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  • A long story and request for pain med info

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    Old 09-17-2004, 04:07 AM   #1
    Bilbo
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    A long story and request for pain med info

    Background (long, skip to the asterics if you dont want to read)

    2 car accidents in 10/01, 1 month apart, left me with a very sore right shoulder and neck. Pain came and went. 6 month later I caught a very bad cold and had several very bad sneezing and coughing fits. Every time I sneezed I felt a searing pain in my right shoulder. The pain would drop me to my knees and last for hours. After the cold passed I slowly got better and my shoulder and neck only bothered me when I either slept on it or did too much physical activity. I could deal with it without meds. In 6/03 I went golfing with my brother and that morning, before we started, my shoulder was sore. I should have skipped playing but golf is my passion. On the 3rd hole we had a long drive bet and I stepped up to rip a big drive. Boy did I. I swung and just as I hit the ball it felt like someone stuck a hot knife in my back/shoulder. It hurt between my spine and my scapula (rhomboid muscles). Later that day the pain didnt subside like it normally did and my arm was hurting too. Also, my elbow felt tingly and my pinky was a little tingly.

    At this point it was clearly time to see a Doc. Because I rarely got sick I didnt have a regular Doc so I went to a Urgent Care Clinic. They gave me Vicodin 5/500 and Flexiril. After a month of follow ups and more meds the pain didnt go away. At this time they sent me to PT. PT only aggrevated my shoulder and neck. Because of this the doc ordered a MRI of cervical and thorasic spine. The cervical spine MRI showed moderate narrowing on the nueral foramin and the doc felt that this narrowing was causing the neck, shoulder and arm issues. I felt uneasy about this diagnosis because my primary compaint was my SHOULDER. The doc imformed me that a cervical problem can cause these issues. In retrospect I guess I didnt help the doc link the events listed above to the pain. She sent me to a nuerosurgeon to discuss options. 1/12/04 I had a C4-C6 ACDF with hardware. Right after surgery, besides the incision pain, I felt tremendously better. Withing 3 weeks, however, it all came back. I attribute feeling better to the increased pain meds given post opp. Pre op I was taking the Vicodin 5/500 every 4 hours. Post op I was taking 2 Norco 10/325 every 4 hours and had changed from Flexiril to Soma.

    My nuerosurgeon was baffled at my return of symptoms and upon return visits to him he became less and less helpfull and even went so far as to tell me that my pain was a function of being addicted to narcotics. Needless to say I stopped seeing him and I went back to my doc in a box.

    Fortunetly this Doc listened to me and ordered another Cervical MRI and a right shoulder MRI. The cervical MRI was pretty normal but showed that the disk right above the fusion was bulging a tiny bit. The shoulder MRI showed significant tendenosis and a POSSIBLE labrum tear. Because of this they sent me to an Orthopedic. Because I live in FAR Norther California and the Medical system here is weak I decided to take a drive down to UC Davis Med Center in Sacramento. There I saw an Orthopedic at Dr Eric Heiden's (olympic speed skater) office. They sent me to Pain Management and ordered a EMS. The EMS was normal but the Pain Management Doc was very sharp and thourough and he was convinced that I had a torn rotator cuff. On the spot they did a Cortisone injection. With a cortison injection they also inject lidocaine and xylocaine which immediatly numb the site and joint to make the injection more tolerable. Yipee, immediatly my shoulder pain was GONE. I went from a 7/10 to a 0/10 on their pain scale. Unfortunetly the fast acting 'caines wore off and the cortisone had no effect. They sent me back to the Ortho with these results.

    This time I got to see Dr. Heiden which was awesome because I was such a fan of his. Even with the evidence from the injection and its immediate effect he was skeptical about a cuff tear because I had pretty good ROM and my MRI looked pretty good to him. He thought the space between my Acromion and my cuff was limited and possible causing the irritation. He decided to do another shot himself but this time he didnt go all the way into the joint, at least it didnt seem so. He was vauge about what he was doing and just called it a "differential diagnostic tool". My guess is that he was seeing if his theory on the diminished space was true. He put me off for another 2 months to see if it worked.

    I already had a f/u appt to the PM docs and they decided that it would be best if I went on a new med since the Norco was having less and less effect and I was having to take more and more which was making my regular doc uneasy. Just yesturday they put me on 10mg Oxycontin. This PM center doesnt do any fast acting meds so they told me to go to my regular doc for Norco in case I had breakthru pain. I thought this was odd but its their policy.

    ****Anyway, I am curious as to how Oxy differs from Norco other that its a time released opiate. Are they the same basic meds just deliver differently? I am now 2 days in and experiencing tremendous pain. I just took my first Norco for breaktru bacause I just couldnt get to sleep (its 4am!!!).

    Can someone help me with understanding the pain me heirarchy and how they differ. I was taking 2 10mg Norcos every 4 and now I am taking 10mg every 12 hours. They way I see it I went from 60mg of opiate to 10mg in a 12 hour period. I this an incorrect way to look at it. I need info because I plain to call the PM doc in a few days if this doesnt improve.

    Sorry for being so lond winded but I felt it was neccessary to give the whole story.

    Thanks, Bilbo
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    Old 09-17-2004, 01:07 PM   #2
    Bilbo
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    Re: A long story and request for pain med info

    Finally got some sleep. I took my 10mg Oxy at 7:30am and guess that I fell asleep around 8:30. I woke at 11ish with a wicked headache and in a lot of pain. I took one 10mg Norco and was able to nap for about an hour so I figure I got about 4.5 hours sleep and I am hurting still and have the same wicked headache.

    So far I am not pleased with this Oxy. I was much more comfortable taking 2 10mg norco every 4 hours.

    I also see that the USA is getting trounced by Europe in the Ryder Cup (golf). Doesnt help with the headache.

    Ugggh.
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    Old 09-18-2004, 01:49 AM   #3
    KateInAustralia
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    Re: A long story and request for pain med info

    I've been in a similar situation to you.

    I have RSD, a chronic pain condition that affects my right arm, but one day my right shoulder felt like it tore when I reached up to a top shelf and I suffered immense pain from then on.

    I was diagnosed with tendonitis, then bursitis, then a torn rotator cuff. I was given a cortisone injection and felt instant relief, that lasted for 2 weeks. I went back for another, but it didn't help, just created more pain. My dr tried to give me 2 more but they didn't help either. When he wanted to give me a 5th one, I said no. If you have too many, it can cause chronic problems in the joint, and I didn't want to risk that when they weren't working anyway.

    They then decided to call the problem "scapula thoracic dysfunction", which basically meant the joint and all the muscles around it had shifted forwards and down due to me using my shoulder instead of my elbow, as that is where the pain had been for so long from the RSD. The tendonitis seemed to have been treated, but the joint and muscles weren't functioning properly and were causing intense pain, and now will do in an ongoing nature, as they can't fix it.

    So I was put in physical therapy twice a week to get my ROM back. But it just created more pain. So in the end, I was put on MS Contin. The dr believed if I had enough pain relief, I could do the physio exercises and get my range of motion back. I went up to 30mg daily. I was permitted to go up to 60mg daily, but the side effects of confusion, dizziness and tiredness were too much for me to increase the dose. But the MS Contin definately gave me my life back and I was able to increase my strength and range of motion.

    By this time, I had been suffering the shoulder pain for a year, on top of my arm pain. However, unfortunately for me, the RSD has now spread into my shoulder and MS Contin doesn't help anymore, its just all merged as one problem.

    I don't have personal experience with oxycontin, but with the MS contin, it took a while to get used to, and the dose was slowly lifted to a rate that gave me pain relief, though with the side effects I mentioned earlier. As they both work as a slow release, you can't take them when you're in pain, you take them at the same times every day. They are long acting, instead of giving you an instant relief in your pain levels. Sometimes you need something else for breakthrough pain.

    I hope you get some pain relief and good sleep soon!

    x Kate

     
    Old 09-20-2004, 06:19 AM   #4
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    Re: A long story and request for pain med info

    Hi bob, Hydro is roughly 50% weaker than oxy, meaning 10 mgs of oxycodone would be equal to 15 mgs of hydro if you compared both as short acting meds.

    However a 10 mg oxyC does not maintan 10 mgs of oxy in your sytem. Each strength of oxy maintains half it's mg strenght so a 10 mg OxyC would be like taking 1 percocet every 4-6 houtrs, 20 mgs of oxyC would comaparable to 10 mgs of Oxycodone short acting every 4-6 hours. a 40 maintains a 20mg serum level , an 80 mg oxyC maintains 40mgs of oxy for 8-12 hours. And so on...

    So by switching from 20 mgs of norco every 4 hours and going to 10 mgsof oxy , you actually took a major step down blood serum wise. The OxyC is only mantaining 5mgs of oxy in your system for 8-12 hours, the Hydro maintained all 20 mgs for 40 hours so your conversion is low and the increase in pain is somewhat expected. It's a shame even at Name brand hopitals a drug conbversion is still tricvky even for PM professionals.By the way Hydrocodone and oxycodone are in the same family of synthetic opoids, oxy is just stronger and available without the apap.

    The converseion tabels are called Equianalegesic if you want to find a chart and you can read the full prescribing info at the manufacturers web site, got to product list, click on OxyC full prescibing info and it explains how it a 10 mg OxyC release half it's med at about 1 hour and the other half around the 6th. Even 20 mgs of OxyC twice a day would leave you taking less than the norco. Twice a day dosing of Oxyc Is also contreversial as most folks feel it wear off in about 8 hours. so 3 times a day would be more apropriate if Purdue Frederick Pharma, the manufatcturer wasn't so adament abou the 12 hour wonder drug that last 8. Hope you at least got a autograph. LOL

    Actually removing the bursa cold give you the added space you need, My wife had her rotor cuff repaired and the bursa removed to open things up. The second injection was likely in the bursa, If it numbed you pain completely it would have pinpointed the cause of pain,"the bursa" Since the inner capsule injection relieved your pain it sounds like a torn labrum in additional to maybe needing the bursa removed, just a matter how severe the tear is. You need an MRI of the shoulder to confirm this.
    Good luck, Dave

     
    Old 09-20-2004, 09:04 PM   #5
    Bilbo
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    Re: A long story and request for pain med info

    Quote:
    Originally Posted by Shoreline
    Hi bob, Hydro is roughly 50% weaker than oxy, meaning 10 mgs of oxycodone would be equal to 15 mgs of hydro if you compared both as short acting meds.

    However a 10 mg oxyC does not maintan 10 mgs of oxy in your sytem. Each strength of oxy maintains half it's mg strenght so a 10 mg OxyC would be like taking 1 percocet every 4-6 houtrs, 20 mgs of oxyC would comaparable to 10 mgs of Oxycodone short acting every 4-6 hours. a 40 maintains a 20mg serum level , an 80 mg oxyC maintains 40mgs of oxy for 8-12 hours. And so on...

    So by switching from 20 mgs of norco every 4 hours and going to 10 mgsof oxy , you actually took a major step down blood serum wise. The OxyC is only mantaining 5mgs of oxy in your system for 8-12 hours, the Hydro maintained all 20 mgs for 40 hours so your conversion is low and the increase in pain is somewhat expected. It's a shame even at Name brand hopitals a drug conbversion is still tricvky even for PM professionals.By the way Hydrocodone and oxycodone are in the same family of synthetic opoids, oxy is just stronger and available without the apap.

    The converseion tabels are called Equianalegesic if you want to find a chart and you can read the full prescribing info at the manufacturers web site, got to product list, click on OxyC full prescibing info and it explains how it a 10 mg OxyC release half it's med at about 1 hour and the other half around the 6th. Even 20 mgs of OxyC twice a day would leave you taking less than the norco. Twice a day dosing of Oxyc Is also contreversial as most folks feel it wear off in about 8 hours. so 3 times a day would be more apropriate if Purdue Frederick Pharma, the manufatcturer wasn't so adament abou the 12 hour wonder drug that last 8. Hope you at least got a autograph. LOL

    Actually removing the bursa cold give you the added space you need, My wife had her rotor cuff repaired and the bursa removed to open things up. The second injection was likely in the bursa, If it numbed you pain completely it would have pinpointed the cause of pain,"the bursa" Since the inner capsule injection relieved your pain it sounds like a torn labrum in additional to maybe needing the bursa removed, just a matter how severe the tear is. You need an MRI of the shoulder to confirm this.
    Good luck, Dave
    Thanks Shore, I will be talking to the PM folks tomorow about stepping up because even with 10mg of Norco every four hours for breakthru pain Im still strugglin.

    I did have a shoulder MRI and it showed a "possible torn labrum" along with moderate tendenosis of all the ligaments in my shoulder. Just to recap, the 1st injection I got was definetly into the bursa a it took the doc a little work to get the needle all the way in. When he injected the 'cain + cortizone cocktail into my shoulder I could feel the joint expand under the presure and the 'cains worked dramatically well for short term. The second shot was nothing even close. Not only did he not go very far under the skin, he was much quicker about it. I also didnt feel that same joint pressure....and subsequently got litte immediate relief and no long term relief. When I see the gold metal carrying Ortho in October I plan to push him a little for either an Arthrogram or to just scope it.

    This pain is getting old and Im convinced that its a fixable problem if they would just get around to it.

    Thanks for the info. Another question, and I know its subjective, but can you tell me what dose you think I should be on. I got pretty good relief from 2 10mg norco every 4. Occasionally even that dosage wouldnt cut it but I never took more. My PM doc already knows that I do research and even asked me if I was in the medical field becuase of the terminology I was using. What dosage should I tell him I think is neccessary. I now understand how Oxy works and I think that I could make a convincing arguement. I definetly think that goin to 3x a day is more wise. Do you think that 20mg 3x day would be right?

    Tanks, Bilbo.
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    Old 09-21-2004, 10:59 AM   #6
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    Re: A long story and request for pain med info

    Hey Bilbo, sorry about the errors in my typeing, I watch my fingers , not the screen and have a sticky keyboard from having kids.

    OxyC 3 times a day definitely prevents the highs and lows of the last 4 hours between doses.

    Even with TID some folks pain will spirall out of contol because the second release is so far after the 4th hour the pain has wound up again, possibly beyond the small doses ability to catch it and bring it back under control. Personally I prefer the release system of Kaadina, time relief morphine, It last 12-24 hours so t's a never a fight about dosing and a very smooth med for around the clock control f sever pain.. Oxy is actually stronger than morphine mg:mg so it's not like morphine is the big guns.

    The only problem with 3 times a day dosing is that Purdue, the manufacturer sent out letters to every PM doc they can find and everyone getting free meds through their patient asistance program and to as many pharmacies as possible, telling docs not to write OxyC more frequently than BID and telling pharmacist they should outright not fill TID scripts for OxyC. People in the PAP had to have their scripts written BID or no free meds from Purdue.

    There are also many tracking systems set up specifically for OxyC due to all the over reporting of 500 Oxy related deaths in as many years. Forget the 17k a year that die from OTC NSAIDS and Apap. So a surgeon can be hinky about long term use, and from 40mgs TID you would defintely need to taper and surgeons are not axactly the best at tapering you comfortably off the meds. Even PM docs are getting away from oxycontin due to the press and tracking systems in place. Big bro's watching. My state was the first state and Purdue paid for it as their way to solve the abuse problem. It just scares docs from writing it. VA didn't have a huge abuse problem.

    It was all part of their patent litigation to keep generics off the market, and by docs following the manufacturer's guidelines they lower their risk of liability should someone abuse and OD on TID dosing, Or get cought selling the 3rd dose Purdue says we don't need. The best defense in any position is, I followed the FDA aproved prescribing instructions and didn't exceed twice a day dosing.

    Although The gold medalst thing is cool and all, Ortho surgeons are not god PM docs, They usually have a problem managing the pain pre op because they don't want you to have a problem getting relief from post op meds. Ideally every surgical patient is opiate naive and one vicodin a day would work. Post op pain control is easy and limited because they believe they have fix you.

    20 mgs of oxyC will maintain 10 mgs of oxycodone in your sytem for 8+ hours, 20 mgs of norco every 4 is still a higher dose than what a 20mg OxyC can deliver and you have a duration problem mainly because Doc Heiden isn't a PM doc, right? Remeber, a 20mg OxyContin tablet only contains 20mgs of oxycodone, so you get half now and half later. There is no way a 20 mg OxyContin tablet taken BID will sustain the same serum level as taking 20mgs of instant release oxycodone every 4 hours.

    The time release aspect occurs in the bowels not some magic in the blood stream that makes oxycontin stay in there twce as long. I swear there are docs and folks that don't undertand it, and think that way.

    It's called a dual phasic time release system.. People bypass the time release system easily but it only lasts 4 hours then. If you do that I wouldn't expect an early refill because you had to take twice what was prescribed. Once into PM, compliance is about the most important thing.

    I really wouldn't expect a surgeon to do a lot of titrating of meds to make you comfy especially prior to surgey.Telling him 20 BID isn't working may be a better indicator of how much pain your in than actually get you an increase. Perhaps it will speed up the process if he understands this really hurts and is efecting you very negatively. It would really take closer to 30 mgs TID to give you equal relief as the norco and 40 mgs of Oxy TID to actually give you any better relief.

    I think I might have mistated yesterday but Hydro is 3/4 as strong as oxy so 15 mgs of oxy would be ballpark equal to 20 mgs of hydro. Some may need 50% more hydro than oxy some may get by on less. But not being totally opiate naive, you've been exposed and will have a higher tolerance than the average bear after several surgeries.

    If he's thinking surgery, he's likelly considering your tolerance. I came home from all 3 back surgeies, prior to opiate PM with 2 Percocet every 4 hours after 3-4 days of PCA dilaudid. The last surgery was a 6 level fusion with 12 screws and 8 rods and took 11 hours. Percocet didn't cut that pain. The next day he did add 2mg dilaudid but 40 mgs of oxyC is alot of pre-op meds if your thinking surgery.

    PM may be the way to go but
    not every PM doc is the same, some don't believe in opiates at all. Some have limits as to what they think someone may require, some use BT meds and some don't.

    Another thought about having an Olympic gold medal surgeon is he's going to expectect olympic effort at rehab and sucking up pain is certainly part of that mentality. He may have a great background, be a great technical surgeon and a poor post op PM guy. Ortho's cut you off when they are ready, not always when you are? Just a thought. An olympic effort is great but were not all 20 years old anymore

    If the arm isn't corectable, and I wouldn't agree that no other surgeon may be comfortable doing the surgery. All docs are have an opinion whhether it's a harvard degree, Satanford, Baylor or a gold medal. They all have their own ideas and it's up tous to figure out what makes the most sense, how much pain we are in, what's the laternatives and what odds am I willing to risk if have surgery.

    An arthogram will tell you alot more. The way you described the rinjection procedure, It sounded like the second was the bursa and the first the capsule, correct,?
    Keep us posted. You could ask him about something for better pain control, it won't hurt, but he may not be a gold medal PM doc.

    Good luck, Dave

    Last edited by Shoreline; 09-21-2004 at 11:41 AM.

     
    Old 09-21-2004, 12:53 PM   #7
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    Re: A long story and request for pain med info

    Thanks Shore,

    Once again great thoughts.

    One thing I wasnt clear on is that Heiden isnt the one prescribing my meds. I see a different team of folks over at the UC Davis Pain Intervention clinic. The doc there is Dr. Mahajan and he is wonderful.

    I understand about the Olympic gold medal post opp rehab. Im all for that assuming that my shoulder is fixed. Before all of this I was pretty active and always have been sports minded.

    Thanks again.
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