Breakthru meds

Lately there seem to have been some confusion concerning the use of B/T meds in several posts and some folks have gotten their feelings hurt or gotten angry and taken the explanations some give as personal attacks intended to imply that they were miss using or abusing their meds. This is not the case and I was thinking maybe I can show you a view from the medical side.

This is in no way a response to any ones post or thread or comment and the numbers and meds I am using came off the top of my head and if they happen to coincide with what anyone here uses it is purely by coincidence.

Hypothetically now: If you are on Oxy-C 40mgs 2xs a day for your maint. med and Oxy IR 10mgs up to 3xs a day for b/t and you get 90 a month of the IR and at the end of the month your filling that oxy ir because you have used them all or used 60 of them for a straight 3 months then your B/T med is no longer a rescue med it is just an increase of 20-30mgs of Oxy-C.

If your doing this or something like this but with other meds say, then you need to speak to your Dr and let them know your taking your B/T meds on a daily basis so your maint med can then be adjusted to meet your increase in pain levels as this is obviously not a flare if it has been going on for 3 months or more.

If he is any kind of Dr at all he is going to 1st ask if your using other things to help with the pain or are you just reaching for the med bottle?

I think many times and I have in the past been guilty of this myself especially post-op, upon feeling a twinge of pain that might turn into something bigger and might not either, but out of fear that it will grow grab a med hoping to steer it off or nip it in the bud and this can become a really bad habit and we tend to do it without even thinking about it after awhile.

B/T meds are what we call rescue meds and it means just that,they should be used to rescue you when nothing else will or has but you shouldnt have to use them until all other attempts have failed to do so.

The more opiates we flood our systems with the more tolerant we become and the harder it is for them to help us in a dire situation such as surgery or an acute incident.

I no longer use a B/T med except OTC meds and my base med was increased properly to obtain theraputic levels to knock out the majority of my pain issues and I say majority simply because if I was shooting for a pain-free everyday place? The amount of meds would be lethal and its the same with alot of the folks here,it would just be too much med and too much to hope for with all of our conditions.

Maybe this will help clear some of the b/t questions and issues that seem to come to light here and if this is your situation please discuss it with your Drs.

Vickie

Well said Vickie,this is exactly what my last 3 PM's drs have said too. Sometimes people tend to think the more medication they take the better as far as pain control goes and that is not true. By taking their BT meds like their scheduled meds every day all that is doing is getting the body use to that dose every day and before you know your body needs that dose every day. Although, my script bottle for BT meds says one thing, my dr & I have a verbal understanding on when those meds will be used. I know also some people just cannot resist taking a pill if there is one in a bottle. I really try to be careful with the Ibuprofen because of the crohns disease.

Susie

Great post Vickie!!

I think the main point is that hopefully someone's Dr. has prescribed them BT meds that are there when they need them. If people (we are speaking of the majority, that doesn't mean "all") are taking them every single day, the exact same dosage...then they don't have anything to take when their pain really spikes upwards.

I think David (Purgatory) just mentioned this on another thread that his Lortabs (he takes 6 a day, every day), are not working for him anymore and we hope that his Dr. will find something stronger to have around when the pain gets bad to be able to quickly calm it back down.

My PM is more like Vickie or Susies in that I have OxyIR 5mg and have leeway to take all the way up to 8 a day which I only use that amount when I have a terrible flare. If someone is taking theirs every single day which means they are having higher pain all the time...then my PM believes in upping the dosage of the long acting medication. Once we are stable on this....we then have the BT med ready for it's purpose...."Breakthrough" pain and it works quickly and effectively:)

Another issue surrounding this is that the states are getting much more strict about people being prescribed BT meds and many are limiting their dosages each day. And if someone is "only" prescribed a short acting medication (as in no long acting one) for more than 3 months, this is starting to raise a red flag for the Dr. and the patient as they obviously have "chronic" pain and not acute pain, then moving to a long acting med is more appropriate as there is no need to try and chase the pain everyday.

Exceptions are those with clear metabolism issues like previous gastric bypass, etc.

The other great point is that there are so many other things that I try first before reaching for my BT med, I try to only use this as my last resort as sometimes ice helps, or my muscle relaxer, or resting a bit, or even going for a walk.

No one is saying that this should change from what their Dr. is prescribing or telling them, I think it's a great informational post to those on the board to explain why some of us mention raising the ER med when someone is talking about having "constant" higher pain every day or what we are saying when we discuss the BT med.

Thanks for the thread Vickie!

I agree with you to the extent that one is dealing with a type of pain that responds to long acting pain medicine with some short acting for flare ups. The reality is that pain issues are so varied that it's difficult to make a blanket statement for all chronic pain sufferers. If that's how your doctor has directed you to take it, then that's what you should do.

I have Ehlers Danlos Syndrome, a genetic connective tissue disorder where my DNA doesn't make collagen correctly. I have loose joints that often dislocate. EDS sufferers have the constant overall chronic pain along with constant acute pain due to miniscule tears in our muscles that work so hard to keep our joints in place. We have a need for the long acting med for the chronic pain and short acting for the acute pain. EDS doctors advise us to take the medicine regularly to stay on top of it. So, I'm not really sure in this case you would call it breakthrough medicine, but many do call it that.

I've been on fentanyl for my long acting and norco for short acting for five years and I still find it to be very effective. I've even been able to lower the strength of the fentanyl patch and have reduced the number of norco I take. I believe what you said is true for certain kinds of pain, but as I said before pain issues are so varied that I think you need to figure out if you're just dealing with chronic pain with occasional flare ups or are you actually getting daily acute pain (newer injuries) along with chronic pain from older injuries or disease.

I clearly forgot about the folks with medical conditions that warrant taking short acting meds on a daily basis.

There are few the medical prof. acknowledges,Loosie yours is one of them,you said it yourself by stating the word "acute" and documented metabolism disorders and gastric staple etc. those kinds of surgeries and some folks with partial bowel removals,colostomy' s and such as some meds continue to be absorbed into the intestinal tract.

The DEA is very stingy with these disorders acceptable to continue acute meds on a year's and year's basis. 1st the design of these meds would require you to take way more after years to achieve the same goal then is recommended by the FDA and the manufacturers and the safety regs set in place by these folks to prevent you from destroying yourself in the never-ending search for pain relief by Cpers and cancer patients terminal or not.

They won't however excerpt the diagnosis of "this is what works for me" I don't make these regs and policies so those who are going to post the nasty over the statement will just be wasting their time.

The manufacturers and researchers all say that can't be acceptable. Of course flooding ourselves with new quick peek meds is going to help and at the same time destroy whatever tolerance we have left,destroy our G.I system as well can cause numerous disease processes and an example would be alcohol/drug induced cirrhosis or hepatitis. Cpers are not eligible for the organ transplant when it's due to destruction of an organ by way of long opiate use. It would occur again with anew organ.

I have seen and treated many of those folks who depend overly and rely heavily on their b/t meds post-op. It's ridiculous the amount of meds it takes to put and keep you under in surgery as well they generally end up in Er within 48 hrs post op or release from out patient surgery with totally out of control pain.

Far too many times we reach for the meds before we have exhausted our other resources. I'm like SB and some of the others here, I will do anything to keep from grabbing more meds,walk,get in the tub,get my daughter to massage,even sat in a chair with my foot pressed against wall as hard as I can,why? It releases the pressure of my spine on the sciatic never therefore relieving the pain.

I'm not passing judgement here and only giving an inside look at how this is viewed and with all the abuse and related deaths they are going to slow it down and or stop it somehow,,the population is demanding it and it's the short acting meds that are out there on the streets and they have a ten-fold larger abuse probability.
Let's face it the street doesn't want our opanas and ms contins, they can't IV run these meds and they're designed to prevent that. The short acting can't be designed as such as it would destroy its early release and peak.

It's you folks that are using the largest quantities of short acting meds that they will target and literally force by way of regulations your Dr to change to long acting. Have they not already set ceilings on how many daily can be scripted? They have pushed for limited use policies on those meds and most Drs follow the suggestion.

Where is that going to leave all those folk?

Everyone's added some great points here and this is a huge issue right now between the Fda,Dea and the Drs as well as those war on drugs folks. The folks who have the ability to change the prescribing methods are going to keep at it.

I'm not saying for anyone to do anything that your Dr says otherwise but just because labeling states 2 tabs 3 times daily prn that doesn't mean he wants nor expect you to do that everyday for month after month.Prn means as needed. Thus the reason you have seen here ppl post "it says I can take 3times a day but he only gave me 60? He didnt intended for you to do that everyday.

Ask your doctor next appt just see what his response is. Tell the whole truth and say your using all your b/t meds every month for say 5 months now. Just like its ordered. Then come back post it here or start a new thread. Let's see what the drs are saying and you have to have been honest,don't forget to tell him you tried this or that before and each and every time.

Be interesting to see what the different drs say. It would be really great to see the difference in the type of Dr,pm,Neuro,pcp,you know it always seems to be interesting to see how they each prescribe opiates.

Thanks for reading and posting as its always interesting to see how different everyone treatments are and how others respond to pain issues.

Vickie

Post Edited (nvrthesame98) : 2/13/2013 6:35:55 AM (GMT-7)

I'm just the opposite of many of you. I don't use a LA med at all. I have Percocet 10/325 that I take 3 times a day but for me they last a good 6 - 7 hours. Sometimes I'm able to get away with breaking it in half on a good day.

One of the reasons I like it this way is I take my last dose around 5pm, and my first dose of the day is around 5am, but not having it in my system 24/7 (like it would be if it had an LA med) I don't have withdrawals after not having a pill for 12 + hours, it also (in my case) seems to keep my tolerance down, as I've been on this regimen for just over a year. Granted I do have flair ups occasionally and my Doc has approved me to take an extra half if I need to because I can make it up with the good days.

Oh gosh no Barbara we are mainly talking about those folks who have reached whatever therapeutic level they think fits and have been taking it this way for well months and months.

I like.SB don't think your Drs reached a good baseline for you since he can't raise your La med he needs to either rethink it or come up on your rescue med. 2 mgs of dilaudid when your on methadone is like taking a.drink of water. You have to realize the chemistry of methadone was designed to keep folks from getting high and they realized it has great pain relieving qualities as well.

I have the same problem with qt waves as well and its a pitfall of long term methadone use. Most of us take it because we have trouble with other opiates or it works for us as nothing as does. I have been on many different meds over the years and nothing works as well for me.

It works on totally different receptor then other opiates so this probably plays some role in why some can take it and others can't.

Dilaudid seems to act as an antagonist towards methadone so.most Drs don't use the two together and I have meant to ask you a couple of times Barbara what kind of Dr prescribes your pain meds.

This is something that has come up thru the years and as more Drs started using methadone.

Alsoinpain like stated with all the big hoopla over CPers being prescribed SA meds lately don't be at all surprised if one month you go in and they have changed you to a LA med.

Vickie

Vicki and SB, i will just try to answer a couple of your questions. SB you are totally correct my pain levels are sticking at an 8 most of the time. I normally start my day off at a 4 and am really stiff. As the day moves forward my pain increases.

Yes, my BT meds are written take 1 tab every 4 hours as needed for pain. Do I take my BT meds daily NO, if I feel I can get by w/o it I do. I've been through a lot of the opioids.

The Dr who prescribes my meds is an Internal Medicine Dr. She has been caring for me since 2006. Lots of folks don't necessarily understand how military medical centers and clinics work. My PCM requested PM to give me ketamine to attempt to reset my pain receptors.

PM came did the inpatient consult and directed my PCM to start me on the methadone with the dilaudid for BT pain. I signed what the military calls a sole provider contract, she IS, the only Dr that can prescribe controlled substances for me. That contract isn't in effect when I'm an inpatient or in the ER. She doesn't come to the ward to see me durning those times, I strictly get the admitting team I'm assigned. They usually let her know I'm in the hospital but that's it.

The military PM's are so busy with the wounded soldiers they do not see anyone but active duty military. However, they know me and are always willing to guide her if need be. The hard part is that the military Drs ARE NOT on call after 4pm, or on holidays and weekends. If I'm that sick I'm told to visit the ER. If I call in a telephone message for ANY of my Drs they have up to 72 hours to respond to my phone call.

I have tried and do many other things to attempt to control my pain. My lupus is considered severe, my RA is eating up my joints, the MDS is advancing rapidly. I've been on high dose and long time steroid usage, which that in itself has caused loads of side effects. I'm currently in the hospital with two broken ribs, and I had NO trauma to cause it. They just broke cause they are so thin.

My chest pain that I have is never ending it is caused by inflammation around my heart, with having ZERO immune system removing my pericardium isn't their first choice. Even though I'm now up to 30mg of pred daily my inflammation markers are off the charts. Plain and simple they DON'T have my auto immune issues under control.

Now, they are trying to find out WHAT immuno deficient disease I have too. Mt T cell count is lowertha a person who has full blown AIDS, they dont know why. My MDS has been changing and it now looking like its totally advanced to the maligancy stage, hence the need for a new bone marrow biopsy. Unsure where my treatment will go from there.

I so totally agree 2mg of dilaudid doesn't EVER pull my pain down around a 4, but it does help pull it from 8 to 7 or 6. Because I'm dealing with so many complex issues my Drs are doing the best they can. I'm hoping and praying that the folks here at NIH may find a clinical trial for me. I'm willing to put my life on the line to be better.

I would gladly go for either stem cell or bone marrow transplant at this time. Even knowing that it may not work, or I may get an infection and die. Like I've said lately my QOL is bad something's gotta give.

I hope that answers some of your questions. I have real tolerance issues I was on demerol for almost 8 years straight, by the time they were ready to change my meds, when I was flaring and was IN the hospital they were giving me 150mgs of IV Demerol IV push every 3 hours.

If I can clarify anything please ask. I just kinda felt like the finger was being pointed with this original post. Some of us have to use our BT meds on a daily basis, I guess I'm kinda in a place where David is in. I kinda felt like we were being judged, sorry I interpreted it wrong.

I have enough issues with my sister in law, who is a Dr telling my hubby that because I take narcotics I'm an addict. She DOES NOT believe in prescribing narcotics and refuses to do so for any of her patients. I'm always reminded by her when we speak about drug seekers and how NO one should be on pain meds. I'd love to see her spend just 12 hours in my body and then see what she thinks about pain meds.

Sorry, if I took this thread to heart to strongly.

Hugs,
Barbara

Oh also Barbara have meant to say this many times when replying to you and somehow it doesnt get from my brain to the screen!! Imagine that!

We changed my dosing of the methadone to my entire dose one time a day and that helped greatly with the bradycardia and the off QTS intervals My Dr seem to think maybe re-introducing the med every few hours was causing more episodes of this QTS problem and after trying it this way and monitoring my heart rate while I was already inpatient for something else it proved right and that is now how I take the methadone,all 40mgs one time a day and as you know the med is designed to not matter whether its taken all at once or like the one time only,its chemistry is such it stays at those levels for 24 hrs and still has some remaining on the 48th hr from the dose the day before.

Thought it might be interesting to you since you have the same problems with the cardio part.

I am sorry that I stirred up a lot on this thread. I was in the hospital and really didn't follow this thread to closely.

All I can say I may have taken it to personally, and I'm sorry for that. The drug that I'm currently taking makes me extra sensitive on things.

I have to say though it did sound kinda like this thread was making BT meds were a bad thing. Again, it's that we can't read the "tone" of the post. It's truly hard to tell when it's in writing.

As for my BT meds I try to use them as little as possible. While I was in NIH last week, the NP of pain and palletive care stopped by to see me. She said that I was under medicated. She also noted that I'm taking several medications that affect my QT interval. She was going to make some recommendations for changes to my medications.

Of course, with my lung issues and my requirement for oxygen worries my Drs when increasing my pain meds.

Time will tell I guess. Thanks for your responses, and sorry for being to touchy.

Barbara

chronic pain is so destructive.

people are over medicated to chase the pain because being in pain 24/7 is such an awful way to live

or they take just the amount they're "supposed" to and still live with pain and/or side effects because to try and get anything changed these days can be so humilitating and disheartening...

or they're under medicated because the drs dont care/understand, or because of the terrifying thought that one day nothing will work because the tolerance is so high and the allowance is less and less

in the end, we're all just trying to get by from one day to the next and we're all in this together and sometimes all we can do is share our thoughts and feelings

This is something that I spoke to my PM about as we are friends outside our appts. so over the years we have talked so much about PM from all the angles and what it's like on his side of things. (Obviously never violating the HIPAA law)

I should have stated that this will be "coming down the pike" in the next few years. There are not any specific laws that I am aware of right now but he is stating that there is greater scrutiny when a Dr. treats a long term chronic pain patient with only a short acting medication. As well as it's not the "norm" in treatment in general if someone needs 24/7 pain relief to be chasing the pain all day long. He says that if a Dr. is prescribing large dosages of short acting meds to many patients, you can bet there will be an "audit" of that Drs. prescribing and patients.

So I apologize for the wording in this post on that part. He just got back from another nationwide PM "summit" where they all discuss what is likely to become more regulated by states in the upcoming years. Same thing when I mention that non PM Drs. will need to go through more training and certification to prescribe certain meds. All of this is "coming soon".

Obviously there is always exceptions and someone who has issues like gastric bypass or other illnesses that prevent the use of long acting medications and can only take short acting meds are ok, it just needs to be well documented.

Thank you for catching when I get typing too fast about something and use the wrong wording!

Post Edited (Snowbunny21) : 2/18/2013 12:52:38 PM (GMT-7)

I thought it would make good reference for future use as well SE. It seemed for about a week there we were getting people that kept saying out of b/t meds a week early or took 6 a day when 4 are prescribed. We all were repeating ourselves over and over.

Some folks didn't appreciate some of our opinions or answers to their questions. I thought if I started this and everyone replied and gave their 2 cents worth we can refer those folks next time to come look here take what pertains to you and is useful and leave the rest.

Vickie