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Transcript
Chapter 7 Drugs for Pain and Sleep Problems Barriers to Good Pain Management Patient’s and health care workers fear of addiction Patient’s fear of meaning of pain, for example: o Worsening of condition o Threats to independence o Impending death Patient’s and health care worker’s belief that pain is an expected part of aging Patient’s fear of testing Health care workers fear of “drugging the older adult” Health care provider’s fear of overdosing a patient Acute Pain Sudden onset Often has an identifiable cause Limited duration Triggers physiologic responses: o Increased heart rate and breathing o Increased blood pressure o Sweating Improves with time Variable intensity Relatively superficial Described as sharp, stabbing, pricking, or electric Chronic Pain Intermittent or persistent Exact cause may or may not be known Unlimited duration Physiologic responses disappear with time Does not improve and may even worsen Intensity may increase over time Deeper pain Described as burning, aching, throbbing Main Features of Cancer Pain The most distressing and most feared complication of cancer Complex, with many emotional and physical issues More than one cause Shares features with acute pain and chronic pain Can be present in more than one body area at the same time Usually occurs later in cancer progression Can be managed by usually requires more than one drug type for adequate control Type of pain in which nonopioid miscellaneous drugs play a major role Common Opioids morphine (Morphine Sulfate, Duramorph, Epimorph, Morphitec, Roxanol, MS Contin) hydromorphone (Dilaudid, Hydrostat) meperidine (Demerol) codeine (Paveral) fentanyl (Fentanyl, Actiq, Oralet) fentanyl transdermal (Duragesic) oxycodone (OxyContin, OxyFast, Supeudol) oxycodone with acetaminophen (Endocet, Percocet, Tylox) oxycodone with aspirin (Endodan, Oxycodan, Percodan) oxymorphone (Opana, Numorphan) hydrocodone (Lortab, Vicodin) hydrocodone with acetaminophen (Dolacet, Polygesic, Vicodin) tramadol (Ultram) Common NSAIDs Drug class: Acetic acid Drug Examples: ketorolac (Toradol) Drug class: Cox-2 selective Drug Examples: celecoxib (Celebrex) Causes of Sleep Problems Acute Sleep Problems Stress (job loss, moving, ending a relationship) Jet lag Use of stimulants (caffeine, nicotine) Use of alcohol Noise, light, extreme temperatures Minor illnesses (cold, flu) Worries (work, school, finances, family) Chronic Sleep Problems Medical conditions (chronic pain, obesity, head injury, cancer, asthma, arthritis, heartburn) Mood disorders (depression, anxiety) Schedule changes (working nights) Other sleep problems (sleep apnea) Genetics (some sleep disorders run in families) Common Drugs for Insomnia Benzodiazepine Receptor Agonists zolpidem (Ambien) zaleplon (Sonata) Benzodiazepines flurazepam (Dalmane, Novoflupam, Somnol) quazepam (Doral) triazolam (Gen-Triazolam, Halcion, Novotriolam) estazolam (ProSom) temazepam (Restoril) OTC Antihistamines diphenhydramine (Allerdryl, Benadryl) dimenhydrinate (Dramamine, Gravol, Nauseatol) Sedating Antidepressants trazodone (Desyrel) amitriptyline (Apo-Amitriptyline, Elavil) doxepin (Novo-Doxepin, Sinequan, Triadapin) Drugs for Narcolepsy methylphenidate (Riphenidate, Ritalin) modafinil (Provigil) sodium oxybate (Xyrem) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. Pain is whatever the patient says it is and exists whenever he or she says it does. Assess the patient for pain whenever you check his or her vital signs Check behaviors for pain in patients who cannot point or express pain in words Pain perception occurs in the brain, not at the site of injury Different types of nerve fibers are responsible for the types of pain felt and which type of pain drug is most effective at relieving the pain Nonmodifiable factors affecting pain perception are age and the presence of disease. These factors cannot be changed. Do not assume that a patient who is tolerating pain well is comfortable Common physiologic changes with acute pain include elevated heart rate, blood pressure, and respiratory rate, cool, clammy skin; dry mouth; restlessness; and inability to concentrate The four most common sources of chronic pain are: Neck and back pain; Arthritis pain; Migraine headaches; nerve pain Do not rely on changes in vital signs to indicate the intensity of chronic pain Do not rely on non-drug therapies alone for pain control Analgesics include: Opioids; Nonsteroidal anti-inflammatory drugs (NSAIDs); nonopioid miscellaneous drugs Pain drugs have varying strengths and dosages to achieve the same level of pain relief Drug dependence is a physical problem; drug addiction is a psychologic problem Never substitute one opioid for another without an order from the prescriber that includes a recalculation of the dose. Strengths vary. What is painful for an adult is painful for a child Check the patient’s pain level 30 minutes after giving a pain-control drug and then hourly If a mother receives an opioid during labor, watch her newborn closely for the first 2 to 4 hours after birth for any sign of respiratory depression Avoid the use of meperidine in the older adult Avoid giving NSAIDs with acetaminophen (Tylenol) Teach the patient to avoid chewing or crushing an NSAID capsule or enteric-coated NSAID tablet. NSAIDs should never be taken with warfarin (Coumadin) Most NSAIDs should not be given to women during the last 3 months of pregnancy Most NSAIDs increase blood p0ressure and reduce the effects of antihypertensives, especially ACE inhibitors Acetaminophen can be toxic to the liver and kidneys and should not be taken by anyone with health problems of these organs Teach parents to read the label on liquid acetaminophen bottles for infants and small children very carefully and ensure that the correct dose is given for the child’s size. Teach parents to telephone the nearest pharmacy and talk with the pharmacist to ensure that the dose is correct if they are not confident in their own calculations. The three major symptoms of narcolepsy are cataplexy, vivid hallucinations, and total paralysis at the beginning or end of the sleep episodes Monitor patients for seizure activity when they also take CNS stimulants 29. Remind women taking modafinil (Provigil) to use an additional form of birth control to prevent an unplanned pregnancy 30. To better monitor for side effects, assess the level of consciousness before giving a drug for insomnia 31. Teach patients taking benzodiazepine receptor agonists to go to bed immediately after taking a dose of these drugs 32. Teach patients to be sure that there is adequate time (4 to 8 hours) for sleep before taking a drug for insomnia 33. Teach patients taking an insomnia drug to avoid alcohol and other CNS-depressing substances because of the risk for oversedation