NEED ADVICE PLEASE! Switching or adding opiates! - Pain Management Message Board

IZZY'SMOM · 05-21-2007, 07:23 PM

Hi all of my pain buddies!
Im on 50 patch every 2-3 days and 15 mg hydo LA MAX 4 a day...I really want a short acting med. When i asked my doc, he stated we could do the 7.5 hydo but only 1 every 8 hrs. Well that would be like p*sswater...
I want to go to something better for b/t meds. I asked him once about oxy and he balked...that was about a year ago, and we had just started pt relationship. ive not ever asked for meds early, or anything, Im not under contract. he doesnt believe in it, and says if he has to have a pt under contract, he rather not have them as a pt....when i have b/t pain, it is ACUTE!!! and when i take my la hydro, it takes over 2 hrs to kick in!!! it does help, but id rather have something to kick it in the butt fast for b/t pain...My LA hydro is a sched. II now that there is nothing in it except the hydo...I get my meds from a compunding pharmacy that I LOVE!!!! So would it be that far off to ask him for the oxy that would be the same, a sched II?
So Im thinking of telling him I want the Oxy IR...for b/t meds. What strengths does it come in? Remember hes not a PM doc, but he is really good to me...So i want to be able to suggest what strenghts it comes in...
Hes so funny...he looks everything up in the PDR...hes about 62 yrs old...Donht tell me to find another cause without him, id be screwed.
We have No other PM docs ther than 7 or 8 hrs away one way.
I wanted to talk to him about rotation opiod therapy, but i dont want to come across as too pushy...any suggestions would be so appreciated....
p.s.....hes very mellow, and nice~

Shoreline · 05-21-2007, 10:04 PM

Hey Izzy, Oxy comes in 5mg casule and I think 10 mg capsules, it also comes in 5, 15, and 30mg tabs without tylenol, the brand names for the 5 mg capsule is OxyIR and the tablet are called Roxicodone but there are generics for both that are just as efective. Capsules disolve a few minutes faster but liquids are the fastes way to absorb a drug other than transmucosal "pops like aqtiq".

They do make a 5mg and 20 mg solution of liquid oxy called Oxyfast, it also comes in generic. I don't really see the huge point in compounding 15 LA hydro, the expense and strength Vs a 10 mg generic Norco just doesn't seem to make it worth while. If it's 15 mg LA than it releases 15mgs over the course of 2-8 hours. A 10 mg Norco would be more than a 50% increase in strength. Norco is 10/325 of hydro and apap and like most orals releases entirely within an hour and wears off in 4. The liquid may work in 35 minutes 45 minutes for capsule or 50 minutes for a pill, neither is hugely different oRals have to make two pases through the syetem, be broken down into metonolites that cross the blood brain barrier so it takes this long to get into the blood stream.

It really comes downm to the strength of the base drug and the strength of the BT med. The idea of BT meds are to increase your serum level suffecient enough to make a difference. Most manufacturers and docs recomend 20-30% of the strength of one of a twice a day or 12 hour dose, With the patch, you shoot for that increae in the hourly rate. The idea is to increase your serum level 20-30% to provide relief. The problem is that 15 mgs of compounded hydro is so much weaker than a 50ugh path, your probably closer to 5-7% increase using a LA med for BT, it's just not strong enough especially after some time. Maybe dscussing the math and asking him what percent does a 15 mg compounded hydro increase your serum level, if he calcuates the way I do he should releaize 5% isn't enough to make a difference.

Generic plain oxy costs pennies and the 30 mg roxi is about 1 buck a pill with no apap if you use generic. Not being able to afford expenseive compounded meds when there are plenty of alternatives is another reason to change to something readily available.

When it comes down to it, your not going to be more dependent on oxy than you are hydro or the patch, if he's already crossed that bridge, his only problem is lack of knowledge and what's available.

As far as contratcs, that's what the DEA wants and thatt's what PM docs thathave constant contsac with them provide. Drug testing pill counts, all that doesn't change someones level of responsablity, all it does is increase their knowledge about the use of these meds. It also clearly explains expectations, the result of specific action, It leaves nothing to be guessed about. Their is no such thing as an early refill, no drugs are called in and you know this from day one. It really cuts down on those after hour calls from every addict that thinks he has an excuse for running out that the doc has never heard before.

I don't rerally see the harm in informing patients and holding them too a standard. I know my doc takes measures to deter doc shoppers and it just makes me feel safer as far as not picking up the paper and reading about my doc being busted after 4 people OD in the last month. I've read enough of those in this area. Not having a contract doesn't make it better if you self medicate and run out early or overdose by mixing your gp's med with alcohol, the results are pretty much the same whether you have a contract or not. You can't say you didn't know it wasn't right or what the consequences will be.

It's really a non issue when it comes down to needing treatment and contracts, UA's and pill counts is what keeps the doc in practice and the DEA happy. Law enforcement pays much more attn to a clinics, groups of PM docs or one in private practice that may writes thousands of scripts a month for class 11 opiates Vs a GP that hopes his couple patients don't draw that same attn.

Sorry to get off topic, But the DEA requires my doc to take an active role in preventing diversion, so to make contratcs sound demeaning or something that implies their is a lack of trust really isn't why they are used IMO, Personally I think employers doing UA's is a greater violation of cilvil rights than signing an agreement with your doc.

Hope you get things worked out, Take care, Dave

conductor · 05-22-2007, 12:15 AM

Dear IZZY'SMOM and Dave,

The reply by Dave to IZZ is an excellent one. Dave...This particular response has such a concentrated amount of tremendously on-point and helpful medical explanations that I'm specifically going to vote the highest rating available. I don't know about the rest of you, but I don't typically vote. In fact, I'm not completely sure what the votes are used to calculate.

I'm appreciative of my Internist who handles my Pain Management--because she is absolutely aware that the 4 or 5 PM docs in our area are not effective. Even though I use, what I consider to be, a large amount of C-II's (Schedule 2's), my doc simply doesn't allow the Rx's to be written very early. If you phone in your Rx request--and it's too early in their opinion--they will call you back to discuss it. For instance, when I recently left a request on their Rx line--they called to let me know that I just had that particular Rx written a week or so earlier. They were absolutely correct--I left the name of the wrong medication when I called. It was time for my patches, and I said I needed my Dilaudid--which, like they said, had just recently been written. THEY ARE VERY CAREFUL. While I am not under contract (and she doesn't have a great deal of PM patients), she (my doctor) simply will not Rx anything very early unless there is an excellent reason!

Thanks, you guys, for this thread. It addressed a great issue and received a chock-full-of-info response. Then, of course, it has my babbling commentary.

Sincerely,
Jon (Conductor)

Fabrashamx · 05-22-2007, 08:20 AM

Hi Izzys, Dave, and Jon,

This thread made me wonder about something. I agree with what Dave said about contracts, my new doctor has a much stricter one than my last doctor did, and he also does UA's, which I dont mind at all, Like Dave, knowing how careful he is reassures me he is here for the long haul.
What I'm wondering is this: We all know there are people out there who are doctor shopping, or simply trying to get pills to turn around and sell on the street, possibly to convert money for drugs such as cocaine and heroin.
We all talk about how many times a doctor has probably heard about pills lost, stolen, or dropped in the sink, But I'm wondering what the percentage is, are there 10%? 50%? maybe there are even more of those people than there are of us! Even 50% would be terrible, and if sincere people who are compliant and benefit enormously from opiate therapy are in the minority, are we ultimatly doomed to a life of pain because the doctors will get sick of trying to weed out the troublemakers?
Of course I am not talking about people who are dependant on their medicatations, I mean people who know walking in that they are going to try and scam a doctor out of meds. have there ever been any studies done of this? any ideas?
And Jon, you do NOT babble, your posts are always worth reading, unlike some of my own, lol.
Thanks, Fabby

conductor · 05-22-2007, 06:55 PM

Dear Fabby,

I appreciate your kindness! Also, don't be hard on the quality of your posts either.

This is an interesting thread, isn't it? I want to say something regarding UA's.

Back when I had a true Pain Management Doctor (1996 - 2000/2001), I had a vague, verbal contract. Around 1998 or so, this doctor wanted me to have a urinalysis concerning my fentanyl patches. If I remember correctly--which is always questionable--this was prior to the start of my Actiq usage. I did my first UA, which came back looking like I didn't have any fentanyl in my system. So, I did a repeat, which came up with the same results. So...I brought in the remaining patches and showed my doctor the "markings" on my upper arms to "PROVE" I had been using them.

Even though these findings made my doctor scratch his head in a philosophical manner, he did NOT question me any further. Frankly, I was a "safe" patient in his opinion. My doctor told me that fentanyl levels in UA's were not always as reliable as tests for other medications. As far as I know in my large, infinite amount of knowledge...I had NO IDEA!!

Again, the concept of getting to the correct numbers and/or percentages of true pain med users vs those simply abusing the whole system is intriguing--to put it mildly. Is anyone aware of a specific test concerning this subject? I'm sure that many of us would be greatly interested.

Thank you all again.

Sincerely,
Jon (Conductor)