Lortab for Pain... I'm concerned about my liver

[wildcardlv]

I have been reading bluelight posts for a while now, so I kind of have a basic understanding about the medications I'm on. I am really bad about remembering how many I have taken or when because of a crazy busy work/school schedule. The level of pain isn't very helpful since my back just always hurts (military injury) when it flares up... The drugs do little more than make me able to get through the day like a normal person (I.E. not laying around in bed all day). So anyways when I'm in pain I just take two doses per day so that I don't take more than 4,000mg of APAP. One when I wake up and one more sometime throughout the day.... 4 pills at a time of Hydro 10/500's per dose


My back normally only gets bad two or three times per year so I never really worried about liver damage in the past, but this past year I have been on and off of bad spasms/pain for about 9 months. So I'll go maybe a week of bad pain with that type of dosing (2 doses per day, 4 pills per dose), and then a few days/weeks of no pain/no meds. I'd say the longest period I've stayed on that type of dosing is maybe 2 weeks.

I was wondering if you guys think I'm completely killing my liver. I never take more than 4 grams of APAP per day (well… I did a couple of times before I did some internet research about APAP), but I take twice the single dose limit every time I take a dose... Anything less does nothing for my pain and stronger types of opiates make me sick. I tell my doctor I take two at a time/4 times day because I don't want him to freak out... I know that's stupid, but I kind of told him that once back when my pain wasn't so chronic and I wasn't worried about my liver.

Oh and I don't CWE because I'm only taking 4 at a time and when I tried it a few times I lost enough of the opiate that it didn't help with the pain... Or maybe the APAP helps... I don't know.

Ideas?

 

[Swimmingdancer]

3000 mg to 4000 mg (depending on the source) is considered the maximum safe amount of APAP to take in a 24 hr period, but that does not mean taking the maximum every day is safe. Plus some people are more sensitive to APAP and liver damage than others. And you are taking 2000 mg per dose. You are taking 4000mg APAP per day for up to 2 weeks at a time, and on a fairly regular basis? I really don't think this is a good idea. Could you maybe work on your CWE technique and CWE larger amounts at a time?

 

[wildcardlv]

Thank you for your reply Swimmingdancer.

I have thought about doing that, but I feel like I am walking on the line of becoming addicted as it is.... I don't want to become dependant or addicted and have talked to my doctor about that. All he did was give me oxy so that I wouldn't have to dose as often... But the stronger stuff was just making me sick and I couldn't operate at work and school (I was falling asleep).

I like the hydro's becuase I feel like I can control myself. The problem is that I just keep developing more and more of a tolerance which has taken me to the total safe max (daily) amount. I stopped drining alcohol completely while on meds and even for weeks after I'm off them, and occasionaly take the recomended stuff I found on this site (milk thistle and the acy-blahblah... can't remember the correct name) but just like with the hydro's I am just too busy to remember to take them or even if I HAVE taken them... (I'm in a particularly demanding field of Graduate School).

Also, I am taking 2000mg per dose... not 1000mg. I know I should take a stronger opiate, but that scares me, and short of failing school and quitting my job so that I can lay in bed all day I don't really see an alternative.

Do you have any other recommendations that I may have missed while searching bluelight?

 

[Swimmingdancer]

Sorry 1000 was a typo - fixed

By CWE larger amounts I didn't mean take larger amounts, I meant like CWE a few days supply instead of one dose at a time. CWEs tend to work better that way and you would lose less hydrocodone. You could measure the liquid to determine how many mg per ml is in it and use a measuring syringe or something.

I think you are wise to avoid switching to a stronger opioid.

Take the milk thistle every day instead of just occasionally. Milk thistle can really help.

If you do decide to switch to a different med surely there must be something in between hydrocodone/acetaminophen 10/500s and oxycodone? Was the oxycodone Percocet (oxycodone and APAP)? What about trying dihydrocodeine without APAP, or hydrocodone with aspirin or ibuprofen instead of APAP? Ibuprofen and aspirin still have about the same daily "safe" maximums as APAP but are way less hard on your liver. Taking lots of ibuprofen on a regular basis can cause stomach/gastro problems for some people though.

 

[Alex000]

First of all, with the 10-500's, as you are dosing them, I would suggest CWE'ing! And, milk thistle is a very good idea, too. But, there is an option, which I might recommend, if your doctor is okay with it, which he probably would be, to switch to the 10-325's (Norco 10's). Those contain 10 mg hydrocodone, but only 325 mg APAP, and not the 500 mg APAP you have to take with the 10 mg hydrocodone as of now. I would still recommend, STRONGLY, CWE'ing the Norco's if you were to get them, because it would just make it so much better on your liver to do so. Even what we think of as small doses of APAP influence the liver negatively, and APAP really is very dangerous to the liver. Chronic dosing of the same amount of APAP per day is more dangerous, obviously, than dosing the same amount of APAP per day for only a few short periods here and there, BUT even acutely, APAP can harm your liver.

Another idea - switch from the Lortab to oral morphine. Oral morphine, at the right dose, is very good for pain, and is longer lasting than hydrocodone would be, even if the morphine is instant-release. But, there are a number of extended-release morphine formulas you might benefit from like MS-Contin or Avinza, for example. I think a lower dose of oral morphine, throughout the day, would really help the pain and would become quite tolerable if the dose were low. As of now, you are taking 40 mg hydrocodone two times daily, so I'd probably recommend starting at a low dose of maybe ~ 30 mg morphine (orally) over a 24-hour period, with an increase if needed. The only problem I might see with that would be the sedating effects of morphine, but this would be a lower dose in terms of how much "opiate" there is, and I think if you could play around with the dose of oral morphine, very slowly upping it until you have a good amount over 24 hours where you are not too sedated but are in a state of much less pain, you could find the right dose for you. You might find the initial low dose would be very little in effect compared against your current dosing, so that is why I say I think it could be upped from a hypothetical 30 mg/day. But, different people respond to different opiates differently. You could keep a lower dose of the hydrocodone for breakthrough pain, when it really flares up, and use that on top of the morphine, if you decide to try that route.

I might also suggest you look into NSAID's such as ibuprofen, naproxen (both OTC), or maybe others that are rx, to see if they would help at appropriate doses in addition to opiate therapy, or even alone. Another thing I would look into would be Lyrica or Neurontin, both having good analgesic properties by themselves, and when combined with opiate therapy for pain management. Soma is another potential option for pain relief, but I would reserve that more for as needed use, and not daily use - only for when the pain would get really bad or the muscles would tighten. Just throwing out ideas. You could look into tramadol, too, at lower doses, and see how that might work for your pain, and if you could tolerate it.

So, do stop with the APAP somehow, some way - even if you have to CWE, but do so ALL OF THE TIME, and use that milk thistle even if you aren't taking the APAP - it will help your liver from what it has gone through. Switching to Norco sounded better to me initially than it does now, for you will still end up consuming a fair deal of APAP if you do not CWE, and with a CWE, I doubt there'd be a difference if done properly. So, maybe CWE if you want to stick with hydrocodone/APAP, or as I suggested maybe try oral morphine as an opiate analgesic for round-the-clock control, starting at a lower dose and gradually feeling out what doses are better for you. Tramadol is another potential option, I think, if you could tolerate it. With either, I would suggest that you spread the total daily dose out more throughout the day into smaller doses, allowing for some build-up in the bood, and a steadier relief. Above, I stated a few other drugs that could be of help, but ALWAYS know what you are taking, and how it is effecting you, the safety of it, the risks etc. Education is very important on drugs, used for whatever reason, because they are potentially very dangerous. One more thing - in July 2013, it is planned that a pure hydrocodone product will hit the market (no APAP, nothing, just hydro), and that could be an option then if you wanted to switch back from whatever meds you end up on, or add that in somehow. You could always talk to your doctor very openly, and ask about him prescribing a compound of pure hydrocodone for pain relief now, and why that would be reasonable, because he can and there are pharmacies that compund special rx's like that. It is not unheard of at all, though not terribly common. This might be a very good option.

 

[Swimmingdancer]

to switch to the 10-325's (Norco 10's)
....
I might also suggest you look into NSAID's such as ibuprofen, naproxen (both OTC), or maybe others that are rx,
....
Tramadol is another potential option, I think,

All good suggestions. I have actually found some prescription anti-inflammatories (such as ketorolac, diclofenac, etc) more helpful for pain than hydrocodone.

 

[Alex000]

Yes, some report VERY good results with NSAID's, non-rx and rx.

 

[tyrael]

I....I was wondering if you guys think I'm completely killing my liver.... Anything less does nothing for my pain and stronger types of opiates make me sick. I tell my doctor I take two at a time/4 times day because I don't want him to freak out...

I'm surprised no one has suggested to the OP to go back and see his GP! As others have said, although technically below the suggested toxic level, chronic use of paracetamol isn't health or good for the liver.

I wouldn't worry about making your doctor "freak out"! By the sounds of it you have a legitimate condition, seemingly (quite/often) negatively effecting your life, there's no problem here at all to insist on alternatives! You say opiates make you sick, there are more options then narcotic analgesics. There may be a need for a combination therapy. (for example, low doses of a narcotic in addition to other analgesics, anti-inflammatories, steroids).

An aside, pain - it's causes, diagnoses/treatments, and (physical, physiological, and physiological) effects of acute v. chronic conditions are all - being (re)investigated and quite different approaches taken (in terms of these ^^^ ). The prevailing thought is of (chronic) pain as a condition in of it's own. Obviously there's still the association to (specific) cause(s), yet in chronic conditions the pain being seen as taking on a life of it's own!

Good luck mate, keep us posted on your progress

 

[tokenname]

it's common for anyone to develop a tolerance to opiod/opiate chronic pain treatment.
md's know this.
i'd think your best bet is to speak to your md about your concerns.
you mentioned spasms..
why not a muscle relaxer as an adjunct to your lortab?
could help you cut back your dose.
good luck.

 

[Cane2theLeft]

^ I would also recommend adding a muscle relaxant or benzodiazepine because they can treat muscle spasms (and subsequent pain) far better than opioids do. A good regimen of core-strengthening exercises and PT can go A LONG way in minimizing back pain as well.

There are a lot of other medications than can produce opioid-sparing effects so you get more pain relief from less opioid. These include (but are not limited to) tricyclic antidepressants, anticonvulsants such as lyrica (which has muscle-relaxing effects as well and taken daily may help prevent pain flare-ups), NSAIDS as has been mentioned, cannabinoids and others.

Lidoderm patches are another novel way to treat back pain that I found partiularly effective. They are a patch that contains a local anesthetic that numbs the area quite well for 12 hours at a time. I found these similar to putting a strong ice pack on the area without the cold or discomfort.

I also found personally that taking opioids for my back and leg problems exacerbated the problem in some ways because while on them, I wasn't as careful about posture and activity that made the pain worse. When you take away the warning signal, it's easy to engage in activities and so forth that make the pain worse or cause it to remain bothersome for longer periods.

Transcutaneous Electrical Nerve Stimulation (TENS devices) can be another effective way to treat the pain and minimize the hydrocodone you are taking.

Lastly, tramadol may be an effective alternative to the hydrocodone or supplement to it so you can reduce your doses or frequency.

 

[Swimmingdancer]

A good regimen of core-strengthening exercises and PT can go A LONG way in minimizing back pain as well.

^This. I was skeptical that anything other than opioids could help my back/neck pain, and taking drugs seemed a lot easier, but I went to the physio a lot and did a lot of intense yoga (you can/should start with the gentle yoga though) and it made a huge difference. Opioids actually made the pain worse in the long run, as it enables you to not work on fixing the cause and can eventually make you more sensitive to pain.

 

[wildcardlv]

Hi everyone,

I have been busy and haven't checked up in a while and would like to keep everyone posted just in case there are others with similar problems.

I'd like to thank you all for the time you have taken to offer me advice. I didn't mention it before, but I am also on benzodiazepine for spasms as needed and a daily dose of Neurontin. The Valium didn't really help so I don't take it much unless I was getting spasms in the evening and needed to sleep. They are awesome when combined with lying down, haha.

As for the Neurontin, my doctor has had me slowly increasing the dose I'm taking to see if it helps, and I am up to 600mg once daily and it really seems to help a lot! I didn't see much of an effect from it at first and was skeptical but once I got to around 400mg they really started to help me a lot. Once they started to take effect I felt like my old self again and the pain was down to a much more tolerable level. One thing I don't like about it though is that if you forget to take a dose or run out, they take a while to become effective again. I didn't plan ahead once around a week ago and ran out of my prescription... Two days later the full force of the pain was back and I was taking the heavy dose of lortabs again for about 5 days. But they are working again and I'm back in the gym doing a lot of core exercises and feeling great.

As for the CWE I did... It didn't really seem to be very effective. I think maybe the APAP has more of an effect on my pain than I thought. I still got the 'buzz', but my pain wasn't really helped. With the Neurontin I'm hoping my tolerance will drop back to a safer level and I've programmed my phone to remind me when to get refills and when to take my daily dose.

Anyways, that’s my update! I’ll keep you all posted if anything changes but I have really high hopes for the Gabapentin. It feels really good to be clear headed on a normal basis. Thanks again for all of your support and ideas! You have all been great!

 

[8000 RPM]

I'm in a similar situation as the OP. I hope some of my questions may be able to help both of us and anyone else who has been on an APAP containing opioid for a good length of time.

I've been taking 4-6 10/500 Lortabs per day for pain from a back condition. After hearing more and more bad things about APAP's effect on the liver, I've switched to a non-APAP medication regimen. However, I've been very worried lately that I may have damaged my liver during this time.

1) I feel physically fine and all of my bloodwork panels (CBC - Complete Blood Count) have come back normal, but I've never had any specialized test done on liver function. Is it possible that there might be any fair amount of liver damage that I'm just not seeing yet?
2) Could the effect any damage from 2-3g APAP, for three years, on the liver for 3 years be reversable?
3) Is there anything else that would help liver recovery besides milk thistle, high water intake and no alcohol? Would continuing on non-APAP opioid medications slow my liver from healing?
4) Is there a specific type of blood test that is best for evaluating liver condition?

Thanks in advance for any help. Just have been getting pretty nervous lately about this...

 

[Swimmingdancer]

1) I feel physically fine and all of my bloodwork panels (CBC - Complete Blood Count) have come back normal, but I've never had any specialized test done on liver function. Is it possible that there might be any fair amount of liver damage that I'm just not seeing yet?

A CBC only provides information about the kinds and numbers of cells in your blood, you need to get liver tests/liver function tests done. Just ask your doctor to order a liver panel. Even liver tests are not perfect, because they are indirect measurements from the blood to try to assess what is happening in the liver. They are just a guide for your doctor along with patient history, symptom questionnaire and physical examination, to aid in the diagnosis and management of a number of liver problems. But if you feel (and look) completely fine and your liver panel comes back completely normal then you most likely have nothing to worry about. A liver panel varies depending on where you live, your insurance, and the doctor and lab, but the specific liver tests done can include:

- Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) - some of the most commonly used indicators of liver damage
- Alkaline phosphatase - elevation of this enzyme may be found in drug-induced hepatitis (as well as many other disorders) and is used test to detect obstruction in the biliary system
- Bilirubin - the main bile pigment, which can be elevated in many forms of liver disfunction
- Albumin - chronic liver disease can cause a decrease in the amount of albumin produced, and therefore a low level of albumin in the blood
- Total Protein – measures albumin and all other proteins in blood

Depending on the doctor and the lab, other tests that may be included in a liver panel are:

- Gamma-glutamyl transferase (GGT) – another enzyme found mainly in the liver
- Lactic acid dehydrogenase (LDH)
- Prothrombin time (also called the “protime” or PT) and/or INR - the liver produces proteins involved in the clotting (coagulation) of blood; the PT measures clotting function and, if abnormal, may indicate liver damage

Then there are other more specific tests that may be done if you get an abnormal result on one of the above tests, or there is another reason to suspect you may have a specific liver disease.

2) Could the effect any damage from 2-3g APAP, for three years, on the liver for 3 years be reversable?
It really depends how bad it is and whether you stopped the APAP in time. I would guess it's likely reversible (assuming you have any damage at all).

3) Is there anything else that would help liver recovery besides milk thistle, high water intake and no alcohol? Would continuing on non-APAP opioid medications slow my liver from healing?
There are some other supplements/vitamins/herbs you can take to help cleanse/heal the liver. Other drugs can definitely affect the liver, especially if it is already damaged. For example, when people start on methadone they generally have to get a liver panel and viral hepatitis tests done.

4) Is there a specific type of blood test that is best for evaluating liver condition?
As mentioned above, a full liver panel test.

 

[8000 RPM]

Very informative reponse. It's much appreciated and it gives me a starting point. I'll start looking into herbs/vitamins that help with liver health, get a liver panel very soon and take it from there.

1) I feel physically fine and all of my bloodwork panels (CBC - Complete Blood Count) have come back normal, but I've never had any specialized test done on liver function. Is it possible that there might be any fair amount of liver damage that I'm just not seeing yet?

A CBC only provides information about the kinds and numbers of cells in your blood, you need to get liver tests/liver function tests done. Just ask your doctor to order a liver panel. Even liver tests are not perfect, because they are indirect measurements from the blood to try to assess what is happening in the liver. They are just a guide for your doctor along with patient history, symptom questionnaire and physical examination, to aid in the diagnosis and management of a number of liver problems. But if you feel (and look) completely fine and your liver panel comes back completely normal then you most likely have nothing to worry about. A liver panel varies depending on where you live, your insurance, and the doctor and lab, but the specific liver tests done can include:

- Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) - some of the most commonly used indicators of liver damage
- Alkaline phosphatase - elevation of this enzyme may be found in drug-induced hepatitis (as well as many other disorders) and is used test to detect obstruction in the biliary system
- Bilirubin - the main bile pigment, which can be elevated in many forms of liver disfunction
- Albumin - chronic liver disease can cause a decrease in the amount of albumin produced, and therefore a low level of albumin in the blood
- Total Protein – measures albumin and all other proteins in blood

Depending on the doctor and the lab, other tests that may be included in a liver panel are:

- Gamma-glutamyl transferase (GGT) – another enzyme found mainly in the liver
- Lactic acid dehydrogenase (LDH)
- Prothrombin time (also called the “protime” or PT) and/or INR - the liver produces proteins involved in the clotting (coagulation) of blood; the PT measures clotting function and, if abnormal, may indicate liver damage

Then there are other more specific tests that may be done if you get an abnormal result on one of the above tests, or there is another reason to suspect you may have a specific liver disease.

2) Could the effect any damage from 2-3g APAP, for three years, on the liver for 3 years be reversable?
It really depends how bad it is and whether you stopped the APAP in time. I would guess it's likely reversible (assuming you have any damage at all).

3) Is there anything else that would help liver recovery besides milk thistle, high water intake and no alcohol? Would continuing on non-APAP opioid medications slow my liver from healing?
There are some other supplements/vitamins/herbs you can take to help cleanse/heal the liver. Other drugs can definitely affect the liver, especially if it is already damaged. For example, when people start on methadone they generally have to get a liver panel and viral hepatitis tests done.

4) Is there a specific type of blood test that is best for evaluating liver condition?
As mentioned above, a full liver panel test.

 

[wildcardlv]

Back after a loooong time! So the herniated disc just got worse and worse. I took more and more Hydrocodone, and then switch to oxycodone. I felt like I was loosing control of my ability to "not get dependent" (which by the way isn't possible. Chemistry is chemistry), so I switched back to hydro.

Well the hydro wasn't strong enough, so I decided to try a more "natural" remedy. I started using poppy seed tea for the pain, which of course worked awesome since the morphine in it is fairly high. Well, after a while I realized I was hooked on both the hydro and the tea. Not that it mattered because the pain was still more than I could cope with.

Eventually I was up to like 24 10/325 hydros per day OR ~30oz of poppy seeds. I was scared I was going to die.

My pain doc gave me a third set of spinal injections (the first two didn't work) as a Hail Mary, and it freakin worked!!

So I spent a few weeks in withdrawal hell, but am now clean from both and feeling normal again. 5 years of pain and painkillers, but after just three weeks I feel good again.

I just wanted to share and maybe give people a little hope that it usually does end (herniated discs) if you stick with the physical therapy, and follow your doctors recommendations (mostly). Also the withdrawals are hell and seem like they'll never end, but they do. Before long you really do feel wonderful again... Not just normal. Don't do what I did and take extremely dangerous amounts of apap (I still never got the knack of a CWE), instead be honest with your doc and let him/her know that your tolerance is building. They expect it and understand it.


Cheers and good luck!

 

[T. Calderone]

That's good to hear and I'm glad you're doing so much better! Thanks for the update!

 

[The Doc.]

that's so great you got clean I screwed my liver up at age 18 by taking pills like Norco/perocet all the time and im healing today but still watch any apap I take so these days I don't take it at all im on buprenorphine now though didn't get clean like you but at least I have a liver I suppose which is always nice. apap poisoning is a horrible ordeal for anyone to have to go through.