Pain ControlPain Control

Dent 6205Dent 6205

Summer Session 2008Summer Session 2008

StrategiesStrategies

KISSKISS Follow the rules: Medical history, allergies, Follow the rules: Medical history, allergies,

bleeding Hx, blah, blah, blahbleeding Hx, blah, blah, blah Good drug reference (Drug interactions)Good drug reference (Drug interactions) Pharmacist or Pharm D?Pharmacist or Pharm D? Beware of drug-seeking behaviorBeware of drug-seeking behavior Write a clear Rx to avoid changes by the patientWrite a clear Rx to avoid changes by the patient

Barry Brainfart Dental Clinic 666 Bite Me LnCrossbyte Falls, MN Ph: 555 -Y OU-HURT

P t. Name: I.M. Snorting Address: XXX DOB: 3 -3-59

_ Rx: Tylenol 3 Date: 5/29/04

_ Disp: 15 caps

_ Sig: i q4-6h prn pain

Refill__ _ __ Barry Brainfart, DDSDEA: AB000000

Barry Brainfart Dental Clinic 666 Bite Me LnCrossbyte Falls, MN Ph: 555-YOU-HURT

Pt. Name: I.M. SnortingAddress: XXX DOB: 3 -3-59

_ Rx: Tylenol 3 Date: 5/29/04

_ Disp: 115caps

_ Sig: i q4-6h prn pain

Refill__ _ __ Barry Brainfart, DDSDEA: AB000000

Barry Brainfart Dental Clinic 666 Bite Me LnCrossbyte Falls, MN Ph: 555-YOU-HURT

Pt. Name: I.M. SnortingAddress: XXX DOB: 3 -3-59

_ Rx: Tylenol 3 Date: 5/29/04

_ Disp: 15 caps (fifteen) or (XV)

_ Sig: i q4-6h prn pain

Refill__ _ __ Barry Brainfart, DDSDEA: AB000000

Personal PhilosophiesPersonal Philosophies

Narcotics vs. no narcoticsNarcotics vs. no narcotics Fear of addiction or aiding an addictionFear of addiction or aiding an addiction Leads to under-medicationLeads to under-medication Leads to after-hours phone callsLeads to after-hours phone calls Leads to fear of addiction or aiding an addictionLeads to fear of addiction or aiding an addiction It’s a question of painIt’s a question of pain How much? How long?How much? How long?

How Much Pain?How Much Pain?

Individual response and tolerance to painIndividual response and tolerance to pain Procedure? Procedure? Infection/inflammation presentInfection/inflammation present Quantify if possible—VASQuantify if possible—VAS Mild; Mild-Moderate; Moderate-Severe; SevereMild; Mild-Moderate; Moderate-Severe; Severe Many dental procedures will be in the mild-Many dental procedures will be in the mild-

moderate rangemoderate range

How Long?How Long?

Most dental procedures: 3-4 daysMost dental procedures: 3-4 days Notable exception: WeekendsNotable exception: Weekends No documented addictions in 4 days, except No documented addictions in 4 days, except

oxycodoneoxycodone Call for more medicationsCall for more medications patient needs to be patient needs to be

seen. Inform the patient a procedure WILL be seen. Inform the patient a procedure WILL be done. This is a major deterrent.done. This is a major deterrent.

Prescription StrategiesPrescription Strategies

Explain “Breakthrough Pain” to the patientExplain “Breakthrough Pain” to the patient If the initial pain medication does not control the If the initial pain medication does not control the

pain.pain. If the pain returns before the next dose is If the pain returns before the next dose is

scheduled.scheduled.

StrategiesStrategies

NSAID—First choice, but have alternativesNSAID—First choice, but have alternatives Acetaminophen (Tylenol, APAP)Acetaminophen (Tylenol, APAP) Narcotics—Breakthrough painNarcotics—Breakthrough pain Combination drugs—Ohh baby….Combination drugs—Ohh baby…. Remember to ask what works for the Remember to ask what works for the

patientpatient

NSAIDs—Mild-Moderate PainNSAIDs—Mild-Moderate Pain

Aspirin 325mg q4h (consider platelets)Aspirin 325mg q4h (consider platelets) Ibuprofen 400mg q4h; 600mg q6h; 800mg q8h; Ibuprofen 400mg q4h; 600mg q6h; 800mg q8h;

max. daily dose: 3200mg/daymax. daily dose: 3200mg/day Naprosyn (Naproxin Na) 200mg q12h—long Naprosyn (Naproxin Na) 200mg q12h—long

onset of actiononset of action

NSAIDs—Moderate-Severe PainNSAIDs—Moderate-Severe Pain

Ansaid (Flurbuprofen) 100mg q8hAnsaid (Flurbuprofen) 100mg q8h Cataflam (Diclofenac) 50mg q8h—small pillCataflam (Diclofenac) 50mg q8h—small pill Ketoprofen 400mg—long onset of actionKetoprofen 400mg—long onset of action Vioxx 50mg q24h—No longer available. Vioxx 50mg q24h—No longer available.

Selective COX2 inhibitor—decreased GI Selective COX2 inhibitor—decreased GI irritation, unless patient already has a history. irritation, unless patient already has a history. Theoretically, no effect on platelet activity. Theoretically, no effect on platelet activity. Expensive.Expensive.

NSAIDs—Severe PainNSAIDs—Severe Pain

Toradol (Ketorolac) 30mg q8h IM/IV; follow Toradol (Ketorolac) 30mg q8h IM/IV; follow with 10mg q8h—beware GI bleedswith 10mg q8h—beware GI bleeds

TylenolTylenol

Acetaminophen (APAP) 650mg-1000mg q4hAcetaminophen (APAP) 650mg-1000mg q4h There is a ceiling of 1000mg. There is a ceiling of 1000mg. Does not compete with NSAIDs. Does not compete with NSAIDs. Antipyrrhetic, but no anti-inflammatory Antipyrrhetic, but no anti-inflammatory

properties.properties. Consider alternating with NSAIDs for mild-Consider alternating with NSAIDs for mild-

moderate pain.moderate pain.

NarcoticsNarcotics

Central Acting—”Dave’s not here”Central Acting—”Dave’s not here” More extensive side effect profileMore extensive side effect profile Addiction potential: moderate to highAddiction potential: moderate to high Morphine—accompanying sense of euphoriaMorphine—accompanying sense of euphoria

addictionaddiction Codiene: Codiene: ~ 10% of the metabolite~ 10% of the metabolitemorphine; most morphine; most

frequent complaint: N & Vfrequent complaint: N & V Hydrocodone: 5mg, 7.5mg, 10 mg; semi-synthetic Hydrocodone: 5mg, 7.5mg, 10 mg; semi-synthetic

codiene; ↑’d N & V with ↑’d dose; advise the patient to codiene; ↑’d N & V with ↑’d dose; advise the patient to lay down to avoid; more reports of high addiction ratelay down to avoid; more reports of high addiction rate

NarcoticsNarcotics

Oxycodone: 2.5, 5, 7.5, 10mg Oxycodone: 2.5, 5, 7.5, 10mg HighHigh addiction rate; addiction rate; Star/Trib Saturday May 29, 2004: M.D. was disciplined Star/Trib Saturday May 29, 2004: M.D. was disciplined for Rx for a pregnant patientfor Rx for a pregnant patientbaby was born addicted. baby was born addicted. Comes as either a stand-alone drug (Oxycontin) or in Comes as either a stand-alone drug (Oxycontin) or in combinations (Percocet, Tylox, Percodan, Roxicet) All combinations (Percocet, Tylox, Percodan, Roxicet) All are Schedule II.are Schedule II.

Talwin—Schedule IV due to combination with Narcan Talwin—Schedule IV due to combination with Narcan (Naloxone)(Naloxone)instant withdrawal or Tylenolinstant withdrawal or Tylenolpainful painful injectioninjection

NarcoticsNarcotics

Demerol—POOR oral absorption; good effect as Demerol—POOR oral absorption; good effect as IM or IVIM or IV

Fentanyl—Patch is NOT for acute painFentanyl—Patch is NOT for acute pain Darvon compound (Darvocet, Darvocet N-100); Darvon compound (Darvocet, Darvocet N-100);

pain relief is almost entirely due to the Tylenol; pain relief is almost entirely due to the Tylenol; Schedule IVSchedule IV

Ultram—Schedule IV, some addictive potentialUltram—Schedule IV, some addictive potential

DEA LicenseDEA License

Apply over the internet. (Google DEA)Apply over the internet. (Google DEA) Schedule I-V. VI may be added for herbal meds.Schedule I-V. VI may be added for herbal meds. Schedule I: No medicinal use. May be used for Schedule I: No medicinal use. May be used for

research/inpatient. (heroin, MJ, cocaine, etc.)research/inpatient. (heroin, MJ, cocaine, etc.) Schedule II: High addiction potential. Needs a Schedule II: High addiction potential. Needs a

WRITTEN prescription. In some states, it needs WRITTEN prescription. In some states, it needs to be in triplicate.to be in triplicate.

Schedule III: Moderate addiction potential. Can Schedule III: Moderate addiction potential. Can be phoned in.be phoned in.

DEA LicenseDEA License

Schedule IV—Low addiction potential.Schedule IV—Low addiction potential. Schedule V—No reported addiction potential. Schedule V—No reported addiction potential.

(antibiotics)(antibiotics) OTCOTC Consider: Apply only for Schedule III, IV, V* Consider: Apply only for Schedule III, IV, V*

(can’t do this any more)(can’t do this any more) Consider: Phone in all your Rx’s—avoids “lost” Consider: Phone in all your Rx’s—avoids “lost”

prescriptions.prescriptions.

Prescription StrategiesPrescription Strategies

Mild-Moderate Pain--NSAID Mild-Moderate Pain--NSAID ± APAP ± ± APAP ± NarcoticsNarcotics

Alternative NSAID ± APAP + NarcoticAlternative NSAID ± APAP + Narcotic Example: Ibuprofen 600mg q6h alternating with Example: Ibuprofen 600mg q6h alternating with

APAP 650mg; if inadequate reliefAPAP 650mg; if inadequate relief Ansaid Ansaid 100mg q8h, consider adding Vicodin q4-6h 100mg q8h, consider adding Vicodin q4-6h (consider adding 1 regular strength 350mg (consider adding 1 regular strength 350mg Tylenol/dose of Vicodin)Tylenol/dose of Vicodin)

Prescription StrategiesPrescription Strategies

Moderate-Severe Pain—NSAID + Moderate-Severe Pain—NSAID + APAP/Narcotic for breakthrough painAPAP/Narcotic for breakthrough pain

Example: Ansaid 100mg q8h; Vicodin 5/500Example: Ansaid 100mg q8h; Vicodin 5/500

Questions?Questions?

Thank YouThank You