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dub1 08-15-2006 09:48 PM

norco substitution???
I have been on norco for the last year 6 times a day. I have recently switched to avinza 30mg which didn't even touch the pain. Then I moved to Kadian 30mg twice a day. This has helped quite a bit i feel much more leveled out no ups and downs. I am still having b/t pain and the norco still isn't taking the edge off. Does anyone have suggestions. I am looking for something comparable a little stronger but not so strong i can't go about my daily activities. Do these meds sound acceptable for a grade 2 degen L-4/5, grade 4 degen L-5/S-1, spondylosis, spondylothesis, DDD??????/

Shoreline 08-17-2006 04:26 AM

Re: norco substitution???
Hey Dub, You have mechanical defects and slippage that you shoud probably discus with several surgeons before comiting to a liofetime of opiate dependnecy. The longer you put off surgery you may need, the les likely you will have a psoitive outcome. Don't take surgical advice from a PM doc or tyour GP, they aren't surgeons. If your mom developed some type of psychosis, would you let your GP treat her or would you find the best psychiatric diagnostician available. The same hold true for your spine. Your the one that has tolive with it and the goal of PM is never to eliminate all your pain even if it was posible to do for a short period of time.How many surgical opoinions have you had before decding to be dependnet on opiates for the rest of your life?

The kadian more than replaces 60 mgs of hydrocodne and removes all he ups and downs, when you take additional hydro, your more than doubling what you were before. I'm not sure if there is such a thing as more relief with less side efefect other than loking ofr a surgical cure or using interventioanal procedures like nerve blocks, triger point injections, and other non opiate modalities.

When surgery fails and verything else has been tried and failed, when you can't increae orals due to side effects, PM docs may suggest lookng at an intrathecal pump . Your a long way from having a pump implanted but even with pumps, a succesful pump is one that relieves 50% of your pain. A succesful pump trial is one that relieves 50% of your pain. If your getting 50% relief now, your gettinmg more relief than some folks with much more serious problems that truly are at the end of the line. What does your PM doc want to shoot for as far as goals and percentage of relief.

If the meds relieve back pain but don't relieve leg pain, that's normal. Nerve pain isn't as responsive to opiates as back pain. That's what adjunct meds are for. Antiseizure meds, anti depressants, and read the present thread on learning coping skills. Because if you have pain, you will have to learn to cope with what the meds can't do. Which is relieve all your pain.

Good luck and nobody canreally answer what will work for you. If there is a potential cure through surgery available, I can't imagine why anyone would choose to live the rest of their life on meds if surgery could relieve all your pain. Surgery is more likely going to relieve the nerve pain than the back pain but the remaining back pain can be delt with. There just isn't an instant answer or one that doesn't have consequences such as physcial dependece and side efefcts you may not be ready to live with. It's pretty much a given, the more meds you take the more side effect you will experience. Everything from constipation, drowsiness, urinary retention "can't pee" to loss of labido and possible loss of ability to perform. These aren't benign side effects to be taken lightly if a surgeon can fix your problems before the window of opportunity closes.

IF your spondy is greater than grade 2, surgery would be indicated. Everyone over the age of 30 has some form of DDD but you can expect it to get worse which means more meds with less reults. If you don't do something to stabalize it or prevent further detioration. You simply grow tolerant to each dose as the problem progresses and have to learn to live with less and less relief from the pain meds or learn to live with more and more side effets

.Eventually you wll reach a point where side efects prevent increasing your dose any more. That's the wrong time to start looking into fixing it. A surgeon wants an opiate dependnet patient taking more dope than he's ever prescribed in his life the way he wants a patient with a history of abuse or dependnecy that regardless of the outcome, will never be satisfied with any benefit from surgery. Post op pain control becomes a problem due to tolerance and finding a doc willing to operate become a problem due to dependnece on opiates.

Opiates should be the last resort when all else fails, not the first thing when PT doesn't seem to help. Perhaps PT didn't help because you need to have the problem corected rather than trying to mask it with increasing doeses of pain meds.What other treatment methods and modalities have you tried to manage your pain? There is alot more out there than pain meds that don't cause the side effects opiates do or have the consequences that being dependnet on pain meds has.

JMO, Good luck, Dave

dub1 08-17-2006 07:48 PM

Re: norco substitution???
Hey dave,
First of all I want to say thank you for helping not just me but a lot of other people on this board with your advice and wealth of knowledge. I think that it is unfortunate circumstances that have lead you here but i think it's great you are willing to assist everyone else because you have been there.

I have been dealing with these issues for the last 6 years. In 97 I herniated my L4, that did get better but i always had lingering pain. About 2 years after the herniation i started injuring my back, little hiccups that would put me down for a day and i would shake it off and keep going. This kept up through the present. I couldn't afford insurance from 99-05 and therefore never saught treatment accept through work. I realized there was a real problem when the occupational doctor said there was nothing more they could do. I was like, thats it? and that was it! I then scheduled with my gp and to make a long story short was simply told that i was too young to have these problems. I am 27 now. He did a physical and told me he would see me in a year. I was asking what i should do for the pain i was in and he prescribed me some darvocet. That was all. I then researched and found a Paim management doc and asked my GP's nurse for a referal, which he did give me. The PM doc scheduled an MRI and gave me norco to help me sleep and function. To tell you the truth i didn't want to get out of bed back then simply because i just wanted to pretend it wasn't gonna hurt that day. The PM got the MRI results and scheduled nerve blocks, radio-frequency burns, and esi's. Not all at once but this was over 6 months and finally i thought that i would be fixed especially with the first 1-5 prcedures. Slowly on i began realizing that i wasn't getting better. I asked the pm about a surgeon or bone scan or something more diagnosically we could do. He told me that i didn't want surgery that i was much to young and to continue getting injections. I left that day knowing i had to take control and again called the gp and asked the nurse for a referral to an othepedic surgeon specializing in spines. I recieved the referal in feb of this year. In the meantime I have tried chairopractic, massage, yoga, and anything else to try and alieviate this myself as i am not a fan of doctors. I began with p/t which is normal and i failed that miserably. Went back to surgeon and was scheduled for the discogram which i had aug 10th this year. I am waiting now until the 30th to get the results and meet with the surgeon. The doc performing the disco said i was a canidate for adr and fusion. I can't wait to have surgery, my goal with the meds has always been to just make living okay till we figure this out. It was just soo long of dealing with chronic pain that i would've taken anything at that point just to sleep all night and to be moderatly okay during the day while at work. So yes i am definitly doing the surgery and don't wanna commit to long term opiates. I hope this surgery fixes everything and i can take my kids roller skating or mow the lawn. I have to admit i am scared that this won't fix it and i will end up in the same if not worse shape but it is the only option i see for myself.

The leg pain is very cumbersome but i can live with it. I have been having really bad sciatic pain again and thats why i was wondering if there was something a little stronger.

Sorry so wordy but i just wanted to explain my situation, and again thank you for the words of encouragement and wisdom. I hope they can find a positive outcome for you some day.

Shoreline 08-18-2006 06:25 AM

Re: norco substitution???
Hey Dub, AIt certainly sounds like you have been through the ringer. Gp's and PM's giving surgical opinions or treating problems utside their specialty is justy a pet peve of mine, Partly from bad experiences where Gp's and the radiologist they use don't even detect broken hardware and some other defects and partly because it's simply crossing the line and giving an opinion in an area that's not their specialty. If youi have a blown disc , that's releasing fragmants and impinging outlets, all the interventional procedures won't fix what needs to be surgically fixed.

A surgeon will look at an MRI or diagnsotic and make his own determination for the need for surgery, regardless of what the GP or PM doc has said. He's the one that goes in and sees exactly what the effects of haveing a nerve entraped by a disc fragment or the effect of bone grinding on bone when diiscs completely collapse. Regardless of what someone from another specialty may think, their opinion rregarding surgery is just that, their opinion. There is no such thing as being to young to have damaged your spine servely enough to need surgery. The reverse is also true, if a GP looks at a diagnostic finding and says you need to have surgery right away, if the surgeon doesn't agree, you wouldn't be having surgery. Another docs opinion from a different specialty, or no specialty at all carries no weight with a surgeon when determining the need for surgery. You age has little to do with it other than actually increasing your odds of having a positive outcome the younger you are, the more you have to lose and your drive to work to get better during recovery. This is where being young is a benefit. I was 27 when I had my first surgery, it wan't a situation where a PM doc or GP opinion really mattered at all once you loose control of your bowels or and blasdder. Fortunately surgery did relieve those problems and did relieve the leg pain although the fusions did fail and left my back a mess. But back pain does respond to pain treatments much better than nerve pain.

As far as your question about something stronger than Norco or lortab 10, the next step up is oxyCodone,wehter it's 5, 7.5 or 10 mg percocet or 5, 15 or 30 mg oxycodone tablets. Oxy is probably closest to hydro in the side effects it causes, the keto synthetic opiates, Hydrocodone oxycodone, hydromorphione and oxymorphone pretty much have the same side efect profile, they tend to be more stimulating then drugs in the morphine class or drugs like methadone. If droswiness is a problem, It's not likely stepping up to oxycdone is going to cause signifacantly more drowsiness. The drowsiness from morphine is usually the most discouraging side effect but most docs suggest you try to get passed the initial newness of the med and that side effect does deminish long before the pain relief deminishes from tolerance.

Hopefully your onth right track and they have some definitive answers from the disco. I would still sugest getting a second opinion, not necesassrily about the need for surgery if the disco indicates it, , but the technique and aproach used to corect the problem. ADR's ahve been aproved for les than 2 years in the US. Unless you hapened to find a surgeon that took part in the decade of clinical trials and has done hundreds of ADRs' , when something like that is aproved, docs can learn the technique in a weekend and go off on their own and start implanting AD's. Personally I done the guinea pig thing enough times and don't want to by a surgeons 6th or 20th ADR. if they have only been doing them 18 months. As far as fusions, there are som many variations in techniques, that's why you want to get a second opinion if the doc is leaning in that direction. Fisons can be done from the back :posterior" with screws and rods and their choice of harvested bone, Cadavor bone, both crushed up and mixed with bone growth enzymes, or fusions can be done from an anterior aproach where they go in from the front and remove the disc completely and replace the disc with 2 vented cylynders that are packed with bone and the growth enzyme called BMP2. There are advantages and disadvantages of both aproaches, So the question to ask is why this aproach and why it's beter than one of the many others. Why this type of hardware versus the other options.

It's not an insult to the surgeon to want another surgical opinion. You are talking about your life and the outcome may greatly efect your future, whether it's positive or neagative. Simply wanting to know why a doc would choose an apoterior aproach Vs an anterior aproach to fusion is a valid question. From the docs POV, they normally learn a specific technique during their residency or fellowship and tend to stick with one or the other throughout their practice.

There are reasons why an anterior aproach to fuse L5 to the sacrum makes more mechanical sense, but it is more invasive. With a doc that does 95% posterior fusions, you may not get all the available info on anterior aproaches and why it may be a better opotion if the surgeon you happen to see simply prefers a posterior aproach. There is also a global fusion, where they use both posterior screws and rods in the back and implanrted cages from the front.

There's no point into getting into it all now. But if you could see all the different types of hardware and each specifc benefit from each design, it makes you wonder how do they choose or are they just using the hardware they are used to and technique they learned years ago. If you get bored, Spine Universe is a great site to look at all the different rigs and available options in hardware and the different aproaches to fusing and the benefit of each.

So good luck with the PM for now and hopefully there is a a more permanent solution down the road with corretive surgery.

Take care, Dave

jesses5 08-18-2006 12:39 PM

Re: norco substitution???
[QUOTE=dub1]I have been on norco for the last year 6 times a day. I have recently switched to avinza 30mg which didn't even touch the pain. Then I moved to Kadian 30mg twice a day. This has helped quite a bit i feel much more leveled out no ups and downs. I am still having b/t pain and the norco still isn't taking the edge off. Does anyone have suggestions. I am looking for something comparable a little stronger but not so strong i can't go about my daily activities. Do these meds sound acceptable for a grade 2 degen L-4/5, grade 4 degen L-5/S-1, spondylosis, spondylothesis, DDD??????/[/QUOTE]

You don't say what dosage norco you're taking or how often you take it. How long did you stop taking norco while taking avinza? If you take avinza and take norco every day throughout the day, then all you've done is pushed up your tolerance threshold and made your body send stronger pain signals.

I started out taking norco every day with increasing dosages and then my doctor switched me to Oxycontin. I found that I still had to take the Norco every day to get the same pain relief, I wasn't even feeling the oxycontin at 40mg.

One day, due to a related issue, I had to stop taking the norco entirely. I went through a week of very bad withdrawels and after that I noticed that I didn't need the Norco because the oxycontin was working just fine without it. Stopping the Norco for a while lowered my body's tolerance for opiates and then oxycontin started working.

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