Shoreline

Hey DLFO, It realy doesn't sound like your doc knows what' he's talking about when it comes to pumps. You may still need oral meds for BT pain or incidental pain, but any more than that can be managed by the pump.

What are you presently taking and I can give you an idea of where you would be with a pump.

He's describing the old synchromed pump with an 18 ml resevoir. It's a closed sealeled conatiner so there is no way to just put more in it. The synchromed 1 was the original battery operated programabale pump. Mine delivers a higher dose from 7pm untill 9am so the night pain is managed and I can get and moving when my daughter does for school, I use Roxicodone for BT but no LA meds, it would be redundent. The pump out now is the synchromed 2, It comes in a thinner version with a 20ml resevoir up to about the same size of the old but it has a 40 ml resevoir. The concentration of the solution is were the strength of the med is determioned and the rate of delivery. If your a high dose patient they would use a 25 -30mg per ml concentration. and run your pump in the 15-20 mgs a day range, that's if you were taking 600 -800 mgs of morphine per day and getting relief. In the old pumps with the 18 ml resevoir, I could have agone a few days longer but you want to refill before the alarm goes off when it reaches 2ml left in the resevoir. At that point the pump begins to slow to prevent it from running dry and it slows down enough to cause the most severe withdrawal you can imagine.

I learned early and scheduled a refill on the alarm date. There was still 1.8ml in the pump but I had been puking for the previious 16 hours and was a mess.

Now with pumps that have 40 ml resevoir using concentration of morphine or dilauid at 25-30 mgs per ml, you at least double the duration with morphine and if that's not log enough they switch to dilaudid or one of the fentanyls which last even longer. Simply going to a med that's 3-5 times stronger than morphine when delivered IT, my refill interval went from 30 days to 74 days. at 25 mgs per ml. They could go to 30 and that would mean an extra
40ml x 5mgs =200 more mgs of dilauid in the pump , at 5 mgs a day, thats 20 more days. I was tyaking 150 mgs of meth when I switched and my prebvious morphine dose was 600 plus up to 4 30 mg roxi a day. They started me at 2mgs.

Fentanyl is about 100 times stronger than morphine. So your talking mcgrams per ml and could easily go 3-5 months even delivering huge doses of fent. Not being able to go beyond 30 days or being able to deliver as much as your oral dose of any med makes no sense at all. He saying time to see the surgeon, meaning he doesn't do the implants himself, who's going to manage the thing and make adjustment?.

IF your going to go the pump route, you might want to find a doc who actually knows how they work and how to manage one. The new
synchromed11 even has a take home telemetry device he may or may not give you, so patients can give themselves limited bolus doses instead of using BT oral meds.The home device has limis set by the doc, no more than .2 mgs per hour and nop more than 3 times a day. They can program whatever they want your ranges to be.

Conversion factors are just guides. when you first start hearing about the device I heard it made meds 300 times more potent, as surgery came closer it dropped to about 100 times more potent than oral. Based on my present use, it's about 60 times more efective. but those factors will be different for everyone.

What concerns me is the idea of taking your pain away. If that's your expectation, you shouldn't have it done. When managing your pain they ask the same questions they did with oral meds, what;'s your average score on a pain scale, what's your highest, lowest etc. 100% relief is not the goal just like it wasn't the goal of oral meds. A trial that relieves 50% of your pain when you discontinue your oral meds is considered a succesful trial. I went cold turkey from oral to pump and sure it was miseerable the first few weeks or months but the office was very accomadating.However once you reach 50% relief, that's the target.

Things like constipation or urinary retention, may prevent you from obtaining better relief. Groggynees,drowsiness, feeling doped and loss of labido if not loss of function if your shooting for 100% will certainly occur. IF your ready to give up sex, they can keep increasing beyond 50% relief. If nodding off in the lazyboy for the next 30 years is cool with you, you may obtain better relief.

When I mention people do have to cope with some degree of pain , it's an honest answer, If you constantly shoot for 100% relief, your would increase at the same rate as a junkie, never satisfied, always trying to recapture that first big dose you got. A few weeks after the increase it won't be 100% anymore, if you expect an increase because the relief dropped to 80 or 90 % relief, it;'s no different than an addict or a dog chasing his tail. 50% relief is what medtronics advertises they shoot for. For some people 50% relief means they can return to work. For others it means they can walk and stand in the shower without help. Even 50% is very patient dependent.. No amount of meds will hide the sensation of screws pulling out or bone grinding on bone.

A pump is a tool, not a cure all to take all your pain away. Medtronics recomends doing a psych eval to be sure the patient has reasonable expectations. If you tell them you expect all your pain to be masked so you can start skiing again or mountain climbing, a decent shrink would say your not a good candidate. Medtronic also recomends doing trials and they recomend using a plecebo dose. I have seen folks washed out of pump trials by reporting amazing results from saline.The power of suggestion, that you're now getting drugs delivered to your spine making them 300 times more potent is a powerful thing.

Excpect to start low and increase over time. The saw me every week the first 6-8 weeks, then every 2 weeks then every 3 and eventually by the 6th month I was at 50% relief which is what I got from meth, but I wasn't dripping buckets of sweat, I was able to have sex and my head was clearer than it had been in years. It's like turning the lights on in a dim room going from equal relief from oral meds to a pump. IF you go beyond that mark, the meds do start to impair, you will nod off and loose your sex drive. It's not a gaurenteed way to relieve all your pain nor something the even shoot for.

If a doc is selling you this, you won't be happy with it.Those steps in the tiral process are there for a reason. Just because it's a more eficient way to deliver meds doesn't mean it's for everyone.

Even if it does relieve enough pain to return to work, you have to think about the liability issues anyone highering a guy with a morphine pump in his belly is taking. You won't be driving a bus or going back to be a cop or fireman, pilot, air trafic controller, or anything that requires absolute focus and concentration with a morphine pump in your belly. Nobody is going to believe you're perfectly safe to drive and take full liability for any damage you may cause while having meds delivered non stop via pump

You can go to medtronics.com and look up infusion drug delievery systems or specifiaclly the synchromed 11 pump. They do make the isomed which doesn't use a battery and is a lifetime pump but you have no programability and any increase is done by increasing the concentraion since the meds are delivered at the same constant rate.

Good luck and I hope it does what you want and I hope what you want is realistic. ) pain isn't a goal of most PM docs. YOu may find you can increase your dose and tolerate a higher proportioanl dose when meds are delivered IT, but ebventually the same side effects of high dose oral meds will start to build with meds delivered by a pump.

If you can only go 30 days on morphine because you need 30 mgs a day, which is huge, then they should switch you to dilaudid which is 3-5 times stronger which means 3-5 times longer at the same concentration. Fentanyl and Suffentanyl are even stronger. But be sure you have a succesful trial or your going to take risks you shouldn't and not be satisified with what the pump can do. That would be the only reason to continue oral LA meds but if your not satisfied with a pump at what point would you be satisified? When is enough pain relief enough. When the meds impair you and hinder you more than they help. If I wanted to spend the rest of my life with a catheter sleeping 20 hours a day, they could make that happen. But that's not improving quality of life just because your reporting no pain.

IF your not dying, they consider more than your level of pain. Nodding off during the last few weeks of life is humane, nodding off the next 30 years is what an addict shoots for. You become tied to a doc for life, yu have to trust your doc will make necesarry increases in a timely matter while titrating. But I have met folks that had questionable suces during a trial, spend 6 months trying to titrate morphine, another 4 months trying to titrate dilaudid, then another 8 months plauying with fentanyl and suffentanyl only to be never satisfied and have the pump removed.

Good luck and if this surgeon doesn't suggest doing a tiral because he ofers a gaurentee IT meds will work better than orals, find another surgeon that will do it right and let you actually experience what IT meds can do and what it feels like.

Good luck, Dave