My PM said no to my change of meds request

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Veteran Member

Date Joined Oct 2010
Total Posts : 932
   Posted 7/26/2011 11:58 PM (GMT -6)   
I've been seeing my current PM for about 2 years and has been very flexible thus far.
He seems to have no reservations about prescribing any opioid for me as well as benzodiazepines, etc..

I don't think he's just easy going with prescriptions in general, but he has said to me in the past that he has "no worries" about my needs -- implying that he sees at least some of his other patients differently.

But during this appointment, he seemed to not want to discuss options with me and said no to all that I proposed.

I currently take 300mg of Ultram ER and use Hydrocodone or Oxycodone for BT pain (I vary as the latter helps more with pain but hinders my work more than the former). about 6 months ago, because I no longer felt that the Ultram was helping adequately, he switched me to Kadian. The effects were quite bad. I informed him and I returned to Ultram.

After some discussion, he suggested that it was worth trying to augment the Ultram with an anti-depressant type medication. We tried Wellbutrin, which had no effect, then Savella, whose side effects caused me to stop taking it (and was advised to return to Ultram until my next appointment).

During my recent appointment, I figured we would talk about trying Cymbalta and I also wanted to bring up Provigil. The former is a common medication for pain, of course. My rationale for the latter is that rather than trying to bring a level 5 pain down to a level 3 with an opioid, perhaps I could improve my concentration and focus on work even with the pain.

He said that the Provigil wouldn't help in that way. Perhaps he's right. But oddly, he then said (sarcastically), that if I wanted something to help me ignore the pain, he could just write me a script for a massive dose of xanax. Bad analogy on his part -- my goal remains being active doing what I enjoy in life , not just knocking myself out.

I then brought up Cymbalta or something else to supplement the Ultram. He said no. I also brought up the idea of increasing the Ultram to 400mg. I understand the risks here. I also know that it is prescribed to that dose in other countries and told him that. Again, no.
He had his pad out to write another script for hydrocodone or oxycodone if I needed it, but was otherwise just done listening.

I can chalk this up to a bad day on his part -- he looked tired and disheveled. But I'm also now worried about his attitude towards me. My main pleasure in life is writing. But my hip hurts, my back hurts, my neck hurts, my arm burns, etc.. I can ignore pain at levels 1-3. At 4 or 5, I turn to hydrocodone and can work again. But, I am not willing to take BT meds every day. So, some days I just have to spend in bed. Some days, I'll just get a bit of writing done and end up filling my time with distractions from the pain. Maybe 30% of my time is lost to pain as it is. Taking more hydrocodone will help, but I can't take much without it too making it difficulty to focus. Thus, something other than an opioid seems appropriate -- to me.

But to my doctor? I now wonder how he sees me. By continuing to ask for alternatives to opioids, have I come across in some objectionable or suspicious way? Maybe he is now thinking that my pain can't be so bad, or maybe I just like to experiment, or maybe I'm looking for a nootropic and not really there about the pain. To be honest, a genuinely safe and effective nootropic would be great, but that interest stands right along with my need to work while in chronic pain.

So, from this meeting, no longer do I feel like a partner in my medical care but rather a patient -- patiently waiting for the doctor to tell me what he wants me to take.
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

Veteran Member

Date Joined Apr 2009
Total Posts : 856
   Posted 7/27/2011 7:50 AM (GMT -6)   
Hi Cognito. I'm sorry you're going through this. I don't really have advice, but I'm kind of surprised that your doctor didn't want to change around your medications. Could there have possibly been cross-reactions or something like that? Just trying to think of a reason. Did he give any reasons at all as to why he didn't want to try the other ones that you suggested?

I hope that you get some relief soon, and I hope that you have a better appt. next time.



Heather Lynn
Regular Member

Date Joined May 2011
Total Posts : 283
   Posted 7/27/2011 11:04 AM (GMT -6)   

I suspect you have probably gone beyond what your pain management doctor is comfortable with. Provigil itself is a somewhat controversial drug, and what you are suggesting is pretty far off label use. It's definitely an idea that has merit, but I suspect your doctor is hoping you'll be willing to try more traditional pain relief. Opioid pain relievers are well known to treat pain, and as a pain management doctor, he feels treating your pain is his role.

You are clearly an academic, and I understand your concerns about work and being able to perform cognitively. I'm quite surprised he wasn't receptive to Cymbalta, as it seems like it could help and it's now approved for back pain.

Have you considered keeping a pain/work journal? It might help you to strategize better. I also perform cognitively demanding work, and opiates definitely affect my focus a bit, but they can also keep me working, albeit a bit diminished. For me, I find this much better than not being able to work. Maybe you could keep a journal of your pain, your medication use, and how able to work you are. You may find that the BT meds are not affecting your work as adversely as you think.

For pain relief, have you tried Tylenol Arthritis? It's the extended release form of tylenol, and it can help the Ultram work better. Tylenol has gotten a lot of bad publicity lately for liver problems, and I talked to my doctor and she said that the maximum dose of 4g is safe, which is the equivalent of 2 Tylenol Arthritis 3 times a day. I usually take it just twice a day, just to be on the safe side.
Fibromyalgia, low back pain/SI joint dysfunction, anxiety, obstructive sleep apnea, endometriosis, asthma

Veteran Member

Date Joined Jul 2009
Total Posts : 2042
   Posted 7/27/2011 12:00 PM (GMT -6)   
What about doing an "end around" on your PM and talking with your PCP about trying Cymbalta. You could mention that dealing with the pain has you down a bit and you were thinking Cymbalta might help since it is an anti-depressant and since it also is known to have some pain relieving properties that in addition to treating your mild depression it might help a little in that department too.
2 confirmed herniated lumbar discs. Spinal Arthritis. Spinal Stenosis, diabetic peripheral nueropathy.

Regular Member

Date Joined Jun 2011
Total Posts : 95
   Posted 7/27/2011 12:54 PM (GMT -6)   
We're told to be proactive in our medical treatment, not just simply accept what a doctor says. But I've found that the more questions you ask or the more suggestions you make, the less your doctor likes dealing with you. Don't get me wrong, I'll tactfully mention things to my doctor every now and then, but I'm honestly afraid to push him too far. I don't need him refusing to refill my pain meds because he thinks I'm being a pain in the butt or is worried I might be dope fiending him. And I'll certainly never ask him to increase my tramadol. That would be asking for trouble.
Would my doctor be vindictive or paranoid if I asked for something stronger or an increased dosage? He's a nice guy, so I doubt it. You never know, though, and I've never been one to push my luck.

Veteran Member

Date Joined Oct 2010
Total Posts : 932
   Posted 7/27/2011 1:55 PM (GMT -6)   
Thanks for the feedback.

I wish I could go to my PCP about this, but I'm not sure how he will respond if I ask him to prescribe something my PM said no to. I think that's too risky -- and I wouldn't want to try to hide it from my PM either as that would violate my pain contract.

Also, thanks to Heather Lynn for recognizing the situation. I'm very active in research and though I can be flexible with (self-imposed) deadlines on articles, I have recently accepted a contract for a book and have 18 months to write it. Thus, I need to make sure the forthcoming months are very productive. That means either taking more opioids or finding something different.

I've tried various workspace adjustments such as setting up my monitors, keyboard, books, etc., to work from my recliner -- but lying in the recliner made me too sleepy.

For now, I'm going to up my supplements (vitamins, magnesium, l-glutamine, omega 3, etc.) and see if that can take a bite out of the pain and/or increase my concentration. I'll also up my use of ibuprofen and/or acetaminophen.

I want to limit my opioid use to no more than once every 3 days, though in the past 6 months or so, that has migrated to more like 5/7 days. As a result, they are getting less effective and though I don't go through withdrawal the days I don't take them, I assume that would start happening if I continue with this frequency. Perhaps this last point is something I should have been more clear about with my PM. Depending upon his mood next time around, I might bring it up.
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

spinal soldier
Veteran Member

Date Joined Dec 2009
Total Posts : 687
   Posted 7/27/2011 5:04 PM (GMT -6)   
hello, i have heard through the grapvine in March something happened that made pain med prices go up across the board and my doctor was nervous one day recently and he and i are pretty close friends so i just asked him directly what the stressor was, (i also know the laws because of job, he told me they have a internet watch-dog type system, which is not new but this one watches doctors not patients. he has gotten rid of about a dozen patients because of bad urine screens or finding a patient is seeing 4 other doctors and getting 2-4 opioids and benzo's, say you get methadone for pain and your doctor shopping gets you a script for Valium, a long half-life tranquilizer, you could have a lethal interaction in your sleep and the spotlight would be on your good and flexible pain doctor, the DEA would investigate them and all their record keeping had better be in order. what upsets me is drug dealers and drug-addicts are ruining our life-long treatment. it is normal to use Provigil, Wellbutrin, and Dexedrine IR or the SPANSULE (my #1). they all raise norepineprine and dopamine which are natural pain filters in your CNS. i was taking Adderall 20mg 2 a day but i have switched to a far better/cleaner version; the Dexedrine spansule 10mg a.m., 5mg 2-3pm and i sleep great. the Ultram ER or Ryzolt or something at 300mg can cause sedation because it has more action on other types of neurotransmitter receptors as a agonist, one of the serotonins and light norepineprine. Opana ER is a effective efficiant steady level pain med when you find which dose you need, every 12hrs. it may work at a low to middle dose so not to sedating. if they will not give you some kind of psychostimulant the amino acid L-tyrosine is the precusor to norepineprine, the form N-acetyl-L-tyrosine is best. DLPA is also a precusor for norepinephrine (L-phenylalanine), and the D-phenylalanine blocks a enzyme involved in the degradation of endorphins, enkephalins, and opioid pain meds. you can take the version D-phenylalanine with L-tyrosine without risking hypertension (i see you take verapamil?). i see it's for tachy., since it's controlled with a continuous release med. i do not think it would hurt, just check your pule if you try that. L-tyrosine 500-2000mg a day on EMPTY stomach, D-phenylalanine 500-2000mg a day EMPTY stomach. the herb; HOLY BASIL is known as a adaptogen, it does create a higher natural energy and is great for the cardiovascular system. GOOD LUCK P.S. there is nothing wrong with asking for a nootropic by that term if you are a chronic pain patient.
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