ORAL MEDS FOR PAIN. Pain Tolerance 4/11/2018

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1 ORAL MEDS FOR PAIN Pain Tolerance Varies with each individual Signs usually should match symptoms Have compassion but don t panic when someone appears to be in pain 1

2 The Psychology of Pain A firm, calm, confident and competent voice and manner will go a long way to reassuring patient The Reasons People are in Pain Chemical injury Corneal/conjunctival abrasions RCE Foreign Bodies Uveitis Herpes Zoster Migraine attacks Very high IOP/angle closure Preseptal cellulitis/ acute chalazion 2

3 Severe Pain Quick VA and pinhole Diagnose the problem fast Topical anesthetics will help your exam If topicals aren t enough. Oral Pain Meds: Double Dose OTC Alleve/Motrin/Tylenol Non-narcotics and narcotics 3

4 Tylenol (Acetaminophen) Aka APAP N-acetyl-para-aminophenol** In the news. While the medicine is effective in treating headaches and reducing fevers, even recommended doses can cause liver damage in some people. And more than 400 people die and 42,000 are hospitalized every year in the United States from overdoses. 4

5 Jul 28, 2011 Tylenol's maximum dose reduced to help prevent overdoses The maximum daily dose for Tylenol will be lowered on all acetaminophencontaining adult products from 4,000 mg (8 Extra Strength Tylenol pills) to 3,000 mg (6 pills), the manufacturer said today. The move is intended to reduce the risk of accidental acetaminophen overdoses that can lead to liver failure and death. Old Guidelines Extra Strength Tylenol 500 mg per geltab, gelcap, caplet or tablet Two every 4-6 hours Do not exceed 8 in any 24 hr period Regular Strength Tylenol 325 mg per tablet Two every 4-6 hours Do not exceed 12 in any 24 hr period 5

6 New Guidelines Extra Strength Tylenol 500 mg per geltab, gelcap, caplet or tablet 1 to 2 tabs every 6 hours* *Unless directed by physician Do not exceed 6 in any 24 hr period* Regular Strength Tylenol 325 mg per tablet Two every 4-6 hours** *Dosing instructions coming this year Do not exceed 10 in any 24 hr period PRESCRIBING CONTROLLED SUBSTANCES Don t pre-print your DEA number on your Rx pad Do not leave Rx pads where patients have access Closely monitor what prescriptions are called in to the pharmacy and keep a record of refills especially glaucoma and narcotics 6

7 Edward C. Eyedoc, O.D. Major Payne, O.D. Omni Eye Services of Atlanta NAME AGE ADDRESS DATE Rx REFILLS-- DEA PRESCRIBING GUIDELINES Write legibly Specify length of treatment for acute care Narcotics: write out number of pills Ex: 12(Twelve) Vs which could become 7

8 Before you prescribe Allergic to anything? What systemic conditions do they have? Especially note hepatic and renal problems Drug interactions/precautions Narcotics and Alcohol don t mix I am allergic to narcotics What exactly happens when you take them? I get nauseous or I become sleepy DISTINGUISH SIDE EFFECTS FROM ALLERGY! 8

9 SIDE EFFECTS OF PAIN MEDS Constipation Nausea and vomiting Sedation Dizziness Addiction ALLERGIC REACTIONS Skin rash, hives, or itching Wheezing or trouble breathing Swelling of the face, lips, or throat Discontinue use immediately Consult doctor immediately Severe reactions demand emergency care 9

10 Schedule I (C I): High abuse potential and no accepted medical use (heroin, marijuana, LSD) Schedule II (C II): High abuse potential with severe dependence liability (narcotics, amphetamines, and barbiturates: Percoset (apap), Percodan (asa), Oxycontin (oxycodone), Ritalin, Adderal, Methadone, Fentanyl Previously, only pure hydrocodone considered Schedule II but now ALL HYDROCODONE COMBINATIONS MOVED INTO SCHEDULE II 10

11 Schedule III (C III): Less abuse potential than schedule II drugs and moderate dependence liability (nonbarbiturate sedatives, nonamphetamine stimulants, limited amounts of certain narcotics: CODEINE IS NOW THE ONLY SCHEDULE III WE USE FOR PAIN Its Final! With the issuance of this final rule, the Administrator of the Drug Enforcement Administration reschedules hydrocodone combination products from schedule III to schedule II of the Controlled Substances Act. This rule was effective October 6,

12 Unintended Consequences Intended to prevent opioid abuse, the effect caused OD s in 16 states to lose their prescribing authority for narcotics with hydrocodone. Schedule IV (C IV): Less abuse potential than schedule III and limited dependence liability (some sedatives, antianxiety agents, and non-narcotic analgesics) sleep medications (such as Ambien ) and anxiety medications (such as Xanax ). 12

13 Schedule V (C V): Limited abuse potential. Primarily small amounts of narcotics (codeine) used as antitussives or antidiarrheals. Under federal law, limited quantities of certain schedule V drugs may be purchased without a prescription directly from a pharmacist. The purchaser must be at least 18 years of age and must furnish suitable identification. All such transactions must be recorded by the dispensing pharmacist. For a complete list of what s what ml Or Google Scheduled Narcotics and it s the first link to come up 13

14 GETTING A DEA NUMBER On-line application Optometrists are mid-level practitioners (MLP) unfortunately wasn t always that way First time applicant-form 224 Renewal-Form 224a Cost $551/Good for 3 years Should I Get One? Should I Renew Mine? It s Expensive 14

15 TYLENOL #3 for Mild Pain Schedule III Central acting narcotic analgesic 300mg acetaminophen + 30mg codeine Avoid in liver disease/alcoholism No extra Tylenol by patient in addition No alcohol GI distress and sedation are main side effects *** Paul C. Ajamian, O.D. Omni Eye Services of Atlanta 7505 Main, Suite 370 Atlanta, GA NAME Leslie Smith AGE ADDRESS Rx Tylenol #3 One q4-6h for pain #12(twelve) Date REFILLS--Zero Ajamian, OD Paul DEA# MA

16 Hydrocodones for Moderate to Severe Pain LORTAB and generics : Schedule III narcotic Hydrocodone with acetaminophen Also available with aspirin (Lortab ASA) Was available in 5.0/500, 7.5/500, 10/500, 5.0/500 5 mg hydrocodone 500 mg acetaminophen (tylenol, APAP) Hydrocodones for Moderate to Severe Pain LORTAB and generics : Schedule II narcotic Hydrocodone with acetaminophen Also available with aspirin (Lortab ASA) Was available in 5.0/500, 7.5/500, 10/500, 5.0/325 5 mg hydrocodone 500 mg acetaminophen (tylenol, APAP) 16

17 Omni Eye Services 5505 Peachtree Dunwoody Rd. Ste 300 Atlanta, GA Phone (713) NAME Doug Addact AGE ADDRESS DATE Rx Lortab 5 s 1 po qid x 3 days #12(twelve) REFILLS--ZERO Ajamian, O.D. Paul Most internists/dentists still use hydrocodone because it is a synthetic form of codeine Stronger, more effective in reducing pain Less severe side effects Vicodin/Lortab prescribed far more frequently than Tylenol #3 17

18 Other Hydrocodones Old Vicodin ES (APAP w/hydrocodone) 650mg APAP + 7.5mg hydrocodone Schedule III Vicoprofen 200mg ibuprofen + 7.5mg hydrocodone When Tylenol is contraindicated/liver disease New Vicodin VICODIN 5mg/300mg (was 500mg) VICODIN ES 7.5mg/300mg 750mg) (was VICODIN HP 10mg/300mg 660mg) (was 18

19 Your Go To Prescription Narcotic Drugs for Pain Tylenol #3 Lortab Vicodin Pearls on Foreign Bodies Be ready to take out even if you have never seen anything quite like it! Act with confidence and charge for your time Make sure they know how much skill was involved and what could happen if they try and remove it at home! 19