Thanks for all the replies, they were very informative and appreciated. Please understand that I’m taking these pills because I have to, not because I want to. I’ve investigated every form of treatment to help with my pain but there just aren’t any. I use a TENs unit, but the effects are limited and only work while the unit is on. The only option I’ve been given is for a surgeon to go in and “have a look around”. Thanks, but no thanks. Three back surgeries is enough in one lifetime.
As far as my doctor, he is very dedicated and truly wants to help. The move to immediate release was requested by me as I pleaded to be off the extended release pills because I was sleeping so much and tired when awake. Today for instance I finally took my first dose at 1:30pm. My last dose was at 12:30am last night. Over twelve hours between doses! On an extended release is be getting the drug even though I didn’t need it. With the immediate release I can be “drug free” when possible.
I realize that 180 pills seems like a massive amount, but it really isn’t much for a chronic user. That’s 6 pills per day. Yes, 30mg of oxycodone is a high dose, but remember I’ve been taking opiods for more than ten years now. Tolerance has made lower does ineffective.
I also have nothing against the DEA and is fight against illegal prescription drug use. But the paranoia that I see in the doctors, pharmacist and others really unfairly points a finger at those of us who haven’t any other options to deal with crippling pain.
I wish there was another way to fix my pain. Both I and my doctor read all we can about promising treatments, but truthfully there really isn’t much or there. If anyone has a suggestion, I’m all ears. I more than anyone would be happy to never have to put another oil in my mouth ever again.
Not necessarily. Being dependent on a drug and lethargy are two separate side effects. Dependence is basically determined by the presence of one or more symptoms usually characterizing a withdrawal syndrome, while lethargy, as I stated earlier, can come from direct sedative effects of the drug, or can arise as a manifestation of worsened depression or the development/worsening of apnea.
Given that Acetaminophen can have a positive effect on pain control by serving as an additional modulation of pain signaling in brain-spinal nerve pathways, I won’t agree that eliminating it altogether (if that is indeed what the OP has done) is necessarily good for the OP’s health or pain control. Absent poor nutrition or use of other hepatotoxic agents, acetaminophen can be used safely and effectively and can act as an opioid sparing therapy (meaning less of the opioid is necessary to achieve the same level of pain control, which in turn will lessen opioid side effects).
Taking an opioid with food will generally delay the time to onset and time to maximum plasma concentration, though to the best of my recollection, it doesn’t effect overall exposure/duration of effect.
You might be surprised to learn that there is technically no ceiling on the dose of opioids you can work up to. The only limitations are the rates you develop tolerance to various side effects (tolerance from a pain standpoint develops at a different, generally faster, rate than tolerance to the respiratory depressant effects, to name an important example), the presence of side effects making a given dose intolerable, and the absorption kinetics of the specific dosage form. While 90mg of oxycodone per day isn’t low by newer guideline standards (it’s roughly the equivalent of 135mg of morphine), older guidelines allow for up to 200mg of morphine equivalence, and most of the more serious/difficult to treat side effects are generally, but not absolutely, more prevalent above 200mg of morphine.
Having a good relationship with your pharmacist(s) is incredibly important, in cases like chronic opioid therapy, though I’m of course biased. I might not even bat an eye at a prescription for high dose in one patient, whom I know, know their medical history, know they aren’t attempting early refills, while an equivalent dose in an unknown patient is going to get quite a bit of initial scrutiny, because I’m required under the law (with every fill) to determine if a prescription is for a “legitimate medical purpose” and to perform Drug Utilization Review (DUR) to check for things like drug interactions, duplications, over/under-dose, over/under-utilization, etc, and that is harder to do without asking lots of questions of a patient and their doctor if I don’t know them.
While opiates provide some pain relief in neuropathic conditions, the evidence so far suggests they don’t provide much, if any, functional improvement in performing activities of daily living and activities a patient enjoys but can’t perform due to pain, and that it takes higher doses than for somatic pain conditions to achieve the same reduction in pain, which puts one at greater risk for side effects and actually impairing functionality further. Antidepressant agents, be they tricyclics (like amitriptyline, desipramine, nortriptyline) or SNRI (evidence is best for Duloxetine, known commercially as Cymbalta, though Venlafaxine is also an option), tend to do a better (if still imperfect) job at neuropathic pain relief.
I’d be intrigued to know what exactly she was arrested for. We usually only involve the police if we know or very strongly suspect a prescription is fake, someone trying to fill scheduled drugs under multiple fake identities (had it actually happen), are dealing with a patient who is making overt threats, or are involved in theft/robberies. Otherwise, forceful negative confrontation tends to work opposite the way we want it to, in my experience, leaving a patient less likely to trust me, instead of more likely to do so.
Fibromyalgia, though, tends to function like the above mentioned neuropathic pain. You can get a pain relief response with opioids, but generally they impair or fail to improve function in the process, and most guidelines (that I’ve read, at least) recommend non-pharmacologic therapies (and/or neuropathic pain therapies) as being more effective than opioid therapy.
To put things into perspective, if we assume the above Percocets were the 10/325 form, 125 per month is roughly 4/day per 30 day period with 5 extra for breakthrough and/or volitional pain, which works out to 40mg of oxycodone, and 60mg of morphine equivalents. Ohio’s “push pause” initiative sets 80mg of morphine equivalents as the “re-evaluate if this is the right therapy, that you are doing everything correctly, etc” point, so this dose falls under that. If Grumpy were elderly, some literature suggests a lowering of said point to 50mg of morphine equivalents, but Ohio just sticks with 80mg across the board. Not too long ago, we filled a prescription for a patient with cancer for up to 10 oxycodone 30mg/day (450mg morphine equivalents), and while I’m not exactly thrilled with this prescription from a pharmacokinetic standpoint, that’s not a dose that’s all that hard to work up to when we’re talking cancer.
A study published not all that long ago in Pain found that generally this seems to hold true for many of the patients involved (it involved dihydrocodeine, which isn’t used here in the USA, to my knowledge). The potential problem with regards to more frequent IR dosing is again, duration of effect can have an impact on the amount and quality of sleep, which can worsen pain, and that the more frequent (and rapid) the rise in drug levels, the more likely we are to see a shift towards problematic drug-use behaviors (called aberrant drug-related behaviors in some literature), which can be a sign we’re moving towards, or have ventured into, substance use disorder (addiction) territory, which is why we hoped the introduction of long-acting forms would curtail some of the addictive risk.
To be fair to the neurologist, we have practically no good evidence of efficacy for opioid therapy beyond the subacute range (6-12 weeks), and an ever increasing body of epidimiological literature strongly suggesting that at best, we’re not reducing the overall reported pain levels, and at worst, we’re actually making them worse, with chronic opioid therapy. Provided he wasn’t opposed to intermittent use on a chronic basis, I can see his point. Moreover, to go pedantic, hitting him with a ball-peen hammer for 72 hours would be an example of an acute pain scenario, for which the evidence of benefits for opioids is much greater than with chronic treatment. Instead, you should have asked him to go old school, like Head who in 1905 purposefully divided the cutaneous branch of his radial nerve in his OWN arm. Doctors these days, pansies, the lot of them.
A few months ago, we had a late 60’s patient who, despite receiving opiate therapy from a pain doctor (who eventually “fired” her from his practice for constant uncorrected aberrant drug-related behaviors), then opiate therapy from family pratice doctors who had her sign a pain contract including random urine drug testing, who still ended up getting “fired” a second time because she was using heroin on the side. The elderly are not immune to addiction, and are even more likely to experience some of the more problematic side effects than younger, usually healthier, individuals are. If we were dealing with a 100% all risks explained, informed consent scenario, where the patient and family waive the right to sue if the patient experiences those effects, because they were warned in advance that up to and including death from cardiac arrest secondary to respiratory arrest were possible with this therapy, or we had GOOD evidence that chronic opioid therapy was actually beneficial for pain, then I might agree.
Hey, don’t forget pharmacists! Wait, no, that’s not a good thing to be proud of. Forget Pharmacists!
Seriously, though, you aren’t wrong. I’ve got colleagues whom I’ve explained the difference to who still state stupid stuff like, “well yeah, but they’re an addict so I don’t care if they’re actually in pain”. Not very many, but a few. A most epic face palm was experienced on THAT day.
Except that, as I’ve stated, as Qadgop the Mercotan (sorry to name drop, but dude, you’re like legendary) has stated, as countless other healthcare practitioners have stated, Opioids are NOT the panacea the general public and the media like to portray them as. They are a messy, hitting the entirety of the brain in ways we’re still trying to work out, may render you less functional, more prone to excessive healthcare utilisation compared to other pharmacologic and non-pharmacologic strategies, but still SOME of the time useful tool. They are not “good drugs”, the “good stuff”, “the shit” (in a positive sense), and any other terms patients have used to describe them. They aren’t just analogous to fire, they ARE fucking fire in the damage they can wreak, and until people understand that, I’m gonna be a Debbie Downer (while still trying to provide as accurate of information as I can) with regard to their long term usage.
Do phamarcies make significant money from Schedule II drugs? If not could this policy by the company be intended to actually discourage patients from ever buying them in their chain, hence getting rid entirely of the problem?
