requirements for opioid prescription course Managing acute paiN

Welcome to Module Four: Managing Acute Pain NARRATOR V.O.: Welcome to Module Four: Managing Acute Pain. This module guides the Learner through a progressive approach to pain management that weighs the need to address the patient’s short term comfort needs against the side effects of commonly prescribed non-opioid and opioid analgesics. Section One: Understanding Acute Pain provides a brief overview of what acute pain is and how it is treated. Section Two: Treating Mild to Severe Acute Pain introduces the opioid and non-opioid analgesics commonly used to treat dental and oral pain, including safety and dosage considerations. This module guides you, the prescriber, through a progressive approach to pain management that weighs the need to address the patient’s short term comfort against the side effects of commonly prescribed non-opioid and opioid analgesics. Section One: Understanding Acute Pain provides a brief overview of what acute pain is and how it is treated. Section Two: Treating Mild to Severe Acute Pain introduces the opioid and non-opioid analgesics commonly used to treat dental and oral pain, including safety and dosage considerations.  @ copyright New York State Dental Foundation

Section One Defining Acute Pain  Section One Understanding Acute Pain Defining Acute Pain Analgesics and the Treatment of Acute Pain

Defining Pain Most dental pain is usually in the “mild to moderate” range. The best pain control prescription should be effective and have minimum risk for side effects/adverse reactions and abuse potential. Acute Pain is defined as pain from disease, accident, intentional trauma, or injury that is reasonably expected to last only a short period of time. Analgesic prescriptions for acute pain can be for up to seven days. Chronic Pain is a complex diagnostic and therapeutic challenge. If a practitioner does not have special training in this area, he/she should refer the patient to a professional who does. Examples of chronic pain may include TMD, burning mouth syndrome, fibromyalgia, cancer, pain associated with end-of-life, or pain treated as a part of palliative care practices.

 Analgesics and Acute Pain Different analgesics are recommended based on the level of acute pain experienced:  acetaminophen aspirin celecoxib ibuprofen naproxen Mobic Diflunisal Mild acetaminophen w/codeine (Tylenol #3) Snyalgos DC acetaminophen w/tramadol (Ultracet) hydrocodone w/acetaminophen (Vicodin) hydrocodone w/ibuprofen (Vicoprofen) Moderate hydrocodone w/acetaminophen (Dilaudid, Norco, Xodol) oxycodone w/acetaminophen (Percocet) oxycodone w/aspirin (Percodan) Severe Learn more about each of these medications in the following section.

Section two Mild Pain: OTC and Initial Prescriptions Treating mild to severe acute pain Mild Pain: OTC and Initial Prescriptions Moderate Pain: Initial Prescriptions Severe Pain: Initial Prescriptions

Initial OTC Prescriptions for Mild Pain Treating Mild pain Initial OTC Prescriptions for Mild Pain Rx Aspirin 325 mg (OTC) Disp based on provider judgment Sig 1 to 2 tablets every 4 to 6 hours, as needed for pain or as prescribed MDD 4,000 mg/24 hours Note: The illustrated prescriptions are intended for the normal adult population. Dosages must be adjusted based on weight of a child, as well as the medical/physical status of all patients (e.g., liver and/or kidney disease).

Side Effects of Aspirin Treating Mild pain Side Effects of Aspirin Mild effects include: Nausea Stomach pain Heartburn Vomiting More serious effects require immediate attention and include: Swelling of the eyes, face, lips, tongue, or throat Ringing in the ears or loss of hearing Wheezing, difficulty breathing, hoarseness, or fast breathing Fast heartbeat Cold, clammy skin Hives or rash Bright red blood in stool/Black or tarry blood Bloody vomit or vomit that resembles coffee grounds

Initial OTC Prescriptions for Mild Pain Treating Mild pain Initial OTC Prescriptions for Mild Pain Rx Ibuprofen 200 mg (OTC) Disp based on provider judgment Sig 1 to 2 tablets every 4 to 6 hours, as needed for pain or as prescribed MDD 3,200 mg/24 hours Note: The illustrated prescriptions are intended for the normal adult population. Dosages must be adjusted based on weight of a child, as well as the medical/physical status of all patients (e.g., liver and/or kidney disease).

Initial OTC Prescriptions for Mild Pain Treating Mild pain Initial OTC Prescriptions for Mild Pain Rx Naproxen (Aleve) 200 mg (OTC) Disp based on provider judgment Sig 2 tablets to start, then one every 8 to 12 hours, as needed for pain or as prescribed MDD 3 tablets/24 hours Note: The illustrated prescriptions are intended for the normal adult population. Dosages must be adjusted based on weight of a child, as well as the medical/physical status of all patients (e.g., liver and/or kidney disease).

Initial OTC Prescriptions for Mild Pain Treating Mild pain Initial OTC Prescriptions for Mild Pain Rx Acetaminophen 325 mg (OTC) Disp based on provider judgment Sig 2 tablets to start, then one every 8 to 12 hours, as needed for pain or as prescribed MDD 3 tablets/24 hours Note: The illustrated prescriptions are intended for the normal adult population. Dosages must be adjusted based on weight of a child, as well as the medical/physical status of all patients (e.g., liver and/or kidney disease).

Initial OTC Prescriptions for Mild Pain Treating Mild pain Initial OTC Prescriptions for Mild Pain Special Considerations for Acetaminophen Acetaminophen may be given if patient has an allergy, bleeding problems, or stomach problems secondary to aspirin and NSAIDS. Warn patients not to combine acetaminophen with other acetaminophen containing prescriptions or products. Note: The illustrated prescriptions are intended for the normal adult population. Dosages must be adjusted based on weight of a child, as well as the medical/physical status of all patients (e.g., liver and/or kidney disease).

Initial Prescriptions for Mild Pain (not OTC) Treating Mild pain Initial Prescriptions for Mild Pain (not OTC) Rx Ibuprofen 600 mg Disp 24 tablets Sig 1 tablets every 6 to 8 hours as needed for pain or as prescribed MDD 3,200 mg/24 hours Note: The illustrated prescriptions are intended for the normal adult population. Dosages must be adjusted based on weight of a child, as well as the medical/physical status of all patients (e.g., liver and/or kidney disease).

Initial Prescriptions for Mild Pain (not OTC) Treating Mild pain Initial Prescriptions for Mild Pain (not OTC) Rx Anaprox 275 mg Disp 15 tablets Sig 2 tablets to start, then 1 tablet every 8 to 12 hours as needed for pain or as prescribed MDD 1,375 mg/24 hours Note: The illustrated prescriptions are intended for the normal adult population. Dosages must be adjusted based on weight of a child, as well as the medical/physical status of all patients, e.g. liver and/or kidney disease.

Initial Prescriptions for Mild Pain (not OTC) Treating Mild pain Initial Prescriptions for Mild Pain (not OTC) Rx Celebrex 200 mg Disp 15 capsules Sig 2 tablets to start, then 1 tablet every 8 to 12 hours as needed for pain or as prescribed MDD 400 mg/24 hours CAUTION: Celebrex is a sulfa drug and should not be prescribed for patients who have a sulfa allergy. Celebrex should not be used for long-term therapy. All NSAIDS may be taken with food to minimize gastric upset.

Initial Prescriptions for Mild Pain (not OTC) Treating Mild pain Initial Prescriptions for Mild Pain (not OTC) Rx Mobic 7.5 mg Disp 7 tablets Sig 1 tablet daily as needed for pain or as prescribed MDD 1 tablet daily CAUTION: All NSAIDS have been associated with a risk of serious cardiovascular and gastrointestinal events.

Initial Prescriptions for Mild to Moderate Pain Treating Mild to Moderate pain Initial Prescriptions for Mild to Moderate Pain Rx Diflunisal 250 mg (or 500 mg) Disp 14 tablets Sig 1 tablet twice daily as needed for pain or as prescribed MDD 1500 mg NOTE: Various dosing regimes are available. See product detail to determine individual recommendation. Use the lowest effective dose for the shortest effective treatment duration. Remember cardiac and gastrointestinal concerns.

Initial Prescriptions for Moderate Pain Treating Moderate pain Initial Prescriptions for Moderate Pain Rx Tylenol #3 (Combination product – 300 mg acetaminophen PLUS 30 mg of codeine) Disp 16 tablets Sig 1 tablet twice daily as needed for pain or as prescribed MDD 4000 mg of acetaminophen/24 hours CAUTION: It is recommended that products with more than 325 mg of acetaminophen be avoided. Warn patient about other acetaminophen containing products. Generic form available.

Initial Prescriptions for Moderate Pain Treating Moderate pain Initial Prescriptions for Moderate Pain Rx Synalgos DC (Combination product – 16 mg dihydrocodeine PLUS 356.4 mg of aspirin PLUS 30 mg caffeine) Disp 28 tablets Sig 1 to 2 capsules every 4 to 6 hours as needed for pain or as prescribed MDD 10 capsules/24 hours

Initial Prescriptions for Moderate Pain Treating Moderate pain Initial Prescriptions for Moderate Pain Rx Vicoprofen (Combination product – 7.5 mg hydrocodone PLUS 200 mg ibuprofen) Disp 16 tablets Sig 1 tablet every 4 to 6 hours as needed for pain or as prescribed MDD 5 tablets/24 hours

Side Effects of Hydrocodone Treating Moderate pain Side Effects of Hydrocodone Central: Drowsiness Dizziness Lightheadedness Fuzzy thinking Anxiety Abnormally happy or sad mood Skin: Rash Itching Respiratory: Slowed or irregular breathing Chest tightness Intestinal: Constipation Pupils: Narrowing Throat: Dryness Gastric: Nausea Vomiting Urinary: Difficulty urinating

Initial Prescriptions for Moderate Pain Treating Moderate pain Initial Prescriptions for Moderate Pain Rx Ultracet (Combination product – 325 mg acetaminophen PLUS 37.5 mg of tramadol) Disp 32 tablets Sig 2 tablets every 4 to 6 hours as needed for pain or as prescribed MDD 8 tablets/24 hours CAUTION: It is recommended that products with more than 325 mg of acetaminophen be avoided. Warn patient about other acetaminophen containing products.

Side Effects of Tramadol Treating Moderate pain Side Effects of Tramadol Milder effects include: Dizziness Drowsiness Insomnia Headache Nervousness Agitation Dry mouth Itching skin Sweating Chills Diarrhea Constipation Muscle tremor Muscle tightness Muscle weakness Heartburn/indigestion Nausea Vomiting More serious effects require immediate attention and include: Hallucinations Nose sores Swollen tongue/lips Mouth sores Skin hives or rash Labored breathing Eye sores and/or swelling Face swelling Throat sores and/or swelling Difficulty swallowing Hoarseness Swelling of the hands, feet, ankles, or lower legs Overall flu-like symptoms Seizures

Initial Prescriptions for Moderate Pain Treating Moderate pain Initial Prescriptions for Moderate Pain Rx Vicodin (Combination product – 5 mg hydrocodone PLUS 300 mg acetaminophen; other names: Norco, Xodol) Disp 16 tablets Sig 2 tablets every 4 to 6 hours as needed for pain or as prescribed MDD 4000 mg of acetaminophen CAUTION: It is recommended that products with more than 325 mg of acetaminophen be avoided. Warn patient about other acetaminophen containing products.

Side Effects of Vicodin Treating Moderate pain Side Effects of Vicodin Milder effects include: Dizziness Anxiousness Drowsiness Headaches Mood changes Ringing in ears Blurred vision Dryness of the face, lips, or tongue Intestinal distress Nausea Vomiting Constipation More serious effects require immediate attention and include: Fainting Confusion Fear Distressing thoughts or unusual behavior Slowed heart rate Loss of appetite Stomach pain Skin hives, itching, or yellowing Labored breathing Yellowing eyes Face swelling Throat swelling Swollen tongue/lips Difficulty urinating Dark urine Clay-colored stool Seizures

Initial Prescriptions for Severe Pain Treating severe pain Initial Prescriptions for Severe Pain Rx Dilaudid 2 mg Disp 16 tablets Sig 2 tablets every 4 to 6 hours as needed for pain as prescribed MDD 8 tablets/24 hours

Initial Prescriptions for Severe Pain Treating severe pain Initial Prescriptions for Severe Pain Rx Percodan (Combination product – 4.84 mg oxycodone PLUS 325 mg aspirin) Disp 16 tablets Sig 1 tablets every 6 hours as needed for pain as prescribed MDD 4000 mg aspirin/24 hours CAUTION: It is recommended that products with more than 325 mg of acetaminophen be avoided. Warn patient about other acetaminophen containing products.

Side Effects of Oxycodone Treating Severe pain Side Effects of Oxycodone Milder effects include: Dizziness Anxiousness Drowsiness Headaches Mood changes Smaller pupil Redness of the eyes Dryness of the mouth, lips, or tongue Loss of appetite Nausea Vomiting Constipation More serious effects require immediate attention and include: Fainting Confusion Dizziness Hallucinations Slowed or quickened heart rate Skin hives or rash Labored breathing Swelling of the eyes Face swelling Throat swelling Swollen tongue/lips Swelling of the hands, feet, ankles, or lower legs Seizures

Initial Prescriptions for Severe Pain Treating severe pain Initial Prescriptions for Severe Pain Rx Percocet 5 mg (Combination product – 5 mg oxycodone PLUS 325 mg acetaminophen) Disp 16 tablets Sig 1 or 2 tablets every 4 to 6 hours as needed for pain or as prescribed MDD 4000 mg of acetaminophen/24 hours CAUTION: It is recommended that products with more than 325 mg of acetaminophen be avoided. Warn patient about other acetaminophen containing products.