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Pain Control

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.

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Pain Control

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  1. Pain Control Dent 6205 Summer Session 2008

  2. 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

  3. Personal Philosophies • 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?

  4. How Much Pain? • 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 mild-moderate range

  5. 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.

  6. 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.

  7. 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

  8. 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

  9. NSAIDs—Moderate-Severe Pain • 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.

  10. NSAIDs—Severe Pain • Toradol (Ketorolac) 30mg q8h IM/IV; follow with 10mg q8h—beware GI bleeds

  11. Tylenol • 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 mild-moderate pain.

  12. Narcotics • 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

  13. 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

  14. 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

  15. 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.

  16. 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.

  17. 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)

  18. Prescription Strategies • Moderate-Severe Pain—NSAID + APAP/Narcotic for breakthrough pain • Example: Ansaid 100mg q8h; Vicodin 5/500

  19. Questions? Thank You

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