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Old 12-09-2008, 11:13 AM   #1
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Need help understanding the different pain relief qualities of meds

My PM feels that since I have to take Norco every day for pain from serious lower back injury and subsequent surgery, he wants to move me on to a morphine pump! I am really not comfortable with this, and as he tells it, there is really nothing in between Norco and Morphine! YEAH RIGHT!

I know a few things, but obviously not enough, and I just keep going around and around with him. Can anybody tell me what the different meds in between the two are that I could possible try before implanting ANOTHER device in my body? I already have lots of hardware on my spine, and a neurostimulator!)

 
Old 12-09-2008, 02:29 PM   #2
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Re: Need help understanding the different pain relief qualities of meds

There's a boatload of stuff between. Norco is a fairly weak medication. I have constant pain, too, and take




<Edited: do not post doseage...what works for you is not what works for others.>




Opana, and the occassional Lyrica for burning. I am also undergoing evaluation for the Morphine pump (my Dr says he'll infuse fentanyl with it). Perhaps you can try Opana (oxymorphone)ER and IR (I've never tried IR, but ER works reasonably well). I have a titanium rod as well but the origin of my pain is spinal injury.

Best of luck to ya.

 
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Old 12-09-2008, 09:27 PM   #3
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Re: Need help understanding the different pain relief qualities of meds

Hi kerry, All dos have their preferences as far as what meds or modalities they use as far as treating pain. There are long acting versions of oxycodone, morphine, and oxymorphone. Some docs prefer to use methadone and some docs like fentanyl patches. These meds last from 8 hours to 3 days for some on the patch.

I do have a pump but I spent many years with no [sain meds at all and then 3 years on long acting orals before having a pump trial. before the invention of OxyContin, morphine andwas only used post op and for terminally illpatients. Fortunately things have changed but there are a lot of other methods that may be worth investibgating or can be used in conjunction with long acingmeds.

The Idea behind meds that last anywhere from 8 hours to 24 hours or 2-3 days with patches is that it gets you off the constant dosing and rollercosater of pain and meds short acting meds create when they wear off. It's easier to keep pain in check than to bring a high level down by maintaing a constant level of meds in your system and this frees you from clock watching waiting for time for the next dose because the last already wore off.

The long acting meds crrate a steady serum level to basically replace our own inabilty to manaufacture enough chemicals to control the pain. With the constant serum levels you don't have to live your ife in 3-4 hour increments, The abuse rate is believed to be less because you don't have the sense of the drug kicking in, just continous relief when you maintain a constant level the way long acting meds can. That's just some of the philosphy behind long acting meds like oxycontin, MSContin , Duragesic patches and methadone.

There are also dozens of non opiate methods and lots of PM docs that don't believe in using opiates at all. So it's truly a matter of trial and errer as far as finding a doc and what works for you.. If your present doc simply isn't able to manage your pain with norco because it's limited by the amount of apap in it, The long acting meds are pure opiates so there is no real ceiling as far as how much you can take if you alow you body to safely adjust and become tolerant to the dangerous side efects of opiartes, like respirtory supression.

Side efects usually dictate what someone can tolerate dosage and med wise and whether the meds are helping or hinding you. Living a life in a stupor is no better than living a life in pain, so the idea is to find a balnce of what works and still alows you to function to your best abilty given the condition of your back.

I eventualy had the pump put in and the big difference is cognative impairment that orals cause. They onl;y have to use 1/100 the dose and meds are delivered to where you have the most receptors and it bypasses drugs first pass and problems with crossing the blood brain barrier. . I get pretty much the same pain relief, at best it's a 5 because my back is so unstable from failed fusions, but I can live with a 5. I switched from a high dose of oral meds where the side effects had just become intolerable, To a few mgs a day that dont cause near the problems orals did.

If you reach a point where the side efects or the cost of these orals are preventing you from getting relief or functioning, then you consider doing something as drastic as implanting a pump. The general rule now seems to be start with the least invasive and work you way up. If you haven't tried some of the non opiate alternatives like chiro, acupuncture, Tens, PT, mssage, nerve blocks, trigger point injections, epidural srteroids, nerve ablation, medication infusions, Bio feedback and all the other relaxation techniques tought by some PM docs and shrinks, your next doc may want to see you try some of these before deciding pain meds are your only option or he may simply incorporate them into a multi facted aproach.

Your treating doc sounds more like a surgeon than a PM, and there are GP's that are willing to prescribe long acting meds. I came through the PM system when you tried everything imaginable first and then opiates were used to treat CP, mostly because they had been invented yet. These meds have only been used for non malignant pain for a little over a decade. Thoughts on the benefits and training about their use on chronic pain greatly changed. 10 years and 3 failed surgeries later I was offered LA pain meds after everything else had been tried. Times are very different now from when I came through the PM system so I doubt it will take 10 years to find a doc willing to try a long acting med. There are still a lot of older school docs that will insist on trying other methods and won't use specific meds but when talking about learning to cope with pain the rest of your life, I would expect to have to do some trial and eror before you find what works for you.

I do think a new patient that refuses to try anything other than pain meds will have a harder time simply because it doesn't show that level of desperation. If someone said lay in a bed of peanut butter for 3 hours a day, I would have done. If it happened to work, I would still be doing it. I still use several of the alternative methods I found worked to ad to what medication simply can't do.

Personally I wouldn't burn bridges with your doc, I would simply investigate what else is out there, tell him you want to give something he isn't offering a try and consult with other PM docs or clinics in your area. Leaving a doc to try something he can't offer leaves things on good terms. If you find you need his services again, you haven't burned that bridge if ten years or 3 years down the road you decide you want to do a pump trial and the doc that's been managaing your pain doesn't do pumps. It's not a now or never offer, If not him, someone else can do a pump, but like you, I think there is too much else to try before doing anything that invasive.

I know we live in an instant gratification society and trying something else when you know pain meds work seems tough, but there is a price to pay once you go down the long acting opiate route. There is no way to avoid physical dependence, tolerance develops and meds have their limit as far as relieving all pain. That combined with side efects is a pretty healthy price to pay in my book and shouldn't be taken lightly. Trying those alternatives may give you an option that doesn't make you dependent on a doc for a med for the the rest of your life and all the hoops that doc may put you through.

I love my docs, I know their rules are to protect themself and prevent abuse, So I can except monthly pill counts for my oral meds, I do randome UA;'s, I have a contract with very specific rules and they make no exceptions. Those that came and abused before us have used every excuse you can imagine for runnng out early so I know it's not an option even if the meds did fall in the sink or were stolen or eaten by the dog. My docs work to comply with legal and medical guidlines that are in place to attempt to prevent abuse, diversion and properly screen patients before deciding their only option is to be on pain meds the rest of their life. I actually feel better knowing my doc is doing everything he can to protect himself, his practice and the legitimate patients that need these meds to function. I also feel better knowing I did give all those non opiate methods a honest and fair try. That's all there was saso that's what you used.

To answer your question, there are dozens of options, your prsent doc is only going to offer what he believes is the right way to manage pain. The next doc you see will have his own opion and the one after that a different opionion from the first 2. When it comes to pain management It's just a matter of trial and eror. I agree, you're along way from a pump with everything else there is to try and it seems wrong to me not to try anything else first. But that's just my opinion.
Take care, Dave

 
Old 12-10-2008, 07:39 AM   #4
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Re: Need help understanding the different pain relief qualities of meds

Thank you soooooooo much! I have had the steroid injections, nerve blocks, the neurostimulator, a chiro, and on and on. It has been 7 years since my injury, so this is a long term thing, and I have been with him for 4 years. I did a cannon ball into a swimming pool that was not deep enough, and crushed my L5 and surrounding disks. Quite a bit of nerve damage. I have lived in so much pain for the last 7 years, up until 3 months ago he would only give me 3 vicodin, soma and neurontin. I finally told him that it was not working for me, I needed more relief. He changed me to norco 4X day, Big Deal! I took my husband in with me to my last appointment because this doc just doesn't like to listen, and I wanted EVERYBODY in on what I was asking for. I asked for an RX for up to 6 norco a day, he was angry, but said ok. Then we got to the pharmacy, and gues what, he only wrote it for 4 a day. I called him, it took me 5 days to get him on the phone, and then he called my husband and I liars, he never agreed to 6, and if thats what I want, then I should just go to a morphine pump. That is where this post comes in. I think that I have decided to ask for Oxycontin to get into the long acting, so no crashes, because that is a major problem, pain related and mentally watching the clock. Do you know for sure if Oxy contains the APAP? That is is MAIN concern right now, although he has refused to do a liver panel to see what may be happening. Needless to say, it concerns me also! I, like you, feel that there are still many things we can try before a pump, and yes, he is a spine surgeon!!!! He calls himself pain management, but it's not really his forte. He has so many patients, works in a large ortho clinic, and cannot even remember who I am every time I talk to him or see him, even after 4 years and allowing him to implant the stim (I was his first stim patient, which he did not tell me until after) and now he is angry that it did not relieve the pain as he wanted it to. He feels that it should have removed all pain, although in the trial I did get the nerve pain relief in my leg, but no back pain relief. I am biding my time with him waiting for disability to come through, and then my MD is going to send me to a new PM doctor, but I just can't rock the boat until that is done. I just want to be able to keep my pain down to a 3-4, I don't expect better than that, and refuse to live as a zombie, I have three kids! I have never asked for a refill early or abused my RXs in any way. It hurts my feelings that he treats me this way, and yet I DO understand his reluctance to up meds, but he should be a little more open to trying in between steps in my opinion. I see him again on Monday, and I am going to take a tape recorder with me because of our last experience. My husband can't stand the man and is very angry at him right now, but I need to keep the peace, just like you said. I cannot burn bridges and have him saying bad things about me to my next doc, and since he is a surgeon, if I eventually need to go to a pump, I may have to see him again! My original surgery was done by one of the top ten neurosurgeons in the country, and he was fantastic, I am lucky to be walking at all! I will post after I have seen the doc just so you know what we came up with and his reaction to my request. Frankly, I am scared to death. He was very upset when I told him that I had been on this board speaking to other people in my situation, acting like I was second guessing his judgement. I simply told him that it's my body and I need as much information as I can get in order to make informed decisions, not to second guess his "expertise." He didn't really buy it. Anyway, thank you so much for your information, everything helps, especially mentally!!!!

 
Old 12-10-2008, 03:52 PM   #5
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Re: Need help understanding the different pain relief qualities of meds

That is the strangest thing I have read in a long time. There are SO many medications in between to try before the pain pump is implanted.

It sounds to me like your Dr is trying to get you to Disapear and scare you off so you find another Dr as this is just to unreasonable to even be believed.

Really, something is up with your Dr where he doesn't want to treat you anymore so he is offering you this implant to scare you off.

A pain pump is usually offered when all medications have failed and your not getting any relief from your narcotics or other modulalities.

I would start looking for a new Dr now and in the interm stay on the Norco until you can find a new Dr. I cannot beleive what I am hearing, really its not even reasonable.... good luck, SS

 
Old 12-10-2008, 07:21 PM   #6
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Re: Need help understanding the different pain relief qualities of meds

I agree with Slippery Slope as that is almost unbelievable. As for your question about oxycontin containing APAP, it does not, it contains no acetamenophin or ibuprophen.

Good luck.

Kat

 
Old 12-10-2008, 10:58 PM   #7
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Re: Need help understanding the different pain relief qualities of meds

Actually - I think there is a different thing going on here Slipperyslope. How interesting that just this night I went as a guest of someone else to a presentation on neurostim and pain pumps by their PM and the device company reps were at the meeting (and supplied the drinks and snacks).

I had already previously researched this option for myself and decided not for me. Originally my PM had mentioned it in one of our visits that it could be one modality we could investigate if I wanted, but he didn't take it further than that and giving me a few brochures and a DVD. He was waiting for me to make the next move on it. Which is how I would like it to go instead of this approach I saw tonight.

The impression I am getting from this is there is a BIG market out there and the device companies are making a big push with the doctors. They said at this presentation something like It is estimated that 15% to 33% of the U.S. population suffer and are treated for chronic pain. If I were in that business I think I would find that very enticing. Couple that with all the rules and regulations the medical community has to deal with prescribing narcotics - I would see it be kind of an easy sell to the docs to steer patients in that direction. In fact they even brought in a patient speaker who had a neurostim and pain pump implant to speak about her experience. Her pain level was 0 today. She had to have the pump put in after the neurostim programs stopped helping her (after 6 months). Now she was the "worst case" scenario type person who it seemed was an appropriate use of the device. But it is kind of bad that they use that as an example so it makes people right away say - oh they helped her case, they surely will make mine great.

Half the audience (and alot of them were much older/retired), no offense I am 50 myself, ate this stuff right up and were ready to sign up tonight for an evaluation. Forgetting that it is an invasive procedure, very costly, etc...... Kind of easy prey, reminds me of some other situations in medical history that made big pushes to globalize and made billions before some controls were put on them.

My personal opinion agrees with what you guys have implied, I think this stuff should be reserved for kind of the worst cases that are not being helped/controlled by medications and alternative treatments. Lots of people do fine on the oral meds and there are so many combinations to try - thankfully I think I have finally found my right combo.

These kind of things are going to drive all our healthcare costs up. It's kind of like lots of people would like a facelift, but don't get it because THEY have to pay. Well lots of people will get a pain pump or neurostim because THEY won't have to pay and the insurance company will.

Just my personal thoughts.

 
Old 12-11-2008, 12:27 AM   #8
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Re: Need help understanding the different pain relief qualities of meds

Hi Kerry, Back in 93 when I had my first injury, there wasn't eve a board certification proces for any specialty that practiced PM. Many docs practiced it, surgeons, physiatrists, neuros etc, But That was a long time a ago. Now there are three specialties that have PM as sub specialties that offer Board cert programs as sub specialties. Those specilties are Anersthesiology, Physical medecine or physiatrist and Neurology.

Anyone can write a script but that doesn't make them a true PM doc. There are several docs at the Pm clinic I go to and they all have multiple specialties and have gone through the Board cert program for each one from their specific sopecialty. The doc that manages my pump is a Anesthesiologist/DO that is also Board cert in PM by the acadamy of anesthesiologist. my Main doc that manages my case and decides when it's time to change meds or make adjustments is A Psychiatrist/ Neurologist that is board cert in PM through a Neuro program. Sometimes a see the pHysiatrist that's board certified in PM under the specialty of Physical medecine or physiatry.

Anyone can call themself a PM doc, and it sounds what your surgeon has done is gotten Certied by one of the pumps manufacturers to implant and manage pumps the same way my anesthesiologist did. Medtronics won't sell or allow just anyone to install intrathecal pumps or spinal stims.

If he doesn't like to use orals, I doubt any one patient is going to change that. Avoiding the LA class 11 orals keeps him off the DEA radar the same way a pump would. One script to a compounding pharamcy every 3-6 months doesn't raise red flags at the DEA where docs that use LA meds are heavily scrutuinized and they must justify their prescring and show other methods have or are being tied. The pump is really a beter way for him to manage pain and stay off the radar. I doubt one patient is going to change his POV on LA meds but there is nothing wrong with asking about them, just don't ask for a specific one because you don't know which one will work for you, That you don't second gues about ssince you don't iknow. But you can ask why he doesn't use them if that's his position.


I had been with their group for several years exausting all oral options before a pump was even onsidered. I did ask about pumps when I first started with this group and was told that They had a lot of tricks up their sleeve before they felt a pump waould be apropriate and I totaly agreed.

It doesn't sound like your surgeon is really comfortable managing pain other than doing the interventional procedures like blocks and Epidurals, Injections and using pumps to deliver opiates. He may be great at that and those may work for some people, But as I learned over the years, when a doc believes in one school of thought, they tend to offer that same and only option to every patient. Kinda like trying to hammer every size peg through the same small round hole. Personally I wouldn't ask for a specific med,I would just ask why he wouldn't be willing to try any of the long acting meds before going to a pump. Your insurancce may even require it. It;'s impossible to say that he has tried everything and your only option is a pump. That leaves you stuck in the middle with a doc that doesn't like using LA meds and an insurance co that won't pay for a pump untill you give them a try.

You know it's an option but hopefully someone else wll have a different opinion about when it's time and apropriate for a pump.
Just a heads up, since your dealing with nerve pain, that's one the pumps limitations./ Nerve painjust doesn't respond as well to opiates as other types of pain. There are alot of anti seizure meds you can try aside from neurontin if it isn't effective, antidepressants are also used to treat neuropothy so most likely it's going to take a multi faceted aproach to treat both the back pain and the leg pain or neuro pain. A succesful pump is one that relieves 50% of your pain. They don't shoot for 0 pain or even 1 and 2 with pumps. If they can relieve half your pain with a pump they still have other methods to treat the nerve pain.

It honestly sounds like your surgeon isn't going to be willing to go the LA route, usng a pump keeps him off the DEA radar and from having to write hundreds of C-2 scripts a month to hundreds of patients. Pumps aren't for everyone and that's why they do trials, either in patient or out patient to see how your pan responds to Intrathecal opuiates. I would bet you will get better back pain relief and less leg pain relief, exactly oppsosite of what you found with the stim. The stim is designed for nerve pain, not back pain. The pump claims to be used for both, but since PM docs know nerve pain is a different animal and doesn't respond as well to opiates. If your only complaint was leg pain, I can't imagine my group of docs offerigng a pump. Since you have both, it may still be an option but there is just too much else out there not to give LA orals a try in adition to meds used for nerve pain.

Good luck and don't apear to be trying to write your own treatment plan, but there is nothing wrong with asking about other modalities you know about.. LA pain meds are just one.
Goodluck, Dave

 
Old 12-11-2008, 11:56 AM   #9
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Re: Need help understanding the different pain relief qualities of meds

Kerry I hope you didn't ask your Dr for Oxycontin by name. That is one of the worst things you can do, is to ask for a specific medication by Name. If your Dr is uncomfortable giving you 4 Norco's a day, He probably will be horrified to hear you ask for oxycontin ..I hope you saw these post before your apt and before you went in asking for what you think will work for your pain. Its always better to let the Dr reccomend what he thinks is best.. Let us know how your apt went, I hope it went good.

Take care, SS

You have to trust your Dr

 
Old 12-11-2008, 03:55 PM   #10
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Re: Need help understanding the different pain relief qualities of meds

Oh god, kerry ... you are lucky to be up! I read the cause of your CP and it sent chills down my spine. I was injured in a snow-skiing accident 5 years back and I wasn't so fortunate

 
Old 12-12-2008, 04:55 AM   #11
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Re: Need help understanding the different pain relief qualities of meds

I couldnt agree more with you Dave, everything you said was 100%

 
Old 12-12-2008, 09:01 AM   #12
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Re: Need help understanding the different pain relief qualities of meds

Thank you all sooooooooooo much!!! Your advice and experience is all truly helping me with my situation. My appt got changed to Monday, and now I feel ready to address this situation with him. I am simply going to tell him that I am against the pump, that I know that there are several LA meds out there that I would like to try first, and let him recommend which one he thinks. If he is against the LA orals, I will ask him why and if it is because he is not experienced with these, would he please do some research. Hopefully, he will be receptive to the idea. If not, I will have to go ahead and change doctors even though it is not a good time to do so. Again, thank you all so much for your help!

 
Old 02-02-2009, 12:45 PM   #13
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Re: Need help understanding the different pain relief qualities of meds

I agree that there is a vast number of choices of meds and treatments between the two you were offered; I would be frustrated too. I've been fighting unrelenting pain from a partial removal of a brain tumor since 1990. I've tried every treatment and very high dosages of strong narcotics. I'm currently beginning the journey that will ( I'm sure) lead me to the implantating of a pain pump. I can see they are not very popular here and I wouldn't opt for such an invasive procedure if I wasn't out of options.... Having said all that, I am wondering if anyone who has a pump knows anything about the different brands?? I saw several models at the pain clinic today but didn't get the chance to ask about this. I like to be prepared. Anyone?
emalyn

 
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