N212A Final Exam Focus Guide

Pain  management

Adjuvant drugs

• Adjuvant drugs are commonly used in the treatment of neuropathic pain, in which opioids are not completely effective. Neuropathic pain usually results from nerve damage secondary to disease (e.g., diabetic neuropathy, postherpetic neuralgia secondary to shingles, AIDS, or injury, including nerve damage secondary to surgical procedures [e.g., post-thoracotomy pain syndrome occurring after cardiothoracic surgery]). Common symptoms include hypersensitivity or hyperalgesia to mild stimuli such as light touch or a pinprick or the bed sheets on a person’s feet. This is also known as allodynia. It can also manifest as hyperalgesia to uncomfortable stimuli, such as pressure from an inflated blood pressure cuff on a patient’s limb. It may be described as heat, cold, numbness and tingling, burning, or electrical sensations. Examples of adjuvants commonly used in these cases are the antidepressant amitriptyline and the anticonvulsants gabapentin and pregabalin.

• Adjuvants (also called coanalgesics) are drugs originally developed to treat conditions other than pain but also have analgesic properties. They enhance pain control and are given alone or with analgesics.

  Common Adjuvant Drug Classes

  Antidepressants:

  • Tricyclic antidepressants (e.g., nortriptyline)

  • Particularly effective for chronic and neuropathic pain

  Anticonvulsants/Antiepileptic Drugs:

  • Examples: gabapentin

  • Successfully treat chronic pain, especially neuropathic pain

  Corticosteroids:

  • Relieve pain from inflammation and bone metastasis

  NSAIDs:

  • Used as part of multimodal pain management

  Local Anesthetics:

  • Infusional lidocaine for neuropathic pain

  Bone Pain Medications:

  • Bisphosphonates

  • Calcitonin

  Benefits of Adjuvant Therapy

  Multimodal approach advantages:

  • Allows smaller opioid dosages

  • Reduces opioid adverse effects (respiratory depression, constipation, urinary retention)

  • Produces synergistic effects through different mechanisms of action

  • Very effective for overall pain treatment

  Neuropathic Pain

  Adjuvants are especially important for neuropathic pain, where opioids alone are not completely effective.

  Neuropathic pain characteristics:

  • Results from nerve damage (diabetic neuropathy, postherpetic neuralgia, AIDS, surgical injury)

  • Symptoms include hypersensitivity/hyperalgesia to mild stimuli (allodynia)

  • Light touch or bed sheets can cause pain

  • Exaggerated response to uncomfortable stimuli

  Important Distinction

  NOT adjuvants: Sedatives, antianxiety agents, and muscle relaxants have no analgesic effect, though they may be effective for their specific indications (anxiety, muscle spasm).

  Supportive medications like antiemetics and laxatives may also be needed to prevent or relieve opioid-related constipation, nausea, and vomiting.

NSAID patient teaching

• Nonsteroidal antiinflammatory drugs (NSAIDs): A large, chemically diverse group of drugs that are analgesics and also possess antiinflammatory and antipyretic activity.

  • For example, visceral and superficial pain usually require opioids for relief, whereas somatic pain (including bone pain) usually responds better to nonopioid analgesics such as nonsteroidal antiinflammatory drugs (NSAIDs)

• Timing & Food:

  • Take with food, milk, or antacids to reduce GI upset

  • Take at same time each day for chronic conditions

  • Don't crush or chew enteric-coated or extended-release forms

  Dosing:

  • Use lowest effective dose for shortest duration

  • Don't exceed recommended dosage

  • If a dose is missed, take as soon as remembered unless close to next dose (don't double up)

  Safety Precautions

  Avoid combining NSAIDs:

  • Don't take multiple NSAIDs together (including OTC products)

  • Check labels - many OTC cold/flu medications contain NSAIDs

  • Aspirin is also an NSAID

  Drug interactions:

  • Inform all healthcare providers about NSAID use

  • May interact with blood thinners, blood pressure medications, and other drugs

  • Avoid alcohol (increases GI bleeding risk)

  Warning Signs to Report

  Seek immediate care for:

  • Black, tarry stools or blood in stool

  • Vomit that looks like coffee grounds

  • Severe stomach pain

  • Chest pain, shortness of breath, weakness on one side

  • Sudden weight gain or swelling in legs/ankles

  • Skin rash, itching, or allergic reactions

  Contact provider for:

  • Persistent heartburn or indigestion

  • Ringing in ears or hearing changes

  • Vision changes

  • Unusual bruising or bleeding

  Special Considerations

  Cardiovascular & renal risks:

  • NSAIDs increase risk of heart attack, stroke, and kidney problems

  • Risk increases with longer use and higher doses

  • Stay well-hydrated

  Bleeding risk:

  • NSAIDs affect blood clotting

  • Notify dentist and surgeon before procedures

  • Use soft toothbrush, electric razor to prevent bleeding

  Pregnancy: Avoid NSAIDs, especially in third trimester

  Self-Monitoring

  • Monitor blood pressure regularly if hypertensive

  • Watch for signs of fluid retention (swelling, weight gain)

  • Keep track of pain relief effectiveness

Tylenol vs. NSAIDs

• The mechanism of action of acetaminophen is similar to that of the salicylates. It blocks peripheral pain impulses by inhibition of prostaglandin synthesis. Acetaminophen also lowers febrile body temperatures by acting on the hypothalamus, the structure in the brain that regulates body temperature. Heat is dissipated through vasodilation and increased peripheral blood flow. In contrast to NSAIDs, acetaminophen lacks anti-inflammatory effects. Although acetaminophen shares the analgesic and antipyretic effects of the salicylates and other NSAIDs, it does not have many of the unwanted effects of these drugs. For example, acetaminophen products are not usually associated with cardiovascular effects (e.g., edema) or platelet effects (e.g., bleeding), as are aspirin and other NSAIDs. It also does not cause the aspirin-related GI tract irritation or bleeding, nor any of the aspirin-related acid-base changes.

• Acetaminophen is generally well tolerated and is therefore available over the counter and in many combination prescription drugs. Possible adverse effects include skin disorders, nausea, and vomiting.

• Key Differences

  Feature	Acetaminophen	NSAIDs
  Mechanism	Acts on CNS by inhibiting COX	Blocks prostaglandins via COX inhibition in peripheral nervous system
  Properties	Analgesic, antipyretic	Analgesic, antipyretic, anti-inflammatory
  Inflammation	NOT effective	Effective
  Pain types	Mild-moderate nociceptive pain	Mild-moderate nociceptive pain; limited benefit for neuropathic

  Safety Profiles

  Acetaminophen:

  • Most tolerated and safest analgesic available

  • Does NOT increase bleeding time

  • Low incidence of GI adverse effects

  • Analgesic of choice for older adults

  • ⚠ Risk: Liver toxicity with excessive doses

  • Maximum: 3-4 g/day total (including combination products)

  • Check hepatic risk factors before administration

  NSAIDs (ibuprofen, naproxen, ketorolac):

  • More adverse effects than acetaminophen

  • Most common: Gastric toxicity and ulceration

  • Increased bleeding time

  • Risks: GI bleeding, kidney dysfunction, myocardial infarction, stroke

  • All NSAIDs carry cardiovascular risk

  • Higher risk if age >60, history of peptic ulcer or CV disease

  Clinical Use

  Can be given together:

  • Acetaminophen + NSAID is safe and effective

  • No need to stagger doses

  • Often recommended for postoperative pain

  Combination products:

  • Acetaminophen often combined with opioids (oxycodone, hydrocodone)

  • Abbreviated as "APAP" on labels

  • Example: "oxycodone/APAP 5/325" = 5 mg oxycodone + 325 mg acetaminophen

  • Reduces opioid dose needed for pain control

  Prescribing Principle

  NSAIDs: Use lowest dose for shortest time necessary

  Both: Routinely given as scheduled doses (not PRN) for surgical patients as foundation of multimodal pain management

  Bottom Line

  Choose acetaminophen for patients with GI, bleeding, or CV concerns. Choose NSAIDs when inflammation is present. Use both together for enhanced pain control.

NSAIDS complications

• Gastrointestinal Toxicity

  Most common and potentially serious:

  • Ranges from mild heartburn to life-threatening GI bleeding

  • Most fatalities from NSAIDs are GI bleeding-related

  • Over 100,000 hospitalizations annually

  • More than 16,500 deaths reported per year

  • Higher risk if age >60 or history of peptic ulcer disease

  Cardiovascular Risks ⚠

  FDA Black Box Warning (strengthened 2015):

  • Increased risk of heart attack or stroke

  • Risk can occur as early as the first weeks of use

  • Risk increases with longer use and higher doses

  • Patients treated with NSAIDs after first MI are more likely to die in first year

  • Increased risk of heart failure

  • Even patients WITHOUT heart disease or risk factors are at increased risk

  Renal Complications

  • Acute renal failure is quite common

  • Especially dangerous if patient is dehydrated

  • Can cause fluid retention, edema, weight gain

  • May worsen hypertension

  Hematologic Effects

  • Increased bleeding time

  • Impaired platelet function

  • Risk of bruising and bleeding

  Overdose Toxicity

  CNS effects:

  • Drowsiness, lethargy, mental confusion

  • Paresthesias, numbness

  • Aggressive behavior, disorientation, seizures

  GI effects:

  • Nausea, vomiting, GI bleeding

  Severe cases:

  • Intense headache, dizziness

  • Cerebral edema

  • Cardiac arrest, death

  Treatment: Activated charcoal with supportive care. Hemodialysis is NOT effective due to high protein binding.

  Risk Factors

  • Age >60

  • History of peptic ulcer disease

  • Cardiovascular disease

  • Dehydration

  • Higher doses

  • Prolonged use

  • Concurrent anticoagulant use

  Key Nursing Points

  • Use lowest effective dose for shortest duration

  • Monitor for black/tarry stools, coffee-ground emesis

  • Assess hydration status

  • Monitor blood pressure and weight

  • Educate about cardiovascular warning signs

  • Consider acetaminophen as safer alternative when appropriate

Fluid and electrolytes

Dehydration diagnosis and cues