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Switching from OxyContin to Xtampza ER - dosage changes?

Long story - shortest version I can make:  I’m a long term chronic pain-er from endometriosis, pelvic pain, adhesions, etc.  I’ve been taking OxyContin 80mgs 3x daily plus 30mgs oxycodone 4x daily (or as needed) for well over a decade.  My insurance is insisting I do a one month trial of the Xtampza which I start today.  My pain was well managed on my old meds but the insurance won’t cover them any longer unless I at least try The Xtampza for the month.  My doctor is a family MD but she takes on a few trusted well vetted chronic pain patients since we live in a small rural area with the closest pain management clinic at least an hour’s drive away.  I’ve looked at the dose conversions and to get the equivalent amount of medicine I should be getting 2 36mgs of Xtampza capsules 3x daily (180 capsules a month).  She’s prescribed only 2 doses a day (120 capsules a month).  I’ve been communicating with her through this change via her nurse/assistant, leaving messages, getting calls back, etc which hasn’t been very effective so I have made an appointment to see her face to face on Friday to discuss.

I’m worried about the decrease in dose and how it will affect my pain levels.  Should I be?  It seems like a cut of this size (a full third of my old dose) is a lot. She’s always been fine with prescribing my meds, I sign a pain management contract every year and am compliant with the conditions in it.  

The last call back from her assistant is the first time I realized that she actually wants to CUT my dose downward.  I called her office because my pharmacy initially got the prescription from her with only 60 pills/month and I knew that wasn’t right. I know she hasn’t prescribed this medicine before for any other patients so I just figured she made a mistake in converting to the equivalent dose.  She then upped it to 120 pills/month so I called again and when I talked to her assistant I got a basic “take the 120 pills OR give up the 30mg oxycodone breakthrough pain meds and she’ll give you the full 180 pills”.  Either that or we’ll refer you to the closest pain management clinic.  I was gobsmacked!  I said I’ll take the 120 pills and keep my breakthrough pain med - which I need.  I’m feeling a little “Deal or No Dealed” at this point.  I made the first available appointment I could get with her and I guess by then I’ll know if the new med -  Xtampza - at the lower dose is going to work.  We’ve never discussed a lower dose situation in the 10 years + that I’ve been seeing her and I know she trusts me so I’m wondering if something got lost in translation between the assistant (someone new whom I haven’t met yet), me & my dr.

Complicating factor:  I also take Xanax (1 nightly) for insomnia & the insurance folks say that they won’t cover the Xtampza unless I discontinue the Xanax (no benzodiazepines with Xtampza). Dr. switched me from Xanax to Trazadone (which is not working) so I’ll have to discuss that with her as well on Friday.

I’m probably over emotional about this because I’m not getting proper sleep but I feel like she’s about to fire me as a patient and that worries the heck out of me.  What should I do?  Does anyone else here have experience with transitioning from OxyContin to Xtampza?

Thanks in advance for any advice you can give me.
3 Responses
18524847 tn?1465595901
For good or bad (and I understand often bad), pain management and especially with oxy is under heightened scrutiny.  There really is that whole situation of managing your chronic conditions while dealing with the fact you are likely addicted to the meds you've been taking.  So, the idea of changing is, I'm sure, terrifying.  We get psychologically wrapped up in our routine and it works, so why wouldn't we?  I understand how you are feeling.  I think the best you can do is to try what they are asking.  And if it doesn't work, there will be the time of re evaluation.  Totally stinks to have a month or a bit longer that may not be like you usually are in terms of keeping the chronic issues at bay.  But they are saying you have to so I would try to fight the fear and try with an open mind.  Chronic pain patients are being taken off meds around the country.  Xanax is a little bit different.  Xanax is not really a treatment for insomnia.  It really just numbs you.  There definitely better treatments for insomnia than that.  That one may be harder to continue for an insomnia diagnosis.  But you do need proper pain management.  Trazadone is usually a good choice for insomnia.  I'm sorry that isn't working for you.  Maybe the dose can be tweaked.  I'd say it is unlikely you'll get put back on xanax with this doctor.  Again, try to be open minded as to 'what else' you can do.  

I doubt your doctor wants to fire you.  Most doctors really do want to help you.  hugs
20803600 tn?1546262537
COMMUNITY LEADER
Conversion from one opiate to another is never a 1:1 conversion. Even in pain management practices, when converting from one opiate to another there is a reduction in dosage with the new medication. Cross tolerance issues are considered, since even in long term chronic pain patients- they typically need less of the new medication to achieve equal or better pain control using a lesser dosage. The new opiate uses different receptors and that’s why. Secondly, in order to avoid side effects , accidental overdose , drug interactions -a new medication is reduced.
A typical reduction is 20-30% of the previous dose- so it appears your doctor is doing the conversion exactly right.
Xanax is not recommended for use with opiates, since both cause sedation and respiratory suppression. I’m not surprised they don’t want you taking the amount of opiates you are on and the Xanax as well.
Trazadone can be titrated up in dose safely and effectively if the current dose is not working.
Avatar universal
I’m still battling this.  I had an appointment with my doctor & we discussed all of the alternate meds which are covered by my insurance.  We settled on one (which required a PA) and they outright rejected it - at least in the dosage necessary to replace my current regimen.   I’m in a situation that is untenable and think the only way to reconcile it is to file a complaint with my state’s insurance commissioner.  I’ll be doing that very soon.  I thank all of you for your suggestions and comments.
Btw, I’m no longer taking Xanax and have switched to Lunesta.  I don’t sleep well but I’m at least no longer taking a benzodiazepine.
1 Comments
Unfortunately, it’s unlikely that you will find any doctor to give you a straight 1:1 mg for mg conversion to any other opiate. As I explained in my earlier response- when converting from one opiate to another- mg for mg conversions don’t occur and aren’t the standard of practice.
You were on a high dose of OxyContin -360 mg of Oxycodone is an astronomical amount , even for a long term pain patient.
Almost every doctor you see would be alarmed at that dosage.
Long acting opiates (extended release) are typically dosed once or twice daily, and breakthrough doses are limited to two to three times daily, depending on mg strength.
I understand your concerns but at the same time- I think you may need to adjust your expectations and expect a reduction and change in dosage from OxyContin/Oxycodone  combinations may be the likely outcome.
Most of us long term chronic pain patients find changing meds periodically and keeping the use of breakthrough meds lower still affords adequate pain management , and we can adjust to them with little difficulty.
If the Xtampza isn’t working, there are other options in long acting medications such as morphine, fentanyl, and a few others.
I’d hate to see you loose access to treatment for your pain if the insurance company or doctor become concerned about the current dosage.
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