long acting pain meds vs short acting

HI,

I was curious if long acting pain medications would make it easier for you to become tolerant to the drug as opposed to using short acting pain medications.

With short acting meds there are times I can skip hours, even 12 hours if I get lucky.  I would think this would be better than having a continuous stream of medication in your system.  Since I know I'm not going to be able to function without pain meds I don't want to rocket up on the dosages.  (My pain levels are somewhat variable)

I'm hypersensitive and there are many drugs I can't take, such as NSAID's, neurontin, and I don't mix well with anti depressants medication used off label for pain.  My pain is too diffuse for steroid injections.

My doctor wants to put me on long acting meds with short acting for breakthrough pain, but I'm sure this is going to lead to a quicker tolerance.  I can't talk to her as she insists this is pain management protocol and won't listen to my concerns.   ( I know she considers me a hard case and would prefer not to work with me.  Long story.)  I would rather try a higher short acting drug and then if I can't make it work I would have to go long acting.

Any thoughts or information would be appreciated.

Thanks

[geminigirl1963]

This is just my opinion, but I personally think a long acting med would have LESS chance of tolerance building than short acting meds, simply because they ARE longer acting and therefore, you typically have to take a lesser number of them throughout the day than you would a short acting med.  In other words, let's say you were taking 10mg oxycodone in short acting form (percocet) three times a day, you would be taking a total of 30mg of oxycodone.  However, if you are prescribed 10 mg oxycontin (long acting version of oxycodone minus the acetaminophen that is in percocet) every 12 hours, you would only be taking a total of 20mg of the narcotic a day.  

While many doctors do prescribe a short acting med along with the long acting med, the short acting meds are typically written to be taking AS NEEDED for breakthrough pain (of course, also giving a time frame such as every 6 hours) - the breakthrough meds are not typically written to be taken EVERY day.  In fact, the goal of a long acting med is to reduce the need for breakthrough meds.  therefore, you may or may not need to take any more narcotic than what is in your long acting med.

However, all that being said, everyone is different and the way they react to medications is different as well.  So what works for one person may or may not work for you.

The main questions you need to ask yourself and discuss with you doctor are:

1) Is your short acting med sufficiently relieving your pain - both in severity and for the amount of time it should (if you're prescribed to take 1 tablet every 6 hours when needed, does it last those full 6 hours)

2) Are you finding you're having a lot of peaks and valleys with pain control where shortly after you take your meds, they provide good pain control, but by the time comes when you COULD take anotehr dose if needed, is your pain level high enough that it either takes a long time for the meds to help or the pain level is beyond what your current dose can help?

3)  If you're finding that your current dose does not always cover your pain, how often are you finding this happens?  Is it daily?  Once a week?  Only when you've overdone with activity?

While I personally do think that long acting meds would have a lower chance of tolerance (although ANY pain med that you take for an extended period of time will cause tolerance, whether it be short acting or long acting) - in reading your post and the fact that you say you can currently sometimes go 12 hours between doses of the short acting med AND that your pain is variable - you may want to continue with the short acting meds as long as you can.  Simply explain to your doctor that since you're currently getting good pain control with your short acting med AND you sometimes don't need to take it for up to 12 hours between doses, you'd rather wait to go to a long acting med when you are no longer able to go that amount of time between doses or when you find your current short acting med dose is not sufficient.

Finally, if you find that your doctor is not listening to you or you feel you cannot talk to her about these things, you may also want to consider trying to find a new doctor - one who will listen to you and work with you to find the best possible pain control for you and not simply lump you into "pain management protocol".

Best of luck!

[femmy29]

I understand where your pain management doctor is coming from when she said "pain management protocol".  Many PM doctors want their patients that have chronic pain on an extended release medication as the euphoria is much less or nonexistant on ER medications; whereas, short-acting medications peak very quickly in the bloodstream which can cause a strong sense of wellbeing or euphoria that many doctors believe are at the root of addiction/abuse of prescription pain killers.  However, this is not true in most cases but many doctors are convinced of just the opposite.

If you can get by for 12 hours without taking any pain medication, that is fabulous!!!  Most chronic pain patients have pain that is not as benign as yours such that regular doses of a short-acting medicine is needed throughout the day everyday, which makes extended release medications so very helpful.  As geminigirl stated, I would explain to your doctor your pain levels and the duration of action that one dose of a short-acting medication provides you.  

As far as tolerance, I think tolerance builds regardless of if you are on an extended release medication or an immediate release medication.  Personally, I think for most people tolerance builds a little bit faster on short-acting medications because the medication peaks rather quickly (30-60 mins vs. 2 hours for ER meds) and stays at the peak level for a very short amount of time (30 mins vs. 8-12 hours for ER meds) such that many find that over time the medication no longer lasts 4-6 hours like it was originally intended to and they begin to clockwatch for when they can take their next dose or they have to take more or a stronger dose to try to achieve analgesia for 4-6 hours.  In your case, it is obvious that the short-acting medication is lasting much longer than intended so I don't think you are nearing the point of needing more medicine to cover your pain.  However, over time you may find that your pain doesn't retreat for 12 hours anymore but 8 hours and then 6 hours...etc.  This is when I think an ER medication would be very beneficial to you.

And also as geminigirl stated, if you are disatisfied with your doctor's approach and you both cannot come to compromise, definitely look into finding another PM doctor that shares your same views on pain management.  But I also think that you could begin an ER medicine at a low dose and end up taking less medicine over a 24 hour period and have more consistent coverage of pain.  Refering to geminigirl's example of 10 mg of Oxycontin over 12 hours versus 20 mg of oxycodone IR taken 2x within a 12 hour period...you might be able to get by on less ER medicine as the steady stream of pain medicine eliminates the pain spikes that would require more of a short-acting medication to reduce the pain levels caused by the spikes.  Futhermore, I don't believe taking this approach with ER dosage would increase your tolerance anymore than if you remained entirely on short-acting medications.  In fact, ER meds might slow your tolerance build up as you might be able to maintain the same dosage of an ER med for a longer time as short-acting meds work more erratically and are more inconsistent often requiring dose modifications sooner.  And as geminigirl stated, you will more than likely be able to get by with just an ER medicine without a short-acting medication for breakthrough pain as you can get by for 12 hours without pain medicine already.

Lastly, even with the build up tolerance given years of taking opioid medication for pain, there are many tactics that can be used to ensure that you have adequate pain relief...opioid rotation being one example.  With opioid rotation, you can switch to an entirely different opioid and take less than the equivalent dosage of the previous opioid due to incomplete cross tolerance.  Continual opioid rotation has been shown to slow the build up of tolerance.  So I wouldn't fear tolerance as much as you are right now.  I think all of us should be aware of tolerance and not take more medication than we truly need but you shouldn't skimp by for 12 hours without medication if you have pain due to fear of tolerance.  

I think whatever you decide will be the right choice for you and that you will be most comfortable with.  Hopefully, geminigirl and I provided some good points to think about as you make your decision.

Wishing you more days with less pain.  Take care.  

femmy

[Sjoggie]

Hi,
Hi and thank you for writing me back,

I can see from my post that I am doing a denial of my pain levels and trying desperately to believe I can somehow control them using pilates/pt massage and the meds are temporary.

Part of this is because my family doctor insisted I could get control and reduce the pain if I could just build up my muscles.  Then today, I get hit with-it is the pain medication that is supposedly causing the pain.  

The physiatrist I see, who is giving me the medication has never, even checked my tests, and I wouldn't have been seeing her except my doctor wanted me to see a physiatrist and I thought this doctor had gone over all my MRI's etc. but I just found out that is not the case.  I don't know if she knows what she is doing.

Ok, my pain levels have jumped lately and I can no longer make it 12 hours.

I think I have been on the codeine for too long, plus when I can remain more in control of pain is when I'm in bed, not doing anything.  The pain is now not being so kind, but I was hoping it was just a fluke or flare and would go back to how it had been.  It is somewhat hard to figure out what the heck is causing what.

I have a myriad of things wrong with me from degenerative disk disease, stenosis, spondyarthritis and just for fun I have an autoimmune disease that will increase pain and add new pain points when I hit a flare.

My muscles are somehow tied into this, but I have repeated been told it is not fibromyalgia.

Not long ago I had an x-ray and it shows my neck has now picked up the degenerative problem.  I did not get an MRI, but I was getting very bad headaches.  I have reached relief of these with PT and massage.

I can see I am going to have to find a decent pain management doctor.  I'm really not up to the challenge.  I guess I wanted to believe that the pain was controllable if I could just build up my muscles, but I think I have known better than that all along.  This is the same pattern I followed before it was discovered my lower back had a disk collapse.  

I cannot thank the both of you for writing me.  You have given me so much knowledge.

I am having trouble with the pain medication holding the pain.  To my knowledge, I have never had that great feeling people are supposed to get.  I just get pain relief and if I start a new drug I generally am sick until I can tolerate it.

I went through a jump up on medications before my back surgery.  Too long a story, I but I wound up on oxycontin before surgery, which I should not have been on.  I wanted to get it down before surgery but the doctor said it wouldn't be a problem getting off of.  Well, because of the autoimmune, which hadn't been dx'd at that point, I took a very long time to heal and was really stuck on those darn medications.  It was pure heck to get off of and I'm terrified of anything like that.

I guess I really felt that the shorter acting drugs would give me a better chance of cutting if I could ever build myself up enough.  Actually, that was what I was led to believe.

First thing I need to do is try to find a decent pain management doctor.  My last experience with pain management was horrible. Supposedly it was to help me get off the oxycontin, and teach me some pain management technics, but it really was to get all they could out of my insurance.  In fact they weren't helping cut and I came up with an idea, which my pharmacist later said was a plan that was setting me up for failure, and I did fail, even though I was encouraged to try cutting way too much by the pain management.

I stayed off of anything narcotic for about 7 to 8 weeks and I was taking neurontin, which it turns out I cannot take and is not good for me, so when I came off of that I had pain and tried tramadol, which did nothing and I was afraid of all I had read about it, so I went back on the Tylenol with codeine.  All of these were doctor's prescriptions.
  
Do you know if this was long enough to have the drugs out of my system to show I have real pain as opposed to narcotic induced pain?

I'm really confused after my appointment today and I'm having trouble figuring anything out tonight so I apologize for any mistakes I have made.  I will be re reading your help so I can figure out how to proceed.

Again, I cannot thank you enough for taking the time to share with me.

Lizzy

[marycarmel]

Briefly, IMO, if you get good pain management, you may be able to build yourself back up a bit and then back down.  Long-term/short-term ... debatable.  I've done both.  I had Fentanyl and took a while to jump from that to oxycontin.  I didn't have trouble dropping from oxycontin to oxycodone.  Mine's a long story with my own personal feelings and worries about addiction, though I'm just dependent  Tylenol with codeine, IMO, isn't much better than tylenol and ibuprofen is probably better.  Find the best docs, research the meds they want you on ... go in with full knowledge.  When you do get good relief, then work on building yourself up and see how it goes.

[peekawho]

There is also Opana ER (the long acting form) that is prescribed either with oxycodone or hydrocodone for breakthrough pain.   I was on that for about 6 months, and had no trouble coming off that and onto hydrocodone.  

Good luck to you.  I'm still struggling with pain, and had to change my career focus, and drop my hours down to virtually nothing.  To be honest, that's what helped more than anything.  

I hope something helps you.  Codeine is a poor choice for chronic pain management.  It simply isn't very effective.

[geminigirl1963]

I agree, getting a GOOD PM (pain management) doctor is in your best interest and doing so could very well help get you to the point you are looking for.  Many, if not most, good PM docs will offer their patients a variety and combination of therapies to help reduce their pain and increase their stamina/mobility - they may offer you injections, massage therapy, water therapy, other forms of physical therapy, etc., etc., along with your medications.  The goal of GOOD pain management is to provide you, the patient, with as good of pain control as possible - hopefully with the smallest amount of medication as possible.

You said "to my knowledge, I have never had that great feeling people are supposed to get.  I just get pain relief ....."  This is how pain meds are SUPPOSED to work.  The TRUE way pain meds are supposed to work are to give pain relief, NOT give that high or euphoric feeling - although many patients do experience that type of feeling when they first begin taking a medication (same as they may experience drowsiness when first starting to take an antihistamine)  Then, as their body gets used to the medication, that feeling should go away, only leaving behind the pain relief that the meds are supposed to give.  You cannot gauge whether a pain med is working based on that "high" feeling - only by how well it relieves your pain.

It is very possible if you've been on the tylenol with codeine for a while that your boday HAS develoepd a tolerance for it, but it's also possible that the condtions you have that cause your pain have gotten worse.  One way to determine if this is the case would be to get a new Xray, CT or MRI and have it compared to your other one/s.  While it's possible that building up yoru muscles may HELP reduce some of your pain, if the root cause of the pain is still there or has worsened (such as another collapsed disk or a broken bone, etc.) - no amount of building up your muscles is going to solve that/those problems.

I can empathize with you in regards to having multiple conditions that cause pain.  I, too, have several - severe athritis in every (and yes I do mean EVERY joint), degenerative disc in my back, a couple of bulging discs in my back, lupus and fibromyalgia.  So I can understand how frustrating it can be trying to determine exactly which condition is causing the pain at that moment.

I agree with marycarmel about the tylenol with codeine. I also don't feel it is much more effective than plain extra strength tylenol, especially when it comes to chronic pain.  There are many other short acting medications that, in my opinion, would be a much better choice.  It may simply be a matter of switching to one of those other short acting meds for you to be able to get back the decent pain control you were getting from the codeine, still allowing you to avoid the long acting meds if you don't want to try them.  Again, this goes back to finding a  GOOD pain management doc - one who is willing to listen to you, not only about your symptoms and pain, but also about what you have already tried and what has worked and what hasn't.

Narcotics can cause "rebound pain", but in my opinion (again, ONLY my opinion), the low amount of narcotic you are taking, along with you going completely off all narcotics for 7-8 weeks, you would not be experiencing rebound pain from the meds - it's my honest opinion that what you are having is "TRUE" pain, not a rebound pain.

There are some resources that may be able to help you find a PM doc.  Check with your local hospital and ask if they have a physician referral line - many hospitals do and they can provide you with names/numbers of doctors who you can call.  When you do call the doctor's offices, be sure and ask what therapies they offer their chronic pain patients - whether they ONLY offer non-medicinal things such as injections, PT, etc. - or if they use a combination of therapies (meds along with some of the other things I mentioned).  Ideally you want a PM doc who utiilizes a combination of things to help get your pain under control.

You can also contact your local Social Services Department - they also may keep a listing of doctors in your area that you can contact.  If your area has a local Health Department, they also may be a good source to check out for names of PM docs.

I wish you the best of luck.  Please keep us posted on what you find out and how you're doing.  I hope you can get some good pain relief soon.

Robyn

[Sjoggie]

I cannot thank you enough for your insights.  I may have a doctor that I can work with but I need to meet with and see how things go.

My doctor just told me that he Under Medicates because he doesn't want to have a call because someone overdosed and it would be his name on the prescription!?!  I have worked with this doctor for years.  He has made me feel like I'm taking too much so my last years have been one of not being able to do more than I have some medicines for or if I save some up then I might be able to do more on a day.  Long boring story there, but he has destroyed me.

I thought he knew what was wrong and now,  I find out that isn't the case.  I'm such an idiot.  I had complete faith this doctor cared about me.  Therefore I felt horrible that the pain meds wouldn't work and felt I was totally in the wrong.

Again, I cannot thank you enough.  I am going to have to get through the fact I was totally duped by my doctor and then move on, but at least I now have some knowledge and I hope you don't mind, if when I get my head on a bit straighter, that I ask some more questions.

Thank you Robyn for confirming what I always thought, that if I was off all narcotics for about 7 to 8 weeks that the pain would be real pain and not whatever my doctor convinced me of.

I'm sorry you also have multiple issues.  That just make things so much worse.

I have been living under such guilt for so long and really made to feel like I'm an addict, because the pain is supposedly because I am taking the pain pills.  Now, to find out, not only were not good pills, but I have been suffering because my doctor, well I have no idea what my doctor was doing.

It is good hear that you can drop down.  My doctor insisted once I went up I would never be able to cut.  I should know better.  

Anyway, I will quit, but again I'm so incredibly glad you all answered my post.  

Hopefully, my next post will be when I've come to terms with some things and I do hope you will be willing to help me again.

Thank you,

Lizzy