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Pharmacology Spring 09 – Unit 2

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1 Pharmacology Spring 09 – Unit 2
Carla Hilton, MSN, RN, CNE Lecture 3 Chapters 28, 77

2 Learning Outcomes Compare and contrast fundamental concepts related to the use of specific central nervous system drugs, including those used for management of pain, drugs related to the maintenance of bowel function and the management of constipation. Acquire a working framework for studying drug classifications and nursing implications.

3 Classifications: Opioid (Narcotic) Analgesics, Opioid Antagonists, and Non-opioid Centrally Acting Analgesics Chapter 28

4 Intro to Opioids Chemical class: Opioid vs opiate
Opiod means they act like an opiate Opiates are from poppy seeds Functional class: Narcotic Analagesic MOA – body peptides (3) enkephalins, endorphins, dynorphins (they produce their effects at these receptor sites) Opioid receptors - mu, kappa, and delta Agonist, partial agonist, antagonist Partial agonists produces low to moderate activation alone, but will block actions of full agonists if given simultaneously Strong and moderate to strong

5 Table 28-1

6 Opioid Agonists Prototypes MOA / TE Strong: morphine [Duramorph] CII
Moderate to strong: codeine [Paveral] CIII MOA / TE Mimics action of endogenous opioid receptors (mu) to produce analgesia and thereby relieve pain Other effects include drowsiness, mental clouding, anxiety reduction, sense of well-being. CNS Depressant Oral dose is a lot higher than IV in this case

7 Adverse Effects Resp. depression Others Toxicity
Diminished by “tolerance” Most common cause of OD death Others Constipation, orthostatic hypotension, urinary retention / urgency, cough suppression, biliary colic, emesis, elevated ICP (intracranial pressure), dysphoria, sedation, miosis (small pupils), neurotixicity, immune and hormone suppression with prolonged use Toxicity Classic triad (coma, resp. depression, pinpoint pupils)

8 Miosis- tiny little pin point pupils
Mydriasis- with the d in the word, think dilated pupils

9 ADME (Pharmacokinetics) Nursing implications?
Given by several routes Slowest to fastest Time-frame for TE varies by mode of administration If you want the drug now, do IV. We need to know how long it takes these to work Denatured in liver Hard to cross blood-brain barrier Precautions / Contraindications Decreased resp reserve, pregnancy, head injury, infants (crosses placenta) / elderly, hypotension, liver disease Interactions CNS depressants, antihistamines, antihypertensives, MOAIs*, antiemetics, amphetamines, agonist-antagonist, antagonists

10 Dosage – Highly individualized Administration
Table 28-6 Administration po, IM, IV, SQ, topical, PCA Oral associated with chronic Preferably fixed schedule Site specific – hazards (epidural, effects delayed…)

11 Other Strong Opioids Fentanyl (Sublimaze)
Anesthesia primary use (injectable) 100 X mg potency of morphine Commonly seen as transdermal No children under 2 / none for under 18 less than 100 lbs. Transmucosal (popsicle) Breakthrough cancer pain Store carefully very large amts of drug (can kill!)

12 Hydromorphone [Dilaudid] Methadone Heroin – crosses blood-brain easier
Meperidine [Demerol] Interacts with several drugs – esp MAOI’s Toxic metabolite (had problems in the elderly) Avoid use past 48 hrs and not to exceed 600mg/24hr. Hydromorphone [Dilaudid] Methadone Help people addicted to heroin Heroin – crosses blood-brain easier

13 Table 28-6 – Dosing for Opioids

14 Moderate to Strong Opioid Agonists
Codeine Usual dose of 30 mg = about same relief as 325 mg of ASA or Tylenol Combo meds more effective Extremely effective cough suppressant at 10 mg dose range Oxycodone [OxyContin, Percodan] & CR forms Hydrocodone [Lortab, Norco, Vicodin] CIII Proproxyphene [Darvon, Darvocet] CIV

15 Special Clinical Concepts r/t Use of Opioids
Pain assessment – including evaluation! Dosing amt and schedule Fear of addiction in clinical setting Avoiding withdrawal – 20 days or more They can have withdrawal symptoms Patient controlled anesthesia (PCA) Morphine: DOC - heart attack (MI) Meperidine [Demerol]: DOC OB Doesn’t cross placenta Avoid opioids in Head Injury…

16 Nursing Implications Link to ATI pp. 133 (150)

17 Class: Opioid Agonist-Antagonists
Prototype: pentazocine [Talwin] Others: nalbuphine [Nubain], butorphanol [Stadol] MOA - act mostly at mu kappa receptor to produce analgesia and relieve pain. Alone = agonist action With agonist = can antagonize (blocks mu receptor) Adverse effects – similar to opioids ADME (Pharmacokinetics) Less respiratory depression, low abuse potential Less effective pain relief *Can start withdrawal sxms in opioid addiction

18 Class: Opioid Antagonists
Prototype: naloxone [Narcan] MOA – TE / Use competes for opiate site and blocks effects of opioid agonists / agonist-antagonists – no significant effect given alone – resulting in REVERSAL of narcotic ADME Rebound effect (narcan wears off and they are back under the morphine…) Adverse effects: acute withdrawal Dosage/Admin: 04. mg IM, IV, SubQ Others: naltrexone [ReVia] ETOH/Opioid abuse

19 Non-opioid Centrally Acting Analgesics
Prototype: Tramadol [Ultram] Others: clonidine [Duraclon] is another centrally acting analgesic – pain / HTN MOA / TE / Use Analog of codeine – binds w mu receptor producing analgesia to relieve pain. Also blocks re-uptake of norepinephrine (lots of this in your system) ADME (Pharmacokinetics) Minimal potential for dependence or resp depression Adverse effects Rare – most common: sedation, dizziness, HA, dry mouth, and constipation Precautions Can intensify other CNS dep. – ABSOLUTELY avoid MAOIs

20 Laxatives Chapter 77

21 Bulk-forming Prototype(s): methylcellulose, psyllium (Metamucil)
Action / Use Behave like dietary fiber – nonabsorbable – swell to form viscous solution / gel and softening fecal mass and increasing transit. Temp relief of constipation, diarrhea, irritable bowel, ostomies Adverse effects Esophageal & intestinal obstruction if not enough fluid  ? If you don’t take with enough fluid you can obstruct stuff. Builds a brick in the gut that doesn’t move (If this, then?)

22 Surfactants Prototype: docusate sodium (Colace) Action / Uses ADME
Lower surface tension of stool and softens by facilitating penetration of water into the feces Act on intestinal wall to inhibit fluid absorption and stimulate secretion of water and electrolytes into the intestinal lumen. Brings water into the stool and makes it softer ADME Full glass of water Sit upright for 30 min (kind of oil based and you can aspirate the stuff and get pneumonia) Effectiveness dose related (min 200 mg/day) Adverse reactions – rare Dosage: 50 to 500 mg daily ( but usually at least 200 mg a day)

23 Stimulants Typically abused the most
Prototype(s): bisacodyl (Dulcolax), senna (Senekot) Action / Legitimate Uses Directly stimulate gut motility, increase secretion of water and ions into intestine, and reduce water and electrolyte absorption. Uses: Treatment of (1) opioid-induced constipation and (2) slow transit constipation Dosage: related to formulation administered Take bisacodyl no sooner than 1 hour after ingesting milk or antacids – do not crush Adverse reactions Bowel rupture can occur If you have gut surgery and your sutures are healing, if you give them this is makes their gut move and can tear open the incision

24 Osmotics Salts Prototype: sodium phosphate (Fleet) and magnesium salts
Action /Uses Non-absorbable and retains water in the colon Adverse reaction Dehydration, diarrhea and loss of water (more with salts than with glycol) Magnesium can accumulate to toxic levels in renal failure Sodium can retain fluid – so…. Contraindicated in patients with heart failure HTN and edema Other: glycol (MiraLax) – fewer side effects / safer

25 Miscellaneous Lactulose (sugar base) Glycerin Suppository
Action / Uses Poorly absorbed and cannot be digested – by product of breakdown results in osmotic diuresis Enhances excretion of ammonia in liver failure SEs – flatulence, cramping Glycerin Suppository Polyethylene Glycol-Electrolyte (GoLytely) Safe in dehydrated or electrolyte sensitive

26 Additional Nursing Implications
High risk patients Contraindicated in abdominal pain, nausea, cramps, regional enteritis, diverticulitis, ulcerative colitis, acute surgical abdomen, fecal impaction, bowel obstruction. Abuse Castor oil (powerful stimulant – avoid at night – not to children)


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