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Levorphanol?

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Posted 3/1/2011 10:40 PM (GMT 0)
My father is in his late 70's, is bedridden, and in severe pain due to scoliosis (which I inherited). He has been on morphine and methadone, but his PM rotated him back to oxycontin recently, which isn't touching the pain (Oxycontin 20mg 3x, oxycodone IR 10mg 4x).

I had suggested oxymorphone prior to his latest PM visit, but it apparently is still not available in Canada. So, my new suggestion is Levorphanol. In addition to the three main opioid receptors, it has NMDA antagonist and SNRI properties. My thought is that it offers a "shot gun" approach, targeting so many mechanisms related to pain.

Has anyone here used it and can comment on its efficacy and side-effects?

Thanks.
Posted 3/3/2011 10:25 PM (GMT 0)
hey Cogito, I have not taken levorphanol ,"Levo-Dromoran", is the trademarked brand name in the states, i'm not sure about Canada. i think ICN Pharmaceuticals still makes a "brand" 2 and 4mg tablet. it is also available in generic version but no pharmacy within 50 miles probably has it, why? money, kickbacks to pharmaceutical fat cats. they push Oxycontin hard now that it has been reformulated. Opana ER is another one that's 1,000 dollars per month, Embeda is the new morphine they figured out how to re-invent for the 50th time. i think i talked to my pharmacist if it was in stock ever (regional hub Walgreens) and he had hardly ever seen it and they could order it. every report from a pain patient i have heard is absolutely great. the WHO(world health organization) considers it a "third tier" opioid, above fentanyl and dilaudid; so i would give it a shot but make sure you have some back-up meds just in case. Levorphanol's properties are very similar to oxymorphone(not ER) which has a fairly fast kick in but a longer half-life than most until you get to the methadone and buprenorphine type duration of action. Have you tried to suggest Dilaudid or HydromorphContin? the Fentanyl fast acting products are darn good but you have to watch for tooth decay: Actiq, a lollypop, and there are two buccal forms. if Levorphanol is not a hassel to try i think i would.
Posted 3/3/2011 10:47 PM (GMT 0)
Thanks Spinal Soldier.

My father did try the Fentanyl patch about 5 years ago and couldn't stand the nausea. Unfortunately, my parents rarely revisit options so when I suggested the Fentanyl at a lower dose, they rejected it. I'm not sure about hydromorphone, I vaguely recall that he's tried it, but I'll ask.

Given that levorphanol is such an old drug, supplanted by so many costly opioids, it may be hard to get. But my parents live in Toronto and if it is available anywhere in Canada, they can get it delivered to their pharmacy. The big challenge is getting my father's PM to go with it. My plan is to put together a proposal for the PM, discussing its mechanisms of action, efficacy and side-effect data.
Posted 3/4/2011 8:24 AM (GMT 0)
Hi cogito~

I'm sorry your father is suffering so much. I know it was so hard to watch my father suffer through his last weeks with prostate cancer. We gave him more and more pain meds...which barely touched the pain. We had him at home with Hospice care so it was watched carefully but it's still hard to see a parent suffer.

I'm wondering if your doctor is balking with some of these pain relievers due to his age? The older patients get the harder pain meds are on their bodies. The constipation can begin with only one dose of an opioid and last for the duration. Also it doesn't take much for euphoria or worse to make them either out of it or even beligerent. It's hard to know. It's also very hard on the liver and kidneys of the elderly since these are excreted through those channels.

I'm just taking some guesses here in hopes of giving you options to think of. Keep asking your fathers' doctor and always feel free to ask here. It's why we keep coming back...to help our fellow CP family friends.

Keep in touch, OK?
Chutz
Posted 3/4/2011 1:41 PM (GMT 0)
Hi cogito,

I am sorry you father is suffering so much! It is very difficult to feel like you can not help someone you love. I have been on Levorphanol and would almost give my right arm to be on it again!! Nothing managed my pain like Levorphanol did and now I can't get it. Originally we were told it was backordered for a month (we being myself and the pharmacist) and that was in February of last year. Every time my pharmacy checked on it...it was backordered for longer and longer. He still checks for me each month when I go in to get my morphine filled and now it just says not available....it does not say discontinued, however, but it has been over a year now! I would highly recommend it if you can get it, but I worry about starting it and then not being able to get it again! Like I said the pain control is amazing and I really had no side effects....except a little sleepy when I first started taking it, but it was worth it! Anyway, good luck...maybe it will not be a problem in Canada!

Take care,
Beckey
Posted 3/4/2011 3:17 PM (GMT 0)
Chutz and Antbuggey,

Thanks for the replies.

I assume that my father's age (and severe physical degeneration) is a factor in the PM's decisions, but he has been dealing with the usual array of side effects from opioids for some time and he is on many meds (oxycodone & oxycontin, ativan, remeron, etc..). I don't know if the Levo will cause more severe constipation, etc., than what he has so far taken, but if the net effect of side effects and pain relief is not suitable, then the Levo can be discontinued.

As Antbuggey reports, and as I've seen elsewhere, it can help immensely and my father needs it. His days are spent in bed, just lying in the dark, too much pain to do anything, 3 minutes out of bed for a meal or the bathroom every 3 hours is as much as he can do. So in my opinion, if something can have a meaningful impact on the pain, then he'll have a window of opportunity to regain a bit of life, even if that's just enough strength to chat with my mother for more than 3 minutes, a daily walk up and down the hall, or (I hope) a monitored visit to his building's indoor swimming pool or hot tub.
Posted 3/4/2011 7:56 PM (GMT 0)
hey cogito, i am familiar with parents not visiting options but i keep trying. Auntbuggy backs up it's reputation even more. describing the nature of your father's pain it is similar to a phase i was stuck in for about three months. i believe my situation was due to the side effects of different psychotropic drugs used in addition to opioids. Intractable pain is another problem which is pain that is not easy to control using normal treatments, so an opiate that you can push to a high dose without causing high side effects is required and their are not many. I think your right into looking into Oxymorphone because it has no ceiling and in high doses it does not have the histamine releasing effect as Morphine, nausea is not as severe because of that. It is also 6-8 times more potent than Morphine so you can get more analgesic effect before the bad side effects come like respritory depression although it sounds like your father has a tolerance and can handle it no problem. I cannot believe Canada has not given this approval like a Schedule2 in the US. Hydromorphone is 5-7 times morphine in analgesic terms but is short-acting in IR form so a sustained-release med is needed. Remeron may cause apathy or somnlence so that should be explored. I have seen Modafinil or Bupropion used to break the apathy, even dextroamphetamine. Hydroxyzine or Promethazine can be used to potentate opiates. Even in non-neuropathic pain Pregabalin or Tricyclic-anti-depressants/SNRI's can help. Anyway best of luck to you and your father.
Posted 3/4/2011 8:49 PM (GMT 0)
Thanks Spinal Solider,

From what I've seen of my father's reaction to Remeron, I am very frustrated that he's still on it. I did mention dextro to my mother recently, but they aren't the type to experiment.

I would like him off Remeron and switched to one of many SNRI's or Tricyclics that don't make users to drowsy.

I agree that it is odd that Canada does not yet have oxymorphone. I read a few articles that all the marketing arrangements have been made, but it seems that Health Canada (like the FDA) still hasn't approved it... at least it isn't listed on their equivalent to the orange book.
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