Morphine Fantanyl Pain Essay

Morphine Fentanyl PainEffective Pain Relief In Post Operative Patients. Is Morphine or Fentanyl more effective in reducing pain in postoperative adult cardiac patients?

Pain is physiological mechanism and a means of the body alert the person about either currently present or impending damage to it. It can be defined as the “unpleasant sensory and emotional experience associated with actual or potential damage” (Gelinas, 2004). Consequently, the words discomfort has also been used interchangeably with pain in the past and can be defined as a “negativeaffective and/or physical state subject to variation in magnitudein response to internal or environmental conditions” (Gelinas, 2004).Morphine Fantanyl Pain Essay.

Pain is a very important component in care of the surgical patients, both preoperative and post operative. Surgery itself afflicts large amounts of trauma on the patient. The pain that the patient has to incur afterwards adds his anxiety levels and stresses the body. Lack of or inadequate amounts of pain management by the staff, impacts the patients healing process. Their mobility and in the long terms their duration of hospital stay is also affected.

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It is important that, for optimal patients health management and care, a means tool must be available to measure the patients pain assessment and relief requirement through pharmacological and non pharmacological means. Little research has been done to properly assess and document the prevalence of pain and its management protocols in post operative patients.

The pain scoring systems are available to attempt to quantify pain and manage it accordingly. These subjective ones include the categorical rating scales (CRS) in which patient rates pain from “No” to mild moderate or severe. Another one is the “Visual Analog score (VAS) where the individual scores are placed on a 10-cm line where the left anchor point is labeled “no pain” and the right anchor point is labeled “worst possible pain”. (Venkateswaran, P., 2006)

Since every patient has a varying threshold for pain, and requires varying levels of drugs, to over come the pain, it is better for there to be both a subjective indicator for pain as well as an objective one, that is to say, that the nurses an also assess how much pain the patient is in, by using a tool she is provided with.

Cardiac surgery is a major thoracic surgery and patients post operatively require lot analgesics to manage pain so that their morbidities associated with pain (like pain in breathing, walking etc) can be eliminated. Usually morphine is used for the purpose of pain relief but there are indications that Fentanyl can perform a similar relief without much of the side effects associated. There needs to be some focus into this theory.

This can be achieved by placing 2 similar populations of adult cardiac patients who have just undergone cardiothoracic surgery on morphine or Fentanyl.  As is the standard procedure nowadays, quality indicators, both subjective and objective can be used. The VAS pain scoring card can be provided to the patients for them to record the different levels of pain that they feel. The nurses would be provided with indictors to record objective findings which can indicate pain.

“These can be physiological and behavioral indicators. The physiological indicators can be clustered into cardiovascular, respiratory and cerebral responses” (Gelinas, 2004). Pain associated responses would include tachypnea in respiratory, tachycardia and increased blood pressure in cardiac and raised ICP in cerebral responses. After assessment of the pain levels with the quality indicators, the pain management drugs will be administered and later the subjective and objective pain assessment will be repeated to see which drugs effects were greater and lasted longer.

A study conducted by Celine Gelinas on critically ill incubated patients, to find out what are the protocols and tools used to assess pain management are and if the patients were being given effective relief. He used subjective as well as objective tools.Morphine Fantanyl Pain Essay.  The results revealed that physicians placed no role in documenting pain in patients. Most of the reporting was done by nurses and the patients.

It was also noticed that nurse’s assessment of pain was much less than that reported by the patients themselves. The research concluded that the documentation overall about the pain and its management was incomplete in general with little attention being given. The research also noted that even after being notified about the pain, its effective management only took place 60 percent of the time. (Gelinas, 2004).

In and interventional study conducted by Francoise Bardiau in 2003, the quality indicators e.g. VAS were introduced in the surgical and anesthesia department. After a survey of assessment of knowledge of nurses, VAS to assess pain was the nurses worked to improve pain management. After further surveys, it was noted that initiation of programs to setting of quality indicators improves the overall pain management system. (Bardiau, F., M, 2003)

Idvall E tested a 5 point scale to measure the effects of quality indicator maintain pain relief measurements. “The results suggest initial support for the new instrument as a measure of strategic and clinical quality indicators in postoperative pain management, but it must be further refined, tested and evaluated”. (Idvall E 2002)

A multidisciplinary program development was introduced based on evidence based medicine to focus on construction of proper management protocols to implement clinician as well as patient based pain relief programs “The results suggest that addressing pain management through a variety of strategies targeted at the level of the institution, the clinician, and the patient may lead to desired changes in practice and better outcomes for patients.” Bedard, D (2006). A survey conducted on post operative cardiac ICU patients, about their pain experiences revealed that despite the pain management regimes in place nowadays, the pain frequencies, and intensities were the same as they were more than a decade ago.

Pain management is a vital component of patient care. Quality of pain management can only be assessed through proper indicators. These can be multimodal. The patient populations on which these indicators can be applied are preoperative and postoperative patients. Post operative cardiac patients under nursing care can benefit well from implementation of quality indicators such as VAS. In the nursing profession subjective scoring by the patients themselves enables the nurses to manage the pain properly. Morphine Fantanyl Pain Essay.

This will lead to quicker recovery by the patients and earlier discharge. In the long term this means leads financial implications on the patients due to reduced hospital stay. Also nursing work load gets reduced as the patient tern over is increased. The healthcare cost gets reduced. A Post operative pain management (POP) project was conducted in 2003. A nationwide survey was done to see the implementation of quality improvement projects in the field of pain management, it was noted that more than 70% of the hospitals were reportedly satisfied with the implementations and the outcomes of the quality improvement programs.

Summary

Based on the analysis, it is noted that on the positive side, proper implementations of the quality indicators and improvement programs in the healthcare system and especially in the ICU and surgical wards, the patients stay can become quite comfortable. The stay can be reduced and the cost of healthcare to the system, the insurance companies, and the patient themselves can be reduced. In the other hand we can clearly see that by using the indicators we in effect are placing more workload on the nurses.

If the subjective VAS and the objective physiological changes in the patient has to be monitored regularly just to assess the pain levels, a lot of quality time will be wasted. This time could have been used to tend to more critical patients. Now the question arises if it is worth the effect to implement the QI programs.

The answer would lie in Force field analysis and the Lewin’s theory. If the benefits out way the set backs, we can implement the system. The idealistic thing would be that we assess the pain management needs of each department of the health care system and implement the QIs in the ones in which the implementation benefits out way the costs.

References

Bardiau, F., M., Taviaux, N., F., Albert, A., Boogaerts, J., G., Stadler, M, (2003), An Intervention Study to Enhance Postoperative Pain Management. Anesthesia and Analgesia. Retrieved on February 26^th, 2008, from http://www.anesthesia-analgesia.org/cgi/content/abstract/96/1/179

Bedard, D (2006). The pain experience of post surgical patients following the implementation of an evidence-based approach. Pain management nursing. Retrieved onFebruary 26^th, 2008, from http://www.find-health-articles.com/rec_pub_16931414-pain-experience-post-surgical-patients-following-implementation.htm

Gelinas C, Fortier,M., Viens, C., Fillion, L., Puntillo, K., (2004). , Pain Assessment and Management in Critically Ill Intubated Patients: a Retrospective Study. American Journal of critical care. Retrieved on February 26^th, 2008, from http://ajcc.aacnjournals.org/cgi/content/full/13/2/126

Idvall E., Hamrin E., Unosson M. (2002). Development of an instrument to measure strategic and clinical quality indicators in postoperative pain management. Journal of Advanced Nursing. . Retrieved on February 26^th, 2008, from http://www.ingentaconnect.com/content/bsc/jan/2002/00000037/00000006/art02130;jsessionid=2n189mrighst7.alice?format=print

Venkateswaran, R., Prasad K. N., (2006). Management of postoperative pain, Indian journal of anesthesia. Retrieved on February 26^th, 2008, Morphine Fantanyl Pain Essay.

Transdermal Fentanyl is a synthetic narcotic analgesic that is widely used in clinical anaesthesia which was originally synthesised by Dr Paul Janssen in the early sixties. It is approximately one hundred times more potent that morphine; which is thought of a the golden standard for opiods; this is where other opiods are compared and tested against morphine. Due to its potency, Fentanyl is mainly used for chronic long term illnesses such as cancer; however it is also used in short term acute pain for example child birth (a Fentanyl epidural would be used in this situation). Fentanyl can be administrated in many ways, which include: patch, ionysys, lollipop, injection and epidural.

Biochemistry

Figure Janssen’s synthesis of fentanyl was to react N-phenethylpiperidone with aniline to create 4-anilino-N-phenethylpiperidine. This compound is then reacted with propionyl chloride to give pure fentanyl, which is toxic and must be diluted in order to administrate to patients. American Chemical society 2005.http://pubs.acs.org/cen/img/83/i25/8325fentanyl.gif

Transdermal Fentanyl works by binding itself to the µ-opioid receptors found in the Central Nervous System and the Gastro-Intestinal tract. It has high lipid solubility therefore it binds strongly to plasma proteins and can quickly cross the blood-brain barrier. This in turn causes the patient to have a sense of euphoria by increasing the patients pain threshold (the amount of discomfort a person feels enough to consider pain) and reducing the sensitivity of pain.

Side effects and Benefits

Transdermal Fentanyl is a more popular choice among patients as it provides a better quality of life and produces fewer side effects compared to that of other opiods. The side effects of Fentanyl are generic for all opiods, these include; respiratory depression (where the patients breathing becomes depressed and slow) muscle spasm’s, abnormal blood pressure (could be both high or low), nausea, vomiting, blurred vision, itching (caused by the substance making direct contact with the skin), euphoria, dizziness, weight loss and constipation. Morphine Fantanyl Pain Essay.

On the other hand there are many benefits that come from using the drug, example; A longer period of release i.e. Fentanyl patch can be released throughout the body for a seventy two hour period using the patch; and according to clinical studies provides an improved pain relief compared to that of morphine. A smaller volume is needed due to its potency and less constipation and less sedation occurs (the patient recovers motor function quicker).

Converting a patient onto Transdermal Fentanyl Patch from Morphine

The direct adaptation from Morphine to Fentanyl was first determined and tried by cancer patients. These patients are seen to have a steady and unvarying level of pain, and are receiving a constant dosage of Morphine to relieve it. On unstable pain Fentanyl does not work at its best.

Below is an example of a patient receiving 100mg IV Morphine Sulphate and is going home on Fentanyl patch.

1) Convert to 24h oral MS dose

100mg/ IV MS

=

x

10mg/d IV MS

30mg/d oral MS

2) Adjust for cross-Tolerance

300mg/d oral MS x 0.65† = 200mg/d oral MS

† Deriving a 35% reduction is equivalent to multiplying by 0.65

3) Convert adjusting to dose to Fentanyl Transdermal Patch dose

200mg/d oral MS =

55µ/hr Fentanyl Patch

3.6

4) Round to closest Fentanyl Patch dosage from (25, 50, 75, 100)

55µ/hr → 50µ/hr Fentanyl patch†â€

††Replace patch every 3 days

5) Provide oral morphine q2-4h for a break-through -pain at 10% of 24hr period total

200mg/d oral MS x 0.10 = 20mg oral MS q2-4h prn breakthrough pain

Ali Olyaei PharmD, 2005. Morphine Fantanyl Pain Essay.

Fentanyl patch

The Fentanyl patch is generally deliberated if there is no access oral for the patient and is unable to take Fentanyl orally in a tablet/lozenge form or If the patient is reluctant to continue on morphine to due unpleasant side effects such as constipation, tolerance; or if the patient is know to overdose or not taking the medication this is where the patient will become supervised.

The Transdermal Fentanyl patch is often seen as the most common and easy way to treat chronic and non-chronic pain. It allows the patient to self administer the drug at home and has the longest effect on the body. (Margaret Gibbs 2009) The Patch can also be assisted by the lollipop, by using it as a top up mechanism to pain relief. Many health care professionals suggest that the patch should only be used for patients who are opioid-tolerant and cannot successfully manage there pain with other dugs such as morphine. The Patch can come in two forms which include; a Reservoir patch, where the patch is suspended in a matrix and placed onto the skin; and a Matrix patch where the drug is distributed evenly throughout a matrix.

Reservoir Patch

Figure The principle of this patch is to understand and evaluate the stability and skin penetration profiles of Fentanyl.http://corpreform.typepad.com/.a/6a00d8341c716c53ef01157205fb1a970b-pi

For this patch the Fentanyl is limited within a reservoir within the patch in a gel form.

Dangerous drugs, Justinian Lane 2010

Figure Matrix Patchhttp://corpreform.typepad.com/.a/6a00d8341c716c53ef01157205fb2a970b-pi

Unlike the Reservoir patch there is no Fentanyl gel contained within the patch. This style of patch places the Fentanyl within the adhesive so it makes direct contact with the skin. (Causing the side effect of itching). This design of patch is seen as safer as is it unable to leak gel. Dangerous drugs, Justinian Lane 2010

How to apply the Patch

There are many guidelines according to Drug and Therapeutics Committee August 2009; that a patient is required to follow in order to use the patch successfully.

Apply to clean, hairless skin such as the upper arm (which has not exposed to radiotherapy) and seize in place for 1 minute.

The patch works by creating a deposit of drug under the skin through the pores of the skin. Morphine Fantanyl Pain Essay.

The patch should be replaced every 72 hours. Rotate position so not to irritate the skin.

Avoid direct heat – and if the patient has a fever observe for opioid toxicity.

Fentanyl is causes less constipation than morphine. Therefore use half the dose of laxative if needed and repeat.

Prescribe strong opioid for breakthrough with either immediate release morphine sulphate /oxycodone or subcutaneous strong opioid

Figure The Patch works by releasing Fentanyl (either from the matrix gel or the Fentanyl Adhesive) into the body fats through the pores of the skin, which in turn releases the drug slowly and constantly around the bloodstream eventually passing the blood brain barrier allowing it to bind to µ-opiod receptors, giving a constant pain relief of between forty-eight and seventy-two hours which is usually constant. However, it takes approximately four- twelve hours for the patch to begin releasing Fentanyl into the body. At this point the Fentanyl lollipop would be used to keep the patients pain relief up.http://pi.watson.com/product_shot_images/00591_3213_72.jpg

Dosage is based on the size of the patch and absorption rate is usually regular, depending on many factors which include body temperature, size of the patient, skin type, quantity of body fat, and placement of the patch; can all have major effects on pain relief and dosage. Morphine Fantanyl Pain Essay.

Fentanyl patches are manufactured in five sizes: 12.5 µg/h, 25 µg/h, 50 µg/h, 75 µg/h and 100 µg/h.

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Fentanyl Lollipop

The Transdermal Fentanyl Lollipop is a fast end effective method of administrating the drug, as the drug enters the body via mucous membranes in the mouth. It is primarily used as a “top up” method of pain relief in conjunction to the Fentanyl Patch, when the patient requires it. It is an beneficial form of administration as the lollipop doesn’t require trained medical staff regarding administration Richard Payneb et al. It is preferred among patient as it is portable and fast-acting. The dosages for the lollipop are the following:

200 µg in gray

400 µg in blue

600 µg in orange

800 µg in purple

1200 µg in green

1600 µg in burgundy

Fentanyl is prescribed after an assessment of the patient’s condition, medical history and known tolerance to pain medication, such as Morphine. In addition, the dosage is decided based on the severity of the pain over a twenty-four hour period.

Conclusion

To summarise Transdermal Fentanyl is a potent synthetic analgesic which was manufactured for the treatment of both chronic and non chronic pain management which include situations such as cancer or childbirth. It is widely used for the treatment of cancer as is it approximately one hundred times more potent than morphine which is described as the “golden standard” for opiods. The Fentanyl patch is manufactured in two different styles; Matrix and Reservoir; they work by diffusing the drug through the pores of the skin and allowing it to be transported around the body’s blood system furthermore crossing the blood barrier binding to the µ-opiod receptors. The lollipop as a top up mechanism in conjunction according to the patient’s pain level. The patch is effective and preferred by patients as it has fewer side effects than the majority of opiods i.e. morphine, and provides the patient with a better quality of life as it can be administrated at home and last for approximately seventy-two hours. Morphine Fantanyl Pain Essay.