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Narcotics

Nonnarcotic and Narcotic Analgesics

QuestionAnswer
Nursing Interventions for Narcotics Account for ALL controlled drugs. Must have witness and Co-sign discarded or wasted medication. Ensure records & drug count matches. Double lock all narcotics & keys must be accounted for. Ensures pt & nurse safety Prevents error & holds nurse accountable
Who regulates Narcotics Federal, State, and Agency policies. Board of Nursing/Nurse practice act. Board of Pharmacy. Ohio revised Code.
Physical vs Emotional pain Pain is an unpleasant sensory & emotional experience. Many physiological/emotional effects of non relieved pain. Quality of life effected.
Treatment of pain Varies with type and duration. Requires good assessment and knowledge of pain to treat/control adequately.
Barriers to pain control: Health care professionals Inadequate knowledge. Poor assessment skills. Concern about regulation of controlled subst. Fear of pt addiction.
Barriers to pain control: Patients Reluctant to report pain or take pain medication (culture, gender differences, inadequate description or reporting of pain, fear loss of control, side effects) Problems r/t health care system: cost, access health care providers' barriers
Results of Unrelieved Pain Increase resp rate, HR, BP. Stress response: fluid retention, glucose intolerance, impaired immune response-pneumonia. Constipation, weakness, confusion. Psychological suffering. Extended hosp stay & readmits
Addiction psychologic and physical dependence on a substance beyond normal voluntary control. Usually after prolonged use of a substance***
Dependence reliance on a substance, that if not present, will cause impairment in function can be physical or psychological. Need regular use to prevent withdrawal***
Tolerance requiring increased dose to maintain same effect, (frequently occurs with chronic pain such as cancer pain, need more drug to get same level of pain control)****
Choice of drug depends on type of pain Acute, chronic, somatic, vascular, visceral.
Pathophysiology of Pain Damaged cells release chemical mediators. Prostaglandins, bradykinins, serotonin. Nociceptors: in all types of tissue.
Prostaglandins regulates the contraction and relaxation of smooth muscle tissue
Bradykinins causes blood vessels to dilate (enlarge), and therefore causes blood pressure to lower
Serotonin Approximately 90% of the human body's total serotonin is located in the enterochromaffin cells in the alimentary canal (gut), where it is used to regulate intestinal movements Remainder is synthesized in CNS, where it regulates of mood, appetite, & sleep
Non-opiods (OTC) Acetaminophen (prototype). NSAIDs-Ibuprophen
Opioids (narcotics, controlled substances) Morphine: methadone, oxycodone.
Adjuvants Used in addition to pain med, may control some types of pain, depending on source, ie inflammation or neuropathic. Ex. corticosteroids, anticonvulsants, tri-cyclic antidepressants
NSAIDs Nonsteroidal anti-inflammatory drugs. Non addictive, less potent that opiates. All have analgesic, antipyretic, anti-inflammatory effects (except acetaminophen, very little anti-inflammatory effect)*** Some have antiplatelet action****
Uses for NSAIDs Mild to moderate pain***
NSAID Actions Relieve pain by effects on chemical mediators. Inhibiting cyclooxygenase decreases prostaglandin synthesis.
Cycloxygenase 1 protects stomach and regulates platelets**
Cycloxygenase 2 triggers pain and inflammation** Used to control arthritis type pain-pts would be able to take drugs without as much stomach problems, but later found to increase risk of cardiac problems, so now drug given less frequently and more selectively
ASA and many other NSAIDs... inhibit both types of prostaglandins-which increase the risk of gastric ulcers by inhibiting the prostaglandin that promote the mucosal barrier protecting stomach from high acid load**
Example of Salicylate aspirin
Example of NSAIDs Naproxen (Aleve) indomethacin (Indocin)
Example of COX-2 inhibitors Celecoxib (Celebrex), rofecoxib (vioxx)
Example of Propionic acid group Ibuprofen (Motrin, Advil)
NSAIDs Side Effects/Adverse Reactions GI irritation, ulcers**** Inhibitor of platelet aggregation**** (increase bleeding tendencies, increase effect of anticoagulants) Hypersensitivities (bronchospasm).
Why do NSAIDs create GI irritation Due to inhibition of COX1 and COX2
Aspirin to children <12 yrs DO NOT GIVE for any fever. Risk of Reye's Syndrome***
Chronic use of NSAIDs may cause renal impairment*** esp propionic group like Ibuprofen
Acetaminophen Scant anti-inflammatory effect. May not be very effective if cause of pain is related to inflammation. Common ingredient in 25% of all OTCs sold! NO effect on gastric lining or platelets*** Short 1/2 life.
Acetaminophen Safety Margin Has a fairly wide safety-margin-but toxicity (acute liver failure) can occur with single large dose***
Toxic effects of Acetaminophen overdose Acute liver failure (hepatotoxicity) hepatic necrosis (increase risk when ETOH also taken)****
Acetaminophen overdose Mucomist. Can occur if > 4gm/day****This is 8 tabs of extra strength (500mg tabs)! Arthritis strength tabs are 650 mg each! Many overdoses are accidental b/c people don't realize how much they are taking, can be using acetaminophen plus taking OTC
Treatment of Acetaminophen Mucomist
Corticosteroids Suppress inflammation by inhibition of immune process-depress lymphocyte activity**** Ex prednisone, dexamethasone, solu-cortef
Side Effects of Corticosteroids Glucose intolerance, weight gain, osteoporosis, skin changes, increased risk for infection/poor healing, Must be tapered off if used for more than 1-2 weeks****
DMARDS (disease modifying antirheumatic drugs) Gold, Immunosuppressive agents, immunomodulators
DMARD-Gold Used as antirheumatic. Gold salts: Ridaura, Solganal. Watch for S.E. metallic tast, rash, diarrhea
DMARD-Immunosuppressive agents Inhibit inflammatory process, larger doses of some may be used to treat cancer, or transplant rejections
Immunomodulators Inhibit inflammatory process by: Interleukins (IL-2) receptor antagonists. Tumor necrosis factor (TNF) receptor blocking. Ex: Ethanercept (Enbrel), Adalimunab (Humira), Infliximab (Remicade)
Other drugs used for pain Some antidepressants or anticonvulsants are used as adjunct drugs for pain, esp if it is neuropathic (diabetic neuropathy). Ex. Gabapentin, Elavil, Pregabalin (Lyrica)-very effective also in some chronic pain conditions
Narcotic Analgesics Used for moderate to severe pain*** Act on CNS: suppress pain perception, respiration, cough (antitussive properties***), GI motility (constipation***). Opioid (morphine, codeine).
Morphine (opioid prototype) Used to determine equivalent doses of other narcotic analgesics. Admin IM, IV, & PO. Very effective in acute severe pain. Offers euphoria. Relief of resp distress in terminal illness near death-for comfort to relieve sensation of suffocation or air hunger
Morphine treatment for chronic pain Effective in treating chronic pain if in extended release forms
Morphine and acute heart failure Effective in acute heart failure if pulmonary edems: reduces preload, afterload, Gives sense of euphoria.
Meperidine (Demerol) No antitussive effect. Very dangerous in renal insufficiency b/c of active metabolites*** Can be neurotoxic*** (tremors, seizures). Does not diminish uterine contractions*** May be given during labor for pain control. Not for chronic pain***
Meperidine (Demerol) side effects Some suggest this drug should be abolished!! B/c of potential problems.
Tramadol (Ultram) Binds to U receptors. No dependence. Used for moderate to severe pain. Contraindicated in alcoholism or with use of opioids.
Narcotic Side Effects/Adverse Reactions** Resp depression, orthostatic hypotension***, constipation***, nausea & vomiting, somnolence***, pruritis-does not mean allergy unless hives or systemic rash develops. Tolerance & dependence.
Withdrawal symptoms of Narcotics*** Agitation, tachycardia, HTN, GI symptoms. Skin sensation of "crawling bugs"
Nursing Assessment: Resp Rate Resp depression, narcan ready, Administer if RR<10. This does not usually present a problem for chronic pain control, unless starting new drug or renal, liver fx decreased
Nursing Assessment: Pupils pinpoint May need narcan, closely monitor. Sedation "score"- they will be drowsy, this is expected, if unarousable or slow response to painful stimuli=narcan required.
Opioid Naieve Drug accumulation ie renal disease, hepatic disease. Do NOT cut dose if pt tolerant ie chronic cancer pain
Nursing Responsibilities Safety: risk r/t BP changes, sedation. Constipation: must make sure pt has order for bowel med, this is easier to prevent than to fix! CAUTION if pt has liver or renal disease. CAUTION in elderly, lower dose! Accurate assessments!
Listen to pt What works, what doesn't, don't go by "usual" dose in chronic pain. Many have developed tolerance and need what we would usually consider extreme dose
Selected Narcotic Antagonists Antidote. Naloxone (Narcan), most commonly used. Naltrexone HCl (ReVia). Competes for same opiate receptors*** Purpose--reverse effect of opiate such as resp depression. MUST BE GIVEN SLOWLY & CAREFULLY
Contraindications for Narcotic Use*** Head injuries (can't differentiate if drugs or neuro impaired from injury to CNS). Resp Dysfunction (bronchospasm) Could be used to control cough-codeine. Shock states (it will decrease BP further). GI motility problems (could be used to control diarrhea)
Narcotic Agonist-Antagonists Combo: narcotic agonist-antagonists. Less risk for tolerance to develop (Pentazocine [Talwin], most commonly used. Butorphanol tartrate. Buprenorphine) Advan/Disadvant-lower narcotic dose needed. Safe during labor (Nubain)
Addicted Persons There are many drug dependent nurses (1 in 6). Rehab program: replaces w/ less dependency prone narcotic. Weaning program. Maintenance program.
Methadone treatment program Rx's should be written if it is NOT part of the rehab program and prescribed for pain. May be used as part of pain management plan, esp for chronic pain.
Created by: senmark