Question about going up in pain meds~Dr Steve?

[krashleen]

Well, tolerance..we were discussing tolerance right?

I have been on oxycontin 20mg 3x day, with 10mg at night, and 6 5mg for b/t pain when I need it. And I do need most of them.

I am at the point where I think the baseline needs to be upped. I have been at the same level for almost 2 1/2 years..so I guess it's time.

Problem is, when I went up to 40mg(prior to surgery), the PM doc went to 2x a day, and my body totally rejected that time line. I was still in pain. I preferred the 3x a day dosing schedule. Post-op brain surgery and extraction fusion skull to c4 I was on 40mg 3 x a day and did fine.

How do I handle this? Stay where I am at? And just buffer this with the 5mg and keep my mouth shut for a while?
I am in a quandry and not sure what to do. I need to be out of pain.
We played with my zonegran, but that didn't help much.

Thoughts, ideas?

[Mark N]

krashleen, why won't your doctor go back to 40mg TID since it worked so well for you? If this doctor won't increase your baseline meds based on your pain levels then you may need to find another PM, although that isn't easy to do. I would talk to the PM about your pain and how 40mg BID isn't getting the job done. I don't understand why your PM would go from 20 mg TID to 40 mg BID. If the PM was willing to go with three times a day before find out why he wouldn't go to 40 mg TID. I understand he could be looking at total mg and not wanting to go from 60 mg for your baseline to 120 mg. If this is the issue then maybe he would be willing to go with 30 mg TID which would be 90 mg daily.

Good luck, I hope you get it worked out soon.

[krashleen]

We thought that the surgery worked better than it.
at one point I thought that I would be titrating the pain meds out of my life, but its now apprarent that I will be on pain meds for a long time.
and now I need to get to go back up to the 40's.

Thanks Mark, I can always count on you for a response. You are a kind man.

Merry Christmas!

[BrokenBladder]

Krashleen,

I went through this with my doctor several months back. I just told my doctor how my pain relief was bottoming out after 5-6 hours.

I use Oxycontin as my base med and I was taking it 80mg BID. Of course the problem was that it was not working for long enough so she changed it to taking it TID.

I hope you can get your pain under control soon.

Merry Christmas!!

[lobelsteve]

I cannot speak for your care or your doctor.

If a patient was being treated with a total of 100mg daily total oxycodone and has unrelieved pain, I would increase (if no aberrant behaviors, other modalities employed, adequate safegaurds in place) to 120mg total daily dose.

Oxycontin 40mg tid.

3 bigger pills to replace 10 little pills.
You'll still hurt, just less than before, and we will diffuse the pill taking behaviors. Go get yourself gummi-vites and take them for breakthrough pain, they are equally effective.:D

[Peter B]

Steve,
What are gummi-vites?

Pete

[Rozia]

they are vitamins

[lobelsteve]

Steve,
What are gummi-vites?

Pete

http://www.drugstore.com/popups/largerphoto/default.asp?pid=67653&catid=83574&size=300&trx=29888&trxp1=67653&trxp2=1

Stave off pill taking behaviors by using a substitute. When folks get on moderate to high doses of opioids, the 5-10mg BT pain meds are too low a dose to act as anything but placebo, so I tell folks to take as many kids gummivites as they want to substitute for the short acting pain med. Rainbow diarrhea is better than hyperalgesia and increasing tolerance.

[Kira]

Hey Dr Steve,

I still get 5-10 mg oxycodone IR for breakthrough pain, and they don't do much of anything.

For long-acting meds, I use 62 mcg/hr of fentanyl patches (changed every 3 days)... a 50 mcg/hr patch and a 12 mcg/hr patch.

Do you think that's a high enough dose of long-acting meds that the 5-10 mg oxycodone pills shouldn't really work? Because they don't seem to.

[krashleen]

Hmm, interesting. I take one or two of the 5mg oxycodone and still get SOME pain relief from them. Some days, good relief.

Some days I do well on the 20's, and other days, not so much.
That's what has me in the pain med quandry. That's why pain management is so hard. I do decrease the 20's to two a day if the third is not needed, but some days the three is not enough. When I wrote that post, I was suffering a really bad day. That day, the pain meds weren't working too well, more pain meds doesn't mean pain relief. Sometimes just brings pain to the forefront.

Kinda like the mult-colored stool. IF it were only so easy...
Thanks Lisa, Dr Steve, Mark and Kira.

[lobelsteve]

BT meds about 20% of long acting daily total.

So 80mg bid Oxycontin = 160mg

20% is 32mg = 30mg Oxycodone.

More than 1 breakthrough med per day is not the best treatment. The long acting shoul be titrated to the next highest dose unless side effects occur.

There is something called paying the price for being a chronic pain patient, and due to escalating doses and the inherent risks of abuse.addiction/diversion/ hyperalgesia/worsening psychological state with pill taking behaviors: fewer and bigger gets my vote. The standard ofcare is very wide and your doctor can do most anything, as long as the diagnosis and documentation support the treatment and measures are in place to assess for addiction/abuse/diversion.

[krashleen]

Yeah, I have the back-up, and have been through psych exams. If anything the psychiatrist says I should have more pain meds.

I appreciate the math being broken down. That's what I was looking for, my analytical mind needs something like that. I need to understand the method behind the PM's prescribing 'madness'

Yeah, and gummi-vites? I dunno, I prefer my M'M's dark chocolate, OK?

[gizmogirl]

sounds like all the more reason to make sure that your prescription is for what you need. I've told my doctor that I need 3 on average per day and somedays take less and he's ok.
Worrying about developing tolerance is supposed to be second priority to pain relief, right? Especially with those researchers thinking they can prevent tolerance in a few years...

[Lea]

I take the 50 mcg of Fentanyl and use 10 to 20mg of Hydrocodone for BT, BUT I really limit my BT meds so when I really really am beside myself, they actually work.

I guess it is a matter of tolerance, but I don't think we need to throw out BT meds.

Dr.Steve, if BT meds are not anymore effective than placebo, then why are they a staple of pain management?:confused:

[lobelsteve]

1. Opioids are less effective for chronic pain than any of us would like.
2. BT meds are typically underdosed when long acting meds are titrated.
3. BT meds are overused. They are overprescribed and are best used no more than once daily (45 tablets per month).

Not a staple.

[Spiney]

I use M&Ms for middle of the night breakthrough but the dang things have this annoying side effect................weight gain. Durring the daytime, it is much easier to get distracted and that seems to work as long as the base med is properly titrated.

Personally, I prefer magic pixie dust but Pain Man is out of it most of the time and the dang pharmacy doesn't carry it anymore. Go figure.

Susan

[krashleen]

1. Opioids are less effective for chronic pain than any of us would like.
2. BT meds are typically underdosed when long acting meds are titrated.
3. BT meds are overused. They are overprescribed and are best used no more than once daily (45 tablets per month).

Not a staple.

Ok, IF we agree on this, what is your first choice for pain management?

Cancer patients? Incurable other intractable pain that isn't spine related?

[Lea]

1. Opioids are less effective for chronic pain than any of us would like.
2. BT meds are typically underdosed when long acting meds are titrated.
3. BT meds are overused. They are overprescribed and are best used no more than once daily (45 tablets per month).

Not a staple.

I get 30 count of Norco which lasts me up to 2 months sometimes 3 months, which I guess indicates that my Fentanyl dosage is adequate, although I am never completely out of pain. I even dream about being in pain at night.

Fortunately my BT meds are helpful because I limit their use so much. If I start requiring more BT meds, then my PM and I know it is time for a titration upward of the Fentanyl.

So if Opiates are underdosed and overused what is the solution. I'm easily confused:o

As far as BT meds being a "staple" apparently it is in my neck of the woods with PM's.

[illusion129]

Here's my 2 cents worth...

As far as tolerance goes, I definitely believe it happens with anything that is not "natural" to our body.

I was on the same dose of Morphine SR/ER for about 2 years. Last month, I told my doctor that it just wasn't doing what it used to and I was afraid that either my pain was getting worse OR the pain medicine was beginning to stop helping.

Of course I had read about tolerance, so I figured that was what was going on, but I also had the well known fear we all have when bringing up a dosage increase question to our doctors.

Well, right off the bat she said I was probably not having more pain problems but simply experiencing tolerance issues. She wanted to increase my dosage from 100mg BID to 130mg BID and I asked to do 115mg BID first and when I see her this coming month increase if needed.

Before the increase, I had an allowance of FOUR 5mg OxyIR capsules a day for B/T pain. I would say I needed all four of them AND more then; now I'm quite content with just having four a day, unless of course I do something out of the ordinary like babysit all day!

I'm going to ask my doctor about going up to the 130mg BID during my next visit. I think it will be a great dosage for me because the 115mg has been a miracle; I was actually able to take my trip to Tennesse right before Christmas (4 day vacation) and I actually was able to enjoy it moreso than I would have if I had only been on the 100mg...I know this for a fact! The walking still made me hurt like H#LL but it was more tolerable with the increased dosage.

And with regards to what Steve said - I also believe that once you start getting into higher dosage medications that the "little" pills (low milligrams) don't do a thing as a "breakthrough" drug. You really might as well substitute them for M&Ms or whatnot. During my next visit I'm also going to ask about increasing my B/T meds to a stronger dosage but cut back on how many I can have a day...and titrate up if needed, but that probably wouldn't be needed with the increased L-A dose.

Honestly, I'm not quite sure what type of fast-acting drug would be good for B/T pain...for me, that is. :confused: I know when I've had to take a larger dosage of a fast-acting drug for serious pain I had 20mg of Oxycodone and that did take the edge off. Would 30mg MS-IR basically be equivalant? Do they make Oxycodone in fast-acting dosages higher than OxyIR 5mg and Percocet 10mg? I don't like taking tylenol (Percocet) because it seems to have a negative effect of causing insomnia. :rolleyes:

Krashleen - the point is, it happens. So, don't ever sweat asking your doctor about tolerance issues and when it seems to you that your pain medicine isn't doing its job as usual. As far as how often you need an increase, there is no set time for any person, you just have to go on what your body tells you and hope that you don't become tolerant really quickly; I would think the same dosage should last a person at least 1 year, if not 2 years.

I hope the increase in pain medicine helps you! Let us know how it's going.

[gizmogirl]

I have the same problem with sometimes it seems that no amount of pain killer can help and other times I need very little. But I tell the doctor that I can skip pills, and then tell him what I need as a minimum to be sure I am covered for my monthly prescription.
Good luck

[krashleen]

Well, I have good days and bad days. Sometimes the baseline of oxycontin is good.
I have been reading up since my last appt. It was with the PA. I have a good relationship with the PA, but things kinda were 'different', and I am wondering why.
The conversation turned to methadone. I have not wanted to go down the methadone road. The discussion turned to another patient who suffers HA's, cervical pain, and how she was on oxycontin and now is back to work, her husband barely recognizes her(in a good way), all because of methadone.

The PA discussed and explained how it would work. I have my own set of fears, 1, I don't want to start down this treatment modality if they(PM clinic) won't be there to help me taper/or detox from this med if I am 'cured' or a surgery works. 2, I worry about the dental issues. 3, I worry about the medication itself, and how problems have ensued because of the doc's overisght of some patients (or lack of) 4, what about pain treatment after surgery?? Or God forbid, an accident that requires pain meds?

I dunno. The PA said I could continue the oxycontin, and the decision WAS MINE. But, just because I brought up the issue, there was the conversation, and unless the DEA shuts them down(they keep excellent records on me and follow rules/regs and test all their patients) so I don't think that is going to be a problem, the methadone is going to be the next pain medication that will be discussed for me.
I am in this for the long-term. Is this the only viable option? Why the push towards methadone? I don't want to go this route. As long as I can afford to take the oxycontin, well I prefer this.
The PA also eluded to the interesting factoid that I may be burning out the relief factor in the opiod receptors in the brain. Is this a well-known fact?

The PA also said some things that were totally off the wall in regards to my condition. I do lots of research on my condition and associated syndromes and the PA was really off the mark yesterday.

Whew, what a day yesterday was!