wolfmarket
01-01-2006, 12:10 AM
Dave, as you suggested I discusses switching from Ms Contin to OxyContin but as I surmised, Doc won't RX oxyContin.
So, I decided to go back to Fentanyl patch, 100 mg change 72 hours. Still use 30mg Roxi for BT.
My pain is getting worse. My right side is now awful all of the time. Do I find another PM that will look at things like OxyContin and Actiq? If so, how would I change without violating contract?
For a while, I made no big deal because I was comfortable even though still in pain. Now, I'm not even comfortable.
Thanks!
Alan
So, I decided to go back to Fentanyl patch, 100 mg change 72 hours. Still use 30mg Roxi for BT.
My pain is getting worse. My right side is now awful all of the time. Do I find another PM that will look at things like OxyContin and Actiq? If so, how would I change without violating contract?
For a while, I made no big deal because I was comfortable even though still in pain. Now, I'm not even comfortable.
Thanks!
Alan
Sponsor
Shoreline
01-01-2006, 01:55 PM
Hey Allen, I understand the panic when we are started two low. Everyone’s response is different to each drug, fentanyl is fairly unique in certain aspects but even though your not getting relief at 100, whose to say you wouldn't at 200mcg. You may need to change more often than 72 hours. It's all part of the titration process.
I was talking about a change do to some side effects that started with Dilaudid, I really don't want to go to Fentanyl of or several reasons, but don't want to upset those happy with the patch. But it really may just not be enough or near enough. Just because it's the largest dose they make, doesn't mean you can only use one. You may need 150, 200 or more? Ideally your doc works with you untill it's resolved.
If you don't have that kind of care I would look for a new doc or clinic anyway. Contracts don't prohibit consultation with other docs. You are certainly allowed to look into any method he doesn't offer. If h e doesn't do TP injections, Than you tell him you want to consult with a doc that does. When you see that doc, you explain your position, and that you can't manage under this docs care and there must be something they can do. He will either explain how he thinks he can or exlains he can’t do anything your not presently doing. IF that’s the case, thank you for you time and part ways. Hopefully you aven’t burned the bridge with doc #1 for merely wanting to check into something he doesn’t offer.
The obvious thing is to increase your meds. It's the easiest and most immediate. That's given the doc believes in opiates, understands your condition, what your condition is and how you tolerate more medication. There are adjunctive meds available some docs use and some don't. You can consult with a new doc for any reason you want to investigate a treatment your present PM doc doesn't use.
You meet with a new doc, discuss your case, ask if he can think of anything do bring your pain under control.. If you like what you here, You can switch docs right then. Accept the scripts, call the old doc and say Thankyou for all that you tried but you have to consider this is your life and if something he can't offer could help, he you have to try. I shouldn't burn bridges if you can help it, He did try given his knowledge and understanding of opiates , tolerance, and the individual aspect of treating each patient from a psychological POV to a Neuro, physical medicine, and rehabilitation aspect. You can’t really blame someone for being uncomfortable with every theory and stick within their comfort zone.
Ask if the door will be left open should these methods not work and I'm willing to try anything at this point. You thank him, tell him how you appreciate his belief and trust, obviously a GP or surgeon preferred not to prescribe or they would. You’re just at a dose higher than the couple of percs they have always used and usually works on sever post op pain
. The docs teaching our new docs still have that POV, IT will take time for pain management to be an important part of general practice. But until then, GP and surgeons are still being taught opiates are for short term use and they simply aren’t comfortable with prescribing beyond their comfort zone or for long periods of time. It’s probably easier to find a new doc than try and change a docs POV on something he has had since their residency. IF you happen to be you docs highest dose patient, or at his limit. Because he thinks that if they only make a 100ugh patch that's all that should be used. You will likely have to part ways.
I know plenty of people using multiple patches, from 150mcg -700mcg plus other LA meds. IT takes what it takes to reach that wall, where more doesn't help and just impairs you more. You have to find a doc willing to go there. IF I had stopped at 400 mgs of oral morphine I would have never gotten a god year out of 600mgs a day of LA oral morphine.
Most docs believe and are taught about cross-tolerance, meaning hopefully you will respond to a lower dose of the next med you try do to the subtle difference. Then you may be able to switch back to a previous med they had a concern about tolerance with at a lower effective dose.
Opiates and receptors are like puzzle pieces and everyone gets a better fit from a different piece. You may do much better on what appears to be an equianalgesic dose of a new med, But their thinking is why start high if we can work their way up when we have to. But when changing docs he may just realize your not gettig relief because your not getting enough med. That’s easy to fix if they believe in the benefit of opiates and the patients need. Your DX, prognosis, medical history is what their prescribing practices are judged by if questioned, that's what justifies use in the present school of legal medicine and what protects them.
Given your condition, Take a complete history, typed up on as few pages as possible, preferably one, and list every modality, medication, treatment, PT, acupuncture, Chiro, Surgery, psych PM you learned or tried techniques with and their effectiveness and present it to him. He can insert in your chart if he believes he can help. IF you believe you can accept scripts then and there and just call doc#1 and thank him and let him know doc #2 will be managing all your meds. Let him know you have called any remaining refills in his name as not to cause a conflict. And you off and running with a nw doc and hopefully a a lot of hope and some immediate pain reduction. The document should explain everything really quick and gives him a list with names dates, people, contact info to confirm he he wants too. Your entire history. It will avoid duplicated attempts at previously tried modalities, some may be worth repeating, because I have had trigger point injections from docs that did nothing to different docs that can hit that spot 99% of the time and make a huge difference.
If your present doc doesn't offer Botox, and you want to consult with doc that uses Botox, that isn't excluded in any contract I can imagine. Whatever he isn't offering and hopefully the new guy or group does do it all That's the difference in a doc in private practice and a clinic. I guess some crazy one sided contract where you sign your house or child over in the deal and say you will never seek alternative treatment may preclude getting other opinions?? The "mine forever contract" NOT!!!
IF you don't agree what the new doc suggests at the consult, just tell him you will stick with what is working. Your interviewing him as much as he you. Is this the doc your going to trust not to let you suffer. However bad the present guy is doing, He's trying. You really may just need an increase and wear 2 or more patches. After 3 or 4 cycles you have a pretty even serum level and know this is as good as it gets and the patterns in that dosng schedule. If your at his comfort zone, then you probably have to find a new doc.
I don't see why you couldn't find a more aggressive doc that may have some other tricks up his sleeve that your doc may not know or believe in. How can a doc believe in anything working or not working, straight across the board? It's your life and you have to do what you have to. I you have to explain the consult to PM 1, just exlain the interest in the new modality or treatment he doesn't offer.
Good luck, Dave
I was talking about a change do to some side effects that started with Dilaudid, I really don't want to go to Fentanyl of or several reasons, but don't want to upset those happy with the patch. But it really may just not be enough or near enough. Just because it's the largest dose they make, doesn't mean you can only use one. You may need 150, 200 or more? Ideally your doc works with you untill it's resolved.
If you don't have that kind of care I would look for a new doc or clinic anyway. Contracts don't prohibit consultation with other docs. You are certainly allowed to look into any method he doesn't offer. If h e doesn't do TP injections, Than you tell him you want to consult with a doc that does. When you see that doc, you explain your position, and that you can't manage under this docs care and there must be something they can do. He will either explain how he thinks he can or exlains he can’t do anything your not presently doing. IF that’s the case, thank you for you time and part ways. Hopefully you aven’t burned the bridge with doc #1 for merely wanting to check into something he doesn’t offer.
The obvious thing is to increase your meds. It's the easiest and most immediate. That's given the doc believes in opiates, understands your condition, what your condition is and how you tolerate more medication. There are adjunctive meds available some docs use and some don't. You can consult with a new doc for any reason you want to investigate a treatment your present PM doc doesn't use.
You meet with a new doc, discuss your case, ask if he can think of anything do bring your pain under control.. If you like what you here, You can switch docs right then. Accept the scripts, call the old doc and say Thankyou for all that you tried but you have to consider this is your life and if something he can't offer could help, he you have to try. I shouldn't burn bridges if you can help it, He did try given his knowledge and understanding of opiates , tolerance, and the individual aspect of treating each patient from a psychological POV to a Neuro, physical medicine, and rehabilitation aspect. You can’t really blame someone for being uncomfortable with every theory and stick within their comfort zone.
Ask if the door will be left open should these methods not work and I'm willing to try anything at this point. You thank him, tell him how you appreciate his belief and trust, obviously a GP or surgeon preferred not to prescribe or they would. You’re just at a dose higher than the couple of percs they have always used and usually works on sever post op pain
. The docs teaching our new docs still have that POV, IT will take time for pain management to be an important part of general practice. But until then, GP and surgeons are still being taught opiates are for short term use and they simply aren’t comfortable with prescribing beyond their comfort zone or for long periods of time. It’s probably easier to find a new doc than try and change a docs POV on something he has had since their residency. IF you happen to be you docs highest dose patient, or at his limit. Because he thinks that if they only make a 100ugh patch that's all that should be used. You will likely have to part ways.
I know plenty of people using multiple patches, from 150mcg -700mcg plus other LA meds. IT takes what it takes to reach that wall, where more doesn't help and just impairs you more. You have to find a doc willing to go there. IF I had stopped at 400 mgs of oral morphine I would have never gotten a god year out of 600mgs a day of LA oral morphine.
Most docs believe and are taught about cross-tolerance, meaning hopefully you will respond to a lower dose of the next med you try do to the subtle difference. Then you may be able to switch back to a previous med they had a concern about tolerance with at a lower effective dose.
Opiates and receptors are like puzzle pieces and everyone gets a better fit from a different piece. You may do much better on what appears to be an equianalgesic dose of a new med, But their thinking is why start high if we can work their way up when we have to. But when changing docs he may just realize your not gettig relief because your not getting enough med. That’s easy to fix if they believe in the benefit of opiates and the patients need. Your DX, prognosis, medical history is what their prescribing practices are judged by if questioned, that's what justifies use in the present school of legal medicine and what protects them.
Given your condition, Take a complete history, typed up on as few pages as possible, preferably one, and list every modality, medication, treatment, PT, acupuncture, Chiro, Surgery, psych PM you learned or tried techniques with and their effectiveness and present it to him. He can insert in your chart if he believes he can help. IF you believe you can accept scripts then and there and just call doc#1 and thank him and let him know doc #2 will be managing all your meds. Let him know you have called any remaining refills in his name as not to cause a conflict. And you off and running with a nw doc and hopefully a a lot of hope and some immediate pain reduction. The document should explain everything really quick and gives him a list with names dates, people, contact info to confirm he he wants too. Your entire history. It will avoid duplicated attempts at previously tried modalities, some may be worth repeating, because I have had trigger point injections from docs that did nothing to different docs that can hit that spot 99% of the time and make a huge difference.
If your present doc doesn't offer Botox, and you want to consult with doc that uses Botox, that isn't excluded in any contract I can imagine. Whatever he isn't offering and hopefully the new guy or group does do it all That's the difference in a doc in private practice and a clinic. I guess some crazy one sided contract where you sign your house or child over in the deal and say you will never seek alternative treatment may preclude getting other opinions?? The "mine forever contract" NOT!!!
IF you don't agree what the new doc suggests at the consult, just tell him you will stick with what is working. Your interviewing him as much as he you. Is this the doc your going to trust not to let you suffer. However bad the present guy is doing, He's trying. You really may just need an increase and wear 2 or more patches. After 3 or 4 cycles you have a pretty even serum level and know this is as good as it gets and the patterns in that dosng schedule. If your at his comfort zone, then you probably have to find a new doc.
I don't see why you couldn't find a more aggressive doc that may have some other tricks up his sleeve that your doc may not know or believe in. How can a doc believe in anything working or not working, straight across the board? It's your life and you have to do what you have to. I you have to explain the consult to PM 1, just exlain the interest in the new modality or treatment he doesn't offer.
Good luck, Dave
catnap
01-01-2006, 08:12 PM
I am going through the same exact thing right now. Looking for a doctor with a good attitude that will treat my pain and not undertreat it. This last pcp thinks just because Janssen makes the largest patch at 100 mcq that it is a very high dose. He doesn't stop to think they just don't want to make the patches any larger. I guess he also believes that just because a patient sees him for the first time he is supposed to prescribe them at a "starting dose" no matter the amount they have been taking for the last 5 years is over 400 mgs per day.
Dave you make some good points but you just don't know until you see the doctor at the first appointment as to what and how he will do to treat your pain. Looking for a doctor is a job that I am not in very good shape to keep doing. I live in the country, 2 hours away from Dallas, it seems, where all of the best or better pcps are located. I have been looking for someone closer to me but I have come up with nothing good so far. I believe when my good pcp told me how bad insurance companies and Medicare were to deal with and get his money I started hoarding my meds thinking he might close up shop. Anyway, its an ordeal to have to drive that far and right now my pain level is up there. A lot of long distance phone calls. Even making a copy of my records is a major task. I know there are others that drive distances even further. You gotta do what you gotta do is right.
Being in severe pain over the holidays was a real drag. I couldn't have gotten in to see someone new anyway. But there is another doctor I am thinking about and have even called his office. He wants to review my records before I can even make an appointment. That, hopefully, will keep me from wasting my time and money.
And the same for me, I was still in pain but at least got comfortable from time to time. Now, there is no comfort at all. I don't have an endless supply of meds to keep me very long so I had better do something soon. I have an answer to my question of "I wonder how much pain I would be in if I didn't take anything at all"?
Please excuse my rambling, I am just not myself these days.
Thanks,
Carol
Dave you make some good points but you just don't know until you see the doctor at the first appointment as to what and how he will do to treat your pain. Looking for a doctor is a job that I am not in very good shape to keep doing. I live in the country, 2 hours away from Dallas, it seems, where all of the best or better pcps are located. I have been looking for someone closer to me but I have come up with nothing good so far. I believe when my good pcp told me how bad insurance companies and Medicare were to deal with and get his money I started hoarding my meds thinking he might close up shop. Anyway, its an ordeal to have to drive that far and right now my pain level is up there. A lot of long distance phone calls. Even making a copy of my records is a major task. I know there are others that drive distances even further. You gotta do what you gotta do is right.
Being in severe pain over the holidays was a real drag. I couldn't have gotten in to see someone new anyway. But there is another doctor I am thinking about and have even called his office. He wants to review my records before I can even make an appointment. That, hopefully, will keep me from wasting my time and money.
And the same for me, I was still in pain but at least got comfortable from time to time. Now, there is no comfort at all. I don't have an endless supply of meds to keep me very long so I had better do something soon. I have an answer to my question of "I wonder how much pain I would be in if I didn't take anything at all"?
Please excuse my rambling, I am just not myself these days.
Thanks,
Carol
jenonastar
02-21-2006, 03:12 AM
shorelinehave you ever had a spinaltap before?
Shoreline
02-22-2006, 12:47 AM
Hey carol, You absolutely right about it being hard to fnd a doc. You don't know untill you see the whites of his eyes, and they may not agree with a dosage or med the last doc had you on and want you to try new things or things that have failed in the past. If the end result is greater pain relief, you jump through just about any hoop there is looking for releief. Titration of new meds and dosages sucks, and it's part of our every day life.
If I sounded like it was going to be easy that wasn't my intent at all. What should be easy, In this particlur case is to adjust the medication. But if you have hit a docs ceiling of his comfort zone, you may have to fnd a new doc. Even if you hav to drive 2 hours or see another half dozen that believe in his case an increase is truly reasonable. When it's a quality of life issue allowing for tolerance is the only answer.
I feel I know what Allens condition is and what he's been through enough to feel comfortable saying, "you need to find a doc to work on adjustng your meds." It's rarely my first hand advice or the type of thing I would say to someone I don't know. I don't want to see soemone go from Lortab to methadone because they read about it working for someone else. There are alot of steps in between folks don't understand the need to take them because the price for pain relief is extremely high and often very disapointing.when the best they can do regardless of dose is take the edge off, but they can do it.
In this case, If the doc won't make an adjustment, he needs to consult with other PM docs. He may want to talk about a pump or a stim if ecan't find somene agressive enough with written prescriptions for many doses that atract attn to a doctor. The best consult is something the present doc doesn't offer.
I did mis type something . When or if you except prescriptions from a new doc, cancel any remaining refills from doc #1 before you call doc # 1 and thank him for his help but your leaving diplomatically. You just don't know if he will be the only guy within 200 miles 3 years from now. Why should he care if you reason for leaving was to try something he didn't think would help, most likely because he never learned how to or never tried it. A legit patient shouldn't take advantage of having the remaining pills eft from their previous doc. It's a tremendous show of good faith if the new doc is willing to take over your vcare now to offer to flush your old meds. At least take a script printout so he can figure what you have into a dose increase. Trying to hord anything that may even have the sligfhtest appearence of wrongdoing isn't worth risking your relationship with a doc. It also makes titration of a new med hard if somene is supplementing with meds from the old doc.
Bottom line is I feel Allen needs to figt for an increase, if his resent doc has refused, you have to do what ya gotta do. But give the new doc a chane, let him know how things have gotten. Let him know where your at and your willing to try anything.
Good luck , Dave
Jenon, I have never had a spinal tap to withdrawal fluid, but I have had several injections directly into the spinal cord,It's one method to do a trial for a pump. I've also had more injections and blocks than I can count.
The same risks that apply when injecting into the spine or placing a catheter like a pump apply to spinal taps, You can have a seizure, you can have a leak or get an infection, those are the 3 biggies but still uncommon .Odds are in your favor nothing bad will happen but if you do have a leak, they can fix it and it's pretty impressive how fast it fixes things.
Don't let fear of a test or procedure prevent you from finding the cause of your problems or a cure.
Take care, Dave
If I sounded like it was going to be easy that wasn't my intent at all. What should be easy, In this particlur case is to adjust the medication. But if you have hit a docs ceiling of his comfort zone, you may have to fnd a new doc. Even if you hav to drive 2 hours or see another half dozen that believe in his case an increase is truly reasonable. When it's a quality of life issue allowing for tolerance is the only answer.
I feel I know what Allens condition is and what he's been through enough to feel comfortable saying, "you need to find a doc to work on adjustng your meds." It's rarely my first hand advice or the type of thing I would say to someone I don't know. I don't want to see soemone go from Lortab to methadone because they read about it working for someone else. There are alot of steps in between folks don't understand the need to take them because the price for pain relief is extremely high and often very disapointing.when the best they can do regardless of dose is take the edge off, but they can do it.
In this case, If the doc won't make an adjustment, he needs to consult with other PM docs. He may want to talk about a pump or a stim if ecan't find somene agressive enough with written prescriptions for many doses that atract attn to a doctor. The best consult is something the present doc doesn't offer.
I did mis type something . When or if you except prescriptions from a new doc, cancel any remaining refills from doc #1 before you call doc # 1 and thank him for his help but your leaving diplomatically. You just don't know if he will be the only guy within 200 miles 3 years from now. Why should he care if you reason for leaving was to try something he didn't think would help, most likely because he never learned how to or never tried it. A legit patient shouldn't take advantage of having the remaining pills eft from their previous doc. It's a tremendous show of good faith if the new doc is willing to take over your vcare now to offer to flush your old meds. At least take a script printout so he can figure what you have into a dose increase. Trying to hord anything that may even have the sligfhtest appearence of wrongdoing isn't worth risking your relationship with a doc. It also makes titration of a new med hard if somene is supplementing with meds from the old doc.
Bottom line is I feel Allen needs to figt for an increase, if his resent doc has refused, you have to do what ya gotta do. But give the new doc a chane, let him know how things have gotten. Let him know where your at and your willing to try anything.
Good luck , Dave
Jenon, I have never had a spinal tap to withdrawal fluid, but I have had several injections directly into the spinal cord,It's one method to do a trial for a pump. I've also had more injections and blocks than I can count.
The same risks that apply when injecting into the spine or placing a catheter like a pump apply to spinal taps, You can have a seizure, you can have a leak or get an infection, those are the 3 biggies but still uncommon .Odds are in your favor nothing bad will happen but if you do have a leak, they can fix it and it's pretty impressive how fast it fixes things.
Don't let fear of a test or procedure prevent you from finding the cause of your problems or a cure.
Take care, Dave