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  • MORPHINE ER - Best time to take?

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    Old 02-25-2014, 11:56 PM   #1
    WhistleDixie
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    MORPHINE ER - Best time to take?

    Hello Everybody...Although I know you've grown weary of me and my issues, I beg for your thoughts and input. I began pain management in late January. The doctor started me on Methadone 5 mg 2xday. I rode out the waves of side effects for 3 weeks before seeing my doctor again. I told him the side effects were unbearable and I could identify no lessening of pain. The worst effect was the comatose state I felt I was in. I could not function day to day with my career. All I wanted to do was retreat to my bed in the darkness and just "disappear".

    On February 19 I stopped the Methadone and began taking Morphine ER 15 mg 2xday. There are adjustments that I am coping with (sleepiness being the worst, as the itching is easing since stopping the Methadone). I need your input as to how long it should be before I feel some degree of pain relief? My BOB pain, skeletal pain, sciatic pain and pelvic/rectal pain remain steady. He said we can certainly increase the dosage til I get relief, but won't that INTENSIFY the fatigue/sleepiness?

    I'm trying to figure this out, as maybe I'm doing this wrong. Is there a "better" time of day to take the Morphine ER @ 12 hour intervals? Should I ask my doctor for mg increase or increase 15 mg to 3xday? I feel so dumb because I don't know how these drugs function. I don't even understand the terms/lingo that I see so often used on this forum. What is bioavailability? What is breakthrough? Please be gentle...I know I'm clueless=)

     
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    Old 02-26-2014, 07:51 PM   #2
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    Re: MORPHINE ER---Best time to take?

    It would typically be recommended to increase the times a day you take the medication if you notice the dose running out early. However, since you say you notice no noticeable relief, it may not make a difference at this point...the goal would be to get you to tolerate an increase in the daily dose, then optimize the schedule, although I believe that dosing three times a day (or even four for some folks) is required (or at least helpful) more than not.

    It may be possible to do both at the same time. Splitting up the dose more may also make the side effects more tolerable, especially with a relatively short acting long acting med like MS Contin. For example, the 45mg MS Contin you mentioned split three times a day will likely give more stable pain levels and slightly less side effects than that 45mg split twice a day. If it was a difference medication that was very long acting though, splitting the dose up more wouldn't make a difference.

    My doctor had me take it three times a day from the start when I tried it. I'm outside the norm as I always have medications run out early, but I couldn't even get it to help for 6 hours. Yes the side effects would typically increase with dose increases. However, they can definitely decrease over a period of weeks or months. I have even had some side effects which I am 99% sure are from methadone not start up for 3-6 months after a dose increase.

    Usually it would be recommended to give a medication a few weeks before increasing the dose, unless the patient is having withdrawal from a switch, or it is obvious the dose is quite a ways off. However, as you are struggling with side effects, I'd think you would have a greater chance of succeeding with this medication if you can try to wait it out (such as until you are due a new script), and see if the side effects subside.

    Otherwise you're likely to make yourself pretty miserable with the sedation, as its likely your dose is quite a ways off. Hang in there! Although it may not seem like it, you are making progress towards your pain relief goal. When you see your doctor I would present exactly how you are doing...where your pain levels are, how much relief (if any) you are getting, the side effects you are having, etc.

    See what they suggest. If you are still having intolerable side effects at this dose after 4 weeks for example, you'll have to think whether you want to give this time, or need to try something else. Since you are paying cash, if you can't afford the Fentanyl patch, it may be worth it to give this time, as I don't know what other affordable long acting opiates your doctor could try...Methadone, MS Contin, and Fentanyl patches are the most affordable (generic) ones as far as I know.

    Bioavailability is how much of the medication is absorbed. This depends on the route (IV vs. oral for example). With a low bioavailability medication, you take a higher dose (milligrams for most medications). Breakthrough usually means breakthrough pain, which for most folks mean spikes in the pain level above a baseline level which is being controlled by their long acting medication, and which they may take a short acting "breakthrough" pain medication for.

    It should only matter what time of day you take the medication if you were having it run out before the next dose was due...then you would want to schedule it so you took the medication when you had the most pain during the day (which varies by person). For example, when I was under dosed on methadone, I would take it twice a day, but only 6 hours apart (not 12), both in the morning, so I got the most relief at work, when I needed it.

    I think this had its problems though, as then I would wake up with very low medication levels, so it would take until that second dose of the day to get any relief. Looking back, I think I would have been better off taking it evenly spread, even though at the time I had tried it (maybe not long enough). Otherwise it would make no difference as the medication dose should be taken in a way that it is steady. Note that with these medications for some folks it makes a big difference whether they take it an hour late for example (for a 12 hour med).

    Pain being controlled doesn't mean 100% relief...50% is a common reasonable goal, and can make a huge difference for a lot of folks. You'll pick up a lot of information as you read. Don't be afraid to do a web search for topics either. I've (unfortunately) had over 8 years of constant pain, and I've been on some form of opiate pain medication for almost 7 of those years, the last 4 or so were on long acting meds. Best wishes.
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    Last edited by tortoisegirl; 02-26-2014 at 07:59 PM. Reason: adding response on time of day

     
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    Old 02-26-2014, 10:31 PM   #3
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    Re: MORPHINE ER---Best time to take?

    Thanks, Tgirl...I have so many questions, but I don't want to irritate people with my stupid questions. I am so grateful for the information and support on these boards. I think without it, I would not have sustained the courage to seek another shot at pain management. I guess I had conceded to the fact that there was no help for me, no one who understood or cared, and I was destined to a life of untreated pain.

    I have no delusions of being 100% pain free. I'm not looking for miracles, just less painful mobility=) I will welcome any amount of relief that allows me to function more efficiently with less tears=)

    I wondered today if possibly the 3 week trial of Methadone is somewhat still in my system. If so, could it be blocking the benefit of the Morphine for pain relief? My worst pain levels are upon waking through the early morning. I feel a little better in the afternoon, but in agony again at night.

    Constipation, though I've battled it for years, is EVEN MORE of a battle with pain meds. But I suppose they create that as a side effect for the most "regular" people prior to PM. I switch back and forth from Miralax to Perdiem to Senokot and currently prescription Linzess. Even so, I still go FOR DAYS with no BM.

    I'm not giving up. I'm no quitter. I know that I am BLESSED to finally have a PM doctor that seems to care...also don't have to drive 2 hrs. one way. I will work with him to find the best treatment for me as long as he's willing. I was very upfront with the challenges he would face with my gastric issues.

    I just need to figure this out. Of course I'm still fixated on why the Methadone did not help me the way it seems to be helping so many. I'm very hard on myself. I keep wondering what I did wrong? What am I now doing wrong with the Morphine? Though I am a self confessed IMPATIENT person, I do not expect instant magic relief. I can deal with the wait for results, as long as I can believe the results will come.

    I'm sure I'll continue to have questions. I need credible information.

    Last edited by Administrator; 03-06-2014 at 07:42 AM.

     
    Old 02-26-2014, 11:30 PM   #4
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    Re: MORPHINE ER---Best time to take?

    Hey there WDixie....
    You go right on asking all the questions you need to....none of them are stupid. Everyone has been new to pain management at some time. Hang in there with this new pm doc and be really detailed and honest with him about all of it....you and he will get it figured out and get some relief for you! God bless you m'dear....

     
    Old 02-27-2014, 07:32 PM   #5
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    Re: MORPHINE ER---Best time to take?

    Definitely, ask away, no worries. No the methadone could not be blocking any therapeutic effects of the morphine. Its a common myth that taking methadone "blocks" other opiates. At very high doses it may block any euphoric effects of other opiates (such as those taken for breakthrough pain), but not any pain relieving properties.

    Plus, if anything, there would be pain relief benefit, but that would probably be well gone by 12 hours after stopping it. There is probably a small amount still left in your bloodstream (as it has such a long half life), but the only lasting effects of that would be the potential for withdrawal.

    I too also had constipation issues even before the pain meds. Currently taking Miralax + Senna. They have very different mechanisms, so you may want to try the combo. You have a GI doctor, right? Also, there is no max dose on Miralax, so you can keep slowly increasing it if you find that necessary. Dose increases can take quite awhile to take effect, so that is why I say slowly. My issue however is that the laxative use only turns everything to mush for lack of a better word, and doesn't speed things up for me at all. I think my record is 9 days.

    If you're on a high fiber diet, it may be worth testing out the opposite. Some of us have such slow motility with these meds that the fiber actually makes things worse. I also found out somewhere along the line I became sensitive to fructose. I've tried all the otc stuff, Linzess, Amitiza, and even Relistor (injection), but the Miralax + Senna works the best for me...either something does nothing, or it just makes my system very unhappy with increased cramping & bloating.

    Its common to struggle with side effects from medications, and some folks have it worse than others. It sounds like its not so much that the methadone & morphine didn't help, but that you aren't able to tolerate a dosage that would help. I've definitely had that happen. In fact, I've had several medications where I literally could not take more than one pill, it made me so sick. Thankfully no reactions that required medical attention though.

    Have patience that you will find something helpful. I do think its possible for you, although I foresee cost being an issue, as many of the options are expensive. It sadly took me years to get this. I wish I had insisted to see a pain management doctor sooner. Even now I am struggling as we've hit a wall with my methadone, in that my doctor won't be comfortable increasing the dose down the road (although I don't need an increase right now), and I wouldn't want to anyways because the side effects are piling up.

    Plus I've tried all the other pain medications and know I really don't have other options (I got little to no relief from then at doses that should have been plenty high enough). Therefore its been suggested to pursue an inpatient switch to Suboxone.

    I have my follow up about that next week (hospital stay probably a minimum of 2-3 months away though, as we need to switch my medication to something shorter acting to make the withdrawal process easier). Suboxone seems to be an up and coming medication in pain management; previously it was reserved for addiction, or pain management + addiction patients. Best wishes.
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    Old 03-06-2014, 07:12 AM   #6
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    Re: MORPHINE ER---Best time to take?

    Hi whistledixie, Different timed released narcotic meds have different endings that are part of their name like ER for extended released, Contin for continuous release, LA for long acting release, dura for duration & some timed released meds have no indication in the name that they are timed released meds like avinza, kadian,etc & the release mechanisms of the medicines are all different & last different lengths of time, usually 8, 12, or 24 hours & some can be affected by metabolism. When i was recently changed from avinza to morphine ER capsules my dr said that if he prescribed the morphine er tablets for me that i would need to take one every 8 hours instead of every 12 or 24 hours with the capsule. I have been taking morphine for a long time & 15 mg twice a day is a relatively ,as compared to my dosage, small dose & if the drowsiness, sweating & itching are subsiding then if i were you i would give the medicine a little more time. However, if i was still not receiving any pain relief at all i would call my dr & tell him now, because he may change the dosage or just the scheduling or try another medicine but LA meds tend to be expensive. Sometimes I cannot feel pain relief per se from my long acting meds i just notice i get up & do more like when i was "normal"! I had one dr suggest miralax & another dr fiber, my mom suggested milk of magnesia, my grandmother told me to forget all of that & try dried prunes & they taste great & work better for me than any medicine.
    P.s. As i am sitting here praying for you I realized that i forgot to say how sorry i am that you are still struggling along! But dont lose hope because it does take time & trial and error for the dr to find the right combination of meds to achieve optimum pain relief & its even harder when limited by side effects, cost prohibitives, drug allergies etc but something will work! Look at all of us here who are prescribed all different meds "across the board", literally!:-) Lol Pain management to a tolerable level will be achieved for you as well! Did you ever ask the pcp about another antispasmodic/anticholenergic medicine to help with cramping after donnatal was discontinued? And i have tremendous results with lyrica to help the pain but i had to stick with it for 3-4 weeks before the drowsiness disappeared. But also, are you still taking neurontin, has the dr considered a different adjunct therapy medicine like lyrica, cymbalta, topomax, etc to help relief the pain?

    Last edited by gmak; 03-06-2014 at 02:05 PM. Reason: ps

     
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    Old 03-06-2014, 07:21 AM   #7
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    Re: MORPHINE ER---Best time to take?

    Sorry you are still struggling so much. It'll be tough to know if this medication will work for you until you can get the dose up, and see if you can get pain relief without intolerable side effects. To increase your chances of tolerating the medication, you may want to wait until your next appointment to have the dose increased, to let the side effects subside some more first.

    Its also best to combine opiate pain meds with other therapies, so I hope your doctor works with you on that too. I think you had mentioned they wanted to get you some pain relief first though.

    Or if by then you still can't fathom any increase in side effects (from a dose increase), and if you've got a price quote on the Fentanyl patches that is affordable, that seems like a good next step.

    Not sure is there are any other long acting opiate options for cash patients besides methadone, morphine, and Fentanyl patches. Morphine & Fentanyl would have a pretty similar likely side effect profile, although possibly less chance of itching and lesser constipation, although you add patch-related issues like getting them to stick & skin irritation. In contrast, oxycodone products are typically more stimulating than sedating.

    I don't however notice that side effects are always linear...although side effects usually increase with dose, with pain meds, I don't find the side effects to be double with double the dose for example. Every person and medication is different though.

    Long acting, sustained release, controlled release, extended release, etc, typically all mean the same thing. Different medications or sometimes even generics of the same medication (like morphine) will use different terms.

    It sounds like you will need to work with your GI doctor to find a good bowel regimen, as you will likely have increased constipation with any medication, although some can be worse for some folks. Itching can also likely be helped with medication. Sedation is trickier, as doctors are more hesitant to prescribe stimulants (which are also controlled substances), and they are expensive. Time can help though.

    I also really struggle with side effects. With the methadone, I'm getting everything from the usual constipation & sweating & sedation to the more bizarre skin flushing & leg jerks in my sleep. Best wishes.
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    Old 03-06-2014, 11:34 AM   #8
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    Re: MORPHINE ER---Best time to take?

    Hello gmak and tgirl...THANK YOU BOTH SO MUCH for always "showing up" for me. I apologize for EVERYTHING. Fortunately, I finally achieved a BM. Yes, the Linzess was prescribed last April or May by my GASTRO. I guess maybe our colon grows "accustomed" to stimulants/softeners (like shampoo/conditioner for our hair). Perhaps I need to do like I've had to for years, which is switch back and forth to get optimal results. I "think" I understand your explanation of "release times" of meds. I agree with both of you as I am determined to "stick it out" with the Morphine. I have a horrid fear of the effect of larger doses of ANY drug. I am truly TRYING to evaluate my pain level, but as you know, it's beyond difficult with my belly battle. I am weary. I am worn to a frazzle (and then some) I think I need to just disappear for a while, maybe inflate some colorful balloons and throw myself a pity party. Wanna join me?

    I never see PAIN (physical or emotional) as a contest. I hesitate to ask questions of other people (like y'all) who are suffering far more than I, so I will try to refrain. I can never thank all of you @ HB for your unwavering support=)

     
    Old 03-06-2014, 03:05 PM   #9
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    Re: MORPHINE ER---Best time to take?

    Quote:
    Originally Posted by WhistleDixie View Post
    Hello gmak and tgirl...THANK YOU BOTH SO MUCH for always "showing up" for me. I apologize for EVERYTHING. Fortunately, I finally achieved a BM. Yes, the Linzess was prescribed last April or May by my GASTRO. I guess maybe our colon grows "accustomed" to stimulants/softeners (like shampoo/conditioner for our hair). Perhaps I need to do like I've had to for years, which is switch back and forth to get optimal results. I "think" I understand your explanation of "release times" of meds. I agree with both of you as I am determined to "stick it out" with the Morphine. I have a horrid fear of the effect of larger doses of ANY drug. I am truly TRYING to evaluate my pain level, but as you know, it's beyond difficult with my belly battle. I am weary. I am worn to a frazzle (and then some) I think I need to just disappear for a while, maybe inflate some colorful balloons and throw myself a pity party. Wanna join me?
    I never see PAIN (physical or emotional) as a contest. I hesitate to ask questions of other people (like y'all) who are suffering far more than I, so I will try to refrain. I can never thank all of you @ HB for your unwavering support=)
    Hi dixie, There is no reason to apologize,& for what? , so glad you are cleared out, & of course you are trying really hard because you have been putting up with alot of side effects & unrelieved pain, bless your heart! Ask away, thats what we all do here & we are all here asking questions too. Dont worry about understanding the names with Er or La because they are all different & with no rhyme or reason that i know of. I so understand the worn out feeling from belly issues problem because when i had colitis sometimes i felt like my very life's strength went down when flushing! And if you disappeared we would all miss you very much! Pain is subjective meaning no one can feel or know if one persons is greater than the
    others, pain is pain & unmanaged pain is the worst for me but
    soon you will be pain managed as well! We are here to support you
    just like you are here to support us!

    Last edited by gmak; 03-06-2014 at 03:09 PM.

     
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