Pain: Non-narcotic and Narcotic Analgesics

Analgesia

“Painkillers”, opioid analgesics, non-opioid analgesics, adjuvant analgesics, for many alternative therapies are tried first (ice, heat, etc.)

Acute pain

Normal, expected; sudden onset, usually subsides once treated, potential causes include tissue damage, inflammation, infection, acute injury

Chronic pain

Not normal, not expected; persistent or recurring, >3 months, often difficult to treat, considered a health condition in itself, potential causes include migraines, back pain, arthritis, cancer, neurogenic

Substances released from tissue injury

Bradykinin, histamine, potassium, prostaglandins, serotonin

Step 1 analgesic

Non-opioid analgesic, +/- adjuvant therapy (not controlled substance)

Step 2 analgesic

Weak opioid analgesic, +/- non-opioid, +/- adjuvant therapy

Step 3 analgesic

Potent opioid; +/- non-opioid, +/- adjuvant therapy

Acetaminophen (Tylenol) indications

Mild to moderate pain, fever, ASA/NSAID alternative

Acetaminophen (Tylenol) mechanism of action

Not fully understood

Acetaminophen (Tylenol) contraindications

Liver issues, hypersensitivity

Acetaminophen (Tylenol) adverse effects

Lethal when overdosed-hepatotoxicity (Antidote: N-Acetylcysteine (Mucomyst))

Acetaminophen (Tylenol) nursing implications

Liver tests (ALT, AST), chronic overdose because in combination drugs

NSAID overview

Large Group with multiple indications, analgesic, anti-inflammatory, antipyretic, platelet inhibition; black box warnings include MI, stroke, GI perforation

NSAID implication

Pain, fever, inflammation

NSAID contraindications

Hypersensitivity; severe RENAL disease, GI bleeding/bleeding disorders, anemia

NSAID interactions

Anticoagulants, alcohol (increases bleeding risk)

NSAID averse effects

Heartburn, severe GI bleeding, acute renal failure, MI, stroke, tinnitus, hearing loss, blurred vision

NSAID nursing implications

Should see improvement in pain/fever; watch for toxicity, bleeding, heart/stroke symptoms, kidney failure; avoid with hx of ulcers; labs for renal, liver function, CBC; take with food; may be weeks before benefit

NSAID patient education

Patient should notify provider of bleeding or blood in stool, epigastric pain, fatigue, syncope; do not crush or chew enteric coated tablets

Aspirin (ASA) forms

Oral, topical, rectal suppositories

Aspirin uses

Mild pain, platelet aggregation

Aspirin major concerns

Reye’s syndrome

Reye’s syndrome

Extremely rare but severe/fatal neurologic deficits/coma, thought to be triggered by virus/ASA combo, contraindicated in children with flu-like symptoms

Indomethacin indications

Pain, patent ductus arteriosis (PDA) closure

Ketorolac (Toradol) implications

Powerful analgesic (Acts like weak narcotic without addictive properties) up to 5 days

Ketorolac (Toradol) adverse effects

Renal problems & GI pain, bleeding

Celecoxib (Celebrex) implications

Arthritic pain

Celecoxib (Celebrex) contraindications

Sulfa allergy

Celecoxib (Celebrex) adverse effects

CV risk

Ibuprofen (Advil, Aleve) indications

Pain, fever

Opioid implications

Moderate to severe pain; anesthetic properties, cancer

Opioid contraindications

Known allergy; respiratory insufficiency, obesity, paralytic ileus, pregnancy, increased ICP

Opioid adverse effects

Abuse potential, itching, hemodynamic changes, CNS depression (respiratory depression), constipation

Opioid nursing implications

Overdose (naloxone (Narcan)), withdrawal symptoms, respiratory depression, assess pain level and respiratory status before administration, consider safety, assess for allergic reactions, monitor elderly frequently

Opioid considerations

Controlled substance, legal procedures regarding administration; caution with Hx of addiction, determine patterns/evaluate alternatives if used long-term for chronic pain, interactions with CNS Depressants or antihypertensives

Opioid combination drugs

Vicodin (Acetaminophen-Hydrocodone), Percocet (Acetaminophen-Oxycodone), Tylenol-codeine #3 (Acetaminophen-Codeine)

Opioid tolerance and dependence

Common physiologic response to chronic opioid use, builds tolerance-patient needs larger dose to maintain same level of pain control, tolerance is expected with long-term use; addiction is defined as psychological dependence