Tolerance/Ineffective Pain Meds

[Mom_of_Seven]

I have an appt. with my pain management doctor on Wednesday morning.  It is my second appt. with him.  I am currently taking MS Contin 30 mg every 8 hours(3 x a day) and a Percocet 10/325 (4 X day).  Honestly I end up taking about 6 percs a day because of tolerance and just ineffective pain management.  I usually find myself up at  least five nights out of a 7 day week.  I have been on this dosage of percocet for 18 months.  I feel like something could provide better pain relief.  How do I ask for something more without appearing as though I am a drug seeker.  I am afraid if I do not get good relief soon I am going to lose it.  I try not to take xanax but I might have to.  I also take lyrica, cymbalta and zanaflex to relieve DDD, spinal stenosis, neuropathy, etc.  Help please any advise would be appreciated.

[erin183]

I was in the exact same boat many times. My pain mngmnt doc has seen me cry more than my own family I think because it is so frustrating when nothing helps! I too was supplementing with leftover percocets on the side and he said "You can't do that!" But you know what? It helped - until I ran out. Oxycontin didn't do jack. Now I'm on Fentanyl patches. I've had good days, but I still have bad days. It's too soon to tell if this is a fix or not. But I've been to 2 different chiropractors, 3 different physical therapists, 2 different pain management docs, have seen 3 neurologists, 2 neurosurgeons...I've tried heating pads, ice packs, massage machines and real massages, TENS units, traction, acupuncture, different types of therapeutic or "neck" pillows, nerve conduction study, EMG (which was the most painful procedure I've ever endured), discogram, surgery 7/31/07 (Discectomy and Instrumented Anterior Cervical Fusion at C4-C5), all kinds of medications including ibuprofen, tramadol, vicodin, neurontin, lyrica, lidoderm, voltaren, zanaflex, percocet, methadone, oxycontin and now 50 mg fentanyl patches and many supplements too, plus multiple epidural steroid injections, facet-joint injections, trigger point injections and nerve blocks...You name it, I've tried it yet the pain still persists. Good luck! I honestly know how you feel. And it's no fun.

[nurseaudrea]

I totally agree with Jaybay. I have done many drug holidays to reset my receptors and to also find out how much pain I am really in.When you are in chronic pain you have to readjust your expectations and mourn the loss of your former life. I had to go through that in my 20's. My first fusion happened when I was 22. I kind of understand why your doctor might want you to wait simply because fusions do cause stress on levels above and below the level of the fusion, but it has been 14 years since I had L4-L5-S1 fused and L3 has not been touched. I just make sure I keep in shape and keep the muscles strong in my back and abdomen so I do not need further surgery in the future. It scarey to think a doctor is telling you to put off surgery as long as you can because you can also be doing more harm than good. If you have any nerve involvement it is quite likely after 6 months of compression you will not get that back. In cases like that surgery has to be done as soon as possible to fix the problem. Hopefully you do not have any radiculopathies and will not develop any with your condition. You did not say what was going on so there is no way to even contemplate what could be going on.
I also used to have high expectations each time I went to the doctor with pain control. I wanted my pain gone. I was not used to pain and did not expect to have to live with it for the rest of my life. What 22 year old college student does? You will learn after going time after time and not getting the relief you so desperately want you will start to settle for comfort rather than absolution. Say a 3 or 4 instead of an 8 or 9 out of 10. You learn to adjust those expectations with experience and time.

[Jaybay]

Rather than approach this problem from an "I need more meds" position, you might open the conversation by asking your doctor how he deals with tolerance issues.  Sometimes simply changing meds can help fool your body so that you get a bit more relief.  Some doctors recommend an "opiate vacation" to reset your brain receptors.  When you go back on opiates, you won't need as much to achieve some kind of relief.  Of course, that technique means some suffering for a few weeks so most people won't consider it.

Another thing to think about is your own expectations of pain management.  If you're looking to be cured or even to reach a level of pain around 1 or 2, that may not be realistic.  That's another great conversation to have with your doctor.  Your goals may differ drastically from his goals.  Both of you can avoid a lot of misunderstanding by exploring this topic.

It wouldn't hurt to get a second (or third) opinion on your surgery.  It is not a guarantee that you will need yet more surgery in the future.  I have 3 cervical levels that have been fused and plated since 1995 and there is zero problem with the surrounding discs.  People who dedicate themselves to rehab work to rebuild muscle after surgery and carry on with that work tend not to need more surgery later in life.  

Just as there are no guarantees of full recovery with any surgery, there are no guarantees of additional damage either.  If the meds aren't working now, higher doses will only be a temporary fix.  It may be time to start thinking seriously about having that surgery if it's your only real chance of relief.  

[nurseaudrea]

If you are new to this doctor you new to ask the doctor what he thinks you should do. Don't ask for a change, just state that you are still in a lot of pain and describe it to him. You might also want to wait until it is your 3rd appt. Doctors are real leary about increasing a dose of a new patient they don't know. If you can make try to, but if you can't just explain what you are going through and ask if he/she has any suggestions. Don't ever ask for an increase because then they will think you are seaking because you are new. You  need to develop that relationship.

[Mom_of_Seven]

I'm sorry, I guess I wasn't clear. This is the second appointment with this doctor.  I have been seen by two other pain management physicians in the last seven to eight years.  In those years I have been through every sort of injection and while most were ineffective we have continued to try other options.  I have been told I need a 2/3 level fusion in my c-spine and a 4/5 level fusion in the lumbar region.  The neurologist said that I should try to put off the surgery as long as possible.  He said if I went through with the surgery when I was in my late 30s/early 40s; I would face a revision in 15 to 20 years.  The injections were of every type...facet joint, epidurals, trigger point, si joint, radio frequency ablation, etc.  I have also been to a pain psychologist, chiropractor, massage therapist, physical therapy, non-opiod meds, lidoderm, etc.  Nothing has really worked.  I currently take MS-Contin to provide me longterm pain relief and the percocet is for breakthrough pain.  I make sure I never take more than 4 grams because of the acetominophen content.  I started as many do with Tramadol, Vicodin, Norco, and graduated to Opana with Roxicodone for breakthrough, Methadone, etc.  I really wonder how I approach the doctor....my pain level increased to where I have increased periods of nausea and can sometimes barely walk (like today).  The doctor did not change the pain meds at my first visit and I have been on this dose and medication for about 3-4 months.  Don't you think that is enough time?  I'm not sure how I approach the fact that it isn't working?  Any suggestions?

[mellie4]

I think you need to be very honest with your doctor.  They probably won't be happy with you taking the extra percocet (and you need to be careful because it has Tylenol in it and you don't want to take too much of Tylenol; it can really damage your liver.)  But maybe the combination you're on just isn't working for you.  It can take a lot of trial and error to get the right combination.  Maybe you would do better with a long-acting medication and then something for breakthrough??  It can be very hard to bring up medication changes.  There can still be a lot of stigma attached to being on narcotics for chronic pain.  You mention it will be your 2nd pain management appointment.  Did they change any of your meds at your first appointment that your previous doctor put you on?  Have you given it enough time to see if there are any changes?  Have you asked about any procedures or therapies that might be beneficial?  Pain management isn't always about just meds.  Often there are blocks, infusions, etc. that can aid in managing the pain.