Pain management referal (help)

[Guest guest]

Ive been referred to a pain management doctor for some guidance and advise on

high dose opioid treatment by my primary care doctor. He is concerned about the

large doses of IR (immediate release) morphine. Also he wants to see what other

things can be done to improve the quality of my life and allow me to achieve a

higher level of functioning and comfort. My primary care has my best interests

at heart, this I am sure of.

After 6 or so visits going through their through intake process I finally got to

see the main medical management palliative care physician at the pain clinic.

About 4 years ago I discontinued all medications after being fed up of being a

guinea pig. I was on and tried every medication to help with pain or treat side

effects from medications I was on antidepressants, anticonvulsants, lidocaine

patches, nsaid patches, nsaids, pain meds, proton pump inhibitors,

benzodiazepines for sleep, the last straw they had me try a psychotic medication

" geodone " for sleep. This geodone medication caused chest pain and paralyzed me

in place for hours wide awake. After I stopped it all as quickly as I could self

tapper.

I was medication free for over 1 year. After living with reduced function and

severe pain my wife urged me to go back on pain medication and I concurred as I

was suffering along with a inability to function or get out of bed at times let

alone nearly never leaving the house. I was stabilized on a routine of fentanyl

and dilaudid at a dose similar to what I use today nearly 3 years ago. This

allowed me to get my life back.

Fast forward to today unfortunately the pain has not gone away and feels just

like it did when my femur was broke and similar to the pain when it was healing.

The medication still works as it did. The PM doctor explained I developed the

tolerances to opiates due to all the wild drugs they tried to give me besides

opiates. He said there was nothing wrong with the opiates and that's all they

should have used.

This was the first doctor ever to understand or admit this as well as telling me

he has prescribed more opiates than anyone in my state. He further explained I

could stay on my current medication regime and he would tell my doctor that

their is good reason for the tolerance I have developed calling for the doses I

need. He also said today if treated properly I would basically never need no

more that 200mg of morphine a day however we can't go back.

Then he proceed to tell me I could stay on what I currently take (fentanyl

100mcg every 48hours, 120mg morphine IR every 4 hours as needed). The other

option would be to do a narcotic rotation changing to medications my body is

most naive to. He wants to change the morphine to oxycodone then introduce

methadone as a long acting pain medication replacing the fentanyl.

I have a lot of concerns about methadone and its side effects including heart

problems and death, sweating, underdosed/overdosed during transition, long qt

effect on heart, effects on serotonin receptors and norepinephrine like

antidepressants and tramadol as well as the anticonvulsants all of which I had

bad reactions to, effects on nmda receptor and in is involved in memory,

sedation, ineffective pain relief as duration of effect is 4-6 hours initially

stretching to about 8-12 max after accumulation, lastly upon employment and

within school as I will be drug tested this will cast a stigma on me as they all

will all be like yeah right for pain as everyone associates methadone with

addicts.

Now I am not holding this stigma and as you can see I have done a lot of

research about methadone and how it works and its potential value as a pain

medication and I see more value later when everything else no longer effective.

I use the patches due to the fact when I used 12 hour extended release

formulations it was a roller coaster effect with 2 hours of being in pain

waiting for them to kick in, mainly with oxycontin I felt high for the next 2

hours along with excellent pain relief followed by another solid 2 hours of pain

relief, the next 2 hours the pain started to come back and the last 4 hour was

plain hell as I hurt as if they were no longer in effect. Even doing 8 hours

still came with the highs and lows I came to hate as they interrupted my sleep

and activities to dose. I also disliked taking all the pills in public as I

could not even wait 30min to take a dose.

I feel on methadone there may not be a strong of a roller coaster effect (as I'm

going to call the experience I described), however I will again be a slave to

the dosing regime and everyone asks hey whats that.

I have a history of heart problems in my family, my brother has a right bundle

branch block and my sister has spells of tachycardia where she experiences chest

pain and has passed out. I'm concerned with the long qt effect of the methadone

as I could die. I do not have hyperalagesia so I don't see the need for nmda

antagonist and besides the effects also involve chemicals involved in memory and

being in school I can't risk a side effect like this or heavy sedation as I

can't do a medication switch during school.

I get good pain control from my breakthrough medication when I take it bringing

my pain from a 7 to under 3 in 30 minutes. I would benefit from taking more long

acting medication and this I am sure of however in past I was hesitant to wear 2

patches I am now willing to do so to get more effecting pain control. The point

of my referral was to maximize my functioning to include tweak medications if

need be. I was not needing a dose increase and haven't had one in 3 years;

actually I was on over 6 times the number of morphine after the last surgery to

remove all the hardware 2 years ago and weaned down on my own titrating to my

pain level. I would be more willing if my current medications were ineffective

or if I was needing more and more medication asking for increases frequently.

I'm also concerned about the difficulty to come off of methadone as people say

its even harder to discontinue than many other opiates. Also I feel that it has

truly the most incomplete cross tolerance of everything out there and that the

dosing when switching from high levels of morphine can be as low as 20:1.

Basically I feel I should save this advantage for some day when even morphine

doesn't work or has stopped working as well. Then I would use its advantages of

methadone's best use. For example currently I would need about 42ish mg

methadone for the 600mg or so morphine I use however if I was on 1000mg of

morphine I would need 50mg methadone basically around 5mg more. I could wind up

using far more opiates without realizing and I think because of the lower

numbers and the fact doctors think it will also curb any abuse that it is dosed

more liberally than other opiates when drugs like oxycodone for example are

under-prescribed doses in most cases or at least doctors always trying to and

are reluctant to increase dosages.

There is a good possibility I could benefit from methadone nmda receptor action

once I really need even higher doses as it can reduce morphine tolerance. This

benefit would be greater the more morphine I need.

I discussed all of this with my primary care doctor and he seamed to understand

my concerns and doesn't seem to feel so strongly about methadone as my pain

management doctor did. He said he would call the PM doctor and discuss thing and

call me back saying he finds them useful to consult on dosage changes and will

discuss other options to increase the long action medication as well as what to

switch to besides methadone.

Well I know I went over a lot but I really would like your thoughts on a few

matters. What do you think about methadone for pain? What about methadone's

greater side effects; decreasing the benefit to risk ratio? What other

medications should I possibly suggest besides the fentanyl? I really want some

feedback as this is a difficult and important decision. Please respond with any

thoughts or ideas, and please do not hesitate.

Thank you everyone for your help!