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    Old 01-17-2005, 03:28 PM   #1
    blueswimmer
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    Tolerance question from chronic back pain sufferer

    Hello all,

    I've posted thsi question previously on the 'back pain' board, but didn't get as much feedback as I wanted, so I thought I'd try here. I've been through a lot of pain the past few years. I'm only 33 and feel like I've got a lifetime of back pain to deal with.

    My question is about how I can reduce the extent to which my body builds a tolerance to pain meds. I have 3 herniated disks. Thankfully, my pain is not 24/7. It usually gets worse during the day and only gets to the 'medication' point usually late in the afternoon. But by evening, sometimes it is unbearable.

    My doctor has prescribed percocet 5/325 as needed. At first, I was worried about taking narcotics, but I'm nearly past this internalized stigma. I felt guilting asking for strong pain meds, but my doctor was very supportive after he saw my MRI. When I take pain meds, I usually only take 1 percocet, sometimes with an Advil because I'd rather not have to take a second perc if an advil with the first perc will do it. But there have been times when I've needed 2 or 3 percs (total during the day, not all at once) but this is not the norm.

    So.... how fast does a person typically build up a tolerance to percocets? My doctor said that he had no problems whatsoever prescribing the meds I need but he also said that if it got to the point of taking 5 or 6 percs a day, that he said we should talk about a long-acting med like oxycontin. I'm kinda scared of getting to that point because then it becomes "every day, all the time" rather than "as needed."

    How quickly does tolerance develop at the level I'm taking them? Maybe I'm being overly concerned. I will say that taking percocet really helps the pain and let's me do "normal" things like cook, household chores, etc. Without it, I'm miserable and avoid life activities which I enjoy but are excruciatingly painful.

    -blueswimmer

     
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    Old 01-18-2005, 04:13 PM   #2
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    Re: Tolerance question from chronic back pain sufferer

    Hey Blue, Nobody can really answer that as everyone is different, Your use is minimal, as long as yu keep it that ay, tolerance will buld slowly. If yo u can work and get by on one perc a day or 3, your doing well. There just isn't a way to say how much pain someone is in by any diagnostic test and how medication it takes to help. The thing to keep in mind is that if the meds start hindering you more than helpng it's time to reevaluate things. The LA meds may be the next step or maybe things will progress to the point of needing surgery.

    Meds can mask a fixable problem to the point the problem can't be fixed so get several opinions and educate yourself as far as other methods of pain management. If the only method you ever use is opiates simply because it's a gaurenteed instant fix, it has a price. Nobody has crystal ball to see what that price may be, but your doing the right thing in taking an advil with the percs, why take 2 perks if 1 perk and one advil will help.

    There are dozens on non opiate pain rlieving modalities to look into, PT, Chiro, Acupuncture, Tens, Epidural steroids injections,Self hypnosis, bio-feedback, guided imagry, TINS, TENS, nerve blocks, trigger point injections etc etc. If a non opiate method works, this wouldn't b an issue, but folks tend to swant instant relief, I did, I still did all that stuff, but if someone would have prescribed aI certainly would have taken pain meds my frst 7 years of pain management.

    There are alllso mrore PM docs that won't prescribe opiates than will. Eventually your GP becomes uncomfortable with continued use, you will likely be cut off or referred to a surgeon or pain maagement.

    Sounds kind of quick to condem yourself or let some doc condem you to alife of pain and medication. Some docs will start you on LA opiates without having tried another method to manage your pain. Those docs put themself at risk because they may have to justify their prescribng practices, and if you have never tried anything else, It's pretty hard to justify OxyContin as your only option because you needed more and more percs.
    Good luck, Dave

     
    Old 01-18-2005, 05:29 PM   #3
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    Re: Tolerance question from chronic back pain sufferer

    Thanks Dave, I appreciate your insight. Just to add to what I wrote (I had tried to keep it short...), I have gone through multiple physical therapists (and still incorporate specific stretches and exercises into my daily routine) to help. I also tried the ESI's but they simply didn't help. My TENS unit helps a little bit, but can't always lug that thing around. But it does help on long drives.

    My family practicitoner, who sent me through the physical therapists and the ESI's finally sent me to a pain doctor (after the x-rays and MRI's), who reviewed everything, including the MRI's and is very unwilling to consider surgery because of the thoracic region because of the adjacent nerves and organs. Both of these guys were comfortable with the percocets, but I really wanted the feedback on avoiding tolerance.

    THanks again!

    -blueswimmer

     
    Old 01-18-2005, 07:03 PM   #4
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    Re: Tolerance question from chronic back pain sufferer

    sorry to hear about thoracic as i have thoracic and cervical herniations.
    i statred taking cymbalta which seems to work for both pain and associated depression. has helped me get my sleep back so far. are you in ny?


    Quote:
    Originally Posted by blueswimmer
    Thanks Dave, I appreciate your insight. Just to add to what I wrote (I had tried to keep it short...), I have gone through multiple physical therapists (and still incorporate specific stretches and exercises into my daily routine) to help. I also tried the ESI's but they simply didn't help. My TENS unit helps a little bit, but can't always lug that thing around. But it does help on long drives.

    My family practicitoner, who sent me through the physical therapists and the ESI's finally sent me to a pain doctor (after the x-rays and MRI's), who reviewed everything, including the MRI's and is very unwilling to consider surgery because of the thoracic region because of the adjacent nerves and organs. Both of these guys were comfortable with the percocets, but I really wanted the feedback on avoiding tolerance.

    THanks again!

    -blueswimmer

     
    Old 01-19-2005, 07:13 AM   #5
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    Re: Tolerance question from chronic back pain sufferer

    Hi Larry,

    Nope, I'm not in NY. I'm in central Missouri. I'll have to look into cymbalta. Thanks for mentioning it.

    -blueswimmer

     
    Old 01-19-2005, 08:11 AM   #6
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    Re: Tolerance question from chronic back pain sufferer

    Hey Blue swimmer, I know it would take an entire page or several pages to give complete histories of what you have tried and what you have done. But PT, ESI and Tens are just the start, that's what everyone does before they end up in pain management
    This is what you wrote,

    "My family practicitoner, who sent me through the physical therapists and the ESI's finally sent me to a pain doctor (after the x-rays and MRI's), who reviewed everything, including the MRI's and is very unwilling to consider surgery because of the thoracic region because of the adjacent nerves and organs."

    I understand the thoracic area creates more problems but if your basing a decision to have surgery on a GP and a PM doc you still letting non surgeons tell you that there isn't a surgery to fix you. Even when talkng to surgeons you may run across 3 that aren't comfortable working on the thoracic area and the 4th says , Good God, we better do something before you end up with permanent nerve damage or worse.

    GP's and PM are not surgeons, and shouldn't be making surgical opinions. It may be what you want to hear, but may not be the best thing for you. Just like a PM doc masking your pain ,It may be what you feel you need, but may simply allow your problem to progress to the point that no surgeon would ever touch you or untill you have so much pain the meds won't mask it. IF there is a mechanical disfunction, like stenosis, Thoracic outlet syndrome, buldging discs, There are surgeons trained not to turn every case away that they have never done that type of surgery on.

    For example, Say you need L5 fused to your sacrum, the surgeons you see will decide whether the problem is severe enough to warrent surgery, what the consequences will be if you put off or don't have surgery and then suggest the aproach that they learned while doing a spine fellowship and that's the way they continue to do fusions throughout their carrer.

    Some docs are more cutting edge as far as new aproaches, new hardware, new biochemicals. The best way to fuse L5 to S1 is likely an anteror aproach from a mechanical point of view, but if the surgeons you see have always done posterior aproaches, it sounds less invasive, there is less risk of damaging nerves and causing abdominal adhesions, but a higher success rate when aproached through the front. If the doc you happen to see doesn't do anterior fusions, they don't normally proclaim their limitations and send you to a specialist in global or anterior fusions. Same with thoracic.

    There are spine surgeons that specialize in the thoracic area, If you happen to see an OS that doesn't touch the thoracic area, but feels confident enough to do cervical and lumbar surgeries. It doesn't mean his answer is the right answer, It may be what you want to hear because surgery would be a nightnmare, It's not good timing, you don't have disability ins and all the other reasons not to have surgery, but how do you know if you would be better off having it, taking 6 months to recover and walking away from PM and meds and go on wit your life.

    It's never a good time and usally isn't pleaseant. But a fix is much better than life spent on these meds if you don't need them because you don't want to consider thoracic surgery.

    IF someone crushes 1 or several thoracic vertabrea in an MVA, the don't say sorry, we don't do thoracic fusions, you will just have to live paralyzed. They fly you off to a doc that's compepatent in the area your need. Nobody wants to have surgery, but if you understood all the ramifications of not addressing a fixable problem , and your GP and PM are not qualified to make that assesment, then your basing a decison that will effect the rest of yorur life on docs that aren't trained, have never done the surgery but somehow know you don't need surgery. Getting a doc to agree with you isn't always in your best interest.

    If you haven't talked to a surgeon at all and proceed with medication, eventually you will need LA meds, eventually your dose will increase, eventually the pain becomes imprinted into the nerves and even the best surgeon could fix the problem and you would still have pain.

    Another example. After my second fusion, I went to my GP because my back was killng me, he did Xrays, and said everything looked in tact, they sent my Xrays off to a radilogist who read them and sadid everything was in tact. After months of PT and PM techniques that didn't work I demanded a surgical oponion. The surgeon didn't even read the radiologist report, He broke out the read pen and circled 2 broken screws and a bent rod that the GP and the Radiologist missed.

    Surgeons want to come to their own oponion, someone untrained in surgery doesn't carry any weight. I have yet to to meet a surgeon that gave a radiologist more weight than it takes to through the report in the trash, because a radiologist has never opened a spine up and doesn't know what a small bulge slightly compressing a nerve will result in. You get 3 different opninions off the same diagnostics from 3 different docs.

    Personally I would take the surgeons opinon over the radiologist that never layed a finger on me and a GP who knows little about surgery other than the risks. I wouldn't take one surgeons opnion either, would get 3 or 4 and ask why their opinion differs from another.

    You can always find a doc to agree with you, That's whyuyou get multiple opinions, particularly regarding your spine. There are less invasive surgical methods than were around 10 years ago, what was the satandard then isn't now, so what if your doc is basing his opionion on what he learned in 1988 and has no idea about the new technology, new apraoches,new hardware, less invasive surgery and new bio agents used to help surgeries.

    I'm just saying get a surgical opinion because you haven't, get several so you can ask why would this be better than that. Your simply going with what works for now without the forward sight to see what may be coming down the road. Yup they make 7.5 perks and they make 10mg perks and they make 15 mg oxy tabs and 30 mg oxy tabs. AT some point, you need a surgical opinion or 3.

    Yes tolerance develops to SA meds much faster than Long acting meds, They may try Percocet 10's before you go t la meds, by then your consumption of opiates is greater than the average hip replacement, spinal fusion, TKR or any surgery where the basic post op meds the doc is used to using won't be even close to being effective.

    Read the post about the person whose doc won't do a TKR because of the 300+ mgs of OxyContin they now take for a back that's never been operated on.

    I posted several reasons why an average surgeon wouldn't do it, then saw a comercial for the latest artificial knee the other day, one of the last things they said was the patient has to be ambulatory enough to actually rehab the knee. Doing a TKR on a person that has a high toerance to opiates, that you know can't push through rehab due too other problems has poor odds of a succcesful TKR because they aren't able to do the rehab.

    IT would be like being bed ridden from back pain, taking large amounts of meds and wanting your knee replaced. It may be degenerated, arthritic, painful and part of what keeps them in bed, But where is the benefit of dong a TKR on a bed ridden person that can't do the PT to rehab the leg. You got opinions you agree with, well that will work for now, but what about down the road, Could you continue to work on a slew of LA opiates and adjunct meds to manage your pain. If it's that severe. Or would the meds themself be the disabling factor. Some people can take meds and work and some can't, some can toerate the side effects to mabnage extreme pain with opiates and some can't.

    Simply driving on opiates is just as illegal as driving while drunk. You can be charged convicted and then thrown out of PM because of this indescreton, all it takes is a rolling stop at a stop sign, and an over zealous cop that thinks your pupils are too small. There is a consequence to every decision, The consequences of opiates use are tolerance, physical dependence, constipation, the stigma attached when friends and family start thinking your an addict. etc etc etc.

    You at the beginning of the road, I'm at the end. There is alot in between but you found a doc that you agree with and managed to skip the first 7 years of PM where all the non opiate modalities are tried. PT and an Epidurals are basic stuff that everyone complaining of back pain are referrred too.

    As far as tolerance, the first sign is shorter duration of action, than lack of relief, so you increase, how much can you tolerate, how much pain can you tolerate. Your opiate use now is minimal which is great, Itleaves other modalities open to be tried and be succesful and then you DC the opiates. But if the only trick your doc has is PT, ESI's and opiates, You don't know what else is out there. IF a nerve block or some other modality would do the trick, why have to deal with the meds. If your PM doc ccan't or doesn't do nerve blocks, he can keep you coming back by saying they wouldn't help, but how do you know. Eventually you may be in enough pain to venture away from the docs that agree with how you want to be treated.

    continued

     
    Old 01-19-2005, 08:12 AM   #7
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    Re: Tolerance question from chronic back pain sufferer

    Don't get mad because we may not agree, you may not need surgery, but to be condemed to a life of pain by your GP and one PM doc is BS and I wouldn't let it happen just because he's presently willing to presecribe what you need. Would your choice not to consult with surgeons be different if nobody was prescibing anythng? Or are you simply being short sighted and hoping for the best. At least get the surgical opinion from a surgeon. That's all I'm suggesting. I'm not suggesting you give up the meds or change PM docs, Just get some surgical opinions from thoracic surgeons.

    If you had ben paralyzed you would looking from the pacific to the atlantic and checking every major spine center in the country. Why wouldn't you do the same now, because percs are an easy answer and help for now?

    Good luck and I hope you stick around to learn a little about what is available rather than simply asking a qestion nobody can answer. What's my future?
    Take care, Dave

     
    Old 01-19-2005, 09:54 PM   #8
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    Re: Tolerance question from chronic back pain sufferer

    I must say I agree with Shoreline and his response of searching for specialists in your case. My first neck surgery was in November 2000; at which time when the Neurosurgeon (best in his field, even operated on a previous President of U.S.) was reviewing the MRI, stated I had a piece of disc which had broken off and this needed to be removed "Immediately," (nevermind it took me 6 months to get my GP to approve an MRI); I questioned all these red grease penciled marks on the MRI and was told, "These marks represent area's in your neck which may become problems in the future." Oh, Ok. What did I know, right? He's the specialist. Had the surgery, came out with more pain than originally went in with. After 3 bouts of physical therapy; trigger point injections; facet injections; nerve blocks; radio frequency injections; X-Rays, and every other test under the sun, darvocet, percosets, muscle relaxers, neurotin, anti-depressents and oxycotin--I finally, had my fill. I trashed the medications, went cold turkey (dumb move on my part) and started all over again. Searching for an answer to my pain, I found an orthopediac Dr., whom after reviewing 2 X-Rays, told me I had two ruptured discs in my neck and he could help me by performing a two level fusion. After weighing the odds, I went for it. Unfortunately, all the time that passed has left me with chronic pain because of nerve, tissue and muscle damage. I believe that because other's can't see one's dissability, they tend to not believe; hence in the area of pain. When I go to my boss and tell her I have to leave because my pain level is a 7, knowing full well in a matter of minutes it can shoot straight to a 10; she just looks at me, as though I'm insane. The same is true when searching for Dr.'s. Finding one who takes time, doesn't rush you and is truly a specialist in the field. Too many times we are shoved aside, told to take this medicine, or that one; change this dose, until one day our injury which one day might have been improved, is now a chronic condition because your passed through dr.'s office's like cattle. I found, its up to no one but myself to find my answers. Since the 2nd surgery, I"ve tried everything (TENS, accupuncture, etc.) and am now looking for a good PM Dr., close to PA. If anyone has any suggestions, I'd certainly appreciate them!! I encourage you to research, search for a specialist, don't put aside the way you feel for what you feel is true pain and pain is saying that something is wrong. Let me know if I can be of help in your searching.

    Good luck,
    Candi

     
    Old 01-20-2005, 07:20 AM   #9
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    Re: Tolerance question from chronic back pain sufferer

    Dave and Candi -

    Thanks for your advice and sharing your experiences. I had an appointment with my family doctor yesterday and showed him my 'pain diary' that I've been keeping. I think that really helped. He could visually see what I've been telling him for a year and a half. My diary includes pain levels through the day, the kind of exercise/stretches I'm doing, any meds I take, notes of any additional muscle spasms, etc. I think this finally sunk in for him.

    He suggested getting a second MRI in a few weeks to see if there was something else going on, and then moving on to a second opinion from another physical medicine/pain doctor. I literally had tears in my eyes on the drive home! I was so hopeful that he is willing to help me explore other options other than just meds. Although I had hinted at a second MRI before and he had leaned away from it, I think he really sees this as a next step now.

    He's a very competent, compassionate doctor; that's one reason I've stuck with him. I think the issue that has prolonged my suffering has been that he has a different timeline for trying the alternative/next therapy than I do. He's willing to give things more (too much) time, whereas if something clearly isn't working for me, then I want to talk about the next option. Thankfully, I feel that we've moved to the next step together yesterday.

    Thanks again, Dave, for the other therapies you mentioned. I also appreciate you cautioning about "nerve imprinting" if I wait too long. I hadn't realized that could happen. I'll be lurking here and in the "back problems" forum to learn from and share with others with my plight. with hope renewed,

    -blueswimmer

     
    Old 01-27-2005, 06:39 AM   #10
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    Re: Tolerance question from chronic back pain sufferer

    blueswimmer-where in Central Mo are you, I am in Kansas City, used to live in Columbia? Newbie here with chronic back pain, have had 2 steroid injections in the last 3 weeks, suffered from severe, debilitating hip pain and numbness, bad enough to cry at work and have to leave early. MRI, Degenerative Disk Disease, L4, L5, significant, L2,L3 moderate, some bulging disks, etc.....the list goes on. Am on breakthrough oxycodone 5 mg, 2 pills, 3 x day, helps me to work, but does not get rid of pain. Manageable, Pain Doc has scheduled one more injection in 2 weeks, but I don't know how long they will last. Have Hep C, am on Pegasys/Ribavirin combo treatment, 3 months treatment now, and the side effects compound any problems I had before starting treatment. I have til Oct. to finish treatment, and my Primary Doc prescribes my pain meds, but do you have any info on long term pain relief. I don't want to become a walking pill factory, but cannot work or live my life with the severe pain. Don't want to become indigent either. Single, self supporting, no kids though, so I don't qualify for state assistance programs, make more than $750 a month. Any ideas? Thanks Diana

     
    Old 01-30-2005, 04:37 PM   #11
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    Re: Tolerance question from chronic back pain sufferer

    hey, Pumpkindundee,

    yeah, I'm in Columbia. Sorry to hear about your back situation; it sounds much worse than mine. I assume that you're on the hydro without the tylenol in it, right? I would think the tylenol would be a no-no with your Hep C diagnosis -- extra hard on your liver.

    I've been doing all sorts of stretches and start a meditation-and-pain-management class next week. I dunno how much it'll help, but I'll try it. Wish I had some suggestion for you. My pain is still pretty bad later in the day. I'll probably have a second MRI in a few weeks/months (said my Dr.), so hopefully they will be able to take a second look at surgery or something. The shots didn't help me much at all. Hang in there!

    -blueswimmer

     
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