience Response Question 4 Which classification does not describe a property of salicylates? Analgesic B. Antipyretic C. Antiplatelet D. Sedative E. Antiinflammatory A. Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 20-27 Drug Class: Salicylates (cont.) Drugs Aspirin (ASA, Empirin), diflunisal (Dolobid), magnesium salicylate (Doan’s, Novasal) Common adverse effects GI irritation Serious adverse effects GI bleeding; salicylism (tinnitus, impaired hearing, dimming of vision, sweating, fever, lethargy, dizziness, mental confusion, nausea and vomiting) Use in children not recommended due to risk of Reye’s syndrome Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 20-28 Miscellaneous Analgesics Drug: acetaminophen (Tylenol) Actions Synthetic nonopiate; no antiinflammatory activity Uses Fever and pain reduction, therapeutic effects similar to aspirin Common adverse effects Gastric irritation Serious adverse effects Hepatotoxicity Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 20-29 Acetaminophen (cont.) Signs of toxicity: anorexia, nausea, vomiting, low blood pressure, confusion, abdominal pain Later signs, jaundice, and increased AST/ALT levels Maximum daily adult dose: no more than 4 grams of acetaminophen daily Antidote is acetylcysteine Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 20-30 Analgesic Combination Products Table 20-4 Examine products containing the following and note dosages of each drug Aspirin and caffeine, aspirin and codeine Aspirin, acetaminophen, and caffeine Acetaminophen, caffeine, and butalbital Aspirin, caffeine, and butalbital Acetaminophen and hydrocodone, acetaminophen and codeine Acetaminophen and oxycodone Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 20-31 Drug Class: NSAIDs Actions “Aspirin-like” but unrelated to salicylates Prostaglandin inhibitors Block cyclooxygenase (COX-1 and COX-2) Varying degrees of analgesic, antipyretic, and antiinflammatory activity Uses Relief of pain and inflammation from rheumatoid arthritis, osteoarthritis, ankylosing spondylitis, gout Dysmenorrhea, minor aches and pains Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 20-32 Drug Class: NSAIDs (cont.) Drugs Diclofenac (Cataflam, Voltaren), etodolac, fenoprofen (Nalfon), flurbiprofen (Ansaid), ibuprofen (Motrin, Advil), others Common adverse effects Gastric irritation, constipation; dizziness, drowsiness Serious adverse effects GI bleeding; hepatotoxicity; confusion; hives, pruritus, rash, facial swelling; nephrotoxicity; blood dyscrasias Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 20-33 Audience Response Question 5 What is a common but serious adverse effect of nonsteroidal antiinflammatory drugs (NSAIDs)? Increased upper GI bleeding B. Excessive drowsiness C. Antipyretic action D. Diarrhea A. Mosby items and derived items © 2013, 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 20-34