Pharmacological Pharmacological Management of Pain In Management of Pain In The Dental Care SettingThe Dental Care Setting

Charles Sharkey M.S., Charles Sharkey M.S., M.B.A. Pharm D Pharmacy M.B.A. Pharm D Pharmacy

Site Manager Site Manager

Learning ObjectivesLearning Objectives At the conclusion of this presentation a At the conclusion of this presentation a

practicing dentist will have an improved practicing dentist will have an improved understanding of the following:understanding of the following:

Definition of painDefinition of pain Pharmacological actions contrasted for Pharmacological actions contrasted for

nonopioid and opioid analgesicsnonopioid and opioid analgesics Stepwise approach to pain managementStepwise approach to pain management Adverse effects of analgesicsAdverse effects of analgesics

Definition of PainDefinition of Pain ““An unpleasant sensory and An unpleasant sensory and

emotional experience arising from emotional experience arising from actual or potential tissue damage or actual or potential tissue damage or described in terms of such damage” described in terms of such damage” as stated by The International as stated by The International Association for the Study of PainAssociation for the Study of Pain

Large subjective componentLarge subjective component Perception and ReactionPerception and Reaction

Visiting the DentistVisiting the Dentist Pain can be a major cause for Pain can be a major cause for

seeking dental careseeking dental care Fear of pain is a significant reason Fear of pain is a significant reason

why people avoid a dental visitwhy people avoid a dental visit Fact of life is that most dental Fact of life is that most dental

procedures have tissue trauma, procedures have tissue trauma, inflammation, and pain.inflammation, and pain.

AspirinAspirin Developed in 1899Developed in 1899 Inhibits prostaglandin synthesisInhibits prostaglandin synthesis Analgesic, anti-inflammatory, Analgesic, anti-inflammatory,

antipyreticantipyretic Acute dental pain-mild to moderateAcute dental pain-mild to moderate Adverse effect profile is numerousAdverse effect profile is numerous Drug InteractionsDrug Interactions

AcetaminophenAcetaminophen Inhibits prostaglandin synthesis in Inhibits prostaglandin synthesis in

the Central Nervous Systemthe Central Nervous System Treatment of mild to moderate painTreatment of mild to moderate pain Acute postoperative dental pain in Acute postoperative dental pain in

adults, and childrenadults, and children Good risk to benefit balanceGood risk to benefit balance

AcetaminophenAcetaminophen Oral dosage of 500mgs to 1000mgs Oral dosage of 500mgs to 1000mgs

every four to six hoursevery four to six hours Chronic alcoholism or hepatic disease Chronic alcoholism or hepatic disease

keep below 2gms orally per daykeep below 2gms orally per day Normal patients keep below 4gms per Normal patients keep below 4gms per

day orally.day orally. Analgesic of choice in patients who Analgesic of choice in patients who

have a contraindication to NSAID’shave a contraindication to NSAID’s

AcetaminophenAcetaminophen Analgesic and antipyretic actionsAnalgesic and antipyretic actions NO Anti-inflammatory actionsNO Anti-inflammatory actions Adverse effects include hepatic, and Adverse effects include hepatic, and

renal dysfunctionrenal dysfunction Insufficient by itself for severe painInsufficient by itself for severe pain Used in combination with narcotic Used in combination with narcotic

analgesicsanalgesics

AcetaminophenAcetaminophen Analgesic of choice when there is a Analgesic of choice when there is a

contraindication to use of NSAID’s.contraindication to use of NSAID’s. Analgesic of choice in all stages of Analgesic of choice in all stages of

pregnancy.pregnancy. Analgesic of choice in lactation.Analgesic of choice in lactation. Analgesic of choice in children, and Analgesic of choice in children, and

agedaged Combination product with other drugsCombination product with other drugs

Nonsteroidal Anti-Inflammatory Nonsteroidal Anti-Inflammatory (NSAID’s) Drugs(NSAID’s) Drugs

Block cyclooxygenase (COX) Block cyclooxygenase (COX) enzymes responsible for synthesis of enzymes responsible for synthesis of mediators such as prostaglandinsmediators such as prostaglandins

COX-1 and COX-2 enzymesCOX-1 and COX-2 enzymes Management of mild, moderate, or Management of mild, moderate, or

severe dental painsevere dental pain Analgesic, anti-inflammatory, and Analgesic, anti-inflammatory, and

antipyretic effectsantipyretic effects

NSAID’ sNSAID’ s More than a dozen of these drugs More than a dozen of these drugs

available either by prescription or available either by prescription or Over The Counter (OTC)Over The Counter (OTC)

Differences are centered around Differences are centered around pharmacokinetics, and pharmacokinetics, and pharmacodynamicspharmacodynamics

Relatively inexpensive medicationsRelatively inexpensive medications

NSAID ClassNSAID Class Ibuprofen (Motrin) 400mgs orally Ibuprofen (Motrin) 400mgs orally

every 4 to 6 hours with a maximum every 4 to 6 hours with a maximum of 2,400mgs per dayof 2,400mgs per day

Naproxen 250mgs orally every 6 to 8 Naproxen 250mgs orally every 6 to 8 hours with a maximum of 1,375mgs hours with a maximum of 1,375mgs per dayper day

Etodolac 200mgs-400mgs orally Etodolac 200mgs-400mgs orally every 6 to 8 hours with a maximum every 6 to 8 hours with a maximum of 1,200mgs per dayof 1,200mgs per day

NSAID’s Clinical PearlsNSAID’s Clinical Pearls Allergic reactions in hypersensitive Allergic reactions in hypersensitive

patientspatients Careful with anticoagulantsCareful with anticoagulants Coingestion with alcohol can lead to Coingestion with alcohol can lead to

GI distress/bleedingGI distress/bleeding Careful in Oncology patientsCareful in Oncology patients

NSAID’s Clinical PearlsNSAID’s Clinical Pearls May be more effective if given early to May be more effective if given early to

prevent prostaglandin synthesis.prevent prostaglandin synthesis. Concept of a Loading Dose. Usually Concept of a Loading Dose. Usually

double the maintenance dose early.double the maintenance dose early. Naproxen 500mgs followed by 250mgsNaproxen 500mgs followed by 250mgs Preoperative dosesPreoperative doses Regular dosing instead of prn dosing Regular dosing instead of prn dosing

for one or two daysfor one or two days

Clinical PearlClinical Pearl Always maximize the nonopioid dose Always maximize the nonopioid dose

such as acetaminophen or NSAID such as acetaminophen or NSAID before adding an opioid.before adding an opioid.

These no opioid drugs are better These no opioid drugs are better tolerate and have lower adverse tolerate and have lower adverse effect potential than other opioid effect potential than other opioid drugs in the classdrugs in the class

Opioid AnalgesicsOpioid Analgesics Centrally acting drugs working at mu Centrally acting drugs working at mu

and/or kappa opioid receptorsand/or kappa opioid receptors Treatment of moderate to severe Treatment of moderate to severe

pain depending on the drug and pain depending on the drug and route of administrationroute of administration

No ceiling on there analgesic effectNo ceiling on there analgesic effect Dosing of these drugs is limited by Dosing of these drugs is limited by

development of adverse effectsdevelopment of adverse effects

Opioid Analgesics-Adverse EffectsOpioid Analgesics-Adverse Effects

SedationSedation Nausea and vomitingNausea and vomiting ConstipationConstipation MiosisMiosis ToleranceTolerance Use of these drugs in dental practice Use of these drugs in dental practice

is short term.is short term.

Opioids--CodeineOpioids--Codeine First to consider in dentistryFirst to consider in dentistry Combination with AcetaminophenCombination with Acetaminophen Dose of 30mgs to 60mgs orally every Dose of 30mgs to 60mgs orally every

four to six hoursfour to six hours Maximize dose of the nonopioid Maximize dose of the nonopioid

component before increasing opioidcomponent before increasing opioid

Opioid--OxycodoneOpioid--Oxycodone Next to use if codeine is insufficientNext to use if codeine is insufficient Available in combination with aspirin Available in combination with aspirin

(Percodan) or Acetaminophen (Percodan) or Acetaminophen (Percocet)(Percocet)

Oxycodone 5mgs to 10mgs orally Oxycodone 5mgs to 10mgs orally every four to six hoursevery four to six hours

Opioids—Hydrocodone bitartrateOpioids—Hydrocodone bitartrate

Hydrocodone bitartrate 5mgs and Hydrocodone bitartrate 5mgs and acetaminophen 500mgs (Vicodin) acetaminophen 500mgs (Vicodin)

Analgesic combinationAnalgesic combination Now a Schedule Two DrugNow a Schedule Two Drug

Opioids--HydromorphoneOpioids--Hydromorphone Most potent oral agent for dental useMost potent oral agent for dental use Reserved for more serious painReserved for more serious pain (Dilaudid) 2mgs to 4mgs orally every (Dilaudid) 2mgs to 4mgs orally every

four hours as requiredfour hours as required Short-term use onlyShort-term use only

Clinical Pearls Drugs to AvoidClinical Pearls Drugs to Avoid Propoxyphene napsylate 50mgs-Propoxyphene napsylate 50mgs-

100mgs and Acetaminophen 325mgs 100mgs and Acetaminophen 325mgs (Darvocet-N 50)(Darvocet-N 50)

Not used anymore due to active Not used anymore due to active metabolite, and adverse effectsmetabolite, and adverse effects

Pentazosine (Talwin) is not frequently Pentazosine (Talwin) is not frequently usedused

A comment about MeperidineA comment about Meperidine Meperidine (Demerol) can be Meperidine (Demerol) can be

reserved for patients allergic to reserved for patients allergic to morphine and codeine derivativesmorphine and codeine derivatives

Oral agent is not a great choice but Oral agent is not a great choice but can be dosed at 100mgs orally every can be dosed at 100mgs orally every four hoursfour hours

Active metabolitesActive metabolites Adverse effect profileAdverse effect profile

TramadolTramadol Centrally acting agentCentrally acting agent Now a Controlled Drug (C4)Now a Controlled Drug (C4) Treatment of moderate to severe Treatment of moderate to severe

painpain Dosage of 50mgs-100mgs orally Dosage of 50mgs-100mgs orally

every four to six hours. Maximum of every four to six hours. Maximum of 400mgs orally per day.400mgs orally per day.

Nausea, vomiting.Nausea, vomiting.

Specific Clinical SituationsSpecific Clinical Situations Pregnancy/Pregnancy/

Lactation=AcetaminophenLactation=Acetaminophen Geriatric=AcetaminophenGeriatric=Acetaminophen Oncology=AcetaminophenOncology=Acetaminophen Pediatrics=AcetaminophenPediatrics=Acetaminophen

Pain Treatment PathPain Treatment Path AcetaminophenAcetaminophen Nonsteriodal anti-inflammatory Nonsteriodal anti-inflammatory

agentsagents CodeineCodeine OxycodoneOxycodone HydromorphoneHydromorphone Use combination therapy where Use combination therapy where

possiblepossible

Guiding PrincipleGuiding Principle Analgesics are the second best Analgesics are the second best

means of managing dental pain. means of managing dental pain. Removing the source of the pain with Removing the source of the pain with local anesthesia via pulpectomy, local anesthesia via pulpectomy, extraction, or incision/drainage are extraction, or incision/drainage are preferred.preferred.

BOTTOM LINE IS GET TO THE CAUSE BOTTOM LINE IS GET TO THE CAUSE OF THE PAINOF THE PAIN

Internet System For Tracking Internet System For Tracking Over Prescribing (I-Stop) ActOver Prescribing (I-Stop) Act

Legislation that requires Legislation that requires Commissioner of Health to update Commissioner of Health to update Prescription Monitoring ProgramPrescription Monitoring Program

Electronic ( E ) PrescribingElectronic ( E ) Prescribing Controlled Substance Schedule Controlled Substance Schedule

Change for select drugsChange for select drugs EducationEducation Safe DisposalSafe Disposal

I-StopI-Stop Legislation passed to combat rising Legislation passed to combat rising

rates of prescription drug abuserates of prescription drug abuse E-Prescribing by March 27, 2016E-Prescribing by March 27, 2016 Consult Prescription Monitoring Consult Prescription Monitoring

Program (PMP) prior to prescribing Program (PMP) prior to prescribing controlled substances (C2, C3, C4)controlled substances (C2, C3, C4)

Hydrocodone is Schedule 2, Hydrocodone is Schedule 2, Tramadol is now Schedule 4Tramadol is now Schedule 4

I-StopI-Stop Consult registry within 24 hours of Consult registry within 24 hours of

prescribingprescribing Document consultDocument consult Exempt from I-Stop if prescribed Exempt from I-Stop if prescribed

quantity is no more than five day quantity is no more than five day supply used as directedsupply used as directed

AND NOW A TIME FOR AND NOW A TIME FOR QUESTIONSQUESTIONS

QUESTIONSQUESTIONS