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I.
II.
III.
IV.
V.
VI.
VII.
Definition of Pain
A. The International Association of Pain defines it as: an unpleasant sensory and
emotional experience most often associated with actual or potential tissue damage or
described in terms of such damage.
Sensory Aspects
A. Physiologic Changes
B. Flight or Fight
Emotional Aspects
A. Most overlooked portion of pain management
B. Past Experiences
C. Fear
D. Aware of Consequences
E. Suggestions and Placebo affect
Objective Measure of Pain
A. There are none.
B. Physiologic Changes
1. Heart Rate
2. Blood Pressure
3. Pupil Dilation
4. Sweating
5. Decreased blood flow to the skin
C. Mistrust People in Pain
1. Manipulate employer/Worker’s comp
2. Feed addiction
3. Sell prescription
D. Drug Dependency
1. Increased tolerance
2. Physical dependence
3. Addiction
Subjective Measure of Pain
A. Borg Scale
B. Goal of Pain Management is not zero pain
C. Pain Thresholds
1. Factors that decrease pain threshold
a. Insomnia
b. Fatigue
c. Nausea
d. Anxiety
e. Fear
f. Depression
2. Factors that increase pain threshold
a. Diversion
b. Sympathy/Understanding
Types of Pain
A. Acute Pain
1. Follows injury tissue or damage
2. Well defined onset
3. Obvious physical signs
4. Easy to localize
5. Disappears when body heals
B. Chronic Pain
1. May not have well defined onset
2. Can last months to years
3. May have no physical signs
4. May be accompanied by depression
5. May require higher dosages of meds for same effect
Doctor’s Concerns for Prescription
A. Insurance and Paperwork Issues
B. Side Effects from oral medicines
VIII.
IX.
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XII.
XIII.
XIV.
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C. Addiction
Complete Pain Management
A. Acknowledgement of severity of patient’s pain
B. Sympathy
C. Reassurance
D. Giving a prescription gives the control back to patient
Ocular Pain Management Options
A. Reassurance only
B. Placebo
1. 32% of people respond to placebo affect
2. Ethical considerations
3. Doctor’s bias
C. Pressure Patch
1. Insurance considerations
2. Infection considerations
D. Bandage Contact Lens
1. Fit lens tightly with little movement
2. Newer options in Silicon-hydrogel lenses
E. Topical NSAIDS
1. Mechanism of Action of NSAIDS
2. Adverse reactions
3. Combination of Topical NSAID and Bandage CL
F. Oral Over-the-Counter Analgesic
1. Used for Mild to Moderate pain
2. Mechanism of Action
3. Examples with pro’s and con’s
Acetaminophen
A. Liver toxicity
B. No anti-inflammatory properties
C. No Rx strength dosages
D. Currently being scrutinized by FDA
1. May reduce max daily dosage to 3250 mg from 4000 mg
2. May reduce max single pill dosage to 650 mg
3. May eliminate combo drug preps
4. May eliminate acetaminophen-narcotic compounds
E. Accidental overdose
Aspirin
A. GI problems
B. Contraindicated in children
C. Current baby aspirin recommendations
Ibuprofen
A. Use cautiously in patients with hypertension and diabetes
1. Rx dose is double OTC dose
B. Cardiac questions raised after Vioxx
Naproxen Sodium
A. Less frequent dosing
B. Use cautiously in patients with cardiovascular disease, diabetes
Prescription Options
A. Cox-2 Inhibitors
1. Discussion of controversy surrounding
2. Rx recommendations
3. Cautions
4. Law suit update, settlements
5. Ramifications for future developments in NSAIDs and non-selective NSAIDs
Schedule III Medicines
A. Definition of Schedule III
1. Potential for abuse
2. Accepted medical use
XVI.
XVII.
XVIII.
XIX.
3. Abuse of drug may lead to moderate or low physical dependence or high
psychological dependence
4. For moderate to moderately severe pain
5. Contraindications
a. Head injury
b. Acute abdominal pain
c. Patients with impaired kidney or liver function
6. Adverse Reactions
a. Sedation
b. Nausea
c. Lightheadedness or dizziness
d. Respiratory depression
7. Examples
a. Codeine with Acetaminophen
b. Hydrocodone with Acetaminophen
Drug Abuse and Dependence
1. Addiction
2. Psychological Dependence
3. Physical Dependence
4. Tolerance
Drug Enforcement Administration
A. Tracking
B. Rx requirements
C. State differences
The second part of the talk will consist of example cases presented in a grand rounds
format, concentrating on the pain management aspects of the case. Cases will include the
following:
A. Recurrent Corneal Erosion
B. Corneal Ulcer
C. Hyphema
D. Herpes Simplex Blepharitis
E. Herpes Simplex Keratitis
F. Chemical Splash
G. Conjunctival laceration
H. CLARE
I. Blunt ocular trauma
J. Pseudo-papilledema
Helpful Websites
A. www.medscape.com
B. www.medlineplus.gov
C. www.rxlist.com
D. www.drugstore.com
E. www.epocrates.com
References
1. Schilling A, Corey R, Leonard M, Eghtesad B. Acetaminophen: Old drug, new warnings.
Cleveland Clinic Journal of Medicine. 77(1):19-27 2010
2. Rainsford KD. Cardiovascular adverse reactions from NSAIDs are more than COX-2 inhibition
alone: ‘The gun must be loaded for COX-2 inhibitors to pull the trigger and cause
cardiovascular toxicity’. Rheumatology Advance Access published on January 22, 2010, DOI
10.1093/rheumatology/kep451.
3. Berger J, Brown D, Becker R. Low-Dose Aspirin in Patients with Stable Cardiovascular Disease:
A Meta-analysis. American Journal of Medicine 121:43-49, 2008
4. Mattia C, Coluzzi F: COX-2 inhibitors pharmacological data and adverse effects. Minerva
Anestesiologica, 71:461-70 2005
5. Chandrasekharan N et al: COX-3, a cyclooxygenase-1 variant inhibited by acetaminophen and
other analgesic/antipyretic drugs: Cloning, structure and expression. PNAS 99(21):1392613931 2002
6. Petrovic P et al: Placebo and Opioid Analgesia-Imaging a Shared Neuronal Network. Science
295:1737-1740 2002
7. Bennett D: Breakthrough Pain: Treatment Rationale with Opioids. Medscape Sept 2003