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Concept Pain / Comfort:

Narcotics, Narcotic Antagonists
and Antimigraine Agents
CHAPTER 26

DEFINITION
NOXIOUS STIMULATION OF ACTUAL OR
THREATENED TISSUE DAMAGE.

HIGHLY SUBJECTIVE.

ACTS AS A BODY ALARM.

IT IS WHATEVER THE PERSON SAYS IT IS….

TYPES OF PAIN
ACUTE- UNDER 3 MONTHS DURATION.
EXPECTED RECOVERY.
CHRONIC- 3 MONTHS OR LONGER-LIMITS
NORMAL FUNCTIONING. NO PREDICTABLE
END. PERSISTENT.
RADIATING- PERCEIVED AT SOURCE AND
EXTENDS TO NEARBY TISSUE.
REFERRED- PAIN FELT IN A PART OF BODY
THAT IS CONSIDERABLY REMOVED FROM
CAUSE.

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Figure 46-1

PAIN PHYSIOLOGY
NOCICEPTORS- PAIN RECEPTORS THAT
RECEIVE AND TRANSMIT IMPULSES.
LOCATION- MOST BODY TISSUES.
MOST ABUNDANT IN:
SKIN
PERIOSTEUM & JOINT SURFACES
ARTERIAL WALLS
NOT LOCATED IN LUNGS OR BRAIN.

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PHYSIOLOGY (CONT)
 NOCICEPTORS STIMULATED BY:
 DAMAGE TO CELLS-MECHANICAL, THERMAL, CHEMICAL.
 THIS CAUSES:
 RELEASE OF CHEMICAL SUBSTANCES- BRADYKININ,
HISTAMINE, SUBSTANCE P, WHICH ACTIVATE
NOCICEPTORS.
 NEUROTRANSMITTERS LIKE PROSTAGLANDIN ARE
RELEASED - ↑ SENSITIVITY TO THE EFFECTS OF
BRADYKININ & HISTAMINE, THUS CAUSING
INFLAMMATION.
 ANTIINFLAMMATORY DRUGS WORK AT THIS
LEVEL. (ASA, IBUPROFEN ). TOPICALS –
CAPSAICIN, LOCAL ANESTHETICS.

PHYSIOLOGY (CONT)
 PAIN IMPULSES TRAVEL THRU PERIPHERAL NERVE
FIBERS TO SPINAL CORD THRU DORSAL HORN.
(TRANSMISSION)
 IMPULSES ARE TRANSMITTED FROM CORD THRU
ASCENDING SPINOTHALMIC TRACTS TO BRAIN
STEM AND THALMUS. HERE IMPULSES ARE
INTERPRETED.
 SIGNALS ARE TRANSMITTED FROM THALMUS TO
CORTEX. PATIENT IS THEN CONSCIOUS OF PAIN.
 OPIODES (NARCOTICS) BLOCK PAIN AT ASCENDING
SPINE.

PHYSIOLOGY (CONT) PHASE III

PAIN PERCEPTION (CONSCIOUS AWARENESS)

OCCURS IN CORTEX.

DISTRACTION THERAPY (MUSIC, GUIDED

IMAGERY…) WORKS AT THIS LEVEL.

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PHYSIOLOGY (CONT)
DECENDING TRACT - NEURONS FROM BRAIN
STEM SEND IMPULSES DOWN CORD TO
DORSAL HORN.
DECENDING FIBERS RELEASE :
ENDOGENOUS OPIODES (ENDORPHINS,
DYNORPHINES, ENKEPHALINS).
SEROTONIN
NOREPINEPHRINE
ALL 3, IF NOT TAKEN BACK INTO BODY, CAN
INHIBIT PAIN AT ASCENDING DORSAL HORN.

ENDOGENOUS OPIODES
MORPHINE-LIKE SUBSTANCES FOUND IN CNS.
(PITUITARY, HYPOTHALMUS, AND CORD).
OUR OWN INTERNAL MORPHINE.
INCREASED AMOUNTS IN HAPPY,
CONTENDED PEOPLE (ESP.ENDORPHINS).
DECREASED IN DEPRESSION.
↓NEURORECEPTION, PAIN
TRANSMISSION. ex athletes
DOES NOT FUNCTION IN CHRONIC
PAIN.
ACUPUNCTURE, TENS, PLACEBOS -
STIM. ENDOGENOUS OPIODE
PRODUCTION.

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CONCEPTS ASSOCIATED WITH PAIN

 PAIN THRESHOLD –LEAST AMT OF STIMULATION
REQUIRED BEFORE FEELING PAIN.

 PAIN REACTION- RESPONSE TO PAIN (PHYSIOLOGIC

& BEHAVIORAL).

 PAIN TOLERANCE- MAXIMUM AMT. OF PAIN AN

INDIVIDUAL IS WILLING TO ENDURE.

ASSESSMENT (CONT)
 LOCATION
 INTENSITY – PAIN SCALE OR FACE SCALE 1-10
INTENSITY RATING
 QUALITY- DESCRIBE AS DESCRIBED BY PATIENT.
 PATTERN- ONSET, DURATION, CONSTANCY.
 PRECIPITATING/CONTRIBUTING FACTORS.
 ALLEVIATING MEANS.
 ASSOCIATED ASSESSMENTS. (OBJ/SUBJ).

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COMPARISON OF ACUTE AND CHRONIC

PAIN
ACUTE CHRONIC
 MILD-SEVERE  MILD-SEVERE
 SYMPATHETIC NS  PARASYM. NS.
 ↑PULSE, RESP, BP.  P., RESP, BP-NORMAL
 DIAPHORESIS  DRY, WARM SKIN
 DILATED PUPILS  PUPILS NORMAL OR
 TISSUE INJURY TO DILATED
HEALING  BEYOND HEALING
 RESTLESS, ANXIOUS  DEPRESSED, WITHDRAWN
 REPORT OF PAIN  DOES NOT MENTION PAIN
 CRYING, RUBBING,  PAIN BEHAVIOR ABSENT
SPLINTING.

INTERVENTIONS
INDIVIDUALIZE CARE FOR PATIENT WITH
PAIN. CONTROL PAINFUL STIMULI
TIGHTEN LINENS, REPOSITION, PATIENT TO VOID.
DECREASE DISTURBING STIMULI
↓ LIGHTS, NOISE, CLOSE
DOORS/SHADES.

INTERVENTIONS (CONT)
 CUTANEOUS STIMULATION- CLOSE GATE
STIMULATES LARGE FIBER IMPULSES.
BACKRUB (LINAMENTS / OINTMENTS)

MASSAGE - ↑ CIRC TO AREA.

ICE- 5-10 MINUTES UNTIL

NUMB ↑ NOREPINEPHRINE

HEAT- STIMULATES SEROTONIN (SAFE /

SERENE). TUB / SITZ BATH, HEATING
PAD.

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INTERVENTIONS (CONT)
CONTRALATERAL STIM.- SKIN IN
OPPOSITE AREA. USED WHEN CAN’T
TOUCH AREA.

ACUPRESSURE- PRESSURE TO POINTS

ALONG NERVE ROOT

TENS (TRANSCUTANEOUS ELECTRICAL

NERVE STIMULATOR. RELEASE
ENDORPHINS.

INTERVENTIONS (CONT)

USE OF ANALGESICS

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ANALGESICS
NARCOTIC-OPIODS (MOD-SEVERE)
NON-NARCOTIC- NSAIDS (MILD)
COANALGESICS - ACT IN CONJUNCTION WITH
ANALGESICS.
PLACEBO – NO THERAPEUTIC PROPERTIES.
Read P 441 Box 26.1 Narcotics across the
lifespan.

NARCOTICS/OPIODES
• P. 442-443 Table 26.1 Narcotics or opioids
originally derived from opium plant – now
most are synthetically produced with similar
chemical structure.
• Potential to develop physical dependence –
classified as controlled substances.
• Actions - act at specific opioid receptor sites
in the CNS to produce analgesia, sedation,
sense of well-being (ascending route).

NARCOTICS(CONT)
• Contraindications - pregnancy, labor, lactation
, and diarrhea caused by poisons.
• Cautions - Respiratory dysfunction, GI or GU
surgery and acute abdomen and ulcerative
colitis.
• Adverse reactions - respiratory depression
with apnea, cardiac arrest, shock, orthostatic
hypotension, nausea, vomiting, constipation,
biliary spasm, dizziness, psychoses, anxiety,
fear, hallucinations.

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NARCOTIC AGONISTS(OPIODES)P442-443
• morphine (Roxanol) mod-severe pain
• Codeine Mild-Mod pain, cough
• fentanyl (Actiq, Duragesic patch)acute/chr.
• hydrocodone (Hycodan)
• hydromorphone (Dilaudid)
• meperidine
• opium (Paregoric)
• oxycodone (OxyContin) tramadol(Ultram)
• oxymorphone (Numorphan)

NARCOTIC AGONIST-
ANTAGONISTS
• Stimulate certain opioid receptors but block
other such receptors. Less abuse potential
than narcotic agonists but with more
psychotic-like reactions.
• Action - at specific opioid receptor sites in the
CNS, produce analgesia, sedation, euphoria,
and hallucinations.
• Indications - moderate to severe pain,
adjunct to general anesthesia, relief of pain
during labor and delivery.

NARCOTIC AGONISTS-
ANTAGONISTS(cont)
• buprenorphine (Buprenex)
– Treats mild to moderate pain
• butorphanol (Stadol)
– Preoperative medication.
– Relieves moderate to severe pain.
• nalbuphine (Nubain)
– Treats moderate to severe pain.
– Adjunct for general anesthesia.
– Relieves pain during labor and delivery.
• pentazocine (Talwin)
• Labor/delivery, postpartum
• P 443

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NARCOTIC AGONIST-
ANTAGONISTS(CONT)
• CAUTION
• COPD and diseases of the respiratory tract,
acute MI and documented CAD.

• Adverse reactions - Respiratory depression,

nausea, vomiting, constipation, and biliary
spasm.

NARCOTIC ANTAGONISTS
• Indications - Reversal of the adverse effects
of narcotics, treat narcotic and/or alcoholic
dependence.
• Adverse reactions - acute narcotic abstinence
syndrome (characterized by N&V, sweating,
tachycardia, HTN, tremulousness and feeling
anxious). CNS excitement and reversal of
analgesia, tachycardia.

NARCOTIC ANTAGONISTS (cont)

• naloxone (Narcan)
– Reverses adverse effects of narcotics; diagnoses
suspected acute narcotic overdose – 0.4-2mg IV
• naltrexone (ReVia)
– Used orally in the management of alcohol or
narcotic dependence in adults – 50mg/day PO.
– P 443

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NARCOTIC ANTAGONISTS(CONT)
• See 26.1 p443
• naloxone Narcan can be given IV, IM or
SubQ. Repeat every 2-3 min.
autoinjector for first responders/family.
• naltrexone (ReVia) - can see severe
withdrawal syndrome if used in patients
receiving/ taking narcotics- should be
narcotic free for 7-10 days. Use a
naloxone challenge first.

NARCOTIC ANTAGONISTS(CONT)
• To reverse the effects of meds below may
need larger doses of antagonists:
buprenorphine (Buprenex),
• butorphanol (Stadol),
• nalbuphine (Nubain),
• pentazocine (Talwin).

HEADACHES
• Migraine headaches:
– Severe, throbbing headaches on one side of the
head – women 3X > men.
• Cluster headaches:
– Begin during sleep; sharp, steady eye pain,
sweating, flushing, tearing, and nasal
congestion – men > women.
• Tension headaches:
– Usually occur at times of stress; dull band of
pain around the entire head – women > men.

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HEADACHES(CONT)
• Migraine headaches – two types: believed to
be caused by arterial dilation with
hyperperfusion.
• Common migraine – often occur without an aura,
cause severe unilateral pulsating pain frequently
accompanied by N&V, sensitivity to light and
sound – often aggravated by physical activity.

• Classic migraine - usually preceded by an aura or

a sensation with sensory or motor disturbances –
occurs about ½ hour before the pain begins.

ERGOT DERIVATIVES
• See P. 453 Table 26.2
• Actions - block alpha-adrenergic and
serotonin receptor sites in the brain to cause
constriction of cranial vessels.

• Indications - prevention or halt progression

of migraine or vascular headaches.
• Pharmacokinetics - rapidly absorbed from
many routes, onset of action range from 15
to 30 minutes.

ERGOT DERIVATIVES (cont)

• ergotamine - prevention or halt
progression of migraine or vascular
headaches, given sublingual for rapid
absorption. Give every 30 min. x3.
Inhalation route –every 5 min x 6 doses.
• dihydroergotamine (Migranal, D.H.E. 45)
– rapid treatment of acute attacks, can
be given IV or IM, also have a nasal
spray.

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ERGOT DERIVATIVES(CONT)
• Contraindications – Pregnancy (Ergotism –
vomiting, diarrhea, seizures seen in affected
infants), CAD, HTN, PVD – could be
exacerbated b/c CV effects of drugs.
• Adverse reactions - numbness, tingling of
extremities, muscle pain, weakness,
pulselessness, chest pain, arrhythmias, MI,,
N&V, diarrhea. Causes many systemic SE so
their usefulness is limited in some patients.

TRIPTANS
• New class of drugs which are not associated
with all the vascular and GI effects of ergot
derivatives. Patient may have poor response
to one and respond well to another.
• See P 453 Table 26.2 (420). Each used for
treatment acute migraines in adults.(NOT
PREVENTION)
Actions - bind to selective serotonin receptors
sites to cause vasoconstriction of cranial
vessels.

TRIPTANS(CONT)
• Pharmacokinetics - rapidly absorbed
from many routes, onset of action range
from 15 to 30 minutes.

• Contraindications – Pregnancy
Vomiting, diarrhea, seizures seen in
affected infants, CAD, HTN, PVD – could
be exacerbated b/c CV effects of drugs.

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TRIPTANS(CONT)
• Cautions - in the elderly, risk factors for CAD,
and lactation.

• Adverse reactions - numbness, tingling,

burning sensation, feeling of coldness,
weakness, dysphagia, and blood pressure
alterations.

TRIPTANS P 453
• sumatriptan (Imitrex) oral & nasal
spray
• almotriptan (Axert)
• eletriptan (Relpax)
• frovatriptan (Frova)
• naratriptan (Amerge)
• rizatriptan (Maxalt, Maxalt-MLT)
• zolmitriptan (Zomig, Zomig-ZMT)

Migraine Headaches

• Botox injections every 3 months for

migraines

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