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    Old 05-11-2004, 09:46 PM   #1
    StarfieldJane
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    Question MSContin advice needed

    I have been prescribed MSContin 15mg two times a day, and 10mg Lortab three times a day. I dropped my Lortab in the toilet and ruined it, the pain clinic won't give refills until due for any reason. So, I couldn't stand the pain anymore and crushed two MSContin and put it in applesauce and took it. I know you're not supposed to do that, so I was wondering if anyone out there has ever done it and suffered any ill effects. Thank you, I'm new here so hope I'm doing this right.
    Thanks,
    StarfieldJane
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    Old 05-12-2004, 08:40 AM   #2
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    Re: MSContin advice needed

    Hey Jane, Talk about a bad chain of events.There is a consequence for every action, Because you dropped the Lortab now your going to take extra morphine and run out of that early. You know they won't fill that early either don't ya, You are in for a heck of a ride.

    The reason they say not to crush, chew, snort or inject the time release meds is because instead of 15mgs of morphine being released over 8-12 hours what you did was dump 30 mgs of morphine into your system imedietely. You quadroupled your normal serum level. How did you know you could physically handle something 4x stronger than you used too.

    A 15 mg MSContin sustains 7.5 mgs in your system for about 8-12 hours, chewing 2 up with applesausce or mash potatoes it still dumps all 30 mgs in your system giving you 4x the serum level you are used too.

    I'm sorry but increased pain doesn't justify abusing your meds. The doc was obviously convinced by you, to prescribe these meds. Do you think it's right for the doc to get shut down and every patient he sees go through withdrawal because you lost some meds and then decided to self medicate. If you ended up in the ER, the Doc very well could hve been investigated for misprecribing potent opiates to someone that's not compliant.

    Your little ripple could put the doc in the position of loosing his licence while he defends why he prescribed you the meds you abused. Then every one of his patients is out in the cold because of what you did. They no longer have a PM doc and get to go through withdrawal due to no fault of their own.

    Take it farther, you could have died, then your surviving family sues the doc for believing that your pain was so severe that you needed meds strong enough to kill you if you take them the wrong way or abuse them, same ripple happens, every patient looses their doc and goes through withdrawal because of what you did. Then every doc in the area is scared to prescribe opiates to true CP patients for fear of non compliance, abuse and eventual prosecution. Do you think your family diserves a pay day because you chewed up your long acting meds despite every warning and every news program in the last 5 years. I guess you never heard that could be dangerous.

    Anyone of us could use the pain excuse to self medicate, but because addicts have used up all the "good excuses" we have to toe the line just to not be treated like a junkie that seeks out PM docs and lies about their condition to obtain , abuse and sell these meds.

    Personally I would get back on the program real qiuick and not keep taking a days worth of meds and make them last 4 hours. You will run out and the withdrawal from morphine will be worse than having to do without the Vikes. Not to mention after trying to use the toilet excuse you may not recieve another script, particularly if you make up another excuse as to why you ran out of MSContin early.

    Sorry if you were expecting support for abusing your meds. There are many people that can barely walk or get out of bed that don't use their condition as an excuse to abuse opiates. Because of the abuse problems even the folks with the most severe problems that would seem unimaginable to you don't have the fredom to chew up a days worth of meds for a few hours of relief. It kind of leaves you short the rest of the day, so how many more MSContin did you take that day?

    If your given BT meds, that's what they are for. Not to take 3 times a day because you allowed to if you need it. If you don't need them 3 times day and you take them simply because your allowed you will become tolerant to them and when you have a real need for aditional relief you won't have the means to deal with additonal pain even though the doc has given you BT meds to do just that. BT meds are for when needed, not part of your daily regemin that you would die without.

    Does you doc not use any form of PM contract to expalin these things to you? You are in for a rough ride if you don't get with the program and learn to fly under the radar. Calling and getting the whole office involved in the pills in the toilet isn't the way to fly low. If your pain is so severe you need these meds I would sugest you learn the concept of the whole 30 day supply thing. 2 pills a day X 30 = 60 pills, That's a 30 day supply, not a 28 or 26 and doesn't depend on how bad you report your pain for the previous month. If your meds are not working, you need to be seen, not take matters in your own hands. No doc is going to replace meds lost in the toilet, sink, the dog ate them or they were stolen from your car or desk.

    PM won't happen unles the doc has some degree of trust when he gives you meds strong enough to kill an oppiate niave patient, it doesn't usually take long for a decent doc to put 2 and 2 together and they don't have the luxery of giving every patient a second chance. Right now you have a chance of putting this month back together and not making it worse. I really hope you can if you truly need these meds. The increased pain during withdrawal will make your daily pain seem like a walk in the park.

    Good luck, Dave

    Last edited by Shoreline; 05-12-2004 at 08:49 AM.

     
    Old 05-12-2004, 09:40 AM   #3
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    Re: MSContin advice needed

    Hey Jane, I know some folks will think I flamed you or was harsh, But better to understand and get with the program before you make a step down the wrong path.

    I know I can be sarcastic but tha's just my personality. I do shoot from the hip and call it as see it. I hope you do think about the ramifications of what you did aside from was it safe for me to abuse my meds at that level or scale. Fortunately your dose isn't that high and you didn't hurt yourself. But if you keep increasing for the wrong reasons and then chew up a whole days meds at once it could kill you, and I don't want to see another dead CP patient that gets blamed on these meds that nobody can take reposiblly.

    The best figures suggest as litttle as 3% of true CP patients abuse their meds or as much as 10-15%. It's probably somwhere in between, but seeing a felow PM doc get prosecuted sends a ripple effect through the whole comunity. Like trying to find a PM doc in Northern VA after they shut down Dr Horowitz and two other PM docs in Northarn VA.

    All the real patients suffer and the addict only thinks about there own use and safety.They will keep doc shoppping or buying from the net. But is it safe to do this. No it isn't. But it also has a huge impact on all CP patients. Even the patients the nurses see after recieving a call that another bottle of meds fell in the toilet and the patient the doc sees and now has a cynical view of the patient he trusted a week or two or whatever ago. Ideally he stepped in to try to help you and improve the quality of your life, not just make you feel better for 4 hours a day.

    I have a history of substance abuse 18 years ago. It wasn't PM meds or opiates, But I read at the addiction fourum just to keep myself in check. I don't post. Don't want to taint what they have going on because of the different views of PM and opiates and addiction and opiates.

    But you can clearly see what the drugs of choice are. How many people started with good intentions and self medicated untill ahuge monkey was on their back. when 1 Lortab doesn't work you take 2, when 2 doesn't they take 3, you don't think about liver failure or it doesn't stop them regarless of what they have to loose, and they certainly don't think about the repercusions to the doctor, his staff, the phartmacy and how every other pain patients is treated the rest of the day or week after another addict tries to scam a doc or pharmacist.

    Your doc probably gets the pills in the toilet several times a month. It doesn't mean it can't hapen or didn't happen in your case, but because of abuse, even the real excuses have been fried.

    I hope you read my post and don't just react to feeling like your being picked on. I have plenty of friendly relationships with folks that have started in the same position and just need to know the rules to keep from geting in trouble.

    Just one phone call to the doc to ask a question actaually crerates several hours of work for the entire staff. Take the message, Pull your chart. research the script history, check for possible answers, return your call, suggest a treatment or make an apt.Maybe call in a script, log the scrpt and request, Refile the chart. Etc ect etc.

    Just stuff you pick up after years of dealing with docs in this system.
    Take care, Dave

    Last edited by Shoreline; 05-12-2004 at 09:49 AM.

     
    Old 05-12-2004, 10:52 PM   #4
    Ralinda30
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    Re: MSContin advice needed

    Hey Shore, just a quick question if I may? My husband is currently taking Ms contin,msir,midrin,pamelor,zoloft,ultram ,and zonegran.Do u know if these have any serious drug interactions? The pharmacist told me to question the doc about a couple of these,but he said these r what works best for my husband.Anyways jsut concerned....Thanks

     
    Old 05-13-2004, 06:11 AM   #5
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    Re: MSContin advice needed

    Pamalor, Zoloft and Ultram are quite a combination, They are all SSRI's, even the Ultram has an effect on serritonin reuptake.

    I just ran those meds through a drug checker and this is what it cameup with
    The interactive effects of


    MS Contin + MSIR + Midrin + Pamelor + Zoloft + Zonegran + Ultram


    are as follows:

    Major Interaction -- Drug-Drug
    sertraline and tramadol

    GENERALLY AVOID: The coadministration of selective serotonin reuptake inhibitors (SSRIs) with tramadol, which has weak serotonin reuptake inhibiting effect, may potentiate the risk of serotonin syndrome, which is a rare but serious and potentially fatal condition thought to result from hyperstimulation of brainstem 5HT1A receptors. Patients receiving this combination may also have an increased risk of seizures. Pharmacokinetically, coadministration with certain SSRIs, namely fluoxetine, paroxetine and possibly sertraline, may result in decreased plasma concentrations of the active O-demethylated (M1) metabolite of tramadol due to inhibition of CYP450 2D6, the isoenyzme responsible for the formation of the metabolite. The clinical significance of this potential interaction is unknown. However, M1 is thought to possess up to 6 times the analgesic effect of tramadol, thus diminished therapeutic response to tramadol should be considered. MANAGEMENT: In general, the concomitant use of SSRIs and tramadol should be avoided if possible, or otherwise approached with caution if potential benefit is deemed to outweigh the risk. Patients treated with the combination should be closely monitored for signs and symptoms of excessive serotonergic activity such as CNS irritability, altered consciousness, confusion, myoclonus, ataxia, abdominal cramping, hyperpyrexia, shivering, pupillary dilation, diaphoresis, hypertension, and tachycardia.



    Major Interaction -- Drug-Drug
    nortriptyline and zonisamide

    MONITOR CLOSELY: Certain drugs such as carbonic anhydrase inhibitors and drugs with anticholinergic activity (e.g., antihistamines, antispasmodics, neuroleptics, phenothiazines, tricyclic antidepressants) may potentiate the risk of oligohidrosis and hyperthermia associated occasionally with the use of zonisamide, particularly in pediatric patients. These agents may alter electrolyte and fluid balance (carbonic anhydrase inhibition), inhibit peripheral sweating mechanisms (anticholinergic effect), and/or interfere with core body temperature regulation in the hypothalamus (neuroleptics and phenothiazines), resulting in the inability to adjust to temperature changes, especially in hot weather. Also, agents with anticholinergic activity frequently cause drowsiness and other central nervous system-depressant effects, which may be additively or synergistically increased in patients also treated with zonisamide. MANAGEMENT: Caution is advised when zonisamide is prescribed with other drugs that predispose patients to heat-related disorders, including carbonic anhydrase inhibitors and drugs with anticholinergic activity. Patients, particularly pediatric patients, should be monitored closely for evidence of decreased sweating and increased body temperature, especially in warm or hot weather. Proper hydration before and during vigorous activities or exposure to warm temperatures is recommended. Patients (or their guardians or caregivers) should contact their physician immediately if they are not sweating as usual, with or without a fever. Ambulatory patients treated with zonisamide and agents with anticholinergic activity should also be made aware of the possibility of additive CNS effects (e.g., drowsiness, dizziness, lightheadedness, confusion) and counseled to avoid activities requiring mental alertness until they know how these agents affect them.



    Moderate Interaction -- Drug-Food
    sertraline

    MONITOR: Grapefruit juice may increase the plasma concentrations of some orally administered drugs that are substrates of the CYP450 3A4 isoenzyme. The proposed mechanism is inhibition of CYP450 3A4-mediated first-pass metabolism in the gut wall by certain compounds present in grapefruits. The extent and clinical significance are unknown. Moreover, pharmacokinetic alterations associated with interactions involving grapefruit juice are often subject to a high degree of interpatient variability. MANAGEMENT: Patients who regularly consume grapefruits and grapefruit juice should be monitored for adverse effects and altered plasma concentrations of drugs that are metabolized by CYP450 3A4. Grapefruits and grapefruit juice should be avoided if an interaction is suspected. Orange juice is not expected to interact with these drugs.

    continued on next page......................

     
    Old 05-13-2004, 06:13 AM   #6
    Shoreline
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    Re: MSContin advice needed

    Moderate Interaction -- Drug-Food
    zonisamide

    MONITOR: Grapefruit juice may increase the plasma concentrations of some orally administered drugs that are substrates of the CYP450 3A4 isoenzyme. The proposed mechanism is inhibition of CYP450 3A4-mediated first-pass metabolism in the gut wall by certain compounds present in grapefruits. The extent and clinical significance are unknown. Moreover, pharmacokinetic alterations associated with interactions involving grapefruit juice are often subject to a high degree of interpatient variability. MANAGEMENT: Patients who regularly consume grapefruits and grapefruit juice should be monitored for adverse effects and altered plasma concentrations of drugs that are metabolized by CYP450 3A4. Grapefruits and grapefruit juice should be avoided if an interaction is suspected. Orange juice is not expected to interact with these drugs.



    Moderate Interaction -- Drug-Drug
    APAP/dichloralphenazone/isometheptene and sertraline

    MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients. MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be made aware of the possibility of additive CNS effects (e.g., drowsiness, dizziness, lightheadedness, confusion) and counseled to avoid activities requiring mental alertness until they know how these agents affect them. Patients should also be advised to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.



    Moderate Interaction -- Drug-Drug
    APAP/dichloralphenazone/isometheptene and morphine

    MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients. MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be made aware of the possibility of additive CNS effects (e.g., drowsiness, dizziness, lightheadedness, confusion) and counseled to avoid activities requiring mental alertness until they know how these agents affect them. Patients should also be advised to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.



    Moderate Interaction -- Drug-Drug
    APAP/dichloralphenazone/isometheptene and morphine

    MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients. MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be made aware of the possibility of additive CNS effects (e.g., drowsiness, dizziness, lightheadedness, confusion) and counseled to avoid activities requiring mental alertness until they know how these agents affect them. Patients should also be advised to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.



    Moderate Interaction -- Drug-Drug
    APAP/dichloralphenazone/isometheptene and nortriptyline

    MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients. MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be made aware of the possibility of additive CNS effects (e.g., drowsiness, dizziness, lightheadedness, confusion) and counseled to avoid activities requiring mental alertness until they know how these agents affect them. Patients should also be advised to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.



    Moderate Interaction -- Drug-Drug
    APAP/dichloralphenazone/isometheptene and zonisamide

    MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients. MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be made aware of the possibility of additive CNS effects (e.g., drowsiness, dizziness, lightheadedness, confusion) and counseled to avoid activities requiring mental alertness until they know how these agents affect them. Patients should also be advised to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.



    Moderate Interaction -- Drug-Drug
    sertraline and morphine

    MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients. MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be made aware of the possibility of additive CNS effects (e.g., drowsiness, dizziness, lightheadedness, confusion) and counseled to avoid activities requiring mental alertness until they know how these agents affect them. Patients should also be advised to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.



    Moderate Interaction -- Drug-Drug
    sertraline and morphine

    MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients. MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be made aware of the possibility of additive CNS effects (e.g., drowsiness, dizziness, lightheadedness, confusion) and counseled to avoid activities requiring mental alertness until they know how these agents affect them. Patients should also be advised to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.



    Moderate Interaction -- Drug-Drug
    sertraline and nortriptyline

    MONITOR: The coadministration of sertraline and some tricyclic antidepressants (TCAs) may result in significantly elevated plasma concentrations of the latter. Data are available for desipramine and imipramine only. The mechanism is probably decreased clearance of TCAs due to inhibition of CYP450 2D6 enzymatic activities by sertraline in a concentration-dependent manner. In addition, the combination of sertraline (or any other selective serotonin reuptake inhibitor) with a TCA may potentiate the risk of serotonin syndrome, which is a rare but serious and potentially fatal condition thought to result from hyperstimulation of brainstem 5HT1A receptors. MANAGEMENT: In general, the concomitant use of serotonergic agents and TCAs should be avoided if possible, or otherwise approached with caution if potential benefit is deemed to outweigh the risk. Close monitoring for signs and symptoms of TCA toxicity (e.g., sedation, dry mouth, blurred vision, constipation, urinary retention), excessive serotonergic activity (e.g., CNS irritability, altered consciousness, confusion, myoclonus, ataxia, abdominal cramping, hyperpyrexia, shivering, pupillary dilation, diaphoresis, hypertension, and tachycardia), and TCA plasma concentrations is recommended.



    Moderate Interaction -- Drug-Drug
    morphine and nortriptyline

    MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients. MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be made aware of the possibility of additive CNS effects (e.g., drowsiness, dizziness, lightheadedness, confusion) and counseled to avoid activities requiring mental alertness until they know how these agents affect them. Patients should also be advised to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.



    continued on next page...............

     
    Old 05-13-2004, 06:14 AM   #7
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    Re: MSContin advice needed

    Moderate Interaction -- Drug-Drug
    morphine and zonisamide

    MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients. MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be made aware of the possibility of additive CNS effects (e.g., drowsiness, dizziness, lightheadedness, confusion) and counseled to avoid activities requiring mental alertness until they know how these agents affect them. Patients should also be advised to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.



    Moderate Interaction -- Drug-Drug
    morphine and tramadol

    GENERALLY AVOID: Tramadol may reinitiate physical dependence in patients who are dependent on opioid drugs or precipitate withdrawal symptoms in patients who have recently received large doses of such drugs. In addition, additive CNS-depressant effects may occur when tramadol and other opioid drugs are administered concurrently. MANAGEMENT: Tramadol should be avoided in opioid-dependent patients and administered cautiously to patients who have recently received large doses of opioids. Dosage adjustments may be required in patients concurrently receiving opioids. Patients should be monitored for withdrawal symptoms (e.g., tremors, anxiety, sweating, nausea, diarrhea, or insomnia) and excess CNS depression.



    Moderate Interaction -- Drug-Drug
    morphine and nortriptyline

    MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients. MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be made aware of the possibility of additive CNS effects (e.g., drowsiness, dizziness, lightheadedness, confusion) and counseled to avoid activities requiring mental alertness until they know how these agents affect them. Patients should also be advised to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.



    Moderate Interaction -- Drug-Drug
    morphine and zonisamide

    MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients. MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be made aware of the possibility of additive CNS effects (e.g., drowsiness, dizziness, lightheadedness, confusion) and counseled to avoid activities requiring mental alertness until they know how these agents affect them. Patients should also be advised to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.



    Moderate Interaction -- Drug-Drug
    morphine and tramadol

    GENERALLY AVOID: Tramadol may reinitiate physical dependence in patients who are dependent on opioid drugs or precipitate withdrawal symptoms in patients who have recently received large doses of such drugs. In addition, additive CNS-depressant effects may occur when tramadol and other opioid drugs are administered concurrently. MANAGEMENT: Tramadol should be avoided in opioid-dependent patients and administered cautiously to patients who have recently received large doses of opioids. Dosage adjustments may be required in patients concurrently receiving opioids. Patients should be monitored for withdrawal symptoms (e.g., tremors, anxiety, sweating, nausea, diarrhea, or insomnia) and excess CNS depression.



    Moderate Interaction -- Drug-Drug
    nortriptyline and tramadol

    MONITOR: The risk of seizures may be increased during coadministration of tramadol with selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs), neuroleptic agents, opioids, tricyclic antidepressants, other tricyclic compounds (e.g., cyclobenzaprine), and/or any substance that can reduce the seizure threshold. These agents are often individually epileptogenic, with potentially additive effects. Many of these agents also exhibit CNS- and/or respiratory-depressant effects, which may be enhanced during their concomitant use with tramadol. MANAGEMENT: Caution is advised if tramadol is administered with any substance that can reduce the seizure threshold, particularly in the elderly and in patients with epilepsy, a history of seizures, or other risk factors for seizures (e.g., head trauma, metabolic disorders, alcohol and drug withdrawal, CNS infections).



    Moderate Interaction -- Drug-Drug
    zonisamide and tramadol

    MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients. MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be made aware of the possibility of additive CNS effects (e.g., drowsiness, dizziness, lightheadedness, confusion) and counseled to avoid activities requiring mental alertness until they know how these agents affect them. Patients should also be advised to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.

    Don't panic, because this lists all possible DI, it doesn't mean you will expereince them all but he is taking alot of drugs tha effect serritonin levels which can cause serritonin syndrome.
    Good luck, Dave

     
    Old 05-13-2004, 05:44 PM   #8
    Ralinda30
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    Re: MSContin advice needed

    Thanks Dave......

     
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