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Old 07-19-2011, 10:02 AM   #1
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Tolerance Question

I'm wondering what everyone's schedule for their PM looks like? I go back every 3-4 months, and it seems that when I go back I am in terrible pain. But then they adjust my dose and I am good for 2 months.

Does 2 months look like a good time to go back? How long does it take for a person to build tolerance?

Example: 3 months ago- 30MG oxy at 7am, morphine IR 10:30am, Oxy 3pm, Morphine 7:30Pm, Oxy 11pm

NOW: oxy 7am, morphine 9:30am (pain at 6)... pain at 7 (1 pm).. oxy 2pm (can't make it!), morphine 5pm, Oxy 9pm!

Is that tolerance ?

 
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Old 07-19-2011, 11:49 AM   #2
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Re: Tolerance Question

Hi, and welcome.

Ummm...what you're describing isn't really tolerance. I"m assuming that Morphine is a your Long Acting Med and Oxycodone? is your Break thru med.

Break thru meds shouldn't be included on a daily schedule, they're to be taken only if you have a major pain flair that your morphine won't take care of. An "as needed" king of thing. Also you shouldn't have to have your meds tweaked every 2 months, thats a bit unusual.....some people go years with only 1 or 2 changes in their med dosage.

I see my Dr. every month. Now having said that, I'm not sure it's the norm. I've had the same doc for 12yrs, we have a very close relationship, at each monthly appt. I'm there about 45 min. talking with her and discussing changes or things that need discussed. I live right outside of Raleigh, NC, but my Dr.s practice is now out in the country and rather relaxed.

Sooooo....with what you told us about your med schedule, I would have a serious talk with your Doc, see if they can significantly increase your LA med, so that you're not having to take your BT med everyday. Or, perhaps the morphine is not working well for you in covering your pain, you could discuss switching to something else, there are many choices.

I've been doing pain management off and on for 25 years, since I was 17, with the last 9 yrs being daily. I'm on Morpine 60mg in a.m., 60mg. in p.m. I have percocet 10/325 for BT pain and can take up to six a day as needed and Ibuprofen 1200mg per day. I also use heat, Lidocaine patches and Voltaren gel to help manage the pain. On good days I can keep my pain at around a 4, which is manageable and I can live with.

Your ultimate goal should be to limit the amount of Narcotics as much as possible while effectively managing your pain. Remember this is not pain elimination, pain will always be there, but it's a matter of what you can live with comfortably. You should also be employing as many non-narcotic measures you can to help manage your pain.

So, there you go, that's my opinion.....and remember these are just opinions, in the end it's going to boil down to what your Dr. is comfortable with.

Take care, nice to meet you.

Kat

 
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Old 07-19-2011, 12:08 PM   #3
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Re: Tolerance Question

Okay.. I go to the best clinic in the USA for pain management so I assume my doc knows what she is doing?

Now that I think about it I have been on the same dose (total) since last November, just different combo of IR and ER...

Nope. I am on OxyContin ER and morphine IR. Just switched about 3 months ago from only morphine.

I understand that pain will always be there, but I also understand the pain scale, and when you cannot concentrate because of pain you are at a level 6+, when you physically can't sit then it's a good 7-8. That is my daily pain. It is NEVER below a 5 now.

Just called them and left a message at nurse line to call me back.
I just feel like the meds are not lasting at all, or working properly.

I don't understand what you are saying about breakthrough meds.. some meds do not last the full 8 hours or 24 hours, that's a fact. The OxyContin worked for me for the first 2 months - I was at 8 hours. Now it doesn't and I am in pain even when I take the morphine for breakthrough because I wait until it gets bad. But there are some meds that claim (like Embeda) to work 24 hours.. they don't. It depends on what you eat, etc.. and your metabolism.

I get the whole heat pad etc... I have all that and use. But that provides minimal relief.

I have a spinal cord issue and central sensitization- not sure if that is why you are having different results with your meds...

 
Old 07-19-2011, 12:33 PM   #4
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Re: Tolerance Question

You seem to have extrememly high med tolerance. My course of treatment is pretty close to the norm. Generally Oxycontin is a 12 hr. med to be taken twice a day. I was on Oxy for several years, but when Purdue switched their formula last year, it stopped working for me as it did many others. The new formula (that is safer for all the would be addicts out there)is not as effective at managing pain, most folks couldn't get 6 hrs. out of a dose.

I hope I didn't come off as judgmental of you, that was definitely not my intent. Just trying to answer your questions effectively, so you have the most info.

Honestly though if you're having to take both your LA med and your BT med on a daily schedule together, then something is not working right, even in the best clinic in the USA. Yes your doc is more than qualified to do his/her job, but their job is to treat you according to YOUR symptoms, not what they think they should be. If your in that much pain with the meds your taking, you need to talk to you doc about other or additional treatment.

Good luck.

kat

 
Old 07-19-2011, 12:37 PM   #5
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Re: Tolerance Question

My dose is only 30MG Oxy every 8 hours and 15MG morphine x2 (as needed). When I first started the Oxy I was on 30MG x 3 and didn't take the morphine, now I have to.

She originally prescribed the new long acting Dilaudid (don't remember name) but it was so expensive!

I am a bit cranky today, sorry

 
Old 07-19-2011, 12:57 PM   #6
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Re: Tolerance Question

No need to apologize, I think most of us pm'ers stay on the "cranky" side. *S*

Unfortunately they disallowed regular Dilaudid for out patient use, so that's why the new stuff is sky high. When the patent is up they'll send out the generic and the price will go down.

One trick my dr. is good at is pairing 2 meds that work off of "different" pain centers in the brain, it seems to give me a broader control of the overall pain. Your doc seems like she might be of that persuasion with the Morphine/Oxy combo. I've never liked morphine in an IR because it just doesn't seem to be effective, but it works very well for me in the ER form.

Have you been on other meds, or is this the beginning of your PM Journey?

kat

 
Old 07-19-2011, 01:34 PM   #7
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Re: Tolerance Question

Well I have been on everything, including Nucynta, Norco, Vicodin, dilaudid, Embeda, Opana, Tramadol.. etc etc

The central sensitization is a big problem as it effects my whole body, I have knots from head to toe, that if uncontrolled daily make my hands and legs numb (totally numb for 6+ hours), vision and noise sensitivity, severe all over pain.. basically MS symptoms (was tested)- take Savella and narcotics

And then the spinal cord, that feels like a toothache in my lower back, a really bad need a root canal one.

I also have nerve damage to my legs, so burning and electrical pain...(neurontin)

It's really a sad situation that I have to be on all these meds, I don't like being in pain though, and really there is no way I could function with out them. My doctor and neurologist believe I developed sensitization from inadequate pain relief when I was misdiagnosed. You know the whole "oh I bet she is a junkie because we can't see the problem". In reality they messed up and missed it on my MRI... if I could sue I would.

I do appreciate the advice! Just spoke with her nurse and they will either give me something over or schedule my appointment for sooner.

 
Old 07-19-2011, 05:10 PM   #8
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Re: Tolerance Question

Hi Bunny ,
What Katlin09 was trying to explain is that you have what is supposed to be a long acting base pain medication, then you have a short acting , immediate release pain medication. The base medication should be dosed so that it covers your every day, base levels of pain. The immediate release pain medication should only be taken when you are doing something that increases your pain level significantly , and can't be controlled by another means.
What happens when you take both types of pain medications daily is that all you wind up doing is increasing your "base" medication dosage. Then, when the pain levels do jump sky high, you have nothiing to help ease that pain, because you are taking the immediate release every say 4 hours, plus your base ( long acting ) medication too.....
What your doctor is going to have to do, is adjust your oxycontin dose, and then give you immediate release meds for those sky high pain level days. Don't wait until the pain levels are so high before using the immediate release meds though, because that is not going to work so well for you.
Try using all those other modalities, and if within an hour, the pain levels aren't decreasing, then use one of the immediate release meds.
I've also been doing this pain management thing on and off for the last 25 years, daily for the last 7, so have tons of experience with this stuff, like Kat does. I also have a spinal cord injury for the 2nd time, extensive damage to my lower half of the body's nerves, amongst facing a second bout with Cauda Equina Syndrome, and severe stenosis in the entire lumbar area , so I do empathize with you, but with the nerve sensitization that you are talking about, there are other, better medications for help with the pain caused by nerves than opiates. Opiates, while they help some, do not necessarily hit the right receptors in the brain. Lyrica, neurontin, topamax, and the old classic antidepressants are far more helpful when it comes to treating nerve related pain than opiates.
I think that it might be time to sit down with your doctor and discuss other options as well as adjusting your base medication dose and even consider changing it since many people, me included have had great difficulty with the new formulation of oxycontin not giving adequate pain relief and have had to change medications.
Best of luck to you,
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Old 07-20-2011, 10:00 AM   #9
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Re: Tolerance Question

Thanks for the reply.
Not sure if you saw but I am on long acting and short acting...

The issue is that on top of my spinal cord stuff I have central sensitization. Meaning my body does not respond to pain the same way another person does. It is always in "flight" mode like something is about to happen.

I do use other moralities... that is why I posted the question on tolerance because I could not figure out what the problem was.

When I go to the doctor, every 3 months we "fix" my meds, but the dose has stayed the same since November (if Not August), I don't know if it's an increase in overall pain, or tolerance.

Although I have to say I am kind of confused by both of your answers, obviously tolerance exists. That is why drug addicts end up taking 30+ pills to get high, that is why medication is changed. There are countless studies on this. It seems to me you do not believe in the existence of tolerance?

My physician is giving me an extra 10mg x 3.. and she thinks I did become tolerant since I have been on the same dose for at least 8 months if not longer. (prior to that I had another doc with the same doses on and off)

 
Old 07-20-2011, 12:16 PM   #10
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Re: Tolerance Question

I understand exactly what you are saying. I do go see my PM every 2 months for medication/scripts. And as needed for injections. I had one PA in the practice refuse to increase me from 7.5 mg Perc for my BT as she felt I had reached a ceiling effect on my meds ( MSContin for LA and percs for BT ). I relied on my BT almost on a daily basis as a result of not having any changes made. I finally started seeing a PA that herself is a pain management patient and she UNDERSTANDS. She has since changed my meds TWICE and next month we will probably make another change. Not so much a tolerance issue but getng that perfect combination . So far Opana is my LA med and i have cut back on the n eed for the allowed 4x a day BT med. But there have been times when my level in my UA test was lower than what they expected and they figured I metabolised faster. People are all different and metabolize quicker, adjust to meds differently etc. That is why there are so many out there. What works for some may not even touch someone else's pain.
As long as i can keep my pain at a tolerable level, I continue to work and stay as active as I can. Sounds like you are having a hard time getting your meds to a point that mange your pain for more than a month or two at a time

 
Old 07-20-2011, 12:48 PM   #11
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Re: Tolerance Question

Okay, it's not so much that we don't understand tolerance, I think your view of it is a bit skewed....

Tolerance occurs when your body gets used to a medication so that either more medication is needed to give you the desired effect or a different medication is needed. Depending on the drug, tolerance can develop in several days or happen more gradually over a number of weeks.

Tolerance can have positive result such as a reduction in unpleasant side effects due to the medication. However, as your body becomes tolerant to the medication, it becomes less effective.

That's the formal definition of medication tolerance. Some people have a very high ceiling on their tolerance, mine is pretty high, I can take many drugs that are just like popping aspirin, and they affect me in no way. If others took these drugs it would put them under the bus! When we've been on pain meds, both narcotic and nerve related our bodies get used to them, this is a continual process, therefore your tolerance increases over time. Depending on your metabolism, type of meds and type of pain, this can happen rather quickly. Each individual has a choice, keep going up on the meds due to their tolerance issues, or fine a semi-comfortable dose and just stay there, until they absolutely have to increase. When you are looking at a lifetime of Pain management, you have to consdider the fact that if you peak to soon, your later years will be spent in considerable pain. And also someone like me has to consider the many operations that I have to go through, 21 in the last 12 yrs, and several more to go in the next few years. The ability for inpatient pain releif and post surgical pain relief has to be considered into the equation.

So, thats pretty much as clear as I can make it about tolerance......trust me I understand tolerance, I've just made the conscious decision to not exhaust mine in my "younger years" I have a long way to go with my illnesses/injuries and that has to be taken into consideration. For once you truly reach your medication tolerance.....there's not much help for you after that.

regards,

kat

 
Old 07-20-2011, 12:55 PM   #12
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Re: Tolerance Question

Oh My katlin.. I hope you can get decent pain relief with these surgeries. Post Surgical pain is the WORST to control in my opinion.
I guess I have been lucky in that the few changes we have made in my meds have kept me at a fairly low dosage as I too am looking at lifetime of meds

 
Old 07-20-2011, 02:38 PM   #13
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Re: Tolerance Question

Quote:
Originally Posted by bunny23 View Post
Thanks for the reply.
Not sure if you saw but I am on long acting and short acting...

The issue is that on top of my spinal cord stuff I have central sensitization. Meaning my body does not respond to pain the same way another person does. It is always in "flight" mode like something is about to happen.

I do use other moralities... that is why I posted the question on tolerance because I could not figure out what the problem was.

When I go to the doctor, every 3 months we "fix" my meds, but the dose has stayed the same since November (if Not August), I don't know if it's an increase in overall pain, or tolerance.

Although I have to say I am kind of confused by both of your answers, obviously tolerance exists. That is why drug addicts end up taking 30+ pills to get high, that is why medication is changed. There are countless studies on this. It seems to me you do not believe in the existence of tolerance?

My physician is giving me an extra 10mg x 3.. and she thinks I did become tolerant since I have been on the same dose for at least 8 months if not longer. (prior to that I had another doc with the same doses on and off)
Bunny,
We do understand tolerance but as Kat explained , I don't think that you are understanding what we are saying.
Central pain syndrome used to be known as RSD. I lived with RSD for many years so I understand the syndrome pretty well , as well as the treatments, and options available for you. That is why I suggested an increase in your base meds, less use of your breakthrough meds, and looking into some of the other medications that aren't opiates to help with the nerve pain. Nerve blocks, spinal cord stimulation, TENS, physical therapy are all standard care in dealing with central pain syndrome.The more you feed the beast of central pain by disuse, or laying in bed, the worse the beast becomes.
The use of drugs like Lyrica, Neurontin, topamax, cymbalta, and many other older SSRI medications are used successfully to help decrease the pain caused , chronic, central or acute. Topical meds like lidocaine may also help some to reduce some of the pain. Methadone works really well for both chronic pain and for neuropathic pain. It is also really inexpensive.
Spinal cord stimulation may be something that you need to consider since it is used pretty successfully in central pain snydrome/reflex sympathetic dystrophy. There is also a pain pump, which is implanted in your body, and then the opiate medications , lidocaine, and other medications are delivered directly to the spinal cord through a catheter attached to the pump. The pump is filled periodically with the combination of medications determined by your doctor.
I understand the issues you face, and sympathize with you, but pain management is not just oral medications, it is a combination of treatments and therapies, both prescribed and not that will help reduce the pain some, and some we just have to learn to live with.
Addiction is not the same as tolerance. Tolerance is simply the body's ability to adjust to having a certain level of a medication, any type of medication in the body, and to acclimate to the negative side effects.
The reason that addicts take more and more pills at a time , is that they are chasing the "feelings"/"high" that they got the first time they took that particular drug. They are two different things. One is physical, one is mental/physical.
I think that your doctor needs to stop adding more short acting medications to your daily dosages and just increase your base med or change it to something else and then you need to not rely on the breakthrough meds so often. That is increasing your body's tolerance. The way that your meds are being taken now, leaves you constantly chasing the pain levels.

Last edited by backhurtz; 07-20-2011 at 02:41 PM. Reason: To include information regarding Methadone

 
Old 07-20-2011, 04:35 PM   #14
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Re: Tolerance Question

I see my PM doctor every month. He requires it since I am on MS Contin.

I have been on 30 mg MS Contin 3x/day, Neurontin 600 mg 3x/day, Percocet 7.5 1-3x/day, and Soma 350 1-3x/day. I also am on Celebrex and Voltaren Gel.

Since the MS Contin is morphine my PM requires anyone on this or oxy be seen monthly. At the visit I fill out a two sided form that asks if I've been fully compliant, what helps, what doesn't, current pain level, lowest since last visit, highest since last visit, any crisis pain moments and if so explanation.

Then the medical assistant talks to me to discuss any changes, any concerns, etc. The doctor then comes in to discuss. Sometimes this is brief and sometimes this is long depending on how I'm doing. When the pain became worse (or I had reached tolerance to some degree) he and I discussed increasing my LA (MS Contin) or my BT (Percocet). I chose to increase the Percocet (had been Norco and bumped it to Percocet).

ESI no longer work for me, I do use TENS on occasion, I used to do massage but can't afford that anymore, and have had RFA.
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