Discussions that mention morphine

Pain Management board


Hi Dave, i posted this on the Spine BB and Marcia said I should talk to you. My husband is thinking about getting a pump so that he won't have to take so many medications. His neck was broke two years ago. Acfe ? ABCD? I don't know what all the letters stand for but he had the operation. Wire in back T1-C5 and plates and pins put in later at C7,8 and C6,5. His doctor and the Doctor that put the pumps in believe that he is a good canidate for the pump with dalada..(i know the spelling is wrong, but that is how it sounds). He can't take morphine. Anyway, I understand that you went this route. I am a little concerned and would just like to here from someone that has been there and not just from the doctors. I have read a few of your more resent posts so I understand why you know so much. What would be good things and bad things to know about this. My husband knows that it is not a fix all. That it may or may not work. that it might only give him 50% or less relief from the pain he now lives with. But his thinking is that it will stop him from having to take so many different meds. and allow him to maybe live without having to think about the meds. all the time. You know like sometime he will want to do something and thinks he will wait on the meds. because he wants to feel when he has done enough. With the pain meds he would over do, so he doesn't take them until he knows that he will not hurt himself further. I am sure that I am not tellin gyou anything that you didn't go through yourself.

I just would like to here your ideas on this and personal experience, if you don't mind. Like after the pump was put in how long were you down and how much could you do those first few weeks. My husband will never work at his job again. He will not sky dive again or ride horses. This is only three of the things that he has had to give up. There are others. But he also knows that there are things that he will be able to do. Just not for too long at a time and he will have to continue to make changes to make his life the best it can be. He isn't paralized or dead and he should have been one or the other. So we both know that each day is a gift.

I look forward to talking with you. Thank you Vicki
HI Vicki, Have you checked out the Medtronics web site, They have a ot of information at the site and the folks at medtronics are mopre than happy to talk to atients considering an implant and provide a list of certified pump implants doc. Heis looking at this at the right time. The synchromed 11 is the pump being implanted now, a new version of the old pump. It's pretty much the same size but stead of having a 18ml resevoir in the older pump the newer pump can carry up to 40ml or 50ml, can't remember as it was just beeing test marketed when I had my implant in June. The larger resevoir allows you to go 4-6 months before needing a reflill, not that the refill is painful but it does get old in the beginning as you titrate the dose, moving it up slowly evry couple weeks and they start with the mildest concentration and work up. With morphine they start with 0mgs per ML then 20mgs per ml then 30mg per ml.

The increases will seem small compared to oral doses. It's taken me almost 4 months to get to 7.7mgs of morphine a day in .4 mg increases. Now that I know what a .4 mg increase actually is, I can request withnhj resaon the increase I think Ineed. I gage this on the 2 different doses I recieve during the 24 hour perriod. Medtronics pumps are programable and can be set to give additional meds during any point in the day. They pretty much start with a single continous dose, But in my case I have alot of extra pain in the evening that prevented me from enjoying the dinner I cooked and preventing me from sleeping. I hadn't slept through the night since 99, when My last failed fusion was attempted to be corrected. The bolus dose has allowed me to sleep through the night for the first time in almost 5 years.

So in the last 6-8 weeks we have added a Bolus dose to be delivered from 7pm untill 1AM. The time can be set for whenever and however long he and his doc are comfortable with. I basically got tired of recievin a standard .4 or .5 increase with little thought given to how it was distributed. So I make 3X5 cards showing the options and exactly what say .4mg increase equates to on an hourly rate and what adding .3 mgs would equate to hourly on the evening bolus. I create several cards with poptions showing how each ncrease effects each dose , Continous and bolus. More than one bolus can be programmed say if he need more relief at night and more relief upon rising.

How I have adjusted my pump is based on the higher dose I recieve during the day, If that's manageable, and I require minimal BT meds and it's not too sedating,I know I can toerate that setting we move that setting to my day time continous dose and adjust my evenmning bolus. Idealy I will reach a pont where I need minimal BT meds

With Dilaudid, because it's about 7.5X stronger the increases may seem even smaller, like.1 or even less .05 increases may be more apropriate for Dialaudid because it's so much stronger than morphine. Any of the Fenatnyls can be used if Dilaudid causes intolerable side effects. Fentanyl, Affentanyl, Carfentanyl and Suffentanyl can be used along with adjunct meds like Clonidine, Baclofin for spasms or spacticity or Bupivicaine to add a small amount of numbing agent to it.

The good thing about it is they do a trial of the pump, eeither in patient with a temp cath into the intrathecal space and a portable pump or they can use the standard PCA devices to infuse the meds. He may stay in the hospital for 3-4 days as they adjust it and try to achieve a 50% reduction in pain. If he's in patient they encourage him to get up and walk around, walk the floors and try to get a better idea of the relief you get aside from being sedebntary.

They can also place a cath in his spine and attach to a portable pump wherehe cmes home and goes back for adjustments daily, this might be a truer test of how the pump works in his environment andprobably gives you a better idea of how i will work. The 3rd alternative is a single bolus injection into the intrathecal space and keeping him around the clinic, If his doc or docs have a clinic setting more than an office and a waiting room.

Any of the methods are valdid test and it really just depends on what your insurance will pay and what method your doc is comforatble with. There ccould be more risks at home so likely the doses would start lower and the require more adjustement to reach a comfortable level.

Prior to the implant, Medtronics recomends a psych eval, some people just won't ever get used to having a tuna can placed under their skin or for other reasons may not be a candidate.

It's pretty much a lifetime commitment and there will be future surgeirres to replace the pump when the battary dies. 4-6 years depending on flow rate.

I din't find revovery to be that bad comapred to the spine surgery, It's mostly incision pain whcih is very different from having the black and decker stuff whippied out and havng harware placed and bone removed and rplanted elsewhere.

I would definitely recomend getting the $18 abdominal binder, just an elastic waste band that prevent the pump from bouncing while in the car or walking. It takes a2-3 months for scar tisue to encapsulate the pump and hold it in place. Additional BT meds are needed for the implant pain but nothing compared to the doses reqwuired for the failed neck surgery.

My first question would be what are the preent meds he's taking and the doses, how much of his pain is arm pain a"nerve pain" and how much is cetralized in his neck. The pump will be more effective on the neck pain but at higher doses nerve pain can be controlled.

I've got to run to the bank but will be back.

Hopefully you can tell me abou the meds he's on, who is doing the implant, who ismanagng them. His ortho or Neuro surgeon may be doing the implant but that doesn't gaurentee they wllill be manageing the adjustment and refills, It's time consuming and requires more edxpertise, He realy needs a PM doc to manage the pump even if his sprevious surgeon is doing the implant.

I do have more to say but have to run for now. I'm getting where I hope I would be, I still have some major mechanical problems that the pump won't drown out, when my hardware shfts, the pump doesn't mask that big crunch but in general my head is so much clearer, I take minimal BT medsand adjunct meds. I've done the shutgun aproach where everything but the kitchen sink is thrown ninto the mix which really clouds things menatlly and it clouds which med is actually helping. Achieing the right pain relief could do away with many of the drugs he presently needs to manage his pain.
Good luck, Dave
Her is an excerpt from an article by Danial Brookoff, a PM doc and professor at the university of Tennesee.
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Gabapentin, an anticonvulsant widely used for treatment of neuropathic pain, also inhibits calcium flux through N-type channels. Despite its name, gabapentin does not appear to have any effect on GABA receptors. However, GABA-agonist medications such as baclofen are among the drugs being investigated for GABA-like pain-relieving effects.

As new findings about the various elements of the antinociceptive system have emerged, a number of other drugs are being reevaluated for analgesic potential. The observation that alpha2-adrenergic receptors are involved in inhibiting pain signals, led to reformulation of the oral hypertensive agent clonidine as a potent intrathecal pain reliever. The demonstration of clonidine's benefits in treating chronic pain syndromes has focused attention on other alpha-adrenergic drugs. Both tizanidine, an antispasmodic agent, and oxymetazoline, a nasal decongestant, are currently being assessed for their utility as pain relievers.
Hey Vicki, saw you were on line and wanted you to know I'm working on a reply, can I ask has he tried any of the long acting meds like OxyCOntin, MSContin, Duregesic or methadone, sorry it took so long but I had to check out the Isomed to be sure I knew what I was talking about. It's similar to the arrow syytem works, on vacume pressure and is obviously much thinner than a synchromed and is using the larger resevoir which is great once your stable, But I'm dose adjustment # 14 in 3 months and my 3rd refill is next week. It takes time to adjust these pumps so they work eficiently and having complete refills can be expensive at every adjustment, possibly a deterent to a doc to make the adjustments if they lose money through medicare if that is what your hubby has. My refill days run about 35 bucks where an adjustment is 15 bucks with medicare. Each time they refill they increase the concentration of the morphine so I can go longer between refills but the difference between a 18ml resevoir in a giant pump and a 40ml in a smaller pump is a + for someone very thin. The synchromed is basically like a tuna can burried under the skin. IT will still be apearent but for smaller people it would keep it from getting wacked on the counter . I've seen the synchromed in a very thin girl and it flat looked like a can of tuna stuck under the skin. The big difference is the pump is not programable, and any adjustment in medication would require a completely new fill rather than using telemetry and computer capability of the programable synchromed pumps.
Dave
Hi Vicki, I'm kind of confused, Is the only med for pain he is on Darvecet N 100?

Does he have a Pain management doc or is this the surgeons idea as a way to manage his pain without having to write a script, who would manage the pump.

They normally base a starting dose on 1/600th of the strength of his present opiate intake, with dilaudid that would be something like .0000001 mg a day divided by 24 hours. Honestly I couldn't calculate the conversion from darvecet to dilauadid. Darvecet is the same synthetic opioid family as methadone only 1/100 the strength, levorphanol "levordromoran" is also in this class of meds.

I understand the addiction concerns, But he has to understand the difference between addiction and simple physiological dependence.
What he was doing during active addiction was destructive in some way regardless of whether he was a functional addict or a non functional adict. Functional meaning, still go to work without the addiction causing a problem. Functional doesn't mean that it wasn't still destructive to his health or relationships, obviously it was if he decided to give up his DOC "drug of choice"

I know a bit about addiction having done the rehab thing myself when I was 20 and having lived with a highly functional military pilot that was an alcoholic for 26 years. Pop could drink a 5th after work and get up every morning at 5am and be in the air by 7am. He was very functional at work, He excelled and was the youngest Captain in the navy when he was promoted, but pretty much a non member of the family at home alone in his office every day.

His addiction didn't land him in the gutter, It stole years from his life, his children, caused a divorce and cost every other relationships in his life. He has been in recovery for 11 years, since the day my brother killed himself while intoxicated trying to manage pain with alcohol.

He's a different person now, sober, retired, does community work, Facilitates AA meetings at the local state prison and the changes are indescribable, He's simply not the person we feared and tip toed around growing up. Addiction doesn't have to mean non-functional, homeless bum in the gutter. I completely understand the many faces of addiction and how it crosses every social, economical and racial border.

Physical dependence is just a consequence of using pain meds around the clock. You become physically dependent on IT meds, even if the dose is minimal. If a pump runs out you experience withdrawal. That doesn't mean he has relapsed simply because he's dependent on a med or experienced withdrawal when the pump ran out. He may have a few bad days if he stopped the Darvecet too, that doesn't mean he has to throw 18 years of sobriety out and start over with a new 30 day chip.

The idea of implanting a pump in a person that has not tried oral opiates, is very unorthadox. I'm would think having to use meds for post op pain would have showed him, that you don't get high when your in pain. He may have not felt as clear headed as he would have liked, but post op pain management is different from Chronic pain management. It's OK to be sleepy and sleep away the first few painful days. His body would not have healed, he would not have been able to eat, he wouldn't have been able to recover from surgery and go through PT without some means of pain control

When the pain become chronic, the very first side effect to diminish when using opiates is the high that addicts seek. The only way to sustain the high from opiates would be to increase the dose on a constant basis to maintain the same high. However the high disappears, the sleepiness diminishes and your simply left with the analgesic properties of opiate medication. I'm not saying that he wouldn't feel some of the CNS depression and feel a bit altered but that improves with time as you become accommodated to the dose and the side effects other than analgesia and constipation diminish
Even
while taking 600mgs of morphine a day I could carry a conversation and nobody would ever know I was on any med. I can fool people for a while before the physical problems begin to show, Like breaking into a drenching sweat and my legs shaking and scanning the room for a place to lay down.

But using opiates doesn't have to mean feeling impaired. If the meds impair function more than they help, the dose is too high or the med isn't right for that person and you try a different one. I will say the pump has reduced any feeling of impairment to virtually nothing and being able to walk is certainly worth the side effects I have had to deal with.

Replacing a few darvecet with a pump is like replacing a go cart engine that runs on a lawn edger engine with 2 solid rocket boosters used to put a shuttle into space.

The price we pay for pain relief is physical dependence, but if this simple physiological response to exposure to meds improves the quality of his life, improves his ability to function and doesn't hinder him, then there is no sign of addiction. His addiction didn't improve the quality of his life so comparing something that restores some quality of life to something that destroy quality of life is an oxymoron. They are not the same in any way.

There are many recovering addicts still sober that use pain meds to manage intractable pain to function. Long acting meds don't have the ups and downs of short acting meds that are more likely abused.

With the pump you don't have control over things so I can see why he would see it as a safe alternative to using oral meds. But the dependence will occur whether he is in control of the daily dose or not. I'm not in control of my daily dose other than working with the doc every few weeks adjusting the dose to reach maximum benefit from this very invasive way to manage pain.

I know I'm certainly dependent after months of IT opiate use and years of oral opiate use, but they have done nothing but improve the quality of my life and allow me to walk, sit and participate in taking care of our daughter and home. I do the cooking and cleaning and shopping, get my daughter off to school and am here when she gets home, then make dinner so my wife has to do little more than work.
I was bed ridden prior to seeing a PM doc that believed opiates can be used responsibly in patients that everything else to manage the pain has failed.

When you say he can't work, I would assume he has major limitations on standing, walking and just normal function that most people take for granted. Compared to being bed ridden for 9 months and needing my wife to hold me up in the shower, I would say it's worth it, even with my short history of drug abuse when I was 20 .

I went the fast and furious route and ended up sick and in rehab after 3 months of cocaine use.The thing I was most grateful for was I learned at the age of 20 and hadn't wasted my life like so many other people I met at rehab did.

If his neck is as stable as it will get, and they haven't told him that if you turn your head too quickly he will be paralyzed, then masking the pain is the whole purpose of an IT pump or oral opiate medication. I understand he doesn't want to override his natural warning system. But every PM clinic that doesn't use opiates, teaches you do exactly that. The pain is no longer a signal that you have hurt yourself,. The pain is now chronic, constant and has a completely different method of transmitting the signal, uses different biochemicals than then the pain the says take your hand of the grill. It's processed in a different part of the brain, and that pain s no longer a warning. Sometimes, even when pain is relieved, as in amputation. The pain signal, and cell changes, and death and other changes that occur can't be changed and the pain signal is engrained into the nerve tisue and the chemical reactions continue. This is what explains phantom pain.

So not wanting to mask the pain so he doesn't increase the pain, will simply leave him guarded all the time rather than free to live as full a life as possible. My pump increases at night because everything I have done that day does cause increased pain. No amount of med would mask the pain when I crunch and squeak and the rig shifts but it manages the every day pain and the bulus '''increase in dose" at night manages the increased pain at night from doing the laundry, from spending too long in the grocery store and from generally being in the upright position. But I have gone from couldn't get out of bed and physically stand to take a shower, to being MR mom, I pay for it in the evening, but with the Bolus dose and the use of break through meds, "short acting meds" like percocet,dilaudid, morphine, Roxicodone etc. I can manage additional pain caused by my days activity.
continued
Just a note to say I also have the intrathecal morphine pump and I love it. It has helped so much with my pain. I recommend it whole-heartedly and without reservation to anyone whose doctor thinks it would help.

Carol
I know my doses sound high. But I didn't slowly increase after increase to get there. That's what it took from the start to get me out of bed and recovering. walking again, participating in what I could, simply going to dinner, taking my daughter to a movie, even a normal relationship with my wife. I pretty much jumped from nothing to what it took, and what it took was 600mgs of morphine a day. I accommodated quickly, had to move back and forth from Morphine to methadone due to insurance limits or lack of prescription beni's, methadone is pretty much the only med someone without insurance can afford.

A generic dose of 600 mgs of morphine a day would cost 800 bucks a month, Name brand kadian was 1400, It was great when insurance paid for morphine but when we lost insurance, meth is the only option. 1400 dollars worth of kadian, 24 hour morphine, was replaced with 60 dollars a month worth of methadone. Methadone is a potent pain med, not just for heroin addicts, It doesn't have the high that addicts seek and with a 24 hour half life allows addicts to go a day between doses, using it for pain management does have a stigma in some peoples mind but when it's your only choice, that's what you use.

While I was using these meds I did one trial of the pump in patient back in Dec of 2002, The catheter caused a spinal fluid leak and the classic spinal headache. I had a blood patch the day after I was released but the headache that makes you barf when you stand certainly skewed any positive result from the pump.

So I put the idea of the pump on the back burner. The way my clinic works, If they think you might be a candidate for a pump and there are many things involved in being a good candidate, You start with a psyche eval, then every doc and Nurse practitioner meets once a month and if they have a candidate they discuss the implant, are you the patient they want to take on for life, will you be able to handle the slow titration, are your expectations reasonable, was the trial a success. I pretty much had to exhaust other recourses to manage pain and I had. The dose had reached intolerable side effects, I couldn't afford to change meds without insurance, I didn't qualify for free med programs or medicaid. I was doing it for the right reasons and my expectations were within the pumps capability.

The pumps really aren't designed to manage radiculopothy, "arm pain" in your husbands case. Would he do the implant if the pump didn't touch the arm pain but reduced the neck pain 50% If they tried to use the pump to manage the arm pain tit would take much higher doses of opiates Intrathecally to do so, and he would likely have have some cognitive effects from the pump. Also when your on a high dose of the pump, not all pump docs are comfy maintaining that dose. If I was maxed out and my PM docs were leaving the area, would I be able to find a doc to continue at the same dose or would they want to back the dose down?

I feel like I had to try everything else before doing anything as invasive as a pump. Your treated differently with a pump too, just like CP patients that take oral meds. If he went to the ER for a terrible flair up with a pump, would his pain be treated, or would he get a shot of toradol and be sent home with instructions to talk to his doc. I've had dental work done since the implant, had a tooth pulled and wasn't given meds. Docs outside the PM field tend to think your getting the strongest opiates in the the most potent route of administration, so why should he need anything more. Regular docs do think it's a cure all, that prevent you from feeling additional pain which isn't true at all.


Statistically, CP patients have a very low incidence of abuse and addiction. You don't get the high of short acting meds with LA meds because of the slow onset, the slow termination and the constant serum level. It just become part of your chemistry that is created to accept opiates and do no organ damage.

When it comes to nerve pain, the drugs of choice are neurontin, Toppamax, dilantin, "anti-seizure meds" which tend to cause more impairment and more side effects than opiates themselves. If I wanted to spend my days sedated I cold have increased Neurontin to the point of just sleeping all day and not remembering what I had for lunch.

The pump is really indicated for patients that haven't or don't respond or can't tolerate side effects of large doses of oral opiaites. Based on my reporting and improvement, although I couldn't work and I didn't see improvement from day to day or week to week. I could see that 1 year previous I never would have tried to sit through a movie, Then go to the grocery store, then cook dinner and do laundry and eventually be able to enjoy going to the water park and just hang out in the sun while my daughter plays. Every now and then I'll go on one of the safer rides I know won't twist me.
I started this hours ago and have taken a couple breaks. I'm feeling more and more from the fall iout of the shower so I'm pretty confident meds aren't going to make him feel so good he will want to go skydiving or horseback riding.

But back to the pump, so after the unsuccessful trial, I waited another year, a couple more screws had broken and I needed an increase in meds, I didn't want he additional side effects so I did another trial, this time a single bolus at the clinic and hung out there for a about 5 hours, walked around the block a few times and was impressed with the intrathecal meds, But that was really additional meds on top of all the meth that was still in my system, so trying to find the same relief as the trial without the long acting meds has been tougher. Like I said, I'm on adjustment 14, my 3rd refill and it's expensive. The tuna can doesn't bother me though, My head does feel clearer and I know I will get there eventually, maybe not back to full time work but maybe something to supplement SSD.

If I had great script insurance, I would probably still be using orals, they worked as well as I could hope, My head was clearer on oral morphine than on methadone, But because my only choice was meth or the pump, I went with the pump. I don't think I would have or could have started my PM with opiates with an IT pump. Hell my my first 7 years and 3 surgeries I had plenty of PM docs and went through PM clinics and work hardening and nerve blocks and ESI's and learned every relaxation technique, tried every antidepressant, Had a Tens unit, tried TINS, acupuncture, myofacial release, chiropractic, Months and months of PT and I simply suffered needlessly because of the doctors fear of prescribing opiates. I wouldn't let my own fear of meds keep me bed ridden with no means of feeling any self worth by not being able to contribute for fear of pain or masking a new injury, If he hurts himself , he will know.

The biggest shame would be to do nothing at all and except that this is how he has to live. Going from darvecet to the pump seems a bit drastic, If he's on oral LA opiates and they are not working, or causing problems you don't even have to taper off orals to switch to a pump.The pump will always be an option, But It's usually considered the last option. I went right from 150mgs of meth to the pump, the first few weeks while adjusting it were tough but I knew there was light at the end of the tunnel. Has he tried other methods and other meds for nerve pain, antiseizure meds, nerve blocks, ESI's, Acupuncture. There just isn't any reason to let any docs opinion or his own fear to prevent him from leading as full a life as possible.

I truly wish him the best and hope he finds a way to restore some quality of life that you can both live with. I know it's not easy on you watching him suffer when there really is no need.
Good luck, Dave

PS. Sorry this is so long, I can just really relate to the whole situation. I skipped the whole heart attack and cardiac cath story on my 36th Bday from having High BP from pain for almost a decade. I've had docs tell me nobody every died from pain, but that's just another lie opiate phobic docs tell patients. They figure you walked in with pain, you can walk out with it. Another friend that was disabled by back surgerres was told by his doc if he could sell pencils he could work. Compassion isn't something you find often in the medical field particularly among surgeons. If this will help, It's worth doing the trial. But if it takes a combination of meds to function, it's better than not functioning.
Hi Dave, I am sorry to here about your fall. You have been through a ruff (undrerstatemnet ) time over the past few years and that was something that you didn't need.

Yo said that one reason for the pump would be if the person could not tolerate the opiaites. My husband can't. Even in the hospital under controlled conditions. Morphine is completely out of the question as he breaks out in hives and swelling.

I am going to put another story to you and you can ask your father about this one. Maybe it will explain a little more how an addicts mind works. You said that your father was in AA and has 11 years, so you understand a little about addiction. Lets pretend that your father has a medical problem and his doctor says the best way to treat that is with a shot of your fathers favorite or rather the same dirnk he use to drink a fifth a day of. So he starts off with just that one shot of whatever a day. Everyday. Ask your father how long it would be before that fifth a day problem would be part of his life again. Amd which do you think he would rather have himself in control or someone else. Of course alcohol is a lot easier and less expensive than buying opiaites on the street. But I hope this helps with the picture a little. This is a dalema that any addict, meaning one that knows he is before the problem starts that he gets the chronic pain from.

We are going to ask many more questions of the PM before we make a final decission. But it is a choice that will take the drugs out of the house fofr the most part except for the ones that are needed for the unexpeced pain. And yes he knows it is not a cure all and there will be a long time before the correct setting is found. But, this still sounds better than having to battle in his mind everyday with the drugs that he must take everyday for the rest of his life. Thank you for all your help. You are a God sent to many of us. Thanks for your support. Vicki
Hey Vicki, The difference between using alcohol as a medical remedy, if it actaully was one, would be completely different from using because of an addiction.

There is no psychological craving for alcohol if it's medicine, Just as there is no psychological craving to tripple my own dose to get high.

Addiction is destructive, Physcical dependence is just a physiclological rsponse to using specific meds.

My dad would probably have a problem using alcohol, mentally that is. But it's not a realsistic anology.

Lets say he was a rcovering heroin addict that was hit by a bus. He's been clean 14 years and inviolved in NA and AA.

Now reason for using the meds is purely physical and to improve quality of life, The addict should be given a chance and the addict should give the meds a chance. If the only reason to use the meds is toget high, then no, he shouldn't use them, But by depriving himself the use of meds for fear of relapse, what else is he depriving himself, you and your kids of.

It's certainly not better to remain disabled and non functional strictlky to maintain the claim of sobriety. CP patients don't get high on their meds, If they are attempting to, it will show. Running out early, going through withdrawal, buying additional meds from the street and the internet.Doc shopping, forging scripts, taking twice as many pills because one works well, two must work better. That's addicticve behavior, you would recognize it, so would he. Meds will onlyrstore so much function in some cases.

No dose of meds would allow me to stand or walk a sales floor 12 hours a day, even with meds walking for an hour is brutal. BUt If I were to deprive myself of pain meds, I would be depriving my wife and child of any possible benefit they could have due to lack of understanding between addiction and physical dependence. How long would it take for him to become so depressed, that you became worn out and he decided to give up, all for the sake of being able to claim I'm sober. It's foolish.

Nothing about addiction is positive, When opiates are used as directed with the understanding there is a limit on what he can take daily and a limit oion what they can actually do for you they improve quality of life. Nothing about addiction improves anyones quality of life.

My dad is very involved in AA and hithe first 2 years I got the get off the dope speach, untill he came to the hospital after the heart attack, sat and talked with me and thought they had discontinued the opiates. They hadn't, I was taking the normal dose, and he had no clue, not because I can hide the side effects, but simply because I became acomamdated to the side effects, had used the same dose for the previous year and all the warm fuzies and all the anoying side effects disapear. Even if the first few days he's groggy after a dose change, doesn't mean he's getting high. That will disapear and he will seem just as normal as anyone else.

I understand he's alergic to morphine, But anything they can put in the pump he can take orally or by transdermal patch, He will develop the same tolerance to the euphoric effects and many of the other side effects. If he's realistic about how much relief the meds can give, his actions 14 years ago have nothing to do with his actions now.

Lets say Pallidine hits the market this month. It already has FDA aproval and they are likely just working on the marketing stradagy or are going to sell the distribution rights to another company. Paladine is the newest LA med, It's a 24 hour Dilaudid tablet, similar to 24 hour versions of morphine like Kadian or Avinza. It can't be broken down, crushed, chewed or injected, It maintains a constant and smoth level so there is no high from going up and down every 3-4 hours with short acting meds,because of the slower onset, the slow termination and the constant level of in his system.

He becomes acommadated to any euphoric effect and simply gets the anelgesic effects from the med. Only someone with a great misunderstanding of what addiction is and how destructive it can be would try to convince you that physical dependence is the same thing as addiction. If the dependence improves quality of life, Improves function, allows him to participate and make a contribution to the house, even if it's simply being able to sit and listen and talk with you without every thought being about how much pain he is in it's a hgge benefit with minimal negatives, refusing orals just deprives you and him from having as much of a normal life as possible.

The masking of pain is not an issue, You learn with chronic pain, every increase from activity doesn't need an increase in pain meds, doesn't need an Xray to look for changes, It's just something that is always there. The pain he has now, is not a warning that if he turns his head to fast he will be paralyzed, That pain signal is simply part of the gateway theory of pain, It contues after the acute phase, Is interpreted by a different part of the brain and actucal physiological changes occur from acute to chronic pain.

The whole idea of long acting meds is to reduce the frequent dosing, clock watching, trying to squeeze activity into a 2 hour window, and to maintain a costant serum level because it's easier to keep pain in chack than to bring a high level down.

The reason the do the psych eval and trial fo the pump is to try to weed out people that are not suited and don't respond or will never be satisfied with what the pump can do. He could just as easily use the pump to get high by asking for never ending increases in dose. Say they put a pump in, make several adjustments and he says he can live with that. 4 months later he's asking for an increase, not because the pain increased but because the good feelings addict want from meds have decreased. An addict can abuse the pump and his doctor just as easly as if he were on orals.

There have ben cases of addicts removing the opiate from the resevoir with a needle and injecting into a vein to get high, they have all died because it's so stupid and reckless but it's classic addictive behavior, never being satisfied and no care or concern of safety. But if he adjust the pump or adjust oral meds to a level at which his pain is manageble, increases functon and mproves the quality of everyones life, there isn't a single indicator of addiction.

Being alergic to morphine only limits himn from using morphine, codeine and heroin. All the other opioids are synthetic and it's highly unlikely he would be allergic to them all.

The duragesic patch for instance is a patch that delivers X amount of Fentanyl for 48-72 hours, He has no control over the amount it deleivers, It's based on the size of the patch, and once the right dose is found and the right timing, because most people can't last 72 hours, He can maintain Duragesic and have no control over it.

If you wake up and find him applying hot compresses to the patch in order to cause faster release, then that would be addictive behavior, using the med to get high. Any med delivered in any fashion can be abused. It's all about why he is using them, his expectations being reasonable and the benefits outweighing the negaitive side effects. Constipation may limt a dose, urinary retention may limit a dose, sweating may limit a dose. with any form of delivery.

A trial of IT meds, that he won't use orally and doesn't even know if the med will help or to what point it helps could be time consuming, he will remain in pain untill the pump is adjusted properly, he may have to switch meds from dilauauid, to fenatnyl , to carfentanyl,affentanyl or suffentanyl, then try adding baclofin or clonidine or bupivicaine.

It would be nice not to have to take meds and worry about addiction, It would be even better if the meds didn't cause physical dependnece, But if the pump runs out, before he can refill, he will experience withdrawal the same way someone on oral meds does.

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If oral meds could begin to ease suffering now while he goes through the trial process and testing, the oral meds would at least give the doctors an idea of a starting point for the pump, Otherwise they are working blindly and will start at the absolute lowest dose and titration will take months, not that it hasn't for me, But why suffer and not use orals why titrating the meds, which eventually can be replaced by orals. I did a cold switch, stopped methadone the day they put the pump in. They based the starting dose on my previous opiates use. If nothing else the meds can give relief while going through the process and gve the docs an idea of his tolerance and where a starting point would be.

I understand his dilema, I undertsand what he has been tought about addiction. Once and addict always an addict. But I and many others have proven this theory wrong. I have never abused my meds, I have never taken more than presccribed regardless of how much I hurt. My only goal is to improve function. If I reach a point where the mds themself cause impairment and lmimit my function because I'm too wasted on opiates, then I would be showing signs of addction if I fought to keep myself high and numb.

That's why they only shoot for 50% reduction in pain. The rest you accept and modify your lifestyle too. You use meds for rescue pain so you don't have to deal with an ER doc that has no clue what to do once you have a pump, they have no clue what to do when your taking orals too. You also use orals for rescue because you don't want to crank the pump up so high that it manages your worst pain because the rest of the time, when your not flaired up or on better days, you would be over medicated.

When my pain is out of control, I use BT meds, mainly at night, not counting this weekend.LOL But I know not to drive while taking BT meds or additional meds my I'm not used to taking every day at the same time at th same dose. This way I actually get relief from rescue meds.

People that take 4 pills a day every day for rescue because it's prescribed that way, have simply turned ther rescue meds into part oftheir daily regemin. Then when an real increase in pain occure, the meds have no more power than they have for he previous weeks months or years that you have taken the max amount allowed every day.

I'm allowed to take up to 2 30mg Roxidocone at a time twice a day. If I did ths every day, the meds wouldn't bdo squat for inccedental pain like falling in the shower. because they don't cover incedental pain anylonger the patient starts thinking they have hurt themselves and seek medical attn for something the doc has already given them the means to manage.

There is the 1 right way to use meds and ways people use meds that leave them thinking they need an increase evertime there pain goes up and their everyday rescue meds no longer work. They would work if they han't become part of the daily routine.

You als have to reset your thinking about masking pain. CP is no longer asignal that something is wrong and needs to be fixed. We live with tpain every day, we already know everything has ben done and that ur spine is as stable as can be.

I'm not trying to influence you to use orals. If the pump is what he feels better with, that's fne. But to go straight to the pump when you have no idea of what opiates could even do, whether they will improve function, whether they will help the arm pain, being able to determine how much of the pain is arm pain and how much is neck, could leave him ver unsatisfied with the pump and still needing lots of oral meds to manage the rest of the pain, particularly the nerve pain.

It is a very personal choice, I can respect whatever choice he makes. But I spent 4 years , 2 trials , talking to others with pumps, talking to medtronics, talking to the medtronics reps and talking to my docs. They encourages using orals untill I developed intolerable side effetces. I got tired of meth side efects and couldn't afford to go back to the traditional long acting meds.

The only way to get high for a CP patient is to either continually increase or abuse the meds. It's not that hard to tell when someone is simply getting used to a new dose and experiencing additional side effects that deminish in a week or so from a patients who's goal is to get high.

He simply wants as much of his life back as he can fnind. If it takes oral meds, It doesn't mean he is no longer sober, If it akes a pump it doesn't mean he's no longer sober. But people with a pump, with the wrong intentions can abuse meds just as easily with BT meds, with constant increases and no matter what never being satisfied. I'm looking ofrward to when the pump is adjusted to it's max ability, I won't go so high that all I do is lseep all day. The bolus dose at night has allowed me to go days without BT meds. IF I wanted to get High, I could save 3 days of BT meds and chase em with booze, I would get high, But next time it would take more, I wouldn't have the BT meds when I need them and my own actions would be self defeating just as addiction is.

I hope he finds relief with whatever method works. I'm not saying it's wrong to go straight to the pump. It just leaves the pumps ability to control pain up in the air because you don't know what these meds will do for him and he can't compare his relief to what he was taking orally. I can say, I could live with te old dose of oral morphine, or duragesic or Oxycontin or methadone, I know how much relief I got so I'm simply looking to replace the meds, obtain the same or maybe better relief and have less side effects.
I hope he is able to the same. If it takes 20 adjustments, it just wastes alot of meds with the Iso med pump because they have to withdrawal all the present solution and replace it with a more concentrated solution. With the synchromed they simply program it to run faster, thus delivering more meds. Whatever works to get his life back without hindering his ability to function is the gold ring.

As far as the surgery itself, Nothing compared to spine surgery, 2weeks to feel normal, get the binder to kep the pump from bouncing and in 3 months he can stop worrying about the pump shifting or flipping making access and more surgery neccesarry. The area where the cath ataches to the port is more sensetive than other areas still, but I've lost 15 lbs and the pump is much more promenent and so is the side access port and the cath hook up. Adjusting the dose takes time an doing a trials of meds and doses will give them an idea of a ballpark starting dose.

Good luck and keep us posted. Dave