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Old 01-11-2007, 11:23 PM   #1
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Pain meds not working any more need help

I have pretty bad lower back pain and I have been on MS Contin for a year. I started on Tylenol 3's then moved up to Tylenol 4's. When those stopped working I was prescribed MS Contin. I started on 15mg twice daily. After about four months I moved up to 30mg three times daily, and after about five months I moved up to 45mg three times daily. I have been on 45mg three times daily for three months, and they are not working well anymore. Is it common to build up resistance so fast and to move up in dose like that?

My problem is that I really don't want to just keep upping the dose when I start to build more resistance. Besides that, I don't think my doctor will go up any more, I think the next dose would be 60mg three times daily. The pain is getting bad enough that I have to lay in bed for most of the day, and I can't do anything that I usually do. The worst part is the mental aspect. Going through this much pain for so long is driving me crazy, literally. I am having panic attacks, getting depressed and feeling hopeless. I also feel like a slave to the morphine. If I have this much pain when I take the meds, then how much pain would I have if I didn't take them.

My question then becomes, what should I do? Going up in dose is probably not an option. Getting a breakthrough med is also out of the question as my doctor has already told me he won't give me a breakthrough med. My only option then is to somehow lower my resistance to the MS Contin. I always feel like a drug addict criminal when I discuss things like this, but I am not abusing these meds, nor do I plan on abusing these meds. If there is any way to lower resistance please let me know. I would also like to know what is considered an average dose of MS Contin, and what is considered a high dose of MS Contin. Any help would be greatly appreciated.

 
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Old 01-12-2007, 04:43 AM   #2
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Re: Pain meds not working any more need help

Hi catpoo, My wife has several neuro and bone problems and was already in PM when she hwas involved in an MVA that started a serries of headaches then seizures that ead to the an MRI that diagnosed shiari 1 malformation, Instead of using more opiates to treat her increased pain our PM doc added Nemanda and started using botox. It wasn't what she expected when she talked to him about the her aditional pain and abscent seizures she was having but the two new therapies eventually alowed her to decrease her dose by almost 2/3rds and the end result was feeling beter, better pain control and less side effetcs. It's our laymans respjnse hat leads us to think all they can do is increase opiates, there are other modalities and meds that work with opiates. Even something as simple as Clonodine or the clonodine patch may bring extra relief. The thing is the doc can't do anything if he doesn't know what's going on, so don't be afraid to tell him what you want, but don't expect to make your own treatment plan and decide what you need prior to consulting the doc.

We go to PM for help, not to have get prescriptions for the drugs we think we need . I know we think we know what's best for us but we realy aren't the specialist or , neurologist, anethesiologist, phs=ysical med and rehab are all advanced degrees and specialties that take a decade to obtain. Our basic understanding of pain meds respond to opiates doesn't mean it our only option. If that was the case outr GP would just give us what we want. You don't need to be an anesthesilogist to write scripts for opiates, but you do need that specialty in PM to look at the big picture, and treat all the patients symptoms.

I read something over the holidays about sleep and it basiclly said that if you deprived patients from reaching delta wave sleep, within 48 hours they would test positive for fibro and have 4 times the level of substance P in their spinal fluid. Sub P is a potent neuro inflamatory agent and a big part of chronic pain and Fibro.Adressing poor sleep may solve something in a round about way. Wearen't docs so we don't know only opiates can help.

Anti depressants have been used since the 80's to target decreasing substance P production, Clonidine has been used to close the calcium channels that carry GABA, another neuro chemical seen in high concentration in CP patients. CP is all about brain chemistry and neuro transmitters, and opiates play a small role in those specific areas. Have some faith n your doc and as a group lets not question our PM docs every move and doubt their compitence when they don't respond to an increase in pan with an increase in opiates. That's just one alternative.The one lay folks understand. I can't imagine questioning anyother specialty the way we quesion what our PM docs are doing.

Give hime a chance to do what he's been trianed to do. If you convince yourself only an increase will help, you can pretty much gaurentee nothing else will.

Good luck, Dave

 
Old 01-12-2007, 09:00 AM   #3
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Re: Pain meds not working any more need help

Quote:
Originally Posted by cptpooface
...Is it common to build up resistance so fast and to move up in dose like that?

My problem is that I really don't want to just keep upping the dose when I start to build more resistance....

...The worst part is the mental aspect. Going through this much pain for so long is driving me crazy, literally. I am having panic attacks, getting depressed and feeling hopeless. I also feel like a slave to the morphine. If I have this much pain when I take the meds, then how much pain would I have if I didn't take them.

My question then becomes, what should I do?...
I totally agree with everything Shoreline shared.

Plus, you need to know more about why your pain has increased. As Shoreline said, it's easy for us to focus solely on the pain meds, for a solution, as well as blaming them when they no longer seem to work. Oftentimes an increase in pain is the result of a worsening condition. Tolerance is not always the culprit. Lots of times it's not that pain meds "stop working," but rather that a back condition has gotten worse. You might want to work with your dr to re-evaluate your back to see what's up.

It's really good you're able to identify the mental aspect to chronic pain. And it just so happens that antidepressants are used extensively in pain management. Of course, depression can and does oftentimes go hand in hand with chronic pain. But it goes further than that. For nerve type pain (neuropathic), there's aspects of certain antidepressants that actually attack this pain. So it's common for an antidepressant to be prescribed even though the patient isn't exhibiting symptoms of depression. This is another angle to consider.

Our bodies and minds have unique ways of responding to opioids. In the beginning of treatment we may feel a rush or other type feeling when the meds "kick in." Pain relief may well be "kicking-in" then as well. So we equate this feeling with pain relief. But this "rush" doesn't last very long, and we become tolerant to it very quickly, even though the pain relief remains. Then, as we no longer feel the rush, we believe the meds aren't working. An increase in dose will bring this feeling back, but only for a short time. I'm not talking about addiction or abuse, yet. It's just a natural response, but we need to learn early-on to really focus on pain levels and relief exclusively. Just something to consider.

Finally, there's loads of research on tolerance to opioids. Pain relief from opioids is the result of a chemical relationship between the meds and opioid receptors in our bodies. There are other receptors that can also be activated, or prevented from activating, that also provide pain relief. The antidepressants are one example, and there are others. Methadone is unique in that it while it activates opioid receptors, it prevents activation of certain receptors that are believed to cause tolerance. This is why many patients on methadone can remain stable on a given dose for a long, long time. Some patients are given ketamine along with opioids to achieve the same thing. They are even experimenting with adding very small amounts of naltrexone, and anti-narcotic so to speak, along with pain meds like morphine, that hopefully accomplish the same prevention of tolerance (and also help with constipation).

So there's alot to consider with your treatment. You might explore the use of an antidepressant with your dr. I was using Celexa but it was causing bad side effects. They switched me to Cymbalta which seems good and does not have the nasty side effects. Cymbalta is actually prescribed for pain relief with nerve pain.

Best of Luck!

steve

 
Old 01-12-2007, 09:45 AM   #4
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Re: Pain meds not working any more need help

I agree with everything shoreline said. I am just another example of why you may need to try different things to accomplish an acceptable level of pain control. I have tried morphine before and it has never seemed to help. When I was in the hospital post surgery they gave me the legal limit allowed. I was on one of them pain machines that you press the button every six minutes to receive a constant dose of morphine. It wasn't helping at all so my wife asked the doctor to up my dose of morphine. He said that I was on the max amount allowed so they switched me to oxycontin. I had immediate results and that controlled my pain much better. So just because the ms contin is not working does not nescassarily mean you need a higher dose. It may simply meen you need a different pain regimen. Good luck and tell the doctor you would like to try some other method to control your pain. A multi-disciplinary approach to pain management has been proven to be more successful than a opiate alone approach. Meaning you may also need to do something along with the opiates like stretching, exercising, walking, pool therapy, psycholoical treatment, anti-depressants, anti-inflamatories etc etc. It is a long trial and error process to find out what combination works best for you. For me I find that being totally inactive only increases my pain significantly however I have to be careful how active I am.

 
Old 01-12-2007, 09:45 AM   #5
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Re: Pain meds not working any more need help

Hi there,

Sorry to hear that you are having more pain and that the medicine is not working as well.

I also agree with Shoreline and Steve....I just had my 3rd neck fusion in 5 years and this time was a doozy.....5 hours and they cut through the front AND the back to put cages, plates, rods and screws.....And have been on different types of pain medicine those past years as well so have dealt with both a tolerance issue as well as the situation actually getting worse. I have also dealt with cruel dr.s.....Dr.s who don't believe in any medicine....and others that all they wanted to do was hand me prescriptions.

I think it would be a good idea to get re-evaluated to make sure there isn't anything getting worse and then find a Pain Mgmt. Dr. who is going to treat the "whole" issue with other things and not just medicine....

I would run from a Dr. who just wanted to keep upping my medicine and not do anything else.....and I would run if Dr. was afraid to NOT give me the medicine I need....

It's a delicate balance to find but as Shoreline said....I found out that the sleep issue is CRUCIAL.....I hated to add another medicine to the mix but I would toss and turn all night long being so uncomfortable with my neck pain so I wouldn't get the sleep I needed.....My Dr. gave me a prescription for Ambien 10mg (not the CR)...and I break it in half most nights but use a whole one if I didn't do much that day and not very tired so it helps me fall asleep.

This has been a HUGE difference in my pain levels during the day!!!! Getting a good night's sleep and getting to the REM sleep that we all need to have our immune system restore itself has kept me from having to keep upping my pain meds....

Another option....as Shoreline said if you have fibro.....is taking a Flexeril before bedtime....this not only helps with muscle pain but it's a medicine that helps you reach Stage 4 sleep.....i was diagnosed with Fibro back in '95 but hardly have any symptoms now and consider myself "cured" from it. Again, that's just my personal story and doesn't happen to everyone....

Also.....even though we suffer from chronic pain.....an exercise program is also crucial to our well being.....Doing something....anything.....whatever you are capable of doing each day.....Just walking around your house.....stretching......yoga......this helps you muscles stay strong and limber which in turn helps with our pain.....

The other suggestion is getting on an anti-deppresant......i am a very optimistic and joyful person and have never been "diagnosed" with depression per say.....but feel that the Cymbalta that I take....for nerve pain as well.....has helped me greatly deal with the chronic pain I have.....as people have said....it's a cycle of pain....being down because of it.....which can cause more pain....etc.....I don't have any adverse effects from the Cymbalta and find, for me, it keeps me in a cheery mood all of the time

So, again....even though it's another medicine to the mix.....I feel that most of us have benefitted from an anti-deppresant.....the key is finding the one that works best for you.....

And then working with your dr. to do physical therapy, injections, accupunctue, ulrasound therapy, etc......doing these other things in conjunction with medicine will help your body not rely soley on opiates.....

Like others have said....i'm a firm believer in listening to our bodies and we have to be our own health advocates.....So....if it's been awhile since you have x-rays or and MRI to make sure nothing has gotten worse....then please do that....

If you and your Dr. have exhausted ALL other options....then surgery might be the way to go.......again.....as we can attest.....it may not be the "cure all" and take away all the pain since many of us have had to have more than one surgery....

Just wanted to offer my suggestions that we all need to look at how our Dr. treats us both physically and mentally......Someone who cares for what we want to achieve daily.....someone who will offer us lots of modalities to treat us......

This has taken me a few years to find Dr.s that I love and who treat me wonderfully.....so don't give up.....they are out there

Blessings,
Ingrid

 
Old 01-12-2007, 10:46 AM   #6
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Re: Pain meds not working any more need help

One other thing I found helpful.

Goal setting.

In my first go-round with pain management we just continually raised my level of meds (fentanyl patches) until the dose was astronomical. That was the wrong way to go. I had no idea of what my pain level should be, realistically, and we were just shooting in the dark.

This time I sat down with my dr and I told her that I'd like to achieve a steady 5 out of 10 in the visual (analog) scale (0 being no pain and 10 being the worst you can imagine). The dr took to this very well and it became our goal. I reached this goal with methadone at 65mg daily. But when we discontinued one of my other meds the pain level shot up some. So we increased the methadone to 80mg per day and I've been with that dose ever since. And my pain level remains at about a 5.

Now at each visit she asks me if we are keeping at a 5, and if not, we examine the situation and work towards returning to a 5. Very rarely is the solution to adjust the methadone. I just chose to discontinue my breakthrough med as it didn't really seem to be all that helpful, but we left my methadone at the same dose.

Try goal setting. Your dr may respond positively like mine did and be open to finding ways to get and keep you at that goal.

Cheers!

 
Old 01-13-2007, 06:13 PM   #7
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Re: Pain meds not working any more need help

Thank you everybody for all your help and posts. I would just like to tell you a little more about my situation, but don't for one second think that I think any of your advice is not good. I think that everything you all said is extremely relavent and I don't want to come across as someone who thinks they know it all, or is ungrateful. I live in a little town in Southern Alberta, which is in Canada. The health system here is really bad. Some people have told me they have excellent medical systems in places with larger populations, but there are very few specialists in my area. I have another post, it's on the back problem forum, [url]http://www.healthboards.com/boards/showthread.php?t=461833[/url] is the link. This explains my situation pretty well, and if you want to go there and read it, you will understand my problem a little better. If you don't want to go there and read it, I will just write some info here.

I was a track athlete in high school and ended up with a scholarship to a university in Utah. The summer just before I was supposed to go to University, I injured my back, that was six years ago. I am 24 now, and have had this back problem for six years. For about the last three years the problem has been fairly severe. There is only one pain specialist within four hours of me. I went to him and found it to be a very bad situation. I have clinical depression, and anxiety disorders, and have had them for seven years, this pain specialist told me to go off the anti-depressents because I was too young to have depression. I decided then that maybe I didn't want to be going to this guy. I also found out that he had screwed up an operation, he was the anasthesiologist, I can't spell that word, he is the guy that puts you to sleep, the gas passer. He left an operation to make a personal call and was out of the room for a while when the nurse came out and told him they were having a problem and needed him. He yelled at her and told her never to bother him in the middle of a call again. He finally went back to the operation but it was too late, the kid getting the operation had been damaged beyond repair because the gas passing equipment had broken down, now the kid is a vegetable. He was only 15. So I stopped going to him. He had done one of those epidural and injection, I can't remember what it's called. I needed those records though, and when I called to get them, they told me the doctor had just one day taken all his records home, and nobody has heard from him since then. So now there are no pain specialists in the area.

I have had some really good physiotherapists working on me. My uncle is a physiotherapist, and he worked with a guy that was the head physiotherapist for the U.S ski and snowboard team, so I went and lived with my uncle for a while, and went to this physiotherapist. I have also had the physiotherapists from the university I went to work on me. I have tried pretty much all the therapies you guys mentioned, acupuncture, traction, ultrasound etc...

The last three years have been the worst, so the first two of the last three years I have been going to many different doctors. I have tried a ton of different meds, mostly meds for nerve pain, I can't remember the name for most of them, but for two years I tried everything but opioid pain killers. I found that nothing helped until I started on opioids. I hate discussing these opioid meds with my doctor and with anyone else, I am always afraid that people will think I am just trying to get drugs so I can get high. As I mentioned I have depression and anxiety problems, and that is why the first few doctors I saw wouldn't try opioids. One doctor I saw told me I would just have to learn to live with the pain. I had to go to the hospital E.R once for an unrelated problem. My doctor was on call and he came in to see me. A few minutes later he left and closed the curtain that gave me some privacy. I heard another doctor come in and my doctor started talking to him. I listened while for about five minutes while my doctor told this other doctor about how I was faking this problem so that I could get some drugs. He was so stupid, he didn't realize I could hear through this paper thin curtain. I live in a small town so everyone knows everyone, that is why I knew this other doctor, and I guess that is why my doctor was discussing me to the other doctor.

After the first year of treatment I finally got a MRI scheduled, but being in Canada I had to wait for eight to twelve months to get the MRI. I think I waited around ten months. I had really mixed feelings when the results came in, I was still going to the doctor that thought I was faking everything, so it was kind of nice seeing his face when he found out I wasn't faking, but I also was sad because I found out I had a back problem. After that the doctor still wouldn't do anything but give me anti inflammatories. I finally changed doctors, I had tried all the doctors in town except one, and he ended up being a very nice guy. He saw all the reports and said that I should have been on pain killers for a while, because obviously the other meds weren't working.

The reason I am so scared is because if it's not the disc, I will have to wait for a long time to get into any other specialist. The best case scenario is to have the discography show that the disc is causing the problem. My worst fear is that the discography will show it's not the disc, (this is hard to explain), but that the problem is the disc, but maybe the disc problem isn't severe enough to show up on a discography. Or that they won't try enough discs, because they think it could only be the disc that is bulged. I wouldn't worry if I thought it was the disc, but I don't think that I have severe enough pain, or the right symptoms for the disc to be causing the problem.

I know what to expect from pain meds, I know that they won't take the pain away, and I use the 1-10 scale to see how much pain I am in. I also know to only expect a little bit of pain relief from the pain killers. I promise I am not just trying to lower my resistance so I can get a high from these pain killers, I am just sick of the pain. I talked to my doctor yesterday, and we decided to go from MS Contin to Oxycontin, then after a month go back to MS Contin. The way he explained it was that, after a month of being off MS Contin my resistance will have gone down for the MS and up for the Oxy, so if you just keep changing each month or maybe every two months, you can stay on the lower doses and not need to up the dose. He isn't a pain specialist so I can't really blame him if he makes a mistake with these pills. I would really like some input on this though. I was on 45mg of ms three times daily and he changed me to 40 mg of oxy three times daily. I don't know if he did the conversion right on the strengh. Is 40mg of oxy closely equal to 45mg of ms, and do you think this method will work? Thanks again for all the help, and sorry for posting such a long post, I just get frustrated sometimes and need to vent.

 
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