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

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?

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

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  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  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.

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

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