1. Anesthetics and Narcotics © Paradigm Publishing, Inc.
Chapter 6
Anesthetics and Narcotics
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2. © Paradigm Publishing, Inc.
Learning Objectives
Understand the central and peripheral nervous systems, their functions, and their relationship to drugs.
Recognize different dosage forms and understand how the drug delivery system works.
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
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3. © Paradigm Publishing, Inc.
Learning Objectives
Define the action of neuromuscular blocking agents in reducing muscle activity.
Distinguish between narcotic and nonnarcotic analgesia.
Understand the different classes of narcotics and the role of the technician in monitoring these drugs.
Become familiar with the various types of agents for migraine headaches.
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4. © Paradigm Publishing, Inc.
The Nervous System
Transmits information over vast network throughout the body
Neuron: nerve cell that transmits information
Neurotransmitter: chemical substance released from neuron
Stimulates or inhibits activity in target cells, especially other neurons
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5. Neurotransmitters Being Released from a Neuron
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6. Divisions of the Nervous System: CNS
Central Nervous System (CNS)
Brain and spinal cord
Spinal cord receives information and sends to brain
Brain evaluates information and sends out a response
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7. Divisions of the Nervous System: PNS
Peripheral Nervous System (PNS) made up of nerves and sense organs
Afferent system: nerves and sense organs bring information to CNS
Efferent system: nerves send information out from the CNS
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PNS Efferent System
Autonomic nervous system (ANS)
Involuntary activities: respiration, circulation, digestion, body temperature, metabolism, blood glucose, sweating
Somatic nervous system
Voluntary activities: skeletal muscles
Acetylcholine only neurotransmitter between CNS and skeletal muscles
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9. Autonomic Nervous System
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10. CNS and PNS Primary Neurotransmitters
Acetylcholine (Ach)
GABA (gamma-aminobutyric acid)
Dopamine
Norepinephrine
Serotonin
Glutamate
PNS
Acetylcholine (Ach)
Norepinephrine
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11. Sympathetic and Parasympathetic Primary Neurotransmitters
Sympathetic System
Acetylcholine (Ach)
Norepinephrine
Dopamine
Epinephrine
Parasympathetic System
Acetylcholine (Ach)
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ACh and GABA
ACh acts on receptors in smooth and cardiac muscle, and exocrine glands
ACh receptors blocked by anticholinergics
GABA regulates message delivery system of the brain
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13. Dopamine, Epinephrine, and Norepinephrine
Dopamine acts on receptors in the CNS and kidneys
Epinephrine acts on cardiac and bronchodilator receptors
Norepinephrine acts on alpha and beta receptors
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14. Serotonin and Glutamate
Serotonin acts on smooth muscle and gastric mucosa
Causes vasoconstriction which decreases blood flow
Emotional responses: depression, anxiety
Glutamine may be crucial to some forms of learning and memory
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Types of Receptors
Alpha
Vasoconstriction, raises blood pressure
Beta-1
Increases heart rate and contractive force of the heart
Beta-2
Vasodilation, increases blood flow
Bronchodilator, relaxes smooth muscles
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Discussion
What are three important types of receptors in the study of drugs?
Three important types of receptors are alpha, beta-1, and beta-2.
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17. Drug Effects on the Nervous System
Two types of effects on receptors
Stimulating, causing a reaction
Blocking, preventing a reaction
Anticholinergics
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18. Side Effects of Anticholinergics
Decreased GI motility (constipation)
Decreased sweating
Decreased urination
Dilated pupil and blurred vision
Dry eyes
Dry mouth
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Terms to Remember
neuron
neurotransmitter
central nervous system (CNS)
peripheral nervous system (PN)
afferent system
efferent system
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20. © Paradigm Publishing, Inc.
Terms to Remember
autonomic nervous system (ANS)
somatic nervous system
alpha receptors
beta-1 receptors
beta-2 receptors
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21. © Paradigm Publishing, Inc.
Anesthesia
Allows painless and controlled surgical, obstetric, and diagnostic procedures
Most potent anesthetics are gases or vapors
Two classes of anesthesia: general and local
Anesthesiologist oversees administration of anesthesia during surgery
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Anesthesia
One anesthetic may be superior to another, depends on clinical situation
Final choice based on drugs and anesthetic techniques safest for patient
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23. Physiologic Effects of Anesthesia
Involves many systems
Nervous
Respiratory
Endocrine
Cardiovascular
Skeletal muscular GI
Hepatic
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24. Goals of Balanced Anesthesia
Amnesia to eliminate patient’s memory of procedure
Adequate muscle relaxation, no contracting of muscles
Adequate ventilation by maintaining oxygen concentration
Pain control
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25. © Paradigm Publishing, Inc.
Discussion
What are some of the indicators used to assess general anesthesia?
Some indicators include: blood pressure, hypervolemia, oxygen level, pulse, respiratory rate, tissue perfusion, and urinary output.
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26. © Paradigm Publishing, Inc.
General Anesthetics
General anesthesia is the unique condition of reversible unconsciousness and absence of response to painful stimuli
Four reversible actions
Unconsciousness
Analgesia (relieving pain)
Skeletal muscle relaxation
Amnesia on recovery
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General Anesthetics
Preanesthetic medications
Control sedation
Reduce postoperative pain
Provide amnesia
Decrease anxiety
Drugs often used: narcotics, benzodiazepines, phenothiazines
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General Anesthetics
Malignant hyperthermia is a serious side effect of anesthesia
Fever of 110°F or more
Life threatening
Treatment: dantrolene (Dantrium)
Always check
expiration date
Warning!
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Drug List
Inhalant Anesthetics
desflurane (Suprane)
enflurane (Ethrane)
halothane (none)
isoflurane (Forane)
nitrous oxide (none)
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30. Side Effects of Inhalant Anesthetics
Reduce blood pressure
May cause nausea and vomiting
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31. © Paradigm Publishing, Inc.
nitrous oxide
Causes analgesia only
Given alone or with more powerful anesthetics to hasten uptake of other agent(s)
Commonly used for dental procedures
Advantage: rapidly eliminated
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desflurane (Suprane)
Easily controllable
Rapid onset and recovery
Often used in ambulatory surgery
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33. Injectable Anesthetics
Very lipid soluble
Most dispensed by IV drip
Most are controlled substances
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34. © Paradigm Publishing, Inc.
Drug List
Injectable Anesthetics
alfentanil (Alfenta)
etomidate (Amidate)
fentanyl (Sublimaze)
fentanyl-droperidol (none)
ketamine (Ketalar)
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Drug List
Injectable Anesthetics
morphine (various)
propofol (Diprivan)
remifentanyl (Ultiva)
sufentanil (Sufenta)
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Drug List
Injectable Anesthetics
Barbiturates
methohexital (Brevital)
thiopental (Pentothal)
Benzodiazepines
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Drug List
Injectable Anesthetics
Benzodiazepines
diazepam (Valium)
lorazepam (Ativan)
midazolam (Versed)
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propofol (Diprivan)
Used for maintenance of anesthesia, sedation, or treatment of agitation
Antiemetic properties
Side effects: drowsiness, respiratory depression, motor restlessness, increased blood pressure
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39. Dispensing Issues of Injectable Anesthetics
Warning!
Diprivan (anesthetic) and Diflucan (antifungal) may be confused
A mix-up could be life-threatening
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40. © Paradigm Publishing, Inc.
fentanyl
Used extensively for open-heart surgery due to lack of cardiac depression
Analogs used in the operating room
Alfentanil (Alfenta)
Sufentanil (Sufenta)
Reminfentanil (Ultiva)
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Benzodiazepines
Used for induction, short procedures, and dental procedures
Used in controlling and preventing seizures induced by local anesthetics
midozolam (Versed)
fastest onset of action
greatest potency
most rapid elimination
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Drug List
Antagonist Agents
flumazenil (Romazicon)
nalmefene (Revex)
naloxone (Narcan)
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Antagonist Agents
flumazenil (Romazicon) reverses overdoses of benzodiazepine
nalmefene (Revex) and naloxone (Narcan) reverse overdoses of narcotics
All operating and emergency rooms maintain a supply of antagonists
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44. Neuromuscular Blocking Agents
Causes immediate skeletal muscle relaxation of short, long, and extended durations
Used to facilitate endotracheal intubation and ensure patient does not move during surgery
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45. © Paradigm Publishing, Inc.
Drug List
Neuromuscular Blocking Agents
Short Duration
succinylcholine (Quelicin)
Long Duration
atracurium (Tracrium)
cisatracurium (Nimbex)
rocuronium (Zemuron)
vecuronium (Norcuron)
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46. © Paradigm Publishing, Inc.
Drug List
Neuromuscular Blocking Agents
Extended Duration
mivacurium (Mivacron)
pancuronium (none)
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47. Neuromuscular Blocking Agents Dispensing Issues
Warning!
Be conscious of storage requirements
Store away from look-alike drugs
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48. succinylcholine (Quelicin)
Often called “sux”
Only depolarizing agent; all others are nondepolarizing agents
Persistent depolarization at motor endplate. Shorts out electrical signal.
Result: sustained, brief period of flaccid skeletal muscle paralysis
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49. Reversal of Neuromuscular Blocking Agents
Antiacetylcholinesterase agents increase action of acetylcholine
Inhibits acetylcholinesterase
Restores transmission of impulses, reversing neuromuscular blocking agent
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50. © Paradigm Publishing, Inc.
Drug List
Anticholinesterase Agents
edrophonium (Enlon)
neostigmine (Prostigmin)
pyridostigmine (Mestinon)
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51. © Paradigm Publishing, Inc.
Local Anesthesia
Relieves pain without altering alertness or mental function
Affect all types of nervous tissue
Commonly combined with other drugs
Variety of combinations available
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52. Dosage Forms of Local Anesthetics
Topical: drops, sprays, lotions, ointments
Infiltration: superficial injection
Nerve block: injection IV
Epidural: regional anesthesia
Spinal: blocks afferent pain nerve impulses from lower part of the body
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53. © Paradigm Publishing, Inc.
Discussion
What are the two classes of local anesthetics?
The two classes are esters and amides.
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Local Anesthetics
Esters
Short acting
Metabolized in plasma and tissue fluids
Excreted in urine
Amides
Longer acting than esters
Metabolized by liver enzymes
Excreted in urine
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55. © Paradigm Publishing, Inc.
Drug List
Local Anesthetics
Esters
benzocaine (Americaine)
chloroprocaine (Nesacaine)
dyclonine (Cēpacol Maximum Strength)
procaine (Novocain)
tetracaine (Cēpacol Viractin, Pontocaine)
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Drug List
Local Anesthetics
Amides
bupivacaine (Marcaine)
levobupivacaine (Chirocaine)
lidocaine (L-M-X, Solarcaine Aloe Extra Burn Relief, Xylocaine, Lidoderm)
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Drug List
Local Anesthetics
Amides
lidocaine-epinephrine (Xylocaine with Epinephrine)
lidocaine-prilocaine (EMLA)
mepivacaine (Carbocaine)
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Discussion
What functions are lost with local anesthetics?
Functions that are lost include: pain perception, temperature sensation, touch sensation, proprioception, and skeletal muscle tone.
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Discussion
Under what conditions would a local anesthetic be used over a general anesthetic?
It is chosen when a well-defined area of the body is targeted.
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Terms to Remember
anesthesiologist
general anesthesia
malignant hyperthermia
neuromuscular blocking
endotracheal intubation
anticholinesterase
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Terms to Remember
local anesthesia
ester
amide
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Pain Management
Pain is protective mechanism to warn of damage or the presence of disease
Part of the normal healing process
Can be a disease
Considered the “fifth” vital sign
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Pain Management
Acute Pain
Associated with trauma or surgery
Warns of a problem
Easier to manage by treating the cause
Disappears when body heals
Has beginning and end
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Pain Management
Chronic nonmalignant pain
Lasts more than 3 months
Diagnosed or undiagnosed cause
May respond poorly to treatment
Depression, sense of helplessness and hopelessness
Affects all aspects of life
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Pain Management
Chronic malignant pain
Accompanies malignant disease
Often increases in severity with disease progression
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Major Sources of Pain
Source: somatic
Areas: body framework
Characteristics: throbbing, stabbing, localized
Treatment: narcotics, NSAIDs, nerve blockers
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Major Sources of Pain
Source: visceral
Areas: kidneys, intestines, liver
Characteristics: aching, throbbing, sharp, gnawing, crampy
Treatment: narcotics, NSAIDs, nerve blockers, antiemetics
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Major Sources of Pain
Source: neuropathic
Areas: nerves
Characteristics: burning, aching, numbing, tingling, constant
Treatment: antidepressants, anticonvulsants
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Major Sources of Pain
Source: sympathetically mediated
Areas: overactive sympathetic system
Characteristics: occurring when no pain should be felt
Treatment: nerve blockers
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Narcotics
Pain-modulating chemicals that cause insensibility or stupor
Opiates
Derived from opium or synthetic
Agonists of opioid receptor sites
Main effects on CNS and GI tract
Lesser effects on peripheral tissues
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Natural Opioids
Endorphins, enkephalins, and dynorphins
Brain produces in response to pain stimuli
When receptors are activated
Causes decreased nerve transmission
Sensation of pain diminished
Opioids bind to these same receptors
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Effects of Narcotics
Analgesia: reduces pain from most sources
Sedation: decrease anxiety and cause drowsiness
Euphoria and dysphoria: feelings of well-being, disquiet, restlessness
Narcotics have potential for tolerance and dependence
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73. Patient-Controlled Analgesia Pump
PCA pump effective means of controlling pain
Patient regulates, within limits, amount of drug received
Better pain control with less drug
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74. Analgesic Ladder of Pain Relief
Mild to moderate pain
Acetaminophen or NSAID and an adjuvant
If adequate relief not achieved
NSAID plus a “weak” opioid (codeine)
Strong opioid (morphine) with an adjuvant analgesic if indicated
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Transdermal Patch
Provides pain control
Allows patient to remain more alert than with most other methods
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76. Analgesic Ladder of Pain Relief
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77. Addiction and Dependence
Chronic opioid therapy has low risk of addiction when used appropriately
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Discussion
What is the difference between addiction and dependence?
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79. Dependence and Addiction
Physical and emotional reliance on a drug
Withdrawal
Addiction
Compulsive disorder
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80. Signs of Narcotics Addiction
Preoccupation with drugs
Refusal of medication tapers
Strong preference for a specific opioid
Decrease in ability to function
Medication often not taken as prescribed
Tendency to rely on multiple prescribers and pharmacies to conceal behavior
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Withdrawal
Patients more successful overcoming addiction if withdrawal symptoms are handled appropriately
Opioid antagonists have stronger attraction for receptors than analgesic agents
Blocking opioid action may prevent withdrawal symptoms
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Drug List
Drugs to Treat Opioid Addiction
buprenorphine (Buprenex, Subutex)
buprenorphine-naloxone (Suboxone)
methadone (Dolophine)
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83. Dispensing Issues of Narcotics
Warning!
Technicians have a legal and moral responsibility to alert pharmacist of suspected abuse and addiction
Documentation must be in medical record
Low addiction rate if no history of addiction
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Narcotic Analgesics
Analgesic is a drug that alleviates pain
Narcotic analgesic is pain medication containing an opioid
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Drug List
Narcotic Analgesics
butorphanol (Stadol)
codeine (Codeine Contin)
fentanyl (Actiq, Duragesic, Fentora, Ionsys)
hydromorphone (Dilaudid)
meperidine (Demerol)
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Drug List
Narcotic Analgesics
morphine (Astramorph/PF, Avinza, Duramorph, MS Contin, MSIR)
oxycodone (OxyContin)
oxymorphone (Numorphan, Opana, Opana ER)
pentazocine (Talwin)
propoxyphene (Darvon)
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Narcotic Analgesics
Dose requirements vary with
Severity of pain
Individual response to pain
Patient’s age and weight
Presence of concomitant disease
Morphine is standard against which all other narcotic analgesics are measured
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88. Goal of Narcotic Analgesics
Many dosage forms and strengths
Delivered by various routes
Goal: Patient comfort
Key to reaching goal: Constant reassessment
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89. Dispensing Issues of morphine
Warning!
Avinza (morphine) and Invanz (eratpenem) often confused
Morphine sulfate (MSO4) and magnesium sulfate (MgSO4) often confused
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90. Dispensing Issues of Narcotic Analgesics
Warning!
Consult policies and procedures of workplace to use the required check systems to make sure narcotic counts are correct.
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91. Side Effects of Narcotic Analgesics
Side effects anticipated and minimized for patient comfort
Mental confusion
Reduced alertness
Nausea/vomiting
Dry mouth
Constipation
Inflammatory process
Bronchial constriction
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fentanyl
Patch (Duragesic)
Approved for chronic use, not acute pain after surgery
Lozenge (Actiq)
Swabbed on mucosal surfaces inside the mouth and under the tongue
Not as effective if swallowed
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93. Combination Drugs for Managing Pain
Combinations of narcotics and nonnarcotics are common
Increases pain relief
Allows use of lower doses
Limits intake of addictive substances
Decreases side effects
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Drug List
Combination Drugs for Pain Control
acetaminophen-codeine (Phenaphen with Codeine, Tylenol with Codeine)
hydrocodone-acetaminophen (Lortab, Vicodin, Lorcet)
meperidine-promethazine (Mepergan)
oxycodone-acetaminophen (Endocet, Perocet, Tylox)
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Drug List
Combination Drugs for Pain Control
oxycodone-aspirin (Endodan, Percodan)
oxycodone-ibuprofen (Combunox)
pentazocine-naloxone (Talwin NX)
propoxyphene-acetaminophen (Darvocet-N 100)
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96. Dispensing Issues of Analgesic Combinations
Warning!
Serious risk of aspirin or acetaminophen toxicity if dose is overlooked
Technicians—check that patient is not getting more than 4 grams of aspirin or acetaminophen per day
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97. Dispensing Issues of Analgesic Combinations
Warning!
Pharmacy technicians should check C-III, CIV, and C-V drugs
Refills no more than 5 times
Refills good for no more than 6 months
C-II drugs have NO refills
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98. meperidine-promethazine
Produces less nausea than similar drugs
Promethazine controls nausea
Very sedating
Used for patients who develop nausea from opioid use
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Terms to Remember
pain
narcotic
opiate
opioid
patient-controlled analgesia (PCA)
nonsteroidal anti-inflammatory drugs (NSAIDs)
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Terms to Remember
analgesic ladder
dependence
addiction
analgesic
narcotic analgesic
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Migraine Headaches
Migraine Headache
Severe, throbbing, vascular headache
Recurrent unilateral head pain
Accompanied by neurologic and GI disturbances
90% of migraine sufferers report nausea
Sensitivity to light, sound, and stimulation also common
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102. Components of Migraine
Classic migraine components (all five not experienced by everyone)
Prodrome
Aura
Headache
Headache relief
Postdrome
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103. Components of Migraine
Prodrome: Symptom indicating onset
Aura: Subjective sensation or motor phenomenon that precedes onset
Flashing lights
Shimmering heat waves
Bright lights
Dark holes in visual fields
Vision blurred, cloudy transient or loss of
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104. Components of Migraine
Headache and Headache Relief
Generally dissipates in 6 hours, but may last 1 to 2 days
Postdrome
Knowing headache is gone
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105. Cause of Migraine Headaches
Serotonin appears involved in cause
Decreased levels causes excessive vasodilation in cranial arteries and migraine occurs
By stimulating serotonin receptors vasoconstriction occurs, alleviating migraine
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106. Causative Factors of Migraine Headaches
Diet
Stress
Depression
Sleep habits
Certain medications
Hormonal fluctuations
Atmospheric changes
Environmental irritants
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107. Initial Treatment of Migraine Headaches
At first hint of migraine, identify and eliminate triggers
Quiet environment and sleep may help
Lying down in a dark room
For severe or debilitating and frequent attacks, drug therapy may be indicated
Sedative, antiemetic, and narcotic agents
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Discussion
What are the two classes of migraine drug therapy?
The two classes are prophylactic therapy and abortive therapy.
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109. Therapy for Migraine Headaches
Prophylactic Therapy
Attempts to prevent or reduce recurrence
Abortive Therapy
Taken after acute migraine occurs
Taken at first sign of a migraine, such as aura or headache
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Prophylactic Therapy
Anticonvulsants
Beta blockers
Calcium channel blockers
Estrogen
Feverfew
NSAIDs
SSRIs
Tricyclic antidepressants
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Abortive Therapy
Simple analgesics
NSAIDs
Ergotamine-containing medications
Serotonin-containing medications
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Drug List
Migraine Headache Agents
Triptans—Selective 5-HT Receptor Agonists
almotriptan (Axert)
eletriptan (Relpax)
frovatriptan (Frova)
naratriptan (Amerge)
rizatriptan (Maxalt, Maxalt-MLT)
sumatriptan (Imitrex)
zolmitriptan (Zomig)
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113. rizatriptan (Maxalt-MLT)
Sublingual tablet, quickly absorbed
Most rapid onset of action of all oral migraine therapies
May receive relief after 30 minutes
Maxalt not absorbed as quickly as Maxalt-MLT
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114. sumatriptan (Imitrex)
Causes vasoconstriction of blood vessels
Use at first sign of headache
If brings partial relief, patient may receive second dose at least 1 hour after first
Available in injection, nasal spray, and tablet
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Drug List
Migraine Headache Agents
Ergot Preparations
dihydroergotamine (D.H.E. 45, Migranal)
ergotamine (Ergomar)
ergotamine-caffeine (Cafergot)
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Drug List
Migraine Headache Agents
Antiemetic Agents
chlorpromazine (Thorazine)
metoclopramide (Reglan)
prochlorperazine (Compazine)
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117. metoclopramide (Reglan)
Reduces nausea and vomiting
Enhances absorption of other antimigraine products
Metoclopramide and aspirin prescribed together in place of sumatriptan (Imitrex) due to fewer side effects
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Drug List
Migraine Headache Agents
Opioid Analgesic
butorphanol (Stadol, Stadol NS)
Beta Blocker
propranolol (Inderal)
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119. butorphanol (Stadol, Stadol NS)
Nasal spray used more commonly than injection
Used for moderate-to-severe pain
Can be addictive
C-IV controlled substance
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Drug List
Migraine Headache Agents: Other
acetaminophen, aspirin, caffeine (Excedrin Migraine)
butalbital-acetaminophen-caffeine (Fioricet)
butalbital-aspirin-caffeine (Fiorinal)
isometheptene-dichloralphenazone-acetaminophen (Midrin)
tramadol (Ultram)
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tramadol (Ultram)
High success rate when given with NSAIDs (ibuprofen)
Slow onset of action
Not a controlled substance, but has shown potential for addiction
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122. Dispensing Issues of Migraine Agents
Warning!
Tramadol and Toradol could be confused
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123. isometheptene-dichloralphenazine-acetaminophen (Midrin)
Fewer side effects than ergotamines
Combination of analgesic, sedative, and vasoconstrictor
For mild to moderate headaches
Take 2 capsules at onset of headache, then 1 every 1 to 2 hours until pain stops, up to 5 capsules in 12 hours
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124. acetaminophen, aspirin, caffeine (Excedrin Migraine)
Combination reported to give very good results in migraine pain
Many common headaches, including migraines, respond to this combination
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Discussion
What are some of the issues facing migraine sufferers and the medication that is used?
Some issues are nausea and vomiting, 0.5 to 2 hour onset of action, and side effects.
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Terms to Remember
migraine headache
a severe, throbbing, unilateral headache, usually accompanied by nausea, photophobia, phonophobia, and hyperesthesia
aura
a subjective sensation or motor phenomenon that precedes and marks the onset of a migraine headache
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Assignments
Complete Chapter Review activities
Answer questions in Study Notes document
Study Partner
Quiz in review mode
Matching activities
Drug tables
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