PPT_Chapter_08 - Analgesics and Antagonists Chapter 8 Copyright 2013 Wolters Kluwer Health | Lippincott Williams Wilkins Pain Unpleasant sensory and

PPT_Chapter_08 - Analgesics and Antagonists Chapter 8...

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Unformatted text preview: Analgesics and Antagonists Chapter 8 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Pain Unpleasant sensory and emotional experience that is associated with actual or potential tissue damage Pain is subjective Can be considered the fifth vital sign Acute pain Less than 3–6 months Chronic pain >6 months Associated with malignancy Not associated with malignancy or unknown Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Actions of Salicylates Aspirin and related drugs Analgesic, antipyretic, and anti-inflammatory effects Aspirin has greater anti-inflammatory effects than other salicylates. Functionality not fully understood but thought to inhibit prostaglandin synthesis Prolong clotting time by inhibiting platelet aggregation Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Uses of Salicylates Relief of mild to moderate pain Reduction of elevated body temperature Treatment of inflammatory conditions Reduction of the risk of myocardial infarction (MI) Reduction of the risk of transient ischemic attacks or strokes Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Adverse Reactions of Salicylates GI upset Heartburn Nausea Vomiting Anorexia GI bleeding Relatively safe, although some are allergic to aspirin and other salicylates Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Adverse Reactions of Salicylates Salicylism may occur with use of high levels Dizziness Rapid deep breathing Tinnitus Tachycardia Impaired hearing Diarrhea Nausea Mental confusion Vomiting Lassitude Flushing Drowsiness Sweating Respiratory depression and coma Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Contraindications, Precautions, and Interactions of Salicylates Contraindicated: Known hypersensitivity Bleeding disorders or bleeding tendencies Children or teenagers with influenza or chickenpox Precautions: Hepatic or renal disease Preexisting hypoprothrombinemia or vitamin K deficiency Lactation Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Contraindications, Precautions, and Interactions of Salicylates Interactions: Food containing salicylate Activated charcoal Antacids Carbonic anhydrase inhibitors Heparin NSAIDs Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Patient Management Issues with Salicylates Patients should be monitored for pain relief Report unusual or prolonged bleeding or dark stools Take medication with food or milk or a full glass of water to prevent GI upset Stop taking for 1 week before any type of surgery Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Educating the Patient and Family about Salicylates Notify physician if symptoms of salicylism Do not take if the medication has a vinegar odor Watch for duplication of ingredients in OTC and Rx medications Notify health care provider or dentist prior to any surgery or procedure Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Actions of Nonsalicylate Analgesics • Since aspirin is contraindicated for use in children because of increased risk of Reye syndrome, nonsalicylate analgesics are used • Also useful for adults who are allergic to salicylates, experience GI upset with aspirin, or have a contraindication • Acetaminophen – Also known as “APAP” – Mechanism of action is unknown, but has both analgesic and antipyretic properties Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Uses of Nonsalicylate Analgesics Mild to moderate pain relief Reduction of elevated body temperature (fever) Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Reactions of Nonsalicylate Analgesics Few adverse reactions seen when used correctly Excessive dosage is harmful to the liver Alcoholics should limit their intake to no more than 2 g/d Signs of acetaminophen toxicity: nausea, vomiting, confusion, liver tenderness, hypotension, arrhythmias, jaundice, and acute hepatic and renal failure Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Contraindications, Precautions, and Interactions of Nonsalicylate Analgesics Contraindications: Hypersensitivity Chronic alcoholism Avoid alcohol if taking more than an occasional dose of APAP Avoid APAP concurrently with a salicylate or NSAID Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Contraindications, Precautions, and Interactions of Nonsalicylate Analgesics Precautions: Patients with severe or recurrent pain High or continued fever Interactions: Alters blood glucose test results Barbiturates, hydantoins, isoniazid, rifampin, loop diuretics Contact health care provider if pain persists for more than 5 days or if redness or swelling are present Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Patient Management Issues with Nonsalicylate Analgesics All patients should be monitored for relief of pain If mobility is affected, patient may need assistance Take with a full glass of water May be taken with meals or on an empty stomach Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Educating the Patient and Family about Nonsalicylate Analgesics Notify health care provider if patient experiences dyspnea, weakness, dizziness, blue discoloration of the nail beds, unexplained bleeding, bruising, or sore throat Do not drink alcoholic beverages Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Actions of Nonsteroidal Antiinflammatory Drugs (NSAIDs) • Not a steroid, so the adverse effects of steroids are not experienced • Properties: – Anti-inflammatory – Antipyretic – Analgesic effects • Act by inhibiting prostaglandin synthesis by inhibiting the action of the enzyme cyclooxygenase – COX-1 – GI effects – COX-2 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Uses of Nonsteroidal Antiinflammatory Drugs (NSAIDs) Signs and symptoms of osteoarthritis, rheumatoid arthritis, and other musculoskeletal disorders Mild to moderate pain Primary dysmenorrhea Fever Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Adverse Reactions of Nonsteroidal Anti-inflammatory Drugs (NSAIDs) Non–COX-2 specific NSAIDs GI upset, nausea, epigastric pain, heartburn, abdominal pain COX-2 specific (celecoxib) Less GI upset Abdominal pain, cough, diarrhea, dizziness, fever, headache, nausea, upper abdominal pain, vomiting Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Contraindications, Precautions, and Interactions of Nonsteroidal Antiinflammatory Drugs (NSAIDs) Contraindications: Known hypersensitivity to any NSAID (crosssensitivity) Hypersensitivity to aspirin Precautions: Elderly (>65) Patients with bleeding disorders, renal disease, cardiovascular disease, hepatic impairments Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Contraindications, Precautions, and Interactions of Nonsteroidal Antiinflammatory Drugs (NSAIDs) Interactions: Anticoagulants, lithium Cyclosporine Hydantoins Diuretics Antihypertensive drugs Long-term use with acetaminophen Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Contraindications, Precautions, and Interactions of Nonsteroidal Antiinflammatory Drugs (NSAIDs) Celecoxib History of peptic ulcer, patients older than 60, patients taking anticoagulants or steroids Ibuprofen Increases risk of lithium toxicity Decreases effect of diuretic and beta-adrenergic blockers Naproxen Cautions in patients with asthma, hypertension, cardiac problems, peptic ulcer disease, impaired liver or kidney Decreases effect of antihypertensive and diuretics Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Patient Management Issues with Nonsteroidal Anti-inflammatory Drugs (NSAIDs) Monitor for pain relief Assess for dehydration Assess joints for reduced inflammation and greater mobility Report adverse reactions that indicate GI bleeding Patients who do not respond to one NSAID may respond to another NSAID Take with a full glass of water or food Additional comfort measures may be necessary Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Educating the Patient and Family about Nonsteroidal Anti-inflammatory Drugs (NSAIDs) • Must understand that the drug should be taken even when symptoms are relieved • Patient should understand the indication, drug–drug and drug–food interactions, possible adverse reactions, and need to read and heed all of the manufacturer’s instructions • Do not take for fever for greater than 24 hours • Do not take with aspirin or other salicylates • Take with food or full glass of water • Notify health care provider if pain or fever indicates a serious illness Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Natural Remedies • Willow bark — Use dates back to time of Hippocrates • Salicylate was originally isolated from willow bark • Willow bark has fewer adverse reactions than salicylates • Use with caution in patients with peptic ulcers and medical conditions where aspirin is contraindicated • Should not be used in patients taking an anticoagulant or antiplatelet medication Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Actions of Narcotic Analgesics • Controlled substances • Opioid — Derived from poppy plant – Morphine – Codeine – Hydrochlorides of opium – Tincture of opium Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Actions of Narcotic Analgesics • Classified: – Agonist – binds to receptor and causes a response – Partial agonist – binds to receptor but has only a limited response – Agonist-antagonist – has both agonist and antagonist properties • Categorized based on the receptor sites where they are active: – Mu – Kappa – Delta Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Uses of Narcotic Analgesics Manage moderate to severe acute and chronic pain Lessen anxiety and sedate a patient before surgery Support anesthesia Obstetrical analgesia Relieve anxiety in patients with dyspnea associated with pulmonary edema Intrathecally or epidurally to relieve pain for extended periods Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Uses of Narcotic Analgesics Pain relief associated with heart attack (morphine) Detoxification and temporary maintenance of narcotic addiction (methadone) Induce conscious sedation before a diagnostic or therapeutic procedure Severe diarrhea and intestinal cramping (tincture of opium) Relieve severe, persistent cough (codeine) Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Uses of Narcotic Analgesics • Use in management of opioid dependence – Methadone – synthetic narcotic – Relief of pain – Detoxification and maintenance treatment of those addicted to narcotics – Maintenance therapy is designed to reduce the patient’s desire to return to the drug that caused addiction and to prevent withdrawal symptoms. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Adverse Reactions of Agonists Respiratory depression Lightheadedness Dizziness Sedation Constipation Anorexia Nausea Vomiting Sweating Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Adverse Reactions of AgonistAntagonists Narcotic withdrawal symptoms Sedation Nausea Vomiting Sweating Headache Vertigo Dry mouth Euphoria Dizziness Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Symptoms of the Abstinence Syndrome Early Symptoms Intermediate Symptoms Late Symptoms Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Contraindications, Precautions, and Interactions of Narcotic Analgesics Contraindicated: Known hypersensitivity Patients with acute bronchial asthma, emphysema, or upper airway obstruction Patients with head injury or increased intracranial pressure Patients with convulsive disorders, severe renal or hepatic dysfunction, or acute ulcerative colitis Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Contraindications, Precautions, and Interactions of Narcotic Analgesics • Use cautiously in: – Elderly – Patients with undiagnosed abdominal pain, liver disease, history of addiction to the opioids, hypoxia, supraventricular tachycardia, prostatic hypertrophy, renal or hepatic impairment – Lactation – must wait 4–6 hours after taking the drug before breastfeeding Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Contraindications, Precautions, and Interactions of Narcotic Analgesics Interactions: Other central nervous system depressants MAOIs Agonist-antagonists may cause opioid withdrawal symptoms in those who are physically dependent on an opioid Increased risk if administered too soon after barbiturate general anesthesia Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Patient Management Issues with Narcotic Analgesics • Evaluate the pain using a standardized scale. • Regularly ask about the pain during therapy. • Adjust controllable factors that may decrease the patient’s tolerance to pain. • Monitor respiratory depression. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Patient-Controlled Analgesia Allows patient to administer his or her own analgesic by means of an IV pump system Dose and time interval are controlled. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Relieving Chronic Severe Pain • Morphine • OxyContin • Fentanyl transdermal • Goal: to prevent or control the patient’s pain, not to prevent addiction Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Epidural Pain Management Catheter is placed into the epidural space outside the dura mater of the brain and spinal cord Morphine and fentanyl are used Used for postoperative, labor, and cancer pain Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Educating the Patient and Family about Narcotic Analgesics Explain that the drug is for pain. Patient should understand how and when to take the medication. Educate the patient about the adverse reactions and how to best manage them. Patient should avoid alcohol. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Actions of Narcotic Antagonists Naloxone and naltrexone Prevents or reverses the effects of the opiates Exact mechanism of action is not understood Competes at the opiate receptor site Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Uses of Narcotic Antagonists Complete or partial reversal of narcotic depression Intentional or accidental overdose Opiate dependency Patient should be detoxified and enrolled in a program for treatment of narcotic addiction. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Adverse Reactions of Narcotic Antagonists Not a true adverse reaction, but the abrupt reversal of narcotic depression may result in nausea, vomiting, sweating, tachycardia, increased blood pressure, and tremors Other effects: anxiety, difficulty sleeping, abdominal cramps, nasal congestion, joint and muscle pain, nausea, vomiting, dizziness, irritability, depression, fatigue, drowsiness Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Contraindications, Precautions, and Interactions of Narcotic Antagonists Naloxone Contraindicated if hypersensitivity Use cautiously in patients with a narcotic addiction, patient with cardiovascular disease, lactating women, and infants of opioid-dependent mothers Must not have taken any opiate for the last 7–10 days May prevent the action of opioid antidiarrheals, antitussives, and analgesics Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Contraindications, Precautions, and Interactions of Narcotic Antagonists Naltrexone Contraindicated in those with a hypersensitivity Used cautiously in those with a narcotic addiction, cardiovascular disease, acute hepatitis, liver failure, or depression and those who are suicidal or lactating Must not have taken any opiate for the last 7–10 days Concurrent use with thioridazine may cause increased drowsiness and lethargy May prevent the action of opioid antidiarrheals, antitussives, and analgesics Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Patient Management Issues with Narcotic Antagonists Respiratory depression Monitor blood pressure, pulse, and respiratory rate frequently Treatment of opioid dependency Monitor for signs of ineffective coping related to difficulty staying drug free, anxiety, and indifference to the requirements of the treatment program Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Educating the Patient and Family about Narcotic Antagonists Patients should wear or carry identification indicating that they are receiving a narcotic antagonist. Educate patients and family on the impact of therapy. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins ...
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