percocet to butrans patch.... help!!!

[caiti87]

Hello all, I am knew to this forum. I'll give a little history and then to my questions and concerns... I was diagnosed with chronic interstitial cystitis, I have multiply stones in each kidney and was very recently diagnosed with chronic hep c as well. I started taking narcotics for the pain about five years ago, shortly after having my son. I then had about four surgeries. Needless to say my pain has increased immensely over the last year and my pain was never in control unless i was admitted to the hospital with a pca pump or around the clock heavy narcotics. last year around august i was finally referred to a pain management doctor. My family doctor had started me on the 50mcg/hr fentynal   patches a week before i was to see my pain doc, anyway when i saw the pain doc he decided to keep me on the patches since they seemed to be working so well, it was the first time in years that i had some pain free days with energy and ambition. well i started having a problem with the patches sticking to my skin, and before i could get the manufacturer to send me covers, my doc took me off saying that if they weren't sticking there was no point in continuing them, he then switched me to percocet which i had good results with in the past. i was to take four a day of of the 10/325 tabs, they worked great, but i started to figure out that they just werent covering my pain for long enough, making me want to take more in between doses or larger doses to cover the pain. well before i could address this with my doc i was hospitalized for about a week in a half (initially for my ic and kidney infection) my liver enzymes were sky high and had been elevated for a few months prior (which the docs attributed to a mvi) anyway they were alarmingly high and the docs decided to fly me out of my small town hospital to a bigger hospital in the city. they then found the hep c, in the chronic phase. while in the hospital i missed my pain doc appt so the doc in hospital just wrote exact same script id been getting of percs to take home, and called my pain doc office to let them know. well i had an appt tues and he decided to take me off of the percs because f the Tylenol (understandably) so i i suggested going back to fentynal, he ignored me and gave me a script for talwin, i go to fill it at the Walgreens where they inform me that one of the components of talwin is nalexone which i have a known allergy to. i call pain doc to inform him of this and he says he will call in tramadol instead, which if he ever bothered to look at my chart would know that they don't touch my pain and give me these electric shock sensations..... he said he would look at my chart and call me back with something else. he never did, i had to call his office numerous times just to be ignored and left without pain meds, finally i called today and practically had to throw a fit and demand to speak to him or his nurse while reminding them that I pay a whole lot of money to them out of pocket (no insurance) and drive three hours for his services and that I will not be ignored any longer. the nurse got on the phone and proceeded to tell me that because of my hep c i basically wont be able to have my pain controlled, which is not true. finally he told me he was going to call in butrans patches for me, i know nothing of this medication, and how well it works to control pain. he aslo never told me if it will have any interactions with my other meds, clonopin, ditropan, norco, and pheneragan........ compared to the percocet will this medication even touch my pain? the only real thing i can find on the internet is that its used to detox addicts from opiates..... why would he prescribe me something like that? im not an addict, just in chronic pain! does anyone have any info on hep c and chronic pain? please help me understand.... sorry in advance for this rambling on and on......

[Jaybay]

While buprenorphine is used in products like Subutex and Suboxone for weaning addicts off street drugs, it is also a powerful semi-synthetic narcotic that has been used to treat pain since the 1980's.  The patch has been on the market in Europe for a number of years and only just passed through the maze of FDA approvals recently.  

I suspect that what your doctor meant about not being able to treat your pain is the problem of pain meds being metabolized in the liver.  I'm not a doctor or an expert by any means, but I'm not aware of any opiate that isn't metabolized by the liver.  Even burprenorphine is handled by the liver so it would be an excellent idea for you to have a discussion with your hepatologist about pain management.  I'm honestly more concerned about the norco you're taking than the Butrans patch because the tylenol it contains is so toxic to the liver.  Your clonopin also isn't a great idea to be taking with any narcotic on board.

You are right to be concerned about drug interractions.  In my experience,  our doctors aren't always the best ones to turn to for advice in that area.  There are so many drugs on the market now that it's impossible for them to keep up with every side effect and interraction.  Your pharmacist is your best resource for solid information.  It's easy to forget that a pharmacist is also a medical specialist and there is a whole lot more to that career than counting and dispensing pills.  Nowhere else can you get a personal, in-depth medical consultation free of charge.  :-D

[marycarmel]

Great advice from JayBay.  I consider my pharmacist to be part of my pain team and often contact them about interactions, side effects, etc.

[caiti87]

I talk to my pharmasist all the time, he probably thinks "oh great the question lady" every time he sees me... Anyway I i live in a small town with only two pharmacies, they both knew next to nothing about the patch... one of the pharmacists had the wits to tell me to wait a good eight hours after taking my last dose of percocet or more (if i could get through it ) or that i might be pretty uncomfortable if i didnt.... the docs never even thought to mention that to me

[femmy29]

You need to get down to the reason why your doctor won't put you back on the Fentanyl patches especially since the covers were being sent to you by your pharmaceutical company.  Go see your hepatologist like JayBay said to get the all clear that Fentanyl is okay to use for your pain.  There shouldn't be anything extra special about the Fentanyl and how it is metabolized by the liver than the other opioid medications as all opioid medications are metabolized by the liver.

Something seems very fishy to me about your story.  It is apparent to me that your pain managment doctor has an issue with prescribing you the Fentanyl patch.  Not sure the reasoning but the fact that he wants to try other extremely less potent medicines like Tramadol, tells me that he has concerns over DEA scrunity of his practice.

Burprenorphine can be extremely potent, even more so than methadone, dilaudid, and oxymorphone; and falls just short in strength to Fentanyl.  Problem is, Burprenorphine in patch form and also under the tradename Suboxone and Subutex is not very potent due to the low amount of burprenorphine contained within these products even within the highest packaged dose by the pharmaceutical company.  There is no luck in going over that amount either as the naloxone will kick in and throw you into severe withdrawal (only in the case of Suboxone and Subutex as the patch doesn't have nalaxone but there is a ceiling effect built in).  I believe the burprenorphine in Europe is more therapeutic as they have stronger doses but the US doesn't carry those.  

It may work for your pain but don't be too surprised if it doesn't.  It may take a few days to reach max potency so give it a fair trial before throwing in the towel.  If you pain management doctor refuses the Fentanyl again if the burprenorphine fails, can you go back to being treated under your primary care doctor, as he is the one that started you on the Fentanyl?

femmy

[caiti87]

you are soo right something seems very fishy to me as well with my pain doc... part of the problem is that there is no personal care, he cant even remember what he has or hasnt done for me in the past, for example at my last visit I asked him what he thought about whatever the doc talked to him about over the phone concerning my hep c results and being in the hospital, He proceeded to tell me that he never talked to any doctor, and also said "aren't you the one that we called in some tramadol for a few weeks ago?". Seems like he cant even keep his patients straight... and given he is correct in saying that i only have one liver so its either have poor pain control or keep my liver.... idk what to think im confused, even though i do obviously want to keep my liver as healthy as possible, there had to be some sort of balance here. My doc just pulled me straight off of the  percocet and straight to patches without even trying to taper my perc dose first, and didnt bother to tell me that i would end up with precipitated withdraws when starting the patch and stopping the perc..... I need a doctor that is going to work with me and my other docs as a team, not the treatment im getting...

[caiti87]

oh and i forgot to add that the patches arent touching the pain! not even close, so im taking advil as often as i can to not hurt. that cant be much better than all the percocet i was taking, right? I was up all night, litterally watched the sun come up because i couldn't sleep due to pain... it's making me a horrible mother as well... I almost wonder if the patch is making me feel worse!

[femmy29]

Your post describes a physician that is providing you with less than optimal treatment.  You stated in one of your earlier posts that you were doing well on the Fentanyl without experiencing any liver complications.  It wasn't until you started the Percocet did your liver enzymes elevate to dangerous levels and understandably so and it was most likely caused by the Tylenol contained with the Percocet.  Do you have your last liver panel test results available to you?  If so, check the ALT number.  This number is typically the one elevated when the liver is having trouble metabolizing the Tylenol.

Can you go back to your primary care physician and tell him that the pain management doctor is providing suboptimal care and that your life has suffered immensely because of this due to the increase in pain that is intolerable?  Tell him also that this doctor took you off the Fentanyl patch due to them not sticking even though covers were on order from the pharmaceutical company.

I believe you can be on Fentanyl safely to have better pain control, you just need to have a doctor that is going to be more involved in your care.  You may want to get periodic liver panel tests every 1-3 months to monitor your enzyme levels.  I would google, "opioid pain medications and hepatitis C" to see what pops up.  The medical research could already be out there that shows which opioids are harder for the liver to metabolize and which opioids are easier on the liver.  Keep in mind, you may need to do periodic tapers to lower the liver enzymes and then you can restart the opioid medication.

There is also the option of a pain pump implant.  The opioid medication bypasses the gastrointestinal system and is pumped directly into the spinal cord to provide relief.  And you know what?  Now that I just typed this, I REALIZE that Fentanyl is probably the best med for your pain as it is absorbed directly into the blood stream versus going through the gastrointestinal system and requiring more liver metabolization.  I believe that the liver still has to metabolize some of the medication but it is less because of the route of administration.  But like I said, research this yourself on google and bring the information into your next doctor's appointment.  If things still go sour you may need to go back to your PCP for pain management or a different pain management physician.

femmy

[caiti87]

hey there, you are so very right. from what i've read about hep c and opioid meds, fentynal is one of the most recommended and safest for the liver. I will try to discuss this with him. wish me luck! if he does not give me the time of day again, i will most def find a new doc..... the butran patches just arent working very well and the side effects are terrible. i keep having these like electric shock type feelings, feels like i just short out for a sec and it effects my speech and hands are very shaky... almost like a petit mal seizure, that just seems the best way to describe them..... it's so weird and uncomfortable feeling, not to mention the lack of pain control!

[marycarmel]

Definitely find a new doc if you aren't being responded to!!!  I had a very bad reaction when they tried me on Nucynta and spent 11 days with increasingly bad side effects.  In hindsight, I should have insisted they switch me off after a couple of days.