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Old 08-25-2008, 04:18 PM   #1
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How much pain is too much?

Hello to all,
I'm a regular on the back board and I've been "cruising" over here for a few weeks. Please bear with me while I tell my story and then please I need some input.

Injured my back at work catching a falling IV pump in June of 2007. Herniated L5-S1 and had a broken off piece on the L5-S1 nerve root. Laminectomy, PT, nerve blocks, ESI's, TENS unit, EMG shows permanent nerve damage, last MRI shows bulging of L4-L5 and again at L5-S1 and scar tissue. I have not been pain free since 3 weeks post op.

Meds.....I am very sensitive to just about all meds. I've tried and couldn't take.....Cymbalta, Lyrica, Neurontin, Topomax, and many more. I've been managing my pain with Darvocet mostly and occasional Percocet. Some days I may only have to take 1 Darvoce, and some days even with 3 Darvocet the pain is still a 7-8. My pain varies so much day to day and throughout the day. I have a high pain tolerance (had a 10 lb baby the "regular" way with minimal drugs) but lately I am not handling the pain well at all. Also the surgeon told me last week he wants to change my med to Tramodol (worried about addiction to the Darvocet). I have been using it for a week and it does not seem to control the pain as well. I went to a PM for a while and he did my ESI's and he is a MAJOR JERK!!!! He is actually the meanest man I have ever met. He said I was not in pain (how does he know) and to keep doing my back exercises!!! I will not go back to him!!! I am on W/C so they have to approve me seeing someone else.

I am working 4 hours a day (sedentary, no patient care), I can walk at the store for about 30 minutes, I don't do any lifting or strenuous activity. Some days I struggle to work and lay on the sofa all day, which is so very "not me".

I can have a good day of a 2-3 and turn right around and have a week of 7-8's, regardless of what I do. The pain totally dictates my life.

I know I don't have the pain that some of you have.....but my question is what do I do when the pain is so very inconsistent? What should I do or expect in the way of pain management? Is my pain bad enough to warrant something different? Is this a pain that I just continue on and learn to live with?

Pain is a 7 today and the Tramodol isn't doing a thing!

Thank you all so much!

Deb

 
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Old 08-25-2008, 04:49 PM   #2
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Re: How much pain is too much?

Deb,
please don't be discouraged by your heartless PM saying that you don't have any pain. You are on W/C that is why he is doing it to you. Many people here go through the same thing with W/C.
I suggest you to insist to see someone else; obviously he is not a DR who is interested to help you. And how can he help you if he even doesn't believe you have any pain?
Honey, pain is pain and it needs to be under control. I am very sensetive to many meds as well, had reaction to many of them too, but still a good DR who is willing to work with you can provide you with some relieve by Rx meds. There are so many of them on market, he can try them on you, adjust doses and so on. Whatever is good for you,may not be good on me and v.versa.
That is why your treatments can't be "one size fits all". But again, it takes a good Dr who will work on it for you.
My PM put me on Morphine while ago - did nothing for me. Than other meds and until he got the right once, took some time.
I have very strong tolerance as well. My body gets used to meds very fast, too fast in fact. In June he puts me on Oxy and month later I am at square one with same pain. Dose needed to be adjusted again.
And so on. But nobody has the right to give up on you or tell you how much pain you are in or not.

Best of luck to you, honey

 
Old 08-25-2008, 10:20 PM   #3
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Re: How much pain is too much?

Hi Deb,

I agree with Moldova and suggest you find a new pm doc and possibly another surgeon, at least for a 2nd opinion.
The other thing I wanted to add is that darvocet is one of the lowest narcotic pain meds, so I'm not surprised you don't receive good pain relief from it...Pain is best treated by taking meds before it gets to bad and if you're having a 7+ pain day, a darvocet probably won't touch it no matter how many you take. You mentioned that you take percocet occasionally, is the surgeon the doc who gives you the rx? If so, I'd imagine that he wouldn't want to rx percocet either since he's so worried about addiction to darvocet.

You have some serious issues with your back and I'm surprised that any doc would question your pain...The scar tissue alone is enough to cause severe pain and tramadol probably won't cut it...Please contact your wc and tell them you want to see a new pm doc. I wouldn't trust any doc who would even hint that your not in pain, especially with your back surgery/scar tissue. There are treatment options for your pain, but it does take time to find the right doc.

Good luck

 
Old 08-25-2008, 10:21 PM   #4
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Re: How much pain is too much?

Deb,

So sorry you had to deal with a jerk like that. I think we all have had some similar experience at one time or another. (even more, probably, for some) I really feel that if your pain is reaching 7's and 8's you definitely need something stronger for the pain. And please don't ever feel like your pain is less than anyone elses. Pain is pain, and we all have our breaking points. As far as my PM doc is concerned, anything over a 5, is not acceptable. And I've seen plenty of other's here post that their doc's feel the same.

I am not really familiar with W/C, but I believe I have read/heard that they have to allow you second (and possibly third) opinions. There is a board here that deals with insurance issues and that includes W/C. I'm sure if you checked over there, you'd get some good info. Either way, you are in pain and you deserve to have some help.

If you have taken Percocet with some success and few or no nasty side effects, then any meds in the oxycodone family would probably be a good bet for you. The problem is, getting you to a doc who will believe in you and do what is right and best for you. I've always heard that W/C docs have one goal and that is to get the patient back to work and out of the PM loop, so the employer will be happy. And that's why they refuse to admit or concur that you have legit pain. What creeps!

I wish I could help more with the W/C part, but hopefully you can find out what your rights are on the other board, and get in to a good doc, who will treat you with dignity and respect. Please keep us posted as to how it's going. Take care and God Bless, CMP/MM

 
Old 08-26-2008, 01:56 AM   #5
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Re: How much pain is too much?

Deb, I'll write more later, but you certainly have *too much* pain! Really sorry you had to deal with a jerk - I have a hard time imagining that anyone on this board has managed to have a jerk-free experience. I too do not know the WC rules but you *have* to see a decent PM. If you have to borrow money to see a PM on your own dime, then you have to do that....A WC doctor is working for WC, not for you - they want to close up the claim and get rid of you. So, of course you have no pain. Does your reg. insurance pay for a PM?

I truly have to go to bed right now but my hackles went up when I saw your post. You have had such a great attitude despite having so much pain - you should be so proud of yourself.

BTW, I have not heard good things about Darvocet - it's an odd medictation and I believe that you can have problems [not just dependency] if you take it for long. Percocet [which does not sound even remotely strong enough to tackle your pain] is a better choice. But, seriously, you need to get some recs for good PMs and see one. Now. No question you are in too much pain. I'm not sure I would mention your pain goes all the way down to a 2 at times though - I would try to get a sense of the doctor first. I say this only because I do not want you to have your pain dismissed again. When you get a good sense of a doctor, I think you can talk about the variability - for now, I would talk about how your pain restricts your ability to function, where you feel the pain, what kind of pain you feel, ....

I have a good feeling about the acupuncture, but you're going to need something stronger for a while - you should be thinking of the acupuncture as one aid in a multi-pronged approach to pain. It may allow you to take less pain medication at some point, but right now, I think you are severely under-medicated. Tramadol works for some people, but does nothing for others. I would really try not to go back to the darvon/darocet - I don't remember the problems with it, but I would look into the medication to find out what I'm vaguely recalling. Vicodin is probably a better choice than darvocet. But I think you honestly need to be on something considerably stronger than vicodin or percocet. If percocet is all you can get right now, try to get a decent scrip. Take care and keep stopping in for pain support.

 
Old 08-26-2008, 08:47 AM   #6
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Re: How much pain is too much?

Hi Deb! I am glad to see you and have the opportunity to chat with you again but am at the same time very sad that you need us.

I suspect if you are asking this question that you are undertreated and experiencing to much pain. If the new medication is not working, you need to speak up and tell them. If they are not listening, you need to find a new doctor and be sure to bring someone to your appts that can verify your meds are not working or add further reinforcement of this. Once my hubby started coming with me to my appts my docs began listening and even putting in the notes hubby said, this or that, they began doing something about my pain.

You are in my thoughts and prayers.

 
Old 08-27-2008, 11:11 AM   #7
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Re: How much pain is too much?

I pretty much say ditto with everything everyone else has already said.
I do want to say once again that any pain that keeps you from quality of everyday life needs to be treated. Everyones pain matters. Everyone has a level of pain tolerance. I feel so bad & helpless when I hear stories like yours, after all you have been through how can a doctor say you dont have pain. Its amazing how different doctors are. I cant understand why any doctor would become a PM doctor if they do not have any compassion. I have been told on several occasions that when someone is in alot of pain you can see it, in their face, body langauge & so forth. It makes no sense to leave some one in pain. I can tell you I tried many meds, & alot of them did nothing at all for my pain. I can see why a doctor would be concerned about narcotics but that is what contracts & rules are for. They can sit down go over the risks involved & so on. There is no reason to leave someone in that much pain.
If you can get to another doctor asap & let that doctor know that you just want some quality in your life, at the very least a level of pain you can function with. Good luck & I hope you can find a more compassionate PM. God bless, Sammy

 
Old 08-27-2008, 03:43 PM   #8
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Re: How much pain is too much?

Any doc who tells a patient what they do and do not feel has stepped way over the line.

Any PM who is worried about addiction to darvon/darvocet is not qualified to be a PM. Any PM doc who prescribes this med for any kind of regular or severe pain is over their head and should get another job.

You need to be seen by a competent physician. A PM would be best. I have no experience with WC so I do not know how to go about getting that kind of help, but please do whatever you can to get to a pro. Even if you have to pay out of pocket just so another doc can have input from a decent PM would be good. If a good PM can recommend helpful therapy (e.g. a med regime that actually works), then maybe whatever other doc you have will feel comfortable prescribing what a specialist (PM) has recommended.

steve

 
Old 08-28-2008, 09:37 AM   #9
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Re: How much pain is too much?

Steve, as always to the point, you have such a way with words. Steve has gave you the best advice in a nutshell. Good luck, I will keep you in my prayers. Sammy

 
Old 08-28-2008, 01:09 PM   #10
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Re: How much pain is too much?

Thank you all so very much for your responses.
I am hearing loud and clear that I need a competent PM. The PM who is the jerk, who I haven't seen in 6 months, is in the same practice as my surgeon. My surgeon is the primary doctor for the W/C case. I absolutley love him, he has been great. But, he is reluctant to send his PM patients anywhere else. I will have to call W/C and get the names of other approved PM's. My surgeon is the one who is worried about addiction to Darvocet...he prescribed the Tramadol. It doesn't touch the pain and reading the literature, it seems you can get addicted to that drug also!
One of my big worries is that my pain is not consistent. I'm not complaining...I'm just wondering if I will be taken seriously. From what I see on here most of you have consistently high pain levels and mine can range from 3-8 in a single day.
I will try to call W/C and hopefully they will help me find someone else. They just approved acupuncture for me so hopefully they will be receptive to a new PM.
Thanks again!

Deb

 
Old 08-28-2008, 01:38 PM   #11
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Re: How much pain is too much?

Deb-
My pain in inconsistent as well and my pain management doctor takes me seriously. He just increased my vicodin because I told him when my pain hits, it gets real bad and I cannot function. He knows that I have some good hours in between the bad ones. In fact, today it is 3:30pm and I have only taken one vicodin all day so far. I am about to take a second, but today was a good day. Other days I need to lie down with a pain pill.

I really believe it is all about quality of life as others have said. I have a 2 and 3 year old to take care of. I cannot be lying around all day. I have playdates, preschool, volunteering. and I do work from home as well. I don't have a housecleaner and have no famly to help with the kids. So, it is all up to me and I must function. I am still flighting my pain pills as I HATE to think I must rely on them, but then i look at my kids eyes and see that they deserve a mom who will play with them.

I also remember a comment my orthopedic surgeon told me. He told me to get off the vicodin and to only take tylenol. Then in the next breath he told me I should not be doing any housework and not to lift my kids under any circumstances.....that just made no sense to me. It is my PM doctor who really understands the levels of pain I have.

Good luck!

 
Old 08-28-2008, 04:55 PM   #12
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Re: How much pain is too much?

Quote:
Originally Posted by deb53 View Post
...My surgeon is the one who is worried about addiction to Darvocet...he prescribed the Tramadol. It doesn't touch the pain and reading the literature, it seems you can get addicted to that drug also...
Deb,

Are you aware of the difference between addiction and dependence?

Please disregard if so, but here's a short explanation.

Everyone who takes opioids on a regular basis will become physically dependent on them. It's called tissue-dependence, and it's simply the body becoming accustomed to it to the point that if stopped abruptly, the body will crave it and exhibit flu-like symptoms until the dependence is gone - usually 3-5 days for light use and longer for heavy use. Dependence is a natural occurrence and not a matter of fault or guilt. Addiction is an uncontrollable urge to obtain and use opioids. The addict is consumed with getting and using narcotics, even when such obtaining and using has become harmful. They spend all waking hours devising ways to get more narcotics and then use them. It's totally consuming.

As you can see, the difference between the two are significant. The saddest part is when professionals like surgeons don't understand the distinction.

Yes, it is possible to become dependent on Tramadol (Ultram). It is a mild opioid with some anti-depressant modes thrown in for good measure and can be effective.

steve

 
Old 08-28-2008, 07:33 PM   #13
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Re: How much pain is too much?

Steve...thanks so much, I do see the difference. If they don't want me on Darvocet and the Tramadol is not helping, what would you think would be the next drug they would try? Is Tramadol a drug that must be taken on a regular basis for it to help? I have only taken it on a PRN basis.

10sox....thank you for sharing that your pain is also very inconsistent. I just need to find a good PM, but it seems that most of the people on this board have gone through a number of "jerks" before they find the right one. Has that been your experience?

Deb

 
Old 08-30-2008, 02:39 AM   #14
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Re: How much pain is too much?

Quote:
Originally Posted by deb53 View Post
Steve...thanks so much, I do see the difference. If they don't want me on Darvocet and the Tramadol is not helping, what would you think would be the next drug they would try? Is Tramadol a drug that must be taken on a regular basis for it to help? I have only taken it on a PRN basis. Deb
*Deb, I misread your question - you asked what the next med they (surgeon or difficult PM) might try, not what might make sense to try - at least I think this is your question. I think your surgeon would probably try vicodin, norco or percocet -short acting medications [though these produce dependency as much as any other opioid medication if taken regularly.] It's possible a good PM might want to see if your pain could be handled with a short-acting med taken on an as needed basis, in which case he or she might use the same meds listed above. I think most/many PMs would rather put you on a very low dose of a long acting med. I could be wrong about this though. What I wrote below is probably what a good PM would use if he/she decided you needed LA meds. Steve would know if you need to take tramadol consistently to get a decent benefit from it. I suspect you need to take it regularly to get the full benefit, but I honestly don't know.

I wrote a fairly serious critique of wc below and suggested that this was part of the reason why you weren't getting better PM doctors. However, I reread your post and see that you like you surgeon a lot, so maybe WC isn't giving you doctors that will tow the line and work for them, rather than for you. You know a lot more about WC than I do, so you can probably figure out if they are trying to prevent you from seeing someone who could say your pain is chronic [which might cost them a lot more in the long run]. I do think most surgeons are anti meds for the most part and work w/ very conservative pain management doctors - at the very least, this was my experience, so I might think about trying to find and get a referral to a PM from someone else like your PCP. Anyway, post I wrote a few days ago is below, just wanted to add this part...I may be wrong about WC or even the referrals your surgeon has given you. I'm only speaking from experience and some speculation here. . . .

--------------------

The next step up from a short-acting medication or from tramadol would probably be an extended release form of morphine. The generic is MS Contin, and there are several to choose from as brand versions of LA [long acting] morphine - Avinza and Kadian. Some doctors like Kadian because it is more difficult to abuse, but it's unlikely a GP or surgeon would know anything about the differences. Oxycontin is another possibilty, though it is only available in brand. It's gotten a lot of bad press (but then so have many other meds]. You can start on very low doses of these. You might try a stronger short acting medication first, like Percocet, or even Norco, but with your pain levels it's possible/probable that you will need a LA med [and then another med for break through pain - pain that "breaks through" your long acting medication when you have a flare up of pain. This would be particularly important for inconsistent levels of pain. I don't know if you need a SA or LA since your pain is sometimes very low. It is nice to be able to take pain meds on an "as needed" basis if you can do that - however, your tolerance goes up faster, it's harder to manage the pain, and there is actually a slightly higher chance of addiction with SA [or short-acting] meds b/c you get more of a high when you take them infrequently and b/c your brain associates pill-taking with pleasant feelings, or whatever effect you're getting from the meds. If taken infrequently, you do feel some euhporia and some of the other "addictive" aspects of opiods. You also have trouble thinking straight! This isn't the case when you take opiods regularly - you might feel this initially or when you have dose increase, but the only side effect that remains is the inevitable constipation.

The upside is that you can avoid physical dependence if you take them infrequently [a few times a week]. If you take them more often, or if your pain isn't relieved by SA meds (you play "catch up with pain when you use SA meds, which makes it harder to control the pain as well). Steve stated a lot this quite eloquently in a post on Sammy's thread [I know she has a few, but the most active one??] - explaining the differences between SA or LA meds] Ironically, surgeons and GPs are often afraid of LA meds and think of SA meds as "safer" when it's actually the opposite. They are used to prescribing for acute pain after a surgery or an injury, and in these cases, a SA med makes sense. If you see a decent PM, I would be very honest about the inconsistency of your pain -they will understand. I only cautioned you b/c you haven't seen a "good doctor" who understands pain at this point.

There is also a thread, and Steve may just list the meds here, kind of stacking up the meds in terms of steps/potency - I think it might have been started by Kmit..

Quote:
Originally Posted by deb53 View Post
I just need to find a good PM, but it seems that most of the people on this board have gone through a number of "jerks" before they find the right one. Has that been your experience?Deb
Deb, my first year was jerk after jerk [well, not all of them were jerks, but they were all opiophobic [it's an actual term] *Very surprisingly,* ;-) *all* of these doctors were either surgeons or the PM's they sent their patients to when they got nervous about the pain meds and had to prescribe something stronger than vicodin or norco. Again, I think that most surgeons are anit-meds - they believe that their surgery will eliminate the pain in many cases - if it doesn't they may feel some sense of failure. They also just don't understand pain medication very well. I don't know if it was a coincidence that the PM's they sent their patients to were also somewhat opiophobic and reluctant to prescribe enough pain medication [I don't think so....]. I later looked at some reviews of the pain management doctors my neurogsurgeons sent me to, they *all* received very poor reviews from patients.

While there are plenty of lousy PMs out there, there are also a number of good ones. I think you've been consistently getting jerks for two reasons. First, as I discussed above, your referrals are coming from surgeons. Second, you're stuck in the WC system - their goal is to pay as little as possible - their doctors are not going to give you the kind of objectivity you need - they are working for and approved by WC, which may be working hard to discredit your injuries and pain.

I think you may need to get out of this system and see a pain mangement doctor who is not affiliated with WC, and is not a referral from a surgeon. I don't know the rules, but I would think that it would help your case to get a PM outside of the system to evaluate your condition and pain. You might still wind up with a jerk, but I think the chances of this would drop dramatically once you got out of the system (particularly if you could find a PM that has been recommended). I suspect that WC does not want you to see anyone who isn't on their payroll b/c it could wind up costing them much more over the long term if they have to pay you money to settle your claim or pay for ongoing treatment for chronic pain.

My hope is that you can get a good referral from your PCP - this can be kind of a crapshoot but you almost always need a referral to see a PM. You might also try to find reviews of PM doctors in your area and tell your PCP that you have heard good things about "Dr. Brown", for example, and would it be possible to see her? I don't think WC can *stop* you from seeing a PM that isn't on their list if you pay for it [I realize your insurance may refuse to pay b/c it's a WC claim]. I don't know, but I think that it could help your case to have an "independent" PM evaluate you. It might get you a better settlement [if that's in the cards] than you would get if your evaluations come exclusively from WC doctors. They have a conflict of interest when they treat you b/c they are working for WC and their jobs depend in part on keeping WC claims as low as possible.

I'm not saying you can't find a good PM from WC or that no surgeon will refer you to a good PM. I'm only saying that I think it is much less likely. While I don't understand the system well, I think WC chooses doctors who will minimize their costs. Has it ever struck you as odd that you have to see WC's doctors? If the system were fair, and not biased against the patient, you would be able to see whomever you wanted.

I'm suggesting you do this, even though it will probably be out of pocket. If the opinion of a doctor who is not on WC's payroll can be considered in your claim, you may wind up recouping the cost of the visit and more. But, I realize you may have to obey certain rules to avoid messing up your claim and that one of them is probably just to see their doctors.

Obviously, if you're going to see a doctor you have to pay for, you want the doctor to be good -if you think your GP would be helpful and would make a good referral, I would request a referral from him/her. Otherwise, I think I might suggest that you ask people on the board if they know of anyone in your area or try to find reviews of good Pms, and then see if your GP [or maybe your surgeon], would refer you to the PM. Who knows, mabye you can give WC a name and they will allow you to see the PM. I wish I knew the WC system better - there may be a board that is helpful with this.

Anyway, those are a few of my thoughts on how to see a PM who will treat your pain seriously. Nothing is guaranteed, of course. You could wind up paying out of pocket for a PM who is not better than the PM you saw. A little research ahead of time may make this less likely.

Last edited by Confused089; 09-02-2008 at 02:01 AM.

 
Old 08-30-2008, 05:02 PM   #15
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Re: How much pain is too much?

Quote:
Originally Posted by deb53 View Post
Steve...thanks so much, I do see the difference. If they don't want me on Darvocet and the Tramadol is not helping, what would you think would be the next drug they would try? Is Tramadol a drug that must be taken on a regular basis for it to help? I have only taken it on a PRN basis...
Next up is probably hydrocodone (Vicodin). I imagine that until your pain is chronic, daily, that a short acting med is most appropriate. Vicodin is short acting. Regarding Ultram, you do not have to take it every day for it to work, if it is going to work. It really depends on your level of pain. It is a complex drug as it also has some anti-depressant properties. It works for some and not for others. It works best for nerve pain.

I wish you the best of luck in getting relief. Please keep us advised.

steve

 
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