Re: How to reduce medication to avoid withdrawl/Jennette

[Guest guest]

> Jennette wrote:

>The whole idea of having to find a new pain doctor makes me hurt all over and a

wave of fear washes over me. I'm scared to death of withdrawals and being in

horrible pain.

Jennette,

Dr. Tenent (here I go again) and my previous Doctor who was a re known pain

specialist and dual trained as a pain psychiatrist and in pain management state

that if you can you should have a months worth of meds besides what you take so

you do not get stuck without medication.

My Doctor assisted me and told me he was going to write me a medication for a

different mg and then I take the one he wants me to take so I have that to take

and the lower mg I keep on hand if I get stuck and I also I can take it at night

as my 24 hour timed medication does not last but 12 hours.

My Doctor has done research with this and he says that different people have

different metabolisms and so they metabolize their medications differently and

when they have other medications they may effect the efficacy of the 24 hour

timed medication so I actually only get 1-5mg (maybe) an hour and that is

nothing and if you look this up trying to understand the peak levels, the

medications that effect it, and other diagnosis' I have.

Here is my example, I am a on a timed Morphine of a milligram under current

" Best Practices " would be considered too much as 200 mg per day is too much and

this information to new doctors and those that poo poo this, Doctors will

probably have their patients flag that take over this amount and 1600 is the Max

for timed Morphine.

From my medical insert:

Warning

Morphine is available as long-acting capsules or tablets. These capsules or

tablets contain enough morphine to relieve pain for 12 or 24 hours and are

designed to release the medication slowly over that period of time. It is very

important not to split, chew, or crush these tablets or capsules and not to

dissolve the beads contained in the capsules in any liquid before you swallow

them. This would release all of the medication into your body at once and could

cause serious health problems or death.

If you are taking Oramorph SR or MS Contin brand long-acting tablets or Avinza

or Kadian brand long-acting capsules, you should swallow the tablets or capsules

whole. If you are unable to swallow the capsules, you can carefully open a

capsule, sprinkle all of the beads that it contains on a spoonful of cold or

room temperature applesauce, and swallow the entire mixture immediately without

chewing or crushing the beads. Then rinse your mouth with a little water and

swallow the water to be sure that you have swallowed all the medication. Do not

save mixtures of medication and applesauce for later.

If you are taking Avinza brand long-acting capsules, you should not drink any

drinks that contain alcohol or take any prescription or nonprescription

medications that contain alcohol. Ask your doctor or pharmacist or check the

list of ingredients if you do not know if a medication contains alcohol. Alcohol

may cause the morphine in Avinza® brand long-acting capsules to be released in

your body too quickly, causing serious health problems or death.

Why is this medication prescribed?

Morphine is used to relieve moderate to severe pain. Morphine long-acting

tablets and capsules are only used by patients who are expected to need

medication to relieve moderate to severe pain around-the-clock for longer than a

few days. Morphine is in a class of medications called opiate (narcotic)

analgesics. It works by changing the way the body senses pain.

How should this medicine be used?

Morphine comes as a tablet, a solution (liquid), a controlled- or

extended-release (long-acting) tablet, and a controlled- or sustained-release

(long-acting) capsule all to take by mouth. The regular tablet and liquid

usually are taken every 4 hours. The long-acting tablet is usually taken every 8

to 12 hours. Kadian brand long-acting capsules are usually taken with or without

food every 12 hours or every 24 hours. Avinza brand long-acting capsules are

usually taken once a day. Follow the directions on your prescription label

carefully, and ask your doctor or pharmacist to explain any part you do not

understand.

If you are taking morphine solution, use the spoon or dropper that comes with

the medication to measure your dose. Be sure that you know how many milliliters

of the solution you should take. Ask your pharmacist if you have any questions

about how much medication you should take or how to use the spoon or dropper.

If you are taking Kadian brand long-acting capsules and you have a gastrostomy

tube (surgically inserted feeding tube), ask your doctor or pharmacist how to

administer the medication through your tube.

Your doctor may start you on a low dose of morphine and gradually increase your

dose until your pain is controlled. Your doctor may adjust your dose at any time

during your treatment if your pain is not controlled. If you feel that your pain

is not controlled, call your doctor. Do not change the dose of your medication

without talking to your doctor.

Morphine can be habit-forming. Take morphine exactly as directed. Do not take a

larger dose, take it more often, or take it for a longer period of time or in a

different way than prescribed by your doctor.

Do not stop taking morphine without talking to your doctor. Your doctor may

decrease your dose gradually. If you suddenly stop taking morphine, you may

experience withdrawal symptoms such as anxiety; sweating; difficulty falling

asleep or staying asleep; chills; shaking of a part of your body that you cannot

control; nausea; diarrhea; runny nose, sneezing or coughing; hair on your skin

standing on end; or hallucinating (seeing things or hearing voices that do not

exist).

Other uses for this medicine

This medication is sometimes prescribed for other uses; ask your doctor or

pharmacist for more information.

What special precautions should I follow?

Before taking morphine,

• tell your doctor and pharmacist if you are allergic to morphine, any other

medications, or any of the inactive ingredients in the type of morphine tablets,

capsules, or liquid you plan to take. Ask your pharmacist for a list of the

inactive ingredients.

• tell your doctor and pharmacist what prescription and nonprescription

medications, vitamins, nutritional supplements, and herbal products you are

taking or plan to take. Be sure to mention any of the following: anticoagulants

('blood thinners') such as warfarin (Coumadin);antidepressants such as

amitriptyline (Elavil), amoxapine (Asendin), clomipramine (Anafranil),

desipramine (Norpramin), doxepin (Adapin, Sinequan), imipramine (Tofranil),

nortriptyline (Aventyl, Pamelor), protriptyline (Vivactil), and trimipramine

(Surmontil); antihistamines (found in cold and allergy medications); beta

blockers such as atenolol (Tenormin), labetalol (Normodyne), metoprolol

(Lopressor, Toprol XL), nadolol (Corgard), and propranolol (Inderal);

buprenorphine (Subutex, in Suboxone); butorphanol (Stadol); cimetidine

(Tagamet); diuretics ('water pills'); medications for anxiety, mental illness,

pain, seizures, or nausea; muscle relaxants; nalbuphine (Nubain); pentazocine

(Talwin, in Talacen); sedatives; sleeping pills; and tranquilizers. Also tell

your doctor if you are taking any of the following medications or if you have

stopped taking them within the past 2 weeks: monoamine oxidase (MAO) inhibitors,

including isocarboxazid (Marplan), phenelzine (Nardil), procarbazine (Matulane),

selegiline (Eldepryl), and tranylcypromine (Parnate). Your doctor may need to

change the doses of your medications or monitor you more carefully for side

effects.

• tell your doctor if you drink or have ever drunk large amounts of alcohol and

if you have ever had major surgery. Also tell your doctor if you have or have

ever had a head injury; a brain tumor; seizures; mental illness; difficulty

swallowing; lung disease such as asthma, chronic obstructive pulmonary disease

(COPD; a group of diseases that cause gradual loss of lung function), or other

breathing problems; prostatic hypertrophy (enlargement of a male reproductive

gland); urinary problems; low blood pressure; irregular heartbeat; 's

disease (condition in which the body does not make enough of certain natural

substances); or liver, kidney, pancreatic, intestinal, or gallbladder disease.

• tell your doctor if you are pregnant, plan to become pregnant, or are

breast-feeding. If you become pregnant while taking morphine, call your doctor.

• if you are having surgery, including dental surgery, tell the doctor or

dentist that you are taking morphine.

• you should know that this medication may make you drowsy. Do not drive a car

or operate machinery until you know how this medication affects you.

• talk to your doctor about the safe use of alcohol while you are taking this

medication.

• you should know that morphine may cause dizziness, lightheadedness, and

fainting when you get up too quickly from a lying position. To avoid this

problem, get out of bed slowly, resting your feet on the floor for a few minutes

before standing up.

of morphine. THE DAILY DOSE OF AVINZA MUST BE LIMITED TO A MAXIMUM OF 1600

MG/DAY. AVINZA DOSES OF OVER 1600 MG/DAY CONTAIN A QUANTITY OF FUMARIC ACID THAT

HAS NOT BEEN DEMONSTRATED TO BE SAFE, AND WHICH MAY RESULT IN SERIOUS RENAL

TOXICITY.

Pharmacodynamics

Morphine concentrations are not predictive of analgesic response, especially in

patients previously treated with opioids. The minimum effective concentration

varies widely and is influenced by a variety of factors, including the extent of

previous opioid use, age, and general medical condition. Effective doses in

tolerant patients may be significantly higher than in opioid-naïve patients.

In all patients, the dose of morphine should be titrated on the basis of

clinical evaluation of the patient and to achieve a balance between therapeutic

and adverse effects.thrombocytopenia.

Metabolic and Nutritional Disorders: edema, weight loss. Musculoskeletal:

skeletal muscle rigidity. Nervous System: abnormal dreams, abnormal gait,

agitation, amnesia, anxiety, ataxia, confusion, convulsions, coma, delirium,

euphoria, hallucinations, lethargy, nervousness, abnormal thinking, tremor,

vasodilation, vertigo.

The reason I mention and listed everything on the medical insert above that

often do we read our inserts and ask if the longer we take it, the side effects

might happen if it is not excreated out.

Don't be scared, be empowered by reading how to do it, look at the other options

in the area or where you live if you change. My current pain management Doctor

is just over a year and I am concerned if

she gets sick, who covers for her so I have already been contacted several other

offices with two or more but not like the Doctor I

had before that was nice at first but started asking single service doctors

would come to work with him and it is now like a franchise and you don't get

call backs.

I waited to send a narrative why, he doesn't care and their review rating is 2

so you can see it is bas and that is over 70 reviews. There is nothing wrong

asking another doctor to do a second opinion review and ask what they what do to

treat your care.

Bennie

[Guest guest]

Thanks for posting the information Bennie.

My doctor does pill counts and will not prescribe more medication than I take in

one 30 day period. She does see me every other month, giving me a script to

hold till the date written on it. I can not refill it prior to that date.

I don't have to do a urine test every visit, she calls me one of her " good

patients " .

I comply and agreed to her contract. So be it, at least I am not in continuous

pain anymore and she's ok with upping the dose if/when necessary and I keep a

daily pain log that she looks at every visit.

I wish the pain doctors were free to treat their patients without the government

looking over their shoulder.

Here is some specific dosing information for MSContin taken from the RxList.com

Conversion from Immediate-Release Oral Morphine to MS CONTIN

A patient's daily morphine requirement is established using immediate-release

oral morphine (dosing every 4 to 6 hours). The patient is then converted to MS

CONTIN® (morphine sulfate controlled-release) in either of two ways: 1) by

administering one-half of the patient's 24-hour requirement as MS CONTIN on an

every 12-hour schedule; or, 2) by administering one-third of the patient's daily

requirement as MS CONTIN on an every eight hour schedule. With either method,

dose and dosing interval is then adjusted as needed (see discussion below).

The 15 mg tablet should be used for initial conversion for patients whose total

daily requirement is expected to be less than 60 mg. The 30 mg tablet strength

is recommended for patients with a daily morphine requirement of 60 to 120 mg.

When the total daily dose is expected to be greater than 120 mg, the appropriate

combination of tablet strengths should be employed.

Conversion from Parenteral Morphine or Other Opioids (Parenteral or Oral) to MS

CONTIN

MS CONTIN can be administered as the initial oral morphine drug product; in this

case, however, particular care must be exercised in the conversion process.

Because of uncertainty about, and intersubject variation in, relative estimates

of opioid potency and cross tolerance, initial dosing regimens should be

conservative. It is better to underestimate the 24-hour oral morphine

requirement than to overestimate. To this end, initial individual doses of MS

CONTIN should be estimated conservatively. In patients whose daily morphine

requirements are expected to be less than or equal to 120 mg per day, the 30 mg

tablet strength is recommended for the initial titration period. Once a stable

dose regimen is reached, the patient can be converted to the 60 mg or 100 mg

tablet strength, or an appropriate combination of tablet strengths, if desired.

Estimates of the relative potency of opioids are only approximate and are

influenced by route of administration, individual patient differences, and

possibly, by an individual's medical condition. Consequently, it is difficult to

recommend any fixed rule for converting a patient to MS CONTIN directly. The

following general points should be considered, however.

1. Parenteral to oral morphine ratio: Estimates of the oral to parenteral

potency of morphine vary. Some authorities suggest that a dose of oral morphine

only three times the daily parenteral morphine requirement may be sufficient in

chronic use settings.

2. Other parenteral or oral opioids to oral morphine: Because there is lack of

systematic evidence bearing on these types of analgesic substitutions, specific

recommendations are not possible.

Physicians are advised to refer to published relative potency data, keeping in

mind that such ratios are only approximate. In general, it is safer to

underestimate the daily dose of MS CONTIN required and rely upon ad hoc

supplementation to deal with inadequate analgesia. (See discussion which

follows.)

Use of MS CONTIN as the First Opioid Analgesic

There has been no systematic evaluation of MS CONTIN as an initial opioid

analgesic in the management of pain. Because it may be more difficult to titrate

a patient using a controlled-release morphine, it is ordinarily advisable to

begin treatment using an immediate-release formulation. (See Special

Instructions for MS CONTIN® (morphine sulfate controlled-release) 100 and 200

mg Tablets)

Considerations in the Adjustment of Dosing Regimens

Whatever the approach, if signs of excessive opioid effects are observed early

in a dosing interval, the next dose should be reduced. If this adjustment leads

to inadequate analgesia, that is, “breakthrough†pain occurs late in the

dosing interval, the dosing interval may be shortened. Alternatively, a

supplemental dose of a short-acting analgesic may be given. As experience is

gained, adjustments can be made to obtain an appropriate balance between pain

relief, opioid side effects, and the convenience of the dosing schedule.

In adjusting dosing requirements, it is recommended that the dosing interval

never be extended beyond 12 hours because the administration of very large

single doses may lead to acute overdose. (N.B. MS CONTIN is a controlled-release

formulation; it does not release morphine continuously over the dosing

interval.)

For patients with low daily morphine requirements, the 15 mg tablet should be

used.

Jennette