Transcript PAIN - Nevada Optometric Association

PAIN, PAIN, GO AWAY….
Jill Autry, OD, RPh
Eye Center of Texas, Houston
[email protected]
Disclosures – Jill Autry, OD, R.Ph.
• Speaker’s Bureau/Consultant/KOL Board
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Allergan
Alcon
Inspire
Ista
Bausch and Lomb
• Owner
– Tropical CE
– Eye Center of Texas Ophthalmology Center, Houston
• Editorial Board
– Primary Care Optometry News
– Optometry Times
PAIN
• Most common reason to seek medical care
• Acute
– Sudden and severe
– Burn
– Corneal abrasion, preseptal cellulitis
• Chronic
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Lasts longer than 3 months
Back pain
Post-herpetic neuralgia
Sinusitis
Migraine
TYPES OF PAIN
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Somatic
Visceral
Neuropathic
Psychogenic
ANALGESIA
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Word of Greek origin
“an” meaning without
“algein” meaning to feel pain
Generally classified
– Mild
– Moderate
– Strong
MILD ANALGESICS
• Acetylsalicylic acid
– Aspirin or “ASA”
• Acetaminophen
– Tylenol® or “APAP”
• Propoxyphene (Schedule IV)-removed from
market
– Darvon®
– Darvocet®
SALICYLATES- THE FOUR “As”
• Analgesic
– Relief without sedation
– Works on peripheral pain receptors
– Decreases synthesis of prostaglandins and
bradykinins
• Anti-inflammatory
– Blocks kinin precursors
– Blocks histamine precursors
– Need high doses for arthritic pain
• Approx 4-6 grams daily
SALICYLATES- THE FOUR “A”
• Anti-platelet
– Not related to pain treatment
– For heart attack and stroke prevention
– Inhibits platelet adhesiveness and coagulation
– Regular strength is 325mg; baby aspirin is 81mg
• Antipyretic-“pyrexis” Greek for heat
– Affects the hypothalamus which is responsible for
temperature regulation
– Decreases temperature but not below normal
– Inhibits pyrogen stimulated prostaglandins
ASPIRIN SIDE EFFECTS
• Max daily dose = 4000mg (4g)
• Reye’s Syndrome in children with flu-like
symptoms
• GI irritation
• Bleeding ulcers
• Increased anticoagulation
• Nausea
• Tinnitus
– Often seen at arthritic doses
ALLERGIC TO ASPIRIN?
• Triad leading to anaphylaxis
– Aspirin allergy
– Asthma
– Nasal polyps
• Avoid the following:
– Aspirin
– Oral NSAIDS
– Topical NSAIDS
ACETAMINOPHEN
• Clear mechanism of action elusive
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– May affect oxidation of cyclooxygenase (COX) and
inhibit prostaglandin synthesis in the CNS
– May increase endogenous cannabinoids
Analgesic action
Anti-pyretic action
No anti-inflammatory action
No anti-platelet action
ACETAMINOPHEN DOSING
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aka APAP
OTC 325mg regular strength
500mg extra strength
4000mg/day (4 gram) max dosage
Used extensively in flu/cold/pain preps
Watch ingredient lists to avoid overdosage
ACETAMINOPHEN
SIDE EFFECTS
• Generally well tolerated at therapeutic
dosages
• Overdosage causes irreversible kidney and
liver damage
• Cannot use in patients with hepatic disease
or alcoholics
• Do not use with alcohol
• Check ingredients on cough/cold preps
MODERATE ANALGESICS
• Codeine (Tylenol #3®, Tylenol #4®)
• Hydrocodone (Vicodin®, Vicoprofen®,
Lorcet®, Lortab®)
• Oxycodone (Percocet®, Percodan®)
• NSAIDS (ibuprofen, Naproxen®, others)
• Tramadol (Ultram®, Ultracet®)
CODEINE
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Naturally occurring substance
From the opium poppy
1/12 the strength of morphine
Rarely used alone
Tylenol #3® (APAP and codeine)
Empirin #3® (ASA and codeine)
Also used as an antitussive in cough syrups
CODEINE COMBINATIONS
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Tylenol #3® and Tylenol® #4
Increasing codeine amount from #3 to #4
APAP amount is 325mg in each
#3-30mg codeine + 325mg APAP
#4-60mg codeine + 325mg APAP
Tylenol with codeine® elixir is APAP
120mg/5cc with 12mg codeine/5cc
TYLENOL #3
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Schedule III
Central acting narcotic analgesic
325mg acetaminophen + 30mg codeine
Avoid in liver/renal disease/alcoholism
No extra Tylenol® in addition
No alcohol
GI distress and sedation are main side
effects
Edward Wade, M.D.
Chris Allee, O.D.
Ting Fang-Suarez, M.D.
Jill Autry, O.D.
Mark Mayo, M.D.
Randy Reichle, O.D.
6565 West Loop South
Bellaire, TX 77401
Phone (713)797-1010
4415 Crenshaw Rd.
Pasadena, TX 77504
Phone (281)998-3333
15400 SW Frwy
Sugar Land, TX 77478
(281)277-1010
450 Medical Ctr Blvd, #305
Webster, TX 77598
(281) 332-1397
11914 Astoria Boulevard, #325
Houston, TX 77089
(281) 484-2030
21700 Kingsland Blvd.
Katy, TX 77450
(281) 578-4815
NAME
Jack Cooper
AGE ________
ADDRESS 6565 Golden River Drive, Houston, TX 77082
Rx
REFILLS--
DATE 3-3-11
Tylenol #3 #20 (twenty)
1-2 po q4-6h prn pain
zero
Jill Autry, O.D.
MA0123456
ALLERGIC TO CODEINE?
• Most codeine “allergies” are just GI side
effects or codeine initiated histamine release
– “Stomach upset”
– Flushing
– Itching
• True IgE mediated allergic reaction low
• Can use hydrocodone because it is a semisynthetic form of codeine
HYDROCODONE
• As effective as Class II narcotics but with Class
III status
• Significantly more pain relief and duration of
action compared to codeine
• Induces euphoria
• Highly addictive
• Also has antitussive properties
HYDROCODONE PRODUCTS
• Vicodin® (APAP w/hydrocodone)
– 500mg APAP + 5mg hydrocodone
– Schedule III
• Vicodin® ES (APAP w/hydrocodone)
– 750mg APAP + 7.5mg hydrocodone
– Schedule III
• Vicoprofen®
– 200mg ibuprofen + 7.5mg hydrocodone
– When Tylenol® is contraindicated/liver disease
– Schedule III
Edward Wade, M.D.
Chris Allee, O.D.
Ting Fang-Suarez, M.D.
Jill Autry, O.D.
Mark Mayo, M.D.
Randy Reichle, O.D.
6565 West Loop South
Bellaire, TX 77401
Phone (713)797-1010
4415 Crenshaw Rd.
Pasadena, TX 77504
Phone (281)998-3333
15400 SW Frwy
Sugar Land, TX 77478
(281)277-1010
450 Medical Ctr Blvd, #305
Webster, TX 77598
(281) 332-1397
11914 Astoria Boulevard, #325
Houston, TX 77089
(281) 484-2030
21700 Kingsland Blvd.
Katy, TX 77450
(281) 578-4815
NAME
Jack Cooper
AGE ________
ADDRESS 6565 Golden River Drive, Houston, TX 77082
Rx
REFILLS--
DATE 3-3-11
Vicodin 5/500 #30 (thirty)
1-2 q4-6h prn pain
zero
Jill Autry, O.D.
MA0123456
Edward Wade, M.D.
Chris Allee, O.D.
Ting Fang-Suarez, M.D.
Jill Autry, O.D.
Mark Mayo, M.D.
Randy Reichle, O.D.
6565 West Loop South
Bellaire, TX 77401
Phone (713)797-1010
4415 Crenshaw Rd.
Pasadena, TX 77504
Phone (281)998-3333
15400 SW Frwy
Sugar Land, TX 77478
(281)277-1010
450 Medical Ctr Blvd, #305
Webster, TX 77598
(281) 332-1397
11914 Astoria Boulevard, #325
Houston, TX 77089
(281) 484-2030
21700 Kingsland Blvd.
Katy, TX 77450
(281) 578-4815
NAME
Jack Cooper
AGE ________
ADDRESS 6565 Golden River Drive, Houston, TX 77082
Rx
REFILLS--
DATE 3-3-11
Vicodin ES #30 (thirty)
1 q4-6h prn pain
zero
Jill Autry, O.D.
MA0123456
Edward Wade, M.D.
Chris Allee, O.D.
Ting Fang-Suarez, M.D.
Jill Autry, O.D.
Mark Mayo, M.D.
Randy Reichle, O.D.
6565 West Loop South
Bellaire, TX 77401
Phone (713)797-1010
4415 Crenshaw Rd.
Pasadena, TX 77504
Phone (281)998-3333
15400 SW Frwy
Sugar Land, TX 77478
(281)277-1010
450 Medical Ctr Blvd, #305
Webster, TX 77598
(281) 332-1397
11914 Astoria Boulevard, #325
Houston, TX 77089
(281) 484-2030
21700 Kingsland Blvd.
Katy, TX 77450
(281) 578-4815
NAME
Jack Cooper
AGE ________
ADDRESS 6565 Golden River Drive, Houston, TX 77082
Rx
REFILLS--
DATE 3-3-10
Vicoprofen #30 (thirty)
1 q4-6h prn pain
zero
Jill Autry, O.D.
MA0123456
NSAIDS
• Nonsteroidal anti-inflammatory drugs
(NSAIDS)
• Very popular
• None are controlled substances
• Little to no abuse potential
• Some available in OTC strength
• Patients vary in response to various products
NSAID ACTIONS
• Inhibit cyclo-oxygenase pathway
• Results in decreased prostaglandin
formation
• Reduce pain
• Reduce inflammation
• Reduce edema
COMMON ORAL NSAIDS
• OTC
– Ibuprofen 200mg
• Motrin®, Advil®, Nuprin®
– Naproxen 200mg
• Alleve®
• Rx
– Ibuprofen 400mg, 600mg, 800mg
– Ketorolac (Toradol®) 10mg
– Celebrex 100mg, 200mg
Edward Wade, M.D.
Chris Allee, O.D.
Ting Fang-Suarez, M.D.
Jill Autry, O.D.
Mark Mayo, M.D.
Randy Reichle, O.D.
6565 West Loop South
Bellaire, TX 77401
Phone (713)797-1010
4415 Crenshaw Rd.
Pasadena, TX 77504
Phone (281)998-3333
15400 SW Frwy
Sugar Land, TX 77478
(281)277-1010
450 Medical Ctr Blvd, #305
Webster, TX 77598
(281) 332-1397
11914 Astoria Boulevard, #325
Houston, TX 77089
(281) 484-2030
21700 Kingsland Blvd.
Katy, TX 77450
(281) 578-4815
NAME
Joe Johnson
AGE ______________
ADDRESS_____________________________________________________DATE
Rx
REFILLS--
3-3-11
Ibuprofen 600mg #30
1 po q6h
0
Jill Autry, O.D.
NSAID INDICATIONS
• Arthritis
– Osteoarthritis
– Rheumatoid arthritis
• Moderate pain
– Post-operative pain
– Dental pain
• Headache
• Premenstrual cramping
• Additional control of ocular inflammation
– Episcleritis, iritis, non-specific ocular pain
NSAID SIDE EFFECTS
• All oral NSAIDS have been associated with
inducing ulcers
– Risk increased for elderly
– Risk increased for patients on steroids,
anticoagulants, daily aspirin
– Consider Zantac® 150mg bid for extended NSAID
therapy
– Take with food or milk
NSAID SIDE EFFECTS
• Kidney toxicity
– Dose and duration-dependent
– Risk factors for kidney failure
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Elderly
Diabetes, hypertension, heart failure
Concomitant diuretic use
Concomitant ACE inhibitor or Angiotensin II
blocker use
TOPICAL NSAIDS
• Ketorolac
• Generic 0.5% available—dosed qid
• Accuvail®
• Bid non-preserved
• Nevanac®
• Tid
• Bromfenac
• Xibrom® bid
• Bromday® qd
STRONG ANALGESICS
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Morphine
Hydromorphine
Methadone
Meperidine
– Demerol®
SIDE EFFECTS OF
OPIOID ANALGESICS
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Constipation
Nausea and vomiting
Sedation
Dizziness
Miosis
Itching
Respiratory depression
Addiction
ANALGESIC PAIN
MANAGEMENT PEARLS
• Synergy
– Topical and orals
– Central acting and Peripheral acting
• Concerns
– Pain that worsens despite treatment
– Hepatic disease
– Renal disease
– GI ulcer history
– Anticoagulants/antiplatelet use
– Diabetic
– Aspirin/Codeine allergies
CONTROLLED SUBSTANCES
• A substance subject to the Controlled
Substances Act (1970), which regulates the
prescribing and dispensing of substances
according to:
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Potential for or evidence of abuse
Potential for psychological or physiological dependence
Contributing to a public health risk
Harmful pharmacological effect
Role as a precursor of other controlled substances
• List of medications and corresponding
schedules found at www.deadiversion.usdoj.gov
PRESCRIBING FOR SELF/FAMILY
• AMA Code of Medical Ethics states
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“physicians generally should not treat themselves or
members of their immediate family”
• “…there are situations in which routine care is acceptable
for short-term, minor problems.”
• Stay within prescriptive scope of practice
PRESCRIBING FOR SELF/FAMILY
• Controlled substances under federal law
• Legitimate medical purpose
• Patient-physician relationship
• Acting in the usual course of sound professional practice
– Maintenance of a written medical record, etc.
• Some states have specific rules/regulations
• No controlled substances to immediate family members
• No controlled substances for physician’s own self
GETTING A DEA NUMBER
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On-line application
www.deadiversion.usdoj.gov
Optometrists are mid-level practitioners (MLP)
First time applicant-Form 224
Renewal-Form 224a
Cost $551/Good for 3 years
Takes 1-3 months to receive
CONTROLLED SUBSTANCE Rx
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Doctor name and address
Patient name and address
Patient age/birthdate
Date of Rx
– Good for six months from date of issue
Drug name/quantity written as number and word
Refill line
– Schedules III, IV, and V allow 5 refills in 6 months
Signature of prescriber
DEA number
Edward Wade, M.D.
Chris Allee, O.D.
Ting Fang-Suarez, M.D.
Jill Autry, O.D., RPh
Mark Mayo, M.D.
Randy Reichle, O.D.
6565 West Loop South
Bellaire, TX 77401
Phone (713)797-1010
4415 Crenshaw Rd.
Pasadena, TX 77504
Phone (281)998-3333
15400 SW Frwy
Sugar Land, TX 77478
(281)277-1010
450 Medical Ctr Blvd, #305
Webster, TX 77598
(281) 332-1397
11914 Astoria Boulevard, #325
Houston, TX 77089
(281) 484-2030
21700 Kingsland Blvd.
Katy, TX 77450
(281) 578-4815
NAME
Jack Cooper
AGE __32______
ADDRESS 6565 Golden River Drive, Houston, TX 77082
Rx
REFILLS--
DATE 3-3-11
Tylenol #3 #20 (twenty)
1-2 po q4-6h prn pain
zero
Jill Autry, O.D.
MA0123456
TOPICAL STEROIDS
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Reduce inflammation
Reduce pain
Reduce photophobia
Ocular conditions
– Iritis, sterile corneal infiltrates, episcleritis, postoperative pain due to inflammation, inflamed
pterygia/pingueculae
• Pred Forte® 1%, Durezol®, Lotemax®, FML
Forte®, etc.
ORAL STEROIDS
• Take with food or milk
• Generally start 60-80 mg/day
– For posterior uveitis, Giant cell, after IV steroids for
optic neuritis, pseudotumor, scleritis
– Must taper dosage over 1-2 weeks depending on
response
– 40-60 mg x 2-3 days does not need taper
• Consider Medrol Dosepak
– For allergic reactions, zoster, anterior uveitis
– Less serious inflammations
Edward Wade, M.D.
Chris Allee, O.D.
Ting Fang-Suarez, M.D.
Jill Autry, O.D.
Mark Mayo, M.D.
Randy Reichle, O.D.
6565 West Loop South
Bellaire, TX 77401
Phone (713)797-1010
4415 Crenshaw Rd.
Pasadena, TX 77504
Phone (281)998-3333
15400 SW Frwy
Sugar Land, TX 77478
(281)277-1010
450 Medical Ctr Blvd, #305
Webster, TX 77598
(281) 332-1397
11914 Astoria Boulevard, #325
Houston, TX 77089
(281) 484-2030
21700 Kingsland Blvd.
Katy, TX 77450
(281) 578-4815
NAME
Joe Johnson
AGE ______________
ADDRESS_____________________________________________________DATE
Rx
REFILLS--
3-3-11
Prednisone 20mg #30
3 tabs (60mg) qd with food/milk
0
Jill Autry, O.D.
Edward Wade, M.D.
Chris Allee, O.D.
Ting Fang-Suarez, M.D.
Jill Autry, O.D.
Mark Mayo, M.D.
Randy Reichle, O.D.
6565 West Loop South
Bellaire, TX 77401
Phone (713)797-1010
4415 Crenshaw Rd.
Pasadena, TX 77504
Phone (281)998-3333
15400 SW Frwy
Sugar Land, TX 77478
(281)277-1010
450 Medical Ctr Blvd, #305
Webster, TX 77598
(281) 332-1397
11914 Astoria Boulevard, #325
Houston, TX 77089
(281) 484-2030
21700 Kingsland Blvd.
Katy, TX 77450
(281) 578-4815
NAME
Joe Johnson
AGE ______________
ADDRESS_____________________________________________________DATE
Rx
REFILLS--
3-3-11
Medrol Dose Pack
TUD
0
Jill Autry, O.D.
STEROID SIDE EFFECTS
• Increased intraocular pressure
– Topical will increase in 2-4 weeks
– Oral/IV can increase within 3-4 days
• Cataract
– Usually posterior subcapsular
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Steroid induced diabetes/decrease control
Adrenal suppression
Reduced immunity/infections
Mood swings/erratic behavior
TOPICAL ANESTHESIA
• Topical anesthesia
– Onset of action within 20 seconds
– Duration of action 15-20 minutes
– Anesthesia of surface nerve endings
– Work by blocking both the initiation and
conduction of nerve impulses
– May retard epithelial regeneration with
prolonged and repeated use
– Consider “comfort drops”
ANESTHETIC REACTIONS
• Anesthetics generally have either an amide
chemical structure or an ester chemical structure.
• In cases of allergy or increased side effects, an
anesthetic from the alternate class may often be
utilized without cross sensitivity.
AMIDE ANESTHETICS
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Bupivicaine
Etidocaine
Lidocaine
Mepivacaine
Dibucaine
ESTER ANESTHETICS
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Chloroprocaine
Procaine
Tetracaine
Benzocaine
Cocaine
Proparacaine
Benoxinate ***Found in Fluress***
CYCLOPLEGICS
• Provides ocular pain control in certain
inflammatory ocular conditions
• Relaxes ciliary spasm by ciliary body
paralysis
• Ocular pain uses are numerous
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Iritis
Corneal abrasions/RCE
Corneal foreign body removal
Post-operative pain
• Contraindicated in pain from angle closure
• Atropine, scopolamine, or homatropine
Edward Wade, M.D.
Chris Allee, O.D.
Ting Fang-Suarez, M.D.
Jill Autry, O.D.
Mark Mayo, M.D.
Randy Reichle, O.D.
6565 West Loop South
Bellaire, TX 77401
Phone (713)797-1010
4415 Crenshaw Rd.
Pasadena, TX 77504
Phone (281)998-3333
15400 SW Frwy
Sugar Land, TX 77478
(281)277-1010
450 Medical Ctr Blvd, #305
Webster, TX 77598
(281) 332-1397
11914 Astoria Boulevard, #325
Houston, TX 77089
(281) 484-2030
21700 Kingsland Blvd.
Katy, TX 77450
(281) 578-4815
NAME
Joe Johnson
AGE ______________
ADDRESS_____________________________________________________DATE
Rx
REFILLS--
3-3-11
Homatropine 5% 5ml
1 gtt tid OD
0
Jill Autry, O.D.
CASE EXAMPLES