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  • Multiple Long-Acting Pain Meds?

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    Old 05-28-2016, 07:54 PM   #1
    Eva 14
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    Question Multiple Long-Acting Pain Meds?

    I just saw a new PM doctor who is not an anesthesiologist, like my now-retired PM doc was.

    My former PM doc prescribed a single long-acting pain med, with multiple short-acting pain meds for breakthrough pain. My new PM doc says that is how anesthesiologists deal with pain, but it's different for internal medicine doctors.

    My new PM doc told me a single long-acting pain med (with multiple short-acting meds for breakthrough pain) is the approach that anesthesiologists take to managing chronic pain. My new PM is an internist who is certified in pain management. He told me that from an internal medicine perspective, the approach to managing pain is to prescribe 2-3 different long-acting pain meds, all at once. Then he would prescribe very little for breakthrough pain.

    Has anyone every heard of this approach? I've researched a lot about pain management, but I've never really heard of this approach before. At this point, I really don't have much choice but to give this approach a try.

    My current regimen of one long-acting pain meds and multiple short-acting pain meds is working quite well, and I hate to have to make changes. it took years to discover what works for me.

    I have a lot of pain and nausea, so I need to take Dilaudid suppositories. The Dilaudid suppositories provide far superior pain relief to me than Dilaudid tablets. I also get superior pain relief from nasal sprays, injectibles, or sublingual fentanyl or Actiq. (I'm not currently taking these meds, but I have tried them in the past). These routes of administration provides superior pain relief to pills.

    When I told my new PM doctor this, he said he'd never heard anyone say that these alternate routes of administration were superior to pills. (I think this is pretty common knowledge, but I didn't want to contradict him. I just told him my personal experience and what has worked for me).

    I also mentioned to my doctor that long-acting pain meds cause me to sweat a LOT, whereas short-acting pain meds don't have that effect on me. (This is another reason that I prefer to use only one long-acting pain med). I was very surprised to hear my new doctor say that he'd never heard of anybody sweating from long-acting pain meds. This is COMMON knowledge---just Google 'opiates and sweating'.

    My doctor proposed adding the Fentanyl patch to my current dose of Exalgo. I said I'm willing to give it a try, but I did have side effects of nausea and VERY dry mouth from the Fentanyl patch. I had to drink water constantly when I was on the patch! My new doctor also mentioned adding methadone to the mix. Again, I'm willing to give it a try.

    Oddly enough, the new PM doc prescribed all of my current medications to me for this month, with no directions to taper. (He said he wants me to taper off the short-acting meds and add in long-acting meds 'eventually').

    Has anyone heard of this approach of prescribing multiple long-acting pain meds? What about breakthrough pain? I suppose I should be happy that this PM doc appears to be willing to continue me on my current (rather high) dose of pain meds. What is strange is the fact that this doctor's son (also an internist certified in chronic pain) didn't seem to want to continue me on my current dose. But the younger doc referred me to the elder doc due to the 'complexity of my case', so I'm just following doctor's orders.

    I'd be very interested to hear if anyone has ever tried being on multiple long-acting pain meds, and how it worked for you. Is there literature to support this method of treatment? Thanks for any advice.

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    tiggertoo2174 (05-29-2016)
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    Old 05-29-2016, 06:25 AM   #2
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    Re: Multiple Long-Acting Pain Meds?

    I haven't necessairly heard of it as an approach, but it does kind of make sense from an internal medicine kind of standpoint. They presceibe more than one type of say blood pressure or diabetes medicine at a time so I can see taking the same kind of approach to pain. There was someone on this board back when I first started that was on multiple LA meds, I don't recall her name right off, but I think she might still be around over on the back board.


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    Eva 14 (05-29-2016)
    Old 05-29-2016, 08:38 AM   #3
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    Re: Multiple Long-Acting Pain Meds?

    From my reading, the norm (despite of the type of doctor) for chronic pain when using opioids is one long acting med with one short acting med. Plus in some rare cases a "rescue" med. I've heard of very few people started on more than one long acting or more than one or two short acting meds. I would think it would only increase the chance of side effects and make things more complicated and expensive. I could actually see them doing that however if the doctor thinks it would lower their risk, as they are prescribing a lower dosage and/or quantity of each med.

    For example, when I was on high dose Methadone, my doctor wrote me a script for 2 weeks at a time, as they wouldn't go over 200 pills per script (and it only comes in 5 & 10mg pills). I would specifically ask why they think 2 or 3 long acting meds are better than an equivalent dose of one med. Do they think you'll get better pain relief as they have different mechanisms of action, keep your tolerance lower, lower side effects, etc? I have heard however of some doctors frequently rotating the long med (like every 6 or 12 months) to try to keep tolerance down.

    It sounds like you have to go with this though, especially since they are willing to actually treat your pain with the dosages you are accustomed to (unless you think you have a better option?). Its good to be open to trying anything a doctor recommends, unless you have previous documented experience with that med and had an intolerable side effect (like a serious reaction, or something like nausea which didn't go away over time), or your insurance doesn't cover it. I would be concerned if they severely limited breakthrough meds. However, the norm I think is 1-3 dosages a day, so if you were getting more than that, it'll likely be reduced. They want it to truly be for breakthrough and not taken around the clock. Ideally the long acting med covers the baseline pain at around 50% relief for the majority of the time.

    Its tough though when patients have huge variations in pain levels. I've always struggled with breakthrough pain as my pain levels vary widely. At my best I do very well and wouldn't consider a higher dose even if it was offered to me. But at my worst, my breakthrough meds don't touch my pain. Sometimes I spend days at a time with high pain levels. Best I can do is try to catch the pain before it gets really bad, and combine several meds to treat the breakthrough pain. Currently I have Oxycodone, Sumatriptan a migraine med, Diclofenac a NSAID, and Ketamine which I get a low dose compounded into capsules and is very helpful although there is a stigma against it. My neuro prescribes the Ketamine; my pain doc won't take over the prescription, but thankfully doesn't object to it. Best wishes.
    constant headache since 2006

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    Eva 14 (05-29-2016)
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