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Harm Reduction The Pain Management Mega Thread - for all your questions on dealing with chronic pain

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hydro vs perks

im just curious if anyone else has had this happen.. i have been on hydro's for about 5 years i take the 10/500 mg. well last week my dr changed me to perococet 10/325 and i dont get the relief i get with the hydro's.. why i have no idea. i thought the perks were stronger and i was hopping i would take less , i was up to about 15 hydro;s a day they also gave me a good buzz.. i take the perks and dont feel a thing.. so now im in pain and no buzz..has this happened to anyone else.? i guess i will throw them away and wait to dr next month.. any idea's to help make them work for the pain?
 
^150mg of hydrocodone equal to how much oxycodone? I always thought (and through personal experience agree that) hydrocodone and oxycodone have a 3:2 equivalence, at least equianalgesically speaking.
 
Your doctor was prescribing you up to 15 vicodin a day? This seems very irresponsible, even if you were doing a CWE. If you require this many opioids then you really should be on 12 hour medication so that you have a constant amount of the opioid in your blood stream. The 4 hour medications create peaks and troughs so you go from peaks of side effects (some desirable like the 'highs') and troughs where the levels of medicine dips and you have more pain.

When the pain medicine dips you have to take more, sometimes excessively to take care of that pain and usually when people are converted to 12 hour+ medications, they can take a smaller amount overall of the opioids and have pain that is managed better. I am really surprised, maybe shocked, that your doctor would prescribe that much of a 4 hour medication and not transition you over to an extended release drug like MS Contin, OxyContin, Opana ER, fentanyl, methadone (not extended release, but longer lasting requiring less frequent dosing) or even temgesic/buprenorphine.

What is the reason that you are taking the pain medicine? Are you managing your pain with any adjunctive medications like anti-inflammatories? anticonvulsants? muscle relaxants? etc.
 
yea, i also find your doc prescribing 15 hydros a day strange. when there is better stuff out there where you would have to take less.
 
RainingDownOxy said:
I i forgot to add that I use Lidoderm pathches and also a new patch called Flector (Diclofenac Epolamine topical patch) pretty new to the market and I must say that it works really well, not as well as the Lidoderm though. I was on Lyrica doe awile but it didnt help much so I stoped it. I gave Gabapentin a whirl and it has been ok thus far.

Hey Cane2- have you ever heard of a patch or cream that has a solution of Ketamine and lidocaine in it? I heard it is used for nerve pain and supposedly works reallywell--
Click to expand...

I have heard bits and pieces about topical ketamine application but nothing substantive. I asked my doctor about this once and he looked at me like I was insane... he was a PCP and I think I knew more about pain management meds than he did.

I found this that I think is interesting and somewhat addresses your questions (and adds to the chronic pain discourse)

Proceed only if you don't mind medical journal language.

Topical Ketamine Gel: Possible Role in Treating Neuropathic Pain

ABSTRACT

Neuropathic pain is often resistant to opioids, so other medication classes, such as tricyclic antidepressants, anticonvulsants, and local anesthetics, are often used. Central sensitization, or pain 'wind-up', may perpetuate chronic neuropathic pain even when ongoing peripheral sensory input is absent. Wind-up is thought to cause allodynia, hyperalgesia, and hyperpathia. Receptors such as NMDA, AMPA, and M-glu have recently been identified for their role in central sensitization or pain 'wind-up'. Ketamine has been proposed recently for neuropathic pain secondary to its NMDA receptor activity. The current application as a topical gel stems from the theory that ketamine has peripheral action at both opioid and Na+-K+ channels. This case study involved 5 patients from 25 to 70 years old (3 RSD, 1 lumbar radiculopathy, 1 post-herpetic neuralgia). Dose used was determined by site and surface area of involvement and ranged from 0.093 mg/kg to 9.33 mg/kg. All five patients reported significant pain relief at initial application and wished to continue treatment. The average numerical analogue scale (NAS) score preapplication was 8.8. The average 15 minutes post application NAS was 1.6. Patients reported alterations in temperature sensation, feelings of relaxation and decreased tension in the area of application, and pain relief. Reduction in numerical pain scores postapplication of ketamine gel ranged from 53-100% using a 1-10 numerical pain intensity scale. No significant side effects were reported. Ketamine Gel may provide clinicians with a new option in the battle against chronic neuropathic pain. Until further information is available and larger trials can be conducted, we can only recommend this type of therapy for refractory cases in which all primary and secondary options have been exhausted. Source
Click to expand...

I think this is really interesting. I am excited to see how NMDA antagonism plays in the future of neuropathic pain management. ketamine comas (as featured on House m.d.) is another exciting prospect.
 
Good Extended-Release Pain Medication?

I've been dealing with neuropathic pain due to a surgery that healed improperly for several months now. It's frustrating going from doctor to doctor not knowing how to properly treat my condition, especially when the diagnosis was not known (seeing 2-3 different doctors a week), and the fact that doctors are hesitant to give CII let alone CIII medication due to the fact that I'm a young male. The only doctor that will write me narcotic prescriptions is my PCP who I have known since I was a little kid and seems to be the only doctor thus far that is willing to actually sit and have a conversation with me.

My regimen of pain meds is:
  • 25mcg/hr fentanyl q3d (although I hesitate using these, only when the pain is bad or predict being in a situation where carrying around my Norco is not feasible)
  • 10mg-325mg Norco q4h prn (I tend to use this exclusively instead of the fentanyl)
  • 150mg Lyrica bid (I always use this, but it does nothing for the pain and higher doses make me ataxic)

I want to be able to take something that is sustained-release (like the fentanyl) but that is not a patch (patches tend to fall off easily and are hard to deal with in the shower). I used the fentanyl for a solid two weeks once and was abruptly cut off, cold turkey, due to insurance issues at the pharmacy. I went through crazy withdrawals for several days. I'd like to try MS Contin, Oxycontin, or Opana ER, and see if those prove to be any more help.

What sustained-release medication has proven helpful to anyone with neuropathic pain?
 
^It is scary how many similarities we have in our situation.

Abstract:

-I am a 21 year old male
-I have chronic neuropathic pain of largely unknown origin
-for a time I was going to specialist to specialist and none wanted to treat without a clear Dx
-my PCP at the time was the only one willing to prescribe me strong enough medicine
-we are on almost the same meds at the same dosages

I have tried both MS Contin and OxyContin and for me, oxycontin was far more effective... I could take lower doses, it was less sedating, less nauseating and was more effective at treating the hyperalgesia and allodynia that accompanied my neuropathic pain. Eventually I decided to manage my pain with only the norco (and others), but oxycodone for me was much more effective than morphine. In studies, they are equally effective (NNT=2.5) for neuropathic pain. Everyone is different though and the only way you will find a pharmacological regimen that works is through experimentation.

Also, my doctors were much more receptive to prescribing medications (and accepting that other doctors did) because I went through months of physical therapy and tried many non-pharmacological means of managing my pain before getting on Rx medicines as well as while I was on them.

I also kept plenty of herb around, especially when I wasn't prescribed any or adequate opioid analgesics. I find the high-THC sativas can sometimes exacerbate my nerve pain while moderately high-THC indicas were optimal for good rest (which makes a huge difference in pain levels) and was itself a great analgesic with very few side effects. It also enhanced the analgesia provided by the opioids without increasing their side effects.
 
Cane2theLeft said:
Modafinil has shown a lot of promise as a treatment for Opioid Induced Sedation (OIS) and seems preferred over other, more controlled options like methylphenidate or various amphetamines. I think you should tell your doctor what you told us about being very nervous about changing your PM regimen because you finally found the right dose and ask him for something like provigil to help with the OIS. Modafinil/provigil does not have a whole lot of abuse potential (especially compared to the other aforementioned stimulants) and I don't think it would be like asking a doctor for xanax for something. Of course some doctors will do anything to keep you on the least medications possible even if more will be more beneficial while other doctors will be much more open to adding another drug to combat the side effects of the first. I don't know your doctor so its hard for me to tell. My suggestion is to just have a plan for what you would like to accomplish and be prepared for any way that the doctor can respond.I doubt the doctor will refuse to give you a drug for OIS and demand you reduce your dose, but I suppose its possible so be prepared. Good luck!
Click to expand...

Cane2theLeft: many thanks for your thoughtful and informative post.

My present GP is my new GP bcause I've just moved into a completely different part of England to where I was living before.... but I think he's reasonable as hell because I just marched in there as a brand new patient and informed him what meds I was on, including the 75mg of daily methadone.

He did mention that it seemed quite a high dose of methadone but after I explained how my pain management consultant had worked me up to that dose from dihydrocodeine and tramadol, then dihydrocodeine and fentanyl to finally methadone on its own he prescribed for me no problemo.

Hopefully he'll be reasonable and thanks again for your advice.

Do I understand correctly that I should talk about Opioid Induced Sedation (O.I.S.) or is that a specifically American medical term? I don't want to come off as drug-seeking nor do I want to come off as either knowing more than my GP or thinking I know more than my GP!!!!

(British GPs, in my experience, are phenomenally bristly about always having to be more clever than their patients.... I don't know how it is in the U.S.....)
 
dhcdavid said:
Cane2theLeft: many thanks for your thoughtful and informative post.

My present GP is my new GP bcause I've just moved into a completely different part of England to where I was living before.... but I think he's reasonable as hell because I just marched in there as a brand new patient and informed him what meds I was on, including the 75mg of daily methadone.

He did mention that it seemed quite a high dose of methadone but after I explained how my pain management consultant had worked me up to that dose from dihydrocodeine and tramadol, then dihydrocodeine and fentanyl to finally methadone on its own he prescribed for me no problemo.

Hopefully he'll be reasonable and thanks again for your advice.

Do I understand correctly that I should talk about Opioid Induced Sedation (O.I.S.) or is that a specifically American medical term? I don't want to come off as drug-seeking nor do I want to come off as either knowing more than my GP or thinking I know more than my GP!!!!

(British GPs, in my experience, are phenomenally bristly about always having to be more clever than their patients.... I don't know how it is in the U.S.....)
Click to expand...

I am so glad that I can help in any way and don't be afraid to ask ANY questions about all of this stuff, I have been around the block with it all (in the states) and have spend hours upon hours researching this stuff so I could better understand and get the best treatment I could. I can't tell you how much I would love to help you!

I use an HMO in the states and so my primary care physician regularly sends me to specialists within the HMO. The first time I saw their pain management specialist, he recommended gabapentin and while he was explaining what it was I interrupted and explained that I understood that it was an anticonvulsant, etc. and he seemed quite frustrated that I already knew that. The doctors here are just as bristly!

I am not sure that OIS is strictly an American term, but I think it would be reasonable for you to tell your GP that you read online about opioid induced sedation while you were searching for something to help with your problem. I have in the past brought in articles to my PCP and it may even be beneficial to bring in the below abstract and tell him that you found this online and you wanted to discuss it with him. You are 100% right, its always in your interest to seem deferential to your doctor but you have to guide your treatment in the direction that you think it needs to go in. You may even want to say something like, "I read about amphetamines or ritalin being used for sedation from pain medicine but I don't want to go that route with those dangerous drugs. I have however read about this other drug that has helped..."

Its all about word choice with doctors!

Modafinil treatment of opioid-induced sedation

ABSTRACT

STUDY OBJECTIVE: The purpose of this study was to assess the efficacy of modafinil in combating opioid-induced sedation. DESIGN: A 1-year retrospective chart review of all patients receiving modafinil, a wake-promoting agent, to treat opioid-induced sedation. Opioid-induced sedation was measured using Epworth Sleepiness Scale (ESS). SETTING: Outpatient, private practice. PATIENTS: Eleven adult patients, six female and five male, being treated with opioids for chronic, nonmalignant pain. RESULTS: A significant decrease was observed between pretreatment and posttreatment ESS measurements during modafinil treatment. CONCLUSION: The results suggest an improvement in opioid-induced sedation in patients treated for nonmalignant pain. Source
Click to expand...
 
Maximizing opiate effect

If you are in chronic pain, and have a tolerance to opiates, and are given x amount of opiates from a doctor, and can't get any more opiates anywhere else, and the aforementioned x amount is not enough to give you pain relief, because of your tolerance, what can you do to make x amount work better, besides stretching it out longer (not really an option), or just sucking it up and trying to get your tolerance down?

Is there something you can mix it with to make it work better?
Or any other ideas?

I've been given 200mg's of morphine a day but I'd need more like the effect that 400mg's a day would give me. (orally)

Any ideas?
 
^
use the search option it will answer 99% of your questions


merging into the pain thread since this is pain related


do note a lot of the stuff mentioned in the potentiation thread only enhances the sedative effects

p.s have a look at the 2d page folks there is a question on hydrocodome versus oxycodone pain relief wise
 
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Cane2theLeft said:
I am so glad that I can help in any way and don't be afraid to ask ANY questions about all of this stuff, I have been around the block with it all (in the states) and have spend hours upon hours researching this stuff so I could better understand and get the best treatment I could. I can't tell you how much I would love to help you!

I use an HMO in the states and so my primary care physician regularly sends me to specialists within the HMO. The first time I saw their pain management specialist, he recommended gabapentin and while he was explaining what it was I interrupted and explained that I understood that it was an anticonvulsant, etc. and he seemed quite frustrated that I already knew that. The doctors here are just as bristly!

I am not sure that OIS is strictly an American term, but I think it would be reasonable for you to tell your GP that you read online about opioid induced sedation while you were searching for something to help with your problem. I have in the past brought in articles to my PCP and it may even be beneficial to bring in the below abstract and tell him that you found this online and you wanted to discuss it with him. You are 100% right, its always in your interest to seem deferential to your doctor but you have to guide your treatment in the direction that you think it needs to go in. You may even want to say something like, "I read about amphetamines or ritalin being used for sedation from pain medicine but I don't want to go that route with those dangerous drugs. I have however read about this other drug that has helped..."

Its all about word choice with doctors!
Click to expand...

Once again Cane2theLeft, I thank you for taking the time to answer my questions.

Just in case my doctor doesn't prescribe me modafinil I've researched online and found sources for both modafinil and methylphenidate. Both are fairly similar in price and this raises one more question for you :

Considering my intake of methadone (typically 100mg daily) which stimulant out of modafinil and ritalin would you recommend to me in order to count-act the opioid-induced sedation?

(I've only had ritalin a few times - when on holiday in the States - and really enjoyed it but have no experience of taking it for therapeutic purposes in conjunction with reasonably large doses of methadone. Modafinil I've taken more times - perhaps 20 times in total, of doses of 400mg - and have found it to go beautifully with methadone.)

I would only consider getting hold of ritalin or modainil over the net if my GP doesn't end up prescribing me modafinil. It goes without saying that I'd feel more comfortable taking whichever out of modafinil and ritalin I'm least likely to build a fast tolerance to.

I thank you in advance for your help again!
 
^
Ritalin acts on dopamine and will give you euphoria and might even make sedation stronger like a speedball wil


modafinil has a different (and indirect) method of action , it would be better to say that it inhibites sleepyness than that it gives you energy


i think modafinil would suit your needs better , especially if you enjoyed ritalin there are chances that you wil start binging on it or snort it which will shorten the duration of your methadone even more than taking it orally.

my 2 cents
 
Thanks Bingeboy..... your 2 cents pretty much chimes in exactly with my 2c on the subject!

(Namely that ritalin would be more fun than modafinil but because of this I'd almost definitely end up abusing it and seeing my tolerance go through the roof. I too reckon modafinil is the way to go.)

Now I only have to convince my Doctor of the inherent wisdom of this plan!
 
^I complete agree with bingeboy. Modafinil, adderall and ritalin have all tested pretty similarly in treating OIS except modafinil has the lowest side effect profile and fewest people leaving the studies due to side effects.

I imagine if your doctor is open to prescribing a drug to treat OIS, they would start with modafinil and precede to methylphenidate or amphetamines if modafinil is insufficient just like they start treating pain with drugs like tramadol before escalating to fentanyl, morphine, methadone, etc.

Are you seeing your doctor soon? I will be keeping an eye on this threat (the PM threads are why I originally joined BL) so please keep us updated!
 
That was a very interesting Cane2 about the use of Ketamine for nerve pain. And your doctor's reaction when you brought it up was like my doc's reaction. I casually brought it up when we were talking about Lidoderm and Flector patches and which 1 worked* better for me. I said I had been doing some research on other options and that I came across Ketamine patches/cream. He said no way bascilly and that there arent many pharmacies thateven carry it. A certain pharmacy in my state (MIchigan) is the only make and seller of Ketamine topical cream, and its elly expensive!Oh well never hurts to give it a try.Also about the Provigil for OIS.I was prescribed this de to the fact I take 3-4 differant meds a day that make me extremely tired (on top of I hae bad Insomnia) and I must say it works really well for being a non-amphetamine. I was only given a 7 pill pack to try and after it work well I found out my insurance didnt cover Provigil and for a #30 count was around 250 $8o not the amount f money im willing to fork over for 30 pills. So my doc just put me on Adderll IR to take as needed. Works good bt I honestly would have rather had been on the provigil, what can you do though;)
 
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