1. requirements for opioid prescription course
Managing acute paiN

2. 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

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

4. 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.

5.  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.

6. 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

7. 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).

8. 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

9. 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).

10. 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 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).

11. 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).

12. 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).

13. 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).

14. 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.

15. 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.

16. 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.

17. 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.

18. 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.

19. Initial Prescriptions for Moderate Pain
Treating Moderate pain
Initial Prescriptions for Moderate Pain
Rx Synalgos DC (Combination product – 16 mg dihydrocodeine PLUS 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

20. 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

21. 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

22. 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.

23. 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

24. 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.

25. 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

26. 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

27. 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.

28. 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

29. 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.