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 ???
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.
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
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
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.
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.
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.
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.
...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.
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.
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.
...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?
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.
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.
If that's the quote, then I think you're right, she doesn't want you to use BT's and she has a reason - it sounds like she is more than happy to explain it to you.
Quote:
Originally Posted by 123dietdrpepper
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.
Pepper, not a moment of stupidity (!) Hope, desire for a fuller life, confusion perhaps, but not stupidity. This sounds like the depression talking.... You may very well be able to walk outlet malls and amusement parks. Your body isn't used to much activity yet, and you have to build up to what you want to do. What I've found [and I'm not suggesting you go to outlet malls and amusement parks every day! That could get very expensive among other things;-)] is that my body will allow me to do things I do on a regular basis w/ no extra pain]. When I try to do something I'm not used to/new or something that just doesn't work with my condition, my pain flares out of control. But my pain has been low enough in the past that I could do just about anything I wanted [granted, this did not last long and everyone's condition is different], but don't give up hope yet! The point of pain med is to become as functional as possible - and this includes walking around the mall and possibly going to the amusement park (not so sure about the amusement park rides) since this can be torture for someone's body who has no pain issues. But, you can work up to walking a certain amount every day so that a trip to the mall isn't exhausting. Your muscles have probably atrophied - you can't go from no activity to lots of activity all at once - this is true for people who aren't on meds as well. They have to work up to a lot of activity. As your body gets stronger, you'll be able to do [much] more on the same amt. of meds.
I would talk to the PM about some of your feelings - go ahead and say you're feeling down b/c it wipes you out to go to the mall and now you think you'll never be able to do that again. I think she'll tell you to give it some time and to "train" for it. Think back on times before you were injured and how you may have had to "train" a bit to do the activity if it wasn't something you had done before.
I think it's ok to have high expectations and try to pursue them - it's just going to take time. I would try to focus on what you *can* do now and think of ways to work up to what you would like to do, slowly. And again, talk to your doctor about all this. I think she'll understand and be helpful. Tell her why you feel distressed about the BT meds - you might feel scared to try new things b/c you're afraid it's going to cause a flare up of pain you can't handle. This is something that prevents me from doing new things at times. When my overall pain level is lower however, I feel less scared, and the flare-ups aren't as tough either.
You might also look for additional ways to handle flare-ups. For me, one of the most reliable ways has been acupuncture. Acupuncture might not be the solution for you, but you can find other tools to help you with break-through pain and flare-ups. Do express whatever your concerns are however. She sounds like a very good PM - she's looking out for your long term interests as well as short-term relief. I'm glad she's going to be checking in while she's away.
Have a great conversation w/ her tomorrow.
Last edited by Confused089; 09-02-2008 at 11:12 PM.
Pepper I just wanted you to know I am the same. I push thoughts of the future into the back of my mind. I am afraid to think to far head. The same with the past. I am with you my friend on so many levels in our ways of thinking. So you are not alone there.
I would think that indeed your muscles are trying to adapt to being "used" abit more.
My PM stated that if he moved me to LAs he would allow me a breakthru med, this is what I need. Makes me nervous to think I may be left in any major pain waiting for the next dose of LA, but that is me because of past experiances.
I agree with Steve, it sounds like you have hit the PM jackpot with this doctor & you deserve the very best. I would assume it will take some time for her to find a balance of meds for you. Just dont hold anything back, in other words dont be like me & beat around the bush. It will just leave you going in circles. Make you fears known. At least you will get your answers & not left wondering & regretting that you did not ask. In other words do not make the same mistakes I did. I have been wondering where you have been & hoping everything was OK. God bless Pepper & take care of yourself. Sammy
My appt is over and it went well. I feel blessed to have a wonderful compassionate doctor and just wish she could take my case full time but I understand that she needs to do other things.
As far as nerve pain, we are terminating the cymbalta since it is doing nothing for me. She talked to some pharmacists concerning my nerve pain and trying lyrica or topomax and even went as far as calling the manufacturers and they strongly recommend that I do not try these medications due to the severe reaction I had with neurotin. Apparently the ingredients/chemicals are close enough that based upon my reaction to neurontin the manufacturers discouraged my doctor from prescribing this medication because they were afraid I would stop breathing.
The pharmacist suggested that I add a Mega B vitamin and that it might provide me up to 20% neuropathic relief after taking it for 6 to 8 weeks.
The only other recommendation the pharmacist had re: nerve pain is for me to go onto methadone. Methadone is apparently recommended for neuropathic pain.
As far as my depression, we are adding prozac back into my regimen since it worked well for me in the past.
She talked to my family doctor yesterday and he is okay re: writing my scripts at the current dosage.
She has agreed to allow me 3 to 4 breakthru's of 10 mg. of oxycontin per week which is better than none. She wrote this specifically in my record to allow me the extra 3 to 4 10 mg. oxy's per week so there would be no misunderstanding changing from one doc to another.
We discussed how my pain has a tendency to increase towards late afternoon and she does not want to increase my dose anymore for now. She feels that my meds may be still leveling out and if we need to increase anymore that I will need to move to methadone. She has recommended that I start researching this med. She has also suggested that I institute laying down during the day and maybe I just need to say that after 1:00. I am done for the day and need to stay off my feet. I am not really happy with this part so maybe I do need to consider moving to methadone.
Anyway that is the scoop - thanks again for listening and being here for me.
Pepper, I am so glad that she was available for you today. I know she is not taking full-time cases, but she sounds like a really caring and knowledgeable doc, and even if she will be more of a consultant, this is so much better than what you were dealing with before.
I can't recommend methadone, one way or another, because I have never taken it, but I know there are several here who do and I know they will give you all the advice they can.
I'm sorry I haven't been posting much to other threads the last week or so. Just so much going on, personally. I have a thread on the Addiction boards re: my brother, if you want to know more. It's been a bit of a rough road lately.
Anyway, back to you my love. I am sorry you've been feeling so disappointed. I'm sure the Prozac will help with that. It is so hard in the beginning of PM. You are by no means the first or the last to over-do it, when you finally get the proper meds. It will take some time, but I know you will gradually be able to do a little more, as you learn more about your meds and your body's response to certain activities. It is most definitely a process. And I can attest to the fact that you'll look back on this in 6 months and be amazed at how far you've come.
Please don't beat yourself up about any of this. You are on the right path, even though it might not seem like it just yet. I truly believe with this doc's help and guidance, and with listening to your body, you'll be able to do most of what you want/need to do. It might take some recoup time, when you do certain things, but in the long run, when it means spending time with your family, the pay-back is so worth it.
Hang in there my friend. I hope you are feeling more like your "new" old self soon. I'll be checking in when I can, and if there's anything you need, please just ask. I will try my hardest to help. You're in my thoughts and prayers, every day. Many, many hugs, CMP/MM (((((Pepper)))))
Pepper I am willing to give the Mega B a try, any particulair suggestions or brands? Heck why not, I am miserable & I know Bs work in other areas for me. How nice to have a pharmacist kick in & make some suggestons to. Sammy
