Advice please -- medications (tolerance vs. opioid-induced hyperalgesia)

[muddy]

Hi. I'll post my profile tomorrow. I had an opinion at UCLA by a conservative doc who said that I'm not a surgical candidate due to extensive DDD and that my L stenosis pain (like a baseball bat on the shin) cannot be taken care of by a foraminotomy b/c the facets compress against the foramen(s).

Saw a PM doc at UCLA who put me on Avinza 30 mg; then, 2 months later, went up to 45, and now it's 60 mg (plus Celebrex 200 mg/twice/day). I got a referral to another pain med doc/interventionist (just responded well to a two level facet injection) and she wants me to taper off opioids ASAP or go into detox. I must attend school but could over summer.

My sense is that a good PM doc will experiment with different Rx's and "mix it up". She was concerned about opioid hyperalgesia. From my limited reading, this can present as a sorta CRPS thing *and* increased tolerance. I will get more surgical opinions for if the formens are stenosed fully and I'm not responsive to a trans ? foraminal injection that worked (as did an S-I joint injection) that I'll want my leg sawed off.

What should I do? Should I see another PM doc who will even go higher on Avinza (I can think on it!), start PT and continue vigorously (am deconditioned), or truly give merit to tapering now while doing PT (this concerns me b/c of pain). Also, I want to lower my Celebrex dosage due to cardiac risk (at this dose 3X heart attack risk) plus it makes me sick to my stomach (despite taking Nexium for GERD).

In short, and b/c I am seeing my internist tomorrow, I don't have time to educate myself which I know is lazy but:

Am I already experiencing hyperalegesia by virtue of my tolerance?

Any suggestions will be taken seriously. This is all probably here but I got a call-back from the "fundamentalist" PM doc who said I must taper now or go into detox and am not sure if I should go with her or see someone who will give me such narcotics as I start PT to break the deconditioning syndrome and get opinions re: what do I do when fully stenosed.

Thanking in advance; apologies for my intellectual laziness.

m

[muddy]

Night, woke up.

Now that was a sad, needy post. Good form.

My hope is that this tolerance is less a reflection of opiate hyper-analgesia but I don't know enough to judge. Nor do I know if the morphine is intensifying pain.

This is a good site re: long-term opiate use for non-cancer patients. I doubt that my tolerance as they state is from my pain intensifying though. (I got this site from a forum many of us know from a radiologist (formerly an interventional type) who read ~ 5000 journal articles before going for an ADR (my type of guy!):

Pain Medicine & Palliative Care: Pain Medicine

This subject is fascinating and I wish I knew molecular biology to better understand this stuff.

Best - ans

[Katie]

Hi Muddy, and welcome.

I can't speak to your physical problem, but can give you my experience with pain medication.

I have gone through a great number of different ones because I am allergic to many. Naproxin put me in anaphylactic shock, amytriptilene (sp??), an old anti-depressant also used for pain control gave me horrid nightmares, on and on. Spinal injections did not help, although accupuncture did to some extent.

My conservative family doctor put me on low, low doses of morhine and I was suffering badly for over a year. I finally found a wonderful pain management doctor who increased my dose, and also played around with a few more before just sticking to what worked.

We had to increase the dose to a significant amount, but it is keeping me pretty comfortable. Once we hit the right amount, I have not had to increase it, and the only change has been to start using long acting as well as short acting to get me through the night and day. The LA really only lasts for about five to six hours, but it still is a great improvement. When it was tried before, it was too high a dose and made me quite ill.

Anyway, I have checked with several doctors and pharmacists, and they all said as long as I take it correctly as directed, I cannot take too much. That the dose is fine and I can stay on it as long as necessary.

Of course I will have a hard time coming off it when the time comes, when I finally have my surgery. We have a plan for that, using Suboxone, but that is a whole other story. To try and force someone in severe pain to reduce their pain medication 'in case' they have possible problems is not ethical in my opinion. What else are we supposed to do?

Again, this is just my opinion and experience with several years into this pain journey. Others may have another view. I would find another pain specialist to help if I were you. I think, after reading many posts on this board, that the doctors down there are much more conservative about narcotics than here, or else I just was very lucky with finding a good doctor.

Good luck with this.

[Justin]

My sense is that a good PM doc will experiment with different Rx's and "mix it up". She was concerned about opioid hyperalgesia. From my limited reading, this can present as a sorta CRPS thing *and* increased tolerance. I will get more surgical opinions for if the formens are stenosed fully and I'm not responsive to a trans ? foraminal injection that worked (as did an S-I joint injection) that I'll want my leg sawed off.

Hi Ans,

A good pain management doctor will try many different prescriptions, most of them non-opioid. In my opinion, opioids serve their purpose in the short-term. Long-term use is not ideal, and as you mentioned, there is concern about opioid-induced hyperalgesia with patients on long-term use.

In terms of injections, I had no relief from transforaminal lumbar injections in 2008, but had instant relief with sacroiliac joint injections a couple weeks ago.

What should I do? Should I see another PM doc who will even go higher on Avinza (I can think on it!), start PT and continue vigorously (am deconditioned), or truly give merit to tapering now while doing PT (this concerns me b/c of pain). Also, I want to lower my Celebrex dosage due to cardiac risk (at this dose 3X heart attack risk) plus it makes me sick to my stomach (despite taking Nexium for GERD).

This is not medical advice and I would consult with your treating physicians about changes in your medications. Anyway, I was in a similar situation--on high doses of opioid medications (Fentanyl, oxycodone, etc.) and I decided to taper off them as I knew the opioids were keeping me in pain. Once I got off my narcotic-based medications, my entire world changed.

Celebrex is a great drug, except at high doses like you mentioned. Do you get relief while on Celebrex, despite it's side effects (do the benefits of taking it outweigh the risks for you?)?

In short, and b/c I am seeing my internist tomorrow, I don't have time to educate myself which I know is lazy but:

Am I already experiencing hyperalegesia by virtue of my tolerance?

With tolerance, your body requires an increased dosage to achieve the same therapeutic effects. Essentially, your body gets "used" to your dosage and requires an increased amount to be "effective."

With opioid-induced hyperalgesia, you actually become more sensitive to the pain you are experiencing, so with increased dosages you actually will experience more pain.

It's hard to separate out tolerance from opioid-induced hyperalgesia, but they are distinctly different. (I'm not sure if I did "justice" to them above).

This is a good site re: long-term opiate use for non-cancer patients. I doubt that my tolerance as they state is from my pain intensifying though. (I got this site from a forum many of us know from a radiologist (formerly an interventional type) who read ~ 5000 journal articles before going for an ADR (my type of guy!):

Pain Medicine & Palliative Care: Pain Medicine

This subject is fascinating and I wish I knew molecular biology to better understand this stuff.

Best - ans

Great thanks for the link, ans!

BTW: how did your appointment go today?