Transcript Pain Control - University of Minnesota

Pain Control
Dent 6205
Summer Session 2008
Strategies
 KISS
 Follow the rules: Medical history, allergies,
bleeding Hx, blah, blah, blah
 Good drug reference (Drug interactions)
 Pharmacist or Pharm D?
 Beware of drug-seeking behavior
 Write a clear Rx to avoid changes by the patient
Barry Brainfart Dental Clinic 666 Bite Me Ln
Crossbyte Falls, MN Ph: 555-YOU-HURT
Pt. Name: I.M. Snorting Address: XXX
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Rx: Tylenol 3
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Disp: 15 caps
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Sig: i q4-6h prn pain
Refill__Φ__
DOB: 3-3-59
Date: 5/29/04
Barry Brainfart, DDS
DEA: AB000000
Barry Brainfart Dental Clinic 666 Bite Me Ln
Crossbyte Falls, MN Ph: 555-YOU-HURT
Pt. Name: I.M. Snorting Address: XXX

Rx: Tylenol 3

Disp: 115 caps

Sig: i q4-6h prn pain
Refill__Φ__
DOB: 3-3-59
Date: 5/29/04
Barry Brainfart, DDS
DEA: AB000000
Barry Brainfart Dental Clinic 666 Bite Me Ln
Crossbyte Falls, MN Ph: 555-YOU-HURT
Pt. Name: I.M. Snorting Address: XXX

Rx: Tylenol 3

Disp: 15 caps (fifteen) or (XV)

Sig: i q4-6h prn pain
Refill__Φ__
DOB: 3-3-59
Date: 5/29/04
Barry Brainfart, DDS
DEA: AB000000
Personal Philosophies
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Narcotics vs. no narcotics
Fear of addiction or aiding an addiction
Leads to under-medication
Leads to after-hours phone calls
Leads to fear of addiction or aiding an addiction
It’s a question of pain
How much? How long?
How Much Pain?
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Individual response and tolerance to pain
Procedure?
Infection/inflammation present
Quantify if possible—VAS
Mild; Mild-Moderate; Moderate-Severe; Severe
Many dental procedures will be in the mildmoderate range
How Long?
 Most dental procedures: 3-4 days
 Notable exception: Weekends
 No documented addictions in 4 days, except
oxycodone
 Call for more medications patient needs to be
seen. Inform the patient a procedure WILL be
done. This is a major deterrent.
Prescription Strategies
 Explain “Breakthrough Pain” to the patient
 If the initial pain medication does not control the
pain.
 If the pain returns before the next dose is
scheduled.
Strategies
 NSAID—First choice, but have alternatives
 Acetaminophen (Tylenol, APAP)
 Narcotics—Breakthrough pain
 Combination drugs—Ohh baby….
 Remember to ask what works for the
patient
NSAIDs—Mild-Moderate Pain
 Aspirin 325mg q4h (consider platelets)
 Ibuprofen 400mg q4h; 600mg q6h; 800mg q8h;
max. daily dose: 3200mg/day
 Naprosyn (Naproxin Na) 200mg q12h—long
onset of action
NSAIDs—Moderate-Severe Pain
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Ansaid (Flurbuprofen) 100mg q8h
Cataflam (Diclofenac) 50mg q8h—small pill
Ketoprofen 400mg—long onset of action
Vioxx 50mg q24h—No longer available.
Selective COX2 inhibitor—decreased GI
irritation, unless patient already has a history.
Theoretically, no effect on platelet activity.
Expensive.
NSAIDs—Severe Pain
 Toradol (Ketorolac) 30mg q8h IM/IV; follow
with 10mg q8h—beware GI bleeds
Tylenol
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Acetaminophen (APAP) 650mg-1000mg q4h
There is a ceiling of 1000mg.
Does not compete with NSAIDs.
Antipyrrhetic, but no anti-inflammatory
properties.
 Consider alternating with NSAIDs for mildmoderate pain.
Narcotics
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Central Acting—”Dave’s not here”
More extensive side effect profile
Addiction potential: moderate to high
Morphine—accompanying sense of euphoria
addiction
 Codiene: ~ 10% of the metabolitemorphine; most
frequent complaint: N & V
 Hydrocodone: 5mg, 7.5mg, 10 mg; semi-synthetic
codiene; ↑’d N & V with ↑’d dose; advise the patient to
lay down to avoid; more reports of high addiction rate
Narcotics
 Oxycodone: 2.5, 5, 7.5, 10mg High addiction rate;
Star/Trib Saturday May 29, 2004: M.D. was disciplined
for Rx for a pregnant patientbaby was born addicted.
Comes as either a stand-alone drug (Oxycontin) or in
combinations (Percocet, Tylox, Percodan, Roxicet) All
are Schedule II.
 Talwin—Schedule IV due to combination with Narcan
(Naloxone)instant withdrawal or Tylenolpainful
injection
Narcotics
 Demerol—POOR oral absorption; good effect as
IM or IV
 Fentanyl—Patch is NOT for acute pain
 Darvon compound (Darvocet, Darvocet N-100);
pain relief is almost entirely due to the Tylenol;
Schedule IV
 Ultram—Schedule IV, some addictive potential
DEA License
 Apply over the internet. (Google DEA)
 Schedule I-V. VI may be added for herbal meds.
 Schedule I: No medicinal use. May be used for
research/inpatient. (heroin, MJ, cocaine, etc.)
 Schedule II: High addiction potential. Needs a
WRITTEN prescription. In some states, it needs
to be in triplicate.
 Schedule III: Moderate addiction potential. Can
be phoned in.
DEA License
 Schedule IV—Low addiction potential.
 Schedule V—No reported addiction potential.
(antibiotics)
 OTC
 Consider: Apply only for Schedule III, IV, V*
(can’t do this any more)
 Consider: Phone in all your Rx’s—avoids “lost”
prescriptions.
Prescription Strategies
 Mild-Moderate Pain--NSAID ± APAP ±
Narcotics
 Alternative NSAID ± APAP + Narcotic
 Example: Ibuprofen 600mg q6h alternating with
APAP 650mg; if inadequate relief Ansaid
100mg q8h, consider adding Vicodin q4-6h
(consider adding 1 regular strength 350mg
Tylenol/dose of Vicodin)
Prescription Strategies
 Moderate-Severe Pain—NSAID +
APAP/Narcotic for breakthrough pain
 Example: Ansaid 100mg q8h; Vicodin 5/500
Questions?
Thank You