Analgesic Dose Checker Training Slides
IntroductionThis slide set is intended for use by qualified
clinical staff e.g. Nurse Advisors and Dental Nurse AdvisorsIt
provides basic information on:The use of analgesics in managing
painThe dangers of deliberate or accidental overdose with common,
simple analgesicsGuidance on restarting analgesics after accidental
overdoseFurther information can be found in the BNF and NHS
Evidence
1Dental Pain Guidance UKMi October 2015Learning outcomesOutline
the key features of paracetamol, ibuprofen and other simple
analgesicsUnderstand how and why overdoses of analgesics occurKnow
when to refer calls about paracetamol and ibuprofen Be able to give
appropriate restarting guidance
2Dental Pain Guidance UKMi October 20152Why worry about
overdoses?Very commonHarm to the patientSelf harm / psychological
issuesMedicines readily availablePatient misconceptions of
safetyRisk factorsDental pain
3Dental Pain Guidance UKMi October 20153Overdoses may be taken
on purpose or accidentally, but are a common occurrence.Prolonged
or large overdoses can cause many types of harm to the patient,
depending on patient factors and the drug that has been taken.
There can be many reasons for overdoses. If it is suspected that
self harm is involved, the patient will require referral.
Paracetamol and ibuprofen are readily available over the counter
and GSL. Pack size reductions in paracetamol have reduced the
number of overdoses caused by this agent. However it may appear in
different formulations such as cold remedies etc.Because
paracetamol and ibuprofen are so readily available and widely used,
there may be a public perception that they are unlikely to cause
harm if a couple of extra doses are taken or the maximum dose on
the pack is disregarded. Patients may have risk factors that they
may not consider when taking medicines.If they have persistent
pain, they may be more likely to take doses more frequently than is
directed.
Supratherapeutic overdosesExamples:Taking ibuprofen every 3
hours instead of every 6-8 hours as pain isnt controlledTaking
paracetamol along with co-codamol tablets for extra pain relief,
without realising both contain paracetamolTaking 3 paracetamol
tablets per dose instead of 2 tabletsTaking more than the
recommended maximum dose for therapeutic purposes4Dental Pain
Guidance UKMi October 2015Single dose overdosesClassic overdose
scenarioPossible self-harmImpulses may last 30 mins, then regret
and seek helpAlcohol relatedPeak age range 15-24 years; Women >
MenRefer these calls large single doses are unlikely to be an
accidental overdoseDental pain more likely to be staggered
overdoses over a period of time5Dental Pain Guidance UKMi October
20155Women are often more involved than men in self harm scenarios,
but the gap is closing. Generally, men are more successful at
committing suicide than women.In dental pain scenarios, you will be
more likely to be dealing with staggered overdoses over a period of
time. People taking large single doses should be referred as this
is unlikely to be an accidental overdose.
WHO Analgesic ladder for acute & chronic painMild PainStep
1Simple painkillersParacetamolNSAID (e.g.Ibuprofen) Severe PainStep
3Strong opioidsMorphineTramadolOxycodone
Moderate PainStep 2Weaker
opioidsCodeineDihydrocodeineCo-codamolCo-dydramol
If pain persists6Dental Pain Guidance UKMi October 20156We will
be focusing on analgesics in step 1 and 2 of the ladder.As pain
persists move up to the next rung of the ladder.First line
treatment of painFirst choice Single painkiller at full doseOptions
if paracetamol alone or ibuprofen alone do not control symptomsFor
adults - consider an analgesic higher up the pain control ladder
e.g. co-codamolTake regular paracetamol, if get breakthrough pain
towards end of dose interval - take single dose of ibuprofen (or
other way around)Risks if advise regular alternate doses of
paracetamol and ibuprofenConfuse / forget what has been takenDelay
diagnosis of a more serious conditionStep 1: Simple
painkillerParacetamolIbuprofenStep 2: Weak
opioidCodeineDihydrocodeineCo-codamolCo-dydramolStep 3: Strong
opioidMorphineTramadolOxycodone7Dangers of paracetamol in
overdoseVery safe if used appropriately, but.Highly toxic in
overdoseSupra-therapeutic doses may be as toxic as a one-off single
overdoseBe aware of hidden sources e.g. cold remedies,
combination-medicinesThe more serious effects can be delayed
Abdominal pain 12-36 hoursDelayed hepatotoxicity 2-3 days before
liver function declinesAntidote must be given as soon as possible
to be effective9Dental Pain Guidance UKMi October 20159Paracetamol
has very few side effects if used as directed, and is generally
very safe in use. However, in overdose it can be highly toxic.
Evidence is emerging that supratherapeutic overdoses can be just as
toxic as one off single doses. Hidden sources of paracetamol may be
in cold remedies e.g. Sudafed combinations, Lemsip drinks etc, or
co-medicines e.g. co-codamol, co-dydramol. A patient may not
realise that a product has paracetamol in. A problem with overdoses
with paracetamol is that the more serious effects can be delayed -
so if an overdose is taken the patient may not feel very unwell
(perhaps a little nausea and/or vomiting), yet develop serious
features such as abdominal pain (12-36 hours) or signs of liver and
renal failure after 2 to 3 days.There is an effective antidote to
paracetamol overdose- N-acetylcysteine. However, this works better
if it is given sooner rather than later so time is of the essence
when dealing with these calls.Combination analgesicsCo-codamol
Codeine & paracetamolParacodolPanadol
UltraSolpadeineCo-dydramolDihydrocodeine &
paracetamolParamolMany painkillers contain more than one drug and
are known as combination, compound or co-analgesicsCodeine and
dihydrocodeine are stronger than paracetamol or ibuprofen and are
known as opioid analgesics Co-analgesics available OTC can be used
for short-term pain not relieved by paracetamol or ibuprofenDo not
use for more than 3 days unless advised by doctor.10Brand namesMany
Over-the-Counter (OTC) medicines have the same brand name attached
to different products
Similar sounding and looking products have different ingredients
so it is important to obtain the exact name e.g.
Lemsip Max Flu Lemon contains paracetamol Lemsip Max Flu 12 hour
capsules contain ibuprofen
Although both these products are called Lemsip Max, they contain
completely different analgesics11Dental Pain Guidance UKMi October
201511IbuprofenUsesRelieves mild to moderate pain Reduces
feverReduces inflammationLicensed for children from 3 months if 5kg
or moreSide effects Heartburn / indigestionStomach
ulcersBleedingContra-indications (must not take)Allergic to
aspirinPrevious peptic ulcer / bleedTaking another NSAIDSevere
heart failure
Cautions (take only on advice)AsthmaKidney or liver problemsHigh
blood pressureDrug interactionsInteracts with a number of other
medicinesCheck the patient information leaflet for advice about
other medicinesAllergyRashWheezing / breathlessness12Dental Pain
Guidance UKMi October 201512Recommended dose without a prescription
is 200mg to 400mg up to three times a day; maximum total daily dose
of 1200mg in 24 hours. A prescribed dose can be higher than
this.Ibuprofen overdoseAlthough it has a number of side effects
with therapeutic use it has quite low toxicity in overdoseMost
patients develop no more than:Nausea, vomiting, epigastric pain or
more rarely diarrhoeaTinnitus, headache, GI bleeding also
possibleAcute kidney damage - most serious complication (large
doses)CNS toxicity in serious overdose
13Dental Pain Guidance UKMi October 201513Most patients who have
ingested clinically important amounts of NSAIDS will develop no
more than nausea, vomiting, epigastric pain, or more rarely
diarrhoea. Tinnitus, headache and gastrointestinal bleeding are
also possible. Acute kidney injury is the most frequent serious
complication but is usually seen only after large doses and/or in
patients with co-morbidity.In more serious poisoning, toxicity is
seen in the central nervous system, manifesting as drowsiness,
occasionally excitation and disorientation or coma. Occasionally
patients develop convulsions. Metabolic problems in serious
poisoning may include acidosis and an increase in INR, probably due
to interference with the actions of clotting factors in the
circulation. Liver damage is possible, but is not to be expected
without other features of significant poisoning.
Ibuprofen different salts
Ibuprofen products are most commonly available as plain
ibuprofenIbuprofen is also available in other forms in some
productsThe following few slides describe non-standard ibuprofen
products and their equivalenciesDental Pain Guidance UKMi October
201514Ibuprofen Lysine Nurofen brand Nurofen Express 342mgNurofen
Express 684mgNurofen Migraine Pain / Tension Headache 342mgNurofen
Maximum Strength Migraine Pain 684mg
Plus others Paramed Migraine Relief 342mgSuperdrug Migraine
Relief 342mgSainsbury's Migraine Relief 342mgBoots Rapid Ibuprofen
Lysine 342 mg Morrisons Migraine Relief 342mg Tesco Migraine Relief
342mg Tesco Express Pain Relief 342 mg Asda Migraine Relief 342mg
Feminax Express 342 mg
342 mg equivalent to 200 mg ibuprofen684 mg equivalent to 400 mg
ibuprofen15Dental Pain Guidance UKMi October 201515Toxbase toxicity
info as per ibuprofen 200mg and 400mg.Ibuprofen Sodium Nurofen
brand Nurofen Express 256mg256 mg equivalent to 200 mg ibuprofen512
mg equivalent to 400 mg ibuprofen16Dental Pain Guidance UKMi
October 201516Ibuprofen 300mg Sustained Release
Adults and children over 12 years: 1 capsule twice a day.
Maximum 4 capsules in 24 hoursChildren under 12 years: Not to be
givenDo not take more frequently than every 8 hoursNot to be chewed
or suckedNot the usual strength or release pattern of ibuprofen
Refer for further guidance if necessaryNurofen Back Pain 300mg SR
Capsules17Dental Pain Guidance UKMi October 2015NuromolIbuprofen
200mg with Paracetamol 500mg
Adults over 18 years: 1-2 tablets up to three times a day.
Maximum 6 tablets in any 24 hour period Under 18 years: Not to be
takenLeave at least 6 hours between doses No matter how many
tablets are taken, the paracetamol will cause toxicity before the
ibuprofen Calculate total amount of paracetamol taken18Dental Pain
Guidance UKMi October 201518Maximum 6 tablets in any 24 hour
period: 6 x 200mg is the same maximum OTC dose as for simple
ibuprofen 200mg tablets.The maximum OTC paracetamol dose is 8 x
500mg.
Table 1: List of Non-Steroidal Anti-Inflammatory Drugs
(NSAIDs)ACECLOFENAC ACEMETACIN ASPIRIN (incl. low dose)AZAPROPAZONE
CELECOXIBDEXIBUPROFEN DEXKETOPROFEN DICLOFENACETODOLACETORICOXIB
FENBUFEN FENOPROFEN FLURBIPROFENIBUPROFENINDOMETACIN
KETOPROFENKETORALACMEFENAMIC ACID MELOXICAMNABUMETONE NAPROXEN
PARECOXIBPIROXICAMPHENYLBUTAZONESALICYLATESALICYLIC ACIDSULINDAC
TENOXICAMTIAPROFENIC ACID19Dental Pain Guidance UKMi October
20151919IMPORTANT NOTE: the patient may also be taking other NSAIDS
prescribed by their GP and so adding in ibuprofen would not be
recommended.Tell the caller:The recommended OTC dose of ibuprofen
is 1 x 400mg or 2 x 200mg every 6-8 hours but no more than 3 x
400mg or 6 x 200mg (1200mg) in 24 hoursBe aware of hidden sources
of ibuprofen (e.g. in cold remedies, muscle creams)Do not take any
other anti-inflammatory medicines (NSAIDs) (except in oral gels)
when taking ibuprofen (see list of NSAIDs in Table 1)You can
restart ibuprofen provided you do not take more than 1200mg (3 x
400mg or 6 x 200mg) ibuprofen in any 24 hour
periodIbuprofen20Dental Pain Guidance UKMi October 201520CodeineAn
overdose of tablets containing codeine:Co-codamol 30/500 Co-codamol
8/500 May cause drowsiness, constipation, GI upset Severe -
respiratory depression21Dental Pain Guidance UKMi October
201521Calls involving too much of the 8/500 co-codamol ie. 8mg
codeine and 500mg paracetamol combined, would mean the patient
would reach paracetamol toxicity before the codeine level would be
a cause for concern (other than predictable side effects such as
constipation).
However, the 30/500mg combination (or any combination with more
than 8mg codeine to 500mg paracetamol) would mean that the patient
may experience codeine toxicity in addition to paracetamol toxicity
so those calls need to be referred for further guidance.
Co-analgesicsCo-Codamol = Codeine & ParacetamolAmount of
codeine in co-codamol can be 8mg, 15mg or 30mg.Co-codamol
8/500OTCCodeine 8mg & paracetamol 500mgBrands: e.g. Feminax,
Migraleve Yellow, Panadol Ultra, Paracodol, PanadeineCo-codamol
15/500POMCodeine 15mg & paracetamol 500mgBrands: e.g.
CodiparCo-codamol 30/500POMCodeine 30mg & paracetamol
500mgBrands: e.g. Kapake, Tylex, Solpadol 22Dental Pain Guidance
UKMi October 201522Co-Dydramol = Dihydrocodeine &
ParacetamolAmount of dihydrocodeine can be 7.46mg, 10mg, 20mg,
30mg.Co-dydramolOTCParacetamol 500mg, dihydrocodeine
7.46mgParamolCo-dydramolPOMParacetamol 500mg + dihydrocodeine
10mgIf no strength specified on the prescription.Co-dydramol
POMParacetamol 500mg + dihydrocodeine
20mgRemedeineCo-dydramolPOMParacetamol 500mg + dihydrocodeine
30mgRemedeine Forte23Dental Pain Guidance UKMi October
201523Co-Codamol / Co-dydramolUsesMild to moderate painLowers fever
(paracetamol alone is first choice)Side effects Codeine /
Dihydrocodeine collapse, drowsiness, confusion,
constipationParacetamol overdose150mg/kg/24hr or if risk factors,
75mg/kg/24hrCautionsKidney or liver problemsLimit use to 3 days
unless advised by doctorDrug interactionsOther paracetamol and / or
opiate containing medicinesAntidepressantsAnti-anxiety medicines /
sleeping tablets Check the patient information leaflet for advice
about other medicines24Dental Pain Guidance UKMi October
201524Guidance for restarting paracetamol following inadvertent
overdoseThis is designed to help you deal with patients who have
taken more than the recommended amount of paracetamol but less than
a toxic amount requiring referral Commonly, these patients will
want to know when they can take their next dose of paracetamol.
However we need to ensure not to restart too soon which would put
them back into an overdose situation againAdvise the patient that
they may restart such that they take no more than the maximum
recommended amount in any 24 hour period. i.e. 8 x 500mg (4000mg)
paracetamol in 24 hrsThe easiest way to do this is to use a
timeline and mark the 24 hour period. It is important to check
exactly how much has been taken and at what times
25Dental Pain Guidance UKMi October 2015Restarting guidance case
study46 years oldSymptoms of toothacheNo medical health issues, no
other medicines, no allergiesHas taken Paracetamol 500mg tablets
Friday : 08:00 - 2 tablets12:30 - 2 tablets18:00 - 2 tablets21:00 -
2 tablets23:00 - 2 tabletsSaturday: 07:00 - 2 tabletsWhen can she
take her next dose?
26Dental Pain Guidance UKMi October 2015 I have an impacted
wisdom tooth and its really hurting me. I know Ive taken some extra
doses of my painkillers today will I be ok?
Rings at 8:00 am on Sat morning.Has been avoiding seeing the
dentist.Flare up for the last 2 days.Weight 13 stone26Restarting
guidanceStep 1: Draw a timelineStep 2: Fill in the doses the
patient has takenStep 3: Find how many tablets the patient has
taken in the last 24 hoursStep 4: At 8am when the caller rings,
they have had 12 paracetamol tablets in the last 24 hours. Now you
can shift the 24 hour period along, until they are under the
recommended amount in 24 hours (the amount on the pack, which is 8
x 500mg tablets in 24 hours)Step 5: Work out how many paracetamol
tablets the patient can still have in this 24 hour period. Restart
so that there is the recommended dose interval (4 hrs for
paracetamol) since the last dose was taken
27Dental Pain Guidance UKMi October 201527Restarting guidanceDay
1 Day 2 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 1 2 3 4 5 6 7
8 9 10 11 12 13 14 15 16 17 18 19At 8:00 - 12 tablets have been
taken in the preceding 24 hours08:00 Phones Service28Step 1: Draw a
timelineStep 2: Fill in the doses the patient has takenStep 3: Find
how many tablets the patient has taken in the last 24 hoursStep 4:
At 8am when the caller rings, they have had 12 paracetamol tablets
in the last 24 hours.Now you can shift the 24 hour period along ,
until they are under the recommended amount in 24 hours (the amount
on the pack, which is 8 x 500mg tablets in 24 hours)Step 5: Work
out how many paracetamol tablets the patient can still have in this
24 hour period.Restarting guidanceDay 1 Day 2 8 9 10 11 12 13 14 15
16 17 18 19 20 21 22 23 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
18 19At 12:00 - 10 tablets have been taken in the preceding 24
hours08:00 Phones Service29Restarting guidanceDay 1 Day 2 8 9 10 11
12 13 14 15 16 17 18 19 20 21 22 23 1 2 3 4 5 6 7 8 9 10 11 12 13
14 15 16 17 18 19At 16:00 - 8 tablets have been taken in the
preceding 24 hours08:00 Phones Service30Restarting guidanceDay 1
Day 2 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 1 2 3 4 5 6 7 8
9 10 11 12 13 14 15 16 17 18 19At 18:30 - 6 tablets have been taken
in the preceding 24 hours The patient can restart paracetamol by
taking another two tablets at 18:30 hours08:00 Phones
Service31Since 18:30 on the patient had only had 6 paracetamol
tablets in this 24 hour period, so she will be able to continue
with another 2 tablets, providing she takes no more than the
recommended amount from then on e.g. take at about 11:00pm.
