UK Opioids For Genuine Pain Relief - Slipped Spinal Disc

[Rybee]

Hi Guys,

After some advice from those in the UK...

Carrying a wardrobe upstairs, slipped, fell down the stairs and have a slipped spinal disc in the lower lumbar. I'm literally bed-bound at the moment, and I'm in agony. I've never really responded too well to Codeine/Dihydrocodeine/Tramadol in terms of pain relief. I can only assume this is because I don't metabolise it too well since they're all, largely, metabolised by CPY2D6? I'm not too techy with pharmacology so please correct me if I'm wrong? I know that Tramadol is a little bit more complicated, in its serotonergic actions but I think CPY2D6 is largely responsible as the main metabolite for all 3 of them.

My doctor is so hesitant on prescribing me Oramorph, and despite explicitly asking for it, he's rejecting my request every time in favour of something else. I started on codeine, then tramadol, then dihydrocodeine, then naproxen, then diazepam and baclofen... Whilst I understand his reservations I've done a lot of damage to my spine, and a slipped disc is incredibly painful. Oramorph is a fairly strong painkiller and I don't think it's unreasonable to be requesting it, since the alternatives just aren't working.

I know in the USA they use other opioids such as Oxycodone and Hydrocodone, but as far as I'm aware, these are rarely prescribed in the UK, if at all?

So I'm after suggestions for something other than Codeine/Dihydrocodeine/Tramadol that he may be more willing to prescribe, because he's just adamant on refusing Oramorph.

Just for the record he's also prescribed:
500mg Naproxen x2 per day to help with the inflammation
1,000mg Paracetamol x4 per day to help with the pain
10mg Baclofen x4 per day to help with the muscle spasms
10mg Diazepam x4 per day to help relax the muscles

I'd really appreciate any replies as I'm in a hell of a lot of pain and feel like I'm being refused the care that I really need.

Thanks in advanced guys,

 

[Tommyboy]

I'm going to move this to your regional forum since you are after answers from fellow people from the UK.

OD --> EADD

 

[Rybee]

I'm going to move this to your regional forum since you are after answers from fellow people from the UK.

OD --> EADD

Thanks Tommyboy, fairly new to bluelight and find all of the different subforums quite overwhelming!

Appreciate your help

 

[Chemical Samile]

I can't really comment on what opies the dr will prescribe - but I suspect they won't give up the good stuff without a fight.

Are you taking the paracetamol and naproxen at the same time? Not sure exactly how those two interact together, but they're both NSAIDs and so I'd perhaps be wary of liver damage with extended use. Something to mention to your doctor maybe?

 

[Rybee]

I can't really comment on what opies the dr will prescribe - but I suspect they won't give up the good stuff without a fight.

Are you taking the paracetamol and naproxen at the same time? Not sure exactly how those two interact together, but they're both NSAIDs and so I'd perhaps be wary of liver damage with extended use. Something to mention to your doctor maybe?

Yes I take the paracetamol and naproxen at the same time.

I am actually concerned about liver damage because blood tests in September showed I was in the early states of liver disease from long-term painkiller use for chronic daily migraine. I also take Agomelatine for depression which is notoriously toxic on the liver, and was the original reason for having my liver checked out by a consultant.

I think I'm going to request a scan to verify the slipped disc, but the wait will be ages and I've exhausted my BUPA allowance for the year.

All in all, at the moment I'm taking
4x150mg Tramadol
4x60mg Dihydrocodeine as well as:
4x1000mg Paracetamol
4x10mg Baclofen
4x10mg Diazepam
2x500mg Naproxen
1x50mg Quetiapine
1x50mg Agomelatine

For someone who was in the early stages of liver disease just 8 weeks ago, I can't help but think this isn't a good move. IMO I'd be much better if I cut out all the Tramadol, Dihydrocodeine, Paracetamol, Baclofen, Diazepam, Naproxen and just stuck to Oramorph which would really ease the pressure on my liver.

I might request another blood test on my liver to see what state it's in.

 

[Ismene]

Have you ever tried oramorph rybee? I've tried it and got very little in the way of pain relief and a lot of nausea. Just doesn't seem to be the greatest drug when taken orally. Your mileage may vary of course.

 

[BigG]

Hi, I saw your post over in the chronic pain forum and thought id chip in. Having been a chronic pain patient for 17 years and been on every opiate there is in the uk as well as having worked in th NHS for over 15 years I thought I'd be able to offer some constructive comment. Im supprised you cant get your doc to script oramorph as they are usually more willing to prescribe this that other opiates. Although oramorph is morphine sulphate its relatively weak concentration (10mg in 5ml of solution) means it doesnt fall under the remit of a controlled drug the way stronger morphine formulations do. Its also extremely cheap (wholesale £1.84 for 100ml). On the opiate ladder you have codeine, dyhydrocodeine and tramadol at the bottom and things like MST, Oxycontin, fentanyl, methadone etc at the top. There isnt much unfortunately "in between" these two steps as hydrocodone isnt available in the uk. This is why doctors usually move to low strength morphine formulations like oramorph when the patients pain is more than can be treated with the lower strength drugs mentioned above. Usually Oxycontin is much harder to get a script for than oramorph so the only thing I could maybe suggest is trying a different doctor. Just as in the US, UK doctors vary massively in their willingness to prescribe opiates for chronic pain.
As for the other stuff you're on, I would be rightly wary of the 4000mg/day of paracetamol if you have liver issues. As for the Naproxen its stomach issues you should be more concerned about as Naproxen is notorious for causing problems with stomach lining. Those doses of Tramadol and DHC you mention, are they what your are scripted to take? that the maximum recomended dose of Tramadol is 100mg x 4 per day and DHC 60mg x 4 (but not usually together). Also 40mg of dizapam is quite a lot. Im suprised your doc scripts you that and wont give oramorph as usually its the other way round.
Im summary the drugs he's prescribing you seem a bit erratic to say the least. My advice would be to simply see another doctor. Hope this is of some help.

 

[blondin]

Like yer man said 40mg of valium with no tollerance would knock you out...try and get a refferal to a pain clinic as they as skilled in this area your gp obviously doesn't know sjit about treating chronic pain. Anothewr solution if you can afford it is to go private usually about £100 p/m or trhere abouts but you will get a better choice of meds. sorry canyt type mixture of no glasses and strong gear

 

[Rybee]

Have you ever tried oramorph rybee? I've tried it and got very little in the way of pain relief and a lot of nausea. Just doesn't seem to be the greatest drug when taken orally. Your mileage may vary of course.

Yes I have, quite a few times. About this time last year for a slipped disc over the period of 3 months. Thought it was prescribed by a different doctor. I've also had it twice for post operative kidney stone removal surgery pain. I found it to get rid of the worst pain, certainly more than the cocktail of things I'm taking right now.

Hi, I saw your post over in the chronic pain forum and thought id chip in. Having been a chronic pain patient for 17 years and been on every opiate there is in the uk as well as having worked in th NHS for over 15 years I thought I'd be able to offer some constructive comment. Im supprised you cant get your doc to script oramorph as they are usually more willing to prescribe this that other opiates. Although oramorph is morphine sulphate its relatively weak concentration (10mg in 5ml of solution) means it doesnt fall under the remit of a controlled drug the way stronger morphine formulations do. Its also extremely cheap (wholesale £1.84 for 100ml). On the opiate ladder you have codeine, dyhydrocodeine and tramadol at the bottom and things like MST, Oxycontin, fentanyl, methadone etc at the top. There isnt much unfortunately "in between" these two steps as hydrocodone isnt available in the uk. This is why doctors usually move to low strength morphine formulations like oramorph when the patients pain is more than can be treated with the lower strength drugs mentioned above. Usually Oxycontin is much harder to get a script for than oramorph so the only thing I could maybe suggest is trying a different doctor. Just as in the US, UK doctors vary massively in their willingness to prescribe opiates for chronic pain.
As for the other stuff you're on, I would be rightly wary of the 4000mg/day of paracetamol if you have liver issues. As for the Naproxen its stomach issues you should be more concerned about as Naproxen is notorious for causing problems with stomach lining. Those doses of Tramadol and DHC you mention, are they what your are scripted to take? that the maximum recomended dose of Tramadol is 100mg x 4 per day and DHC 60mg x 4 (but not usually together). Also 40mg of dizapam is quite a lot. Im suprised your doc scripts you that and wont give oramorph as usually its the other way round.
Im summary the drugs he's prescribing you seem a bit erratic to say the least. My advice would be to simply see another doctor. Hope this is of some help.

Hi mate, appreciate you taking the time to reply,

Yeah I've actually spoken to 3 different doctors, every time I've called, they've all steered me well away from oramorph.

Yeah the Tramadol and DHC doses were agreed with a doc yesterday morning.

I'm glad to have an objective view on this matter, because I too feel that my whole treatment has been erratic. I know for the general public, oramorph may be quite scary, but really it's only oramorph. I've used it on 3 separate occasions in the past and have had absolutely no issues. They just seem to be on a crusade to deter me from it and I just can't for the life of me fathom out why.

I think I will take your advice and see another doctor, the one who originally prescribed it to me last year.

I do appreciate your advice though, I didn't know whether I was being unreasonable or whether it would actually be more logical to swap. Thanks mate,

Like yer man said 40mg of valium with no tollerance would knock you out...try and get a refferal to a pain clinic as they as skilled in this area your gp obviously doesn't know sjit about treating chronic pain. Anothewr solution if you can afford it is to go private usually about £100 p/m or trhere abouts but you will get a better choice of meds. sorry canyt type mixture of no glasses and strong gear

I do have tolerance to Benzos, been taking Lorazepam daily since about July and the guide of my Psych and have literally just come off of it, in favour of Quetiapine so I didn't really want to jump on the benzo bandwagon again.




Really appreciate your replies guys, going to phone my doc now.

 

[brayne]

some basic advice you probably already got somewhere else

not sure if your case is an exception to the rule,
but in cases of spinal disc hernia the general recommendation is to keep moving.

long periods of sitting, laying or standing will cause you more pain.
the discs need movement, broken or not.

also u should consider drug tolerance.
if you take oramorph, will u be able to continue at the same dose or will u have to keep increasing?

because spinal disc injuries dont heal by themselves.



my friend told me ketamine is the best painreliever he knows, and he smokes h so it's not like he hasnt tried opiates.
even if u can get oramorph, it might be wise to go off of them sometimes and use ketamine for a while, to keep ur tolerance down ?

but dont mix ket with opiates i dont think thats safe.



and if u got the cash, try to get a decent mattrass.
u dont necessarily have to buy the most expensive one out there.
just get one that adjusts to the position of ur spine while still giving enough support, to minimize pressure on the discs so they can heal a bit at night.

i bought an expensive setup and it really helps with the pain.
i also do two exercises one or two times a day. they just take a minute.

dont blindly trust doctors or kinisetherapists on the exercis they give u.
if they feel uncomfortable/slightly painful.. .this may be indication that the exercise just isnt right for u.

as an example,
personally i discovered that laying on a chair and keeping my legs and arms up in the air,
while my crotch is resting on the chair, helps me to train the muscles in the lower back properly.

i do that a couple times a day for one min, in combination with some stretching and i live painfree.
i have spinal hernia on the lower back.

i once read about some women whom doctors had already recommended her to do surgery.
but first she tried doing yoga extensively aand she became painfree just because she was able to train her muscles so heavily that her discs no longer experienced pressure.

 

[wcote]

Paracetamol is not a NSAID

 

[BigG]

No problem mate. I just wish I could be of more help. I really dont understand why the unwillingness to script you oramorph especially considering the doses of tramadol, DHC and valium he's giving you. As I mentioned doctors are usually quite willing to prescribe oramorph mainly due to the fact that it is a POM and not a CD. It really is the next step when tramadol and codeine have been maxed out (which in your case they have......more than maxed out in the case of the tramadol). If you dont kind me asking do you have any documented history of substance abuse that your doctor knows about? Thats about the only reason I can think of why he would deny it to a genuine pain patient. Either way i would see someone else. Also before you go in try to have your facts and logical arguments clear in your head. Tell him you are aware of its addictive potential but that your current drug regime isnt working and explain logically and concisely why you need it. Doctors are much more likely to respond well to a well put together concise argument that just saying that you want or need it. I genuinely wish you all the best as ive had my fair share of fights with doctors in the past......some of which have decended into real chaos.

 

[knock]

I broke a bone in my foot and had a metal fixator attached to the bone and sticking out the side of my foot for six weeks, they gave me fuck all for it! So I drank poppy tea. It didn't really help with the pain that much but it took my mind off it!

 

[BigG]

Yeah they can be total cunts sometimes. I once had a tumour removed from my spine and was sent home with a box of paracetamol. Admittedly I had stuff in the house for my arthritis but what fucking good is paracetamol going to do after surgery?

 

[Rybee]

Ended up with 600mg of Morphine (Oral) which I've shot through pretty quickly. Feeling much better though =)

 

[wcote]

Did you take the paracetamol?

Did it do much?

 

[benzoman12345]

My back Is done in and I've took plenty Opiates/Opiods , ATM I get prescribed 99mgs Gabapentin Per Day and 400mgs Tramadol per day , I am in Scotland, I have to self medicate, I can't even get DHC, Clonazepam and Gabapentin is an amazing combination for my back , it started off in my lower right disc as well,

You should definitely try Gabapentin, it really does help, and when taken with Clonazepam it is amazing for relaxing the tensed muscles, of course you can still take ur diazepam as well wich is even better, an Opiate/Opiod is always required as well, but going down the muscle relaxant road Does work, for me anyway, PM me if you want a chat about it mate, I know what it's like I go through it every day

 

[Rybee]

My back Is done in and I've took plenty Opiates/Opiods , ATM I get prescribed 99mgs Gabapentin Per Day and 400mgs Tramadol per day , I am in Scotland, I have to self medicate, I can't even get DHC, Clonazepam and Gabapentin is an amazing combination for my back , it started off in my lower right disc as well,

You should definitely try Gabapentin, it really does help, and when taken with Clonazepam it is amazing for relaxing the tensed muscles, of course you can still take ur diazepam as well wich is even better, an Opiate/Opiod is always required as well, but going down the muscle relaxant road Does work, for me anyway, PM me if you want a chat about it mate, I know what it's like I go through it every day

I've tried Gabapentin/Pregabalin/Amitriptyline for nerve pain before and had great results. Particularly with Pregabalin. It just makes me a bit slow in the head and I respond very well to physiotherapy so if I can get away with acute opioid/NSAID use with a bit of diazepam/baclofen then I'm happy with that. Going to pop back to the doctors this morning and ask for some more morphine, though I can see me it being hard work. My GP thinks paracetamol is more than adequate for all pain 8(

Thanks for the PM offer though buddy

 

[Rybee]

As said, popped back to the doctors today and he's weary of my past liver disease problems so we've opted to go for Fentanyl patches to avoid as much metabolism in the liver as possible. Fentanyl seems very popular on BL so I've got a lot of reading to do... Not too sure Fentanyl patches are great for what I have though, which is sharp sporadic unpredictable pain. From what I gather the onset time is ~8 hours delivering constant pain relief. So I've got some morphine and Tramadol to use for break-through pain.

Also been put back on Pregabalin and referred to a pain specialist.

What's peoples thoughts on Fentanyl? As far as I can remember they're 50 mcg/h which I expect is quite weak, though he's prescribed me 10 and put that on repeat prescription for me.

Will get reading up about it all I guess!


edit: Also if anyone can point me towards a reliable conversion dose to the equivalent oral morphine dose I'd appreciate that, used several online calculators all with wild answers.


gpnotebook.com: 50mcg/h ~120mg Oramorph
palliativedrugs.com: 50mcg/h ~160mg - 210mg Oramorph
palliativecareguidelines: 50mcg/h ~120mg - 180mg Oramorph
yacpalliativecare.co.uk: 50mcg/h ~135 - 190mg Oramorph

So it kinda looks approximately 50mcg/h ~150mg Oral Morphine?