Analgesics

Presenter: Zohra Asif Jetha

Acknowledgement:
Saleema Allana
Ms. Erum Lalwani
 Objectives
By the end of the session, learners will be able to:
Define pain and discuss its management.
Describe the neural mechanism for pain at the level of
Spinal cord.
Define the terms Analgesic, Narcotic/Opioid and Narcotic
Antagonist.
Differentiate between non-narcotic and narcotic
analgesics
List the characteristics of Opioid analgesics in terms of its
mechanism of action, indication, major Side effects &
contraindications.
Explain why higher doses of Opioid analgesics are needed
when the drugs are given orally. 2
 Objectives
 Discuss the principles of therapy for nursing process
while administering Opioid/Narcotic analgesics.
 Discuss the signs and symptoms of Opioid overdose, its
withdrawal and treatment of each.
 Illustrate client teaching regarding safe and effective
use of Opioid analgesics.
 Describe the indication, mechanism of action and major
side effects of Non Steroid Anti-Inflammatory Drugs.
 Discuss the nursing care, including client teachings
associated with NSAID’s and Narcotics.

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 Pain

Definition:
It is an unpleasant sensation that often indicates tissue
damage and requires the person to remove the cause of the
damage.
(Abrams, 2001).
Pain Experience:
The pain experience is highly subjective and influenced by
behavioral, psychological, sensory, emotional, and cultural
factors
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 Types of pain

• Acute pain
• Sudden onset
• Usually subside once treated

• Chronic pain
• Persistent recurring
• Often difficult to treat

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Characteristic Of pain

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 Neural Mechanism of Pain Sensation
Tissue damage

Chemical Mediators are released (e.g., Bradykinin, serotonin,

Prostaglandin)

Stimulate Pain receptors (Nociceptors) located peripherally

throughout the body

Nerve impulse of pain sent to spinal cord

Neurotransmitter (Substance P) passes the message along to next
neuron

Pain impulse reaches the brain

Pain is sensed 7
Substance P is a neurotransmitter
is responsible for continuing the
pain massages.
 Endogenous opioids
modify sensory
information at the
level of spinal card. If
pain impulses reaches
to the brain , patient
shows action Jerk
away from sharp
object

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 Endogenous Opioids

• These are naturally occurring neurotransmitters in the

central nervous system, which reduce pain sensation
by acting on mu and kappa receptors
• They also inhibit the release of substance P; inhibition
of substance P reduces the transmission of pain
impulses in central nervous system, thus reducing pain
sensation.

For e.g. Endorphins, Dynorphins.

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Receptors in CNS Responsible for Analgesia
• Mu and Kappa receptors in CNS are responsible for pain
control or analgesia.

• Effects produced by the activation of Mu receptors are:

Analgesia, Decreased GI motility, Respiratory Depression,
Sedation, Physical dependence

• Effects produced by the activation of Kappa receptors are:

Analgesia, Decreased GI motility, and Sedation

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 Analgesic Drugs
Analgesics:
These are the medications used to relieve pain.
(Kee, 2006).
Types of Analgesics:
• Opioid or Narcotic Analgesics:
• These drugs act on the brain (CNS) and reduce the appreciation of
moderate to severe pain

• Non Steroidal Anti Inflammatory Drugs (NSAIDs)/Non-Narcotic

Analgesics:
• These drugs reduce inflammation and release of inflammatory
mediators at peripheries, thus reducing onset of the neural
mechanism of pain sensation by nerve fibres

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 Difference b/w Narcotic and Non-
Narcotic Analgesics
Narcotic Non-Narcotics (NSAIDs)
 Actsmostly on the Central Acts on Peripheral nervous
Nervous System system at the pain receptor sites.

 Suppress moderate to severe Suppress mild to moderate pain.

Pain as well as it suppresses Performs Analgesic, Anti-pyretic
respiration and coughing by and Anti-inflammatory actions.
acting on medulla of the
brainstem.
 Effective for severe pain during  Effective for dull, throbbing pain
and after surgeries, during of inflammation, minor abrasions,
invasive diagnostic procedures, mild to moderate arthritis.
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L&D etc.
 Opioid/Narcotic Agents
Complete Opioid Agonists:
These drugs act as complete agonists to endogenous
opioids, and thus they act on and stimulate both
mu and kappa receptors. These are the most potent
analgesics. E.g. Morphine, Pethadine, Fentanyl

Partial Opioid Agonist- Antagonists:

These agents have agonist activity at kappa
receptors and antagonist activity at mu receptors.
Therefore, though they are not as potent analgesics
as complete opioid agonists; however, these have
fewer side effects.
E.g. Pentazocine

(Abrams, 2001)
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 Narcotic/Opioid Analgesics
Mechanism of Action:
Opioid Drugs bind to Mu, Kappa receptors

Stimulation of Mu and Kappa receptors

Prevents release of substance P (responsible for pain impulse

transmission in CNS)

Transmission of nerve impulses related to pain suppressed

Decreased Pain sensation 14

 Narcotic/Opioid Analgesics
Examples: (Narcotic Agonists)
Morphine.
Pethidine
Fentanyl.
Codeine.
Hydromorphone.
Examples: (Narcotic Agonists- Antagonist)
Nalbuphine (Nubain)
Pentazocin (Talwin)
Buprenorphine (Buprenex).
Tramadol (Ultram).

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 Narcotic/Opioid Analgesics
Indications: These drugs are usually given to prevent and relieve
acute & chronic pain when other measures and milder drugs are
ineffective.
• Pre, Intra and Post-Op surgical patients.
• Invasive diagnostic procedures (Angiograms,
• Endoscopic examination).
• GI disorders (abdominal cramps, pain).
• Angina (Chest pain)
• Burns and other traumatic injuries.
• Cancer
• Renal colic

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Narcotic/Opioid Analgesics
Will you administer opioid patient has
12 breaths per minutes?
Contraindications:
• Hypersensitivity.
• Respiratory Depression.
• Chronic Lung diseases.
• Head injury.
• Liver/ Kidney diseases.
• Shock.
• Pregnancy (Crosses placenta)
• Children & Elderly (given cautiously)

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 Side Effects
• Depressing Effects:
• Depresses the perception of pain
• Depresses respiratory center– respiratory depression
• Depresses cough center--- depressed cough reflex
• Reduces anxiety--- causes euphoria
• Depresses alertness– causes drowsiness and sleep
• Decreased Peristalsis--- Constipation, less bowel sounds
• Spasm of sphincters--- Urinary retention
• Stimulating Effects:
• Stimulates Chemoreceptor trigger zone (CTZ)--- causes nausea
vomiting
• Stimulates Occulomotor nerve--- pupillary constriction
• Stimulates vagus nerve– bradycardia, hypotension
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 Narcotic/Opioid Analgesics

Oral doses of drug undergoes hepatic bypass (liver

metabolizes 75% of the drug); therefore mostly given
through I/V or I/M routes in controlled doses

It crosses the blood brain barrier to produce analgesic effects.

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Narcotic/Opioid Analgesics: Nursing
Process
Assessment:
• Assess type of Pain, its location & duration.
• Obtain medical history related to any disorders
contraindicated for the therapy.
• Assess Vital signs and urinary output.
• Assess any substance abuse history, dependence or
withdrawal symptoms.
• Check doctor’s order for the method of Opioid
administration either IV, PCIA or IM.

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 Narcotic/Opioid Analgesics

• Assess for Drug interactions:

• CNS Depressants (Alcohol, antipsychotics, antihistamines etc.)---
Increased effect.
• Diuretics (Morphine can reduce the efficacy of diuretics)
• Narcotic Antagonists--- decreased effect.

• Assess for the safety measures including keeping side rails up and
instructing the patient to avoid activity till 30-60 min after Opioid
administration.

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Narcotic/Opioid Analgesics
Patient controlled Intravenous Analgesia (PCIA):
• The device consist of a syringe of diluted drug connected to an IV
line and infusion pump.
• The client controls the release of narcotic analgesic, depending
on the amount of pain.
• The syringe delivers the predetermined dose when the client
pushes a button connected with the PCIA
device and placed it on clients hand.
• A lock out mechanism on PCIA machine
prevents the client from constantly pushing
the button and causing drug overdose.
• Examples of drugs given through PCIA:
Pethidine, Morphine & Tramadol. 22
 Opioid Antagonists
• Narcotic antagonists reverse the analgesic and depressant
effects of narcotic agonists by displacing the agonists from
their receptor sites E.G. Nalaxone (Narcan).

• These are used in case of opioid overdose

(Abrams, 2001).

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 Narcotic/Opioid Analgesics

Relevant Nursing Diagnoses for patients on Opioids:

• Pain r/t Surgery, tissue injury.

• Ineffective breathing pattern r/t decreased respiratory
effort secondary to sedation and drowsiness.
• Constipation r/t decreased peristalsis.
• Altered tissue perfusion r/t decreased cardiac output &
BP.

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Narcotic/Opioid Analgesics
Nursing Interventions:
• Administer the narcotic before pain reaches its peak to maximize the
effectiveness of the drug.
• Monitor V/S (HR, BP, Respiratory rate and effort) at frequent intervals to
detect alterations.
• Record client’s urine output.
• Check bowel sounds for decreased peristalsis. Dietary changes (high fiber
diet, increased fluids) may be required.
• Check for Pupillary changes. Pinpoint pupils indicate Morphine
overdose.
• Have Naloxone available as an antidote and emergency equipment at
bedside if Opioid overdose occurs.
• Validate child’s and adult’s doses before administration.
• Administer anti-emetic (drugs that prevent vomiting) along with opioids,
as prescribed.
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 Narcotic/Opioid Analgesics

Patient Teaching:
• Instruct client to take medicines as prescribed, and not to increase the
dose or its frequency.
• Encourage client not to use alcohol or CNS depressants with narcotic
analgesics.
• Discourage client for driving or operating any machinery while
drowsiness, after taking narcotic analgesics.
• Encourage for high fiber diet such as whole grain cereals, fruits &
vegetables, drink 2-3 quarts of fluid daily to prevent constipation.
• Suggest non-pharmacological measures to relieve pain .

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 Non-Narcotic/Non-Opioid Analgesics

The non-narcotic analgesics are less potent than narcotic

analgesics, and are not addictive. E.g. NSAIDs, Acetaminophen
(Kee , 2006).
• Most NSAIDs have analgesic, anti-pyretic and anti-
inflammatory action i.e. relieve pain, fever and inflammation.
• These drugs act by suppressing the formation of prostaglandin,
which increases the nociceptors’ sensitivity to pain.
• Aspirin is the prototype of this group.

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 Non-Narcotic/Non-Opioid Analgesics
What will be causation
for patient when
taking NSAID
Mechanism of Action:
Aspirin and other NSAID’s inhibit the enzyme cycloxygenase
(COX 1 & 2), needed for the synthesis of
prostaglandin.

It Protects stomach lining, It triggers pain, fever

and
Promotes platelets aggregation (blood inflammation
Clotting)
Inhibition Inhibition
Loss of stomach lining protection Decreased pain
& leading to GI ulcer, release 28
bleeding tendency.
inflammation, fever
Non-Narcotic/Non-Opioid Analgesics
Examples:
1. Acetaminophen (Tylenol).
2. Acetylsalicylic Acid (Aspirin).
3. Ibuprofen (Motrin).
4. Flurbiprofen (Ansaid)
5. Ketorolac (Toradol)
6. Naproxen (Aleve). NSAID’s
7. Mefenamic Acid. (Ponstan).
8. Diclofenac (Voltren).

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Non-Narcotic/Non-Opioid Analgesics
Indications:
1. Prevent/ treat mild to moderate pain for e.g. Osteoarthritis,
Rheumatoid Arthritis, Fever, Cold , Flu, Dysmenorrhea.
2. Prevent risk for MI, stroke by thinning blood (e.g. Aspirin).
Side Effects:
• Gastric irritation.
• Anorexia, Nausea, vomiting, rash
• Increased bleeding tendency.
• Bone marrow depression. (anemia, leucopenia,
thrombocytopenia).
• Nephrotoxicity.

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Non-Narcotic/Non-Opioid Analgesics: NSAID’s

Contraindications:
• Peptic Ulcer disease.
• GI or other bleeding disorders.
• History of hypersensitivity reactions.
• Impaired renal function.
• Children (Cautious use).

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Non-Narcotic/Non-Opioid Analgesics: Aspirin

Important aspects while administering Aspirin:

1. Used as an analgesic, anti-inflammatory, antipyretic or anti-
platelet.
2. Enteric coated aspirin is slowly absorbed.
3. Administer aspirin with meals to reduce gastric irritation.
4. Monitor Platelet count (150-450)
5. Manifestations of Aspirin overdose include: Nausea,
vomiting, Fever, Fluid electrolyte imbalance, tinnitus,
drowsiness, confusion and hyperventilation.

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 Non-Narcotic/Non-Opioid Analgesics:
Acetaminophen
• Acetaminophen is not an NSAID.
• It is a weak inhibitor of prostaglandin, and decreases pain
and fever. Does not have anti-inflammatory properties.
• It does not cause gastric distress and not involved in platelet
aggregation.
• Preferred for children <12 years of age.
• Adverse effects are uncommon but overdose may result in
dangerous liver damage.
• Examples:
• Tylenol, Panadol.

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Non-Narcotic/Non-Opioid Analgesics: Nursing
Process

Assessment:
• Obtain medical history for any disorders contraindicated
for medicine.
• Assess the severity of pain.
• Assess V/S, inflammation or edema
• Assess for allergic reactions to Aspirin or NSAID’s

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Non-Narcotic/Non-Opioid Analgesics: Nursing
Process
Nursing Interventions:
• Administer NSAID’s with food or full glass of water to reduce GI
irritation.
• Observe for therapeutic effects.
• Check Liver enzymes, Renal Function test results.
• Instruct the client about Live damage can
• occur with continuous use of acetaminophen.
• Check serum Acetaminophen level (5-20 ug/ml).
• Toxic level is between 50 ug/ml and 200 ug/ml (considered as
hepatotoxicity).

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References
Abrams, A.C. (2001). Clinical drug therapy: rationales
for nursing practice. (5th.ed.). Philadelphia: Lippincott
Kee, J. Hayes, E. (2006). Pharmacology: A nursing
process approach. (4th ed.). New York: Saunders
Lilley, L.L. Aucker, R.S. (2001). Pharmacology and the
nursing process. (3rd ed). Philadelphia: Mosby
Mosby, T. (2002). Clinical Nursing, 5th ed.Mosby, Inc.
McCuistion, L.E. Gutierrez, K.J. (2002). Pharmacology.
USA: Saunders

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