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Old 07-12-2011, 12:10 PM   #1
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Question Pain Management/Refill issues - HELP appreciated

Hello All. New to the board....while I've searched through the forum and read about 100+ posts on the subject, still hoping for a little guidance as it relates to my current situation.

I've been suffering from moderate to severe lower back pain for a couple of years, due to bulging disc issue and early stages of arthitis....and have been under care of pain management for about 8 months. I received Radiofrequency ablation injections to help offset some of the pain. Now at stage of going to PT regularly and working with PM to help bring down med dosages as I build up strength in the area to help further minimize pain.

Anyway, without boring everyone with more of an intro....I've brought the meds down quite a bit since January and last one was filled 3 weeks ago of 7.5/325 hydro 2-3 times a day as needed. Unfortunately due to some bad choices in housework/heavy lifting a couple of weekends back...it turned into taking 3-4 times daily for about a week.

Admittedly I should have been planning ahead or observing the remaining pill count better (never my strongsuit), but noticed last night I was down to just two pills remaining and my refill appointment not scheduled until next Tuesday (one week).

In hindsight, I realize calling after the flare-up 2 weekends ago or realizing the pill bottle was close to empty sooner would have been ideal...both major oversights.

Since I've been a model patient and have never asked for a refill even a day early, thought I'd just call to explain the situation and ask to see the doctor today or see if they could call in a 7-day supply until next week.

Well, it turned out my doctor is on vacation this week...the nurse asked the other doctor backing him up about calling in something, and he simply told her no. I was shocked, explained to her the details further and asked if the doctor would at least talk to me or allow me to schedule an appointment to explain....again, she asked and came back with a firm NO.

If this was something like Sprint charging me unfairly for some overage minutes, I would have insisted on speaking to a supervisor and demanded justice...however, with how fragile these PM doctor relationships tend to be from other accounts, I simply said how unfair I thought they were treating me and still hung up very politely.

I did call back a few minutes later, asking that under the agreement I signed, can I still go to an ER if I can't tolerate the pain before my next visit...and the nurse replied "yes, if you really need to".

Now, I am stuck sitting here, not only fearful of the intense pain which Advil never seems to help....but also upset that I'll likely endure some type of withdrawal from having to stop for a week cold-turkey. When the very goal that I've had all along, and my doctor has agreed with, was taking down the dosage monthly while PT hopefully helped enough to make the pain managable without meds.

Sorry for how lengthy this has become, but few questions I'm now pondering?

--if I go to ER (or more likely urgent care), do I tell them everything about the PM (contract, fact they won't refill me til next week, etc.)? I always prefer going with complete truth, but I can't see how a stranger (Urgent Care doc) would decide to prescribe a week supply after hearing that the doctor's office who's been treating me won't even do it.

--How visible are these contracts among physician networks? If I decided to not divulge anything about PM to Urgent Care doctor and just mentioned injury from heavy lifting, could that work? (really prefer not doing this, but feel pretty betrayed at this point so not 100% opposed).

--If I try to suddenly just go with Advil, besides the ridiculous level of pain I suffer through for the next week, how bad will withdrawal be on top of that with my current levels?

Any help/feedback/comments/ are sincerely appreciated? Glad I found this place...seems like some great support and wisdom.

Thank you in advance!

Last edited by DesertDog37; 07-12-2011 at 07:45 PM. Reason: title change

 
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Old 07-12-2011, 04:40 PM   #2
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Question Re: Pain Management/Refill issues

One other quick note, I noticed the pill bottle itself said take one tablet every 6 to 8 hours as needed. If I took every 8 hours, I would be out by tomorrow. Every 6 hours, I'd be done a few days ago....yet the backup doctor denying to see me or call in a refill claims I should be good until next Tuesday, the 19th.

Really seems like a major misunderstanding, but unfortunately the nurse and/or backup doctor won't even hear of it so there seems to be no method of escalating for help with this.

Last edited by DesertDog37; 07-12-2011 at 07:43 PM.

 
Old 07-12-2011, 08:12 PM   #3
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Re: Pain Management/Refill issues

Okay, sorry this is gonna sound harsh,,,,you messed up big time. First off I wouldn't waste your money going to ER or Urgent Care unless your life or death. The odds of them giving you pain meds are little to none. If you do make the decision to go, honesty is the best policy, don't try to con any Dr. into giving you meds while under the care of a PM....major bad decision.

Next, your doc does your refills based on what you and he discussed in his office and the dosage he has you on. In other words, he gave you a month supply of meds based on what the 2 of you decided you should take. There's no misunderstanding about the RX on the bottle....you don't get to call "foul" when you overuse your meds and run out early. That part is spellled out clearly in your pain contract. yes, if your doc where in town he'd probably do it for you, citing your relationship. But another doc in the practice is not gonna give you meds....might as well get used to that, it's a fact of PM life.

When they prescribe these drugs to us, they expect us to follow their instructions to a T, if there's an issue you call right then. There's not a lot of leeway in PM treatment and it's like that for a good reason.

As for w/d's from being without meds for a week, you've been on a pretty low dose med and only for 8 months.....they shouldn't be that bad. probably some stomach stuff, definitely pain, maybe nightsweats/jitteryness and lack of energy.

Sorry, I know that none of this is what you want to hear, but it's the reality of the situation. I've been doing this daily CP Med pain management for 8 yrs now, and in Chronic Pain since I was 17......you learn how these docs and programs work. But like I said if you sit back and think about, it's for a good reason.

Good luck and take care....

kat

 
Old 07-12-2011, 09:46 PM   #4
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Re: Pain Management/Refill issues

I agree with Kat, except for one part of her response, but I'll get to that in a second. The prescriptions that you are given each month are based on a 30 day supply of meds. So, if you were given 90 pills, that means that the most that you can take are 3 a day, even if it does say on the bottle 1 tablet every 6-8 hours.....that doesn't give you four pills a day, only three because the total number of pills is 90 for that 30 day period.
Most contracts state explicitly, no early fills, no replacement of "lost" or "stolen" prescriptions.....and asking for them in most PM practices can get you dismissed just for asking. Even for patients who have a "good" relationship with their doctor. Breaking the rules of the contract , for whatever reason, are simply a basis for getting dismissed.
NEVER, under any circumstances take more than you are prescribed by your doctor......unless and until you have called them and the doctor tells you that you can increase the dosage for a day or two...and that is reflected in your chart.
It's not so much the physician network that you need to worry about regarding the contract, it is the DEA's tracking system for opiate (schedule II or III medications). It will show that you got a prescription for the same or another opiate from another doctor. The pharmacy can and will contact your PM doctor and let them know that you got a script from another doctor. That also can result in your dismissal from PM and getting yourself red flagged with the pharmacy and blacklisted with other PM's /doctors in your area. That is not something you want . If your doctor regularly pulls pharmacy records, then it will show up that you filled a script from another doctor.
Don't be surprised if you get pulled for a random urine screen when you do go back to see your regular PM since you called for an early refill. The contracts generally have a section that allows them to test you with no notice. Not having the right amount of medications in your system as well as having too much can also get you dismissed.
We have to act as responsible patients, and if anything about our pain condition changes, we must call the doctor to discuss what he would like us to do to manage the change- a temporary increase in dosing/dosage, ice, heat, pain patches- over the counter, heating pads, anti inflammatories, etc, all are part of the management of chronic pain and we have to hold up our end of the deal- if we want our doctors to prescribe the medications which are only a small part of the management program.
I am a bit confused though, you said that you took one extra pill a day for about a week- that's only 7 pills. If you weren't supposed to see your doctor until next Tuesday- that means that you should have those other 14 pills left. If that is the case, then you can use those , to kind of hold off withdrawal, which shouldn't be too bad, given the medication that you were taking.......

 
Old 07-12-2011, 11:57 PM   #5
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Re: Pain Management/Refill issues

I completely understand the feedback from both of you...very informative and and makes a lot of sense. I guess I was naive in this sense and never realized how regulated every step in the process truly is.

Regarding the pills left, I may have been unclear in original post, but doctor actually only filled it with 75 pills (not 90) for 30 days, saying to try taking two when possible but up to three as needed. He basically indicated that if I needed to take 3 everyday, then just call and come back in to fill 5 days early....but obviously the vacation/backup doctor situation threw a wrench into that strategy. I'm also still a little upset with their handling of this in that the doctor probably should have been more clear on exactly what to take rather than leave room for leeway.

With the pain levels at the last meeting, I knew I would probably be needing 3 every single day....so I now realize I can't try to act tough or anything like that when meeting with him. If my back hurts like crazy and I know what he is suggesting won't cut it, then voicing that concern in the meeting is probably the best route.

I've already got the heating pad/advil combo in full effect and will suffer through the pain until next week....as bad as the thought is. I went to PM to avoid the whole different doctor thing I've heard about, so guess I'll tough it out.

I'm hoping my call-in asking for the early refill won't be as much of a red flag considering the doctor was on vacation and it can be cleared up with a simple discussion. In addition, I never once had a negative tone on the call and understood there wasn't anything to be done.

However, it was interesting they did indicate to go to ER or Urgent Care if I couldn't tolerate pain until the appointment...my only last ditch thought was telling Urgent Care the truth and adding that PM recommended Urgent Care for the interim until my next appointment.. I'll only even consider that if the pain truly gets to levels I haven't ever felt.

Thanks again for all the feedback both of you, awesome stuff!

 
Old 07-13-2011, 06:36 AM   #6
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Re: Pain Management/Refill issues

DesertDog,

Well it sounds like you learn pretty quick. At your appt. it is always best to be totally clear on what dosage you can take. Yes, in some ways it was ignorant on the docs part to leave that much leeway, but you are your own advocate, you need to make sure that everything is completely clear before you leave that room. I would be very clear at the next appt. and say, "look, you said X last time, but I need to know exactly how many pills I am allowed to take per day, and what the prescription you're writing me reflects." In this particular "program" total honesty is always the best and only way to go.

Take care,

Kat

 
Old 07-13-2011, 12:33 PM   #7
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Re: Pain Management/Refill issues

If I were you and I could actually get someone on the phone that would listen to what you're saying, this is the route I'd take. I'd explain that I was prescribed X amount of pills. My instructions were to take one every "whatever it was" and if you do the math, I ran out of pills exactly when I told you I did, one week early. I am assuming the doctor made a miscalculation in the amount or in the frequency I was to take the meds. I really need to make this "right". What are "we" going to do?

It really does sound like something may be wrong. If a doctor gives you a 30 day supply and your instructions say one pill every 6-8 hours, that's 120 pills. They don't go on the the longer timeframe. That's just the way it is. Good Luck!

 
Old 07-13-2011, 01:24 PM   #8
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Re: Pain Management/Refill issues

Whoopee,

I understand where you're coming from and as the pain levels have increased all day, I've come close to going that exact route. However, after hearing about how even a polite call with valid reasoning can be looked at by PM doctors as a major red flag or even grounds for discharge, I'm really hesitant despite the suffering.

Despite my mistake of not giving more notice about the pills running around ahead of my scheduled appt date....bottom-line is I'm in a major amount of pain and the prescription instructions (along with notes on bottle) were unclear to say the least.

Quite the dilemma.

 
Old 07-13-2011, 01:43 PM   #9
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Re: Pain Management/Refill issues - HELP appreciated

I have to say I think the posters on here are being a little harsh on you, as is the other physician.
This has happened many times, especially when this is your initial consult with a PM, they are still unsure of how much medication you may need. With that being said you should have called and said you are not getting adequate relief with the current dose because you have been doing more than usual.
As for the "flagging", I have seen a good 20+ PM's before getting diagnosed and it has only happened to me once that a physician printed out a list, and she did it because I told her my PM was only giving me 15 Norco at a time and making me drive back and forth! I don't think she believed me until she saw how crazy that was!
There is a small risk that that will happen, otherwise you should be okay.

Also, I have had scheduling mess up and I showed up to see the physician and to get refills and another PM had to fill the script for me- for schedule 2 Oxycontin. So them not doing it for you is a bit unusual, my refill has also fallen on my docs vacation time and it was never a problem. This PM's partner or whoever he is seems like a bit of a jerk!

I would suggest having a good conversation with your physician and making sure you are getting the correct dosing, so that you are not in the same situation a few months down the road. Make sure this is someone that you trust and you can have a back and forth with, you should not be too scared to call and ask about a refill or to explain a situation because you fear the PM. That means you should probably get a new one ASAP.

Try to taper the medication a bit and see if you can make it, wish you luck!

 
Old 07-13-2011, 06:03 PM   #10
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Re: Pain Management/Refill issues

May I ask what has happend the previous months with the same prescription? Or is this the first time on this dosing schedule? I also am not sure about how you are completely out now with only one extra for some days...

My PM prescribes for 30 days...and even through he writes it for a certain amount every 4-6 hours...specifically on the instructions are 'no more than 8 a day' to not cause any confusion....Some days I don't need as much...so I take less than...and other days I take the max of 8...

I absolutely agree that how you handle this is extremely important....being kind, calm, and honest will get you much further...

I agree with speaking with your Dr. next time to ask specifically how much he thinks you should be taking per day and how long he wants it to last...and then do the math in the room with him to see if it makes sense...if it doesn't...then speak up with saying that you are confused...

I have to say with the lower doses you are on...going to the ER would not be a wise choice at all....by law they have to say this to you if you are calling them on the phone about pain and they can't help you right then and there....They have no way to know if you are having new pain like an appendicitis...so they say if it's extremely bad...then go to the ER...

Personally...for me...I have only gone to the ER twice...Once with a ruptured ovarian cyst that at the time I thought it was my appendix with pain on that side...I was crying in a ball and called for an ambulance....and then when I was a kid and fell off my bike and blacked out...again an ambulance was called to take me in and admitted to the ICU..

So...I truly would never go for pain management even though I get up to an 8 on some rare days...but I know it's not going to kill me...I just curl up in bed that day and don't move around too much.

And yes...if you do decide to go to the ER, your Dr. will know by pulling up any pharmacy/ER records for the state...But more importantly would be you telling the ER and having them speak to your Dr.s office to verify you see them...as well as bring in your bottle of the meds now to show how many were prescribed and in what dosage to show that you ran out...I would also bring in the bottle and any others that the ER prescribed as well as their discharge sheet....

You can't be too honest in PM...

Again...I think some Dr.s expect their patient to take their meds 'as needed'...which means less some days..and others the regular prescription to last 30 days...Make sure it's crystal clear and in writing next appt.

Every time I get home I put my pills in the 'pill daily/weekly' dispenser box....Then I put them all in there each week...along with a calendar where I scratch out when I take that dose...I have dosing 4 times a day and then my Ambien at night...It's our responsibility to keep count...

And I think that next time...if you are having a harder day or two...then call the Dr. first to see what he says to do...it's never good to just take more than prescribed...

I also have a muscle relaxer I can take on bad days to add into the mix...

Our meds should be used in conjunction with all the other modalities to use daily/weekly to help with our pain...and not rely solely on a pill to make it go away...

I use exercise each day 30 to 45 min. with my dog, yoga/stretching, aqua therapy, acupuncture, massage, TENS unit, CBT, injections, don't smoke, eat all Organic, sleep well, try to limit stress...etc...The Dr. expects us to be a part of the team to help manage our pain..

I wish you luck

 
Old 07-13-2011, 07:47 PM   #11
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Re: Pain Management/Refill issues

Desert,
I don't think that any of us were trying to be too harsh with you, but instead, were trying to help you not make mistakes that could result in your being dismissed from pain management or red flagged with your doctor, the ER or the pharmacies.
Many, many pain management practices pull monthly pharmacy records on their patients, especially new ones and so called problem patients before they come in for their monthly refills. They don't have to tell you that they pulled them since you gave consent when you signed the opiate contract. A urine test is mostly done with new patients, patients where there is suspicion of abuse of medications or once a year for most of the established patients, but the doctors' office retains the right to ask you to submit at any time.
Most ER's these days have electronic records and do in fact contact your PM practice if you come in for pain management.
Most opiate withdrawal lasts only a few days, and by the end of day three or the beginning of day four, things start improving. The symptoms can be managed by over the counter anti diarreheals, hot baths and showers help and make sure to drink lots of fluids. Despite the horror stories about opiate withdrawal , it for the most part isn't life threatening.
Most of us have been in pain management for some years, and the mistakes that you made aren't any that haven't been repeated by most people new to this, but the rules have changed a great deal in recent years and if we aren't compliant , don't follow the rules, then we are subject to dismissal at best and at worst , having tremendous difficulty in finding further care with any other doctor. We are only trying to help you avoid the pitfalls of loosing your pain care treatment. I think that you know that, since you haven't taken offense to what has been said so far.
Calling early, for any patient causes the staff to let the doctor know- no matter what the "reason" may be....taking more meds due to a flare of pain, without the doctors permission is considered abusing the medications, and is cause for dismissal, and for a new patient, it really makes both the doctor and the other office staff think twice about whether or not you will become one of those problem patients down the road...many PM's won't give you the chance for them to find out. They would rather avoid having to deal with the problem altogether and will dismiss you.
It is true that some, and I mean very few doctors will let one time slide, but it does put them on high alert that they need to keep close tabs on that particular patient. We are trying to help you avoid any of the things that might set off flags for any of the people involved in your care....and to give you some strategies for talking with your doctor about the plan for flares of pain, and the dosage that he wants you to take each day....that way, you are on a more level playing field with him....
Best of luck to you,
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Old 07-13-2011, 08:37 PM   #12
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Re: Pain Management/Refill issues

In those months in which I don't use my full allocation I retain those in case I loose meds, need more, etc. I too never call in for an early refill. The only time I did call in is when I realized they scheduled me 5.5 weeks out instead of 4. When I called that's all that I mentioned and the medical assistant noticed it as well. She re-scheduled me and then asked if I need a refill right away and I said yes. I would not have asked if she did not suggest it. Just don't want it in my records.
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Old 07-13-2011, 08:52 PM   #13
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Re: Pain Management/Refill issues

Desert,

I don't think I was too harsh with you, and I'm sure if you thought I was you'd have said something. I've been doing PM since I was 17 and i'm now 42. It's a hard racket to get right. The doctors are usually high stress, in a hurry and they expect these instructions to be followed to the letter. And all your PM's partner was doing was going by your contract.

If your in with your Dr. like you say, you should just be able to discuss it with him and get it cleared up.

Kat

 
Old 07-14-2011, 07:58 PM   #14
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Re: Pain Management/Refill issues

Quote:
Originally Posted by DesertDog37 View Post
Regarding the pills left, I may have been unclear in original post, but doctor actually only filled it with 75 pills (not 90) for 30 days, saying to try taking two when possible but up to three as needed. He basically indicated that if I needed to take 3 everyday, then just call and come back in to fill 5 days early....but obviously the vacation/backup doctor situation threw a wrench into that strategy.
I'm sorry about what you're having to deal with and the pain you're experiencing. It is unfortunate that your Doctor's partner is not understanding your issue and I'm sure a problem that arises is he may not realize that your Doctor has said you can take up to 3 a day (with the prescription being written for 75 pills) and you don't know how this information is being communicated by the receptionist - so it makes it all the more difficult.

It appears there isn't much you can do at this point. However, I would definitely have a talk with your Doctor about the number of pills of prescribed per month. Because if you are allowed a maximum 3 per day, than I would think your Doctor would write your prescription for 90 per month and make adjustments as your pain is more under control and your pain is definitely managed with less pills per day. It appears how he wrote it (and I'm just speculating) is as allowing for 2 per day with 15 extra per days for the days when you have more pain than normal.

However, since your pain seems to be escalating, I would think a worthy discussion would be to talk about the possibility of raising the prescription to 90 per month, until your pain is under control again. I noticed another poster mentioned a TENS unit - I have to say having a TENS unit prescribed has been SO beneficial. There are mornings I wake up and can barely move my neck, on 20 minute session on my TENS unit and my neck feels like NEW. The same goes through the spasms in my lumbar spine. So, there are worthy non-narcotic options you can discuss with your Doctor about that will be beneficial to have in your "pain management toolbox" at home.

To ensure this situation doesn't arise again, I think you realize the importance of keeping the lines of communication open with your Doctor when your pain is escalating.

In the meantime alternating ice and heat might be beneficial to at least help the pain and maybe purchasing some of those topical OTC pain patches might be beneficial as well.

You're in my thoughts! Keep us posted on how you're doing.

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Old 07-14-2011, 08:23 PM   #15
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Re: Pain Management/Refill issues

Hey Desertdog, just wanted to stop in and see how you are doing? I hope not too bad, wanted to also mention that those disposable heat wraps that you can get at the pharmacy, they're in a red box, can't remember the name, anyways they work wonders. And you wear them with your clothes for 4 to 6 hours. Are you taking any Ibuprofen to keep any swelling and joint stiffness down? How are you sleeping?

kat

 
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