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    Medications That Treat Pain

    Chapter 28-30

    NSG 220

    1

    What we will review:

    What is Pain?

    Types of Pain

    Drugs used to Treat Pain

    Adjuvant Analgesics

    Non-Opioids

    Opioids

    Narcotic Agonist

    Definitions of the class of medications

    Anti-Rheumatic RX-

    RX to treat inflammation/pain

    Gout (meds)

    Clinical Pearls

    Pain

    Pain- Universally unpleasant emotional and sensory experience that occurs in response to actual or potential tissue trauma or inflammation

    5th vital sign that should be assessed in all patients

    Influenced by multiple factors

    Emotional

    Physical

    Psychologic status

    Subjective: “whatever the client says”

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    Pain

    Can further be classified according to its sources.

    Most common:

    Somatic Pain- Originates from skeletal muscles, ligaments, and joints

    visceral pain –originates from organs and smooth muscles

    superficial pain originates from the skin and mucous membranes

    deep pain –occurs in tissue below skin level

    They may be appropriately treated when the source of the pain is known. For example, visceral and superficial pain usually require opioids for relief, whereas somatic pain including bone pain usually respond better to non opioid analgesics such as non steroidal anti inflammatory drugs .

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    Types of Pain

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    Acute pain

    Mild to severe

    lasting 6 months usually due to injury

    ↑ pulse rate, ↑ b/p, respirations, ↑ glucose levels (sympathetic nervous system responses)

    Chronic pain

    Mild to severe

    Lasts longer than 6 months

    Parasympathetic nervous system responses

    May not demonstrate symptoms associated with acute pain symptoms

    May lead to depression and decreased functional status

    Types of Pain (cont.)

    Nociceptive pain- due to an injury or damage to the body tissue

    External Injury- hitting part of the body against something or procedure (surgery)

    Joints, muscles, skin, bones, tendons

    Described as achy, throbbing or sharp

    Inflammation- due to an abnormal immune response

    Ex: cellulitis

    Neuropathic- due to nerve irritation

    Shingles/neuropathy (feet/hands-diabetics)

    Burning, shooting, pins and needles, sensitive to touch

    Radicular- compressed or inflamed spinal nerve

    Radiates from the back & hips into the legs (sciatica-sciatic nerve)

    Aggravated when walking, sitting and other activities

    Types of Drugs that Treat Pain

    Definitions

    Analgesics- Medications that relieve pain without causing loss of consciousness.

    Agonist- drugs that activates opioid brain receptors giving full effect (heroin, methadone, morphine). Initiates a specific response.

    Antagonist- drugs that block opioids drugs from attaching/activating opioid receptors (Naloxone/Narcan)

    Partial agonist- activates opioid receptors in the brain, but does give have the full effect (buprenorphine, tramadol, pentazocine). They can also block agonist drugs (buprenorphine, butorphanol, nalbuphine, pentazocine) – “antagonist effect”.

    Meds have a limited effect "Ceiling”.

    Can have a withdrawal effect on patient who are opioid-dependent patients

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    Agonist/Mixed/Antagonist

    Agonist- a full response (initiates a response)

    Antagonist – blocks response

    Agonist/Antagonist mixture- while under other conditions, behaves as an antagonist- a substance that binds to a receptor but does not activate and can block the activity of other agonists.

    Ex: Works to relief pain without the full side effect. Less effect on respirations. Not much of an pain relieving effect.

    Agonist-Antagonist Opioids (Pentazocine, Butorphanol, Nalbuphine, Buprenorphine)

    MOA: Blocks access of the pure agonist to mu receptors. They also prevent receptor activation, thereby triggering withdrawal. "

    Also called a partial agonist or a mixed agonist, binds to a pain receptor and causes a weaker pain response that does a full agonist.

    Not a first-line analgesic. Sometimes useful in pan management of OB patients.

    Medications have an analgesic effect

    Can cause a withdrawal effect if given to people who are physically dependent on pure agonist

    NOT A REVERSAL MEDICATION

    Advantages:

    Low potential for abuse

    Have less effect on respiratory depression

    Disadvantage

    Less powerful analgesic effect

    **Buprenorphine- used to treat opioid addiction.

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    Opioids Morphine, Fentanyl, Hydromorphone, Hydrocodone, Oxycodone, Oxymorphone, Methadone

    Advantages

    MOA- bind to An opioid pain receptor in the brain and causes an analgesic response. The reduction of pain sensation

    Forms: Injectable, patches, tablets, capsules (long and short acting)

    Indications:

    Used to alleviate moderate to severe pain

    Surgical/post-operative pain.

    1st line analgesics for immediate post-op settings.

    Disadvantages

    Constipation

    Excessive sedation and respiratory depression*

    Some can produce metabolites that can accumulate and produce toxicity (morphine 3-glucuronide)

    Screening for appropriateness

    Ongoing monitoring via therapeutic relationship with patient and prescriber are required for safe and effective long-term therapy

    Can be highly addictive

    Tolerance can develop

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    Non-Opioid(Aspirin, Diclofenac, Ibuprofen, Ketoprofen, Ketorolac, Meloxicam*, Naproxen, Celecoxib)Acetaminophen-antipyretic & analgesic)

    Advantage

    Versatile with multiple agents, formulation, and routes of administration available

    Can be given in combination with opioids

    Flexible and useful for a wide variety of mild to moderate nociceptive (injury to tissue)-type pain conditions

    Disadvantage

    Ineffective neuropathic pain

    NSAIDs- caution in pts with CV and/or GI risk factors, bleeding disorders and impaired kidney fx

    Not exceed daily maximum daily dose

    Acetaminophen- monitor hepatic status

    Side Effects

    Vary according to the medication type

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    Opioid Schedule

    5 Scheduled Drug Classes

    Schedule I*- not seen or administered in the U.S.

    Schedule II- high likelihood of abuse; Risk of developing a severe physiological addiction (Percocet, OxyContin, Codeine)

    Schedule III- likelihood of abuse is lower than that of schedule one or two (Lortab, Vicodin)

    high risk of developing physiological dependence

    Moderate to low- risk for developing a physical dependence

    Schedule IV- Likelihood of abuse or developing a physiological or physical dependence is lower than Schedule III

    Schedule V- likelihood of abuse or developing a physiological or physical dependence is lower than Schedule or IV (Codeine cough medications)

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    Nursing Implications

    Always count this drug**

    Witness any waste**

    Do not leave medication alone with patient. Watch them take it!

    Do not walk around with the RX in your pocket! Return it immediately. __________________________________________

    Assess patient first! Assess pain level and administer as ordered (if groggy, lethargic, vitals abnormal, low saturations?)

    Reassess patient one after administering.

    May need to administer RX before pain to improve pain control (give exactly on schedule, don’t wait until the patient asks**

    But do not give before scheduled time (example: PRN 3 hours)

    *** Physical dependence is extremely rare when given in hospital for short term therapy.

    Narcotic Antagonist (Naloxone*, Relistor, Naloxegol, Alvimopan, Naltrexone)

    Action: Opioid antagonist block (or antagonize) opiate-receptor sites. Principal use is the treatment of opioid overdose.

    Uses: Reverse the opiate effects of narcotic overdose and respiratory depression

    **The drug of choice when there is an uncertainty of type of overdose.

    Side Effect:

    Return of the symptoms the narcotic was used for.

    Watch for ↑ B/P

    Tremors

    Hyperventilation

    Severe diarrhea**

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    Adjuvant Analgesics(Gabapentin, Venlafaxine, Bupivacaine, Baclofen, Cyclobenzaprine, Ketamine, Duloxetine, Nortriptyline)

    Advantages

    Drugs that are not primarily identified as a primary analgesic but can have analgesic (pain relieving effects) or complimentary analgesic effect when used in combination with opioids.

    help manage concurrent symptoms that exacerbate pain

    treat side effects caused by opioids

    Useful for neuropathic pain

    Disadvantages

    Pain relief is limited and less predictable

    Pain relief is usually slow

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    Anti-Rheumatic Drugs (treat cancers & pain)

    Rheumatoid Arthritis

    Autoimmune, inflammatory immune disease

    Joint stiffness, swelling, and pain

    Can develop at any age, usually found amongst men and women 60 years and older

    Drugs can slow down disease progression

    Drug Treatment

    Nonsteroidal anti-inflammatory drugs (NSAIDs)

    Provide relief but do not slow disease progression

    Glucocorticoids

    Slow down disease progression

    Given short term because they can cause serious toxicity

    Disease-modifying antirheumatic drugs (DMARDs)

    Reduce joint destruction and slow down disease progression

    Recommended to start within 3 months of RA diagnosis

    Medications

    Methotrexate- interferes with growth of certain cells of the body (quick growing)

    Treats inflammatory response (in arthritis)

    Category X – contraindicated in pregnancy, can cause miscarriage/teratogenic effects causing deformities/ interrups the grown and division of a fertilized egg.

    ———————————

    Prednisone*

    Prednisolone* (*Most common used)

    NSAIDS (1st and 2nd generation)

    Nursing Implications

    Methotrexate should be taken with folic acid to reduce GI and hepatic toxicity.

    DMARD- disease modifying anti-rheumatic drug/ antineoplastic (cancer drugs)

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    Gout

    Inflammatory condition caused by elevated levels of uric acid (>6 mg/dL)

    High uric acid leads to accumulation in joint spaces

    Commonly found in hands and feet (redness, swelling, extreme tenderness to palpitation

    Pharmacologic treatment can be used during acute episodes and/or for prophylactic therapy if symptoms occur more than 3 times a year.

    Antigout Medications(Colchicine, Allopurinol, Probenecid, Indomethacin, Prednisone)

    Therapeutic Goals

    Decrease inflammation in joints during acute attacks

    Decrease uric acid levels for long-term prevention of flares

    Medications

    Acute phase

    Indomethacin

    1st choice for gout flare

    Used for short term

    Colchicine (take every 1 hour) *

    Can be used alone or with NSAID

    Decreases inflammation

    Take until the symptoms resolve or until they have diarrhea.

    Maintenance

    Allopurinol (take for a life time)

    Chronic

    Prevents uric acid formation

    Probenecid

    Chronic

    Lowers uric acid by Increases excretion of uric acid in urine

    **Can also be used in the acute phase

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    Definitions to know:

    Acute pain – pain that is sudden in onset, usually subsides when treated, and typically occurs over less than a six months.

    Chronic pain- persistent or recurring pain that is often difficult to treat usually more than 6 months.

    Adjuvant analgesic drugs –drugs that are indicated for other purposes but also have an analgesic effect. Usually added for combined therapy with a primary drug.

    Breakthrough pain- pain that occurs between doses of pain medication.

    Patient Controlled Analgesic (PCA)- Narcotic will be on a pump. Examples: Morphine, Dilaudid,

    Family members nor the nurse are not allowed to press the button to give the patient a dose.

    Routes of Administration

    Oral (preferred route of administration)

    Rectal

    Transdermal (if you put one on, take the other off)

    Intraspinal

    Intraventricular- delivered via external infusion pump through a catheter to the cerebral ventricles or through a subcutaneous reservoir (intermittent administration).

    Intravenous/Subcutaneous- used when unable to administer (oral, rectal, transdermal)

    Works fastest

    Allow for rapid administration and increasing dosage

    IM –least preferred route

    Unable to adjust or give repeat doses due to inconsistent absorption from IM sites.

    Patient-Controlled Analgesia (PCA)- On demand deliver of medication

    Delivered vial IV ipr subQ in which the patient can control the amount of medication administered to them

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    Clinical Pearls

    A large number of anti-inflammatory medications are enteric-coated or extended release. Do not crush or split these medications.

    Be careful when administering aspirin to certain patients

    children – could develop Reye’s syndrome

    Patients due to have surgery- will need to stop medication up to 1 week to reduce risk of bleeding (NSAIDS)

    Asthma patients –could develop adverse reactions such as bronchospasms, angioedema and urticaria (NSAIDs)

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