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    Old 10-04-2004, 04:49 AM   #1
    atibbert
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    Shoreline I need some advice

    Shoreline
    That post you wrote to the guy whose doc got mad at him for needing a refill too early really helped me out. I am having trouble finding a pain doc to see me. I have severe TMJ and many of these pain docs don't want to treat us, they don't do facial pain. I have tried to see 6 different ones and can't get one to see me. I currently take 3 to 4 vicodin ES daily with valium (10mg) nightly. I suffer endless pain and the vicodin ES barely touches the pain. I have tried PT, bite guards, trigger point injections, licoderm patches on my face, tramadol, vioxx, celebrex, nuerontin, zanaflex, flexeril, robaxin and skelaxin, 600mg ibuprofen, have endured 4 surgeries and still am in pain. My GP absolutely refuses to give me anything (except an antidepressant) because all this pain makes me depressed. My oral surgeon who did these 4 surgeries has given up on me and I am seeing a new one on the 14th of this month with high hopes. Every week I have to go through what I call the doctor dance, that is when I ask for a refill, get the run around, stress out whether or not he will refill it and spend most of my days stuck to a heating pad. What do you think? You seem to know quite a bit. I don't over medicate even when I am tempted because the pain is unbearable. I will take a 200 to 400 mg ibuprofen chaser with the vicodin, but it seems to help little. I am at my wits end trying to find a pain doctor to do facial pain.
    Amy

     
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    Old 10-04-2004, 09:11 AM   #2
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    Re: Shoreline I need some advice

    Hey Amy, I have read your other post about problems finding a doc in Richmond that treats facial pain. Personally I think you are narrowing the field of pain management by looking for a doc that treats nothing but facial pain. I've yet to meet a PM doc that specializes in a particular type of pain. pain is pain. How is facial pain different from any other type of invisable pain, and yours isn't entirely invisable having had 4 surgerries. neuralgia is neuralgia whether it's caused by Diabetes, compreesed nerve or an unknown cause.

    You have had 4 surgeries to relieve it, another oral surgeon or dentist that's quick to cut again can't be looking out for your best interest.

    Pain is pain, whether it's back pain, nerve pain, TMJ migraines, IC, RSD or whatever the source is. If there isn't a cure, than all that remains is palliative care, "comfort" and increase function. If you shift from relieving #10 pain to explaining howit eeffects you abilyty to function you might do better too. But a PM clinic or doc that doesn't treat trigemeinal Nuralgia or TMJ disfunction is limited by his own abilities, nNot by your condition. If something wqorks on nerve pain it doesn't matter if it's your foot, your hands or your face. Nerve pain is harder to treat but not impossable.

    My wife has TMJ dysfunction to, I know about the bite guards and teeth grinding and most of the symptoms associated with TMJ. Instead of narrowing your search to a dental specialist that also treats chronic pain try to think of this as just one of the many conditions that cause pain and other methods to manage it have failed.

    If you also had a failed fusion and you got into a PM clinic referred by the ortho surgeon, The exact same meds that relieve back pain will also relieve the facial pain. Many people with back pain also have nerve pain or "radiculopothy." So regardless of the cause, regardless of the unique symptoms associated with facial pain whether it's TMJ dysfunction, or just too many surgeries attempting to solve the problem or an unknown cause of trigeminal neuralgia. The treatment of pain is the same.

    After 4 surgeries, you jaw may beyond curing, just like folks that have 3-5 or 8 back surgeries. If surgery is the only thing really being offered than it's human nature to take poor odds and role the dice and hope for the best.

    I know you have an idea that a a PM doc with a dental background will somehow be more effective than a Neurologist that practices PM or an Anesthesiologist that practices PM. But honestly, Even oral surgeons are no better trained to treat pain than any other surgeon, If anything they may have less experience with treating high levels of pain with high levels of pain meds. I've probably nerve met an oral surgeon that ever even considered admitting a patient after ripping every tooth out for dentures so they would have adequate pain management with IV meds. Most dentists or surgeons don't even have hospital privileges unless they have sub specialties like plastic surgery and facial reconstruction. So all these Dentists and oral surgeons are used to performing surgery, writing a few scripts for percocet and that's the extent of their pain management knowledge.

    Their isn't a med school criculum for pain management. Part of the reason is because of the elitist attitudes of the specialties that a pain management curriculum would draw from.

    A Pm curriculum would draw from anesthesiology, yet they wouldn't be anesthesiologist or able to function as one in a surgical setting. Part of the curriculum would draw from Neurology and yet they wouldn't be qualified neurologist. Same with Physical medicine and rehabilitation. "physiatrist". The list can go on to include psychiatry, but not enough training to be one, DO's "doctors of osteopathic medicine" but not enough training to be one. each individual specialty fights for funding, the students compete for internships and specialty fellowships but these specialties don't want to give up funding, space in their programs or put out a partially trained anesthesiologist that isn't capable of performing in an OR.

    So the present Pm docs we have are true anesthesiologist or true neurologist or have multiple specialties by doing multiple fellowships. One doc in my practice is a Psychiatrist /Neurologist, another is an Anesthesiologist /DO. One is a psychologist that went on to med school and did a fellowship in physical medicine "physiatry"

    Although these docs have the qualification to exclusively practice their specialty, they are using their combined knowledge and Interning with practicing pain management docs.

    IMO a neurologist/Anesthesiologist would be more appropriate to manage facial pain than any dentist or oral surgeon. yes DDS can prescribe the meds, but managing chronic long term pain isn't their specialty. . You said your changing oral surgeons because his bag of tricks is no empty. he tried what he could to correct the problem. He's tried the meds the PM docs have pioneered the off label use of, but a dentist or oral surgeon or even a oral surgeon that's gone on to plastic surgery, which is what my wives TMJ doc has done, seems very qualified to surgically treat TMJ dysfunction

    My wife wasn't willing to have the surgery, knowing the odds of success and knowing there are alternatives. My wife has a degenerative nerve and muscle disease called charcot marie tooth, or now they call it Hand and motor sensory neuropothy. Her neurologist left the area a couple years ago and because my doc is a neurologist I ask him if he's treated CMT patients, he said of course. All her old neurologist ever did was chart the progression of the disease, try Neurontin and prescribe Ultram for pain. The rest was basically genetic disorder you have to live with. WRONG!!!
    She's had both feet and ankles reconstructed or fused, ligament and nerve transfers, ostiotomies and over 40 fractures in her feet so she has chronic pain from charcot malformation from so many bone breaks that have healed wrong. The meds My PM doc/neurologist uses to treat the pain in her feet also manages the pain in her jaw and the pain in her neck and shoulders from some spinal problems.

    There isn't a med or technique to manage pain exclusive to to facial pain that only DDS or oral surgeons use or have access too.

    In fact an anesthesiologist that devotes his full time practice to pain management is going to have so much more to offer as far as pain management than any tooth doc, "sorry tired of writing dentist/oral surgeon, LOL Have you ever had an occipital block or a lidocaine or robaxin infusion? These are tools of a PM doc aside from medication. When it comes to medication, how many tooth docs prescribe Long acting morphine, fentanyl patches, methadone or anything more potent than percocet.

    Any PM doc or clinic that treats pain with a multifaceted approach, meaning not only having one trick up their sleeve they believe works on everyone, Is who I would look for. By narrowing your search to a facial pain specialist your making finding a doc with those credentials like finding a needle in a hay stack, where any competent PM doc that uses a multifaceted approach will have much more to offer.

    It doesn't mean you have to give up on a cure and except this is it, I'll never be able to chew steak or open my mouth more than 20mm. You can continue to follow what's new , what's being tested and in clinical trials specifically for facial pain. But honestly, their may be no such pain as a doc that limits his PM practice to facial pain. Why would a doc do this that is capable of treating failed back syndrome, RSD, Migraines, MS or any painful condition. The goal of PM is rarely to cure your condition but to improve function and ease pain.

    continued on next page 10K characters.LOL

     
    Old 10-04-2004, 09:13 AM   #3
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    Re: Shoreline I need some advice

    The way pain management was presented to me and the use of opiates combined with other modalities is that it's the end of the line for now. There isn't another surgery to roll the dice on, you haven't responded to splints, mouth guards, PT , the basic nerve pain meds that "tooth docs" docs have learned to use from PM docs.

    Excepting there isn't a present solution doesn't mean you have to except this is it for the rest of your life. Pain management 10 years ago was what I called Voodoo medicine. My first PM doc believed that evany pain could be managed by the right antidepressant "prozac was her favorite, the right relaxation technique like self hypnosis or guided imagery and she also believed in acupressure and would have you lie on a table and drive her elbow into the most painful spasm you had to push the blood out of the contracted muscle. This may work for some people, but that won't fly on a cancer ward or on every non cancer pain you can name. But that's what was offered 10 years ago and that was the standard of care.

    Obviously things have changed. Even with my back, In 99 when that fusion failed, I saw 3 docs that all said 3 surgeries have failed why would you think a 4th would work. So I accepted for the time being there wasn't a surgical solution, continued to work with various M docs until I found what worked for me. More than a dozen PM docs in all over 11 years.

    I happened to be reading at a ste specific for spines and noticed an article on long fusions. It's incredibly radical and would take more than 10k character to describe but the next day when I saw the doc that was to implant my intrathecal pump, he actually suggested trying that surgery I had read about. This doc had great credentials, Me school at Duke, Internship at Beth Isreal and the hospital for special surgeries and a fellowship at the Einstein Institute.

    What was not available or hadn't even been thought of in 99 is now an option. Mechanically it makes sense, But I have to be ready for another 12 hour surgery and a very long recovery which emotionally I'm just not ready to roll the dice again. If this method becomes the standard to repair long fusion's maybe someday. The same goes for you or any condition, maybe one day there will be a minimally invasive way to correct your problem. But until then you can't just curl up and spend years in bed. Aside from the psyche damage that would do, the physical atrophy and ability to recover would b lost. So for now we manage the pain, with the goal to achieve the most function possible and not obe overmedicated. Once the meds turn you into a zombie on the couch and you have no desire to get up, although that may manage your pain, it's not functioning.

    You have kids that need you and with the right PM you could do most of the things you want. There will be some things that you can't or may hurt but ou don't have to be a zombie to be getting pain relief. Nobody I meet could ever tell I have a continuos flow of morphine into my spine? PM is more about function than relieving all pain. Even the goal they shoot for with the pump isn't only 50% reduction in pain. But But a 50% reduction can mean the difference between bed ridden and able to cook, clean, shop and take care of your kids.

    So open the field of search, realize treating facial pain is no different than other pain and the tooth docs aren't capable or aware of all the modalities to manage your pain.
    yes nerve pain is harder to treat. Pain that has a mechanical dysfunction component is harder to treat, But not impossible.

    I have a tremendous amount of mechanical problems with my back, failed bone growth, broken hardware, toggling screws, nerve damage and few other treats that go along with all chronic pain. But your case isn't so unique only a tooth PM doc can manage your pain. If you can even find such a tooth doc.
    Good luck, Dave

    PS, I hope you were able to get the info on the CPM in portsmouth. They will treat you and keep working until they find what works. I have no doubt.

     
    Old 10-04-2004, 09:34 AM   #4
    atibbert
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    Re: Shoreline I need some advice

    I have not narrowed my search for a PM doc who does facial pain, its just I have tried to get in with 6 different PM docs who all refuse me because they won't treat facial pain only joint pain (??? what is the jaw? just another joint) I am desperate right now and ready to have yet another mental melt down from the pain. I have tried and tried to find a PM doc. My oral surgeon was the one who suggested I go see one. He gave me one name and after finally tracking this guy down, he won't see me because he has narrowed his PM practice to a very specific group of people (I am not one of them). I am currently waiting on pins and needles to see if he is going to refill my vicodin. I just called the pharmacy and as of yet he has not. I cannot take much more of this pain. The only reason I don't just end it all is my 3 beautiful young sons and wonderful husband even though I have not been much of a mother or wife for the last year. I just don't know what to do. Richmond VA, where I live is not exactly a mecca for medicine and these pain docs are far and few between. I have even looked outside the city to neighboring cities without luck. Anyways, thanks for your reply and help.
    Amy

     
    Old 10-04-2004, 10:31 AM   #5
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    Re: Shoreline I need some advice

    Hi Amy,

    I just read your posts. I am so very sorry that you are going thru this awful hell. I know how frustrating it can be. I live with trigeminal neuralgia with all 3 branches of the nerve effected. My pain doc took me, although now I wish he hadn't. That way my insurance would have been forced to send me somewhere else. But anyway, I'm sure that there's somebody out there that can help you. What my doc is doing is sending me to a neurosurgeon to get the gamma-knife radiosurgery done. That should help. He's still the only one that is allowed to give me any pain meds and he has no clue. He has me on the fentyl patch (the lowest dose) and only 5mg oxycodone (percocet). He only gives me enough so I can take 4 a day. I've been on those for 3 mos. now, my body's used to them at that dose so they no longer work but he won't increase. I've had unsuccessful blocks, hence the gamma-knife. He sent me to er for morphine instead of coming to his office when my pain changed, after 3 shots they gave me morphine instant release tabs, he agreed with the er doc on that yet he will not re-fill the script I'm not trying to scare you, I'm actually trying to reassure you. The doc you finally find will definately be better than mine Let me know how you're doing. I know it's rough, I'm a wife and mom as well. I'll say a prayer for you Kathy

     
    Old 10-04-2004, 10:47 AM   #6
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    Re: Shoreline I need some advice

    Thanks Kathy, My next stop will be the ER if I cannot get this refilled. And my body too has built a tolerance for the vicodin and they really don't work to well for me anymore but my doc will not increase my dosage either. I tried switching to vicoprofen because the vicodin was giving me diarhea daily but the vicoprofen made my stomach hurt to bad I was dry heaving. God willing I will find a PM doc who will take me. I am waiting to hear from one who my oral surgeon was supposed to send my records to. I don't know if he has done so yet. As of last week he had not. I hate to go to the ER because I dread getting the bill (YIKES). We are already swimming in doctor bills.
    Amy

     
    Old 10-06-2004, 05:52 PM   #7
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    Re: Shoreline I need some advice

    Ati, 4-5 people gave you the names of their doc in your original post. Hopefully you got a chance to read it before it as removed, I guess were not to list names of specidfic docs. But in your post you specifically said you can't find a doc to treat your facial pain. You didn't mention if it was all from TMJ or partially from TGN

    . You specificaly ask for advice on how to find a doc that treats facial pain and after my 10,000 + character reponse you shot me in the foot saying you were not narrowing your field by speciifcally looking for a doc to treat facial pain.??? Hello, that's exactly what you asked. Perhaps if you are as unclear to the docs as to the cause or type of pain that you were in your post, that may be why your having difficulty.

    But your welcome; for my time spent trying to help and the personal referal to my own PM docs along with the other 4 that were posted by others. Nobody was trying to sneak anything into a post but apearently the mods removed the very specific names addys and phone numbers of our personal docs. It was a great rminder to protect our docs and not freely pass their name along to just anyone.

    Honestly as dismissive as you were to my suggestions I wouldn't feel comfy giving you the name of my doc again. They do have a new system of excepting new patients though, Your doc makes contact, which is proabbly best in your case, They send you a packet to fill out, your case is discussed at a monthly meeting and they decide whether or not to make an apt for an initial eval. If you miss that first apt another will not be set and you will not be seen ever. Sounds tough, but opiates shouldn't be easy to get.

    It took me years of living with pain and learning ways to live with pain before pain meds were even offered. Just because they work, they may not be the best treatment for everyone. If you not open to any other treatment aside from opiates you will likely continue to have the delema your presently in.

    You might want to change your aproach if you may be coming across as someone simply looking for a doc to prescribe opiates for facial pain, whether it be TGN or from TMJ. I'm Still unclear what the problem is after several post other than you can't fnd a doc willing to give you meds that you think work best.

    When you keep getting the same response and treatment from people it may be time to re think the way you communicate with people. It may not be everyone else that has a problem treating facial pain. It may very well be your particular aproach to finding pain relief. If a doc spent an hour talking or writing to you about how to find relief and you dismiss everythng said in the first words that come out of your mouth, the reponses and first impression you make on people may need some work.

    When you point one finger at the jerk docs that don't treat facial pain, you might consider who the other 3 fingers are pointing at. You are the the first person I have ever met that was denied treatment simply because the souce of pain is facial. TGN is considered one of the 7 great pains of old school medicine but nobody knows if that's even the problem? In the 11 years I have been involved in pain management, you are the first person I have met that has been denied treatment do to the source of their pain.

    People with Migraines find treatment, people with all types of hidden or invisable pain generators treatment are not denied treatment. But if your contact with docs is in any way similar to your contact with me, It's becoming more and more understandable why you are having a problem.
    God luck, Dave

    PS. The ER is the last place a CP patent needs to look for meds, At best you get one shot and a script for motrin, But it's your bill, If it's worth 400 bucks for a shot for 3 hours of relief, have at it.

     
    Old 10-07-2004, 05:23 AM   #8
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    Re: Shoreline I need some advice

    Shoreline, I am sorry if I came off as dismissive. I have tried calling the PM docs here and they are the ones who say they will not treat TMJ pain. I have had my records sent to them by my doctor. One of them sent a letter to my doctor explaining they do not treat this disorder (TMJ) and I should go see doctor so and so. So I did go see him. My doctor never sent my records to him, but he say me anyways. He said he would not see me because I was only 3 months post operative. He wouldn't see me until I was at least 6 months post operative. I had arthroplasty in June. I have tried other methods besides opiods. I have had PT, massage, every NSAID out there (including the wonder drug VIOXX), just about every muscle relaxer, trigger point injections, 3 arthrocentethis and finally arthroplasty. It was my oral surgeon that suggested I go to see a PM doc. I call them, tell them I have TMJ and they say "We don't treat that". I don't even get to the point of getting them to review my records. They flat out say they don't treat TMJ pain. My doc keeps promising me a tens unit but has yet to get one for me. I don't know enough about these to shop around for myself.
    Someone else told me to look for a doctor who treats facial pain not just any PM doc. I don't know anything about all of this. I know my life has been ripped away from me a year ago by a JERK DOCTOR who did this to me. I am open to any type of treatment offered to me if I could even get seen. IF they told me to stand on my head and spit wooden nickles and I would feel better I would do it! I have not poo-poo any suggestions by any doctor. I have seen a nuerologist and an ENT at the suggestion of my doctor. I have got to PT at the suggestion of my doctor. I have worn patches on my face at the suggestion of my doctor. (Even went to a X-mas party with one of these lovely things on) I tried trigger point injections at the suggestion of my doctor which was a disaster because I had a bad reaction to what ever it was they injected me with. SO don't think I have been dismissive to anyone. I have tried heat, moist heat, ice packs. I want to be cured not spend the rest of my life in pain and on meds. I am a recovering addict and have been clean and sober 15 years so this is the last route I want! I am just trying to find some relief and I don't really care what form it comes in.
    Amy

     
    Old 10-07-2004, 06:32 AM   #9
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    Re: Shoreline I need some advice

    Hey Ati, Have you ever been DX with trigenmininal neuralgia? The Trigeminal nerve is the main nerve branch thaty controls sensory and movement of the face, What I'm thinking is that if you aproached it as trigeminal neuralgia secondary to 3 TMJ surgeries, You may find the help you need. Do you have pain/ numbness on that side of your face to the tip of your nose and point of your chin.

    It's very possible some nerve damage was done during any of the 3 surgerries. If you aproached it as nerve damage to your face secondary to surgery you may have better results. pain really is pain, I guess I'm used to seeing all types of pain being treated in the clinic I go to, some do well with opiates, some do well with botox, some do well with nerve blocks or steroid injections. Have you had a CT or MRI of your Head to look for damage to the nerves? With documented problems it really may be your best aproach.

    I know it's frustrated only being offered the same modalities you have already tried, But a new doc may want o see for himself that a method that normally works on others with the same condition doesn't help you, If it means jumping through the same hoop, as we have all done with different PM docs as we try modality after modality, your wllingness to try anything shows the true nature of your needs.

    There is a back door way to find a PM doc but you would still need a referral.

    If you contact medtronics, the maker of the pump and SCS and all kinds of hardware used in surgery, They will give you a list of docs that are certified to do these device implants. I understand your not ready to jump to a pump if you haven't tried LA opiates but a doc that does pump work likely is part of practice that does believe in opiates.

    Once you have a list from medtronics narrow it down and although these docs can do pumps and manage them, most likely they would have to show that other methods to manage your pain havn't worked before insurance would agree to pay for a 30k pump plus the surgeons fee , anesthesia, hosptal stay etc. And one of those methods is failure to respond to oral opiates

    It must be frustrating to read these forums and it can give the impression that these meds are easy to obtain or a doc is easy to find. But these are folks that have seen a dozen docs too, been called an addict simply for asking for pan meds , been told learn to live with it or it's all in your head. "no pun intended"
    But Very few of us went straight from go without having to move all the way around the monopoly board. Some may move faster than others but very few go straight to I'm still in pain to LA meds after a surgery fails.

    You could have things working against you that your not even aware of. If your present doc or dentist, doesn't believe in the use of opiates as a way to manage pain that doesn't repond to other modalities, he's not going to refer you to a doc he knows has very different beliefs from his own. So he's not ging to lead you to a doc that uses opiates to treat pain.

    If your simply getting names of docs that believe in antidepressants, antiseizure meds for nerve pain and doing nerve blocks, the fact they can't block that nerve without temporarilly paralyzing your face untll the block wears off they wouldn't consider you as a candidate for the treatment they offer. That's wear the problems lies, Dealning with a doc or a group of docs that believ everyone benefits from the modalities they offer and there isn't a patient out there that needs opiates to survive or function. I've met a dozen so I know there out there. But once I found treatment from a doc that did use Opiates it was like someone teaching me the secret handshake and I have list of docs 4 deep should something ever happen to my present group.

    Sometimes you have to ge outside of the loop of docs your presently in to get a fresh perspective, your age will work against you just as a guy with a pony tail and a harley would work against him. It's not fairr and extremely judgmental but The harley guy is presumed to be a drugy biker. My brother with 2 PhD's has a pony tail almost down to his belt line? Hardly a biker, more so the guy we joked for the horn rim glasses in high school. But people tend to cmake those asumptions.

    The idea of starting someone young on a lfetime of opiates is also hard for docs to except. But there are kids that find treatment for cycle cell, which is extremely painful. So don't give up, Skips in williamsburg and has a great doc. I'mm at the beach and have several docs in tidawater that I could turn too, once I got away from he surgeons that insisted his fusion was a success, even after his hardware snapped. He was such an [email protected]@ he wouldnever have referred me to a PM doc he new used oaiates. There is a huge trade involved but in pain are judgement is a little skewed and like you=said, you get to the point where you would do anything, like go to the ER for the hope of a few hours of relief.

    I basically had to get outsode my circle of docs to find treatment because of their beliefs in the use of pain meds.

    I think your best bet is to contact medtronics and the will give you a list of PM docs in your area or if you expand your search down to the beach or up to washington, having to travel a couple hours each month or more frequently in the beginning is better than going bonkers from he pain. Look for anstheslogist or neruologist that practice PM and manage pumps, they would most likely work with any type of nuralgia. You also have to stand up to nurses that are blocking you frtom allowing the doc to make the decion and somtimes you have to stand up to docs and surgeons that have put you in this position and now hung you out to dry.

    With my docs, when I was on orals, I was stable for years and at that point I only needed to be seen every 3 months to pick up 3 months worth of meds at a time. You can't fill 3 months worth of class 2's but a doc can wrtite for the next 3 consecutive months and place fill on or after dates on the scrpts. This way he's not post dating them which is not legal, but simply controlling the refll date with a fill ion or after date wqritten on each script. So travel may be unapealing in the beginning but down the road it's very possible they can find something that works that you can stabalize on and reduce your trips to 4-5 a year.

    Anyway, Good luck and the same group of docs treating me know had always been in my area , farther back then wnhen my Cp exprerience and first surgery even began. But they didn't want to refer a 27 year old "11 years ago" to a doc they knew would likely use opiates if other methods didn't work.

    Take care, Dave

     
    Old 10-07-2004, 07:13 AM   #10
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    Re: Shoreline I need some advice

    Thank you Shoreline,

    Prior to my arthroplasty I was evaluated by a neurologist for TGN, after squeezing her fingers and doing some otherwise silly motions for her, she said I do not have TGN. I have read about Atypical TGN which presents alot like TMJ, constant dull aching pain. Since my surgery I have had some numbness is the surgical area that sensation is slowly returning to. I have also had some numbness and burning of the lips and tongue, but it comes and goes. I mentioned this to my Oral SUrgeon, who said, "What is that all about?" My response to him was "How the hell do I know, you are the doctor". He and I have reached the end and I am seeing a new doctor next week, someone who is a world renowned TMJ specialist at MCV. I have had one MRI, prior to arthroplasty which was "NORMAL". But upon opening me up the doc found bone spurs and bone that did not look right and recontoured my jaw line and sutured my disc into place. I have a new and wonderful grinding noise in the joint with a fun pinching sensation too. I suggested to my Oral surgeon another MRI or a tomogram, to which he replied, those are just X-rays! Well how else are they gonna know what is going on in there? We moved here 2 years ago from the Boston area and I wish to hell I was there now. Boston has a great huge medical community second to almost none, while Richmond seems tiny compared to. I did call an osteopathic doctor who is also PM doc over in Williamsburg and got the same response, "I don't think he treats that" You don't think he does?? Can't you find out - I am thinking. An oral surgeon who pulled my wisdom teeth a year ago is the one who did this to me. I was a healthy happy person a year ago, so I am not too keen on doctors right about now. I don't want a life of pain and opiods, your right I am too young (40). I was working towards my PHD at VCU and had to drop out. I have never had any serious medical problems and am trying to figure out how these docs work. I am a timid wimp and seem to be unable to get my point across to my current Oral surgeon about my concerns or he just is afraid his surgery failed and doesn't want to know. He is well aware of the fact that I have filed a complaint with the Virginia Dept of Health Professionals against the wisdom tooth doc and is probably afraid I will complain about him too. The pump thing scares me. But my stomach has had it and I am afraid of what all the oral meds are doing to it and my liver. The only treatment I have refused so far is Botox. The thought of someone injecting me with botulism scares the hell out of me. I would like to try a LA drug but my doc is reluctant to give me anything other than vicodin. (I did get percocet after surgery). I will give your suggestion a try. Like I said, I will try anything (except Botox).
    Amy

     
    Old 10-07-2004, 09:08 AM   #11
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    Re: Shoreline I need some advice

    Hey Ati, It's Bizare you mentioned numbness inside your mouth and toungue, My wife was in a car accidentmid august, She's aready seing my PM doc for Charcot marrie toth, a degenerative nerve,muscle and tendon disease in the xtremities. She has periheral neuralgia and has had over 40 factures and breaks in her feet and both entirely reconstructed.

    But the bizzare numbeness from the accident was traced back to her neck. They did Xrays, mri and CT and aside from a couple bulging discs that were impinging the thecal sac , the natural lordotic curve of her neck has reversed into kyphosis from the muscle spasm of whiplash and osteo perosis has weakened the bones and stress fractues of the spine a pretty common occurance these last few years. Just to complete the story of the accident she broke her foot and ankle in 5 places when she stomped on the brakes.So she's been a hurting pup.

    When we went to the Neurosurgeon follow up to read the films, which are a little more than Xrays,LOL Funny the things docs say" He major complaints or most concerning were the facial and mouth numness whcich was something entirely new. She said her mouth and toungue are so numb she feels she can go have aroot canal without any ocal anesthetic. Anyway, he recomended PT and to flollow up with her/our PM doc.

    He did give her Bextra which has actually given her some relief, It did take 2 weeks and a letter from her GI doc explaining her hiatal hernia and the need to use this NSAID aside from all the others. Less stomach irritation. The insurance comapany actually recomaned motrin or Viox, this was about a week before the Viox recall. More great medical advice.LOL

    SO we took the films to our PM doc, the Anesthesologist/do that does the majority of the pump and needle work recomended an ESI at; I believe
    C-5. I'll have to confirm the location of the ESI when she gets home, she's in court today and can't be reached but I will let you know what level. It was where one of the discs is impinging the thecal sac. After the the ESI and using bextra for 3 weeks 80% of the bizzare mouth numbness has subsided.

    I'm not big on ESI's but my docs don't use depomedrol due to the preservative "polyethelene glycol/ anti freeze" and the damage it can do to the arachnoid layer of the cord and demylanization of the suroundings nerve tissue.

    Have you ever seen a dermatome map, It's a map of the spine and shows where the nerves come from and the areas that each nerve can cause symptoms, apearently C-5 maybe C-4, have to ask her, does cover areas of the face. It's very poosible to have nerve impingements in the spinal area and have no symptoms in your neck but be very symptomatic in the areas the nerve cover.
    ie, Leg pain from a compressed lumbar nerve with no back pain. It's not that unusual. But if nobody is considering your neck that's another posibility. They have suggested botox but haven't been able to get insurance to aprove it.

    You don't happen to have Keiser permannt do you, I've heard horror stories of the insurance practices and lack of referring to specialists/ limited list of preferred specialists and minimal use of expensive diagnostics. That's a whole nother subject though.

    I know with all that's going on starting over sounds rediculous but there is so much truth to being stuck in a circle of docs that all refer to each other because they know of their techniques, practices and thoughts on specific modalities. My present group of docs has always been in my own back yard all the while I was being pushed from one voodoo PM doc to the next. But if your docs don't want to send you to a doc they know use opiates it's very tough to get in and could be the cause of not being able to find one in your bck yard.

    If acupuncture didn't work on you, the pain was in your head. If trigger points didn't work, the pain was in your head. The excuse as to why the one or two modalities each PM doc believed would manage anyones pain didn't work was always somehow the patients fault, non compliance, addiction, menatl llness, depression and the always poular "it's all in your head because the problem had already been surgically corected." As if all surgerries are 100% succesful and when it goes wrong it's never the surgeons fault.

    I never tried to assign blame for something not working, I just wanted the docs to acknowledge the posibility and keep digging which was extremely tough,. It took 2 IME "Independent medical evals." I don't blame the docs, But know the odds say no surgical procedure has a 100% success rate, But surgeons don't like to have surgeries be unseccesful, so all mine were deemed a succes right up untill the hardware broke each time.

    BY the way, an IME isn't independent if it's your surgeons buddy, I traveled to Duke for one and MCV for another. Simply to get away from the local loop that wouldn't ever insuate their buddy might be wrong or tha surgery might have failed. It was pretty amazing what the docs that did the IME found and how they went through every diagnostic and were able to tell me what the problem was. Coming home with MRI's with problems circled in red pencil and a complete report from the head of Dukes NeurSrgery departmant was hard forthe local loop to dispute.

    I still left the old group of docs that wouldn't listen, was hooked up with another circle of docs but this time my symptoms and complaints were acknowledged and validated and at least some effort to treat me was made.

    I can't blame a suegeon for a fusion not growing or titanium snapping, but to have it utterly dismissed can leave you feeling like you must be nuts if they keep telling me all was fine. It really took something grossly abnormal for anyone to take it serriously, so I walked around and crunched and squeeked untill the hardware snapped and something had to be done.

    all the non opiate PM methods were tried and failed untill surgery was deemed neccesarry. I've had the same comments about treating pain with opiates as everyone else, The same it's all in your head, their addicting, your addicted, learn to live with it, read this book etc etc etc.


    Untill getting away from the original circle of docs, getting IME's and actually having snapped hardware did they actually take me serrously. Sorrry to ramble on about me. But I've been disabled since the last surgery/fusion failed and now this set of hardware has snapped. So I know how totally devestating pain can be and how it can destroy all hopes and dreams. What I'm trying to get across is you don't have to accept one docs or 10 docs opinion when you know there is something wrong.

    continued on next page, too many characters..
    I am long winded LOL

     
    Old 10-07-2004, 09:17 AM   #12
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    Re: Shoreline I need some advice

    The idea of using medtronics to find an agressive PM doc is not to go there with the idea of needing a pump, but to simply find a doc that believes in relieving pain with whatever means neccesarry. Most don't start with opiates but work through modalities untill it becomes clear it's your only option.

    When I called medtronics I was given a name and surprise surprise the anesthesiologist in my group was listed, so I know this way works. It's simply a way to get the names of docs that are truly their to relive pain and increase function. You can use that list of names to find a group of docs that's outside your present one, call the office office number, find the name of the clinic or center and then have your GP or oral urgeon referr you to that group or clinic.

    The pump may not even work for severe machanical disfucntion. When My hardware shifts, the pump doesn't touch that pain, but in general it's much more effectve than oral meds, doesn't run through your body systemcically and stays in the spinal fluid that bathes the dorsal horn and your brain; binding to all those receptors. My heads clearer and side effects are miniaml.

    By the way, It;s not opiates that will damge your stomache, kidneys or liver. It's the apap in them and the NSAIFDS they use in conjuction with other modailities.

    A friend from another cyber plavce lost 1/3 of his stomach trying to manage his pain with OTC NSAIDS and a couple years later thanother thrid before someone realized this guys pain needs to be controlled or he's going to die from the OTC meds opiate phobic docs are using and suggesting. Pure opiates have no ceiling as long as they are improving function and you tolerate the side effects, other than Demerol which can cause seizures froma specific metabolite. Pure opates cause no internal organ damage and the CNS depresion or cognative impairment is absolutely minimal once you become acomadated to the meds. After continued use your simply left with the anelgesia and constipation, which can be managed.

    So if someone planted a seed that opiates will damage your kidneys orliver that's another great untruth docs use when they are not comfortable with prescribing meds because the DEA does track the use of potent C-2's. But if a doc documents everything and documents all the other methods of trying to manage their pain and their lack of success, aA PM doc doesn't have to worry about being audidted. VA has a psoition statement on the use of opiates to trreat pain. I'll find it post it. We reallyy aren't backwards, you have just met PM doc that aren't able to treat the more severe cases and aren't comfortable with their own charting as a way to justify the use of long term use of meds. You really could complete your PhD program while on LA opiates once you become acomadated to the side effects. The proof of acomadateion is : when was the last time you felt any sort of buzz from a vicodin? The same thing happens with LA morphine . OxyContin, Duragesic and intrathecal opiates delivered through an implanted pump. When your in pain, you don't get high, you do become dependent but not addicted, and so many docs ado not distinguish between the two.

    I went to a dentist that once I told him I had a pump, His first question was, how long have you been addicted? I said I've never been addicted, they don't implant pumps to deliver addicts meds directly to the spine and your lack of knowledge scares the hell out of me and walked out.

    If the meds impair you to the pont of not being able to stay awake in school then the dose is just too hgh or you haven't accomadated to the sedative properties of opiates..

    It doesn't sound like you have been properly tested for TGN, you definitely need diagnostics of your neck and head including your face. Because you said things got worse after an extraction, If it was an upper tooth, It brings to mind the posability of having an open area from your mouth through the sinus cavity. Do you have crackling in your cheek where are mihgght be infiltrating into your face from the sinuses. Upper tooth roots do go into the sinuses and I've experienced the same thing where a hole was created from an extraction and my face balooned after I sneezed and blew air into my face, sounds weird but anything is possible. Smoldering infections, complicatins from surgery, nerve damage from surgery or TGN are all possibilities that there are treatment options for. If you find a doc or group of docs that are capable of treating all pain syndromes. The procedure rooms at my PM groups is nicer than any OR I have ever seen and just as well equiped.


    The folks that find relief, are not just lucky, but determined not to let an injury, illness or condition totally destroy their lives. When I say I saw 12 PM docs that wouln't prescribe opiates on a cancer ward because they thought their non opiate methods would work on any pain, I probably underestimated how many I have actually seen. Throw in another dozen surgical consults and two IME's and I know exactly what the surgical and PM mill is like. been there, took the tour, tried every method offered and didn't even get a Tshirt.

    You just have to stick to it, get out of the present loop, Demand proper testing be done like fresh CT/MRI's and be prepaired with a list of everything you have had done and tried and the results. The who, where and when and contact info. You go in with nothing to hide, everything verifiable and a doc can safely treat you with all that info about previous attempts to manage your pain.
    Hang in there, Dave

     
    Old 10-07-2004, 09:40 AM   #13
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    Re: Shoreline I need some advice

    This is Virginia guidlines and position statement on the use of opiates.
    The shame is I doubt anyone other than a PM doc that already believes in the use of opiates has read it.
    Virginia

    ------------------------



    Virginia Board of Medicine
    Source: Provided by the Virginia Board of Medicine








    Guidelines for the Use of Opioids in the Management of Chronic, Noncancer Pain


    All practitioners with the authority to prescribe controlled substances Schedule II-V must have a clear understanding of their obligations and responsibilities when using these agents. As the medical community promotes the new advances in the management of the patient with chronic pain, all practitioners must understand not only that the use of opioids is an important part of the armamentarium for managing the chronic pain patient, but also that opioids must be prescribed, dispensed and administered in good faith for accepted medicinal or therapeutic purposes.

    In 1997, the Medical Society of Virginia, at the request of the Joint Subcomittee of the General Assembly, appointed a special committee, which included Board members and staff, to develop guidelines to meet the needs of physicians in the Commonwealth regarding the prescribing of opioids for chronic, noncancer pain management. These guidelines were passed by the House of Delegates of the Medical Society during an annual meeting in November 1997.

    The Executive Committee of the Virginia Board of Medicine endorsed these guidelines on December 5, 1997, and the Board confirmed this endorsement on February 5, 1998. The Board welcomes these guidelines and, although they do not carry the weight of law or regulation, believes these guidelines will be of help to those who treat pain patients as to the proper use of opioids and the documentation required.




    Guidelines for the Use of Opioids in the Management of Chronic, Noncancer Pain

    For the purposes of this document the following terms shall have the following definitions:

    Addiction is a disease process involving the use of opioid(s) wherein there is a loss of control, compulsive use, and continued use despite adverse social, physical, psychological, occupational, or economic consequences.

    Substance abuse is use of any substance(s) for nontherapeutic purposes; or use of medication for purposes other than those for which it is prescribed.

    Physical dependence is a physiologic state of adaptation to a specific opioid(s) characterized by the emergence of a withdrawal syndrome during abstinence, which may be relieved in total or in part by re-administration of the substance. Physical dependence is a predictable sequelae of regular, legitimate opioid or benzodiazepine use, and does not equate with addiction.

    Tolerance is a state resulting from regular use of opioid(s) in which an increased dose of the substance is needed to produce the desired effect. Tolerance may be a predictable sequelae of opiate use and does not imply addiction.

    Withdrawal syndrome is a specific constellation of signs and symptoms due to the abrupt cessation of, or reduction in, a regularly administered dose of opioid(s). Opioid withdrawal is characterized by three or more of the following symptoms that develop within hours to several days after abrupt cessation of the substance: (a) dysphoric mood, (b) nausea and vomiting, (c) muscle aches and abdominal cramps, (d) lacrimation or rhinorrhea, (e) pupillary dilation, piloerection, or sweating, (f) diarrhea, (g) yawning, (h) fever, (i) insomnia.

    Acute pain is the normal, predicted physiological response to an adverse (noxious) chemical, thermal, or mechanical stimulus. Acute pain is generally time limited and is historically responsive to opioid therapy, among other therapies.

    Chronic pain is persistent or episodic pain of a duration or intensity that adversely affects the function or well-being of the patient, attributable to any nonmalignant etiology.

    Co-Assessment, Documentation and Treatment

    A. History and Physical Examination

    The physician must conduct a complete history and physical exam of the patient prior to the initiation of opioids. At a minimum the medical record must contain documentation of the following history from the chronic pain patient:

    Current and past medical, surgical, and pain history including any past interventions and treatments for the particular pain condition being treated.
    Psychiatric history and current treatment.
    History of substance abuse and treatment.
    Pertinent physical examination and appropriate diagnostic testing.
    Documentation of current and prior medication management for the pain condition, including types of pain medications, frequency with which medications are/were taken, history of prescribers (if possible), reactions to medications, and reasons for failure of medications.
    Social/work history.
    B. Assessment

    A justification for initiation and maintenance of opioid therapy must include at a minimum the following initial workup of the patient:

    The working diagnosis (or diagnoses) and diagnostic techniques. The original differential diagnosis may be modified to one or more diagnoses.
    Medical indications for the treatment of the patient with opioid therapy. These should include, for example, previously tried (but unsuccessful) modalities/medication regimens, diverse reactions to prior treatments, and other rationale for the approach to be utilized.
    Updates on the patient's status including physical examination data must be periodically reviewed, revised, and entered in the patient's record.
    C. Treatment Plan and Objectives

    The physician must keep detailed records on all patients, which at a minimum include:

    A documented treatment plan.
    Types of medication(s) prescribed, reason(s) for selection, dose, schedule administered and quantity.
    Measurable objectives such as:
    Social functioning and changes therin due to opioid therapy.
    Activities of daily living and changes therin due to opioid therapy.
    Adequacy of pain control using standard pain rating scale(s) or at least statements of the patient's satisfaction with the degree of pain control.
    D. Informed Consent and Written Agreement for Opioid Treatment

    Written documentation of both physician and patient responsibilities must include:

    Risks and complications associated with treatment using opioids.
    Use of a single prescriber for all pain related medications.
    Use of a single pharmacy, if possible.
    Monitoring compliance of treatment;
    Urine/serum medication levels screening (including checks for nonprescribed medications/substances) when requested.
    Number and frequency of all prescription refills.
    Reason(s) for which opioid therapy may be discontinued (e.g. violation of written agreement item(s)).
    E. Periodic Review

    Intermittent review and comparison of previous documentation with the current medical records are necessary to determine if continued opioid treatment is the best option for a patient. Each of the following must be documented at every office visit:

    Efficacy of Treatment
    Subjective pain rating (e.g. 0-10 verbal assessment of pain)
    Functional changes.
    Improvement in ability to perform activities of daily living (ADLs)
    Improvement in home, work, community or social life.
    Medication side effects.
    Review of the diagnosis and treatment plan.
    Assessment of compliance (e.g. counting pills, keeping record of number of medication refills, frequency of refills and disposal of unused medications/prescriptions).
    Unannounced urine/serum drug screens and indicated laboratory testing, when appropriate.
    F. Consultation

    Most chronic noncancer patients, like their cancer pain counterparts can be adequately and safely managed by most physicians without regard for specialty. However, the treating physician must be cognizant of the availability of pain management specialists to whom the complex patient may be referred. The physician must be willing to refer the patient to a physician or a center with more expertise when indicated or when difficult issues arise. Consultations must be documented. The purpose of this referral should not necessarily be to prescribe the patient opioids.

    G. Medical Records

    Accurate medical records must be kept, including, but not limited to documentation of:

    All patient office visits and other consultations obtained.
    All prescriptions written including date, type(s) of medication, and number (quantity) prescribed.
    All therapeutic and diagnostic procedures performed.
    All laboratory results.
    All written patient instructions and written agreements.
    A licensed practitioner who prescribes opioids in the Commonwealth of Virginia does not need a license from the Virginia Board of Pharmacy, but he must have a valid controlled substance registration from the Drug Enforcement Agency of the United States Department of Justice.

    Last edited by Shoreline; 10-07-2004 at 09:57 AM.

     
    Old 10-07-2004, 10:04 AM   #14
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    Re: Shoreline I need some advice

    My concern for my stomach and liver is from the APAP. I have been on vicodin ES (7.5/750) and the bottle says take 1-2 every 4-6 hours. The pharmacist was the one who was alarmed with this and said that much can cause liver damage. I switched to vicoprofen for one week but that was even worse on my stomach and I was dry heaving all week. So I am back to the vicodin, but this time doc gave me 5/500. I called him yesterday and said the 7.5/750 is barely touching my pain. He said double up on the 5/500 and call him if I need anything else. The pharmacist said 10/325 would be better for my liver and stomach and probably give my better pain relief. But of course I am too wimpy to ask for what I need. I do not get high from the vicodin, don't feel cloudy headed, in fact feel quite normal. I am scared to drive on it though even though I feel ok, what if I got in an accident and was blood tested? They would say i was impaired. That scares me. I dropped out of school because I could not concentrate with the pain I was in. I would not take medication and then drive to school. So I would sit in a 3 plus hour class in agony. If I could get a chaffeur, I would be all set! Like I said, next week I am seeing a new doc. My husband was talking about it in the ER at MCV (he is a paramedic for Richmond) and someone piped up and said he was excellent, thorough and I would not have to go through the same pain med issues I have been having. What about the duragesic patch? Do these work without the APAP side effects? This is something I would be interested in exploring. My poor tummy can't take anymore and my bowels can't either as I have a bout of diarrhea every morning. I am quite sure this new doc will order some type of new xrays whether it be an MRI or a tomogram. I will not be mad at my present doc if the surgery failed, many if not most TMJ surgeries do. He warned of this prior to surgery and I had read that on line too. I just want to know what is going on inside that joint and if it can be fixed.
    I did have neck problems many years ago from lifting weights. I chiropractor did wonders for me and I have not had any neck problems since.
    Ufortunately for us TMJ folks, once we get to this point, there is little hope for us to ever really get better. It is one of the most controversial and most misunderstood conditions in medicine today. Many a docs say it is all in our heads and a psychological issue not a medical one. I believe that is crap!
    Amy

     
    Old 10-07-2004, 11:30 AM   #15
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    Re: Shoreline I need some advice

    Hey Amy, Pain management is made for people like you. You have done the surgerires, over and over . Rolling the dice for a cure rather than having to depend on docs for ever.

    You could ppe in your concerns about the apap, which will make your tummy sick and will cause liver damage.
    Norco has the last amount of apap of all the hydro cmbo's. It also comes in 7.5/325 and 5/325, so if you afraid of having the whole rugged yanked out from under you you can certainly voice your concerns about apap. With the Vicodin ES, If you take 2 at a time your exceeding the recomaneded max dose of 100mgs per dose or 400mgs per day. When you take apap daily for chronic pain, those numbers should be cut in half to 2000mgs per day and 500mgs per dose..

    You could even print out the full prescribing instructions from Watson's web site so he wouldn't have to open his PDR. Everyone is afraid of being the problem patient that complains or asking for an increase because we are afraid the whole rug will be yanked out from underneath us and we will be left with nothing. It's totally normal, But you have to be honest with your PM doc or you will never reach a comfy level. Once you find a real PM doc that uses these types of meds, they know the never get the dose right on the first try.

    It's a ballpark guess and he relies on patient reporting and his own observations at apts to achieve a maximum beneficial dose with minimal side effects.
    It's better to get things right from the get go than it is to keep going back every month and saying you need an increase. That may look like rapid tolerance which may scare even the best doc when it's truly a problem of having not titrated the dose correctly from the get go because you were afraid to complain and willing to accept whatever you could get. You have to talk to the doc about the goals of treatment. With most LA meds you reach steady serum level in 3 days, so after weak you know and after two you don't have any doubt. Some meds take longer to get used too, some people have to titrate slower because of sensetivity. But there really is a PM doc out there that will manage your pain.

    The way I came into PM with opiates was by being in the same position your in. There was no other surgery to even try, surgeons were telling me 3 have failed what makes you think a 4th would work. I had tried all the non opiate methods and honestly given it afair she. There are some non opiate methods I still use for flair ups. So you just toss the BS and keep what works for you. If that doc didn't manage your pasin, youmay still have learned or tried something worth keeping.

    I would just bet my PM that there are a few doc in Richmond or even if you had to drive down here you can find relief amy,. It's tough. Even though there are societies that PM docs, they don't all agree with the mission state,mment and statement on the use of opiates. Some won't gve you a T-3 but give you enough Neurontin to stay sedated 24/7. Once I found the right level of opiates I was able to give up Neurontin, Remeron, sleep meds, motrin and apap. Moved the rented hospital bed out of the den and pretty much take care of the house. That;'s what a true PM doc can due, Unfortunately your running into what I call the voodoo docs, One or two tricks up there sleeve they believ weorks for everyone. If they don't you supposed to learn to live with it because they believe there way is the only way to mange pain. I believe in Karma so it will come back n all the people he made suffer.

    As far as febtany, Duragesic works for some, It does seem lke it causes more initial sedation, nausea and dizziness at the beginning. I also have a friend that was involved in the clinical trials of Duragesic for non cancer pain to get FDA aporval for non malignant pain. Only 6% of the people in the trial got 72 hours relief, That tiny fraction allows them to claim up to 72 hours of relief. UP TO being the key phrase. Most peole I have met change every 48 hours and they are expensive.


    Endo has a generic ready and distribution righs sold to another company to market the generic. They also have a Carfentanyl patch in the in clinical trials called Chronogesic. Fentanyl breaks down into carfentanyl wich is the stronger metabolite. They have a long acting version of Oxymorphone "Numorphan" ready for final aproval.

    There are a lot of new meds in the works. fentanyl is very potent and the delivery stem suited well for fairly sedentary patients. In Richmond on 95 degree days and the humidity, adhesion may be a problem . However Jansen will send you Bioclusive covers at no charge after you have called them and complained about the adhesion twice.

    There have been some studies that showed Fentanyl binds to the NMDA receptor which isn't a good thing when your serum level drops. Meds that block the NMDA receptor have shown and are believed to increase a patients tolerance to pain, decrease a patients tolerance to opiates and be more effective on neuropathic pain. There are NMDA blocking agents that can be used with it or just use 48 hour dosing to prevent a drop in serum level that may cause hyperalgesia, "increased pain".

    The only real flaw in the design is the size of the steps. Having not been exposed to high dose opiates for prolonged periods you would start at the 25ugh patch "25 micrograms delivered every hour" but the next step up is a 100% increase to the 50 ugh patch. This large steps up can be harder to accommodate too and the large steps down can be a little rough if yo have to discontinue or switch. It does bypass the stomach but nausea from opiates is caused by a reaction in the brain, not the medicine sitting in your stomach. The apap will make your stomach sick, But pure opiates only cause nausea from a chemical reaction in the brain and it's easily managed and you become used to it like most side effects. The only side effect that doesn't diminish with time is constipation, opiates slow bowel contractions and smooth muscle contraction, urinary retention is another side effect that may not improve.

    We all respond differently to meds, But it would make more sense to start with LA morphine and work your way from there if the doc you will find isn't comfy prescribing Oxycontin, due to Purdue's initiative to create a tracking system of all docs that prescribe and all patient that use it as a way to deter diversion, it's not real popular in VA with PM docs because of this system. You also have to get docs off the 12 hour dosing, It doesn't last 12 hours
    7-8 at best. TID dosing would work with OxyC if you find a doc willing to prescribe it, and there are some...

    Other than that, You have to avoid direct heat with Duragesic because it can cause rapid release, no more saunas and keep your arm out of a jacuzzi. But some folks do great on Duragesic.

    The best source of info and finding ut wat is in the works, Is to start a favorites file or database of pain management med manufactures, Bookmark their web site and keep an eye on products in development , plus the full prescribing info is available at each site for each drug. Purdue, Watson, Endo, Jansen, AAI pharma, Teva, Roxane, and a few others or the makers of some of their anti seizure meds will make it easy to find med information straight from the horses mouth.
    Good luck, Dave

     
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