Dr Steve: ? re: side-effect of opioids

[GardeniaGirl]

Steve - wondering if you have and ideas for me.

I have inflammatory arthritis that has slowly spread from my hands 12 years ago through all of my joints and up my spine since then. I am on a number of immunosuppressants and these keep the pain and inflammation down, but not completely.

I keep having the same problem with most of the opioids -

so far I have been on Oxycontin, Methadone, and now Levorphanol. (also been on percoset, vicodin, and darvocet)

Also have been on all forms of Morphine - currently on avinza.

With the Oxycontin, Methadone, Levorphanol, Percoset, vicodin, and darvocet, this is what happens:

I get pain relief in some of my joints -but then the pain flares up the joint pain primarly in my hands.

My rheumatologist referred to this as "opioid-induced arthralgia."

The morphine does not cause this. But all the other ones have so far.

Morphine causes severe headaches and nausea, but I am currently on a low-enough dose that I can avoid that- using Avinza.

Can you think of any commonality between all the meds that I get that effect from?

I am hoping that I will be able to find something I can use for pain - but it seems like there aren't too many more options.

Thanks for any info you might have

GG

[lobelsteve]

I'm unaware of any literature on opioid induced arthralgias.
Hyperalgeisa yes, but your med list makes me think you have enough reasons to have arthralgias and that the pain meds are not causing this.

Discuss with your doctor, try other meds, try nonnarcotic supplements like Limbrel.

[Kathi49]

Steve,

Limbrel sounds like something I would be interested in. Do you have any patients taking it? And if so, has it been effective?

[mrsdoubtfyre]

a quality fish oil for you. This also blocks cox-2 and reduces inflammation naturally.

I know a woman with severe RA, and she takes methotrexate and Humira.
She says that of all the drugs, salsalate (Disalcid) works the best for her.
This is an older drug and a version of aspirin, without the bleeding side effects.

http://www.rxlist.com/cgi/generic/salsalate_cp.htm

Aspirin has always been the basic best anti-inflammatory. Disalcid, does not cause the bleeding risk that aspirin does. You might discuss this with the doctor. My friend at one time could not walk before treatment. And she has been on this regimen for years, now, and actively working.

[lobelsteve]

Salsalate is still an NSAID, older, less expensive, thought to have less of a bleeding risk than aspirin, but the risk is still there.

From Medline Plus Drug Information: (http://www.nlm.nih.gov/medlineplus/druginfo/medmaster/a682880.html)

People who take nonsteroidal anti-inflammatory medications (NSAIDs) (other than aspirin) such as salsalate may have a higher risk of having a heart attack or a stroke than people who do not take these medications. These events may happen without warning and may cause death. This risk may be higher for people who take NSAIDs for a long time. Tell your doctor if you or anyone in your family has or has ever had heart disease, heart failure, a heart attack, or a stroke; if you smoke; and if you have or have ever had high cholesterol, high blood pressure, or diabetes. Get emergency medical help right away if you experience any of the following symptoms: chest pain, shortness of breath, weakness in one part or side of the body, or slurred speech.

If you will be undergoing a coronary artery bypass graft (CABG; a type of heart surgery), you should not take salsalate right before or right after the surgery.

NSAIDs such as salsalate may cause ulcers, bleeding, or holes in the stomach or intestine. These problems may develop at any time during treatment, may happen without warning symptoms, and may cause death. The risk may be higher for people who take NSAIDs for a long time, are older in age, have poor health, smoke, or drink large amounts of alcohol while taking salsalate. Tell your doctor if you take any of the following medications: anticoagulants ('blood thinners') such as warfarin (Coumadin); aspirin; other NSAIDS such as ibuprofen (Advil, Motrin) and naproxen (Aleve, Naprosyn); or oral steroids such as dexamethasone (Decadron, Dexone), methylprednisolone (Medrol), and prednisone (Deltasone). Also tell your doctor if you have or have ever had ulcers, bleeding in your stomach or intestines, or other bleeding disorders. If you experience any of the following symptoms, stop taking salsalate and call your doctor: stomach pain, heartburn, vomiting a substance that is bloody or looks like coffee grounds, blood in the stool, or black and tarry stools.

Keep all appointments with your doctor and the laboratory. Your doctor will monitor your symptoms carefully and will probably order certain tests to check your body's response to salsalate. Be sure to tell your doctor how you are feeling so that your doctor can prescribe the right amount of medication to treat your condition with the lowest risk of serious side effects.

Your doctor or pharmacist will give you the manufacturer's patient information sheet (Medication Guide) when you begin treatment with salsalate and each time you refill your prescription. Read the information carefully and ask your doctor or pharmacist if you have any questions. You can also visit the Food and Drug Administration (FDA) website (http://www.fda.gov/cder) or the manufacturer's website to obtain the Medication Guide.


Limbrel is flavocoxid, http://www.medscape.com/viewarticle/524011

Not classified as an NSAID and appears promising. Once a few million people start taking it, we can really see what side effects will crop up.

It will be expensive and not widely available. It is my first choice anti-inflammatory, replacing Celebrex.

[GardeniaGirl]

Steve and MrsDoubtfyre - thank you for your suggestions.

I have been researching this stuff for years and have never heard of either salsalate or limbrel.

What is kind of funny is I had seen the term "limbrel" on an arthritis forum but I assumed someone was misspelling the name of the medication "Enbrel."

Thanks for the ideas!

[Kathi49]

Thanks Steve,

I will definitely ask about Limbrel.

[mrsdoubtfyre]

http://www.limbrel.com/professional/pro_prescriber.php#05
Question: Is Limbrel effective in rheumatoid arthritis (RA)?

Answer: Limbrel’s effectiveness in RA has not been researched or clinically tested. Additionally, the research to determine the distinctive nutritional requirements of RA patients to support Limbrel as a medical food product for RA has not been completed. Therefore, Limbrel is not promoted for RA, and any usage for RA would be solely at the physician’s initiative.

So the data are not in yet about this product and inflammatory type arthritis.
It is only approved for osteo. But certainly Limbrel is vastly SAFER than Celebrex! After all Celebrex narrowly escaped being taken
off the market. I do wonder however, at its usefulness in RA. I suspect it will become OTC in the future.
I myself use SAMe. This has been nothing short of miraculous for me. I have actually more cartilage now than I did in 1999 when
I started. And very little pain and no inflammation in my knee any longer. (I had tons of pain in 1999). SAMe is not cheap either, and it takes time to work, but it is
very good, and not an NSAID etc. I've posted about it many times, you can PM me for details if you are interested.

Also this quote:
n addition, Limbrel is the first and only prescription product to help nutritionally manage the 5-Lipoxygenase (5-LOX) pathway to reduce the production of Leukotriene B4 (LTB4), a potent chemoattractant molecule of white blood cells which can cause additional inflammation at the site of injury. Elevated LTB4 has been shown to contribute to gastric damage in mucosal lesions.* In fact, Limbrel’s unique COX/LOX Dual Mechanism of Action dampens AA metabolites, but allows the body to maintain pools of these necessary AA metabolites to perform essential functions. At the same time, Limbrel’s dual mechanism of action still manages the underlying metabolites which with chronic over production contribute to the progression of osteoarthritis.

I am uncertain as to comparing Celebrex to Limbrel. Celebrex is a cox-2 inhibitor with very little cox 1 activity. Limbrel claims to be a dual acting Cox-1 and cox-2 agent. This makes it quite different. Fish oil also blocks excess AA inflammatory activity and is much less expensive than Limbrel and does not require an RX.
I find the Leukotriene blocking action interesting... you know that Singulair also acts this way? In fact Singulair is very potent LTB4 blocker at the receptor.

Fish oil is very similar, and much less expensive.
http://www.mayoclinic.com/health/fish-oil/NS_patient-fishoil

I also wonder~~~ when you take opiates, there are times when the drugs are decreasing just before the next dose. That period sometimes resembles
a mini-withdrawal. Methadone especially comes off the pain receptors before the blood levels fall. During that time, arthralgia may present...
since it is a sign of withdrawal.