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  1. 1. <ul><li>Analgesic Drugs </li></ul>
  2. 2. Understanding Pain <ul><li>Most common symptom prompting people to seek health care </li></ul><ul><li>Occurs when tissue damage activates free nerve endings of peripheral nerves </li></ul><ul><li>Cerebral cortex analyzes messages and determines actions </li></ul><ul><li>Activation of opiate receptors in CNS inhibits pain transmission </li></ul>
  3. 3. Understanding Pain <ul><li>Pain is a subjective experience </li></ul><ul><li>People differ in their perceptions, behavior and tolerance of pain </li></ul><ul><li>Stressors increase pain </li></ul><ul><li>Diversionary activities tend to decrease pain- </li></ul><ul><ul><li>deep breathing, listening to music, visual imagery, others? </li></ul></ul><ul><li>Acute pain can be super-imposed on chronic pain </li></ul>
  4. 4. <ul><li>Try alternative measures for pain control in addition to drugs </li></ul><ul><li>Promote circulation and musculoskeletal function </li></ul><ul><li>Use heat or cold as ordered </li></ul><ul><li>Relieve pain ASAP </li></ul><ul><li>Administer analgesic before pain producing activities </li></ul><ul><li>Use the least amount of the mildest drug likely to be effective </li></ul>
  5. 5. Types of Pain <ul><li>Acute pain </li></ul><ul><li>Chronic pain </li></ul><ul><li>Superficial pain </li></ul><ul><li>Deep pain </li></ul>
  6. 6. <ul><li>Opioid-any derivative of opium plant or any synthetic drug that imitates natural narcotics </li></ul><ul><li>Opioid agonists-include opium derivatives and synthetic drugs w/similar properties (Kee p.332) </li></ul><ul><li>Decrease pain without losing consciousness </li></ul><ul><li>Opioid antagonists </li></ul><ul><ul><li>Block effects of opioid agnoists </li></ul></ul><ul><ul><li>Used to reverse drug reactions-RD, CNS depression </li></ul></ul><ul><ul><li>Narcan (always keep antagonist nearby) </li></ul></ul>NARCOTICS OPIOIDS
  7. 7. <ul><li>Opioid agonists </li></ul><ul><ul><li>Any route </li></ul></ul><ul><ul><li>Inhalation uncommon </li></ul></ul><ul><ul><li>Absorbed from GI tract </li></ul></ul><ul><ul><li>Transmucosal / intrathecal fast acting </li></ul></ul><ul><ul><li>IV provides most rapid and almost immediate </li></ul></ul><ul><ul><li>Sub Q and IM delayed absorption </li></ul></ul><ul><ul><ul><li>Poor circulation can cause further delay </li></ul></ul></ul><ul><ul><li>Metabolized extensively in the liver </li></ul></ul><ul><ul><ul><li>Administration of meperedine > 48 hours increases risk of neurotoxicity and seizures from buildup </li></ul></ul></ul>
  8. 8. <ul><li>Pharmacodynamics </li></ul><ul><li>Reduce pain by binding to opiate receptors in PNS/CNS </li></ul><ul><li>Stimulation of opiate receptors-mimic effects of endorphins –the body’s naturally occurring opiates </li></ul><ul><li>Cause dilation of blood vessels in head, neck, face – could result in increased cranial pressure </li></ul><ul><li>With the exception of Demerol, suppress cough center to have antitussive effect </li></ul><ul><li>Adverse / Side effects include constipation, respiratory depression, nausea, vomiting, urinary retention, orthostatic hypotension </li></ul><ul><li>Morphine – relieve dyspna r/t pulmonary edema </li></ul>
  9. 9. <ul><li>Nursing process </li></ul><ul><ul><li>Assess pain before and after administration </li></ul></ul><ul><ul><li>Monitor for adverse reactions / side effects </li></ul></ul><ul><ul><li>Monitor for tolerance dependence </li></ul></ul><ul><ul><ul><li>Shortened duration of effect </li></ul></ul></ul><ul><ul><li>Evaluate respiratory status before each dose </li></ul></ul><ul><ul><ul><li>Respiratory depression </li></ul></ul></ul><ul><ul><ul><li>Restlessness </li></ul></ul></ul>
  10. 10. Mechanisms by Which Opioid Analgesics Work <ul><li>Reduce the perception of pain sensation </li></ul><ul><li>Produce sedation </li></ul><ul><li>Decrease emotional upsets associated with pain </li></ul>
  11. 11. Characteristics of Opioid Analgesics <ul><li>Most are Schedule II or III drugs </li></ul><ul><li>Morphine (MSO4) is the prototype </li></ul><ul><li>May be given PO, IV, IM, SQ, or topically </li></ul><ul><li>Oral drugs undergo significant first-pass metabolism </li></ul><ul><li>Metabolized by liver and excreted in urine </li></ul>
  12. 12. <ul><li>Exert CNS effects </li></ul><ul><li>Use cautiously in clients with renal or hepatic disease, respiratory depression or increased intracranial pressure </li></ul><ul><li>Exert depressant effect on GI tract </li></ul><ul><li>Not recommended for prolonged periods of use except with chronic pain or malignant diseases </li></ul>
  13. 13. Morphine <ul><li>Naturally occurring opium alkaloid </li></ul><ul><li>Used to relieve severe pain </li></ul><ul><li>Maximum analgesia occurs in 10-20 minutes with IV route </li></ul><ul><li>Controlled released tablets given for chronic pain </li></ul><ul><li>May be given intrathecally or epidurally </li></ul><ul><li>Route determines time interval or frequency of administration </li></ul>
  14. 14. Hydromorphone (Dilaudid) <ul><li>Synthetic derivative of morphine </li></ul><ul><li>Same actions, uses, adverse effects as morphine </li></ul><ul><li>More potent on a mg per mg basis </li></ul><ul><li>More effective orally than morphine </li></ul><ul><li>Effects last longer than morphine </li></ul>
  15. 15. Meperidine (Demerol) <ul><li>Synthetic drug similar to morphine </li></ul><ul><li>Dose of 100mg is equivalent to Morphine 10mg </li></ul><ul><li>Has shorter duration </li></ul><ul><li>Has less respiratory depression and little antitussive effect </li></ul><ul><li>Causes less smooth muscle spasm </li></ul>
  16. 16. Codeine <ul><li>Naturally occurring opium alkaloid </li></ul><ul><li>Used for milder pain </li></ul><ul><li>Acts as an antitussive (found in cough meds) </li></ul><ul><li>Often combined with acetaminophen </li></ul><ul><li>Preferred analgesic with head trauma </li></ul>
  17. 17. Oxycodone <ul><li>Semisynthetic derivative of codeine </li></ul><ul><li>Used to relieve moderate pain </li></ul><ul><li>More potent and more likely to produce abuse than codeine </li></ul><ul><li>Available in combination with acetaminophen </li></ul>
  18. 18. Opioid Antagonists <ul><li>Reverse or block analgesia, CNS and respiratory depression of opioid agonists </li></ul><ul><li>Compete with opioids for opioid receptor sites in brain </li></ul><ul><li>Do not relieve depressant effects of anti-anxiety drugs or antipsychotics </li></ul><ul><li>Naloxone - oldest, most commonly known </li></ul><ul><li>Nalmefene - newer with longer duration </li></ul><ul><li>Naltrexone - used in maintenance of opiate free states in opiate addicts </li></ul>
  19. 19. Client Teaching For Opioid Analgesics <ul><li>Narcotics may be alternated with a non-narcotic analgesic </li></ul><ul><li>If pain relief not achieved notify physician </li></ul><ul><li>Do not drink alcohol or take other drugs that cause drowsiness </li></ul><ul><li>Do not smoke, cook, drive a car or operate machinery after taking </li></ul>
  20. 20. <ul><li>Constipation is a common adverse effect </li></ul><ul><li>Do not crush or chew long acting tablets </li></ul><ul><li>Decrease dose or omit if adverse effects occur </li></ul>
  21. 21. Use In Older Adults <ul><li>Use cautiously if debilitated or hepatic, renal or respiratory impairment </li></ul><ul><li>Start with lower dose and increase gradually </li></ul><ul><li>Give less often? </li></ul><ul><li>Give opioid analgesic with short half-life (Oxycodone) </li></ul><ul><li>Monitor for sedation or confusion </li></ul><ul><li>Monitor urinary output </li></ul><ul><li>Assess ability to self-medicate </li></ul>
  22. 22. Characteristics of Withdrawal From Opiates <ul><li>Generalized body aches </li></ul><ul><li>Insomnia </li></ul><ul><li>Lacrimation </li></ul><ul><li>Rhinorrhea </li></ul><ul><li>Perspiration </li></ul><ul><li>Pupil dilation </li></ul><ul><li>Piloerection </li></ul><ul><li>Anorexia </li></ul><ul><li>N/V/D </li></ul><ul><li>Increased vital signs </li></ul><ul><li>Abdominal and other muscle cramps </li></ul>
  23. 23. Treatment Of Withdrawal Syndrome <ul><li>Gradually reduce the opioid over several days </li></ul><ul><li>Substitute methadone and slowly reduce dose over a longer time </li></ul><ul><li>Clonidine reduces withdrawal symptoms </li></ul>
  24. 24. <ul><li>Salicylates-produce peripheral blood vessel dilation </li></ul><ul><ul><li>Most common pain reliever </li></ul></ul><ul><ul><li>Control pain </li></ul></ul><ul><ul><li>Reduce fever-stimulate hypothalmus </li></ul></ul><ul><ul><li>Reduce inflammation </li></ul></ul><ul><ul><li>ASA is oldest nonnarcotic analgesic </li></ul></ul><ul><ul><li>Bonus effect-inhibits platelet aggregrate </li></ul></ul><ul><ul><li>Guideline </li></ul></ul><ul><ul><ul><li>Use lowest dose that produces analgesia </li></ul></ul></ul><ul><ul><ul><li>Highly protein bound-can interfere w/other drugs </li></ul></ul></ul><ul><ul><ul><ul><li>Heparin,methotrexate, oral antidiabetic meds, insulin </li></ul></ul></ul></ul>NONNARCOTICS SALICYLATES
  25. 25. <ul><li>Adverse reactions </li></ul><ul><ul><li>Hearing loss </li></ul></ul><ul><ul><li>Diarrhea </li></ul></ul><ul><ul><li>Thirst </li></ul></ul><ul><ul><li>Sweating </li></ul></ul><ul><ul><li>Tinnitus </li></ul></ul><ul><ul><li>Confusion </li></ul></ul><ul><ul><li>Dizziness </li></ul></ul><ul><ul><li>Impaired vision </li></ul></ul><ul><ul><li>Hyperventilation </li></ul></ul><ul><ul><li>Reye’s syndrome-when given to children (do not use < 12 yrs old) </li></ul></ul><ul><li>Common side effects </li></ul><ul><ul><li>Gastric distress </li></ul></ul><ul><ul><li>Bleeding tendencies </li></ul></ul><ul><ul><li>NVD </li></ul></ul>
  26. 26. <ul><li>Give w/food </li></ul><ul><li>May crush except enteric coated </li></ul><ul><li>Hold and notify MD for bleeding </li></ul><ul><li>Stop ASA 5-7 days before elective surgery </li></ul><ul><li>Salicylate hypersensitivity </li></ul><ul><ul><li>Tinnitus or hearing loss </li></ul></ul><ul><ul><li>Vertigo </li></ul></ul><ul><ul><li>Bronchospasm </li></ul></ul><ul><ul><li>Urticaria </li></ul></ul><ul><ul><li>Need to avoid prunes, raisins, paprika, licorice </li></ul></ul>
  27. 27. <ul><li>Acetaminophen </li></ul><ul><ul><li>Antipyretic and analgesic </li></ul></ul><ul><ul><li>IS NOT ANTI INFLAMMATORY </li></ul></ul><ul><ul><li>Drug of choice for children with flulike symptoms </li></ul></ul><ul><ul><li>Risk of liver disease </li></ul></ul><ul><ul><ul><li>Phenytoin, barbituates, INH, ETOH </li></ul></ul></ul><ul><ul><li>Rarely cause GI distress-may cause LIVER toxicity </li></ul></ul><ul><ul><ul><li>Monitor total daily dose (adults 4g max.) </li></ul></ul></ul>ACETAMINOPHEN
  28. 28. <ul><li>Phenazopyridine hydrochloride </li></ul><ul><ul><li>Pyridium-now OTC </li></ul></ul><ul><ul><li>Dye used in commercial coloring-analgesic effect on urinary tract </li></ul></ul><ul><ul><li>Relieves pain, burning, itching, urgency, </li></ul></ul><ul><li>Teach </li></ul><ul><ul><li>Urine orange </li></ul></ul><ul><ul><li>Stains fabric-contact lenses </li></ul></ul><ul><ul><li>Notify in ineffective </li></ul></ul>
  29. 29. <ul><li>Anti Inflammatory Drugs </li></ul>
  30. 30. <ul><li>Anti inflammatory agents </li></ul><ul><ul><li>Reduce body temperature </li></ul></ul><ul><ul><li>Relief of pain </li></ul></ul><ul><ul><li>Anticoagulant (ASA) </li></ul></ul><ul><ul><li>Reduce inflammation </li></ul></ul><ul><li>ASA – oldest </li></ul><ul><li>NSAIDS- reduce inflammation & pain for arthritic conditions </li></ul><ul><li>Inhibit enzyme COX </li></ul>
  31. 31. <ul><li>OTC </li></ul><ul><ul><li>Ibuprofen, Motrin, Nuprin, Advil, Medipren </li></ul></ul><ul><ul><li>Naproxen (Aleve) </li></ul></ul><ul><ul><li>Motrin only available in 200 mg form </li></ul></ul><ul><ul><ul><li>MD must prescribe higher dose </li></ul></ul></ul>
  32. 32. <ul><li>Second generation NSAIDS </li></ul><ul><ul><li>COX-2 inhibitors </li></ul></ul><ul><li>COX 1 inhibitor </li></ul><ul><ul><li>Decreased protection of lining of stomach </li></ul></ul><ul><ul><li>Clotting time decreased-benefit cardiovascular patients </li></ul></ul>
  33. 33. <ul><li>NSAIDS </li></ul><ul><ul><li>Inhibit prostaglandin synthesis </li></ul></ul><ul><ul><ul><li>Prostaglandins produced / released in inflammatory disorders </li></ul></ul></ul><ul><ul><li>Ankylosing spondylitis </li></ul></ul><ul><ul><li>Moderate to severe arthritis </li></ul></ul><ul><ul><li>Osteoarthritis </li></ul></ul><ul><ul><li>Acute gouty arthritis </li></ul></ul><ul><ul><li>Dysmenorrhea </li></ul></ul><ul><ul><li>Migranes </li></ul></ul><ul><ul><li>Bursitis, tendonitis </li></ul></ul>
  34. 34. <ul><li>Adverse reactions </li></ul><ul><ul><li>Abdominal pain, bleeding </li></ul></ul><ul><ul><li>Anorexia </li></ul></ul><ul><ul><li>Diarrhea, nausea </li></ul></ul><ul><ul><li>Ulcers </li></ul></ul><ul><ul><li>Liver toxicity </li></ul></ul><ul><ul><li>Drowsiness </li></ul></ul><ul><ul><li>Headache </li></ul></ul><ul><ul><li>Tinnitus </li></ul></ul><ul><ul><li>Confusion </li></ul></ul><ul><ul><li>Vertigo </li></ul></ul><ul><ul><li>Depression </li></ul></ul><ul><ul><li>Blood in urine, bladder infection, kidney necrosis </li></ul></ul><ul><ul><li>Sodium & water retention </li></ul></ul><ul><ul><li>Heart failure </li></ul></ul><ul><ul><li>Pedal edema </li></ul></ul>
  35. 35. <ul><li>Nursing implications </li></ul><ul><ul><li>CBC, platelet count, PT </li></ul></ul><ul><ul><li>Monitor hepatic / renal function </li></ul></ul><ul><ul><li>Bronchospasm </li></ul></ul><ul><ul><li>Monitor for s/s of bleeding </li></ul></ul><ul><ul><li>Take w/meals </li></ul></ul><ul><ul><li>Avoid alcohol </li></ul></ul>
  36. 36. <ul><li>Corticosteroids </li></ul><ul><ul><li>prednisone / prednisolone / dexamethasone </li></ul></ul><ul><ul><li>Suppresses components of inflammatory process at the injured site </li></ul></ul><ul><ul><li>NOT THE DRUG OF CHOICE FOR ARTHRITIC CONDITIONS </li></ul></ul><ul><ul><li>USED TO CONTROL FLARE UPS </li></ul></ul><ul><ul><li>Must taper dose when D/C </li></ul></ul>
  37. 37. <ul><li>DMARDS-disease modifying antirheumatic drugs </li></ul><ul><ul><li>Toxic </li></ul></ul><ul><ul><li>Alter disease process </li></ul></ul><ul><ul><li>Gold/Gold Salts </li></ul></ul><ul><ul><ul><li>IM/PO </li></ul></ul></ul><ul><li>Used for relief of symptoms </li></ul><ul><li>Immunosuppressive agents-used when antiinflammatories do not work-cytoxan, methotexrate/cancer drugs </li></ul><ul><li>Antimalarials-when all other tx fails </li></ul>
  38. 38. <ul><li>Antiinflammatory Gout Drugs </li></ul><ul><ul><li>“ gouty arthritis” </li></ul></ul><ul><ul><li>Urinary calculi </li></ul></ul><ul><ul><li>Gouty nephrophaty </li></ul></ul><ul><li>Increase fluid intake </li></ul><ul><li>Avoid foods rich in purine - organ meats, sardines, salmon, gravy, legumes </li></ul><ul><li>Avoid alcohol, caffeine, large doses of vitamin C </li></ul><ul><li>Zyloprim - inhibits final steps of uric acid </li></ul><ul><li>Colchicine - first drug, inhibits migration of leukocytes to the inflamed site </li></ul>
  39. 39. Propionic Acid Derivatives <ul><li>Ibuprofen (Motrin) - prototype; ketoprofen (Orudis), naproxen (Naprosyn) </li></ul><ul><li>Used as anti-inflammatory agents in gout, arthritis, tendonitis </li></ul><ul><li>Used as analgesic for dysmenorrhea, episiotomy, minor trauma </li></ul><ul><li>Used as antipyretic </li></ul>
  40. 40. <ul><li>Better tolerated than ASA but more expensive </li></ul><ul><li>Similar adverse affects as with ASA </li></ul><ul><li>May lead to renal impairment </li></ul><ul><li>Inhibits platelets only while drug molecules in bloodstream </li></ul><ul><li>Combined with other drugs </li></ul>
  41. 41. Acetic Acid Derivatives <ul><li>Indomethacin (Indocin) - prototype; Tolmetin (Tolectin), Sulindac (Clinoril) </li></ul><ul><li>Used to treat moderate to severe rheumatoid arthritis, osteo-arthritis, gouty arthritis, bursitis, pericarditis for anti-inflammatory effects </li></ul><ul><li>Prescription drug </li></ul><ul><li>Has increased incidence and severity of adverse effects </li></ul>
  42. 42. Client Teaching Guidelines <ul><li>Take ASA and NSAIDS with full glass of water and food </li></ul><ul><li>Drink 2-3 quarts of fluid daily with NSAIDS </li></ul><ul><li>Report signs of bleeding </li></ul><ul><li>Avoid or minimize alcoholic beverages </li></ul><ul><li>Do not take more than prescribed amount </li></ul><ul><li>Do not take more that 3 days for fever or 10 days for pain </li></ul><ul><li>Read labels of other OTC medications </li></ul>