Question

Discuss 5 classes of medications used for chronic pain and the nursing responsibilities for each.

Answer 1

QUESTION:

1.Discuss 5 classes of medications used for chronic pain and the nursing responsibilities for each.

ANSWER:

 

TYPES OF PAIN MEDICATIONS AVAILABLE

NONOPIOIDS

· Acetaminophen

· Ibuprofen

· Naproxen

· Diclofenac

WEAK OPIOIDS

· Codeine

· Tramadol

COMBINATION OPIOIDS

· Acetaminophen + Codeine

· Acetaminophen + Hydrocodone

· Acetaminophen + Oxycodone

· Acetaminophen + Tramadol

· Codeine + Acetaminophen + Butalbital + Caffeine

· Codeine + Aspirin + Butalbital + Caffeine

· Dihydrocodeine + Acetaminophen + Caffeine

· Hydrocodone + Ibuprofen

STRONG OPIOIDS

· Alfentanil

· Fentanyl

· Hydrocodone

· Hydromorphone

· Methadone

· Morphine

· Oxycodone

· Oxymorphone

· Sufentanil

OTHER

· Ketamine

 

1.ACETAMINOPHEN

This drug is used to treat mild to moderate pain (from headaches, menstrual periods, toothaches, backaches, osteoarthritis, or cold/flu aches and pains) and to reduce fever.

Drug name

Generic name: acetaminophen (n-acetyl-p-aminophenol)

Brand name:

• Suppositories: abenol (can), acephen
• Oral: aceta, apacet, atasol (can), genapap, genebs, liquiprin, mapap, panadol, tapanol, tempra,tylenol

Classification: antipyretic, analgesic (nonopioid)

Pregnancy category b

Dosages

Adults

• Po or pr
• By suppository, 325–650 mg q 4–6 hr or po, 1,000 mg tid to qid. Do not exceed 4 g/day.

Pediatric patients

• Po or pr
• Doses may be repeated 4–5 times/day; do not exceed five doses in 24 hr; give po or by suppository.

Therapeutic actions

• Antipyretic: reduces fever by acting directly on the hypothalamic heat-regulating center to cause vasodilation and sweating, which helps dissipate heat.
• Analgesic: site and mechanism of action unclear.

Indications

• Analgesic-antipyretic in patients with aspirin allergy, hemostatic disturbances, bleeding diatheses, upper gi disease, gouty arthritis
• Arthritis and rheumatic disorders involving musculoskeletal pain (but lacks clinically significant antirheumatic and anti-inflammatory effects)
• Common cold, flu, other viral and bacterial infections with pain and fever
• Unlabeled use: prophylactic for children receiving dpt vaccination to reduce incidence of fever and pain

Adverse effects

• Cns: headache
• Cv: chest pain, dyspnea, myocardial damage when doses of 5–8 g/day are ingested daily for several weeks or when doses of 4 g/day are ingested for 1 yr
• Gi: hepatic toxicity and failure, jaundice
• Gu: acute kidney failure, renal tubular necrosis
• Hematologic: methemoglobinemia—cyanosis; hemolytic anemia—hematuria, anuria; neutropenia, leukopenia, pancytopenia, thrombocytopenia, hypoglycemia
• Hypersensitivity: rash, fever

Contraindications

• Contraindicated with allergy to acetaminophen.
• Use cautiously with impaired hepatic function, chronic alcoholism, pregnancy, lactation.

NURSING CONSIDERATIONS

Assessment

• History: allergy to acetaminophen, impaired hepatic function, chronic alcoholism, pregnancy, lactation
• Physical: skin color, lesions; t; liver evaluation; cbc, lfts, renal function tests

Interventions

• Do not exceed the recommended dosage.
• Consult physician if needed for children < 3 yr; if needed for longer than 10 days; if continued fever, severe or recurrent pain occurs (possible serious illness).
• Avoid using multiple preparations containing acetaminophen. Carefully check all otc products.
• Give drug with food if gi upset occurs.
• Discontinue drug if hypersensitivity reactions occur.
• Treatment of overdose: monitor serum levels regularly, n-acetylcysteine should be available as a specific antidote; basic life support measures may be necessary.

Teaching points

• Do not exceed recommended dose; do not take for longer than 10 days.
• Take the drug only for complaints indicated; it is not an anti-inflammatory agent.
• Avoid the use of other over-the-counter preparations. They may contain acetaminophen, and serious overdosage can occur. If you need an over-the-counter preparation, consult your health care provider.
• Report rash, unusual bleeding or bruising, yellowing of skin or eyes, changes in voiding patterns.

2.IBUPROFEN

Drug name

Generic name : ibuprofen

Brand name: advil, advil liqui-gels, advil migraine, apo-ibuprofen (can), children’s advil, children’s motrin, genpril, infants’ motrin, junior strength advil, junior strength motrin, menadol, midol, midol maximum strength cramp formula, motrin, motrin ib, motrin migraine pain, novo-profen (can), nuprin, pediacare fever, pediatric advil drops

Classification: nsaid, analgesic (nonopioid), propionic acid derivative

Pregnancy category b

Pregnancy category d (third trimester)

Dosage & route

Adults

• Do not exceed 3,200 mg/day.
• Mild to moderate pain: 400 mg q 4–6 hr po.
• Osteoarthritis or rheumatoid arthritis: 1,200–3,200 mg/day po (300 mg qid or 400, 600, 800 mg tid or qid; individualize dosage. Therapeutic response may occur in a few days, but often takes 2 wk).
• Primary dysmenorrhea: 400 mg q 4 hr po.
• Otc use: 200–400 mg q 4–6 hr po while symptoms persist; do not exceed 1,200 mg/day. Do not take for more than 10 days for pain or 3 days for fever, unless so directed by health care provider.

Pediatric patients

• Juvenile arthritis: 30–40 mg/kg/day po in three to four divided doses; 20 mg/kg/day for milder disease.
• Fever (6 mo–12 yr): 5–10 mg/kg po q 6–8 hr; do not exceed 40 mg/kg/day.

Therapeutic actions

• Ibuprofen exhibits anti-inflammatory, analgesic and antipyretic activities. Its analgesic effect is independent of anti-inflammatory activity and has both central and peripheral effects. It potently inhibits the enzyme cyclooxygenase resulting in the blockage of prostaglandin synthesis. It also prevents formation of thromboxane a2 by platelet aggregation.

Indications

• Relief of signs and symptoms of rheumatoid arthritis and osteoarthritis
• Relief of mild to moderate pain
• Treatment of primary dysmenorrhea
• Fever reduction
• Unlabeled uses: prophylactic for migraine; abortive treatment for migraine

Adverse effects

• Oral: dyspepsia, vomiting, abdominal pain, heartburn, nausea, diarrhoea, epigastric pain, oedema, fluid retention, dizziness, rash, tinnitus. Parenteral: intraventricular haemorrhage, skin irritation, hypocalcaemia, hypoglycaemia, gi disorders, anaemia, apnoea, respiratory infection, sepsis.
• Potentially fatal: severe cv thrombotic events. Severe gi bleeding, ulceration and perforation.

Contraindications

• Active peptic ulcer; hypersensitivity. Neonates with congenital heart disease, suspected necrotising enterocolitis and active bleeding (parenteral).

NURSING CONSIDERATIONS

Assessment

• History: allergy to ibuprofen, salicylates or other nsaids; cv dysfunction, hypertension; peptic ulceration, gi bleeding; impaired hepatic or renal function; pregnancy; lactation
• Physical: skin color, lesions; t; orientation, reflexes, ophthalmologic evaluation, audiometric evaluation, peripheral sensation; p, bp, edema; r, adventitious sounds; liver evaluation, bowel sounds; cbc, clotting times, urinalysis, lfts, renal function tests, serum electrolytes, stool guaiac

Interventions

• Black box warning: be aware that patient may be at increased risk of cv event, gi bleeding, monitor accordingly.
• Administer drug with food or after meals if gi upset occurs.
• Arrange for periodic ophthalmologic examination during long-term therapy.
• Discontinue drug if eye changes, symptoms of hepatic impairment, or renal impairment occur.
• Warning: institute emergency procedures if overdose occurs: gastric lavage, induction of emesis, and supportive therapy.

Teaching points

• Use drug only as suggested; avoid overdose. Take the drug with food or after meals if gi upset occurs. Do not exceed the prescribed dosage.
• Avoid over-the-counter drugs. Many of these drugs contain similar medications, and serious overdosage can occur.
• You may experience these side effects: nausea, gi upset, dyspepsia (take drug with food); diarrhea or constipation; drowsiness, dizziness, vertigo, insomnia (use caution when driving or operating dangerous machinery).
• Report sore throat, fever, rash, itching, weight gain, swelling in ankles or fingers, changes in vision, black or tarry stools.

3.NAPROXEN

Drug name

Generic name : naproxen , naproxen sodium

Brand name: apo-naproxen (can), apo-naproxen ec (can), apo-naproxen sr (can), ec-naprosyn, gen-naproxen ec (can), naprelan, naprosyn, novo-naprox (can), novo-naprox-ec (can) ,aleve, anaprox, anaprox ds, apo-napro-na (can), apo-napro-na ds (can), midol extended relief, novo naprox sodium (can), novo naprox sodium ds (can), novo naprox sodium sr (can)

classification: nsaid, analgesic (nonopioid)

pregnancy category b (first and second trimesters)
pregnancy category d (third trimester)

Dosage & route

• Available forms : tablets—250, 375, 500 mg; 220, 275, 500 mg (as naproxen sodium); dr tablets—375, 500 mg; cr tablets—375, 500 mg; suspension—125 mg/5 ml
• Dosages : do not exceed 1,250 mg/day (1,375 mg/day naproxen sodium).

Adults

Rheumatoid arthritis or osteoarthritis, ankylosing spondylitis:

Delayed-release (ec-naprosyn)

• 375–500 mg po bid.

Controlled-release (naprelan)

• 750–1,000 mg po daily as a single dose.

Naproxen sodium

• 275–550 mg bid po. May increase to 1.65 g/day for a limited period.

Naproxen tablets

• 250–500 mg po bid.

Naproxen suspension

• 250 mg (10 ml), 375 mg (15 ml), 500 mg (20 ml) po bid.

Acute gout:

Controlled-release (naprelan)

• 1,000–1,500 mg po daily as a single dose.

Naproxen sodium

• 825 mg po followed by 275 mg q 8 hr until the attack subsides.

Acute gout:

Naproxen

• 750 mg, followed by 250 mg q 8 hr until attack subsides.

Mild to moderate pain:

• Controlled-release (naprelan)
• 1,000 mg po daily as a single dose.

Naproxen sodium

• 550 mg po followed by 275 mg q 6–8 hr.

Mild to moderate pain:

• 500 mg followed by 500 mg q 12 hr or 250 mg q 6–8 hr.

Otc

• 200 mg po q 8–12 hr with a full glass of liquid while symptoms persist. Do not exceed 600 mg in 24 hr.

Pediatric patients

Juvenile arthritis:

Naproxen

• 10 mg/kg/day given in two divided doses.

Naproxen sodium

• Safety and efficacy not established.

Otc

• Do not give to children < 12 yr unless under advice of physician.

Geriatric patients

• Do not take > 200 mg q 12 hr po.

Therapeutic actions

• Naproxen has anti-inflammatory, analgesic, antipyretic actions. It reduces prostaglandin synthesis by inhibiting the enzyme cyclooxygenase. It also inhibits platelet aggregation.

Indications

• Mild to moderate pain
• Treatment of primary dysmenorrhea, rheumatoid arthritis, osteoarthritis, ankylosing spondylitis, tendinitis, bursitis, acute gout
• Otc use: temporary relief of minor aches and pains associated with the common cold, headache, toothache, muscular aches, backache, minor pain of arthritis, pain of menstrual cramps, reduction of fever
• Treatment of juvenile arthritis (naproxen)

Adverse effects

• Edema, palpitation, dizziness, drowsiness, headache, light headedness, vertigo, pruritus, skin eruption, ecchymosis, purpura, rash, fluid retention, abdominal pain, constipation, nausea, heartburn, diarrhea, dyspepsia, stomatitis, flatulence, gross bleeding/perforation, indigestion, ulcers, vomiting, abnormal renal function, hemolysis, ecchymosis, anemia, increased bleeding time, elevated lfts, visual disturbances, tinnitus, hearing disturbances, dyspnoea, diaphoresis, thirst.
• Potentially fatal: anaphylactic/anaphylactoid reactions. Exfoliative dermatitis, stevens-johnson syndrome (sjs), toxic epidermal necrolysis (ten).

Contraindications

• Hypersensitivity. Aspirin or nsaid allergy. Perioperative pain in the setting of cabg surgery. Pregnancy (3rd trimester).

NURSING CONSIDERATIONS

Assessment

• History: allergy to naproxen, salicylates, other nsaids; asthma, chronic urticaria, cv dysfunction; hypertension; gi bleeding; peptic ulcer; impaired hepatic or renal function; pregnancy; lactation
• Physical: skin color and lesions; orientation, reflexes, ophthalmologic and audiometric evaluation, peripheral sensation; p, bp, edema; r, adventitious sounds; liver evaluation; cbc, clotting times, lfts, renal function tests; serum electrolytes; stool guaiac

Interventions

• Black box warning: be aware that patient may be at increased risk for cv event, gi bleeding; monitor accordingly.
• Give with food or after meals if gi upset occurs.
• Arrange for periodic ophthalmologic examination during long-term therapy.
• Warning: if overdose occurs, institute emergency procedures—gastric lavage, induction of emesis, supportive therapy.

Teaching points

• Take drug with food or meals if gi upset occurs; take only the prescribed dosage.
• Dizziness, drowsiness can occur (avoid driving or the use of dangerous machinery).
• Report sore throat; fever; rash; itching; weight gain; swelling in ankles or fingers; changes in vision; black, tarry stools.

4. DICLOFENAC

Drug name

Generic name : diclofenac, diclofenac potassium, diclofenac sodium

Brand name: cataflam, novo-difenac-k (can), voltaren rapide (can), novo-difenac (can), novo-difenac sr (can), nu-diclo (can), solaraze, voltaren, voltaren nu-diclo sr (can), ophtha (can), voltaren-xr

Classification: anti-inflammatory, nsaid

Pregnancy category b

Dosage & route

Adults

Oral

• Pain, including dysmenorrhea: 50 mg tid po; initial dose of 100 mg may help some patients (cataflam).
• Osteoarthritis: 100–150 mg/day po in divided doses (voltaren); 50 mg bid–tid po (cataflam).
• Rheumatoid arthritis: 150–200 mg/day po in divided doses (voltaren); 50 mg bid–tid po (cataflam).
• Ankylosing spondylitis: 100–125 mg/day po. Give as 25 mg qid, with an extra 25-mg dose hs (voltaren); 25 mg qid po with an additional 25 mg at bedtime if needed (cataflam).

Topical

• Actinic keratosis: cover lesion with gel and smooth into skin; do not cover with dressings or cosmetics (solaraze).

Ophthalmic

• 1 drop to affected eye qid starting 24 hr after surgery for 2 wk.

Pediatric patients

• Safety and efficacy not established.

Therapeutic actions

• Diclofenac has potent anti-inflammatory, analgesic and antipyretic actions. It inhibits the enzyme, cyclooxygenase, thus resulting in reduced synthesis of prostaglandin precursors.

Indications

• Acute or long-term treatment of mild to moderate pain, including dysmenorrhea
• Rheumatoid arthritis
• Osteoarthritis
• Ankylosing spondylitis
• Treatment of actinic keratosis in conjunction with sun avoidance
• Ophthalmic: postoperative inflammation from cataract extraction

Adverse effects

• Gi disturbances; headache, dizziness, rash; gi bleeding, peptic ulceration; abnormalities of kidney function. Pain and tissue damage at inj site (im); local irritation (rectal); transient burning and stinging (ophthalmic).
• Potentially fatal: stevens-johnson syndrome, exfoliative dermatitis, toxic epidermal necrolysis.

Contraindications

• Active peptic ulcer; hypersensitivity to diclofenac or other nsaids. Treatment of perioperative pain in cabg surgery. 3rd trimester of pregnancy. Topical: not to be applied onto damaged or nonintact skin.

NURSING CONSIDERATIONS

Assessment

• History: renal impairment; impaired hearing; allergies; hepatic, cv, and gi conditions; lactation, pregnancy
• Physical: skin color and lesions; orientation, reflexes, ophthalmologic and audiometric evaluation, peripheral sensation; p, edema; r, adventitious sounds; liver evaluation; cbc, clotting times, renal function tests, lfts, serum electrolytes, stool guaiac

Interventions

• Black box warning: be aware that patient may be at increased risk for cv events, gi bleed, renal insufficiency; monitor accordingly.
• Administer drug with food or after meals if gi upset occurs.
• Arrange for periodic ophthalmologic examination during long-term therapy.
• Warning: institute emergency procedures if overdose occurs (gastric lavage, induction of emesis, supportive therapy).

Teaching points

• Take drug with food or meals if gi upset occurs.
• Take only the prescribed dosage.
• You may experience these side effects: dizziness, drowsiness (avoid driving or using dangerous machinery while using this drug).
• Report sore throat, fever, rash, itching, weight gain, swelling in ankles or fingers, changes in vision; black, tarry stools.

5.MORPHINE

Drug name

Generic name : morphine sulfate
brand name:

• Timed-release: avinza, kadian, m-eslon (can), ms contin, oramorph sr
• Oral solution: roxanol, roxanol t
• Rectal suppositories: rms
• Injection: astramorph pf, duramorph
• Preservative-free concentrate for microinfusion devices for intraspinal use: infumorph
• Liposome injection: depodur

Classification: opioid agonist analgesic
pregnancy category c
controlled substance c-ii

Dosage & route

Adults

Oral

• Initial dose, 15 mg po daily, as a single dose in evening. One-third to one-sixth as effective as parenteral administration because of first-pass metabolism; 10–30 mg q 4 hr po. Cr: 30 mg q 8–12 ;hr po or as directed by physician; kadian: 20–100 mg po daily–24-hr release system; ms contin: 200 mg po q 12 hr; avinza: 30 mg po daily; if opioid naive, increase by 30 mg (or lower) increments q 4 days.

Im or subcutaneous

• 10 mg (range, 5–20 mg)/70 kg q 4 hr or as directed by physician.

Iv

• 2.5–15 mg/70 kg of body weight in 4–5 ml water for injection administered over 4–5 min, or as directed by physician. Continuous iv infusion: 0.1–1 mg/ml in d5w by controlled infusion device.

Rectal

• 10–30 mg q 4 hr or as directed by physician.

Epidural

• Initial injection of 5 mg in the lumbar region may provide pain relief for up to 24 hr. If adequate pain relief is not achieved within 1 hr, incremental doses of 1–2 mg may be given at intervals sufficient to assess effectiveness, up to 10 mg/24 hr. For continuous infusion, initial dose of 2–4 mg/24 hr is recommended. Further doses of 1–2 mg may be given if pain relief is not achieved initially.

Liposome injection

• 10–15 mg by lumbar epidural injection using a catheter or needle prior to major surgery or after clamping the umbilical cord during cesarean section.

Intrathecal

• Dosage is usually one-tenth that of epidural dosage; a single injection of 0.2–1 mg may provide satisfactory pain relief for up to 24 hr. Do not inject > 2 ml of the 5 mg/10 ml ampule or > 1 ml of the 10 mg/10 ml ampule. Use only in the lumbar area. Repeated intrathecal injections are not recommended; use other routes if pain recurs. For epidural or intrathecal dosing, use preservative-free morphine preparations only.

Pediatric patients

• Do not use in premature infants.

Im or subcutaneous

• 0.05–0.2 mg/kg (up to 15 mg per dose) q 4 hr or as directed by physician.

Geriatric patients or impaired adults

• Use caution. Respiratory depression may occur in the elderly, the very ill, those with respiratory problems. Reduced dosage may be needed.

Epidural

• Use extreme caution; injection of < 5 mg in the lumbar region may provide adequate pain relief for up to 24 hr.

Intrathecal

• Use lower dosages than recommended above for adults.

Therapeutic actions

• Morphine is a phenanthrene derivative which acts mainly on the cns and smooth muscles. It binds to opiate receptors in the cns altering pain perception and response. Analgesia, euphoria and dependence are thought to be due to its action at the mu-1 receptors while respiratory depression and inhibition of intestinal movements are due to action at the mu-2 receptors. Spinal analgesia is mediated by morphine agonist action at the k receptor. Cough is suppressed by direct action on cough centre.

Indications

• Relief of moderate to severe acute and chronic pain
• Preoperative medication to sedate and allay apprehension, facilitate induction of anesthesia, and reduce anesthetic dosage
• Analgesic adjunct during anesthesia
• Component of most preparations that are referred to as brompton’s cocktail or mixture, an oral alcoholic solution that is used for chronic severe pain, especially in terminal cancer patients
• Intraspinal use with microinfusion devices for the relief of intractable pain
• Treatment of pain following major surgery, er liposome injection for single-dose administration by epidural route at the lumbar level

Adverse effects

• Convulsions; nausea, vomiting, dry mouth, constipation; urinary retention; headache, vertigo; palpitations; hypothermia; pruritus, urticaria; tachycardia, bradycardia; blurred vision; miosis; dependency; drowsiness; lightheadedness; dizziness; sweating; dysphoria; euphoria.
• Potentially fatal: respiratory depression; circulatory failure; hypotension; deepening coma; anaphylactic reactions.

Contraindications

• Respiratory depression, acute or severe asthma; paralytic ileus; obstructive airway disease; acute liver disease; comatose patients; increased intracranial pressure; acute alcoholism. Pulmonary oedema resulting from a chemical respiratory irritant.

NURSING CONSIDERATIONS

Assessment

• History: hypersensitivity to opioids; diarrhea caused by poisoning; labor or delivery of a premature infant; biliary tract surgery or surgical anastomosis; head injury and increased intracranial pressure; acute asthma, copd, cor pulmonale, preexisting respiratory depression; acute abdominal conditions, cv disease, supraventricular tachycardias, myxedema, seizure disorders, acute alcoholism, delirium tremens, cerebral arteriosclerosis, ulcerative colitis, fever, kyphoscoliosis, addison disease, prostatic hypertrophy, urethral stricture, recent gi or gu surgery, toxic psychosis, renal or hepatic impairment; pregnancy; lactation
• Physical: t; skin color, texture, lesions; orientation, reflexes, bilateral grip strength, affect; p, auscultation, bp, orthostatic bp, perfusion; r, adventitious sounds; bowel sounds, normal output; urinary frequency, voiding pattern, normal output; ecg; eeg; lfts, renal and thyroid function tests

Interventions

• Black box warning: caution patient not to chew or crush cr preparations.
• Warning: dilute and administer slowly iv to minimize likelihood of adverse effects.
• Tell patient to lie down during iv administration.
• Warning: keep opioid antagonist and facilities for assisted or controlled respiration readily available during iv administration.
• Warning: use caution when injecting im or subcutaneously into chilled areas or in patients with hypotension or in shock; impaired perfusion may delay absorption; with repeated doses, an excessive amount may be absorbed when circulation is restored.
• Reassure patients that they are unlikely to become addicted; most patients who receive opiates for medical reasons do not develop dependence syndromes.
• Black box warning: liposome preparation is for lumbar epidural injection only; it should not be given intrathecally, iv, or im.

Teaching points

• Take this drug exactly as prescribed. Avoid alcohol, antihistamines, sedatives, tranquilizers, and over-the-counter drugs.
• Swallow controlled-release preparation (ms contin, oramorph sr) whole; do not cut, crush, or chew.
• Do not take leftover medication for other disorders, and do not let anyone else take your prescription.
• You may experience these side effects: nausea, loss of appetite (take with food, lie quietly); constipation (use laxative); dizziness, sedation, drowsiness, impaired visual acuity (avoid driving or performing tasks that require alertness and visual acuity).
• Report severe nausea, vomiting, constipation, shortness of breath or difficulty breathing, rash.

6 .FENTANYL

Drug name

Generic name : fentanyl

Brand name: actiq; duragesic 12, 25, 50, 75, 100; fentora, ionsys, sublimaze

Classification: opioid agonist analgesic

Pregnancy category c
controlled substance c-ii

Dosage & route

Available forms :lozenge on a stick (actiq)—200, 400, 600, 800, 1,200, 1,600 mcg; transdermal—12.5, 25, 50, 75, 100 mcg/hr; injection—50 mcg/ml; buccal tablets—100, 200, 400, 600, 800 mcg; ionic delivery system—40 mcg/10 min

Adults

Parenteral

• Premedication: 50–100 mcg im 30–60 min before surgery.
• Adjunct to general anesthesia: initial dosage is 2 mcg/kg. Maintenance dose, 2–20 mcg iv or im when changes in vital signs indicate surgical stress or lightening of analgesia.
• With oxygen for anesthesia: total high dose is 20–50 mcg/kg iv.
• Adjunct to regional anesthesia: 500–100 mcg im or slowly iv over 1–2 min.
• Postoperatively: 50–100 mcg im for the control of pain, tachypnea, or emergence delirium; repeat in 1–2 hr if needed.

Transdermal

• Initiate therapy with 25 mcg/hr system; adjust dose as needed and tolerated. Apply to nonirritated and nonirradiated skin on a flat surface of the upper torso; may require replacement in 72 hr if pain has not subsided; do not use torn or damaged systems, serious overdose can occur.

Lozenges

• Actiq: place unit in mouth between cheek and lower gum. Start with initial dose of 200 mcg. Until appropriate dose is reached, an additional dose can be used to treat an episode of breakthrough pain. Redosing may start 15 min after the previous lozenge has been completed. No more than two lozenges should be used for each breakthrough pain episode. Can consider increasing dose if requiring more than one lozenge for treatment of several consecutive breakthrough pain episodes. If more than four lozenges are needed daily, increase the dosage of long-acting opioid. Actiq should be sucked slowly over 15 min.
• Buccal tablets: initially, 100-mcg tablet placed between cheek and gum for 14–25 min; may be repeated in 30 min if needed. Adjust slowly to control pain.

Ionic delivery system

• Apply to chest or upper, outer arm. With each activation, 40 mcg delivered over 10 min. Each system contains 80 doses. May use up to 3 units sequentially, if needed.

Pediatric patients 2–12 yr

Parenteral

• 2–3 mcg/kg iv as vital signs indicate.

Transdermal

• Do not exceed 15 mcg/kg.

Lozenges

• 5–15 mcg/kg transmucosal.

Therapeutic actions

• Fentanyl is a potent opioid analgesic that increases pain threshold, alters pain reception and inhibits ascending pain pathways by binding to stereospecific receptors within the cns.

Indications

• Analgesic action of short duration during anesthesia and immediate postoperative period
• Analgesic supplement in general or regional anesthesia
• Administration with a neuroleptic as an anesthetic premedication, for induction of anesthesia, and as an adjunct in maintenance of general and regional anesthesia
• For use as an anesthetic agent with oxygen in selected high-risk patients
• Transdermal system: management of chronic pain in patients requiring continuous opioid analgesia over an extended period of time who cannot be managed by other means and who are already receiving opioid therapy
• Actiq: treatment of breakthrough pain in cancer patients being treated with and tolerant to opioids
• Fentora: management of breakthrough pain in cancer patients being treated with and tolerant to opioid therapy for underlyng cancer pain

Adverse effects

• Nausea, vomiting; bradycardia, oedema, cns depression, confusion, dizziness,drowsiness, headache, sedation, transient hypotension, peripheral vasodilation; increased intracranial pressure. High iv dose may cause chest wall rigidity. Transdermal: rash, erythema and itching.
• Potentially fatal: respiratory depression, trunk rigidity, laryngospasm, bronchoconstriction.

Contraindications

• Hypersensitivity.

NURSING CONSIDERATIONS

• Clinical alert! Name confusion has occurred between fentanyl and sufentanil; use extreme caution.