Chronic Pain Management: An Appropriate Use of Opioid Analgesics

[Jack-of-all-trades]

Seems kind of an odd response from a surgeon. Did you ask him why and to explain his reasoning? There are no anticoagulants in Avinza. If anyone would object, it would be the anesthesiologist and they should easily be able to handle your Avinza dose and yawn through it. People get operated on daily with does much larger than that. Keep in mind to that, while your does is kind of high, you are taking it by mouth and oral MS is poorly adsorbed by mouth.

Tell him your PM doc will handle all pain meds for you post-op. It sounds like he doesn't know much about handling chronic pain people.

As a side note, I would talk it over with my PM doc about your kind of rapid increase in dose. You may need to change to some other form of opioid. Also realize that for the long haul, you need to be at a level where your pain is tolerable, not completely gone. Also there is a difference in pain control and the "rush" from opioids. The rush disappears long before the pain control.

I haven't been around much lately. I've been sick for over a month with some sort of sinus thing I think. I'll try to check for your response later.

[muddy]

Thank you Jack. The hospital is Cedars-Sinai of LA whose pain clinic is fervently anti-"narcotic". She may be towing the line. I sure hope that you are right b/c it kinda freaks me out e.g. if I need an appendectomy. (You seem to know what you're talking about though!).

I am far from that initial "rush" in the early days and am thinking of moving to suboxone that reportedly doesn't have a problem with tolerance (I researched this and it looked like Calvin-Cycle gobbleygook to me!). Ahh, but would this render me truly inoperable due to the naltrexone component.

I'm sorry you're ill and maybe you have sinusitis. I had it for a month, didn't realize it/why I was weak, etc. and then a cycle of antibiotics make me feel like a new man (or semi-cripple!).

Appreciate your time. Be well. - Allan

Seems kind of an odd response from a surgeon. Did you ask him why and to explain his reasoning? There are no anticoagulants in Avinza. If anyone would object, it would be the anesthesiologist and they should easily be able to handle your Avinza dose and yawn through it. People get operated on daily with does much larger than that. Keep in mind to that, while your does is kind of high, you are taking it by mouth and oral MS is poorly adsorbed by mouth.

Tell him your PM doc will handle all pain meds for you post-op. It sounds like he doesn't know much about handling chronic pain people.

As a side note, I would talk it over with my PM doc about your kind of rapid increase in dose. You may need to change to some other form of opioid. Also realize that for the long haul, you need to be at a level where your pain is tolerable, not completely gone. Also there is a difference in pain control and the "rush" from opioids. The rush disappears long before the pain control.

I haven't been around much lately. I've been sick for over a month with some sort of sinus thing I think. I'll try to check for your response later.

[Jack-of-all-trades]

Thank you Jack. The hospital is Cedars-Sinai of LA whose pain clinic is fervently anti-"narcotic". She may be towing the line. I sure hope that you are right b/c it kinda freaks me out e.g. if I need an appendectomy. (You seem to know what you're talking about though!).

I am far from that initial "rush" in the early days and am thinking of moving to suboxone that reportedly doesn't have a problem with tolerance (I researched this and it looked like Calvin-Cycle gobbleygook to me!). Ahh, but would this render me truly inoperable due to the naltrexone component.

I'm sorry you're ill and maybe you have sinusitis. I had it for a month, didn't realize it/why I was weak, etc. and then a cycle of antibiotics make me feel like a new man (or semi-cripple!).

Appreciate your time. Be well. - Allan

I hadn't thought about the use of suboxone and surgery. There are so many non-opioid drugs available these daysfor useduring surgery, I doubt it would be a problem. My wife is an anesthesis. I'll ask her and get back.

[muddy]

Wow, your wife is "in the know"? So what's her favorite charity for my hypothetical student-rate contribution.

I noted your signature and it's great how well you are doing and so fast. Do the X-Rays show fusion yet? You're lucky that you got your pain generators right - or maybe not luck.

Thank you again for your time. One thought: one sinister thing I think about opiods is that they affect other drugs' potentialities (right word?). For instance: I had a procedure and noted that the Versed barely affected me while in the old days it was a very pleasant rush. I think this is in the benzodiazapam family - and this was affected. So I wonder if other drug families used to put one under for surgery and on waking up re: post-surgical pain will work well. Naturally I fear the Nurse Ratched's (and this includes doctors) who have severe prejudices against opiod therapy for a relatively inoperable back.

Sorry to lean on you; I am studying to be a therapist and am showing scary signs of a Dependent Personality Disorder.

Chow/my best..

I hadn't thought about the use of suboxone and surgery. There are so many non-opioid drugs available these daysfor useduring surgery, I doubt it would be a problem. My wife is an anesthesis. I'll ask her and get back.

[Jack-of-all-trades]

Wow, your wife is "in the know"? So what's her favorite charity for my hypothetical student-rate contribution.

I noted your signature and it's great how well you are doing and so fast. Do the X-Rays show fusion yet? You're lucky that you got your pain generators right - or maybe not luck.

Thank you again for your time. One thought: one sinister thing I think about opiods is that they affect other drugs' potentialities (right word?). For instance: I had a procedure and noted that the Versed barely affected me while in the old days it was a very pleasant rush. I think this is in the benzodiazapam family - and this was affected. So I wonder if other drug families used to put one under for surgery and on waking up re: post-surgical pain will work well. Naturally I fear the Nurse Ratched's (and this includes doctors) who have severe prejudices against opiod therapy for a relatively inoperable back.

Sorry to lean on you; I am studying to be a therapist and am showing scary signs of a Dependent Personality Disorder.

Chow/my best..

It is just as I thought, the anesthesiology folks wouldn't have any problems AS LONG AS THEY KNOW. For instance, just this past week, she had a patient who was a 51 yo female in for a hysterectomy. She was on 125 mcg fentanyl patches change every day and dilaudid every 4 hours +valium 10mg every 4 hours. the pre-op people missed the fact that the patches most likely were not changed every day but were rotated every day. In other words she had two of the 125 mcg patches on at a time. They didn't want to put warming blankets, etc. over a patch. They got to looking around and found the other one. They can deal with it easily during surgery. Versed is a benzo. I'm not sure how it is metabolized, you could look it up. Some drugs that are metabolized in the liver use the same pathway and can either slow down or speed up metabolism of others.

When I had my surgery it was the continuity of care that broke down. Plus it was a teaching hospital that tends to be more anal about opioids. If I have any more surgeries, I'm gonnna make a sign for my bed, the door, my chest, my butt that says "opioid tolerant patient". "If you under medicate me or put me in withdrawal while I'm lying here trying to recover there will be hell to pay when I get home".

I recently had to get a new cell phone as my other one died. It is a Droid like seen on TV (Verizon). One of their free apps is called "Epocrates" It is good for looking up a brief synopsis on drugs and other info.

Also, I made a bit of a mistake in my implication about Avinza. The max daily dose is 1600mg every day.

[KBear]

When I had my surgery it was the continuity of care that broke down. Plus it was a teaching hospital that tends to be more anal about opioids. If I have any more surgeries, I'm gonnna make a sign for my bed, the door, my chest, my butt that says "opioid tolerant patient". "If you under medicate me or put me in withdrawal while I'm lying here trying to recover there will be hell to pay when I get home".

LOL... I needed one of those signs too. Not only am I opioid tolerant, but I have always had issues with medication. I will not stay numb at the dentist, they will inject and inject my mouth, and finally just tell me to "tough it out". With both of my children being born, my epidural lasted all of 30 minutes, refill, 30 more minutes, then nothing had to go without. About 50% of my procedures I have not been sedated enough, I will remember (and feel) everything that happened, when I supposedly shouldn't. It's a matter of does the anesthesiologist believe me that I am hard to sedate or not? When I had ADR surgery, I went through all of this with the anesthesiologist and she replied "this is not the same, it will knock you out" What was the first thing the surgeon said to my husband after surgery? "It took us forever to get her knocked out, that was like drugging a horse!"

[Researcher]

I am currently taking Hydrocodone 7.5/APAP 650 for pain caused by my degenerative cervical discs. This is just to get by while I determine what surgical solution is right for me and which surgeon is going to do it. To lower the pain to a point that allows me to work and do my chores around the house, I have to combine this with muscle relaxers (Methocarbomal and/or Cyclobenzaprin) and an NSAID (Etodolac). The need to do this may be partly responsible to an increase in my tolerance to the hydrocodone. I don't really like combining the medications due to potential interactions, although I have not experienced any so far. I am also concerned about the potential for acetaminophen induced hepatotoxicity. Everyone responds to medications differently, but I would be interested in hearing about which pain medications worked best for others. My pain is not severe unless I get my head in the wrong position, so I certainly don't need anything radical like a morphine pump. I'm looking for something a little stronger than the 7.5/650 that might enable me to drop the muscle relaxers and NSAID.

Thanks,

Phil

[KBear]

Phil,
Honestly, I would stick with the muscle relaxer if it is helping. I used muscle relaxers at night for sleep, and throughout the day if my pain was bad and the hydrocodone wasn't cutting it. In my opinion, the less opiods you take the better. You could ask for the hydrocodone 10/325 (this is higher dose of the opiod and lower dose of the acetamenophin). I'm not sure about taking an NSAID and the hydrocodone, but I'm assuming if your doctor prescribed you these, then it is safe. When I was at the height of my pain I took Cymbalta for pain and depression, Zanaflex- muscle relaxer and sleep, Lyrica- nerve medication, and Hydrocodone- pain. It was the combination of these things that allowed me more relief, plus I was able to keep my opiod dose lower with the other medications.

[Researcher]

Thanks, that makes sense KBear.


I'm going to talk to a surgeon on Wednesday, so I will include medication in the discussion. For readers that may not be aware, Drugs.com has a drug interaction checker that is easy to use. I put the four drugs I have been taking for pain into the checker. You can see the results by clicking this link:

Drug Interactions Checker Results - Drugs.com

It shows two moderate interactions, which come as no real surprise; if you mix opioids and muscle relaxers you get
"central nervous system and/or respiratory depressant effects"; that is, you move slower, think slower, breathe slower. I just have to be careful not to slow things down to the point where they stop.


Phil

[KBear]

Thanks, that makes sense KBear.


I'm going to talk to a surgeon on Wednesday, so I will include medication in the discussion. For readers that may not be aware, Drugs.com has a drug interaction checker that is easy to use. I put the four drugs I have been taking for pain into the checker. You can see the results by clicking this link:

Drug Interactions Checker Results - Drugs.com

It shows two moderate interactions, which come as no real surprise; if you mix opioids and muscle relaxers you get "central nervous system and/or respiratory depressant effects"; that is, you move slower, think slower, breathe slower. I just have to be careful not to slow things down to the point where they stop.


Phil

Phil- Not sure if your surgeon is your prescriber or not, but they may not be much help on knowing the mix of medications that is best. This is why it is so essential to have a pain management doctor, as they are much more knowledgeable.

On the bolded above, I read that too on a new Fentanyl medication patch I had, after I had it on and had taken my normal muscle relaxer. I was pretty convinced I was going to be dead by morning, the warning scared the sh$t out of me. I called my pm the next day and also saw my family doctor, to make double sure it was okay. They both told me that because I was opiate tolerant that it wasn't a problem. It would be more of a problem if I had never been on opiates, was prescribed them for the first time and a muscle relaxer for the first time. I would take the warning serious, but if the same doctor prescribed these medications and you are taking them as prescribed, then I wouldn't worry about it. I think that warning is aimed a lot toward abusers, people who are taking these medications in higher quantities than prescribed, or taking medication not prescribed to them and mixing them without a doctors supervision (think of all the high profile Hollywood drug overdoses, most are from this and not under a doctors supervision)