OK-So I have looked around this board and others, literally done days worth of research on the subject and also read about other experiences with Fentanyl (in all in its forms, patch 'types' and dosages).
I have also read a lot of information concerning the sheer potency of fentanyl and the dangers associated.
That said, here's a bit of my story and the questions associated:
I have a nasty dis herniation/degeneration in my neck at C4-C5 and I am currently in the process of receiving a series of ESI's in an effort to avoid surgery at such a young age (26). I also have nerve pain in my left arm, that alternates between shooting pain, numbness and tingling- as well as some severe back pain (musculo-skeletal) my doc believes.
I have, for months been taking 30 mgs a day of Oxy IR (10mg, 3/day) and after my last visit to the doc, I explained how while the Oxy worked enough to curb my pain (just barely- still no where close to a 4/5 pain scale wise,which, to my understanding it the goal of any PM treatment. That is, getting to a sustained 4-5 that is livable) but I was having serious issues with the 'hills and valleys' of short acting pain medicine. That is to say, after my morning dose wore off (usually i get about 4 hours out of an OXY IR) I was in more pain than I thought acceptable until (I work nights, as a chef- I only mention that to be not only thorough, but to bring up the point that I work a very physical and fast paced job. Lots of reaching, lifting, bending, stooping...all those things someone with hernaited disc should be avoiding at all costs...) I waited to take my second does just before work and was in pain really most of the night (the nature of my work tends to negate the relief from a 10mg OXY) until I could get home for my last dose, which, that at point, really only just barely curbed any pain I was in from work. My apologies for the lengthy post, but I thought all of this information would be of use in answering my questions and concerns.
SO, I suggested and my doc agreed, that it would be to my benefit to move on to a LA medication in conjection with something for BT pain. After some research, mostly into cost since I self pay all my meds, he settled on a 25mcg Fentanyl patch- which seemed to be the most cost effective of the LA/ER drugs available.
Seems like most people either love or hate the fent. patch. I love it, personally. I use a 25mch generic Watson gel patch that nearly totally eliminates any hills and valleys between med doses...which brings me to my question(s).
With the patches being sooo potent, I feel it has raised my opiate tolerance considerably, in a short period of time. The doc kept me on my usually oxy to IR 3/day, written the same, not 'as needed'...and I understand that the entire point of LA pain meds to to eliminate the need for regular dosing of shorter acting drugs. Well, considering (I feel, at least) that my tolerance has shot through the roof after 3-4 patches and the 10mg Oxy IR is nearly worthless now (AND being written/used as part of regular analgesia and NOT a BT pain reliever)- I am most deinitely going to need some adjustment,
My question(s) is this: when I see my doc next, should it be taken into account, or would you suggest a small step in dose from the 25mcg patch to the 50mcg patch to help eliminate the need to BT meds and ALSO, the BT med issue has to be addressed-
I've done some reading and I personally feel like one of three options would work best for me, which is where I need your help/opinions (also with the step in dose of the fentanyl patch).
1- a 30mg oxy IR allotted 3-4 times daily
2- a 10 mg Opana IR (dosage suggestions would be greatly appreciated)- I'm thinking allotment for 3-4 time daily as well (suggestions?)
3- a 8mg Dilaudid 3-4 allotment daily as well.
My reasoning is is- a 30mg oxy ir (all in conjunction with a 50mcg patch) would compensate for a newly acquired much higher tolerance, with a 3-4/day RX giving me enough room to have plenty left over at the end of the month...only having to use it 3-5 times a week. The 10mg Opana IR is significantly stronger than oxy IR and would require less dosing (not dosage), again, though with a 3-4/daily allotment, should leave plenty- if not more room to only have the need for 3-5 per week. The Dilaudid, I find is also close to or perhaps stronger than an oxy IR at that dose (30mg), but to my knowledge is available generic where the Opana is not (I think-on both counts?) and may be more cost effective to me having to self pay. However, money is (almost) not an issue as long as I'm out of pain, and should either of the three be effect/strong enough so that I only need them occasionally throughout the week, I will be left with a fair amount at the end of the month (why I'm thinking a 120 qty RX would be more advantageous- while it would cost more up front, I wouldn't need a refill for some time and would still have plenty left to save me from an immediate monthly refill and I could simply pick up a script from my doc when I am out or nearly out.
So, what do you think?
Any advice, insight, info you have is greatly appreciated and I thank you in advance soooooo much for not only taking to the time to read this but to also help me in this quandary.
I think the jump in dosage of fentanyl from 25 mcg ( micrograms, not milligrams) to 50 is far too great of a dosage increase. If the PM doctor feels that an increase in fentanyl is necessary, there is a 12.5 mcg. patch that he can use, rather than jump another 25 mcg in your base meds.
As to increasing your oxycodone med to 30 mg -4 times a day is a bit much , both in dosage and in frequency for what you are describing. You are worried about your tolerance now, adding that much of any opiate for breakthrough will send your tolerance through the roof in a very short time frame.
I don't make medication recommendations or dosage recommendations simply because I don't believe that we are in a position to make those type of recommendations. That should come from a discussion with your PM doctor, since he knows your physical condition, any other medical issues that may complicate your medication needs and honestly what works for one of us, may in fact not work for you at all.
The one thing that I will tell you , is that less is more when it comes to pain management. Oral meds should be just one small part of your overall comprehensive pain management program- physical therapy, TENS, ice, heat, massage, accupuncture, injections, and other modalities recommended by your surgeon and PM doctor should all be part of your pain management program.
I think you should leave these medication/dose decisions to your doctor. So, I won't common specifically on meds/doses. I would go into your appointment with your specific concerns, and see what your doctor thinks is appropriate. When they make a suggestion, you can then express your concerns on it, whether you automatically feel it may be too much or too little, too expensive, you didn't respond to it in the past, etc.
If you have literally only been on 3-4 patches (6 to 12 days depending on your changing schedule), then you should be giving this more time to see if your baseline pain level drops more. As you are new to long acting meds, I would think it would be more appropriate to take a month to adjust to this. Also keep in mind that sometimes as our pain gets relieved, our perception of our goal pain level can change. I find it easier to base on what activities I can or cannot do, or how easy it is to do them.
By the way, I'm surprised your doctor would use fentanyl as a first line LA med as it is the most potent. I believe the cost of MS Contin would be less (and methadone much much less), but as a lot of folks have an insurance tiered copay system for generic, preferred brand, non-preferred brand, etc, often if doesn't matter.
I can see why your doctor would think the 10mg oxy dose three times a day should be sufficient for bt as previously you took it by itself, and now you have a baseline med. So, if your baseline pain is lower, it should take less of a bt med. However, if after an acclimation period you still find the need to take a bt med 3 times a day to get your pain to a reasonable level, then it could be prudent for your doctor to increase your LA dose, whether that is a 25+12.5 or a 50, or even a different LA med.
50% relief is a common reasonable goal for a LA med. For example, an 8 to a 4. A 100% increase from 25 to 50 is A LOT for someone who previously was on 30mg oxycodone a day. It would be typical to have less than 3 bt doses a day as beyond that, the patient's pain isn't being well controlled by your LA med (or they have too high of goals for relief). Some folks have different types of pain, such as that which is very constant (little to no use for a bt med), or it may have a lot of spikes (more prudent to dose their LA med lower and give them more bt meds).
I hope you can work closely with your doctor to best manage your pain. Opiates should be only one of the ways to do this, and not a first line treatment. I am also 26 and have already been on opiates since 19 (although daily only in the last 3 years). I can relate to how hard it is to keep working with this pain. At our age tolerance can build very quickly. Fentanyl is a med which will raise your tolerance even quicker. For me, methadone has been a good med both for pain, and I believe, for minimizing my tolerance increase.
Not all doctors will use methadone, and not all would agree to use it as a first line opiate (same with fentanyl). I thought I would throw it out there in case your doctor gives you this as an option. If so, it would be my opinion that you should try it (and ignore the stigma that goes with it, as well as the public's general perception that it is dangerous or only for heroin addicts). You may also consider if there would be a career which would be easier on your body (but something you still enjoy) such that your opiate needs would decrease.
You may also want to work with your doctor to build in a higher dose to take during work hours (as long as you can maintain functional on it), if work increases your pain level. This is when taking pills can be an advantage, as you could have a slightly higher LA dose then. Best wishes.
constant headache since 2006
The Following User Says Thank You to tortoisegirl For This Useful Post: prodigalguy (08-27-2012)
I will echo the others in that none of us are medical professionals and just giving our personal opinions based on years of being in PM ourselves.
May I ask what else you do for pain management each day? Have you done injections? How about cortisone treatments or a Medrol dose pack?
And I am very surprised that you are not on an actual nerve pain medication like Lyrica, Neurontin, or Cymbalta. An opiate does not help nerve pain at all.
Same thing with having a muscle relaxer to take as needed. This is either Flexeril, Robaxin, Skelaxin, Soma or Baclofen. Opiates do not help muscle pain either.
So, it seems like from what you have written that you are only relying on the opiates to take all your pain down to a level 5. This is why your tolerance has jumped so quickly.
I use dozens of modalities to help keep my pain level at a 5-7 and I haven't had an opiate increase in more than 3 years!
I've had 3, two-level, cervical fusions...so I can definitely understand cervical/spine issues. I still have 4 active herniations in my cervcial/upper thoracic and lumbar areas but will not do another surgery unless it's absolutely necessary.
As others mentioned the other modalities to help chronic pain are daily exercise, physical therapy, aqua therapy, massage, acupuncture, TENS unit, ice, heat, injections, cognitive behavioral therapy, biofeedback, nerve ablations or RFAs, not smoking, eating well and maintaining a healthy weight, etc...
Along with the nerve pain med and/or muscle relaxer...some people are on an antidepressant which helps both pain and possible depression that comes from chronic pain.
So, I would be making sure that your PM Dr. is Board Certified and is looking to help you manage your chronic pain in a more comprehensive way. If he is only interested in just giving you opiates in larger and larger doses each appt., if he ever leaves the practice you will most likely be stuck with finding a Dr. who does this same approach.
Most of us that have been in chronic pain for years and years..(I've been at this for over 11 years now), use every single modality that I mentioned to help keep our pain levels down. It's not about trying them once and done....Every single thing puts a tiny dent in the pain to have them all added up to a 5 or so. Expecting the opiates to bring you to that 5 is why your tolerance is so low.
The other part I will mention is that most PM's will only go so far to keep managing pain if there is a surgical option that can help you get better. Even though you are young, I would seriously be speaking with Board Certified Neurosurgeons and asking them their opinion...As I asked earlier....have they done injections, traction, physical therapy?
First- thank you everyone for taking the time to respond, offer advice, etc. Please allow
me to clarify a few things brought up in responses and reiterate a few things stated in the original post.
Yes- I am, like I mentioned, receiving a series of cervical ESI's in an effort to avoid surgery. Although if after 3 injections and some time for the corticosteroid to work it's magic, I still feel little relief, my doc is going to send me to a neurosurgeon to discuss surgery.
I have not (although I do some exercises at home) go to or receive any formal physical therapy- also, like I mentioned before, I have no insurance and that would be waaaay out of my realm to realistically pay.
Also, I have been taking cymbalta- my doc gave me some samples for the month until I see him again in about a week and a half. I also take a muscle relaxer (soma 350mg 3-4 times/day as needed for back pain. I also take some other medications to treat my GAD symptoms.
I don't want anyone to get the impression I am just out for pills- as far as I'm concerned the less the better- I pay out of pocket for
My meds with a paycheck (not huge mind you) that comes from working an extremely physically demanding job (I am a chef, have been for ten years- I see no career change in my future at all. I love what I do and I want to get well so I can continue to do it.)
Also, I understand that medication and decisions regarding it are
Fully up to my doctor- he holds the pad and pen, not I. I fully understand this.
I only came here to state my case and reach out for
Suggestions and ideas- some of which have been great. I honestly only seek to arm myself with as much knowledge as possible so that when my doc and myself discuss these things in a few weeks-ish, I (he is very open to hear me out- not the type to shoot me down when I mention a drug or dose etc- he listens and we bounce things off one another. I couldn't ask for a better, more understanding, !!listener!!, and responsive and caring doc). He only wants to see me get the best treatment I can afford and is available to me. He REALLY
So when I stated that I noticed the fent patch threw my tolerance through the roof and made my normal 10mg dose of oxy IR seem like a skittle, I was just being honest. I think having a BT med allotment just for work-time (great idea) is a superb suggestion- just the kind of thing I was reaching for. I TOTALLY understand that you all are not doctors and can't act as such, but suggestions like that are GREAT! Also, I agree that the fentanyl patch probably wasn't a great idea first try, but I've tried it and I love it. Now- if I'm using the patch and 3 10mg oxy a day and still in pain that's where my issue is. The patch has eliminated the hills and valleys of SA meds but I remain in pain. Does it
Not seem reasonable, in conjunction with a muscle relaxer,
Cymbalta, ESI's and home exercise that I work with my doctor to find a fentanyl dose that will keep me out of 50% of my pain (to bring me to a 4-5 ideally) along with a dose of oxy IR or something that will actually be effective in killing my breakthrough pain?
Only asking for suggestions- perhaps meds for BT you have tried.
Thus far I think it would be a great idea (as suggested) to add a 12.5 patch to try for the following month along with a reasonable dose of oxy IR, perhaps 20 or 30 mg since 10 mg is clearly no longer effective for my BT pain whatsoever, it just happened to be what k was taking before the patch and it was continued. It was not taken into account that the potency of the fentanyl would skyrocket my opiate tolerance. So perhaps a 20 or 30mg oxy IR dose with enough written each moth to allow for an extra one or two per day solely
For BT pain associated with my work? Then whatever else is left of my other BT meds- thinking maybe a 120 RX maybe as opposed to a 90 RX, will be just that, left over- and both the increase in patch dose will greatly lower my need for BT meds, but when I need BT meds it will be strong enough to work at the written dose and hopefully leave some left over so I'm no always filling a full script.
I hope that clarifies a bit, thank you all again.
Also, thoughts, comments, advice is greatly appreciated!!