Harm Reduction I'm back (for good this time!): GP advice

[djsim]

I've moved on from the previous role which was holding back all my free time.

So...ask away...

HR questions
Want a Dr's advice? (unless you're ODing; my advice there is go to the ER ASAP)
etc

Some real case studies to come.

I'll do my best to answer what I can, but i have the time now to do so, which hasn't been so for ~7 years.

 

[crzydiamond]

OMG welcome back!! You have provided much helpful advice in the past. It's great to see your name reappear

 

[Runtoparadise]

M'k, I have a question that I can't answer. At what point would you say ketamine Infusions just aren't working for flare ups of neuropathic pain?

I'm prescribed 200mg total oxy daily for musculoskeletal pain, which works well. My flare ups are not exacerbations of this pain, but neuropathic in nature.

Ketamine is the only treatment offered to me now, I've done blocks/shots/trigger pt injections/ physio..however that's been in regard to my normal pain.

I have 1000mg subcut over 24hrs, usually for around a week. I understand ketamine helps my oxy "work better", & theoretically should calm down my excitable cns. I've been diagnosed with central neuropathic pain disorder .& or central sensitisation.

These infusions help around 50% of the time which is why I'm not sure about continuing them. It's better than nothing as that seems to be the other approach.

Thoughts or ideas?

Trainspotter/DOC was helpful but he's been AWOL a length of time. Hope he's ok. Anyone?

Rtp

 

[pinpoint]

What are tomorrow's winning lottery numbers?

Jk welcome back!

 

[cj]

Welcome back djsim!

My question is about opiate constipation. I'm on methadone maintenance. So everyday I take a dose of polyethelene glycol brand name miralax. And 2 doses of docusate sodium stool softener. Am I hurting myself by taking these everyday? Before I started this regiment I was lucky to poop once a week under great strain. Now I go everyday and it's much more comfortable.

Also a few times when I was straining to poop I would get an extreme sharp pain in my head like the worst headache I've ever had. Followed by feeling lightheaded. What's up with that?

 

[Runtoparadise]

Teh Doctor has left the house it appears..

 

[djsim]

M'k, I have a question that I can't answer. At what point would you say ketamine Infusions just aren't working for flare ups of neuropathic pain?

I'm prescribed 200mg total oxy daily for musculoskeletal pain, which works well. My flare ups are not exacerbations of this pain, but neuropathic in nature.

Ketamine is the only treatment offered to me now, I've done blocks/shots/trigger pt injections/ physio..however that's been in regard to my normal pain.

I have 1000mg subcut over 24hrs, usually for around a week. I understand ketamine helps my oxy "work better", & theoretically should calm down my excitable cns.

These infusions help around 50% of the time which is why I'm not sure about continuing them. It's better than nothing as that seems to be the other approach.

(Apologies; I replied but the reply got lost, so this reply is more to the poijnt since I'm having to retype it all ggrrr )

1. Are you taking any adjuvents besides the oxycodone? Neuropathic pain responds very well to pregabalin, gabapentin and amitryptaline
2. The ketamine infusions are giving you the best results one can hope for IME. So don't expect the ketamine to reverse your opioid tolerance, because...
3.

I've been diagnosed with central neuropathic pain disorder .& or central sensitisation.

This was what I was concerned about before I even read your post fully; your usage of long-acting opioids has induced a hyperalgesic state, whereby IME, patients simply stub their toe and the pain is unbearable. Sadly, most doctors think this is a psychological issue

 

[djsim]

Welcome back djsim!

My question is about opiate constipation. I'm on methadone maintenance. So everyday I take a dose of polyethelene glycol brand name miralax. And 2 doses of docusate sodium stool softener. Am I hurting myself by taking these everyday?

Absolutely not! I would never forego stool softener in any of long term opioid patients as constipation is a real issue in patients on long acting opioids (methadone included). It's also the main side effect which doesn't really dissipate with time. I personally prefer coloxyl (docusate) and senna, but the PEG (miralax) / docusate is fine too (very similar)

How long have you been on methadone?

Before I started this regiment I was lucky to poop once a week under great strain. Now I go everyday and it's much more comfortable.

Fantastic! Drinks lots of water, maybe try a fibre supplement.

Also a few times when I was straining to poop I would get an extreme sharp pain in my head like the worst headache I've ever had. Followed by feeling lightheaded. What's up with that?

pretty common IME. It's a typical (constipation relate) straining blood pressure spike.

Though it sounds a bit gross, if you know you're going to be really straining, an option is to get antibiotic ointment to use as a lubricant. It doubles as a good hemorrhoid preventative measure.

 

[djsim]

Teh Doctor has left the house it appears..

No, I'm here! It's just not going to be a 2hr turnaround. I can be reliable on a 24 hour time scale. Maybe quicker, but it's usually going to be that timeframe.

I'll come back to share a case study or two later on.

Any more questions, feel free to ask.

 

[deos68]

just wanted to extended a hardy hello djsim

 

[Runtoparadise]

(Apologies; I replied but the reply got lost, so this reply is more to the poijnt since I'm having to retype it all ggrrr )

1. Are you taking any adjuvents besides the oxycodone? Neuropathic pain responds very well to pregabalin, gabapentin and amitryptaline
2. The ketamine infusions are giving you the best results one can hope for IME. So don't expect the ketamine to reverse your opioid tolerance, because...
3. This was what I was concerned about before I even read your post fully; your usage of long-acting opioids has induced a hyperalgesic state, whereby IME, patients simply stub their toe and the pain is unbearable. Sadly, most doctors think this is a psychological issue

Hi there, thanks for your reply.

Yes, have been on gabapentin & endep for most of the duration, switching the above for lyrica a few mths back.

It's been confirmed by three PM specialists that I do not have opiate induced, or any state of, hyperalgesia.

Thanks again, especially hvng to re type the reply

Rtp

 

[cj]

Thanks for the reply doc. I was worried I was close to having an aneurism or something lol. I've been on. Ethadone maintenance for 2 months now. I actually find the constipation more manageable than when I was on suboxone maintenance for whatever reason. But thanks again for the response! So glad to have someone with your expertise willing to lend an ear on here

 

[missingmyheart]

How dangerous/toxic is levamisole really for an occasional cocaine user?

 

[missingmyheart]

Are you familiar with Dr. Berkson and his treatment of Hep C with alpha lipoic acid? Care to venture an opinion?

 

[djsim]

Yes, have been on gabapentin & endep for most of the duration, switching the above for lyrica a few mths back.

It's been confirmed by three PM specialists that I do not have opiate induced, or any state of, hyperalgesia.[/QUOTE]

OK, pretty clear that you've really exhausted most of the first line treatments. I do realise you didn't ask any of the above, but if I'm going to answer the ketamine question, it's pretty important I check you need to be on a ketamine infusion; it would certainly appear you've done your due diligence here.

Ketamine infusions are in the same ballpark as nootropics and such: medical science has only very recently started even entertaining the thought that the anecdotal evidence (of effectiveness) could be true. The pharmacological and physiological evidence is somewhat lacking, which is where it comes down to (doctors) listening to what works and what doesn't.

Funnily enough, patients I know who were in similar situations to yourself (on SR oxycodone) sometimes responded well to ~30mg codeine daily, and I know several pain specialists who can confirm this. I have no idea why, though I'd assume it's a pharmacogenomics / metabolism rationale.

Re: treatment options, have you tried or discussed:

1. Clonidine
2. Mirtazapine
3. Phenibut (similar to Lyrica, but more effective)
?

Best of luck!

 

[djsim]

How dangerous/toxic is levamisole really for an occasional cocaine user?

Do you mean as an adulterant?

It's similar to clozapine (the most efficacious antipsychotic) in regards to risk of agranulocytosis (white blood cells start degrading). Agranulocytosis is a really serious complication, but exceedingly rare. You'd see ~500 sepsis cases (a lot!) before even 1 of these in IV cocaine users.

I'm kind of out of the loop on this though: is levamisole used on purpose as an adulterant? ie does it potentiate cocaine high?

Are you familiar with Dr. Berkson and his treatment of Hep C with alpha lipoic acid? Care to venture an opinion?

I'd have to brush up on that: most Hep C patients I dealt with were on Incivo (telaprevir) and had been referred by a specialist. ALA rings a bell though, so I'll read up on that and Dr Berkson to refresh my memory.

 

[djsim]

Thanks for the reply doc. I was worried I was close to having an aneurism or something lol. I've been on. Ethadone maintenance for 2 months now. I actually find the constipation more manageable than when I was on suboxone maintenance for whatever reason.

2 months? OK, so you'd still be getting drowsy from the methadone? If so, then the constipation will get marginally better over the next few months

But thanks again for the response! So glad to have someone with your expertise willing to lend an ear on here

Happy to help. I'm on ORT (buperenorphine) myself, which tbh, I think makes me a lot more tolerant than some other doctors; I certainly understand a lot of these experiences either personally, or the next best thing.

 

[djsim]

just wanted to extended a hardy hello djsim

OMG welcome back!! You have provided much helpful advice in the past. It's great to see your name reappear

Jk welcome back!

Thanks all! I'm kind of surprised people remember me from 5 years ago! Either way, I appreciate the warm welcome!

Re: PMs, I will reply, I have ~15 PMs sitting in there though, so it won't be a 24 hour turnaround just yet. (And FWIW I prefer not to use PMs unless really necessary if it's about advice)

 

[Sobliss04]

New. Been using lortab, then Percocet, then roxys up the nose on year three now. I want off. I try to quit and I get so DAMN sick. Can't go to rehab. Can't tell anyone. I'm at my end. I have 24 percocets left that is the prescription from my doc. I haven't had roxys in 48 hrs. I ache all over. What's the best taper method. I have a bulging C7, but that never stopped me from life, this addiction to opiates has.

 

[jammin83]

Not sure if you can help or not, it seems like no one can really help me on this but anyway...I'll try and keep it brief.

I have been withdrawing from zyprexa for a while now. It has been over a year since I started tapering down from 20 mg. In January I switched to seroquel at 100 mg because I was down to 5 mg of zyprexa. It has been hell on earth for a long time to make it short. There was an acute phase that lasted about 3 months then I thought it was better but got worse again. I was even hallucinating for a while and it got pretty sketchy to say the least (my original diagnosis was BP II no psychosis). Parts of it come and go, mania (which I never had full blown mania before), depression, some mental stuff sure, I expect that. I am sure that what I am going through now is withdrawal and not a return of my symptoms but no doctor seems to believe me on that.

What has been troubling me has been more the neurological symptoms and I fear I may have done some permanent damage to my brain. Nausea (different from the initial nausea I got when I stopped), stomach pain, muscle tension (bad), burning sensation, paranoia, vomiting (almost every day), dizziness, and I have also developed verbal tics similar to tourettes that I think may be TD related and/or anxiety related, dizziness, loss of coordination, that kind of thing, it doesn't seem to go away.

In the past couple of weeks I have been taking 5-10 mg doses here and there of zyprexa and it helps some with the depression and anxiety but it doesn't make everything go away. I really don't want to reinstate it and taper even slower and go through what I went through again. I really can't go through that again. Not possible. It seems this stuff is impossible to come off of. I still take neurontin and want to stop taking that too at some point but am trying to get off of this first. Im considering reinstating and tapering, but now I have seroquel in the mix too that I still take 100 mg of. I was down to 25 mg at one point but it flared up again.

I've been to the doctor and told him what my symptoms were with the nausea and stuff, I tried explaining it to him but he was a total prick and didn't even listen to what I was trying to tell him and he sent me home with a bipolar diagnosis at a walk in clinic. Waste of money. Anyway not sure what to do here and most docs don't seem to know much about this type of withdrawal. I am scared about what's happening with my brain. Feels totally fucked up and I really can't take much more of this. It has been hell for almost a year.

So right now I am on 900 mg of neurontin at night (seems to help some with the wd but not looking forward to WDing again after this)
100 mg of seroquel
Some zyprexa at around 10 mg for relief.
I also supplement with 5000 mcg B12 (sl) and a magnesium supplement (both help)


Have access to plenty of meds and drugs none of it is helping. I think I fucked something up in my brain, I know that doesn't sound reasonable but I've been in the same place for a while now)

Drink alcohol and smoke weed to cope, I know it's counterproductive but I'm on the edge here.