This document provides an overview of chapter 6 which discusses anesthetics, analgesics, and narcotics. It begins by outlining the chapter topics and learning objectives which include understanding the nervous system, neurotransmitters, anesthesia, pain management, and migraine headaches. It then defines the central and peripheral nervous systems and their divisions. It discusses the major neurotransmitters like acetylcholine, GABA, dopamine, epinephrine, and serotonin. It explains general anesthesia, including goals, types of inhalant and injectable anesthetics. It also covers local anesthesia, neuromuscular blocking agents, and their reversal. Finally, it discusses classifications of pain, narcotic and non-narcotic analgesia, and the risks of addiction.

1. Chapter 6
Anesthetics, Analgesics, and
Narcotics
By SANJAY RAJPUROHIT

2. Chapter 6 Topics
• Divisions of the Nervous System
• Major Neurotransmitters
• Anesthesia
– General Anesthesia
– Local Anesthesia
• Pain Management
• Migraine Headaches

3. Learning Objectives
• Understand the central and peripheral nervous
systems, their functions, and their relationship to
drugs.
• Become aware of the role of neurotransmitters.
• 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.

4. Learning Objectives
• Define the action of neuromuscular blocking
agents in reducing muscle activity.
• Distinguish between narcotic and nonnarcotic
analgesia.
• Become familiar with the various types of
agents for migraine headaches.

5. Divisions of the Nervous System
• Central Nervous System
– Brain
– Spinal cord
• Peripheral Nervous System
– Nerves
– Sense organs

6. Divisions of the Nervous System
• Central Nervous System
1. Brain receives information
2. Evaluates information
3. Sends out a response
• Peripheral Nervous System

7. Divisions of the Nervous System
• Central Nervous System
• Peripheral Nervous System
– Somatic Nervous System
– Autonomic Nervous System

8. Divisions of the Nervous System
• Central Nervous System
• Peripheral Nervous System
– Somatic Nervous System
Voluntary action: skeletal muscle contraction and
movement
– Autonomic Nervous System
Involuntary activities: respiration, circulation,
digestion, sweating

9. Autonomic Nervous System

10. Review
The nervous system has two
components. What are they?

11. Review
The nervous system has two components. What
are they?
Answer
– Central nervous system (CNS)
– Peripheral nervous system (PNS)

12. Major Neurotransmitters
• Acetylcholine
• GABA
• Dopamine
• Epinephrine
• Serotonin

13. Major Neurotransmitters
• Acetylcholine (ACh)
– Smooth muscle, cardiac muscle, and
exocrine glands
– Anticholinergics block ACh receptors
• GABA
• Dopamine
• Epinephrine
• Serotonin

14. Major Neurotransmitters
• Acetylcholine
• GABA (gamma-aminobutyric acid)
Regulates message delivery system of
the brain
• Dopamine
• Epinephrine
• Serotonin

15. Major Neurotransmitters
• Acetylcholine
• GABA
• Dopamine
Acts on the CNS and kidneys
• Epinephrine
• Serotonin

16. Major Neurotransmitters
• Acetylcholine
• GABA
• Dopamine
• Epinephrine
–Acts on cardiac and bronchodilator
receptors
–Known as Adrenaline
• Serotonin

17. Major Neurotransmitters
• Acetylcholine
• GABA
• Dopamine
• Epinephrine
• Serotonin
– Acts on smooth muscle and gastric mucosa
(causes vasoconstriction)
– Emotional responses: depression, anxiety

18. Communication by
Neurotransmitters
Neurotransmitters are released from one
axon and received by another neuron’s
dendrites.

19. Discussion
What are three important
types of receptors in the study
of drugs?

20. Discussion
What are three important types of receptors
in the study of drugs?
Answer
– Alpha
– Beta-1
– Beta-2

21. Types of Receptors
• Alpha
Vasoconstriction, raise BP
• Beta-1
Heart stimulation
• Beta-2
Vasodilation and bronchodilation

22. Drug Effects on Receptors
Drugs can have two types of effects on
receptors.
– Stimulating, causing a reaction
– Blocking, preventing a reaction
• Dopamine blocking
• Anticholinergics

23. Anticholinergic Side Effects
• Decreased GI motility
• Decreased sweating
• Decreased urination
• Dilated pupils
• Dry eyes
• Dry mouth

24. Anesthesia
In the “old days” the following were used for
anesthesia.

25. Anesthesia
In the “old days” the following were used for
anesthesia.
– Alcohol
– Drugs
– Ice for numbing
– Blow to the head
– Strangulation

26. Anesthesia
Now, anesthesia is designed to focus on
specific systems, such as

27. Anesthesia
Now, anesthesia is designed to focus on
specific systems, such as
• Nervous system • Skeletal system
• Respiratory system • GI system
• Endocrine system • Hepatic system
• Cardiovascular system

28. Anesthesia
Goals of Balanced Anesthesia
– Amnesia

29. Anesthesia
Goals of Balanced Anesthesia
– Amnesia
– Adequate Muscle
Relaxation

30. Anesthesia
Goals of Balanced Anesthesia
– Amnesia
– Adequate Muscle Relaxation
– Adequate Ventilation

31. Anesthesia
Goals of Balanced Anesthesia
– Amnesia
– Adequate Muscle Relaxation
– Adequate Ventilation
– Pain Control

32. Types of Anesthesia
• General
• Local

33. Types of Anesthesia
•General
• Local

34. Discussion
What are some of the indicators
used to assess general anesthesia?

35. Discussion
What are some of the indicators used
to access general anesthesia?
Answer: Blood pressure,
hypervolemia, oxygen level,
pulse, respiratory rate, tissue
perfusion, urinary output

36. General Anesthesia
Preanesthetic Medications
– Control sedation
– Reduce postoperative pain
– Provide amnesia
– Decrease anxiety

37. General Anesthesia
Malignant Hyperthermia
– Side effect of anesthesia
• Fever of 110°F or more
• Life threatening
– Treatment: dantrolene (Dantrium)
Always check
expiration date.
Warning!

38. Inhalant Anesthetics
• desflurane (Suprane)
• enflurane (Ethrane)
• halothane
• isoflurane (Forane)
• nitrous oxide
Drug List

39. Inhalant Anesthesia Side Effects
• Causes reduction in blood pressure
• May cause nausea and vomiting

40. nitrous oxide
• Causes analgesia only; no amnesia or
relaxation
• May be given alone or may be given
with more powerful anesthetics to
hasten the uptake of the other agent(s)
• Commonly used for dental procedures
• Rapidly eliminated

41. desflurane (Suprane)
• Has rapid onset and recovery
• Often used in ambulatory surgery

42. General Anesthesia
• Often dispensed by IV drip
• Very lipid soluble

43. Injectable Anesthetics
• etomidate (Amidate)
• fentanyl (Duragesic, Sublimaze)
• fentanyl-droperidol
• ketamine (Ketalar)
• morphine
• propofol (Diprivan)
• sufentanil (Sufenta)
Drug List

44. Injectable Anesthetics
Barbituates
– methohexital (Brevital)
– thiopental (Pentothal)
Benzodiazepines
– diazepam (Valium)
– lorazepam (Ativan)
– midazolam (Versed)
Drug List

45. propofol (Diprivan)
• Used for maintenance of anesthesia,
sedation, or treatment of agitation
• Has antiemetic properties
– Drowsiness
– Respiratory depression
– Motor restlessness
– Increased blood pressure

46. Injectable Anesthesia
Dispensing Issues
Diprivan (anesthetic) and Diflucan
(antifungal) may be confused.
This mix-up could be life-threatening.
Warning!

47. fentanyl
• Dosage Forms
– IV (Sublimaze)
– patch (Duragesic)
– lozenge (Actiq) for children
• Used extensively for open-heart
surgery due to lack of cardiac
depression

48. Benzodiazepines
• Used for induction, short procedures, and
dental procedures
• Useful in controlling and preventing
seizures induced by local anesthetics
• midozolam (Versed)
– fastest onset of action
– greatest potency
– most rapid elimination

49. Antagonist Agents
Antagonist agents reverse
benzodiazepine and narcotic
overdose.

50. Antagonist Agents
• flumazenil (Romazicon)
• nalmefene (Revex)
• naloxone (Narcan)
Drug List

51. flumazenil (Romazicon)
• Antagonizes benzodiazepines by competing
for receptor site
• Used for complete or partial reversal

52. naloxone (Narcan)
• Competes for opiate receptor sites
• Has a shorter duration of action than
narcotics, so it must be given repeatedly

53. Neuromuscular Blocking Agents
• Causes immediate skeletal muscle
relaxation.
– Short Duration
– Intermediate Duration
– Extended Duration
• Used to facilitate endotracheal intubation.
– Allows for easier insertion of endotracheal
tube.
– Keeps airway open.

54. Neuromuscular Blocking
Agents
• atracurium (Tracrium)
• cisatracurium (Nimbex)
• mivacurium (Mivacron)
• pancuronium
• rocuronium (Zemuron)
• succinylcholine (Quelicin)
• vecuronium (Norcuron)
Drug List

55. Neuromuscular Blocking Agents
Dispensing Issues
• Very expensive
• Be conscious of storage requirements
• Store away from look-alike and drugs
Warning!

56. succinylcholine (Quelicin)
• Often called “sux.”
• Only depolarizing agent. All others work as
competitive antagonists to ACh receptors.
• Persistent depolarization at motor endplate.
• Causes sustained, brief period of flaccid
skeletal muscle paralysis.

57. Reversal of Neuromuscular Blocking
Agents
• Increases the action of acetylcholine by
inhibiting acetylcholinesterase
• Used for reversal of nonpolarizing agents

58. Anticholinesterase Agents
• edrophonium (Enlon)
• neostigmine (Prostigmin)
• pyridostigmine (Mestinon)
Drug List

59. Types of Anesthesia
• General
•Local

60. Local Anesthesia
Relieves pain without altering
alertness or mental function.

61. Local Anesthesia
Variety of Dosage Forms
– Topical
– Superficial injection (infiltration)
– Nerve block
– IV
– Epidural
– Spinal

62. Discussion
Local anesthetics are classified
by their chemistry into two
classes.
What are they?

63. Discussion
Local anesthetics are classified by
their chemistry into two classes.
What are they?
Answer
– Esters
– Amides

64. Local Anesthesia
Esters
– Short acting
– Metabolized in the plasma and tissue fluids
– Excreted in urine

65. Local Anesthesia
Amides
– Longer acting
– Metabolized by liver enzymes
– Excreted in urine

66. Local Anesthesia
Esters
• benzocaine (Americaine)
• chloroprocaine (Nesacaine)
• dyclonine (Cēpacol Maximum Strength)
• procaine (Novocain)
• tetracaine (Cēpacol Viractin, Pontocaine)
Drug List

67. Local Anesthesia
Amides
• bupivacaine (Marcaine)
• levobupivacaine (Chirocaine)
• lidocaine (L-M-X, Solarcaine, Xylocaine)
• lidocaine-epinephrine (Xylocaine w/ Epinephrine)
• lidocaine-prilocaine (EMLA)
• mepivacaine (Carbocaine)
Drug List

68. Discussion
What functions are lost with
local anesthetics?

69. Discussion
What functions are lost with local anesthetics?
Answer
– Pain perception
– Temperature
– Touch sensation
– Proprioception
– Skeletal muscle tone

70. Discussion
Under what conditions would
a local anesthetic be used over
a general anesthetic?

71. Discussion
Under what conditions would a local
anesthetic be used over a general
anesthetic?
Answer: It is chosen when a
well-defined area of the body is
targeted.

72. Pain Management
What is pain?
– A protective mechanism to warn of damage or
the presence of disease
– Part of the normal healing process
Managing pain can be a challenge.

73. Discussion
What are the classifications of
pain?

74. Discussion
What are the classifications of pain?
Answer
– Acute
– Chronic
• Nonmalignant
• Malignant

75. Pain Management
Acute Pain
• Associated with trauma or surgery
• Easier to manage by treating the cause
• Has a beginning and an end

76. Pain Management
Chronic Pain
• No end to the pain
• Patients may have a sense of helplessness and
hopelessness
• Affects different aspects of life
– Physical
– Psychological
– Social
– Spiritual

77. Pain Management
Chronic Nonmalignant Pain
• Cause may be diagnosed or undiagnosed
• Pain lasts for more than 3 months
• Patients may have signs and symptoms of
depression

78. Pain Management
Chronic Malignant Pain
• Accompanies malignant disease
• Often increases in severity with disease
progression

79. Major Sources of Pain
Source Area
Involved
Characteristics Treatment
Somatic body
framework
throbbing,
stabbing
narcotics,
NSAIDS
Visceral kidneys,
intestines,
liver
aching,
throbbing,
sharp, crampy
narcotics,
NSAIDS
Neuropathic Nerves burning,
numbing,
tingling
antidepressants,
anticonvulsants
Sympathetically
Mediated
overactive
sympathetic
system
no pain should
be felt
nerve blockers

80. Pain Management
Narcotic
• Pain-modulating chemical derived from
opium or is synthetically produced
• Also called opioid
• Causes insensibility or stupor
• Mainly effects on CNS and GI tract
• Lesser effects on peripheral tissues

81. Pain Management
Natural Opioids
• Endorphins, enkephalins, and dynorphins
• Produced by the brain in response to pain
stimuli
• When receptors are activated
– causes decreased nerve transmission
– sensation of pain is diminished
• Opioids bind to these same receptors

82. Discussion
What are the three effects of
narcotics?

83. Discussion
What are the three effects of
narcotics?
Answer
– Analgesia
– Sedation
– Euphoria and Dysphoria

84. Pain Management
Effects of Narcotics
• Analgesia
Reduce pain from most sources

85. Pain Management
Effects of Narcotics
• Analgesia
Reduce pain from most sources
• Sedation
Decrease anxiety and cause drowsiness

86. Pain Management
Effects of Narcotics
• Analgesia
Reduce pain from most sources
• Sedation
Decrease anxiety and cause drowsiness
• Euphoria and Dysphoria
– Can cause feelings of well-being and disquiet or
restlessness
– Potential for tolerance and dependence

87. Pain Management
Patient-Controlled Analgesia Pump
– Patient controls (within limits) when and how
often medication is administered
– Allows for better pain control

88. Pain Management
Analgesic Ladder
1. Onset of mild to moderate pain
Administer acetaminophen (APAP) or an
NSAID

89. Pain Management
Analgesic Ladder
1. Onset of mild to moderate pain
Administer acetaminophen (APAP) or an NSAID
2. Adequate relief is not achieved in Step 1
Administer NSAID plus a “weak” opioid
(codeine)

90. Pain Management
Analgesic Ladder
1. Onset of mild to moderate pain
Administer acetaminophen (APAP) or an NSAID
2. Adequate relief is not achieved in Step 1
Administer NSAID plus a “weak” opioid
(codeine)
3. Adequate relief is not achieved in Step 2
Administer a strong opioid (morphine)

91. Pain Management
Chronic opioid therapy has a low risk of
addiction when used appropriately.

92. Discussion
What is the difference between
addiction and dependence?

93. Pain Management
• Dependence
Physical and emotional reliance on a drug
• Addiction
Compulsive disorder

94. Pain Management
Symptoms of Addiction
• Preoccupation with drugs
• Refusal of medication tapers
• Strong preference for a specific opioid
• Decrease in ability to function
• Medication is typically not taken as prescribed
• Have a tendency to visit many different doctors
and pharmacies in order to get the drug(s)

95. Narcotic
Dispensing Issues
Pharmacy technicians have a legal and moral
responsibility to alert pharmacist of suspected
abuse and addiction.
Warning!

96. Pain Management
Patients are more successful overcoming
addiction if withdrawal symptoms are handled
appropriately.

97. Addiction Treatment
• buprenorphine (Buprenex, Subutex)
• buprenorphine-naloxone (Suboxone)
• methadone (Dolophine)
Drug List

98. methadone (Dolophine)
• Uses
– Detoxification
– Maintenance of narcotic addiction
• Dispensed in clinics or in hospitals
• Binds to opiate receptors without giving a
euphoric feeling

99. Discussion
What are the pros and cons of
methadone clinics?

100. Pain Management
Combinations of narcotics and nonnarcotics is
common.
– Enhances relief
– Facilitates use of lower doses
– Decreases side effects

101. Pain Management
Combinations can be dangerous if the ASA or
APAP dose is overlooked.
Technicians should be aware of this risk and
assess each prescription for possible toxic doses.
Warning!

102. Narcotic Analgesics
Varying dose requirements due to
– Severity of pain
– Individual response to pain
– Patient’s age and weight
– Presence of concomitant disease

103. Narcotic Analgesics
• Many different dosage forms and strengths
are available.
• Goal: Patient comfort
• Key to reaching goal: Constant
reassessment
• Side effects should be anticipated and
minimized for patient comfort

104. Narcotic Analgesic Side Effects
– Mental confusion
– Reduced alertness
– Nausea/vomiting
– Dry mouth
– Constipation
– Inflammatory process
– Bronchial constriction

105. Narcotic Analgesics
• APAP-codeine (Tylenol With Codeine)
• hydrocodone-APAP (Lortab, Vicodin)
• hydromorphone (Dilaudid)
• meperidine (Demerol)
• morphine (MS Contin)
• oxycodone (OxyContin)
Drug List

106. Narcotic Analgesics
• oxycodone-APAP (Endocet, Percocet, Tylox)
• oxycodone-ASA (Endodan, Percodan)
• oxymorphone (Numorphan)
• pentazocine (Talwin)
• pentazocine-naloxone (Talwin NX)
• propoxyphene (Darvon)
• propoxyphene-APAP (Darvocet-N 100)
Drug List

107. Narcotic Analgesic
Dispensing Issues
• Be careful of multiple strengths.
• Lortab and Lorabid can be confused. Pay
attention to dosing schedule.
• Morphine sulfate and magnesium sulfate
are often confused.
Warning!

108. Migraine Headaches
Migraine
– Severe, throbbing, vascular
headache
– Recurrent unilateral head pain
– Combined with neurologic and
GI disturbances

109. Migraine Headaches
• 90% of migraine sufferers report nausea.
• Sensitivity to light, sound, and stimulation
are also common.

110. Migraine Headaches
Components of classic migraine (all five not
experienced by every migraine sufferer):
– Prodrome
– Aura
– Headache
– Headache relief
– Postdrome

111. Migraine Headaches
Prodrome
Symptom indicating the onset

112. Migraine Headaches
Aura
Subjective sensation or motor phenomenon that
precedes and marks the onset of a migraine attack
• Flashing lights
• Shimmering heat waves
• Bright lights
• Dark holes in visual fields
• Blurred or cloudy vision
• Transient loss of vision

113. Migraine Headaches
Headache and Headache Relief
Headache generally dissipates in six hours, but
may last one to two days

114. Migraine Headaches
Postdrome
Knowing the headache is gone

115. Migraine Headaches
Serotonin appears to be involved in cause.
– Decreased levels = excessive vasodilation in
cranial arteries = headache.
– By stimulating serotonin receptors,
vasoconstriction will occur thereby alleviating
the migraine.

116. Migraine Headaches
Causative Factors
• Diet
• Stress
• Depression
• Sleep habits
• Certain
medications
• Hormonal
fluctuations
• Atmospheric
changes
• Environmental
irritants

117. Migraine Headaches
Initial Treatment
• Identifying and eliminating triggers
Ex: red wine, caffeine, certain foods, bright
lights
• If attacks are still frequent, drug therapy
may be indicated

118. Discussion
Migraine drug therapy can be
divided into two classes. What
are they?

119. Discussion
Migraine therapy can be divided into two
drug classes. What are they?
Answer
– Prophylactic Therapy
– Abortive Therapy

120. Migraine Headaches
• Prophylactic Therapy
Attempts to prevent or reduce recurrence
• Abortive Therapy

121. Migraine Headaches
• Prophylactic Therapy
Attempts to prevent or reduce recurrence
• Abortive Therapy
– Treats acute migraine attacks
– Taken after headache occurs, at first sign of a
headache

122. Migraine Headaches
• Prophylactic Therapy
– Anticonvulsants
– Beta blockers
– Calcium channel
blockers
– Estrogen
– Feverfew
– NASAIDs
– SSRIs
– Tricyclic
antidepressants
• Abortive Therapy
– Simple analgesics
– NSAIDs
– Ergotamine-
containing
medications
– Other drugs

123. Migraine Headaches
Triptans—Selective 5-HT Receptor Agonists
• almotriptan (Axert)
• eletriptan (Relpax)
• frovatriptan (Frova)
• naratriptan (Amerge)
• rizatriptan (Maxalt, Maxalt-MLT)
• sumatriptan (Imitrex)
• zolmitriptan (Zomig)
Drug List

124. sumatriptan (Imitrex)
• Binds to serotonin receptors causing
vasoconstriction of blood vessels in the
dura
• Use at first sign of headache
• Available in injection, nasal spray, and
tablet

125. rizatriptan (Maxalt-MLT)
• Sublingual tablet, quickly absorbed
• Has most rapid onset of action of all oral
migraine therapies
• May receive relief after 30 minutes
• Maxalt is not absorbed as quickly as
Maxalt-MLT

126. Migraine Headaches
Ergot Preparations
• dihydroergotamine (D.H.E. 45, Migranal)
• ergotamine (Ergomar)
• ergotamine-caffeine (Cafergot)
Drug List

127. Migraine Headaches
Antiemetic Agents
• chlorpromazine (Thorazine)
• metoclopramide (Reglan)
• prochlorperazine (Compazine)
Drug List

128. metoclopramide (Reglan)
• Reduces nausea and vomiting
• Enhances absorption of other antimigraine
products
• Metoclopramide (Reglan) and aspirin have
been prescribed together instead of using
sumatriptan (Imitrex)

129. Migraine Headaches
Opiod Analgesic
• butorphanol (Stadol, Stadol NS)
Beta Blocker
• propranolol (Inderal)
Drug List

130. butorphanol (Stadol, Stadol NS)
• Nasal spray is used more commonly than
injection
• Has analgesic properties for moderate-to-
severe pain
• Can be addictive and abused
• A controlled substance in some states

131. Migraine Headaches
Other
• butalbital-APAP-caffeine (Fioricet)
• butalbital-ASA-caffeine (Fiorinal)
• isometheptene-dichloralphenazone-APAP
(Midrin)
• tramadol (Ultram)
Drug List

132. Migraine Agents
Dispensing Issues
Tramadol and Toradol could be confused. Be
sure of which drug is being prescribed.
Warning!

133. tramadol (Ultram)
• High success rate when given with NSAIDs
(ibuprofen)
• Has slow onset of action
• Is not a controlled substance, but has shown
potential for addiction

134. isometheptene-dichloralphenazine-
acetaminophen (Midrin)
• Has fewer side effects than ergotamines, but
may be less effective
• Combination of analgesic, sedative, and
vasoconstrictor

135. Discussion
What are some of the issues facing
migraine sufferers and the medication
that is used?

136. Discussion
What are some of the issues facing migraine
sufferers and the medication that is used?
Answer
– N/V
– 0.5-2 hour onset of action
– side effects of medications