Break Through Pain? Pleasrd to be joining this community.
ThistleTheValkyrie posted:
I do know that the term "doctor shopper" is typically derogatory, but we still have a capitalist system of medical care, and as patients and as people we have every right to do what ever it is we need to do to find a provider that fits with our needs and is receptive and compassionate, not judgmental.
I had dealt with moderate to severe pain for several years, never using narcotic painkillers, or taking anything other than naproxen and ibuprofen. I went through an extremely life changing, stressful time in my life and crashed into a wall of major depression. I had suffered from abuse for many years at the hands of my partner, and finally escaped with my life and my daughter, and now I am learning that sometimes there are scars that even though you can't see them, are very much real. After having progressively increasing pain for the last year and half, nine months ago, at age 23, I was diagnosed with fibromyalgia. I also learned I have mild scoliosis in my neck and lumbar, and the beginnings of a form of arthritis called spondilosys in the thoracic area of my spine. Over time, in the last few months, there have been more and more bad days and less and less good. I had a doctor who would not help me with my pain, and I went to see a family NP who works in a clinic that does health, adult therapy, and children's dental. I went to her to prescribe my psychiatric meds because I was seeing a therapist there. She said she would be happy to help me with whatever I needed, so after seeing her a couple times about various other things, I decided to ask her to act as my pain health-care provider. She has been amazing. She is aware of the dangers of narcotic drugs, but she uses scientific evidence and my anecdotal reports to gauge the level of my pain, and when small doses of hydrocodone (7.5, 4-5 times per day, as needed) scarcely effected me, she put me on long-acting morphine. When the long-acting morphine at 15 Mgs pers pill, 2-3 times a day failed to effect me, she put me on long acting morphine 30 mgs a day, 1-3 times a day, as needed. This has been helping me a lot more, but I still have stints of acute pain, and of course as it is a new medication I have been foggy and extremely tired, but I hope those elements will recede with time. I really think this woman has saved my life, because with this I couldn't even be a mother to my four-year old daughter. I couldn't get out of bed, or off the couch. Walking to the bathroom was a trial, and trying to cook or fix food in the kitchen was a nightmare. Now at least part of the time these things seem managable. I shudder to think what my life would become with out this medical intervention. Pain not only made me miserable, but unable to function, unable to cope, and stressed to the point of insanity....I wish this on no one.
Another thought... How reasonable is it to request break through medication for intense episodes of pain that supersede the effects of morphine ER 30 Mgs 3x a day? I just started it this week, but is it likely to become more effective if I wait a few weeks? Hoe can you tell the difference between too little medication and "break through" pain.

Take the Poll

Which is better? a Higher dosage of a long-acting opioid medication, or maintained dosage combined with a different, and/or faster acting medication for "break through" pain.
  • Higher dosage of long-acting opioid meds
  • Maintained dosage combined with faster acting meds
  • It depends on the situation, everyone is different
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Anon_160307 responded:
It can take a few days for the medication to reach a steady state level in the blood stream. This typically happens after the 3rd day of taking the higher dose of the opioid medication. Honestly, you should give a titration a good 30 day trial before making the determination that it is not effective for your pain.

90 mgs of extended release morphine is quite a lot of medication to be on at the age of only 23. Your tolerance is going to be sky high 20 years from now if you continue taking opioid medications for pain. I wasn't on 90 mgs of morphine until I was 29 years old. And I had initially started taking Tramadol for 3 years at age 26 and then was switched to Vicodin for about a year before starting morphine and I stayed on 30 mg twice a day with percocet for breakthrough pain for a year. I have been struggling with chronic pain since I was 19 years old and I am now 31. I now take around 200 mgs of morphine equivalent per day of a different opioid medication from morphine but I plan to remain at this level for several years. You should also know that many doctors have a soft limit to how much they are willing prescribe for pain. Some will prescribe more than others; however, as there is no golden rule.

I think your doctor is giving you dramatic increases in opioid medication within a very short amount of time but this is just my opinion. You are prescribed 30 mg of morphine every 8 hours (3x a day) when initially the dosing schedule is every 12 hours (2x a day). Also, extended release medications are meant to be taken on schedule not as needed. Immediate release medications are to be taken as needed.

I would hope that your doctor discussed with you that the morphine is not going to stay as effective as it is today forever. You will build a tolerance to the medication and need more of it to maintain adequate analgesia. Also the goal is not to be 100% pain free but to have a meaningful reduction in pain.

Taking just opioid medications is not going to provide you the relief you are seeking. There are other components to a comprehensive pain management program that will help the opioid medication work better and can help you take less of it. Typically, in addition to opioid medications a muscle relaxer, anti-convulsant, anti-depressant, and/or anti-inflammatory medications are prescribed together with opioid pain medication. I take all categories of these adjuvant medications as well as receive spinal injections every 3 months. All of these together help considerably reduce the pain I experience everyday.

I also have mild scoliosis and have been told by my spine orthopedic specialist that it is not the cause of my pain. Scoliosis has to be moderate to severe to really cause significant pain. What does cause my pain is nerve damage due to a ruptured disc at L4-L5 and a bulging disc at L5-S1 that are pushing on the nerve roots as well as osteoarthritis and bone spurs.

What other things have you tried for pain relief other than opioid medications?

Extended release medications are not perfect in how they work even though some work better than others. Therefore, many chronic pain patients including myself are prescribed breakthrough opioid pain medication in addition to the extended release opioid medication. So it is not unusual to be prescribed both.

Too little extended release pain medication presents itself through significant pain throughout the day. When the extended release medication is optimal, the chronic pain patient only has pain spikes 1 or 2 times a day.

Lastly, you may want to consider a different extended release opioid. Many people don't metabolize morphine properly and when this happens, it isn't very effective. You are on quite a bit of morphine and it sounds like you are still having a lot of pain so it may be that morphine is not the right medication for you.

I do hope that you are able to get your pain controlled.
dfromspencer replied to Anon_160307's response:
I too am on extended release morphine. I take 700mg per day. Two tabs in the morning, two tabs in the afternoon, and three tabs at bedtime. Each tab is 100mg. I also take oxycodone 5mg for breakthrough pain. This is the third medication i have tried for my nerve damage. Even at this level, my pain is quite intense. I started with tramadol, which seemed to make me feel as if i was stupid? It did nothing for my pain. Then my Dr. tried Methadone, this seemed to work, so i stuck with that for three years. Once i got to three hundred mg. i was switched over to the Morphine. This Morphine has been the most effective pain reducer yet. However; my Dr. has been reluctant to up this dosage. I dont blame him, but something has to give, and soon. My pain level at this dosage is becomming intollerable. I am calling his office today to speak with him about this. I hope he will understand that i am sick of taking medication for this pain, and can find some alternative again. I have been thru the radial freaquency and pain block treatments, all to no avail. There has got to be something he hasn't tried? Any help here? I would certainly appreciate it! Dennis
annette030 replied to dfromspencer's response:
Good luck to you. How did the phone call go?

I always see my doctor in person to discuss pain med increases or increased pain. She wants to make certain it is still the original pain and not something new. I agree with her, mainly because I have seen how they work and prefer the privacy and focus given to me in person vs. on the phone.

I have been on daily opioid therapy for about 15 years now and have never gotten to the dosages you use. I can't believe you got to 300 mg. of methadone in three years. I have been on it for 2.5 years (after taking morphine ER continually before that) and take only 20 mg. of methadone daily and also use oxycodone 15 mg. for breakthrough pain.

Keep in touch.

Take care, Annette
Anon_160307 replied to dfromspencer's response:
I also have nerve damage and I find that a combination of gabapentin, flexeril, valium, long-acting and short-acting opioids, anti-depressant, and anti-inflammatory works best for me. When the nerve damage flares up (typically around the time that I am due for another epidural steroid injection), my medications don't work very well to relieve my pain...especially the opioid medications.

Opioid medications are not the first line treatment for nerve pain. Nerve pain is best treated with an anti-convulsant such as gabapentin (brand name Neurontin) or Lyrica. Have you tried gabapentin or Lyrica for your nerve pain? You might find that adding one of these helps with the nerve pain you experience. Typically a low dose is started at first (e.g., 300 mg 3x daily) and the max dose is 3600 mg per day.

Also, have you considered rotating to a different opioid such as Opana or Fentanyl? Opioid rotation could allow you to take less and have better pain relief than you are getting right now from the morphine due to the incomplete cross tolerance factor. With a tolerance as high as yours, the only way you may get meaningful relief is through switching opioids every few years along with adding non-opioid adjuvant medications previously mentioned.
annette030 replied to Anon_160307's response:
I use gabapentin for nerve related pain and I started at 300 mg. per day at bedtime, not three times a day. It made me feel kind of drunk for awhile, then that feeling went away. I stabilized at 800 mg. per day in the evening.

Take care, Annette
finn2 replied to Anon_160307's response:
Everyone is different but just for the record, I tried Lyrica for 3 months, was very sleepy on it, couldn't think, had to talk slowly, couldn't follow conversations, everything was foggy, could not drive of course, fell asleep whenever I sat down (computer, toilet), it was awful, I absolutely hate feeling that way. Can't remember the dosage but it was a starter dose. Tried the fentanyl patch before that, at 12 mg. it did the same thing, couldn't stay awake, but wasn't quite as goofy as when on the Lyrica. And neither of those meds or dosages, diminished the pain, just saying to be careful as you have that 4 yr old to look after. Everyone is different though and I have had some strange reactions to various drugs before finding what worked for me and didn't make me sleepy and goofy.
Anon_160307 replied to finn2's response:
Hi Finn2,

I wasn't responding to the original poster when I recommended gabapentin and an opioid rotation to Opana or Fentanyl. The original poster is not opioid tolerant enough for Fentanyl or Opana. I was responding to DfromSpencer as he stated he was taking 700 mg of morphine per day so I thought I would offer some suggestions to him on how he might be able to get increased pain relief without another titration in morphine. Sorry for the confusion. My first post to this thread was to the original poster; however, my second post was to DfromSpencer.
cweinbl responded:
Recent research suggests that high-dose opiates can be more effective with chronic pain than starting with the lowest dose. Of course, there can be side effects. However, most side effects diminish within the first few months.

But the real solution lies in understanding that we are all different and we all respond differently to pain medication. Thus, it is in our best interest to try virtually every combination of drugs available. Only by doing this can we determine which combination is best for our unique body chemistry.

I have stressed "combination." After 40 years of chronic pain and trying virtually every drug available, I determined which combination is best for me. For chronic pain patients, that often means a long-acting narcotic (Kadian, Oxycontin, Fentanyl Transdermal, etc.) as our mainstay drug. Add to that a short-acting medication (Oxycodone, Hydrocodone) for breakthrough pain. Add to that an anti-depressant (Cymbalta seems to have decent pain-fighting qualities) because they inhibit the reuptake of Seratonin, one of the body's own pain-fighting chemicals. Add to that an anti-convulsant if you have neuropathic pain. Add to all of these an anti-inflammatory if you have auto-immune related pain, such as osteo or rheumatoid arthritis, etc.

The combination of medications appears more efficacious than any of them would be used alone. Fins a physician who will allow you to experiment with each one. Eventually, you'll know how to best manage your pain with medications.

But that's only half the story. Many of us use common pain management techniques that we have learned from a comprehensive pain management program. For example, I can decrease my pain by about 20% with biofeedback. Many others benefit from TENS, PT kinesiotherapy, injections, acupuncture, hypnosis, etc. These represent a non-invasive, safe and effective part of your pain management arsenal. Ask for a referral to a comprehensive pain management program. Good luck.

P.S. When used as directed, there are very few, if any, "dangers" asssociated with using narcotics.