Chapter Summary 11-1

Lilley’s Pharmacology for Canadian Health Care Practice, 4th Canadian

Edition
Chapter 11: Analgesic Drugs

Chapter Summary

OVERVIEW

 Pain is the most common reason that patients seek health care and is the underlying reason
for 78% of emergency department visits annually in Canada.
 To provide quality patient care, as a nurse you must be well informed about both
pharmacological and nonpharmacological methods of pain management.
 Pain is an individual experience and involves unpleasant sensations and emotions. It is
influenced by age, ethnoculture, spirituality, and all other aspects of the person.
 Pain can be defined as whatever the patient says it is, and it exists whenever the patient
says it does.
 Pain is associated with actual or potential tissue damage and may be exacerbated or
alleviated depending on the treatment and type of pain.
 The cause of the pain, the existence of concurrent medical conditions, the characteristics of
the pain, and the psychological and cultural characteristics of the patient need to be
considered.
 The level of stimulus needed to produce a painful sensation is referred to as the pain
threshold.
 The patient’s emotional response to the pain is also moulded by the patient’s age, sex,
culture, previous pain experience, and anxiety level.
 Whereas pain threshold is the physiological element of pain, the psychological element of
pain is called pain tolerance. This is the amount of pain a patient can endure when it is not
interfering with normal function.
 Acute pain is sudden and usually subsides when treated.
 Chronic pain is persistent or recurring, lasting 3 to 6 months. Changes in the nervous system
may require increased dosages, known as tolerance or physical dependence.
 Somatic pain originates from skeletal muscles, ligaments, and joints.
 Visceral pain originates from organs and smooth muscles.
 Superficial pain originates from the skin and mucous membranes.
 Deep pain occurs in tissues below skin level.
 Vascular pain is believed to originate from the vascular or perivascular tissues and is thought
to account for a large percentage of migraine headaches.
 Referred pain occurs when visceral nerve fibres synapse at a level in the spinal cord close to
fibres that supply specific subcutaneous tissues in the body.
 Neuropathic pain usually results from damage to peripheral or central nervous system (CNS)
nerve fibres by disease or injury but may also be idiopathic (unexplained).
 Phantom pain occurs in the area of a body part that has been removed surgically or
traumatically and is often described as burning, itching, tingling, or stabbing.

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Chapter Summary 11-2

 Cancer pain can be acute or chronic or both. It most often results from pressure of the tumour
mass against nerves, organs, or tissues.
 Central pain occurs with tumours, trauma, inflammation, or disease (e.g., cancer, diabetes,
stroke, and multiple sclerosis) that affects CNS tissues.
 The body is also equipped with certain endogenous neurotransmitters known as enkephalins
and endorphins, which are produced within the body to fight pain.

Treatment of Pain in Special Situations

 It is estimated that one of every five Canadians experiences ongoing pain.
 Effective management of acute pain is often different from management of chronic pain in
terms of medications and dosages used.
 Routes of drug administration may include oral, intravenous (IV), intramuscular,
subcutaneous, transdermal, and rectal.
 Patient-controlled analgesia (PCA) is an IV method commonly used in the hospital setting.
PCA administered by someone other than the patient is called PCA by proxy. Deaths have
occurred when family members engaging in PCA by proxy have administered too much of an
opioid drug. The Institute for Safe Medication Practices www.ismp.orgadvises against PCA
by proxy.
 Opioid tolerance is a state of adaptation in which exposure to an opioid drug causes changes
in drug receptors, changes that result in reduced drug effects over time.
 Breakthrough pain often occurs between doses of long-acting opioids for pain. Treatment
with as-needed (PRN) doses of immediate-release dosage forms may be given between doses
of extended-release dosage forms to relieve breakthrough pain.
 Adjuvant drugs (from other chemical categories) assist opioids in relieving pain. Using
adjuvant drugs allows the use of smaller dosages of opioids and reduces some adverse effects
seen with higher dosages of opioids. It also permits drugs with different mechanisms of
action to produce synergistic effects.
 The three-step analgesic ladder defined by the World Health Organization is often applied as
the pain management standard for cancer pain. Step 1 is the use of nonopioids (with or
without adjuvant medications) once the pain has been identified and assessed. Step 2 is
defined as the use of opioids with or without nonopioids and with or without adjuvants. Step
3 is the use of opioids indicated for moderate to severe pain, administered with or without
nonopioids or adjuvant medications.

OPIOID DRUGS

 Types of analgesics include the following:

o Nonopioids, including acetaminophen, aspirin, and nonsteroidal anti-inflammatory drugs
(NSAIDs)
o Opioids (natural or synthetic drugs that either contain or are derived from morphine
[opiates] or have opiatelike effects or activities [opioids]) and opioid agonist–antagonist
drugs
o Natural health products
 An agonist binds to an opioid pain receptor in the brain and causes an analgesic response (the
reduction of pain sensation).

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Chapter Summary 11-3

 An agonist–antagonist, also called a partial agonist or a mixed agonist, binds to a pain

receptor and causes a weaker pain response than does a full agonist.
 An antagonist is a competitive antagonist that competes with and reverses the effects of
agonist and agonist–antagonist drugs at the receptor sites.
 Opioid analgesics are very strong pain relievers. The amount of pain control or unwanted
adverse effects depends on the drug, the receptors to which it binds, and its chemical
structure.
 Contraindications to opioid analgesics include known drug allergy and severe asthma.
 All opioid drugs have a strong potential for being misused. They are common recreational
drugs of misuse among the lay public and also among health care providers, who have easy
access to them.
 The most serious adverse effect of opioid use is CNS depression, which may lead to
respiratory depression.
 Naloxone and naltrexone are opioid antagonists; they bind to and occupy all receptor sites.
These drugs are used in the management of opioid overdose and opioid addiction.
 Potential drug interactions with opioids are significant.

NONOPIOID AND MISCELLANEOUS ANALGESICS

 Acetaminophen (Tylenol®) is the most widely used nonopioid analgesic. Over four billion
doses of acetaminophen are sold each year in Canada; approximately 15% of these sales are
for prescription products (Health Canada, 2015). Despite its OTC status, acetaminophen is a
potentially lethal drug when taken in overdose.
 Acetylcysteine is the recommended antidote for acetaminophen toxicity and works by
preventing the hepatotoxic metabolites of acetaminophen from forming.
 Miscellaneous analgesics include tramadol and transdermal lidocaine.
 Capsaicin is a topical product made from several different types of peppers. It works by
decreasing or interfering with substance P, a pain signal in the brain. Capsaicin is available
over the counter. It can be used for muscle pain, joint pain, and nerve pain.
 Milnacipran is a selective serotonin and norepinephrine dual-uptake inhibitor. It is indicated
for the treatment of fibromyalgia.
 Feverfew (Chrysanthemum parthenium) is a natural health product that is a member of the
marigold family known for its anti-inflammatory properties

NURSING PROCESS

Assessment
 The challenge for the nurse is that pain is a complex and multifaceted problem that requires
astute assessment skills and appropriate interventions based on the individual, the specific
type of pain, related diseases, and health status.
 Adequate analgesia requires a holistic, comprehensive, and individualized patient assessment
with attention to the type, intensity, and characteristics of the pain and the levels of comfort.
 Perform a thorough health history, nursing assessment, and medication history as soon as
possible or upon the first encounter with the patient. Include in your assessment the factors or
variables that may affect the individual’s pain experience.

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Chapter Summary 11-4

 Assess and document vital signs, including blood pressure, pulse rate, respirations,
temperature, and level of pain (the fifth vital sign).
 A variety of pain assessment tools are available to gather information about pain.
 At the initiation of pain therapy, conduct a review of all relevant histories, laboratory test
values, nurse-related charting entries, and diagnostic study results in the medical record.
 When opioid analgesics or any other CNS depressants are prescribed, focus the assessment
on vital signs, allergies, respiratory disorders, respiratory function, presence of head injury,
neurological status, gastrointestinal-tract functioning, and genitourinary functioning.
 With patients who are taking opioid agonists–antagonists, such as buprenorphine
hydrochloride, assess vital signs with attention to respiratory rate and breath sounds.

Implementation
 Develop goals for pain management in conjunction with the patient, family members,
significant others, or caregiver.
 Collaborate with other members of the health care team to select a regimen that will be easy
for the patient to follow while in hospital and, if necessary, at home.
 Begin pain management immediately and aggressively in conformity with the needs of each
individual patient and situation.
 Be aware that most regimens for acute pain management include treatment with short-acting
opioids plus the addition of other medications, such as NSAIDs.
 Be familiar with equianalgesic doses of opioids, because lack of knowledge may lead to
inadequate analgesia or to overdose.
 Opioids or any analgesic must be given before the pain reaches its peak, to help maximize
the effectiveness of the opioid or other analgesic.
 Crucial safety measures include keeping bed side rails up, turning bed alarms on (depending
on the policies and procedures of the health care institution), and making sure the call bell is
within reach of the patient.
 When giving agonists-antagonists, remember that they react very differently depending on
whether they are given by themselves or with other drugs.
 Opioid antagonists must be given as ordered and be readily available, especially when the
patient is receiving PCA with an opioid, is opioid naïve, or is receiving continuous opioids.
 Use an analgesic appropriate for the situation (e.g., short-acting opioids for severe pain
secondary to a myocardial infarction, surgery, or kidney stones).
 For cancer pain, the regimen usually begins with short-acting opioids, with eventual
conversion to sustained-release formulations.
 Use preventative measures in regard to adverse effects.
 Consider the option of analgesic adjuvants, especially in cases of chronic pain or cancer pain;
these might include other prescribed drugs, over-the-counter drugs, and herbals.
 Be alert to patients with special needs, such as patients with breakthrough pain.
 Identify community resources that can assist the patient, family members, or significant
others.

Evaluation
 Because the prevention of falls is of utmost importance in patient care, monitor the patient
frequently.

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Chapter Summary 11-5

 Include a review of the effectiveness of multimodal and nonpharmacological approaches to

pain management in your evaluation.
 Pediatric dosages of morphine must be calculated very cautiously and with close attention to
the dose and to kilograms of body weight. Cautious titration of dosage upward is the
standard.
 Older adult patients may react differently than expected to analgesics, especially opioids and
opioid agonist–antagonists.
 Remember that older adults experience pain the same as does the general population, but
they may be reluctant to report pain. They may also metabolize opiates at a slower rate; they
are thus at increased risk for adverse effects such as sedation and respiratory depression. The
best rule is to start with low dosages, re-evaluate often, and go slowly during upward
titration.
 Regardless of the drug(s) used for the pain management regimen, individualization of
treatment is one of the most important considerations for effective and quality pain control.

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