Analgesic Drugs

Understanding Pain
• Most common symptom prompting
people to seek health care
• Occurs when tissue damage activates
free nerve endings of peripheral nerves
• Cerebral cortex analyzes messages
and determines actions
• Activation of opiate receptors in CNS
inhibits pain transmission
 Understanding Pain
• Pain is a subjective experience
• People differ in their perceptions,
behavior and tolerance of pain
• Stressors increase pain
• Diversionary activities tend to decrease
pain-
– deep breathing, listening to music, visual
imagery, others?
• Acute pain can be super-imposed on
chronic pain
• Try alternative measures for pain
control in addition to drugs
• Promote circulation and
musculoskeletal function
• Use heat or cold as ordered
• Relieve pain ASAP
• Administer analgesic before pain
producing activities
• Use the least amount of the mildest
drug likely to be effective
Types of Pain

• Acute pain
• Chronic pain
• Superficial pain
• Deep pain
 NARCOTICS
OPIOIDS
• Opioid-any derivative of opium plant or any
synthetic drug that imitates natural narcotics
• Opioid agonists-include opium derivatives and
synthetic drugs w/similar properties (Kee p.332)
• Decrease pain without losing consciousness
• Opioid antagonists
– Block effects of opioid agnoists
– Used to reverse drug reactions-RD, CNS
depression
– Narcan (always keep antagonist nearby)
• Opioid agonists
– Any route
– Inhalation uncommon
– Absorbed from GI tract
– Transmucosal / intrathecal fast acting
– IV provides most rapid and almost immediate
– Sub Q and IM delayed absorption
• Poor circulation can cause further delay
– Metabolized extensively in the liver
• Administration of meperedine > 48 hours increases
risk of neurotoxicity and seizures from buildup
Pharmacodynamics
• Reduce pain by binding to opiate receptors in
PNS/CNS
• Stimulation of opiate receptors-mimic effects of
endorphins –the body’s naturally occurring
opiates
• Cause dilation of blood vessels in head, neck,
face – could result in increased cranial pressure
• With the exception of Demerol, suppress cough
center to have antitussive effect
• Adverse / Side effects include constipation,
respiratory depression, nausea, vomiting, urinary
retention, orthostatic hypotension
• Morphine – relieve dyspna r/t pulmonary edema
• Nursing process
– Assess pain before and after administration
– Monitor for adverse reactions / side effects
– Monitor for tolerance dependence
• Shortened duration of effect
– Evaluate respiratory status before each dose
• Respiratory depression
• Restlessness
 Mechanisms by Which Opioid
Analgesics Work
• Reduce the perception of pain sensation
• Produce sedation
• Decrease emotional upsets associated
with pain
 Characteristics of Opioid
Analgesics
• Most are Schedule II or III drugs
• Morphine (MSO4) is the prototype
• May be given PO, IV, IM, SQ, or topically
• Oral drugs undergo significant first-pass
metabolism
• Metabolized by liver and excreted in urine
• Exert CNS effects
• Use cautiously in clients with renal or
hepatic disease, respiratory depression
or increased intracranial pressure
• Exert depressant effect on GI tract
• Not recommended for prolonged
periods of use except with chronic pain
or malignant diseases
 Morphine
• Naturally occurring opium alkaloid
• Used to relieve severe pain
• Maximum analgesia occurs in 10-20
minutes with IV route
• Controlled released tablets given for
chronic pain
• May be given intrathecally or epidurally
• Route determines time interval or
frequency of administration
 Hydromorphone
(Dilaudid)
• Synthetic derivative of morphine
• Same actions, uses, adverse effects as
morphine
• More potent on a mg per mg basis
• More effective orally than morphine
• Effects last longer than morphine
 Meperidine
(Demerol)
• Synthetic drug similar to morphine
• Dose of 100mg is equivalent to
Morphine 10mg
• Has shorter duration
• Has less respiratory depression and little
antitussive effect
• Causes less smooth muscle spasm
 Codeine
• Naturally occurring opium alkaloid
• Used for milder pain
• Acts as an antitussive (found in cough
meds)
• Often combined with acetaminophen
• Preferred analgesic with head trauma
 Oxycodone
• Semisynthetic derivative of codeine
• Used to relieve moderate pain
• More potent and more likely to produce
abuse than codeine
• Available in combination with
acetaminophen
 Opioid Antagonists
• Reverse or block analgesia, CNS and
respiratory depression of opioid
agonists
• Compete with opioids for opioid
receptor sites in brain
• Do not relieve depressant effects of
anti-anxiety drugs or antipsychotics
• Naloxone - oldest, most commonly
known
• Nalmefene - newer with longer duration
• Naltrexone - used in maintenance of
opiate free states in opiate addicts
 Client Teaching For Opioid
Analgesics
• Narcotics may be alternated with a
non-narcotic analgesic
• If pain relief not achieved notify physician
• Do not drink alcohol or take other drugs
that cause drowsiness
• Do not smoke, cook, drive a car or operate
machinery after taking
• Constipation is a common adverse effect
• Do not crush or chew long acting tablets
• Decrease dose or omit if adverse effects
occur
 Use In Older Adults
• Use cautiously if debilitated or hepatic,
renal or respiratory impairment
• Start with lower dose and increase
gradually
• Give less often?
• Give opioid analgesic with short half-life
(Oxycodone)
• Monitor for sedation or confusion
• Monitor urinary output
• Assess ability to self-medicate
 Characteristics of Withdrawal
From Opiates
• Generalized body • Piloerection
aches • Anorexia
• Insomnia • N/V/D
• Lacrimation • Increased vital signs
• Rhinorrhea • Abdominal and other
• Perspiration muscle cramps
• Pupil dilation
 Treatment Of Withdrawal
Syndrome
• Gradually reduce the opioid over several
days
• Substitute methadone and slowly reduce
dose over a longer time
• Clonidine reduces withdrawal symptoms
 NONNARCOTICS
SALICYLATES
• Salicylates-produce peripheral blood vessel dilation
– Most common pain reliever
– Control pain
– Reduce fever-stimulate hypothalmus
– Reduce inflammation
– ASA is oldest nonnarcotic analgesic
– Bonus effect-inhibits platelet aggregrate
– Guideline
• Use lowest dose that produces analgesia
• Highly protein bound-can interfere w/other
drugs
– Heparin,methotrexate, oral antidiabetic
meds, insulin
• Adverse reactions
– Hearing loss
– Diarrhea
– Thirst
– Sweating
– Tinnitus
– Confusion
– Dizziness
– Impaired vision
– Hyperventilation
– Reye’s syndrome-when given to children (do not use < 12
yrs old)
• Common side effects
– Gastric distress
– Bleeding tendencies
– NVD
• Give w/food
• May crush except enteric coated
• Hold and notify MD for bleeding
• Stop ASA 5-7 days before elective
surgery
• Salicylate hypersensitivity
– Tinnitus or hearing loss
– Vertigo
– Bronchospasm
– Urticaria
– Need to avoid prunes, raisins, paprika,
licorice
 ACETAMINOPHEN
• Acetaminophen
– Antipyretic and analgesic
– IS NOT ANTI INFLAMMATORY
– Drug of choice for children with flulike
symptoms
– Risk of liver disease
• Phenytoin, barbituates, INH, ETOH
– Rarely cause GI distress-may cause LIVER
toxicity
• Monitor total daily dose (adults 4g max.)
Phenazopyridine hydrochloride
– Pyridium-now OTC
– Dye used in commercial coloring-
analgesic effect on urinary tract
– Relieves pain, burning, itching, urgency,
• Teach
– Urine orange
– Stains fabric-contact lenses
– Notify in ineffective
Anti Inflammatory Drugs
• Anti inflammatory agents
– Reduce body temperature
– Relief of pain
– Anticoagulant (ASA)
– Reduce inflammation
• ASA – oldest
• NSAIDS- reduce inflammation & pain for
arthritic conditions
• Inhibit enzyme COX
• OTC
–Ibuprofen, Motrin, Nuprin, Advil,
Medipren
–Naproxen (Aleve)
–Motrin only available in 200 mg
form
• MD must prescribe higher dose
• Second generation NSAIDS
– COX-2 inhibitors
• COX 1 inhibitor
– Decreased protection of lining of
stomach
– Clotting time decreased-benefit
cardiovascular patients
• NSAIDS
– Inhibit prostaglandin synthesis
• Prostaglandins produced / released in inflammatory
disorders
– Ankylosing spondylitis
– Moderate to severe arthritis
– Osteoarthritis
– Acute gouty arthritis
– Dysmenorrhea
– Migranes
– Bursitis, tendonitis
• Adverse reactions
– Abdominal pain, bleeding
– Anorexia
– Diarrhea, nausea
– Ulcers
– Liver toxicity
– Drowsiness
– Headache
– Tinnitus
– Confusion
– Vertigo
– Depression
– Blood in urine, bladder infection, kidney necrosis
– Sodium & water retention
– Heart failure
– Pedal edema
• Nursing implications
– CBC, platelet count, PT
– Monitor hepatic / renal function
– Bronchospasm
– Monitor for s/s of bleeding
– Take w/meals
– Avoid alcohol
Corticosteroids
– prednisone / prednisolone /
dexamethasone
– Suppresses components of
inflammatory process at the injured site
– NOT THE DRUG OF CHOICE FOR
ARTHRITIC CONDITIONS
– USED TO CONTROL FLARE UPS
– Must taper dose when D/C
DMARDS-disease modifying
antirheumatic drugs
– Toxic
– Alter disease process
– Gold/Gold Salts
• IM/PO
• Used for relief of symptoms
• Immunosuppressive agents-used when
antiinflammatories do not work-cytoxan,
methotexrate/cancer drugs
• Antimalarials-when all other tx fails
Antiinflammatory Gout Drugs
– “gouty arthritis”
– Urinary calculi
– Gouty nephrophaty
• Increase fluid intake
• Avoid foods rich in purine - organ meats,
sardines, salmon, gravy, legumes
• Avoid alcohol, caffeine, large doses of vitamin C
• Zyloprim - inhibits final steps of uric acid
• Colchicine - first drug, inhibits migration of
leukocytes to the inflamed site
Propionic Acid Derivatives
• Ibuprofen (Motrin) - prototype; ketoprofen
(Orudis), naproxen (Naprosyn)

• Used as anti-inflammatory agents in gout,

arthritis, tendonitis
• Used as analgesic for dysmenorrhea,
episiotomy, minor trauma
• Used as antipyretic
• Better tolerated than ASA but more
expensive
• Similar adverse affects as with ASA
• May lead to renal impairment
• Inhibits platelets only while drug
molecules in bloodstream
• Combined with other drugs
Acetic Acid Derivatives
• Indomethacin (Indocin) - prototype;
Tolmetin (Tolectin), Sulindac (Clinoril)
• Used to treat moderate to severe
rheumatoid arthritis, osteo-arthritis, gouty
arthritis, bursitis, pericarditis for anti-
inflammatory effects
• Prescription drug
• Has increased incidence and severity of
adverse effects
Client Teaching Guidelines
• Take ASA and NSAIDS with full glass of
water and food
• Drink 2-3 quarts of fluid daily with NSAIDS
• Report signs of bleeding
• Avoid or minimize alcoholic beverages
• Do not take more than prescribed amount
• Do not take more that 3 days for fever or
10 days for pain
• Read labels of other OTC medications