Breakthrough Pain Meds ... input/insights requested.

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cogito
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Date Joined Oct 2010
Total Posts : 785
   Posted 9/18/2011 12:53 PM (GMT -6)   
Hi All,

I suppose I'm looking for some input regarding my breakthrough (BT) med use.

I've been on pain meds now for about 6 years and a combo of Ultram ER and BT meds for about 4 years.

The pain has been getting worse, the efficacy of the meds diminishing. I've worked with my PM trying some alternatives, but none turned out well. We tried switching to a low dose of Kadian vs. Ultram. That made me too sleepy. Hydromorphone doesn't work for me, oxymorphone gives me headaches and I would prefer not switching to oxycontin for various reasons, including the multiple dosing and not wanting to become tolerant to it for I use oxycodone as a BT on my worst days.

We've also tried anti-depressants to help with the pain (I'm actually very not-depressed).

So, aside from nutritional supplements (which I've added), and adjustments to my workspace (I've tried many, retained a few) the only remaining path seems to be to use my BT hydrocodone and oxycodone with greater frequency. But that worries me.

A few years ago, 7.5mg of hydrocodone had the efficacy that 10mg-15mg now does -- and a few years ago, I would only take a BT med about 2-3x per week. Now, I'm taking something roughly 5 days a week. Typically, that's 10mg of hydrocodone, perhaps 5mg more if needed. Or, if I'm in pain and it is later in the day, I'll take 5mg-7.5mg of oxycodone (though typically just once or twice a week). Thankfully, I still find 5mg of the oxycodone very helpful, and 7.5mg may even be at the edge of being too much.

That may not seem like a lot, but I feel that I'm on the brink of not being able to go a day without. Today, for instance, would be my 6th day in a row if I were to take a hydrocodone. So I'm writing this in a state of indecision. My back hurts, my hip hurts, my arm burns, etc.. I could lie down for a few hours and it will go away. Or, I could take a hydrocodone and be able to spend the afternoon active... probably at my desk writing (which is what I mostly do for my job), and/or help out my wife with some chores around the house.

This is basically what I find myself dealing with daily: I could avoid BT meds if I just lie down for a few hours, or could remain active if I can tamp down the pain. Even at this moment, the pain is at the point of it getting too hard to continue with this post.

The answer may seem obvious to some: just take the meds. But as I said, I feel I'm on the brink of a level of use I don't want to permit. Now and then, I'll have a good few days (Aug 20-26 for example, I only had to take one BT med). But more typically, I'm taking a BT meds 4-5 days in a row, then I force myself to stay in bed and not work, or take so many breaks through the day that I can't get much done (i.e. 30 minutes of work to 2 hrs in bed).

So, I suppose I'm looking for comments from those who've been at this point: is my near-daily use of BT meds trivial, worrisome, inevitable, etc..
C4-T4 Scoliosis (disk degeneration, stenosis, narrowed neuroforamen, bone spurs), RT hip and SI joint damage from car accident. Also, pectus excavatum, supraventricular tacycardia and mitral valve prolapse syndrome.
Current meds: Ultram ER 300mg daily, breakthrough - hydrocodone 10mg, or oxycodone 5-7.5mg. .25-.5mg ativan as needed for sleep, Verapamil 240mg SR (for tachycardia). [/gray

mrsm123
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Date Joined Dec 2007
Total Posts : 1102
   Posted 9/18/2011 2:51 PM (GMT -6)   
Cog,
I wind up taking my breakthrough meds daily as well simply because without them, I can't do anything. I can take them up to six times a day but keep them at three or under...
I tried all of the other, lesser modailites, I can't use a TENS unit, heat patches don't help, in fact, they can make things worse. Ice doesn't work for me at all, never has....and topical creams and ointments don't help.
What does help at times is an anti-inflammatory , have you given that a try? I take a prescription one, that does offer some relief, especially when the weather is a contributor to my increased pain levels, so if that is a contributor for you, it may help you to try that.
Other than that, I would suggest maybe alternating your breakthrough's- you said if I understood correctly that you use both hydrocodone and oxycodone? If so, maybe rotating which one you take each time may help to keep the tolerance issue at bay.
Good luck,
Sandi
Motorcycle accident 1992, Back problems from 92 to 2005. August 2005- early 2006- Chiropractor care
March 2006- consult with surgeon -PLIF/TLIF L4-5, spondylolysthesis, canal and foraminal stenosis, multiple herniations
Post Op Cauda Equina Syndrome
Revision August 2007- salvage op
March 2011- 2nd onset of Cauda Equina Syndrome
Needs surgery to prevent paralysis

mtgman
Veteran Member


Date Joined Mar 2005
Total Posts : 1277
   Posted 9/18/2011 3:08 PM (GMT -6)   
hi there. i'm kind of dealing with a similar situation except i am only on oxycodone...I've gone from 5/325 x 4 a day to 15 mg oxycodone x 6 a day. I'm pretty sure some of it is my body acclimating to the pain meds but my condition has also worsened over the past year. I'm scared as the amt of pain meds i'm taking continue to increase that when it's time to stop my body is going to be so dependant that it's going to be awful. I try to space them out, take less etc. but the pain is so consistant and bad that it's really tough to do. We're going to try the patch as soon as it cools off a bit here in AZ. i can't take oxycontin 1- because it scares me to dealth and 2- bc i have crohn's disease and my absorbtion of meds, vitamins, supplements etc. is screwy so i'd pass the pill without the benefir of all of the meds. i hope the patch works as my primary pain med and then i can lower the frequency of the oxycodone and use only as a breakthrough med. i've asked about switching meds every month or so to avert dependancy etc. but my doc said not really a good option bc i'm already taking so much oxy...
37 year old male living in AZ. Diagnosed with Crohns at age of 15.
Currently on 20 mg prednisone. still taking Asacol. Done with Remicade- antibody level was over 8! Waiting for scope results to see about Humira or Cimzia.
In the middle of a bad flare now for 2 years...it's been one heck of a ride!

spinal soldier
Veteran Member


Date Joined Dec 2009
Total Posts : 595
   Posted 9/18/2011 3:59 PM (GMT -6)   
MSIR "morphine sulfate IR", 15,30mg. codiene comes in a 60mg tab. Nucynta, transmucosal fentanyl. what has your exp. been with hydromorphone? there are a few poor generic versions and some need 8-40mg per dose. you could add D-Phenylalanine to your supp. list. it blocks the degradation of opioids. Vistaril or Phenergan are boosters along with Soma, Norflex, Clonidine. best wishes, i know there is one you will land on that works.

Blessedx8
Forum Moderator


Date Joined Aug 2008
Total Posts : 3190
   Posted 9/18/2011 4:09 PM (GMT -6)   
Cogito....

I do understand what you are saying... the whole medication issue - tolerance, dosing, etc; the whole "do I take the BT med or not?; all of it. I've been at all spectrums over the last 8+ years.

I've been on HUGE amounts of ER meds and no BT meds. I've been on the opposite, too - as I am now - not much ER meds, but plenty of BT meds to use, as needed. I'm choosing to stay on this path, because (for me), I find it easier to pull back on my BT meds (for whatever reason) vs. having to decrease my ER med (if the need every arises). Does that make any sense? lol....

Just my opinion - but, over the years, I've decided that it's just a quality of life thing for me. I, too, could probably bring my pain levels down some if I were to lie down, etc. I don't have that choice now, particularly w/ twin babies. So, in order to function, I have to take my meds. Since I don't have side effects and they DO help w/ my pain - I'm fine w/ taking them....

I do understand your concerns; yet, on the other hand, you are on pretty low doses of meds. That's a plus, even if you have to use the BT med daily. What are your main concerns? Needing more and more (an increasing tolerance)?

For me, I've gotten past that hurdle of just accepting that I DO need the medication and I use what I need. It took me a long time to get here, though. I still have times where I'm so sick of needing to take daily meds; but, when I do decrease the meds - I quickly realize the "whys" of taking them!

Oh, another thought - I also use a muscle relaxer and a nerve med - and these are just as important to controlling my pain as my narcotics. Just a thought, because you didn't mention those....

Maybe the others will have some different thoughts. Again, I do empathize w/ what you are saying... but I also think you are on such low doses, relatively - that I wouldn't be overly worried about it....

Take good care - Tina

Retired Mom
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Date Joined Feb 2010
Total Posts : 1747
   Posted 9/18/2011 4:49 PM (GMT -6)   
Hello,

I can really understand where you are with this conflict. I have really struggled with taking meds when I don't feel I "really" need them and then having to take so much when I REALLY do need them. I don't want to become so completely reliant on meds because I have seen what they can do to a family (best friend's family). My PM wants me to take my Oxy 15's 4 times a day and my Ultracet 4 times a day (exactly as written). My psych, PCP, Gastro, and even the NeuroSurgeon want me to take them as needed. It is always a very difficult decision. I try to take it as closely to written as possible, but I don't take every pill every day.....just more (so they will still work) when the pain is at its most absolute worse. There are times when it is so bad that NOTHING will give me relief. That's one of the most important reasons that I don't want to take them when I don't have to......so they will work when I need them!!!!

I wish I could help you with your decision, but I think that is a personal one. My current PM (I'm on the lookout for another right now) presents himself as easty to talk to and understanding, but then is all over the place with meds....up/down/then more for a while/then less.....then RFA's then wait a year....who knows.

I hope things work out well for you and your PM is understanding and can talk to you about what is best in this situation.

All my best!
TLIF L5-S1/failed, Pituatary disorder w/HGH deficiency, Fibro, Failed Bladder Surgery & Nissen, GERD, OCPD, GAD, MDD, CFS, TMJ, Migraines, Pre-glaucomic, HBP, Idiopatic Reactive Hypoglycemia w/Diabetic reaction to HGH, Bi-lateral CTS (surgery related trigger finger), Edema, Tarsal Tunnel Syndrome, Peripheral Neuropathy, Plantar Fascitis, Tibular Tendionitis, Adult Onset Flat Feet & much more.....

LordWood
Regular Member


Date Joined Aug 2011
Total Posts : 59
   Posted 9/18/2011 9:42 PM (GMT -6)   
Might I suggest one of the following: ~Neurontin (which because of your tolerance don't discredit it until u reach a dosage of 300mg x3 daily or more)
~Lidocaine Patches
~Fentanyl Patches
~One of the multiple different creams made by Transdermal Therapeutics (these are no ordinary creams as they have a mixture of medications in them unlike other pain creams.)
Your doctor would have to get the form from one of the representatives and together you could see which of the combos work for you.
~I know you mentioned Hydromorphone didn't work but might I ask what dosage they had you on?
Hope your able to find some relief, wishing you less painful days ahead!!!
I currently take: Cimzia 2-200mg injections, Adderall 5mg 1x daily, Vyvanse 70mg 1x daily, Dilaudid 8mg 4x daily
Health Issues: RSD, Crohns, Gastroparesis, Arthritis, Osteoporosis, Dysautonomia, & Remicade Induced Psoriasis.

cogito
Veteran Member


Date Joined Oct 2010
Total Posts : 785
   Posted 9/18/2011 10:38 PM (GMT -6)   
Thanks for all the replies. A few of the suggestions are new, some I've tried, including all the muscle relaxants out there (either make me feel terrible or don't help), standard anti-inflammatories (800mg of Ibuprofen, 500mg tylenol, etc. without any noticeable improvement), Neurontin & lyrica (woozy/dizzy-- couldn't function), lidocane patches (some help with muscle pain, but not the radicular nerve pain or hip joint pain). I've also tried Nucynta -- but that's still an opioid.

I also use heat and ice. But the ice never lasts long enough (nor can cover all the areas in pain) and the heat often makes the pain worse. I've also tried working from a recliner, but was never productive. I would end up feeling sleepy; I would also have difficulty getting at all the materials I need when I write (typically about a dozen books and/or journal articles ready to hand). Aside from hiring a carpenter to build a specialized desk multi-leveled and sloped, surrounding a zero-gravity chair (I've contemplated it!), there's no ergonomic solution that will make a significant dent.

My main reason for my original post, however, concerns the psychology of the issue and I'm having a hard time even getting clear on why it troubles me so. I'm already taking ultram ER daily -- so I've accepted the need for constant medication. So why is the idea of daily BT use so troublesome? It upsets me, but I need to gain a clearer sense of why...
C4-T4 Scoliosis (disk degeneration, stenosis, narrowed neuroforamen, bone spurs), RT hip and SI joint damage from car accident. Also, pectus excavatum, supraventricular tacycardia and mitral valve prolapse syndrome.
Current meds: Ultram ER 300mg daily, breakthrough - hydrocodone 10-15mg, or oxycodone 5-7.5mg. .25-.5mg ativan as needed for sleep, Verapamil 240mg SR (for tachycardia). [/gray

LordWood
Regular Member


Date Joined Aug 2011
Total Posts : 59
   Posted 9/18/2011 11:05 PM (GMT -6)   
Wow you are very sensitive to medications. Woozy/sleepy/bad feelings that prevent you from functioning are when a medication is to much for your body to handle, which in this case if this happens at low doses and with wide variety its going to be hard to find something to help you, thankfully your not like some that get violently ill even with low dose pain meds. At least the lidocaine patches did work for one aspect of your pain, in terms of the hip joint pain your going to need to find a arthritis med instead of a pain medication to find help with it something like Celebrex. Nerve pain is hard to treat so hopefully with some of the new suggestions you might be able to find something I severely hope you can instead of ending up like some of us that are basically told to live with our pain after all options of meds and treatments fail. Wishing you the best of luck and keep us posted!!
I currently take: Cimzia 2-200mg injections, Adderall 5mg 1x daily, Vyvanse 70mg 1x daily, Dilaudid 8mg 4x daily
Health Issues: RSD, Crohns, Gastroparesis, Arthritis, Osteoporosis, Dysautonomia, & Remicade Induced Psoriasis.

cogito
Veteran Member


Date Joined Oct 2010
Total Posts : 785
   Posted 9/19/2011 10:21 AM (GMT -6)   
Lordwood, your "Wow you are very sensitive to medications" reads as sarcastic, but you might not have intended it so. Flexeril, Skelaxin, Lyrica, Neurontin, etc. have resulted in some side effects that are pretty common according to their labels. I've tried Neurontin for as much as a month, hoping that over time the side effects would subside, but the wooziness (sort of like feeling drunk -- in a bad way) never went away.

However, I do think that I am quite sensitive to many classes medications. Another example is that when I tried Savella this summer, I couldn't even make it to the full dose in the titration pack as the side effects (cloudiness, feeling like my head was going to explode, complete constipation for 5 days, etc.) were too much for me.

Even opioids, after all these years... I can't 20mg of hydrocodone over the day, or 10mg of oxycodone without feeling too drugged that day and very crappy the next day. Likewise, a low dose of Kadian, when I tried that (I forget the dose now), just knocked me out.

So perhaps I should count myself lucky for now, at least, since I can manage the pain with fairly small doses of BT meds.... and one of my main worries is that daily use will far more quickly lead to greater tolerance. This may not be scientifically accurate, but I've thought that if I can have frequent days where I don't take any BT meds, the biochemical causes of tolerance will not get established (downregulation of receptors, etc.).

I think that's why I feel I'm at the cusp of a significant change in my opioid use. The frequency and intensity of pain is drawing me to a daily use, but in the past, I've been comforted by being able to have many days where I didn't use any BT meds. Those days have gotten fewer and fewer and are at the brink of vanishing.
C4-T4 Scoliosis (disk degeneration, stenosis, narrowed neuroforamen, bone spurs), RT hip and SI joint damage from car accident. Also, pectus excavatum, supraventricular tacycardia and mitral valve prolapse syndrome.
Current meds: Ultram ER 300mg daily, breakthrough - hydrocodone 10-15mg, or oxycodone 5-7.5mg. .25-.5mg ativan as needed for sleep, Verapamil 240mg SR (for tachycardia). [/gray

Heather Lynn
Regular Member


Date Joined May 2011
Total Posts : 283
   Posted 9/19/2011 12:23 PM (GMT -6)   
I think there is very much a psychological difference between occasional use of BT meds and daily use. Have you talked to your doctor about your concerns about using more BT meds? I remember from past posts, your doctor wants to give you more aggressive pain management but you generally have chosen not to go for more heavy-duty meds.

I know I personally don't like to feel "dependent" on meds. Unfortunately, physical dependence is a natural result of taking opiod painkillers, and there's not really anything you can do about it. I understand your hesitation, but I believe your hesitation/resistance to more pain medication is probably making you suffer more than is necessary.

Have you tried Cymbalta or amitriptyline? They may help take the edge off the pain and are non-narcotic.

You might seriously consider setting up a custom ergonomic solution. I used to suffer from upper back pain and devised a system where I could sit in my recliner and work. It made a HUGE difference in my quality of life. For me, sitting at a regular desk was the biggest aggravating factor for my pain, so avoiding it really changed my daily pain levels. Maybe a pivoting over bed table or two could hold the rest of your work?
Fibromyalgia, low back pain/SI joint dysfunction, anxiety, obstructive sleep apnea, endometriosis, asthma

cogito
Veteran Member


Date Joined Oct 2010
Total Posts : 785
   Posted 9/19/2011 1:08 PM (GMT -6)   
Hi Heather,


You remember correctly that I've declined many of my PM's recommendations, trying to find something other than more opioids. Regarding amitriptyline, I can't use tricyclics for heart reasons. I brought up Cymbalta last visit, but he thought that given my reaction to Savella, I should probably stay away from the SNRI's (I'm not persuaded, though).

As for ergonomic solutions, I have my eye on a zero gravity chair, but I'd need a custom desk built. I have the $ for such things, but I wouldn't want to spend it unless I am quite sure it would work. As an experiment, I brought my recliner up to my desk and got boxes, etc. to simulate surrounding desk space. That didn't work, however. I was always sleepy and couldn't get myself to focus. I might give it another go, with a less comfy chair, however.

It is now 2pm here and I decided to spend the day differently than usual. I told my wife to leave me with the grocery list and I'd do the shopping. So, after my morning coffee and emails, I headed out. By the time I returned to my car, my hip hurt from pushing the heavy cart (VERY full)... but still not too bad. I decided to buy some lamb (my favorite, but my wife rarely buys it). So, when I got home I prepared the marinade. That meant doing something extremely painful for me, leaning forward. I do what I can to stand over the counter in ways that alter my posture, but still, 20 minutes of measuring, chopping, etc. brought my pain to around a 6. Yet there's now a nice dinner in the fridge: pepper, garlic, and dijon leg of lamb; rosemary garlic red potatoes; salted squash. The potatoes will be baked. The rest, grilled.

I'm off now to lie down with some ice. No pain meds for me today... mid way through chapter two of my book... but it will just have to wait.
C4-T4 Scoliosis (disk degeneration, stenosis, narrowed neuroforamen, bone spurs), RT hip and SI joint damage from car accident. Also, pectus excavatum, supraventricular tacycardia and mitral valve prolapse syndrome.
Current meds: Ultram ER 300mg daily, breakthrough - hydrocodone 10-15mg, or oxycodone 5-7.5mg. .25-.5mg ativan as needed for sleep, Verapamil 240mg SR (for tachycardia). [/gray

LordWood
Regular Member


Date Joined Aug 2011
Total Posts : 59
   Posted 9/20/2011 12:30 AM (GMT -6)   
Cogito my reply to you in which started with "wow you are very sensitive..." is in no way being sarcastic which if you read my reply it is clear to see that. Its simply stating the fact that you are very sensitive to medications which is very unfortunate. I can see from your attitude that my attempt to simply suggest options and try to help you is not appreciated, in which I apologize for posting at all.
I currently take: Cimzia 2-200mg injections, Adderall 5mg 1x daily, Vyvanse 70mg 1x daily, Dilaudid 8mg 4x daily
Health Issues: RSD, Crohns, Gastroparesis, Arthritis, Osteoporosis, Dysautonomia, & Remicade Induced Psoriasis.

Heather Lynn
Regular Member


Date Joined May 2011
Total Posts : 283
   Posted 9/20/2011 11:59 AM (GMT -6)   
Totally anecdotal, but I was a basket case on Effexor (an SNRI) and have been fine on Cymbalta. If you were to try it, you'd need to start low and go slow. It only comes in 30mg and 60 mg capsules though - not sure if they can be broken open for slower titrating.
Fibromyalgia, low back pain/SI joint dysfunction, anxiety, obstructive sleep apnea, endometriosis, asthma

Screaming Eagle
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Date Joined Sep 2009
Total Posts : 4964
   Posted 9/20/2011 12:55 PM (GMT -6)   
 
 
            I believe Cymbalta comes in 20mg ....30mg....and 60mg...and no.. you are not to break it up. This comes from their website. So far it has done me a good job like it has for Heather. I have been able to reduce my BT med's, and now take them only when needed as BT,... instead of a regular schedule like I was before.
 
       SE wink
Moderator Chronic Pain Forum

Weekly Quote!

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Post Edited (Screaming Eagle) : 9/20/2011 1:08:12 PM (GMT-6)


cogito
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Date Joined Oct 2010
Total Posts : 785
   Posted 9/21/2011 10:31 AM (GMT -6)   
Lordwood,
I probably should have kept my reaction to myself, but I did note that your comment may not have been intended as it seemed to me... anyhow, sorry.

On the issue of Cymbalta,

It seems like a very reasonable move for me. But when I brought it up with my PM, he rejected it. about 3 visits ago, I briefly discussed it with his PA, who seemed amenable to the idea, but suggested we try wellbutrin first, then we went on to Sevilla. After both of those failed, I assumed we would try Cymbalta, but my PM said no.

Something was also off with him that day -- he looked very tired and disheveled. I think he wasn't in the mood that day to think about anything and so other than repeat scripts for existing meds, he didn't want to do anything. So I'm actually hoping I see the PA next time, who likes to ask me about my work and to tell me about the chemistry behind the meds. He's always more chatty and so we can toss around options. My appointment is in less than a month.

Nevertheless, there is both a practical issue and a psychological issue I am concerned with. Most of the thread has responded to the practical -- what else I can do other than BT meds. But bear in mind that I've been going through just about every alternative for years now and aside from chasing a few options that have been missed (or overruled by my PM), my deeper concern is the psychological issue: living with a level of chronic pain that forces me to choose between (a) medications that the more I use them, the less effective they will be; (b) not doing what I find fulfilling. At least until my next appointment, and possibly after it as well, that's my dilemma.

Post Edited (cogito) : 9/21/2011 12:35:45 PM (GMT-6)


yellowness
New Member


Date Joined Sep 2011
Total Posts : 1
   Posted 9/21/2011 8:20 PM (GMT -6)   
Hi cogito - New member here who found the site while looking for info on the Butrans Patch, which I literally just started (seriously? I can't have a beer after a long day at work? *sigh*). I'm on some less strong medications than you are - my docs and I have narrowly avoided opiates thus far (and the Butrans sort of rules them out at this point), but I have a combination of extended release and break through meds as well.

And let me tell you - I *hated* taking my break through meds. My tendency was to wait until I was significantly in pain during the day before taking them. So I'd wake up, begin to ache, then the pain would increasingly flare until I'd finally give in and take something more - and by the time I did, often the BT meds weren't quite enough to fully help. They'd just be playing catch up to pain I'd put myself in. I'd still end up suffering through my day at work...

And my docs questioned me about this closely; why wouldn't I take my medication? It was there to take to help keep me from being in pain, so that I could live and function like a normal human. My pain psychiatrist gently scolded me and pointed out that by putting myself through this, I was putting my body through more tension, more stress, and more of the things they were working to avoid - not to mention dumping chemicals like cortisol in my system which was just making it worse. The docs started to try to regulate my medicine intake by having me break my meds in half and take some on a schedule to try to make it seem less threatening, then taking more on an as needed, break through basis. I resented the heck out of them for it though... I still didn't want to be taking all the drugs all the time.

As my pain began to decrease, I began to get more used to the idea though. I'm at a point now where the medications I'm on are no longer effective enough, so we're trying the Butrans patch, but I absolutely understand the hesitancy in taking BT meds all the time. If I had to add in the fact that they were opiates (with all the valid concerns that go along with them)... I would have fought taking more kicking and screaming. It took a lot of talking to my doctors and thinking about things to come to the decision that living with less pain had to be a priority, and taking medication with the help of my doctors to do it as safely as possible, along with all the exercise and all that, was one important way to live in less pain.

Sorry for the novel... but a lot came up when I read your question. I have a lot of sympathy for your questions and situation, and know I'll in the same boat again myself at some point. Be well, and take care of yourself!

Mysti
Regular Member


Date Joined Jul 2011
Total Posts : 101
   Posted 9/22/2011 8:58 AM (GMT -6)   
Hi Cogito,
Many here have given you well-intended advice of different meds to try, but I know you've tried them all and been there and done that...so I'm not going there....and really, when it comes down to it, it's not like we can pick and choose freely what we want to try...the docs have to agree and write the rx. 
 
I've noted that you have multiple times said that this is more of a "psychological" issue with you.  I get the sense that you are in a struggle with, perhaps, a stigma regarding the use of opiate painkillers and other meds....and feeling like this is a moral issue because of the social stigma that is out there.  Or maybe you just don't want to "give in" and take these break-thru meds because it makes you feel "weak" as a person.  I hope I'm not missing the mark here, but I'm only suggesting this because I feel that way, too, and for me, this whole chronic pain thing is somewhat new to me...and I am trying to find my way.
 
I have to admit that one of the reasons I sought out a chronic pain forum is because I felt I couldn't talk to my family about the use of narcotic meds.  The subject has long been an issue in our family...for various reasons (brother got in trouble with the law years ago on drug charges; grandmother had serious chronic pain issues and literally had a "pharmacy" in her house.  She, sadly, actually died of a prescription drug overdose)  So it's an issue that my family has swept under the rug and nobody talks about.  I know, completely dysfunctional, to say the least...but my point is, I do understand the "psychological" issue you may be speaking of here.
 
Sorry to be rambling on about my personal issues, but one thing I do know for certain (as working as a nurse for many years) that the reason we ALL have to increase the dosages on our meds is because of the completely NORMAL tolerance to these drugs.  So that's just a given there and we cannot change that.  With that in mind, I believe it is simply going to have to be a personal decision you are going to have to make.  Break-thru meds have been incorporated into pain management for a reason:  they work.  So if they are helping you...and you have a better quality of life...you have the choice to either use them (and that includes working with your dr. and increase them as needed) or not use them and relent to the pain.
 
Personally, I have decided to use them, but I still have hang-ups about discussing them with anyone.  I hope you find some peace with this struggle and feel better soon.  Take care...
DDD, 3 bulging lumbar discs, bone spurs, facet joint arthrosis/sclerosis, osteoarthritis, possible fibromyalgia (my dr's are telling me that I "most likely" have fibro but won't actually diagnose it...)

cogito
Veteran Member


Date Joined Oct 2010
Total Posts : 785
   Posted 9/22/2011 9:09 AM (GMT -6)   
Hi yellowness,

Welcome to the board. You might want to begin your own thread to introduce yourself. Other members would likely want to welcome you and those in a similar boat would appreciate your telling your tale.

I appreciate your response to my situation. I just looked up Butrans Patch and Buprenorphine. If it alone can manage my pain, it seems a possible option. I think the non-opioid side of the Ultram has been beneficial and I would like to keep using it, if only I could find a way to augment it without BT meds. I suspect I couldn't use it along with the Butrans Patch.

If all else fails, I might address this with my PM, but I suspect that this is one of those precarious conversations for it is also used for opioid addiction and I don't want my PM to think I'm subtly hinting that I have an abuse concern. Maybe I'll bring it up with my GP who actually has a suboxone practice in addition to his routine patients.
C4-T4 Scoliosis (disk degeneration, stenosis, narrowed neuroforamen, bone spurs), RT hip and SI joint damage from car accident. Also, pectus excavatum, supraventricular tacycardia and mitral valve prolapse syndrome.
Current meds: Ultram ER 300mg daily, breakthrough - hydrocodone 10-15mg, or oxycodone 5-7.5mg. .25-.5mg ativan as needed for sleep, Verapamil 240mg SR (for tachycardia). [/gray

Zap2
Regular Member


Date Joined Oct 2010
Total Posts : 20
   Posted 10/5/2011 12:38 PM (GMT -6)   
It sounds to me you're being careful with the BT meds, but at some point, you do need them. Constantly increasing dosages is something we all have to deal with(if we're on medicines which we grow a tolerance to), six years is quite a while and I think your responsible usage helped you get through not having to increase you dosage tons. I wouldn't be overly concerned with using your breakthrough medicines, just be open with your doctor about when you use them and ask if he/she thinks that amount is ok. At one point I was using Vicodin at the maximum amount prescribed for breakthrough medicine and I told my doctor I could feel it being less effective, she told me she didn't want to just keep increasing my dose as that's just going to lead to a cycle, so she came up with adding a new daily medicine, so my BT wouldn't be needed and it worked for a while. But after a while, I started needing the BT medicine so she re-prescribed them to me. It's a balancing act, one that you and your doctor have to do as a team, we don't have their training and they don't know exactly how things are effecting us unless we talk with them.

Maybe it's time to work on your daily medicine so your break through medicines aren't needed as much? I saw you tried some other medicines but the side effects turned you off, but now you're tolerance is higher so maybe medicines you've tried in the past will be better not. Also another medicine you could try is Butran patches, they might help.

cogito
Veteran Member


Date Joined Oct 2010
Total Posts : 785
   Posted 10/7/2011 8:35 AM (GMT -6)   
Hi Zap2,

I've been away for a couple of days and just saw your response.

I see my PM in just over a week and what to discuss with him is very much on my mind.

Yesterday, I had a conversation with my closest friend, who also suffers from CP plus has severe RLS. He has been taking hydrocodone for years, though recently has started tramadol and goes back and forth between them. He is also fortunate to have something of an insider's relationship with his PM as he is on a number of hospital boards, teaches at a medical school, and is otherwise "connected". He's not an MD, but a JD consultant for the medical community.

He emphasized to me how paranoid PM's are and, sadly, how careful patients must be in what they say to their PMs. I told my friend that as I have been migrating to near daily use of BT meds, if I have a fairly good day and don't take one, I'll feel a bit of withdrawal (cold sweat, fatigue). To my surprise, he told be I absolutely should NOT tell my PM that for the PM will then pull BT meds. He didn't quite say it explicitly, but I think he meant that the PM would be afraid I would sue him, accusing him of getting me addicted. He might be right, or as an attorney, generally advises extreme caution.

But I do need to talk to my PM about my increased level of use. Since my PM doesn't seem to want to add an anti-d (Cymbalta, etc.), and I don't want to give up ultram (as its SNRI effects have, I think, been very beneficial), what I'm now considering is keeping the ultram and adding to it a minimal dose of some other time-release opioid.

My PM had me try 30mg Kadian earlier in the year, and I have in mind something equivalent to about 1/3 of that. So if he goes for it, I'll be taking 300mg of Ultram + something equivalent to 10mg of Kadian.

I will do some research to see what time-release options there are which equal to 10mg of morphine over 24hrs.

If anyone had some ideas, please let me know.
C4-T4 Scoliosis (disk degeneration, stenosis, narrowed neuroforamen, bone spurs), RT hip and SI joint damage from car accident. Also, pectus excavatum, supraventricular tacycardia and mitral valve prolapse syndrome.
Current meds: Ultram ER 300mg daily, breakthrough - hydrocodone 10-15mg, or oxycodone 5-7.5mg. .25-.5mg ativan as needed for sleep, Verapamil 240mg SR (for tachycardia). [/gray

Heather Lynn
Regular Member


Date Joined May 2011
Total Posts : 283
   Posted 10/7/2011 10:07 AM (GMT -6)   
Hey cogito,

I think you can safely talk to your PM about needing to take more meds for adequate pain control without mentioning the withdrawal. I do think something long-acting sounds like a good idea.

Your controlled-release dose should be based on the average amount of BT you are taking to control the pain right now. The lowest doses of CR meds are usually equivalent to about 20 mg of morphine, which is equivalent to 10 mg of oxycodone or 20 mg of hydrocodone. The 300 mg of tramodol you take are roughly equivalent to another 15-30 mg of morphine, so it might be easier to get the dosing right if you were to come off the tramodol and use something else for the norepinephrine effect.

I hope you are able to find something with your PM that works. Also, I would make sure to give your body a week or two to make the adjustment to a new medication, and understand that your functioning might be off for a few days. Usually the initial side effects/weird feelings subside.
Fibromyalgia, low back pain/SI joint dysfunction, anxiety, obstructive sleep apnea, endometriosis, asthma

Medicalkid2
Regular Member


Date Joined Oct 2010
Total Posts : 147
   Posted 10/8/2011 11:18 AM (GMT -6)   
OxyContin will increased your tolerance to oxycodone as well as oxymorphone as oxymorphone is simply put the end product of oxycodone..either way pain meds all have cross tolerance and its inevitable. If OxyContin works and you need multiple dosing then do it...for me their is no inconvenience of pain relief...sure I don't like pulling out a bottle of hydrocodone and taking it in front of people but then again its none of their business and I have a valid script...(I never carry an entire supply in one bottle though, older lady I met said she would put a days worth of pills in an old bottle so as to make it look like she didn't take them allot).

Back to tolerance though..what long term pain patients have to do sometimes is opioid rotation; they will take something like OxyContin for 3 months then switch to HydromorphContin or MS Contin...the cross tolerance with opioids isn't perfect so this can actually keep tolerance down...it's had some pretty good success and I bet if you mentioned it you might spark some interest and pain relief from your doc. I try and help out since it detracts from my discomfort so I hope this helps! :)
C6 Herniation, gen. nerve pain, Crohns, Anxiety, Aspergers, and Mild Insomnia.
-Adderall XR 30mg am, Hydrocodone 5mg 2x daily, Skelaxin 800mg 3x daily, Klonopin 1mg night, Zoloft 100mg night, and Naproxen 550mg am/prn. It could be worse :)

cogito
Veteran Member


Date Joined Oct 2010
Total Posts : 785
   Posted 10/8/2011 12:11 PM (GMT -6)   
Thanks for your thoughts Heather Medicalkid.

Given how weird my PM was during the last visit, I'm somewhat anxious about my appointment next week.

But now, as I finally think I have a GP worth having, if something goes awry with my current PM, my GP will be able to get me into another.
C4-T4 Scoliosis (disk degeneration, stenosis, narrowed neuroforamen, bone spurs), RT hip and SI joint damage from car accident. Also, pectus excavatum, supraventricular tacycardia and mitral valve prolapse syndrome.
Current meds: Ultram ER 300mg daily, breakthrough - hydrocodone 10-15mg, or oxycodone 5-7.5mg. .25-.5mg ativan as needed for sleep, Verapamil 240mg SR (for tachycardia). [/gray
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