Need help understanding ER pain meds

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(Seashell)
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   Posted 3/2/2017 8:14 AM (GMT -7)   
Hypmom3:
The lowest Fentanyl patch available is 12.5 micrograms. It may be that your physician made a typographical error in writing your prescription for a 10 microgram patch.

I would take the prescription to your pharmacist today (Thursday) and have them contact your physician for clarification, given that you are supposed to start the patch tomorrow (Friday).

You have been on instant release medication, hydrocodone/Norco, for several years. Your physician is acting in good conscience in starting you on the lowest dosing of Fentanyl in transitioning you toward an extended release medication.

Once the patch is applied and begins to release medication at the time-released dosing correlated to the patch's dose strength, you cannot reverse or remove the medication in your system should you have a reaction. Starting you at the lowest dose of Fentanyl is a wise decision to monitor for your initial reaction to the drug and its time released effects.

Anyone with chronic pain is used to experiencing uncomfortable occasions where pain is moderate/severe despite prescription medication. It is the reality of living with chronic pain that pain control is not a guaranteed given. Your concern that starting the Fentanyl on a low dose on a Friday may leave you with inadequate pain coverage over the weekend is a reality of living with chronic pain. Inadequate pain control is not reserved to instances where an individual, such as yourself, is starting a new medication regimen. Just as with starting the Hysingla, you will have to do the best that you can do in starting the Fentanyl and give the medication time to reach its full effect before deciding if it is "successful" or a "failure."

Even with my potent cocktail of Fentanyl + oral dilaudid, I have instances where my pain is poorly controlled. It is the reality of living with ongoing pain. Fully control pain, 24-7, is not a realistic reality for many people with chronic pain.

Check with your pharmacy today regarding your physicians' written prescription for the Fentanyl patch and have the starting dosing clarified.

Give the first patch adequate time to begin to release the medication into your system before your pass judgment on its effectiveness. The patch will release the medication into your system slowly at a pre-determined rate but its pain effectiveness will not be felt immediately as is the case with instant release hydrocodone/Norco that you are familiar with.

Fentanyl has been an excellent choice for me. I get good baseline coverage that is even in dose delivery. No peaks or valleys of medication effects. Transdermal administration has been good for me in that I have no GI effects - no nausea, no vomiting, no GI distress.

Fingers crossed that the Fentanyl dosing is a good fit for you and your pain needs.
- Karen -
Pituitary failure, wide-spread endocrine dysfunction
Addison's disease
Mixed connective tissue disorder
Extensive intestinal perforation with sepsis, permanent ileostomy
Avascular necrosis of both hips and jaw
Receiving Palliative Care (care and comfort)

straydog
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Date Joined Feb 2003
Total Posts : 15335
   Posted 3/2/2017 11:21 AM (GMT -7)   
I too looked up Fentanyl & could not find a 10mcg dosage. I would not wait until Friday to turn my script in at the pharmacy. The pharmacy should catch this immediately if there is an error. They always look up on the computer to see if they have medications in stock & if this is indeed a mistake it should be caught then.

I would do this now, do not wait until Friday because if this is a mistake you may not have time to get the dr to rewrite the script & get it all taken care before the close of the day at the drs office.

Take care.
Susie
Moderator in Chronic Pain & Psoriasis Forums

hpymomof3
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Date Joined Oct 2011
Total Posts : 66
   Posted 3/2/2017 11:49 AM (GMT -7)   
I actually already turned in the script and didn't realize it was a mistake until I got home. Hopefully they can still fill it. I can't start it until tomorrow because the pharmacy had to order it. Hopefully the patch will work well. I wish they gave me breakthrough just for the beginning but I guess I am used to being in pain. It's just been hard the past two months since I haven't had much pain control with the Hysingla.

straydog
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Date Joined Feb 2003
Total Posts : 15335
   Posted 3/2/2017 12:24 PM (GMT -7)   
I will tell you right now, Fentanyl is much stronger than what you have been taking for years, so I wouldn't go down that path & stress yourself out. It will take some time for it to get in your system completely since its trans-dermal, so do not expect immediate relief when you put it on. Keep positive thoughts going.

Take care.
Susie
Moderator in Chronic Pain & Psoriasis Forums

Mercy&Grace
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Date Joined Jun 2013
Total Posts : 1703
   Posted 3/2/2017 1:53 PM (GMT -7)   
hpymomof3, the pharmacy cannot fill it with an incorrect dosage on the prescription. You need to call your pharmacy Today. Maybe you can get things straighten out before the weekend. If not, you will have to wait until Monday or maybe later in the week to get your prescription.

hpymomof3
Regular Member


Date Joined Oct 2011
Total Posts : 66
   Posted 3/3/2017 1:51 PM (GMT -7)   
Will I have any problems abruptly stopping the Norco? I realize I may be in more pain until the Fentanyl gets into my system but I'm wondering if I will have any withdrawal symptoms since I've been on the Hydrocodone for so long. It was a nurse practitioner who prescribed the Fentanyl and she didn't seem too confident with some of the answers she gave me.

straydog
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Date Joined Feb 2003
Total Posts : 15335
   Posted 3/3/2017 7:04 PM (GMT -7)   
You should not have a problem, the Fentanyl is much stronger than Hydro. Try not to stress over the change, it will just send the pain way up.
Susie
Moderator in Chronic Pain & Psoriasis Forums

hpymomof3
Regular Member


Date Joined Oct 2011
Total Posts : 66
   Posted 3/5/2017 2:53 PM (GMT -7)   
Well unfortunately my fears have been realized. Maybe I'm super sensitive to medication but I had awful withdrawal when I had to go off of Tramadol 6 years ago and I wasn't even on a large dose

Anyway my last dose of Hysingla was Friday at 10 am. By last night I was having a big increase in pain as well as a shaky, restless and unwell feeling. This morning the pain and other symptoms are even worse. I definitely feel like I did when I went off Tramadol but my pain is much worse.

I called my pharmacy to see if perhaps this was just a reaction to the Fentanyl. She says it takes a week for me to get the full benefit of the Fentanyl patch and since it's such a low dose I'm not getting any much pain relief. She also said that I should have been given short acting meds until the Fentanyl is fully in my system not only for pain relief but so I don't get withdrawal symptoms.

So now the question is how do I handle this with the nurse practitioner. I already got the feeling she wasn't sure how to transition me from the Hysingla to the Fentanyl. It took her a long time to do the conversions. She is also young and I believe this is her first job besides medical school etc. I don't want to come off as telling her she was wrong but I also want her to know what the pharmacist said. I feel they know more about medications sometimes. I also wish I could get comfortable. I've taken my anti inflammatory medication as well as Lyrica but I'm still miserable. I got no sleep last night.

straydog
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Date Joined Feb 2003
Total Posts : 15335
   Posted 3/5/2017 5:36 PM (GMT -7)   
I am sorry that you are still having such a rough time. But, I have not ever heard of it taking a week for the Fentanyl to get in your system. I looked on several pharmaceutical web sites & could not find a 10mcg patch. The lowest dose was 12.5mcg which I had told you about earlier. Do they look like the patches your mom used? How often are you suppose to change your patch? You should have a little pamphlet in the box be sure you read it.

All you can do is call the NP tomorrow & tell her what happened & let her know you did call the pharmacy & spoke to the pharmacist. In no way am I defending the NP, but many times I have seen seasoned drs struggle with the conversion issues. Drs go to school to become drs & they really do not have the expertise that a good pharmacist has when it comes to medications.

Hopefully you can get this resolved in the morning.
Susie
Moderator in Chronic Pain & Psoriasis Forums

hpymomof3
Regular Member


Date Joined Oct 2011
Total Posts : 66
   Posted 3/5/2017 6:42 PM (GMT -7)   
I was completely wrong about the 10 mcg. I don't know where I got that. I had already dropped it off when I posted. I was sure it said 10 mcg but it was the correct amount. They are the same as my moms and I'm supposed to change every 3 days. Maybe the 12.5 is too low for me and since it takes awhile I'm not getting much benefit yet. I'm guessing I will get relief somewhere between what the NP said which was 12 hours and what the pharmacist said of one week.

I called the pharmacist back since I was desperate. My pain was so intense and I was having full on withdrawal symptoms (cold sweats, even diarrhea and all the other symptoms). The pharmacist said I could take a Hysingla. I'm hoping it won't be a problem since the pharmacist suggested it and I had just been on it. Should I even tell my NP? Sure enough now that the Hysingla has started to work most of my symptoms are better or getting better so it was definitely due to going off the Norco. Maybe I'm just extra sensitive to going off meds since it was brutal when I went off of Tramadol and that was gradual. This was sudden and I had been on it for several years.

I understand about the conversions. I have seen them online and most don't even go directly from Norco to Fentanyl. It looks very tough to figure out. I just hope the NP is understanding and will realize that I will need to take something before it kicks in and possibly a higher dose. Also possibly a breakthrough to have on hand. The pharmacist was really surprised about that.

(Seashell)
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Date Joined Dec 2012
Total Posts : 682
   Posted 3/5/2017 11:08 PM (GMT -7)   
Hypmom3:
I would not be too judgmental of your NP.

Transitioning from a short-acting opiate to a long-acting opiate, as you are, is not always an easy process. Every person reactions to opiate medications differently based on individual variations - opiate receptor sensitivity, the variations in chemical mechanisms by which we metabolism opiate medications, individual tolerance to opiates based on prior use and duration.

I am on the fentanyl patch. It has not been my experience that it takes a week to reach full effectiveness. Obviously, there is a necessary time period required for the medication to enter your system at the prescribed dose due to the time release characteristic of the patch, but I have felt substantial relief within 48 hours of my initial patch.

Work with your NP. Explain the difficulties that you are having. Work toward a mutually agreed plan of treatment moving forward.

I have severe bone pain due to avascular necrosis. I consider that there will be episodes and periods where my pain will not be well controlled for a variety of reasons, where the dose prescribed will be inadequate. It is what it is. It is the reality of living with chronic pain.

My advice/opinion: You are a new patient to her. She is a new NP/physician to you. Building a relationship of mutual respect and trust between the two of you will serve you well in the future for treatment of your pain.
Pituitary failure, wide-spread endocrine dysfunction
Addison's disease
Mixed connective tissue disorder
Extensive intestinal perforation with sepsis, permanent ileostomy
Avascular necrosis of both hips and jaw
Receiving Palliative Care (care and comfort)

hpymomof3
Regular Member


Date Joined Oct 2011
Total Posts : 66
   Posted 3/6/2017 12:33 AM (GMT -7)   
I don't mean to come off as I'm overly upset with her. I just feel that she didn't take any of my concerns seriously about the transition especially since it was the weekend. My withdrawal from Tramadol was horrible and I had been on a fairly low dose for less than 6 months. I've been on Norco for 5-6 years. I realize Norco isn't really strong but I think maybe I'm extra sensitive. At first I thought maybe I was just having anxiety over the possibility of having problems but then I had full blown symptoms. I thought maybe it was a reaction to the patch but my pharmacist said it was due to going off the Hysingla abruptly after being on Hydrocodone for so long. She was very surprised that I wasn't given anything to transition for the first few days at least. I think she meant 7 days for my blood level to reach the maximum level. She also mentioned that she never sees someone given such a small dose. I realize I was starting from a fairly weak Opiod and the pharmacist knew that. She said that since it's such a low dose that I wouldn't have received very much of the med yet into my system. It probably would have been best if I was given a short acting med for the first few days but I wasn't given anything. Also I know I can't expect to me painfree but this is the worst pain I have ever had and of course withdrawal symptoms shouldn't be something for me to have to experience.

I also believe I have had a big increase in symptoms over the past few months. I have 4 cysts on the nerves of my spinal cord. They have spinal fluid in them and cause pain and pressure. They are pressing on other nerves and also eroding my sacral bone. I now have weakness in my right leg and some numbness and tingling and constant pain in my foot. I also have ankylosing spondylitis, inflammatory arthritis and fibromyalgia. I feel that I have needed stronger meds for awhile but things have deteriorated rapidly. Most likely the 12 mcg just isn't enough. I understand the reason for starting slowly but I do feel I should have been given something to take additionally at first.

straydog
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Date Joined Feb 2003
Total Posts : 15335
   Posted 3/6/2017 11:57 AM (GMT -7)   
Let us know how things work out after you speak to the drs office. Hopefully there will be some relief in sight soon.
Susie
Moderator in Chronic Pain & Psoriasis Forums

hpymomof3
Regular Member


Date Joined Oct 2011
Total Posts : 66
   Posted 3/7/2017 12:53 PM (GMT -7)   
It's been a rough couple of days. I literally have had about 5 hours a sleep total the whole weekend. I finally fell into an exhausted sleep last night. My stomach symptoms were better yesterday as well as the cold sweats but the pain was pretty bad once the Hysingla started to wear off. This morning since it had been while again since I had the Hysingla I started back with the stomach problems and cold sweats.

I was finally able to talk to a nurse on the phone a little while ago. She definitely thinks I have withdrawal symptoms. We are guessing a combination of me being extra sensitive to discontinuing meds as well as the Fentanyl patch taking awhile to work and being an extra low dose. She said usually they try to wean you off the one medicine when you start the patch so she isn't sure why they didn't with me. She was understanding and wants me to take a Hysingla to stop the withdrawal symptoms until I can see the nurse practitioner tomorrow.

(Seashell)
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Date Joined Dec 2012
Total Posts : 682
   Posted 3/7/2017 4:03 PM (GMT -7)   
hypmomof3:
Experiencing withdrawal symptoms is horrible. You have my genuine empathy for having to experience withdrawal due to inadequate
dosing transitioning to the fentanyl patch.

Hopefully, the worst of this experience is behind you and in your rear view mirror.

The addition of a dose of the Hysingla should ease the withdrawal symptoms and help you feel somewhat like yourself. Meeting with the nurse practitioner tomorrow should hopefully allow you to air your grievances and for the both of you to decide on a dosing strategy moving forward.

One of the real and concerning drawbacks of being reliant on a prescription opiate/narcotic is the intensity of withdrawal symptoms if you are in a situation where you are lacking the usual dosing of medication.

My first withdrawal experience was of my own fault. I naively did not understand that not getting my narcotic prescription refilled on the exact date would be a "big deal." It turned out to be a Big Deal, as I spiral into intense withdrawal symptoms within a few hours of my last dose. I have learned never to be without my prescription. All to say . . I know how awful is the experience of withdrawal and how crappy one can feel.

Sending you positive karma that tomorrow's appointment with the nurse practitioner is a positive one,
- Karen -
Pituitary failure, wide-spread endocrine dysfunction
Addison's disease
Mixed connective tissue disorder
Extensive intestinal perforation with sepsis, permanent ileostomy
Avascular necrosis of both hips and jaw
Receiving Palliative Care (care and comfort)

hpymomof3
Regular Member


Date Joined Oct 2011
Total Posts : 66
   Posted 3/7/2017 5:34 PM (GMT -7)   
Thank you. Yes I think the worst is over. The Hysingla helped within 2-3 hours.

hpymomof3
Regular Member


Date Joined Oct 2011
Total Posts : 66
   Posted 3/8/2017 12:31 PM (GMT -7)   
I saw the nurse practitioner today. She saw that I had a Tegaderm patch on and claims that was my problem. First it says right on the pamphlet that comes with the patch that you can use one. Also that is what they used on my mom in hospice. She says because I was sweating (I told her I had cold sweats) that it caused it to dump the medication and caused my symptoms. I tried to explain to her that I didn't get the sweats until I'd been wearing the patch about 24 hours. I told her that 2-3 hours after I used the Hysingla the sweats and other symptoms went away. She made it sound like I was having a reaction to the dumping rather than withdrawal but if that's true it wouldn't get better with taking the Hysingla.

So she made me put on a patch without the Tegaderm patch on it. She said I could tape the edges. I have the 12 mcg patch and it is tiny. It's pretty hard to only tape the edges.

She is also contradicting herself so much. She was a bit upset that I took the Hysingla basically telling me I would probably have more problems now since that pretty much doubled my dose. Quite honestly I don't think the patch was really working yet since I felt no difference in pain. Then she asked why I would take the Hysingla instead of the Norco since they really want me off the long acting med with the patch. I reminded her that they did not give me anymore Norco except for 6 pills they gave me last Wednesday so I could take 2 each day with the Hysingla since we knew my pharmacy would not have the patches until Friday. It even said that on my script. She said normally they would have me take Norco for breakthrough pain while on the patch but she never gave me anymore. She acted surprised when I told her that. She really treated me like everything was my fault. I went along with her on the Tegaderm even though I knew she was wrong. I also tried to have more of an attitude of just moving forward and what should I do now.

So she kept me on the same dose of Fentanyl, gave me 20 Norco up to 2 a day for breakthrough and then increased my Lyrica. I had mentioned doing that last week since I am only taking 150 mg daily. She said she wanted to hold off so if I had problems they would know which med is causing the problems. Today though she implied that I would have more withdrawal symptoms since she feels I was basically on a double dose of meds between the patch and Hysingla. So I find it a bit odd she wouldn't want me to wait a bit to increase the Lyrica.

At this point I'm hoping that I will become steady on the meds and have no more problems but I don't have a lot of faith in her since there have been so many discrepancies.

straydog
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Date Joined Feb 2003
Total Posts : 15335
   Posted 3/8/2017 1:11 PM (GMT -7)   
Well, I have to disagree with the NP about Tegaderm. Back when I was on Fentanyl that was the only way I could keep them on & my dr approved me using it. The only time I had the dumping of it was when I got too hot. I am talking about a too hot of a shower or when I was outside in the heat during the summer.

I will be honest with you, I was very worried they would fire you because of using both Fentanyl & the Hysingla. I understood previously that you called their office & I thought it was the NP that said it was ok to use both until you were seen this week.

Perhaps since you have not been on both very long hopefully you will not have any problems switching over. When do you return back to the dr? Is the 20 pills for one month? Also, how hard is it to see the dr instead of the NP?

Take care.
Susie
Moderator in Chronic Pain & Psoriasis Forums

hpymomof3
Regular Member


Date Joined Oct 2011
Total Posts : 66
   Posted 3/8/2017 1:30 PM (GMT -7)   
The first time the pharmacist told me to take the Hysingla (Sunday night) the 2nd time it was the nurse. I was scared too about Sunday but they have no one to call after hours. I am going back in two weeks. The Norco is for 1-2 per day so that will be fine. I'm hoping I won't need it at all once I'm stable. The doctor only sees new patients and patients who are getting injections. I'm hoping the patch will stay on in the shower. If I have trouble I wonder if I should bring the package insert from the drug company that specially suggests the Tegaderm. I don't want to make her mad at me though.

(Seashell)
Veteran Member


Date Joined Dec 2012
Total Posts : 682
   Posted 3/8/2017 2:44 PM (GMT -7)   
hypmomof3:
I have been holding out hope that your nurse practitioner would mature in her relationship and prescribing parameters with you if you had the advantage of seeing her for 1-2 additional visits . . . but I am losing faith in this nurse practitioner.

Tegaderm patches are routinely recommended to keep the duragesic patches in place. For the NP to imply that you caused dumping of the medication by placement of a Tegaderm patch (to wit sweating under the patch released the medication at a faster rate than designed) is far-fetched . . . and, honestly, is an attempt to inappropriately displace fault that the 12.5 mg patch was inadequate to avoid withdrawal on you.

Gggrrrr. . . Gggrrrr.

I am firmly in your corner on this one.

For anyone who is already opiate tolerant, as you are in having taken hydrocodone/Norco over the past 5 years, the 12.5 mcg fentanyl duragesic patch is a low dose.

I can see the NP's reasoning in starting you on the 12.5 mcg duragesic patch, however. You are/were a new patient to her, not yet established. You had not yet been established on a long-acting narcotic - he hysanglia had not proven to be a good "fit" for you. So, she had reason to be cautious in the initial dosing prescription of the fentanyl duragesic patch.

She made a calculated error in not providing you with any hydrocodone/Norco to limit the potential of withdrawal symptoms due to the low starting fentanyl dose in relation to the daily hydrocodone/Norco equivalent that you had been taking. But with the federal oversight and regulatory culture ever more restrictive on prescription leeway, she may have been limited in her ability to co-prescribed hydrocodone/Norco with the fentanyl.

Your symptoms over the weekend, in my opinion, reflected opiate withdrawal from insufficient fentanyl dosing at the 12.5 mcg dose. I do not "buy" her interpretation that the patch dumped the active narcotic due the the placement of the Tegaderm patch. You are opiate tolerant having been on 10 mg hydrocodone/Norco x 5 per day for the past 5 years. That the addition of a dose of hysanglia eased the withdrawal symptoms adds credibility to the theorem that the 12.5 mcg fentanyl was simply insufficient to meet your established level of physiological opiate tolerance.

I applaud you for keeping a calm and composed composure in meeting with the NP in followup today. You showed yourself to be the better person by not taking the "low road" and arguing with her - despite your legitimate position to challenge her thinking and deflecting the burden of the weekend episode to you.

When I was first started on fentanyl, I was provided the 12.5 mcg patch (just as you were) despite being already opiate tolerate (also, just as you were). Like you, the 12.5 mcg patch had only a marginal effect. For me, the dosing was increased after a few days at the 12.5 mcg dosing.

I am coming to see an advantage of being on Palliative Care is that I have medical practitioners who are well versed in dosing pain medication and in grading its effectiveness for the person prescribed. While being sick enough to qualify for Palliative Care is not by no means fun, it does come with some advantages.

All to say . . . I think you acted exceptionally well poised in your follow-up with the NP. I think this shows that you are the more respectful and stronger in character in the relationship between you and the NP.

I hope that the 12.5 mcg fentanyl + hydrocodone/Norco breakthrough allowable is the beginning of a successful pathway for you.

It is frustrating to be a patient with pain in the current federal and state regulatory and oversight environment. At times, it feels as though I am being punished for having a body that is ailing.

Sending you positive karma for better days ahead,
- karen 0
Pituitary failure, wide-spread endocrine dysfunction
Addison's disease
Mixed connective tissue disorder
Extensive intestinal perforation with sepsis, permanent ileostomy
Avascular necrosis of both hips and jaw
Receiving Palliative Care (care and comfort)

straydog
Forum Moderator


Date Joined Feb 2003
Total Posts : 15335
   Posted 3/9/2017 7:32 AM (GMT -7)   
Yes, I would certainly take the pamphlet to the appt.. It sounds like she is sticking her head in the sand. Most people with Fentanyl need something to have on hand for break thru pain. So, in other words what I am telling you is do not decline a script for it because there is a chance you will need something when this happens.

If I remember correctly, didn't this NP tell you that normally they wean their patients off of a medication before switching to a different one? If this is true, that is the most absurd thing I have ever heard of. I am almost 64 years old & have been in pain mgt since my early 40's. Not one time did the drs ever wean me off of one medication before switching me to something different.

I understand fully well the guidelines that the drs are going by & have for several years. The best I can tell from your posts, this NP is has little knowledge of chronic pain. They are operating on an extremely conservative side. Have they received a copy of the surgeon's report stating that you are a surgical candidate?

I hope things settle down for you.
Susie
Moderator in Chronic Pain & Psoriasis Forums
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