Gerontologic Alert

The use of the transdermal route in the elderly is questionable because the amount of subcutaneous tissue is reduced in the aging process.

On rare occasions, when pain is not relieved by the narcotic analgesics alone, a mixture of an oral narcotic and other drugs may be used to obtain relief. Brompton's mixture is commonly used to identify these solutions. In addition to the narcotics, such as morphine or methadone, other drugs may be used in the solution, including antidepressants, stimulants, aspirin, acetaminophen, and tranquilizers. The pharmacist prepares the solution according to the primary health care provider's instructions.

It is necessary to monitor for the adverse reactions of each drug contained in the solution. The time interval for administration varies. Some primary health care providers may order the mixture on an as-needed basis; others may order it given at regular intervals.

When narcotics are administered for severe pain, the goal is to prevent or control the pain, not to prevent addiction. Patients taking the narcotics for severe pain rarely become addicted. Although some dependence may occur in rare instances, if the patient recovers from the illness, he or she may be gradually weaned from the drug.

When long-acting forms of the narcotic are used, a fast-acting form may be given for breakthrough pain. Patients should be given the drug as ordered and on time. Oral transmucosal fentanyl (Actiq) is used to treat breakthrough pain. Making the patient wait for the drug may result in withdrawal symptoms, which will only add to the pain of the illness.

Tolerance results over a period of time in the patient taking a narcotic analgesic. The rate the patient develops tolerance varies according to the dosage, the route or administration, and the individual. Patients taking oral or transdermal morphine develop tolerance more slowly than those taking the drug parenterally. Some patients develop tolerance quickly and need larger doses every few weeks, whereas others are maintained on the same dosage schedule throughout the course of the illness.

The risk of respiratory depression is a concern for many nurses administering a narcotic and may cause some nurses to hesitate to administer the drug. However, respiratory depression rarely occurs in patients using a narcotic for pain. In fact, these patients usually develop tolerance to the respiratory depressant effects of the drug very quickly. Naloxone (see Chap. 20) can be administered to reverse the narcotic effects if absolutely necessary.

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