Pain

Contraindications for DIRECT acting skeletal muscle relaxants

- Hepatic disease - Lactation

What does phantom pain not usually respond to?

Common pain therapies

Codeine can also be used for what?

Cough suppression

Diphenoxylate can also be used for what?

Decrease peristalsis for an antidiarrheal (decreases frequency of stools)

What may or may not be present?

Aura may or may not be present Jagged lines, flashing lights, special smells/tastes/sounds

Drug to drug interactions with muscle relaxants

CNS depressants

What is the most common side effect with opioids?

Constipation

Who has hard time with pain scale?

Dementia and kids

What goes hand in hand with chronic pain?

Depression - almost all on antidepressants

How do patients describe neuropathic pain?

Described as burning, shooting or numb pain

Management of neuropathic pain?

Difficult to manage

Adverse reactions to muscle relaxants

Drowsiness Fatigue Weakness Confusion Headache Nausea dry mouth hypotension

What do you do if headaches or migraines continue?

Drug therapy

Inhibitory endogenous NT

Endorphines - feel good hormone that will prevent production from going on in pain pathway

Botulinum toxins and dantrolene

Enter muscle fibers directly botox- used for migraine

drug to drug interactions with DIRECT acting skeletal muscle relaxants

Estrogen Neuromuscular junction blockers

Adverse reactions with DIRECT acting skeletal muscle relaxants

Fatigue Weakness Confusion GI irritation Enuresis

What do sublingual and buccal exempts drug from?

First pass effect

What happens when gates are open vs. closed

Gates open - Pain impulses transmitted from periphery to brain Gates closed - Reduces or modifies the passage of pain impulses

Location of chronic pain

Generalized usually

Timing of chronic pain

Occurs over extended time; may be recurrent

What is there a risk for with narcan?

Risk of hepatotoxicity (effects liver) - doesn't matter if liver is effective if not breathing

Who is Prophylactic Therapy used for?

Used for people where abortive therapy is not effective or d/t frequency

What does chronic pain reduce tolerance to?

Usually reduces tolerance to additional pain

How can you standardize patient's conveyance of pain and measure progress during drug therapy?

Utilize surveys and scales

Triptan (sumatriptan) causes what effect

Vasoconstricts intracranial arteries

Side effects of tramadol (ultram)

Vertigo, dizzy, h/a N/V constipation, lethargy

What might occur with acute pain

Vomitting - very strong emotional response

When will phantom pain resolve?

WIthin weeks-months

What should you watch for with triptan?

Watch for cardiac ischemia * first dose in MDO

What should you watch for with combination drugs?

Watch for hepatic toxicity with acetaminophen

How is the pain signal transmitted with nociceptive pain?

Way that pain signal is transmitted to brain is because of nociceptive nerve fibers (kinin and prostaglands - chemical stimulation) or mechanical stimulation (nail) or thermal (heat) KNOW!!

Acute pain initiates what physiologic stress responses?

↑ blood pressure and heart rate; cool, pale, moist skin; ↑ respiratory rate; ↑ skeletal muscle tension

Referred pain

- Source may be difficult to determine. - Pain may be perceived at site distant from source.

TENS Treatment

When signals are going and synapsing to first synapse, if you bring stimulation in from other nerve fibers that can jump in in front of noceceptive receptor coming through and block it. Additional nerve receptors

Cautions with DIRECT acting skeletal muscle relaxants

Women All patients older than 35 years Cardiac disease

How does tramadol (ultram) work?

Works by inhibiting reuptake of norepinephrine and serotonin in spinal neurons

Why does nociceptive pain respond to conventional pain relief?

because with NSAID we are blocking prostaglanin production meaning nociceptive nerve wont be stimulated by prostaglandin anymore. Chinin might still cause some pain which is why we often combine NSAIDS with narcotics.

Opioid antagonists

block opioid receptors (block mu and kappa)

Pure opioid antagonist

block receptors so not stimulated - will feel pain

What is a migraine headache characterized by?

by throbbing or pulsating pain

Administeration routes of triptan?

Available in oral, intranasal and subuctaneous

Pure opioid agonists will stimulate wat?

Both mu and kappa

Neuromuscular Abnormalities

- muscle spasms - muscle spasticity

Abortive therapy

Attempt to stop a migraine that has started

Neuropathic pain is caused by what?

Neuropathic pain is caused by injury to the nerves

What happens during tension headaches

- Muscles of head/neck become tight d/t stress - Results in steady/lingering pain

Treatment of chronic pain

Usually more difficult to treat than acute pain

Non-Opioid Analgesics

- NSAIDS- non-steroidal anti-inflammatories - acetaminophen - centrally acting drugs

Avoid triptan in what patients?

**Avoid in pts. with recent MI, h/o angina, HTN, Diabetes

Several drugs are obtained from opium

- Natural substances -Morphine/Codeine - Synthetic substances- Meperidine (both called opiates/opioids)

Cluster headache

Pain is in and around one eye

Who does phantom pain usually occur with?

adults

Thalamus and limbic system

Emotional factors

Migraines are usually accompanied by what?

N/V

Nociceptic pain is characterized by what 2 things?

1. "somatic" pain 2. "visceral" pain

What is pain considered?

- A universal experience - A defense mechanism

Pain fibers

- Afferent fibers - Myelinated A delta fibers - Unmyelinated C fibers

Patient-controlled analgesia (PCA)

- Alternative pain medication delivery system - Patients self-medicate with opiate medication by pressing a button - Medication delivered intravenously via infusion pump

What are both kappa and mu responses?

- Analgesia - Decreased GI mobility - Sedation

Kappa receptor responses

- Analgesia - Decreased GI mobility (const.) - Miosis (pupils constrict) - Sedation

Psychological influence- what increases pain perception?

- Anxiety - Fatigue - Depression

Dermatome

- Area of skin innervated by a specific spinal nerve - Somatosensory cortex → "mapped" - Corresponds to source of pain stimuli Dermatomes - how we know how neurons are mapped (if have nerve pain in 2 fingers, we know which spinal nerve is affected)

Role of nurse with opioid therapy

- Assess potential for opioid dependency Have narcotic antagonists available to reverse negative effects - Assist with activity - Monitor urine output for retention - Monitor patient's bowel habits for constipation

Administration

- Breakthrough pain - Titration

Examples of referred pain

- Characteristic of visceral damage in the abdominal organs - Heart attack or ischemia in the heart

What can stimulate pain?

- Chemical receptors: prostaglandins and kinins which are released during inflammatory response - Mechanical - Thermal

Combination Drugs

- Combine opioids and non-narcotic analgesics into a single tablet/capsule - Work synergistically, can keep dose of opioid small reduces dependence and narcotic-related side effects

Role of the Nurse:Opioid Antagonist Therapy

- Continue careful monitoring of patient's condition Especially respiratory status - Have resuscitative equipment available

Theory of pain: Gate Control Theory

- Control systems, "gates" built into normal pain pathway - Can modify pain stimuli conduction and transmission in the spinal cord and brain

Neonatal pain scale

- Dependent on your observation of how that baby is behaving then score the number and add them up to figure out if baby is comfortable or not

Titration

- Dose adjustment based on assessment of analgesic effect versus side effects - Use the smallest dose to provide effective pain control with fewest side effects.

caution with skeletal muscle relaxants

- Epilepsy - Cardiac dysfunction - Conditions marked by muscle weakness

Action of skeletal muscle relaxants

- Exact mechanism of action is not known - Thought to involve action in the upper or spinal interneurons

Fentanyl/Duragesic

- Fentanyl transdermal system - Also nasal spray, and lozenge - Controls moderate to severe chronic pain - Provides longer lasting relief from persistent pain

Opioid agonists

- First line choice for moderate to severe pain - More than 20 different options, classified by effectiveness - Strong or Moderate

"Visceral" pain

- Generalized dull, throbbing, aching sensations - Organs - Conducted by sympathetic fibers - acute or chronic Ex. liver inflammation from hep, viral nephlitis (just organs)

Pain control

- Ice - TENS - Opiate-like chemicals (opioids)

Physiologic reactions to chronic pain

- Individual may be fatigued, irritable, depressed - Sleep disturbances common - Appetite may be affected. Leading to weight gain or loss

DIRECT acting skeletal muscle relaxants actions

- Interfering with the release of calcium from the muscle tubules - This prevents the fibers from contracting - Does not interfere with neuromuscular transmission

Reflex Response

- Involuntary muscle contraction away from pain source - Involuntary muscle contraction to guard against movement

Pain threshold

- Level of stimulation required to elicit a pain response - Usually does not vary between individuals

Signs, Symptoms and Diagnosis of pain

- Location of pain - Description terms - Timing of pain - Physical evidence of pain

Spinothalamic bundle in the spinal cord

- Neospinothalamic tract - Paleospinothalamic tract Spinothalamic tracts connect with reticular formation of brain

Pain scale assessment

- Numeric scales 0-10 - Face scales - Pain thermometer - Neonatal pain scale

Muscle spasm

- Often results from injury to the musculoskeletal system - Caused by the flood of sensory impulses coming to the spinal cord from the injured area

Pain assessment characteristics

- Onset - Location - Duration - Characteristics - Aggravating factors - Relieving factors - Treatment (OLDCART)

Because pain begins at the nociceptors in peripheral tissues and proceed throughout the CNS, allows several targets for pharmacologic intervention

- Opioids- act within the CNS - Non-steroidal anti-inflammatories- act at the peripheral tissue level (near noceceptors)

Administration routes for opioids

- Oral - Sublingual and buccal - Intranasal - Rectal - Transdermal - Parental - Intraspinal - Implantable pumps - Patient-controlled analgesia (PCA)

Process of pain

- Pain transmission begins when pain receptors (nociceptors) are stimulated (by prostaglands, kinins, or mechanical or thermal) - Nerve impulse signaling pain is sent to spinal cord via sensory neurons (aka: pain fibers) - Pain impulse reaches spinal cord and needs to travel to the next set of neurons- NEUROTRANSMITTERS are responsible for assisting (substance P) - If pain signal reaches the brain, the person responds

Physical evidence of pain

- Pallor and sweating - High blood pressure or tachycardia

Chronic pain

- Persists over a longer time - 6 months is the standard - Interferes continuously with daily activities

Psychological influence - what decreases pain perception?

- Positive attitudes - Support from caregivers - Awareness of cause - Awareness of treatment options

Opioid Dependence

- Potential to cause physical and psychologic dependence - Patient-controlled analgesia (PCA) - Combinations with nonnarcotic analgesics

Pharmacokinetics of muscle relaxants

- Rapidly absorbed and metabolized in the liver - Excreted in the urine

Adverse effects of opioid agonists

- Respiratory depression - Sedation - N/V - Physical & psychological dependence - Pruritis (histamine release)

Muscle spasticity

- Result of damage to neurons within the CNS - May result from an increase in excitatory influences or a decrease in inhibitory influences within the CNS

Reticular activating system (RAS)

- Reticular formation in the pons and medulla - Awareness of incoming brain stimuli

What does narcan do?

- Reverses respiratory depression and other acute symptoms - Can result in BP increase, RR increase, N/V/drowsy/tremors

Opiate-like chemicals (opioids)

- Secreted by interneurons of the CNS (endogeneous) - Block conduction of pain impulses to the CNS - Resemble morphine Enkephalins, dynorphins, beta-lipoproteins

Somatic pain

- Sharp, localized sensations - Bone, muscle, skin - Conducted by sensory fibers Ex. shingles

Other uses for opioid agonists besides pain

- Slow the GI tract motility - Suppress the cough reflex - CNS depressant effects

Pharmacokinetics of DIRECT acting skeletal muscle relaxants

- Slowly absorbed from the GI tract - Metabolized in the liver - T ½ 4-8 hours - Excreted in the urine

Opioids with Mixed Agonist-Antagonist Activity

- Stimulate opioid receptor, thus causing analgesia - Withdrawal symptoms and side effects not as intense as those of opioid agonists

Treatment for Opioid Dependence

- Switch from IV and inhalation forms to methadone, the oral form - Methadone maintenance * Does not cure but avoids withdrawal symptoms * Treatment may continue for many months and years.

Benefits of variable routes of opioids

- Target a particular source - Achieve therapeutic blood levels rapidly - Avoid certain side effects - Provide analgesia when patients cannot swallow

Most common headahces

- Tension headache - Migraine headache

Pain tolerance

- The ability to cope with pain - Culturally related - Varies between individuals (subjective)

Somatic sensory area in cerebral cortex is located where and is responsible for what?

- The somatic sensory area in the cerebral cortex located in the parietal lobe - Perception and localization of sensation

Breakthrough pain

- Transient, moderate to severe - Occurs beyond treated pain - Usually rapid onset and brief duration with variable frequency and intensity

Unmyelinated C fibers

- Transmit impulses slowly - Chronic pain - Diffuse, dull, burning, or aching sensation

Myelinated A delta fibers

- Transmit impulses very rapidly - Acute pain - Sudden, sharp, localized

Indications for DIRECT acting skeletal muscle relaxants

- Treatment of spasticity directly affecting peripheral muscle contraction - Management of spasticity associated with neuromuscular diseases

Examples of combo dugs?

- Vicodin: hydrocodone; acetaminophen 500mg - Percocet: oxycodone; acetaminophen 325mg - Percodan: oxycodone; aspirin 325mg

Muscle relaxants

- Work in the brain and spinal cord - Interfere with cycle of muscle spasm and pain

Action of Centrally Acting Skeletal Muscle Relaxants

- Work in the upper levels of the CNS to interfere with the reflexes causing the muscle spasm Possible depression anticipated with their use - Lyse or Destroy Spasm Often referred to as spasmolytics

Classification of pain

- acute - chronic - nociceptive pain - neuropathic pain

Mu receptor responses:

- analgesia - decreased GI activity - Euphoria - Physical dependence - Respiratory depression - Sedative

Which are the two most important receptors for pain management?

1. Mu 2. Kappa

How often do you change fentanyl transdermal patch

72 hours

Descriptive terms of pain

Aching, burning, sharp, throbbing, widespread, cramping, constant, periodic, unbearable, moderate

Non-pharmacologic Techniques for pain management

Acupuncture Imagery Biofeedback therapy Chiropractic manipulation Massage Hypnosis Heat/cold Therapeutic touch Meditation/Prayer TENS Relaxation therapy Reiki/Qi gong Art therapy

How is narcan administered?

Administered IV- repeat Q 2-3mins

Indications of skeletal muscle relaxants

Alleviation of signs and symptoms of spasticity; use in spinal cord injuries or diseases

When does phantom pain often occur following?

Amputation - pain, itching, tingling

Acute pain

An intense pain occurring over a brief period of time

Examples of prophylactic therapy drugs?

Anti-seizure drugs Beta-adrenergic blockers- Inderal Calcium channel blockers Antidepressants- Elavil Neuromuscular blockers Botox

Timing of pain

Association with an activity

Headaches

Headaches are one of the most common complaints of patients

Intraspinal delivery

Highly potent (smaller doses necessary)

WHen is phantom pain more common

If chronic pain has occured

Non-pharm techniques for pain magaments May be used alone or in conjunction with pharmacotherapy, if so can result in what?

If used concurrently, can result in lower doses and fewer drug-related adverse effects

Ice

Impulses from temperature receptors close gates

TENS

Increases sensory stimulation at site, blocking pain transmission

Sources of pain

Inflammation Infection Ischemia and tissue necrosis Stretching of tissue Stretching of tendons, ligaments, joint capsule Chemicals Burns Muscle spasm

What do non-opioid analgesics do? NSAIDS

Inhibit cyclooxygenase, therefore inhibit prostaglandins ASA, IBU, Cox-2

Who do you use wong-baker faces pain scale with?

Kids, elderly, language barriers

Contraindications in skeletal muscle relaxants

Known allergy Rheumatic disorders - kidney failure

Contraindications of DIRECT acting skeletal muscle relaxants

Known allergy Spasticity

What triggers a migraine?

MSG, red wine, perfume, caffeine, chocolate, aspartame, food additives

Max dose of triptan?

Max dose is 2x/day (60 min apart)

Location of acute pain

May be localized or generalized

What is a drug we give for heroin or narcotic abusing people?

Methodone which effects kappa receptors but not mu so helps by giving them what they need as far as dependence drive but safer - still works for analgesia so will feel good

What is the most painful type of headache?

Migraine

Types of abortive therapy

NSAIDS or Acetaminophen- first line Non-opioid prescription medsAsacomp/Fioriciet- Triptans- Serotonin 5Ht agonists Ergot Alkaloids

Example of opioid antagonist

Nalaxone- Narcan

What do you give for overdose on heroin or morphine?

Narcan

Nociceptive Pain is caused by what?

Nociceptive pain is caused by damage to tissues

How do opioids work?

Opioids exert their actions by interacting with 6 types of receptors

What is the route of chocie when have a functioning GI tract?

Oral

Headaches lead to what

Pain and inability to focus and concentrate= Work related absences, difficulty caring for home and family

What is pain?

Pain is an experience characterized by unpleasant feelings

Sinus headache

Pain is behind the forehead and/or cheekbones

Migraine headache

Pain, nausea, and visual changes are typical of classic form

Patients with chronic pain might have periods of what?

Periods of acute pain may accompany chronic pain conditions.

Phantom Pain

Phantom pain happens because when one thing gets stimulated its because of finger down here - with amputations think hand is still there bc nerves still stimulating that same spot in brain

What does nociceptive pain respond to for treatment?

Responsive to conventional pain relief medications

Cause of chronic pain

Specific cause may be less apparent.

process of pain

Stab finger- prostglandins and kinins released -stimuales noceceptical fiber and gets into dorsal route of spinal cord, once it gets there is synpases onto 2nd neuron which is myelinated brings it up into brain into thalamus. In thalamus it synapses to 3rd neuron which then goes to diff areas of brain so can feel it and bring into conscious thought and know it happened

pain pathway review

Stimulus (nail through them) Noceceptor is stimulated Peripheral nerve - afferent pain fiber (going towards) Coming into dorsal horn where first synapse is! 2nd order neuron is myelinated so will be fast track to brain Subsatnce P -can block this with TENS unit or massage Nerve transmission crosses over and comes up spinal thalamic track and into brain Distrubted to 3rd order neuron Into limbic system, thalamus is where we recognize it Where it is in the brain is where we get conscious thought

The psychological reaction to pain is what?

Subjective - varies from person to person

Opioid Antagonist

Substances that prevent the effects of opioid agonists Block opioid activity

When do you take triptan

Take as soon as migraine h/a is beginning

What is the most common type of headache?

Tension headache

How fast does triptan work?

Terminates migraine h/a in 10-20 minutes

Centrally acting drug

Tramadol (Ultram)- weak opioid activity

What is pain usually associated with?

Trauma or disease

What do you treat tension headaches with

Treat w/OTC analgesics- asa/ibu/acetaminopthen

Treatment of migraines

Treatment- tx before reaches severe level Abortive therapy Preventative therapy

5-HT receptor drug

Triptan (sumatriptan)

What therapy can you also use?

Use combination non-opioid pain alternatives if needed - Fioricet- acetaminophen, butalbital - Ascomp- asa, caffeine, butalbital

Who gets neuropathic pain

diabetics and shingles

Narcotic

general term used to describe opioid drugs that produce analgesia and CNS depression

Tension headache

pain is like a band squeezing the head

What is an example of Opioids with Mixed Agonist-Antagonist Activity

pentazocine (Talwin)

Prophylactic Therapy

prevent migraine headaches

Massage, heat/cold therapy

providing another sensation that needs to go up that nerve to the brain blocking the noceceptive receptors

Opioid agonists

stimulate opioid receptors (mu and kappa)

Signs travel from what 3 places

thalamus - somatic sensory area - limbic system

What does acute pain indicate?

tissue damage

Timing of acute pain

very sudden and severe, short term

Mixed opioid agonist

will stimulate only mu or only kappa (kappa is better)