Pharmacology Exam 3

3 factors of Pain

1) pain perception-point at which a person becomes aware of a painful stimulus 2)pain threshold-point at which a person acknowledges the stimulus of pain 3)pain tolerance-maximum level a pain is able to endure

Pain Scale

1-10 scale 1 being least intense 10 being most intense

contraindicatins and interactions

Alcohol (increase depressant effects), aspirin and warfarin (due to bleeding)

patient tips

Avoid alcohol consumption - intensifies CNS depressant effect Eat high-fiber diet (cause constipation) Avoid driving or operating heavy machinery until effects are known - due to drowsiness

indications

Focal seizures - aware and unaware Trigeminal neuralgia Depression and bipolar disorder

3 types of Anesthesia

General, local, regional

indications

Generalized, absence, and atonic seizures Migraine prophylaxis

Demerol and morphine

Incompatible CANNOT be used in the same syringe have potentiation effects-one increases the other too much- causing respiratory depression and death

adverse effects

Nausea, vomiting, confusion, nightmares, agitation, orthostatic hypotension, somnolence, hallucinations, vision problems Psychotic reactions, hallucinations, paranoia, dyskinesias

adverse effects

Nausea, vomiting, abdominal cramping, liver failure and pancreatitis Sedation and drowsiness are most common Prolonged bleeding

what are the categories of analgesics?

Opioid opiate nonopioid coanalgesia adjuvant nonsalicylates salicylates nonsteroidal anti-inflammatory

Prescription Drugs

Oral (NSAIDs, Schedules III, IV opioids) Transdermal Opioids (fentanyl) Rectal opioids

Medications used to increase or hasten the action of the principal medication(s) are called adjuvant medications. Select all true statements from the list below.

Patient education for individuals taking corticosteroids and analgesics must include instructions to not abruptly discontinue the use of the drug. Neuropathic pain might be treated with both an analgesic and an anticonvulsant. Most adjuvant medications cause CNS depression, thus potentiating those same side effects of the analgesics with which they are taken. Therefore, patient education should include a warning to not drive or do manual activities requiring alertness and coordination while taking these medications.

Synergistic Interaction

Pharmacologic effect greater w/ summation of the 2 drugs beneficial: aminoglycoside(antimicrobial)+ penicillin Harmful: barbituates+alcohol

Antagonism Interactions

Pharmacological effect less than the summation of the 2 drugs Beneficial: naloxone(reverse the effect) in opiate overdose harmful: zidovudine(antiretroviral drug)+ stavudine(antiviral drug)--compete with each other diminishing the antiviral effectiveness

patient tips

Prolonged use can lead to psychological and physical dependence Do not stop abruptly - can cause seizures or other withdrawal symptoms Do not drink alcohol or take other CNS depressants Take as prescribed Do not take during pregnancy as it can cause fetal abnormalities Do not drive or operate heavy machinery until you understand the effects of the drug

mechanism of action

Promotes sodium efflux (sodium leaving) across cell membranes Does not affect the motor cortex

Endorphins

Released to decrease the stimulus; until it is removed.

Difference between sedatives and hypnotics

SEDATIVES- produce relaxation HYPNOTICS-produce sleep *effects are determined by the dosage amount*

Drug names of Salicylate analgesics

Salicylates acetylsalicylic acid-aspirin, excedrin, anacin, bufferin, ecotrin

Choosing a Route of Administration

Speed of absorption intensity of pain ability to self administer adverse affects availability of drug form

Mechanism of action

Stabilizes neuronal excitability especially in the motor cortex - delays entry of calcium into neuron cells by blocking calcium channels

Around-the-clock (ATC) administration may be necessary to maintain analgesia for severe, acute pain and chronic pain of terminal illnesses.

TRUE

Phenytoin should be used cautiously and at lower doses in elderly patients to avoid toxicity.

TRUE

Sedative-hypnotic medications have the potential for psychological and physical dependence.

TRUE

The only FDA-approved drug for restless legs syndrome is ropinirole, a dopamine agonist.

TRUE

Search PDR.net for amitriptyline hydrochloride drug summary (Links to an external site.) and select all true statements about this drug that may be prescribed as an adjuvant with analgesics for management of certain conditions.

The boxed warning for this drug identifies the risk of suicide in pediatric patients less than 18 years of age as well as young adults. It is not considered to be safe or efficacious in children less than 12 years. Orthostatic hypotension, memory impairment, constipation, and blurred vision are listed as moderate adverse reactions to this drug. This drug is indicated for the relief of symptoms of depression and neuropathic pain; e.g. diabetic neuropathy and postherpetic neuralgia. Amitryptyline is a tricyclic antidepressant and while the precise mechanism of action is not known, it decreases the reuptake of norepinephrine and serotonin in the central nervous system..

mechanism of action

benzo bind to BZD receptors in the brain to enhance the inhibitory effects of the gamma-aminobutyric acid lowering activity of neural cells

Preoperative medications commonly used

benzodiazepines opioid analgesics antacids H2 receptro antagonists gastric acid pump inhibitors antiemetics anticholinergics

Which drug treats Parkinson disease by inhibiting the muscarine receptors in the basal ganglia by blocking acetylcholine which lessens the imbalance between the extrapyramidal and pyramidal pathways?

benztropine

list of drug/ route of administration

benztropine (Cogentin), biperiden (Akineton), diphenhydramine (Benadryl), procyclidine(Kemadrin), trihexyphenidyl (Artane) *All are PO

What drug might be ordered for a 75-year-old man who is experiencing chronic urinary retention due to benign prostatic hyperplasia?

bethanechol

endorphins and enkenphalins

bind to opiate receptors in the CNS inhibit transmission of pain impulses.

Mechanism of Action

bind to opioid receptors, mainly in the CNS, activating the endogenous analgesia transmission of pain from peripheral nerve is blocked, release of prostaglandins is inhibited in central and peripheral nerves RESULTS: analgesia, sedation, euphoria, decreased GI motility

Combinations: Coanalgesics opioids+ nonnarcotic

Vicodin: hydrocodone+Tylenol Percocet: oxycodone+Tylenol Percodan: oxycodone+ASA Tylenol+ codeine

Alternative Therapy in Pain Management

WebMD acupuncture, message therapy, mind-body, glucosamine sulfate and chondroitin sulfate, chiropractic manipulation

The initial diagnosis for migraine headaches includes _____. Mark the manifestations that are used to differentiate migraine type headaches.

accompanied by nausea or light/sound sensitivity severe headache restricting or prohibit routine daily activity >5 attacks of unprovoked headache lasting 4-72 hours

nonsalicylates

acetaminophen relieves pain and fever, but not inflammation

Cholinergic drugs mimic the action of the neurotransmitter ____, which is part of the action of the _____ nervous system.

acetylcholine; parasympathetic

Coanalgesia with aspirin and acetaminophen combined in one tablet is an example of a drug-drug interaction that provides a/an _____ effect in which the total drug effect is equal to the sum of the 2 drugs.

additivity

increases or hastens action of principal medication

adjuvant

Message Therapy

back and neck pain improvements reduce stress relieve tension enhances blood flow

types of AED

barbiturates benzodiazepines hydantoins(DIlantin) Succinimides

cyclooxgenase-1(COX-1)

base line levels of prostaglandins are produced.

severe chronic pain (including cancer)

fentanyl

2017 international classification of seizures

focal onset- aware; impaired awareness EX: motor, non-motor generalized onset-impaired awareness EX: motor, non-motor absence unknown onset EX: motor(tonic clonic), non-motor absence

Antihistamines, such as diphenhydramine (Benadryl), have an extended half-life, leading to "morning after" problems (the hangover effect) when used as a/an ______ in older adults.

hypnotic

Which is not an adverse effect of adrenergic drugs?

hypotension

nonsteroidal anti-inflammatory drugs(NSAIDs)

ibuprofen reduce fever, pain-but not inflammation

Chiropractic manipulation

improvement in neck and back pain

Axon

impulse is transmitted away from the cell body to another neuron, muscle, or gland terminates at the synaptic end button

Insomnia

inability to sleep or stay asleep can disrupt day to day living

Low concentration of prostaglandins

increase pain sensitivity change pain threshold

Lidocaine is both a topical and injectable ________, which reduces sensitivity to pain without loss of consciousness. Some of these types of anesthetics may be mixed with ______ to cause vasoconstriction and prolong anesthestic effects in the region.

local anesthetic epinephrine

Questions asked by and evaluator(pain)

location, duration, intensity, quality, participating factor, relieving factor

cyclooxgenase-2(COX-2)

body is injured, or inflammation occurs activated and produce extra prostaglandins that facilitate the bodies response.

Central Nervous System

brain and spinal cord

drug/route of administration

bromocriptine (Parlodel), pramipexole (Mirapex), ropinirole (Requip), tolcapone (Tasmar), pergolide (Permax) levodopa (Dopar), amantadine (Symmetrel), carbidopa-levodopa (Sinemet) - PO

Dopaminergic drugs are metabolic precursors of dopamine that readily cross the blood-brain barrier. One of the adverse effects of these medications is nausea and vomiting. The combination drug Sinemet is a dopaminergic drug used to treat Parkinson disease that can result in less nausea and vomiting because the ______ prevents _____ from being broken down before it reaches the brain allowing for a lower dose of this drug.

carbidopa levodopa

Prostaglandins maintain functions:

cardiovascular, pulmonary, renal, and gastrointestinal systems. EX: vasoconstriction to prevent blood loss increase or decreased BP constricted airways affecting ventilation decreased secretion of gastric juices increased secretion of intestinal mucus increase in intestinal motility

Opiates and OTC nonopioids have a/an _____, which occurs once the maximum effect of pain relief is achieved and increasing the dose does not increase the drugs' therapeutic effects.

ceiling effect

cyclooxgenase(COX).

chemical reaction that produce prostaglandins, that is carried out by enzymes.

Neurotransmitters

chemical substance released by neurons allow communication from one nerve cell too another EX: Acetylcholine, norepinephrine, dopamine, serotonin, gamma-aminobutyric acid, glutamate

Special populations

children and elderly

2 analgesics given together for a synergistic effect

coanalgesia

Peripheral nervous system

composed of nerves that connect the CNS to the rest of the body

Ideal anesthetic agent

rapid and pleasant induction and withdrawal from anesthesia skeletal muscle relaxation Analgesia- pain relief while still conscious high potency therapeutic index nonflammability chemical inertness

Dendrites

receive signal transmit toward the cell body- electrical impulse

Benzodiazepine (diazepam) and barbiturates(secobarbital)

reduce anxiety and produce amnesia *mild sedation

adverse effects

skin rashes, hirsutism, dizziness, visual disturbances, postural imbalance excessive bruising, bleeding in the gums or mouth, ringing or vibrations in ears, general loss of motor skills, severe anorexia, chest pain or irregular heartbeat, persistent fever or pain gingival hyperplasia (can result in gingivitis, plaque buildup, and dental caries) toxicity - rarely fatal, but can cause neurologic symptoms ranging from nystagmus to ataxia to coma

Factors of decreasing pain sensitivity

sleep empathy diversion tolerance medications addiction

Factors for increasing pain sensitivity

sleeplessness anger tiredness fear anxiety isolation depression hunger

stages to treat short-term insomnia

step 1: REM, dreaming stage step 2: non-REM stage. *many hypnotics upset the REM stage of sleep

what is the goal of using analgesics?

sufficient pain control to ensure comfort, especially in acute and terminal illnesses

The goal of migraine management is to prevent and/or treat migraines to eliminate pain, nausea, and vomiting. One treatment for an episode of migraine headache that can be administered intranasally or by subcutaneous injection is ____. zolmitriptan

sumatriptan

Leroy Wright is an 67-year old who had major abdominal surgery. Because of surgical pain and nausea/vomiting that can occur as an adverse effect of general anesthesia, the surgeon ordered the narcotic and antiemetic (nausea and vomiting preventative) drugs to be given together in the same syringe q6h prn for pain relief. The use of the antiemetic given with the narcotic allows for a lesser dosage of the narcotic, but with a the same pain-relieving effect plus the additional antiemetic effects. This is an example of a/an _____ drug effect in which the summation of the 2 drugs provides a greater therapeutic pharmacologic effect.

synergistic

moderate, chronic pain

tamadol

Nonopioids

prostaglandins are produced by the body with cyclooxygenase exzymes (COX-1/COX-2) inhibit COX-1

CNS Medications and Analgesics

CNS medications taken for a long period of time can cause adaptations that are beneficial or detrimental. Tolerance and physical dependence

The International Associate for the Study of Pain

"unpleasant sensory and emotional experiences associated with actual or potential tissue damage."

indications

*Anxiety disorders (generalized anxiety disorders, panic disorder, phobias, social anxieties, obsessive-compulsive disorder, post-traumatic stress disorder - not regular old run-of-the-mill anxiety we all experience on a daily basis) *given preoperatively to relax patients *insomnia- short term *Neuromuscular diseases *ICU patients often receive these drugs. If they are able to relax, both breathing and myocardial work decrease, and patients use less oxygen and energy on vital functions which can now be used in the healing process. *Nursing home residents are another common patient population prescribed this category of drugs. (However, regulations require routine evaluation (monthly) to justify indications in treating elderly with these types of drugs. If behavior is an issue, behavioral modification should be used before drugs.)

Warnings/contradictions

*Remember that benzodiazepines are relatively safe (i.e., compared to other CNS depressants that are much more dangerous) if not mixed with other CNS depressants - including alcohol *Hypersensitivity, renal or hepatic impairment (e.g., aging or history of alcoholism) *Respiratory impairment, sleep apnea, myasthenia gravis, history of mental illness *Elderly; pregnancy, lactation

Steps in the transmission of nerve impulses

1. Polarization of the neuron's membrane:Cell membranes surround neurons just as any other cell in the body. When a neuron is not stimulated — it's just sitting with no impulse to carry or transmit — the membrane is polarized. Being polarized means that the electrical charge on the outside of the membrane is positive while the electrical charge on the inside of the membrane is negative. The outside of the cell contains excess sodium ions (Na+); the inside of the cell contains excess potassium ions (K+). 2. Resting potential gives the neuron a break:When the neuron is inactive and polarized, it's said to be at its resting potential. It remains this way until a stimulus comes along. 3.Action potential: Sodium ions move inside the membrane. When a stimulus reaches a resting neuron, the gated ion channels on the resting neuron's membrane open and allow the Na+ that was on the outside of the membrane to go rushing into the cell. As this happens, the neuron goes from being polarized to being depolarized. 4. Repolarization: Potassium ions move outside, and sodium ions stay inside the membrane. After the inside of the cell becomes flooded with Na+, the gated ion channels on the inside of the membrane open to allow the K+ to move to the outside of the membrane. With K+ moving to the outside, the membrane's repolarization restores electrical balance - although it's opposite of the initial polarized membrane that had Na+ on the outside and K+ on the inside. Just after the K+ gates open, the Na+ gates close; otherwise, the membrane couldn't repolarize. 5.Hyperpolarization: More potassium ions are on the outside than there are sodium ions on the inside. When the K+ gates finally close, the neuron has slightly more K+ on the outside than it has Na+ on the inside. This causes the membrane potential to drop slightly lower than the resting potential, and the membrane is hyperpolarized because it has a greater potential. After the impulse has traveled through the neuron, the action potential is over, and the cell membrane returns to normal (i.e., resting potential). 6.Refractory period: Everything goes back to normal. The refractory period occurs when the Na+ and K+ are returned to their original sides: Na+ on the outside and K+ on the inside. While the neuron is busy returning everything to normal, it doesn't respond to any incoming stimuli. After the Na+/K+ pump returns the ions to their rightful side of the neuron's cell membrane, the neuron is back to its normal polarized state and stays in the resting potential until another impulse occurs.

Mrs. Jones is a 65 y/o who has been ill for several days experiencing flu-like symptoms with muscle cramping, fever and headache plus nausea and two episodes of vomiting. She is currently on ASA daily post MI. You would recommend she take a/an ______ for her pain and fever.

ACETAMINOPHEN SUPPOSITORY

Types of pain

Acute, Referred, chronic

Coanalgesics may contain both narcotic and nonnarcotic combinations used for relief of mild to moderate pain. Select all true statements about coanalgesics from the list below.

Acetaminophen or aspirin combined with oxycodone is a C-II medication. Because orthostatic hypotension can be a side effect of many coanalgesic combinations, instruct patients to exert care when changing positions such as lying to standing or sitting to standing. Most side effects for coanalgesics arise from CNS depression including sedation, dizziness, and lightheadedness Some coanalgesics are OTC preparations including combinations of aspirin and acetaminophen or aspirin-acetaminophen with caffeine or sodium bicarbonate. Narcotic-nonnarcotic, nonnarcotic-butalbital, and nonnarcotic-tramadol combinations are indicated for moderate to severe pain

Chemical classifications of neurotransmitters across synapse

Acetylcholine- cholinergic Biogenic amines/catecholamines- dopamine, norepi, epi, indoleamines, serotonin, histamine Amino acids- GABA, glycine, aspartate, glutamate Neuropeptides- substance P, endorphines, enkephalins, somatostatin, gastrin, cholecystokinin, oxytocin, vasopressin, luteinizing hormone releasing hormone (LHRH) Purine- adenosine, ATP Gases and lipid- nitric oxide, carbon monoxide, cannabinoids

Antiadrenergic drugs have a sympatholytic effect. ______ dilate arterioles and veins, decrease BP, and GI motility. _____ cause norepinephrine return to presynaptic site and decreases the release of additional norepinephrine.

Alpha-blockers; Beta-blockers

The Nervous System

Anatomical division: *central nervous system *peripheral nervous system together they have 3 general functions: 1. sensory 2. integrative 3. motor Motor neurons: *somatic-mvmnt of skeletal muscles *autonomic-involuntary actions; HR, digestion, perspiration(Sympathetic, parasympathetic)

Salicylates

Aspirin can perform all 3 things

Lecture notes 6.1

Assessing and treating Pain

patient tips

Avoid ergot medicines used for treating migraine headaches Avoid driving or operating machinery until you understand how it affects alertness Drug therapy often loses efficacy in ~ 5 years Do not abruptly stop therapy Avoid foods rich in vitamin B6 Be careful getting up as these medicines can cause hypotension

Drug Interactions

CNS medications and depressants psychotropics alcohol sedatives hypnotics muscle relaxants antihistamines antiemetics antihypertensives

______ is a polypeptide that mediates inflammation, increases vasodilation, and contracts smooth muscle. The hormone-like substance that controls that controls blood pressure, contracts smooth muscle, and modulates inflammation is _________.

Bradykinin; prostaglandin

drug interactions

CNS depression alcohol antacids anticoagulants antibiotics sulfonamides isoniazid glucocorticoids antidepressants MAOIs oral contraceptives

What are seizures and how are they managed?

CNS hyperexcitability seizures- epilepsy event convulsion-abnormal motor movement

Contraindications and interactions

Cardiac or liver impairment Should not be used during pregnancy Interacts with calcium channel blockers, MAOIs, thyroid meds, and oral contraceptives

adverse effects

Cardiovascular disturbances, blood disorders, liver and kidney dysfunction

lecture 6.2

Categories of Analgesics

contraindications and interactions

Caution administering to those with cardiac disease Interactions with neuroleptics, erythromycin, methyldopa, dobutamine, isoproterenol, cimetidine, levodopa, ciprofloxacin, estrogens Avoid abrupt discontinuation - *may cause neuroleptic malignant syndrome (NMS), especially when the patient is taking a neuroleptic drug. [NMS manifestations - tachycardia, muscular rigidity, fever, mental status changes, diaphoresis, tachypnea, and increased serum creatinine.] *rebound parkinsonism - paradoxical increase of similar motor syndromes (e.g., withdrawal dyskinesias, parkinsonian symptoms, dystonias)

The Brain

Divided into 4 portions: 1. cerebrum- largest part, sensory/motor function, memory/reasoning, *composed of: outer cerebral cortex and inner cerebral medulla* **medulla-gray matter-basal ganglia(motor activity)Parkinson's Disease** 2. Diencephalon- sensory information; regulate visceral activities 3. cerebellum- voluntary muscular movmnt 4. spinal cord- motor impulses

patient tips

Do not increase or decrease medications without consulting the prescriber Do not stop abruptly - doing so may result in seizure or status epilepticus (seizure lasting more than five minutes or two or more seizures within a five-minute period without the person returning to normal between seizure activity) Avoid driving or operating machinery until adverse effects are evaluated Do not use OTC medications (without consulting prescriber) or drink alcohol when taking this drug Obtain ordered blood work so that prescriber can titrate drug levels Maintain optimum lifestyle to avoid triggering seizures - adequate rest, appropriate nutrition (avoidance of stimulants) and minimize stress Record information about each seizure - date, time, length of seizure, loss of consciousness, amount of current medication, and any missed doses May cause blood disorders - report signs of sore throat, fever, or bruising

patient tips

Do not increase or decrease medications without consulting the prescriber Do not stop abruptly - doing so may result in seizure or status epilepticus (seizure lasting more than five minutes or two or more seizures within a five-minute period without the person returning to normal between them) Avoid driving or operating machinery until adverse effects are evaluated Do not use OTC medications (without consulting prescriber) or drink alcohol when taking this drug Obtain ordered blood work so that prescriber can titrate drug levels Maintain optimum lifestyle to avoid triggering seizures - adequate rest, appropriate nutrition (avoidance of stimulants), and minimize stress Record information about each seizure - date, time, length of seizure, loss of consciousness, amount of current medication, and any missed doses Advise patient to watch for bleeding disorder symptoms - e.g., increased bruising or petechiae Report any signs of sore throat or mucosal ulceration

patient tips

Do not increase or decrease medications without consulting the prescriber Do not stop abruptly - doing so may result in seizure or status epilepticus (seizure lasting more than five minutes or two or more seizures within a five-minute period without the person returning to normal between them) Avoid driving or operating machinery until adverse effects are evaluated Do not use OTC medications (without consulting prescriber) or drink alcohol when taking this drug Use good oral hygiene to prevent gingivitis Obtain ordered blood work so that prescriber can titrate drug levels Maintain optimum lifestyle to avoid triggering seizures - adequate rest, appropriate nutrition (avoidance of stimulants) and minimize stress Record information about each seizure - date, time, length of seizure, loss of consciousness, amount of current medication, and any missed doses

dopaminergic Drugs

Dopaminergics bind to dopaminergic postsynaptic receptors in the brain. These drugs were initially used for patients experiencing "on-off" fluctuations and dyskinesias as a complementary therapy to levodopa. They are now mainly used on their own as initial therapy for motor symptoms with the purpose of delaying motor complications. In late Parkinson disease, they reduce the "off" periods.

Adverse effects

Drowsiness, diarrhea, dizziness, headache, hiccups, loss of appetite, stomach pain, weight loss Blood dyscrasias, allergic reaction, dysuria, suicidal thoughts, hallucinations, lupus symptoms, unusual bleeding

adverse effects

Dystonia, nausea, vomiting, abdominal pain, dysphagia, dry mouth, mental changes, headache, dizziness, hand tremors Anxiety is a common side effect Agitation and confusion, urticaria, urine retention, paresthesias, sinus tachycardia

When Sinemet is prescribed for patients who have Parkinson disease, the health care practitioner should observe for which of these adverse effects?

Dystonia, dyskinesia, nausea/vomiting, and mental changes

pg. 396-400

Epilepsy

mechanism of action

Exert antiparkinsonian effects by acting directly on dopamine receptors and mimicking dopamine and crosses the blood brain barrier.

The goal of surgical anesthesia is medullary depression so that there is absence of sensory impulses to the brain, unconsciousness, and muscle relaxation.

FALSE

Non-steroidal anti-inflammatory drugs are indicated for inflammatory and musculoskeletal disorders. Select all the true statements about NSAIDs from the list below.

In general, NSAIDs are indicated for mild to moderate pain accompanied by inflammation; e.g., osteoarthritis, spondylosis, repetitive stress disorders. NSAIDs have antipyretic properties. Side effects of NSAID use include gastric ulcers, prolonged bleeding after injury, and potential for nausea, vomiting and decreased appetite.

mechanism of action

Inhibit muscarinic receptors in the basal ganglia lessening the imbalance between the extrapyramidal and pyramidal pathways by blocking acetylcholine

on-off phenomenon

It is the sudden changes in movement control, which can last for a variable period of time. These fluctuations are called the 'on-off' phenomenon. 'On' time is when levodopa is working well and symptoms of Parkinson disease are controlled.

warnings and precautions

Kidney disease, lupus or blood disorder - porphyria, mental illness, suicidal ideation or attempts Pregnancy, lactation - teratogen

Use PDR.net to research drugs by name. Look up the drug summary for morphine sulfate (MS Contin) (Links to an external site.) and select all true statements.

Morphine is classed as an opioid agonist. Contraindications or precautions include hypersensitivity, alcoholism, respiratory disease, and substance abuse. Morphine sulfate is indicated for relief of moderate to severe acute and chronic pain, preoperative sedation, and as a supplement to anesthesia. It is supplied as oral tablet or capsule, oral liquid, intramuscular injection, and intravenous solution.

Schedule II narcotics:

Morphine(prototype) Codeine fentanyl dilaudid meperidine methadone oxycodone(Oxycontin) hydrocodone2

Warnings and precautions for opiate/opioids

hypersensitivity(allergy) renal and hepatic impairment respiratory distress, COPD, neurological impairment

Acetaminophen is the prototype for the non-salicylates. From the following, select the true statements about non-salicylates.

Non-salicylates are the medication of choice for children with fever and flu-like symptoms. Non-salicylates have antipyretic properties. Patients need to be warned about combining cold and flu preparations and non-salicylates, like acetaminophen, because of the potential to exceed the recommended daily dosage. Non-salicylates are indicated for treatment of mild to moderate pain. Excessive use of non-salicylates can result in liver toxicity.

A chronic, nervous system disease characterized by fine, slowly spreading tremors and muscular weakness and rigidity, accompanied by a characteristic shuffling gait is known as

Parkinson disease

How is Pain Assessed?

Pain is a stimulus to our Nervous System, Somatic and visceral organs.

Adequate Pain Management

Pain relief is based individually acute and terminal pain are to be managed aggressively chronic pain concerns: dependence, tolerance, addiction

Role of endorphins and Enkephalins

pain impulses are transmitted by neurotransmitters in the CNS. Neurotransmitters= endorphins and enkenphalins

Salicylates are the most frequently used of the nonopioid analgesics. Check all true statements regarding salicylates

Salicylates can increase bleeding potential in individuals with bleeding disorders, on anticoagulant therapy, or have gastric ulcers. Salicylates are indicated for mild to moderate pain. Salicylates have both antipyretic and anti-inflammatory properties. Individuals taking prophylactic aspirin for MI, stroke, or angina should stop taking this medication 5 days before elective surgery Salicylates can be administered orally and rectally.

DEA Classifications for Analgesics

Schedule I: high abuse risk, NO safe, accepted medical use. EX: heroin, marijuana,LSD,PCP, crack, cocaine Schedule II: high abuse risk, have safe medical uses. Can cause psychological dependence and physical. NArcotic, stimulant, depressant drugs. EX: morphine, Oxy, methylphenidate, dextroamphetamine Schedule III, IV, or V: abuse risk is less than schedule II. Dependency and addiction Non-narcotic, anti anxiety, tanquilizers, sedatives, stimulants, non-narcotic analgeics EX: acetaminphens w/ codeine(tylenol), hydrocodone w/acetaminophine, alprazolam(xanax), diazepine(valium).

4 stages of general anesthesia

Stage 1: Analgesia *pain sense is diminished and patient is conscious, *inhaling of nitrous oxide and oxygen. *Sense of hearing is usually increase EX: childbirth and trauma Stage 2: Excitement *more or less conscious, but in a shaking and violent way. *fear is felt. *Goal is to keep this stage as short as possible. *sudden death can occur-vagal nerve inhibition. Stage 3: Surgical Anesthesia *Marked by a skeletal muscle relaxation *decreased reflexes *muscular paralysis, ends in respiratory failure(INTUBATION) *Corneal reflexes and pupillary sizes can help maintain the correct amount of anesthetics . Stage 4: Medullary Paralysis *This stage should be avoided *respiratory failure, circulatory collapse *anesthetic accident *IV administration

Pain Receptors

Stimulus to the brain where we perceive it as "painful"

patient tips

Take with food to avoid upset stomach Swallow capsules whole - do not chew, crush, or break to avoid mouth, throat, and stomach irritation Syrup form may be added to foods/liquids to improve taste

The Role of Prostaglandins

They are synthesized in every cell. play a role in pain, inflammation and fever. Hormone-like act as chemical messenger. body's response to harmful agents, as long as the agents persist. At least 8 types exist.

Alternative OTC medications for insomnia

Valerian root- taken a week before effects kick in melatonin

Adverse effects

When the drug is to be discontinued - taper the dose to avoid withdrawal symptoms (If on long-term, can cause potentially fatal seizures) Toxicity - respiratory depression or failure, coma Some elderly display paradoxical anxiety

Around the Clock Administration (ATC)

administered when the patient do not request the pain medication. to gain control of acute pain and for chronic terminal pain(hospice) not controlled by PRN medications REHAB PATIENTS: should receive medication 30-60 minutes before therapy starts. These medications can affect: orthostatic hypotension, dizziness, confusion or sedation throughout their therapy session. EDERLY IN NURSING HOME: who suffer chronic muskuloskeletal pain should be given meds before performing ADLs

Sympathomimetics, also called ____ drugs, mimic the action of ____ or stimulate the release of the neurotransmitter.

adrenergic; epinephrine

Mind-body therapy

affect body functions and symptoms relaxation techniques meditation guided imagery biofeedback hypnosis

Regional anesthesia

affects a large part of the body used in obstetrics, during labor and delivery spinal and epidural anesthesia no unconsciousness

Intentional and non-intentional opioid overdoses are occurring routinely in the US. As a result many emergency medical services now maintain a supply of naloxone hydrochloride (Narcan) nasal spray to reverse the effects of an opioid overdose. The Narcan exerts a/an _______ effect, which is a type of drug-drug interaction that produces a pharmacologic effect that is less than the summation of 2 drugs resulting in the reversal of respiratory depression.

antagonism

Atropine

anticholinergic dry secretions decrease incidence of bradycardia

Drugs other than anesthetics may be given preoperatively or perioperatively. Match the indication description with the drug or drug category

anticholinergic to dry secretions and decrease incidence of bradycardia(atropine) induction of general anesthesia or conscious sedation(midazolam) reduce anxiety and produce amnesia(benzo)

First-line prophylaxis for migraines that occur frequently and/or are severe includes ______. Mark only the first-line migraine prophylactic drugs.

antiepileptics beta-adrenergic blockers

secondary parkinsonism

applies to the symptoms that occur as an adverse effect of certain drugs (often antipsychotic medications), poisons, and traumatic injury to the basal ganglia in the brain. These symptoms may resolve with removal of the causative factor - but not always.

Coanalgesics are combination medications with other nonnarcotic or narcotic medications. For each drug combination identify if it is a narcotic combination or nonnarcotic combination and schedule, if indicated

aspirin- caffeine(nonnarcotic) acetaminophen-tramadol(nonnarcotic, C-IV) acetaminophen-hydrocodone(narcotic, C-II) aspirin-butalibital-codeine(narcotic,C-III) acetaminophen-butalbital-caffiene(nonnarcotic, C-III) acetaminophen-aspirin-caffeine(nonnarcotic) acetaminophen-oxycodone(narcotic, C-II)

The 3-Step Analgesic Ladder

created by the WHO treatment of cancer pain If pain occurs, prompt oral administration of drugs, is given in the following order: 1) nonopioids 2)mild opioids(codeine) 3)strong opioids(morphine) *until the patient is free of pain* Drugs are given ATC -every3-6 hours 80-90% effective

mechanism of action

decrease electrical activity within the motor cortex potent broad-spectrum antiepileptic

Acupuncture

decrease pain by increased release of endorphins, to block the pain message that is delivered to the brain

Adverse Effect of opiates/opioids

decreased GI motility- nausea and vomiting urinary retention physical dependence respiratory/CNS depression- lethargy to coma confusion dizziness, lightheadedness, orthostatic hypotension

The prototype drug for benzodiazepines is generic ______, which is indicated for anxiety disorders, alcohol withdrawal, preoperative medications, insomnia, seizures, and skeletal muscle spasms. While these drugs are safer than barbiturates, administration should be intermittent and prescribed for only 2-3 weeks because of the risk of_______ . However, the withdrawal syndrome is usually mild. With longer use, benzodiazepines should be tapered over weeks to months to prevent ________, a severe adverse effect.

diazepam tolerance seizures

Anesthetic Agents

discovered in 1840 3 agents: chloroform, ether, and nitrous oxide

Acute Pain

does not last long responds to analgesics caused by tissue damage

Parkinson disease is thought to be caused by ____ deficiency and an _____ excess within the central nervous system.

dopamine acetylcholine

Barbiturates

dose-dependent CNS depression mood alteration schedule II or III phenobarbital(luminal)-schedule IV therapeutic effects decline after 2 weeks can cause tolerance withdrawal symptoms can occur after stopped chronic use use with caution in elderly adverse effects with those of renal or hepatic impairment

Opiates

drugs derived from opium poppies EX: morphine and codeine

indications

early or late parkinosnism

Glucosamine sulfate and chondroitin sulfate

effective for knee osteoarthritis

The goal of adjuvant therapy is to enhance the analgesic efficiency of opioid and opiate medications, treat symptoms that might exacerbate pain, and provide analgesia for specific types of pain. Match the adjuvant medication drug category to its desired effect and type of pain to be treated - there is more than one response per category.

elevate mood; enhance opioids; direct analgesic effect (tricyclic antidepressant) suppress spontaneous nerve stimuli (antiepileptic) elevate mood; strong anti-inflammatory action; stimulate appetite(corticosteroid) relieve anxiety, insomnia, nausea, itching(antihistamine) dull, aching or throbbing neuropathic pain-headaches, herpes, arthritis, back pain(tricyclic antidepressant) sharp, shooting or burning neuropathic pain - neuralgia, cancer, herpes(antiepileptic)

What are the neurotransmitters that are capable of binding with opiate receptors in the CNS and inhibit the transmission of pain impulses? Mark all that apply

endorphines enkephalins

indications

epileptic and nonepileptic seizures caused by head trauma fosphenytoin (injectable) used when oral medications contraindicated

Pain Clinics

established to help patients with chronic pain help people function more effectively wean off of drugs/decrease drug use exercise improved diet improved sleep habits mindfulness meditation therapies: acupressure and acupuncture

Pain Assessment

eyes pr "feelings" of the beholder affected by the environment, culture, mental condition, and physical stamina

Nonverbal cues to pain and pain management

facial expressions posture grasping, grabbing, holding a body part absence or restlessness irritability vital signs

Types of seizures

generalized tonic clonic(contraction-relaxation) EX: grand mal generalized absence seizures EX: petite mal generalized myoclonic seizures and partial seizures non-motor absence seizures or atonic seizures

drug routes/administration

generic names end in -toin hydantoin(DIlantin)-prototype- given PO fosphenytoin(Cerebyx)-IM,IV

drug route/administration

generic names end in -suximide ethosuximide (Zarontin) methsuximide(Celontin) - PO

Inflammation

harmful agents enter the circulatory system, causing a production of prostaglandins(in the CNS) EX. anterior hypothalamus this causes: fever malaise anorexia

drugs to treat parkinson disease

he main families of drugs include levodopa, dopamine agonists, and MAO-B inhibitors.

Tissue injury releases chemical substances that initiate an action potential along a sensory nerve fiber or pain receptor. What are these chemical substances? Mark all that apply.

histamine bradykinin serotonin prostaglandin

Which AED has the adverse effect of gingival hyperplasia?

hydantoin

drug interactions

hydantoins valporic acid

Warning/precautions of Salicylates

hypersensitivity or allergy to NSAIDs, asthma or seasonal allergies, nasal polyps renal or hepatic impairment or disease do not use in kids less than 15 who have a viral infection- Reyes syndrome do not take 5 days before elective surgery-anticoagulant bleeding or clotting-hemophilia, peptic ulcers, patients taking anticoagulants(makes the bleeding worse) pregnancy or breastfeeding

Whether analgesics are prescribed narcotics or anti-inflammatory medications or over-the-counter medications, the elderly are more prone to adverse effects like gastric irritation, GI bleeding, renal or hepatic toxicity. What are some of the reasons elderly may experience more adverse effects?

increased number of chronic diseases with greater number of routine medications and potential for drug-drug interactions decreased metabolism or excretion functions leading to cumulation sedation and central nervous system depression may lead to falls and fractures

Adverse Effects

increased potential for bruising or bleeding; GI bleeding

Epilepsy is a group of disorders characterized by hyperexcitability within the CNS. Abnormal stimuli can produce symptoms from short periods of unconsciousness to tonic-clonic seizures. Match the antiepileptic drug (AED) to its mechanism of action.

increases the bioavailability of GABA(valproic acid) binds to BZD receptors in brain to enhance inhibitory effects of GABA(diazepam) decreases electrical activity with the motor cortex(hydantoin) promotes sodium efflux across cell membrane(carbamazepine) stabilized neuronal excitability in the motor cortex by blocking calcium channels into neuron cells(methsuximide)

Midazolam(Versed)

induction of general anesthesia conscious sedation minor surgery or endoscopy

What are the antipyretic properties of analgesic and anti-inflammatory drugs? Select the correct responses.

inhibit prostaglandin synthesis in the CNS central action in the hypothalamic heat regulation center

ASA and NSAIDs

inhibit the synthesis of prostaglandin in PNS/CNS acetaminophen inhibits synthesis in the CNS fever is reduced by re-setting hypothalamic temperature control- vasodilation and sweating(diaphoresis)

mild to moderate pain

inhibits synthesis of prostaglandins from damaged tissues

Analgesics/ nonnarcotics/ narcotics

interactions with the nervous system

parkinson disease

is progressive, neurogenerative disorder of the extrapyramidal nervous system

levodopa

is the most effective drug to treat Parkinson disease, but dopamine agonists may also be used. While only 5-10% of oral dopamine crosses the blood-brain barrier, levodopa, the metabolic precursor of dopamine, does cross the blood-brain barrier and is converted to dopamine by the dopaminergic neurons in the brain. This is thought to be the mechanism whereby levodopa relieves symptoms of Parkinson disease.

Sedatives and hypnotics

known as barbiturates depress CNS activity decrease anxiety **also called anxiolytics**

Chronic Pain

lasts a long time can become used to the pain over time pain last beyond the expected period of healing can interfere with ADL, ability to work, and cause the overuse and abuse of drugs

Injury or Inflammation

leukocytes flood the area to minimize tissue destruction. prostaglandins, histamine,serotonin, and bradykinin are released to bring the inflammatory response. this also allows for pain and fever

Route of administration

lipid soluble- need to cross the blood brain barrier Dosage should be the lowest to produce the desired effect without causing daytime somnolence or drowsiness PO, IM, IV

Determining type of analgesia is based on several factors including route of administration. Analgesics may be given by mouth, injection, suppository, or transdermal application depending on how fast relief is needed, the availability of the medication form, the ability of patient to self-administer, and the intensity of the pain. Match the advantages to the route of administration of these analgesics.

long duration of action from 24-72 hrs- transdermal fentanyl faster onset of action than oral-rectal opioids wider range of drug choice and easily administered by patient or family-oral NSAIDs continuous release without invasive techniques-transdermal fentyanyl can be used with nausea and vomiting- rectal opioids

Anti-epileptic drugs (AED)

main type of treatment for most epileptic people 70% of patients can have epileptic treatment increased suicidal ideation and behavior Encourage the individual to work closely with the prescriber and to not omit, increase, decrease, or discontinue medications without consulting the prescriber. Taking the prescribed medication regularly is essential to seizure control. The individual should not stop or change medication without discussing with the prescriber - stopping the medication abruptly can result in severe adverse effects - including seizures.

Antipsychotics and antidepressants

may take 6-8 wks for the therapeutic effects to kick in may experience adverse effects almost immediately

severe pain, opioid withdraw

methadone

The Brief Pain Inventory (BPI)

method to determine pain in patients with chronic pain or cancer pain. used at MD Anderson EX: scale that measures pain during activity, mood, walking, work, relations w/ other people, sleep, and enjoyment of life anatomical drawings to identify location 0-10 pain scale, past week and current pain questions about medication use patients perception of effective medication

Nonopioid analgesics are used for?

mild to moderate pain act on the PNS *except acetaminophen

local anesthetics

minor procedures, dentistry no unconsciousness small amounts can relieve anxiety or pain numb small areas of tissue usually ester derived lidocaine is the most common injectable sometimes mixed with epi

affects of parkinson disease

mobility control of musculoskeletal system

Elderly and Analgesics

more prone to gastric irritation, GI bleeding, renal toxicity, and constipation take medications with food more adverse effects- decreased metabolism polypharmacy and drug interactions OTC drug use-interactions with prescription sedation CNS depression orthostatic hypotension prone side effects: confusion, ototoxicity, nausea and tinnitus

moderate to severe pain

morphine sulphate codeine meperidine oxycodone

Drug Names

most are Schedule II narcotics-due to being addictive alter pain perception by mimicking endorphins that block neurotransmission of pain threshold. Can cause sedation-reducing anxiety and pain relief. *Morphine is the standard for narcotic analgesics

list of drugs

most end in -pam or -lam diazepam(Valium)- prototype alprazolam(Xanax) lorazepam (Ativan) temazepam(Restoril)

Salicylate Analgesics

most frequently used may be combined with caffeine-slows the elimination of ASA may be combined with antacid- minimize GI problems have an enteric coating to prevent irritation-resistant to acidic pH

Opioids

natural, synthetic, or endogenous morphine-related substances EX: meperidine(Demerol) and fentanyl (Duragesic)

Abrupt discontinuation of dopaminergic drugs may cause

neuroleptic malignant syndrome

_____ are chemicals that bridge the synaptic clefts.

neurotransmitters

What are the free nerve endings that are located throughout the body that act as pain receptors?

nociceptors

indications

non-motor impaired awareness absence seizures focal and generalized motor and atonic seizures

analgesic that does not contain opium, opium derivatives, or synthetic opioids

nonopioid

Patient education

not addictive when treating short term take before the pain becomes severe stand slowly in case you get dizzy with a decrease in BP increase fluid intake take oral meds with food to minimize GI problems do not use with CNS meds or depressants

Referred Pain

not apparent at physical pain site, felt in other areas of the body EX: person with spondylosis of the lumbar spine causing pressure on the peripheral nerves at that site, but the pain is felt in the thigh, leg, or foot.

Children and Analgesics

observe pain behaviors comfort measure to reduce pain amount per kg of body weight keep medications away from children child-proof containers

Ceiling Effect

only seen in opiates once the max effect of pain relief is met, increasing the dosage will cause an adverse effect rather then relieving the pain.

drug containing purified opium

opiate

synthetic drug that produces effects similar to opium

opioid

Reasons for preoperative medications

optimized physical condition relieve anxiety and pain provide amnesia facilitate anesthesia induction, smooth operative outcomes and smooth the recover of waking up reduce nausea and vomiting prevent aspiration

Routes of administration (opiate/opioid)

oral SC, IM, IV, rectal Intrathecal, epidural Transdermal-only fetanyl

Nonprescription drugs

oral analgesics (acetaminophen, aspirin, NSAIDs) Rectal analgesics

High concentration of prostaglandins

pain at the nerve endings

Pain sensation:

pain impulses are sent to the CNS via sensory nerve fibers the brain releases natural pain relievers to reduce the pain analgesics are prescribed when the endogenous analgesia is not enough to control pain physical discomfort: results in ANS signs/symptoms-hypertension, diaphoresis, pallor, restlessness, anxiety, muscle tension and inability to focus

Anticholinergic drugs block the action of acetylcholine and are termed ________,

parasympatholytics

indications

parkinsonsim- signs/symptoms

moderate pain

pentazocine

Anxiety

persistent and irrational fear of specific objects, activities, or situations. self-limiting may be followed with mild reactive or endogenous depression Anxiety Disorders Association : most common form of mental illness, effects 40 million people, higher in women than in men. PHYSICAL: tachy, palpitations, trembling, dry mouth , sweating, weakness, fatigue and SOB TREATMENT: *behavior therapy, psychotherapy or drug therapy, *SSRIs are used first with amitipyline/nortiptyline. *Benzodiazepines- lorazepam, clonazepam, alpraolam

Additivity Interaction

pharmacological effect less than the summation of the 2 drugs beneficial: aspirin+acetaminophen harmful: neutropenia(decrease in the number of WBCs) with zidovudine+ganciclovir(treats cytomegalovirus retinitis)

peripheral neuropathy, potherpetic, neuralgia, fibromyalgia

pregabalin schedule IV

Indications of Salicylates

prevention and treatment of mild to moderate pain, fever, inflammation daily low dose therapy(81mg)- used for stroke or heart attack

prevent or treatment antiplatelet for MI, stroke, angina

prevents aggregation of platelets

Anti-inflammatory

reduces synthesis of prostaglandin

symptoms of parkinson disease

related to depletion of dopamine in the corpus striatum administration of dopamine is an ineffective treatment because it does not cross the blood- brain barrier symptoms can be managed with medications

Endogenous analgesic compounds

released in response to painful stimuli

Coanaldesics and Adjuvant Medications

rely on drug interactions 3 types of drug-drug interactions: 1) Synergistic 2)Antagonism 3)Additivity

What are the opioid and opiate analgesics

require a prescription nonopioids can be prescribed or OTC

characteristics of parkinson disease

resting tremor rigidity bradykinetic movements not curable

Gate Control Theory of Pain

rubbing it makes it better pain signals are shown in the dorsal horn of the spinal cord(before transmitted to the brain) rubbing the site sends sensory signals to the same area on the spinal cord and releases it to the brain, resulting in a gated action, only allowing one signal to the brain at a time

Drug interations

sedatives alcohol Cimetidine, omeprazole, ketoconazole - inhibit liver metabolism causing increase in benzodiazepine half-life Fluvoxamine or fluoxetine - prolong benzodiazepine effects

Pain Evaluation

severity, source, physiologic, and disease characteristics

Indications for use of opiates/opioids

short term treatment of moderate to severe pain chronic pain colic associated w/ GI and renal system pulmonary edema-morphine severe, non productive cough-codeine

contraindications and interactions

should not be used during pregnancy

OTC antihistamines

that are marketed as sleep aids can cause dizziness, blurred vision, GI signs/symptoms, and dry mouth. Also, an important fact is that individuals develop tolerance in less than 2 weeks resulting in reduced effectiveness. most common- diphenhydramine (Benadryl, Nytol, Sominex) used in PM- tylenol, Advil, ZzzQuil These antihistamines, like benadryl, often cause a "morning after effect" or hangover effect. [Hangover symptoms include fatigue, weakness, excessive thirst, dry mouth, headaches, muscle aches, nausea, vomiting, stomach pain, shakiness, inability to concentrate.]

Medications, such as the benzodiazepines, can be indicated as an anxiolytic or a hypnotic. What is the difference in the action?

the difference in action is dose dependent

Preoperative/Perioperative Drugs

these medications are called preanesthetics given 45-70 minutes before a surgical procedure

warnings/precautions

thyroid, liver or kidney disease; diabetes mellitus, lupus, mental illness pregnancy, lactation allergy to other seizure medications

Timing

timing of pain medication administration Do not chase the pain take medication at the first sign of pain do not wait for the pain to escalate

Adjuvants

to calm fears and anxiety

3 pharmacological uses

to relieve pain fever inflammation

Mechanism of action

unknown possibly increases the bioavailability of GABA

Benzodiazepines

used as sedatives antianxiety agents lower potential for abuse fewer adverse effects fewer drug interactions fewer deaths *lots of people try to OD on benzo. but just sleep for a long time* mixing with alcohol can be fatal benzodiazepines most commonly treat anxiety and insomnia

General anesthesia

used to produce loss of consciousness before and during surgery blocks all sensory impulses to the brain causing unconsciousness depressed the CNS IV and inhalation drugs ADVERSE EFFECTS: dizziness, drowsiness, weakness, tiredness

hypnotics

used to treat insomnia sleep medications not prescribed for more then 2-4 weeks try relaxation techniques-warm baths, bedtime rituals, avoidance of alcohol and caffeine EX: chloral hydrate (Noctec) temazepam(Restoril)

Antipyretic

vasodilation sweating reset hypothalamic to normal temperature

Neurons

we have 100 billion help coordinate all body functions to maintain homeostasis thinking, remembering, feeling, moving, and being aware of the world. has a cell body, dendrites, and an axon