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Baileysmom
Regular Member


Date Joined Mar 2012
Total Posts : 21
   Posted 3/25/2012 1:55 PM (GMT -7)   
Hey guys.
So I'm preparing myself for another lumbar steroid injection, which I hope wil help with pain, since according to the neurosurgeon, I have nothing surgical to repair. I'm just kind of supposed to live like this because my herniation was so bad that they think it might take years to recover, if ever. It was repaired May 2011.
Anyway, I have a Rx for Lortab, which I take pretty sparingly, neurontin, which I also take sparingly because it makes me dizzy. Lots of Ibu 800mg.
I do all the usual things to help: ice, tens, PT, Chiro, stretching.
To make a long story short: I recently started a trial of Nucynta 100mg which seems to help the most.
I know it's chemical similar to tramadol, which I really don't like. Plus, because I take Cymbalta 90mg, and I worry about seratonin syndrome.
I see mt first pm doctor next week, and I know we'll do the injection.
My question is, how do you guys bring up the idea of taking meds in addition to the injection? In TX, it's gotten ridiculous about docs Rx pain medication. I mean, it sounds counterintuitive to me that pain docs don't want to Rx meds and just do procedures. I know it's all about the $$$, but I think there needs to be a reality check. I'm willing to do whatever it takes to get better, whatever procedure they want me to do.

Ok so the two questions: how do you approach pm about meds in addition to doing procedures?
Second, what has been y'all experience with Nucynta? I know they have an ER version. Any difference?

Thanks for being so supportive and I hope everyone is having a relatively pain free day!
L5-S1 microdiscectomy 5/11; right ulnar nerve transposition repair 3/11
MRI 3/12: C4-C7 disc bulge, C5-6 broad bulge with cord effacement
MRI 3/12: L3-L4 disc bulge, L4-L5 diffuse annular disc bulge with bilateral foraminal narrowing, L5-S1 laminotomy defect with granulation tissue surrounding L S1 nerve root. Disc bulge to bilateral foramen. Impingement of L5 nerve root.

sjkly
Veteran Member


Date Joined Dec 2007
Total Posts : 2113
   Posted 3/25/2012 5:38 PM (GMT -7)   
Sounds like you have had at least one injection before. So the conversation (if it were me) would go something like this.

I am in X amount of pain on most days, on some days it goes up to XX. Pain interferes with these things that I would like to be able to do. In addition to the lumbar injections I have tried.... This helps the most, with this being next most helpful. I tried ....but it didn't seem to make a difference.
What would you suggest, in addition to the lumbar injections to help me get my pain to Y level so that I can enjoy a reasonably normal life?

cogito
Veteran Member


Date Joined Oct 2010
Total Posts : 836
   Posted 3/25/2012 6:34 PM (GMT -7)   
As for approaching the PM about meds vs. injections, I'm not sure what advice to give. It depends quite a bit about your medical history and the nature of the practice. But you can discuss what you would like to be able to do (work, sit, go for walks, etc.) and what the PM can offer to help you restore more quality of life. You can also find a PM that specializes in or exclusively deals with meds. In my case, I have one who does, and I see a different PM for injections.

Regarding Nucynta, though it is suppose to be similar to Tramadol, I find them very different in effects. Tramadol tends to activate me and when I first started using it, kept me up. Nucynta, on the other hand, makes me groggy. For pain, I haven't found either as effective as Hydrococone or Oxycodone.

As for the new ER option, it surely will be pricey, but so is Nucynta.
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 & 2-3x 10mg Hydrocodone daily. Oxycodone 10mg for BT. .25-.5mg xanax as needed for sleep, Verapamil 240mg SR (for tachycardia). [/gray

Screaming Eagle
Forum Moderator


Date Joined Sep 2009
Total Posts : 4996
   Posted 3/25/2012 6:58 PM (GMT -7)   
Baileysmom….generally…if a PM gives injections (Epidurals)…I doubt they will script out pain med's at the same time, as they will want to see the results based solely on the injection first. They may also want to do a series of three first as well. Then, if there are no positive results from the injections….they can review other options at that time, which may include scripting pain med's according to your pain relief needs.

My only advice would be that if you are indeed scripted pain med's because the Epidural's failed to bring about relief to you….stay on the lowest does possible, but enough to give you some sort of quality of life. Pain med's do have their own set problems as well. I personally have hated having to be on them.

Good luck!

SE wink
Moderator Chronic Pain Forum

Weekly Quote!

"Getting over a painful experience is much like crossing monkey bars. You have to let go at some point in order to move forward."

Post Edited (Screaming Eagle) : 3/25/2012 7:05:11 PM (GMT-6)


Snowbunny21
Veteran Member


Date Joined Jan 2010
Total Posts : 3557
   Posted 3/25/2012 8:39 PM (GMT -7)   
You definitely have room to tirate up on the Nucynta if needed. Is it just 100mg for the day? or per dose?

And how many of the Lortab are you adding in per day for BT pain?

I would think it might be a bit easier for you to talk with the Dr. as you are in the medical field yourself...So you know their ways of asking the right questions..

For my Dr. I've known him so long that he can tell just by looking at me if it's been a good week/day or not.

So hopefully you all can discuss the follow up for the Nucynta and let him know how it's working and if it needs going up more...

Have you tried Lyrica before since you say the Neurontin makes you dizzy? I had that side effect for the first few weeks but it went away....I would think being on a good nerve pain medication should help some as well.

What about any type of muscle relaxer? Have they offered or talked about this?

I hope the injection offers some relief too....As you know...it's really about adding all these things together to keep the pain at a 5-6 level....that it's never going to be just a magic pill...(We all wish for this! LOL)...

And maybe they can suggest some more therapies like aqua therapy, massage, acupuncture, stretching bands, yoga....

I wish you luck!

Post Edited (Snowbunny21) : 3/25/2012 9:08:13 PM (GMT-6)


Blessedx8
Veteran Member


Date Joined Aug 2008
Total Posts : 3193
   Posted 3/25/2012 8:41 PM (GMT -7)   
Baileysmom,

I hope your injections will help w/ the pain..... I've had some that DO help; and others that didn't seem to do anything. It's been a hit or miss for me.

Aren't you a PA? Maybe your connections might help you find a good PM doctor. My PM doctor does both - meds and procedures. I've been on meds from the beginning w/ him... and, when I need a procedure (injections... he did the pain pump trial w/ me, etc).. I do that with him as well.

The way I would approach pain meds is simply being upfront and honest. Listing out the things you are currently doing. Letting them know your pain isn't covered....

I've been on about every pain med out there; but I haven't tried the Nucynta. I was already on high doses of other stuff, by the time they were using that med. I sure hope it works for you.

Let us know how your PM appointment goes - and how the med works for you. Take good care.
--Tina
Moderator - Chronic Pain Forum

My faith and family sustain me even on my worst days... as well as my wonderful friends here at HW.

Health/Pain Issues - too many to list; feel free to ask

Screaming Eagle
Forum Moderator


Date Joined Sep 2009
Total Posts : 4996
   Posted 3/25/2012 10:38 PM (GMT -7)   
Baileysmom….I do have a question for you. I see you are on neurontin! …and see that you are using it sparingly? If you don't mind…what dose are you on. and how often do you take it? My PCD started me on it a couple of weeks ago at 300mg x4…..does this sound like too much…..and should I be using it sparingly as well? I hate taking med's…..but am hoping that it will help with any nerve damage that I have.

I figure as a PA you might have some insight about this med…..and I would be grateful for your thoughts on it. smilewinkgrin

Thanks!

SE wink
Moderator Chronic Pain Forum

Weekly Quote!

"Getting over a painful experience is much like crossing monkey bars. You have to let go at some point in order to move forward."

rjbeck
Regular Member


Date Joined Feb 2008
Total Posts : 241
   Posted 3/26/2012 1:41 AM (GMT -7)   
this is about the Nucynta. I use methadone 45mg's BID for my long term pain med..Then I use 15mg Oxycodone for a break thru med 1 pill 4x's daily and I use the Nucynta 100mg's-1-pill 3x's daily... Depending how I feel I will use 2 of the oxy's and 1-nucynta together for break thru and this works very well, And if I am having a real bad time I will use 2-oxy's and 2-nucynta's together and that works very well.. My PM Doc told me to try the break-thru med's in different combinations for the best relief. This was after I knew that the Nucynta didn't have any adverse affects... Feel better. Hope this helps...
AVASCULAR-NECROSIS (AVN) in 6 joints. HIPS,KNEE'S and SHOULDERS-Replaced RT shoulder.Left hip 2011
Bilateral Empyema-Thoracotomy with Decordication.(Removed the Lining of left lung)Bilat Pneumothorax (2005-2008)
COPD.
MED'S-methadone 45mg's Bid---oxycodone 30mg's Bid--nucynta 100mg-Prn
Former Respiratory Therapist/Perfusionist

CoralToe
Regular Member


Date Joined Oct 2011
Total Posts : 24
   Posted 3/26/2012 2:46 PM (GMT -7)   
Thought I would post my experiences on Nucynta. When I first started pain management in Oct of 2010, I had been on 30mg oxycodone every 6hrs, and had very little (if any) pain relief. The first thing my pain management doc tried me on was Nucynta IR, 100mg 4x a day.....It worked unbelievably well! Last fall, when Nucynta ER came out, I switched over to that. I am on the max dose (250mg every 12 hour), and it still works great. It took me about 1 month on Nucynta before some of the side effects went away (they weren't really horrible to begin with anyway), and it has really helped me to keep working. Hope that Nucynta keeps working for you!

Baileysmom
Regular Member


Date Joined Mar 2012
Total Posts : 21
   Posted 3/26/2012 8:07 PM (GMT -7)   
Hey guys.
First, thanks for your replies and kindness.
I take maybe one lortab a day, in the evening, since y'all know I'm a PA and can't really take anything at work. Well, I can take tramadol at work, but for some reason it just doesn't do much for me. The lortab is ok, but it kind of makes me feel stoned, you know? The thing that really stood about the nucynta is that it was activating for me. I actually went out and walked my dog (that's Bailey) and we went swimming! Usually I just lay around on the weekends, thinking about the life I used to live a few years ago. I got stuff done around the house! I mean, this sounds so silly and basic, but I know y'all understand.
I think I took max 200mg total in one day. I have zanaflex and have tried flexeril and soma, but the soma just knocks me out and flexeril does nothing for me, for some reason, though I write a lot of it for patients.
I am Rx neurontin 300mg TID, but I usually just take one when it gets bad. I know better than to take it like that, as you really need to take it three times a day. I have some folks that are on 1200mg TID! And that's an acceptable dose.
You're right though, I should take something for nerve pain.
I guess I'm just nervous about going through the steroid injection process and knowing that it's hit or miss, I do want to have some medication option as a back up.
I asked one of my colleagues today about the good PM guys in our area and he called the lot of them "useless" because all they want to do is procedures and not med management. And it falls back to primary care, when we don't have the specialized knowledge of meds like they do.
Catch 22.
Thanks guys.
L5-S1 microdiscectomy 5/11; right ulnar nerve transposition repair 3/11
MRI 3/12: C4-C7 disc bulge, C5-6 broad bulge with cord effacement
MRI 3/12: L3-L4 disc bulge, L4-L5 diffuse annular disc bulge with bilateral foraminal narrowing, L5-S1 laminotomy defect with granulation tissue surrounding L S1 nerve root. Disc bulge to bilateral foramen. Impingement of L5 nerve root.

Blessedx8
Veteran Member


Date Joined Aug 2008
Total Posts : 3193
   Posted 3/26/2012 9:51 PM (GMT -7)   
Baileysmom,

I hope you can find something that works for you.... I don't know about medication making you feel "stoned" - I wish I even felt my pain meds work.....

--Tina
Moderator - Chronic Pain Forum

My faith and family sustain me even on my worst days... as well as my wonderful friends here at HW.

Health/Pain Issues - too many to list; feel free to ask

CoralToe
Regular Member


Date Joined Oct 2011
Total Posts : 24
   Posted 3/26/2012 11:47 PM (GMT -7)   
@ Baileysmom....I totally understand not wanting to take meds that fog your mind at work. I am a researcher at a cancer center - so have a similar situation. Up until I started pain management, I had nothing I could take during the day, and thus ended up in agony by around 3 or 4pm each day. I remember my first pain doc appt - all I asked for was better control of pain at night so that I could sleep. She agreed, but then asked me to just try Nucynta during the day. It was a Godsend! I finally had something that could control my pain, but not affect my brain. To this day, I truly think she single handedly saved my career. Not sure where you live - but if you are in the Seattle area, I could point you toward an awesome pain doc :)

grainofsalt
Regular Member


Date Joined Aug 2010
Total Posts : 215
   Posted 3/27/2012 3:33 AM (GMT -7)   
BaileysMom,

I am glad to hear you are getting relief from the Nucynta (tapentadol). I've been on it since 2010 (occasionally switched out with Vicodin for 1 month) and its worked better than hydrocodone and tramadol and with similiar efficiency to roughly 10mgs of oxycodone with a longer duration (at the 75mg level) and less side effects. Also, it builds tolerance MUCH slower than Oxycodone. RADAR actually put out a report in Feb 2012 that used an 18 month study and found misuse and abuse of tapentadol has actually decreased since it came out. I personally feel this is partially due to its slow building tolerance and the fact that it doesn't cause as much sedation. It causes LESS mental fogginess than oxycodone too. Of the C-IIs, it seems (in my opinion) to have the least abuse potential and least opioid related side effects.

As for Nucynta concerning seratonin syndrome seems to be less of a risk than with tramadol. Tramadol has stronger SSRI properties than Nucynta. However, Nucynta does have mild seratonin effects but unlike tramadol, the increase in Seratonin isn't considered clinically significant to its pain relief properties. Nucynta CAN still cause Seratonin syndrome. This is partially because Nucynta has moderately potent Norephedrine Reuptake Inhibitation (NRI) properties. The NRI properties have an indirect effect on Seratonin levels. However, as I understand, the risk is still less than tramadol as well as anti depressants.

The fairly potent NRI properties of Nuncynta is also key to its comparable pain relief to moderate doses of other C-IIs, as its Mu opioid receptor binding affinity is 18x weaker than morphine, yet its about 1/3rd the stregnth of oral morphine in terms of pain relief. It is important to note that Nucynta IS more potent than tramadol in its Mu opioid receptor agonism and while similiar to tramadol has some differences. Older studies showed that 200mgs of Nucynta was superior in pain relief to 60mgs of oral morphine.

Sorry that this is practically a repeat discussion on my part as I've posted to answer Nucynta questions a few times now. It's still a relatively new medication so I'm happy to provide my personal insight on both the benefits and risks of the medication.

Be sure you drink plenty of water with it as it WILL dehydrate you. Also, at doses of 75 mgs, it had mild but noticable and tolerable mental effects. It seems to have a mild anti like depressant effect on mood. However, because the medication is mildly stimulating, you might find you need to take your last dose of the day about 2 hours before bedtime instead of right at bedtime. Also, if your doctor allows for a breakthrough dosing for flare ups (mine allows me to use 150 instead of 75 for flare-ups), the side effects increase substantially. For this reason, I'll try to get by with just an extra half one if I have a flare-up, which does cause some increase in side effects, but its tolerable. At 150mgs, it will literally drop my pain from an 8 to 0 but while shorted lives (about 90 minutes to 2 hours) the breakthrough dose causes a feeling of losing touch with reality as far as body effects go, as well as anxiety and naseua. Mentally (only at the 150 dose) it causes mild auditory hallucinations and closed eye visuals and "corner of eye" peripheral effects. These can be unpleasant but if they do happen, they usually improve within 2 hours.

Also, it seems that the effectiveness of the medication increases a little with repeated dosings (by this I mean if you take a second one 6 hours after the first dose, it seems to have better pain killing effects than if you didn't take it till the next day.

All in all its a great medication, ESPECIALLY for nueropathic pain! Again, at the 50-100mg dosings, low level of side effects compared to most narcotics. With less stomach related effects, its also easier to take asprin. Its effects on cognition are noticable but less than oxycodone or morphine so it has little impact on my "living life" and being outgoing. Please only take my advice with a grain of salt as I'm not a medical professional, just someone who has kept himself well informed concerning the medication since its a daily regiment.

I hope this helps and best of wishes. Remember to stay well hydrated :)
MRI revealed disc bulge and test injections revealed RA. Radio Freq procedures helped for months, but pain is up and im having the procedure done again. Currently on 75 mgs of Nucynta (tapentadol - A MOR + NRI) 2 to 3 time per day and Soma 350 as needed.

Post Edited (grainofsalt) : 3/27/2012 3:41:14 AM (GMT-6)


Baileysmom
Regular Member


Date Joined Mar 2012
Total Posts : 21
   Posted 3/27/2012 6:22 PM (GMT -7)   
Grainofsalt,
You have a fantastic pharm knowledge and I LOVE pharm and medication mgmt in general. You gave a fantastic and thorough account of this medication and it makes total sense to me.
I really wish I could write it for some of my patients, but since it's CN-II I can't write it, which is frustrating. I really miss Darvocet too. That was a great drug.
Anyway, guys, thanks for your help. I have an appt with a PM 4/19 and if he won't Rx medication I will just ask him who does.
L5-S1 microdiscectomy 5/11; right ulnar nerve transposition repair 3/11
MRI 3/12: C4-C7 disc bulge, C5-6 broad bulge with cord effacement
MRI 3/12: L3-L4 disc bulge, L4-L5 diffuse annular disc bulge with bilateral foraminal narrowing, L5-S1 laminotomy defect with granulation tissue surrounding L S1 nerve root. Disc bulge to bilateral foramen. Impingement of L5 nerve root.

straydog
Forum Moderator


Date Joined Feb 2003
Total Posts : 11526
   Posted 3/28/2012 9:10 AM (GMT -7)   
BaileysMom is the appt on April 19th for an eppie or is it your first consult with this dr? If its for a consult, rather than not knowing until the appt, I would call and just ask if this PM dr writes scripts for meds if he feels they are warranted. Just say you know some do procedures only with no meds.

Just a thought.
Moderator, Chronic Pain Forum & Psoriasis Forum

grainofsalt
Regular Member


Date Joined Aug 2010
Total Posts : 215
   Posted 3/29/2012 9:02 PM (GMT -7)   
Aww thanks Bailymom :)

I love researching and dicussing pharmacoloy and pharmadynamics (as well as medication magt, medical studies, nuerotransmitter science, receptor types, ect). I love knowing how things click and finding peices to the puzzle. It started out as a desire to find out not only more about the medications I'm taking and how they affect my body. Over time, it became a hobby and fascination to research and learn about pharmacology and medical science in general. This was further fueled by realizing my knowledge could help others. I'm certainly not a doctor and no doubt there's still a lot for me to learn, but in understanding how medications work and the body's biochemstry functions I can help someones understand so that when they talk to their doctor, they hopefully have a better understanding before the appointment. There really are some great doctors out there, but then there are some that I truly wish would explain things better to their patients.

I also have a huge fascination with radiology (rads, fission, how nuclear materials differ, exploring the aftermath of Chernobyl, ect) and I used to be into researching the paranormal.


Bailysmom, my pain management doctor have talked about the mechanism of action and how Nucynta should be in a lower schedule. Considering the new RADAR report on citing low abuse potential, do you think it will be rescheduled to C-III in time and that it will become a more common prescription than oxycodone for pain?

As for Darvocet, I think it was a good drug for non around the clock use for moderate pain. IMO its more effective than codeine, the system doesn't have to break it down to become active, and it lasts for about 7 to 8 hours. Its downsize is that when used around the clock, it can be dangerous, especially for the elderely because its metabolite builds (due to a long half life) and if the levels build too high, it can cause heart issues.

Also, this might sound strange but I favor asprin over ibu or naproxen for quicker pain relief via the NSAID route. My doctor recently prescribed me Mobic because she was concerned that the asprin (even in normal doses) would do serious stomach damage over time. While I understand her concern, it seems like Mobic isn't very effect for a prescription NSAID.
MRI revealed disc bulge and test injections revealed RA. Radio Freq procedures helped for months, but pain is up and im having the procedure done again. Currently on 75 mgs of Nucynta (tapentadol - A MOR + NRI) 2 to 3 time per day and Soma 350 as needed.
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