Disclosures. Pain Management in the Optometric Practice. Optometric indications. Optometric indications. Before treatment 4/18/16

Transcription

1 4/18/16 Disclosures Pai Maagemet i the Optometric Practice Speakers bureau/advisory board: Marc R Bloomestei, OD, FAAO Schwartz Laser Eye Ceter Scottsdale, Arizoa Alco Allerga Akor B&L OCuSOFT Bruder TearLab AMO Macular Health Optometric idicatios For ocular pai, process is usually acute Need for pai relief for oly hours or less Most ofte, topical oly may be eough Cycloplegia Topical NSAIDs Optometric idicatios Coreal/cojuctival trauma abrasio foreig body Before treatmet Traumatic hyphema Surgery Refractive Cataract Retial Determie etiology of pai ad treat before begiig pai maagemet! Nature of pai: FOLDAR: frequecy, oset, locatio, duratio, associatio, relief Severity What have you doe already that helps/ does t help? 1

2 Before treatmet Before treatmet Assess the level of pai before iitiatig treatmet Numerical scale Pictures: Wog-Baker Make sure level is decreasig with treatmet Numerical Scale Before treatmet Before treatmet Wog-Baker Pai Classificatio Scale Medical history pregacy, alcohol use, ati-depressats Drug history CNS medicatios, coumadi, digoxi, OTC s, etc. Allergy history Esp. ASA etc. Topical Pai Relievers Topical Pai Relievers Steve Ferrucci, OD, FAAO Cycloplegics block acetylcholie, a stimulatory eurotrasmitter of the ANS Cause pupillary dilatio ad relaxatio of ciliary body Relaxatio of ciliary spasm causes pai reductio as well as stabilizes the bloodaqueous, decreasig iflammatio 2

3 Topical Pai Relievers Topical Pai Relievers Cycloplegics Tropicamide: 0.5-1%; qid; 4-6 hrs Cyclopetolate: 0.5, 1, 2%; tid; 2-24 hrs Homatropie: 2, 5%; bid-qid; 1-3 days Scopolomie: 0.25%, bid, 3-7 days Atropie: 0.5,1,2%; bid-tid; 6-12 days Cycloplegics Tropicamide: 0.5-1%; qid; 4-6 hrs Cyclopetolate: 0.5, 1, 2%; tid; 2-24 hrs Homatropie: 2, 5%; bid-qid; 1-3 days Scopolomie: 0.25%, bid, 3-7 days Atropie: 0.5,1,2%; bid-tid; 6-12 days Topical Pai Relievers Topical Pai Relievers NSAID s Ihibitio of prostagladi sythesize by blockage of cyclooxygease (COX) Classic Triad effect Reduced iflammatio Maitaied pupil dilatio Iduced aalgesic effect No-steroidal Ati-iflammatory Agets Ketorolac (Acular): 0.5%; qid Diclofeac (Voltare): 0.1%; qid Bromfeac (Prolesa): 0.07%; QD Nepafeac (Ilevro): 0.3%; QD Flurbiprofe (Ocufe): 0.03% Suprofe (Profeal): 1% Steroid optios Durezol, lotemax ug Durezol (diflupredate 0.05%) First steroid to receive a idicatio for postoperative pai maagemet Also for postoperative iflammatio FDA approved Jue 2008, available early 2009 Sirio Therapeutics Acquired by Alco March 2010 QID startig day after sx $100 per 5 ml Lotemax 0.5% Ophthalmic Oitmet Idica(os Treatmet of Post Opera(ve Pai ad iflamma(o followig ocular surgery ½ ich ribbo qid x 2 weeks star(g day acer surgery 3

4 Lotemax 0.5% Ophthalmic Oitmet I 2 studies of 805 pa(ets: less post opera(ve iflamma(o at post op day 8 vs. vehicle (34-32% vs %) Higher rate of pts pai free at post op day 8 (73-78% vs %) Lotemax 0.5% Ophthalmic Oitmet Cotraidicatios: Viral disease of corea/coj (HSV), mycobacterial or fugal ifectio of eye Should ot be used i childre May iterfere with amblyopia therapy by hiderig ability to se out of operated eye Adverse effects: AC reactio (25%):, cojuctival hyperemia, coreal edema, eye pai ( 4-5%); HAs (1.5%) IOP icreased > 10 mm i 3 pts Check IOP after 10 days of use Diluted proparacaie? Small Caadia study evaluated 0.05% (or 1/10 th ) diluted proparacaie for coreal ijuries Proparacaie arm had sigificat improvemet i pai reductio vs. AT s No ocular complicatios No delayed woud healig Proparacaie i ER? Really? CJEM Sep;12(5): Dilute proparacaie for the maagemet of acute coreal ijuries i the emergecy departmet. Ball IM, Seabrook J, Desai N, Alle L, Aderso S. CONCLUSION: Dilute topical proparacaie is a efficacious aalgesic for acute coreal ijuries. Although o adverse evets were observed i our study populatio, larger studies are required to evaluate safety. Acad Emerg Med Apr;21(4): Topical tetracaie used for 24 hours is safe ad rated highly effective by patiets for the treatmet of pai caused by coreal abrasios: a double-blid, radomized cliical trial. Waldma N, Desie IK, Herbiso P. CONCLUSION: Topical tetracaie used for 24 hours is safe, ad while there was o sigificat differece i patiet VAS pai ratigs over time, patiet surveys o overall effectiveess showed that patiets perceived tetracaie to be sigificatly more effective tha salie. Oral Aalgesics Three mai categories Over-the-couter Aspiri, tyleol, advil No-Narcotic prescriptio Narcotic prescriptio Over-The -Couter 4

5 Aspiri (Acetylsalicytic acid) Aspiri (Acetylsalicytic acid) Over the couter Geeric, Bayer, Excedri etc 325 mg, 500 mg Dose: mg q 4 hr Not great for pai relief 81 mg for stroke prevetio Cotraidicatios Upper GI disease (ulcers) Bleedig disorders Kids < 18 with viral illess (flu, pox) Reye s disease More tha 3 alcoholic beverages/day Aspiri allergy pregacy category D: positive evidece of risk Acetamiophe (APAP) Acetamiophe Tyleol Much better pai reliever tha ASA o platelet or ati-iflammatory fuctio 325 mg, 500 mg (extra stregth) Dose: mg q 4 hr New max: 3000 mg/day 8 regular, or 6 extra-stregth OK with pregacy Cotraidicatios liver disease alcoholism hypersesitivity to APAP i past Ok to use i pregacy, kids with viral ifectios, bleedig disorders, upper GI disease ad ASA allergy OTC NSAID s OTC NSAIDs Ibuprofe Advil, Motri, Geeric 200, 400, 600, 800 mg q 4 hr max dose 2400 mg/day less GI toxicity<1600mg/day Best used for atiiflammatory cotrol Naproxe sodium (Aleve, Aaprox) 220 mg q 8-12 hr 2 pills as loadig dose No more tha 3 pills per 24 hrs Ketoprife (Orudis OTC) mg q 4-6 hr 5

6 Excedri Various amouts of ASA ad APAP Tesio Migraie Extra-stregth 65 mg caffeie pai reliever aid 2 tabs q 6 hr Not to exceed 8/24 hrs No-Narcotic Prescriptio Prescriptio NSAIDs Prescriptio NSAIDs Naproxe (Naprosy) 500 mg iitial dose, the 250 mg q6-8h Feoprofe (Nalfo) 200 mg q4-6 hr Oxaprozi (Daypro) mg qd For RA oly Idomethaci (Idoci) 25 mg bid-tid o geeral pai idicatio Ketorolac (Toradol) 10 mg qid Etodolac (Lodie) mg qid Prescriptio NSAIDs Prescriptio NSAIDs Diclofeac (Voltare) 75 mg bid Diclofeac Potassium (Cataflam) 50 mg bid or tid 75 mg bid Sulidac (Clioril) mg bid Nambumetoe (Relafe) mg bid RA oly Tolmeti (Tolecti) 400 mg tid or qid 6

7 Prescriptio NSAIDs NSAIDS Flurbiprofe (Asaid) 50 mg qid Piroxicam (Feldee) mg qod RA or osteoarthritis oly Meloxicam (Mobic) 7.5 mg qd RA or osteoarthritis oly Cotraidicatios upper GI disease hypersesitivity to NSAID or ASA diabetics with kidey disease avid alcohol use pregacy Other uses for oral NSAIDs Uveitis iflammatory cotrol may prevet reboud whe taperig chroic cases CME ot as good as topical Episcleritis Scleritis very useful drugs Oral Narcotic Agets DEA Schedules DEA Schedules Schedule I High Abuse potetial No approved medical use Oly available for ivestigatioal use Ex: MJ, LSD, heroi Schedule II High Abuse potetial Writte prescriptio oly with o refills Ex: amphetamies, cocaie, hydrocodoe Schedule III Moderately high abuse potetial Writte or telephoe prescriptios with refills allowed ex: Tyleol with codeie Schedule IV Moderate abuse potetial Writte or telephoe prescriptios with refills allowed ex: pheobarbital 7

8 DEA Schedules State Laws Schedule V Low abuse potetial No prescriptio eeded ex: Robitussi A-C (cotais less tha 100 mg codeie per 100 ml) Arizoa State Law For Optometrists Schedule III oly Colorado ay cotrolled substace for ocular pai ad iflammatio except those specified i schedules I ad II New Mexico Oral aalgesic medicatios, icludig schedule III through V cotrolled substaces Washigto: Schedule III-V Limited to 7 days per sigle coditio Morphie Codeie Stadard drug of referece whe discussig opioid effects/pai maagemet Very poor whe admiistered orally May side effects Serious potetial for abuse ad addictio Useful for mild to moderate pai Ca be fairly sedatig GI effects commo, esp. costipatio Combied with either ASA or APAP w/ APAP, works o separate CNS areas w/ ASA also has ati-iflammatory actio DEA Class III Potetially causes mild or low physical depedece, but possibility of high psychological depedece if abused Codeie Codeie Tyleol with codeie Tyleol 2: 15 mg codeie/300 mg APAP 1-2 tabs q 4-6hr Tyleol 3: 30 mg codeie/300 mg APAP 1-2 tabs q 4-6 hr Tyleol 4: 60 mg codeie/300 mg APAP 1 tab q 4-6 hr Max dose: 360 mg codeie ad 3000 mg APAP Tyleol 3: 30 mg codeie/300 mg APAP 1-2 tabs q 4-6 hr Max: 10 tab/day 8

9 Codeie Hydrocodoe Codeie with aspiri 30 mg codeie/ 325 mg ASA: Empiri with codeie #3 1 tab q 4-6 hr 60 mg codeie/325 mg ASA: Empiri with codeie #4 1 tab q 4-6 hr About 6 x more potet tha codeie May cause less sedatio ad costipatio tha codeie Available with APAP ad Ibuprofe Switched from DEA Class III to Class II, effective October 6, 2014 Pts will eed writte prescriptio ad doctors will o loger be able to call i RX Hydrocodoe Hydrocodoe Switched maily i respose to abuse of prescriptio paikillers LA times study: of 3,733 prescriptio drug fatalities from 2006 to 2011, 945 deaths related to hydrocodoe Issue is some mid level practitioers (ODs) caot prescribe, so may limit pts access to eeded paikillers Not all groups are advocates of this chage Trade ames NORCO LORTAB Hydrocodoe: oe of most prescribed agets i US 131 millio prescriptios for 47 millio patiets i 2011 More tha #1 atibiotic ad HTN med Hydrocodoe Hydrocodoe Vicodi: hydrocodoe 5 mg/300 mg APAP 1-2 tabs q 4-6 hr max dose 8/day Vicodi ES: hydrocodoe 7.5 mg/300 mg APAP 1 tab q4-6 hr max dose 5/day Vicodi HP: 10 mg vocodi/300 mg APAP 1 tab q 4-6 hr max dose 6/day Vicoprofe: 7.5 mg vicodi/200 mg IB 1-2 tabs q4-6 hr max dose 5/day 9

10 Oxycodoe Oxycodoe Similar i potecy to morphie 10-12x more potet tha codeie Possibly less side effects tha morphie or codeie Produces euphoria, so serious abuse potetial exists DEA class II Percoda: 4.75 mg oxy/325 mg ASA 1 tab q 4-6 hr Percocet: 5 mg oxy/325 mg APAP 1 tab q4-6 hr Tylox: 5 mg oxy/500 mg APAP 1 tab q 4-6 hr Tyleol Plus Ibuprofe Narcotic agets: Side Effects Some studies suggest that perhaps two tyleol with oe IB is ot iferior to Tyleol # 3 for post operative pai relief More cost effective Fewer side effects Greater patiet satisfactio Abuse/addictio potetial CNS effects Liver toxicity Real failure/uriary retetio Nausea ad vomitig Costipatio To cosider To cosider Start with simplest treatmet first Topicals OTC APAP or IB Prescriptios Narcotics Prescribe aalgesics o 24 hr basis Tyleol #3 sig: 1-2 tab q 4-6 hrs disp #12 (TWELVE) 10

11 Rod Coe, O.D. 321 Mai Street Columbus, OH (610) Optom Lic # DEA Lic # XXOXOX Name: Joh D oh DOB: 08/08/1968 Address: 74 Evergree Terrace Rx: Tyleol #3 Sig: 1-2 tablets p.o. q 4 6 hrs Disp: #12 (TWELVE) Refills: Noe Geeric substitutio: yes Sigature: Rod Coe, O.D. To cosider Mild: OTC Tyleol or IB Mild/moderate pai Tyleol #3 ( 30 mg codeie/300 mg APAP) 1-2 tabs q 4-6 hrs max 10 tabs/24 hrs Moderate/severe pai Vicodi (5 mg hydrocodoe/300mg APAP) 1-2 tabs q 4-6 hr max 8 tabs/24 hrs To cosider To cosider Severe pai: oxycodoe Percocet (5 mg oxy/325 mg APAP 1 tab q 4-6 hrs Percoda(4.5 mg oxy/325 ASA) 1 tab q 4-6 hrs CAN T DO IN MOST STATES!! Make sure oly Rx for eye related pai Most states Schedule III Tyleol 3 Check o Schedule II Vicodi Most states, 72 hrs max! Review laws i your state State Laws To cosider CA State Law for Optometrists Schedule III if direct idicatio for ocular pai No more tha 3 days (72 hrs)!!! NEW: Also ca request Schedule II for hydrocodoe (Vicodi) Do t be afraid to use opioids if eeded ADDICTION AND ABUSE POTENTIAL IS LOW WHEN USED APPROPRIATELY AND FOR SHORT TERM! 11

12 Case 1 Case 2 Case 3 Case 4 Case 5 Case 6 12

13 Case 7 Case 8 Case 9 Case 10 Thak You!!! 13