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    Old 04-24-2005, 05:06 PM   #1
    blueswimmer
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    Need advice w/ dosage issue and doctor

    Hey, Friends,

    I would appreciate your insight into balancing enough pain medication to address pain issues, yet not taking too much to have "mini withdrawal" symptoms on days that I have lower pain levels.

    Background: chronic back pain due to 3 disc herniations in thoracic area (yeah, really fun...); have been through 3 physical therapists, ESI's, exercises/stretches, etc. I have a neurological test next week to help a neurosurgeon decide whether surgery is the answer.

    The issue is that I have pain often enough and to the pain level extent that I take between 1 and 4 percocets (5/325) per day; usually 2 or 3. I've been at this level of percocet for several months. I also take aleve/ibuprofen and tylenol daily to supplement. The problem I'm having is that on the occasional days that I don't have high pain levels, I often get "mini withdrawal" from taking lower or no doses of percocet. The symtpoms are mostly headache and nasty nausea -- no fever, chills, sweats. When the symptoms get really bad, I sometimes have to take 1/2 or 1 percocet just to keep the symptoms at bay -- times when my pain level really isn't that bad.

    I've mentioned this to my doctor and while he has been very supportive in general, I don't think he understands how unpleasant these other symptoms are. Any suggestions? At what point do you go to a long-acting pain medication instead of the short acting stuff that brings a mini-withdrawal when the pain med starts wearing off? I mean, I realize the LA meds also will have withdrawals, but do the LA meds "balance out" in your symptom so as to make the mini withdrawals more gradual? Or, does taking a LA med simply make it worse in the long run because you're always taking something?

    -blueswimmer

     
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    Old 04-24-2005, 07:37 PM   #2
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    Re: Need advice w/ dosage issue and doctor

    BlueSwimmer,
    I think it's about time you get a REAL doctor. I'm not putting yours down so much as I'm saying he musn't know much about pain control. 1st of all your taking, at the most, 20 mg's of oxycodone a day, to combat THREE herniations. NOW...I have 2 herniations and Sciatica from them as well. My pain never quits. It can only be softened by medication. Now...If a Dr. told ME to just take 3 or 4 5mg percocets a day I'd be in ROUGH shape. I've also had the ESI's, and PT, etc. They didn't help me, and obviously there not helping you. How long have you been dealing with this pain, I'm wondering that. Because, technically, if it's 6 months or more pain everyday, then they call it chronic pain. And chronic pain NEEDS to be treated withe a LA opiate of some sort. And then save those little percocets for your BT medication. Because, from what I've read on this board and know to be true for myself...your going to have 'flare-up's' anyways, while on your LA med. So really...how long have you been having the pains?

    -James

     
    Old 04-24-2005, 07:44 PM   #3
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    Re: Need advice w/ dosage issue and doctor

    I agree with James. Your doctor (specialist??) should have you on a long-acting med like oxycontin or mscontin, avinza, etc and use the percs for breakthrough pain. I have only 1 bulging disc in the thoracic and I can tell you that I have a world of sympathy for you! Talk to your dr. about a different medication; it will also be better for your liver. You shouldn't be taking so much of the ibuprofin along with the tylenol or you'll be heading for stomach problems.

    Good luck, and let us know how you make out, will you?

    Carol
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    Old 04-24-2005, 09:47 PM   #4
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    Re: Need advice w/ dosage issue and doctor

    Thanks, James and Carol.

    In response to James' question, I've had progressively worsening back pain the past 2 to 2 1/2 years. I first saw my doctor about it about 1 1/2 years ago because it was getting so bad that I noticed it was changing my personality -- I was getting to be a grump and overall nasty person to be around. Being in so much pain can really wear on you. I'm sure you both know this.

    I think I simply need to be more assertive with my doctor (or find a new one). If there isn't major progress after my neurological test next week, I think James' suggestion of finding a new doctor is my next step. It's hard to talk to the doctor about the pain meds not working out so well without feeling guilty or feeling paranoid that he might think I'm a druggie or something.

    thanks for the advice and support. This has been so tough!

    -blueswimmer

     
    Old 04-25-2005, 09:32 AM   #5
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    Re: Need advice w/ dosage issue and doctor

    Hi Blue swimmer, What you are describing would be considered chronic pain due to the length of time. However if you have had perriods of relief and perriods where pursung further testing and a possible surgical answer to the problem hasn't been the focus of her life , a month or two before you have surgery is not the time to start long acting opiates. Unless you enjoy the mini withdrawal and want to find out what major withdrawal is.

    If they put you on some soort of LA med now, say 4-6 weeks prior to surgery, You dose and tolerance would escalate, you would be taking meds on days you admit you don't need them and your surgeon would be quick to discontinue meds after the surgery to see how well his surgery worked.

    This statement is what caught my eye.
    " technically, if it's 6 months or more pain everyday, then they call it chronic pain. And chronic pain NEEDS to be treated withe a LA opiate of some sort."

    I'm just wondering where it says that everyone that has had chronic pain for 6 months or more needs to be on LA opiates. You only need to be on LA opates if your pain is intractable, meaning there is no other way to manage it. There are dozens of non opiate methodsto manage pain. You wouldn't start a patient on OxyContin that has never tried Ultram? 6 months is not the magic number that alows docs to prescribe anything they want without fear of investigation. Particularly when very few non opiate modailities to treat pain have been tried.

    Opiates are not the ony way to manage pain, they are a last resort when everything else fails. Although it's been several years it hasn't been bad enough to push the docs into doing the proper testing or even getting a second surgical opinion.

    If LA opiates were needed for every patient that has experienced pain for 6 months or longer, Opiates would out sell BP medication, diebetic supplies, and even antibiotics. 6 months is not the magic number that allows docs to prescribe LA opiates when other methods haven't been tried yet.

    What would make more sense is to give you something milder for those days where you don't feel the need to take anything. Even taking something milder when you don't need anything sounds hard to justify, so lets call it days that aren't as bad as others. Something as simple as a couple darvacet on your good days would likely prevent feeling bad on those days.

    Rather than looking for more meds, so you have to take them even when your not in pain simply to prevent withdrawal sounds more like addiction mangement or methadone maint. Her pain is managed, it's the physical dependency that's causing the problem and I don't agree more and stronger meds are the answer

    3 herniated discs doesn't neccesarrily hurt more than 2 herniated discs, there isn't an equation docs use to prescribe for specific conditions. I would be thankful you have a doc prescribing something for your bad days. Going to a long acting med in which you will become completely dependent on, meaning skpping days will cause real nasty withdrawal is a huge trade not to be taken lihghtly. Simply because the meds are available and you fit into a catagory called chronic, it doesn't mean you need or are entitled to LA opiates.

    It means you should continue to look for answers, ruling out one thing after another, continue to look for treatment options, ruling one thing out after another. When you get to the end of the road and their is nothing left to try, if your pain is preventing you from working or enjoying life, then docs can justify the use of these meds. But simply being in pain for 6 months doesn't mean you need LA opiates. If that were true, every Knee replacement and hip replacement patient should have been on LA opiates for the years prior to the eventual surgery. You don't just wake up and need a TKR, nor do you need LA opiates when you hit the 6month mark.

    My mom just had a TKR, They did injections, PT, she lost weight,had arthroscopic surgry, she researched and talked to other patients and when the pain became to great and the diagnostics indicated the knee couldn't be treated any other way, she did start using short acting pain meds for the couple months prior to surgery. She had the TKR weeks ago, is walking fine and doesn't have to worry about being detoxed from LA opiates. She went from the standard 2 5mg percs most othor surgeons use for all surgery to regular vicodin and is doing well.

    You simply can't lump everyne into the same boat. Chronic pain is not the same for everyone. Think of a bell curve, everyone is somewhere on that curve where your level of pain is and what it requires to manage it. Hitting the 6 month mark doesn't automatically through you to he far right side where use of LA opaites can be justfied or you need a morphine pump when other methods haven't been tried.

    This type of demand for meds will get you treated like a drug seeker. Why go to something stronger and longer lasting when you don't need it? You said your doing fine with 3-4 percocet a day, Why increase your dose to the point you have to take pain meds when you don't have pain simply to avoid withdrawal.
    Sorry James, I don't agree with you on that one,, but it's OK. We don't have have to agree on everything. Somthing milder on the good days will likely prevent you from experiencing withdrawal. Something stronger every day isn't even what your asking for or need at this time. If the problem has gotten worse, then start pushing for more diagnostics and other opinions, not stronger meds so you go into surgery taking 3-4 times the dose of meds that works for 95% of othopedic surgery patients.

    Even the last fusion I had, 6 levels with 8 rods, and 12 screws I got the same exact meds I got for my frst laminectomy/discectomy and my first 3 level fusion. 2 percs every 4 hours.

    This is what surgeons are used to prescribing for pain, They aren't going to suddenly be comfortable prescribing a dose 5 times stronger than they ever have in the past for post op pain simply because some PM doc drove their tolerance through the roof trying to mask a problem that needs to be fixed.

    PM docs shouldn't be giving surgical opinions. You should arive at a PM doc after you have gotten 4 or 5 surgical opinions and the posibility of surgery corecting the problem has been ruled out. PM docs shouldn't start with LA opiates, they need to document every other effort they have made to manage pain before they can justify that LA opiates are your only option and your pain is truly intractable.

    Slow down on the LA opiate advice when folks haven't even had the diagnostics to determine if sugery is necesarry or would be helpful. Yes opiates work, but they come at a price and aren't prescribed in doses to remove all your pain. You do have to learn some coping skills or have other modalities to fall back on in order to deal with pain that they arent going to try to totally eliminate with opiates.

    Most PM docs shoot for around 50% pain relief, It didn't sound like Blue wasn't getting 50% relief, it sounds like she's growing more and more dependent on opiates and It's time to either fix it, get more opinions or start down the PM road where you learn to live with what you can and try every other method you can before any doc decides opiates are the only option.

    They may appear to be the fastest and most certain method but there are negatve aspects about pain managemnt and opiates. Particlularly when your friends start stealing them to get high which means you get to experience withdrawal so they could catch a buzz.

    Other docs and family mebers do label people addicts simply because you take these meds. There is a lot of heart ache involved in pain management and consequences to everything that need to be weighed.

    I just don't think every patient that has arthritis or DDD or any chronic pain generator that has lasted more than 6 months needs to be on long acting opiates, They aren't the front line pain management treatment recomended by any medical pain society. People did somehow manage prior to '96 when OxyContin hit the market. Two 5mg percocet actually worked for most people after a hip or Knee replacement or a 6 level fusion.

    Yes, they should be available when nothing else works, but not passed out like a diploma after 6 months of pain and a few months in PT. I understand Blue has had this problem for several years but she has managed to function and hasn't been driven to surgery or doctor after doctor and procedure after procedure by pain. She's simply showing the first signs of physical dependence which is inevatable once on LA opiates.
    JMO
    Take care, Dave

     
    Old 04-25-2005, 10:16 AM   #6
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    Re: Need advice w/ dosage issue and doctor

    Dave,

    Just wanted to commend you on your logical and educated responses to this thread and many others. I have recently started perusing this board and am hoping to offer any insight that I might have. I began working in the pain management field almost 10 years ago and enjoy seeing people obtain relief from and learn to cope with/live with chronic pain conditions when necessary. The job of educating health care providers and patients is never ending.

    The stigma and erroneous perceptions are many.

     
    Old 04-25-2005, 04:36 PM   #7
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    Re: Need advice w/ dosage issue and doctor

    Dave,
    I love how you go on this long winded post and then wrap it up with an ABREVIATED 'JMO'. It's poetic! Dave, once AGAIN...your reading to deep into my post. I don't know where you get this arrogance to just go off and absorb 100 or so words and rebut with 2000+ words to attack my post. When you should of just gave Blue your opinion on her question, not using her question posting area to rebuttle what I had told her. Chill out for once. Maybe Blue is tired of huring, maybe Blue doesn't WANT or NEED more PT. I believe in ending suffering. Here you are...you've taken every damn opiate in the book, you've had every metal substance known to man put in your body, you've done every kind of PT exluding the 'tour de france'. You've done it all. Congratulations! NOW...put all that behind you and realize there are other people involved in this world that have gone through LESS, but maybe they have MORE heart to offer. Saying to Blue 'try a LA opiate' was my compassion coming through. What she does with it is her deal. I'm not trying to BE her dr. - It sounds to me, the way you post, your trying to BE peoples dr's. People here even say, Oh Dave...he knows just as much if not MORE than most dr's. Mmmmm, so you can read a book or look things up on the internet, doesn't make you a Dr.
    Whatever it's irrelevent. I'm over your heartless analytical (JMO) posts. Tis why this is my Last on here.

     
    Old 04-25-2005, 04:58 PM   #8
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    Re: Need advice w/ dosage issue and doctor

    I've been on and off of pain meds for nearly 3 years now and let me just say, I experienced a very rough time when I stopped using the Duragesic patches I was given after only 2 weeks use. This may be an exception to the norm but when I was given the Duragesics, they only gave me 2 weeks worth to see how I'd do. Well, I had either a reaction to the adhesive or to the meds because I kept breaking out at the spot where the patch was applied, no matter where it was placed. Even though they made me itch, and my skin would break out in a red rash, I had nothing else around for pain relief so I continued to use them for the duration. I ran out on a Monday and didn't have a PM appointment until that Thursday. From Monday to Thursday, I was so stinkin' sick I wanted to die! Maybe I am mistaken on what had me so sick but I was convinced that my body became physically addicted to the Duragesic just that fast. I normally have zero problem just putting down meds, too. I have stopped Percocet, Oxycontin and Lorcet cold turkey.

     
    Old 04-25-2005, 05:03 PM   #9
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    Re: Need advice w/ dosage issue and doctor

    Ok - hey guys -

    I appreciate all of your support. I found help in what both of you offered. Yeah, I thought that there was a long-winded answer to my note (and some of it was not quite fitting my situation), but I figure that I can take it or leave it. And I so much appreciate the compassionate help from James and Carol. James, please don't give up on helping others with your compassion -- let me tell you I cried when I read it and even read it out loud to my partner because it really struck home. Even my partner appreciated your comments because he can relate -- we both are suffering with my pain.

    Anyway.... I think the differences of opinion that you both have is frankly, a really good visible symbol of the internal struggle I have with this darn back pain. My docs have told me that I'm too young and that it "isn't quite bad enough" for surgery because it's in the very risky thoracic area (and it's 3 discs, not just 1)....but it hurts so freaking bad most of the time!

    Maybe the funniest thing here is that somehow along the way, Dave or James referred to me as a "she/her" -- I'm actually a guy! Maybe I mentioned my "husband" or something in one of my posts. I'm gay and when I feel close to others I sometimes just refer to him as "my hubby" -- let that at least be a tribute to how "close" you all are to me on this discussion board. I've found great strength and calm from all of you.

    -blueswimmer

     
    Old 04-25-2005, 05:29 PM   #10
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    Re: Need advice w/ dosage issue and doctor

    Blue LOL - I refered to you as a 'she' because that's what Dave had said. Hey, I'm gay as well, so no hard feelings there! (sister, lmao). Let me tell you....if it wasn't for my Boyfriend (husband really) of 9 years - and I'm only 26 - I would be up *****'s creek, he's a TREMENDOUS support mentally, physicaly and finacially. Thus the 'board' was my liittle private place to ask questions and give compassion. I don't want to give that up, but at the same time, I dont' want this place to become something that would annoy me, it's just not right. Blue, MWAH xo - be strong no matter what you decide.

    - xo JAmes

     
    Old 04-25-2005, 07:44 PM   #11
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    Re: Need advice w/ dosage issue and doctor

    I have noticed a subtle change in some of Dave's posts and I cannot put my finger on quite why that would be. First of all, sometimes the sheer length of the posts seem to make the point(if we can ever find it) overdone. I think that truly there is a feeling that he has to have the answer...look what he's been through. I guess it would be difficult to just say," I don't know" . But lately I've noticed the understated focus on getting people to check out all the "other modalities" before having the nerve to ask for opiate relief. It seems to be a blanket statement lately and I do not go along with it. My body is my body and if I choose to wish to speak with a physician about a LA narcotic med at whatever time I choose by God, I am going to do it and I encourage anyone else to do the same. It's a decision to be made between a pt. and a Dr. and no one else. It has been proven to my satisfactiion that many of these so called "other modalities" and yes, I, too know the list by heart, are, in many cases, revenue makers for the PM Drs. and little more. Or, at the very least...try other things, yes but why not be comfortable doing them? So we take the chance of perhaps having to withdraw; well again, most of us are grown ups and we accept that possibility. I do feel that upping narcotics prior to surgery is unwise...can make for some sticky situations with anesthesiology during surgery and your PCP post surgery.
    I almost get the feeling that since the pump...there is this drive to steer pts. away from the notion of "easy narcotic relief" but there are many of us who still need, desire and deserve narcotic pain control. The "other modalities" aren't going to work for me and if I can help it, I am not going to be miserable doing my every day things. I know it would help me, Dave, if you could condense down your long letters so that I could identity the one or two points you are thinking are the most important. I have to admit, I do get lost along the way. And yes, to read what appears to be a "book" can be a little intimidating to other posters. Sometimes it even feels like a sermon.
    JMO,
    Shesparkles

     
    Old 04-25-2005, 07:51 PM   #12
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    Re: Need advice w/ dosage issue and doctor

    James, you made my evening! Cheers, man!

    -blueswimmer (andrew)

     
    Old 04-26-2005, 09:19 AM   #13
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    Re: Need advice w/ dosage issue and doctor

    James, I'm sorry you felt me not agreeing with you is a personal attack. I don't agree that someone asking how to get through days when they can do without opiates should be prescribed a more potent longer lasting opiate.

    It's simply makes someone completely dependent. Swimmer even made a point to say it wasn't that full blown kind of withdrawal that people really dependent experience.
    So lets get him there faster?

    As far as subtle changes, yes things change. I see more and more abuse. I see folks that think you simply need to have your ticket punched after 6 months to have these meds available and these folks have no clue as to the consequences they may face. Heck some folks don't even know they become dependent and want to sue the doc for making them an addict. .

    I changed from morphine to dilaudid last week and went through my 3rd withdrawal since having the pump implanted last june. That's a pretty hefty price if you ask me. If someone is working, will their employer put up with 2-4 weeks a year for withdrawal or being sick when you switch from one med to another. The withdrawal wasnít from anything I did wrong, itís just one of those major consequences.

    First time was the initial conversion and when I was given nothing extra for post op pain, second time was when I went past the alarm date but nobody explained the consequences of passing the alarm date. 3rd is now, when switching from one med to another med safely.

    The only thing that has changed over the years is, I have seen more consequences. If thatís taboo, I can just sit back and watch the train wreck.

    My advice to ask for something milder for the days that are better hasn't changed but if that's somehow slamming the door on the opiate vault I'm sorry it's seen that way or bothers people. My ideas and views on using LA opiates when appropriate havenít changed. The appropriate part is something that people won't always agree on. But I didn't suggest or question anyones use being inapropriate.
    A little drama keeps things interesting.LOL
    It's OK not to agree on everything.
    Dave

     
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