Opioids Changing Painkillers: Methadone --> ?? Suggestions?

[vintage]

For years, I have had psoriatic arthritis and psoriasis pretty bad, with the former causing the most debilitating pain, and some neuropathy thrown in lately. The severity comes and goes in breakouts, with my breakouts lasting anywhere from six months to two years, and then I'll be clear for six months to a year. So sometimes, for a year or more, I don't need any pain medications, and then I'll go through a bad breakout cycle where I'll need pain medication almost constantly. Unfortunately, I am coming off a long period of not being broke out to a pretty bad, extended breakout, that has me rotating back on to pain killers. I've always had my PCP write all my pain medications and have never been to pain management.

In the past, I was using Methadone combined with Oxycodone for breakthrough, and this worked very, very well for me. The Methadone was cheap, and I didn't need a ton of it to get relief. However, in between my last breakout and this one I moved from Texas to Delaware, and my new PCP states that he cannot write me Methadone, although he has written me just about everything else. I have been experimenting these last couple of months trying to find something that worked as well (and also allowed me to buzz out every once in a while), and have been through Fentanyl patches and lollipops, Oxycontin, Oxycodone, Morphine extended, and hydromorphone. In fact, I just returned from an appointment, and I'm currently taking 180mg twice daily of Oxycontin (3 x 60mg), and then I have 120 x 30mg Oxycodone for breakthrough. In my drawer, I have some 30mg Morphine extended (didn't do shit for me), some 100mcg Fentanyl patches, 120 x 8mg hydromorphone and a dozen Actiq 800.

My question is: Any recommendations as to something besides the Methadone that I could try that I haven't tried already, or possibly some dosages/combos I haven't tried yet? The Oxycontin/Oxycodone seems to be the best so far at controlling the pain. Hydromorphone does pretty good, but it takes 10-12 of the 8mg for me, and then they are SO short lived it's ridiculous. I could easily go through 120 x 8mg in 10 days.

The Oxycodone I don't recognize and seem different from my 15mg that I used to get. These are a small green pill with K | 9 on them. My old ones were A 214's.

Thanks,
Don

 

[TheLostBoys]

How about asking for oxymorphone, its like 3 to 4 times stronger than oxycodone........only problem is, you will have to snort the oxymorphone to make it work. (When snorting oxymorphone for long period of time, it can cause an irreversible lung problem).

Have you tried Levorphanol? Check it out........

 

[vintage]

The oxymorphone I was looking at today, and had considered adding it to my list for when I see him again in two weeks. If it's that much stronger, then that might be a good choice. Obviously, tolerance is a major issue with me, so working around that has been my biggest problem. Especially when I want to get buzzed every once in a while. Nice thing is, I have a $0 co-pay on all prescriptions, so money hasn't been a problem. He can prescribe away.

What's the bioavailability for plugging as compared to insufflation? I assume you're saying to snort because the oral bioavailability is crap?

Also, I've never looked into Levorphanol, but it's on my list, and I will have him prescribe that and the Oxymorphone next time I go.

 

[TheLostBoys]

From everything I have read because I don't plug anything myself, they say plugging is the best way to go before entering the needle route.......

Levorphanol was an amazing high & lasted for over 8 hours & was administered with a needle by my doctor as an outpatient procedure.

I've never taken them by pill form but I've read some pretty good results on this forum by pill form.

 

[fizzymk]

IDK, if your new PCP would not script you methadone, I doubt he will give u Opana..but its worth a shot I guess.

 

[vintage]

The situation with the PCP not prescribing Methadone he is presenting as a "I don't have the license required to prescribe you Methadone." This is one I've never heard of, and was always able to get it from my PCPs in Texas, but it could be some type of State restriction. Methadone is the only thing that he's balked at prescribing ... I have a pile of bottles full of painkillers to prove that ... so I tend to believe that there is some type of block, or he just doesn't want to prescribe Methadone.

Too bad the dilaudid only comes in 8mg tablets.

 

[cosmicjive]

I'm amazed that you go on off these drugs for years at a time. I'm interested in how you do that. Do you taper when the pain starts getting better? It was the on-off that got me into trouble.

When I was taking pain meds, I had cyclical pain so I only took the meds for 7-12 days a month. Well, that's what I was supposed to do, anyhow. I was prescribed Opana ER and hydromorphone for breakthrough pain. Now, a lot of people don't like the newest incarnation of the Opana ER, but I loved it. I would get a sturdy pill cutter (those pills are like diamonds...they're so fucking hard to cut), cut the Opana ER pill into eighths and then put each cut pill into about 5mls of water (I would put each pill into separate small containers), then I let the pills sit until they turned into a watery goo. At that stage, I would put the goo into an oral syringe and plug away...it was awesome. However, I will say that Opana jacks your tolerance and the withdrawals are the worst ever (for me anyhoozle).

I always IV'd my Dilaudid...I'm not suggesting that for you. However, you can plug it and it's almost as nice. Also, NEVER EVER IV Opana ER. You can read about what happens if you do on the interwebs.

They do make an ER hydromorphone. I think it's called Exalgo. However, I've heard it's not the greatest.

Also, I never knew GPs couldn't prescribe methdadone. I was always told it wasn't in the formulary. Maybe try a PM doc.

 

[TheLostBoys]

The situation with the PCP not prescribing Methadone he is presenting as a "I don't have the license required to prescribe you Methadone." This is one I've never heard of, and was always able to get it from my PCPs in Texas, but it could be some type of State restriction. Methadone is the only thing that he's balked at prescribing ... I have a pile of bottles full of painkillers to prove that ... so I tend to believe that there is some type of block, or he just doesn't want to prescribe Methadone.

Too bad the dilaudid only comes in 8mg tablets.

I hate to recommend Fentanyl but have you asked about it for your kind of pain?

As you may know, its a dangerous opiod & would be a last resort IMO........

 

[fizzymk]

The situation with the PCP not prescribing Methadone he is presenting as a "I don't have the license required to prescribe you Methadone." This is one I've never heard of, and was always able to get it from my PCPs in Texas, but it could be some type of State restriction. Methadone is the only thing that he's balked at prescribing ... I have a pile of bottles full of painkillers to prove that ... so I tend to believe that there is some type of block, or he just doesn't want to prescribe Methadone.

Too bad the dilaudid only comes in 8mg tablets.

Depends on the state you live in, but here in KY, they do have very strict rules about methadone, I think this is the most tightly controlled narcotic in pharmacies. Here in my state, only some doctors can prescribe methadone, GPs cannot anymore, this was changed couple years ago when our state decided to crack down on pill abuse. Strangely though, the pharmacy I go to does not keep the methadone in the narcotic time delay safe..?? I guess most people that rob pharmacies ask for oxy, roxi, opana, etc. though and not methadone.

 

[vintage]

Thanks to everyone for your replies and keeping it a good, informative conversation. One option that I actually discussed with my wife last night is flying back to Texas to have Methadone prescribed from my old PCP. I have my old Texas driver's license, so I can fill the 'scipts there, and then bring them back. Flying is only around $300 round trip, so I could swing that easily every quarter. This may be the best alternative, although I hate to do it. I would much rather find a good alternative.

So what I have on my list to try next month when I go to my PCP will be Opana and levorphanol so far.


As for IV'ing, I did that 20-25 years ago (I'm 46, by the way), and don't want to head back down that route. For a four to five year period in my late teens, early 20s, I was a heavy drug user, taking just about everything you can think of with a money supply to allow me to do whatever I wanted. Bad combination. Anyway, I've always kept it lightly recreational since then, and have succeeded all this time.


I do have a referral for a pain management doc, but it's been tough to find any that will accept my insurance, which is Cigna. Doesn't seem to be widely accepted up here. I'm going to cast my net a little wider and see what I can find in some of the larger metropolitan areas around here.


It's a high deductable plan so that once I'm past the deductable, everything is 100%. I was a bit skeptical, but this year, I did an outpatient surgery that basically ate that whole deductable up (and I have an FSA that matches the deductable on the plan) in January, so since then, I've been completely 100% on everything, including prescriptions. I'll have to say, I really like it.


This last week, I was hospitalized for an enlarged spleen, and had the worst time getting them to match my pain medication for me, even though in my records, it plainly showed the level of medications I was on. The last time I was in the hospital (and this will let you know how long ago that was), I was getting 100 units of Demerol every hour and a half. It was the most amazing pain killer and rush I'd had. Of course, they don't even use that any more.


At first, they tried giving me IV dilaudid, but they were freaking out that they were having to give me such large shots to match up with what I was taking orally (I usually do 10-12 8mg dilaudid at a time). So, they switched to 150mcg of IV fentanyl, which worked amazingly well, and gave me a very nice rush. They ended up leaving me on that, and doing Oxycodone for breakthrough. They were definitely disturbed by the amounts that it was taking for me, and you could tell they didn't want to do it.


And now, on to answers ...

I'm amazed that you go on off these drugs for years at a time. I'm interested in how you do that. Do you taper when the pain starts getting better? It was the on-off that got me into trouble.

What I've traditionally done is have two treatment pairs (long acting/breakthrough) and I cycle these from month to month. For example, one month, I will do Methadone/Oxycodone, and the next month, I will do my second pair. This usually keeps me from building any type of physical dependence.
Unfortunately, I have never found anything for myself that has worked quite as well as Methadone for pain, so the alternate month kind of sucks, but I have found the method works. The problem now is that I can't seem to get Methadone, so not only do I have to switch to a pair set that doesn't work as well, I have to find yet another pair set to rotate to. Well, that is if I keep my method.
And yes, I always taper when the pain starts getting better. The pain meds are always pain relief first, feeling good/buzz secondary, and if I'm not in pain, I don't take them recreationally. This has helped me, I belive, along with my method, to stay off dependency. Although I *do* have desires to use recreationally even when I'm not in pain, I'll admit that. I just don't.

I hate to recommend Fentanyl but have you asked about it for your kind of pain?

If you check the original post, yes, I have some 100mcg patches, as well as Actiq, which are the fentanyl lollipops. It works quite well, however, I know that it's quite addictive, even more so than most painkillers I've taken, thus I've sort of skirted around it. The fact that you're being dripped the medication constantly, 24/7, I suppose is what's worrying me when it comes to dependence.

Depends on the state you live in, but here in KY, they do have very strict rules about methadone ... Here in my state, only some doctors can prescribe methadone ...

Then this may be exactly what I'm running into here in Delaware, although I will be honest, I have been lazy and haven't done any research on it at all. Texas, as a rule, is quite lax on just about everything. Delaware, on the other hand, seems to be quite anal about everything I've run into. In a few years, I'll be retiring and moving into the PA mountains, so it will be interesting to see how that works out.

 

[vintage]

My morning starts ...

 

[TheLostBoys]

The reason the doctors & nurses were hesitant about giving you those strong high dosage meds was because they probably didn't see many people like you needing that much & probably wondered how you got to such a high tolerance.

Some people no matter what can not understand the other persons pain & they don't want to believe someone can be in that much pain until they are going thru it........its a shame but you know how the difference of opinion & how these doctors minds can vary.

 

[TheLostBoys]

Vintage, is that your morning dosage? That's some serious meds but then again, pain & tolerance are the enemies that we have to deal with all the time........

 

[vintage]

The reason the doctors & nurses were hesitant about giving you those strong high dosage meds was because they probably didn't see many people like you needing that much & probably wondered how you got to such a high tolerance.

Yep, that's what I had figured, and it lined up with some of their comments. They told me at one point "we don't have anything that can match what you're taking". I was nice, but told her I called BS ... it's a hospital, and of course you can match it. It's just whether you WANT to match it. While in the ER (it took 14 hours to get to a room), I started out just using my stuff for breakthrough, but when I got to the room, the first doctor I saw actually listened and matched me up with the Oxycontin, and then large Dilaudid shots for breakthrough.

Vintage, is that your morning dosage? That's some serious meds but then again, pain & tolerance are the enemies that we have to deal with all the time........

That is indeed my morning dosage. The oxycodone is to get me started, since the Oxycontin takes a while to kick in. Unfortunately, I've had a tolerance like this for most of my life. Even when I stay off narcotics for a year or two, when I come back, I have to start strong.

 

[cosmicjive]

Good luck to you!

You know one thing I thought of while reading this...and perhaps this something that you've already considered, is an internal pump; I don't mean a PC pump like you get after a big surgery (although, they should have given you one when you were in the hospital and adjusted your dosage accordingly), I mean the pumps they implant under your skin. It sounds like you have a long enough/serious enough background with pain to be a good candidate for a pump. I know they can use morphine, Dilaudid, probably whatever works best for you. The only thing I don't know is if the internal pump is limited to certain kinds of patients (e.g. terminal patients).

 

[TheLostBoys]

^^^^

I knew someone that should have been on internal pump because he had so many surgeries through out his life & then beat cancer several times, had both knees replaced, had his stomach removed & had the bag on the outside where his wife would help him clean it.

I could go on & on & still they would only give him the 20mgs of OP......I don't know how that guy handled his pain & he would complain once in a while but he should have definitely had an internal pain med pump.

Just goes to show you that you gotta find the right doctor/compassionate doctor willing to help you with your pain.

 

[cosmicjive]

^^^^^Jeez...I am sorry for you friend!

I don't know much about those pumps, but it totally does not surprise me that your friend wasn't getting enough medication to make it worth while. That sucks.

 

[vintage]

Thanks for the mention of the pump. That is something I had considered a while back, and got sidetracked, basically, and forgot about it.

Have an appointment with my PCP today, so I'll bring up the following with him based on this thread. And again, thanks to everyone who input. This has given me a number of directions to go in, and I'm definitely hoping again.

PCP Talk Today: oxymorphone, levorphanol and a pump.

My pain ratcheted up these last couple of days, and yesterday, I ended up taking 210mg of Oxycodone for my evening breakthrough. Now you can see why I'm looking for other options.

Again, thanks everyone!

Will give an update this evening after I see the doctor.

 

[TheLostBoys]

Vintage, you are very lucky that you have a compassionate doctor willing to give you all the pain meds you need.......there are others out there with similar pain that would never receive the pain meds you are receiving......

Keep a good relationship with your doctor.......& keep us posted, hope you get something that will work for the long haul.

 

[fizzymk]

DAMN...thats alot of meds just to start the day?!! LOL