Hello fellow chronic pain (I would say sufferers, but I'm hoping well all have good meds and support),
I am new to this board, having just found it at lunchtime. I do have Q/problem thay maybe some of you might be able to help me with.
I have been on Kadian (12hr type) for about 3 years due to severe back issues (scaring, DDD, heriniated disks, ect) along with B.T. percocets. I have been on 200mg/kadian 3x/day for the past 3 years, and have been on the percocets the same. I go to a chronic pain clinic here in my area.
For the past 4-5 months, I am finding that the Kadian is NOT helping with my pain at the same level or for the same duration at it used it. My activity level has been about the same, as has my work schedule. What I am finding it that the Kadian is lasting at best about 6hrs before really starting to drop-off; this leaves me waiting for the final 2 hrs (in pain) b4 I can take another dosage. I try very hard not to take my percocets during this time, because I really need them for break-thru pain. I am wondering if another opiate (at the same dosage, since I do not want to increase the Kadian, and my dr. WONT increase my dosage) would work better? The clinic doesn't prescribe Oxycotin, and I'm scared of methadone (for personal reasons); Has anybody in the board taken Kaidan, and switched (happily) to the Patch? what about Palladone? I was told by the Nurse Assistant a few weeks ago that Palladone doesn't have the right conversion rate listed by the manf. and that it doesn't last as long as Perdue claims it does; in order to prescribe it correctly, so it gives adeq. pain relief, it must be dosed 2x day, which could bring the DEA's attention to the patient or the clinic. Can I really be getting tolerace after 3 years? Has anybody else hit this "wall", and if so, what were they able to do about it?
First of all let me welcome you. I'm sorry to hear that you are having increased pain. I have not been on the Kadian. However, I checked the literature in my Fentanyl patch information. I'm unsure whether you meant your total dose of Kadian is 600mg a day or 200mg a day. If it is 200mg a day they suggest you start with a 50ugh patch. If it is 600mg a day, they suggest 175ugh fentanyl. It does say that this conversion is conservative. In my opinion, if you haven't had a dose increase in 3 years, you are definitely due for an increase. It is very possible to become tolerant to your dose in 3 years time. Everyone is different on how long it takes to become tolerant. I have been at the same strength for a little over a year now and my previous dose I stayed at for about a year and a half. I will tell you that my doctor doesn't believe that the patch lasts for the 3 days that they claim. He has me change my patch every 2 days. That has worked the best for me. I wish you the best and please continue to post and update us on how things are going.
[QUOTE=Otter66] I am wondering if another opiate (at the same dosage, since I do not want to increase the Kadian, and my dr. WONT increase my dosage) would work better?
I am right in agreement with Sherry; however I had noticed your phrasing and emphasizing certain words in the above sentence and it seemed as though perhaps upping the dose of Kadian may not be at all possible. Neither you nor your Dr. seem to be leaning in this direction so that means probably another drug unlesss you choose the status quo. As I have so often said here (screamed might be a more appropriate description).....if we are in pain it is up to us to rectify the situation. No one will do it for us. So, yes, by all means I would meditate on other drugs. I am not one to suffer pain in silence. There is no need. There is another LA morphine, Avinza, or MSContin and then the fentanyl patch that some of us are on and are at least partially positive about........ Not sure I would try Methadone quite yet and that is just me. I. Sparkles. :):)
Be happy to answer any more questions if I can.
Last edited by SheSparkles; 04-26-2005 at 09:18 PM.
The following is just my opinion and in no way is it backed up by any studies or information that has been released.
I'm just wondering if this major trend toward prescription opiate abuse somehow includes the millions of legitimate patients in pain management or in an arrangement with their PCP's??? It just seems to me that they claim so many people are supposedly abusing pain meds but on all the pain management boards we repeatedly see legitimate patients who are having a terrible time trying to treat their pain. How and where are all these supposed addicts getting their drugs?? I know some will say through internet pharmacies, but have you looked at the prices those places charge?? I don't see how anyone could abuse pain meds on those prices. I don't know, maybe I am way off base here but it just seems things are "backwards". Something doesn't smell right about it. I mean I know how hard it is to find a doctor to treat legitimate pain and we have to go through years of being poked and prodded and try every modality known to man to eventually be prescribed our opiates. How can it be so easy for someone to obtain prescription opiates for abuse?? Even if someone is doctor shopping, unless they pay cash for the prescription, their insurance is going to deny excess scripts. And who in the hell can afford to pay cash for these opiates?? My fentanyl patches are almost 800 dollars a month and my oxy is another 400 dollars and I am not even on extremely high doses. It's my understanding that oxycontin is even more expensive than my fentanyl and oxycodone. Oh well, maybe I just have too much time on my hands to think about this stuff. LOL.
To give you an idea of how much higher dosages are, my Kadian+percocets (combined) without insurance would cost me $1917.00 !!! Yes, that's right - $2k in order to be pain-free for 30 days or $64.00/day. You can now understand why I stay in a dead-end job, with no advancement possible!! My insurance co. literaly pays out MORE in insurance benefits with my pain medication than my SALARY is per year!!! And God knows I am terrified to LOOSE my insurance or have to switch to a job where I would have a waiting period before I could fill my prescriptions (assuming that they don't classify me as a "prior condition" exception) !!! It is all just to scary... Any I don't even want to THINK about how bad my withdraw would be... It might literaly KILL ME....
[QUOTE=Otter66]You can now understand why I stay in a dead-end job, with no advancement possible!! <
Of course that is understandable. The costs are outrageous.
> Any I don't even want to THINK about how bad my withdraw would be... It might literaly KILL ME....<
My husbands work just forced us off the insurance we have had for the last 30 years and can you spell terror? However, the new insurance and PCP picked up my CP care without so much as a blink and even if they hadn't, I would never have been forced into detox c/t. I was practically in heart failure and my heart is just fine, ty, but I didn't know just what we were facing. I did find out that as a CP pt. we should never have to deal with being dumped out of service. So don't worry.
Hi Otter, Welcome, I actualy took the same dose of Kadian, 200mgs TID. That was about 4 years ago, I was the first patient at my clinic to take it and found it worked very well.
Unfortunately due to insurance and the cost for a name brand products, It was only $1400 back then, big savings. Insurance changed and I switched to the generic MSC three times a day and that worked until I had to switch back to methadone when I lost all script coverage.
What really cought my eye was the gross disproportion of the BT med you are allowed. Even if you taking the 10mg percs. That's an absurd BT dose considering your base dose. Equianalgesic charts are not the end all and absolute answer to accuracy, many varry from one to the other, but most will be in the 1:1 or 2:3/1:1.5 range , Oxy being stronger than morphine. Using the lowest conversion estimatate, 600mgs of morph would be equal in srength to 400 mgs of Oxycodone per day. It's rediculous to expect a 4% increase of IR oxy to provide extra relief.
10-20% of the daily total or 20%-30% of the BID dose is what most manufactures and literature suggest and is absolutely safe.
That being said, some docs don't use BTmeds at all. Some docs don't use opiates at all. They do make 30 mg Roxicodone or generic 30 mg oxycodone tabs, that would at least get you 3 times more medication. I don't know your doc or if he can see the logic or just isn't comfy prescribing BT meds. All docs are pretty different.
After a few more years on meth which I grew to hate the way it made me feel. I finally had a pump put in. It took about 3 years from when I first start looking at them and 2 trials and a psych eval to make a decision and go ahead with it last June. It took 6 months and about 15 adjustments to get the dose right and the delivery time right. Medtronics synchromed 1 & 2 are programable so you can set it to deliver a higher dose from 6pm to 2am if you need or whatever your needs are. BUt after 6 months I was getting better relief than I had ever had with so much less side effects. Constipation is pretty much a non issue, and you would be amazed how much clearer your head feals. It's like someone turned the color back on in life.
It wasn't a great 6 months getting there, and I got to enjoy it for a few months untill they told me I should switch to dilaudid, because there is no risk of developing a granular cyst at the catheter tip like there is with morphine at the concentration and rate being delivered. So They swithced me last week, the charts just got me in the ballpark, I urt butr wasn't terribly sick, but it wasn't fun. They adjusted it today and I feel much better pain wise and otherwise. MY Intrathecal dose of Dilaudid is now 4.3 mgs per day. Morphine was 12.3, that's how much more effective IT meds are.
Usually when you start reaching higher doses and still can't get relief, the pump is much more econimcal and can usually be justified and insurance covers it well. All I have is medicare and they cover all but 55 dolars for a refill. Another advantage to dilaudid is it last 3 times longer, so I'm not in so often refilling.
The new pumps that came out at the end of last year have a resevoir 3 times the size of the old. I happened to get an old pump after medtronics told me it would be another year before it was on the market for everyone, back in may it was only available at a few testing areas.
The pump is an option. The patches are an option, but you wouldn't just be using 1 patch per cycle, Your doc would be prescribing a proportionate dose. Duragesic guides would suggest about 225ugh which would be two 100ugh and a 25ugh, maybe more maybe less, but it wouldn't be a dose that flew under the radar like many docs are trying to do.
A large part of my decision along with financial, was something Carol mentioned. I've watched policies in PM change so much in 12 years. A stable patient now has to be monitored monthly, my clinic does pill counts, UA's and has surveilance all to appease a DEA ultimatum. Without needing LA meds, it definitely keeps me under the radar to some degree. I do use BT meds and I use a proportionate dose. I use generic Roxicodone prescribed 2 tabs twice a day. I did get grandfathered when they switched their policy to 60 BT tablets a month. I take 1/2 -2 tabs depending on how bad I hurt.
MY doc hasn't been concerned about my doses, due to my back problems , failed fusions and long history of trying every other PM modality you can imagine, 3 surgeries and 7 years before annyone mentioned PM with opiates and the clinic I go to has always been in my own back yard. However due to docs attitudes, I was steered well clear of any possible opiate use untill their was no other answer.
I know they are the only asnswer for many people, but Carol nailed something that will probably annoy some people that think all pain is the same and all should have equal acces to these meds. But I have seen 3 legit CP patients OD from abuse in the last 4 years. The last you wouldn't think anyone would question, clean cut, working parent, had a 3 level lumbar fusion and they took a rib for donar bone. When he woke up, the doc said he would need another surgery to lengthen the fusion and take another rib. Because he hadn't gotten consent to harvest an extra rib and extend 2 levels, the doc stopped and sewed him up and he woke up only to be told he would need another surgery.
He was more of an aquaintance, but my good friend new him well and every month he had his own system of managing his pain.
Week one take all the BT meds 180 -240 10 mg percs
Week 2&3 use all the LA meds
Week 4, use an entire months supply of Xanax from another doc to get through week 4.
He did this for over a year before it killed him. He thought it worked for him but he was a mess and died a few months ago leaving a new born child behind.
He was 31. Had legit reasons to see any PM doc and they belived his complaints. That was just the last legit PM patient I know that died from abuse. I tend to be too wordy, but thought I would speak the words others don't want too. The abuse comes from patients and that's why it is so dang tough to find treatment for legit patients that would and could follow every direction if they believed it was their last chance and only way to get through life.
Sorry to get off topic, but due to some posts the other day, it's apropriate to touch on somthing carol mentioned about the difficulty in finding treatment.
I would start with finding an apropriat BT,ed, and the first evidence of tolerance is shorter duration. Docs will think this is a 12-24 hour med so rather than focusing on duration, focus on effectiveness. What does it really matter if you take 600mgs a day or 800 if works and the benefits far outweigh the negatives.
Take care, Dave
PS. Medtronics can provide you with a list of certified PM docs in your area to implant and manage pumps.
I would try orals but know there is an option other than orals that wear off.
[FONT=Arial Narrow]Both of you gave some great,thoughtful, and informative answers to some of the questions/concerns I have been having with my pain management care.
Shoreline, you are absolutely right in saying that normal, stable patients are now having to go to extreme measures to get their medications filled. My clinic does ALL of the changes you mentioned. They pill count, have prescriptions with my picture on them, ect. I just hate paying the monthly co-pay!!
I have been feeling additional pain for the past 6 month. I know that stress can increase your pain, and believe me, I am stressed. I am going thru a horrible divorce, with my wife kidnapping my 2yr old littlel girl.. I rarely sleep more than an hour or so before I wake-up in pain, and I mean PAIN! And I believe my pain has increased due to the 50lbs of fat that have attached to my middle due to inactivity. And this from a man that was a state champion long-distance runner....it's all so depressing sometimes...
Sorry, I got off the topic; Shorline; I was grandfather'd on my BT's when the pain clinic changed their policies. I was on #180 10/325mg percocets until the change. This gave me 6xday which really helps alot. After the change, and a letter was given to all patients that no more than #30 pills/mo for break-thru pain be prescribe, I came into the office and asked them not to drop me down that much in one visit. The NA dropped me down from #180 to #160, and then then next visit from #160 down to #120 where I am now. I take (2) at a time, so I have 8hrs out of 24 in the day where I can take BT's. You are ABSOLUTELY RIGHT in saying that they are a drop-in-the bucket; When my back is really bad, I need something stronger, or are tempted to take more than my (2) alloted. I don't take anymore than the two, but it's very hard to do when I'm in pain. Do you think it would be resonable to ask at my next visit (on 5/10) to raise my BT's from the 10mg to the 30's? or is this too-much of a jump?
Also, Shoreline, you switched from Kaidan to MS Contin... Do you think that by switch from the Kadian to another maf. of morphine, that it would help with my tolerance? I had thought about going in and asking for MS Contin instead of the Kaidan (which I believe they would let me do).
Sorry this is such a long post, but I have been stressing out of this for the past 6months, and it's really coming to a head!!
Hey Otter, If your allowed to take 20 mgs of percocet, a 30 mg roxicodne really isn't that much stronger. It's amazing the power the DEA has to enforce their own policies. All these changes are not backed by law, They are simply the wishes of the DEA with a real thrat of making any PM doc miserable that doesn't comply with the todays policy they want to enforce.
Although morphine is morphine, There probabl y are some slight serum changes when taking a med designed to release 00 mgs over 8 hours versus 12-24. All you could do is try and hope for the best. Be sure to use a decent manufacturer, pretty much anyones version except mallinckrodt. They flat out stretch the FDA allowable variance to the max. On their generic for 30 mg roxcodone it plainly states that each 30 mg tab contains 27 mg of oxycodone. The FDFA allows -20% and + 25% variables becaue this range will still create the same basic range in serum levels in most people. A big person sis going to have hmore blood so 30mgs would be more diluted, a small person with less valume would be more concentrated, so when they allow for variances what they are loking for is max and min serum levels created by differences in peple and metabolism. Even given name brand t 100people, not everyone will produce the exact same serum level, but using Malinckrodt your asking for a weaker med. Their 10 mg methadose tablts have sent me int withdrawal twice becuse they are so weak. My broher is in the med research field and he tested a 10 mg Methados tab and it came back at 8.2 mgs of methadone HCL. If another generic is on the high side, say tsay plus 10, a 30$% difference can take some getting used too. I would recomend Endo generic if your going to try a different dlivery system.
I real feall for your marriage and dughter situation. My daughter was born 30 days after my first surgery, when things were more than I could take, a little hnney bun strength would get me through. CP is tough on everyone. I did my best to drive my wife away so she wouldn't see me thethe way I was . Fortnately she hung in there with me and my daughter has been the light of my life.
Does your doc do pumps? I weighed 165 when I had my last surgery, It put me down for a god 9 months in hch I blew up to 212lbs. Since having the pump implanted my activity level has gone up 50% and I"ve lost 30 lbs. I wrestled in HS and never had a problem controlling my weight to the ounce, but it's tough to do when you can't walk more than 15 minuutes or stand in place more than 5 without breaking into a sweat.
The last surgry disabled me in 99 so I know the stress takes a toll and doesn't help pain at all. Just knowing you have the means to mange additional pain allows you to push your comfort level beyond what you may think you can. I spent 3 hours at my daughters softball practice andganme last night which is smething I never could have done on any dose of oral meds. I have exceppted that meds can only do so much. If I can get 50% relief I'm happy and the BT meds can keep you in that range. If you aproach it from a no tylenol standpoint the roxicdone makes sense. Amide makes a good generic, Roxanne sold the name brand rights and now makes a good generic and so does ethics. Avoid the mallinkrodt if at all possible.
Your doc or the PA's or NP's may feel your dose is high, but really what is the difference at this point.
I have met foks that use a combination f LA meds, One n paricular uses 4 100ugh patches, 120 mgs of meth and 300 of Kadian. Using multiple opiates hits a broader range of opiate receptors. Fortunately my doc understands their is no ceiling on opiates, just the dea counting pills. The just came out with generic 40 mg meth so when I took it I needed 12 10 mg pills a day, 360 a month, I guess your doc wouldn't treat me simply because of the strength of the pills available. These laws are absurd and I hate to see things turning back to the way they were. I started in PM before there was OxyC and Antidepressants and the right relaxation was the cure for everything, or acupuncture and Bio feedback, Or trigger point injections and anti seizures. Every doc has their own idea of hw to manage, I understand wanting to feel greatful for what you do have when you see others strigling at lower doses, but struglng is strugling whether it's at 120 mg or 600 mgs. What's baffling is not expecting you to develo any tolerance whatsoever t a dse you have been on 4 years. I spent almost 3 on the same dose of meth and thought that was impressive, but whethe last 3 months prior to the pump I just couldn't stand it and after pointing out I hadave been on the same dose for so long a 30 mg bump was asy to get.
Bottom line, when it comes to needing an increase, I won't even talk to a NP or PA, I will make an apt with one of the docs, they have the final say and you don't have NP's running innerference putting their two cents in. I've had NP's tell me my dose was high and said bring the doc in, and I got what I needed.
Any new med is like starting over, you don't know where the docs comfort level is. I've seen docs that think because the patches highest dose is 100, that's the most they will prescribe, Just another opinion that would leave many people still bed ridden.
If you have reached your docs max comfort level, Yu nm,ay be ableto get your point across be asking to do trial of the pump. Obviously if the kadian was working you wouldn't be asking. You real need to get past the PA's and NP's and have a heart to heart and tell him f this is as good as it gets, you will suport my total disabilty, another statement explaining the desperation. There really is no reason you couldn't stay at 600 of kadian and add enough duragesic to make a diference, Not many docs will mix LA opiates but there is great logic to it.
Talk to him about your expectations and his, What is he shooting for and what is he going to do when he's not there. Some arbitrary number means you have to be disabled or have invasice surgery to implant a pump?
Relating pain numbers like 8's and 9's is something they hear everyday, but putting it into real life expectations, like being able to sit through dinner or sit through a 2 hour movie are reasonable expectations. Medicating enough to run marathons again isn't but that's not what your asking for.
Another option is adding meds that have NMDA blocking ability. There is new drug for alzheimers called Nemanda that in theory should raise your threshold to pain, reduce tolerance to opiates and help better with nerve pain. It does work very well for sme people. Are you familiar with the NMDA receptor, if not I have some info I can post about what blocking this receptor can do. It was basically discovered when they were trying to figure out how people on PCP could take incrediable beatngs and not flinch and keep coming with several bullets in thir gut. PCP totally blocks the NMDA virtually blocking all pain.
Ketamine is another med that has this property. some docsa will formulate topicals that may help if you can get enough Ketamine in your system without the nasty side effects that attract abusers of this med. It's stolen from vets and sold as special K on the streets. But Ketamine, Lidocaine and steroidal topicals can help with certain problems like nuralgia or radiculopothy. Ask him about bracing too, don' leave any stone unturned andlet him know you will try anything to to get beter relief.
It sounds like he gave it a good shot to manage your pain, but wth the far f the dea caufiting you if you don't fly low enough docs arte getting more conservative. If your docs bag of tricks is empty and he doesn't know what else to do other than to continue to do nothing else, It may be time to look elsewhere. I would never burn bridges, but even thesecontracts we sign don't prevent us from getting a second opinion. IF your doc doesn't do pumps, it's not something he will likely offer.
I wish I could offer something more in the way of an answer, But Nemanda would be worth trying, start investigating the pump if you haven' already and be frank with your doc abut your limitations and what this is costing you as far as quality of life. Tolerance is a natral unexplainable thing, denying it is letting the DEA make your medical decisions instead of a doc. I've sen doses escalate 10 fold in a year so keeping you on the same dose any longer really can't be logically justified other than some arbitrary rule about 180 pills a month. They do make MSC in 200 mg pills so there is wiggle room around that rule.
But you never know if Duragesic would work better or methadone would work better unless you try. Palladone is an option although I have never been impressed with oral dilaudid, IV and IT works great. Even IT morphine is much more effective than oral morphine. There are a few meds in clinical trials, a suffentanyl patch, LA oxymorphone and a few others, so don't give up when an answer may be around the corner. The titration of a new med is never fun but with hope and a goal in sight it can be worth it in the end.
Good luck and keep us posted, Glad you found us.
Take care, Dave
Don't worry about long posts, I've been acused myself. It's hard to make a sugestion and not explain why.
Any info you may be looking for I can probably help you find. Just ask.