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Question: when to use breakthrough, when not to?

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Posted 10/28/2010 3:12 PM (GMT 0)
Hi,

I am in my mid-40's and have scoliosis. It never bothered me until my mid-30's and I eventually started to see doctors about it by my late 30's. Through my cervical and upper thoracic spine, I have significant disk degeneration, spurs, narrowed neuroforamen... the usual with this condition. I have pain in my upper back and neck and radiating pain down my left arm with numbness/tingling in some of my fingers.

When I wake up, the pain is minor -- I can go about my business and when occupied, don't notice it. By mid-day, it is bad enough that I start having trouble concentrating and need to take a lot of breaks. I have a sofa in my office where I will periodically lie down. By early evening, I sometimes cannot make it through dinner, the pain just gets overwhelming, and will leave the table to lying down for a few minutes before returning.

I've had injections, PT, traction, tens, accupuncture, and use ice, Tylenol, massage, etc.

For meds, I take 300mg of ultram er daily and 10-15mg of hydrocodone for breakthrough. I've taken stronger opioids, but hydrocodone doesn't interfere with my concentration. I also don't want to move to other time-release drugs (such as oxycontin) unless I absolutely must.

I often do not take my breakthrough meds as I am concerned about tolerance and addiction. So, even though my PM would give me more if I asked, I instead let 90 10mg pills stretch out for 9 months (3 visits). I also dose out of the ultram ER once a year just to make sure that I can do it.

Here's my question. How to decide when to take one's breakthrough medication? I ask myself the following sorts of things: 1) how many days has it been since I took my last pill; 2) is the pain level bad enough that without it, I won't get much if anything done; 3) can I put off what I have to do and just lie down for a few hours; 4) is the desire for the feel-good element of the opioid inciting me to exaggerate my pain levels; 5) is it late enough in the day that I should just take the rest of the day off anyhow, etc..

If I can hold off for a whole week and just bear the pain, I feel proud of my self. If I give in and take a pill after only a day or two, I get worried that I'm getting too dependent/addicted. But the pain is getting worse year by year and I doubt my 90 hydrocodones will last 9 months this time. So far, it has been about 4 months since I filled the prescription and I've used about 50 pills.

I have no history of addiction, nor does anyone in my family (though my father too has scoliosis, is in his late 70's, and has rotated through most opioids, including morphine and methadone). I have a good job, a loving wife, etc.. So, no life-issues I can see that would lead me into addiction.

So I wonder, am I being over cautious? My wife even pushes me to take more since the pain I'm in by dinner time is so bad. I even went to see a pain-management psychologist whose attitude was "hey you're getting prescribed the stuff, so use it". I assume those who actually live with the pain and have to deal with the medication aren't so naive.

I would appreciate some feedback. Does anyone else here just take the pain, even with ample meds available? Do others also go through their own internal "negotiations" before deciding whether to take any breakthrough meds?

Thanks.
Posted 10/28/2010 3:30 PM (GMT 0)
I think it's time to see your PM Doctor.
Go over all this with your pain management doctor as he's there to help you.
and that if you need to take more meds, the script will need to be made out for more medicine
and that requires your doctor to be in this loop. Your doctor maybe able to prescribe something
stronger for you at night or might be able to give you something to take through the day, but
he/she needs to know your pain is not in control. Make a copy of what you wrote here and
take it in with you to your doctor. Maybe it's time to get a MRI done to make sure things are
not getting worse for you, so maybe ask about that.
Hope you can get relief soon, nice to meet you but sure wish it was under better
circumstances than chronic pain, others will come by with better info, heed it and remember
we can only offer up suggestions.
(((((((((((((((((((((((((((((((((((ScoliJoe))))))))))))))))))))))))))))))))))))))))))))
healing Hugz and maybe try using an ice or heating pack to see if that will help.
Hopes that you get a low pain day soon...
Posted 10/28/2010 6:40 PM (GMT 0)
 

   Hello Scolijoe! Welcome to the CP forum!

      Your post was an intresting read for me, and brought back quite a few early memories when I first started having back pain.

      There is a post at the top of this froum titled Chronic Pain 101. It was posted by one of our moderators (Chutz) and I think you will find quite a bit of information regarding the addiction and dependency questions.

      I have to agree with Chartreux, in that you need to revisit your PM and tell them your concerns, and how you feel.

     While I do commend your fears in a sense, there is no need for you to have to suffer as much as you are. It is one thing to be simi comfortable with the right meds, and another to be taking them and still suffer enough pain to keep your mind fixed on the pain all the time. I'm at that place now! I do get some relief, but not enough to keep my mind off the pain.

    Again I have to agree with Chartreux, in that you may need to have some test done to see if your condition has worsened.

I'm a guessing that your taking #5 Hydrocodone X3 to get your 15mg a day. That, in my opinion is a pretty low dose.

     I'm courious as to what your pain level is with out the meds vs, on the meds, ....say on a scale from 1-10

       Take care, and enjoy the forum! wink

     SE wink

 

Posted 10/28/2010 7:49 PM (GMT 0)
Hi Scolio and welcome to Healing Well's chronic pain forum. I am sorry to hear that you are having so many problems with pain but that is the life of a person with true chronic pain. One thing that stuck out with me is your description of pain radiating into your arm and hand and numbness and tingling in fingers is not a good sign at all. Thats the earmarks for a disc problem in the cervical spine and a nerve being pinched or compressed. I have to wonder how long it has been since you had an MRI of the cervical spine. If its been a year or more you should be in your drs office telling them about this situation and getting an MRI done ASAP. That type of pain will not come from scoliosis, that is called radiculopathy.

Providing that you have been checked out for the above and everything appears to be ok, then you need to do a little research on chronic pain and educate yourself. You appear to be misinformed on addiction issues and chronic pain. All studies now show that people with chronic pain rarely ever become addicted to their pain medications. We build up tolerances like anyone will with any medication taken over a period of time. Spacing 90 pills out over a 9 month period of time will not be causing tolerance issues by a long shot. Tolerance comes from taking a medication over a long constant period of time, not something taken here and there or once in a while. I think your lack of education in this area is over shadowing things a great deal. This happens with my blood pressure medications about every two years. Individuals that take pain medications to get high or to get that euphoric feeling, those are the addicts and junkies. I am on class II narcotics and have been for years but I am not an addict nor am I addicted to my medication. There is nothing wrong with being cautious when it comes to pain medications, but you certainly need to be well informed and understand what you are getting into when you go down the CP path. I think you know about medications so I don't being naive is a problem.

You will learn in time that it is best to stay on top of your pain and not under it. What this means is, once the pain level gets high and out of control it takes longer to get the pain level back down. Taking extra pain medication will not help either that is another misconception. My PM dr allows me to cut my pain pill in half that I take for break thru pain if I feel I do not need a full dose, its whatever works best for me for the moment. I will not play a game with my medication of do I need a pain pill or do I want to just suck it up. That is not being a responsible pain patient.

If you are telling us that many times you cannot sit down to a dinner table and eat a meal with your family without having to get up and go lay down then you have a problem. You are the only one that can decide how much pain you want to put up with. The other side of the note by trying to stay off of medication your dr may begin to think you don't need medication either. I would tread lightly on that if I were you. I don't find any reward in allowing myself to suffer with pain because I don't want to take pain medication. None of us want to be on medication but if that is how we can achieve having some quality life then its worth it.

I do hope you will get that neck checked out and soon. Again, welcome to Healing Well's chronic pain forum. Keep us posted on how you are coming along.
Posted 10/28/2010 10:53 PM (GMT 0)
Thank you all so much for your replies.

I really appreciate the support. There's only so much I can say to friends and family -- I don't think they understand and the issues can make them uncomfortable.

Regarding recent tests, I had new MRIs and X-Rays taken in August. From C4-T4 I have mild to moderate disk bulges, leaking nuclei at C4-C6, spurs throughout and "broad based narrowing of the neuroforamen". The scoliosis causes uneven wear and so the radicular pain is due to nerves getting pinched from the narrowed spaces on the concave side of the curve. The films all show that things have gotten worse since my last set in 2007. I recently had some epidural injections, but they didn't help.

As for pain levels -- one respondant asked -- I never know how to answer that. So, here's an attempt. If 10 is pain so bad that it is beyond screaming and doctors would put you in a coma to prevent heart failure, 1 is an ordinary person's ache from sitting in a position too long, and 5 is the pain of stubbing your toe, I would say my pain usually ranges from 1-5 with one problem that brings it higher but only briefly. 3-5 is typical through most afternoons and evenings. My neck pain is mostly muscular -- tight, clenched ache and to move my head much feels like I am forcing it through a wall of pain. My upper back is cramped around the left trapezius and slighly lower to the right of my left scapula there is an area of burning/stabbing -- that's the worst area. When I curve my upper back forward (such as when sitting at a desk writing or while at a table eating, the pain will shoot up to a 7. It is overpowering. That's when I would just have to leave the table to lie down.

With 15 mg of hydrocodone (incl. 750mg of acetaminophen), what was a 4-5 can get to a 3 or so. But there's no stopping the stabbing pain when I curve my back forward. So, when I need to, I wear a brace to keep me from moving that way. The hydrocodone also provides a kind of disconnect from the pain. With chronic pain, there is the pain and there is the suffering -- the major change I would say is on the suffering side -- it offers an emotional relief, a sense of a break from the persistence.

Though my use is quite light by comparison to other members of the board, I do know that a tolerance has started to manifest. I've moved from 200 to 300mg of Ultram ER and five years ago, I was taking 7.5mg of hydrocodone and found it modestly helpful. I would compare the efficacy of 7.5mg five years ago to 10mg today. Related to this concern is that I probably have another 30 years of life. The more pain medication I use, the sooner the tolerance and the less manageable the pain will be, particular once my spine is even worse and the need is even greater. This is another reason why I hold back.

But the downside is that I have some lost days per week -- where I'm pretty much consigned to bed, can't get much if any work done, don't have it in me to go out for dinner, get any chores done, etc.. But given that I'm posting these issues, I'm not sure if I've found the right balance.
Posted 10/28/2010 11:39 PM (GMT 0)
Hello again Scolijoe! I must say that I do enjoy your writing style and you're ability for detailed responses! wink

It is just my own gut feeling, but you seem to be borderline on,...... lets say the negative side of comfort. I know the feeling well!

I'm going to make this short, and ask you to please read straydog's response again. Her reply is pretty good, and worth taking into consideration.

Take care, and please do seek pain management by a PM if you can.



SE:)
Posted 10/29/2010 12:12 AM (GMT 0)
Scoli, I have read your posts and find common ground. I did the same thing you did with trying to minimize the amount of pain meds that I was taking for 9 years. It then got to the point that I was struggling and ended up having multi level fusion surgery. I still tried to limit the pain meds after 2 more surgeries and continued to work. My Dr. was aware of what I was doing and told me that I was making things worse and that I needed to take the meds to help with the problems that come along side chronic pain such as sleeplessness and depression. I finally came to the point where life needed to change. My Dr. increased my meds drastically. A month later he increased them again. I ended up not working anymore but through the break in employment and the increase in pain meds, I was able to function again. My Dr. stated that I was undermediocated for years and that caused the pain to be out of control and it affected my life in many ways. I finally decided that I would worry about next year or ten years when that time gets here. My life has turned around so much it is hard to describe. I now walk 4 to 5 miles 3 times a week. Now I have seen such a difference that my pain meds are being decreased while still managing the pain. I realize I will never be pain free and also know that what I do or don't do at times influences my pain greatly. 

I also appreciate your pain assesssment. My Dr. and I agreed that pain is difficult to describe in terms of intensity. He told me that if I was at 9 or 10, I would not be able to walk or even be in his office. If I were to call him and tell him I was on my pain meds as prescribed and I was at 6 or above, he would have me come in as soon as possible.   

My advise is to assess how much your struggle or pain is affecting the quality of life. When it goes beyond what you are willing to allow, it is probably time to have a serious talk with the Dr. I also encourage you to talk to the Dr. now and be open and truthful about your concerns. How much medication someone else takes is of little value to you as we are each different and the effects of the meds are different.

Posted 10/29/2010 12:48 AM (GMT 0)
I think it is time to have a heartfelt talk with your doctor. Maybe procedures could be tried
have you had any rhizotomies, where they go in and burn the nerve that might be causing
the problem. Or maybe a strong medicine, there are some new meds coming out..
I hope you can get relief soon, well wishes to you.
((((((((((((((((((((((((((((((ScoliJoe))))))))))))))))))))))))))))))))))))))
Hugz
Posted 10/29/2010 4:15 AM (GMT 0)

Good evening Joe,

   My name is Dani. It is very nice to meet you. As you can see we have a great group of caring members. This is a fantastic place for friendship, knowledge and support. Also, I wanted to mention that we have a "Chronic Pain Chat-Night" every Thursday evening. I usually post a "reminder" each week.

   Do you have "degenerative" scoliosis? Or are you adolescent uncorrected scoliosis? I too, have "scoliosis". I am "Adult Idiopathic Progressive". I have a primary progressive thoracolumbar levoscoliosis and secondary thoracic dextroscoliosis. This last year I also have a "compensatory tilt" forming in my cervical area. I was "normal" 3 years ago. Now I am 5ft 4in (I was 5ft 8.5in a year and half ago) with obvious, yet stylish "marked deformity" curves and in a lot pain. Yikes the scoli stuff is terrible!

    I do not see mention of a muscle relaxer. Do you take one? I highly recommend Baclofen. It does take a bit to get used to, but I am a busy woman and am able to function through the days. Just a quick suggestion.

     I noticed a few things in your questions about BT meds, I thought I would put my 2 cents in for what it is worth.

Here's my question. How to decide when to take one's breakthrough medication? I ask myself the following sorts of things:

1) how many days has it been since I took my last pill;
*How many days you are having flares above what your pain meds take care of? It is something to bring up with you doctor regarding your current "daily meds" as it might be something more is going on or your meds might need adjusting. Don't let the "last pill" question decide when you need to reign in your pain.

 2) is the pain level bad enough that without it, I won't get much if anything done;
Yes, true. But as a rule of thumb, if you are hitting 6 and transitioning into an 7, you need to take something. Constant high pain levels have adverse effects on your body in so many ways. Even your heart. Hopefully, I will remember to post you some information to check out. 

3) can I put off what I have to do and just lie down for a few hours;
That is good. I "schedule" bio-feedback or nap time  30-45min per day. (not long because laying / sitting makes my hips burn and hurt terribly).Only problem is that my pain still spikes back up after I wake. Only thing it helps is the overall "muscle fatigue" for a hour or two.

 4) is the desire for the feel-good element of the opioid inciting me to exaggerate my pain levels;
Did you know that less than 2% of chronic pain patients become addicted to their meds? Its true. I wouldn't worry about that. What you describe is "Relief" not the urge to use for the "side effects". smhair

5) is it late enough in the day that I should just take the rest of the day off anyhow, etc..
Gosh, I am so sorry your pain isn't controlled better. You are on so little pain medication. Have you approached your doctor about changing or trying something new?



...Yes, you are being overly cautious. I wonder if you have ever seen a pain psychologist. They can help you in many ways. My pain psychologist helped me tremendously.

     Does anyone else here just take the pain, even with ample meds available?

     In the beginning I told myself all sorts of stuff to justify being under medicated. Constantly just "Tuff it out" sort of thinking. Thinking, foolishly that is was better. That I didn't want to become "addicted" or be "zoned out". There I was putting the same labels on myself, that I was constantly fighting against in society. I have been told quite plainly, by all of them, that I will be in pain the rest of my life. Even with surgical help to "structurally stabilize" my spine. Then later when I was sent to the pain psychologist, one of the first things she did was educate me about just what happens to your body with uncontrolled chronic pain and all the damage it does.

   Your descriptions pain levels? It is inaccurate. You know why? Because each day you increase your body and your minds tolerance to pain. Everyday you increase a little bit more, and a little bit more. Your pain levels today are NOTHING like they were last year. The only reason you aren't on you knees screaming in agony is because you have forced your body learn to "survive" with immense pain. Your "level 5" today, isn't the same as your "Level 5" last year. All the excess adrenaline in your body (automatic response to pain) is doing slow damage as well. There are many aspects about chronic pain that hurt your body if left untreated.

   This might sound silly, but hear me out, okay? ..... you will never feel as good as you do today, tomorrow. You will never feel as good as you do tomorrow, the next day. That is the very nature of Scoliosis no matter what "type" or "cause". So, stop wasting today. Give yourself days that you deserve. If you do decide on stronger meds or adding in a anti depressant or muscle relaxer, no one will just dump a full dose on you. It will be very slowly increased over time so you can still function and work. So, stop worrying about, this, and that... Instead, sit down and have a heart to heart with your doctor. Chances are he has been waiting for you to approach him. Give yourself a chance to be somewhat comfortable. Give yourself the chance to be at a level 4- all day for the first time in years. See what it feels like to have a low pain day and still be able to accomplish all the things you NEED to do. Maybe even a few things you WANT to do. You deserve it.

   I am terribly sorry this ended up so lengthy. I have a terrible habit of rambling on and on. I do hope you get a chance to relax. Again, it really is very nice to meet you.

*hugg*
  dani

~~>           http://www.nationalpainfoundation.org/articles/561/living-with-chronic-pain

Posted 10/29/2010 9:49 PM (GMT 0)
I feel truly moved by the help members are offering me. Many of the responses are very kind, detailed, and informative. Thank you all so much.

In response to Dani, I don't recall the specific terminology related to my scoliosis. I had it since I was young but it was not treated. Apparently, it was not severe enough to justify surgery. In retrospect, that may have been an error.

Dani, you mentioned in your post Baclofen. I have tried Soma, Zanaflex, Flexeril and a few others. They all make me feel incredibly horrible -- similar to the room-spin nausea from being very drunk. I'm wondering if you can tell me more about your experience with Baclofen.

I'd also like to comment on a point made by straydog: "What this means is, once the pain level gets high and out of control it takes longer to get the pain level back down." I agree that is an issue, but if I can make it through until bed time without taking anything, I can wake the next day with only my usual starting ache of just 1-2. That's one factor which influences how often I use any opioid. Also, if I don't need to be working and can lie down for 3 or so hours, that too can sometimes bring the pain down substaintally without using any meds. Some days, I can do that and not feel like I'm losing out on life or falling behind -- I might just have a few movies around to watch for instance. Other days, when I have a project due and have to be at my desk, then if I can't work because of the pain but must work, I'll then be more likely to take something. Also, though I am obviously very cautious about opioid use, I am more easygoing about benzodiazepines. I know how important a good night's sleep is for both pain relief and mental health. So I'll use an ativan without reservation (3-5 nights per week).


Thanks.

Scoli
Posted 10/30/2010 1:53 AM (GMT 0)
The best way not to form an addiction to pain medication is to take it when/before you need it.
Waiting until you just can't stand it anymore is how you become addicted.
Talk to your pain management doctor about how/when to take your break through meds.
Posted 10/30/2010 7:51 AM (GMT 0)
Something I forgot to ask you in my post is have you ever been seen by a good competent neurosurgeon? If so, what was his/her thoughts? I think with the arm pain you speak of and the numbness and tingling in some of your fingers, maybe you should have a consult with a neurosurgeon. You can never have too many opinions from good competent drs. Take care.
Posted 10/31/2010 8:37 PM (GMT 0)
Hi Straydog,

I did see a neurosurgeon a few months ago. The radicular pain and numbness is related to nerve impingement in the lower cervical spine. I was also told that by the surgeon who did my last injections.


I also wonder if it is time to leave the ultram for a different maintenance opioid. Maybe something stronger would reduce the amount of daily pain. But I have felt that ultram's other properties have been beneficial (for mood and energy) and I'm not aware of any other opioid that has a time-release formulation which either boosts serotonin release or inhibits serotonin or norepinephrine reuptake. Surprisingly, nucynta (tapentadol) makes me drowsy despite its NRI properties. In fact, it is the only opioid which makes me drowsy and so I've used it some nights when the pain is bad enough I cannot get to sleep.

Does anyone know of a time-release opioid which affects serotonin levels?
From my online research, I've not found any other than ultram.
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