Fentynal user at VA and Tox Screening

Hi,
  I have been reading some stuff here about Fentynal, the VA, and Tox screening tests.  I am a disabled vet, missing part of my R leg and have 4 herniated disks that give me pain.  My right leg sciatic nerve is paralyzed ON.  I have localized red hot shooting pain in my leg as well as aching pain, and sharp occasional pain, 3 nueroma sites in my remaining part of my leg and recently I was diagnosed with the back problem. Other injuries I have are not PM related.  I am on Flexeril for the back pain.  The use of Flexeril made me unemployable on top of my condition and meds. I try not to take the Flexeril unless my back seizes up.  Typically that will require a three week cycle, and then once my back is no longer giving me extreme pain, I stop taking it. Like the Valium, I take it as needed.   I will not even drive on Flexiril.    I use Fentynal 100ug/hr. Duragesic patch and change them every other day.   They do not last three days.  I take an antidepressant at night that helps with sleep and pain, and use Wellbutrin 20mg in the morning to get some get up and go in my life.  I also use Valium 10mg 3x day as needed during the day to cope with anxiety and lack of patience due to pain. 2 lidocane patches 10mg on my nueroma site.   My background is in Analytical Chemistry, specifically Marine chemistry, and Chemical Safety.  I have multiple grad degrees.  The last is a MS in public health from Tulane.  Just so you know I am no idiot.

Since my back gave out, I am unemployable..  I spend most of my time in an easy chair recliner in front of the tube and my laptop the last two years. Everything I do requires more meds.   I do not smoke or drink except occasionally <2 oz per month, and not when on Flexiril. I am 50 yo married, with one 12 yo boy. I recently obtained a service dog to help me. It has helped me to become more active.

I have been in pain management for 25 years with the Military/VA, and I exited that system a while ago and used private insurance at a good hospital to see if I could get better pain management.  It did.  After 3 years and a good pain management system in place,  I went back to the VA using the same system and had them pay for it, last 5 yrs.   They wanted to give me morphine tabs instead of the patch, but I fought back and got to keep the patch.  

I started my pain management career as a non-narcotic PM.  I used nuerontin, Tramadol, muscle relaxers, etc. as well as trigger point injection of lidocane/steroids, and spinals.   10 TP injections every three days. Spinal every three, but effects lasted only a month.  I then had a plastic surgeon at a private hospital do a exploratory surgery to clean up nerve endings in my damaged leg. He pulled out some necrosis at the main TP site that the injections had been focused on.That was 1998.  Since then I have tried Bier Blocks in my leg that caused more trauma then it was worth and no more spinals due to scarring. They want to be able to give me a spinal if I need it and will not scar me up anymore.  TP injections worked for the Nueromas, but not the whole leg.  

I finally ended up on Fentynal.  What a blessing.  It is the best thing I have ever found to control severe nerve pain.  Morphine and other opiates screw up my GI track and the ups and downs with pills suck.  I worked my way up to 100ug after many years, Starting at 12.5 mg.  Took total of 10 yrs.

I have a big problem with sleep due to pain. With the Flexeril sleep longer sometimes. A very debilitating drug, but necessary I am afraid.  My back is inoperable due to multiple damage sites over the length of the spine.   I am stuck with the pain management system for life.   I can stay up for up to three days before crashing. Then sleep for a whole day.  I try very hard to manage my meds to keep a normal day/night cycle, but I am still in pain. I am never pain free, but I tough it out.  I currently do have a break through med, but choose not to use them unless really needed; if I need to take part in a particularly strenuous activity.  An example, might be going camping.  Then I use the break through drug 10mg Oxycodone that was prescribed to me for that as needed.  I am on dangerous medication, I know it, and I treat it seriously.  

I am signed onto the VA Pain Management agreement.  VA SOP is that if you are pos for abuse on something like weed, it indicates you may be abusing your narcotics also. So, VA protocol is for at least an annual tox screen.  This is however not required to obtain opiate pain management and if you do not sign you cannot be denied opiate PM or effect your VA treatment per their own SOP.  I have read here about people being kicked out of PM.  I don't think they would do that if you were really FUBAR.  After 8 years on Fentynal, they are not likely to stop my scrip.  

My last two visits I have been tox tested.  I have never had a tox screen in 25 years until then.  There is nothing in my history to lead the doctor to assume I abuse my meds or use drugs for recreation.  First test my urine was too clear so I had to do the second.  They were both negative for everything except what I am prescribed, which is almost everything except illicit drugs.   I understand they need one on record per SOP.  Amazing I got this far without one. Neither of the Tox tests tested for fentynal.  I got a new primary care doctor.  Now they want a third, months after the second. That would be one for each of my last three visits.   I asked why...nurse said the new doc wanted a different tox test.  ???? She did not know what was different.  I think it was BS.  Doc did not request any blood work.  I told them no. I will talk to the new doc and see whats up.  

I go to a VA satellite clinic.  They need their urine by 12pm so that it can make to the main hospital the same day.  They give me so much notice that a tox screen is required that it seems more like a CYA situation rather than a true concern I am an abuser.  This test they are asking for is a month away.

I have a very hard time staying hydrated.  I know this is due to the meds.  I drink at least 6 glasses of water a day.  Usually I wake up at 11 am.  I have a very hard time peeing in front of the male nurse at the VA unless I am fully hydrated.  Last test I had to drink a pot of coffee as a diuretic and several glasses of water to pee.   It is a PITA trying to hydrate fast enough to give them urine in time for their pick up.   I drank liquids from 9-11 before I could pee.


1- Can I request my tox screen be done by blood work?  Is this practical? It would be much easier for me.  The nurse stated that Tox screens cannot be done by blood, but my research shows that is false.  

2- Can they store the Urine over night and send it the next day for testing without compromising the results?  or is this just SOP?  

3- Is there something new that is happening at the VA with regards to Tox screening?  Technically they are required to reassess my pain situation every six months, but not my PM.

4- Is there any value in obtaining the amount of Fentynal in my system?  I have been on this dose for almost five years now.  The research shows that results are varied and poorly related to dose.

5-Would a Tox Screen show the levels of all the meds I am on to make sure I don't have a bad interaction of drugs?

I have laid out a lot of history here, so you can have as much info as you need to help me.  I have read here some experienced people in PM, but also a lot of people that are short timers.   I am looking for others that have similar time in PM or the VA system to talk with.