Opioid use for chronic pain tolerance issue

Hi, a uhhh "friend" of mine has been a chronic pain patient going on approx 7-8 years now. After visiting many docs who were either unwilling or too afraid to provide a regimen that would ensure a decent quality of life (severe nerve damage originating in cervical spine from a relatively recent accident, and lumbosacral nerve damage from repetetive injuries over a period of decades). The doc is definitely willing to help without giving any problems with early refills, dose increases, switching meds, etc, and although this was making things incredibly easy for him to control his pain effectively as well as have enough left over to "party" or "get high" every once in a while.

After seeing many examples of what and how much people who post on this and other related sites take regularly, it leaves him a little worried about his tolerance and whether the doc is simply giving him what he thinks he wants in order to keep him happy, without looking at the long-term effects of doing so. Recently his first (and last probably) child was born, and he is constantly living in fear that something may happen that will cut him off from his supply, causing him to go through horrible WD and be unable to work and therefore support his family.

So, I would like to give some examples of what and how much he is taking, what else the doc will gladly switch him to, and have those of you who have a bit more experience try to help and put into perspective how bad his tolerance really is, and which of the regimens the doc is willing to write for would be best (according to your opinion) in both pain relief and recreational value.

So, right now he is taking Opana ER 40mg as his round the clock opiate at 8 tablets per day (3 in the am, 2 in the afternoon, and 3 at night) along with oxycodone 30mg IR tablets as needed every 6 hours for breakthrough pain. What is most concerning about this is that in order to feel any kind of "high" he has to take at least 5 of those 30mg oxy tabs at once which is a whopping 150mg all at once! One tab and sometimes even two hardly even work for pain relief now, and he can remember back to the time when simply a 10mg perc would get him feeling good, and now its not even really worth taking that if he even had it. He has talked to the doc about how the meds were working less and less and each time he has that convo with him, the doc either ups the dose or switches him to another regimen with different opiates. The doc has however recommended cimetidine and benzos (which he gets from his psychiatrist) to potentiate but he sees little or no change when taking them.

Here are a few other things the doc has tried and would be willing to write again:
8mg Hydromorphone IR x2 every 6 hours (8 per day) along with the same opana ER dose or a corresponding dose of those horrible new time release hydro tabs. This has also been tried with Avinza instead, but the doc does not feel comfortable writing for more than 6 120mg tabs per day because they are 24 hour tabs, and according to the opiate calculator for equianalgesia the number should be more like 8 tabs a day which even if the doc would write it, the pharmacy would give him problems. Duragesic patches were also tried at the 100mcg/hr level, but he found himself going through withdrawal symptoms and horrible pain so often that he would end up tearing the patch off and putting it in his mouth next to his gums which would work, but then he would run into trouble when he needed a refill for a months worth after a week of receiving them. The doc has also suggested possibly trying nucynta, but his wife takes it for neck pain (although not as frequently), and he does not like the way the nucynta makes him drowsy, although strangely enough he is able to take the same dose that his wife takes who is not opioid tolerant and actually feel the effects as if he had no tolerance. Also the nucynta seemed to do absolutely nothing for his withdrawal symptoms no matter how many of them he took.

He has also looked into and has actually ordered some proglumide (hasnt received it yet) hoping it could help him get more from his meds so as to avoid having to ask the doc for yet another increase.

So, with that all being said, there are a few questions:

#1 Is his tolerance absolutely insane, or is he just worrying too much?
#2 Is his doctor (perhaps suspiciously) a little too willing to give him more or less whatever he asks for? Maybe time to look for a new doc?
#3 Does anyone have any experience with proglumide regarding the best way to take it, whether he should not give himself the dose he usually takes without it, and whether the proglumide itself would produce any unwanted effects.
#4 Considering he pretty much has his choice of meds the doc will write, what would any of you personally choose in your experience and why?
#5 Are there any other similar medicines that werent listed? IE things he should ask the doc about possibly trying?

BTW this is in the United States, in the New York City area.

Thank you in advance for all your time and feedback, we really look forward to hearing what others have to say.

I dont think this is very 'advanced'.

Yes, it's a lot of opioids, but more importantly, why are you not taking anything else other than opioids? They are notoriously bad at treating nerve pain. Try using medicines with a little better reputation at treating neuropathic pain (amitryptyline, prebagalin/gabapentin, etc)

And also, most patients on chronic opioid therapy will develop some degree of tolerance, and for most patients, the analgesic efficacy will go down over time.

Maybe your "friend" could get an account instead of channeling his problems through other people on the internet..

-->odd

Apologies, I'm new to this forum. I apologize if I had posted in the wrong area, and perhaps I should have used SWIM instead of "my friend".

That being said, gabapentin type medicines have been tried and are extremely unbearable in terms of side effects. The only side effect experienced by the opioids are constipation in this case, but that is much easier to deal with than the side effects from pregabalin and gabapentin. Amitriptyline I do know is a tricyclic anti depressant, but my understanding was that it was used mainly to aid in sleep and to potentiate in chronic pain cases. Is that untrue?

That being said, it does once again bring up some concerns about the doc in that he has never mentioned or suggested anything other than opioids for the pain other than things like robaxin, soma, baclofen, lidoderm, flector, skelaxin. And he is a neurologist. However, when starting with this particular doc he did ask what was tried before and which were effective and which were ineffective and he did indeed ask about those meds as well as maybe a dozen others. The concern about the doc is whether he is prescribing opioids as the main pain management treatment because he thinks it is the best route, or if he's going that direction because of some sort of shadiness with the drug reps (he loves to give opana and nucynta which I find suspicious), or if he is seeing the drug lover deep inside (even though pain relief is first priority, like I had said, SWIM does like to use his meds for fun occasionally) and catering to that to satisfy and therefore keep the patient.

All concerns about the doc aside, SWIM has ordered some proglumide and will give it a try once it arrives. However SWIM was wondering what dose to start with, when to take it (although I've read about an hour before opioids elsewhere), and how much of his opioids SWIM should take when using it (is half normal dose at first a good starting point?).

Thanks so much for responding and taking the time to read all this. Once again I apologize if this is in the wrong part of the forum. I will gladly move it if that is the case.

Thanks!

Once again I apologize, I just "decoded" sekio's reply. Lol he was not referring about anything being odd, rather that this belonged in the other drugs forum. I am going to check and see if I can move it, otherwise would a mod please help me and move it?

Thanks!