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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 – – – – – 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 – – – – – Lasts longer than 3 months Back pain Post-herpetic neuralgia Sinusitis Migraine TYPES OF PAIN • • • • Somatic Visceral Neuropathic Psychogenic ANALGESIA • • • • 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 • • • • – 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 • • • • • • 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 • • • • • • • 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 • • • • • • 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 • • • • • • • 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 • • • • 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 • • • • Morphine Hydromorphine Methadone Meperidine – Demerol® SIDE EFFECTS OF OPIOID ANALGESICS • • • • • • • • 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: – – – – – 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 • “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 • • • • • • • 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 • • • • • • • • 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 • • • • 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 • • • • 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 • • • • • Bupivicaine Etidocaine Lidocaine Mepivacaine Dibucaine ESTER ANESTHETICS • • • • • • • 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 – – – – 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