Transcript Dental Pain Guidance

Introduction
 This slide set is intended for use by qualified clinical
staff e.g. Nurse Advisors and Dental Nurse Advisors
 It provides basic information on:
 The use of analgesics in managing pain
 The dangers of deliberate or accidental overdose with common,
simple analgesics
 Guidance on restarting analgesics after accidental overdose
 Further information can be found in the BNF and
NHS Evidence
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Learning outcomes
1. Outline the key features of paracetamol,
ibuprofen and other simple analgesics
2. Understand how and why overdoses of
analgesics occur
3. Know when to refer calls about paracetamol and
ibuprofen
4. Be able to give appropriate restarting guidance
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Why worry about overdoses?
 Very common
 Harm to the patient
 Self harm / psychological issues
 Medicines readily available
 Patient misconceptions of safety
 Risk factors
 Dental pain
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Supratherapeutic overdoses
Taking more than the recommended maximum dose for
therapeutic purposes
Examples:
• Taking ibuprofen every 3 hours instead of every 6-8 hours as
pain isn’t controlled
• Taking paracetamol along with co-codamol tablets for extra pain
relief, without realising both contain paracetamol
• Taking 3 paracetamol tablets per dose instead of 2 tablets
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Single dose overdoses
‘Classic’ overdose scenario
 Possible self-harm
 Impulses may last 30 mins, then regret and seek help
 Alcohol related
 Peak age range 15-24 years; Women > Men
 Refer these calls – large single doses are unlikely to be an
accidental overdose
 Dental pain – more likely to be staggered overdoses over a period of
time
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WHO Analgesic ladder for acute &
chronic pain
If pain persists
Mild Pain
Step 1
Simple painkillers
Paracetamol
NSAID
(e.g.Ibuprofen)
Moderate Pain
Step 2
Weaker opioids
Codeine
Dihydrocodeine
Co-codamol
Co-dydramol
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Severe Pain
Step 3
Strong opioids
Morphine
Tramadol
Oxycodone
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First line treatment of pain

First choice
 Single painkiller at full dose
 Options if paracetamol alone or ibuprofen
alone do not control symptoms
 For adults - consider an analgesic higher
up the pain control ladder e.g. cocodamol
 Take regular paracetamol, if get
breakthrough pain towards end of dose
interval - take single dose of ibuprofen
(or other way around)
 Risks if advise regular alternate doses of
paracetamol and ibuprofen
 Confuse / forget what has been taken
 Delay diagnosis of a more serious
condition
Step 1: Simple painkiller
Paracetamol
Ibuprofen
Step 2: Weak opioid
Codeine
Dihydrocodeine
Co-codamol
Co-dydramol
Step 3: Strong opioid
Morphine
Tramadol
Oxycodone
Paracetamol
Uses
 Relieves mild to moderate pain
 Reduces fever
 Licensed for use in children from 2
months by mouth
Side effects
 Not usually a problem at
recommended dose
Dangerous in overdose
 Patients ingesting 75mg/kg/24hr or
more should be referred to hospital
 Potentially fatal liver damage
 Kidney damage (less often)
Dose
 Maximum adult dose 8 x 500mg
tablets in 24 hours
Cautions
 Patients with liver problems
 Patients with kidney problems
Drug interactions
 Does not interact with many
medicines
 Must not be taken with other
paracetamol containing medicines
due to overdose risk
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Dangers of paracetamol in overdose
Very safe if used appropriately, but….
 Highly toxic in overdose
 Supra-therapeutic doses may be as toxic as a one-off single
overdose
 Be aware of hidden sources e.g. cold remedies, combination-
medicines
 The more serious effects can be delayed
 Abdominal pain 12-36 hours
 Delayed hepatotoxicity 2-3 days before liver function declines
 Antidote must be given as soon as possible to be effective
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Combination analgesics
• Many painkillers contain more than one drug and are known as
combination, compound or co-analgesics
• Codeine and dihydrocodeine are stronger than paracetamol or
ibuprofen and are known as opioid analgesics
• Co-analgesics available OTC can be used for short-term pain not
relieved by paracetamol or ibuprofen
Do not use for more than 3 days unless advised by doctor.
Co-codamol
Codeine & paracetamol Paracodol®
Panadol Ultra®
Solpadeine®
Co-dydramol
Dihydrocodeine &
paracetamol
Paramol®
Brand names
Many Over-the-Counter (OTC) medicines have the same brand
name attached to different products
 Similar sounding and looking products have different ingredients so it
is important to obtain the exact name e.g.
 Lemsip Max Flu Lemon contains paracetamol
 Lemsip Max Flu 12 hour capsules contain ibuprofen
 Although both these products are called Lemsip Max, they contain
completely different analgesics
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Ibuprofen
Uses
 Relieves mild to moderate pain
 Reduces fever
 Reduces inflammation
 Licensed for children from 3
months if 5kg or more
Side effects
 Heartburn / indigestion
 Stomach ulcers
 Bleeding
Contra-indications (must not take)
 Allergic to aspirin
 Previous peptic ulcer / bleed
 Taking another NSAID
 Severe heart failure
Cautions (take only on advice)
 Asthma
 Kidney or liver problems
 High blood pressure
Drug interactions
 Interacts with a number of other
medicines
 Check the patient information
leaflet for advice about other
medicines
Allergy
 Rash
 Wheezing / breathlessness
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Ibuprofen overdose
 Although it has a number of side effects with therapeutic use it
has quite low toxicity in overdose
 Most patients develop no more than:
 Nausea, vomiting, epigastric pain or more rarely diarrhoea
 Tinnitus, headache, GI bleeding also possible
 Acute kidney damage - most serious complication (large
doses)
 CNS toxicity in serious overdose
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Ibuprofen – different salts
 Ibuprofen products are most commonly available as
“plain” ibuprofen
 Ibuprofen is also available in other forms in some
products
 The following few slides describe non-standard
ibuprofen products and their equivalencies
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Ibuprofen Lysine
342 mg equivalent to 200 mg ibuprofen
684 mg equivalent to 400 mg ibuprofen
Plus others
Nurofen brand
 Nurofen Express 342mg
Paramed Migraine Relief 342mg
Superdrug Migraine Relief 342mg
 Nurofen Express 684mg
Sainsbury's Migraine Relief 342mg
 Nurofen Migraine Pain /
Boots Rapid Ibuprofen Lysine 342 mg
Tension Headache 342mg
 Nurofen Maximum Strength
Migraine Pain 684mg
Morrisons Migraine Relief 342mg
Tesco Migraine Relief 342mg
Tesco Express Pain Relief 342 mg
Asda Migraine Relief 342mg
Feminax Express 342 mg
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Ibuprofen Sodium
256 mg equivalent to 200 mg ibuprofen
512 mg equivalent to 400 mg ibuprofen
Nurofen brand
 Nurofen Express 256mg
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Nurofen Back Pain 300mg SR
®
Capsules
 Ibuprofen 300mg Sustained Release
 Not the usual strength or release pattern of ibuprofen
 Refer for further guidance if necessary
 Adults and children over 12 years: 1 capsule twice a day.
Maximum 4 capsules in 24 hours
 Children under 12 years: Not to be given
 Do not take more frequently than every 8 hours
 Not to be chewed or sucked
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®
Nuromol
 Ibuprofen 200mg with Paracetamol 500mg
 No matter how many tablets are taken, the paracetamol
will cause toxicity before the ibuprofen
 Calculate total amount of paracetamol taken
 Adults over 18 years: 1-2 tablets up to three times a day.
Maximum 6 tablets in any 24 hour period
 Under 18 years: Not to be taken
 Leave at least 6 hours between doses
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Table 1: List
of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
ACECLOFENAC
ACEMETACIN
ASPIRIN (incl. low
dose)
AZAPROPAZONE
CELECOXIB
DEXIBUPROFEN
DEXKETOPROFEN
DICLOFENAC
ETODOLAC
ETORICOXIB
FENBUFEN
FENOPROFEN
FLURBIPROFEN
IBUPROFEN
INDOMETACIN
KETOPROFEN
KETORALAC
MEFENAMIC ACID
MELOXICAM
NABUMETONE
NAPROXEN
PARECOXIB
PIROXICAM
PHENYLBUTAZONE
SALICYLATE
SALICYLIC ACID
SULINDAC
TENOXICAM
TIAPROFENIC
ACID
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Ibuprofen
Tell the caller:
 The recommended OTC dose of ibuprofen is 1 x 400mg or 2 x
200mg every 6-8 hours but no more than 3 x 400mg or 6 x
200mg (1200mg) in 24 hours
 Be aware of hidden sources of ibuprofen (e.g. in cold remedies,
muscle creams)
 Do not take any other anti-inflammatory medicines (NSAIDs)
(except in oral gels) when taking ibuprofen (see list of NSAIDs
in Table 1)
 You can restart ibuprofen provided you do not take more
than 1200mg (3 x 400mg or 6 x 200mg) ibuprofen in any 24
hour period
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Codeine
 An overdose of tablets containing codeine:
 Co-codamol 30/500
 Co-codamol 8/500
 May cause drowsiness, constipation, GI upset
 Severe - respiratory depression
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Co-analgesics
Co-Codamol = Codeine & Paracetamol
Amount of codeine in co-codamol can be
8mg, 15mg or 30mg.
Co-codamol 8/500
OTC

Co-codamol 15/500
POM

Co-codamol 30/500
POM




Codeine 8mg & paracetamol 500mg
Brands: e.g. Feminax®, Migraleve Yellow®,
Panadol Ultra®, Paracodol®, Panadeine®
Codeine 15mg & paracetamol 500mg
Brands: e.g. Codipar®
Codeine 30mg & paracetamol 500mg
Brands: e.g. Kapake®, Tylex®, Solpadol®
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Co-Dydramol = Dihydrocodeine & Paracetamol
Amount of dihydrocodeine can be
7.46mg, 10mg, 20mg, 30mg.
Co-dydramol
OTC

Co-dydramol
POM

Co-dydramol
POM

Co-dydramol
POM





Paracetamol 500mg, dihydrocodeine 7.46mg
Paramol®
Paracetamol 500mg + dihydrocodeine 10mg
If no strength specified on the prescription.
Paracetamol 500mg + dihydrocodeine 20mg
Remedeine®
Paracetamol 500mg + dihydrocodeine 30mg
Remedeine Forte®
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Co-Codamol / Co-dydramol
Uses
 Mild to moderate pain
 Lowers fever (paracetamol alone is
first choice)
Cautions
 Kidney or liver problems
 Limit use to 3 days unless
advised by doctor
Side effects
 Codeine / Dihydrocodeine 
collapse, drowsiness, confusion,
constipation
Drug interactions
 Other paracetamol and / or opiate
containing medicines
 Antidepressants
 Anti-anxiety medicines / sleeping
tablets
 Check the patient information
leaflet for advice about other
medicines
Paracetamol overdose
 150 mg/kg/24hr or if risk factors,
75mg/kg/24hr
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Guidance for restarting paracetamol
following inadvertent overdose
 This is designed to help you deal with patients who have taken more
than the recommended amount of paracetamol but less than a toxic
amount requiring referral
 Commonly, these patients will want to know when they can take their
next dose of paracetamol. However we need to ensure not to restart too
soon which would put them back into an overdose situation again
 Advise the patient that they may restart such that they take no more
than the maximum recommended amount in any 24 hour period. i.e. 8 x
500mg (4000mg) paracetamol in 24 hrs
 The easiest way to do this is to use a timeline and mark the 24 hour
period. It is important to check exactly how much has been taken and at
what times
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Restarting guidance case study
 46 years old
 Symptoms of toothache
 No medical health issues, no other medicines, no allergies
 Has taken Paracetamol 500mg tablets
Friday :
08:00 - 2 tablets
12:30 - 2 tablets
18:00 - 2 tablets
21:00 - 2 tablets
23:00 - 2 tablets
Saturday:
07:00 - 2 tablets
 When can she take her next dose?
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Restarting guidance
 Step 1: Draw a timeline
 Step 2: Fill in the doses the patient has taken
 Step 3: Find how many tablets the patient has taken in the
last 24 hours
 Step 4: At 8am when the caller rings, they have had 12
paracetamol tablets in the last 24 hours. Now you can
“shift“ the 24 hour period along, until they are under the
recommended amount in 24 hours (the amount on the
pack, which is 8 x 500mg tablets in 24 hours)
 Step 5: Work out how many paracetamol tablets the
patient can still have in this 24 hour period. Restart so that
there is the recommended dose interval (4 hrs for
paracetamol) since the last dose was taken
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Restarting guidance
Day 1
Day 2
8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
08:00 Phones Service
At 8:00 - 12 tablets have been taken in the preceding 24 hours
Restarting guidance
Day 1
Day 2
8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
08:00 Phones Service
At 12:00 - 10 tablets have been taken in the preceding 24 hours
Restarting guidance
Day 1
Day 2
8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
1
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
08:00 Phones Service
At 16:00 - 8 tablets have been taken in the preceding 24 hours
Restarting guidance
Day 1
8
Day 2
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
1
2 3 4 5 6 7
8 9 10 11 12 13 14 15 16 17 18 19
08:00 Phones Service
At 18:30 - 6 tablets have been taken in the preceding 24 hours
The patient can restart paracetamol by taking another two tablets at 18:30 hours