Treating Severe Pain with Narcotics

Chapter 23
Drugs Treating Severe Pain
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Pain
• Pain is a multidimensional, subjective experience.
• Multiple studies over the years have shown that health
care providers undertreat pain.
• Pain may be a major indication for drug therapy.

Physiology
• The peripheral nervous system (PNS) and central
nervous system (CNS) comprise an integrated system
that provides a pathway for pain transmission.
• The physiologic mechanisms involved in the pain
response are complex and are not yet completely
understood.
• Transduction is the term used to describe the phenomena
associated with the initiation of a pain signal.
• Pain receptors are found on the peripheral end plates of
afferent neurons.

Components that Influence Pain
• Pain has sensory-discriminative (physical) components
and affective-motivational (emotional) components.
• The sensory dimension of pain encompasses pain’s
location, intensity, and quality.
• Stimulation of the limbic system produces this emotional
response to the physical stimulus of pain.
• Inhibition of pain and transmission of painful stimuli
occur in various regions of the brain.

Components that Influence Pain (cont.)
• Inhibitory substances such as endogenous opioids,
serotonin, norepinephrine, and gamma-aminobutyric acid
(GABA) are released into nerve synapses.
• These substances bind with receptors on primary afferent
and dorsal horn neurons to prevent further transmission
of painful stimuli.

Types of Pain
• Nociceptic pain is caused by the activation of the delta
and C nociceptors in response to painful stimuli, such as
injury.
• Neuropathic pain is the term used to represent pain in
which the underlying pathology is abnormal processing of
stimuli in the peripheral or central nervous systems.
• Acute pain, meaning the immediate phase of response to
an insult or injury, results from tissue damage.
• Chronic pain may persist well beyond actual tissue injury
and healing.

Nonpharmacologic Pain Management
Techniques

Narcotic Analgesics
• Narcotic analgesics are required for conditions, disorders,
or treatments that are accompanied by moderate-to-severe
pain.
• The narcotic analgesics include opiate agonists, mixed
agonist-antagonists, and antagonists based on their
activity at opioid receptors.
• Narcotics have an important role in pain management
and control.
• Narcotics are typically underprescribed and underused.
• Prototype drug: morphine

Morphine: Core Drug Knowledge
• Pharmacotherapeutics
– Moderate-to-severe acute or chronic pain
• Pharmacokinetics
– Metabolism: liver. Onset: 15 to 30 minutes.
Duration: 3 to 7 hours.
• Pharmacodynamics
– Agonist at the mu, kappa, and possibly delta opiate
receptors

Morphine: Core Drug Knowledge (cont.)
• Contraindications and precautions
– Hypersensitivity and respiratory conditions
• Adverse effects
– Respiratory depression, apnea, respiratory arrest,
circulatory depression, cardiac arrest, shock, and
coma
• Drug interactions
– Multiple drug interactions

Morphine: Core Patient Variables
• Health status
– Assess respiratory status
• Life span and gender
– Assess age, pregnancy, labor and delivery, and
lactation
• Lifestyle, diet, and habits
– Assess for tolerance and/or dependence
• Environment
– Closely monitor patients receiving drug
• Culture and inherited traits
– Pain is what the patient says it is.

Morphine: Nursing Diagnoses and
Outcomes
• Ineffective Breathing Pattern, Hypoventilation, related to
respiratory depression caused by the drug
– Desired outcome: The patient maintains effective
breathing despite respiratory depression.
• Constipation secondary to activity of the drug
– Desired outcome: the patient remains free of
constipation.
• Urinary Retention related to indirect anticholinergic
effects of the drug on the urinary sphincters
– Desired outcome: The patient maintains normal
urinary output.

Outcomes (cont.)
• Risk for Injury related to orthostatic hypotension or
sedation secondary to drug effects
– Desired outcome: The patient remains free of
injury.
• Ineffective Airway Clearance secondary to cough
suppression by the drug
– Desired outcome: The patient’s airway remains
patent and clear.

Outcomes (cont.)
• Acute pain related to trauma or disease process and
insufficient analgesia
– Desired outcome: The patient remains free of pain
• Deficient Knowledge related to morphine therapy
– Desired outcome: The patient has adequate
knowledge of the drug and its adverse effects and
their management.

Morphine: Planning and Interventions
• Maximizing therapeutic effects
– Assess pain prior to and during therapy
– Use a pain assessment tool
• Minimizing adverse effects
– Conduct frequent assessment
– Provide additional pain medication for breakthrough
pain

Pain Rating Tools

Morphine: Teaching, Assessment, and
Evaluations
• Patient and family education
– Teach the purpose of the therapy
– Stress the importance of rating pain accurately
• Ongoing assessment and evaluation
– Assess patient’s pain level by using a pain scale
– Monitor for adverse effects

Question
• When administering morphine, the nurse should assess
what?
– A. Pain level
– B. Respiratory rate
– C. Blood Pressure
– D. Both A and B
– C. All of the above

Answer
• D. Both A and B
• Rationale: The nurse should always assess the level
of pain the patient is experiencing prior to
administration of morphine. Also morphine can cause
significant respiratory depression, so respiratory rate
should also be assessed.

Mild Narcotic Agonists
• The mild narcotic agonists include codeine, hydrocodone,
and propoxyphene.
• Prototype drug: codeine

Codeine: Core Drug Knowledge
– Treat mild-to-moderate pain
– Absorbed from GI tract, peaks in 1 to 2 hours;
crosses the placenta and secreted in breast milk
– Acts at specific opioid receptors in the CNS to
produce analgesia, euphoria, and sedation

Codeine: Core Drug Knowledge (cont.)
– Not given with other narcotics
• Adverse effects
– Drowsiness, sedation, dry mouth, nausea and
vomiting, and constipation
– Antihistamines, phenothiazines, barbiturates, tricyclic
antidepressants, cimetidine, and alcohol

Codeine: Core Patient Variables
• Health status
– Assess the need for the patient to cough to maintain
the airway
– Consider the age before administration
– Can cause physical dependency
• Environment
– Assess environment where drug will be given

Codeine: Nursing Diagnoses and
Outcomes
• Disturbed Sensory Perception related to drowsiness and
sedation
– Desired outcome: The patient will be protected
from injury related to sedation and drowsiness.
• Risk for Ineffective Airway Clearance related to
suppression of cough reflex
– Desired outcome: The patient will maintain
baseline respiratory function.
• Constipation secondary to activity of the drug
– Desired outcome: The patient remains free of
constipation.

Codeine: Planning and Interventions
– Actions are similar to those for morphine.
– Provide for patient safety
– Assess respiratory function prior to administration
– Do not administer to patients who need to cough to
clear airway.

Codeine: Teaching, Assessment, and
Evaluations
– Remind patients that drowsiness and impaired
orientation can occur
– Tell patients not to take codeine with other CNS
depressants
– Monitor codeine’s effect on motor control and
sedation, and the patient’s respiratory status

Question
• For which patient would codeine be contraindicated?
– A. Postoperative patient with chest tubes
– B. Postoperative patient with pain after ORIF of left
arm
– C. Patient with mild-to-moderate pain after breaking
right tibia
– D. Patient who has nonproductive cough that is
preventing normal sleep

Answer
• A. Postoperative patient with chest tubes
• Rationale: The patient who has chest tubes will need
to cough and deep breath to facilitate lung
expansion. Codeine also acts directly on the
medullary cough center to depress the cough reflex.

Narcotic Agonist-Antagonists
• Some narcotic analgesics have mixed opioid effects,
being an agonist at some receptors and an antagonist at
others.
• Prototype drug: pentazocine (Talwin)

Pentazocine: Core Drug Knowledge
– Agonist to control pain
– Well absorbed orally and from SC and IM sites.
Hepatic metabolism. Peak: 1-3 hours. Duration: 3
hours.
– Mixed agonist-antagonist. It stimulates kappa
receptors much as morphine does but also exhibits
weak antagonist effects at the mu receptors.

Pentazocine: Core Drug Knowledge
(cont.)
– Hypersensitivity. Use caution with respiratory
conditions.
• Adverse effects
– Nausea, vomiting, dizziness or lightheadedness,
respiratory depression, and euphoria
– Alcohol and CNS depressants

Pentazocine: Core Patient Variables
• Health status
– Assess for contraindications and hepatic disease
– Pregnancy category C
– Assess for abuse potential
• Environment
– Assess environment where drug will be given—oral
forms can be given at home.

Pentazocine: Nursing Diagnoses and
Outcomes
• Disturbed Sensory Perception related to dizziness and
lightheadedness
– Desired outcome: The patient will not be injured
from falls while taking pentazocine.
• Imbalanced nutrition secondary to nausea and vomiting
– Desired outcome: The patient’s nutrition will not be
compromised while on pentazocine.

Pentazocine: Nursing Diagnoses and
Outcomes (cont.)
• Ineffective Health Maintenance related to abuse of
pentazocine
– Desired outcome: The patient will use drug therapy
appropriately.
• Deficient Knowledge related to pentazocine therapy
– Desired outcome: The patient has adequate
knowledge of the drug and its adverse effects and
their management.

Pentazocine: Planning and Interventions
– Provide environmental controls to reduce sensory
stimuli and to aid relaxation
– Ensure that safety precautions are used
– In cases of overdosage, naloxone is indicated.

Pentazocine: Teaching, Assessment, and
Evaluations
– Teach adverse effects
– Teach how to take medication properly
– Monitor the effect of pentazocine on motor control,
sedation, and pain
– Adequate pain control should be achieved without
adverse effects.

Question
• Patients with chronic liver disease should not be given
pentazocine because of increased metabolism of the
drug?
– A. True
– B. False

Answer
• B. False
• Rationale: Chronic liver disease decreases
metabolism of pentazocine.

Treating Severe Pain with Narcotics

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