Can anyone tell me about Morphine equivalence; specifically at what dose do most Physicians begin to feel uncomfortable exceeding? My PCP brought up Fentanyl as an option for me but doesn't Fentanyl follow the same rules of equivalence? What am I missing? My current daily dose is 40mg Oxymorphone + 24mg Dilaudid BT. The equivalent in Morphine is 216mg. Is that considered high?
I'm not sure I understand what you are asking? I don't see the need to do any equivalent to Morphine unless you are switching over to Morphine.
Fentanyl is does in MICROgrams and all other oral meds are dosed in MILIgrams. And there isn't really any magical conversion number as it can be so varied with cross tolerance, metabolism, health issues, and other medications one takes. So a good Dr. will always start low on the transition and move up as needed.
And everyone is different in their pain issues and their pain tolerance levels. So it's really about what works for you. And obviously keep in mind that opiates are just one small piece of the puzzle in one's pain management. So it's not about whether the opiates take the pain down to a certain level...It's every single modality all added up to get to about a 5 or so which is what most Drs. think is acceptable for chronic pain.
Why does your Dr. want to switch to the Fentanyl patch?
**I just rememberd your last post with you saying you were losing your insurance this month...did that change? If so..that is great...So you are able to stay with this Dr.? I was thinking that this current medication was doing so great for you and you said it was helping better than anything you had taken previously.....
So...the patches are certainly one opition...but I didn't care for them as I like to have more control with my medications and only take the least amount on good days and the max if needed on bad ones. With the patch...you are stuck with that amount for 2-3 days.
So...I don't think you will find your answer online...it will be working with your Dr. and see what works for you.
I wish you luck though and keep us posted..
Last edited by Ilovemycutedog; 10-05-2012 at 10:43 AM.
Reason: remembered something..
The current cost of Oxymorphone was what we were discussing -and my need to switch to another more affordable option when my Dr. suddenly brought up this 'Morphine Equivalence' issue. My understanding is that there is some magic number in Milligrams of Morphine per day that is a sort of ceiling dose that prescriber's don't really want to exceed. Perhaps it's related to respiratory depression or some other safety issue...... I'm scratching my head because I wasn't asking for a dose increase, I think he just got spooked as he went over the conversion numbers for another opiate??? My assumption is that a 75mcg/hr patch would be about right -but they are expensive too.... Anyway, thanks for listening.
OK, if I did this right, you are on a morphine equivalent dose of 256mg. How I got that was that oral hydromorphone is 4-7 times more potent than oral morphine so I multiplied your 64mg of oral hydromorphone by 4 and got 256mg.
Then to convert to transdermal patch, fentanyl is 100 times more potent than morphine so take the 256/100=2.56mg fentanyl in 24 hours, which equals 2560 micrograms. 2560Microgram/24 hours equals 106 micrograms an hour so the 100 microgram patch should be the equivalent.
Definitely check this out yourself, I was looking at a site on easy narcotic conversions so as I am not a medical professional I cannot attest to the accuracy of this but I think it's close.
Morphine is often considered the gold standard for comparing doses. Yes doctors may have a ceiling dose in mind of what they are comfortable (which will likely vary based on the patient's age and condition), but each doctor has a different one. I am on a dose which numerous other doctors told me was way too high, yet since my current pain specialist sees a lot of patients which other doctors won't take, for his practice, he said I was on a moderate dose.
Some doctors would consider 216 mg/day of morphine a high dose, but in the scheme of things, it really isn't...I was on 600mg/day at one time and it wasn't doing much of anything. I've heard on some folks being on the equivalent of thousands of mg of morphine a day, several 100mcg fentanyl patches, etc. It depends on the situation.
Fentanyl is a poor choice if you are having to pay cash. It also may be more likely to raise your tolerance fastener than some other meds, and has less flexibility in dose. As far as long acting meds, methadone is by far the cheapest. Probably followed by morphine ER (MS Contin). I agree there really isn't a reason for a patient to need to be doing conversions and thinking about doses and such, and can see how having preconceived notions on how strong a dose is may throw off your results. I'd see where your doctor wants to go with this. Speak up with any concerns you have, such as what worked or didn't work in the past, and cost.
In my opinion, if you haven't tried Methadone and are having to pay cash, if your doctor gives you it as an option, I see no reason not to try it. Many folks do very well on it (including me). It hits different pain receptors than other meds. If your doctor knows how to prescribe it (start low and go slow) and the patient isn't abusing it, its no more dangerous than other opiates. Best wishes.
Hello, Just thought I'd chime in. I am currently a cash pay PM customer. My insurance kicks in soon but I have been w/out for the past year. I recently found a great PM doctor and prior was going to a PCP which was prescribing Percosets 10/325 two pills 3 times per day, which were fine but I grew tolerant and wasn't doing anything for my pain my life consist of bed, couch, repeat...lol Not so simple but you get the message. Anyway, I was very skeptical of Methadone and was prescribed by my new PM doctor it cost me under $12.00 cash no insurance and with in a few days my pain level was from a 9/10 to a 2/3 it was heaven I was so pleased. Although it was short lived and I am allergic and had to change to Morphine currently 30MG dose 3x per day. It doesn't work half as good for me and I still have the percosets for bt and I still have to take them, plus the Morphine gave me a bad headache for the first week and it cos me around $75.00 so if cost is an issue go with Methadone I was at 10MG 3xs per day and I loved it. Short lived but loved it. My PM Doc had a very long conversation with me because I didn't want Methadone or Morphine but we decided being able to have some quality of life was more important and that pro's/con's.
I would suggest going over everything with your doctor, your concerns, your reservations. Never suggest a medication to your PM Doctor because I have been told this raises a red flag but if he ask you can tell him the research you have done and the questions you have on what is available and come to a decision together.
probably not for you given what you deal with. i was up to 390mg oral ms and still no adequate relief. i am doing much better on duragesic patch w perc 10's for bt. i also add zanaflex and klonapin at nite. best wishes. i am getting so much better CONSTANT relief.
Good to hear from you. I remember, maybe a year or two ago you were having a really hard time! Wow, we were worried about you. Was it a GI issue? I can't recall.
As you know, after a while on these various meds we all start to get a feel for what we need. I appreciate all of the 'release' schemes that pharma companies have come up with - Contin, TimeRX (Opana), and Exalgo has their own version. They just add incredible cost to these meds. It would cost me $2,500 a month to be on Opana, and $500 to be on generic Oxymorphone. That is a two thousand dollar bill for saving me the trouble of taking another pill. I've taken them both and I was still TID on Opana! None of them last 12 hours so we may as well take the IR versions TID or QID or whatever.... Don't get me started.... It's all a big-pharma rip off. I can say also, that Dilaudid is VERY short acting, maybe a couple of hours, Norco was maybe 3-4 hours, Oxymorphone a solid 5-6 hours and Opana maybe an hour more than that. This is why I am interested in Levorphanol which in its natural IR state is reported to be a solid 8-10 hours! Now we're talking, and it's cheap. That's my plan of the moment.....
Why don't you simply ask your PCP this question? Since he is the one who brought it up, he would be the one person best equipped to answer this for you, in your specific situation.
Can I ask why you don't see a Pain Management physician instead of a PCP? That might make getting your questions answered far easier if you saw a pain management doctor instead of your primary for your pain needs.
Most PCP doctors won't consider writing pain meds long term but for some reason yours has, through all of the med changes and dose changes, so it may just be simply that he is uncomfortable going over a certain milligram dose per day , because it is truly out of his scope of expertise.
But honestly, the best person to ask would be him. All any one of us can do is guess and that's not going to help you answer your question.
I'm at an uncomfortable time in my life right now, with my benefits going away soon, and now I'm unemployed. The last thing I need is to lose my PCP and my friendly Mom/Pop Pharmacy too. That would put me over the top.
The medical 'team' I have now have really made my life much easier, I give them an A+ for customer service. The best of the best, they get me what I need and the hassle factor is near zero.
As for Pain Management Doctors and Pain Management Clinics, I have heard nothing good about them here or anywhere else. I've been reading the threads here for a long time now, and the general consensus about PM Drs. and their staff is almost always negative. Why would I want that? I hear over and over and over again to never ever ask your doctor (I presume they mean their PM Doc) about a specific drug by name. Basically, act dumb and hope that the Doctor brings it up? What kind of relationship is that? Don't ask, Don't tell, just hope that they bring it up? It's crazy!
I read the stories of UA's, pill counts, being kicked out, contracts, and all of the various strategies that chronic pain sufferers go through just to keep their scripts coming every month, it sounds very stressful and time consuming, expensive, and depressing to me.... Unless I'm missing something. Generally, pain patients that have their scripts written by their PCP's seem to have better experiences than those that are in a PM situation.
Last edited by Isotope; 10-17-2012 at 09:38 AM.
I'm sorry that you are experiencing difficulties right now, but just because you have read some not so good outcomes, on this or other forums doesn't mean that by and large, patients experiences with pain management doctors and practices are less than stellar.
I have been with my PM doctor's practice since mid 2005, even prior to my first surgery. I wouldn't change one thing about my experiences with them, or their staff. I don't hesitate to mention a specific medication to my doctor because I and he have worked hard to establish a relationship based on trust of each other, over the years.
Most of the negative experiences you read about here and in other forums have to do with something that the patient did, running out early, missed appointments, failure of urine tests or screens, lost meds , and a myriad of other problems. Pain management is pretty simple, follow the rules, take meds as they are prescribed, call your doctor if there is a change in your condition that makes the meds ineffective, and don't loose, misplace, have stolen, or try to refill early. If you do those things, there usually isn't a problem. False positives for the most part are a thing of the past with the use of gc/ms testing, rather than 6 or 10 panel in office screenings....although they do happen in an office where the screening tests are not done properly. The easy solution to that is to make sure that you discuss with your doctor, the type of testing done, and to ensure that if there is ever a question, you are given the chance to have the test sent out for confirmation.
Just like patients who have surgically good outcomes don't tend to come back to boards like these to post about how great their outcomes are , after a time frame, pain management boards operate in a similar manner. Only rarely do you see people who have good pain management in place stick around to answer questions for those who come after and are having difficulties.
If you build a relationship with your PM doctor and their staff, like you have done with your GP, a negative experience is not the likely outcome. It does take time and being a cooperative honest patient but if you are truly treating the condition and not misusing the meds, then in a short time frame, you will have a similar relationship with your PM doctor that you have with your GP.
The Following User Says Thank You to backhurtz For This Useful Post: Isotope (10-18-2012)
Iso, I think you are getting a skewed view of PM Drs. on here or other places for some reason. I have been with my PM for close to 7 years now and he is amazing!
The main reason that many people seek out PM Drs. are because their entire speciality is treating patients with chronic pain. They are up to date on all the latest treatments, medications, modalities, and helping people in pain is their sole purpose. My PM has a background in Anesthesiology but is Board Certified now in Pain Mgmt.
It's wonderful that you have a great GP/PCP who is helping you...but just realize that this type of Dr. is just that...a "general" practitioner. So it's just like when I was going to have my fusion surgeries, I wouldn't go to my GP or a Dermatologist...LOL...I go to the best of the best and most highly trained Board Certified Neurosurgeon.
My PM is also trained to do all the injections when/if I need them as well as the medications and other treatments.
I'm not trying to diss your Dr. or your choice at all. Just trying to help you understand why many of us have chosen a PM to see.
And as Back mentioned, it's all about the new laws/regulations that require the pain mgmt. contracts, urine test, and pill counts. It is not really the Drs. choosing or based on trust (as we talked about in another thread). And it's really not a big a deal at all to me to have to do a urine test once a year or bring in my pill bottles for an appt.
And it's not like we have to play dumb at all with these Drs. It is just about my respect for him as a Dr. who has years and years of knowledge....I wouldn't ever go in and tell him what he should prescribe for me.
That is completely different than expressing my pain levels and how medications are working or not working. But I trust him with my life...literally...to make the best decisions and work WITH me in finding the best possible treatment.
I just want you to be aware though that many states are changing their laws in that GP/PCP Drs. or other non PM Drs. will have to go through more training and certification if they want to continue prescribing controlled substances. So many of those Drs. are choosing to back away from doing this and refer their patients to PM Drs.
So don't be surprised if your Dr. decides to do this down the line. I would actually ask them about this at your next visit.
It's all about what works for each of us and I'm truly glad that you have a great Dr. and Pharmacy....just as I am thrilled with my PM and Pharmacy (Sam's club...been going there for 11 years).
I don't think there is a right/wrong choice here
The Following 2 Users Say Thank You to Ilovemycutedog For This Useful Post: Isotope (10-18-2012), sandiemas (10-18-2012)
That's great. Thank you both for sharing some of the GOOD aspects of PM Docs.
As you say, we generally hear the complaints more than the praise. My relationship with my PCP has been good for many years now. He's a young Doc, not too burned out yet, still has conversations with his patients who all adore him. Consequently he is always running an hour behind. If I have an afternoon appointment I often wonder if the lights will still be on by the time I get called. Patients love to talk, they just want an ear. My former job was at a Hospital and I too had patients, and I too spent more time in conversation with my clients, more time talking than performing their procedure.
I'm sure I'm one of my PCP's more annoying patients, clip board in hand, notes and topics I want to cover....and my own medical knowledge. His concern with Levorphanol is that it is not widely used -at all, and he wonders why that is? And I do too. If it is or was such a vital and useful narcotic for pain he wonders why it hasn't been used more widely. So, he said he would read up on it and get back to me. Perhaps there is some dirt on it that he will uncover.
A company called Bio-Quest has bought up the rights to re-package Levorphanol Tartrate into a longer acting version that they will be calling Levorphanol ER when it is released in a couple of years..... No doubt the NEW slow release version will cost an arm and a leg. Levo is already naturally long acting -so it is just another example of big Pharma taking something that no one wants, tweaking it in an irrelevant way, then selling it back to us for ten, twenty, or a hundred times the price of the inexpensive original. Anyway, actual IR Morphine wasn't a good fit when I tried it -side effects like crazy. Oxycodone is an option, it just makes me a bit too revved up and anxiety ridden. Dilaudid is good if you want to take one every hour or so, the stuff is like a vague mirage. Methadone seems to be the best choice, cheap, long acting.... I may bring that one up, the name just screams Junkie*Junkie.....
Just for fun I looked up the cash pay price for long acting Dilaudid, it's called EXALGO. Guess the price of 30 pills, a supposed one month supply. Over $5,000 a month. I kid you not. The few people that actually do take the drug need to take it (BID) 2x a day anyway, so that would be over $10,000 a month! It's no wonder our health care system is buckling and collapsing. The EXALGO folks should be jailed.
I think because Levorphanol has so many more potentially life altering and even potentially deadly side effects than other opiates it is not used very often.
I would urge you to give the MSContin (extended release Morphine) a try as I originally had nausea, headaches, and fatigue my first few weeks taking Morhpine but then it all went away in about a month or so.
And keep in mind that the Morphine we get in the hospital in IV form is so much more potent. I had this after my first fusion surgery and had such side effects that I swore I would never use it again but after Oxycontin was not available in generic anymore, my PM suggested we try the MSContin. Of course he assured me that if I was still having trouble after a month or so that we could try something else.
I have been on it for years now without a single side effect. I can't even tell I take medication except for the lowering of my pain levels.
And it's important to not worry about what others think about a certain medication...I mean...Oxycontin was one of the most abused meds out there for "junkies".....and Methadone has been used for many, many years for those in pain management. You don't have to tell a single person (besides one close family member so they know your medications) about what you are taking.
So, I would never let some other person's stigma or hangup about a medication keep me from taking it for my pain.
I would think that you really don't have too many choices once your insurance is gone as cost is the biggest factor. As I've mentioned numerous times...this is why I use Sam's club for my prescriptions as it is the lowest pricing of any Pharmacy in my area and I'm talking hundreds of Pharmacies....even lower than Walmart as they are the same company! But the Sam's club have a different contract with pricing.
So be sure to call around and price everything and then ask your Mom and Pop place to match the cost elsewhere. I would think since you have been with them so long they will work with you.
My MSContin is very cheap along with my OxyIR for breakthrough pain. My PM has always believed that by having a different opiates for the long acting/short acting med they work better for BT pain.
And about your Dr...my Dr. is so great about spending time with his patients as well. He is pretty good about not overbooking but I always choose the first appt. of the morning anyway. I do this with every single Dr./Dentist as this way I never have to wait
It sounds like you will be able to work with your Dr. to find the best combination of meds/treatments that work for you! Keep us posted..