Pain Management and Wound Healing Flashcards
- Highly variable and depends on patient’s preoperative frame of mind
- Spending enough time discussing post op course helps greatly
- Usually not severe and can be managed with mild analgesics in most patients
- Peak pain 12 hours after extraction then diminishes rapidly
- Pain from extraction rarely persists longer than 2 days
Characteristics of Post op pain
- First dose of analgesic should be taken before anesthetic wears off
- This will avoid sharp, intense pain
- This helps control pain with milder meds
- Post op pain is harder to beat if administration of analgesics is delayed
Post op pain tips
Pain that occurs within the normal course of a disease or condition or as the result of surgery for which controlled substances may be prescribed for no more than 3 months
Acute Pain
Non-malignant pain that goes beyond the normal course of a disease or condition.
Controlled substances may be prescribed for a period greater than 3 months
Chronic Pain
MME
Morphine milligram equivalent
Drugs listed in the Drug Control Act of the Code of Virginia in Schedules II through IV
Controlled Substance
The electronic system within thhe department of health professions that monitor the dispensing of certain controlled substances
Prescription Monitoring Program
What is the goal for managing postprocedural dental pain or pain from limited pathological conditions
Minimize or Limit the pain
What might happen if you don’t tell the patient that the goal is not to fully eliminate pain
They may self prescribe
These drugs work peripherally, interfering with prostaglandin synthesis
Non-narcotics
What is a good alternative if a patient cannot tolerate aspirin
acetaminophen
What is the primary disadvantage of aspirin
potential for postop bleeding
What is the DOC for mild to moderate pain after tooth extraction
NSAIDs
Adult Dosage and Max Daily Dosage for Tylenol
500-1000 mg q4h
MAX: 4000 mg
Adult Dosage and Max Daily Dosage for Aspirin
500-1000 mg q4h
MAX: 4000 mg
Adult Dosage and Max Daily Dosage for Diflunisal
500 mg q8h
MAX: 1500 mg
Adult Dosage and Max Daily Dosage for Ibuprofen
200-800 q4-6h
MAX: 3200 mg
Most commonly used drugs of this class are codeine and the codeine congeners like oxycodone, hydrocodone, dihyrocodeine
Centrally Acting Analgesics
Opiods are rarely used alone…what are they typically paired with
Aspirin, Tylenol, or Advil
1 Codeine
7.5 mg
2 Codeine
15 mg
3 Codeine
30 mg
4 Codeine
60 mg
Dosage of Oral Codeine
30 mg q4h
Dosage of Oxycodone
5 mg q4h
Dosage of Hydrocodone
5 mg q4h
Dosage of Dihydrocodone
30 mg q4h
Dosage of pentazocine
50 mg q4h
Dosage of Meperidine
100 mg q4h
If pairing Aspirin with Codeine, how much aspirin is prescribed
325 mg
How much Tylenol is prescribed when paired with ceodeine
Phenopehn: 325
Codeine: 300
Darvocet N1000: 650
What government agency controls Narcotic Analgesics?
DEA
What do you need to write a script for Narcotics?
DEA permit and number
In 2014 more Virginians died from Opioid overdoses than…..
Car accidents
What percent of fatal drug overdoses are due to opioids?
61%
With over 52,000 deaths in 2015, what was the leading cause of accidental death in the USA
Drug OD
Of the 52,000 deaths, how many of them were due to opioids
13,000
In 2012, how many opioid prescriptions were written in the USA
259 million
What percent of heroin users used opioids as a gateway
80%
Why do people move from Opioids to heroin?
Heroin is cheaper and easier to get
What subpopulation is at an especially high risk for opioid OD
12-17 year old adolescents
Where do most teens get their hands on opioids?
They are given to them by relatives
Why are women at a higher risk for opioid dependence than men
More likely to have chronic pain
May become dependant on Rx drugs more quickly then men
Between 1999 and 2010, the number of narcotic pain med OD’s for men increased 237% for men……what was the increase for women?
400%
How much have fatal heroin OD’s among women increased from 2010-2013
Tripled
What Virginia laws apply to prescribing narcotics for dentists
none
- Perform a health history and physical examination appropriate to the complaint
- Query the Prescription Monitoring Program
- Conduct an assessment of the patient’s history and risk of substance abuse
Things that need to be done before prescribing a narcotic analgesic
- Description of the pain
- Presumptive diagnosis for the origin of the pain
- An examination appropriate to the complaint
- Treatment plan
- The medication prescribed (date, type, dosage, strength, and quant)
Information to be included in patient records
If an opioid is considered, what type should it be
Short acting
Lowest effective dose
Fewest number of days
Max 7 days
Careful and thorough documentation must be maintained if prescription is higher than ________
50 MME/day
What is the threshold dose that requires referral to a pain management physician
120 MME/day
- Patient be evaluated again, and decision to prescribe again documented
- Check patient’s prescription history in the Prescription Monitoring Program
Steps required if a new prescription is required beyond initial 7 days
Rx for Mild PO Pain
Ibuprofen
200-400 mg q4-6
prn (as needed)
Rx for Moderate PO Pain
Ibuprofen 400-600 mg q6h for 24 hrs
Then:
Ibuprofen 400 mg
q4-6h prn
Moderate to Severe Pain
Ibuprofen 400-600 mg + APAP 500 mg every 6 hours for 24 hours
Then:
Ibuprofen 400 mg + APAP 500 mg every 6 h prn
Severe Acute Post-Op Pain
Ibuprofen 400-600 mg + APAP 325 mg hydrocodone 5mg q6h for 24-48 hrs
Then:
Ibuprofen 400-600 mg + APAP 500 mg q6h prn
What is APAP?
acetyl-para-aminophenol
(Tylenol and Oxycodone) 325mg/5mg
What is the max dose for APAP
3000 mg
What is Viviprofen
Rescue med in case patient experiences breakthrough pain
What is the max dose of Ibuprofen (Daily). Who can prescribe a higher dose?
2400 mg
Physician for osteoarthritis
What is a long acting local anesthetics
Marcaine
What is the Rx for preemptive analgesics
600 mg Ibuprofen 1 hour before surgery
- Dexamethasone IV
2. Medrol Pack
Corticosteroids
These have unlimited efficacy in providing pain relief
Opioids
As doses of opioids increase, so does their effectiveness at reducing pain, why not just up the dosage?
Because SE’s and toxicity also icrease
Opioids are identical in their analgesic efficacy at _______ doses
equipotent
What is considered to be the conventional standard for relief of moderately sever pain
Morphine:
10 mg IM
30 mg Oral
What are the multipliers for equipotent (to morphine) doses of Hydromorphone
Codeine
Hydrocodeine
Oxycodone
Hydromorphone: 4 (30/4 = 7.5 mg)
Codeine: 0.15 (30/0.15 = 180-200 mg)
Hydrocodone: 1 (30/1 = 30 mg)
Oxycodone: 1.5 (30/1.5 = 20 mg)
Formula for DME
Daily Morphine Equivalents = (Strength x Multiplier x Quantity)/Days
For our purposes:
Who prescribes for acute pain, and who prescribes for chronic pain
Dentist = Acute Doc = Chronic
