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Episodic Pain, Opiates, Tapering


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Old 01-04-2018, 05:02 PM   #1
Eva 14
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Question Episodic Pain, Opiates, Tapering

Since my late teens, Iíve struggled with extremely severe migraines. As the years went by, my migraines became progressively longer, lasting for several months and eventually even years. My last migraine lasted for 6.5 years, and the doctors I saw thought Iíd never again be migraine-free. I also feared my migraines had become constant and would last for the rest of my life.

For no apparent reason, my marathon migraine finally ended about 7 months ago. Once my migraine ended, I slowly tapered off of the fairly high dose of opiates that Iíd needed to take to control the severe constant migraine pain. I tapered down to just one codeine pill per day, which Iím still taking.

For 3-4 days per month, I do have severe pain during my menstrual period, due to the fact that I have endometriosis. During these 3-4 days per month, I need to take opiates to control the pain. By day 4, Iím back to taking just one codeine per month.

My pain doc has absolutely no problem with me taking one codeine pill daily to avoid withdrawal symptoms. I have the endometriosis pain monthly, and we never know when Iíll go back into migraine, so trying to go down to zero pain meds probably doesnít make a whole lot of sense.

I did recently try to go down to zero opiates, as an experiment.

Since it was fairly easy for me to taper down to just one Codiene pill a day from a fairly high dose of pain meds, I assumed that it would also be fairly easy to go down to zero meds. I was wrong about this, as the withdrawal symptoms when trying to go down to zero were pretty bad. This surprised me, but obviously anyone whoís been on opiates for several years as I have been is going to become physically dependent on them.

Given the fact that I still need opiates during my period, and the strong possibility that I will eventually go into migraine again, would it make any sense for me to try to wean myself off of the one pill a day?

If I knew I would never have ANY pain ever again, I would go through withdrawal. But given my complex history of two different chronic pain problems, it seems I will need opiates at least occasionally, and why go through the extreme discomfort of withdrawal when I know that Iíll still sometimes need to take pain meds?

I just want to be clear that this is physical dependence, not addiction. Iíve never exceeded my prescribed dose, I donít take any other drugs, I donít even drink alcohol, etc.

It is kind of a drag to realize that Iím physically dependent on opiates, even though itís only one pill a day. I do realize that this would happen to anyone and everyone whoís been in chronic pain and on opiates for years, as I have been. Iíve dealt with chronic pain and needed at least some pain meds for 25 years. Since Iíve been taking opiates for my entire adult life (for severe pain), I do wonder if Iíd ever feel normal without anything. I know that studies have shown that opiates change brain chemistry.

Would it make any sense for me to try to go down to zero, and then only take Codeine for the 3 days per month that Iím in menstual pain? I never know when Iíll go back into severe migraine. I donít want to go through withdrawal only to need to go back on opiates.

My current pain doc is great, but Iím going to be moving soon and will need to find a new doctor. Even my current pain doc is now under lots of government pressure to cut back all of his patientsí doses. I know Iím very lucky my migraine ended when it did, because my doctor wanted to reduce my dose last year when I was still in severe status migraine, due to the crackdown.

For now, taking one pill a day seems to make sense in my situation, and my pain doc is fine with that. I do worry about what will happen if the government ever makes it so that doctors wonít prescribe any opiates at all, and I also worry that a new pain doc may not continue even a small dose.

In my case, does taking one pill a day seem to make sense? Or should I be trying to wean myself off completely, even though I still have pain from endometriosis? And knowing that my migraine can recur at any time? Thanks for any opinions; this is a rather difficult and confusing situation to be in.

Eva

 
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Old 01-05-2018, 05:53 PM   #2
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Re: Episodic Pain, Opiates, Tapering

If your doctor is willing to continue prescribing ~1/day, and you think it is very likely you will have another long severe chronic migraine episode in the next year ish, I can see the appeal of not wanting to taper off. I'm surprised that 1/day is enough to keep withdrawal at bay, considering the short half life of codeine. I'm also surprised that a doctor is willing to consider prescribing even that small amount if you are not reporting pain 27/30 days.

I think if it was me, I'd want to at least try to continue slowly tapering down from 1, just to see what happens. If you can get off of them, or even just lower (such as 1/2 or 1/4 of a pill), it will only make things easier if/when you get cut off, and reduce your tolerance.

There is a huge difference from going from 4 to 3 to 2 to 1 pill or whatever and going from 1 to 0 pills - that is too much of a percentage jump probably. It is also tougher to go from 1 to 0 if you had been doing a quick ish taper until then, as you need to let the withdrawal symptoms catch up and subside.

I bet if you tried now to go the slightest bit down from 1 pill that you can manage to cut off a pill, it would be easier. If you decide to get serious about continuing to taper, see if you can get a liquid codeine and do very very small increments, enough that you barely notice any withdrawal symptoms. It may also be helpful to dose a smaller amount more often than once a day when tapering (without increasing the total daily dose from your current level), to keep it more stable in your system, due to the short half life.

However, this is just from my research and my partial opioid withdrawal experience (I've never gone off them since starting daily, as I haven't needed to, although I've done a number of huge tapers and med changes, including a switch from Methadone to Oxycodone to Suboxone and back to Methadone). Congrats on currently being migraine free and getting down to 1 pill/day! That is a huge accomplishment. Try to live it up a bit and not worry so much about if/when the next episode will start. Best wishes.
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Old 01-05-2018, 07:41 PM   #3
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Re: Episodic Pain, Opiates, Tapering

Kate, thanks so much for your reply. I think you’re absolutely correct about the fact that going from 1 pill a day down to 0 is too big of a jump. Cutting up the pills might help, indeed. My Codeine pills are capsules, so they really can’t be cut up, but I do have some left-over 10 mg. Methadone pills.

During my 6.5 year migraine, I tried many different long-acting and short-acting opiates.

In the last year or so, I was prescribed 10 mg. Methadone, 3x daily as my long-acting med. Strangely, I really don’t think that Methadone is any stronger than Codeine, at least in my experience. I also didn’t find the withdrawal symptoms of Methadone to be any worse than those of Codeine.

I do know that Methadone has a longer half-life than Codeine, but in my experience with tapering, the withdrawal from both Methadone and Codeine are the same. I have several Methadone pills left over, so if Methadone would help with my taper, it’s an option. The Methadone pills are much easier to cut in half or quarters; the Codeine pills I have are actually capsules, so I don’t think they can be cut.

I know that Methadone and Suboxone are both prescribed as meds to help taper people off of opiates, but I also know that Methadone is an opiate and that buprenorphine is an opiate agonist-antagonist.

Back in the 1990s, I was prescribed Buprenex (buprenorphine) for migraine pain. I didn’t find it that effective for pain (though it did help a bit), but I found it to be very effective for helping withdrawal symptoms from mu-agonist opioids whenever my migraine finally ended and I was tapering myself off of pain meds. Of course I know that around 2000 buprenorphine was approved for helping people taper off opiates.

I’m curious if you think that a Methadone taper (with the 10 mg. pills I already have) or a Suboxone taper might actually be easier than a Codeine taper? Or perhaps the same? As I said, I really can’t cut up the Codeine capsules.

In my experience, buprenorphine was a very mild drug, and it helped greatly with my withdrawal symptoms in the past. Buprenorphine helped me to taper off of Codeine with minimal withdrawal symptoms, so I definitely think that a taper with buprenorphine is easier than a Codeine taper. This makes me very curious about trying Suboxone, should I wish to try to taper off opiates completely.

My only reservation about asking for Suboxone is the possibility of somehow being labeled an “addict”. Since there’s a good chance I will need opiates for pain in the future, I can’t afford to do something that may put a “red flag” or black mark on my prescription history. I wish buprenorphine didn’t have that stigma to it. Back in the 90s, it was just another medication.

Since I’m only taking 1 Codeine pill a day, I obviously wouldn’t need to use a very high dose of buprenorphine. I think people only have trouble tapering off of buprenorphine if they are taking high doses for a longer period of time, but of course everyone is different. Current Suboxone doses are much higher than the pure buprenorphine doses used in the 90s.

I just wanted to ask your opinion about using either Methadone or Suboxone as a taper? Since you’ve tried both and have experience with tapering, I thought I’d ask.

Best wishes to you and I really hope that you can find something to help with your constant headaches. I know from experience that constant migraine/chronic headache is hell, so I really wish you luck with dealing with it.

Eva

 
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Old 01-05-2018, 11:00 PM   #4
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Re: Episodic Pain, Opiates, Tapering

I'm my opinion you are overthinking / overcomplicating this.

Once option is that capsules can be opened and some of the contents removed, and then the capsule put back together to swallow it. I've only done that with capsules with microbeads in them (Cymbalta, when I needed to taper down by removing some of the beads). I imagine if it is just powder in it, then it would be difficult.

Or, check if they come in a lower dose pill or capsule. I see pure pills down to 15mg. What type of codeine capsule is it anyways? Pure, or anything else in it? Longer acting? I'm only familiar with Fiorinal/Fioricet w/ Codeine.

Or, the easiest would probably be Codeine liquid, as you can even add water and measure it down to a very very small dose, but I think that only comes with other ingredients as well, like Tylenol or Phenergan, but if it would be short term, that is an easy option at least.

I think switching to another med at this point is very likely to increase your total daily dosage (as 1 codeine << 10mg or even 1/2 a 5mg Methadone, etc), which would derail your progress, and make it more complicated. I don't see a reason to switch to Suboxone or Methadone without having given a real try of tapering down more, as yes, that could red flag you.
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Last edited by tortoisegirl; 01-05-2018 at 11:04 PM.

 
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Old 01-08-2018, 08:16 PM   #5
Eva 14
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Re: Episodic Pain, Opiates, Tapering

My capsules are Fiorinal with Codeine. I realize that has other ingredients in it and it isn’t pure Codeine.

Today I just got my period, which means severe cramps due to my endometriosis. I need to take 2 Codeine every 4 hours for the next 3-4 days. My pain doc knows all about my endometriosis pain, which is probably another reason that he realizes I need pain meds at least some of the time, and why he’s fine with me taking 1 pill a day the rest of the month.

I used to get my period every 35 days or so. I was glad I had a long cycle, because my menstrual cramps are so painful. For whatever reason, lately I’ve been getting my period every 25-26 days, which I hate. I’ve already tried surgery and other meds for endometriosis, without success (or with bad side effects from some of the meds).

My endometriosis pain means a need for a higher dose of opiates for 4 out of every 25 days. Given the fact of my endometriosis pain is severe and I need to take opiates for it, it makes even less sense for me to try to taper off of opiates completely. I think I was forgetting just how severe my cramps really are. I was definitely reminded of it today.

Now that I really think about it, tapering off opiates completely when I still need them for 4 out of every 25 days really doesn’t make sense. I could maybe get down to almost nothing, only to need to take 2 pills every 4 hours for four consecutive days. That would really mess up the taper, and then I’d have to try to taper all over again. It almost seems like I would repeatedly be in taper mode, more frequently than even once a month.

No wonder my pain doctor advises me to take 1 pill a day on my pain-free days. It really makes sense now that I’m feeling this severe pain. I think that tapering down to zero would only make sense if I had zero pain days, for longer than a few months. Anything else seems like a lot of unnecessary discomfort on a repeated basis.

Kate, thanks for your advice. I realize now that trying to taper down to zero really doesn’t make sense, given my current pain situation. My pain doc is really happy that I need so little medication these days. I went from being one of his highest dose patients to suddenly being one of his lowest dose patients. He’s happy he doesn’t have to prescribe many pain meds to me, and I’m happy I’m not in constant 24/7 pain anymore. Best wishes.

Eva

 
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