PAIN, PAIN, GO AWAY . Jill Autry, OD, RPh Eye Center of

1
PAIN, PAIN, GO AWAY.

• Jill Autry, OD, RPh
• Eye Center of Texas, Houston
• drjillautry_at_tropicalce.com

2
Disclosures Jill Autry, OD, R.Ph.

• Speakers 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)
• Reyes 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 77504 Sugar Land, TX
77478 Phone [phone] Phone
[phone] [phone] 450 Medical Ctr
Blvd, 305 11914 Astoria Boulevard, 325
21700 Kingsland Blvd. Webster, TX 77598
Houston, TX 77089 Katy, TX 77450 (281)
332-1397
[phone] [phone]
NAME Jack Cooper AGE
________ ADDRESS 6565 Golden River Drive,
Houston, TX 77082 DATE 3-3-11
Rx Tylenol 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 77504 Sugar Land, TX
77478 Phone [phone] Phone
[phone] [phone] 450 Medical Ctr
Blvd, 305 11914 Astoria Boulevard, 325
21700 Kingsland Blvd. Webster, TX 77598
Houston, TX 77089 Katy, TX 77450 (281)
332-1397
[phone] [phone]
NAME Jack Cooper AGE
________ ADDRESS 6565 Golden River Drive,
Houston, TX 77082 DATE 3-3-11
Rx Vicodin 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 77504 Sugar Land, TX
77478 Phone [phone] Phone
[phone] [phone] 450 Medical Ctr
Blvd, 305 11914 Astoria Boulevard, 325
21700 Kingsland Blvd. Webster, TX 77598
Houston, TX 77089 Katy, TX 77450 (281)
332-1397
[phone] [phone]
NAME Jack Cooper AGE
________ ADDRESS 6565 Golden River Drive,
Houston, TX 77082 DATE 3-3-11
Rx Vicodin 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 77504 Sugar Land, TX
77478 Phone [phone] Phone
[phone] [phone] 450 Medical Ctr
Blvd, 305 11914 Astoria Boulevard, 325
21700 Kingsland Blvd. Webster, TX 77598
Houston, TX 77089 Katy, TX 77450 (281)
332-1397
[phone] [phone]
NAME Jack Cooper AGE
________ ADDRESS 6565 Golden River Drive,
Houston, TX 77082 DATE 3-3-10
Rx Vicoprofen 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 77504 Sugar Land, TX
77478 Phone [phone] Phone
[phone] [phone] 450 Medical Ctr
Blvd, 305 11914 Astoria Boulevard, 325
21700 Kingsland Blvd. Webster, TX 77598
Houston, TX 77089 Katy, TX 77450 (281)
332-1397
[phone] [phone]
NAME Joe Johnson AGE
______________ ADDRESS___________________________
__________________________DATE 3-3-11
Rx Ibuprofen 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 availabledosed 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 physicians 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., RPh Randy Reichle, O.D. 6565
West Loop South 4415
Crenshaw Rd. 15400 SW Frwy Bellaire, TX
77401 Pasadena, TX 77504 Sugar Land, TX
77478 Phone [phone] Phone
[phone] [phone] 450 Medical Ctr
Blvd, 305 11914 Astoria Boulevard, 325
21700 Kingsland Blvd. Webster, TX 77598
Houston, TX 77089 Katy, TX 77450 (281)
332-1397
[phone] [phone]
NAME Jack Cooper AGE
__32______ ADDRESS 6565 Golden River Drive,
Houston, TX 77082 DATE 3-3-11
Rx Tylenol 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 77504 Sugar Land, TX
77478 Phone [phone] Phone
[phone] [phone] 450 Medical Ctr
Blvd, 305 11914 Astoria Boulevard, 325
21700 Kingsland Blvd. Webster, TX 77598
Houston, TX 77089 Katy, TX 77450 (281)
332-1397
[phone] [phone]
NAME Joe Johnson AGE
______________ ADDRESS___________________________
__________________________DATE 3-3-11
Rx Prednisone 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 77504 Sugar Land, TX
77478 Phone [phone] Phone
[phone] [phone] 450 Medical Ctr
Blvd, 305 11914 Astoria Boulevard, 325
21700 Kingsland Blvd. Webster, TX 77598
Houston, TX 77089 Katy, TX 77450 (281)
332-1397
[phone] [phone]
NAME Joe Johnson AGE
______________ ADDRESS___________________________
__________________________DATE 3-3-11
Rx Medrol 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 77504 Sugar Land, TX
77478 Phone [phone] Phone
[phone] [phone] 450 Medical Ctr
Blvd, 305 11914 Astoria Boulevard, 325
21700 Kingsland Blvd. Webster, TX 77598
Houston, TX 77089 Katy, TX 77450 (281)
332-1397
[phone] [phone]
NAME Joe Johnson AGE
______________ ADDRESS___________________________
__________________________DATE 3-3-11
Rx Homatropine 5 5ml 1 gtt tid OD REFILLS--
0 Jill Autry, O.D.
53
CASE EXAMPLES