Harm Reduction The Pain Management Megathread (Chronic and Acute Pain Discussion) v6

[Speed King]

Hello Rtp, Jlosnow, Shain77, AnnaBanana333, CfZrz, DiciChik and SKR. Hope things are alright.
Rtp, I went to doctors and she said to stay on my prescribed dose of morphine ER 15mg 2/day. For future refrence, I will not push it with the doctor.
I have an anxiety issue that I'm being treated for. Sometimes mentally, the pain jacks my mind up and I wind up overly focused on the discomfort and pain. I am really working on it.
The doctor and I realized that I have really bad fibromyalgia and siatica that I'm aware of.
As adjunct medication to work with the morphine, I have:
Ambien 10mg,Klonopin 1mg, Lyrica 150mg, Tylenol 500mg,Naproxen 500mg and Vyvance 70mg (prodrug for dextroamphetamine).
I am working on different combinations and timing the medicine with the morphine, to help it work better. Tylenol taken with morphine increases pain relief for me.
Some days I'm pain free, a lot of other days everything hurts.
My left shoulder feels like it has been stabbed and aches and burns. Lifting my left arm and or twisting it makes crazy pain.
As far as the back stiffening up, since I've been taking pain medicine, my back has been looser. It still aches and gets stiff, but less often.
Overall, when the pain flairs up, my wrists, ankles, shins, forearms, head, back and legs hurt very bad.

AnnaBanana333,
I self medicated with alcohol, prescribed over the years opiates and psych meds.
I'm a bigger guy, 6'1, 285 lbs. I don't know how that effects pain meds. I don't have a very big opiate tolerance, but I can take 40mg oxycodone and be comfortable, I have had 3mg Midazolam and 150mcg of iv fentynal in the hospital.
All these things added to my current tolerance.
I know in my heart that if I take my time and don't pressure anyone, the doctors and medicines will work out.
Within the next 10 days, I am seeing a new primary care doctor who will in turn send a referral to a new pain doctor. I'll see him within a month, so things are progression.
I don't know if or how I should explain my tolerance to opiates and medicines that work for me. I just want to start to feel much better.
Thanks everyone

 

[SKR]

Hey SK, glad things are moving for you man well done! And in my experience, being in tears and talking about suicide due to relentless pain in your various Dr's surgeries does not mean you'll get an increase of your dosage of opiates even after being at your current dosage for a year or more, pricks. They think it's all a tolerance issue and don't want me dependent on a higher dose, but I have always advocated for a larger dose from the beginning due to the severity of my pain, it hasn't ever been controlled or successfully managed in my opinion......so I heavily supplement my prescription with oxy bought other ways, of course.

 

[Speed King]

Hello SKR, hope your feeling better today.
I understand what you are saying. I simply want to get close with my medicine. Personally, I think if my dosage switch includes dropping it 20% at first, then I at least should get that 20% back at some point.
I have to read the documents or books that say what conditions call for what medicine.
I believe I was told that my dosage was at the dosage my condition calls for.
Also my doctor said that morphine worked in such a way that body size and metabolic rate didn't effect dosage. I think that may be true.
Personally, I don't get how any doctor can eyeball pain, but I'm not going to push it with my current or future pain management doctor.
In the end, I'm happy I get anything this good at all.
I'm switching my attitude from me, me, me, to I'm greatful for what I have.
Peace,love, hugs and kisses everyone.

 

[FnX]

I have a pretty tough case in my hands. Someone I really want to help. They suffer from multiple chronic pain conditions, psychiatric conditions (susceptible to psychotic episodes at least) and they the addict mentality. Chronic spinal spondylosis accompanied with fibromyalgia, they will probably end up in a wheelchair eventually. They have been taking codeine with paracetamol/acetaminophen so much over the past 9 years along with plenty of alcohol it's basically a miracle their liver is still working. Tramadol for a few years as well, and pregabaling/lyrica + bupe patches as a new addition. Multiple typical anti-psychotics, benzos, clonidine daily and a little sodium valproate occasionally on the top. Basically everything anyone would take to help with opiate wd, except maybe loperamide and they're abusing their meds to the point they might get cut off. They have a failed surgery in the past, so their pain is for life, can't be fixed according to the doc at the pain clinic, so have to just get accustomed to it. I have never seen anyone prescribed so many meds ever before, and they're pretty much at maximum clinical doses, except for the bupe patches which have just been started. They won't get a prescription for stronger opioids like oxycodone because of their history.

Despite all this, they still complain about pain. I know they're a good liar if they want to be, but I believe them. I think the problem is that they don't get proper pain relief because they abuse their meds to get high. So far we have made an agreement that I hide the meds, I asked that if they tell me to give them back, is it ok that I won't give them back without waiting 24 hours first, they told me not to give them back before a week has passed, no matter how much they beg. I think they don't quite know what they're signing up for though, so we'll have to see.

Basically I don't know how to withdraw them to the point so that the chronic pain can be treated appropriately, because this is one hell of a cocktail of drugs. So far I have hidden all the opioids, except for a few pieces of half used bupe patches so they don't have to go 100% cold turkey. Pregabalin dosage has been cut to half, otherwise the prescription will run dry before it's renewed. Clonidine, benzos, zolpidem anti-psychotics are a plenty though. So I've come up with a strategy, quit all opioids for approx one week, then resume with bupe patches as the only opioid and see if they are enough to hold off the pain, as they're the least abusable. Pregabalin dosage will be raised back to 600mg/day if needed in three weeks. Benzo usage has to stop asap to avoid physical dependency, but I suppose it's necessary at this point. Is my strategy good? Will one week be enough to drop the opioid tolerance to a point where low dose bupe patches with pregabalin would be enough of analgesia? I have never used opioids for so long in my life so I have no idea, but luckily the biggest culprit here is mere codeine, though the tramadol can be quite a bitch too. Cannabis helps the pain, but psychotic tendencies are the problem here. Might have access to a CBD strain at some point. Good dose of benzos, clonidine and anti-psychotics is how they sleep right now, but I fear the worst is yet to come.

Regular acupuncture is one form of treatment they are taking. I am also considering taking them to yoga classes, thinking it might help.

 

[Speed King]

FnX, I have to get a notebook to make a proper reply. I will just comment on what I can remember. As far as non narcotics go, Lyrica is a great medicine (one of the best) for the fibromyalgia. Even that one on top of the bupe should be a lot of relief. If it was possible, I'd leave that one alone, but only you know the depth of the situation.(edit: I just re read what you said about the Lyrica. Those withdrawals can be evil, so good idea on splitting that in half).
Something I personally discovered is the order in which you take meds and timing make a lot of difference for me effect wise.
You have left one hell of a post. I will respond further after I map this out.
I will add that a good strain of the cannabis you mentioned would help to a point.
Also, if they are on bupe, aside from the pseudo opioid Tramadol, the other opiates you mention, shouldn't work at all with the bupe and should be taken out of the picture I would think.
Glad your helping someone who cannot help themselves.
Unfortunately, I do not know if a week off opiates will make much difference the way you want it too. If it does, I'll do it.

 

[ScuicidalNod]

Hey all-
I been in some chronic pain with my back for years. Some injuries and abuse as a kid, car accidents, etc. Lots of oxycontin, even fent. patches. Like 10 yrs.
I kinda worked through that.
Got off the opies..
I got some surgery and was doing well for months. Active and all that bullshit. Then pain started getting worse and worse.
Then I had to go in for morphine shots at the ER.
Needed norco. Morphine. Up to 120mg and oxycodone too,
And absofuculutly nothing is touching this pain.

Anyone experienced mesh-patch pain?

 

[Runtoparadise]

^Is there another name for that? I've never heard of it, & much like yourself I've been in the pain game for around ten yrs.

Rtp

 

[FnX]

FnX, I have to get a notebook to make a proper reply. I will just comment on what I can remember. As far as non narcotics go, Lyrica is a great medicine (one of the best) for the fibromyalgia. Even that one on top of the bupe should be a lot of relief. If it was possible, I'd leave that one alone, but only you know the depth of the situation.(edit: I just re read what you said about the Lyrica. Those withdrawals can be evil, so good idea on splitting that in half).
Something I personally discovered is the order in which you take meds and timing make a lot of difference for me effect wise.
You have left one hell of a post. I will respond further after I map this out.
I will add that a good strain of the cannabis you mentioned would help to a point.
Also, if they are on bupe, aside from the pseudo opioid Tramadol, the other opiates you mention, shouldn't work at all with the bupe and should be taken out of the picture I would think.
Glad your helping someone who cannot help themselves.
Unfortunately, I do not know if a week off opiates will make much difference the way you want it too. If it does, I'll do it.

So far so good, I suppose. Increasing complaints of pain and visible symptoms of withdrawal like tiredness, profuse sweating and mood swings. The thing with the bupe is, yeah, I convinced them that it simply doesn't work with other opioids like you said. But that's only half the truth. I believe it does indeed work with them if you are on a very low, analgesic dose of buprenorphine, which I figured might be best if I left unmentioned. After all, why would their doctor prescribe the patch on top of codeine (I know some doctors are plain stupid, but still, I have tested this myself in the past due to curiosity and almost had an OD)? It's just 5mcg/hour, so we are talking about a very low dose which shouldn't saturate all the receptors. Seems like the oral anti-psychotics are out of the equation though, too tiring they say, which I can only imagine on top of opioid wd. The IM anti-psychotics remain.

The timing advice is good, switched their preferred schedule of 2x 150mcg clonidine before sleep to 1x 75mcg every 4 hours to see if it offers relief through out the day without inducing extensive tiredness. There's also moclobemide in the mix now to help with the tramadol WD and tiredness. I'm spending crazy amounts of time to look for interactions, both direct and indirect through various liver enzymes and checking which drugs put strain on the kidneys, I bet I'd make a decent pharmacist. Occasional ibuprofen too, but it seems like it's not really helping at all. Don't doubt the subjective feeling of that after all those opioids at all.

I was afraid one week isn't enough, but I guess this beast should be tackled one piece at a time. Once that one week has passed, I'll try to convince them to go on for longer. Just need to find a good motivator.

 

[Speed King]

FnX, I'm so happy I'm not in your shoes.
First a deicent interaction checker is on drugs.com. You follow the directions and enter in every single drug the person is on. It will spit out every single combo, good, bad or ugly. That should help a bunch.
I agree that the liver is getting a lot of action. You didn't mention, but no alcohol.
If you want to throw in some milk thistle or dandelion tea, that should help a bit, just to be on the safe side.
It would be nice if you could get the fentynal patch bumped up over 5mg. Wishful thinking, I know. Doesn't hurt to try. As far as bupe goes, I don't know enough about it aside from the fact that Tramadol works with it. I have tried bupe on a few occasions and I found it to be strong. I still don't believe many opiates/opioids will work with it.
With all this mess going on, you want to get it simple and effective as possible.
Too many drugs are being"adjusted" at the same time, IMO.
I found that naproxen/Alieve adds to the analgesia of most narcotics, but if that causes too much issues, Tylenol will add to the analgesia as well. If you use the Tylenol, keep the dosages on the lower side to prevent liver toxicity.
Antipsychotic drugs can be adjusted so that they are not as bad as they are experiencing. Risperidone is very nice and doesn't make a person feel retarded if the dose is lower than 2 mg. Each person is diffrent though.
What is/was the dose of Tramadol, and why does it have to be tapered down right now. Just wondering. I was prescribed that. Better than nothing, but I don't like it myself.
I hope that Lyrica script refills soon. That helps a lot.

I have a genuine interest in helping you sort this out. Please PM me if you would like to talk on the fly.

 

[ScuicidalNod]

I convinced them that it simply doesn't work with other opioids like you said. But that's only half the truth. I believe it does indeed work with them if you are on a very low, analgesic dose of buprenorphine, which I figured might be best if I left unmentioned. After all, why would their doctor prescribe the patch on top of codeine (I know some doctors are plain stupid, but still, I have tested this myself in the past due to curiosity and almost had an OD)? It's just 5mcg/hour, so we are talking about a very low dose which shouldn't saturate all the receptors. .

I am on Butrans patch. 20mcg~hr I often wear 2. The low doses the patches deliver will not saturate receptors. I still get pain relief from hydro, and oxycodone, etc, when used for breakthrough pain.

I would let him use it, the dose is so low, and he's in pain...But if he wants to stop opoiods...

 

[ScuicidalNod]

^Is there another name for that? I've never heard of it, & much like yourself I've been in the pain game for around ten yrs.

Rtp

My last Doctor called it neuralgia.

I had a bilateral inguinal hernia repair, using mesh patch implants.
Now the inguinal nerve is agitated by the implants constantly.

 

[FnX]

I would let him use it, the dose is so low, and he's in pain...But if he wants to stop opoiods...

I know! It's a real dilemma, what we want to see is use, not abuse. The patch simply isn't cutting it when it comes to analgesia because of the previous abuse, so this break is all about lowering their tolerance so that the patch alone with pregabalin and perhaps a muscle relaxant (I forgot to mention there's orphenadrine prescribed too) would help. It could be that the patch dosage is too low in the first place as well. I'm not sure if the codeine and tramadol are a good idea to continue because that's their drug of choice when it comes to abuse, that why they have to be taken down. It's the mental aspect of continually adjusting your state of mind when you are uncomfortable with it. There is no logic to it either, I asked them to count their remaining meds because I knew they were taking too much, and when they realized there's too little and they will eventually run out, their reaction was to take a semi-overdose instead of starting to ration them properly. They also told me it's easier for them to quit everything at once and were slightly disappointed when I left a little bit of used patches to help as to have a very rapid taper.

But yeah, like speed king said, target is as simple and effective as possible.

 

[Jlosnow]

FnX- Wow, that is quite the list of meds! I think trying to mess with too many meds at once can end up being a nightmare for your "patient". Withdrawal from opiates is living hell and can make the mental health of anyone dive, let alone someone who has psychosis. Is there a way this person can enter rehab or tell his/her doc that they would like to stop scripts for the tramadol and codeine and instead up the bupe? Bupe is the least abusable of the 3 and offers the best and steady pain relief. What about patches instead of tabs? I understand both wanting pain relief and at the same time wanting to not be so addicted to opiates, I wish I was more help.

 

[Speed King]

^^ Jlosnow I strongly agree with you
FnX, this is an inpatient case. They could unravel and "fix" the medication issue. Everyone is diffrent. If this guy ends up having to taper at home, Gabapentin is an easy to get prescribed medicine and it seems to really help opiate withdrawal. I could explain more, but that's a whole other post and I personally don't completely understand how it works, but it definately eases withdrawal.

Try to get this guy inpatient. I hate to say it, but he sounds like a mess. A complete handful. I'm not nocking him, but the guy sounds like he needs a assistant. I really hope this gets figured out for you FnX.

 

[Rachella666]

Hi guys, hope ye are all in less pain today.? quick question, I'm on dihydrocodeine and codeine tabs for fibromyalgia. I broke my wrist last week and was prescribed 20mg oxycodone per day, zero pain relief, how is this?
I'm baffled, when I went back to my go he put me on 10mg morphine tabs, again no pain relief at all.? why do ye think it is? Is it due to what I'm already on? Any answers greatly appetite xxx

 

[Speed King]

Hello Rachella666, I'm going thru the same thing. I picked up a tolerance over the years. I think some people like myself just develop tolerance to a higher degree. Recreational use and alcohol can push tolerance rise.

 

[FnX]

Jlosnow and Speed King trust me, that's the very first thing I asked/we tried, I can't come to their doctors meetings, but at least the psych department wouldn't admit them, not before full-blown psychosis occurs (recent budget cuts I'd assume?) and the pain clinic would only do that if they were in excruciating pain and had to be put on a bed ward or needed another operation which they are unwilling to do. I am their assistant for a roof over my head right now. No formal training but plenty of experience. They are doing relatively good I guess, which surprises me, I mean they most definitely aren't okay, they might be doing a tiny bit of something other than what they are telling me (which would mean a very rapid taper, but I doubt this and want to believe they're sticking to the plan) or it could be what they told me about always hiding the pain since childhood, still hell of an achievement so far. There's osteoarthritis in at least one of the knees according to a doc who looked at the x-ray which is probably why they keep complaining about the knees the most right now. I suspect this is because of way overdoing exercise at the gym under the influence of tramadol and codeine (I mean they're not that old yet), but I don't know, not a doctor. Told them it's a very bad habit regardless and normally the pain signals are there for a reason.

Cannabis helps very much, but it can only be smoked if I'm next to them basically convincing them what they hear isn't real. You'd think a person going through all this would be content to just rest in bed, but they push themselves so hard (under the circumstances) it's silly, so they're really reluctant taking neuroleptics, except for the biweekly IM injection. Makes them too tired to do anything according to them. Now the bad news is they had to leave out of town for one day because of family drama, which will probably drain them completely. I think I'll roll some joints ready for when they come back. Good news is, there is proper CBD medical cannabis looming on the horizon, but the bad news is we can't have it until approx two weeks.

Rachella: can you get medical cannabis or pregabalin (lyrica)? Lyrica not only helps fibro pain but increases the effectiveness of opioid medicine, so it should help with the wrist issue too. There's plenty of research online to back it up too.

 

[Speed King]

FnX, glad things are okay. At least it sounds okay.
Folks, I'm posting for a diffrent reason. I'm going to confess something. I thought I might be getting a med increase, so I took more of my twice a day medicine, sometimes three or four pills instead of two. I did this because I felt I got gyped.
I mean I was taking 20 mg prescribed Percocet a day. I got switched to two 15mg morphine ER twice a day. I think they are deicent but were a little weaker then the oxycodone. So here is where I am at now. I have one 15mg morphine ER tablet to take each day till the 15th of October (17 days). I screwed up. I want to make it clear that this was not a mater of abuse, but higher tolerance and seeking pain relief. I'm ready to get scolded so bring it on. I know it wasn't the brightest idea, now I have to pay the price. The good news is I'm going to a new PM doctor. Hopefully this guy will understand that I have a tolerance that built up over 20 years. I mean, is 40 mg of Percocet ( I use that as a marker) at one time a monster dose. I don't take that high of a dose all the time, more like once in a while I need that high of a dose to effectively make me pain free.
I did figure out that Tylenol and morphine work well together. Also if you chew up a pill ,get it all liquid and swish it around in your mouth, it seems to hit me harder and stronger. Okay?im done. Good or bad, any comments? I hope everyone is doing as good as they can today.

 

[FnX]

FnX, glad things are okay. At least it sounds okay.
Folks, I'm posting for a diffrent reason. I'm going to confess something. I thought I might be getting a med increase, so I took more of my twice a day medicine, sometimes three or four pills instead of two. I did this because I felt I got gyped.
I mean I was taking 20 mg prescribed Percocet a day. I got switched to two 15mg morphine ER twice a day. I think they are deicent but were a little weaker then the oxycodone. So here is where I am at now. I have one 15mg morphine ER tablet to take each day till the 15th of October (17 days). I screwed up. I want to make it clear that this was not a mater of abuse, but higher tolerance and seeking pain relief. I'm ready to get scolded so bring it on. I know it wasn't the brightest idea, now I have to pay the price. The good news is I'm going to a new PM doctor. Hopefully this guy will understand that I have a tolerance that built up over 20 years. I mean, is 40 mg of Percocet ( I use that as a marker) at one time a monster dose. I don't take that high of a dose all the time, more like once in a while I need that high of a dose to effectively make me pain free.
I did figure out that Tylenol and morphine work well together. Also if you chew up a pill ,get it all liquid and swish it around in your mouth, it seems to hit me harder and stronger. Okay?im done. Good or bad, any comments? I hope everyone is doing as good as they can today.

It could be a tolerance issue, it could be slightly different mechanism of action at different opioid receptors, it could be the switch from IR to ER (Percocet is IR right?) or it could be the much wider variance in bioavailability of oral morphine compared to oral oxycodone. You could bring up these issues to the doctor, if he's competent, I'm sure he'll understand. Morphine has poor oral bioavailability, ranging from 20%-40% according to wikipedia, while oxycodone has 60%-87% again according to wiki. This means you should always get more out of your oxy even if your body isn't absorbing it that well, while some people get only half the effect of morphine than others according to research.

 

[BeachBum4u]

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Fuck that! If it hurts bad enough, we cry! Not trying to be a PITA but hell...