Objective 2.1 (1) Flashcards by Kaitlyn Dominie

An unpleasant sensory and emotional experience associated with actual or potential tissue damage
A personal and individual experience
Whatever the patient says it is
Exists when the patient says it exists

pain

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Level of stimulus needed to produce the perception of pain
A measure of the physiological response of the nervous system-therefore similar for most people

pain threshold

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The psychological element of pain
The amount of pain a person can endure without it interfering with normal function
Varies from person to person
Subjective response to pain, not a physiological function
Varies by attitude, personality, environment, culture, ethnicity

pain tolerance

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sudden, usually subsides when treated (postop pain)

acute pain

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chronic or long-term pain, recurring lasts 3-6 months, and more difficult to treat

persistent pain

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Pain results from stimulation of sensory nerve fibres called nociceptors.
These receptors transmit pain signals from various body regions to the spinal cord and brain

nociception

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pain originating in skeletal muscles, ligaments or joints

somatic pain

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pain originating from internal organs or smooth muscles

visceral pain

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Medications that relieve pain without causing loss of consciousness
Commonly referred to as “Painkillers”

analgesics

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moderate to severe pain

opioid analgesics

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drugs from other chemical categories that are added to the opioid regimen

adjuvant analgesic drugs

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what is the WHO 3-step analgesic ladder?

Step 1: Nonopioids with or without adjuvant medications after the pain has been identified and assessed. If pain persists or increases, treatment moves to:
Step 2: Opioids with or without nonopioids and with or without adjuvants. If pain persists or increases, management then rises to:
Step 3: Opioids indicated for moderate to severe pain, administered with or without nonopioids or adjuvant medications

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Synthetic drugs that bind to the opiate receptors to relieve pain
Classified as both mild and strong agonists

opioid drugs

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codeine, hydrocodone

mild agonists

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morphine, hydromorphone hydrochloride, oxycodone, meperidine, fentanyl, methadone

strong agonists

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not recommended for long-term use because of the accumulation of a neurotoxic metabolite, normeperidine, which can cause seizures

meperidine

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drug reaches a maximum analgesic effect.

opioid ceiling effect

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Bind to an opioid pain receptor in the brain
Cause an analgesic response (reduction of pain sensation)

agonists

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Bind to a pain receptor
Cause a weaker pain response than full agonists
Also called partial agonists or mixed agonists

agonists-antagonists

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Reverse the effects of these drugs on pain receptors
Bind to a pain receptor and exert no response
Also known as competitive antagonists

antagonists

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what are opioids used for?

Mainly used to alleviate moderate to severe pain
Often first line agents analgesic in immediate post operative setting
Often given with adjuvant analgesic drugs to assist primary drugs with pain relief Balanced anaesthesia
Cough centre suppression
Treatment of diarrhea

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what are the contraindications of opioids?

Known drug allergy
Severe asthma
Use with extreme caution in patients with the following:
Respiratory insufficiency
Elevated intracranial pressure
Morbid obesity or sleep apnea
Paralytic ileus (bowel paralysis)
Pregnancy

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what are the interactions of opioids?

Alcohol
Antihistamines
Barbiturates
Benzodiazepines
Promethazine
Monoamine oxidase inhibitors (MAOI’s)-resp depression, seizures, hypotension
Others

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what are the adverse effects of opioids?

Central nervous system (CNS) depression
Leads to respiratory depression
Most serious adverse effect
Nausea, vomiting, constipation, biliary tract spasm
Urinary retention
Hypotension, palpitations, flushing
Itching, rash, wheal formation due to histamine release (more with morphine, less with merperidine)
Pinpoint pupils indicating a possible overdose

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A common physiological result of chronic opioid treatment State of adaptation Result: larger dose is required to maintain the same level of analgesia

opioid tolerance

Physiological adaptation of the body to the presence of an opioid

physical dependance

a pattern of compulsive drug use characterized by a continued craving for an opioid and the need to use the opioid for effects other than pain relief

addiction

From the opium poppy Drug prototype for all opioid drugs; Schedule I controlled substance For severe pain, with high abuse potential Oral, injectable and rectal forms Extended-release form includes MS Contin, Potentially toxic metabolites morphine 6 glucuronide. Accumulation likely to occur in those with kidney insufficiencies.

morphine sulphate

Natural opiate alkaloid (Schedule I) obtained from opium Less effective Ceiling effect More commonly used as an antitussive drug Gastrointestinal (GI) disturbance

codeine sulphate

Synthetic opioid (Schedule I) used to treat moderate to severe pain Parenteral injections, transdermal patches (Duragesic Mat® ), sublingual effervescent tablet (Fentora®

fetanyl

Hydromorphone (Dilaudid® ): very potent opioid analgesic; Schedule I drug 1 mg of intravenous (IV) or intramuscular (IM) hydromorphone is equivalent to 7 mg of morphine.

dilaudid

Synthetic opioid analgesic (Schedule I) Opioid of choice for detoxification treatment of opioid addicts in methadone maintenance programs Renewed interest in the use of methadone for chronic (e.g., neuropathic) and cancer-related pain Prolonged half-life (24-36hours) of the drug: cause of unintentional overdoses and deaths Cardiac dysrhythmias

methadone hydrochloride

Pure opioid antagonist Drug of choice for the complete or partial reversal of opioid-induced respiratory depression Indicated in cases of suspected acute opioid overdose Failure of the drug to significantly reverse the effects of the presumed opioid overdose indicates that the condition may not be related to opioid overdose.

naloxone hydrochloride

Analgesic and antipyretic effects Little to no anti-inflammatory effects Available over the counter (OTC) and in combination products with opioids Mechanism of Action: Similar to that of salicylates Blocks pain impulses peripherally by inhibiting prostaglandin synthesis Also lowers febrile body temp by acting on the hypothalamus Indications: Mild to moderate pain, Fever, Inability to take aspirin products Contraindications/Interactions Should not be taken in the presence of following: Drug allergy, Liver dysfunction, Possible liver failure, G6PD deficiency Dangerous interactions may occur if taken with alcohol or other drugs that are hepatotoxic.

nonopioid analgesics: acetaminophen

Related to the marigold family Anti-inflammatory properties Used to treat migraine headaches, menstrual cramps, inflammation, and fever May cause GI distress, altered taste, muscle stiffness, joint pain May interact with aspirin and other NSAIDs, as well as anticoagulantsincrease in bleeding Contraindicated in those with allergies to ragweed marigolds and those undergoing surgery

feverfew

a state of rest when physical and consciousness levels decrease

sleep

hypnotic drugs affect different stages of the normal sleep pattern.

various sedative

prolonged use of these drugs may reduce the cumulative amount of REM sleep

REM interference

Discontinuing these drugs, can cause REM rebound, and client then has large amount of REM sleep, leading to frequent and vivid dreams

REM rebound

a hormone secreted by the pineal gland in the human brain Is a NHP and a commonly used sleep aid Helps regulate other hormones and maintains the body’s circadian rhythm Often taken for insomnia, sleep difficulties associated with menopause, jet lag and to promote sleep in children with ADHD or autism spectrum disorder. Adverse effects: daytime fatigue, drowsiness, headaches, dizziness. Contraindications: pts on anticoagulants, immunosuppressants, antihyperglycemics or BCP. Not to be used in pts with depression, HTN, reduced liver function or seizure disorder

melatonin

Drugs that have an inhibitory effect on the central nervous system (CNS) to the degree that they reduce: Nervousness Excitability Irritability

sedatives

Cause sleep Have much more potent effect on CNS than sedatives have A sedative can become a hypnotic if given in large enough doses

hypnotics

At low doses, calm the CNS without inducing sleep At high doses, calm the CNS to the point of causing sleep

sedative-hypnotics

what are the 3 classifications of sedative-hypnotics?

barbiturates benzodiazepines non benzodiazepine sedatives

Formerly the most commonly prescribed sedative–hypnotic drugs Nonbenzodiazepines currently more frequently prescribed Benzo’s show favourable adverse effect profiles, efficacy, and safety when used therapeutically in the short term

benzodiazepines

clonazepam (Rivotril® ), diazepam (Valium® ), flurazepam hydrochloride (Dalmane® )

long acting benzodiazepines

alprazolam (Xanax® ), bromazepam (Lectopam® ), lorazepam (Ativan® ), temazepam (Restoril® )

intermediate acting benzos

midazolam hydrochloride, triazolam, zolpidem tartrate (Sublinox® )

short acting benzos

what are the indications of benzos?

Sedation Sleep induction Skeletal muscle relaxation Agitation or anxiety relief Anxiety-related depression Treatment of acute seizure disorders, alcohol withdrawal (ie. Diazepam), Short-term therapy for insomnia

what are the AE of benzos?

Mild and infrequent Headache Drowsiness Paradoxical excitement of nervousness Dizziness Cognitive impairment Vertigo Lethargy Fall hazard for older adults “Hangover” effect or daytime sleepiness

First clinically available benzodiazepine drug. It has varied uses, including treatment of anxiety, procedural sedation, anticonvulsant, and skeletal muscle relaxant following orthopedic injury or surgery. Helps with treatment of alcohol withdrawal. Pg 218

diazepam

Most commonly used preoperatively and for procedural sedation Causes amnesia and anxiolysis (reduced anxiety) as well as sedation Normally administered by IV in adults Liquid oral dosage form is also available for children. Pg. 218

midazolam

Intermediate-acting benzodiazepine One of the metabolites of diazepam Normally induces sleep within 20 to 40 minutes Long onset of action, so it is recommended that patients take it about 1 hour prior to going to bed. Still an effective hypnotic; however, it has been replaced by newer drugs.

temazepam

Short-acting benzodiazepinelike drug Unique advantage of this drug stems from its very short half-life. Short-term treatment of insomnia, 7 to 10 days.

zopiclone

Short-acting nonbenzodiazepine hypnotic Lower incidence of daytime sleepiness compared with benzodiazepine hypnotics Onset of action approximately 30 minutes

zolpidem tartrate

Used to relieve anxiety, stress, and restlessness and to promote sleep May cause temporary yellow skin discoloration (extended, continued intake), scaly skin, and visual disturbances Potential interactions with alcohol, barbiturates, and psychoactive drugs Contraindicated in liver disease, alcoholism, other conditions Patient should not operate heavy machinery during use.

kava

Used to relieve anxiety, restlessness, and sleep disorders May cause CNS depression, hepatotoxicity, nausea, vomiting, anorexia, headache, restlessness, insomnia Many interactions, including with CNS depressants, monoamine oxidase inhibitors (MAOIs), phenytoin, warfarin, and alcohol Contraindicated in cardiac and liver disease Patient should not operate heavy machinery during use.

valerian

First introduced in 1903; were the standard drugs for insomnia and sedation Habit forming; low therapeutic index Only a few commonly used today partly because of the safety and efficacy of benzodiazepines Psychologically habit forming Have a low therapeutic index (Ex. There is a narrow range where the drug is effective, above this can be rapidly toxic) MOA: Are CNS depressants that act primarily on the brain stem in an area called the reticular formation

barbituates

what are the interactions with barbituates?

Additive effects: Alcohol, antihistamines, benzodiazepines, opioids, tranquilizers Inhibited metabolism: MAOIs prolong the effects of barbiturates. Increased metabolism: Reduces anticoagulant response, leading to possible clot formation

what are the AE of barbituates?

Body system/adverse effects Cardiovascular: Vasodilation, hypotension (esp if given too rapidly) CNS: Drowsiness, lethargy, vertigo Respiratory: Respiratory depression, cough Gastrointestinal: Nausea, vomiting, diarrhea, constipation Hematological: Agranulocytosis, thrombocytopenia Other: Hypersensitivity reactions, Stevens-Johnson syndrome

Prototypical barbiturate Long-acting drug Uses: prevention of generalized tonic-clonic seizures and feverinduced convulsions, as well as treatment of hyperbilirubinemia in neonates Rarely used today as a sedative and is no longer recommended to be used as a hypnotic drug

phenobarbital

Nonprescription sleeping aids often contain antihistamines, which have CNS-depressant effect. Doxylamine succinate (Unisom-2 ® ), diphenhydramine hydrochloride (Sleep-Eze® ), acetaminophen/diphenhydramine (Extra Strength Tylenol® Nighttime) As with other CNS depressants, concurrent use of alcohol can cause respiratory depression or arrest.

OTC hypnotics

Act to relieve pain associated with skeletal muscle spasms

muscle relaxants

only one is Dantrolene Act directly on skeletal muscle Closely resemble GABA

direct acting muslce relaxants

what are the interactions with muscle relaxants?

Relief of painful musculoskeletal conditions (Muscle spasms, MS, CP) Work best when used along with physical therapy Only contraindication is a known drug allergy

what are the AE of muscle relaxants?

Extension of effects on CNS and skeletal muscles Euphoria Lightheadedness Dizziness Drowsiness Fatigue Confusion Muscle weakness, others