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    Old 11-02-2004, 10:36 AM   #1
    SpinalMalady
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    Question Shorline this may seem like a STUPID Question

    I'm taking Percocet 10/325 to be taken every 6 hours for a ruptured L-5 S-1....Pain is 24/7 I'd rate it at about an 8. Currently I'm taking, the Percocet, 1/2 (5 mg) valium for spasm at bedtime and to help sleep, Elavil at bedtime to help with BT pain during sleep AND Ambien at bedtime to help sleep. I did not start sleepling through the night UNTIL the doc added the Elavil....

    Here's my question....how much can a doctor prescribe at one time.....a months supply?? OR a weeks supply??? The Elavil and the Valium and the Ambien he gave me a Month's suppy, but the Percocet he only gives me a one week supply....and I have ALWAYS had three or four more than I should have (meaning left over)...I've been trying to stretch out the pain meds when I can tolerate it...

    Is he just CYA...or is it because of the kind of medication it is that limits the amount he can dispense???...I dunno...I'm confused here....I have to go in every week and see him to get the prescription when nothing is changing. That kind of prescription can't be called in, so it's office visit..etc...Am I being taken or is he just being extra cautious that I'm not getting "hooked", or what? Any insight you might have would be helpful...I'm very confused.

    Thanks.

     
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    Old 11-02-2004, 06:48 PM   #2
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    Re: Shorline this may seem like a STUPID Question

    Hiya Bgsigns!
    Not a stupid question at all. Unless the laws are different in different states (?), here in nyc, one can get an rx for percocet for a months supply. It's been a # of years (a big yay!) since I've needed that type of quantity, but in the past I have been prescribed montly amounts (#90-120). I'm not Shoreline, perhaps he will chime in here as well, but it sounds like your doc may be being ultra cautious/watchful of possible misuse. Perhaps he's/she's had a prior experience with a previous patient that has caused him to prescribe percocet in this manner, or would he have seen any indications of drug seeking behavior from you? I am totally not thinking that, just trying to figure out where doc might coming from. Valium, can be just as addicting, so that's a little strange that he seperates the two. Also, if he is charging you (or your insurance Co.) (Oh, I hope not!) for weekly visits vs. monthly visits I'd say maybe that it is a gouging/$$$ factor, which is totally uncool, imho.
    Having said that, I realize that the laws may be different now or where you live. Have you asked him/her why he is prescribing like this. Just a thought.
    Best,
    El

     
    Old 11-02-2004, 07:09 PM   #3
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    Thumbs up Re: Shorline this may seem like a STUPID Question

    Quote:
    Originally Posted by Ellnyc
    Hiya Bgsigns!
    Not a stupid question at all. Unless the laws are different in different states (?), here in nyc, one can get an rx for percocet for a months supply. It's been a # of years (a big yay!) since I've needed that type of quantity, but in the past I have been prescribed montly amounts (#90-120). I'm not Shoreline, perhaps he will chime in here as well, but it sounds like your doc may be being ultra cautious/watchful of possible misuse. Perhaps he's/she's had a prior experience with a previous patient that has caused him to prescribe percocet in this manner, or would he have seen any indications of drug seeking behavior from you? I am totally not thinking that, just trying to figure out where doc might coming from. Valium, can be just as addicting, so that's a little strange that he seperates the two. Also, if he is charging you (or your insurance Co.) (Oh, I hope not!) for weekly visits vs. monthly visits I'd say maybe that it is a gouging/$$$ factor, which is totally uncool, imho.
    Having said that, I realize that the laws may be different now or where you live. Have you asked him/her why he is prescribing like this. Just a thought.
    Best,
    El
    Thanx El for your response. I don't know what his motivation is honestly, that is why I am asking. I am going through a VAX-D program, which is supposed to be "non invasive" and on the first visit, BAM, he put me on the meds....Well honestly, I was thankful, because I WAS is so much pain, my PCP had me on Lortab 5 and it just wasn't touching the pain I was in. The next week, he came in while I was on the Vax-D table and asked if I had enough pain meds, and I told him I was going to run out in the next two days, so he wrote a prescription for me....today, I specifically asked to see him, (and I HAD been told I'd have to pay out of pocket to see him) and the therapist, went to talk with him and came back while I was on the table (the VAX-D table) and said "the Dr. said that he will not be able to prescribe any more pain meds for you and you need to see your pcp and perhaps see a PM Specialist"....Now....the whole reason I ended up at VAX-D is because I could not get into a Pain Mgmt Specialist until 11/22 and did not want to wait that long to try to get some help....I like my primary care physician, but I think I need more help than he can offer, and unfortunatley the wait was from Oct 11 until 11/22.....so that's where I am....Thank God, I've kept a Journal every day....VAX-D therapy has it, and I've made a copy for My PCP, I see him tomorrow....so I was wondering about supply of meds, because I'm hoping he can prescribe the amount I need until I get into see the PM specialist on 11/22. Hope that helps you understand. I don't think I've exhibited any kind of drug seeking behavior to him...I've always had more left over when the week is up....so to me that tells me I'm not abusing....but you never know what a doctor is thinking....

    Anyway....thanks again for your reply...It helped.

     
    Old 11-02-2004, 10:56 PM   #4
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    Re: Shorline this may seem like a STUPID Question

    The best thing you can do is go to a PM DR., & he can safetly describ what meds that you need. He can write the scripts, or in my case, they commincated with my PCP so the pressure was off for there DEA#, & had backup if an audit happens. I am on ocxycodone (no filler, no asprin, no tylanol) yes it is out there, just the pain medication. I have seen conflict in some posts stating that it is not possiable, but if you have any questions, call a Pharm., or PM Doc. They also have benifit to be less of a toxic medication with the liver.(the come in capules & tabs) I take 20 mg. every 4 hours, so I take 4 ,5 mg. 20 a day = 600 per month. Sounds like a lot to some, I also take 30mg of MS cotin 2 times a day. But, I have been on pain medication for 38 years & have a steady record with my health care needs to document my pain & therapies. ( I was born with a strange tumors that are eating thru my bones, & ligaments & skin). Good luck to you, I have found that I have more understanding with the western states, than the east. In the east, many assume you are a drug seeker, in the west, they will do the proper testing & treat accordingly. At least this is my personal opinion. Good luck, & keep me informed, peace & pain free days sent in your direction, kirsten

     
    Old 11-03-2004, 05:30 AM   #5
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    Re: Shorline this may seem like a STUPID Question

    Kisa...Did you know that Oxy comes in 15 and 30 mg too? They're Roxicodone and that would help you with the number of pills you have to take. You should check with your pharmacy, because most don't stock them, but they can order them. In fact, my pharmacist didn't know they came in the 15 and 30 mg strengths. I had to tell him and he looked it up and then ordered them for me. Just thought you might like to know and it'll help with your pill intake. I wish they did it for Methadone. I have to take 540 10 mg tabs a month. I know they make a 40 mg diskett, but I don't like them. I tried them for awhile.

    Take care.

     
    Old 11-03-2004, 05:55 AM   #6
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    Re: Shorline this may seem like a STUPID Question

    Hey BG, Meds are devided into 5 class system, class 1 meds are seen to have no medical value and highly addictive and high risk for diversion and are illegal.

    Class 11 meds are the strongest meds, morphine, oxy, duragesic, methadone, the amphetamines used for ADD and such, these meds must be written on an actual script with each fill and no refills are allowed ,They can't be called in except during an emergency and there is a special protocol for calling in C-11 meds, Percocet is a C-11, The only state I know of that has an actual limit on a months supply of meds is NJ. There you can get 90 pills or a 1 months supply whchever is less, no more than 90 per written script.

    Everywhere else has some variations to the fed classification system and have implimented things like triplicte script pads, Ca, just passed a law that a special machine to create C-2 scripts must be used by 1/05 and the paper has a water seal and imprint from the doc, The idea was to make forging or altering scripts more difficult.

    My 3rd back surgeon told me that it was against the law to write a C-2 script for more than 40 pills but by that time I had already had many scripts for 80 and 120 pills. It was his comfort zone not to prescribe more than 40 AT one time. Calling them on a lie won't get you far unless your on the way out the door for the last time anyway.


    MY PM doc was writing for 450 10mg methadone tablets at a time less than 6 months agonn now I have a pump but still get a script for 120 30mg oxycodone tablets.

    Docs can lie, pharmacist can lie when they aren't comfortable prescribing or filling class 11 scripts. Class 11 meds must be acounted for to the exact pill at each pharmacy. Each pharmacy should have a present and ongoing count of the C-11's, Depending on the state C-11 reports are turned in weekly or monthly to your state board of pharmacy and the medical board for review.

    The other classes of meds are Class 111 which are presently the hydrocodone products like Vicodin and Norco, lortab and some of the tranquilizers. Class 1V meds are seen to have even less potential; for abuse not as tightly controlled. Class 5 scripts can be signed for at the pharmacy, may include things like Robutussin with a timy amount of codeine, most antibiotics are not contyrolled by the class system but still need a scripot, although you can purchase AntiB's ver the internet and other non scheduled drugs.

    Usually as the DEA starts to see a problem with diversion, abuse or whatever they throw it into one of the classes to be acounted for and regulated. MDMA for example was a health food supplemetn in the 70's and easrly 80's, they have since learned the dangers of Exstacy and madeit a class 1 drug and illegal. As new designer drugs pop up they must be classified based on the potential for harm, abuse and medica value.

    I couldn't tell you why your doc isn't comfortable with more than 40 percocet, But if this is a fresh injury, he's likely following the medical model of pain relief, anti inflamatories and muscle relaxers along with PT. Statistically 90 % of these folks will not need surgery andt hey will recovery from a back strain or small bulge. A bulging disc can heal itself.

    I would assume you had an MRI or CT to confirm the disc bulge but have you consulted with a surgeon or several surgeons and what are there opinions as far as the need for surgery?

    A conservative aproach to a very invasive surgery is a good thing. If you have nerve damage or the disc is pressing on the spinal cord you may have to have surgery to relieve the impingement, If this is a surgeon and things are still up in the air, He's likely going to treat you conservatively, and not through a ton of the most potent meds at you. Because, if you need surgery, the standard meds for all 3 of my back surgeries used for post op pain were percocet.

    A virgn back and a non tolerant patient will get relief post surgically from what works for most people. Which would be IV pain meds while in the hospital and oral meds like Tylox or percocet when you come home. IF you become completely tolerant to these meds while waiting for surgery, you better hope your surgeon will prescribe more potent meds and not just leave you with the same meds you became tolerant to while looking for an alternative to surgery.

    You usually start with PT, learn excercises, some comfort PT like message and heat and E-stim but when this doesn't prove to work, you can look at more alternative therapes such as acupuncture and chiropractic.

    IF you have leg pain, "radiculoppothy" then surgey will likely relieve the leg pain if you catch it before it become chronic pain and engraned into the nerve fibers and changes your brains chemical response over from acute pain response to chronic pain response.

    If your only symptom is back pain and you have no nerve component or entrapement to your pain, then surgery to fix back pain isn't usaulaly a good idea.It becaomes explaoratory and very invasive without a defined goal, like relieving a trapoped nerve by doing adiscectmy. They can do further testing and see if the pain is from the disc itself, this test is called a discogram, meylograms can be vry informative, But jumping staright to PM when nothing else will be tried will either get you more PT alternative treatments, Epidural steroid injections, trigger point injections, nerve blocks or some PM docs use opiates when they feel nothing else has worked and your not a candidate fr surgery.

    There are also PM docs that run pill mills and will medietely put you on the strongest meds and smimply treat the pain. The trade is physical dependence which makes you deoendent on the doc to write the script, makes you depenent on the pharmacy haveing and filling your meds and if you stopp abruptly after several months of continued opiate use you will experience wtithdrawal.

    Dependence doesn't automatically equate to addiction, It's the bodies physiological response to taking opiates and if you stop abruptly your experience withdrawal or abstinence syndrome. If you stop benxodiazapines like Xanax, valium , klonopin or a few of the others you also experience withdrawal, same with antidepressants, can'y stop them cold turkey either without problems. Pso physical dependence is just a consequence of usng particular meds.

    My first surgeons phylosophy and I agree is that if your sole reason for using pan meds its to manage physical pain, the likely hood of actual addiction is very low. Addciction is an asortment of dangerous and destructive behavior with no regard to others or your own health. People doc shop, forge scripts and call in there own pretending to be a doc. Thosae are signs of addiction, However simply taking meds as prescribed will not turn you into a drug seeking adduict if your only purpose is to manage pain. The dependence issue is just something you have to accept and deal with and slowly taper off the meds if you have successful surgery. But many surgeons are going to be conservative as they evaluate your diagnostic tests and symptoms and while you work on self help methods like PT and excercise and spine stabalization techniques.

    Mostr PM< docs have different ideas about when touse potent opiates orlong acting opiates they know cause dependence, some PM docs don't use pain meds at all. F any doc uses the same treatemnt on every patient something is wrong. Nerve blocks are not going to help every one with the same DX, nort are using opiates aproopriate for everyone with the same DX.

    Before telling you to find a PM doc I would let the surgeons treat you with non surgcical methods, they will watch and limit opiates, prescribe PT, do further testing if you require, But goning straight from one surgeon saying you have a impingement or bulge to pain management could be doing yourself a great diservice if you happen to find a doc loose with a script pad and not interested in your wel being and trying other methods frst. These docs will have a hard time explaining their use of meds as a last resort if no other method to manage your pain has been tried.
    Can you tell me more about how you got hurt, how long ago, what diagnostic tests have been done and what andthe surgeon thinks and how many surgeons you have seen. Nerve pain or leg pain caused by a bulgjin g disc is harder to manage than back pain from muscle strain and spasm. nerve pain usually requires more opiates and more adjunct meds to manage.

    Can you tell me more about your injury and what you have done and tried? You definitely want more than one surgical opinion and need to understand if you see 10 docs you may get 10 completely different opinions on how to surgicaly corect yur back or what other methods should be tried before going into spinal surgery.When it comes to nerves and your spine, personally I feel more comfy with a neuro syrgeon rather than an Ortho surgeon, but that's not to say there are not some top notch orthos that specailize in spine repair and treatment.
    Good luck, Dave
    By the way, you can check your state prescribing laws by cutting and pasting this into your browser.
    [url]http://www.medsch.wisc.***/painpolicy/matrix.htm[/url]

    Her is a fed link to the food and drug control act of 1970 which lays out the schedulaing and classificataion system.
    [url]http://www.usdoj.gov/dea/pubs/csa/812.htm#c[/url]

    Last edited by Shoreline; 11-03-2004 at 06:14 AM.

     
    Old 11-03-2004, 10:45 AM   #7
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    Re: Shorline this may seem like a STUPID Question

    Director, thanx for the info. I do not think my pharm is aware, when I moved into the state (AZ) about a year ago, I called 20 places before I found a pharm that carried it, & then it was only a small amount. THey have beem prepared since, & I will ask them about the roxi. . I hope for all pain free days, peace, Kisa

     
    Old 11-03-2004, 10:33 PM   #8
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    Thumbs up Re: Shorline this may seem like a STUPID Question

    Quote:
    Can you tell me more about how you got hurt, how long ago, what diagnostic tests have been done and what andthe surgeon thinks and how many surgeons you have seen. Nerve pain or leg pain caused by a bulgjin g disc is harder to manage than back pain from muscle strain and spasm. nerve pain usually requires more opiates and more adjunct meds to manage.
    I had an MRI on Oct 5th. I have a ruptured L-5 that is impinging the root of the S-1 nerve. My pain is constant, 24/7, in my right buttock, thigh, calf, and ankle area....I have NO LOW BACK PAIN AT ALL. I also have no clue as to what I did to cause this injury. I do not remember falling, tripping, twisting, lifting anything heavy or whathave you....

    Back in 1991, I was in a car wreck, and was hit by an undercover narcotics police officer....I was 4th in line at a stop light, he never even applied brakes...just hit me dead on in the rear....hit me so hard that I hit the car in front of me, who hit the car in front of him, and it ended up being a 4 car pile up. I had a concussion from hitting the drivers side windshield, and was sore the next day, and my car was a mess, but that was it....

    About two years later, I started having "back problems"...I don't even know if they were related. My back would "go out" you know "freeze up"...more muscle though....call the doc, get some muscle relaxers and 3 days later, all was good....that went on about 4 or 5 times a year for about 10 years....then it started getting worse, and I noticed this summer, that one time it "went out" but it took like a week and a half to get better which was unusual...always 3 or 4 days tops....then when I started back to teaching college I started getting cramps in my legs, buttock, and thighs, like charley horses, they became worse and worse until I almost could not walk.....I finally went to the doc and he did the MRI and here I sit with a ruptured disc at L-5 not knowing how it happened....I have had MRI's before and it's never shown up before...so it's definitley a new injury...but how or why ???? who knows what I did....

    I saw my PCP today (Which BTW...he did prescribe enough pain meds to get me thru till the appt with the PM Specialist)...because I can't see the PM Specialist until 11/22(took over a month to get in) and he suggessted I go ahead and make the appt with the NS, which is next Wed. This NS and PMD often work together on treatment programs, so I like that I guess. My goal is the less invasive the better, and the sooner I can live without the pain meds the better....This PMD is pill prescriptive cautious so I like that too...

    I'm really frustrated because this past Monday has been 10 weeks that I've been in pain 24/7, and it works on you, mentally, and physically, I'm not eating, or sleeping well, even with the sleep meds (Ambien, Elavil, and Valium) that they are giving me I still wake up at least 4 or 5 times a night with BT pain....I know it's all very relative, and my story is NOTHING compared to yours, but when you take someone fairly active and healthy, (I was walking 2 miles a day when this happened) and BAM! suddenly you can hardly move.....It's a really big blow.......

    I'm praying that there's an answer soon, between the NS, and the PMD we will get it figured out as to the best course. I'd like to try flourscopy(sp?), but I don't even know where to begin to ask about what might help. I can't imaging PT right now because I hurt so bad. I've been doing Vax-d with some results, but not much....My last treatment is next FRiday....and I'm done with that...It's helped me walk straighter, but I think that's the back brace I use....I dunno....

    Any suggestions you may have for options (other than surgery, and know that at this point I've decided if that's my ONLY option then I WILL go there!, I can't keep on like this, I just would rather not, but hey who does want to!), I'm open to any suggestions anyone may have.

    I didn't mean to write a book. I guess a lot of it is just frustration and venting from the pain, and the fact that I basically can do NOTHING....MY hubby does Everything, and I have been reduced to a veggie on the chair sitting on an ice pack...he cooks, cleans, irons, vaccuums, etc....It's demoralizign, depressing, and degrating....I've always been a STRONG woman (I'm 44) and now I almost can't dress myself...terrible....

    If nothing else thanks for listening and thanks for your response. You are very wise, and I've learned a lot from your posts! Thanks tons Dave.


    Becky

     
    Old 11-04-2004, 03:35 PM   #9
    Shoreline
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    Re: Shorline this may seem like a STUPID Question

    Hey Kissa, In the last couple months thay have made genbneric version of Roxicodone so you don't get hit so hard in the wallett. I picked up 120 30mg tabs for 89 dllars. It certainly draws less attn then having to get 720 5mg tabs.They come in 15mg and 30mg , mallinckrodt makes a version, and so does Amide pharma. Just ask your pharmacist to order it a week ahead of time. I would think your doc would apreciate the less atnn to the shere number class 11 pills.

    Becky, Surgery should be the last thing before simply masking pain with long actingpain meds.

    You can actually rupture aq disc by sneezing so how it happened although it's currious is that imprortant. I broke 2 sets of hardware without a fall or slip or ifting. My fusions failed and eventually the hardware fractured from stress.

    But you wouldn't likely start with a fusion You may even be able to get away with minimally invasive surgery, to reduce the compression and repair the disc.
    The problem with not fixing something that can is that you can imprint pain into the nerve fibers and once acute pain turns to chronic pain everything changes. A different part of the brain responds to CP vs acute pain, different neurotransmitters send the signal, INstead of neuro transmitters traveling in one direction, from injury to brain, they ravel back and forth.

    It's part of the gateway theory of pain and with chronic pain basicallythe gate the allows the signals to pass simply stays open. If your able to manage or reduce your pain to the point you don't feel you nned surgery for 2 years, BY then dsurgery may not relieve your pain.

    As far as back injuries, you history is classic, once you tweak it you will tweak it again and again and each time puts you down longer and longer. At least that was what I went through for several years before getting crushed by a pallett of 5 gal buckets of paint., since then it's been tweaked and although I awoke from the first 2 surgeries with my leg pain compltely relieved they kleft my back a mess first from an extensive laminectomy, where they clip the spinous process away to get to the nerves, bulges and disc fragments
    It left my back a mess. The second surgery was a fusion which tok 2 years for the hardware to snap to prove to the surgeon the fusion had failed and the third surgery was just a messa 3 level fusion turned into a 6 level, again I didn't fuse and I'm slolwy snapping screws or causing them to toggle in the holes.

    But there is avery real risk of doing permananet nerve damage that just can't be fixed even if the nerve is decompressed and the disc reapaired. The longer the gate stays open prior to surgery the longer it will remain after surgery.

    But when I had my surgeries there were not many docs doing minimally invasive srgery either throgh a flap or endoscopically. First surgery odds are much greater than 2nd and it just drops about 20% each time and with each level involved. Spine universe and spne world are both great sites to investigate minimally invasive disc surgery, the smaller the scar, the less muscle they cut through and with minimally invasive surgeries they don't do the laminectomies "clipping bone away to get to the problem"
    A friend of mine had excellent results with an edospcopic discectomy of L5, went howm the next day and used pain meds for about a week post op.

    But his problem weas dx quickly and hadn't gone on for a year. If the neuro you see doesn't do minimally invasive spine surgery, knowing what I know now I would be looking for an opinion from smeone that does. Those sites can also help you find a specialist in minimally invasive spine surgery.

    Nerve pain doesn't respons as well to back pain to pain meds, because regardles of wqhat you take, the nerve is still being impinged. Priotr to the first surgery the meds helped my back but my legs were lit up like a christmas tree. They didn't use antiseizure meds like neurontin and topamx or dilantin or Klonopin or Gabbapentin. THere are aat least a dozen anti seizure meds you dould try to interupt the pain signal from nerve pain, But you really don't want it engrained permantnely so that regardles of what surgery or what method you go, it won't make a huge difference.
    The next page will be from doc brookoffs article that exlains the difference between chronic and acute pain.

    You don't want to live with chronic nerve pan if it can be fixed, fixing it is the pinnacle of success, not masking it with meds untill you reach doses in the hundreds of mgs a day and 8 other adjunct meds. A year is too long to let somthing go that obviously needs to be fixed. So I would see your NS next week and if he's an old time open inciosion back surgeon, you need to get some other opinion about less invasive methods to repair the disc.
    Good luck, Dave
    Continued

     
    Old 11-04-2004, 03:49 PM   #10
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    Re: Shorline this may seem like a STUPID Question

    This came from Part one of the article and explains the physiological diference between acute and chronic pain. Cut and paste this in your browser to get the article with diagrams and pictures, It's easier to understand.
    http://www.hosppract.com/issues/2000/07/brook.htm

    Normal Pain Pathways
    Pain serves as an important alarm that warns us of threatened or ongoing tissue damage. The ability to sense pain keeps us alive and functioning. When that ability is compromised--for example, by diabetes or other causes of sensory neuropathy--the risk of severe tissue damage and debility is greatly increased.

    Tissue injuries trigger the release of chemicals that give rise to an inflammatory reaction that in turn triggers pain signals to the brain. These signals, in the form of electrical impulses, are carried by thin unmyelinated nerves called nociceptors (C-fibers) that synapse with neurons in the dorsal horn of the spinal cord. From the dorsal horn, the pain signal is transmitted via the spinothalamic tract to the cerebral cortex, where it is perceived, localized, and interpreted (Figure 1).

    This complex nociceptive system is balanced by an equally complex antinociceptive system (Figure 2). Pain signals arriving from peripheral tissues stimulate the release of endorphins in the periaqueductal gray matter of the brain and enkephalins in the nucleus raphe magnus of the brainstem. The endorphins inhibit propagation of the pain signal by binding to -opioid receptors on the presynaptic terminals of nociceptors and the postsynaptic surfaces of dorsal horn neurons. The enkephalins bind to delta-opioid receptors on inhibitory interneurons in the substantia gelatinosa of the dorsal horn, causing release of gamma-aminobutyric acid (GABA) and other chemicals that dampen pain signals in the spinal cord.

    Spinal interneurons release dynorphin, which activates kappa-opioid receptors and leads to closure of N-type calcium channels in the spinal cord cells that normally relay the pain signal to the brain. Following the release of enkephalins, spinal cord cells release other small molecules, including norepinephrine, oxytocin, and relaxin, that also inhibit pain signal transmission.
    Enkephalin is particularly notable in that it binds to delta-opioid receptors that are selectively exposed on nociceptive nerves when they are actively transmitting a pain signal. These receptors are usually localized on presynaptic vesicles containing neurotransmitters. After the neurotransmitters are released, the receptors are incorporated into the presynaptic cell membrane. Active nociceptors thus become more sensitive than inactive nociceptors to both endogenous and exogenous opiates, which may explain how certain opioid analgesics relieve ongoing pain without impairing the ability to sense the pain caused by new injuries.

    This natural pain-relieving system may be as important to normal functioning as the pain-signaling system. Because of it, minor injuries such as a cut finger or stubbed toe make us upset and dysfunctional for only a few minutes--not for days, as might be the case if the pain persisted until the injury completely healed. We are thus able to cope with life's daily pains without constantly suffering. But just as disorders of the pain-sensing system can give rise to illness and dysfunction, so can disorders of the pain-relieving system. Fibromyalgia, a condition that many clinicians consider to be factitious, may be one example of a debilitating disease caused by antinociceptive dysfunction.

    Chronic Pain Pathways
    Chronic pain is not just a prolonged version of acute pain. As pain signals are repeatedly generated, neural pathways undergo physiochemical changes that make them hypersensitive to the pain signals and resistant to antinociceptive input. In a very real sense, the signals can become embedded in the spinal cord, like a painful memory. The analogy to memory is especially fitting since the generation of hypersensitivity in the spinal cord and memory in the brain may share common chemical pathways.

    Activation of NMDA Receptors. The main neurotransmitter used by nociceptors synapsing with the dorsal horn of the spinal cord is glutamate, a versatile molecule that can bind to several different classes of receptors. Those most involved in the sensation of acute pain, AMPA (alpha-amino-3-hydroxy-5-methyl-isoxazole-4-propionic-acid) receptors, are always exposed on afferent nerve terminals. In contrast, those most involved in the sensation of chronic pain, NMDA (N-methyl-D-aspartate) receptors, are not functional unless there has been a persistent or large-scale release of glutamate. Repeated activation of AMPA receptors dislodges magnesium ions that act like stoppers in transmembrane sodium and calcium channels of the NMDA receptor complex. The conformational change in the neuronal membrane that makes these receptors susceptible to stimulation is the first step in central hypersensitization (Figure 3) and marks the transition from acute to chronic pain.

    Activation of NMDA receptors has a number of important consequences (Table 1). Because activation causes spinal neurons carrying pain to be stimulated with less peripheral input (a phenomenon known as windup), less glutamate is required to transmit the pain signal, and more antinociceptive input is required to stop it. Endorphins and other naturally occurring pain-relievers cannot keep up with the demand and essentially lose their effectiveness. So do opioid medications at the usually prescribed dosage. The clinical implications are clear but underappreciated--inadequately treated pain is a much more important cause of opioid tolerance than use of opioids themselves.

    Table 1. Results of NMDA-Receptor Activation
    Normal
    Windup
    Reduced opioid effects
    Neuropathic
    Injury discharge
    Hyperalgesia
    Allodynia
    Reduced opioid effects
    Inflammatory
    Neuronal responses
    Hyperalgesia
    Reduced opioid effects (time-dependent)

    Long-Term
    Gene induction
    Novel neurotransmission
    Cell death
    Pain memory
    Reduced opioid effects

    Activation of NMDA receptors can also cause neural cells to sprout new connective endings. This neural remodeling can add new dimensions to old sensations. The emotional component of pain may be increased, for example, if the new connections channel more of the pain signal to the reticular activating system of the brain. When that occurs, the signal's pathway into the cerebral cortex is more splayed and the pain signal more diffuse and difficult to localize.

    Neural remodeling may also precipitate the destruction and loss of cells. Some of the brain damage that occurs during strokes is believed to be caused by the torrents of glutamate released from injured presynaptic cells, which overstimulate NMDA receptors on adjacent postsynaptic cells and effectively burn them out. The same phenomenon may occur in parts of the spinal cord receiving persistent pain signals. There is also evidence that NMDA receptor activation can stimulate normal apoptotic mechanisms. Although some of the details have yet to be elucidated, the data obtained thus far suggest that chronic pain is a destructive process that requires timely treatment in order to limit the damage that it causes.

    Activation of NK-I Receptors. A further effect of NMDA-receptor activation is that it causes nociceptors to release the peptide neurotransmitter substance P, which binds to neurokinin-1 (NK-1) receptors in the spinal cord. Activation of these particular receptors amplifies the pain signal and also stimulates nerve growth and regeneration. It is thus interesting to note that the one chemical abnormality repeatedly documented in controlled studies of patients with fibromyalgia syndrome is an elevated level of substance P in the spinal fluid.

    In animal models of chronic pain, substance P binding to NK-1 receptors induces production of the c-fos oncogene protein, which in many respects can be regarded as a biochemical footprint of chronic pain. The presence of c-fos protein in spinal cord cells is a marker for central hypersensitization. At first, it is detectable in afferent spinal cord cells actively receiving pain signals. With persistence of the pain, the protein spreads to progressively higher levels of the spinal cord until it eventually reaches the thalamus, at which point the pain is virtually untreatable.

    This model explains why patients who have had uncontrolled pain for months or years often find that their pain has spread beyond the originally affected organ or dermatome. In these cases, physicians who are not familiar with the concept of neural plasticity are apt to conclude that the pain is psychogenic, because it does not conform to their preconceived map of the nervous system.

    Afferent Becomes Efferent. Although most of us were taught that neuronal cells transmit signals in only one direction, either towards (afferent) or away (efferent) from the brain, we now know that many neurons can carry signals in both directions. With the prolonged generation of pain signals, a dorsal root reflex can become established. This is a pathologic condition in which afferent cells in the dorsal horn release mediators that cause action potentials to fire antidromically (i.e., backwards down the nociceptors). When this happens, packets of chemicals located at the peripheral terminals of these cells are released. Among these chemicals are nerve growth factor and substance P, which is not only a neurotransmitter but also a potent inflammatory agent. Nerve growth factor increases the excitability of nociceptors. Pain signals from peripheral nerves are thus heightened, and the cycle of chronic pain is continued (Figure 4).

    Part 2 of article is here
    http://www.hosppract.com/issues/2000/09/brook.htm

     
    Old 11-08-2004, 05:56 PM   #11
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    Re: Shorline this may seem like a STUPID Question

    Ok here it is , YOur Doctor got caught prescribing too many at one time and the DEA came and questioned him. If they come back he is screwed. Once your Doctor is labled and over prescriber, he can get in alot of trouble. I got a 120 pills for the month.
    And get 20/mg or 10 mg. Five is a waist of time. You also mentioned 10/325 which means 10 codine and 325 tylenol. Make sure you get the Brand name,this sounds generic to me.

     
    Old 11-09-2004, 09:01 AM   #12
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    Re: Shorline this may seem like a STUPID Question

    What are you talking about Idio?
    If a doc looses his DEA licence he can't prescribe any scheduled meds,they don't limit the quantity, the revoke his DEA number.
    Endo makes the name brand 10mg Percocet that contains Oxycodone 10/325, they also make a good generic. Oxycodone is a class 11 med, Codeine and tylenol isn't even the same ballpark or the same class?

    If your getting 20mg OxyIR Idio, you obviousy live in canada, that strength isn't available in the US. But I don't know if your talking about oxycodone or codeine. Things are different down here. The DEA doesn't limit prescribing, you either can or you can't. You have a valid DEA number or your don't. A non valid DEA number won't get past the pharmacy and you need a valid DEA number on any clas 11 medication and that's what she is asking.
    Good luck, Dave

     
    Old 11-09-2004, 09:51 AM   #13
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    Re: Shorline this may seem like a STUPID Question

    bgsigns....
    What your saying sounds alot like what I had been through. I have a L5-S1 herniation, pressing out unto the S1 nerve root. I have bad Sciatic pain as well (down the back of leg into calves - lift right leg up and ouch, into the toes it goes, oh yeah and the BUTT, but odly enough no the lower back really), so it's just like you. About the number of Medication on one script. My surgeon would prescribe the same way. 40 5mg percocets per week. I would have to call the office back talk to his assistant and then they would write a refill to be picked up at the front window, kind of situation. I never had to go back for a visit weekly though. I heard that Dr's will Rx weekly to be on your safe side (less abuse issues) and their safe side. I know it gets more expensive and becomes a pain.
    Just recently my surgeon signed me over to pain managment, for Injections, etc. And my first day there before my injection my new PM dr. said not to take percocet it's too addicting taking it q 4hrs, and prescribed a time released Morphine to last for hours on end. Which makes sense and has really helped. Trust me I know that Nerve pain. Going from sit to stand is UGLY! But if you get into Pain Managment, like shorline says, it's the best thing for you in that situation. Just keep an eye out to see if they do TOTAL treatments, not just presciptions, but interventinal therapys as well (exercise, injections, nerve blocks, etc.)

    - James

     
    Old 11-09-2004, 11:55 AM   #14
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    Re: Shorline this may seem like a STUPID Question

    Hey Libra, THey must teach that 40 pill thing in the massive 1 semester 3 credit class about PM that docs go through in med school. My last 2 surgeons were the same way, 40 pills ata time. It's not even a divisable nmber with Q4 hour dosing, and that's the longest it will last.

    Even post fusion laid out and no way to drive, My wife wpuld have to drive to nthe neiboring city, pay to patrk in a monster garage and then walk across a med university.hopital. To pick up you weekly supply of percocet, the standard drug for post op pain up untill recently with stronger meds available for pain management that aren't recomended for post op pain but some surgeons still use it. It's not good for post op pain because you ccan't make imediate adjustement with it, where they can always make an increase on your next 3-4 hour dose for ost op pain. But you would think the surgeons wopuld have compassion, when they klnow they just did a major fusion, one he hadn't done that lomg in several years and save your family from the drive and the hassle jusdt to get pain meds every week. You would think if they know your goning to need a stronger med for several weeks, they would just right the darn script. But it's very standard wheever you go, whoever does the surgery etc. At least for 3 spine surgereies, a pump implant, numerous stone surgeies, wrist surgery,jaw surgery it's like this is the standard way to right a 6and 1/2 day supply of meds. LOL

    PM mmanagement is diffferent, If they use opiates, most will do a month supply unless the doc excepts adjustments and to be seen every 2 weeks. Personally I have had as many as 450 meth filled at one time prior to thepump being implanted. Developing a relationship with the pharmacist just makes a world of difference as far as knowing your meds will be there, even dojing partial fills on C-2's, as m,any times as we have all been told it's against the law, it's not, as long is it's completed in 72 hours it's legal. Most pharmacist do eekly C-2 counts and havea pretty goo idea of what they have on hand and if they know you and know your cycle, I have had a coule that were great at keeping meds on hand. I have also used a pharm,acy for a yea that was a problem every month, even when I call them a week ahead. I have a PM contract too, and using one pharmacy is part of it, but I'm not going through withdrawal because of some pharmacist that doesn't care.

    I've even had C-2's spotted untill the script was brought in. Pharmacist are humans, The power goes to some of their heads and some are just the same person at home as at work and understand and will go the extra mile. Some are opiate phobic and would never fill a script for 450 pain killers without calling th doc. Some have enough sense to realize you have been takng it for years and will need it every month. My scripts have fill on or after dates, exactly 30 days after the prior scripts, So my Pharmacist knows I can't try to get an early refill and the doc is controlling the meds to the exact day, a supply actually divisable by 30. LOL He doesn't make exceptions without seeing the patient. But it's a PM doc as opposed to a surgeon and having a good pharmacist as part of your team is a very good thing.

    Hope you don't mind me jumping in. The 40 count just made me think about how many times that number is used even when they know it's going to be a rough 3-4 weeks.

    I did want to remind folks, that back surgery isn't always the end of the world, without back pain, if there is a clear fixable problem like a bulge pressing a nerve, there are new micro surgery techniques and endoscopic techniques That required very invasive open surgery to correct up untill a few years ago, the les invasive techniques have much bettter odds and the covery is so much quicker. I have seen 2 of my friends do really well with mcicro surgery to relieve an impingement.

    As much as you may like or respect your present doc. He may not do micro surgery. That's why you have to get several opinions because there are more than one ways to skin a cat. Fixing it the first go round would certainly be better than a life of PM.
    Take care, Dave

     
    Old 11-09-2004, 02:31 PM   #15
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    Re: Shorline this may seem like a STUPID Question

    Here's a question Dave:

    My doc has my percocet 10/325 @ every 6 hrs....I'm really starting to feel the pain BIG TIME by hour 4 and by 5 I'm in tears and 6 I'm into it 15 mins early cuz I can't stand it anymore.....Have I in about 4 weeks become med tolerant to the Percocet 10/325??? I'm SEVERELY allergic to MORPHINE...can you say PROJECTILE VOMITING....??? I had to find out the hard way with an emergency hysterecyomy using a PDA pump, (where you press the button and it goes into your IV, but you can't overdose, and it goes in regardles of whether you press the button or not)...I was cut ovary to ovary....and stapled from one side of the room to the other.....It took the Anestheologist 12 hours to get into the room to disconnect the pump.....ridiculous.....something to do with making sure the meds were witnessed being thrown down the sink (plunged thru the syrynge)....and this was about one hour AFTER they had just come and replaced the darn thing...I tried to tell them...and they said it was just a little nausea.....SO I THREW UP ON THEM.....

    My point is this...if I have become tolerant to Percocet 10/325, and I CAN'T take morphine, what are my other options?.....My PM Dr. Appt. is still not until 11/22....and honestly, I don't know if I can hold on that long....

    I was released from the Vax-D today....it just was making me worse....Now I feel like my tailbone is broken....I know it's not...but it feels like it is.....When I told the Dr. at the VAX-D that I was seeing NS tomorrow...he said "good, Let him do Surgery...." OMG....I thought the point was to try to AVOID, surgery....

    I asked if that NS does the Micro Disk Surgery...he said he didn't know, but I talked to someone else today that had another local Dr. do Micro...so IF surgery is recommended, AND IF this NS doesn't do Micro, then I will go to that NS for a Consult....I'm almost to the point that the pain is soooooo terrible, I'm READY FOR SURGERY...and I thought I'd NEVER hear myself say that. Woke up at 4 am and have been up ever since....It's never ending....

    I know I beef and moan a lot, but you are so wise, I just need to know if I should try to wait out the PM Dr. on 11/22, or IF the NS were to recommend Surgery tomorrow AND he does Micro, should I go for it....?? Would you??? ANyone, your thoughts please, anyone who's been thru MICRO Disk Surgery, I'd love to hear about recovery time...etc.....

    I'm scared out of my WITS! It's like I get more Desperate as each day goes by.....PLEASE HELP ME! GIVE ME SOME IDEAS! INPUT! ANYTHING.....A HUG WOULD BE GREAT...LOL!

    Take care all,
    Becky

     
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