pain, pain, go away…. jill autry, od, rph eye center of texas, houston drjillautry@tropicalce.com

PAIN, PAIN, GO AWAY….

Jill Autry, OD, RPhEye Center of Texas, Houston

drjillautry@tropicalce.com

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

• 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. Ting Fang-Suarez, M.D. Mark Mayo, M.D. Chris Allee, O.D. Jill Autry, O.D. Randy Reichle, O.D.

6565 West Loop South 4415 Crenshaw Rd. 15400 SW FrwyBellaire, TX 77401 Pasadena, TX 77504 Sugar Land, TX 77478Phone (713)797-1010 Phone (281)998-3333 (281)277-1010

450 Medical Ctr Blvd, #305 11914 Astoria Boulevard, #325 21700 Kingsland Blvd. Webster, TX 77598 Houston, TX 77089 Katy, TX 77450 (281) 332-1397 (281) 484-2030 (281) 578-4815

NAME Jack Cooper AGE ________

ADDRESS 6565 Golden River Drive, Houston, TX 77082 DATE 3-3-11

Rx Tylenol #3 #20 (twenty)1-2 po q4-6h prn pain

REFILLS-- 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 semi-

synthetic 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

Rx Vicodin 5/500 #30 (thirty)1-2 q4-6h prn pain

Rx Vicodin ES #30 (thirty)1 q4-6h prn pain

Rx Vicoprofen #30 (thirty)1 q4-6h prn pain

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

NAME Joe Johnson AGE ______________

ADDRESS_____________________________________________________DATE 3-3-11

Rx Ibuprofen 600mg #301 po q6h

REFILLS-- 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. Ting Fang-Suarez, M.D. Mark Mayo, M.D. Chris Allee, O.D. Jill Autry, O.D., RPh Randy Reichle, O.D.

NAME Jack Cooper AGE __32______

Rx Tylenol #3 #20 (twenty)1-2 po q4-6h prn pain

TOPICAL STEROIDS

• Reduce inflammation• Reduce pain• Reduce photophobia• Ocular conditions– Iritis, sterile corneal infiltrates, episcleritis, post-

operative 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

ADDRESS_____________________________________________________DATE 3-3-11

Rx Prednisone 20mg #303 tabs (60mg) qd with food/milk

ADDRESS_____________________________________________________DATE 3-3-11

Rx Medrol Dose PackTUD

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

ADDRESS_____________________________________________________DATE 3-3-11

Rx Homatropine 5% 5ml1 gtt tid OD

CASE EXAMPLES

pain, pain, go away…. jill autry, od, rph eye center of texas, houston drjillautry@tropicalce.com

overdosage slide

ultracet slide

antiplatelet action

grams daily slide

mild moderate strong

pain treatment

market darvon darvocet

codeine combinations

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