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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

Pain Control

Dent 6205

Summer Session 2008

  • 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
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
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
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
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.
  • 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
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
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
NSAIDs—Severe Pain
  • Toradol (Ketorolac) 30mg q8h IM/IV; follow with 10mg q8h—beware GI bleeds
  • 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.
  • 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
  • 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
  • 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
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 license19
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 strategies20
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 strategies21
Prescription Strategies
  • Moderate-Severe Pain—NSAID + APAP/Narcotic for breakthrough pain
  • Example: Ansaid 100mg q8h; Vicodin 5/500


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