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Anesthetics, Analgesics & Narcotics

Pain ManagementOpioids (Narcotics)

Management of Migraine

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General Anesthesia

Reversible unconsciousnessAbsence of a response to painful stimuliCharacteristics

UnawarenessAnalgesiaSkeletal & muscle relaxationAmnesia on recovery

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Types of General Anesthesia

Inhalant AnestheticsNitrous Oxide

Injectable AnestheticsBarbiturates, BenzodiazepinesKetamine – dissociative amnesia

AntagonistsNaloxone

Neuromuscular Blockers

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Local Anesthetics

Transient, reversible loss of sensation in a specific body areaNo change in alertness or mental functioningIndications

Sunburn, bites, cuts, dental work, hemorrhoids

Chemical AgentsBenzocaine, lidocaine, cocaine

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What is Pain?

An unpleasant sensory or emotional experience which we primarily associate with tissue damage.Pathway damages the nerve pain impulse to brain

Opioid Receptor Brain Distribution

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Pain Syndromes

Acute Pain recent onset, transient, identifiable cause

Chronic Pain persistent or recurrent pain, beyond usual course of acute illness or injury

NonmalignantDiagnosed or undiagnosed cause such as a nonmalignant disease

MalignantDisease present pain severity worsens as progresses

Breakthrough Pain transient pain, severe or excruciating, over baseline of moderate pain

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ABC’s of Pain Management

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Non-Drug Pain Management Techniques

DistractionIce/HeatTV/ read/visiting

RelaxationBreathing, yogaTapes, music

MassageBiofeedbackAcupunctureImagery

Pleasant mental picture

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Pain NeuroTransmitters Pain Relief Meds

Substance PGlutamateGABANorepinephrineSerotoninHistamine

NSAIDSAntidepressantsAnti seizure medsMuscle relaxantsLocal salves- capsaicin Narcotics

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Opioids (God Morpheus of Dreams)Narcotics (Narcosis—stupor)

Produce analgesia by binding to opiate receptors in the CNS, brain and spinal cord involved with the transmission of pain impulses.Endogenous opioids are present at brain sites

Released during stress, pain & anticipation of pain

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Common Opioid Side Effects

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Clinical Indications

AnalgesiaAcute Pulmonary EdemaCoughDiarrheaAnesthesia

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Toxicity Opioid Antagonists

ToleranceDependence

PhysicalPsychological

OverdoseDrug InteractionsContraindications

AgentsNaloxoneNaltrexone

MOAIndications

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Analgesic Ladder

NSAID (ASA)Adjuvant analgesic (APAP, antihist)

Non-narcotic analgesic (NSAID)Weak opioid (Codeine, propoxyphene)

Strong opioid (Morphine) with adjuvant analgesic

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PCA (patient-controlled analgesia pump)

Why a Pump?

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Oxycontin Abuse

When tablets are crushed, snorted or extracted & injected.Effective, less toxic, well-tolerated medication.Backlash ‘war on drugs’ challenges legitimate users

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Non-Opioid AgentsNon-Steroidal Anti-Inflammatory Drugs (NSAIDS)

Aspirin (prototype)Indications

Anti-inflammatoryAnalgesicAnti-pyreticAnti-platelet

DosageToxicity

Reye’s Syndrome brain pressure

COX-2 InhibitorsCelebrexMobic

MOAToxicity

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Headache Classification

Primary: no known cause

Tension type EpisodicChronic

Migraine

Secondary: known cause

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Headache Triggers

Physical causesHormonal factors

Menstrual migrainesSleep

Oversleeping, fatigueEnvironmental causes

Weather, seasons, light, odors, altitude...MedicationsDietary factors

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Migraine Tension Headache

Lasts 4-72 hoursProdrome or auraUnilateral,pulsatingModerate-severeAggravated by strainNausea, vomitingphoto/phono phobia

Lasts 30min to 7daysBilateralNo pulsationMild to moderateNot aggravated by strain

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Migraine Headaches

PathogenesisVasodilation5-HT mediated

Ergot PreparationsConstrict blood vesselsRebound HA w/overuseCaution > 40yr

Heart attack risk

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Therapeutic Management

Selective 5-HT receptor agonistBind to serotonin receptors to cause vasoconstriction of the blood vessels

Anti emeticsReduces nausea, vomiting and gastritis

Opioid analgesicsBlocks impulses to the brain

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Prophylaxis Management

AnticonvulsantsBeta blockers

Prevents vasodilation

Ca channel blocker

NSAIDRelieve inflammation & are non-sedating

TCAInduces sleep, relaxation

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Herbal Remedies

FeverfewPeppermint oilValerian rootGinkgoLemon balmCaffeine

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Nondrug Treatments

Physical TherapyAcupunctureAcupressureMassageAroma therapy

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Summary Slide

General AnesthesiaABC’s of Pain Management (drug & nondrug)

Narcotics/Opiates Organ EffectsCommon Opioid Side EffectsAnalgesic LadderNon-Steroidal Anti-Inflammatory Drugs (NSAIDS)

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Summary Slide (cont.)

Headache ClassificationTherapeutic Agents