Medications Affecting Severe Pain and Migraines

What is pain?

An unpleasant, uncomfortable sensation that usually indicates tissue damage

• Ineffective pain management may greatly impair quality of life and ability to perform ADLs

What is the most common symptom prompting one to seek health care?

Pain

When doing a pain management assessment, what should be assessed?

Location, intensity/severity, when the patient notices it in relation to time, activities, and other signs and symptoms (ex: do you notice it more in the morning or evening?)

• use a consistent method for assessing pain

• assess on a regular schedule

• prevent when possible

• manage pain to provide relief and prevent recurrence

What are nonopioid analgesics used for?

Acute and chronic pain and neuropathic or bone patin

What are opioid analgesics used for?

Moderate to severe pain

In medication selection for pain management, you should choose the most potent or least potent medication?

Least potent pain medication that is effective

• combinations of medications may be more effective in pain management

What are some general characteristics of opioid analgesics?

• Relieve moderate to severe pain by inhibiting pain signal transmission from periphery to brain — can work anywhere in pain signal transmission

• Well absorbed with PO, IM, sub-Q, IV administration

• Metabolized in the liver, metabolites excreted in the urine

• Liver or renal impairment can interfere with excretion - might lead to buildup of meds

• Exert widespread pharmacologic effects, especially in CNS and GI

How do opioid analgesics relieve moderate to severe pain?

Relieve moderate to severe pain by inhibiting pain signal transmission from periphery to brain

Opioid analgesics can work ___where in pain signal transmission

anywhere

Opioid analgesics are absorbed well with what administration?

PO, IM, sub-Q and IV administration

Where are opioid analgesics metabolized?

The liver

Where are metabolites excreted?

The urine

Liver or ___ impairment can interfere with excretion of of opioid analgesics, leading to a buildup of meds

renal

What effects do opioid analgesics have on the CNS?

Analgesia, CNS depression, respiratory depression, pupil constriction

What effects do opioid analgesics have on the GI system?

Slow motiliity, constipation, bowel and biliary spasm

What is the number one adverse effect seen with opioids?

Respiratory depression

Why do all opioid analgesics have a black box warning?

Because of potentially fatal adverse effects and risk of drug abuse

• have highest risk of fatal overdoses because of respiratory depression

• have highest potential for abuse (opioid crisis)

What analgesics have warnings?

Fentanyl, hydromorphone, methadone, oxycodone, and oxymorphone

What is the prototype for opioids?

Morphine

What is the method of action for opioids (morphine)?

• Bind to opioid receptors, including mu, kappa, and delta (closing the gate)

  • Brain, spinal cord, peripheral tissues

    • Receptors located throughout the body which is why it can work at all different levels of transmission of pain signal

    • primarily works on mu

• Blocks transmission of pain signal

• Activates the endogenous analgesia system (like your endorphins)

What are the uses/indications of opioids (morphine)?

• Primary use: prevent or relieve acute or chronic pain

• Used in specific conditions: Biliary or renal colic, burns, traumatic injuries, postoperative states, cancer

• Patient-controlled analgesia (PCA)

What are the responsibilities of the nurse when giving opioids (morphine)?

• Assess for existing respiratory depression prior to administration

• Prevent interactions

• Assess pain for therapeutic effect

• Recognize and manage toxicity

What are some side effects of opioids (morphine)?

• CNS depression

• Respiratory depression

• Nausea, vomiting, constipation

• Pupil constriction — good way to assess if pt has enough pain med, especially if unable to talk

• BLACK BOX

  • respiratory depression/failure, coma and death

What education should be given when administering opioids (morphine)?

• Do not increase dose without talking to PCP

• Do not drink alcohol or take other drugs that cause drowsiness

• Do not drive or operate machinery when drowsy

• Ask for help when getting out of bed if dizzy/drowsy

True or false: Different analgesics are equianalgesic

False. Different analgesics aren’y equianalgeisc and there can be differences in dosage between IV and PO administration

When managing opioid dosing, small to moderate doses relieve what kind of pain?

Constant, dull pain

When managing opioid dosing, moderate to large doses relieve what kind of pain?

Intermittent, sharp pain

• often seen in trauma, visceral pain, post-surgical pain

When ordered in variable amounts, smaller or larger amounts of opioids should be given first?

Give smaller dose first and then reassess patient

Opioid doses should be reduced for patients already receiving what kind of meds?

CND depressants (ex: anti-anxiety, antidepressant, antihistamine, antipsychotic medications)

Opioid dosages often differ according to ___ of administration

route

When opioids are changed, are dosages changed?

Yes

True or false: Opioids may be given routinely or PRN

True

Opioid use may differ in special populations. How does opioid use differ in opioid-tolerant patients?

• Larger than usual doses are required to treat pain

• Signs/symptoms of withdrawal occur if adequate dosage is not maintained

*may see tolerance in populations of pts who haver had multiple surgeries, pts that have sickle cell, or that have had a lot of pain meds in life

Why should you be cautious using opioids in older adults?

Should be cautious because of potential for respiratory depression, excessive sedation, confusion etc.

What was the opioid epidemic triggered by?

Triggered by pharm companies pushing it and saying it’s not addictive

What is the prototype for opioid antagonists?

Naloxone

What is the mechanism of action for opioid antagonists (naloxone)?

• Competes with opioids at mu receptor sites

• Prevents binding with receptors (binds to mu receptor sites and prevents opioids from binding)

• Displaces opioids already occupying receptor sites

  • if opioids already bound to receptors, it will push them off

  • works fairly quickly. Pt can instantly go into withdrawal and instantly experience more pain

What are the uses/indications of opioid antagonists (naloxone)?

Relieve opioid-induced CNS and respiratory depression

What are the responsibilities of the nurse when giving opioid antagonists (naloxone)?

• Monitor patient—drug may precipitate withdrawal

• Half life of naloxone shorter than half life of opioid

  • naloxone will stop being active but opioids will still be active in body → may have to give multiple doses of naloxone

Which has the shorter half life, naloxone or opioids?

Naloxone

What are the side effects of opioid antagonists (naloxone)?

• Tremors

• Drowsiness

• Sweating

• Hypertension

• Nausea and vomiting

What education should be given when administering opioid antagonists (naloxone)?

It is available OTC as well as in many ER lobbies

What is the prototype for the opioid agonist/antagonists?

Butorphanol

What is the mechanism of action for opioid agonist/antagonists (butorphanol)?

• Agonist of kappa receptors and partial agonist of mu receptors (same pain receptors in the CNS as morphine and other opiates)

  • Interferes with pain transmission and/or pain sensation

• Antagonist activity at other receptors

What are the uses/indications of opioid agonist/antagonists (butorphanol)?

• 2nd line to moderate-severe pain

• Preoperative medication

• Supplement to multimodal anesthesia

What are the responsibilities of the nurse when administering opioid agonist/antagonists

• Administered IM, IV, or via nasal spray

• Assess for therapeutic effect

• Assess for adverse effects — may produce withdrawal symptoms in people with dependence

What are the side effects?

• Headache, dizziness, drowsiness, vertigo, constipation, nausea and/or vomiting, dizziness, hallucinations, euphoria

• Ceiling effect on respiratory depression — bonus of using this instead of morphine

What is the benefit of using butorphanol over morphine?

It has a ceiling effect on respiratory depression action

What education should be provided when giving opioid agonist/antagonists (butorphanol)?

• Notify prescriber if pain doesn’t improve

• Don’t stop taking abruptly — can still have withdrawal symptoms

What medications are used for migraines?

• NSAID (Naproxen sodium)

• Acetaminophen, Aspirin, and Caffeine (Excedrin)

• Triptans (Sumatriptan)

• Ergot Alkaloids (Ergotamine tartrate)

• Estrogen (Estradiol)

What is the peak incidence of migraine age?

25 to 34 years

What are the types of headaches?

• Cluster headaches

• Tension headaches

• Migraines

• Menstrual migraine

What are cluster headaches?

Recurrent, severe headaches that have a sharp shooting pain on one side of head instead of all over. Associated with histamine reactions

Cluster headaches are associated with what kind of reactions?

Histamine reactions

What are tension headaches?

Intermittent, mild headaches that are a result of contraction of scalp muscles. Most common headache

What headache type is the most common?

Tension

What are migraines?

Severe, disabling, unilateral migraines with a subjective aura (auras can sometimes be colors around light)

What are menstrual migraines?

Migraines specific to when you have a drop in estrogen 2-3 days before your cycle

What is the treatment for cluster headaches?

Sub-Q sumatriptan and oxygen

What is the acute therapy treatment for tension headaches?

• Non pharmacological methods, such as rest, relaxation, or stress reduction strategies

• Pharmacological treatment includes acetaminophen, aspirin, and NSAIDs

Medication therapy of migraines is guided mainly by what factors?

• Severity of the attacks

• Presence of associated symptoms, such as n/v

• type of treatment setting (outpatient or inpatient)

• patient-specific factors

What is abortive therapy?

Treatment for existing migraine headaches (have migraine and want to get rid of it)

What is preventative therapy?

Treatment to prevent development of migraine

Which NSAID is used as an abortive medication for migraines?

Naproxen sodium

What is the mechanism of action for Naproxen Sodium (an NSAID that is an abortive migraine medication)?

• First generation NSAID

• Nonselective inhibitor of cyclooxygenase (COX-1 and COX-2) resulting in the inhibition of prostaglandin synthesis

What are the uses/indications of Naproxen Sodium?

• Reduce pain from acute migraine

• Better for migraines than other NSAIDs (more rapid)

What are the responsibilities of the nurse when giving naproxen sodium?

• Assess effects

• Use with caution in patients with astham, cardiovascular dysfunction, hypertension, GI bleeding, PUD

• CONTRAINDICATED - postop coronary artery bypass graft

What are the side effects of naproxen sodium (a first gen NSAID)?

• Bronchospasm and anaphylaxis

• Gastrointestinal symptoms - nausea, dyspepsia, and GI pain

• BLACK BOX - increased risk for cardiovascular thrombotic events and GI bleeding

What education should be provided when giving naproxen sodium (first gen NSAID)?

• Take with food or liquid

• Drink plenty of fluids

• Report bleeding

• DO NOT TAKE IF:

  • Presence of PUD or bleeding disorders

  • Impaired renal function

  • Hypersensitivity to ASA

  • Alcohol abuse

  • Anticoagulants

What combination of drugs is in Excedrin?

Acetaminophen, Aspirin, and Caffeine

What is Excedrin?

An abortive medication for migraines used to reduce pain related to migraine or tension headaches

• Is a combo of acetaminophen, aspirin, and caffeine

• Each component has adverse effects and contraindications (caffeine’s biggest side effect is tachycardia)

• Pt teaching regarding each medication

What is the prototype for triptan?

Sumatriptan

What is the mechanism of action for triptan (sumatriptan)?

• Selectively binds to the serotonin receptors 5-HT1D

  • works by binding to serotonin receptors in brain

• Produces vascular constriction of the cranial blood vessels

  • less volume of blood going to head, less pressure to help get rid of migraine headache

What are the uses/indications of triptan (sumatriptan)?

• Migraine headache pain with or without aura

• Relieves the nausea, vomiting, photophobia, and phonophobia that accompany the migraine headache

• Cluster headache

What are the responsibilities of the nurse when administering triptan (sumatriptan)?

• Prevent interactions — biggest interaction is with MAO inhibitors

• MAO inhibitors and ergot derivatives cause serotonin syndrome

• Assess effects

• BLACK BOX - increased risk of adverse thrombotic events

What is the black box warning on triptan (sumatriptan)?

Increased risk of adverse thrombotic events

What are the side effects of triptan (sumatriptan)?

• Dizziness, vertigo, headache, anxiety, malaise, myalgia, and fatigue

• Alterations in blood pressure and chest pain as well as the most severe cardiovascular adverse effect, shock

  • shock is the most severe ADE

Triptan (sumatriptan) has the biggest interaction with what?

MAO inhibitors

What education should be given when giving triptan (sumatriptan)?

• Administer at start of symptoms

• Know how to use Sub-Q auto-injector

• No more than 2 injections in 24 hours

• Properly dispose of needles

• Nasal spray as single dose (nasal spray offered as single dose)

• Do not take if pregnant

• Report symptoms of hypersensitivity

What are the ways triptan (sumatriptan) can be given?

Subcutaneous injection or nasal spray (if nasal spray, single dose)

What is the max number of inejctions you can give of sumatriptan in 24 hours?

2

What is the prototype for Ergot Alkaloids?

Ergotamine tartare

What is the mechanism of action for Ergot Alkaloids (Ergotamine tartare)?

• Alpha-adrenergic antagonist

• Produces stimulation of the cranial and peripheral vascular smooth muscles while depressing the effects of the central vasomotor centers

• Vasoconstriction

• Reduce transmission of pain signals

*Get vasoconstriction but it’s not as selective as sumatriptan, so can have vasoconstriction in other areas besides just your brain

Which medication produces stimulation of the cranial and peripehral vascular smooth muscles while depressing the effects of the central vasomotor centers, vasoconstricts, and is an alpha-adrenergic antagonist?

Ergotamine tartrate

What are the uses/indications of Ergot alkaloids (ergotamine tartrate)?

• Abortive therapy for migraine headaches

• May use individually or in combination with caffeine

• Not really used much anymore; Largely replaced with Triptans

What are the responsibilities of the nurse when giving ergot alkaloids (Ergotamine tartrate)?

• Prevent interactions - may increase hypertensive effects of other medications, CYP3A4 enzyme

• Assess effects

What are the side effects of Ergot Alkaloids (Ergotamine tartrate)?

• Absence of pulse, bradycardia, cardiac valvular fibrosis, cyanosis, edema, heart rhythm changes, gangrene, hypertension, ischemia, precordial distress, chest pain, tachycardia, and vasospasm

• Muscle pain, numbness, paresthesia, and weakness

• vertigo, nausea, vomiting, itching, pulmonary fibrosis, and genitourinary retroperitoneal fibrosis

What education should be provided when giving Ergot Alkaloids (Ergotamine tartrate)?

• Take at the onset of the migraine headache

• Notify provider if headaches occur more frequently

• Avoid all cola, coffee, tea, grapefruit juice as they increase the serum concentration (CYP3A4)

  • avoid anything that could make you tachycardic or vasoconstrict

  • the CYP3A4 enzyme breaks down the serum concentration

When taking Ergot Alkaloids (Ergotamine tartrate) what should you avoid?

Avoid all cola, coffee, tea, and grapefruit juice as this can increase serum concentration (avoid anything that could make you tachycardic or vasoconstrict)

What is the prototype of Estrogen?

Estradiol

What is the mechanism of action of Estrogen (Estradiol)?

• Minimizes the premenstrual decline in estrogen that precipitates the development of the migraine headache

• increases the estrogen levels in the late luteal phase of the menstrual cycle that contribute to the development of menstrual migraine headaches

What are the uses/indications of estrogen (estradiol)?

Migraine headaches associated with menstrual cycle

What are the responsibilities of the nurse when giving estrogen (estradiol)?

• Incomplete bone growth

  • Can affect bone growth, so make sure growth plates have closed. Don’t give to teens

• Neoplasms, breast cancer, thromboembolic disorders, fibroids, endometriosis, thyroid disease, and pregnancy

What are some side effects of estrogen (estradiol)?

• Thromboembolic disorders (DVT, pulmonary emboli, stroke)

• Menstrual irregularities

What education should be given when administering estrogen (estradiol)?

Avoid smoking when taking estrogen as there is a risk of deep vein thrombosis

Estradiol can affect growth of what?

Bone

What action should be avoided when taking estradiol due to risk of deep vein thrombosis?

Smoking