Meds and tolerance

Factual Questions
1

Hello Again Everyone,
I am turning to the boards for this one as my Google-fu isn’t finding me the answers and my doctor just wasn’t very clear.

  • Disclaimer: I am not really looking for medical advice, looking for facts about medication. Mainly so that when I discuss things with my doctor I am familiar with what we are talking about. I know that you are not a doctor (or maybe you are?!) so no worries there.*

Currently I am on 60mg morphine xr with percocet a couple of times a day for breakthrough pain. I suffer from FBSS (Failed Back Surgery Syndrome). Recently the morphine doesn’t seem to be working as well as it once did and I suspect that my tolerance to it has increased and shortly it will be necessary to adjust my dosage up again. This is what concerns me. I have worked very hard to lower my dosage because of tolerance. In the last year I have reduced (with my docs help) my intake of morphine from 120mgs a day to 60mgs.

What I am worried about is I am only 44. Obviously the amount I can increase the pain meds isn’t infinite. It seems that the tolerance level builds up on an average about every 12 to 13 months. If I do the math and I live another 30 or 40 years I will eventually need a semi truck load of morphine to handle the pain. Of course there is a limit (yes, I know that the limit is based on personal tolerance etc.) and from what I have found 200mg is the minimum fatal dosage in an adult.

So, to get on with the story, I would like to grow old AND be out of pain. So, I have to find a way to control the pain while at the same time keeping my body from building a tolerance to the meds. Does anyone here know if Opiod medications are “cross tolerant” (I don’t know if that is the correct term, I took a WAG). Meaning if I build a tolerance to morphine will I also have a tolerance to say demerol? If not would it be reasonable to take morphine for 2 or 3 months then switch to demerol for 2 to 3 months than back. That way never building a tolerance to either?

I apologize for this post being so long. I plan on talking with the doc about this in a few weeks at my next appointment. As I mentioned above, I would like to have my facts straight so I can discuss it with him and understand what I am talking about. Thanks in advance for your help.

2

Not qualified to discuss your post, but I would strongly urge you to have your doctor refer you to a pain specialist. That’s really the name, short for chronic pain management specialist. They are experts in working with people who can’t get rid of their pain and want to find alternate relief to opiates.

3

All narcotics are cross tolerant whether they are natural opiates or synthetic opioids.

I recommend a book by Leon Root, M.D. called “No More Aching Back”. It explains why your back is in trouble, why more surgery often makes the problem worse, and what you can do to get some relief. It may be out of print but you won’t regret the time spent to find it on the internet. Really. Get this book. Good luck no matter what you decide.

4

Yes, see a pain specialist. You need to be in a pain management program for the rest of your life. I’ve heard incredible success stories from people in similar positions to yours.

5

IANAD and I know nothing about opiate usage, but I can argue that your concern is serious and real, as the similar problem can happen with other kinds of drugs too. A few years ago, I faced a similar problem with benzodiazepines. I chose to quit the drug and had massive withdrawal problem that lasted a year and a half, for the last 10 months of which I had to go live in a rest home. (This had nothing to do with cross-tolerance, however.)

6

The question is more about what your doctor will be comfortable prescribing than what will kill you – if you have built up a tolerance, the fatal dosage level for you is going to go up as well. I’ve known people who took over a thousand milligrams of morphine daily for cancer pain, and were still conscious.

(This is assuming you’re not also drinking alcohol or taking other sedatives–if you are, things can be quite different.)

7

I am a doctor, and I have a goodly amount of training and practice in pain management and opioid prescribing.

Having said that, I’m not your doc, I haven’t interviewed or examined you, so what follows are generic observations based on the science and my experience. They do not constitute advice for your situation.

The problem with long-term use of opioids for chronic non-malignant pain is that the dose generally continues escalating over time, all in an attempt to achieve the original degree of pain relief. And generally over time, that original degree of relief cannot be completely achieved by increased dosage, save only briefly.

What we do see happen is lesser relief with escalating dosages, increased sedation, increased constipation, and a general and eventual degradation of functioning.

What is also seen is that the patient often comes in and reports that they’re taking enough opioids to kill an elephant, they’re requiring lots of medications to have normal bowel movements, they’re groggy a lot, they have flattened or inappropriate emotional responses to situations, and they have about as much pain as they were having before starting on the opioids.

Which is why I am not a big fan of using opioids long-term on chronic non-malignant pain. Opioids have their place in selected cases and situations, but all too often they’re not a good long-term option. I only prescribe them to achieve specific functional goals, and if such goals aren’t met, I discontinue them.

I advocate much more for other modalities, including meds which change how nerves send pain messages, like gabapentin, amitriptylene, carbamazepine, or others. Regional pain blocks, TENS units, and physical therapy may also help. Also, regular exercise, stretching, distraction, relaxation, meditation, and chronic pain mutual support groups are invaluable for providing relief.

I’d recommend finding a physiatrist who does pain management, as I find as a whole they tend to encompass these modalities a bit better (and I’m generalizing here, YMMV) than anesthesiologists who do pain management.

8

Listen to Qadgop. There are different types of pain, some that opioids will not touch. A good pain specialist can sort out your pain and propose other analgesic strategies, if appropriate. Physical therapy and the other non-pharmacological alternatives Q mentioned can be more effective than medication, and should not be ignored.

This statement:

is incorrect (unless I am misinterpreting it). I knew a man who was taking 1600mg of morphine every four hours.*
mmm
*(I should clarify that this was a hospice patient and does not relate to your situation at all)

9

All that statement means is that there are cases of record of as little as 200 mg of morphine being fatal. It does not mean that every person who takes 200 mg will die nor does it imply that some people can’t tolerate much higher doses and live. It just marks the minimum danger point that a naive user needs to watch for.

10

I will state without a reference that although there is cross tolerance among all opiates, there may be some unique, agent-specific tolerance as well. In other words, upon switching from morphine to dilaudid, say, a person may require less of the latter than you’d expect by using the typical opiate equivalence formulae (example).

11

Ah, I see. I would think that would be a hell of a lot less than 200mg, though.
mmm

12

Thanks for the response, I especailly appreciate comments from a doctor. I will have to say in my doctors defense he has done wonders in working with me to decrease my dependence on pain meds. I use a tens unit on a regular basis, although the relief it provides is very temporary. He thankfully got me off of the fentynal pain patches. My quality of life has improved dramatically since the switch to morphine.

One area he showed quite a bit of resistance to was my plea to do something to combat the sedating effects of the morphine and percocets. It got to a point that my quality of life was in the gutter. I was sleeping more than I was awake and when I was awake I was lethargic. My Doc and I consulted with a trusted pharmacist and decided to add a low dose of Adderal (amphetimine) to my medication regiment. I have to say that my life is 100% better since the introduction of the Adderal. I wake up in the morning and stay awake all day like a normal person. The dosage is very low, so I am not having any effect other than not being sleepy all the time.

I am open to anything that will lower my dependence on the opiods. Unfortunately without them the pain is unbearable. Thankfully I don’t crave the opiods and I have never experienced withdrawl symptoms (minor maybe) the few times I have been without the meds. However, the pain works like clockwork and it doesn’t take much time without the drugs before things turn ugly.

The only non-drug solution I have been offered is surgical and I have to say I am in no hurry to be cut open again. I have been cut on three times and have had no real improvement. The surgeon says that my pain could be coming from the rods and screws that are in my spine. He told me that they are no longer needed as the fusion has taken and that they can be removed. The problem is he can’t give me any decent odds or any odds at all that the removal of the hardware will improve the pain. This makes it difficult for me to justify a surgery this major.

The biggest problem seems to be that the Doctors just don’t know. Several MRI’s and CT scans and no one can seem to identify the problem. I guess spinal surgery isn’t an exact science and the technology doesn’t exist to pinpoint the problem. If anyone has any suggestions please let me know. Hell, the pain has been so bad at times, I have considered traveling to Germany and try the Ketamine procedure where you are put into a Ketamine coma for 10 days in an attempt to “re-boot” the brain. Studies have shown that 85% of the patients that have undergone this treatment are pain free after 5 years. That seems like pretty good odds to me, although the FDA hasn’t approved the treatment for the US.

13

Can anyone tell me what’s the best way to maximise a topical pain medication…with a 10% ketamine as the first ingredient??? Thanks

14

Moderator Action

Since this is an old thread that was only revived for the purpose of discussing drug use, I am going to close it.

As was stated in this thread, the discussion of illegal drug use is prohibited here.

Thread closed.