Question about Dilaudid use for pharmacist.steve and Dr. Steve [Archive]

View Full Version : Question about Dilaudid use for pharmacist.steve and Dr. Steve

Kandra

01-15-2009, 12:12 AM

Pharmacist.steve

01-15-2009, 11:01 AM

Hi all...

I have a question for both pharmacist.steve and Dr. Steve. My PM believes very strongly that Dilaudid is a drug not to be used and IF used then only for a few pills. He states that one gets rapid tolerance to Dilaudid and the dosage has to be increased way too quickly.

I currently take Opana ER and Opana 10mg. for BT but have recently had severe lower back pain which the Opana 10 isn't touching. He VERY reluctantly gave me a small amount of Dilaudid and made it clear it was for a very short time which is fine...but I can't find anywhere that Dilaudid has a problem with creating tolerance more quickly than other short-acting opiates.

Does Dilaudid indeed do this?
Thank you!

Just like any other profession....the practice of medicine is a small amount of "book learning" combined with "a lot" of daily clinic experience treating patients. Sometimes, a couple of patient's experience with a drug will taint a doc's opinion of what can be expected out of a drug - as opposed to what the literature would suggest. I am not aware of anything that would suggest that Dilaudid would develop a faster tolerance than any other opiate.

lobelsteve

01-15-2009, 01:42 PM

Opioids are opioids.

For the most part.

I dislike opioids for certain reasons, but valid reasons.

Methadone, Darvocet, and Demerol for toxic metabolites and side effects not present with other pur agonists.

Mixed agonists and partial agonists due to limited effects and ceilings.

But as far as the rest of them (inlcuding Dilaudid), they are all the same.

The doc may be reluctant becuase of bias taught to him in residency of fellowship, and it is without academic merit. Not that that helps you out in any way. Some meds work better for some people and I do not care what pure agonist opioid floats your boat (relieves pain). All I care about is analgesia, adverse effects, activity levels, and aberrant behaviors. Of course this is within context of what is medically reasonable. Including the use of one long acting and one short acting. Including limiting to short acting to as few as possible and never more than 4 times a day, but more often 1-2 per day. And certainly long acting medications and short acting medication doses totalling a few hundred milligrams (less than 1% of my patients) or less (120mg or less in 90% of my patients).

Lil E

01-15-2009, 04:54 PM

Kandra

01-15-2009, 04:57 PM

Opioids are opioids.

But as far as the rest of them (inlcuding Dilaudid), they are all the same.

The doc may be reluctant becuase of bias taught to him in residency of fellowship, and it is without academic merit.

You're absolutely right in thinking he was taught the bias...he's actually a retired FP that went into pain management and was "taught" the basics of PM
by the previous guy who then retired. When he told me his issue with Dilaudid, I said, "wow, sounds just like Dr. X"...he said "well, he taught me." I tried to inform him that this wasn't true as I had looked this up before but he wouldn't listen, and kept repeating the mantra it caused much more rapid tolerance than other short-actings.

I really don't know what documentation I can show him that his bias isn't founded in any fact...but where I live there's only a couple docs who will
prescribe long-acting meds etc. which is sad considering this is a fairly large metro area.

Thank you!

Kandra

01-15-2009, 05:02 PM

Just like any other profession....the practice of medicine is a small amount of "book learning" combined with "a lot" of daily clinic experience treating patients. Sometimes, a couple of patient's experience with a drug will taint a doc's opinion of what can be expected out of a drug - as opposed to what the literature would suggest. I am not aware of anything that would suggest that Dilaudid would develop a faster tolerance than any other opiate.

Thanks so much for taking the time to reply...I explained in my other msg. to Dr. Steve that he was taught the bias just a few months ago really by a previous PM who retired. I'm sure he hasn't prescribed it to anyone else because of his severe reluctance and he kept looking at my carbons to make sure that the previous guy really had prescribed it for a short time before. I sincerely believe that if I hadn't been, he wouldn't have done it.

Kandra

01-15-2009, 05:09 PM

I have been taking dilaudid for three or four years and it isn't any more addicting than anything else. Takes care of pain better though. I've taken most long acting and a lot of short acting over 12 years and have had less problems with dilaudid than anything else.

Hi Lil...

I think it depends on the type of pain you're having etc....and I totally believe in what you're saying. My current much more acute issue is this severe lower back pain that radiates...and the Dilaudid helps it immensely.

I'm getting an MRI in an hour or so here and so hopefully that will tell us what's up!

Thanks :)

jtroy

01-15-2009, 07:50 PM

Kira

01-15-2009, 08:51 PM

Keep in mind most "pain specialists" are usually anesthesiologists who have also undergone a period of training specifically in pain management.

This is a bit off-topic, but I wanted to say that there are a lot of PM&R docs (Physiatry/ Physical Medicine & Rehab) around here that have specialty training in pain management. My pain doc is certified in PM&R and Pain Mgmt, and Dr Steve is, too (I think). At the clinic I go to, there are also a couple of neurologists... although it is a "Pain and Headache" clinic so maybe that is why the neuro folks are there.

-----

Kandra,

I haven't heard of dilaudid being any different from the other short-acting opioids, either.

One thing I have heard about it, though, is that it is a frequent target for diversion because some opiate addicts like to extract the dilaudid from the pills to inject when they can't get heroin. That is no reason for a doc not to prescribe it for a legitimate pain patient, since just about any opiate is a target for diversion and since you aren't going to go sell your meds anyway... but that MIGHT be a reason for some docs' reluctance to prescribe it.

I personally don't do well with dilaudid. IV dilaudid makes me really sick (vomiting, headaches, itching)... lots of side effects, no real allergy. I do better with IV morphine, for some reason. Oral dilaudid was also not a good med for me. Didn't work that well and lots of side effects. But, it works great as a short-acting for a lot of other people. Just another example of a med working great for some people and poorly for others, I guess.

I am glad you are getting some relief, even if you did have to fight for it.

Kandra

01-15-2009, 09:08 PM

Kandra....the "Steves" are right as are you. Keep in mind most "pain specialists" are usually anesthesiologists who have also undergone a period of training specifically in pain management. There are a ton of "specialists" out there who, while perhaps have taken some CE or even a limited amount of intensive training, have not gone through the necessary steps to become board certified in the specialty.

Hi!

He's not board certified...he just started doing PM in November after he "retired" from his FP....and took over the other doc's practice (who was also a former FP) who was retiring for good. The practice does include anesthesiologists who only do injections. He's the one who does meds only. There's one other that does meds in this area...actually, two more but one has had "issues" in the past with the state pharmacy board. It's amazing that in this city there's not much...and everything is extremely conservative.

I remember back in 2000 when I first joined this board being advised that I should leave the state as it was well known to be at the bottom of chronic pain treatment. Believe me...they were right but it's impossible for me to leave due to finances or I would have been out of here LONG ago.

Keep in mind as well that being boarded in something doesn't mean you are going to be terrific at it. I see it in veterinary medicine also...I have worked with general practitioners who I would trust to perform all kinds of surgery far more than the bulk of the boarded surgeons but as a whole the boarded surgeons are far better at the practice, especially with respect to surgeries rarely performed.

I wholeheartedly agree with that. Being a RN who worked in critical care, I would have many times rather have had a couple LPNs work with patients who I knew were excellent nurses...however they were phased out of the CVICU setting. My point of course is that it probably applies to all sorts of specialties ;)

How about an increase in the immediate-release oxymorphone for a while since you all ready take it?

It doesn't help this particular issue...it usually works for my "usual" breakthrough pain but not this. He had told me I could take up to 6/day of those and I really wasn't comfortable doing that as it wasn't effective in the first place...and I'm not going to take a med that's ineffective...maybe I should have taken more, I don't know.

There have been times when it took 10 of the 100ug/hr fentanyl patches or 800mg/day Methadone to provide me with the relief I required...I've also taken several hundred mgs a day of Dilaudid....most people wouldn't be able to tolerate the side effects and get adequate relief from far less...however, I'm lucky to have had a doc who didn't balk at it.

You really were! In this area one is fortunate indeed to even get ONE 75ug/hr of the patch. There are many people in this area who are suffering, unfortunately.

Thank you so much..and I'm glad your pain levels are currently better!! :)

Kandra

01-15-2009, 09:30 PM

This is a bit off-topic, but I wanted to say that there are a lot of PM&R docs (Physiatry/ Physical Medicine & Rehab) around here that have specialty training in pain management. My pain doc is certified in PM&R and Pain Mgmt, and Dr Steve is, too (I think). At the clinic I go to, there are also a couple of neurologists... although it is a "Pain and Headache" clinic so maybe that is why the neuro folks are there.

Kira,

You're absolutely correct, and there are PM&R docs here who state they do PM. However, what they mostly do is injections. I don't know if its due to the insurance payments or what (I know one PM&R doc took a weekend course for injections and since then that's all she does for pain).
---------------

One thing I have heard about it, though, is that it is a frequent target for diversion because some opiate addicts like to extract the dilaudid from the pills to inject when they can't get heroin. That is no reason for a doc not to prescribe it for a legitimate pain patient, since just about any opiate is a target for diversion and since you aren't going to go sell your meds anyway... but that MIGHT be a reason for some docs' reluctance to prescribe it.

Ahh...well, I guess I was under the assumption that most of the opioides could be used for that purpose in one way or another but I can see how easy it would be to use Dilaudid. He didn't indicate he was concerned about that but it could have been in the back of his mind. He has all my records, and of course the ones that are already part of my chart for the last 2 1/2 years and can see I've never asked for anything early etc. But since he's so new to this I can see where he might be concerned.

I personally don't do well with dilaudid. IV dilaudid makes me really sick (vomiting, headaches, itching)... lots of side effects, no real allergy. I do better with IV morphine, for some reason. Oral dilaudid was also not a good med for me. Didn't work that well and lots of side effects. But, it works great as a short-acting for a lot of other people. Just another example of a med working great for some people and poorly for others, I guess.

I'm sorry it doesn't work for you..I understand those side effects, as I have the same when I get IV Morphine for kidney stones (which I haven't had for 6 years now thank goodness). Also, sometimes I think oral meds need something to potentiate the effect such as some meds given IM. However I don't know what would do that for the oral meds so...

I am glad you are getting some relief, even if you did have to fight for it.

Thank you so much, Kira. I appreciate it!

Nana4&cntn

01-15-2009, 09:39 PM

Kandra,

Kira spells it out pretty well the difference between pain docs that are Anesthesiologists. I call them needle jockeys as they are more inclined to believe ESI's will do the job.

Physiatrists are board certified in pain medicine but also are MD's who are rehab specialists. Mine focuses on meds, PT, exercise and stretches. If he feels I need an ESI he will send me to a needle jockey.

I have to have IV Dilaudid as I am allergic to IV Morphine (anaphylaxis). I find it does a great job in that setting for me. I also have problems with anything with a prefix of oxy, so long actings are out for me.

I guess what I am trying to say is each person does best with a mix of meds that work for them! Your doc should treat you as an individual not a carbon copy of all of his patients.

I know you are limited where you are, we have talked about this before. I have no idea how to get him to understand, but you really need to try and get it thru his head you are an individual, not the norm so to speak.

Kandra

01-16-2009, 03:01 AM

I have to have IV Dilaudid as I am allergic to IV Morphine (anaphylaxis). I find it does a great job in that setting for me. I also have problems with anything with a prefix of oxy, so long actings are out for me.

Have you tried one of the long-acting morphines such as MSContin or Avinza
or even the patch? Morphine IV makes me sick as a dog much like Kira described her reaction to Dilaudid...plus I do get some hives along the vein the IV is inserted into which is strange ;)

I do know what you mean by the physiatrists, but some here do their own ESI's and IMHO without much training.

I guess what I am trying to say is each person does best with a mix of meds that work for them! Your doc should treat you as an individual not a carbon copy of all of his patients.

I really agree...and I think what he's doing is following exactly what the previous doc did and will NOT deviate from that. I totally believe in what Dr. Steve said earlier in that BT meds should only be needed once/twice daily as the long-acting should be in a dose sufficient to cover it...however my doc's solution is to increase the BT meds...:confused:

I know you are limited where you are, we have talked about this before. I have no idea how to get him to understand, but you really need to try and get it thru his head you are an individual, not the norm so to speak.

nod, we sure have...want a roomie?? <g> My pain issues, as you know, don't fit into the usual niche(s). OTOH, everyone's pain is different! :)

I'm really hoping he gets more comfortable with what he's doing so that changes can be made as needed.

Thanks! :):)

lobelsteve

01-16-2009, 09:28 AM

Defining a true Pain Medicine Specialist.

Anybody can call themselves a pain doctor....

From the chiro, to the FP, to the Neurologists, Surgeons, PMR (Physiatrists, Psychiatrists, and Anesthesiologists.

Board certifications are worthless if they are not from the ABMS (American Board of Medical Specialties). Only the American Board of Anesthesia, American Board of PM&R, and American Board of Neurology & Psychiatry have subspecialty certification in Pain Medicine. All other boards are not considered "official". The American Academy of Pain Medicine is a legitimate organization that has a board exam not recognized by the ABMS, but the academy is at least working to attain a higher standard for their docs and patients. The Amercican Academy of Pain Management is thought of as a discredited board by many respected Pain Specialists.

So a real Pain Specialist provides multimodal care and does not JUST do procedures, or JUST write Rx's. The real Pain Specialist puts his hands on you in the exam room, looks at the MRI films and not the report, performs his own injections and implants, and writes his own scripts. He discusses your care with PT and the psychologist.

Anyone who offers their patients less is more interested in their money rather than the patients health.

www.abms.org
www.abpmr.org
www.aba.org

There are needle jockeys and there are pill pushers, there are myofascists, and their are undereducated regular docs who are outgunned by wise addicts.

Kira

01-16-2009, 02:25 PM

So a real Pain Specialist provides multimodal care and does not JUST do procedures, or JUST write Rx's. The real Pain Specialist puts his hands on you in the exam room, looks at the MRI films and not the report, performs his own injections and implants, and writes his own scripts. He discusses your care with PT and the psychologist.

Anyone who offers their patients less is more interested in their money rather than the patients health.

I agree with this. In fact, it is a description of a good doctor in just about ANY specialty (if you change a few words specific to pain medicine... ie "injections" "implants" etc).

I have a lot of doctors... and I got rid of a few bad ones along the way. I am pretty happy with my current team of docs. There are some situations where you don't have much choice (ER, inpatient, geography, insurance, etc). But, in general, it is so important to pay attention and make sure you can trust the doctor(s) that you are entrusting your body to. I have complicated, serious issues and cannot afford to have doctors on my team who are unqualified, apathetic, unreachable, or just plain incompetent. I learned a long time ago that sometimes you NEED to fire a doc and look for a new one.

The first doc I saw when we started wondering about metabolic diseases was an idiot. Even after 4 hospitalizations in 3 months for severe rhabdomyolysis, with grossly abnormal labs to prove it, he insisted that there was nothing wrong (I am apparently just a depressed, melodramatic hypochondriac). He seriously botched my first muscle biopsy, and once when I was inpatient he wouldn't answer my team's pages for 3 days even though he was in the hospital and even on service. If I would have stayed with him... I would be much sicker--possibly dead or a lot more disabled--and would probably still have no diagnosis.

For the most part, the doctors I am willing to entrust with my care are the ones who focus on what is going on with their specialty's organ/disease in the context of my WHOLE body and my WHOLE disease. They look at scans/tests themselves, instead of blindly reading the reports. They want to know what is going on with my overall functioning, my goals, etc. I am still working on getting them to communicate better with each other about my more complex issues, but we are getting there. They are good about at least reading each other's notes in my chart (gotta love electronic medical records). Some of them are better at this than others... my pain doc and mito doc are particularly good about it. A few weeks ago, my PT got emails from my pain doc and my mito doc on the same day. My pain doc emails the PT/OT folks pretty often, but he was surprised by the email from my mito doc, which he said was lllloooonnnngggg.

I'm rambling... just wanted to say that I agree with Steve's description of what makes a good pain doc, and wanted to encourage everyone to stick up for themselves and find a good team of docs instead of settling for the first ones you get.

jtroy

01-16-2009, 03:39 PM

Thanks to Dr. Steve for making a clarification to my reply. He's dead on about it....ultimately, pain is a monster that will not "die" with meds alone...believe me I've lived that. Initially, when it all started with me, I began my "affair" with the human side and as a veterinarian with the "focus on the root of the problem" mentality they drill in your head I went after the cause of my pain. That was when I learned that although for the most part docs boarded were preferable...there was as much inconsistency in how "good" they were..perhaps even more than we see on the veterinary side.

I couldn't even quote an accurate number of boarded neurologists I saw...perhaps as many as 15 give or take a few. After each and every roll through the doughnut or test I got the same answer...."we like the diagnosis your old country doc who is in her 70's gave you"---it's the official diagnosis on my disability forms. Finally I gave in to their advice to see another pain management specialist...this advice was given to me while in the hospital hooked up to a dilaudid PCA pump burning through 25mg on a good hour 35 on a bad one, blowing IV's and driving the hospital pharmacy nuts compounding a 50mg/ml syringe for the silly thing. That was when I met the doc I still have and to everyone's surprise discharged me after weaning the dilaudid by putting on a fentanyl patch...left with 10 on and a script that made my pharmacist's eyes bulge (thank God he was a friend and knew my situation)

I spent alot more days in there but what my pain doc did was basically force me to see a pain psychologist who taught me the basics about how to manipulate you own mind---I used the net to further to "mold" my own techniques into it...saw another neuro agreed to go to the hospital and convert to Methadone...that was when I ended up on 800mg a day which was supposed to be about a 25% reduction give or take...could never have done it without biofeedback and imagery...

I started a very slow opioid reduction while on Methadone...the techniques that are "non-med" that Dr. Steve spoke of truly do work...in the beginning it is easy to dismiss then, or not surrender to them, if they don't seem effective...given time they work better---kinda' like sex...when I was younger I thought I was a stud until my wife informed me that I didn't become one until after I'd turned 30 :) I also spent years getting to a final diagnosis that I had narcolepsy completely not related to meds...a diagnosis made by my PCP which was against what the "sleep doc" indicated. So...the meds I was put on was a complete cure immediately and then my wife noticed something....the Methadone was highly sedating and before my narcolepsy symptoms added with it made it impossible for her to tell....so she came to me and told me that she wouldn't live with my sedation along with my "out of body times" (what I look like when I'm deeply focused on a huge pain flare) and that something had to change. So I did a reduction and was able to cut it in half..but only with other techniques....rotated over to the patch with the stipulation no more than 300ug/hr....was there for over a year....today is my first day of reduction and I just applied 275ug/hr worth and I'll reduce to nothing if the Lord wills.

All that is only to intensively make Dr. Steve's point....pain is a multimodal science and "med only" docs should be avoided like the plague. Block shops aren't the answer either....the problem with us cp'ers, particularly those of us who require opioids, is that going to different docs to find the one you need looks like doctor shopping which is illegal....at best a new doc might seem skeptical. This is why I always tell newbies to this to make it absolutely clear that you are willing to sign the opioid contract at a new doc but that you are absolutely going to get a second opinion and that needs to be documented.

Everyone's right....a board certification (ABMS that is) isn't always a guarantee that a pain doc will help you in a maximal way....however, docs with only one gun in their arsenal cheat their patients out of better, fuller lives. I've only recently truly begun to live---I totally thought that I'd learned my lesson about maximal opioids (i.e., taking the max required to help w/out killing myself...."being a zombie" as my wife puts it)--I lost the first two years of my little girl's life....a life sentence for my hard-headedness and unwillingness to use those other techniques my doc wanted me to immediately.

Anyway....sorry for my novels....it's all only so that others don't follow the path I did which is a common one as a cp'er. I mentioned block shops....I've allowed my pm doc to do probably 10 or more different blocks, just about all he knows to do for head pain....didn't help at all but at the same time would have been stupid not to see just in case. Ultimately finding the complete regimen that helps a person can sometimes take a ton of visits to outpatient facilities or even the dreaded psychological world which is very intimidating, scary, and so on. However, finding that right doc and surrendering to the process will help in the long run...and that run will seem like a marathon. Wishing you all the best....I just hope that back pain eases up for you.

Regards,

T. Jones, DVM

Kandra

01-16-2009, 09:29 PM

I think my PM (the retired FP) joined this particular practice because the anesthesiologists do the injections. He's told me he was looking for something to really help people and all's he had to do was "look down the hall and see lots of people needing help." IOW, I believe his intentions are good...but as the saying goes: the road to h*ll is paved with good intentions; with our particular h*ll being severe chronic pain.

I have to say he's the only one in a long time who's actually, as Dr. Steve said, put his hands on me and do an exam. However, I don't believe he can actually look at an MRI itself to see abnormalities but then I'm not sure...I'll find out. It also takes weeks (interpret that as 2 months minimum) to get an appointment. He's "fitting me in" first week in Feb. for the back pain issue. I did have the MRI yesterday and do have it on CD. I take Coumadin and due to my medical issues can't d/c for a few days which would be a necessity before any injections. I'm not going to have a 5th DVT and 3rd PE.

I really wish I could find someone here such as Dr. Steve describes...it would be...amazing. I'd be first in line...and I've been looking since 2000 for such a doc :eek:

Kira, I understand so much of what you've been through as I'm currently going through those same issues and have been for the last few years. I do have multiple medical issues and have fired a couple idiots myself...heh. However due to HMO reimbursement most specialized docs have disappeared from the state. I need a PM, pulmonologist, and a neurologist at a minimum. I currently have them but desperately need a change as I'm tired of not being listened to..I know you understand, Kira. I'm sure all of us have gone through similiar situations :(

I'm so happy you were able to wean off all that you have, Dr. Jones :) I'm also really happy you have a PM doc that wasn't afraid to give you what was needed then AND now. I do see a pain psychologist and have for 7 years...but it's not been helpful. She made a relaxation tape for me. Great.
I also have sleep apnea and maybe some narcolepsy thrown in...not only do I utilize BiPAP but also need to take a small dose of Adderall before driving, otherwise I nod off and fall asleep which isn't a great thing to do...:eek: My problems with driving/situations needing me to be alert were occuring before I was on anything for CP except Lortabs. Congrats on your efforts to go down even further starting today!

If anyone wants to know (which I doubt...lol!) what pain/medical issues I have please feel free to PM me :)

Thank you to all!!!