Looking for alternative to norco

[codemonk]

I'm currently taking generic norco 10/325 4 times a day. Problem is my bottle last at best for 2 weeks. I have arthritis, a cyst in my spine as well as Schmorl's nodes. I generally need to take 2 - 3 norco in the morning just to get ot of bed with out severe pain.
Another problems with the norco is it wears off really fast and I have to take more within a few hours.
My bottle lasts me maybe 2 weeks at best.
My mother is 83 an I have to help take care of her (and being winter now that includes a lot of chopping wood :( ).

I've been looking at alternatives and while Percocet (Ocycodone) seems like a better option (fewer pills to take), I'm also wondering about the longevity of thier effectiveness.
I've taken Percocet before after a work related injry an had no ill side effects (nauesea etc.).

I'm also looking into MS Contin which from what I understand is the only of these thee that are time released.

I'm also on Medicaid, an all three are approved. So cost should not be an issue.

[philnoir]

Medication like Vicodin, Norco, (hydrocodone), Tylox and Percocet (oxycodone) are all opioid analgesics that reduce pain for 4-6 hours. Thus, these medications are classified as short-acting or immediate release analgesics for mild-moderate pain.

The same active opioids (hydrocodone, oxycodone) are available in long acting form. Hydrocodone is available in a new long acting formulation called Zohydro. Oxycodone is available in a long acting forumlation called OxyContin.

I realize that you're undermedicated, but using your prescription up in two weeks is not advisable for a number of reasons. First, it marks you as a non-compliant patient, which will make it more difficult for you to obtain opioid medications in the future. Second, it will accelerate opiate tolerance so that soon, the same amount of medication will no longer relieve pain.

I use a pill divider to manage my medications, otherwise I lose track of how many doses I've taken during the day and when.

If you can get into a multi-modal pain program, you might have access to other pain relieving procedures and behaviors, which will lower your need for opioid analgesics like hydrocodone. Even adding additional medication, for instance an anti-seizure med like Lamictal, may help improve the quality of your analgesia. Physical therapy may help break up the osteophytes that result from your degenerative disc disease, and allow you to increase your range of motion without pain. If you can work a rest period into your day every few hours, you'll also give your muscles time to relax to reduce your pain.

In the mean time, ask your doctor to switch to a long acting formulation like Zohydro. (This medication is new, and will therefore be much more expensive than generic Norco. You'll probably need an insurance company prior authorization before they'll pay for it.)

Morphine (msContin) is very effective, and less expensive than either Zohydro or oxyContin, however, you may find the side effects interfering with your active lifestyle.

Best wishes.

[codemonk]

Thanks for the advice.
I've heard about Zohydro which sounds like it would be perfect for me.
unfortunately, its not on the drugs covered by medicaid (heres my list : http://www.hpnmedicaidnvcheckup.com/documents/Medicaid%20PDL.pdf ).
I'm also not working since the only jobs around for awhile are warehouse jobs and with my back, thats a no go.
I sometimes have trouble just standing up for more than 5 - 10 minutes without the pain increasing dramatically.
From what I have been reading Percocet is stronger so I won't have to take as many pills. Of course that may also mean the doc reducing pill count.

Generally, in the morning (only a 3 - 4 times a week, I have to take 2 - 3 norco, then wait awhile before I can even get out of bed without screaming.
An even then, I can feel the pain starting to come back within 2 - 4 hours (depending on my level of activity)

Ultram actually works better for the pain, but it messes with my breathing.

I'm also curious being that Percocet is stronger? maybe it will last longer?

That reason is also why I am looking into time release meds.

Do you have any idea what doseage of msContin would keep my at a level similar to 20 -30 mg of norco would be or the majority of the ay?

I've got a  doc appointment tomorrow and will ask him but I wanted some kind of idea.
While Medicaid does cover msContin, they only cover certain dosages.
An the pharmacy would not tell me what dosages they cover unless I gave them the dosage amount (some computer input thing with medicaid I think she said).

Also at this point, I'm more concerned about shoving all that an tylenol down my throat.

Thanks

[codemonk]

In regards to my question : "Do you have any idea what doseage of msContin would keep my at a level similar to 20 -30 mg of norco would be or the majority of the day? "
I found this : http://clincalc.com/opioids/

[philnoir]

When a doctor converts one opioid to another, he uses an equal analgesic chart. While these charts vary, in general the ratio of oxycodone to hydrocodone is 2/3. This means 20 mg of oxycodone equals the analgesia of 30mg of hydrocodone.

The problem with these charts is that people metabolize medications based on their genetics. For some, oxycodone is 3/2 times stronger than hydrocodone. For others, they are equal in analgesic effect.

Also, these charts are subject to current practice, and subject to bias. For instance, in my pain management book published in 2002, oxycodone and hydrocodone are equal in strength. Now we see a 2/3 conversion to oxycodone in most tables. I believe this is direct effect of biases against oxycodone that grew out of its abusive potential, and not its effective analgesia.

Morphine is a stronger medication than oxycodone, but today is believe to be 1:1 with oxycodone, which means that you use the same formula: mg Morphine = mg Hydrocodone * 2/3

Now that hydrocodone has moved to sched. II, we'll probably see an upward adjustment in the strength of hydrocodone, due to the politics of opiophobia.

Usually, when one changes from a codeine-based opioid to a morphine or thebaine-based opiate, we see a phenomenon in analgesia called incomplete cross tolerance.

Because of the pharmacology of these two opiates and the physiology of our nervous system, the body gets more effective analgesia when an opioid tolerant patient changes their regimen. In this case, an equivalent morphine dose may equal 2/3 the hydrocodone dose, minus 10 to 25 % due to incomplete cross tolerance.

For instance, a person taking 60mg of hydrocodone a day may get have the same level of pain control using 60mg * 2/3) - 20% or (40mg - 8mg) = 32mg of morpine / day.

I say maybe, because all changes in opioid medication (called a 'rotation') needs to be titrated to the individual. A doc will start with perhaps 32mg, and you could be very happy. (I imagine you will do well on 30mg of morphine a day). But if not, then your doc will adjust the dose upward to perhaps 45 mg a day, and see how you do.

Or, if you're feeling the side effects of the new drug, the doc may reduce the dose a little.

You'll find that morphine is a very different kind of pain medication than hydrocodone. Many find it causes much more drowsiness, and are bothered by itching. I think you'd do better with 20mg OxyContin twice a day. However, I understand that if Medicare won't cover it, you can't afford the $600 / month they want for OxyContin these days. msContin is closer to $200/month as its generic.

Remember, everyone's response to opioid analgesics is different. Opioid rotation is a process. Keep a pain diary when you rotate. That will document the effectiveness of your new medication.

Good luck.

[codemonk]

The metabolize part is something I think that really messes me up with ANY drugs.
Even OTC stuff like aspirin, Unisom (or any sleeping pill), motrin,
Or things like muscle relaxers like Flexaril, Soma (which no longer take because it started giving my migraines) Valium, etc.
Pretty much ANY medication I have to double or even triple dose for it to have any effect where the "average" person only needs a single dose.
And these are all types of drugs I take VERY VERY rarely, from maybe once a week to once a month, or even less.
Take something like a sleeping pill. A single dose does nothing, so I take a double dose and it works. But then they won't do a damn thing unless I wait several days before I take anymore.I could take a quadruple dose on day 2 (not all at once) and it won't even make me drowsy.
Needless to say, I don't take that stuff anymore.
Except maybe the motrin, which is almost daily; Its the only thing that works on the arthritis in my knees (vicodin doesn't do a damn thing in that area, but 2 - 4 regular motrin takes care of the knees for almost all day).
But motrin doesn't do a thing for my back. If it did, I wouldn't be typing this.

I've had 3 surgeries for cysts in the past 15 years and woke up during 2 of the operations.
(But now the local hospital knows better; had a colonoscopy last Sunday and was out for the whole thing).


And I really hate to put a real downer on this discussion, but the word desperation is starting to become part of my vocabulary.

But so far, you have been the most helpful person I have found online to discuss this with that actually seems to give a damn.

Also, I'm 30 - 45 minute drive to town so its not like I can do weekly visits or drive around and visit multiple doctors on multiple days.
Although I do have a visit with my Doc tomorrow (The booking nurse said next available was the middle of January until I mentioned my ER visit with the Colonoscopy thing; (ER doc said to make an appt with my regular doc)) .

And excuse some of my typing/ bread crumbs or something under the keys I guess :)

[philnoir]

There are many people who require more medication than others.

My wife and I both use the same sleeping pill. I take one pill at bedtime, and often I'm up in 2-3 hours later and sometimes take a second pill. My wife takes 1/2 and sometimes 1/4 of a pill and she sleeps like a baby. At the dentist, I need a double or triple dose of marcaine to numb my gum and jaw.

So, I understand what you're saying.

The metabolism of hydrocodone occurs in two phases - an aggressive phase I involves cytochrome P450 (CYP) enzymes. Phase II metabolism is based on another enzyme, UGT.

An individual's genetics determines his/her ability to manufacture CYP and UGT enzymes meaning that we don't all metabolize any medication equally.

Altered metabolism in a patient or population can result in an opioid or metabolite leaving the body too rapidly, not reaching its therapeutic level, or staying in the body too long and producing toxic effects.

There are now tests available allowing doctors to match opioid therapy to a patient's metabolic capacity. I know little about this.

Perhaps you're taking the wrong drug?

Here's a paper that describes opioid metabolism in detail. Maybe it can help you, along with the genetic test for exploring your metabolism, can help you convince your doctor to rotate your opiates.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2704133/

[codemonk]

Thanks for that info.

Its kind of a moot point now though. Well, at least with this doctor.
Was at the doc yesterday and he told me after the first of the year, he will no longer be prescribing opiates/narcotics other than tylenol/codeine to ANY of his patients.
But he did say that he was going to try to find me a local pain specialist that takes Medicaid.

I would rather just get it fixed and never have to take another pill again.
The cyst can be fixed.
The Arthritis, I dunno.
And according to my Doctors PA (Who I saw after my last MRI) that nothing could be done about the Schmorl's nodes. I haven't looked into the validity of that, but I trust she knew what she was talking about.

But if I do get into see a pain specialist, they will probably know how to treat me better than my GP. Nothing against my GP. he's very smart and a really nice guy.
Back when I worked in IT, we used to talk about computers like two buddies talking about sports over a few beers.
I've been seeing him for over 15 years.
But yesterday he seemed REALLY stressed out.
I really think the DEA or some gov agency has been putting some pressure on him.

[fntn]

I have almost a dozen Schmorl's nodes throughout my spline as well. They told me the same thing, basically there is nothing to be done and that they are fairly common. I've got a couple that have almost eaten through the vertebrae body along with severe degeneration in most.

It's the extra full body joint/CTD attacks that cause me the most pain. So I do see a pain specialist who helps a great deal. Like you, my PCP bowed out when it came to medication.

Good luck in getting relief.