Hurts So Good! The Concept of Pain and Pain Management. The Concept of Pain. The Concept of Pain. Program Learning Objectives

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All Rights Reserved Upon successful completion of this program, participants should be able to: Describe the pharmacology and mechanism of action of non-opioid and opioid analgesics, including their

1 Program Learning Objectives Hurts So Good! Management of Dental Pain and Patient Care Considerations Thomas A. Viola, R.Ph., C.C.P. Fourth District Dental Society May 22, Thomas A. Viola, R.Ph. All Rights Reserved Upon successful completion of this program, participants should be able to: Describe the pharmacology and mechanism of action of non-opioid and opioid analgesics, including their systemic and therapeutic effects, as well as their potential for abuse. Understand the intended role of opioid and nonopioid analgesics in dental settings, especially situations which preclude their use Thomas A. Viola, R.Ph. All Rights Reserved 2 Program Learning Objectives Review appropriate prescribing and dosing of opioid analgesic agents and: Use case scenarios to develop an effective pain management plan based upon a patient s needs and underlying medical conditions Identify those patients at highest risk for substance abuse The Concept of Pain and Pain Management Counsel patients about side effects, addictive nature, and proper storage and disposal of prescription medications 2015 Thomas A. Viola, R.Ph. All Rights Reserved Thomas A. Viola, R.Ph. All Rights Reserved 4 The Concept of Pain Pain is an unpleasant sensory and emotional experience in which the body is made urgently aware of actual or potential tissue damage. Proper management of pain requires an understanding of its complexity and an appreciation for the factors that determine its expression The Concept of Pain Nociception is the sensory detection, transduction, and neural transmission of noxious events. Pain Threshold The lowest intensity of painful stimulation at which the patient becomes aware of the pain Thomas A. Viola, R.Ph. All Rights Reserved Thomas A. Viola, R.Ph. All Rights Reserved 6

2 The Concept of Pain Two components of pain Perception The physical component of pain Involves the transmission of the pain impulse from the injured tissue to the brain Uniform from patient to patient Reaction The psychological component of pain Involves the patient s emotional response to pain Varies from patient to patient The Concept of Pain Factors that lower pain threshold Contribute to a greater reaction to pain Fear Depression Anxiety Fatigue Factors that raise pain threshold Contribute to a lesser reaction to pain Sleep Sympathy Placebo effect 2015 Thomas A. Viola, R.Ph. All Rights Reserved Thomas A. Viola, R.Ph. All Rights Reserved 8 The Dental Pain Paradox Pain is a powerful motivator AND de-motivator for patients to seek help from their dental professional. Pain keeps some patients from seeking help Fear of painful procedure Memory of significant/lengthy post-operative pain Negative feedback reinforcement Treatment on inflamed, hypersensitive tissues Patient mentally fatigued after endurance of pain The Anatomy of Pain Chemical agents that occur naturally in the environment of pain receptors after acute tissue damage are algogenic substances. These include adenosine, adenosine triphosphate, serotonin, histamine, bradykinin, cytokines, and prostaglandins. The release of these substances leads to nociceptor activation, producing the pain impulse Thomas A. Viola, R.Ph. All Rights Reserved Thomas A. Viola, R.Ph. All Rights Reserved 10 The Anatomy of Pain Inflammation promotes the formation of prostaglandins which enhance the effects of the other algogenic substances on nociceptors. The Anatomy of Pain For a person to feel pain, the pain impulse must be transmitted to the spinal cord and then to the cerebral cortex. Traumatic injury may also provoke an initial efferent sympathetic reflex, producing vasoconstriction. Decreased microcirculation in the injured tissue, produces ischemia, further amplifying nociceptor stimulation Thomas A. Viola, R.Ph. All Rights Reserved 11 The pain impulse is transmitted to the spinal cord by peripheral nerve fibers. At the dorsal horn of the spinal cord, peripheral nerve fibers interface with CNS neurons to transmit the pain signal Thomas A. Viola, R.Ph. All Rights Reserved 12

3 COX Inhibition Phospholipids (phospholipase) Arachidonic Acid Non-Narcotic Analgesics (COX Inhibitors) (COX-1) Physiologic Prostaglandins GI protection Renal protection Smooth muscle relaxes Regulate blood clotting (COX-2) Pathologic Prostaglandins Inflammation Pain sensitization Leukocytosis 2015 Thomas A. Viola, R.Ph. All Rights Reserved Thomas A. Viola, R.Ph. All Rights Reserved 14 Formulations Regular ASA (81mg vs. 325mg) Enteric coated ASA (dissolves in intestines) Often formulated with caffeine Formulations Combination products With a buffer Decreases GI side effects (Bufferin) With an opioid Decreases amount of opioid (Percodan) Equianalgesia 650mg of aspirin = 650 mg acetaminophen= 200 mg of ibuprofen = 275 mg of naproxen 2015 Thomas A. Viola, R.Ph. All Rights Reserved Thomas A. Viola, R.Ph. All Rights Reserved 16 Mechanism of action Inhibits the enzymes COX-1 and COX-2 Decreases pain, fever and inflammation Decreases uterine contraction and inflammation Decreases clotting inducers Low doses result in reduced platelet aggregation Pharmacologic effects Antiplatelet Used in low doses to prevent MI or stroke Antipyretic Lowers body temp if above normal Analgesic Used to treat mild to moderate pain Antiinflammatory Decreases pain, redness and swelling 2015 Thomas A. Viola, R.Ph. All Rights Reserved Thomas A. Viola, R.Ph. All Rights Reserved 18

4 Patient care considerations Reye's syndrome Possible hepatotoxicity/encephalopathy Topical application to oral mucosa May result in severe ulceration Zero-order kinetics Increases risk of overdose and toxicity Adverse reactions Gastrointestinal ulceration Decreased production of protective prostaglandins Decreased protective mucous Increased gastric acid secretion Nausea and vomiting GI bleeding 2015 Thomas A. Viola, R.Ph. All Rights Reserved Thomas A. Viola, R.Ph. All Rights Reserved 20 Altered bleeding time Irreversibly reduces platelet aggregation Platelet adhesiveness is reduced for the life of the platelet Replacement of platelets needed for normal clotting May result in excessive or prolonged bleeding after procedures Drug interactions Increased effectiveness of other drugs Displacement of plasma-protein bound drugs Coumadin (warfarin) Increased risk of hemorrhage 2015 Thomas A. Viola, R.Ph. All Rights Reserved Thomas A. Viola, R.Ph. All Rights Reserved 22 Drug interactions Decreased effectiveness of other drugs Decrease renal prostaglandins Increase sodium/fluid retention Antihypertensives Exacerbated cardiovascular disease Contraindications of aspirin Peptic ulcer Pregnancy Gout Hemophilia History of hypersensitivity Cross-sensitivity with 2015 Thomas A. Viola, R.Ph. All Rights Reserved Thomas A. Viola, R.Ph. All Rights Reserved 24

5 Types ibuprofen (Motrin, Advil) naproxen sodium (Anaprox, Aleve) naproxen (Naprosyn) indomethacin (Indocin) etodolac (Lodine) nabumetone (Relafen) meloxicam (Mobic) Types Other COX-1 inhibitors offer no apparent advantage over ibuprofen or naproxen in the treatment of dental pain diclofenac diflunisal flurbiprofen ketoprofen meclofenamate 2015 Thomas A. Viola, R.Ph. All Rights Reserved Thomas A. Viola, R.Ph. All Rights Reserved 26 Mechanism of action Inhibit the enzymes COX-1 and COX-2 Decrease pain, fever and inflammation Decrease uterine contraction and inflammation Decrease clotting inducers More effective if given before painful stimuli is experienced Pharmacologic effects Antipyretic Lower body temp if above normal Analgesic Treatment of mild to moderate pain Very effective in the treatment of dental pain Antiinflammatory Treatment of inflammatory joint disease Treatment of dysmenorrhea Treatment of acute attacks of gout 2015 Thomas A. Viola, R.Ph. All Rights Reserved Thomas A. Viola, R.Ph. All Rights Reserved 28 Patient care considerations Hypersensitivity reactions Cross-sensitivity with ASA and other Anaphylactoid reactions Dermatological reactions Stevens Johnson Syndrome (SJS) Toxic epidermal necrolysis (TEN) Patient care considerations (continued) Teratogenic effects Decrease uterine prostaglandins Premature closures in fetal circulation Prolonged gestation Iatrogenic disease Available OTC Not listed as medications on medical history Maximum daily dose of ibuprofen: 3200mg Maximum daily dose of naproxen: 1500mg 2015 Thomas A. Viola, R.Ph. All Rights Reserved Thomas A. Viola, R.Ph. All Rights Reserved 30

6 Adverse reactions Gastrointestinal ulceration Decrease production of protective prostaglandins Decrease protective mucous Increase gastric acid secretion Nausea and vomiting GI bleeding Altered bleeding time Reversibly reduce platelet aggregation Platelet adhesiveness reduced only until drug is excreted No replacement of platelets needed for normal clotting May result in excessive or prolonged bleeding after procedures Lesser effect than aspirin 2015 Thomas A. Viola, R.Ph. All Rights Reserved Thomas A. Viola, R.Ph. All Rights Reserved 32 CNS effects Sedation, confusion, dizziness, vertigo Advise patients to use caution when driving Renal effects Increase incidence of UTI and cystitis Increase risk of renal failure Cardiovascular effects Exacerbate cardiovascular disease Decrease renal prostaglandins Increase sodium and fluid retention Interfere with cardioprotective effects of once-daily aspirin Oral effects Ulcerative stomatitis Xerostomia 2015 Thomas A. Viola, R.Ph. All Rights Reserved Thomas A. Viola, R.Ph. All Rights Reserved 34 Drug interactions Increased effectiveness of other drugs Displacement of plasma-protein bound drugs Coumadin (warfarin) Increased risk of hemorrhage Drug interactions (continued) Increased effectiveness of other drugs Decreased renal excretion Lithium Increased muscle rigidity 2015 Thomas A. Viola, R.Ph. All Rights Reserved Thomas A. Viola, R.Ph. All Rights Reserved 36

7 Drug interactions (continued) Decreased effectiveness of other drugs Decrease renal prostaglandins Increase sodium/fluid retention Antihypertensives Exacerbated cardiovascular disease Contraindications Asthma Cardiovascular disease with fluid retention Peptic ulcer/ulcerative colitis 2015 Thomas A. Viola, R.Ph. All Rights Reserved Thomas A. Viola, R.Ph. All Rights Reserved 38 Contraindications Renal function impairment Pregnancy History of hypersensitivity Cross-sensitivity with aspirin Types Selective COX-2 Inhibitors Mechanism of action Inhibit COX-2 to a greater extent than COX-1 Decrease pathologic prostaglandin production Decreases pain sensitizers Decreases fever/inflammation inducers Maintain physiologic prostaglandin production Fewer GI side effects 2015 Thomas A. Viola, R.Ph. All Rights Reserved Thomas A. Viola, R.Ph. All Rights Reserved 40 Pharmacologic effects Analgesic Treatment of mild to moderate pain Less effective than traditional in the treatment of dental pain Antiinflammatory Treatment of inflammatory joint disease Treatment of dysmenorrhea Treatment of acute attacks of gout Patient care considerations Hepatic effects Elevated liver enzymes Anaphylactoid reactions Contraindicated in patients with sulfa allergy Teratogenic effects Decrease uterine prostaglandins Premature closures in fetal circulation Prolonged gestation 2015 Thomas A. Viola, R.Ph. All Rights Reserved Thomas A. Viola, R.Ph. All Rights Reserved 42

8 Altered bleeding time Reversibly reduce platelet aggregation Platelet adhesiveness reduced only until drug is excreted No replacement of platelets needed for normal clotting May result in excessive or prolonged bleeding after procedures Lesser effect than aspirin CNS effects Sedation, confusion, dizziness, vertigo Renal effects Increase incidence of UTI and cystitis Increase risk of renal failure Oral effects Ulcerative stomatitis Xerostomia Taste alteration 2015 Thomas A. Viola, R.Ph. All Rights Reserved Thomas A. Viola, R.Ph. All Rights Reserved 44 Cardiovascular effects Thrombotic events Myocardial infarction, stroke (fatal!) Exacerbate cardiovascular disease Decrease renal prostaglandins Increase sodium and fluid retention Interfere with cardioprotective effects of once-daily aspirin Drug interactions Increased effectiveness of other drugs Displacement of plasma-protein bound drugs Coumadin (warfarin) Increased risk of hemorrhage 2015 Thomas A. Viola, R.Ph. All Rights Reserved Thomas A. Viola, R.Ph. All Rights Reserved 46 Drug interactions (continued) Increased effectiveness of other drugs Decreased renal excretion Lithium Increased muscle rigidity Drug interactions (continued) Decreased effectiveness of other drugs Decrease renal prostaglandins Increase sodium/fluid retention Antihypertensives Exacerbated cardiovascular disease 2015 Thomas A. Viola, R.Ph. All Rights Reserved Thomas A. Viola, R.Ph. All Rights Reserved 48

9 Drug interactions (continued) Increased effectiveness of celecoxib Decrease hepatic metabolism of celecoxib Diflucan (fluconazole) Exacerbated liver toxicity Types Tylenol, Panadol Acetaminophen (APAP) Mechanism of action Unknown (hypothesized) Decreases PG synthesis in CNS Elevates overall pain threshold Decreases PG synthesis in hypothalamus Reduces fever 2015 Thomas A. Viola, R.Ph. All Rights Reserved Thomas A. Viola, R.Ph. All Rights Reserved 50 Acetaminophen (APAP) Pharmacologic effects Antipyretic Lowers body temp if above normal Analgesic Used to treat mild to moderate pain Very effective in the treatment of dental pain Considered the most safe analgesic Acetaminophen (APAP) Adverse reactions Hepatotoxicity Converted to a liver-toxic metabolite Inactivated by gluthathione in liver Possible liver failure Maximum daily dose of APAP: 4000mg Acute overdose (6-15 gram single dose) Chronic ingestion (3-4 grams/day for 1 year) Reserves of glutathione are depleted Toxic metabolite damages liver cells 2015 Thomas A. Viola, R.Ph. All Rights Reserved Thomas A. Viola, R.Ph. All Rights Reserved 52 Acetaminophen (APAP) Adverse reactions Hepatotoxicity (continued) Exacerbated by liver-enzyme inducing drugs Alcohol, cigarette smoking, anticonvulsants Delayed reaction Peak hepatotoxicity occurs 3 to 4 days after acute intoxication IF patient survives, recovery may take up to three months Acetaminophen (APAP) Contraindications Hepatitis or other known decreased liver function Chronic alcohol ingestion Other liver microsomal enzyme inducing drugs Impaired renal function 2015 Thomas A. Viola, R.Ph. All Rights Reserved Thomas A. Viola, R.Ph. All Rights Reserved 54

10 used in Dentistry Codeine Combination with APAP (Tylenol w/codeine) (Substance P Inhibitors) Hydrocodone Combination with APAP (Vicodin, Lortab) Combination with ibuprofen (Vicoprofen) Oxycodone Combination with APAP (Percocet, Endocet) Combination with ASA (Percodan) Combination with ibuprofen (Combunox) 2015 Thomas A. Viola, R.Ph. All Rights Reserved Thomas A. Viola, R.Ph. All Rights Reserved 56 Substance P facilitates the transfer of pain impulse from peripheral neurons to CNS signaling neurons. Spinal interneurons respond to stimulation from CNS neurons by releasing endogenous opiates, which block transmission of pain impulses. In the dorsal horn of the spinal cord, peripheral pain neurons meet CNS signaling neurons. At the synapse, the peripheral pain neurons release substance P, a pain neurotransmitter. Endogenous opiates (also known as enkephalins) bind to opiate receptors on the peripheral pain neuron to inhibit the release of substance P. The CNS signaling neurons carry the pain impulse to the brain Thomas A. Viola, R.Ph. All Rights Reserved Thomas A. Viola, R.Ph. All Rights Reserved 58 By binding with any free opiate receptors, opioid analgesics further inhibit the release of substance P and thus further block transmission of pain impulses to the brain. Opioid analgesics supplement and mimic the pain-blocking effect of the endogenous opiates. Pharmacologic effects Analgesia Treatment of moderate to severe pain Cough suppression Treatment of severe non-productive coughs GI hypo-motility Treatment of diarrhea and traveler s sickness 2015 Thomas A. Viola, R.Ph. All Rights Reserved Thomas A. Viola, R.Ph. All Rights Reserved 60

11 Patient care considerations Hypersensitivity reactions Dermatological reactions (pruritis, flushing) Addiction and dependence Tolerance develops to most effects Leads to increasing dose and dependence Withdrawal symptoms upon abrupt cessation Treatment involves use of other opioids Adverse reactions CNS effects CNS depression CNS stimulation Cardiovascular effects Peripheral vasodilation Orthostatic hypotension Respiratory effects Respiratory depression leads to death from overdose 2015 Thomas A. Viola, R.Ph. All Rights Reserved Thomas A. Viola, R.Ph. All Rights Reserved 62 Adverse reactions GI effects Constipation Reduced GI motility Nausea and emesis Direct stimulation of the chemoreceptor trigger zone Drug interactions Increase risk of additive adverse effects Increase risk of CNS depression Increase risk of respiratory depression Alcohol, anti-anxiety medications Increase risk of constipation Anticholinergics Miosis Constricted pupils 2015 Thomas A. Viola, R.Ph. All Rights Reserved Thomas A. Viola, R.Ph. All Rights Reserved 64 Contraindications Chronic respiratory disease (COPD) Head injuries Treatment of Opioid Analgesic Addiction Hepatic, renal function impairment Prostatic hypertrophy, constipation 2015 Thomas A. Viola, R.Ph. All Rights Reserved Thomas A. Viola, R.Ph. All Rights Reserved 66

12 Treatment of Opioid Analgesic Addiction Narcan (naloxone) Pure opioid antagonist Used in the treatment of opioid overdose Found in dental office emergency kit Treatment of Opioid Analgesic Addiction Subutex (buprenorphine) Taken as part of a treatment plan in the management of current opioid addiction Partial opioid agonist and antagonist Naltrexone Opioid antagonist Taken voluntarily to maintain opioid-free state after rehabilitation from opioid addiction Blocks effects if opioids are taken (but not adverse effects) 2015 Thomas A. Viola, R.Ph. All Rights Reserved 67 Suboxone (buprenorphine plus naloxone) Taken as part of a treatment plan in the management of current opioid addiction Naloxone blocks effects if recipient attempts to illicitly liquify and inject this drug 2015 Thomas A. Viola, R.Ph. All Rights Reserved 68 Preventing Opioid Analgesic Diversion Preventing Opioid Analgesic Diversion Since dental offices are potential sources of opioid analgesics, the dental team must take precautions to prevent diversion. Preventing opioid analgesic diversion in the dental office requires that the dental team Recognize drug-seeking behavior Prescribe opioid analgesics appropriately Thomas A. Viola, R.Ph. All Rights Reserved 69 Utilize strategies to prevent order alteration 2015 Thomas A. Viola, R.Ph. All Rights Reserved 70 Preventing Drug Diversion Preventing Drug Diversion Recognizing drug-seeking behavior Emergency calls or visits near the end of office hours, especially before weekends/holidays Requesting specific drugs by name Repeated loss of prescriptions Prescription Drug Monitoring Program!!! Reluctance to provide prior medical records or information for other treating physician(s). Don t bill my insurance, I ll pay cash 2015 Thomas A. Viola, R.Ph. All Rights Reserved Thomas A. Viola, R.Ph. All Rights Reserved 72

13 Preventing Drug Diversion Safeguarding prescription pads Store prescription pads in secure locations away from patient areas Entrust access to blank prescription pads to as few employees as possible Order small quantities of prescription pads at one time to facilitate tracking Do not pre-sign blank prescriptions and do not use prescriptions with pre-printed DEA numbers Preventing Drug Diversion Preventing prescription alteration Complete all required information on the prescription blank, including patient s full name, address and date of birth Date all prescriptions and use words and numbers to indicate quantity to be dispensed Enter the exact number of refills authorized or the word zero if none are authorized (do not leave blank) 2015 Thomas A. Viola, R.Ph. All Rights Reserved Thomas A. Viola, R.Ph. All Rights Reserved 74 Questions and Answers Contact information: thomas.viola@gmail.com facebook.com/tomviolarph linkedin.com/in/thomasviola Thomas A. Viola, R.Ph., C.C.P. All Rights Reserved

disease or in clients who consume alcohol on a regular basis. bilirubin

disease or in clients who consume alcohol on a regular basis. bilirubin NON-OPIOID Acetaminophen(Tylenol) Therapeutic class: Analgesic, antipyretic Aspirin (ASA, Acetylsalicylic Acid) Analgesic, NSAID, antipyretic Non-Opioid Analgesics COMMON USES WHAT I NEED TO KNOW AS A