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I Need Your Opinion

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Old 08-22-2012, 06:01 AM   #1
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I Need Your Opinion

Hello there. I am not new to the board, but new to posting. I have been on the Butrans patch now for about a year. I use the 20mg patch. I have found that it helps so much for my pain management. I have cervical spondylosis and suffer from osteoarthritis. I am prescribed Oxycodone HCL 5mg twice daily when the pain gets too much to bear. I also have been taking Topamax 100mg twice daily for migraine headaches for the past 10 years. I take a small dosage of Nortriptyline at night.

I work each day sitting behind a computer, and my problems and my job do not mesh...the pain is compounded when I sit staring at my computer for hours. So I have no other option than to take the Oxycodone while at work. I would take one tablet, and then the sleepiness would ensue. By 2:30 or 3:00, my head was bobbing at my desk, my e-mails made no sense. When I left work at 5:30, I felt like I was on the verge of falling asleep at the wheel. So when I asked my doctor about this problem, he prescribed Adderall 15 mg for me to take in the mornings. I had no side effects from the stimulant, however, I still had the problem. By 3:30 or so, I was sleeping. So he changed the Adderall dosage to 30mg in the morning and 15 at noon. I have used this dosage for three days, and have not fallen asleep at work. I am having no problems falling asleep at bedtime.

Here is my dilemma...I feel like a walking medicine cabinet. I am getting good results from my medicines, and have starting taking only one Oxycodone daily instead of two. Does anyone else take this cocktail of meds?

Thanks for any replies.

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Old 08-22-2012, 03:55 PM   #2
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Re: I Need Your Opinion

I think the question is more likely, who on this board is not on a cocktail of meds? Honestly, this pain management thing is really hit or miss and there are times when it seems like drugs are being added and others are being taken away. That is, until they get it "just right". Then that may not work for more than a year or so and you're back on the treadmill. But take sollice in the fact that you're clearly not alone or different in what you're doing than most of us here (but I can really only speak for myself). Hopefully others will stop by and give you their opinion on your situation. Hang in there!

Old 08-22-2012, 08:41 PM   #3
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Re: I Need Your Opinion

Welcome! Although I am not on that exact combo, I am on a long acting pain med (methadone), short acting pain med (oxycodone), stimulant (Ritalin), muscle relaxer (Zanaflex), rescue pain/nausea meds, several other daily meds, and several other as needed meds. Yes I too am a walking pharmacy, but I can say with conviction that each medication positively improves my life and the benefits outweigh the risks.

I have been willing to take so many meds (including high dose opiates) so I can continue to have some sense of a normal life with this chronic pain. I also work full time at a desk job and have such a hard time focusing, and also it greatly exacerbates my pain. I have made changes in my life to be able to continue working, and have other ways to manage my pain in addition to the meds.

I think its fine to add in a med to counteract another's side effects if the end result is helpful. What you would want to beware of is adding multiple meds at one time, or not realizing that a new symptoms is actually a med side effect, and then adding in a med to treat it, etc. Every once in awhile I take some time to evaluate what I am on and if any changes could be helpful. Whether something has been giving me increased side effects, has lost effectiveness, etc. Adding meds in one at a time and increasing doses slowly is also the way to go.

Then again, I am very pro-pharma. Other folks are not. I am actually more fearful of supplements due to the lack of regulation (never sure what exactly is in them, and how they interact with our bodies & other meds). Its a great feeling when your pain can be controlled. Just as long as you or your doctor is not pushing for unrealistic results/goals (relieving close to or all of your pain). 50% is a reasonable goal.

You also want to ensure you are not impaired at work / while driving (whether by drowsiness or by euphoria). Most of us with opiate tolerance don't have that issue though. I have always felt more impaired by the pain than by the opiates.

Its great if you can take only 1 of the 2 oxycodone a day as then when you do have a pain spike you have that other one to take on top of what your body is used to. Sounds like if you were on a long acting pill instead of a patch you would do well with having a higher dose during the work day. I do this. I hope this regimen continues to be helpful for you. Best wishes.
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Old 08-23-2012, 06:06 AM   #4
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Re: I Need Your Opinion

Thank you so much for your replies Whoopee and tortoisegirl. I just felt like I was maybe taking too many meds, but after seeing your posts, I realize that someone besides me is having to manage pain this way. I guess we have no other choice - it's the hand we were dealt.

Again, thank you. I think I'm having a better day today. The sun is out and there is no rain!


Old 08-23-2012, 08:28 PM   #5
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Re: I Need Your Opinion

Yeah I see no reason to suffer more than I need to. Even when my pain treatment is at its best its still tough to deal with. Best wishes.
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Old 08-23-2012, 11:00 PM   #6
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Re: I Need Your Opinion

Do not feel like you are alone in being a walking pharmacy. I take methadone for my long acting pain killer with norco (hydrocodone) for break thru pain. Without this combination my quality of life would be poor. You are not alone

Old 08-24-2012, 07:20 AM   #7
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Re: I Need Your Opinion

Hi Deborah, Although many of us are are on PM cocktails whether they include opiates and something for nerve pain or an antidepressant or muscle relaxers, Adding amphetamines is somethng few docs will do. I believe the general consensus in PM is that if the meds are so potent you cant stay awake, how can you complain about your level of pain. I have read about a few docs that use amphetamines in PM cocktails, it's nowhere near the concensus as far as what's normal. First off, The use of opiates to treat chronic pain is so contreversial that adding stims to the mix would be hard for any doc to justify. Why not just cut back on something that makes you so drowsy. Nodding out isn't improved quality of life. Im sure every elderly person could use some extra pep in their step but I have never met an elderly person that is on stims because it improves their quality of life. The whole quylity of life issue has become a catch phrase for every person that wants to justify the meds they take despite the negative side effects and consequences.

You would be hard pressed to find another doc wiling to duplicate that combo and your doc is putting an even larger target on his back unless you have truly been diagnosed with narcalepsy. You simply dealing with a side effect that could be reduced by a med change. To answer your question, stims used in PM is not the norm, it's an exception and rarely used in PM. A handful of people saying it's OK doesn't make it normal nor does a doc here or there willing to put his licence on the line for someone so medicated they cant stay awake.

I get we are all on some type of combo, but ading amphetamines to the mix is part of few combos. Your doc didn't even try non amphetamine stims which makes it even more unususal. So is it normal? From what I have seen and read in the last 18 years my answer would be absolutely not. Amphetmaines are powerful meds that when used wrong can cause so many negative side efects along with being dependent on one more class 2 medication. In the drug culture it's a speed ball, you will need ever increasing doses of stims due to tolerance and now that your awake you can complain more about pain which means lets increasee the opiates, which in turn leads to increasing the stims since the opiates and other meds sedate you so much.

Their is a point where the side efects and risks do outweigh the benefits the meds provide. To treat late afternoon drowsiness you will likely have to take a longer acting or take them later in the day which will then lead to needing more potent sleeping meds. Sleeping meds for a person that cant stay awake and needs stims beause of the pain meds they take sounds more like a rock star combo than a PM combo. Perhaps your expectations of PM are a bit high. In the present atmosphere, It's just to hard to justify the benefit when their were plenty of other alternative to tweak your combo without throwing amphetmamines in the mix. . Prior to being on meds you were able to work, correct, i get you were uncomfortable and in pain but If your PM combo inhibits your ability to work where is the benfit and improvement of quality of life. Your heading down a road few people travel when adding stims to the mix.

Will your doc still be practicing in 2 years, honestly I would be surprised if he takes this aproach with all his patients. Ive been with a group of PM docs for over a decade and stims simply aren't on the menu for anyone. That's just my personal opinion and the group of docs that have treated my pain agressively for the last decade. With or without stims, I couldn't take enough pain meds to allow me to work an 8 hour day and go back the next for another. It takes me a couple days to recover. I have been able to return to work part time, But the use of stims has never crossed my mind because of the risks involved to myself and to my docs for prescribing them.

Combinations of meds are normal, adding amphetamines to the mix isn't. If these meds were that benign why not make them available to everyone that got a bad night sleep or feels they would be more productive with a little pep in their step or is simply over the age of 60 and doesn't have the energy they once had. There are to many risks involved with the use of amphetamines from abuse to psychosis from prolonged use. Yes kids do take these meds, but that's contreversial too. At least most docs stop prescribing during the summer which allows a childs brain chemsistry to reset back to normal after they go through withdrawal every june, But in a situation where you know the dose is going to need to be increased with tolerance and with the addition of meds to relieve pain, where does it stop. If the med combo is what eventually inhibits you from working rather than your medical condition, it's really hard to say the meds have improved your quality of life and that's our only justification for using these meds.

Sorry I just dont agree with the other posters on this issue as far as being normal or following any PM guidelines as far as standard of care and exceptable practices in PM. But again it's just my opinion. We all have to decide for ourselves what we are willing to deal with as far as side efects and risks from the meds we use. Just because your doc is prescribing it doesn't mean the use of amphetamines are normal or benign. Very few other docs would be wiling to go to such extreme measures or would be willing to expose you or themselelves to the tremendous risks continuing down this road. IMHO
Take care and good luck, Dave

Old 08-24-2012, 08:37 AM   #8
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Re: I Need Your Opinion

Dave is 100% right; I was thinking of same thing reading your post, can't agree more with you Dave.
I am no youngster and learned during my ordeal with health issues: just b/c someone wears white coat and has MD degree doesn't mean he/she really cares or knows what they are doing.
I can't believe just to keep you from sleeping at day time from taking opiate, he Rx you this drug. Just doesn't make sense to me.
Another thing, if you are able to keep your pain under control by taking only 1 or 2 pills a day, did you ever try to take something OTC and see if this helps? Why opiates than? And if it makes you so drowsy and sleepy, how do you get behind the wheel? Maybe by cutting the dose in half would take care about this side effect? I don't care about your job, but sleepy behind the wheel this is dangerous not for you only, but for innocent people around you as well!!! This is a scary thought and very irresponsible in my book. Sorry...

Wishing you well dear

Old 08-24-2012, 04:23 PM   #9
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Re: I Need Your Opinion

I have been in Pain Mgmt. for 11 years now and my PM never prescribes stimulants/amphetamines because of fatigue levels. Adderall is for people with severe ADD that has been diagnosed. So your Dr. is choosing to prescribe this "off label".

As mentioned, this can become a problem and why unfortunately many people "OD" on medications because they are taking things that bring them down and then to perk back up again.

I am pretty shocked that he went for the prescription in the first place but to then ramp up the dosage so quickly by more than doubling it (15mg to 45mg a day)...That is actually scary to me and if I were the patient, I would have changed Drs. immediately for someone who thinks meds are the answer to everything.

Even "regular" people...non chronic pain patients have a slump in the afternoon. This is where you get up and do stretches, drink water or green tea to get a natural boost of energy. Or eat a small snack with complex carbs and a protein.

Or try to make sure your sleeping patterns/habits are ok with going to bed at the same time each night. Make sure every single light is out including the computer and/or phone. Keeping the temp at 68 or below. Waking up at the same time each morning.

Making sure that you are getting proper daily exercise of 30 to 45 minutes a day.

Make sure you are eating a healthy diet that especially doesn't include high sugars or simple carbs during lunch that would have you "crash" in the afternoon.

Not smoking (if applicable)

These are just many of the ways to help your fatigue levels naturally.

Please don't get me wrong and think that I think you are doing anything wrong. I am saying that I just have never seen a Dr. do something like this. Filling you up with more medication when not necessary is what would make me finding another PM Dr. quickly.

As mentioned, the larger problem can happen for you is that your body loses it's natural ability to rev itself up. To have your own adrenaline/endorphins by having a stimulant do the work. And if this Dr. ever leaves his practice...I don't know of many Drs. who would continue prescribing this way.

I take pain medication that includes opiates as well as a muscle relaxer. I am fortunate in that my last cervical fusion got rid of most of my severe nerve pain to where I don't need a med for this right now. And opiates are not meant for muscle pain so that is why I have a muscle relaxer to take as needed.

But it has taken me close to 11 years to get to this mixture. I still make sure I use many other modalities daily/weekly/monthly to help keep my pain at around a 5-7.

This includes exercise, aqua therapy, physical therapy, acupuncture, massage, ice, heat, TENS unit, injections, steroids, cognitive behavioral therapy, yoga, stretching, eating organic, etc.

One should never rely on their medication to be the sole source of pain mgmt.

So, the answer to your question is that no, I do not use amphetamines and never will. We have to all do what we feel is best for our own care...

Good luck

Old 08-24-2012, 09:08 PM   #10
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Re: I Need Your Opinion

There are also the legal ramifications to worry about should you get involved in a traffic accident or be found at fault. You can legally be charged with driving under the influence taking either the opiates or the amphetamines and certainly could be with taking both of them. You and everyone taking pain medications or any other medication that is known to cause drowsiness, dizziness, muscle incoordination needs to be aware of their states motor vehicle laws in regards to taking these meds and the legal consequences of them.
Even in a not at fault accident, you can be required to take a blood test if the police have any suspicion of impairment , or you are taken to the hospital for treatment after an accident, and they run your bloodwork, the hospital can require that they run your blod or urine for narcotics or other drugs of impairment and the police and your insurance company can get the results of those tests.
I have to agree with Shoreline, I have never heard of PM doctors using amphetamines except in the cases of diagnosed narcolepsy to counteract drowsiness caused as a side effect of medications. What happens down the road when the dosage of amphetamines gets so high that it effects your ability to sleep at night? Then you add yet another medication to sleep? Then another increased dose of amphetamine to keep you awake from the side effects of the sleep meds? It does become a vicious cycle and one that can potentially be never ending.

Old 08-24-2012, 09:19 PM   #11
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Re: I Need Your Opinion

Great suggestions here. I wanted to clarify that my comments previously were more in general on meds and that in some cases it can be appropriate to counteract a side effect, not agreeing (or disagreeing) on the use of a stimulant...I don't really have the basis for an opinion on that, besides to say that I am on one.

However, mine isn't for medication-related drowsiness (or ADD). My doctor best describes it as hypersomnolence. No matter how much I sleep I have a tough time getting going in the morning and am generally quite drowsy. If I did need it due to the pain meds and my doctor agreed, I would. I think if the pain meds were of enough benefit (no better option) and there wasn't a solution around it (such as switching the med and/or dose), it is feasible. Especially if you are a danger with the drowsiness (driving, work).

Not sure how much was tried in your case though. My sleep specialist and current prescribing doctor for the stimulant didn't focus on ensuring that my drowsiness wasn't from the pain meds. Amphetamines can be a first line stimulant, especially as many insurance companies won't cover Provigil/Nuvigil, and some doctors prefer Adderall over Ritalin.

I do think its possible to have drowsiness from an opiate without it being too high of a dose, but I don't know what is going on in your case. I would hope you have a good dialogue with your doctor about the meds & treatments. Best wishes.
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Old 08-25-2012, 04:12 PM   #12
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Re: I Need Your Opinion

Just a thought but what about switching to a different BT med, I know several people who are drowsy on oxycodone but fine on hydrocodone and vice versa. Everybody is different but I would be very very careful adding a stim to your meds now. In my opinion there are a lot of safer options to try. I have problems with drowsiness sometimes with hydrocodone especially if I am sleep deprived. When that happens a cup of tea does the trick for me or sometimes just taking a 15 min walk makes all the difference in the world.

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