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Old 09-02-2008, 07:20 AM   #1
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Breakthrus

How common is it for doctors to not prescribe breakthrus?

The reason I ask is tomorrow I have a phone appt with my doctor who is stabilizing my medications and she had me complete a questionnaire and email it to her.

This morning I received an email back based upon my response telling me that she was going to address nerve medications, anti-depressent, base medications as well as No Breakthrus.

So it sounds like she is a non-believer in them which has me a tad concerned. Those of us that have spine pain know that one turn is all it takes and you can thru your back out. I guess if this happens it sounds like I will have to tough it out ???

This could be interesting.....

 
Old 09-02-2008, 07:51 AM   #2
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Re: Breakthrus

Sort of interesting correspondence - by email.....I don't know that a dr. has ever sent me the "agenda" ahead of time! Perhaps the PM wants you to be on a high enough dose so that break thru pain is very rare? ? Still, it does seem odd since BT meds are pretty standard.

At one point, I realized I was using my BT meds incorrectly and, as a result, was on a higher dose of meds than necessary b/c my meds had to be able to handle BT pain [not completely, but enuf so that it didn't go off the charts or really high]. Not sure how clear that was - bascially, if I'd been using BT meds corrrectly, my dose could have been lower.

The only med I consistently hear of doctors *not* prescribing BT meds for is Methadone. I"m not sure why this is, but it seems to be related to the fact that people get such strong relief from Methadone that they sometimes don't "need" BT meds. So, I'm wondering if she has a similar philosophy - get you LA meds high enuf so that you're not taking BTs? She seems fairly liberal w/ the LA meds. I suppose some PM doctors might worry about patients using BTs incorrectly/overusing them, etc. This would have to be a personal philosophy of hers though - I can't see how she would single you out on this since she's been in our corner from the day you met her.

Are you at the full dose of LA meds she offered now? A phone call is kind of tough, but could you have a pain journal ready to email to her when the discussion of BT meds comes up? This might help to illustrate your need for BT meds. Did she give you BTs before or say anything about this?

Last edited by Confused089; 09-02-2008 at 08:28 AM.

 
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Old 09-02-2008, 08:32 AM   #3
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Re: Breakthrus

Quote:
Originally Posted by 123dietdrpepper View Post
How common is it for doctors to not prescribe breakthrus?

The reason I ask is tomorrow I have a phone appt with my doctor who is stabilizing my medications and she had me complete a questionnaire and email it to her.

This morning I received an email back based upon my response telling me that she was going to address nerve medications, anti-depressent, base medications as well as No Breakthrus.

So it sounds like she is a non-believer in them which has me a tad concerned. Those of us that have spine pain know that one turn is all it takes and you can thru your back out. I guess if this happens it sounds like I will have to tough it out ???

This could be interesting.....
Top of the day to you Pepper~
I know by my own personal experience that PM Dr's are now trying to give as few breakthrough meds as possible now with the newer meds out there to control nerve pain in chronic pain patients. They now have Lyrica, Neurontin, Tricyclic Antidepressants: such as Elaval, Sinequan, Imipramine, to name a few...these antidepressants block the passage of stimulant chemicals..norepinephrine or serotoin, in and out of the nerve endings, producing a sedative affect. They believe these drugs work by causing long term changes in the way nerve endings function and can block the pain stimulus.

Lyrica and Neurontin, which is another, but a Anticonvulsant, slowing down the GABA-related nerve impulses ...GABA, the major inhibitor of nerve transmission in the brain, thus blocking or shortening the length of the nerve inpulses where they stop short of causing such pain throughout the spine or any nerve endings of the body.

I think they came out with using all of these and then some other's because of the use of these drugs on people with Fibromyalgia, which seem to help quite a few people now with their pain. I for one don't get much relief from using the Lyrica though, so that's another reason for keeping me on the b/t's for severe pain intervals.

I believe in your case as in mine though, your PM might keep you on the b/t's and try you on one of these types of medications just to see if they help for your breakthrough pain instead of/ or with narcotics. Just my opinion though... It might help you and then again it might not work well for you, everyone is different with their ability to maintain their level of pain or how much you're in at a given time.

So, don't give up hope just yet my friend, see what your PM Dr has to say first...I'm sure they wouldn't take you off of your b/t meds without tapering you first anyway or if at all, like me, where I'm still taking b/t's.

Let me know how you make out if you'd like...now you've got me more interested about the use of these meds that are being pushed more onto the PM Dr's!!
I hope you have a sparkling day, and I'll be thinking and wishing you well,
Shelby

 
Old 09-02-2008, 08:51 AM   #4
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Re: Breakthrus

Pepper,

I've missed you sweetie, but I figure you have a lot going on with the home schooling starting up again, and feeling more "up" to doing things that you hadn't been able to do in the last year or more. I hope you are still seeing those 5's regularly!! Or even 4's!!!

I agree with confused that some docs just don't "do" BT meds. There are a few different schools of thought in the PM world, about the need for them or not. I know my PM feels that more LA med and less BT is the better way to go, but he still believes that at least some amount of BT is needed for most CPer's.

It does sound like this new PM of yours is pretty anti-BT. I honestly don't know if you'll be able to convince her otherwise. But that doesn't mean that you shouldn't put it on the table. Remember, as Steve, Ex and so many of us say, communication is key! And there's a great deal of logic in your concerns/questions, and it should be discussed with the PM. If she really is as good as she seems to be, then she should, at the very least, hear you out and take what you say under consideration.

Best of luck with the call. Please let us know how it all goes, OK? Hope all is well and you are still enjoying the "new" you. Hugs and prayers, CMP/MM

PS: Am I correct that you aren't currently taking BT meds, since the increase in LA meds? Just the additional 10mg's of Oxy, if needed?............

Last edited by cmpgirl; 09-02-2008 at 08:55 AM. Reason: PS

 
Old 09-02-2008, 08:55 AM   #5
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Re: Breakthrus

Confused - She is doing some preliminary work ahead of our phone appt tomorrow morning via email because she is getting ready to leave the country for 8 weeks and she is short on time tomorrow.

I have only seen this dr for one month maybe now. She is trying to stabilize everything before she returns my care back to my primary doctor. Prior to seeing her I was on 40 mg. oxycontin and 3 10-25 percocet. She upped my dosage so far to 100 mg. oxycontin, had me dropped the percocet and told me if I absolutely needed a BT I could take an extra 10 mg. of oxycontin. Since it has been such a large increase I have only needed this extra 10 mg. once or twice.

I suspect I need an increase in the evening still.

One of my ?'s was about breakthru meds if I would be allowed any in the future once I returned back to my primary care. I suspect she is not going to allow them and I am suspect that maybe this is her intent. I was wondering if this is common.

Last edited by ms_west; 09-02-2008 at 08:56 AM.

 
Old 09-02-2008, 09:01 AM   #6
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Re: Breakthrus

Intersesting Shelby - about the reduction. So far they have tried neurotin and I ended up with an anayphlatic reaction. Evail and palemor made my hands start swelling. Lyrica we tried and I think it did nothing for me before. Cymbalta has done absolutely nothing for me.

You are right I should wait to see what she says...I just have been burned a few times in my past and I worry about not being properly medicated.

 
Old 09-02-2008, 09:13 AM   #7
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Re: Breakthrus

CMP, To be honest I have been dealing with the wrath of depression and exhaustion the past couple of weeks. I think before my med changes I only concentrated on getting thru the day. I couldn't see / comprehend deailing with tomorrow. Now that I am on more meds, staying on the 3 to 7 on pain scale, I am able to think about tomorrow and yesterday. I need to cope with some of the feelings I have about my future.

I have mentally been sorting out that the pain medication helps me get thru the normal day to day stuff but if I try to do the extra -- I still have to deal with the aftermath pain. In other words, the meds help dull the pain but it has not resolved the underlying mechanical problem. It is still there so I suspect I will have pain. Maybe it is a matter of me building up my strength and muscles again. I don't know. When I went shoe shopping, it set me back for the last two weeks and I am just getting it back together again.

 
Old 09-02-2008, 10:18 AM   #8
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Re: Breakthrus

Pepper, don't think it's common but it is one school of thought. I would definitely try to get the increase since she is leaving for 8 weeks - I wish you were seeing her in person though. It's os much easier to communicate and discuss things in person. I would certainy mention the times you've needed the 10 mg. of oxycodone and I would also tell her that you're concerned since she's leaving town. I do think that if you've managed to get you pain down to a 1-3, BT episodes will be fewer and less severe. I don't know how your pain is now. If it's still hovering around 4-6, I would definitely feel concerned about not having BT meds. Sorry, see you're at a 4-7, IMHO, this isn't low enough to avoid some pretty strong BTs. W/o BT meds, I think you should be shooting for a pain level that is closer to 1-3, then when you have BT pain, it's less likely to become unbearable.

I would make a list of what you want to have happen tomorrow - what you want to push hard on, and what you're willing to let go, and try to come up w/ data to support what you want. I would be a bit wary of starting on new meds [anti-d's or nerve meds (I see you've already tried some) when she won't be around to help. It honestly seems a little early to say you're stabilized - this seems to revolve more around her vacation schedule than your body right now.

I read your post that you've been dealing w/ depression - you're going through so many changes physically and emotionally - I imagine that's going to take so time to sort out. I'm sorry you've had depression - I've had some horrendous episodes of depression during my change of meds, so I can empathize. Acupuncture has helped *a lot* w/ the depression as well as all the other wd symptoms. I'm so grateful for this. If you've stopped the acunpuncture, you might try it again - it is incredibly helpful for stabilizing my emotions and taking the edge of my pain [I just wish it lasted longer] - I literally called 8 or 9 acupuncturists yesterday until I found one that was open b/c I knew it was the only thing that would help me w/ the symptoms from the wds - it has lifted the depression (stimulates endorphins), gotten me centered and relaxed, stopped my shaking/sweating, cleaned me out [won't go into unnecessary detail here!, and just helped me so much during a time when my body is all over the place.. - Just a suggestion - the acupuncture could help stabilize you physically and emotionally].

Last edited by Confused089; 09-02-2008 at 11:37 AM.

 
Old 09-02-2008, 10:54 AM   #9
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Re: Breakthrus

Quote:
Originally Posted by 123dietdrpepper View Post
...the pain medication helps me get thru the normal day to day stuff but if I try to do the extra -- I still have to deal with the aftermath pain. In other words, the meds help dull the pain but it has not resolved the underlying mechanical problem...
Pepper,

You've already been given outstanding advice, and I have a few thoughts to add.

First, are you sure that in the doc's email it indicates "no" breakthroughs, or could it be short for "no [of] breakthroughs, meaning number of breakthroughs? Just curious.

About increases - I recall you reporting that this doc wants to see you at 3-4 on the pain scale, correct? So, if she is "anti-BT", this may be her solution. In many ways, BT meds end up being part of the daily dose, and serve for many to simply increase tolerance very quickly. This may be her experience, and if so, then she's just looking out for you. Allowing an extra 10mg OC is another approach by many of the cutting edge docs - I know it sounds screwy, but it was how I was allowed BTs when I was on methadone, just take another one when needed (up to a limit).

You obviously know that there no med that's gonna solve your underlying mechanical problem, right? I have to believe her approach pharmacologically is to keep your pain below 5 on average. Please do discuss the BT issue with her, but try no to go to the mat on it because I truly believe her approach is going to provide you with the overall best pain relief.

I would opt for the final increase to 120mg daily. You can always go back, but so many have found that by denying an increase, later docs seem to forget or get distracted and they never get the increase when they need it. Go for it now Pepper.

I would seriously hesitate to start anything new while she's gone. Going with the increase in OC is fine, but totally new meds only when she's here. Who else is gonna manage you with a bad reaction if she's 8 weeks away. I would object to new meds on this basis.

I really like this doc Pepper. I'm jealous. I have a great one too, and I can't complain. But your doc is even more cutting edge than mine, and I'd love to be in her practice. You are so fortunate. And, you deserve it/her.

steve

 
Old 09-02-2008, 11:39 AM   #10
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Re: Breakthrus

Just want to 2nd all of Steve's advice :-) I liked his interpretation of no (.?) breakthrough meds...

Last edited by Confused089; 09-02-2008 at 11:40 AM.

 
Old 09-02-2008, 02:46 PM   #11
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Re: Breakthrus

You both could be right re: no breakthrus.

She told me last month because she is going to be gone for 8 weeks that this is why she can't take me on full time. She is doing alot of research on pain medication and some of this research will be taking her out of the country. She has told me that she will help stabilize me; however, if I have any reactions or problems when she is out of town my GP has agreed to take over my care. She told me that she will try to contact me while she is gone but we will have to have telephone calls and appts at around her schedule. If there is any problems, I have to go to my GP. Because she is so good, I am willing to do this. Heck, I would be crazy not to.

It does say No Breakthru - Work hard at avoiding the oxycontin. I know this is tough but in the end makes your body want more med. To me I think she means no breakthru's.

Yes, I know there is no medication that will relieve the mechanical pain but I lost sight of that. I was being stupid and hoped my meds would allow me to do more stuff. Duh!!! My meds will allow me to do stuff with less pain and last a little longer but it is not going to let me walk an amusement park or walk outlets malls. I still have an underlying problem and I guess I was hoping I could do more. I guess it was a moment of stupidity.

Wish me good luck. My appt is tomorrow morning.

 
Old 09-02-2008, 03:29 PM   #12
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Re: Breakthrus

I'm on 120 mgs. of methadone a day and still have 4 30mg. oxycodone tablets available to me for break through pain each day. Methadone is excellent, but it doesn't always cover the entirety of pain. Memere (KathyMac)

Last edited by BrittleBones; 09-02-2008 at 03:30 PM.

 
Old 09-02-2008, 03:30 PM   #13
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Re: Breakthrus

Quote:
Originally Posted by 123dietdrpepper View Post
...hoped my meds would allow me to do more stuff...
Pepper,

I agree, she is saying no breakthroughs. However, with her allowing you to go to 120mg OC, you may have little need for them. Please do go with the increase.

Also, please ask her if it is her intention that you would be able to do more. Just point blank, ask "hey, with the dosing regimen you are giving me, should I be expecting to be able to do more, ultimately even exercise?" "Because, right now, your doses are doing more than I've ever experienced before, however, I cannot actually do more yet." "What is your plan for that, because I had maybe wrongly assumed that's what BTs were for, to allow for and handle pain with added activity." Something like that.

She sounds like a good communicator so with her you probably can talk more normally than with other docs that you have to be careful with. She shouldn't mind direct questions. You can feel her out on this. But if it were me, I'd be curious to hear her thoughts on doing more, and if BTs aren't on the horizon, how are you to handle the added pain that more activity brings?

steve

 
Old 09-02-2008, 05:08 PM   #14
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Re: Breakthrus

Steve, she is very direct and has told me when I have hesitated to just spit it out and then I will tell you that it is or is not possible.

That is a great suggestion and I will ask her. Thanks .

 
Old 09-02-2008, 06:09 PM   #15
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Re: Breakthrus

Cmpgirl is correct when she says that there is wide variety of "theories" in PM. A lot of it has to do with each Doc's given background....Some are anethesiologists, some are rehabilitation Docs, and some are GPs who have developed a speciality in PM. Additionally, I have found in medicine, a lot of the variation tends to be strongly correlated to the Doc's age / length of experience. For example, younger, more recently trained Docs tend to have vastly different approaches vs older Docs....It happens in every field, not just PM.

In your case, I think she means no BTs....I guess you'll find out @ your appt. I would ask her point blank what her reasoning is. My guess is that she wants to keep your BPL as constant as possible. While BTs do a great job of combating short term pain, they also spike your BPL and then drop you off, thus creating dependence issues and raising tolerance faster than normal.

In correlation with this, some Docs don't trust patients (in general) to use BTs wisely and prudently....If they don't, over time the BTs become part of the daily regimen, and aren't really used for true BT any longer, thus, contributing to tolerance and dependance. This "concept" I just outlined can be one of the most plausible reasons as to why she doesn't believe in BTs. If so, then it goes back to how she was trained and there is certainly some validity in these concepts.

However, I will say that she sounds like a very compassionate and understanding Doc. In one appt, she did things that your prior Doc didn't do over a long period of time. I think you'll just have to judge the total package and decide upon your approach. If I remember correctly, she has given you some OC as BTs, but they are LA and not SA. Which means, they will given you the extra punch you need to address the BT pain, but won't spike your BPL....And rather, hold it steady for 12 hours.

The only real downside I see to this theory is if a person where to have really bad flare up pain and really needed something with some punch as a "rescue" medicine. With those type of patients, she may handle them on a case-by-case basis.

Take care, and good luck @ your appt.

Regards,

Ex

Last edited by Executor; 09-02-2008 at 06:17 PM.

 
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