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analgesic dosing, rather than “as needed.” o Post-procedural analgesic selection should be guided by procedure type, amount and duration of trauma, underlying cause of pain, and expected pain scores. o General recommendations below are based on current literature and availability of formulations / dosages of NSAIDs and APAP at IHS and Tribal facilities. They do not take patient’s individual medical conditions into account: 6 Ø MILD PAIN: NSAIDs (e.g. ibuprofen 400 mg q6h) or acetaminophen (325 - 500 mg q6h) should be utilized as the first line analgesic for unless contraindicated. Ø MODERATE PAIN: NSAIDs (e.g. ibuprofen 400-800 mg q6h) + acetaminophen (500-650 mg q6h or 1,000 mg q8h) should be utilized as the first line analgesic unless contraindicated. Ø SEVERE PAIN: NSAIDs (e.g. ibuprofen 400-800 mg q6h) + acetaminophen (325 mg q6h) + low dose opioid (e.g. hydrocodone/acetaminophen 5/325 mg q6h) should be utilized as the first line analgesic unless contraindicated. The opioid prescription should generally be limited to three days, unless indicated by significant trauma and/or infection. Recommendations for Prescribing for Special Populations: • Pre-operative pain management: o Pre-operative NSAIDs should be used with extreme caution in patients with clotting disorders or taking anticoagulants. Standard precautions and contraindications regarding NSAIDs, as outlined below, should also be followed. o Consider the use of an antiseptic mouthrinse without alcohol in patients with a history of substance use disorder to prevent relapse. • Pre-operative or post-operative pain management: o Long-lasting anesthetics must be used with caution in patients where overall epinephrine use must be reduced due to systemic conditions such as: § Heart disease (e.g. arteriosclerotic heart disease, cerebral vascular insufficiency, heart block, hypertension, and use of blood pressure medications or vasopressors) § Hyperthyroidism § Seizures § Severe liver disease § History of aneurysm or stroke § Medication use (e.g. corticosteroids, MAOIs, Maprotilline, sedatives, and tricyclic antidepressants) • Post-operative pain management: o Consider prescribing an antiseptic mouthwash without alcohol in patients with a history of substance use disorder to prevent relapse, if indicated. Allergy & Drug Intolerance 47 o True medication allergies are caused by an immune response to a medication. Symptoms include rash, hives, or more severe symptoms such as anaphylaxis. For true medication allergies, agents from the same drug class should be avoided. o Other reactions, such as generalized flushing, sweating, nausea, vomiting, and upset stomach, are considered pseudo-allergies or drug intolerances and can often be avoided if the medication is taken with food or by selecting an alternative agent in the same drug class. o If a patient has multiple drug intolerances to analgesics being considered for post-operative pain management, consider the following: • How severe was the drug intolerance? • Has the patient previously tolerated other medications in the same class? • Can a medication, such as a PPI, be prescribed to alleviate or minimize side-effects? 7 Anticoagulant Use o Scheduled acetaminophen should be considered first line for mild post-operative pain and preoperative pain control. o Avoid pre-operative NSAIDs. o If low-dose daily aspirin (81 mg) is the only anticoagulant / antiplatelet medication the patient is taking, make sure the aspirin is