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Old 05-22-2012, 07:34 AM   #1
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Opioid-induced hyperalgesia Versus Tolerance

I have been taking roughly the same amount of MS-Contin for two years now. Currently my regimen consists of 90mg controlled release and 60mg of immediate release throughout the day. Recently I have been experiencing an increase in pain symptoms. Some of these have been so bad as to keep me tied to my home for several days at a time. Along with the meds I also have a daily exercise routine and a meditation and yoga schedule. In other words, I try to do what I can without taking the meds but I cant function very well without them.
When I saw my doctor recently, she informed me that she was convinced I was experiencing Opioid-induced hyperalgesia and that she didnt want to change any of the meds or increase anything until I had tried some other measures first. Among these is weight loss (I am about 20 lbs over my regular weight) and also a gluten free diet. While I agree with the WL the studies on gluten mostly point to joint pain and not the kind of chronic, injury induced lower back pain I have.
My question is this: I have read much about Opioid-induced hyperalgesia and some of it points out that it is really difficult to differentiate between OIH and simple drug tolerance. Has anyone else run into this? Is there another thread I should look at or post to? I really need help here because I have a feeling she is going to DC my meds pretty soon. Thanks in advance-KC

 
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Old 05-22-2012, 09:32 PM   #2
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Re: Opioid-induced hyperalgesia Versus Tolerance

I am also very interested in this topic as I have had a few pain doctors I consulted with say that they thought I was experiencing hyperalgesia, was on too high of a dose for my age, etc. In don't think needing a dose increase after two years is out of the norm. I think its better to increase a bit every so often then to let things get our of control until you finally see a doctor which better treats your pain (whether by opiates or another treatment).

I had a pretty similar issue...I had reached my doctor's prescribing comfort level, but they actually didn't have any other ideas for me. I went from doctor to doctor until I finally found a clinic that had treatment ideas for me and was also willing to tweak my pain meds. They recognized I was one of those patients that due to age and history just has a high tolerance. I asked about hyperalgesia and they thought from what I described about my response to pan meds, that I had at one time been stable on them for about 18 months, etc, it was just tolerance.

I think hyperalgesia is thrown around a bit too much by doctors who don't believe as much that patients build tolerance and who have a dose ceiling in their practice...no matter what type of pain, the patient's history, age, etc, they would not prescribe more than X mg a day morphine equivalent (if you reached that you would be tapered off).

However, I do believe that hyperalgesia exists. I don't know how you differentiate or who is at risk though. I can say that every time I've had a dose increase I've found that it helped more, and whenever I've tapered down, I've had an expected amount of pain increase. With hyperalgesia, I believe you would be able to taper down some and sustain very similar pain relief (not sure if immediate or after some time).

I think its reasonable for a doctor to ask you to try some alternative treatments (typically all those options would be exhausted first, but maybe you have gained some of the weight since then), but I would ask so you are clear what her plan would be if those didn't help much. I agree with you on the gluten free thing...I surely wouldn't want to hold up treatment while trying it without medical evidence for it being helpful.

I'd clarify with your doctor and consult with some other pain specialists (without getting meds from them or signing a contract) and see what they think about your case. Ask if you were their patient what would their next steps be. That is a good interview question. It may also be a good idea to see if they think you need to repeat any imaging or otherwise evaluate if anything new is going on, if your physical condition is exacerbated, or if its just tolerance (or hyperalgesia). I'm anxious to see what other info gets posted here as this is a topic I'm quite interested in. Best wishes.
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Old 05-23-2012, 01:42 PM   #3
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Re: Opioid-induced hyperalgesia Versus Tolerance

When I found my current doctor I was going to a pain clinic where they refused to increase the meds I was on (Vicodin, 5/500, no more than 6 a day) and gabapentin, 1200mg a day. I was waking up at night at least three to four times and I was close to suicide. The agreement I had with this doc was that I would tow the line and she would listen to me. I have submitted to the contracts, the UAs and all other requests from her regarding my meds. Now I cant help but feel that Im getting the brush off a little. Perhaps she does have a ceiling that she isnt comfortable breaching. THat doesnt help me though.
My weight gain was a result of the pain and my not being able to exercise regularly. I am now on a strict diet and Ill lose the pounds. The gluten thing seems ridiculous to me though. She swears she isnt going to drop me as a client and I have to take her at her word, but I guess I have been down this road before and Im afraid she will find some way to pawn me off on a pain clinic. She has already asked me if I would consider being seen at one of them again and I passed on the idea. I was, quite frankly shocked, that she even made the offer.
I am fearful and Im tired. I know Im not alone but even my close friends are starting to give me **** about not being able to do certain things. Im glad there are places like this to get some support and to know there are others like myself.

 
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Old 05-23-2012, 06:08 PM   #4
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Re: Opioid-induced hyperalgesia Versus Tolerance

Okay, so you don't say what kind of Dr. you see, but you do say she asks you to consider going to a Pain Management Clinic, does this mean your not seeing a Pain Management Dr.

The amount of Morphine your taking a day is considerable and part of the problem may very well be that your Dr. has you on the same narcotic for both your long acting and break thru meds. There's a reason Pain Dr.'s put patients on different drug for LA meds and breakthru meds, different narcotics work on different pain centers in the brain and therefore when working together can control pain more efficiently. At this point you're just taking a whole lot of morphine a day. 60mgs of breakthru meds a day after only 2 years is excessive, very excessive. Most people Dr.'s only prescribe breakthru meds a few times a week or maybe once or twice a day at most and we're talking Percocet or Vicoden which is normally 10 mgs a pop. A "for example" I've been in Pain Management for 26 years, I'm on 150mgs of LA meds a day and up to 60mgs of bt meds....and that controls my pain to about a 5 most days.

Dr.'s "helping" patients to use opiods/narcotics to get their pain levels to unreasonable daily expectations is a problem. When taking narcotics daily for Pain Management you DO have to consider your age and what you take, because sooner or later you do have to max out, you can't just keep adding more and more. And it's not like they make new narcotics frequently, most of these meds have been around since narcotics began. You can't realistically say, "I'm in pain, I don't care how old I am or how long I have to take the drugs" you have to consider all the factors, because there will come a day when the meds don't work, and there won't be an "up" for your Dr. to go....and that's not their fault. And if your not careful that day can come way sooner than you want it to.

Weight control is a serious issue with Pain Management, it can make a major difference. So, yeah Dr.'s do harp on it quite a bit if you need to lose weight. Lose the weight. Do the things your Dr. tells you to do that make sense for the injury/disease that you have. If you've done extensive research and a Glutein Free diet doesn't correlate with your condition, then don't do it.

Fear is also a big factor in today's Pain Management and it shouldn't be. People run around scared that their Dr.'s will drop them for ridiculous reasons. If you're that unsure of your Dr. and you can't place your trust and best interest in that Dr., you need to find a new Dr. You can't waste all your time questioning everything your Dr. tells you to do because you think she has some ulterior motive, it just doesn't work for either of you.

What are you doing at this point to manage your pain besides taking narcotics? Because generally there is always something you can do to help yourself improve/feel better besides taking meds and it's as much your responsibility as your Dr.'s to look for those things. If your just taking meds waiting for your Dr. to think up new treatments or things to help you, your not caring for yourself and doing all that you can do to manage your pain.

At the amount of narcotics your on daily about the only way you could prove a DX of hyperalgesia would be to be put on a Pain Med Holiday, find out what your true base pain is, and reintroduce narcotics slowly at a lower rate. And even then, your tolerance is so high at this point, there's no guarantee that they could differentiate between the two.

Dr.'s do concern themselves with young patients who take large amounts of narcotics to control pain and nothing else, they have to because they no at some point not too far in the future those narcotics aren't going to work anymore and that patient is going to be without a way to control their pain. Tolerance builds quickly the larger dosages of narcotics you take. 2 years may seem like a long time, but when you think of daily allowable dosages, and for Morphine it's around 600mgs, at which point your not really functioning, that's not too far away, considering your sitting at around a total of about 150mgs a day now...

Instead of spending time worrying about your Dr.'s ulterior motives or if she's going to dump you, you should be working with her to find other treatments, surgical options, testing, etc. to manage and control your pain. Or if she's not a Pain Management Dr., you should be looking for an acutual Pain Management Dr. who knows more about controlling and managing your pain with different methods.

Kat

 
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Old 05-23-2012, 07:44 PM   #5
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Re: Opioid-induced hyperalgesia Versus Tolerance

Kat,
Thank you for your response. You obviously know your stuff and I will follow your directives here as I find them enlightening and thoughtful. It sounds like I should consider something else besides meds. I do PT everyday as well as meditation (Cabot Zinn is a personal favorite). Im not sure what else to say. I have to admit I feel a bit ill at ease here, but Im sure Ill work that out.
Again, thank you for your response.

 
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Old 05-23-2012, 09:29 PM   #6
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Re: Opioid-induced hyperalgesia Versus Tolerance

Kat,
Thank you for your response. You obviously know your stuff and I will follow your directives here as I find them enlightening and thoughtful. It sounds like I should consider something else besides meds. I do PT everyday as well as meditation (Cabot Zinn is a personal favorite). Im not sure what else to say. I have to admit I feel a bit ill at ease here, but Im sure Ill work that out.
Again, thank you for your response.

 
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Old 05-23-2012, 10:50 PM   #7
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Re: Opioid-induced hyperalgesia Versus Tolerance

So what would be bad about seeing a pain specialist? I don't think its so much as pawning you off, but recommending a doctor who could better give you a well rounded treatment plan. Doctors not specializing in pain management honestly aren't ideal for patients on long acting opiates. They often are too quick to put patients on pain meds, and too much of them, and then all of a sudden they are past their comfort range and the pan doctor has to "clean up the mess". Consulting with a pain specialist without actually switching over (making a commitment) may be a great start.

See what they have to say. Multiple opinions never hurt. Switching from my primary doctor to a pain specialist for me was a great move...I actually wanted to do so much sooner but my primary doctor didn't have anyone in mind. I did the legwork myself and after a lot of time and consult visits I found a good fit. I wasn't just looking for someone who would at least continue my meds (I didn't want someone who was against opiates when other treatments had been failed), but someone who had treatment ideas I hadn't tried. Best wishes.
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Old 05-24-2012, 11:59 AM   #8
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Re: Opioid-induced hyperalgesia Versus Tolerance

Quote:
Originally Posted by KillerClown View Post
Kat,
Thank you for your response. You obviously know your stuff and I will follow your directives here as I find them enlightening and thoughtful. It sounds like I should consider something else besides meds. I do PT everyday as well as meditation (Cabot Zinn is a personal favorite). Im not sure what else to say. I have to admit I feel a bit ill at ease here, but Im sure Ill work that out.
Again, thank you for your response.
You've been to a Pain Mgmt Clinic and it sounds like it wasn't a great fit, that is not unusual...sometimes it can take several before you find the right one for you. There are many different treatments out there for back pain, and not just surgical, injections, epidurals, etc. The PT is great and yoga and meditation also, being able to relax is always a plus when your dealing with pain constantly, so don't think that those things are bad. And don't get me wrong, i'm not saying the meds are bad..hey, I'm on them just like everybody else, but if your able to combine them with other modalities of treatment and keep the meds to the lowest possible dose and keep your pain level at the comfort zone that lets you live your life to the quality and comfort level that you want....why wouldn't you shoot for that? When you think about "life" and how long you may have to do this.....it can be daunting....the hope of course is that they'll figure out how to fix your back, because honestly, I don't think their going to come up with a whole rash of new pain meds anytime in the near future....

I'm sorry, my intent is not to make anyone feel "ill at ease", just to make you realistically think about the situation. Dr.'s can be jerks, but they also have that knowledge that "hey, we can literally only treat this pain so far, and then what do we do?" I think, if we as pain patients, think that way from the get go, it makes us more productive in our search for relief.

Everyone hates braking out of their comfort zone, and meeting new Dr.'s can be one of the most uncomfortable things...but, becoming complacent or "stagnant" in your pain management care, can almost be detrimental. Searching for the treatment or combination of treatments that will do the most for you can be a fulltime job and unfortunately it sometimes means finding the right Dr.'s who are willing to work with you....but when you find the right Formula of "Dr. + Treatments = Great Pain Control", it's worth it!

Hang in there,

Kat
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Old 05-24-2012, 07:22 PM   #9
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Re: Opioid-induced hyperalgesia Versus Tolerance

I am going to see one (this will be the second one) on June 1. I agree that hearing from them is very important and I have some questions to ask as well. The responses I have gotten here have been eye opening and honest. I realize I didnt give a complete history here. Perhaps I should have said more about the 12 MRIs, 2 discograms, multiple spinal cortisone injections, four years of PT and yoga, as well as the surgeries (both back related as well as knee and hip). Truthfully, I get tired thinking about it.
I try to live as active of a lifestyle as I can. I am 48 years old and take care of my niece,4 and my nephew 6 on a regular basis. I dont sit on a couch popping pills and moaning about my pain.
THis is my last post on this topic. Good luck to you all and I hope you find relief.

 
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Old 05-24-2012, 08:15 PM   #10
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Re: Opioid-induced hyperalgesia Versus Tolerance

I don't think anyone got that impression, "the sitting on the couch moaning thing". Just taking care of the kiddos will keep you hopping, that's for sure.

I hope that this new Pain doc can help you and get you the relief you seek, in a way that works for you. That's the goal we all strive for after all....

It's always nice to hear from you, how your doing, how things have worked, etc. Take care and may relief filled days find their way to you.

Kat

 
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Old 05-24-2012, 08:35 PM   #11
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Re: Opioid-induced hyperalgesia Versus Tolerance

Perhaps I am overly sensitive here. Actually, I am sur of that. As I am sure it is with many of the folks here, my journey has been fraught with many trapdoors including workers comp insurers, lawyers and, of course, doctors. One bad experience might be okay but when I add them all up, well, it becomes a bit overwhelming. On top of the rest of my activities I am also in school. I went back three years ago (the same time I was really starting to struggle with pain). I recently graduated at the age of 47 and now I am in a Master's of Liberal Arts program. I hope to teach creative writing when all of this is done. I have maintained an almost perfect GPA and if anything have hated the effect the drugs have had on my ability to concentrate.
I like the idea of a med holiday. I like the idea of a pain holiday more. Dont we all. I will talk to my doc about this idea. Detoxing will be difficult. I am a recovering alcoholic with almost ten years sober, and I have held many a heroin addicts hands as they went through hell with cold turkey. I know Ill be okay though.
Maybe I was hasty. I will keep you updated. Thank you for your time and patience.

 
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Old 05-24-2012, 08:55 PM   #12
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Re: Opioid-induced hyperalgesia Versus Tolerance

No problem. *smile* I don't scare off easily. You've got an incredibly full plate that would be challenging for a "normie", for us it gets multiplied tenfold. Don't be so hard on yourself, you've made some awesome accomplishments. I was married to an alcoholic for 24 years, I know that road isn't easy.

Try to hang in there, I know this all sucks, and is extremely frustrating....but whatcha gonna do, like you said you've got 2 kiddo's to take care of, can't just curl up and quit....and Lord I know about wanting to curl up and quit, I could write a book on that one.

Anytime you need to vent or yak...I'm usually around somewhere.

hope you have a good evening, look forward to hearing how your Dr. appt goes.

Kat

 
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