Drug Therapy



Possible ethical issues in the context of patient care



Introduction to Drug Therapy

The use of opioids in migraine causes many problems. Opioids are nociceptive or can cause a series of harmful pathophysiological changes, and these chemical, cellular or molecular changes can lead to adverse clinical consequences. For all of these reasons, opioids must be ignored in the treatment of acute and chronic migraine. Unfortunately, opioids are still the most extremly used drug class for acute migraine treatment in emergency rooms in North America. Migraine is a primary paroxysmal headache disease and one of the most common complaints in emergency department (ED) admissions. Randomized, placebo-controlled studies have demonstrated that migraine drugs can be used to treat acute migraine. In the emergency department, most acute migraine drugs are parenteral preparations. This may be due to nausea and vomiting leading to ineffective oral medications and / or intolerance to triptans or the desire of doctors and / or patients to quickly relieve pain. Intravenous tramadol relieves pain more effectively than placebo at the end of the first hour.

In migraine patients of this composition year, infusion of 100 mg tramadol 100 mg solution was slowly tolerated (Alemdar et al., 2007). When prescribing opioids, practice guidelines must be followed unless there are other methods that can be justified. Additionally, when considering the suitability of opioid prescriptions and its several ethical propositions, the decision can be guided by applying ethical principles of goodwill, non-maliciousness, as well as justice. Similarly, it is necessary to keep abreast of changes in laws and regulations and provincial electronic registration information for opioid prescriptions. Doctors want to make sure that the patients ’pain is correctly evaluated or managed. To achieve optimal control of pain, opioids may need to be prescribed. However, the obligation to give relief from pain should be balance with the equally significant responsibilities, not to expose the patients to the threat of addiction or habbit, and not to make opportunities for drug transfer, trafficking, or addiction to others. Consider the statement and discuss possible ethical issues, in the context of patient care, using current literature to support your discussion (Bunt, 2016).

Possible Ethical Issues in The Context of Patient Care

The use of opiates and opioid medications in the management of chronic migraine is controversial, yet some studies show Tramadol to be effective, and many patients are prescribed opiate based medications to control migraine. It is therefore important that health care professions, including nurses, convey accurate information to service users and carers regarding effective migraine treatment. Opioids are one of the successful drugs for moderate to severe pain. Despite consensus on its use in treating chronic cancer pain, its lasting use in the treatment of the chronic non-malignant pain remains controversial. Although pain experts have reached a consensus, and ethical and medical comments are very important, utilize of opioids in the treatment of moderate to severe pain is considered, but people still worry about Hammer has emerged from undertreatment and overtreatment. The raised prevalence of the medicine opioid abuse has exacerbated this controversy, and clinical opioids use has also increased (Alaa Alhowary, 2014). To resolve this dispute, more research is needed and acceptance of treatment guidelines that can confirm the dual responsibility of the prescriber: optimizing the balance among the analgesia or side effects, promoting other beneficial results, and at the same time evaluating and managing treatment-related risk abuse Addiction or distraction (Burch, 2014).

Rescue using opioids is a failure admission. It is a failure of an acute medicine that makes the patient painless, and admits that you will not allow the patient to recover from the function of the attack, thereby allowing you and your patient to resign and lose their disabilities on time. Hyperalgesia caused by opioids is a paradox, which is the opposite effect of drugs, in which, when a patient is expose to opioids, their pain threshold decreases as well as their sensitivity of pain under any given stimulus, both the pain site and the pain intensity will increase. Hyperalgesia caused by opioids can even be treated with anesthesia in a short time (Casucci & Cevoli, 2013). Increasing the dose of opioids can temporarily overcome the OIH phenomenon, but the basic pathophysiology and tolerance are different. Opioids can interfere with successful treatment of acute migraine, if they upregulate the system or encourage the peptides and neurotransmitters release (such as CGRP and glutamate) that clinicians are trying to block or inhibit.

Pain relief is the basic duties of the medical professionals. Over the previeous some decades, pain control has been greatly improved, if not always optimal. The consequences of opioid abuse and abuse on individuals and society are serious. A study conducted at the Toronto Center for Addiction & Mental wellbeing in Ontario found that the number of people seeking medication for medicine opioid addiction has increased significantly.

A few Aboriginal communities found the problem of addiction so severe that they declared that they were "in crisis." An analysis of approximately 1,000 deaths due to overdose in Ontario showed that 47% of these people had received opioid prescription in 4 weeks before death, indicating that these deaths may be related to drug prescriptions and may be related to abuse (whether intentional Still unintentional), diversion, A recent study concluded that: Deaths related to Opioid are concentrated in patients treated by doctors who often advise opioids." Observe, therefore, this is not a problem unique to Canada.

Physicians themselves cannot reverse this situation. Various measures must be used to solve this serious social moreover health issues. If opioids cause serious issues, can junior physicians cope with this situation by easily avoiding prescription of opioids completely? A few emergency departments or walk-in clinics have made such decisions because they are overwhelmed by the demand for opioids (McNicol et al., 2018). However, the impact of some problem policies has not been studied. For many reasons, it is not an ethical choice for most doctors to avoid prescription opioids altogether. Many people argue that a pain relief is the basic human right.

Therefore, most of the clinicians cannot ignore the difficult and complex task of examining whether an opioid prescription is appropriate in every uncontrollable pain situation and in every encounter with such patients. The recently published “Canada Guidelines for the Effective and Safe Use of Opioids for the Chronic Non-Cancer Pain” provide more detailed decision-making tools (Kapur et al., 2011). Unless you have a compelling reason to make a different decision in a particular situation, you must be familiar with Canadian guidelines moreover follow the suggestions. However, the guidelines do not cover the management of cancer or acute pain, and its application in chronic pain is not simple. Even if other practical tools are utilized, a lot of space is still needed to judge requirements and benefits, threats, fairness as well as responsibility. In the other words, in every step of providing pain control for opioids, ethical decisions must be made and ethical issues must be resolved.

Most of the ethical frameworks can be use to help to make ethical decisions. This article prescribes opioids from an ethical perspective by seeking guidance from four basic bioethical values. Over the past 30 years, these principles have proven their worth. The main beliefs of goodwill and non-maliciousness are based on traditional Hippocrates ethics and are accepted as guidelines for action by medical personnel. The principles of respect and justice for the autonomy have only recently emerged (Thienthong et al., 2012). These principles are related to the impetus to promote human rights and social justice. These principles can guide us to make decisions about the prescription of opioids. The professional and competitive cycling community has received extensive scrutiny due to scandal reports about the use of performance-enhancing drugs among the sports stars. One of the most infamous cases in this regard is American racing driver Lance Armstrong, but the current headlines are made by former British professional racer Michael Barry, who had ride the sky Team, and admitted to secretly using tramadol when racing in 2010 (McNicol et al., 2018).

Although tramadol is known as a drug used to treat chronic diseases such as fibromyalgia and migraine, Michael Barry claims that his air team racer took the drug to relieve the legs pain. Barry felt relaxed and euphoric when taking tramadol during the game, but he also mentioned that losing attention is a side effect. Although tramadol is not listed as one of the banned drugs by the World Anti-Doping Agency, bicycle officials are now closely monitoring Barry's allegations. Tramadol is a prescription drug and is usually recommended for the treatment of pain. This drug is unique in the sense that drug and medical researchers cannot be 100% sure how tramadol interacts with pain and provides relief (Alaa Alhowary, 2014). Tramadol is an opioid analgesic, but it also has certain effects consistent with serotonin-norepinephrine reuptake inhibition (SSRI) drugs. Emergency rooms in many parts of the world reserve injectable tramadol for patients with moderate pain. Patients with chronic migraine can prescribe tramadol as part of a reactive pain management strategy.

This means that migraine sufferers who experience a headache attack and threatened more than twice a month are most likely to benefit from Tramadol. The two names used to sell Tramadol include Ultram and Uiltracet. The latter also contains acetaminophen, an over-the-counter analgesic that is often recommended for migraine treatment. In a 2005 study conducted by researchers at the Philadelphia Jefferson School of Medicine, the effectiveness of Ultracet in migraine patients was confirmed in a randomized trial study that included a placebo (Alemdar et al., 2007). Although tramadol is effective as a treatment for migraine attacks, Ultracet does not reduce the nausea experience in many patients. In fact, tramadol may actually cause dizziness, nausea and dizziness. Some migraine sufferers may also experience the excitement and lack of concentration reported by riders of the British Sky Flying Team. Since tramadol works like an SSRI antidepressant, some patients may experience physical dependence, which can be resolved by treatment.

This Statement May Influence Your Professional Nursing Practice

This statement may affect your professional nursing practice, because it makes me understand that patients undergoing end-of-life care and patients with malignant tumors or orthopedic diseases need proper treatment for their pain, but these patients will not relapse to the hospital. The resident found that the patient had repeated skin ulcers, excessive insulin intake caused hypoglycemia and could not be admitted to the hospital, neglected the wound care to make him admitted again, refused to receive the necessary treatment in order to prolong the hospital stay, and took laxative pseudo Crohn's colitis (J Tepper & D, 2012). I even asked the patient to tear the scar from the abdominal surgery to pull the Diulaid (Dilaudid) strain; another patient took the nasogastric tube from the nose bag, lowered the nose, and blown into the open end to fake the small intestine obstruction. Every day, residents will encounter patients with opioid-related problems. We should correctly recognize patients with anesthesia abuse or abuse. When we encounter it, we should not be afraid to record it.

We should use the correct group code related to the diagnosis and periodically ask the patient about his anesthesia habits. If we cannot correctly identify these patients, how will administrators or policy makers understand the prevalence of the population? We should all learn to recognize abuse and record particular abnormal behavior for reference. Such documents justify our decision not to open hazardous substances. When a doctor suspects the inappropriate use of narcotic drugs and conducts toxicology screening, it is necessary to check with the prescription records of the pharmacy in the state. We should remember that the treatment objective of the patients with chronic non-cancer pain is to get better their functional status (Kapur et al., 2011). This is not a painkiller. We must resist the pressure of time constraints, educate patients who require anesthesia for various reasons for not prescribing, and do not worry about the satisfaction of our doctors. The best interests of patients should be higher than our own interests.

We should never make patients suffer. Whether it is a late-stage cancer patient who died in a hospice care center, a 20-year-old heroin abuser who is actively withdrawing from the hospital, or a mentally ill person with manipulative behavior, they should receive supportive treatment, safety guarantees, and specific needs for their attention. We have a responsibility to look at their care from a natural point of view: relax the anesthetic dose in one case and restrain and restrict them in another. I believe that the lack of data makes it difficult to apply ethics based on moralism and principles (McNicol et al., 2018). These are deductive forms of moral reasoning. To some extent, they rely on applying general concepts to the data to solve specific patient problems. If I do not have long-term results data, then moral commands such as "minimize pain" and principles such as "justice" become ambiguous.

The lack of data makes it impossible to determine whether the pain that is resolved in the short term can be replaced with other pain (such as side effects) for a long time, and it is difficult to determine whether equal access is morally necessary and unproven long-term treatment in the following cases. Therefore, I believe that in the field of data-intensive practice such as chronic opioid therapy, the application of clinical ethics is the most meaningful, that is to say, the process of inductive ethics inference should be summarized from each case because Practice always produces rich experience. Clinical ethics is not population-based. It’s a patient-centric, decision-making, emphasizing patient autonomy, collaborative objective setting, attention to psychosocial and situational factors, as well as improvement of personal quality of life.

Clinical ethics follows the specific circumstances of particular cases, for example the indications for particular treatments, educational methods for probable adverse reactions, and descriptions of the consequences of the decline in suggested treatments (Thienthong et al., 2012). Social-level ethical issues are not at the center of case-based ethics. For example, giving patients the right to receive pain treatment or doctors to provide pain treatment does not revolve around the characteristics of individual cases. Therefore, clinical ethics cannot best solve this problem. Similarly, when making decisions about the well-being of individual patients, it outperforms social factors such as health care costs or equal access to medical services. Because we do not understand the ultimate clinical value of the chronic pain therapy, it is necessary to make a lot of assumptions and speculations to solve the broader moral and social issues, such as access to equal opportunities and costs (Alemdar et al., 2007). Therefore, we believe that clinical ethics can currently be used most effectively in the treatment of pain.

Conclusion on Drug Therapy

Even in areas with complex medical conditions in Australia, in the treatment of chronic migraine, untreated chronic pain is still widespread and costly, unacceptable. Doctors want to make sure that the patients ’pain is correctly evaluated and managed. To achieve optimal pain control, opioids may need to be prescribed. Various guides and practical tools are now provided. It is advisable to use them, but doctors are required to consider moral values, responsibilities, rights and interests, so moral analysis is required. The four basic ethical principles of benevolence, non-maliciousness, respect for autonomy and justice can provide a framework and starting point to help doctors make ethical and reasonable decisions about the prescription of opioids.

Reference for Drug Therapy

Alaa Alhowary, K. (2014). Analgesic Efficacy of Intravenous Paracetamol Plus Tramadol Combination for Pain after Laparoscopic Cholecystectomy: A Double-Blind, Randomized, Placebo-Controlled Trial. Analgesia & Resuscitation : Current Research, 03(03). https://doi.org/10.4172/2324-903x.1000120

Alemdar, M., D, M., Pekdemir, M., & Macit Selekler, H. (2007). Single-Dose intravenous tramadol for Acute Migraine Pain in Adults A single-Blind, Prospective, Randomize, Placebo-Controlled Clinical rail, 29(7). Retrieved 11 May 2020, from.

Bunt, C. (2016). How do single dose intravenous propacetamol or intravenous paracetamol (acetaminophen) compare with other drug treatment in adults with acute postoperative pain?.Cochrane Clinical Answers. https://doi.org/10.1002/cca.1351

Burch, J. (2014). In adults with acute postoperative pain, how does a single oral dose of mefenamic acid compare with placebo?. Cochrane Clinical Answers. https://doi.org/10.1002/cca.369

Casucci, G., & Cevoli, S. (2013). Controversies in migraine treatment: opioids should be avoided.Neurological Sciences, 34(S1), 125-128. https://doi.org/10.1007/s10072-013-1395-8

Derry, S., Cooper, T., & Phillips, T. (2016). Single fixed-dose oral dexketoprofen plus tramadol for acute postoperative pain in adults. Cochrane Database Of Systematic Reviews. https://doi.org/10.1002/14651858.cd012232.pub2

J Tepper, S., & D, M. (2012). Opioids Should Not Be Used in Migraine. https://doi.org/10.1111/j.1526-4610.2012.02140.x

Kapur, D., Cornish, P., Snellgrove, C., & Cherry, D. (2011). Should opioids be used for chronic non‐cancer pain?. Medical Journal Of Australia, 195(9), 513-514. https://doi.org/10.5694/mja11.11127

McNicol, E., Ferguson, M., & Schumann, R. (2018). Single-dose intravenous diclofenac for acute postoperative pain in adults. Cochrane Database Of Systematic Reviews. https://doi.org/10.1002/14651858.cd012498.pub2

Thienthong, S., Chongsomchai, C., & Kemthong, W. (2012). A placebo-controlled, double-blind, randomized study of single-dose intravenous diclofenac for pain relief after a cesarean section.Acta Anaesthesiologica Taiwanica, 50(4), 150-152. https://doi.org/10.1016/j.aat.2012.12.005

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