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Old 06-29-2012, 01:14 PM   #1
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Morphine Absorption

I switched from methadone to morphine ER and have had a pretty rough time with it. The initial conversion was so conservative I was in withdrawal. At my follow up a couple weeks later my dose was doubled from 300mg to 600mg a day, instructed as 1-2 of the 100mg pills three times a day as tolerated. The switch was initially done by the PA, then at the follow up I saw the doctor.

The doctor seemed like he didn't think much of doubling my dose. Ie., he wasn't surprised I wasn't doing well on the 300mg. He discussed morphine has a low bio-availability, its normal to need a high mg dosage, and the conversion from methadone is widely varied. I had been on 50mg methadone plus 180mg morphine a day previously. I slowly increased the morphine dose as although the doctor didn't give me instructions, I know enough not to double my dose in one jump.

My pain is still out of control even with the dose increase. I am getting yo-yo relief with it. Definitely doesn't last 8 hours. I actually gave up taking it before bed as it doesn't seem to make a difference in my pain level when waking up, so for me its kinda pointless since the pain doesn't keep me up. I seem to get a big relief spike, then it drops off very quickly. I've been spacing my doses close together in the morning & afternoon, which is better than 3 equally spaced doses a day, but not by much.

Compared to my experience with the IR morphine and other meds, and how this is supposed to be a higher equivalent dose than I was on previously, I am beginning to suspect I'm not absorbing it as expected. I'm not getting the expected amount of pain relief. It seems like this is similar to when I tried Opana, where I needed a dose many times over what was supposed to match that of what I was getting with previous breakthrough meds

Has anyone else had absorption issues with morphine or other meds, such that they don't get the expected relief? I know I absorb pain meds more quickly than average, but this is pretty ridiculous that I am taking this much morphine and doing worse than I was on my previous meds. Anyone think switching to Kadian or Avinza would make much of a difference? Seems like we'll need to figure out a different med for me to try. Running out of options unfortunately. Thanks! Best wishes.
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Old 06-29-2012, 01:34 PM   #2
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Re: Morphine Absorption

So you are on 600mg of Morphine per day?

The rough calculations from 50mg of Methadone to Morphine with a 25% bioavailability ratio is around 141mg of Morphine...

So added to your previous Morphine of 180....that would be 320mg.

They have definitely close to doubled your opiate intake per 24 hours.....

It just may be you are just not processing the Morphine very well....But it would be pretty rare for a Dr. to continue dosing up from 600mg a day. If you were to every lose this Dr....there won't be many out there that would take on that dosage so just be mindful of this.

Switching to Avinza or Kadian shouldn't matter as they are also Morphine....so once again..you would be having to take the same amount of 600mg a day. It's just dosed differently.

Most Drs. decide that a patient should switch to a pain pump if your dosage gets to a certain level orally to prevent having to keep going up.

Has this Dr. mentioned this possibility as your next step? It seems logical at this point.

Also, it's important that you aren't relying soley on the opiates to bring down your pain level.

Last edited by Ilovemycutedog; 06-29-2012 at 01:35 PM.

 
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Old 06-29-2012, 01:53 PM   #3
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Re: Morphine Absorption

Yup they prescribed 600mg/day. I've got up to 500mg and didn't see much of a change from the 400mg so I'll probably stick to 400mg for now until we get me switched to something else. I definitely don't want to keep increasing it because I haven't responded to the dose increases so I must not be absorbing it right. This confirms my previous thoughts that Methadone was the best bang for the buck.

Actually, the conversions from methadone are all over the place, and depend on the dose, so I don't think you can quote a conversion rate like you could for other meds.

I am waiting for my doctor to bring up the pain pump idea but I'm definitely thinking that is a good option. I heard they can now do Methadone in it so it would be great if I could find someone doing that. I thought even though they were the same med the pellet form (in the capsule) might absorb differently, but that is just an assumption.

I've exhausted all known options for everything else but pain meds. Currently on muscle relaxers, get massage, eat healthy, exercise, etc, but have tried all the typical meds and therapies. I agree its scary to think of if I had to switch doctors. I'm actually starting to think this isn't worth it as I'm only getting about 30-40% relief now. When I first starting long acting meds I was able to get over 50% relief. Thanks!
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Last edited by tortoisegirl; 06-29-2012 at 01:59 PM.

 
Old 07-04-2012, 12:29 PM   #4
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Re: Morphine Absorption

Hi I'm taking 200 mg Kadian a day, and it sure does seem more consistent and carries out longer than the ms contin. there are some good charts available for comparison, as it don't peak as high but does stay at steady state longer as to the 12-24 Hr dosing. I found it to work better for me, they say it's a sustained release different delivery method so it may work good luck

 
Old 07-05-2012, 07:48 AM   #5
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Re: Morphine Absorption

Hi Tourtoise girl, Even if they put you on whatever the pefect conversion is you would likely still experience some differential withdrawal for 3-4 weeks. I flip flopped between methadone and morphine several times due to insurance issues before having my pump put in and the end conversion always worked out the same, I either took 600 mgs of morphine or 120 mgs of methadone. However methadone has properties that other opiates dont have so trying to eliminate differential withdrawal with increasing doses will only jack your tolerance up, if you had started at 600 mgs of morphine you would have still felt funky for several weeks while coming off the methadone. If you could withstand the initial 3-4 weeks of change I would bet you would have settled on less unless your simply werent getting enough relief from the methadone and needed an adjutment for pain reasons anyway. If you were under dosed on meth, then it makes sense to need more morphine to manage your pain. But I would try to ride it out and see where you end up after 4 weeks rather than chasing a type of withdrawal that can't be fixed by taking more of a different opiate than methadone.
Good Luck , Dave

 
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Old 07-05-2012, 10:39 AM   #6
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Re: Morphine Absorption

Yes on the methadone I was not getting good pain relief at all...both overall levels and that it wouldn't last me through the night so I ended up only taking it twice a day, 6 hours apart in the morning, to maximize my pain relief during work. My goals of switching meds are to try to get back to 50% average relief and to not wake up in so much pain that it takes much of the day to get it under control. I don't have a need to take pain meds at night (pain doesn't keep me up), but even when I do take a dose before I go to bed, with all the meds I've tried, I wake up with seemingly no meds in my system.

No I wouldn't have been able to stand the withdrawal from going from 50mg methadone + 180mg morphine to 200mg morphine (for two days) then 300mg morphine. I was shaky and pukey and everything...not just uncomfortable. Once I added back in the 20mg methadone (doctor allowed) the withdrawal was gone. I do understand the need to start lower, but I think my doctor was way off to tell me not to expect withdrawal with that type of switch. Nor do I think they should have done it all in one jump.

Dave-Any comments on if certain folks don't absorb certain meds as well as others? I have been taking the 600mg of morphine for a week now and it still doesn't seem to be doing much for my pain (worse than the methadone and methadone + morphine combo). I don't want to be taking this much--seems like conversion wise I should have needed more in the 400-500mg range. I'm actually hesitant to continue on this much even short term since I don't see much of a difference between the 300mg and 500-600mg, besides that I could discontinue the methadone.

I have an appointment next week thankfully. Curious if my doctor will think its worthwhile to try Kadian or Avinza, as I understand they could give me more stable levels since its pretty apparent I can't get them with the MSC. I'm even spacing out my doses four times a day. However, not sure if the more even dispersal will help much as even at its best output, I'm not doing well on the MSC. If I was getting varied relief, I'd have a different opinion.

I still think that I'm not absorbing the expected amount of the morphine. Never was able to get relief from IR morphine. My best idea right now is to re-try the Fentanyl patch. Seems like if we try that (every 2 days), its my best chance of stable relief. I previously only tried it for two weeks on top of the methadone before the other PA at the clinic decided that wasn't a good combo. So, I never gave it a real try for my full dose. In the two weeks it was apparent the every 3 days wouldn't work for me.

Also curious if my doctor thinks I should look into getting a pump. My tolerance is pretty ridiculous and I've never really been stable on pain meds...it just better than nothing. Pretty sure they don't do them at my clinic so it may not be something they think about much (since they would refer out). I don't understand your statement Dave on the chasing a type of withdrawal that can't be fixed by taking morphine instead of methadone...once I added in more morphine I was able to drop the methadone without withdrawal. Thanks! Best wishes.
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Old 07-06-2012, 05:49 AM   #7
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Re: Morphine Absorption

How long have you been on opiate medication, Kate? Because your tolerance levels adapt to the medication, thus meaning they won't work as well as they did when you first started taking them. I have been on codiene and tramadol for 3 years now, and they recently stopped working as well, so they switched me to buprenorphine SL for a short while, then put me back onto the tram and CPH, and surprisingly, my tolerance levels were back to where they were when I first started taking them. Maybe they should switch you to a block aid (same effects as an opiate, but for some reason different) for about 6-8 weeks like me, then pop you back onto methadone or morphine. Methadone is a much more effective pain killer in a long acting sense over morphine. Morphine is a quick, short term relief medication. I learnt this much from working in accident and emergency for 4 years. But the pain pump is also a very good idea. Maybe you should mention this to your doctor, rather than waiting for him/her to bring it up?
I hope this jargon makes sense and helps you!
Best wishes,
Georgia.

Last edited by Gkettle1; 07-06-2012 at 05:51 AM.

 
Old 07-06-2012, 08:56 PM   #8
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Re: Morphine Absorption

I've been on some form of opiates for over 6 years now. I'm 26 so yes I have built quick tolerance and am very familiar with it. I was on methadone for a couple years but never did too well on it as it doesn't last me more than about 5 hours, so I'd play catch up all day. Plus I was underdosed. Methadone does give me the best pain relief for the buck though (equivalence wise I need a lot more of anything else). I would be very reluctant to switch to suboxone or similar as I have been led to believe you can't take much of anything for breakthrough with it. I have wildly varying pain levels and heavily rely on being able to take a strong dose for breakthrough.

Seems like everything points to morphine not being a good med for me, so I'm hoping my doctor agrees to me going back on the fentanyl patch and giving that a good go. That is the one med that I haven't properly trialed and don't have a known high tolerance too.

I would bring up the pump to my doctor except he still has a few ideas we are working through in addition to the meds. It could be in the next couple visits though. Don't want to be jumping to that though as I have only seen the doctor at the clinic once (second visit next Wednesday) so that seems quite premature for our relationship, but not overall.

I'm definitely one of their more special patients. If I could find someone who did methadone in the pump that seems very ideal, but I know from my reading that finding a doctor who would consider a pump in a 26 year old headache patient would be rare. Hard enough to get pain meds for headache and pain meds if you are in your 20s. Plus, you add that you need that special doctor who you trust as if they leave you are SOL (another practice won't take you in most of the time). If I wasn't working I wouldn't hesitate to take a med holiday. I had one month without my breakthrough meds (doctor thought I didn't need them!) and that really helped the tolerance, but needless to say I was miserable. Thanks! Best wishes.
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Old 07-07-2012, 09:49 AM   #9
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Re: Morphine Absorption

Methadone has properties that other opiates simply dont have, so even at whatever the ideal conversion is, it would be unusual in my experience to not still experience some differential withdrawal. Not the full blown puking type unles way under dosed and when you through in the 180 mgs of morphine you were taking, 600 sounds about right but are you still taking that much short acting mophine.

I'm sorry I'm not completely famiiar with your pain generators, it kinda seems if even large increases still leave you miserable I would be looking for some kind of change in your condition rather than simply increasing and increasing, Where will you be at 38 and 48years old?

It would certainly be worthwhile to consult a doc that manages pumps. I would contact the manufacturer and ask for a list of docs certified to do the trials, implants and manage the pumps. They do start you low on pumps, I started at about 1/10th of where I ended 6 months later and finally got back to the same elevel of relief I had with orals without the head fog. 50% has always been the goal my doc shoots for. If their are other adjunct therapies or meds that would help your condition, the more things you have working to block pain transmission the better off you will be.

It's great you have been able to continue working and their are so many benefits psychologically and physically of continuing work, but eventually you will reach a point with the meds, side effects and ability to manage your pain that disabilility isn't something your chose or make a decision about. It may not be pssible to manage your pain and continue working while on orals or any delivery system at any dose. Only you know when that day comes.But at 600 mgs of morphine a day their is no argument that will defend you if you happen to get in an accident or get charged with DUI. Claiming to be tolerant and to have accomadated is no different than thinking an alcoholoc with a high tolerance should have diifferent standards when they blow over the legal limit when it comes to etol levels and DUI. Just because you feel tolerant and dont feel the impairment doesn't mean 600 mgs of morphine a day isn't impairing you in some way. Your n a slippery slope driving on that level of medication.
Good luck, Dave

 
Old 07-07-2012, 11:21 AM   #10
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Re: Morphine Absorption

I have not been on short acting morphine through any of this (this was all long acting). I've had 60mg oxycodone for breakthrough, which I don't take when I'm in the midst of dose changes. In daily doses, I went from (70mg methadone) to (70mg methadone plus 25mcg fentanyl) to (70mg methadone plus 90mg morphine) to (50mg methadone plus 180mg morphine) to (300mg morphine plus 20mg methadone) to (600mg morphine). My doctor's goal was to get me on a medication that provided me with more steady relief without increasing the daily dose too much above the 70mg methadone.

The 600mg morphine is still way less pain relief than I was getting on any of the previous combos, and barely better than the 300mg morphine. I still believe its the morphine that isn't agreeing with me...any other med and I definitely respond to dose increases. My best guess is I am one of those who doesn't respond well to it orally. Actually, I don't do so well on any oral med--very fast metabolizer.

I actually initially titrated up to 60mg methadone a day when I first started the long acting meds a few years ago, and was stuck with a doctor who wouldn't make any med or dose changes, nor refer me to a PM doc (I had to find one on my own). My condition has been pretty steady, but my head pain varies a lot throughout the day. Current doctor believes I have different body chemistry and high tolerance, although other doctors have thrown out the hyperalgesia comments. Whenever I have increased or decreased doses on meds besides morphine however, I responded as expected.

I do definitely have concerns long term. I've tried just about every adjunct med and therapy the 50 or so doctors I have seen have suggested. I agree that this won't be sustainable long term and that I won't always be able to work. At my age I need to try as long as I can though. Its unfathomable to be disabled at my age. My PM doc has a couple ideas that I haven't tried in my journey yet, then I'll see what he thinks about a pump.

My PM doc has suggested a supraorbital block, possibly a nerve stim implant, and possibly pursing sinus surgery since I responded a bit to nasal lidocaine. I just started at this pain clinic so I am hesitant to already be looking for a new one when I haven't exhausted all the options here. I still believe that they could get me stable on a long acting pain med and then we'll see from there. So far the benefits outweigh the side effects for me.

I still believe I am more impaired by my pain that the meds, but I'm sure there will always be folks who beg to differ. Thankfully my hubby and doctors are on my side. I'd never tell anyone at work though. I've never felt any fogginess from the meds, only from my pain and my fibro. Thankfully in my state it is legal to refuse a field sobriety test. Of course I hope I never have any legal problems with the meds. My hubby keeps a close eye on me, including being a passenger with me driving, and he hasn't noticed any impairment. Thanks! Best wishes.
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Last edited by tortoisegirl; 07-07-2012 at 11:56 AM. Reason: typo in dose

 
Old 07-11-2012, 08:32 PM   #11
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Re: Morphine Absorption

So my doctor didn't have much to say on my suspected absorption issue / lack of response, but he was conducive to changing from morphine to the fentanyl patch on my suggestion (after he asked what had worked in the past). He put me on the 100mcg, so we'll see how that goes. Seems to be an appropriate conservative swap for the 600mg morphine. Glad he didn't push for me to try one of the longer acting forms as I'm pretty sick of it (not helping and side effects).

Hope I don't have withdrawal again though. At least he said I could call and he could give me an ok to up my bt meds if needed. Not sure I'd have enough to do that though. We did the supraorbital block but it isn't hitting my headache location, and so far is causing more pain. The nerve stim we were considering would have had leads there, so that may rule out even wanting to do a trial. Next will probably be a temporal block. Once we exhaust nerve block ideas and if I can't get stable on a med, I'm definitely ready to ask about a pump referral. Best wishes.
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Old 07-15-2012, 01:47 PM   #12
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Re: Morphine Absorption

Update: I've been (back) on the patch for a couple days now. Its been pretty rough with the pain and some withdrawal, so I might need to put a call into the doctor next week. Trying to give it some time still. Even on this first one I'm seeing a big difference between the end of day 1 and the end of day 2; I feel lucky my doctor agreed to start me on the 2 day schedule based on my previous experience (he said almost all his patients do that) and my insurance doesn't appear to have a quantity limit on patches.

They moved me from 600mg morphine to a 100mcg/hr patch. Conversion charts say 150-200 mcg/hr, so there is some room for increase without it being an increase. I got stuck with Watson this month...much tougher to deal with than the 25 mcg/hr Mallincroft ones I had before. I couldn't wait to order and didn't feel like driving to even more pharmacies just based on brand (since I hadn't tried this one).

Any suggestions on where to place these things? I had to move it from my lower back to my lower abdomen within a couple minutes as it wouldn't stay flat (surprised that was successful...but it took a second tegaderm). Too large for my arm (and that isn't desirable in summer). I guess I'll have to try my ribcage or upper back. I've heard mixed results on trying to apply it to your leg (which is against the manufacturer recommendation).

Will try to get Sandoz next month per suggestions here, or better yet, a mixed lot so I can test the brands out, but I may need to stretch these out more than 2 days each to give me time for my pharmacy to order since I only have a two day (one patch) head start since I wanted to start this weekend.

I had to go to a different pharmacy just to find this dose in stock, and I assume next time I'll be needing more than one patch. Are not many folks on the 100mcg? Dealing with some itching under the patch and my body feels overheated. Glad nothing major is going on with the switch though. Planning to ask about a nose spray to use on the skin before application (I have an ointment, but think I could only use that after). Best wishes.
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