1. 14
Drugs for Pain Control

2. Directory
Classroom Response System
Lecture Note Presentation

3. Question 1
The nurse understands that pain signals begin at the ______ and proceed through the central nervous system.

4. Question 1 Choices
Spinal cord
Viscera
Nociceptors
Substance P

5. Question 1 Answer
Spinal cord
Viscera
Nociceptors
Substance P

6. Question 2
The patient is experiencing opioid dependency. Which drug is used to treat this condition?

7. Question 2 Choices Oxycodone hydrochloride (OxyContin)
Propoxyphene hydrochloride (Darvon)
Hydromorphone hydrochloride (Dilaudid)
Methadone (Dolophine)

8. Question 2 Answer Oxycodone hydrochloride (OxyContin)
Propoxyphene hydrochloride (Darvon)
Hydromorphone hydrochloride (Dilaudid)
Methadone (Dolophine)

9. Question 3
When a patient is receiving an NSAID, the nurse must assess the patient for:

10. Question 3 Choices GI upset and bleeding Urinary retention
Blurred vision
Anorexia, headache

11. Question 3 Answer GI upset and bleeding Urinary retention
Blurred vision
Anorexia, headache

12. Question 4
The patient is on sumatriptan (Imitrex) for migraines. For which of the following should the nurse instruct the patient to notify his physician immediately?

13. Question 4 Choices
Chest pain
GI upset
Bleeding
Lethargy

14. Question 4 Answer
Chest pain
GI upset
Bleeding
Lethargy

15. Learning Outcomes
Relate the importance of pain assessment to effective pharmacotherapy.
Explain the neural mechanism for pain at the level of the spinal cord.
Explain how pain can be controlled by inhibiting the release of spinal neurotransmitters.

16. Learning Outcomes
Describe the role of nonpharmacologic therapies in pain management.
Compare and contrast the types of opioid receptors and their importance to pharmacology.
Explain the role of opioid antagonists in the diagnosis and treatment of acute opioid toxicity.

17. Learning Outcomes
Describe the long-term treatment of opioid dependence.
Compare the pharmacotherapeutic approaches of preventing migraines to those of aborting migraines.

18. Learning Outcomes
For each of the major drug classes, know representative drug examples, and explain the mechanisms of drug action, primary actions, and important adverse effects for each.
Categorize drugs used in the treatment of pain based on their classifications and mechanisms of action.

19. Pain assessment is the first step to pain management.
Core Concept 14.1
Pain assessment is the first step to pain management.

20. Pain Subjective experience Termed acute or chronic Source
Nociceptor pain
Injury to the tissue
Somatic – sharp localized

21. Pain Visceral – dull, throbbing, aching, generalized
Neuropathic Pain
Direct injury to the nerve
Burning, shooting, numb

22. Pain Assessment First step in pain management
Several numerical scales and survey instruments are available
Need to know
Location
Severity
Type
Duration
Effect on daily life

23. Concept Review 14.1
What questions would you ask to identify a patient’s type of pain? How would you distinguish between acute pain and chronic pain? Which is the most difficult type of pain to treat?

24. Core Concept 14.2
Nonpharmacologic techniques assist patients in obtaining adequate pain relief.

25. Nonpharmacologic Pain Management
Acupuncture
Biofeedback therapy
Massage
Heat or cold packs
Meditation
Relaxation therapy
Art or music therapy

26. Nonpharmacologic Pain Management
Imagery
Chiropractic
Hypnosis
Therapeutic touch
Transcutaneous electrical nerve stimulation (TENS)
Energy therapies such as reiki and qi gong

27. Other Therapies
Radiation Therapy - shrinks solid tumors that may be pressing on nerves
Surgery - reduce pain by removing part of or the entire tumor
Nerve Block - injection of alcohol or other neurotoxic substance into neuronal tissue irreversibly stop impulse transmission along treated nerves

28. Core Concept 14.3
Pain transmission processes allow several targets for pharmacologic intervention.

29. Targets
Nociceptors - free nerve endings located throughout the entire body.
Several targets where medications can work
Two main classes of pain medications
Nonsteroidal anti-inflammatory drugs (NSAIDs) act at the peripheral level
Opioids act within the CNS.

30. Figure 14.1 Neural pathways for pain

31. Concept Review 14.2
What is a nociceptor? Consider substance P and endogenous opioids, and describe how pain can be regulated.

32. Core Concept 14.4
Opioid analgesic medications exert their effects by interacting with specific receptors.

33. Opiods Natural or synthetic morphine-like substance
Responsible for reducing severe pain
Narcotic substance - produce numbness or stuporlike symptoms
Drugs of choice for moderate to severe pain that cannot be controlled with other classes of analgesics.

34. Figure 14.2 Opioid receptors

36. Concept Review 14.3
Distinguish between the following terms: opioid, opiate, and narcotic. Name six classes of opioid receptors and identify those that are connected with analgesia.

37. Core Concept 14.5
Narcotic opioids have multiple therapeutic effects including relief of severe pain.

38. Effects of Opiates Positive Severe pain relief
Suppress the cough reflex
Slowing GI motility
Sedation

39. Effects of Opiates Negative Respiratory depression Sedation
Nausea and vomiting.

40. Patient Controlled Analgesia (PCA)
Delivered with Infusion Pump
Limits set to prevent overdose
Patient self-medicates by pushing button

41. Combination Medications
Opioids and nonnarcotic analgesics
Single tablet or capsule
Work synergistically to relieve pain
Dose of narcotic can be kept small
Minimizes negative effects

42. Popular Combination Analgesics
Vicodin(hydrocodone, 5 mg;acetaminophen, 500 mg)
Percocet(oxycodoneHCl,5mg;acetaminophen,325 mg)
Percodan (oxycodone HCl, 4.5 mg; oxycodone terephthalate, 0.38 mg; aspirin, 325 mg)

43. Popular Combination Analgesics
Darvocet-N 50 (propoxyphene napsylate, 50 mg; acetaminophen, 325 mg)
Empirin with Codeine No. 2 (codeine phosphate, 15 mg; aspirin, 325 mg)
Tylenol with Codeine (single dose may contain from 15 to 60 mg of codeine phosphate and from 300 to 1,000 mg of acetaminophen

44. Opioid Antagonists
Substances that prevent the effects of opioid agonists
“Competitive antagonists”
Compete with opioid agonists for access to the opioid Receptor site.
Acute opioid intoxication is a medical emergency. Respiratory depression
Naloxone (Narcan)

45. Opioids with Mixed Agonist–Antagonist Activity
Stimulate the opioid receptor causing analgesia.
Withdrawal symptoms/adverse effects
Not as intense
partial activity of receptor subtypes

46. Opioids with Mixed Agonist–Antagonist Activity
Methadone (Dolophine)
Treats opioid dependence
Buprenorphine (Subutex)
Newer option
Given sublingual

48. Table 14.2 (continued) Opioids for Pain Management

49. Table 14.2 (continued) Opioids for Pain Management

51. Core Concept 14.6
Nonsteroidal anti-inflammatory drugs are the drugs of choice for inflammatory pain.

52. NSAIDs Antipyretic (antifever) Anti-inflammatory
Analgesic (pain-reducing) properties
Drugs of choice for mild to moderate pain associated with inflammation.
Act by inhibiting pain mediators at the nociceptor level.

53. COX Inhibitors Prostaglandins
Formed by cyclooxygenase type one (COX-1) and cyclooxygenase type two (COX-2).
Aspirin inhibits both COX-1 and COX-2.

54. COX Inhibitors COX-2 enzyme
More specific for cause pain and inflammation
COX-2 inhibitors developed for specific pain relief.
VIOXX (off the market), Celebrex

55. Acetaminophen Nonopioid analgesics Not classified as NSAIDs
Equally effective as aspirin and ibuprofen
ALso used to reduce fever.

56. Centrally Acting Drugs
Clonidine (Catapres)
Tramadol (Ultram)
Weak opioid activity
Not thought to relieve pain by this mechanism
Ziconotide (Prialt)

57. Figure 14.3 Mechanisms of pain at the nociceptor level

59. Table 14.3 (continued) Nonopioid Analgesics

60. Table 14.3 (continued) Nonopioid Analgesics

61. Concept Review 14.4
Think about cyclooxygenase inhibitors (NSAIDs) and prostaglandins, and then describe how pain might be regulated at the nociceptor.

62. Headaches can be effectively treated with a variety of drug classes.
Core Concept 14.7
Headaches can be effectively treated with a variety of drug classes.

63. Headache One of the most common complaints of patients
Tension headache most common
Migraine most painful type of headache is the

64. Headache Goals for the pharmacologic management
Stop migraines in progress
Prevent migraines from occurring (prophylaxis).

65. Drugs for Migraine Triptans Ergot Alkaloids
Selective for the 5-HT1 receptor subtype
Act by constricting certain vessels within the brain.
Ergot Alkaloids
Interact with adrenergic,dopaminergic, serotonin receptors
Produce multiple actions and adverse effects.

66. Drugs for Migraine Other Drugs
Beta-adrenergic blockers, calcium channel blockers antidepressants , and antiseizure drugs

68. Table 14.4 (continued) Antimigraine Drugs