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Pain Doc to Nurse Practitioner?

Hi all,

So about six weeks ago I went to see the PM doctor for the first time. My pcp has had me in pain meds for awhile but wanted me to start seeing a pm for the pain issues. We had the big long eval appointment. He wrote me scripts for Votram cream, lidocaine patches, and vitamins and told me to consider a trial of Suboxone for pm to be discussed at my next appointment. I take two Norco's a day now, which I usually break in half now because they only last four hours and I hate picking two times of the day to be comfortable and functioning. We talked about switching to a longer acting med and this is what he was suggesting. I have mentioned this in previous threads. I have done a lot of research on it and have decided that I really am not comfortable with the Suboxone at this time and would like to discuss other options.

My question is, I see a nurse practitioner this time. I guess at this office you only actually see the big dog twice a year. Is this normal? I feel kind of weird about this. I had this long conversation with this doc last time, who was really great with his bedside manner and now I'm nervous because I have to go and see someone completely new again. Do you guys see your doctor everytime or do you see a NP for follow ups? This clinics policy is that they usually don't prescribe pain meds on the first visit, which is why they didn't take over the rx from my pcp, but I think they were going to this time. I'm just worried about Friday and don't know what is going to happen. I'm in the middle of a move and a huge flare up at the moment. I'm so scared that she is going to cut me off or something if I decline the Suboxone.
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Avatar universal
thank you for the advice..evidently you know your stuff because the doctor told me the exact same thing word for word,take a medication vacation.let me tell you it is not easy either,but i can function later in the day with high doses of motrin,alternating every four hours with plain aspirin used with high doses of lidocane patches but the damn patches just dont stick very damn good at all.i have to duct tape them on,it works i guess.i am entertaining the idea of asking for 7.5 percocet but one thing i am facing is the area i live in has a bad bad reputation for pain med sales and abuse,primarily oxycodone and hydrocodone.our local hospital here (pikeville medical center) sends people home with broken bones because the ER doctors wont write the mild hydro pills.i think that these people should lose thier priviledge to practace because that is just not right at all.that is like a soldier in battle amputating a limb to save a life and does not use any morphine.maybe a little exagerated but it really is kinda similar.now,this hospital does have a pain management clinic which i do go to but i sure dont go to that ER if i need stitches or a severe sprain or anything like that,and what can you do? there is nobody to report them to..doctors are scared to practice medicine here and it is sooo sad.really it is not that bad here,it the only thing these people have..it is a small rurall area it is not like they have a cocaine ,heroin,or any other drug problem..i think if they stop talking about it so much and stop glamourising the problem then they will see the problem is not as bad as what they think..i dont know maybe i live in a fantacy world..but,if i suggest an oxy in this area i am kinda afraid of him kinda really giving me some **** about it like i am a junkie or something..what do you think????
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Avatar universal
That is so weird, I was looking at that site and realized I know the daughter of the doctor that discovered it.  He passed away earlier this year.  Small world!
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Avatar universal
I haven't gotten it yet. I am moving this weekend and don't want to try anything new until after the move JUST incase anything does go awry....I NEED my meds to work right now.

I'll have it filled and report back. They did say it takes a few weeks to notice anything...
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Avatar universal
Great site, Kitty!  How do you feel it works for your pain?  I think the thing about taking it at night makes sense.  The pictures of the tissue inflamed with Crohn's Disease before and after were amazing.  
Does it make you sleepy or affect your sleep in any way?  
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Avatar universal
Incase anyone is interested, I found this website on lowdose Naltrexone research. I contacted them and asked them about my concern with taking it at night and my pain medication during the day. A doctor wrote me back today and said that since I take the pain medication during the day and the naltrexone during the night (and my pain meds are only short acting), that there should not be a conflict since the Naltrexone will no longer be blocking my receptors in the morning when I take my first dose. It only works for a few hours at night I guess...unlike Suboxone, which is long acting. Interesting....

Here is the site. There is some interesting stuff on there that has actually made me feel a little more encouraged about trying this.

lowdosenaltrexone.org

(also...it is not funded by any pharma companies which is nice to know!!)
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Avatar universal
Here is the article that my therapist gave me on Naltrexone for Fibro:

http://www.medicalnewstoday.com/articles/146634.php

Here is the one he gave me on info that it can "enhance" the pain meds:

http://www.springerlink.com/content/t61pn663j0t42532/

The dosage they are suggesting is 3mg. The dosage for a lot of the infomation out there is 50mg and above, however, I have found information that says that even at 3mg you should not take opiates, which contraindicates the article above...I don't know.

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Avatar universal
Hi there,I want you to know I am concerned about your different situations. So today I searched vigorously for what the purpose of the medication: Naltrexone really is? The research is put together by an organization of Dr.s,and Psycologist with phd's they stated the following; It is a antygonist medication especially designed to block all the pain receptors in the brain to cancel out any type of opiates,or opiods, both "Full",and "Partial agonist'. It said Naltrexone is very similar to Naloxone. generic name for Narcan, and said it blocks all opiods totally. It also said it has 0 pain controll qualities?. (I then typed in why do Dr.s prescibe it to chronic pain patients?), It then said it is used as a last resort when the patient has abused their Soboxone. Or, for people that are in early stages of sobriety,and different stages of recovery and clean from using Opiates,and Opiods, that do not want to Relapse. It also said that the studies are showing  that Naltrexone helps with alcohol addition, but, because of on going trial studies It could not be 100% sure of it currently being prescribed in the USA. solely for alcohol addiction.                                                                                                                                       I realize your situation is totally different,  (BUT) I have been concerned  so much about your complex situation I wanted to get the facts straight the very best that I could from this valid web site. I trust that their information is better than mine. Please remember.  I'm not trying to get in your personal life, confuse, and, or frustrate you in any way. I just am trying to get some information for you so you can make some dicisions that will help you  have a better quality of life. I don't know really what to say?  Other than in my opinion to you is to "maybe?" get a second  opinion from  a  Dr. you feel more comfortable with? What I do not want to do is inflence your dicissions in this sensative matter in a negative fashon. Please remember Naltrexone will bond to all your pain receptors "Tight" also if you take this antagonist medication it will STRONGLY cancel out (ANY) other Opiates, or Opiods to a level of ZERO. and withdraw will be a reality. So I really hope everything works out so you are happy,and not in pain.  As always best wishes to you, Sincerely
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Avatar universal
He said he is concerned with narcotics effecting my "moods". To be honest, I think that he thinks I am taking the pain medication to "lift" my mood. I think this because during our initial interview I was explaining how much difference taking pain medication makes in my life and how sometimes I over-do things when I've taken it because I "try to get as much as I can done" while I am pain free. He asked me if it "hops me up." And I honestly replied that initially yes it does for the first half and hour or so after I take it. But I didn't mean that I get a buzz off of it! I meant that I can feel it working and feel so relieved! I think he took that the wrong way and now wants me on something that won't make me feel euphoric. Seriously...if I want a buzz I'll drink a beer. I don't take my pain meds for a buzz, I take them to function. This may be all in my head, but this is why I suspect he is pushing these other meds and he is way off base.
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Avatar universal
Hi Kat. I'm so sorry that you're going through all of this. I wrote a long post and lost it!

I'm confused. Why is your doctor pushing Low Dose Nal. and Suboxone? You wrote that it's because you're bipolar, but I don't understand what that has to do with him getting your pain under control with hydrocodone.

I've read on other forums about Low Dose Nal. Some people really like it as it helps with their pain. Are you going to give it a try? I know that it's so scary to try new medications, but it may be worth it.

Can you express your fears to your doctor (not your NP)? Is this the first PM you have been to? Some PM patients actually interview PM doctors (without accepting meds. or treatment) before they choose one because it can be hard to find a good fit as some like to only prescribe meds., some only do injections, etc. So, there are always other options.

I'm glad that you're going to try the lido. shot and I hope that it gives you relief.

Please keep us updated.

Hugs,

Flower
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Avatar universal
My pm prescribes the Norco, and my printed instructions from the PM doc says I may continue my use of it, so I am good there.

There IS some research out there on Naltrexone in very low dosage (3mg) for the use of Fibro pain. It's very new. I found some of the studies by googling it and my therapist gave me some printed studies. It is supposed to help with anxiety too. But I've also read about people who take it along with narcotics who basically experience withdrawal symptoms after they take their Naltrexone dose since it cancels out the narcotic...which is interesting and makes sense to me. My providers, however, have not mentioned this. I have to go to a compund pharmacy for it since they do not make it in such small doses and I am going to ask the pharmacist about it.
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Avatar universal
That IS unfair and frustrating and I'm sorry you have to go through this.  I am always more comfortable with the "traditional" route.  I don't think it should matter whether any of us are bipolar, depressed, anxious, etc, when it comes to our pain relief.  It seems kind of strange to me.
I googled Naltrexone and I would just recommend googling it.  Basically the uses are similar to that of Suboxone/Subutex and don't really say anything about PM.  That's not to say that it couldn't give relief.
If it were me, I would either request to see the doctor again or see a different doctor.  I'm sure they all think that med is wonderful but if you don't feel comfortable with it, I wouldn't take it.  That being said, you may have no choice if you don't have any more Norco.  If you do, I would probably keep taking that until you can get in with someone else.  
On the other hand, it sounds like the doctor's office does have some good therapies to try.  Like the lidocaine infusion.  I've never heard of that.  I've also heard of some opiate antagonists working well like Nubain for labor pain, etc.

I'm sorry you're having to deal with all of this.  I have to wonder sometimes that with as hard as it for CP patients to live a normal life, why do some people have to make it more difficult?  I know it's also hard to deal with bipolar/depression/anxiety.  I have an anxiety disorder but at one point a psychiatrist had me diagnosed as bipolar and told me I should be off all pain meds for a "proper diagnoses".  She had no sympathy for me whatsoever and when I had to get off the meds because of pregnancy she refused to even see me or tell me whether or not to continue to take the meds she prescribed.  It's ridiculous how some health "professionals" can be so cold and apathetic.
I'm not saying any of your docs are being cold and apathetic, just sharing that I had a hard situaiton last year when we moved at Christmas time and it was the last thing I needed so I feel where you're coming from to an extent.

Please keep us updated as to how you are.  This have been quiet on the forum lately, but we all care about you!  
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Avatar universal
Hi all,

First off, thanks for the support. It's always so nice to be able to come here to vent and voice concerns to those who understand where I am coming from!!

I met the PA. She seems very nice and was also a good listener. I told her about my recent wave of flare ups and my recent nightmare of trying to switch from Cymbalta to Savella. I told her about my concerns with the Suboxone treatment. She was pushing it pretty hard on me but in the end I politely declined. I told her that the Dr. said this wasn't my "only option" as far as long acting pain meds go and she said that the other one listed in my chart was low dose Naltrexone - one that my therapist has been pushing pretty hard as well. I'm a little frusterated by this and confused because it too is an opiod antagonist, but apperantly at low doses...according to them...can be taken with the Norco I am taking. It just may make it "not work as well." Well WTF? I just told you I am in the middle of a move and in horrible pain and you are putting me on something that a) takes about 3 weeks to kick in so "be patient" and b) may cancel out the only current little bit if relief I get! I told her that I have to break the Norco's in half to be able to get all day pain coverage and she suggested that I not do that and only take a whole one once in the morning and once in the evening at full dose so that they work better. I responded with "I can't do that. I would not be able to function from noon to six." All she said to that was "I'm sorry. The Dr. lays out the roadmap and I just follow it. We have to try what he has recommended."

I started crying and told her that I NEED to be able to function for my family through this move right now and she told me she could offer me IV lidocaine infusion this weekend. She said that it can bring people 1-3 weeks of relief. She did warn me not to over-do it though...as it could make me feel a lot better. So even though it's going to cost me an arm and a leg to do it that I don't have, I've scheduled for tomorrow morning because I have no choice.

I'm also terrified to fill the RX for the new med because I'm afraid of it making my pain meds not work. My therapist keeps telling me that at a low dose it can actually "enhance" opiods, but I don't understand how that is possible since it blocks the receptors. I just went through such an awful time trying to switch meds last week that I don't want to go on the med-go-round again. :( It's just really frusterating. I hate that being "bi-polar II" somehow takes away my right to traditional pain medication, when I know it WORKS for me and that is what helps me FUNCTION and be a mom and wife. It's really unfair and frusterating.
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Avatar universal
I'm sorry I was late getting to this post!  I have seen it a few times and meant to respond and gotten side tracked.  
I remember when you first went to the new PM and he talked about the suboxone.  It seems to me that you are well informed about this med and your pain.  I hope the PMP will respect that and have an open and constructive dialogue with you about it.
I have read that suboxone can be hard to come off of, even though it's made for that. I don't think it's made to taper off if you have pre-existing pain issues.  The stigma thing is an issue as well and you have every right not to want to feel uncomfortable with the med because of it.  I was on methadone for about 8 months or so and it was always a hassle to explain to new specialists or ER nurses that it was for pain, not addiction.

With my PMP, his office is very small and he is the only one who sees patients at all so I see him every time.  At the previous office I went to there were 2 NPs who saw patients as well as the doctor and it was always a matter of who was available to take the next patient.  It was a very busy office.  We could request to see the doctor.  It just meant we had to wait longer and sometimes the wait was hours long.  If the NP needed to change anything he could go and speak with the doctor for a minute and come right back.  I actually felt more comforable with the NP as they seemed to be more compassionate and in touch with the patients.
I hope your appt went well if it was today!  I also hope all goes well with your move.  Don't over-do it with the move and strain something.  That is how my pain became chronic.  I had no idea it would happen and I'm pretty sure I over-did it to the extent that my bulging discs became herniated.  I know we're all hoping for a great report about your appt and will be waiting for your update.
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Avatar universal
Hi there KittyKat, How are you doing today? Did you go to the PM Dr. today?, or is your oppointment next Friday? I have been thinking of you today, and would really like to know how you are doing. Send me a reply, or post something when you feel up to it. "ok"? Take care. Sincerely, Paingotago
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Avatar universal
Will do. :) Like I said before, I emailed him a list of concerns (longer than above) after my last appointment and he responded and said they were all valid and said it wasn't my only option. I just hype myself up about these things way too much sometimes and it's a particularly stressful time right now with my move so I want to make sure I can function for the family both mentally and physically. :)
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Avatar universal
Hi again, I would simply ask your PM Dr. if they have  a problem with you taking a long acting full agonist, or more short acting full agonist? I feel your concern, and if you take something that works just have a heart to heart talk with them., and tell them about all your pain, and pain medication options. If you have never had a problem with the stronger meds. than I don't understand why they would be so dead set on soboxone. I was just trying to help with "some" benifits of suboxone, but right now it is mainly for tappering, and the pyschiatry uses  are still in the trial stages. So I now see more clearly your concern. Before you worry to much remember Dr.s that treat pain are supposed to take you entire health into concideration before making a complete diagnosis. So all I can say to you is tell them about your concerns in a nice, complete mannor,and they should listen. If you have a good record their should not be any worries. So best wishes to you,and please let us know how you make out.
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Avatar universal
My concerns with it are

A) treating flare ups and breakthrough pain. I can't take Tramdol, which is what they generally give people for flare ups on Suboxone. I can't take it because of my other meds.

B) I get migraines that once or twice a year I need a strong narcotic shot for. Since this medication blocks opiates, what treatment would I have left for that? I only get shots when I have tried EVERYTHING else to treat the migraine.

C) Does it work for CP? I have read very mixed reviews. Some say it works and others say it doesn't do squat. I have children and don't really want to give up a month of my life finding out. Why change things when I have something that works? I just need a longer acting maybe slightly stronger dose?

D)Just the general thought of taking something "off label" that is normally prescribed for heroin and narcotic addicts. I take narcotics for pain because I have made the concious decision to to treat my pain and to be able to function. I have to deal with enough judgement from pharmacies and doctors as it is and don't need to add to it by being on a medication that will make most people think I was a "junkie" at one point. (I mean no dis-respect to anyone addicted...these are my own thoughts related to my own anxieties)
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Thanks for the information, I think I was totally incorrect about the medication. I need to do more research also on this medication.  Interesting!!!
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Avatar universal
Hi there. I just wanted to chime in, I am not a doctor ,but I do research in many areas. I don't don't know your personal situation,  but from the information you did give I have "some" good news for you. Soboxone is a partial agonist,and a mu opiod that bonds to  different receptors. The reason your doctor might want to prescribe this for you is that (burprenorphine) or Suboxone  seems to really takes away depression very well because it binds to  different receptors in the brain.                                                                                                                                       It was developed to tapper people off (full agonist) the strong pain killers, because full agonist like morphine, oxycontin,ext. Are much more addictive ,and much more difficult to come off of. So they developed soboxone and it is a strong anelgesic, BUT, being it does not bind to all the receptors that a full agonist does it has its limits for pain.  "IN  SIMPLE TERMS It will help you with the manic depression part of bipolar, and help some what for pain." Also it is easier to wheen off of than say; oxycontin But please remember the Dr.s are still testing its psychiatry effects for the long term, and its pain effect varies from person to person.                                                                                                                             Oh one more thing soboxone has an ingredient that binds to the kappa receptors,and when you are taking suboxone it will cancell out the euphoric effect of other opates, but you Dr. will explain all this to you in laman terms so you will understand it. I really wish you the best, and just talk to your Pain Dr. about this when you see him. Best wishes of health to you.
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Avatar universal
I see my doctor every time.  At the last PM office, I saw the PA more often- she had back problems and every time I would complain I would basically get a "I have back problems too, we all have to deal, quit your whining."  

So now I like my PM doctor ;)
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1468316 tn?1286481952
I always see my pain consultant and never a nurse because the doctor only knows about my condition and understands what I'm going through. I don't have to explain to him each and every time he just knows. Trying to work with more than one person is hard, and getting across what is wrong is sometimes difficult.

The medication that you mention Suboxone is a narcotic medication that is a combination of buprenorphine and naloxone. Buprenorphine is an opioid medication. Buprenorphine is similar to other opioids such as morphine, codeine, and heroin however, it produces less euphoric ("high") effects and therefore may be easier to stop taking.

Why not ask for the Butrans patch? It mimics your body's own endorphins, I use them and don't get any noticeable side effects I don't know what someone with bipolar would be like on these medications as I'm not the expert but I can tell you that they leave me with nothing that I can tell but some skin irritation.

Good luck, and I hope you feel better :)
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Avatar universal
Great, I'm so glad that you have support.  It did seem to be overkill .  I also want you to know a lot of us (INCLUDING ME) are on medication for depression, etc.... I'm on lexapro and there is a common factor with pain and depression.  I'm so happy you did your research and can completely understand why you wouldn't want to be put on that.  Please let me know how it turns out...

Karen
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Avatar universal
Karen - he said that there is "great research" out there that Suboxone is better than taking opiods for pain and that it is his current favorite course of treatment as far as long acting pain medication goes. I did email him my concerns with it and he responded with "good work" and that we would discuss at my next appointment. He did say that it wasn't my only treatment option. I think he is concerned with my being bi-polar, and the effects that opiates can have on my moods, but from my research, suboxone can do the same thing, and for that matter, so can pain!! My therapist and psych doc are both supportive of my decision to decline the suboxone treatment and when I asked my pcp and Rhemy about it, they both agreed that it seems to be "overkill" at this point.

Luckily I have therapy this afternoon and my therapist is wonderful at helping me through my anxiety about these appointments. :) I will try out the pa and see how it goes and if it doesn't go well, I'll request an appointment with the dr again.
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Avatar universal
I can totally understand why you would feel uncomfortable with taking the Suboxone, especially if you are taking such a low dose of pain meds.  Is there a reason why he wants you on that instead of something else?  Did you actually ask your doctor?  I would try to find out the reasoning to that medication versus something else that may be easier to get off of if needed.  I've heard that medication can be hard to taper off.  Also regarding the seeing the nurse practicioner, I always see my doctor but it just may depend on where you go.  I would call the office manager and ask if there's a way to see him more than twice a year.  I was seeing a PA at my Endocrinologist office and she was extremely rude to me when I saw her (I saw her twice and only saw the Endocrinologist once) and I called the office manaager and left a message and when the office manager called me back she agreed that I could see the doctor each visit instead of the pa. I'm not saying that will necessarily happen in your case, but I would at least call and find out what their rules are on that.  Then you can make some decisions on what to do.  I'm proud that you are researching the medication.  The more knowledgable you are, the better decisions you can make regarding your prescriptions.  

Good luck, please let us know how it turns out.

Karen
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