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    Process key to pain management

    Empathizing with patients' discomfort can help you better understand their treatment needs

    Dr. Onofrey
    Scottsdale, AZ—An optometrist's understanding of ocular pain management must always be evolving as you become more immersed in primary care, but, according to recent literature, most doctors under evaluate a patient's pain and discomfort and often don't prescribe enough medication.

    Bruce E. Onofrey, OD, RPh, FAAO, clinical professor at the University Eye Institute of the University of Houston, provided an update on pain management, focusing on how optometrists can better understand and treat their patients' pain, and reviewed analgesics for ocular pain at the 3rd annual American Optometric Society meeting here in February.

    "You should always be aware of the patient's pain," Dr. Onofrey said.

    With ocular infection, pain reduction is typically the first sign of clinical improvement. "The next day, they don't necessarily look better, but they feel better," Dr. Onofrey said. "The first sign of improvement isn't necessarily a reduction of infection, but a reduction in pain. 'Do you feel better?' is the first question I ask."


    The mechanism of acetaminophen is not fully understood, but Dr. Onofrey noted it does lower fever without producing an anti-inflammatory effect or inhibiting platelets. It's often the drug of choice for children, pregnant women, and nursing mothers.

    However, acetaminophen has also been associated with liver failure, he said. Those at greatest risk are children and adults who drink alcohol more than three times a day.


    Endogenous endorphins stimulate the morphine opioid receptors in the brain and spinal column. Opiates bind to these receptors and block the central pain receptors to produce an analgesic or sedative effect, Dr. Onofrey said. Schedule II opiates have high risk of abuse, while schedule V drugs have the lowest risk of abuse.

    Common side effects of opiates include itching, nausea, urinary tract problems, drowsiness, and decreased respiration, according to Dr. Onofrey. "These are normal physiological responses," he said, and not the signs of an allergic reaction. Because opiates can decrease the respiratory rate, never prescribe them in a patient with chronic occlusive pulmonary disease or sleep apnea, he said.

    Combination medications

    NSAIDs in combination with opiates can be especially helpful in addressing pain, Dr. Onofrey said. The most common combination drugs are acetaminophen with either codeine or hydrocodone. The former is Dr. Onofrey's go-to pain medication. "What you're looking for in these medications is the patient's ability to adjust their dose," he said.

    In some scenarios, you may desire an alternative drug—such as when a patient has a history of drug addiction, or you may prefer to not prescribe opiates, or the patient may not want to take them. Acetaminophen in combination with another NSAID can be a good option, Dr. Onofrey said.

    In these situations, he recommended 400–600mg of ibuprofen with 500–1000mg of acetaminophen TID. (Pregnant patients, however, should not have ibuprofen.) Even though ibuprofen is an over-the-counter drug, Dr. Onofrey recommended writing a prescription for higher-dosage tablets. "I don't want them to get used to taking (the drug) at levels above the OTC label," he said.

    Another non-narcotic option is tramadol, which Dr. Onofrey called "super Tylenol." Despite its non-narcotic status, it can produce addiction and induce withdrawal in addicts, he noted.

    If you have a patient with persistent headache, be sure to check for ocular reasons. Then, refer the person to a primary-care physician (PCP), a neurologist, or an ear, nose, and throat specialist.

    To be safe, Dr. Onofrey advised, never prescribe headache medications. "You're there as part of the diagnosis process," he explained. "You are not the person to make the final diagnosis." The PCP or specialist will manage headache pain after the diagnosis.

    Post-herpetic neuralgia

    Some conditions, such as post-herpetic neuralgia, may require a variety of daily medications to manage pain and promote healing. Dr. Onofrey recommended a low-dose tricyclic antidepressant, such as amitriptyline 10mg PO, along with the standard antiviral medications, to manage the associated pain.

    Ultimately, he said, you must recognize the various reasons for ocular pain, from ocular disease or discomfort to postoperative sequelae. "When should you consider systemic medications? When the patient says it hurts. Have empathy for your patients," Dr. Onofrey said.


    Bruce E. Onofrey, OD, RPh, FAAO

    Dr. Onofrey did not indicate a financial interest in the subject.

    Optometry Times A/V