My mother has sever back pain from 2 failed back surgeries (severe )stenosis. She has been on the duragesic patch since feb and has lost over 60 lbs due to the lack of appetitie.
The PMs we have seen only want to treat invasively - neurostim, morph pump, injections.
She just wants a pain med that doesn't affect the I (too badly) and controls the pain. She has tried the Morphine drugs (ms contin). Do the Codeine drugs work any better/differently?
we don't know where to turn. her back surgeon said that he can operate again, but her first 2 surgeries were 7 hours long and now she is 78 and with the weightloss and lack of physical activity, I don't know if she has the stamina for another long (any) surgery.
My Dad is in his 70's also. He has the intrathecal Morphine pump. He claims his PM guy "saved his life". He was suicidal for a number of years--THIS from a guy that never took a sick day off in his life. I can understand ME being tweaked out and suicidal--but my DAD? Anyway, he's just thrilled with how much the pump works and doesn't affect his brain like the oral meds (which made him seem like he had a little dementia going on). Maybe that would be an alternative for your Mom, as opposed to a 7 or 8 hour surgery. That is really tough on people when they get into their 70's, 80's and above!
Hi Sue, Some people just can't tolerate the side effects or oral meds and it seems the older you are the less you are able to tolerate the side effects. Codeine is very harsh on the tummy and has a ceiling of 400 mgs a day, which is nowhere near the strenth of a durageisc patch. They do make a 7.5 patch that I have never seen anyone on the forums use. If she can get by with less pain relief the lower dosage may help but I to am a pumpster and the most profound difference is the lack of cognative impairment from comparitively miniscule doses as far as mgs go.
I went from 600 mgs of Kadian 12-24 hour morphine to 12 mgs of morhine delivered through the pump. The best way to describe the difference between the change from oral meds to meds delivered by pump is it's like going from a very gray world back to a life in full color where you experience the hghs and lows, less effect on personality, less side effects in general and better pain relief with out the stomach upset of oral meds.
Meds delivered to the intrathecal space do not circulate systemically and don't cause the brain fog, nausea and other side effects of oral meds.
I too would be greatly concernd of the risks invovlved in another open surgery with your mom on a vent with full life support. Sattistically the odds of success drop about 20 % with each surgery and the risk of general anesthesia in the ederly is greatly increased. A pump implant takes less that an hour,doesn't reqire anything more than twighligt sedation and could very esily restore her quality of life for her remaining years. The downfall is that pumps and scs devices have to be replaced every 5- 7 years depending on how hard the pump has to work, but with someone with low tolerance to opiates, I doubt your mom would require more than 1/6 to 1/12 of the dose I recieve which means the pump would last that much longer in a pateient with a very low output rate.
Pump Surgery and recovery and healing is so much quicker than anything as invasive as open spine surgery, there is no comparison. The side effects , mainly cognative impairment would greatly decrease because they are using use up to 1/100 the dose of of an oral med becuse the number of opiate receptors in the spinal cord are exponentially greater.
However the pump is designed to manage back pain where the SCS is designed to manage nerve pain like radiculopothy , "leg pain and arm pain" so matching the right implant has more to do with the type of pain patterns she has.
There are other meds like MSContin and several other longer acting morphine preps, there is oxycontin and methadone and Duragesic. Meth can be very sedating andimparing, hard to find the right dose in a drug sensitive patient so the only other drug to try is OxyContin which comes under great scrutiny. The pump really may be a miracle in your moms situation. Having to replace it due to batery life may not even be an issue if it can give her reamining years more function, less side efetcs and greater mobiliy. The good thing about these devices is they do a trial to see how it works before they do an implant, if she doesn't get 50% relief, they won't go ahead with the surgery.
Trials for he pump can either be done out atient with a single bolus injection of an opiate to the intrathecal or epiduaral space or a hospital stay where the dose can slowly be increased over a 3-4 day perriod. THere are some risks involdved like spinal fluid leakage from the cath being placed in her spine. But If She is only under the care of a surgeon, they really aren't trained in long term pain managment. Would this surgeon even be doing the refills or would she be sent to a pain management center for management of the pump? IF the PM group wold be managing the pump It would be best to allow them to asses her before a surgen slaps more hardware and devices into your mom.
THe newest pump on the market is programmable, has a rsevboir that alows refills up to 6 months or longe between and there are many benefits to a pump when a patient can't handle oral meds. By no means are pump cure alls, she may still neeed oral pain meds like vicodin or percocet or somethig weaker like darvecet. But it's a much better alternative to more surgery with general anesthesia. Refills are relitively painless, no worse than an injection.
Due to the greater number of opiate receptors in the spine and keeping all the meds in the spinal fluid prevents systemic reactions like sh's experiencing now. There are also meds for nausea to control side effects of both oral and intrathecal meds but this is where the surgeon is out of his league and an anesthesiologist trained n PM or any number of specialties trained in PM far surpass the surgeons knwledge. I would subject my mom to me spinal surgey when the out come of the first two were so poor. IF he coldn't fix things the first 2 times, how are his odds going to increase on the third attempt.
Exposing her to the risks of general anesthesia and another long surgery with a long recovery doesn't make sense. I drove myself to my first pump adjustment 5 days after the implant. NO worries about counting pills, missinmg doses, it's all maintaned by the pump. With the ability to program, if she always has more pain at night, the pump can be set to deliver more at night, if pain upon rising is worse , again the pump can deliver a little extra in the morning. But pump mamangement is a PM specialty, not a surgical specialty.
Yes the sugeon can implant the pump and start her at 1mg of morphine or .2 mgs of dilaudid delivered per day. All the follow up, adjustments, fine tuning of settings and bolus doses at specfic times of day is a PM specialty. Please get her evaluated by a PM doc and if they agree a pump is the way to go, it may very well be the best alternative.
Yuu do hav to understand that all PM docs do not have the same phylosopy. I saw a dozen PM docs between during and after 3 failed surgeries, failed fusions, broken hardware and non believed in usng pain medication. It was always some modality or injection or alternative medication that can be just as impairing as opiates but doesn't carry the stigma of opiate dependnece. Dependence is just a physiological consequence. meaning if she pulled the patch of today and went cold turkey, she would experience withdrawal. That doesn't equate to addiction.
Addiction is destructive behavior and I have yet to meet an addict who's qualiy of life improved by using their drug of choice. The goal of pain management is increased function, increased quality of life and being able to tolerate the effects of medication to treat failed surgery. Best case scenario she can enjoy her remainig years with the help of a qualified PM doc. She doesn't have the 7 years it took me to find relief and try every injection and procedure and mind control trick availabale that many docs believe work on everyone.
SO this surgeon should already know who he has in mind for pump management "refills, adjustements etc" and refer her to that PM doc for evaluation and trial of a device.
60 lbs is profound weight loss and I can't imagine a doc not being aware of the toll it takes on an elderly patient. She doesn't have to be sedated to find pain relief and it's an intolerable side effect. If it was a young person I would say continue working through everything that is offered, But in an older person, what are you doing to their golden yars by playing guinea pig with their life tryng methods that have a low percentage of success compared to a pump or SCS.
A decent PM doc would have gotten her off the patch 30lbs ago and wuold have found an alternatve that didn't have the side efect the patch is having on your mom. THe surgeon is just out of his field of expertise if it doesn't involve a scalpel. The implant is the surgeons job, but I have never met a sugeon that spent his time managing a pump when they can make 3K an hour in the OR.
ASk to be referred to the PM doc that he would have managing the pump after implant and if they want to try another method of pain management or medication give it a shot, but IN hewr case, a pump or scs sounds very realistic and doesn't reqire the trial of ever other method a doc can think of before the pump is mentioned as an option. It's a tool available and cold very well restore her quality of life and require litle supervison or risk. No additioanl care by anyone but the but the PM doc managing her pump to fine tune the settings. From their, no more checking up on doses taken, patches changed, her mental state and general health. It's a good idea if done by someone that's famliar with pump management. It's a bad idea if the surgeon is offering to implant but can't guide her to someone to manage it.
The surgeon can't predict what dose she will need, IT takes trial and error to adjust the ****ngs, delivery rate, the right med and from their she's off and running , so to speak. BUt lease no more surger untill you find a group of PM docs capable of managing a pump or possibly tryng oher oral meds. It may be the patch is just to strong and the doc isn't comfortable prescribing short acting meds that need to be retaken every 4 hours. IT is much easier to stay ahead of pain than to bring unchecked pain back down to a manageble level, but a pump can certanly do it after a few adjustments.
Take care and learn more about the pump by checking out the medtronics web site.
Thanks for you reply. I probably mislead you on my post. She has gone to a PM, who sugested the scs and the pump, but #1 - she did not like the dr- she felt rushed and he was always looking at his watch, #2 she is afraid of the trial period. Literature says that she should not sit for prolonged periods, but that is was she is doing. She is depressed although denies it. EVERY new drug makes her feel bad - tried the anti d's and all affected her. I am trying to get her to see another PM. Your statement rang too true about the surgeon...and too scary.
I will talk more to her about the pump. Is the constipation greatly diminished on it?
anyone else have success or horror stories about the pump??
Hi Susie, I think she is taking the not sitting for prolonged perriods out of contect. I can barey stand or sit withoutwithout pain meds, Tghe idea is to try to get up and moving to really give it a test and see how well the pump is working. I stil do a lot of sitting, because I can't stand for more than 20 minutes without my legs shaking and breaking intoa a sweat.
My first trial was in the hopital, They placed the vath under twighlight sedation, HOwever I developed a spinla fluid leak and regardless of how much medecine they gave me when I stood up I would almost black out. When you develop a leak the fluid level drops and your brain sets down into your skull, the cure is to lay down or have a blod patch but they hoped the leak would stop on it's own.
I had a very succesfull single bl;us injection trial
Hi Susie, I think she is taking the not sitting for prolonged perriods out of contect. I can barey stand or sit withoutwithout pain meds, Tghe idea is to try to get up and moving to really give it a test and see how well the pump is working. I stil do a lot of sitting, because I can't stand for more than 20 minutes without my legs shaking and breaking into a a sweat.
My first trial was in the hopital, They placed the vath under twighlight sedation, HOwever I developed a spinal fluid leak and regardless of how much medecine they gave me when I stood up I throw up and almost black out. When you develop a leak the fluid level drops and your brain sets down into your skull, the cure is to lay down or have a blood patch done, they hoped the leak would stop on it's own but I called it quits after 3 days and went to the clinic and had the blood patch.
It took 7 months to get he courage to try it again, this time I had a single blolus injection that gave me great relief. The did encourage me to get up and walk around but it's not like they were slave drivers, I could move about meore easily, but sometimes the best they can do is manage your pain when your sedentary. If there is mechanical dyfunction, when you stand or walk and your spine grinds, a pump won't stop that pain.
My spine grinds and squeaks from broken hardware and failed fusion from L1-S1 and nothing blots that out but the pain is managable when I adjust my lifestyle to a more sedentary one. To go from bed wridden to being able to cook and clean as long as I take breaks every 15 minutes is a huge acomplishmnet. I would call that relieving 50% of my pain. For others relieving 50% of their pain means going back to work and being more active, But everyones starting point where the measure 50% relief from is different.
She'ssll know iof it's working whether she's abler to get comfortable sitting where she never could and making small strides in walking.
It did take 16 adjustment and about 6 months to get th pump set right. They do very small increments per day. My acvewrage morphine dose icnease was a from .6mg to
.8mg The dopey surgeon stated me at 2.0 mgs a day and I ended up around 12mg a day. It was life chaging but much better than oral meds. Having reasonable expectations is the important thinmg.The pump is just a tool and the goal is quality of life, not running on the beach lke the celebrex comercial. They got sued for that didn't they?
Constiptaion is an issue but they can manage a lot more pain with less or equal constipation. I have a hospice recipe that works great called Yakima Fruit paste. If you search this site you will see it, if not I can repost it.
You are a wealth of knowledge and an inspiration. I am going to print out your replies and talk to her about them.
A PM tried to inject her with a single dose a few months back, but could not get to the spot he needed...things were too close together - 2 fusions. Can this be a roadblock when trying to have a pump implanted. Do they have to go to a specific spot in the spine?