pookie02
11-04-2004, 09:13 PM
Hello Everyone....I have been observing and learning over the last couple of days as to how Healthboards works and have finally decided to to write my very first post. I have had a back issue for over 3 1/2 years. Was put on Vicodin ES for 2 1/2 of those years and up till recently, it worked. Over the last 6 months, because I guess I have built up a tolerance to the meds...my pain has significantly gotten worse and my PM Dr. has been playing around with a combo of different meds that will hopefully work for me. First he changed me to Percocet 5, then 7.5 and now 10. All ranging from 5 to 8 per day depending on th strength. The 10mg 8x days by itself was working fine until recently. Then he prescribed Actiq 400mg to work alongside Avinza 60mg for BT pain. This cocktail did not work at all. Made me quite ill. Nausious, headache, "LOOPY' etc. Then he took me off those 2 meds and put me back on Percocet 10 with a Duragesic 50 patch every 72 hrs. I was on that for 30 days, but quite honestly, felt no different than just taking the Percocet 10 by itself. Then 2 weeks ago he again took me off all these types of meds and prescribed 2 10mg Methadone pills 3x days (60 mg total). Well, let me just tell you that I was really ill after 10 hours of my first 2 methadone pills in my sytem. Not only did I NOT have any more percocet in my system for at least 10 to 12 hours, but the Methadone by itself made me feel quite irritable, that I thought I was going to die. I had to take a Xanax 0.5mg (which I have not done in several months). I was so anxious, it almost felt like cold turkey. I do not understand that at all. He told me that for One, Methadone because it is 1.5 times stronger than Percocet, I should have not have these feelings at all he said, and for two, told me it would take at least 3 - 5 days for the Methdone to peak out in my system at the full 60mg per day.
From my understanding, Methadone is prescribed with a dual purpose. One for patients that need to detox, and two, for patients that need BT chronic pain management. This just scared me so much because when and if the time comes (hopefully if my back gets better), and its time to come off these drugs, I would have assumed that Methadone would have been the drug of choice for prescribed to me as a titration? And now realizing, that this drug had such an adverse reaction in my system, now what choices would be left for someone like me who cannot take methadone?????
And so my PM Dr. 4 days ago, under my suggestion, don't get me wrong, he is an awsome guy, conservative, but fair, administered Percocet 10 again 8x day, and also increased the Duragesic patch from 50 to 75. So far, seems to be really helping me pain wise, still feel a little loopy and foggy. I am assuming that perhaps in a week or so, these side effects will pass. I did ask him about the "controversial" OxyContin and whether this would be a good med for me. He said he would rather not prescribe this drug, and that there are plenty of NEW, better, more time released drugs out there that perhaps are not as addicting in the long run....I think he is quite reluctant to prescribe this as this drug does have a bad rap, and because of my age...38 :), perhaps he is waiting for me to really beg. I do not beg him for meds, in fact, he was surprised that I got 2 1/2 years on the original Vicodin prescription and strength, with never abusing it or taking more than I should, and never asking for stronger doses up until recently. He did say though, if he had to prescribe it, he would, but I think he would do that after we have exhaused all other meds out there...Well, honestly, I really do not want to go on that drug anyway. I mean Percocet 10mg, 8x day, and Fentanyl 75mg every 72 hours, really is by itself quite impressive :)
Anyway, to all you Pain Suffereing folks like myself out there...have any suggestions that you can think of that may be a good pain management regimen for someone like me that I could ask my PM Dr about. I go to see him every month as he only gives me enough meds for 30 days and wants to see me!!!
Thanks to anyone that reads my post and I would welcome any and all responses. Thanks so much, I am really pleased and happy that this website is out there to help us...as you all know, that living in pain is living a very lonely existence!!!
From my understanding, Methadone is prescribed with a dual purpose. One for patients that need to detox, and two, for patients that need BT chronic pain management. This just scared me so much because when and if the time comes (hopefully if my back gets better), and its time to come off these drugs, I would have assumed that Methadone would have been the drug of choice for prescribed to me as a titration? And now realizing, that this drug had such an adverse reaction in my system, now what choices would be left for someone like me who cannot take methadone?????
And so my PM Dr. 4 days ago, under my suggestion, don't get me wrong, he is an awsome guy, conservative, but fair, administered Percocet 10 again 8x day, and also increased the Duragesic patch from 50 to 75. So far, seems to be really helping me pain wise, still feel a little loopy and foggy. I am assuming that perhaps in a week or so, these side effects will pass. I did ask him about the "controversial" OxyContin and whether this would be a good med for me. He said he would rather not prescribe this drug, and that there are plenty of NEW, better, more time released drugs out there that perhaps are not as addicting in the long run....I think he is quite reluctant to prescribe this as this drug does have a bad rap, and because of my age...38 :), perhaps he is waiting for me to really beg. I do not beg him for meds, in fact, he was surprised that I got 2 1/2 years on the original Vicodin prescription and strength, with never abusing it or taking more than I should, and never asking for stronger doses up until recently. He did say though, if he had to prescribe it, he would, but I think he would do that after we have exhaused all other meds out there...Well, honestly, I really do not want to go on that drug anyway. I mean Percocet 10mg, 8x day, and Fentanyl 75mg every 72 hours, really is by itself quite impressive :)
Anyway, to all you Pain Suffereing folks like myself out there...have any suggestions that you can think of that may be a good pain management regimen for someone like me that I could ask my PM Dr about. I go to see him every month as he only gives me enough meds for 30 days and wants to see me!!!
Thanks to anyone that reads my post and I would welcome any and all responses. Thanks so much, I am really pleased and happy that this website is out there to help us...as you all know, that living in pain is living a very lonely existence!!!
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Shoreline
11-05-2004, 12:50 PM
Hey Pookie, Ifoxycodone works on your pain, I would push for oxyContin or the generic version. The idea of long term pain management is to mantain a steady serum level which you can't do with short acting meds with a 2-3 hour half life. You live in 4 hour increments and try to squeeze activity into the 2&1/2 hours it's working best. Wait 45 minutes for it to start and then you have about 2&1/2 beforeit start to wear off. So your constantly on a rollercoster up and down all day long.
"From my understanding, Methadone is prescribed with a dual purpose. One for patients that need to detox, and two, for patients that need BT chronic pain management"
I'm assuming instead of using the worf better pain relief you used the term BT chronic pain management"
We normally use the abrevieation BT for break through pain, pain that breaks thropugh your long acting med or rescue medication that reduces your level of pain when the base meds isn't working. The lonmg acting meds are the base meds and short acting are used for BT.
You do become acommadated to side effects, if they are too intense with one dose it's better to reduce the dose untill you become used to the side effects, If you only give each med one chance to work, you wil run through every option in a matter of days or weeks.
Your docs conversion from 80 mgs of oxy to 60 mgs of meth is actually quite high. The way a dose of 60 mgs would work, because it has a 20-30 hour half life, Is that the next day you still have 50% of the previous days dose in your sytem, the followning day you have 25% of the first day, 50% of the second day and the entire 60 mgs from the third,. This half life continues for about 5 days so by the end of the 5th day you would have roughly 117.5 mgs in your system or the equivelent serum level as if you took 117mgs in a single dose. It continues to build up for 5 days so ythe 60 mgs a day turns into almost twice that from the residual in your sytem from the previous 5 days. Now the conversion is upside down and your taking more mgs of a much stronger drug.
Methadone binds to every receptor and then some that oxycodone does so it doesn't make sense you would experience withdrawal from 60 mgs of meth or even the 20 mg first dose. IF your just very sensetive to med changes, they could have done a loading dose of 40 mgs in the am to prevent any withdrawl and the other 20 at night, and then go to your regular dosing schedule. But not allowing your doc to work with the dose based on reporting after a single dose, you won't have anything left to try.
You need to give meth a week to reach steady serum level and at least a week more to accommadate before making an increase. But meth is rarely used for break through pain because of the long half life. BT pain doesn't require a med that last 24 hours and stays in your system 5 days.
All meds have side eefetcs, many people have anxiety problems with oxy becuse it's a synthetic and a pro opiate meaning it's energizing where drugs like morphine and meth are more sedating.
When trying new meds, the initial side effects deminish as you become used to taking them, untill you become used to them, taking a med like Xanax or something for nausea or putting up with sedation is just par for the course. There is no perfect answer, Instead of concentrating on how the meds make you feel in terms of tired, anxious, loopy, you need to evaluate a med based on pain relief and realize the meds take time to get used to, and time to reach a steady serum level. All opiates will cause constipation, and urinary retention and most will intally cause nausea, itching and anxiety do to the hystamine release. But side effects can be managed if you give it a chance.
It is hard to adjust to any new med and continue to work daily or live a normal life. If yor expecting to have to deal with side effects, plan on feeling funky for a few days untill you become acomadted. Ideally very feeling other than pain relief will deminish as you become used to the med and the anelgesic effect is the last thing you get used to. You have seen your own tolerance grow and get higher which is very common with short acting meds. You have to realize, no doc can guess what med and how much and how often will relieve your pain and leave you side effect free. It takes months of trial and error for most people to find what works and I doubt any PM doc is going to prescribe short acting meds in ever increasing dose indefinitely. There is no reason you couldn't convert to a long acting version of a SA med you can tolerate.
As far as chronic pain patients using meth to detox, it's not done that often, It's just as easy to detox from any other med and most folks say meth is even harder to detox from, that's why you see folks on meth maint for addiction for decades. As far as using it as a base med for chronic pain it has numerous biochemical benefits as far as NMDA receptor blockningf, NK-1 and substance P reduction. Plus the lon ghalf lke makes it very forgiving, you don't start to withdrawal as soon as it's time for the next dose.
Only 6% of the folks that did clinical trials for duragesic for non cancer pain were able to go 72 hours without experiencing withdrawal, but that 6% was enough to package it as a pain reliever that last up to 72 hours If the problem was worse on the 3rd day, adjusting the schedule to change patches would have solved the problem. If it wasn't giving enough relief after 30 days you increase the dose, not change every med your on. Lordy. You haven't been on a high dose of any long actng med and can't tolerate the side effects.
As far as Avinza, 60 mgs spread over 24 hours would equate to taking a 5mg perc every 4 hours, the Aqtiq would be proportionately to strong and likely why you didn't do well with it. Break through or rescue medication dosing guides suggest a 20-30% increas in meds and the Actiq probaly increased your opiate level by about 10 fold with a base dose as low as 60mgs avinza every 24 hours. But you don't know if the avinza was the problem or the Fentanyl, so 2 of the basic 4 LA meds used got ruled out in one shot after a very short trial.
It just doesn't sound like you have given anything but the old standby that you know works, "percocet" a decent trial long enough to adjust the dose to an effective level or become acomadated to any side effect.
8 10 mg percs would equate to 120 mgs of avinza, does he know what your previus doses were, using BT meds as part of a dily regimin rather than prescribing enough LA meds, It leaves you with nothing to deal with any increase or incedental pain if iall your doing is taking the same dose of the same med you have all along.
Perhaps your doc just isn't comfortable prescribing anything but low doses of meds and when what he thinks shouldwork doesn't, instead of adjusting the dose, he changes everything. So you have run through the gammit of everything availabel other than OxyCOntin and btruly nevr gave morphne a fair trial or methadone a faitr trail or duragesic a fair trial. He might come to the conclusion your just not a candidate for opiates fif these meds at these doses don't help.
Have you looked into fixing your back problem rather than masking it, the longer you mask it the less likely anyone will every be able to fix it. All PM docs have different phylosophies about the use of mds and what's apropriate but it seems the new trend in medical care is to send aeveryone with pain to a PM doc rather than fix the problem. It's not doing you a service, in fact it greatly reduces your chances of every fixing the problem and engrainng pain signals into nerve tissue and alytering neuro chemistry to the point that even if an impingednerve from a disc or whatevr the problem, fisxing it won't reliev or stop the transmission of pain signals.
Personally I would be getting other opinions from surgeons and PM docs that have more to offer than a quick trial of a med without ever adjusting it based on patient repoerting of effectiveness.
JMO
Good luck, Dave.
PS to answer your question, if you tolerated the side efects of the 50 patch but it didn't give relief than yes, you move to the next strength, why not? Other than it's not a cure and the liklyhood of being ale to fix a problem deminishes over time. What exactly is wrong with your back. I guess I'm old school where opiates were not used untill everything else failed, surgery and all the non opiate modalities, PM clinics, Epidurals, nerve blocks, Tens, Tins, Bio feedback, self hypnosis, guided imagry, PT, and there is more than one type of PT, It just depends on the therapists abilities and the methods they learned, chiropractic, etc.
75 ugh may not work, you may need 150mics of fentanyl per hour. but you need a doc to actually titrate a med not DC it if his guess doesn't work. And that's all the first dose is, a guess on what may work. You can't look at anyone or any problem and say X amount of X drug will manage your pain, You have seen that.
Good luck and I would srerously look at fixing a problem as non invasively as posssible. They are doing micro discectomies now, Endoscopic discectomies, a flap procedure that are not open spine surgery with bone removed. These things were not available 10 or even 5 years ago they were just being developed. The hardware to perform these techniques has just this year been aproved although many test cases have been performed
"From my understanding, Methadone is prescribed with a dual purpose. One for patients that need to detox, and two, for patients that need BT chronic pain management"
I'm assuming instead of using the worf better pain relief you used the term BT chronic pain management"
We normally use the abrevieation BT for break through pain, pain that breaks thropugh your long acting med or rescue medication that reduces your level of pain when the base meds isn't working. The lonmg acting meds are the base meds and short acting are used for BT.
You do become acommadated to side effects, if they are too intense with one dose it's better to reduce the dose untill you become used to the side effects, If you only give each med one chance to work, you wil run through every option in a matter of days or weeks.
Your docs conversion from 80 mgs of oxy to 60 mgs of meth is actually quite high. The way a dose of 60 mgs would work, because it has a 20-30 hour half life, Is that the next day you still have 50% of the previous days dose in your sytem, the followning day you have 25% of the first day, 50% of the second day and the entire 60 mgs from the third,. This half life continues for about 5 days so by the end of the 5th day you would have roughly 117.5 mgs in your system or the equivelent serum level as if you took 117mgs in a single dose. It continues to build up for 5 days so ythe 60 mgs a day turns into almost twice that from the residual in your sytem from the previous 5 days. Now the conversion is upside down and your taking more mgs of a much stronger drug.
Methadone binds to every receptor and then some that oxycodone does so it doesn't make sense you would experience withdrawal from 60 mgs of meth or even the 20 mg first dose. IF your just very sensetive to med changes, they could have done a loading dose of 40 mgs in the am to prevent any withdrawl and the other 20 at night, and then go to your regular dosing schedule. But not allowing your doc to work with the dose based on reporting after a single dose, you won't have anything left to try.
You need to give meth a week to reach steady serum level and at least a week more to accommadate before making an increase. But meth is rarely used for break through pain because of the long half life. BT pain doesn't require a med that last 24 hours and stays in your system 5 days.
All meds have side eefetcs, many people have anxiety problems with oxy becuse it's a synthetic and a pro opiate meaning it's energizing where drugs like morphine and meth are more sedating.
When trying new meds, the initial side effects deminish as you become used to taking them, untill you become used to them, taking a med like Xanax or something for nausea or putting up with sedation is just par for the course. There is no perfect answer, Instead of concentrating on how the meds make you feel in terms of tired, anxious, loopy, you need to evaluate a med based on pain relief and realize the meds take time to get used to, and time to reach a steady serum level. All opiates will cause constipation, and urinary retention and most will intally cause nausea, itching and anxiety do to the hystamine release. But side effects can be managed if you give it a chance.
It is hard to adjust to any new med and continue to work daily or live a normal life. If yor expecting to have to deal with side effects, plan on feeling funky for a few days untill you become acomadted. Ideally very feeling other than pain relief will deminish as you become used to the med and the anelgesic effect is the last thing you get used to. You have seen your own tolerance grow and get higher which is very common with short acting meds. You have to realize, no doc can guess what med and how much and how often will relieve your pain and leave you side effect free. It takes months of trial and error for most people to find what works and I doubt any PM doc is going to prescribe short acting meds in ever increasing dose indefinitely. There is no reason you couldn't convert to a long acting version of a SA med you can tolerate.
As far as chronic pain patients using meth to detox, it's not done that often, It's just as easy to detox from any other med and most folks say meth is even harder to detox from, that's why you see folks on meth maint for addiction for decades. As far as using it as a base med for chronic pain it has numerous biochemical benefits as far as NMDA receptor blockningf, NK-1 and substance P reduction. Plus the lon ghalf lke makes it very forgiving, you don't start to withdrawal as soon as it's time for the next dose.
Only 6% of the folks that did clinical trials for duragesic for non cancer pain were able to go 72 hours without experiencing withdrawal, but that 6% was enough to package it as a pain reliever that last up to 72 hours If the problem was worse on the 3rd day, adjusting the schedule to change patches would have solved the problem. If it wasn't giving enough relief after 30 days you increase the dose, not change every med your on. Lordy. You haven't been on a high dose of any long actng med and can't tolerate the side effects.
As far as Avinza, 60 mgs spread over 24 hours would equate to taking a 5mg perc every 4 hours, the Aqtiq would be proportionately to strong and likely why you didn't do well with it. Break through or rescue medication dosing guides suggest a 20-30% increas in meds and the Actiq probaly increased your opiate level by about 10 fold with a base dose as low as 60mgs avinza every 24 hours. But you don't know if the avinza was the problem or the Fentanyl, so 2 of the basic 4 LA meds used got ruled out in one shot after a very short trial.
It just doesn't sound like you have given anything but the old standby that you know works, "percocet" a decent trial long enough to adjust the dose to an effective level or become acomadated to any side effect.
8 10 mg percs would equate to 120 mgs of avinza, does he know what your previus doses were, using BT meds as part of a dily regimin rather than prescribing enough LA meds, It leaves you with nothing to deal with any increase or incedental pain if iall your doing is taking the same dose of the same med you have all along.
Perhaps your doc just isn't comfortable prescribing anything but low doses of meds and when what he thinks shouldwork doesn't, instead of adjusting the dose, he changes everything. So you have run through the gammit of everything availabel other than OxyCOntin and btruly nevr gave morphne a fair trial or methadone a faitr trail or duragesic a fair trial. He might come to the conclusion your just not a candidate for opiates fif these meds at these doses don't help.
Have you looked into fixing your back problem rather than masking it, the longer you mask it the less likely anyone will every be able to fix it. All PM docs have different phylosophies about the use of mds and what's apropriate but it seems the new trend in medical care is to send aeveryone with pain to a PM doc rather than fix the problem. It's not doing you a service, in fact it greatly reduces your chances of every fixing the problem and engrainng pain signals into nerve tissue and alytering neuro chemistry to the point that even if an impingednerve from a disc or whatevr the problem, fisxing it won't reliev or stop the transmission of pain signals.
Personally I would be getting other opinions from surgeons and PM docs that have more to offer than a quick trial of a med without ever adjusting it based on patient repoerting of effectiveness.
JMO
Good luck, Dave.
PS to answer your question, if you tolerated the side efects of the 50 patch but it didn't give relief than yes, you move to the next strength, why not? Other than it's not a cure and the liklyhood of being ale to fix a problem deminishes over time. What exactly is wrong with your back. I guess I'm old school where opiates were not used untill everything else failed, surgery and all the non opiate modalities, PM clinics, Epidurals, nerve blocks, Tens, Tins, Bio feedback, self hypnosis, guided imagry, PT, and there is more than one type of PT, It just depends on the therapists abilities and the methods they learned, chiropractic, etc.
75 ugh may not work, you may need 150mics of fentanyl per hour. but you need a doc to actually titrate a med not DC it if his guess doesn't work. And that's all the first dose is, a guess on what may work. You can't look at anyone or any problem and say X amount of X drug will manage your pain, You have seen that.
Good luck and I would srerously look at fixing a problem as non invasively as posssible. They are doing micro discectomies now, Endoscopic discectomies, a flap procedure that are not open spine surgery with bone removed. These things were not available 10 or even 5 years ago they were just being developed. The hardware to perform these techniques has just this year been aproved although many test cases have been performed