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Old 11-05-2012, 06:37 PM   #1
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LA VS Short Acting...

I have fibromyalgia and at times, severe lower back pain. The fibro-related pain is strange, it seems to flare up with stress, lack of sleep or poor diet but it is always present. Sometimes my pain can flare to an 8 or 9 though without any warning.

I am prescribed 40 mgs of Norco per day to deal with this pain and to make a long story short, after nearly 10 years on this dose, it just isn't working anymore.

For those of you with fibro, what types of LA meds seem to work best? I think my doctor is willing to switch me over to a long acting medication but I'm wondering what works for most people. Since I am on a benzodiazepine, I would prefer to stay away from anything really strong, afraid that the interaction could cause problems. I've heard bad things about methadone and I don't think he's likely to prescribe that, but I'm wondering what the next step up from what I'm taking now would be?? I have tried Lyrica and didn't find it helpful.

I don't have another appointment until December, I told him I wanted to stay on my current medication because I'm going to be doing a lot of driving over the next three weeks. At any rate, I'm sure most of you who are taking opiates started on short acting meds, just wondering what worked best for you and what meds to try to avoid, if that's possible to ascertain.

Thanks,

 
Old 11-05-2012, 07:11 PM   #2
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Re: LA VS Short Acting...

Hi, I started off on 5 mg of oxycodone (percocet) yrs ago for my fibro and back pain. went to 7 mg then 10. (all 4 x day or so). then it got where it wasn't working but I like you was afraid of a LA med like oxycontin. So he put me on Opana ER 20 mg 2 x day and then gave me 5 mg opana IR (short acting) for breakthru in case I needed it and sometimes I do.

I also take ativan at night to help me sleep (which doesn't work well, you know how that goes). lyrica didn't work well for me either, made me swell up.

Opana doesn't give you the highs/lows like other pain meds. You just take it and it manages your pain or it does mine anyways. it has oxymorphone in it. you can get a discount card at their site.

Cathy

 
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Old 11-05-2012, 08:56 PM   #3
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Re: LA VS Short Acting...

The only real difference in the long acting versus short acting medications is the duration of effect. Short acting medications typically have an onset of an hour or less after taking them and last anywhere from 3-6 hours.....depending on the individual. Six hours of pain relief is a bit unusual after being on a short acting formula of any of the pain meds after being on them for a while. The long acting versions usually don't contain tylenol or motrin , and the duration of pain relief is generally around 12 hours and for at least one LA med, 24 hours, with the patches, the duration of pain relief is generally around 72 hours before you need to change them.
Norco is hydrocodone based, with tylenol in them, the lowest opiate on the pain medication scale, so while I understand your concerns regarding going to a long acting pain medication, there really is no need to be concerned about a particular medication since they are much smoother in their delivery- no ups and downs in blood plasma levels once you switch over to the long acting version of a medication. You simply change the time frame between doses, and never, ever cut or break a long acting formulation of a pain medication since it can dump the entire dose at once if you do.
Taken as directed, there is simply less pills to take in a 24 hour period and no noticable ups and downs as there are with the short acting versions.
As far as recommendations go, I will leave that up to your pain management doctor since he knows your medical history best and is best equipped to know what medication will offer you the most as far as pain relief goes.
One thing that all pain patients should remember though, less is more when it comes to managing pain for the long term.....the lower the dose that you can stay with , the more options you leave in your tool chest for later on , as you age and years with the chronic condition go by...

 
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Old 11-05-2012, 09:00 PM   #4
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Re: LA VS Short Acting...

Everyone responds differently to different meds and doses. I'd just have a discussion with your doctor at your next appointment about how you have had an increase in pain lately (also specify if the pills aren't lasting as long as they used to, such as 4 hours instead of 6 hours or whatever). Yes, for chronic pain which hasn't responded to other treatments a long acting med is usually going to be much more effective than a short acting med. Often the two are taken together (the short acting one as needed).

I wouldn't be trying to guess what your doctor may start you on, suggest meds by name, or even say that you think you need to be on a long acting med...just see what they suggest and go from there. I don't see any reason to be any more afraid of methadone than any other med...the reason you may see bad press about folks overdosing is due to them taking it not as prescribed...too much or combing it. Yes the combo with benzos is something for your doctor to work very closely with you on. If you are not seeing a pain management specialist, I would highly recommend asking for this referral before any switch to a long acting med.

I think its best to not have any preconceived notions about meds or doses...this can actually affect the outcome. Every doctor has their preference, which may be based on what their research has skewed to, their patient population, etc. By the way, I was actually started on methadone (more unusual but not unheard of) and did well for awhile. Then I built tolerance so we tried me on just about everything else. I ended up right back on it (at a higher dose) as nothing came even close (even higher doses).

You are smart to plan to not do any driving at first if you start a new med. Similarly, I like to wait until a weekend (no work the next day and hubby at home in case I have a reaction). On that same note, sometimes the adjustment to a new med can be rough and the patient wants to give up. Side effects often subside, so I'd try to stick it out when feasible. The strength of the med is dose specific. Just about any opiate could be dosed for your tolerance (except maybe a fentanyl patch, which is about the only long acting med that is inappropriate for a first timer).

I wouldn't be scared of something being too strong. It is much more likely that your doctor would start you on a lower equivalent dose than you are on now to ensure it isn't too much (cross tolerance varies); its typical to start at half the estimated dose and work up from there. Sometimes this causes patients to go into withdrawal, and often their pain will flare. So, I'd expect to have frequent appointments when starting a long acting med. They may allow you to take some hydrocodone as needed during the transition.

The next step up from hydrocodone is usually oxycodone, but that is still short acting. Sometimes doctors prescribe Tramadol (not actually a narcotic but some folks find it helpful). Codeine is considered a step down, but some folks respond better to it. You can actually get hydrocodone compounded to be long acting but that is rare (and usually a doctor would just switch you to a stronger med). Otherwise, there are long acting forms of Morphine (MS Contin, Kadian, and Avinza), Oxycodone (Oxycontin), Hydromorphone (Exalgo), Methadone, Fentanyl (Duragesic patches), Tapentadol (Nucynta), and Oxymorphone (Opana). Suboxone is more rarely prescribed for pain.

I hope you can find a good treatment plan to best manage your pain. Most often this means combining several methods, such as using adjust meds in addition to the opiates (there are many other meds used for fibro similar to Lyrica like Cymbalta and Savella, or some older meds used for pain like Elavil, muscle relaxers, etc), physical or massage therapy, and lifestyle changes such as diet, exercise, and sleep. Trialing adjunct meds may often require months, so ensure you follow doctor's instructions. Best wishes.
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Old 11-05-2012, 10:45 PM   #5
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Talking Re: LA VS Short Acting...

Thanks everyone for the valuable information! I am actually seeing a pain specialist who is one of the best (if not the best) in my state. I had to wait a year before getting in to see him. I never mention medications by name or request anything, we always fill out a pain sheet before we see him, and he noticed my levels were not getting any better. I've had two epidurals this year, find they help some but the side effects from the steroid cause problems. Not sure if this is common but I get insomnia (which is bad anyway) and an upset stomach.

I don't like driving even after taking my norco, but it can't be helped. I guess I'm so used to it now that I don't really notice when it kicks in, usually my pain levels will drop a bit, but only for a couple hours. Tolerance is brutal, I used to be able to take 10 mg and stay (nearly) pain free for six hours, but those days are gone.

I've heard a lot of good things about Opana, not sure if it's LA oxycodone or hydrocodone, I'll have to look that one up. I don't interact at all with anyone at my pain clinic so I have no idea what doctor normally prescribes when it comes to LA meds. My biggest concern is side effects, I got really sick after receiving dilaudid in the hospital one time. I also had a friend die from a methadone overdose that was said to be accidental. The poor guy had cancer though and yes, you do read about the combination of benzos and methadone being lethal.

I actually tried tramadol a while back, it worked just about as well as the hydrocodone for me which was great, I'd love to be on a drug that isn't controlled the way the stronger opiates are. I would probably save a lot of money as I wouldn't have to visit the clinic nearly as often. Problem was, it started to interact with my antidepressant and soon after, I was experiencing some nasty side effects.

Thanks again for the input, should be interesting to see what my doctor recommends. I'm thinking if it's a C2 med, I will indeed be making more trips to the pain clinic. At the same time, if I could get my pain levels down to where I could work full time again, that would mean a lot to me.

Another issue I wanted to ask about is sleep, do you guys/gals suffer from insomnia? I'm guessing that's a big issue for most CP patients. I would love to be able to ditch klonopin, but every time I try I get horrible insomnia. Wondering if anyone has found a good sleep aid that isn't a benzo or ambien.

 
Old 11-06-2012, 05:34 AM   #6
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Re: LA VS Short Acting...

For sleep, i only need NyQuil. Knocks me out cold! But I'm extremely sensitive to anti-histamines in general. (I also have severe sinus issues and the NyQuil helps that too) But Sleep is one thing i don't have a problem with. 8-)

 
Old 11-06-2012, 06:19 AM   #7
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Re: LA VS Short Acting...

Hi yeas I have sleep issues but can't take a lot of
The sleep aides because i also have Addison's causing
Daytime sleepiness but before then I took
Trazadone and it worked great u should try
That. Cathy

 
Old 11-06-2012, 01:51 PM   #8
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Re: LA VS Short Acting...

Quote:
Originally Posted by no34evr View Post
Hi yeas I have sleep issues but can't take a lot of
The sleep aides because i also have Addison's causing
Daytime sleepiness but before then I took
Trazadone and it worked great u should try
That. Cathy
I'm actually on trazadone right now and I'm still not getting much relief. If I take enough klonopin I can usually sleep but I've been on it for so long and hate taking more than 2 mg, I usually only take 1 to 1.5 I'm wondering if stress is causing it more than pain. Once I get into bed I usually don't have really high pain levels, so I should be able to sleep.

My uncle has Addison's, it took him a long time to get diagnosed but he's still going strong at 77 years old. Not sure if he had a lot of pain, I know his skin has always been sort of bronze. He looked as if he'd been out in the sun, even during the winter. At any rate, I hope yours is under controll and that you have a good doctor.

 
Old 11-06-2012, 05:27 PM   #9
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Re: LA VS Short Acting...

HI Back,
I just wanted to say this is a great post!!! Concise, informative, safe. Well done. Thank you, gmak

 
Old 11-06-2012, 05:43 PM   #10
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Re: LA VS Short Acting...

Tizanadine (a muscle relaxer) is helpful for sleep for me, as well as some of my other health problems. Often for a pain patient with insomnia they will try to prescribe an adjunct med which is sedating, such as a muscle relaxer, Elavil, Trazadone, etc. Definitely ask your doctor before trying anything otc. Some folks respond to melatonin. Yeah you won't get anything stronger than hydrocodone that isn't CII.

However, some doctors will let you pick up a script for your CII med from them in between appointment dates (so you'd only have an appointment every 2 or 3 months when stable). Mine will also give a "fill after" date of 2-4 weeks out if our schedules work out that way. I'll take whatever inconvenience for the best pain control. Between all my doctors, I average 2 appointments a week.

I wouldn't let yourself be scared of side effects. Sometimes they happen. Worst case you feel miserable until it wears off. Often if its more minor (like nausea or drowsiness) they will subside over time. If you have any history of nausea with any pain meds, ask to have something for nausea on hand.

Opana ER is actually long acting oxymorphone (neither oxycodone or hydrocodone). Its still brand only and can actually be tough to find in stock at pharmacies, plus it recently changed formulation such that there are more reports of it not being helpful (plus its a sort of hit or miss med formulation). It might be worth re-trying Tramadol (they have a long acting form) if there is a chance you can respond to that, before going to a CII.

If you are mostly taking the Klonopin for sleep and if its hindering your pain med choices, I'd definitely put that as a priority to switch away from. A sleep study can be a great idea to rule out things which can be affecting you (not just sleep apnea). Also, following good sleep hygiene such as limiting caffeine, having a bedtime routine which doesn't have your tv/computer, set bedtime, etc. Its ideal to not need meds to help us sleep, but a lot of us do. I had insomnia even before all the pain. Best wishes.
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Old 11-06-2012, 07:06 PM   #11
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Re: LA VS Short Acting...

Quote:
Originally Posted by tortoisegirl View Post
Tizanadine (a muscle relaxer) is helpful for sleep for me, as well as some of my other health problems. Often for a pain patient with insomnia they will try to prescribe an adjunct med which is sedating, such as a muscle relaxer, Elavil, Trazadone, etc. Definitely ask your doctor before trying anything otc. Some folks respond to melatonin. Yeah you won't get anything stronger than hydrocodone that isn't CII.

However, some doctors will let you pick up a script for your CII med from them in between appointment dates (so you'd only have an appointment every 2 or 3 months when stable). Mine will also give a "fill after" date of 2-4 weeks out if our schedules work out that way. I'll take whatever inconvenience for the best pain control. Between all my doctors, I average 2 appointments a week.

I wouldn't let yourself be scared of side effects. Sometimes they happen. Worst case you feel miserable until it wears off. Often if its more minor (like nausea or drowsiness) they will subside over time. If you have any history of nausea with any pain meds, ask to have something for nausea on hand.

Opana ER is actually long acting oxymorphone (neither oxycodone or hydrocodone). Its still brand only and can actually be tough to find in stock at pharmacies, plus it recently changed formulation such that there are more reports of it not being helpful (plus its a sort of hit or miss med formulation). It might be worth re-trying Tramadol (they have a long acting form) if there is a chance you can respond to that, before going to a CII.

If you are mostly taking the Klonopin for sleep and if its hindering your pain med choices, I'd definitely put that as a priority to switch away from. A sleep study can be a great idea to rule out things which can be affecting you (not just sleep apnea). Also, following good sleep hygiene such as limiting caffeine, having a bedtime routine which doesn't have your tv/computer, set bedtime, etc. Its ideal to not need meds to help us sleep, but a lot of us do. I had insomnia even before all the pain. Best wishes.
Thanks, your posts are always so well written and informative.

As good as my pain doctor is, he's also very strict in terms of refills, pill counts, UAs and things of that nature. I'm sure 99 percent of that is the DEA though, I read an article recently about people paying 6 bucks a piece for the pills I am on, heartbreaking really. Not only are they hurting themselves, they hurt us as well.

My previous pain clinic in Kentucky was nothing like that, but I normally get a UA every three months and we are definitely expected to be spot-on in terms of our pill count. I had an issue with this earlier in the year but since then, the epidurals and PT have kept my pain levels somewhat tolerable. He even does pill counts in the middle of the month, fortunately, I can just take them to my pharmacist who is two blocks away. His nurse says he does that with everyone. Point being, I don't think it would matter if I was on a C2 or C3, I think he likes to see his patients once a month anyway.

Yeah, I've spent quite a bit of time in the doctor's office this year for various issues. Lately, my insomnia has been bad, so I need to deal with that before it gets out of control. I think you're right about the klonopin, I've heard it said that benzos become ineffective after a few months and I've been on them for 12 years. Since I've become dependent on them, it's like having a monkey on my back. Unfortunately, there are many doctors that don't understand the difference between addiction and dependency when it comes to benzos. I don't understand why people abuse them, I've only ever found them useful for sleep and maybe a severe panic attack.

Interesting, I've heard of oxymorphone but I thought it was simply a metabolite? My doctors decided that I was allergic to tramadol, I don't think that was the case but it does tend to cause problems when you're on an antidepressant. It might be a matter of my serotonin levels getting too high.

You mentioned that you had problems with insomnia before your pain issues started tortoisegirl, did you ever find the root cause? How bad did things get for you if you don't mind my asking?

Fortunately, the only opiate that ever made me (really) ill was dilaudid. It's possible the ER doc gave me too high of a dose, he was a resident and I know they make a few more mistakes. I do have some anti-nausea medication on hand for when I have to fly.

 
Old 11-06-2012, 07:39 PM   #12
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Re: LA VS Short Acting...

Hi, mszach,
I wanted to tell you that there is really informative, wise info on this thread. Also, i was on norco 10mg 6 to 12 a day. I became tolerant. Was put in hospital by my gastro, because the Pm dr i had @ that time wouldnt change it. 6 drs saw & evaluated me. It was recommended that i be sent to a physical medicine& rehab dr, who started me on a fentanyl patch. He & the manufacter of the patch, both said that it is recommended for opiod tolerant patients @ 25 mcg per 72 hours, with breakthru medicine. For me it was hydrocone @ a 7.5 every 6-8hrs. Im still on the patch 12 yrs later. It is recommended not to take trazadone & benzodiazapenes with the patch. Your dr will know that he/ she has to treat you over the decades for chronic pain & give what is appropriate. Just, thought this may help. God bless you, mszach.

Last edited by gmak; 11-06-2012 at 07:44 PM.

 
Old 11-06-2012, 08:24 PM   #13
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Re: LA VS Short Acting...

Mszach, in response to your question on insomnia:

Without meds, its typical for me to take an hour or more to fall asleep. Once I'm asleep I'm usually ok though. So, I've heard of worse, but definitely disruptive Whats weird is I am so fatigued all day, and once asleep I can sleep 10-12 hours a night easily (even for weeks straight...some folks would assume that means I'm sleep deprived and would do that on a weekend).

My doctors have never been keen on sleep meds for me (nor would I want them), so we've stuck with the Tizanadine. Melatonin never did anything for me. Unisom (otc) does, but I only take that in a pinch. I've never been able to "fix" it myself, such as with the usual suggestions. Started in my teen years, but back then I didn't notice is as much as I'd wear myself out and sleep very little.

You are lucky you can even get someone to prescribe a benzo for you, especially being on any narcotic (even if "only" hydrocodone). I've heard they are tough to get than even narcotics for whatever reason. I've always been curious if they would help my pain. They probably suspected serotonin syndrome? They are being more aware of it, the combo of certain meds with anti depressants, and there is definitely some documentation with Tramadol. Sometimes doctors let the patient take the risk...it depends. But not if there are other good options (which is sounds like you have). Best wishes.
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Old 11-06-2012, 09:15 PM   #14
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Re: LA VS Short Acting...

Quote:
Originally Posted by tortoisegirl View Post
Mszach, in response to your question on insomnia:

Without meds, its typical for me to take an hour or more to fall asleep. Once I'm asleep I'm usually ok though. So, I've heard of worse, but definitely disruptive Whats weird is I am so fatigued all day, and once asleep I can sleep 10-12 hours a night easily (even for weeks straight...some folks would assume that means I'm sleep deprived and would do that on a weekend).

My doctors have never been keen on sleep meds for me (nor would I want them), so we've stuck with the Tizanadine. Melatonin never did anything for me. Unisom (otc) does, but I only take that in a pinch. I've never been able to "fix" it myself, such as with the usual suggestions. Started in my teen years, but back then I didn't notice is as much as I'd wear myself out and sleep very little.

You are lucky you can even get someone to prescribe a benzo for you, especially being on any narcotic (even if "only" hydrocodone). I've heard they are tough to get than even narcotics for whatever reason. I've always been curious if they would help my pain. They probably suspected serotonin syndrome? They are being more aware of it, the combo of certain meds with anti depressants, and there is definitely some documentation with Tramadol. Sometimes doctors let the patient take the risk...it depends. But not if there are other good options (which is sounds like you have). Best wishes.
I can't recall the last time I slept more than 7 hours, it just doesn't happen anymore. Unfortunately, I just don't handle stress very well.

Most pyschiatrists I've seen are willing to prescribe them at lower doses, it's rare to find one who is willing to give you 2 mgs a day, which is supposed to be equal to 40 mg of valium. I've also ran into benzo-phobic doctors who hand out seroquel and buspar like candy, but won't touch benzos. A lot depends on the doc and the group they are working with. I've never met a primary or pain doc who offered benzos. As for pain control, I haven't noticed any improvement after taking klonopin. If you have muscle spasms (which I don't) I would imagine it would help in that regard. I've read horror stories about mixing the stronger opioids with benzos, but I've never had any issues with the klonopin/hydro mix.

I think serotonin syndrome can range from mild to severe, mine was definitely the former as the latter can be fatal. Honestly though, if I didn't have insomnia I wouldn't be taking klonopin, I never take it during the day.

gmak, one of my cousins who has MS is on the fentanyl patch and swears by it, she also takes a seemingly high dose of oxycodone for breakthrough pain though. I think fentanyl is the stuff they give you during surgical procedures, isn't it? I've had it before and I can definitely see why it works for pain!

 
Old 11-07-2012, 01:02 AM   #15
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Re: LA VS Short Acting...

Its micrograms, not milligrams & releases over 3 days. I have never felt it @ all. Norco made me forgetful, slurred speech, etc. So, embarrassing! It is used during induction of anesthesia. I mean normal self, except occasional breakthru pain. It is not to be used (the patch) as an acute pain reliever. Only chronic pain. It was like a miracle for my family. Everyone had their normal mom, wife, sister etc back. But, you just see what the dr thinks is best for you. I wanted to point out that after hydrocodone only, that was the drs choice for me. It works, & I can function! Thanks, gmac

 
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