From Norco to MS Contin... Did I go beyond reasonable conversion?

[thistlephile]

First, have to say... Going from hydrocodone (about 100-120 mg/day) to morphine ER in an attempt to *increase* pain control? My PM doc must be high. This shit is nonsense. Having said that, I've been on Norco for six years (10/325) for chronic pain. And for the nod. My usual regimen was 50-60 mg, twice a day. I don't do CWE, so I know I'm torturing my liver, but ANYway, I'm pretty opioid tolerant.

Then two weeks ago, my beloved hydro just stopped working for the pain. I could still manage a nod on an empty stomach, but pain relief, zero. PM doc gave me MS Contin, 15 mg. The first night, knowing nothing about conversion (or how useless this drug actually is), I took one. My pain laughed. Next morning (this morning), I took two. My pain hooted. I got smart and came here to learn about conversion (and how retarded it is to expect ER morphine to manage SHIT, much less intense pain, and FORGET the nod!), saw that I should be okay going upwards of 60 mg of the morphine. But I wanted to be "safe," so I went like this over the day: 30 mg at 8:30 a.m.; 45 mg at 3:00 p.m.; 60 mg at 11 p.m.

After that last dose, I kinda panicked. I'm not a casual user of drugs in general; I don't know about much beyond Norco. I mean, I shamelessly abuse it to a certain degree (did I ever really *need* 50 mg per dose to manage the pain? No. 20mg should have been sufficient, but 30, then 40, then 50 sure felt the hell of a lot better!), but I don't ever get reckless. So after I popped four 15 mg ER morphine pills, it occurred to me that I may have gone way over the reasonably "safe" threshold for overall daily dosing, seeing as how they're extended release and all, and I have no idea how this shit is going to process once it's been consumed.

So sage Bluelighters, have you a consensus? Am I going to start seizing in another hour or so, or am I probably okay? I know this may sound naive and amateur, but I honestly do not know if I did something stupid or not.

 

[fatstep]

60mg of er morphine is equal to taking 2 doses of hydrocodone over twelve hours, with each being about 25mg. Morphine by mouth and hydrocodone by mouth are equivalent, so 60mg of morphine should equal 60mg of hydrocodone, but it doesn't quite work out that well in reality. So maybe that'll help you realize how insufficient 60mg is. You're well safe medically. If anything, medically speaking, you probably need more to manage your pain.

 

[Kittycat5]

They are roughly 1:1 in terms of equivalent analgesia so really you underdosed taking 60mg. Now, the ER factor comes into play slightly as the time that pain relief lasts in theory should be longer possibly allowing for a lower dose of the MSO4. Also, cross tolerance among opioids may be incomplete, so it is very common when switching drugs to calculate the equianalgesic dosages of both, and cut the new one by 25% or so.

Also remember that conversion charts only measure analgesic action, nothing else. Either one could potentially have stronger effects of things like euphoria, the nod, itchiness, constipation when the switch is made.

It seems that even 60mg morphine ER wasnt doing it for you. So pushing it up to 100mg or should be fine (see above for caveats). There isnt really an upper limit for most opioids. Its a matter of what can be tolerated that sets the max.

Why arent you using a long acting like MS Contin plus an immediate release drug like Norco for breakthrough pain? Thats SOP for PM docs. And why not a switch to Percocet or some other when the the Norco failed? Dont forget non- pharmacological therapies, good diet and exercise if you can.

 

[thistlephile]

Ah, I should have added that I have a weird hx regarding non-narcotic pain management, drug allergies, and antithetical reactions to certain medications. It will better explain why my PM doc did what he did.

I am one of the 1% of the general pop who is actually legitimately allergic to all NSAIDs. Started with eye and facial swelling when I was 15 and took aspirin or ibuprofen for headaches, then progressed with subsequent use all the way to a major anaphylactic reaction -I have a lovely trach scar- from IV toradol when I was 22. Other drug allergies followed, most unusual (as in, not normally allergy-inducing meds, such as certain SSRI's). So docs have been wary and particular when they start prescribing for me. Other drugs, such as antihistamines -all of them except promethazine- produce that one rare side effect that is contrary to the expected ones: I develop skin-zipping anxiety. We're talking *unglued*. Docs tread carefully when choosing long-term prophylactic pain treatments: I've been through amitriptyline, gabapentin, Lyrica (UGH. NEVER EVER EVER EVER AGAIN), a few SNRI's, and I still feel like I'm leaving some out. Some worked, but had unliveable side effects (amitriptyline and Lyrica were the worst). The others didn't work at all. I'm still a work in progress when it comes to that. I am already on a low-dose, on-and-off steroid regimen (my condition is inflammatory), and when shit really hits the fan, if a fat Dexpak doesn't help, I wind up in a Level II ICU, mainlining steroid cocktails (I guess when I said I don't know much about drugs other than Norco, I should have clarified that I meant narcotics!) The idea with switching to MS Contin was to bridge what the PM and my Rheumy hope is just a tough flare; if this Dexpak helps, I can pick back up Norco with the expectation that it just was not sufficient unto this particular situation (although in the past, that's never happened, so I'm kinda doubting it, and hoping there is something better than morphine coming up next). Diet and exercise are my best friends and worst enemies: During rough patches, exercise is out of the question, and food doesn't stay down half the time. I am in physical therapy once a week, though, for impeded motility.
Its now almost 24 hours later, and you guys are right: Apart from being WILDLY nauseous, I was fine (meaning, not seizing, or dead... There was slight pain improvement, but nothing like I was hoping might come of potentially ODing). Thank you for your responses. My education will continue from here out, since I suspect I'm not done with new opiate transitions. Norco, Norco... WHY HAST THOU FORSAKEN ME??? <--- Another conversation for another time, but wondering what other folks did when their hydro stopped managing their pain...? (I still have a metric ton of Norco left... But afraid to mix it with the morphine, although I am beginning to realize that there just isn't much to "fear" at all where morphine is concerned.)

 

[Ilove2nod]

^Shit that is rough! You haven't tried oxycodone, oxymorphone, any other opioids besides morphine and hydrocodone for your pain? There are wayyy better opioids out there to help with pain than those 2 you mentioned... If you need something for pain, and take your pills orally as prescribed or in other words don't abuse them, I would ask to try oxycodone! It has a wonderful oral BA, and works great for pain.. way better than hydrocodone or (oral)morphine IMO! Hope you can find something that works for you.. good luck.

 

[CfZrx]

^is oxycodone as good as methadone for pain?