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Chapter 6 Anesthetics and Narcotics © Paradigm Publishing, Inc. 1 Learning Objectives • Understand the central and peripheral nervous systems, their functions, and their relationship to drugs. • Recognize different dosage forms and understand how the drug delivery system works. • Learn how drugs affect body systems and where they work in the body. • Understand the concepts of general and local anesthesia, and know the functions of these agents © Paradigm Publishing, Inc. 2 Learning Objectives • Define the action of neuromuscular blocking agents in reducing muscle activity. • Distinguish between narcotic and nonnarcotic analgesia. • Understand the different classes of narcotics and the role of the technician in monitoring these drugs. • Become familiar with the various types of agents for migraine headaches. © Paradigm Publishing, Inc. 3 The Nervous System • Transmits information over vast network throughout the body • Neuron: nerve cell that transmits information • Neurotransmitter: chemical substance released from neuron – Stimulates or inhibits activity in target cells, especially other neurons © Paradigm Publishing, Inc. 4 Neurotransmitters Being Released from a Neuron © Paradigm Publishing, Inc. 5 Divisions of the Nervous System: CNS • Central Nervous System (CNS) – Brain and spinal cord – Spinal cord receives information and sends to brain – Brain evaluates information and sends out a response © Paradigm Publishing, Inc. 6 Divisions of the Nervous System: PNS • Peripheral Nervous System (PNS) made up of nerves and sense organs – Afferent system: nerves and sense organs bring information to CNS – Efferent system: nerves send information out from the CNS © Paradigm Publishing, Inc. 7 PNS Efferent System • Autonomic nervous system (ANS) – Involuntary activities: respiration, circulation, digestion, body temperature, metabolism, blood glucose, sweating • Somatic nervous system – Voluntary activities: skeletal muscles – Acetylcholine only neurotransmitter between CNS and skeletal muscles © Paradigm Publishing, Inc. 8 Autonomic Nervous System © Paradigm Publishing, Inc. 9 CNS and PNS Primary Neurotransmitters • CNS • PNS – Acetylcholine (Ach) – GABA (gammaaminobutyric acid) – Dopamine – Norepinephrine – Serotonin – Glutamate – Acetylcholine (Ach) – Norepinephrine © Paradigm Publishing, Inc. 10 Sympathetic and Parasympathetic Primary Neurotransmitters • Sympathetic System – – – – • Parasympathetic System Acetylcholine (Ach) Norepinephrine Dopamine Epinephrine – Acetylcholine (Ach) © Paradigm Publishing, Inc. 11 ACh and GABA • ACh acts on receptors in smooth and cardiac muscle, and exocrine glands • ACh receptors blocked by anticholinergics • GABA regulates message delivery system of the brain © Paradigm Publishing, Inc. 12 Dopamine, Epinephrine, and Norepinephrine • Dopamine acts on receptors in the CNS and kidneys • Epinephrine acts on cardiac and bronchodilator receptors • Norepinephrine acts on alpha and beta receptors © Paradigm Publishing, Inc. 13 Serotonin and Glutamate • Serotonin acts on smooth muscle and gastric mucosa – Causes vasoconstriction which decreases blood flow – Emotional responses: depression, anxiety • Glutamine may be crucial to some forms of learning and memory © Paradigm Publishing, Inc. 14 Types of Receptors • Alpha – Vasoconstriction, raises blood pressure • Beta-1 – Increases heart rate and contractive force of the heart • Beta-2 – Vasodilation, increases blood flow – Bronchodilator, relaxes smooth muscles © Paradigm Publishing, Inc. 15 Discussion What are three important types of receptors in the study of drugs? Three important types of receptors are alpha, beta-1, and beta-2. © Paradigm Publishing, Inc. 16 Drug Effects on the Nervous System • Two types of effects on receptors – Stimulating, causing a reaction – Blocking, preventing a reaction • Anticholinergics © Paradigm Publishing, Inc. 17 Side Effects of Anticholinergics • • • • • • Decreased GI motility (constipation) Decreased sweating Decreased urination Dilated pupil and blurred vision Dry eyes Dry mouth © Paradigm Publishing, Inc. 18 Terms to Remember neuron neurotransmitter central nervous system (CNS) peripheral nervous system (PN) afferent system efferent system © Paradigm Publishing, Inc. 19 Terms to Remember autonomic nervous system (ANS) somatic nervous system alpha receptors beta-1 receptors beta-2 receptors © Paradigm Publishing, Inc. 20 Anesthesia • Allows painless and controlled surgical, obstetric, and diagnostic procedures • Most potent anesthetics are gases or vapors • Two classes of anesthesia: general and local • Anesthesiologist oversees administration of anesthesia during surgery © Paradigm Publishing, Inc. 21 Anesthesia • One anesthetic may be superior to another, depends on clinical situation • Final choice based on drugs and anesthetic techniques safest for patient © Paradigm Publishing, Inc. 22 Physiologic Effects of Anesthesia • Involves many systems – – – – – – – Nervous Respiratory Endocrine Cardiovascular Skeletal muscular GI Hepatic © Paradigm Publishing, Inc. 23 Goals of Balanced Anesthesia • Amnesia to eliminate patient’s memory of procedure • Adequate muscle relaxation, no contracting of muscles • Adequate ventilation by maintaining oxygen concentration • Pain control © Paradigm Publishing, Inc. 24 Discussion What are some of the indicators used to assess general anesthesia? Some indicators include: blood pressure, hypervolemia, oxygen level, pulse, respiratory rate, tissue perfusion, and urinary output. © Paradigm Publishing, Inc. 25 General Anesthetics • General anesthesia is the unique condition of reversible unconsciousness and absence of response to painful stimuli • Four reversible actions – – – – Unconsciousness Analgesia (relieving pain) Skeletal muscle relaxation Amnesia on recovery © Paradigm Publishing, Inc. 26 General Anesthetics Preanesthetic medications – Control sedation – Reduce postoperative pain – Provide amnesia – Decrease anxiety • Drugs often used: narcotics, benzodiazepines, phenothiazines © Paradigm Publishing, Inc. 27 General Anesthetics • Malignant hyperthermia is a serious side effect of anesthesia – Fever of 110°F or more – Life threatening • Treatment: dantrolene (Dantrium) Always check Warning! expiration date © Paradigm Publishing, Inc. 28 Drug List Inhalant Anesthetics – desflurane (Suprane) – enflurane (Ethrane) – halothane (none) – isoflurane (Forane) – nitrous oxide (none) © Paradigm Publishing, Inc. 29 Side Effects of Inhalant Anesthetics • Reduce blood pressure • May cause nausea and vomiting © Paradigm Publishing, Inc. 30 nitrous oxide • Causes analgesia only • Given alone or with more powerful anesthetics to hasten uptake of other agent(s) • Commonly used for dental procedures • Advantage: rapidly eliminated © Paradigm Publishing, Inc. 31 desflurane (Suprane) • Easily controllable • Rapid onset and recovery • Often used in ambulatory surgery © Paradigm Publishing, Inc. 32 Injectable Anesthetics • Very lipid soluble • Most dispensed by IV drip • Most are controlled substances © Paradigm Publishing, Inc. 33 Drug List Injectable Anesthetics – alfentanil (Alfenta) – etomidate (Amidate) – fentanyl (Sublimaze) – fentanyl-droperidol (none) – ketamine (Ketalar) © Paradigm Publishing, Inc. 34 Drug List Injectable Anesthetics – morphine (various) – propofol (Diprivan) – remifentanyl (Ultiva) – sufentanil (Sufenta) © Paradigm Publishing, Inc. 35 Drug List Injectable Anesthetics Barbiturates – methohexital (Brevital) – thiopental (Pentothal) Benzodiazepines – methohexital (Brevital) – thiopental (Pentothal) © Paradigm Publishing, Inc. 36 Drug List Injectable Anesthetics Benzodiazepines – diazepam (Valium) – lorazepam (Ativan) – midazolam (Versed) © Paradigm Publishing, Inc. 37 propofol (Diprivan) • Used for maintenance of anesthesia, sedation, or treatment of agitation • Antiemetic properties • Side effects: drowsiness, respiratory depression, motor restlessness, increased blood pressure © Paradigm Publishing, Inc. 38 Dispensing Issues of Injectable Anesthetics Warning! • Diprivan (anesthetic) and Diflucan (antifungal) may be confused • A mix-up could be life-threatening © Paradigm Publishing, Inc. 39 fentanyl • Used extensively for open-heart surgery due to lack of cardiac depression • Analogs used in the operating room – Alfentanil (Alfenta) – Sufentanil (Sufenta) – Reminfentanil (Ultiva) © Paradigm Publishing, Inc. 40 Benzodiazepines • Used for induction, short procedures, and dental procedures • Used in controlling and preventing seizures induced by local anesthetics • midozolam (Versed) – fastest onset of action – greatest potency – most rapid elimination © Paradigm Publishing, Inc. 41 Drug List Antagonist Agents – flumazenil (Romazicon) – nalmefene (Revex) – naloxone (Narcan) © Paradigm Publishing, Inc. 42 Antagonist Agents • flumazenil (Romazicon) reverses overdoses of benzodiazepine • nalmefene (Revex) and naloxone (Narcan) reverse overdoses of narcotics • All operating and emergency rooms maintain a supply of antagonists © Paradigm Publishing, Inc. 43 Neuromuscular Blocking Agents • Causes immediate skeletal muscle relaxation of short, long, and extended durations • Used to facilitate endotracheal intubation and ensure patient does not move during surgery © Paradigm Publishing, Inc. 44 Drug List Neuromuscular Blocking Agents Short Duration – succinylcholine (Quelicin) Long Duration – atracurium (Tracrium) – cisatracurium (Nimbex) – rocuronium (Zemuron) – vecuronium (Norcuron) © Paradigm Publishing, Inc. 45 Drug List Neuromuscular Blocking Agents Extended Duration – mivacurium (Mivacron) – pancuronium (none) © Paradigm Publishing, Inc. 46 Neuromuscular Blocking Agents Dispensing Issues Warning! • Be conscious of storage requirements • Store away from look-alike drugs © Paradigm Publishing, Inc. 47 succinylcholine (Quelicin) • Often called “sux” • Only depolarizing agent; all others are nondepolarizing agents • Persistent depolarization at motor endplate. Shorts out electrical signal. • Result: sustained, brief period of flaccid skeletal muscle paralysis © Paradigm Publishing, Inc. 48 Reversal of Neuromuscular Blocking Agents • Antiacetylcholinesterase agents increase action of acetylcholine – Inhibits acetylcholinesterase – Restores transmission of impulses, reversing neuromuscular blocking agent © Paradigm Publishing, Inc. 49 Drug List Anticholinesterase Agents – edrophonium (Enlon) – neostigmine (Prostigmin) – pyridostigmine (Mestinon) © Paradigm Publishing, Inc. 50 Local Anesthesia • Relieves pain without altering alertness or mental function • Affect all types of nervous tissue • Commonly combined with other drugs • Variety of combinations available © Paradigm Publishing, Inc. 51 Dosage Forms of Local Anesthetics • • • • • • Topical: drops, sprays, lotions, ointments Infiltration: superficial injection Nerve block: injection IV Epidural: regional anesthesia Spinal: blocks afferent pain nerve impulses from lower part of the body © Paradigm Publishing, Inc. 52 Discussion What are the two classes of local anesthetics? The two classes are esters and amides. © Paradigm Publishing, Inc. 53 Local Anesthetics • Esters • Amides – Short acting – Metabolized in plasma and tissue fluids – Excreted in urine – Longer acting than esters – Metabolized by liver enzymes – Excreted in urine © Paradigm Publishing, Inc. 54 Drug List Local Anesthetics Esters – benzocaine (Americaine) – chloroprocaine (Nesacaine) – dyclonine (Cēpacol Maximum Strength) – procaine (Novocain) – tetracaine (Cēpacol Viractin, Pontocaine) © Paradigm Publishing, Inc. 55 Drug List Local Anesthetics Amides – bupivacaine (Marcaine) – levobupivacaine (Chirocaine) – lidocaine (L-M-X, Solarcaine Aloe Extra Burn Relief, Xylocaine, Lidoderm) © Paradigm Publishing, Inc. 56 Drug List Local Anesthetics Amides – lidocaine-epinephrine (Xylocaine with Epinephrine) – lidocaine-prilocaine (EMLA) – mepivacaine (Carbocaine) © Paradigm Publishing, Inc. 57 Discussion What functions are lost with local anesthetics? Functions that are lost include: pain perception, temperature sensation, touch sensation, proprioception, and skeletal muscle tone. © Paradigm Publishing, Inc. 58 Discussion Under what conditions would a local anesthetic be used over a general anesthetic? It is chosen when a well-defined area of the body is targeted. © Paradigm Publishing, Inc. 59 Terms to Remember anesthesiologist general anesthesia malignant hyperthermia neuromuscular blocking endotracheal intubation anticholinesterase © Paradigm Publishing, Inc. 60 Terms to Remember local anesthesia ester amide © Paradigm Publishing, Inc. 61 Pain Management • Pain is protective mechanism to warn of damage or the presence of disease – Part of the normal healing process – Can be a disease – Considered the “fifth” vital sign © Paradigm Publishing, Inc. 62 Pain Management • Acute Pain – Associated with trauma or surgery – Warns of a problem – Easier to manage by treating the cause – Disappears when body heals – Has beginning and end © Paradigm Publishing, Inc. 63 Pain Management • Chronic nonmalignant pain – Lasts more than 3 months – Diagnosed or undiagnosed cause – May respond poorly to treatment – Depression, sense of helplessness and hopelessness – Affects all aspects of life © Paradigm Publishing, Inc. 64 Pain Management • Chronic malignant pain – Accompanies malignant disease – Often increases in severity with disease progression © Paradigm Publishing, Inc. 65 Major Sources of Pain • Source: somatic • Areas: body framework • Characteristics: throbbing, stabbing, localized • Treatment: narcotics, NSAIDs, nerve blockers © Paradigm Publishing, Inc. 66 Major Sources of Pain • Source: visceral • Areas: kidneys, intestines, liver • Characteristics: aching, throbbing, sharp, gnawing, crampy • Treatment: narcotics, NSAIDs, nerve blockers, antiemetics © Paradigm Publishing, Inc. 67 Major Sources of Pain • Source: neuropathic • Areas: nerves • Characteristics: burning, aching, numbing, tingling, constant • Treatment: antidepressants, anticonvulsants © Paradigm Publishing, Inc. 68 Major Sources of Pain • Source: sympathetically mediated • Areas: overactive sympathetic system • Characteristics: occurring when no pain should be felt • Treatment: nerve blockers © Paradigm Publishing, Inc. 69 Narcotics • Pain-modulating chemicals that cause insensibility or stupor • Opiates – Derived from opium or synthetic – Agonists of opioid receptor sites • Main effects on CNS and GI tract • Lesser effects on peripheral tissues © Paradigm Publishing, Inc. 70 Natural Opioids • Endorphins, enkephalins, and dynorphins • Brain produces in response to pain stimuli • When receptors are activated – Causes decreased nerve transmission – Sensation of pain diminished • Opioids bind to these same receptors © Paradigm Publishing, Inc. 71 Effects of Narcotics • Analgesia: reduces pain from most sources • Sedation: decrease anxiety and cause drowsiness • Euphoria and dysphoria: feelings of wellbeing, disquiet, restlessness • Narcotics have potential for tolerance and dependence © Paradigm Publishing, Inc. 72 Patient-Controlled Analgesia Pump • PCA pump effective means of controlling pain • Patient regulates, within limits, amount of drug received • Better pain control with less drug © Paradigm Publishing, Inc. 73 Analgesic Ladder of Pain Relief 1. Mild to moderate pain – Acetaminophen or NSAID and an adjuvant 2. If adequate relief not achieved – NSAID plus a “weak” opioid (codeine) 3. If adequate relief not achieved – Strong opioid (morphine) with an adjuvant analgesic if indicated © Paradigm Publishing, Inc. 74 Transdermal Patch • Provides pain control • Allows patient to remain more alert than with most other methods © Paradigm Publishing, Inc. 75 Analgesic Ladder of Pain Relief © Paradigm Publishing, Inc. 76 Addiction and Dependence • Chronic opioid therapy has low risk of addiction when used appropriately © Paradigm Publishing, Inc. 77 Discussion What is the difference between addiction and dependence? © Paradigm Publishing, Inc. 78 Dependence and Addiction • Dependence – Physical and emotional reliance on a drug – Withdrawal • Addiction – Compulsive disorder © Paradigm Publishing, Inc. 79 Signs of Narcotics Addiction • • • • • • Preoccupation with drugs Refusal of medication tapers Strong preference for a specific opioid Decrease in ability to function Medication often not taken as prescribed Tendency to rely on multiple prescribers and pharmacies to conceal behavior © Paradigm Publishing, Inc. 80 Withdrawal • Patients more successful overcoming addiction if withdrawal symptoms are handled appropriately • Opioid antagonists have stronger attraction for receptors than analgesic agents • Blocking opioid action may prevent withdrawal symptoms © Paradigm Publishing, Inc. 81 Drug List Drugs to Treat Opioid Addiction – buprenorphine (Buprenex, Subutex) – buprenorphine-naloxone (Suboxone) – methadone (Dolophine) © Paradigm Publishing, Inc. 82 Dispensing Issues of Narcotics Warning! • Technicians have a legal and moral responsibility to alert pharmacist of suspected abuse and addiction • Documentation must be in medical record • Low addiction rate if no history of addiction © Paradigm Publishing, Inc. 83 Narcotic Analgesics • Analgesic is a drug that alleviates pain • Narcotic analgesic is pain medication containing an opioid © Paradigm Publishing, Inc. 84 Drug List Narcotic Analgesics – butorphanol (Stadol) – codeine (Codeine Contin) – fentanyl (Actiq, Duragesic, Fentora, Ionsys) – hydromorphone (Dilaudid) – meperidine (Demerol) © Paradigm Publishing, Inc. 85 Drug List Narcotic Analgesics – morphine (Astramorph/PF, Avinza, Duramorph, MS Contin, MSIR) – oxycodone (OxyContin) – oxymorphone (Numorphan, Opana, Opana ER) – pentazocine (Talwin) – propoxyphene (Darvon) © Paradigm Publishing, Inc. 86 Narcotic Analgesics • Dose requirements vary with – Severity of pain – Individual response to pain – Patient’s age and weight – Presence of concomitant disease • Morphine is standard against which all other narcotic analgesics are measured © Paradigm Publishing, Inc. 87 Goal of Narcotic Analgesics • Narcotic analgesics – Many dosage forms and strengths – Delivered by various routes • Goal: Patient comfort • Key to reaching goal: Constant reassessment © Paradigm Publishing, Inc. 88 Dispensing Issues of morphine Warning! • Avinza (morphine) and Invanz (eratpenem) often confused • Morphine sulfate (MSO4) and magnesium sulfate (MgSO4) often confused © Paradigm Publishing, Inc. 89 Dispensing Issues of Narcotic Analgesics Warning! • Consult policies and procedures of workplace to use the required check systems to make sure narcotic counts are correct. © Paradigm Publishing, Inc. 90 Side Effects of Narcotic Analgesics • Side effects anticipated and minimized for patient comfort – – – – – – – Mental confusion Reduced alertness Nausea/vomiting Dry mouth Constipation Inflammatory process Bronchial constriction © Paradigm Publishing, Inc. 91 fentanyl • Patch (Duragesic) – Approved for chronic use, not acute pain after surgery • Lozenge (Actiq) – Swabbed on mucosal surfaces inside the mouth and under the tongue – Not as effective if swallowed © Paradigm Publishing, Inc. 92 Combination Drugs for Managing Pain • Combinations of narcotics and nonnarcotics are common – Increases pain relief – Allows use of lower doses – Limits intake of addictive substances – Decreases side effects © Paradigm Publishing, Inc. 93 Drug List Combination Drugs for Pain Control – acetaminophen-codeine (Phenaphen with Codeine, Tylenol with Codeine) – hydrocodone-acetaminophen (Lortab, Vicodin, Lorcet) – meperidine-promethazine (Mepergan) – oxycodone-acetaminophen (Endocet, Perocet, Tylox) © Paradigm Publishing, Inc. 94 Drug List Combination Drugs for Pain Control – oxycodone-aspirin (Endodan, Percodan) – oxycodone-ibuprofen (Combunox) – pentazocine-naloxone (Talwin NX) – propoxyphene-acetaminophen (Darvocet-N 100) © Paradigm Publishing, Inc. 95 Dispensing Issues of Analgesic Combinations Warning! • Serious risk of aspirin or acetaminophen toxicity if dose is overlooked • Technicians—check that patient is not getting more than 4 grams of aspirin or acetaminophen per day © Paradigm Publishing, Inc. 96 Dispensing Issues of Analgesic Combinations Warning! • Pharmacy technicians should check C-III, CIV, and C-V drugs – Refills no more than 5 times – Refills good for no more than 6 months • C-II drugs have NO refills © Paradigm Publishing, Inc. 97 meperidine-promethazine • Produces less nausea than similar drugs – Promethazine controls nausea • Very sedating • Used for patients who develop nausea from opioid use © Paradigm Publishing, Inc. 98 Terms to Remember pain narcotic opiate opioid patient-controlled analgesia (PCA) nonsteroidal anti-inflammatory drugs (NSAIDs) © Paradigm Publishing, Inc. 99 Terms to Remember analgesic ladder dependence addiction analgesic narcotic analgesic © Paradigm Publishing, Inc. 100 Migraine Headaches • Migraine Headache – Severe, throbbing, vascular headache – Recurrent unilateral head pain – Accompanied by neurologic and GI disturbances • 90% of migraine sufferers report nausea • Sensitivity to light, sound, and stimulation also common © Paradigm Publishing, Inc. 101 Components of Migraine • Classic migraine components (all five not experienced by everyone) – Prodrome – Aura – Headache – Headache relief – Postdrome © Paradigm Publishing, Inc. 102 Components of Migraine • Prodrome: Symptom indicating onset • Aura: Subjective sensation or motor phenomenon that precedes onset – – – – – Flashing lights Shimmering heat waves Bright lights Dark holes in visual fields Vision blurred, cloudy transient or loss of © Paradigm Publishing, Inc. 103 Components of Migraine • Headache and Headache Relief – Generally dissipates in 6 hours, but may last 1 to 2 days • Postdrome – Knowing headache is gone © Paradigm Publishing, Inc. 104 Cause of Migraine Headaches • Serotonin appears involved in cause • Decreased levels causes excessive vasodilation in cranial arteries and migraine occurs • By stimulating serotonin receptors vasoconstriction occurs, alleviating migraine © Paradigm Publishing, Inc. 105 Causative Factors of Migraine Headaches • • • • • Diet Stress Depression Sleep habits Certain medications • Hormonal fluctuations • Atmospheric changes • Environmental irritants © Paradigm Publishing, Inc. 106 Initial Treatment of Migraine Headaches • At first hint of migraine, identify and eliminate triggers – Quiet environment and sleep may help – Lying down in a dark room • For severe or debilitating and frequent attacks, drug therapy may be indicated – Sedative, antiemetic, and narcotic agents © Paradigm Publishing, Inc. 107 Discussion What are the two classes of migraine drug therapy? The two classes are prophylactic therapy and abortive therapy. © Paradigm Publishing, Inc. 108 Therapy for Migraine Headaches • Prophylactic Therapy – Attempts to prevent or reduce recurrence • Abortive Therapy – Taken after acute migraine occurs – Taken at first sign of a migraine, such as aura or headache © Paradigm Publishing, Inc. 109 Prophylactic Therapy • • • • • • • • Anticonvulsants Beta blockers Calcium channel blockers Estrogen Feverfew NSAIDs SSRIs Tricyclic antidepressants © Paradigm Publishing, Inc. 110 Abortive Therapy • • • • Simple analgesics NSAIDs Ergotamine-containing medications Serotonin-containing medications © Paradigm Publishing, Inc. 111 Drug List Migraine Headache Agents Triptans—Selective 5-HT Receptor Agonists – – – – – – – almotriptan (Axert) eletriptan (Relpax) frovatriptan (Frova) naratriptan (Amerge) rizatriptan (Maxalt, Maxalt-MLT) sumatriptan (Imitrex) zolmitriptan (Zomig) © Paradigm Publishing, Inc. 112 rizatriptan (Maxalt-MLT) • Sublingual tablet, quickly absorbed • Most rapid onset of action of all oral migraine therapies • May receive relief after 30 minutes • Maxalt not absorbed as quickly as Maxalt-MLT © Paradigm Publishing, Inc. 113 sumatriptan (Imitrex) • Causes vasoconstriction of blood vessels • Use at first sign of headache • If brings partial relief, patient may receive second dose at least 1 hour after first • Available in injection, nasal spray, and tablet © Paradigm Publishing, Inc. 114 Drug List Migraine Headache Agents Ergot Preparations – dihydroergotamine (D.H.E. 45, Migranal) – ergotamine (Ergomar) – ergotamine-caffeine (Cafergot) © Paradigm Publishing, Inc. 115 Drug List Migraine Headache Agents Antiemetic Agents – chlorpromazine (Thorazine) – metoclopramide (Reglan) – prochlorperazine (Compazine) © Paradigm Publishing, Inc. 116 metoclopramide (Reglan) • Reduces nausea and vomiting • Enhances absorption of other antimigraine products • Metoclopramide and aspirin prescribed together in place of sumatriptan (Imitrex) due to fewer side effects © Paradigm Publishing, Inc. 117 Drug List Migraine Headache Agents Opioid Analgesic – butorphanol (Stadol, Stadol NS) Beta Blocker – propranolol (Inderal) © Paradigm Publishing, Inc. 118 butorphanol (Stadol, Stadol NS) • Nasal spray used more commonly than injection • Used for moderate-to-severe pain • Can be addictive • C-IV controlled substance © Paradigm Publishing, Inc. 119 Drug List Migraine Headache Agents: Other – acetaminophen, aspirin, caffeine (Excedrin Migraine) – butalbital-acetaminophen-caffeine (Fioricet) – butalbital-aspirin-caffeine (Fiorinal) – isometheptene-dichloralphenazoneacetaminophen (Midrin) – tramadol (Ultram) © Paradigm Publishing, Inc. 120 tramadol (Ultram) • High success rate when given with NSAIDs (ibuprofen) • Slow onset of action • Not a controlled substance, but has shown potential for addiction © Paradigm Publishing, Inc. 121 Dispensing Issues of Migraine Agents Warning! • Tramadol and Toradol could be confused © Paradigm Publishing, Inc. 122 isometheptene-dichloralphenazineacetaminophen (Midrin) • Fewer side effects than ergotamines • Combination of analgesic, sedative, and vasoconstrictor • For mild to moderate headaches • Take 2 capsules at onset of headache, then 1 every 1 to 2 hours until pain stops, up to 5 capsules in 12 hours © Paradigm Publishing, Inc. 123 acetaminophen, aspirin, caffeine (Excedrin Migraine) • Combination reported to give very good results in migraine pain • Many common headaches, including migraines, respond to this combination © Paradigm Publishing, Inc. 124 Discussion What are some of the issues facing migraine sufferers and the medication that is used? Some issues are nausea and vomiting, 0.5 to 2 hour onset of action, and side effects. © Paradigm Publishing, Inc. 125 Terms to Remember migraine headache a severe, throbbing, unilateral headache, usually accompanied by nausea, photophobia, phonophobia, and hyperesthesia aura a subjective sensation or motor phenomenon that precedes and marks the onset of a migraine headache © Paradigm Publishing, Inc. 126 Assignments • Complete Chapter Review activities • Answer questions in Study Notes document • Study Partner – Quiz in review mode – Matching activities – Drug tables © Paradigm Publishing, Inc. 127