1. PAIN, PAIN, GO AWAY…. Jill Autry, OD, RPh Eye Center of Texas, Houston drjillautry@tropicalce.com

2. Disclosures – Jill Autry, OD, R.Ph. Speaker’s Bureau/Consultant/KOL Board – Allergan – Alcon – Inspire – Ista – Bausch and Lomb Owner – Tropical CE – Eye Center of Texas Ophthalmology Center, Houston Editorial Board – Primary Care Optometry News – Optometry Times

3. PAIN Most common reason to seek medical care Acute – Sudden and severe – Burn – Corneal abrasion, preseptal cellulitis Chronic – Lasts longer than 3 months – Back pain – Post-herpetic neuralgia – Sinusitis – Migraine

4. TYPES OF PAIN Somatic Visceral Neuropathic Psychogenic

5. ANALGESIA Word of Greek origin “an” meaning without “algein” meaning to feel pain Generally classified – Mild – Moderate – Strong

6. MILD ANALGESICS Acetylsalicylic acid – Aspirin or “ASA” Acetaminophen – Tylenol ® or “APAP” Propoxyphene (Schedule IV)-removed from market – Darvon ® – Darvocet ®

7. SALICYLATES- THE FOUR “As” Analgesic – Relief without sedation – Works on peripheral pain receptors – Decreases synthesis of prostaglandins and bradykinins Anti-inflammatory – Blocks kinin precursors – Blocks histamine precursors – Need high doses for arthritic pain Approx 4-6 grams daily

8. SALICYLATES- THE FOUR “A” Anti-platelet – Not related to pain treatment – For heart attack and stroke prevention – Inhibits platelet adhesiveness and coagulation – Regular strength is 325mg; baby aspirin is 81mg Antipyretic-“pyrexis” Greek for heat – Affects the hypothalamus which is responsible for temperature regulation – Decreases temperature but not below normal – Inhibits pyrogen stimulated prostaglandins

9. ASPIRIN SIDE EFFECTS Max daily dose = 4000mg (4g) Reye’s Syndrome in children with flu-like symptoms GI irritation Bleeding ulcers Increased anticoagulation Nausea Tinnitus – Often seen at arthritic doses

10. ALLERGIC TO ASPIRIN? Triad leading to anaphylaxis – Aspirin allergy – Asthma – Nasal polyps Avoid the following: – Aspirin – Oral NSAIDS – Topical NSAIDS

11. ACETAMINOPHEN Clear mechanism of action elusive – May affect oxidation of cyclooxygenase (COX) and inhibit prostaglandin synthesis in the CNS – May increase endogenous cannabinoids Analgesic action Anti-pyretic action No anti-inflammatory action No anti-platelet action

12. ACETAMINOPHEN DOSING aka APAP OTC 325mg regular strength 500mg extra strength 4000mg/day (4 gram) max dosage Used extensively in flu/cold/pain preps Watch ingredient lists to avoid overdosage

13. ACETAMINOPHEN SIDE EFFECTS Generally well tolerated at therapeutic dosages Overdosage causes irreversible kidney and liver damage Cannot use in patients with hepatic disease or alcoholics Do not use with alcohol Check ingredients on cough/cold preps

14. MODERATE ANALGESICS Codeine (Tylenol #3 ®, Tylenol #4 ® ) Hydrocodone (Vicodin ®, Vicoprofen ®, Lorcet ®, Lortab ® ) Oxycodone (Percocet ®, Percodan ® ) NSAIDS (ibuprofen, Naproxen ®, others) Tramadol (Ultram ®, Ultracet ® )

15. CODEINE Naturally occurring substance From the opium poppy 1/12 the strength of morphine Rarely used alone Tylenol #3 ® (APAP and codeine) Empirin #3 ® (ASA and codeine) Also used as an antitussive in cough syrups

16. CODEINE COMBINATIONS Tylenol #3 ® and Tylenol ® #4 Increasing codeine amount from #3 to #4 APAP amount is 325mg in each #3-30mg codeine + 325mg APAP #4-60mg codeine + 325mg APAP Tylenol with codeine ® elixir is APAP 120mg/5cc with 12mg codeine/5cc

17. TYLENOL #3 Schedule III Central acting narcotic analgesic 325mg acetaminophen + 30mg codeine Avoid in liver/renal disease/alcoholism No extra Tylenol ® in addition No alcohol GI distress and sedation are main side effects

18. Edward Wade, M.D. Ting Fang-Suarez, M.D. Mark Mayo, M.D. Chris Allee, O.D. Jill Autry, O.D. Randy Reichle, O.D. 6565 West Loop South 4415 Crenshaw Rd.15400 SW Frwy Bellaire, TX 77401 Pasadena, TX 77504Sugar Land, TX 77478 Phone (713)797-1010 Phone (281)998-3333(281)277-1010 450 Medical Ctr Blvd, #305 11914 Astoria Boulevard, #325 21700 Kingsland Blvd. Webster, TX 77598 Houston, TX 77089 Katy, TX 77450 (281) 332-1397 (281) 484-2030 (281) 578-4815 NAME Jack Cooper AGE ________ ADDRESS 6565 Golden River Drive, Houston, TX 77082 DATE 3-3-11 RxTylenol #3 #20 (twenty) 1-2 po q4-6h prn pain REFILLS-- zero Jill Autry, O.D. MA0123456

19. ALLERGIC TO CODEINE? Most codeine “allergies” are just GI side effects or codeine initiated histamine release – “Stomach upset” – Flushing – Itching True IgE mediated allergic reaction low Can use hydrocodone because it is a semi- synthetic form of codeine

20. HYDROCODONE As effective as Class II narcotics but with Class III status Significantly more pain relief and duration of action compared to codeine Induces euphoria Highly addictive Also has antitussive properties

21. HYDROCODONE PRODUCTS Vicodin ® (APAP w/hydrocodone) – 500mg APAP + 5mg hydrocodone – Schedule III Vicodin ® ES (APAP w/hydrocodone) – 750mg APAP + 7.5mg hydrocodone – Schedule III Vicoprofen ® – 200mg ibuprofen + 7.5mg hydrocodone – When Tylenol ® is contraindicated/liver disease – Schedule III

22. Edward Wade, M.D. Ting Fang-Suarez, M.D. Mark Mayo, M.D. Chris Allee, O.D. Jill Autry, O.D. Randy Reichle, O.D. 6565 West Loop South 4415 Crenshaw Rd.15400 SW Frwy Bellaire, TX 77401 Pasadena, TX 77504Sugar Land, TX 77478 Phone (713)797-1010 Phone (281)998-3333(281)277-1010 450 Medical Ctr Blvd, #305 11914 Astoria Boulevard, #325 21700 Kingsland Blvd. Webster, TX 77598 Houston, TX 77089 Katy, TX 77450 (281) 332-1397 (281) 484-2030 (281) 578-4815 NAME Jack Cooper AGE ________ ADDRESS 6565 Golden River Drive, Houston, TX 77082 DATE 3-3-11 RxVicodin 5/500 #30 (thirty) 1-2 q4-6h prn pain REFILLS-- zero Jill Autry, O.D. MA0123456

23. Edward Wade, M.D. Ting Fang-Suarez, M.D. Mark Mayo, M.D. Chris Allee, O.D. Jill Autry, O.D. Randy Reichle, O.D. 6565 West Loop South 4415 Crenshaw Rd.15400 SW Frwy Bellaire, TX 77401 Pasadena, TX 77504Sugar Land, TX 77478 Phone (713)797-1010 Phone (281)998-3333(281)277-1010 450 Medical Ctr Blvd, #305 11914 Astoria Boulevard, #325 21700 Kingsland Blvd. Webster, TX 77598 Houston, TX 77089 Katy, TX 77450 (281) 332-1397 (281) 484-2030 (281) 578-4815 NAME Jack Cooper AGE ________ ADDRESS 6565 Golden River Drive, Houston, TX 77082 DATE 3-3-11 RxVicodin ES #30 (thirty) 1 q4-6h prn pain REFILLS-- zero Jill Autry, O.D. MA0123456

24. Edward Wade, M.D. Ting Fang-Suarez, M.D. Mark Mayo, M.D. Chris Allee, O.D. Jill Autry, O.D. Randy Reichle, O.D. 6565 West Loop South 4415 Crenshaw Rd.15400 SW Frwy Bellaire, TX 77401 Pasadena, TX 77504Sugar Land, TX 77478 Phone (713)797-1010 Phone (281)998-3333(281)277-1010 450 Medical Ctr Blvd, #305 11914 Astoria Boulevard, #325 21700 Kingsland Blvd. Webster, TX 77598 Houston, TX 77089 Katy, TX 77450 (281) 332-1397 (281) 484-2030 (281) 578-4815 NAME Jack Cooper AGE ________ ADDRESS 6565 Golden River Drive, Houston, TX 77082 DATE 3-3-10 RxVicoprofen #30 (thirty) 1 q4-6h prn pain REFILLS-- zero Jill Autry, O.D. MA0123456

25. NSAIDS Nonsteroidal anti-inflammatory drugs (NSAIDS) Very popular None are controlled substances Little to no abuse potential Some available in OTC strength Patients vary in response to various products

26. NSAID ACTIONS Inhibit cyclo-oxygenase pathway Results in decreased prostaglandin formation Reduce pain Reduce inflammation Reduce edema

27. COMMON ORAL NSAIDS OTC – Ibuprofen 200mg Motrin ®, Advil ®, Nuprin ® – Naproxen 200mg Alleve ® Rx – Ibuprofen 400mg, 600mg, 800mg – Ketorolac (Toradol ® ) 10mg – Celebrex 100mg, 200mg

28. Edward Wade, M.D. Ting Fang-Suarez, M.D. Mark Mayo, M.D. Chris Allee, O.D. Jill Autry, O.D. Randy Reichle, O.D. 6565 West Loop South 4415 Crenshaw Rd.15400 SW Frwy Bellaire, TX 77401 Pasadena, TX 77504Sugar Land, TX 77478 Phone (713)797-1010 Phone (281)998-3333(281)277-1010 450 Medical Ctr Blvd, #305 11914 Astoria Boulevard, #325 21700 Kingsland Blvd. Webster, TX 77598 Houston, TX 77089 Katy, TX 77450 (281) 332-1397 (281) 484-2030 (281) 578-4815 NAME Joe Johnson AGE ______________ ADDRESS_____________________________________________________DATE 3-3-11 RxIbuprofen 600mg #30 1 po q6h REFILLS-- 0 Jill Autry, O.D.

29. NSAID INDICATIONS Arthritis – Osteoarthritis – Rheumatoid arthritis Moderate pain – Post-operative pain – Dental pain Headache Premenstrual cramping Additional control of ocular inflammation – Episcleritis, iritis, non-specific ocular pain

30. NSAID SIDE EFFECTS All oral NSAIDS have been associated with inducing ulcers – Risk increased for elderly – Risk increased for patients on steroids, anticoagulants, daily aspirin – Consider Zantac ® 150mg bid for extended NSAID therapy – Take with food or milk

31. NSAID SIDE EFFECTS Kidney toxicity – Dose and duration-dependent – Risk factors for kidney failure Elderly Diabetes, hypertension, heart failure Concomitant diuretic use Concomitant ACE inhibitor or Angiotensin II blocker use

32. TOPICAL NSAIDS Ketorolac Generic 0.5% available—dosed qid Accuvail® Bid non-preserved Nevanac® Tid Bromfenac Xibrom® bid Bromday® qd

33. STRONG ANALGESICS Morphine Hydromorphine Methadone Meperidine – Demerol ®

34. SIDE EFFECTS OF OPIOID ANALGESICS Constipation Nausea and vomiting Sedation Dizziness Miosis Itching Respiratory depression Addiction

35. ANALGESIC PAIN MANAGEMENT PEARLS Synergy – Topical and orals – Central acting and Peripheral acting Concerns – Pain that worsens despite treatment – Hepatic disease – Renal disease – GI ulcer history – Anticoagulants/antiplatelet use – Diabetic – Aspirin/Codeine allergies

36. CONTROLLED SUBSTANCES A substance subject to the Controlled Substances Act (1970), which regulates the prescribing and dispensing of substances according to: – Potential for or evidence of abuse – Potential for psychological or physiological dependence – Contributing to a public health risk – Harmful pharmacological effect – Role as a precursor of other controlled substances List of medications and corresponding schedules found at www.deadiversion.usdoj.gov

37. PRESCRIBING FOR SELF/FAMILY AMA Code of Medical Ethics states “physicians generally should not treat themselves or members of their immediate family” “…there are situations in which routine care is acceptable for short-term, minor problems.” Stay within prescriptive scope of practice

38. PRESCRIBING FOR SELF/FAMILY Controlled substances under federal law Legitimate medical purpose Patient-physician relationship Acting in the usual course of sound professional practice – Maintenance of a written medical record, etc. Some states have specific rules/regulations No controlled substances to immediate family members No controlled substances for physician’s own self

39. GETTING A DEA NUMBER On-line application www.deadiversion.usdoj.gov Optometrists are mid-level practitioners (MLP) First time applicant-Form 224 Renewal-Form 224a Cost $551/Good for 3 years Takes 1-3 months to receive

40. CONTROLLED SUBSTANCE Rx Doctor name and address Patient name and address Patient age/birthdate Date of Rx – Good for six months from date of issue Drug name/quantity written as number and word Refill line – Schedules III, IV, and V allow 5 refills in 6 months Signature of prescriber DEA number

41. Edward Wade, M.D. Ting Fang-Suarez, M.D. Mark Mayo, M.D. Chris Allee, O.D. Jill Autry, O.D., RPhRandy Reichle, O.D. 6565 West Loop South 4415 Crenshaw Rd.15400 SW Frwy Bellaire, TX 77401 Pasadena, TX 77504Sugar Land, TX 77478 Phone (713)797-1010 Phone (281)998-3333(281)277-1010 450 Medical Ctr Blvd, #305 11914 Astoria Boulevard, #325 21700 Kingsland Blvd. Webster, TX 77598 Houston, TX 77089 Katy, TX 77450 (281) 332-1397 (281) 484-2030 (281) 578-4815 NAME Jack Cooper AGE __32______ ADDRESS 6565 Golden River Drive, Houston, TX 77082 DATE 3-3-11 RxTylenol #3 #20 (twenty) 1-2 po q4-6h prn pain REFILLS-- zero Jill Autry, O.D. MA0123456

42. TOPICAL STEROIDS Reduce inflammation Reduce pain Reduce photophobia Ocular conditions – Iritis, sterile corneal infiltrates, episcleritis, post- operative pain due to inflammation, inflamed pterygia/pingueculae Pred Forte® 1%, Durezol®, Lotemax®, FML Forte®, etc.

43. ORAL STEROIDS Take with food or milk Generally start 60-80 mg/day – For posterior uveitis, Giant cell, after IV steroids for optic neuritis, pseudotumor, scleritis – Must taper dosage over 1-2 weeks depending on response – 40-60 mg x 2-3 days does not need taper Consider Medrol Dosepak – For allergic reactions, zoster, anterior uveitis – Less serious inflammations

44. Edward Wade, M.D. Ting Fang-Suarez, M.D. Mark Mayo, M.D. Chris Allee, O.D. Jill Autry, O.D. Randy Reichle, O.D. 6565 West Loop South 4415 Crenshaw Rd.15400 SW Frwy Bellaire, TX 77401 Pasadena, TX 77504Sugar Land, TX 77478 Phone (713)797-1010 Phone (281)998-3333(281)277-1010 450 Medical Ctr Blvd, #305 11914 Astoria Boulevard, #325 21700 Kingsland Blvd. Webster, TX 77598 Houston, TX 77089 Katy, TX 77450 (281) 332-1397 (281) 484-2030 (281) 578-4815 NAME Joe Johnson AGE ______________ ADDRESS_____________________________________________________DATE 3-3-11 RxPrednisone 20mg #30 3 tabs (60mg) qd with food/milk REFILLS-- 0 Jill Autry, O.D.

45. Edward Wade, M.D. Ting Fang-Suarez, M.D. Mark Mayo, M.D. Chris Allee, O.D. Jill Autry, O.D. Randy Reichle, O.D. 6565 West Loop South 4415 Crenshaw Rd.15400 SW Frwy Bellaire, TX 77401 Pasadena, TX 77504Sugar Land, TX 77478 Phone (713)797-1010 Phone (281)998-3333(281)277-1010 450 Medical Ctr Blvd, #305 11914 Astoria Boulevard, #325 21700 Kingsland Blvd. Webster, TX 77598 Houston, TX 77089 Katy, TX 77450 (281) 332-1397 (281) 484-2030 (281) 578-4815 NAME Joe Johnson AGE ______________ ADDRESS_____________________________________________________DATE 3-3-11 RxMedrol Dose Pack TUD REFILLS-- 0 Jill Autry, O.D.

46. STEROID SIDE EFFECTS Increased intraocular pressure – Topical will increase in 2-4 weeks – Oral/IV can increase within 3-4 days Cataract – Usually posterior subcapsular Steroid induced diabetes/decrease control Adrenal suppression Reduced immunity/infections Mood swings/erratic behavior

47. TOPICAL ANESTHESIA Topical anesthesia – Onset of action within 20 seconds – Duration of action 15-20 minutes – Anesthesia of surface nerve endings – Work by blocking both the initiation and conduction of nerve impulses – May retard epithelial regeneration with prolonged and repeated use – Consider “comfort drops”

48. ANESTHETIC REACTIONS Anesthetics generally have either an amide chemical structure or an ester chemical structure. In cases of allergy or increased side effects, an anesthetic from the alternate class may often be utilized without cross sensitivity.

49. AMIDE ANESTHETICS Bupivicaine Etidocaine Lidocaine Mepivacaine Dibucaine

50. ESTER ANESTHETICS Chloroprocaine Procaine Tetracaine Benzocaine Cocaine Proparacaine Benoxinate ***Found in Fluress  ***

51. CYCLOPLEGICS Provides ocular pain control in certain inflammatory ocular conditions Relaxes ciliary spasm by ciliary body paralysis Ocular pain uses are numerous – Iritis – Corneal abrasions/RCE – Corneal foreign body removal – Post-operative pain Contraindicated in pain from angle closure Atropine, scopolamine, or homatropine

52. Edward Wade, M.D. Ting Fang-Suarez, M.D. Mark Mayo, M.D. Chris Allee, O.D. Jill Autry, O.D. Randy Reichle, O.D. 6565 West Loop South 4415 Crenshaw Rd.15400 SW Frwy Bellaire, TX 77401 Pasadena, TX 77504Sugar Land, TX 77478 Phone (713)797-1010 Phone (281)998-3333(281)277-1010 450 Medical Ctr Blvd, #305 11914 Astoria Boulevard, #325 21700 Kingsland Blvd. Webster, TX 77598 Houston, TX 77089 Katy, TX 77450 (281) 332-1397 (281) 484-2030 (281) 578-4815 NAME Joe Johnson AGE ______________ ADDRESS_____________________________________________________DATE 3-3-11 RxHomatropine 5% 5ml 1 gtt tid OD REFILLS-- 0 Jill Autry, O.D.

53. CASE EXAMPLES