Adjuvant Therapy Medication used as adjuvant analgesic have been developed for other purpose and later found

und to be effective for pain relief in neuropathy. Usually used along nonopioid and opioid. Examples of adjuvant analgesics include: Anticonvulsants Antidepressants Corticosteroids Antidysrhytmics Local anesthetics

Anticonvulsants (gabapentin [Neurontin]) -act on the peripheral nerves and CNS by inhibiting spontaneous neural firing. They are used for neurophatic pain and the prevention of migraine headaches. Tricyclic Antidepressant (amitriptyline [Elavil) -Prevent the reuptake of serotonin and norepinephrine in the cells. Corticosteroids - are a class of steroid hormones that are produced in the adrenal cortex. -serve as effective analgesics by reducing nociceptive stimuli. Antidysrhytmics (mexiletine [Mexitil) -block sodium channels to reduce pain. Local anesthetics (Lidocaine patch) - can be effective analgesics by interrupting the transmission of pain signals to the brain. Additional cancer treatment given after the primary treatment to lower the risk that the cancer will come back. Adjuvant medications potentiate opioid analgesia for severe persistent pain in diabetic neuropathy, cancer, migraine headaches, and rheumatoid arthritis. Types of cancer treatment that are used as adjuvant therapy include:

Chemotherapy. uses drugs to kill cancer cells. Chemotherapy treats the entire body, killing cancer cells, no matter where they may be located. Adjuvant chemotherapy isn't helpful in all situations. Hormone therapy. Some cancers are sensitive to hormones. For these cancers, treatments to stop hormone production in your body or block the effect of hormones on your cancer may be helpful. Radiation therapy. Radiation therapy uses high-powered energy beams, such as X-rays, to kill cancer cells. Radiation therapy can be given internally or externally. Immunotherapy. Immunotherapy works with your body's own immune system to fight off remaining cancer cells Targeted therapy. Targeted therapy aims to alter specific abnormalities present within cancer cells.

Treatment for Opiod-Addicted Individuals Opioids are narcotic drugs that are generally prescribed to manage pain. When opioids are discontinued suddenly, withdrawal symptoms and rebound pain usually occurs. Symptoms: Diarrhea Abdominal cramps Restlessness Watery eyes Runny nose Nausea One type of program is Methadone treatment program This program works by replacing opiod with methadone, also an opioid but one that causes less dependency than the oppiods it replaces Oral methadone does not lead to the euphoria (high) achieved with injectable opioids. Given once a day. The dosage is 15 to 40 mg daily; the maximum dosage is 120 mg daily.

Other types of Methadone Treatment program include: Weaning Program the recovering addict receives a dose of methadone for first 2 days that approximates the same dose as thestreet drug used. Maintenance Program a client is given the same methadone dose every day. The dose may be less than that of the street drug, but it remains consistent throughout the course of treatment.

Opioid Agonist-Antagonists In the past 20 years Opioid Agonist-Antagonists, medication in which an opioid antagonist (naloxone [Narcan]) is added to an opioid agonist, were developed in hopes of decreasing opioid abuse, Pentazocine (talwin) First opioid analgesics, can be given orally (tablet) and by injection (SubQ,IM and IV ) Butorphanol tartrate (Stadol), Buprenorphine (Buprenex) Nalbuphine hydrochloride (Nubain) are examples of other opioid Agonist-antagonist analgesics Opioid Agonist-Antagonists drugs are not given for cancer pain, because of the risk of potential CNS toxicity from the high doses required. These analgesics are considered safe for using during labor, but their safety during early pregnancy has not been established.

Opiods: Agonist-Antagonists Generic (Brand) Buprenorphine HCL (Buprenex) CSS V Uses and Considerations For moderate to severe pain associated with surgery, cancer, urinary calculi, mycordial infarction, and trauma. Avoid alcohol and CNS depressants.

Butorphanol tartrate (stadol) CSS IV

Management of moderate to severe pain for cancer, urinary calculi, labor, musculoskeletal, and burns.

Dezocine (dalgan) CSS IV

To control moderate to severe pain. -has been found to be an effective painkiller comparable to meperidine (pethidine), and so is a more effective analgesic than pentazocine, but causes relatively more respiratory depression than pentazocine.

Nalbuphine HCL (Nubain) CSS IV

To relieve moderate to severe pain. Inhibition of pain impulses transmitted in the CNS by binding with opiate receptor and increasing pain threshold.

Pentazocine lactate (Talwin) CSS IV

To control moderate to severe pain.

NURSING PROCESS Opioid Agonist- Antagonist Analgesics: Nalbuphine (Nubain) Assessment Obtain the drug history of the patient. Report if a drug interaction is probable. When taken with nalbuphine, CNS depressants can cause respiratory depression. Note the baseline vital signs for the future comparison. Assess the type of pain, duration, and location before giving the drug. Nursing Diagnosis Acute pain related to trauma Planning Clients intensity of pain will be lessened. Nursing Interventions Monitor Vital signs. Note any changes in respirations Check bowel sounds and date of last bowel movement to identify constipation. Decreased peristalsis may result in constipation. Determine urine output. Report if urine output is <30ml/hr or <600 ml/day. Administer IV nalbuphine undiluted. Do not mix with barbiturates. Side effects Instruct to client report side effects of nalbuphine: dizziness, headaches, constipation, dysuria, rash, or blurred vision. Hallucinations, tachycardia, and respiratory depression are adverse . Evaluation Evaluate effectiveness of nalbuphine in relieving pan. If ineffective, another opiod analgesics may need to be ordered.

Determine stability of vital signs. Note whether there is a change in respirations, pulse rate, or blood pressure. Opioid antagonist Opiod antagonist are antidotes for overdose of natural and synthetic opiod analgesics. An opioid antagonist blocks the receptor and displaces any opioid that would normally be at receptor, inhibiting the opioid action.

Opioid Antagonist Generic (Brand) Nalmefene (Revex) Reverses opioid overdose and respiratory depression. To treat opioid overdose. Approved for use in neonates to reverse respiratory depression induced by maternal opioid use.

Naloxone HCL (narcan)

Naltrexone HCL (trexan, ReVia)

Treatment of opioid abuse and alcohol abuse. Three to five times more potent than naloxone. Devreases but does not prevent craving for opiods. Use after client is off opioid for 7 or more days. Do not give if clients is in opiate withdrawal; can cause hepatoxicity,

Opioids: Opium and Synthetics Codeine (Sulfate, phosphate) Effective for mild to moderate ain. Can be used with nonopioid (Acetaminophen) for pain relief. Has antitussive properties. Can decrease respiration and cause physical dependence and constipation.

Hydrocodone bitartrate (Hycodan, Vicodin with acetaminophen)

Treatment of moderate to moderately severe pain. Combination with acetaminophen (Lortab, Vicodin), aspirin (Lortab ASA), ibuprofen(Vicoprofin), and chlorpheniramine (Tussionex). Can be prescribed for analgesic and antitussive purposes

Hydromorphone HCL (Dilaudil)

Treatment of moderate to severe pain. Can be prescribed for analgesic and antitussive purposes.

For moderate to severe pain. Has side effects similar to morphine

Levorphanol tartrate (LevoDromoran) For relief of moderate to severe pain, GI procedures and preoperative sedation.

Meperidine (Demerol)

For relief of moderate to moderately severe pain, including post operative and post partum pain

Morphine Sulfate

Oxycodone HCL (OxyContin)

Oral medications are generally prescribed for the relief of moderate to severe pain. Low dosages have also been prescribed for temporary relief of diarrhea. Avoid taking drug over an extended period of time. As potent as morphine. Take food

to avoid GI distress.

For moderate to severe pain. Percocet contains acetaminophen. Percodan contains aspirin and can cause gastric irritation, so it should be taken with food or plenty of liquid. Oxycodone HCL with acetaminophen (percocet) and oxycodone terephthalate with aspirin (Percodan)

Propoxyphene HCL (Darvon) Propoxyphene Napyslate (darvon-N)

For mild pain. Weak analgesics. Darvocet-N contains acetaminophen and Darvon-compound contains asprin, so should be taken with food or plenty of liquid. Not a constipating drug; has little physical dependence. Opiod analgesic with rapid onset of action. May be given to induced anesthesia or administered by continuous infusion with nitrous oxide and oxygen.

Alfentanil (Alfenta) Short acting potent opiod analgesic. May be used with short term surgery. Dose varies according to age. Drug available as transdermal patch for controlling chronic pain.

Fentanyl (Duragesic, Sublimaze) Potent synthetic opioid; used as part of the balanced anesthesia group. May be used as primary anesthetic.

Sufentanil citrate (Sufenta)

Newest opiod analgesic. Rapid onset of action, short-acting duration (5-10min). can cause respiratory depression, hypotension, and bradycardia.

Remifentanil (ultiva)

Similar to morphine but longer duration of action. Used In drug abuse programs. Helps alleviate craving for opiods. Peak action is 30-60 min.

Methadone (Dolophine)

Hydromorphone Hydromorphone HCL (Dilaudil) Is a semisynthetic opioid similar to morphine. The analgesic effect is approximately six times more potent than morphine with fewer hypnotic effect and less GI distress.

Combination Drugs To treat moderate to severe pain, combination drugs of an NSAID and an opioid analgesic may be used. Ex. Hydrocodone and Ibuprofen (Vicoprofin) Which is combination of an NSAID and an opiod.

Another Combination for treatment of mild to moderate pain is Acetaminophen and codeine. Using a combination of drug for pain helps to decrease drug dependency that may result from ossible long term use of an opioid agent. Patient-Controlled Analgesia (PCA) Patient-Controlled Analgesia is an alternative route for opioid administration for self-adminstered pain relief as needed. Configured for epidural administration of fentanyl and bupivacaine for postoperative analgesia

configured for intravenous administration of morphine for postoperative analgesia Transdermal Opioid Analgesics Provide a continuous around the clock pain control that is helpful to clients who suffer from chronic pain.

The transdermal method is not useful for acute or postoperative pain.

Equianalgesic Opioid Dose table Opioid analgesic Morphine Fentanyl Codeine Hydromorphone Meperidine Oxycodone Hydrocodone Oxymorphone Methadone Oral 30mg 200mg 7.5mg 300mg 20mg 30mg 10mg rectal 20mg Intramuscular 10mg 0.1mg 130mg 1.5mg 75mg 1mg 10mg Intravenous 10mg 1.5mg 75mg 1mg 10mg

Analgesic Titration Analgesic may be titrated to increase or decrease the dosage. Usually post operative pain will decrease over time, and analgesics will be titrated downward. However, the client with cancer-related pain usually has continual increase in pain and will require an upward titration. Titration can be accomplished by changing the dose, the interval between doses, the route of administration or the drug. When titrating analgesics,the dosage is decided after assessing the clients respiratory rate and pain level.

Opioid Use in Special Populations Children Pain management in children is complex, because it is more difficult to assess their pain. Some children will not verbalize discomfort when they are in severe pain. OUCH SCALE

0-Very happy because he doesnt hurt at all. 1-hurts a little bit. 2- hurts a little more 3-hurts even more 4-hurts a whole lot 5- hurts as much as you can imagine, although you dont have to be crying to feel this bad Older Adults adults who are 65 years of age or older require adjustment to drug doses to avoid severe side effects.

Cognitive Impaired Individuals Any cognitive impaired individual may be unable to report pain adequately.the nurse should use a measurement scale that is appropriate for the client. Some physical signs of pain include: Moans Grimacing Clenched teeth Noisy respiration Restlessness

Oncology Clients Cancer Pain is managed according to three levels of analgesia based upon World Health Organization (WHO) Ladder as followed: Step 1 Mild Pain: Nonopioids with or without an adjuvant medication Step 2 Moderate Pain: Nonopioids and mild opioid with or without an adjuvant medication.

Step 3 Severe Pain: stronger opioid at higher dosage levels with or without an adjuvant medication. Individual with History of substance abuse Often clients with history if substance abuse require pain medication. A thorough pain assessment is necessary to find out the cause of pain.