How to ask for an increase dose in pain meds

I think it depends on where you are at in your stage of treatment and what exactly your relationship is with your surgeon.

That is, are you still in the post-op acute pain stage going into rehab (for example less than 6 months out from surgery) or are you entering the more chronic stage of pain and looking for that kind of management. And it depends if this surgeon is the one who is going to manage this for the long term or is he most likely going to refer you to other specialists for long term management.

I have some workable ideas to suggest for either of these situations but I am ready to walk out the door for a 5:30 meeting that my ride-share driver has to be at and I don't dare make him late - especially for a computer "relationship" (he rolls his eyes at that).

When I make it home later tonight, if you are still looking for suggestions I will be happy to offer mine (it will give me time to get my thoughts in order so I don't end up making a long rambling post!

Cloe and Kara,
I know one of the things Chutz suggests - and I certainly would second her on this - is keeping a pain journal. She has a link in one fo these posts, and Ry also posted a link to the one she uses. If you are writing down your symptoms, how the pain and meds are affecting you, in an organized way and take that to your doctor, I thihk you can think show how your current regimen isn't working and ask if there is anything else to help so you can regain more functioning. The problem often comes when we ask for specific drugs. But Disce often has great ideas re:meds, so I'd wait for her reply. And her point about when it's a PM specialist or your surgeon is also relevant, because usually surgeons aren't going to get involved heavily in long term pain management.

PaLady

Finally made it home, and got some "nummies in my tummy", so set for the night, with most of the brain cells working I hope - but no promises.

Basically I think that the best way to present your situation is doing exactly what has been recommended in the other posts: Objectify your pain as much as possible - and to do this use some kind of pain journal. But I caution you - the success of a full scale journal depends on the doctor you see and your medical relationship with him / her, I sincerely believe (based on my experiences as a patient and as a professional). That is why I mentioned earlier that it depends on where you are at in your "stage" of pain.

If you are still relatively close to your surgery date (weeks to months post-op) and your surgeon is still doing typical post-op follow-up appointments to assess your progress / rehabilitation, asking for different or more drugs is pretty routine: it will be part of your assessment. You can relate your pain needs to the fact that you are getting more active etc. Depending on your surgery and rehab schedule surgeons will expect a typical "spike" in medication usage once a patient gets more active. Telling him exactly what makes the pain worse and what makes it better in matter of fact, progress-note type discussion can be very effective. I love the suggestion that was made for you to ask his advice about increasing doses at times that you can relate to increased activity. For example, "Doc, I am able to do things this week that I couldn't do last week; but I notice that my pain will spike while I am walking the dog. Does this mean I am trying too much too soon? or should I try to push a little more each day / week and take an additional pill when i need it? I sure want to try out your handiwork as soon as I can but I don't want to make things worse"..... This can open the door to a good discussion and allow him to suggest options. Most surgeons want their patients to be as active as possible as soon as it is medically feasible and are not averse to increasing or changing meds to accomplish that. But this is only during what they consider a "typical" and "reasonable" post-op time frame. For example, if you are months past the time when they think you should be completely healed and they find no "logical" reason for your continued pain, they will most likely not be open to any discussion of pain meds usage. I have found that surgeons (at least general surgeons) are not champions of chronic pain med use and are very reluctant to concede that an operation was not successful. ( I speak from personal experience with abdominal surgery - I have a WONDERFUL general surgeon who I think the world of....But he does not think I either need or should be on narcotic pain therapy for the rest of my life because he believes that his operations - 3 - completely took care of my problems. He is about the best in the area, and I do not feel that my chronic problems are his fault in any way, but I also know that he did not "cure" me either).

Now, if your situation has moved beyond the typical post-op timeframe and you are looking for chronic, long term pain management my guess is that your surgeon is not going to be open to any suggestion for increasing or changing your medication. But he may be open to getting you into a pain management clinic and most likely will keep you comfortable with meds until you get in. In this scenario I think you can "bargain" with him - again by saying that you do not want to forfeit any progress you have made while waitng to get into the pain clinic and that you understand being active is the key but that being in pain will interfere with your daily activities. And this is what makes the most impression: if you can concisely and objectively relate what the pain prevents you from doing (working, taking care of yourself and your family, keeping you away from socializing and from enjoyable hobbies / relaxation, etc) All of these are "key" items that they use to assess and justify treatment.

I also want to chime in more on the pain journal........I am a big believer in it, but with caution. From a professional standpoint I have been warned that physicians and NPs and PAs as well as RNs interpret a patient who comes armed with a comprehensive journal describing in great detail the daily pain cycle to be a "sign" of a needy and overly dramatic patient. While we all know that this is not necessarily true - that the patient is just trying to foster better communication - I think we need to be aware of this possible pitfall. Basically a health care provider does not have the time to really go through an actual journal; so what I did when i met with my pain doctor the first time was to present her with a two page summary. I included my personal pain scale (like a previous post discussed); and plotted on it my average daily pain with what a "spike" was and what I can get it down to with medication. And then I made a two column table with what made my pain better, what made it worse. I also listed how it interfered with my daily activities. I put all this in summary form - not as a full letter (all of this information was made much easier to sum-up by using the pain journal - it is just that I left the journal itself at home). And finally I ended with a short paragraph (one or two sentences) of what my goals were - and how I saw the pain clinic helping me to meet these objectives. I clearly stated that I wanted immediate relief from pain so that I could stop my inner voice from chanting ceaselessly: "I hurt, I hurt, I hurt, I hurt:......" - That I wanted to hear the outer world again and get my mind focused on how I can adapt to my new situation. Once I was given a chance to "wake-up" I asked that we then work on a long-term plan that included "guaranteed" pain control (medication as needed). I made sure that they knew I was not asking for a "cure" of my pain - just management.

The key to either situation (post-op or chronic pain management) is to be as concise, logical, objective and matter -of - fact as possible. You must make it as routine a discussion as any other aspect of the exam. The more you can quantify your pain - both in terms of how much it hurts on the pain scale as well as for how many hours a day it is at this level - the better you will be. If you can relate it to specific activities and how much you are curtailed in actual minutes / hours because of the pain; and if you can say that with "x" amount of medication you can do "x" amount of activity a day at "x" amount of pain this will help. For example:

if you do gardening you can say "I try to do garden work for two hours a day. If I don't take my percocet I can only work 30 minutes before the pain makes me quit. When I take my percocet you prescribed I can work two hours of low impact work but my pain goes to a 5 or 6; which is pretty hard to bear I really would like to work at least one hour in my garden with a pain level of no more than a 4 and maybe gradually work up to 2 hours with this lower level of pain. Do you see a way I can do this? Is it OK for me to take two pills so I can work outside for two hours a day?" blah, blah. blah.

By presenting your situation in these concrete terms you are laying it out in very precise, logical terms. It is much more effective than just saying you want a life back, etc - you are giving reasonable examples of what you can do and what you want to do. Plus you give him a chance to assess what your expectation are - to see if your goals are set too high or too low; it gives him a glimpse into your life too. It also puts him in a spot in a way; if he refuses you it makes him look like he is not supporting your desire to do as much as you can - like he is stifling your healing. But most importantly it gives him a great way to chart your progress with his therapy recommendations. As you get more active the more your pain is controlled he can actually plot this in his records: "patient now able to work a full eight hour day with pain controlled at levels 3 to 4 with occasional spikes to 6" for example, or "patient is able to walk child to school in the morning and afternoon with current medication regimen"

So, a long explanation for how I see the pain journal fitting into chronic pain management. Basically I believe that the journals are immensely and critically valuable as a personal tool, but I think it should be used with caution when interacting with your health care professional. I see it like a data book that is used in the science lab: It is invaluable for documenting the minute details of an experiment but it is not worthy of being "published" as is: it needs summarizing, editing and paraphrasing.


Other than this long winded explanation I cannot think of any other ideas off-hand. I do believe that if you are dealing with a compassionate, knowledgeable professional - whether for acute post-op, or chronic pain - you should be able to discuss your needs, concerns and wishes frankly, confidently and objectively. And that you will leave the exam room with a workable plan.

I hope this makes sense and offers you some ideas of how you may be able to present your situation in terms that health care professionals will respect. No matter what you do, honesty and sincerity is our biggest asset and I think that most physicians and surgeons really do want their patients to be pain-free. It is just so hard to really "see" pain and the more you can help them see it in scientific terms the greater the chance you will get it addressed. I like to think of it in the same way as trying to describe wind - we can't see it per se, but we can "prove" it exists by describing how it effects known objects.

Sorry that this got unbelievably long.....

Thank you everyone for your advice. I did not have surgery on my back as of yet my surgeon wants surgery to be my last resort. He is trying to manage my pain with pain meds and next month I will be having epidural injections. Give that a try and if that does not work then do surgery.

Cloe,
It's so frustrating, isn't it? I mean, we just want a better quality of life. Here's a thought. Maybe if things do not improve for you in a month, you could move your appointment up from three months on your own. Go in and be honest that it's not getting any better and you really want your life to improve. Either that or it's finding a PM doc.

PaLady

Cloe,
My hunch is you probably won't be able to get the increase over the phone. Some narcotics cannot be called in; must be a written script. Your pharmacist would know. Did you tell your doc about your daughter's wedding? If so, and it's a med that can be called in, it's possible. Otherwise you may need to make an appointment. That may be a good reason for you to go in, that is if her wedding isn't until later in Sept. But if it's early in Sept. -- maybe you could try calling tomorrow and say you forgot to mention about her wedding, and was wondering if something could be prescribed for a few days to give you extra relief.

A lot depends on the med. you need and the doc. It's worth checking out, and that's an event you want to try to enjoy as much as possible.

PaLady

Hi Kara,

Sorry to hear you're in so much pain. I thought I'd throw in my "two cents" for what it's worth.

First, it seems like most docs are careful to say that the pain meds should not be eliminating your pain. If your pain is well enough controlled for you to get out of bed, complete self-care activities (shower, dress, prepare & eat simple meals) and participate in certain socially required activities (generally, either part-time work or homemaking) then they don't seem prone to write for more narcs. I know it seems like we should have a right to be able to do these things without being in so much pain, "like the rest of the world", but that's simply not the case. For that matter, it should seem we should have a right to have some energy left for socializing, hobbies, travel or just having fun, but again, not the case. I'm not sure why the docs seem to believe this, but it's my observation that it generally holds true.

If, on the other hand, you are bedridden, unable to participate in your therapy routines, unable to take care of yourself or, to a more varying degree of importance, if you can't make any contribution to society [which includes contributions that would require further job training/eduction], it seems docs are more likely to up your meds, at least on a short-term, wait and see basis. If you can't do these things, you need to be honest with your doc. Tell him that the only time you are able to [get out of bed, do your therapy exercises ... or whatever the case may be] is when you have just taken your meds / or if you are not able to do those things at all, tell him that.

Keep in mind that in most cases the doctor's whole goal is to get you healthy. Bedridden, sedentary, malnourished and unbathed people are far more likely to get sick or experience serious complications. Also, if the only thing holding you back from work is poorly-managed pain, again it's pretty likely your doc will work with you to resolve that.

I admit that I have a pretty good relationship with my PM. He's gotten me taken care of with very strong narcs when I needed something much stronger than my regular routine just to be able to get myself up out of bed to go to the washroom. The bedbugs told a pretty clear story of how sad of shape I was in then :) & my PCP agreed to help monitor me for the short term while I was on the super high dose. If things are super bad & you still can't get through to your surgeon on your own, maybe your PCP or neurologist or someone can help take up your cause.

On the opposite end of the spectrum, I've had other times where I was just plain exhausted of being in pain all the time & wanted a break for a few days. On occasion, my PM has been willing to help me out during those times, but most of the time he tells me I need to be more consistent with my therapy exercises. Even for my sister's wedding, I was told to manage my activity time and mostly just tough it out (I did get one extra dose of meds for that day, but I'll admit it took every ounce of love I had for my sister & brother-and-law to smile for the pictures). I know it's a lot of responsibility to take on yourself, especially if you're young, but try to hang in there & hold on to hope that things will get better, easier, happier, etc. if you just keep working at it.

Wishing you the best,
frances