Analgesic Agents Flashcards
What are A fibers?
Fibers that carry perception of vibration, stretch and pressure.
There are four types : Alpha, Beta, Delta and Gamma.
What is A-delta fibers?
Fibers that carry the sensation of pain to the spinal cord - usually acute sharp pain.
What are C Fibers?
Unmyelinated nerve fibers - these have a slower conduction due to being unmyelinated. They also carry pain sensation, however it is more of a slow, dull and aching pain.
What is Ergot derivative?
Drug that helps with migraines by causing vasoconstriction in the brain and peripheral areas., however there are a lot of adverse effects associated with these.
What is the gate control theory
The concept that pain is not just about how much damage the tissues receive, but about how pain is transmitted though the nerve fibers and there are ways that we can close the pain gate with alternative means.
For example: if those nerve fibers are stimulated via massage or heath, they are distracted and won’t send the pain signal, or the pain signal will be overwhelmed by the other signals.
What is a Migraine Headache?
Severe unilateral pain in the head that leads to other effects such as nausea, vomiting and photophobia and is usually caused by arterial dilation.
What’s Nociception?
Transmission of unpleasant stimuli to the brain.
What are opioid agonists?
Drugs that enhance opioid receptors
What are opioid agonists-antagonists?
Drugs that both enhances and decreases opioid receptors site activity. They will enhance some sites while inhibiting other sites.
What are opioid antagonists?
Drugs that block opioid receptor sites - these are used to treat opioid OD’s.
What are opioid receptors?
The nerve receptor sites that react with endorphins and encephalins, which are the same sites that react to opioid drugs.
Define pain.
Sensory and emotional experience associated with actual or potential tissue damage
What is the Spinothalamic tract?
The nerve pathway that travels from the spine through the thalamus to the brain,
What is Triptan?
a selective serotonin blocker that causes vasoconstriction in the brain and it is used as medication for migraines.
What is pain?
Pain can be physical or emotional and differs from person to person. Each person perceives it differently.
what can often affect the treatment that patients receive by nurses for their pain?
Preconceived notions of pain by the nurse. This can often result in the patient not getting the treatment that they need. When a patient tells us that they are in pain, we need to take it seriously. This is especially prevalent in the different socioeconomic groups.
What are two times of pain duration?
Acute & Chronic
What is acute pain normally caused by?
Generally cause by new tissue damage. Its letting you know that an injury has occured and you should stop doing the thing that is causing the injury or get away from it.
How do we define chronic pain?
Can be consistent or inconsistent and usually last longer than 3 months. It can affect a persons ADL’s, interrupt sleep and reduce quality of life.
How does drugs used to relieve pain work?
All intended to interrupt or distort the perception of pain in the brain and spinal cord in some way. It works in the CNS to alter the way pain impulses are processed.
Why do we use opioids?
Opium derivatives used to treat many types of pain
What do we use Antimigraine Drugs for?
Reserved for the treatment of migraine headaches.
Explain the Gate- Control Theory of pain in detail.
Its the idea that if we look at how pain is transmitted through the different nerves and nerve types. we can interrupt the pain signal, particularly if we stimulate the A fibers.
The Delta A fibers are responsible for acute pain, and so we can overpower these smaller slower A delta pain signals by stimulating the A fibers more.
The pain signals being sent out from the CNS can be modified using norepinephrine and serotonin, which is why some antidepressants can work for pain management.
What is the reason pain can differ from person to person?
There are many factors that can affect the descending pain signal. some of these are learned experiences, cultural expectations, individual tolerance and the placebo effect.
This is who some treatments work well for some patients and not at all for others.
Other than pain what other things does opioid receptors control?
Pupil size, GI secretions and the effect of chemo receptor trigger zone which controls nausea, vomiting, breathing and coughing
What are the two types of opioid receptors?
Mu and Kappa
What does the MU receptors control?
mostly pain blocking receptors that can also give a feeling of euphoria and cause lower GI motility, pupil constriction, respiratory depression and dependance.
What does Kappa receptors control?
They give some pain relief, and also causes pupil constriction, sedation and dysphoria (general feeling of unease, dissatisfaction or discomfort)
Where are opioid receptors found?
○CNS
○Nerves in the periphery
○Cells in the gastrointestinal (GI) tract
○CTZ - chemoreceptor trigger zone
What are some lifespan considerations that we should keep in mind when administering opioids to children?
- Safety and efficacy not established - use only if necessary.
- Dosage should be carefully calculated
- Monitor closely for ADE
- Methadone should not be used in children and if an alternative is needed an opioid agonist antagonist that can be used is buprenorphine.
What are some lifespan considerations that we should keep in mind when administering opioids to adults?
○Encourage to request pain medication before pain out of control
○Caution in pregnancy/lactation
○Narcotics used during labor- monitor mom and baby closely for ADE
What are some lifespan considerations that we should keep in mind when administering opioids to older adults?
○More likely to experience ADE
○More likely to develop toxicity
○Implement safety measures such as fall prevention.
What is the antidote for an opioid overdose?
Naloxone (Narcan)
When is the best time to take the opioids when taken for pain?
Before the pain becomes unbearable - waiting too long can cause breakthrough pain and it can take longer to get pain under control.
Can we use opioids during labor?
Yes, up until a certain point. After 6 cm of dilation the drug will be passes to the baby and can cause CNS depression if the baby is born shortly after mom has received opioids.
What can happen if Mom is taking opioids regularly during pregnancy?
Babies can develop withdrawal symptoms after they’re born., because now they are no longer getting opioids. Withdrawal usually happens 24-72 hrs after delivery depending on their exposure in the womb.
What will women with an opioid addiction start during pregnancy?
A methadone treatment program, and although the babies will have withdrawal symptoms the methadone reduces the severity.
Define Opioid Agonists.
●Drugs that stimulate opioid receptors
●Cause analgesia, sedation, or euphoria
●Potential for physical dependence
●Controlled substances
●Rising problem of addiction
What drug classes under Opioid Agonists do we need to know?
Morphine,
Hydromorphone,
Codeine,
Oxycodone,
Fentanyl,
Hydrocodone
What are the MOA’s for Opioid Agonists?
○Act at specific opioid receptor sites in the CNS
○Produce analgesia, sedation, and a sense of well-being
Why would we give Opioids Agonists to patients?
- Relief of severe acute or chronic pain
- Analgesia during anesthesia
- A patient can also get a PCA to give themselves doses of opioids after surgery. It takes two nurses to set this up.
What are some factors that would contraindicate the use of Opioid Agonists?
- Allergy
- Diarrhea caused by poisons - this is because and opioid agonist will cause decreased GI motility, whihc will increase poison absorption. This is also why we should be careful in giving opioids to patients with GI obstruction or patients recovering from GI surgery.
What pre-existing patient conditions would prompt us to use caution when administering opioid agonists?
○Respiratory dysfunction, asthma, emphysema - can worsen due to respiratory depression effect.
○Pregnancy, labor, lactation
○GI or GU surgery - will complicate recovery by retaining urine and stool.
* GI obstruction will become worse with decreased motility.
○Acute abdomen or ulcerative colitis - can be masked
○Head injuries, alcoholism, delirium tremens, or CVA - can mask
What are some symptoms of acute onset of severe abdominal pain that opioids can mask?
Pain
Tenderness
Changes in bowel sounds.
If you are performing a neuro assessment to patients who are suffering from head injuries, alcoholism, delirium tremens, or a stroke, and these patients have been given opioids, how do you evaluate if they are acting differently due to these conditions or due to the opioids that were given?
You can’t, which is why is should not be given in these patients unless necessary and diagnosis has been established.
By impairing consciousness and cognitive functioning what can opioids complicate?
Assessment of neurological status in head injury patients.
Opioids can exacerbate confusion and agitation whihc makes management of delirium tremens more challenging.
May worsen neurological outcomes by causing sedation and impairing the patient’s ability to respond to stimuli.
What are some known adverse reactions to opioid agonists?
- Respiratory depression which can lead to apnea, cardiac arrest or shock.
- GI motility and CTZ stimulation can lead to nausea & vomiting & constipation,
- CNS effect such as dizziness, fear, anxiety and hallucinations.
- orthostatic hypotension - ensure aid in position changes and ambulation.
Are there any DDI’s to opioid agonists, and if so, what are they?
- Barbiturate general anesthetics - risk of respiratory depression, hypotension, sedation and coma.
- SSRIs - Increased risk of serotonin syndrome.
- Cholinergic Agents and HTN agents - can case increase in GI effect and Hypotension.
Which are the 3 drug classes that we need to know for Opioid Agonists–Antagonists?
Buprenorphine,
Butorphanol,
Nalbuphine
What are the MOA’s of for Opioid Agonists–Antagonists?
Stimulate mu-opioid receptors and blocks kappa-opioid receptor in the CNS to produce analgesia, sedation, euphoria, and hallucinations.
This is why they are both agonists and antagonists meaning they can treat pain (agonists) and also be used as treatment for people with opioid addiction.
Why would we administer Opioid Agonists–Antagonists to patients?
○Moderate to severe pain
○Some can be used to treat opioid use disorder
What are some factors that would contraindicate the use of Opioid Agonists–Antagonists in patients?
Sulfur allergy - because Nalbuphine also contains sulfur just like Celecoxib (anti-inflammatory, arthritis drug).
Does Opioid Agonists Antagonists have an effect on the respiratory system?
Yes, these drug also causes respiratory depression which become more likely the higher the dose.
What pre-existing patient conditions would prompt us to use caution when administering Opioid Agonists–Antagonists ?
○Physical dependence on a narcotic - may trigger withdrawal symptoms due to antagonist effect.
○COPD and disease of the respiratory tract - can be exacerbated.
○Acute MI or documented CAD, HTN - opioids can stimulate heart and cause exacerbation.
○Renal or hepatic dysfunction
○Pregnancy and lactation - benefit outweigh risk and alternative feeding forms should be used.
What needs to be done in terms of dosing if a patient is switching from an opioid agonist to agonist antagonist?
The dose needs to be slowly adjusted to avoid withdrawal symptoms.
What are some known adverse reactions to Opioid Agonists–Antagonists ?
○Respiratory depression
○ Decreased GI motility : Nausea, vomiting, constipation, and biliary spasm actions
○ CNS changes : Headache, dizziness, psychoses, anxiety, hallucinations
○Sympathetic response : Ureteral spasm, urinary retention
○ Sympathetic response : Sweating and dependence
Are there any DDI’s to Opioid Agonists–Antagonists , and if so, what are they?
○Barbiturate general anesthetics - risk of respiratory depression, hypotension, sedation and coma.
○Narcotic agents - can cause respiratory depression and OD.
For both Opioid agonists & Opioid Agonists–Antagonists, what should we be assessing our patients for prior to administering the drugs?
○Assess for contraindications or cautions
○Perform a pain assessment with the patient (very important)
○Perform a physical assessment
■Assess orientation, affect, reflexes, and pupil size; monitor respiratory rate and auscultate lungs
■Monitor pulse, blood pressure, and cardiac output
■Palpate abdomen and auscultate bowel sounds; assess urine output and palpate for bladder distension
○Monitor the results of laboratory tests such as liver and renal function tests
What nursing diagnoses can be made and anticipated prior to administering Opioid agonists & Opioid Agonists–Antagonists ?
○Altered sensory perception (visual, auditory, kinesthetic) related to CNS effects
○Constipation, nausea, vomiting related to GI effects
○Altered gas exchange related to respiratory depression
What are some implementations that we should be prepare to do when/after administering Opioid agonists & Opioid Agonists–Antagonists to our patients ? (long answer)
○Perform baseline and periodic pain assessments with the patient
○Have Naloxone and respiratory equipment at bedside.
○Monitor injection sites for irritation and extravasation
* Ensure medication is given in richly perfused area to prevent slowed effect therefore use extreme caution when injecting these drugs into any body area that is chilled or has poor perfusion or shock.
○Use additional measures to relieve pain
○Monitor respiratory status before therapy and periodically during therapy
○comfort and safety measures
○patient teaching
What are the 2 drug classes that we need to know for Opioid Antagonists?
Naloxone & Naltrexone
When would we use Naloxone ?
Used for an acute opioid overdose.
Reverses the adverse effects of opioids; diagnoses suspected acute opioid overdose
A person that ahs an opioid dependency and is given Naloxone will most likely experience _____________
Suddenly experience withdrawal symptoms if given too quickly.
When would we use Naltrexone?
Held reduce the cravings and rewarding effects of opioids & alcohol.
It is therefore used orally in the management of alcohol or opioid dependence once they have completed detoxication.
If it is given while the patient is still dependent on the substance it can have a reversed effect and increase cravings.
What are the MOA’s of Opioid Antagonists?
Drugs bind strongly to opioid receptors and prevents them from being stimulated.
Reverse effects of opioids in acute situations
And for treatment once chemical dependency is not longer active.
What is the difference between dependence and addiction?
Dependence : Marked tolerance and withdrawal symptoms experienced when the substance is stopped. Tolerance = when you need more of a substance to achieve the same effect.
Addiction: Range of behavioral, emotional, and cognitive components, such as loss of control, overuse, cravings and continued use despite them being harmful to the patient or others.
Why would we give Opioid Antagonists to patients?
○Reversal of the adverse effects of opioids
○Treat opioid and/or alcoholic dependence
What are some factors that would contraindicate the use of Opioid Antagonists in patients?
Known allergy
What patient condition would prompt the need for increased caution when administering Opioid Antagonists ?
Pregnancy and lactation
What are some known side effects of Opioid Antagonists?
○Acute opioid abstinence syndrome : Nausea, vomiting, sweating & tachycardia
○Blood pressure changes
○Dysrhythmias
Anxiety
What are the 4 symptoms of Acute opioid abstinence syndrome?
Nausea
Vomiting
Sweating
Tachycardia
Are there any DDI’s related to Opioid Antagonists, and if so, what are they?
Larger doses may be needed to reverse effects of opioid agonist-antagonists due to a higher affinity to the receptors than Naloxone.
Prior to administering Opioid Antagonists to patients, what are some things that we need to assess?
○Assess for contraindications or cautions
○Perform a physical assessment : Nero baseline, respiratory baseline and cardiac baseline.
Assess level of orientation, affect, reflexes, and pupil size; monitor respiratory rate and auscultate lungs
What nursing diagnoses can be made and anticipated prior to giving patients Opioid Antagonists?
○Acute pain related to withdrawal and CV effects
○Altered cardiac output related to CV effects
○Injury risk related to CNS effects
○Knowledge deficit regarding drug therapy
When/ After we’ve given patients Opioid Antagonists what are some things that we should implements in their care?
Administration may happen when patient is coding - maintain airways and do CPR.
○Provide continuous monitoring of the patient
○Ensure that patients receiving naltrexone have been narcotic-free for 7 to 10 days
○If the patient is receiving naltrexone as part of a comprehensive opioid or alcohol withdrawal program, advise the patient to wear or carry a Medic Alert warning
○Institute comfort and safety measures
○Provide thorough patient teaching
What causes Migraine Headaches?
Activation of trigeminal nerve that causes inflammation within the meningeal blood vessels.
What are the symptoms of Migraine Headaches?
Severe, throbbing headaches on one side of the head
Men or Women more likely to experience Migraine Headaches?
Women are 3 times more likely to experience migraine headaches.
What are some lifespan considerations that we should take into account when giving antimigraine agents to children?
○Not many drugs are recommended due to the many adverse effects. Triptans are only approved for children 6 yrs +
○Treat first with OTC analgesics
○Need to be evaluated for other causes of HA
What are some lifespan considerations that we should take into account when giving antimigraine agents to adults?
○Need to be evaluated for other causes of HA
○Ergots and triptans contraindicated in pregnancy
○Alternate methods to feed baby
What are some lifespan considerations that we should take into account when giving antimigraine agents to older adults?
○More likely to have chronic diseases that would be exacerbated by ergots and triptans
* Start low, go slow
○Take the least amount of drug as possible
○Monitor closely for CV effects as these can be exacerbated by Triptans and Ergot derivatives.
○Safety measures
How does Ergot Derivatives work?
Works by decreasing the pressure and throbbing in the brain by constricting the vessels by decreasing the size of the vessels in the brain. By decreasing the size of the vessels we alleviate the pain.
What are the two drug classes that we need to know for Ergot Derivatives?
Have -ergot in the name
●Dihydroergotamine
●Ergotamine
Why would we give a patient Ergot Derivatives?
For prevention or abortion of migraine or vascular headaches.
Which Ergot Derivatives can also be used to treat cluster headaches?
Ergotamine
what are the reason for vascular headaches?
Results from changes in blood flow and the dilation of vessels, which is why ergot derivatives are effective in treating them.
What are some factors that would contraindicate the use of Ergot Derivatives in patients?
Absolute : Known allergy & CAD, HTN, Peripheral vascular disease - can become exacerbated because they are given a vasoconstrictor that can further restrict and reduce blood flow.
Relative : Impaired liver function - lead to poor metabolism of the drug
Pregnancy or lactation : Due to ergotism has been reported in babies.
What is Ergotism?
Symptoms such as vomiting, diarrhea and seizures.
It is usually caused by consuming grains such as rye that is contaminated with the ergot fungus which the ergot derivatives are made from.
What patient condition would prompt the need for increased caution when administering Ergot Derivatives ?
○Pruritus - can worsen with vasoconstriction.
○Malnutrition -due to CTZ activation whihc worsen GI symptoms and worsens malnutrition.
What are some known adverse reactions to Ergot Derivatives ?
All related to vasoconstriction properties of the medication:
○Numbness, tingling of extremities, muscle pain - due to reduced perfusion
○Pulselessness, weakness, chest pain, arrhythmias - due to lack of gas exchange
○Nausea, vomiting, diarrhea - due to lack of blood to GI tract.
Are there any known DDI’s to Ergot Derivatives, and if so, what are they?
○Beta blockers - increased risk of gangrene and peripheral ischemia
○Triptans - can cause vasospasms
What does Triptans do?
Medications that causes cranial vascular constriction and relief of migraine headache pain in many patients. The work similar to ergot derivatives, however has less GI and Vascular effects than Ergot derivatives.
What are the 3 classes of Triptans that we need to know?
All have ‘triptan’ in the name.
○Eletriptan
○Sumatriptan
○Zolmitriptan
What are the MOA’s of Triptans?
Bind to selective serotonin receptors sites to cause vasoconstriction of cranial vessels.
If a patient who was prescribed a Triptan medication and this medication does not work, what should the patient do?
The patient should try a different Triptan medication as these drug are highly individualized.
Is Ergot derivatives or Triptans used for migraine prevention?
Ergot Derivatives.
Triptans should be taken after the migraine has started.
Why would we give Triptans to a patient?
For treatment of acute migraine and are not used for prevention of migraines
What are some factors that would contraindicate the use of Triptans in patients?
Allergy,
Pregnancy,
Coronary Artery Disease which would worsen with vasoconstriction.
With what conditions should we exhibit increased caution when administering Triptans?
○Elderly
○Risk factors for Coronary Artery disease - Should be monitored closely
○Lactation - alternative forms should be used.
○Renal and hepatic dysfunction
What are some known adverse reactions to the use of Triptans?
All related to vasoconstriction.
Numbness, tingling, burning sensation, feeling of coldness, weakness, dysphasia, blood pressure
alterations.
Are there any known DDI’s with Triptans, and if so, what are they?
○Ergot-containing drugs - enhances vasoconstriction effect for a prolonged period of time.
○MAIOs -can cause serotonin syndrome
○SSRIs -can cause serotonin syndrome
What are the two sub-categories of CGRP Inhibitors and Serotonin
Agonists?
CGRP INHIBITORS & SEROTONIN AGONISTS
What are the two drug categories that we need to know for the CGRP Inhibitors?
-gepant in the name
●Rimegepant
●Ubrogepant
What is the drug class that we need to know for Serotonin Agonists?
●Lasmiditan
How does CGRP Inhibitors work?
Works by blocking CGRP receptors thus Inhibit CGRP, which is a potent vasodilator that can cause migraine headaches.
How does Serotonin Agonists work?
Selective serotonin agonist leading to vasoconstriction - less adverse effects due to being more selective.
Why would we give patients CGRP Inhibitors?
Acute migraine headache and migraine prevention.
Why would we give patients Serotonin Agonists?
Acute migraine with or without aura in adults
What is a migraine aura?
When someone has a sensory change shortly before migraine kicks in (warning sign). It can present itself as flashes of light, tingling and it can last from a few min up to an hour.
What would contraindicate the use of CGRP Inhibitors and Serotonin Agonists in patients?
Allergy
With what patient condition should we exhibit increased caution when administering CGRP Inhibitors and Serotonin Agonists in patients?
Pregnancy - no data at this point.
What are some know adverse reactions to the use of CGRP Inhibitors?
Nausea
What are some know adverse reactions to the use of Serotonin Agonists ?
Lasmiditan : dizziness, fatigue, paresthesia, and sedation
What DDI’s may we see with the use of Serotonin Agonists & CGRP Inhibitors ?
○Lasmiditan and other serotonergic medications - increased risk of serotonin syndrome.
○Lasmiditan and CGRP inhibitors - CYP3A4 agents
Before administering antimigraine agents to patients, what should be assessing for?
○Assess for contraindications or cautions
○Perform a physical assessment : Neuro for cognition and extremities.
■Assess level of orientation, affect, and reflexes
■Monitor for complaints of extremity numbness and tingling
■Inspect the skin for localized edema, itching, or breakdown with ergot
derivatives
■Assess vital signs; obtain an electrocardiogram
○Monitor liver and renal function tests
What nursing diagnoses may be made prior to administering antimigraine agents to patients, what should we prepare for?
○Impaired comfort related to CV and vasoconstrictive effects
○Altered cardiac output related to CV effects
○Altered sensory perception (visual, auditory, kinesthetic, and tactile)
related to CNS effects
○Injury risk related to changes in peripheral sensation, CNS effects
○Knowledge deficit regarding drug therapy
What nursing implementations should we expect to do after/while administering antimigraine agents to patients?
○Administer the drug to relieve acute migraines based on specific drug
○For abortion of headache, administer at the first sign of a headache and do not wait until it is severe
○Arrange for safety precautions if CNS or visual changes occur
○Provide comfort and safety measures
○Monitor the blood pressure of any patient with a history of CAD, and discontinue the drug if any sign of angina or prolonged hypertension occurs
○Provide thorough patient teaching
Which of these is a contraindication of opioid agents?
GI surgery
Pregnancy
Asthma
Poison Induced Diarrhea
Poison Induced Diarrhea
Which of these is an adverse effect of Opioid agonists-antagonists?
Tachypnea
Respiratory Depression
Tingling in the hands
Polyphagia
Respiratory depression.
What patient education would you provide to a patient taking an opioid antagonist?
Opioid withdrawal symptoms include, nausea, vomiting, fast heart rate and sweating.
