Discussions that mention remeron

Pain Management board


Hey Amy, Pain management is made for people like you. You have done the surgerires, over and over . Rolling the dice for a cure rather than having to depend on docs for ever.

You could ppe in your concerns about the apap, which will make your tummy sick and will cause liver damage.
Norco has the last amount of apap of all the hydro cmbo's. It also comes in 7.5/325 and 5/325, so if you afraid of having the whole rugged yanked out from under you you can certainly voice your concerns about apap. With the Vicodin ES, If you take 2 at a time your exceeding the recomaneded max dose of 100mgs per dose or 400mgs per day. When you take apap daily for chronic pain, those numbers should be cut in half to 2000mgs per day and 500mgs per dose..

You could even print out the full prescribing instructions from Watson's web site so he wouldn't have to open his PDR. Everyone is afraid of being the problem patient that complains or asking for an increase because we are afraid the whole rug will be yanked out from underneath us and we will be left with nothing. It's totally normal, But you have to be honest with your PM doc or you will never reach a comfy level. Once you find a real PM doc that uses these types of meds, they know the never get the dose right on the first try.

It's a ballpark guess and he relies on patient reporting and his own observations at apts to achieve a maximum beneficial dose with minimal side effects.
It's better to get things right from the get go than it is to keep going back every month and saying you need an increase. That may look like rapid tolerance which may scare even the best doc when it's truly a problem of having not titrated the dose correctly from the get go because you were afraid to complain and willing to accept whatever you could get. You have to talk to the doc about the goals of treatment. With most LA meds you reach steady serum level in 3 days, so after weak you know and after two you don't have any doubt. Some meds take longer to get used too, some people have to titrate slower because of sensetivity. But there really is a PM doc out there that will manage your pain.

The way I came into PM with opiates was by being in the same position your in. There was no other surgery to even try, surgeons were telling me 3 have failed what makes you think a 4th would work. I had tried all the non opiate methods and honestly given it afair she. There are some non opiate methods I still use for flair ups. So you just toss the BS and keep what works for you. If that doc didn't manage your pasin, youmay still have learned or tried something worth keeping.

I would just bet my PM that there are a few doc in Richmond or even if you had to drive down here you can find relief amy,. It's tough. Even though there are societies that PM docs, they don't all agree with the mission state,mment and statement on the use of opiates. Some won't gve you a T-3 but give you enough Neurontin to stay sedated 24/7. Once I found the right level of opiates I was able to give up Neurontin, Remeron, sleep meds, motrin and apap. Moved the rented hospital bed out of the den and pretty much take care of the house. That;'s what a true PM doc can due, Unfortunately your running into what I call the voodoo docs, One or two tricks up there sleeve they believ weorks for everyone. If they don't you supposed to learn to live with it because they believe there way is the only way to mange pain. I believe in Karma so it will come back n all the people he made suffer.

As far as febtany, Duragesic works for some, It does seem lke it causes more initial sedation, nausea and dizziness at the beginning. I also have a friend that was involved in the clinical trials of Duragesic for non cancer pain to get FDA aporval for non malignant pain. Only 6% of the people in the trial got 72 hours relief, That tiny fraction allows them to claim up to 72 hours of relief. UP TO being the key phrase. Most peole I have met change every 48 hours and they are expensive.


Endo has a generic ready and distribution righs sold to another company to market the generic. They also have a Carfentanyl patch in the in clinical trials called Chronogesic. Fentanyl breaks down into carfentanyl wich is the stronger metabolite. They have a long acting version of Oxymorphone "Numorphan" ready for final aproval.

There are a lot of new meds in the works. fentanyl is very potent and the delivery stem suited well for fairly sedentary patients. In Richmond on 95 degree days and the humidity, adhesion may be a problem . However Jansen will send you Bioclusive covers at no charge after you have called them and complained about the adhesion twice.

There have been some studies that showed Fentanyl binds to the NMDA receptor which isn't a good thing when your serum level drops. Meds that block the NMDA receptor have shown and are believed to increase a patients tolerance to pain, decrease a patients tolerance to opiates and be more effective on neuropathic pain. There are NMDA blocking agents that can be used with it or just use 48 hour dosing to prevent a drop in serum level that may cause hyperalgesia, "increased pain".

The only real flaw in the design is the size of the steps. Having not been exposed to high dose opiates for prolonged periods you would start at the 25ugh patch "25 micrograms delivered every hour" but the next step up is a 100% increase to the 50 ugh patch. This large steps up can be harder to accommodate too and the large steps down can be a little rough if yo have to discontinue or switch. It does bypass the stomach but nausea from opiates is caused by a reaction in the brain, not the medicine sitting in your stomach. The apap will make your stomach sick, But pure opiates only cause nausea from a chemical reaction in the brain and it's easily managed and you become used to it like most side effects. The only side effect that doesn't diminish with time is constipation, opiates slow bowel contractions and smooth muscle contraction, urinary retention is another side effect that may not improve.

We all respond differently to meds, But it would make more sense to start with LA morphine and work your way from there if the doc you will find isn't comfy prescribing Oxycontin, due to Purdue's initiative to create a tracking system of all docs that prescribe and all patient that use it as a way to deter diversion, it's not real popular in VA with PM docs because of this system. You also have to get docs off the 12 hour dosing, It doesn't last 12 hours
7-8 at best. TID dosing would work with OxyC if you find a doc willing to prescribe it, and there are some...

Other than that, You have to avoid direct heat with Duragesic because it can cause rapid release, no more saunas and keep your arm out of a jacuzzi. But some folks do great on Duragesic.

The best source of info and finding ut wat is in the works, Is to start a favorites file or database of pain management med manufactures, Bookmark their web site and keep an eye on products in development , plus the full prescribing info is available at each site for each drug. Purdue, Watson, Endo, Jansen, AAI pharma, Teva, Roxane, and a few others or the makers of some of their anti seizure meds will make it easy to find med information straight from the horses mouth.
Good luck, Dave