Re: pain meds heirarchy?

[Guest guest]

The next thing to try is extended release oxycodone or morphine. It's hard to

keep on top of pain if the medication is losing it's effect several times a day.

Jennette

>Kitty wrote:

Is there such thing as a hierarchy of pain meds? For instance, I had a wisdom

tooth out and got tylenol #3. When my docs finally started treating my back pain

I

got Vicodin. Now I'm " up to " oxycodone. I guess I want to know what I should be

asking for when my current meds don't work.

[Guest guest]

I think there are some medications that are stronger than others. However,

there are different classes of medications that vary by their action. If you

are not getting relief from a certain class, the doctor will probably try a

different class.

I do not get much relief from pericet or vicodin for example; but I do get

relief from instant release oxycodene. that is just codene without the tylenol

or aspirin component.

Through trial and error, my doctor found a combination of medications that

manage my pain. From what I have heard from several people, it takes a

combination rather than only 1 medication.

Do you see a pain management doctor? If not you should consider asking for a

referral. Many pcps are not comfortable prescribing more than 1 pain med at a

time.

Hope you find relief soon. Lots of gentle hugs, Tami

>

> Is there such thing as a hierarchy of pain meds? For instance, I had a wisdom

tooth out and got tylenol3. When my docs finally started treating my back pain I

got Vicodin. Now I'm " up to " oxycodone. I guess I want to know what I should be

asking for when my current meds don't work. I don't know if a new med or higher

dose is a better alternative. So, anything like what I'm describing? (by the

way: I can't take any NSAIDS). Thanks in advance!

>

[Guest guest]

> " Kitty " wrote:

> Is there such thing as a hierarchy of pain meds?

All,

There is a accepted practice which is known as the pain ladder that lists pain

medication and how they are dispensed on the pain diagnosed. It was developed

by the WHO , World Health Organization for pain.

I also read the " Survival Guide for Intractable Pain Patients " by Dr. Forest

Tenent and he has charts and explanations on nutrition, supplements and other

information essential to pain patients. It is presented in a logical

understandable manner and I have copied and pasted some of the parts on pain

medications and how they are used.

I encourage all to read this guide as it assists you in understanding what it is

needed to help you manage your pain. The guide can be downloaded from the

internet by typing in the title and author or going to paintopics.org. I know

the information below is long but I know that people sometimes do not go to

links.

Hope this answers your questions of heirachy. Bennie

FIRST STEP OPIOIDS

When you first start opioids for treat- ment, you will start with one listed in

the " First Step Table. " These opioids can be taken as needed, or on a regular

basis. This group of opioids have few side ef- fects and create little

dependence. Some contain acetaminophen, ibuprofen, aspi- rin, or other

potentiators which are com- pounds that make the opioid act stronger and last

longer. Some patients may require two of the " First Step " opioids which may be a

preferable treatment approach to the " Second Step Opioids. " First Step opioids

are short-acting in that they usually provide pain relief for only about 2 to 4

hours.

Before going to Step Two opioids patients should attempt to control their pain

with a Step One opioid coupled with one or more of the ancillary medications and

treatments listed in this Handbook. Vigorous attempts should be made to avoid

Step Two opioids, since they may produce complications.

STEP TWO OPIOIDS

If Step One opioids fail to adequately control pain, an IP patient will have to

resort to Step Two opioids. They are much more potent than Step One opioids.

They are usually required if pain is severe and constant � meaning it never

goes away during the entire 24-hour day unless the patient is asleep. Patients

with the " cardiac-adrenal- syndrome " will usually require Step Two opioids.

Unfortunately, these opioids may cause constipation, hormone changes, and weight

gain. Patients who must take them must learn and practice measures to minimize

complications. Some Step Two opioids are often referred to as long-acting, since

they remain in the blood and control pain for several hours.

Long-acting opioid products, including morphine, methadone, oxycodone, and

oxymorphone, are to be taken on a regular, fixed schedule. Depending on the

opioid, the time interval will be every 6, 8, 12, or 24 hours. IP patients

should discipline themselves to take their long-acting opioid on a fixed,

regular sched- ule such as when they first awake, noon, late afternoon, and just

before bedtime. They are NOT to be taken as needed, and when patients attempt to

take them this way, they soon find that their pain is not well-controlled. Many

patients will also need to use Step One opioids during pain flares or

breakthrough pain.

OPIOID

Hydrocodone Propoxyphene Tramadol Codeine Dihydrocodeine Pentazocine Nalbuphine

Butorphanol

FIRST STEP OPIOIDS

COMMON TRADE NAMES

Vicodin�, Lortab�, Norco� Darvon�, Darvocet�, Darvon-N� Ultram�

Empirin�, Fiorinal� Panlor� Talwin� Nubain� Stadol�

STEP TWO OPIOIDS

If Step One opioids fail to adequately control pain, an IP patient will have to

resort to Step Two opioids. They are much more potent than Step One opioids.

They are usually required if pain is severe and constant � meaning it never

goes away during the entire 24-hour day unless the patient is asleep. Patients

with the " cardiac-adrenal- syndrome " will usually require Step Two opioids.

Unfortunately, these opioids may cause constipation, hormone changes, and weight

gain. Patients who must take them must learn and practice measures to minimize

complications. Some Step Two opioids are often referred to as long-acting, since

they remain in the blood and control pain for several hours.

Long-acting opioid products, including morphine, methadone, oxycodone, and

oxymorphone, are to be taken on a regular, fixed schedule. Depending on the

opioid, the time interval will be every 6, 8, 12, or 24 hours. IP patients

should discipline themselves to take their long-acting opioid on a fixed,

regular sched- ule such as when they first awake, noon, late afternoon, and just

before bedtime. They are NOT to be taken as needed, and when patients attempt to

take them this way, they soon find that their pain is not well-controlled. Many

patients will also need to use Step One opioids during pain flares or

breakthrough pain.

OPIOID

Hydrocodone Propoxyphene Tramadol Codeine Dihydrocodeine Pentazocine Nalbuphine

Butorphanol

FIRST STEP OPIOIDS

COMMON TRADE NAMES

Vicodin�, Lortab�, Norco� Darvon�, Darvocet�, Darvon-N� Ultram�

Empirin�, Fiorinal� Panlor� Talwin� Nubain� Stadol�

STEP TWO OPIOIDS

COMMON TRADE NAMES

Methadose�, Dolophine� Kadian�,Avinza� OxyContin� Duragesic�

Levodromoran�

Opana ER�

OPIOID

Methadone Morphine Oxycodone Fentanyl Levorphanol Oxymorphone

BREAKTHROUGH PAIN

Some Step Two opioids are long-acting and prescribed to suppress pain and

possibly pre- vent pain from even occurring. Unfortunately, they may not totally

do the job, and pain will flare or " breakthrough " the barrier of the long-

acting opioid. A severe breakthrough or flare episode can disable you and send

you to bed or worse � to the emergency room. If your pulse rate or blood

pressure rises too high dur- ing a breakthrough episode, you may even have a

heart attack or stroke that could be fatal. Consequently, most severe IP

patients will need to master the use of a long-acting opioid and one or more

breakthrough opioids.

Rapid breakthrough pain relief within 5 to 15 minutes is the goal of the use of

a breakthrough opioid medication. To achieve this rapid action, breakthrough

opioids should be taken as a liquid, lollipop, injec- tion, or suppository. They

are commonly referred to as " short-acting " opioids because they may only act for

1 to 3 hours.

DON'T DEPEND ON ONE FAVORITE OPIOID OR ROUTE OF DELIVERY

One of the biggest mistakes an IP patient makes is to get too dependent on a

favorite opioid such as fentanyl, meperidine, or oxycodone or the way it is

delivered, such as an injection or lollipop. Why? You may eventually get

tolerant to the opioid and have to switch. Also, many are extremely expensive

and health insurance plans simply will not pay for them. Their position is that

the older generic opioids such as morphine, methadone, hydrocodone, meperidine,

and hydromorphone are good enough for pain control.

You must identify several opioids that are effective for you. Do not plan on

getting the one you most want. Cost factors have simply ushered in a situation

that has priced some of the Step Two and break- through opioids out of range.

You should immediately look at the lists of opioids in this Handbook and

determine which ones you have and have not tried. At a minimum, you should

identify four that you can take and which are effec- tive. Also, do not get your

heart set on route of administration such as a lollipop or injection. For

survival, you must learn what your health plan will pay for. Do not expect your

health plan to give you a special exception to their usual opioids and costs

policy. It is usually a bad idea to take brand name opioids. Why? Sooner or

later your health insurance will likely disallow brand names.

BREAKTHROUGH OPIOIDS

OPIOID COMMON TRADE NAMES

Fentanyl Transmucosal ( " lollipop " or buccal tablet)

Hydromorphone (liquid, injection, or suppository) Meperidine (liquid or

injection) Oxycodone (liquid)

Morphine (liquid, injection, or suppository) Oxymorphone (tablet) Hydrocodone

(liquid)

Actiq�, Fentora�

Dilaudid� Demerol� Oxydose�

Roxanol� Opana� Tussionex�

Tennant - Intractable Pain Patient�s Handbook for Survival �2007 12

Estrogen, or testosterone may also be required as pain and/or opioid medications

may deplete them. You may also need mediation for nausea, constipation, or

weight control.

SLEEP

IP and its accompanying high pulse rate keep IP pa- tients awake. You will

likely need a sleep aid, and several of the favorites of IP patients are listed

in the Table. Some antidepressants, which activate serotonin are liked by

patients and physicians because they assist sleep and depression at the same

time. Furthermore, serotonin may promote neurogenesis or healing of nerves.

IP patients all expect 6 to 8 hours of sleep like a nor- mal person. DO NOT

expect this. You will likely not be able to sleep more than about 4 hours at a

time. Many IP patients cannot sleep over 2 to 3 hours at a stretch. This is

particularly true if you have damaged your spine, hips, knees, or nerves in your

arms or legs. Why? If you sleep too long on these damaged tissues, you may crush

them and produce more pain. Your body wants you to awake frequently so you avoid

sleeping in one position and crush tissues which may increase your pain.

IP patients need to take their last daily opioid dose within 1 hour before

bedtime. When you awake in the night, you should get out of bed, stretch, and

use the restroom before returning to bed. If you have pain during the night,

take a dose of your breakthrough opioid.

MUSCLE RELAXANT-ANTI-ANXIETY AGENTS

The severe pain and high pulse rate of IP causes anxiety and muscle contraction.

A high pulse rate may make you feel jittery or nervous. In addition, you may

have an injury that may cause muscle contraction. Most IP patients find that a

muscle relaxant provides consid- erable additional pain relief and comfort. For

reasons that are not particularly clear to me, some muscle re- laxants are not

effective in IP patients. Although phar- macologically classified as

anti-anxiety agents, some are effective in reducing high pulse rates and muscle

spasms. Those muscle relaxant-anti-anxiety agents that have proven to be popular

with many IP patients are listed in the Table. Do not take more than one of the

agents in the Table on the same day. The # 1 cause of sedation, falls, and

accidents in IP patients is overdose of this group of agents.

NERVE BLOCKERS

There are new drugs for pain relief that act by blocking the electricity in

nerves. Pain that is caused by nerve damage in the legs, arm, chest wall,

abdomen, or pelvis is often called " neuropathic pain. " These agents can be used

with opioids, and many patients can use these with a Step One opioid and avoid

the necessity of Step Two opioids. In milder forms of chronic pain, these agents

may work so well that opioids are not even necessary. IP patients can sometimes

reduce their opioid dosage with these

SOME SLEEP AIDS IP PATIENTS FIND EFFECTIVE

AID

Chloral Hydrate Triazolam Temazepam Zolpidem Amitriptyline

COMMON TRADE NAME

Somnote� Halcion� Restoril� Ambien� Elavil�

MUSCLE RELAXANT�ANTI-ANXIETY AGENTS

AGENT COMMON TRADE NAME

Carisoprodol Cyclobenzaprine Methocarbamol epam Clonazepam Lorazepam

Soma� Flexeril� Robaxin� Valium� Klonopin� Ativan�

NERVE BLOCKERS

NERVE BLOCKERS Duloxetine Pregabalin

COMMON TRADE NAME Cymbalta� Lyrica�

Tennant - Intractable Pain Patient�s Handbook for Survival �2007 13

agents. Some of the older antidepressants and anti-seizure drugs are nerve

blockers, and they have been extensively used for pain relief. The two newest on

the market, however, are generally superior, and they are the only ones I now

recommend.

NUTRITIONAL AND HORMONAL AGENTS

IP patients must all take some nutritional and hormonal agents. IP depletes the

body of certain nutri- tional substances and hormones. If these are depleted,

pain worsens, and the patient will experience more fatigue, insomnia, and

depression. IP patients should read about various dietary supplements and try

ones that have an appeal. At this time, there is no marketed vitamin, mineral,

herb, or amino acid that I restrict or condemn. Here are my minimal

recommendations, for all IP patients.

1. Daily multiple-vitamin-mineral tablet or capsule. 2. Calcium, magnesium, and

vitamin D. for osteoporosis prevention. 3. Pregnenolone 50 to 100mg a day. This

is the basic adrenal hormone and nerve healer.

TOPICAL MEDICATIONS

To achieve better pain relief and promote healing, IP patients may find one or

more topical medica- tions, which are rubbed into the skin over painful areas,

to be effective. These agents are known as " topi- cal " because they go on top of

the skin. Since IP patients have tissue damage and scarring, internal

medications may not always reach the damaged nerves because blood vessels in the

damaged tissue area may also be damaged. Consequently, topical medications may

be able to penetrate into damaged areas by diffusion.

The list of topical medications being used and researched throughout the country

is too long to fully list here. IP patients are encouraged to ask their

pharmacist or other IP patients if they recommend a specific topical medication.

Then try it. Topical medications have essentially no permanent side effects, so

you can experiment safely. The most consistent topical pain relievers in my

experience have been morphine and carisoprodol. The formula is to crush tablets

of medication and dissolve one or two tablets in one ounce of cold cream. Apply

as often as necessary for pain control.

An excellent topical pain reliever is lidocaine, which is classified as a

topical anesthetic. It is available as a patch (Lidoderm). This patch produces

excellent pain relief for about 12 hours. It can be placed on the neck, back,

hip, knee or other body area that is painful. Unless an IP patient has pain deep

in the body such as abdominal adhesions, they can usually get good relief from

the lidocaine patch. These patches are particularly effective if there is a pain

flare or you have " overdone " it and caused some addi- tional discomfort in a

joint, back, or spine area by over-exercise.

CONSTIPATION

This troublesome problem often results from opioid drugs and inactivity. To help

prevent it, drink 6 to 8 glasses of fluids a day and take some fiber supplements

which can be purchased over-the-counter at any grocery or drug store. Many

over-the-counter laxatives are effective. I have not observed that one fiber

product is superior to others. Therefore, it is a personal choice. I have

surveyed patients repeatedly to determine a consensus on laxatives, but there is

no agreement among IP patients as to which ones are best.

If fluids and non-prescription, over-the-counter laxatives do not do the job,

there are a number of pre- scription laxatives. Simply ask a physician to give

you a prescription. You may have to try several to settle

Tennant - Intractable Pain Patient�s Handbook for Survival �2007 14

on one you find most effective. I have found that my IP patients with severe

constipation almost always respond to polyethylene glycol (GlycoLax�,

MiraLax�, GoLYTELY�), or a licorice product called Evac-U- Gen�.

NEUROGENESIS: KEY TO CURE

Neurogenesis is the term used to mean new growth or regeneration of nerves. The

key to cure or sig- nificant, permanent pain reduction of IP is neurogenesis �

new nerve growth. A few years ago it was be- lieved that damaged nerves would

not regrow. New research clearly shows that nerves can at least partially

regrow. I have now witnessed so much permanent pain reduction in my IP patients

that I believe permanent cure may even be possible for at least some patients,

and permanent, partial pain reduction is possible in practically all IP

patients.

Research on neurogenesis is starting to occur in a big way. IP patients should

know that nerve growth is greatly dependent upon specific amino acids and

hormones that promote nerve growth. Also, nerves probably can't regrow if pain

is not well controlled because pain produces so much electrical activity in

nerves that they cannot mend. While it is too early and premature to make too

many specific recommen- dations or promises, the schematic in the back of this

Handbook is advocated at this time as the best hope for neurogenesis.

ANABOLIC THERAPY

Everyone is now familiar with " anabolic steroids " and the athletic advantage

they pro- vide by promoting muscle mass, speed, and endurance. The complications

of over-bulking of tissue with anabolic steroids are also well known as too much

bulk may injure knees, ankles, and joints. Anabolic steroids, when used in

excess, can also produce cancer, heart disease, " roid rage, " and impotence.

These complications only occur, however, with mega-dosages that are clearly

known to be dangerous.

What is important for every IP patient to know is that tissue regrowth and

neurogenesis enhanced by anabolic therapy. Anabolic simply means, from its Latin

derivation, " to promote growth.� Therapeutic dos- ages of several anabolic,

tissue-building agents are being studied in IP patients, and early research re-

sults are very promising. Listed here are some of the anabolic agents that I use

in an attempt to promote growth of tissue, healing, and permanent pain

reduction. This list is not complete and may not even con- tain the best agents,

because many physicians are just now experimenting with many different anabolic

approaches. I have only listed ones with which I am familiar and use. When

prescribed by a knowledge- able physician, these agents are very safe and

therapeutic. Other than some of the hormones, the other agents listed in the

accompanying Table on Anabolic Agents can be purchased in health food stores or

through catalogues.

ANABOLIC AGENTS

HORMONES

Pregnenolone Androstenedione

Chorionic Gonadotropin

AMINO ACIDS

Taurine Glycine

Testosterone Dehydroepiandrosterone

(DHEA)

Growth Hormone

Gamma Amino Butyric Acid Phenylalanine

NERVE TISSUE BUILDER

Alpha Lipoic Acid

,

[Guest guest]

I went through this, and went from taking 6 ultram and 2 vicodin at night, plus

muscle relaxers to taking Oxycodone and methadone. My doctor is very strict

about pain meds, and watches people closely. She even tests people to see if

they are taking their meds or selling them.

I do think that after awhile, we have to try new methods and mixes for treating

chonic pain one way is really not effective, at least not for me. Today, I am

more pain free then I ever have been, but I was like so many of you on this

group, I was pro-active and found a doctor I liked and who trusted me and would

treat my pain without hesitation - well, with hesitation, just not having me

take medications that don't work.

My quality of life is better, not pain free, but I can do my job without my pain

level going sky high. I think seeing a pain doctor is the way to go. The ones I

have seen know what works and what doesn't and I wanted to find a doctor that

would let me try different methods until we found what worked. But, not taking

anything too strong to not function in the day.

Good luck and I hope you get what you need to feel better!!

Kitty wrote:

> Is there such thing as a hierarchy of pain meds?

[Guest guest]

> Ellen wrote:

> My meds make me droopy, my pain fluctuates and I am not at

all dependable.

I went through this, and went from taking 6 ultram and 2 vicodin at night, plus

muscle relaxers to taking Oxycodone and methadone. My doctor is very strict

about pain meds, and watches people closely. She even tests people to see if

they are taking their meds or selling them.

I do think that after awhile, we have to try new methods and mixes for

treating chronic pain one way is really not effective, at least not for me.

Today, I am more pain free then I ever have been, but I was like so many of you

on this group, I was pro-active and found a doctor I liked and who trusted me

and would treat my pain without hesitation - well, with hesitation, just not

having me take medications that don't work.

My quality of life is better, not pain free, but I can do my job without my pain

level going sky high. I think seeing a pain doctor is the way to go. The ones I

have seen know what works and what doesn't and I wanted to find a doctor that

would let me try different methods until we found what worked. But, not taking

anything too strong to not function in the day.

Good luck and I hope you get what you need to feel better!!

[Guest guest]

I agree completely. I have found the same situation. There are some medication

that do not even work for me from the start. You need to be flexible and open

minded to changes in treatment.

Wishing you all a manageable day and gentle hugs, Tami

> stephntoby wrote:

> I do think that after awhile, we have to try new methods and mixes for

treating chonic pain one way is really not effective, at least not for me.

Today, I am more pain free then I ever have been,