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How much APAP for how long is too much?

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Old 01-26-2013, 11:38 AM   #1
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How much APAP for how long is too much?

Hello all,

I'm a noob to this sort of thing, so first off, please be patient or pardon any faux pas should I deliver any

Brief background: had a pretty severe injury in a bike accident 24y ago which left me with a torn thoracic nerve and some other (very painful) damage in my back. I went down all the routes, exploring all the options and different avenues which presented the slightest solution. Unfortunately, the one surgery option that could possibly cure my pain brought only a 50% chance of success and a greater chance of paralysis.

For years I went to a pain clinic where I would receive blocks, I would get 3 weeks of no pain and 2 weeks where my neck was ridiculously sore from the needles. A mishap one day with the electrocution when the doc was finding the proper nerve to block left me mentally unable to face that again. It was horrible.

From there I started back on Meds (282 MEPS, etc) but got tired of living life in a haze. About 15y ago I just stopped all my Meds and lived med free and just took the pain. It was horribly difficult. I had to struggle to smile and talk and every facet of life was a strain, but I pressed on. My pain threshold got so high that I no longer needed anesthetic when getting fillings at the dentist. I had an accident with a circular saw and they simply sewed it up with over 60 stitches without same. It was quite bizarre.

I noticed, however, that the joy in life was almost non-existent. i found myself laying in bed at night, tears running down my face, wishing I was dead - almost on a daily basis - just to be free of the pain. Then, about 8 or 9 years ago, my doc talked me into trying some Percocet 5/325s for my pain. I've been taking them ever since (2, 3-4 times a day). My quality of life is amazing. Most days are pretty good, although I still have days where I suffer a fair bit, but nowhere like it was. My kids all love the change in having a dad who can move better and is happy and can smile. And my pain threshold has come back down to more 'normal' levels.

My question is this: does anybody know what effects acetaminophen has on a body at this level - long term? Also, my doc asked if I wanted to try switching to a fentanyl patch... Any thoughts on if that is comparable, and if so, how many mcg should it be?

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Old 01-26-2013, 11:57 AM   #2
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Re: How much APAP for how long is too much?

Depends upon who you ask. If taken daily, every day most now say 2000, some 2400 or even 3,000. My PM targets 1,600 and changes med mix when it approaches 2000.

Percocet comes in 10/325. Take one 10 instead of two 5's. That would cut your acetaminophen in half without changing the Oxy.

Old 01-26-2013, 12:23 PM   #3
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Re: How much APAP for how long is too much?

If I was having good pain control, I wouldn't want to change anything. However, I think the idea to go from two of the 5/325 to one of the 10/325 is a good (it would move you from 1,950-2,600mg to 975-1,300mg). Some folks get a significant part of their pain relief from the Acetamenophen, but mostly not. Worth asking your doctor about. Although you probably aren't on a dangerous amount of Acetamenophen (unless you have some prexisting issue), it wouldn't hurt to decrease it.

Its amazing you have stayed at the same dose for so many years. I personally think the Fentanyl patches are annoying to use (finicky to get them to stick, can cause skin irritation, and less dosing flexibiity without multiple patches) and not as appropriate for a first line long acting med going "only" from Percocet.

Although they can be dosed for a patient with a lower opiate dose requirement, they are the strongest med out there, so most doctors would reserve them until a patient's dose was higher. However, if you are having difficulty controlling your pain, then it would be a good time to switch to a long acting med. There are many options.

Its up to your doctor to decide on an appropriate dose, so there isn't any reason for us to guess. However, once you get a script, double checking the dose with a conversion chart (or asking your pharmacist) isn't a bad idea, to ensure they didn't screw up and try to give you a dangerous dose.

However typically they will start you on a much lower equivalent dose, as they don't know how much cross-tolerance you have to the new med (to avoid potential overdsose). 50% is common. Then, if needed, they increase the new med dose. Are you still seeing a pain specialist? They are the most versed in pain management.

For example: do you get increased pain right before your next dose is due, have times where you have pain spikes above your baseline controlled level, have pain which wakes you up during the night, or wake up in a lot of pain and have to wait for the meds to "kick in"? In those sorts of scenarios, assuming you have constant pain which hasn't responded to other treatments, a long acting plus short acting med combo could be helpful.

Do you know why your doctor is now asking you about the fentanyl? Were you saying your pain was increased or something, or asking about the Acetaminophen levels? Usually pain meds are in the don't fix it if it isn't broken category, as switching meds can be rough (potential side effects and withdrawal). Best wishes.
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