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Management of Pain Using Opioids and Nursing Implications

Pharmacological Management of Acute and Chronic Pain

Abstract

The purpose of the current discussion is to determine the pharmacological management of acute and chronic pain using opioids and nursing implications. The discussion will outline pharmacodynamics properties and actual or potential effects on the patient involved in the treatment process. It will also strive to evaluate and outline the nursing implications as a result of using opioids in the pharmacological management of acute and chronic pain. The discussion will define what pain is and further explain the two types of pain: chronic and acute. The discussion will also outline possible or expected outcomes that nurses should observe during the treatment process of chronic and acute pain and what should be done in case they identify the outlined signs when using opioids.

Introduction

Pharmacology is defined as a branch of biology and medicine that is tasked with the study of how drugs affect the body. On the other hand, drugs are referred to as any natural, man-made or other substance that is produced in the body, and affects the cell, organism or organ both biochemically and physiologically. Chronic pain refers to the conditions which are multifactorial and have both psychological and physical symptoms. According to Moulin et al. (2014), twenty percent of people living in developing countries suffer from chronic pain. Despite the efforts to curb chronic pain, it is still a significant challenge. Acute pain is classified as pain that does not last for long as compared to chronic pain; acute pain lasts for not more than six months. When the cause of acute pain is identified and managed, it disappears. However, if left untreated acute pain may turn to chronic pain. Opioids are defined as drugs that relieve pain in the nervous system, by reducing the strength of pain signals reaching brain cells. Uncontrolled use or abuse of these drugs can result to withdrawal symptoms and physical dependency. Opioids are one of the groups of drugs that are used in the treatment of chronic and acute pain. Drugs categorized as opioids include codeine, hydrocodone, acetaminophen, fentanyl, meperidine, hydromorphone, methadone, oxycodone, morphine, and naloxone. However, there are nursing implications when opioids are used to treat chronic and acute pain; therefore nurses should be aware of these implications when treating patients. Opioids are one of the most commonly used drugs in the pharmacological management of pain. For these drugs to be used effectively, physicians like nurses must be aware of the implications involved in the treatment process.

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Pharmacodynamics Properties and Actual/Potential Effects on the Patient

Pharmacodynamics is defined as the study of how drugs affect the body. According to Dart et al. (2015) chronic pain is one of the medical conditions that prompt most Americans to visit medical centers. It is believed to result in a disability of a large number of people as compared to cancer and heart diseases combined. The primary purpose of treating people suffering from chronic pain is to ensure that the pain they are experiencing is mitigated.

Presently in the disease state, chronic pain can only be curbed but not treated. Pathophysiological understanding of acute and chronic pain has yielded a breakthrough in pharmacological management of pain disorders, which include migraine, headache, lower back, osteoarthritis, post herpetic, rheumatoid, and fibromyalgia.

Opioids are prescribed when a patient experiences severe pain. However, a crucial point in this case is that if used incorrectly opioids may have serious effects. These drugs bind the opioids receptors located in the spinal cord, brain, and other body areas. Hence, they limit the strength of pain signals reaching the brain. As stated earlier, acute pain may progress to chronic pain. Therefore, health care providers treat acute pain with a high level of seriousness in order to prevent the medical conditions from progressing to a condition which cannot be cured but rather controlled (chronic pain). Opioids are effective in the treatment of acute pain; this is associated with their immediate efficacy, onset, and reduced tendency to develop dependency. Kraft, Wiechula, and Conroy (2015) argue that opioids cause more harm than good when it comes to the treatment of chronic medical conditions which are non-cancer in nature such as back pain, headache, and fibromyalgia.

Therefore, it is suggested that they should be used with the utmost caution. When treating chronic pain, opioids are considered to be the last resort when other alternatives cannot function properly. Chronic pain occurring periodically such as migraine, nerve pain, and fibromyalgia is advisable to be treated with other kinds of medications. A pain relief ladder formulated by the World Health Organization outlines a guideline on how pain caused by cancer, acute and chronic pain can be dealt with. Adjuvant medications such as antidepressants can be administered at any step of the ladder. On the other hand, the effectiveness of medications such as analgesic becomes better as you go higher on the ladder. At the same time, the possibility of abuse of these drugs increases as well (Kraft et al., 2015).

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According to WHO, the first stage when it comes to the control of pain is to use nonopioids which include nonsteroidal anti-inflammatory drugs and acetaminophen. The features of the acute pain and the risk factors associated with the patient’s condition should be determined before choosing one of the two types of medications. Acetaminophen is also known as paracetamol in the US. It is also considered as the first drug to treat moderate to mild acute pain. Acetaminophen is considered to be tolerated easily, drug-drug interactions are minimal, it does not affect blood pressure, and most importantly this drug can be consumed by pregnant women. Despite the fact that this medicine does not treat low back pain effectively when compared to nonsteroidal anti-inflammatory drugs, its cost profiles and safety make it a good choice for the treatment of acute pain. The other opioid to consider is Aspirin, which is quite effective when being used to treat acute pain.

However, aspirin is associated with ulcers and gastrointestinal hemorrhage. Other nonsteroidal anti-inflammatory drugs which are used in the treatment of acute pain have anti-inflammatory effects which acetaminophen lacks. As a results, these drugs are a good choice for treating acute pain which is caused by prostaglandin-mediated activities like osteoarthritis or dysmenorrhea. Due to the fact that most of these nonsteroidal anti-inflammatory drugs bear similar analgesic effects, the choice of which drug to use is dictated by the dosing schedule, cost, and severity or frequency of the adverse effects. Some nonsteroidal anti-inflammatory drugs like mefenamic acid are not commonly used due to their associated side effects (Griffin, 2015).

The next stage in the WHO ladder is to use the opioid medications, which are recommended if the nonopioids are not effective. It involves combining opioids with nonopioids in order to treat acute pain not susceptible to the earlier treatment. In the event that even after combining opioids and nonopioids there was no positive results observed, full opioids agonists are used such as morphine, which is considered to be one of the most effective opioids as compared to codeine. Evidence suggests that codeine is less effective, which is associated with the fact that opioids receptors have low affinity to it (Griffin, 2015). When taken under the instructions of a health care professional opioids are effective and safe. However, they are accompanied by side effects and risks especially when abused, as discussed below.

Sedation and Constipation

One of the side effects of using opioids is that they tend to make a person sleepy and tired. As such, it can lead to accidents especially if they are taken when one is working. It is therefore advisable to make sure that opioids are not taken while one is working. Constipation is defined as an infrequent hard bowel movement. Opioids users have been found to experience this side effect regularly. However, constipation can be cured using stool softeners and laxatives (Arnstein & Broglio, 2016).

Decreased Low Sex Hormones

In case patients take opioids, their estrogen and testosterone hormone levels go down. In turn, this leads to low sex drives in men or makes it hard for men to manage an erection. Testosterone is the hormone that controls the sexual desire in men and with its low levels in the body the above side effects are evident. On the other hand, when it comes to women, estrogen is responsible for controlling the menstrual cycle. With its reduced supply in the body, menstrual cycles cease, which especially occurs when opioids are taken orally or via skin patches. Generally, the productivity of both men and women is affected (Arnstein & Broglio, 2016).

Dependency and Tolerance

Continued use of opioids by patients leads to a dependency. This is defined as a condition whereby a pain cannot reside without the use of these medications. What this means is once withdrawn, patients suffer a withdrawal effect. Dependency is not within the control of the patient; however, this does not automatically imply that a person is addicted to opioids. Tolerance, on the other hand, means that for a patient to be able to relieve their pain, they have to continue increasing the amount of opioids dosage that they consume. As a result, the sensitivity of opioids receptors decreases. Increasing opioids dosage increases the side effects. At some point with the increased tendency to increase the dosage, a high dosage may not be able to produce any desired effects. Buprenorphine and methadone have been used successfully to treat opioid addiction (Arnstein & Broglio, 2016). Withdrawal symptoms associated with opioids include, anxiety, agitation, low energy, insomnia and irritability. These symptoms last between one to four weeks, and are known as early stage symptoms which are succeeded by post-acute withdrawal signs. Post-acute signs can incapacitate patients and considerably reduce their productivity. They can also reduce their social life due to emotional surges, which makes it hard for the patients to relate with people around them peacefully.

Sensitivity from Opioid Pain Medicines

If a patient has been using opioids for a long time, they develop a condition called opioid-induced hyperalgesia. It worsens the pain being experienced by the patient; continued use of opioids makes the patient’s body overly sensitive to the things which are considered as not being painful. Thus, continued intake of opioids may result to pain in other areas of the body (Caraceni et al., 2012).

Dry Mouth

Opioids have been known to decrease the amount of saliva produced by the salivary glands. Saliva is responsible for flushing any bacteria that reside in the mouth and cause tooth decay. When used for a short time, opioids cause short-term dry mouth. However, if used for a prolonged amount of time, the problem of dry mouth becomes much more serious. Saliva produced by salivary glands helps in keeping the lips soft, while harbor ptyalin enzyme aids with the initial digestion of carbohydrates. Hence, without this enzyme it becomes hard for the mouth to perform its function in the digestion process (Caraceni et al., 2012).

Central Sleep Apnea

Central sleep apnea is defined as those moments when one cannot breathe while sleeping. These moments are usually brief. With increased dosage of opioids, the risk of central sleep apnea increases. Opioids patients who consume alcohol or drugs that are known to induce sleepiness are at a high risk of suffering from central sleep apnea. The condition results in the patient not getting enough sleep increasing the level of tiredness (Arnstein & Broglio, 2016).

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Lung and Heart Problems

Opioids patients may suffer from both heart and lung problems due to the fact that opioids sedations reduce the ability of the brain to curb breathing process, which results in reduced breathing. With time, this may result in the damaged lungs and heart due to insufficient air supply to these organs. The higher the dosage of opioids, the higher this risk is. Thus, this risk gets even more dangerous when a patient is consuming alcohol, sleep aids, and drugs that cause sleepiness (Arnstein & Broglio, 2016).

Brain Damage

Due to hypoxia conditions, the blood being pumped to the brain by the heart will not have enough oxygen in it. The brain requires oxygen in order to function properly. Thus, with deprived oxygen the capacity the brain will be damaged (Caraceni et al., 2012).

Confusion and Itching

Opioids patients experience cognitive changes, which are caused by the mode in which opioids affect the nervous system. It makes nervous system less responsive making a patient susceptible to drowsiness. Opioids users may sometimes suffer from itching, which mostly occurs when morphine is administered in the form of an injection. Itching is a result of the opioid receptors in the spinal cord reacting to the morphine (Roux et al., 2013).
When managing opioids tolerant patients, the primary goal is to make sure that they do not suffer from withdrawal symptoms, enhance sufficient perioperative analgesia, and provide support in case of social, behavioral, and mental issues. Management has to start during preoperative assessment, before the patient is admitted and should also have a conclusive discharge plan. Strategies to mitigate risks should be put in place before the treatment process begins. The clinician and the patient should be aware of the objectives that they wish to achieve (Arnstein & Broglio, 2016).

Nursing Implications

A nurse is defined as a professional who is highly skilled in the health care profession and uses both their scientific knowledge and the art of caring to help others. Nursing, on the other hand, is defined as the promotion, protection, and optimization of one’s abilities and health, prevention of injury and illness, facilitation of healing, alleviation of suffering by diagnosing and treating human response, and advocating care for the families, individuals, populations, groups and communities. A nurse is one of the most crucial health practitioners in the medical field. This is because they get in close contact with the patient more often that other physicians. They are tasked with administering the dosage of most drugs, monitoring the progress of the patients, keeping records, and reporting to the head physician on the progress of the patient. They should therefore be able to collect all the required medical information. For a successful administration of the opioids drugs, it is crucial to perform a detailed clinical assessment, which is focused on identifying the region of the body that is affected in order to determine what causes pain. Evaluating pain regularly with the help of a pain scale would help the medical physicians in determining how effective the treatment process is and understanding whether it is necessary to make changes (Edlund et al., 2014).

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Allergies are one of factors that make most people unsuitable for using certain drugs. Nurses are tasked with ensuring they are aware of the medical conditions of their patients before prescribing a certain drug to them. Some of the side effects of opioids can be associated with allergies such as itching. It is therefore crucial to make sure that a nurse is aware of the patient’s reaction to different substances and determine whether these substances are contained in the opioids. As a result, in case of an effect they will be in a position to determine whether it is an allergic reaction or a side effect. The nurse is also tasked with understanding the medical record of a patient in order to evaluate the effectiveness of the drug being used (Chou et al., 2015).

Intravenous acetaminophen is considered as a non-opioids analgesic drug used for the mitigation of pain considered being moderate. When used safely, this drug is quite effective. However, nurses are advised to make sure they are well aware of the patients’ use of nonprescription and prescription drugs that contain acetaminophen. The nurse must go further and make sure patients understand the importance of not taking an overdose of acetaminophen. Thus, along with being able to predict some of the challenges associated with taking opioids drugs, a nurse should be able to treat some of the life threatening effects like breathing problems (Trescot, 2016).

Nurses should also be in a position to monitor changes in the use of opioids. For instance, meperidine is no longer a preferable drug due to a compound found in it that affects patients negatively; in its place, hydromorphone is preferred. However, most clinicians confuse the two drugs due to the lack of access to the current medical records. As a result, the cases have been reported showing that the drug has been abused on several occasions especially when a patient is switched between the two medications (Griffin, 2015).

Conclusion

It is clear that chronic and acute pain are one of the most dangerous medical conditions that prompt most people to visit medical centers frequently especially in such countries as the US. Even more dangerous is the chronic pain medical condition which can only be controlled rather than cured. Therefore, it is not possible to ignore the importance of opioids in the treatment of these two severe medical conditions. On the other hand, close attention should be paid to the adverse side effects caused by the abuse of these drugs. Thus, clear instructions should be accompanied with the prescription of these drugs in order to avoid abuse and therefore ensure that more good than harm is accrued from the use of opioids.

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