Nervous System Drugs

Drugs for Pain Management: Non-narcotic and Narcotic Analgesics

Anti-inflammatory Drugs

Analgesics
Non-narcotic Analgesic Drugs Narcotic Analgesic Drugs

Pain

Mild to moderate pain of the skeletal muscles and joints can be treated with non-narcotic analgesics. Moderate to severe pain in the smooth muscles, organs and bones usually requires narcotic analgesics. When tissues are damaged, injured cells release chemical mediators like bradykinin, serotonin and prostaglandins which cause nociceptors on nerve endings to tell the person that they are experiencing pain.

Classification of Pain

Acute pain occurs suddenly, responds to treatment treatment differs for levels of pain Cancer pain pain from pressure on nerves and organs, blockage to blood supply or metastasis to bone usually requires narcotic analgesics Chronic pain persistent pain ( lasting more than 6 months ) non-narcotic with a long half life Somatic pain pain of skeletal muscles, ligaments, joints usually treated with non-narcotics ( NSAIDs ) Superficial pain skin and mucous membrane pain nonnarcotic for mild and narcotic for moderate or severe ( burns ) Vascular pain - migraine or other headaches usually treated with non-narcotics Visceral pain smooth muscle or organ pain - narcotics

Pain Pathway: Gate Control Theory

Parietal lobe Thalamus Substantia gelatinosa Progtaglandin

Pathophysiology of Pain: Gate Control Theory of Pain

Chemical mediators bradykinin, serotonin, prostaglandins, histamine Afferent nerves (sensory); efferent nerve (motor) The gate: Substantia gelatinosa lamina of spinal cord Pain pathway: Lateral spinothalamic tract in the spinal cord Thalamus sensory integrating organ Parietal lobe sensory interpretation center

Pain Assessment

Pain is whatever the patient says it is and whenever the patient says it does. Pain Rating Scales

Adult pain rating scales Pediatric pain rating scales

Vital signs

Non-narcotic Analgesics

Usually OTC Aspirin, Acetaminophen, Ibuprofen, Naproxen Treat mild to moderate pain headaches, dysmenorrhea, inflammation, abrasions, muscular aches, arthritis Non addictive and less potent Most have antipyretic effect Some have anti-inflammatory and anti-platelet effect Act on the peripheral nervous system at the pain receptor sites

Salicylates and Non-Steroidal Anti-Inflammatory Drugs (NSAID)

Analgesic, antipyretic, anti-inflammatory Relieve pain by inhibiting cyclooxygenase, which is needed in the synthesis of prostaglandins ASA should not be used in children under 12 because of the danger of Reyes syndrome ASA decreases platelet aggregation or clotting and is often used to help prevent heart attacks or TIA

ASA and NSAID

Relieve pain by inhibiting cyclooxygenase, necessary for the biosynthesis of prostaglandins Types of cyclooxygenase (COX)

COX-1 protects stomach lining and regulates platelets, promoting blood clotting COX-2 triggers pain and inflammation COX-1 inhibitors can cause gastric discomfort and bleeding COX-2 inhibitors can decrease pain and inflammation

NSAIDS either act as

INHIBITS Cyclooxygenase

Analgesic NSAID

COX 1 Protects gastric mucosa Prevents bleeding

Cox 2

Prostaglandin synthesis Pain

GI discomfort, Bleeding

Analgesia

NSAID

COX 1 & 2 inhibitors

Aspirin (Ecotrin, ASA) Ibuprofen (Motrin, Advil) Naproxyn (Aleve) Indomethacin (Indocin) Ketorolac (Toradol)
Celecoxib (Celebrex) Rofecoxib (Vioxx) Meloxicam (Mobic)

COX-2 inhibitors

Side Effects and Adverse Reactions of ASA and NSAIDs

Gastric irritation, ulcers take with food or full glass of liquid Problems with bleeding Hypersensitivity tinnitus, vertigo bronchospasms and urticaria

Acetaminophen (Tylenol, Tempra)

Also as combination drug with narcotic analgesics

To relieve pain, fever and discomfort (not antiinflammatory ) Well absorbed from GI tract Avoid taking with alcohol, can be hepatotoxic Keep away from children. Maximum dose = 4 g/day Therapeutic serum range: 5-20 mcg/ml Monitor liver enzyme levels Early signs of hepatic damage: N/V, RUQ pain, diarrhea Antidote: Acetylcysteine (Mucomyst)

Narcotic Analgesics

Controlled substance: Schedule II drugs Act on CNS Suppress pain impulses, decrease respirations and suppress coughing by acting on the medulla oblongata Anti-tussive properties (except Meperidine) Common side effects - N/V, constipation, hypotension, respiratory depression and urinary retention, decreased LOC Watch for physical dependence Avoid giving to patients with head injuries since increased CO2 vasodilation increases ICP Antidote: Naloxone (Narcan) Do not give with alcohol, hypnotics, sedatives

Narcotics

Morphine sulfate Hydromorphone HCl (Dilaudid) Meperidine hydrochloride (Demerol) Codeine sulfate Hydrocodone bitartrate (Vicodin) Oxycodone HCl (OxyContin) Propoxyphene HCl (Darvon) Fentanyl (Duragesic) Methadone (Dolophine)

Morphine sulfate

MS is an Opiate effective against acute pain from MI, cancer and dyspnea from pulmonary edema; used as pre-op / post-op medication Acts by binding with opiate receptors in the CNS Undergoes first hepatic pass Only small amount crosses blood brain barrier Crosses placenta, present in breast milk Causes respiratory depression, miosis

Meperidine HCl (Demerol)

Most commonly used narcotic to relieve post-operative pain Shorter duration of action, causes less constipation & urinary retention than morphine Preferred during pregnancy does not diminish uterine contractions, causes less neonatal respiratory depression Not for long term use neurotoxic Maximum dose of 600 mg/24 hrs x 48-72 hours Major side effect: Hypotension Contraindications: chronic pain, liver disease, sickle cell disease, seizures, coronary artery disease, dysrhythmias

Combination Drugs

The combination of an analgesic and a narcotic analgesic may be desired to treat moderate to severe pain Example:

Hydrocodone and ibuprofen (Vicoprofin) NSAID & opioid Acetaminophen and codeine

Combinations can reduce drug dependency with long term use of pain meds

Transdermal Opioid Analgesics

Provide a continuous ATC pain control For chronic pain Not effective for acute or post-op pain Fentanyl (Duragesic) 25-100 mcg Maximum level achieved in 24 hours More potent than morphine

Nursing Responsibilities

Safety considerations Monitor VS Monitor intake and output Monitor elimination patterns Monitor nutritional intake Monitor for CNS depression Monitor for toxicity

Narcotic Antagonist

Naloxone (Narcan) Naltrexone HCl (Revia) Nalmefene (Revex) Higher affinity to opiate receptor site than narcotics Blocks receptor, displaces narcotic Reverse respiratory and CNS depression

Narcotic Agonist-Antagonist

Decreases narcotic abuse Safe during labor Pentazocine (Talwin)* cause dependence Butorphanol tartrate (Stadol)* Nalbuphine HCl (Nubain) Buprenorphine (Buprenex) Methadone for treatment of narcoticaddicted persons

Anti-Inflammatory Drugs

Inflammation is a reaction to tissue injury caused by the release of chemical mediators ( histamines, kinins and prostaglandins ) Signs of inflammation are redness (erythema), swelling (edema ), pain, heat and loss of function Phases: vascular and delayed Prostaglandin inhibitors, analgesic, antipyretic, anticoagulant

Salicylates: Aspirin

ASA acetylsalicylic acid Prostaglandin inhibitor Decreases platelet aggregation Enteric-coated (EC) tablets Not to be taken with other NSAIDs, last trimester of pregnancy (premature closure of ductus arteriosus), children with flu (Reyes syndrome) Drug of choice for arthritis Assess for hypersensitivity, bleeding, tinnitus, vertigo, bronchospasm

Non-Steroidal Anti-Inflammatory Drugs: NSAID

First Generation
Salicylates Aspirin Propionic acid Ibuprofen (Motrin, Advil) Naproxyn (Aleve) Acetic acid Indomethacin (Indocin) Sulindac (Clinoril) Phenylacetic acid Diclofenac Na (Voltaren) Ketorolac (Toradol)

Pyrazolone
Phenylbutazone (Butazolidin)

Anthranilic Acids
Mefenamic acid (Ponstel)

Oxicams
Piroxicam (Feldene)

Second Generation
Celecoxib (Celebrex Rofecoxib (Vioxx)

Corticosteroids

Controls inflammation by suppressing or preventing many of the components of the inflammatory process Prednisone, Prednisolone, Dexamethasone (Decadron) Give with food or milk or pc SE: gastric irritation, hyperglycemia, sodium retention, immunosuppression Taper dose when d/c therapy

Disease-Modifying Anti-Rheumatic Drug

Given when NSAIDs do not control immune-mediated arthritic diseases More toxic Alters the disease process & prevent deformities DMARDs

Gold drug therapy / Chrysotherapy / Heavy metal therapy Immunosuppressants Cyclophosphamide, Methotrexate Immunomodulators Anti-malarials

Anti-Gout Drugs

Gout inflammatory condition characterized by disorder in uric acid and purine metabolism Anti-inflammatory inhibits migration of leukocytes to the inflamed site; Colchicine Uric Acid Synthesis Inhibitor Allopurinol (Zyloprim) Uricosuric Drugs increase excretion of uric acid; Probenecid (Benemid)