Oh boy. (Pain med probs)

[daskool]

It's hard to advise someone over the internet but it's an interesting topic and here's my $0.02.

Current thinking when it comes to managing pain is not to put a patient on high dose slow release analgesics like oxycontin, but rather to give the patient some autonomy in deciding what and how much shorter acting analgesia to take depending on things like planned activities or inability to sleep. You say an NSAID 'gave you an ulcer' when you were 14, have you had yourself checked for H pylori? Tried triple therapy and are you on an ongoing PPI? Worth mentioning because taking short courses of anti inflammatories sounds ideal for your condition and this might be possible for you.

[Jslay427]

Alcohol+pain meds = legal (and deadly)

Weed + pain meds = illegal (Not nearly as

as deadly

[Tears of Lys]

I have severe chronic pain, but I don't take opioids on a regular basis because my main types of pain do not respond well to opiates, it may complicate issues and mainly I haven't looked for it because the few times I've had them for these conditions (including very strong opiates) they have not done much for me, so it's not something I've pursued, if I thought that opiates might give me significant pain relief I would try (and I have seen pain anesthesiologists, just not for opioid prescriptions).

I think the bigger problem here is the way pain and pain medications are dealt with in the US and the way pain patients are treated by health care providers. I have a lot of internet "pain pals" who have pain that responds well to opiates but do not get adequate treatment because the doctors are terrified of the DEA, this causes a great deal of harm and I have several friends with severe chronic pain who committed suicide because they couldn't stand being in pain like that anymore with no relief in sight, I don't know anyone in this situation who hasn't thought about it (many, perhaps most of us quite seriously). I at least don't have be tortured by knowing something works and not being able to get it, instead I'm just considered refractory or intractable and many doctors want nothing to do with that either. Many places that do prescribe are known for being "pill mills", going there runs the risk they'll be shut down in the ongoing crackdowns, but also potentially marks one as a drug seeker/addict making it more difficult to get treatment from other health care providers. This change also will increase costs for patients, and disabled people are much more likely to be poor. Psychological addiction is a real issue, but in all the concern and laws being passed to try to prevent abuse, I've almost never heard any real consideration for people with chronic pain who are being made to suffer greatly by the widespread paranoia and frenzy about drug abuse. I don't consider physical addiction a particularly good argument in this case, since many medications (including many that are not scheduled) cause physical dependence and withdrawal if quit too quickly.

US, you're right, they do look for things like cannabis in the drug tests for schedule ii, at least that is what I understand from people I know who take them and cannot smoke for that reason. I think with hydrocodone now schedule ii there really isn't much else, not schedule ii except tramadol, acetominaphen, NSAIDs etc. it's possible a pain cream might help, or some types of injections depending on the exact condition. Also antidepressants and anticonvulsants can help with pain (again depending on the type), but can have nasty side effects and nasty withdrawal.

QFT.

You know whereof you speak.

My husband has a loooong history of back problems. He's had a tethered spinal cord corrected, a disk replaced with pins and screws, more corticosteroid injections than you can count - including where they supposedly "burn" nerves (layman's term), finally culminating in having a neurostimulator implanted in his hip to administer electronic relief of pain.

When he needs extra help in the way of pain pills like Norco, it takes almost an act of Congress to get his doctor to prescribe them. This guy (my SO) is so not an abuser in any sense of the word, but it's become such an issue that he feels like he should apologize for asking for them.

This is a guy who never even smoked pot in the '60s.

And apparently it's going to get worse with hydrocodone being made a Schedule II drug.

Do we make it impossible for people to drink alcohol because there's so many alcoholics around? I mean, what the fuck is up with this?

[drawkcabi]

My shoulders have been giving me serious pain lately, I can 1500mg of acetaminophen at one time and it does nothing to help. I can't take aspirin, ibuprophen or nsaids because of severe acid reflux and a pre-ulcer condition.

Tramadol is a wonder drug for me though, takes the pain away and puts me in a euphoric mood. I had an issue with not being able to take it due to my psychiatric meds...I chose to stop taking the psychiatric meds because the shoulder pain was a higher priority...I'm trying to work something out with my psychiatrist so I'm not flying without a net...but right now I need the pain management meds more.

[Er Rn]

It really is a case of a few bad apples spoil the whole bunch, in that a few drug seeking or abusing patients have made it nearly impossible for people who genuinely need strong pain medications to get them.

The clinic where I practice has a strict policy that we write no controlled medications of any kind. If you require something stronger than NSAIDs for pain, you have to go to pain management. If you require benzos for severe anxiety, you have to go to psychiatry. This is because several years ago a patient came into the clinic demanding narcotic medication*, the doctor refused. The patient returned a few minutes later with a gun, still demanding the medication. The doctor turned to write the prescription, and the patient shot him in the head in the middle of the nurses' station.

*This was not a patient who had been treated at the clinic with long term pain meds then cut off or anything similar. Not that that would excuse murder, anyway.

[Gareth]

Since they put hydrocodone (lor tab) and some others on schedule 2 they drug test any patients, looking for any illegal drugs, including pot, and I don't drink and only smoke when I'm out which is usually once or twice a week, enough to make me worry about the test. Since I was 16 I've been scripted pain meds, its never been an issue before and started being one because dumb kids thinking they're getting high and eating a bunch of em, giving them liver probs. Tramadol is an opioid, specifically a codeine analog. It is addictive, if you google tramadol you'll find legit sources saying its not addictive, but as soon as you get into personal experiences you'll find anyone who's prescribed it long term is addicted. As in physically addicted, not emotionally. The whole "addiction" thing is so vast and multi layered you shouldn't pre judge.

I've literally joked with the my current doctor, who knows I smoke, about how I'd still get the script had I drank a bottle of vodka the night before, but since I might if smoked a week ago I wouldn't. Even though weed is prescribed for pain in a lot of places.

Initially from its phase I, II pharmacokinetic and phase III pivotal trials, tramadol was not deemed to cause any dependency due to its very weak activity on mu opioid receptor. After decade plus of clinical experience, it has been shown to cause some dependency which can progressed to addiction. I used the term "some" because tramadol doesn't cause the same opiate withdrawal syndrome as other opiates after chronic usage. Nevertheless we do see some dependency and some addictive behaviors with it in clinical practice, thus the upgrade of it from legend status to controlled status by the FDA.

As for smoking (weed or cigarettes), just be awared that smoking induces all the cytochrome P450s enzymes (robust induction of 1A2) which will increase the metabolism of opiates. Probably not something you want if you are in pain.

[Summah]

Er Rn, that may be what made the decision where you work, but generally is because of the DEA (especially going after doctors and asset forfeiture) and state laws requiring a lot of paperwork that has made it difficult to find doctors willing to treat chronic pain.

[Raja]

Wouldn't you be referred to a pain management department, or specialist, say a rheumatologist or orthopaedic surgeon that takes care of you? I'm genuinely curious as to what the procedure is like over there.

Edit: Yeah no, I seem to have misread a couple of posts upthread.

[Summah]

I don't know what the OPs experience is with this, but most people I know with chronic pain see multiple specialists, the types depending on their type(s) of pain, I certainly do.

[Crowfood's Daughter]

tylenol suppositories :drunk:

[Ulthosian Stark]

Too much to quote so I'm just going to address some things

The clinical trials for a drug (Tramadol) don't matter in the long run. The long term effect on real life patients are what a drug gets remembered for, not "oh but in the trial it didn't seem to do it!". Take a look around the internet. It also acts as a mild anti depressant, that may make stopping it worse then it would if it didn't have that action.

I've been on Tramadol for... 3 years now, and about a year ago it started to cut into my appetite. Lost a bit of weight and don't want to lose anymore so hence the asking other peoples experiences with equivalent pain medications in this thread.

Literally anyone you talk to in real life who takes it everyday, will tell you they're physically addicted to an extent. I'm on 400 mgs throughout the day, and its my only pain med. It produces withdrawal symptoms similar to hydrocodone. I know this because I was prescribed hydrocodone before tramadol. Got switched because the acetominophen was burning my stomach.

Now the " ulcer" thing, its technically a hiatel hernia. I was told its like an ulcer by the doctor so its easier to just say that lol. I'd been prescribed ibuprofen for a year at that point, then we bounced around many a different anti inflammatory, diclofenac, meloxin, arthritec, etc and they all messed with my stomach.

Then we tried hydrocodone and at that point I'd seen more then a few different specialists about it and they all agreed, if nothing else is working give it a try. That burned my stomach lol. So then tramadol and it worked amazingly for years. Until the appetite issues.

So that brings us here, I've seen every specialist I can without getting surgery. Those are the only type of pain management clinics around here, post operative only. Makes sense and its good that its that controlled.

I happen to like the new controls they've put out, and am in favor for more, as long as they don't effect the real patient. Like myself, like many older men and women I know, that rely on this certain type of pain med to live a full life. Debilitating pain is no joke.

So please, stop with the whole see your doctor thing. Of course I'm talking to my damn doctor and specialists lol. I really don't get why people immediately assume someone is going to base their health off some forum, that's ludicrous. People just want to hear other peoples experiences, HENCE THE FORUM.

As for the whole cannabis and pain meds, its prescribed in conjunction with these meds to increase they're efficiency so the patient doesn't need to take as many pills. So its harm reduction.

Recently an Israeli scientist, Dr. Ralph Mechoulam I believe, discovered that cannabis increases an opiate medications efficiency to the 5th degree of pain relief. Hence the combination and the reduced opiate intake of the patient.

I'd agree with you on the drug combinations in most cases. This one is not so clear cut though and has been documented to be a combination used in pain relief since feudal china. It doesn't produce any unwanted effects that I know of at the doses it would be prescribed for pain relief.

Thank you all who have actually given me recommendations of actual new treatments, I've been looking into them and will be bringing some up to my doctor in the morning.

Sorry if anyone is put off by the whole seeking other experiences thing. I didn't know it would spark some big debate, its sad that with the demonizing of these pain killers in the media the ignorant think that anyone who wants to talk about them is just trying to get "high"

[Aemon Stark]

A few points.

1) It's more accurate to say that you're dependent on Tramadol. That may be more a function of the SNRI action, though, which also produces withdrawal symptoms.

2) Acetaminophen does not cause GI side effects apart from (maybe) nausea/vomiting in rare cases. It is not an NSAID.

3) A hiatal hernia is a completely distinct entity from an ulcer. It is not an ulcer at all. But it probably makes you more prone to reflux symptoms. When you were trialled on all those NSAIDs, did you ever take anything like Ranitidine or Rabeprazole with it?

4) The appetite issues on Tramadol are probably due to its SNRI action. Unfortunately all opioids slow down GI motility which is probably why you've experienced reflux symptoms on them (especially with a hernia). Again, have you tried any acid-reducidng or blocking medications?

5) Harm reduction pertains to strategies to reduce risky behaviours surrounding substance dependence (shared needles, etc.). Nothing to do with cannabis.

6) I have no idea what is meant by "5th degree of pain relief". And I'm someone who has a perioperative pain management book next to this computer.

7) Overall it seems like you haven't really found any medications that you tolerate without significant side effects. At this point that means that some sort of adjunct therapy (an H2 blocker like Ranitidine (Zantac) or a PPI like Omeprazole (Losec)) is probably needed as your hiatal hernia is never going to go away.

[Lady of Dragonstone]

Amitryptilline. Apart from pain relief, it's also got antidepressant activity and improves sleep. You can't take it with tramadol though.

Amitriptyline is a wonderful medicine and it is quite similar to Tramadol (in my opinion), which I have also taken as well. It does have side effects, but I found that they did wear off over time (been taking amitriptyline for about 4 years now). I highly recommend it to anyone seeking alternatives to narcotics.

[Jslay427]

NM

[Ulthosian Stark]

A few points.

1) It's more accurate to say that you're dependent on Tramadol. That may be more a function of the SNRI action, though, which also produces withdrawal symptoms.

2) Acetaminophen does not cause GI side effects apart from (maybe) nausea/vomiting in rare cases. It is not an NSAID.

3) A hiatal hernia is a completely distinct entity from an ulcer. It is not an ulcer at all. But it probably makes you more prone to reflux symptoms. When you were trialled on all those NSAIDs, did you ever take anything like Ranitidine or Rabeprazole with it?

4) The appetite issues on Tramadol are probably due to its SNRI action. Unfortunately all opioids slow down GI motility which is probably why you've experienced reflux symptoms on them (especially with a hernia). Again, have you tried any acid-reducidng or blocking medications?

5) Harm reduction pertains to strategies to reduce risky behaviours surrounding substance dependence (shared needles, etc.). Nothing to do with cannabis.

6) I have no idea what is meant by "5th degree of pain relief". And I'm someone who has a perioperative pain management book next to this computer.

7) Overall it seems like you haven't really found any medications that you tolerate without significant side effects. At this point that means that some sort of adjunct therapy (an H2 blocker like Ranitidine (Zantac) or a PPI like Omeprazole (Losec)) is probably needed as your hiatal hernia is never going to go away.

http://www.mayoclinicproceedings.org/article/S0025-6196(11)00027-9/fulltext

Cannabis with opioids multiply the efficiency of the opioid by about 5, letting the patient take less opioid, which if not officially is harm reduction it most definitely is for the patient. More opioid < Less with the same benefits, my initial choice of words I now realize wasn't the best.

As to the hernia, all I know about them is all recent and my doctor used the term like an ulcer so I've just been going with that. Also I didn't even know I still had it until I switched doctors, my old doctor literally never told me I still had it or that its permanent. This was only a few months ago. I've been prescribed omeprazole for basically as long as I can remember. My dad passed on his spicy habit to me and we would literally just stuff fresh jalapeños with cheese and eat them haha.

Yes I took Ranitidine OTC as zantac but it was expensive and a perscription of omeprazole was basically free through insurance.

My doctor once referred to acetaminophen as basically an NSAID so I forget it really isnt at times. I don't really trust anything a doctor says at face value nowadays. I've been screwed way too many times. But when I was prescribed lor tab it produced the same burning feeling in my stomach, wasn't as bad as with the NSAIDS but still bad enough to want to switch.

Tramadol is an analog of codeine, it is classified as a semi synthetic opioid. It metablozies into o-desmethyltramadol in your liver, a much more potent agonist about as strong as morphine. So even without the SSRI effects I think there still would be a degree of physical withdrawal. For me more precisely if I don't take it my body is hot, really really don't feel like moving etc. Not quite as bad as the flu but pretty much a head cold.

Compared to hydrocodone withdrawal, its worse. Probably because of the SSRI effect. I've also been prescribed 8 50mg tramadol a day for about 3-4 years though, early on I didn't feel any sort of withdrawal when I would not take them for a day.

Still, nothing I've tried effects the lack of appetite and sometimes pretty bad nausea (usually in the morning). The omeprazole does good for reducing heartburn but nothing else. Friends in Cali and Vancouver keep telling me just to smoke more cannabis, but its expensive around here vs where its medically available. An 8th locally is 50-60 of medical quality which is all I get, but where it is medically legal its about half that. Plus there are edibles that I think would help more then smoking, smoking isn't really a modern method of medicine consumption haha

[MerenthaClone]

"Well, I don't trust doctors but I'll happily combine codeine analogues with opioid-potentiators of unknown strength under dubious dosing conditions based on the say-so of friends."

Also, you linked an editorial, not a research paper. Just to be clear. I don't disagree that further research into cannabinoids is necessary.

edit: Twice now, you've said "well, I was told that it is like an NSAID" or "a hiatal hernia is like an ulcer". It sounds like your doctors are doing a poor job of patient education and there's mis-communication on both sides. They're using analogies to try to explain things, and then you're using those incomplete analogies and making other decisions based on the analogy, rather than taking the analogy at face value. Though I don't get how a hiatal hernia is like an ulcer or why any physician would use that analogy, but I don't work in primary care.

[arya_underfoot]

Tell me if I've understood this correctly:

1. You're keen on the cannabis, in one form or the other.

2. You're keen on tramadol, because you get intolerable symptoms if you discontinue it.

3. You still have intractable pain for which you want something in addition to cannabis and tramadol.

4. However, this something must be undetectable on urine drug screens (this happens??) that look for opiate metabolites but nonetheless be as potent an analgesic as a strong opiate.

[Ulthosian Stark]

The cannabis talk is all hypothetical, if I end up moving somewhere where its medically available then yes I most likely will be but I'm not about to be doing that much illegal shit at all. I don't like having illegal things lol I don't even own a pipe or papers

Plus that's self-medicating, as I wouldn't be able to key in the right mixture of meds by myself since I couldn't tell a doctor, which I'm strongly against because this is why these medications are so taboo. Its really disgusting.

Understand this for me, picture if you had this sort of pain and wanted to be active, if I'm on my feet for 1-2 hours the pain starts where my arch should be and my ankle, then it goes up to my knees an hour later then up to my back. Things are all out of whack. Hence why I might get surgery. I literally have to start limping and my range of motion gets very limited. This is debilitating, even when I was a kid I'd literally sit down in someone's lawn on Halloween and beg to go home because my feet hurt.

Ill post a picture of my feet guys if its come to this haha they physically don't look right. I basically have 2 balls on each ankle, the normal one and a slightly smaller one under it. They splay out to the sides, making my footprints unmistakable, and are completely flat.

The reaction of the supposedly and hopefully best pediatric specialist in WNY when seeing them was "Wow those suckers are flat! Flattest I've seen in a while" and immediately started telling me how I'd benefit from the surgery.

I also dont know what you mean by "keen" but I'd like to get switched from tramadol to an equivalent pain med that's just not tramadol. Hence the reason I made the thread! To see if anyone had experience with them and/or recommend one to suggest to the doctor. Which should be easy to talk about for grown ups, but the ignorant seem to think anyone on them is some terrible person.

Where the hell did I say the medication had to be undetectable? The medication doesn't matter as its going to be prescribed, but my occasional use of weed does as of last summer so I'm looking for something you don't have to get tested for because I don't need that extra worry. You now need to be tested for lor tabs even which I'd been prescribed since 16.

All I'm looking for is other people who are prescribed something similar to tramadol that could recommend mentioning it to the doctor. Not trying to get "high".

[arya_underfoot]

Ok fair enough. There's lot of different drugs that can be used for chronic pain, both opioids and non-opioids. There is some evidence that opioid cycling appears to have a "reset" effect on the mu opiate receptors. So you could potentially substitute tramadol for other opioids and perhaps get some benefit. Then there are heaps of non-opioid drugs used in chronic pain including antidepressants (amitryptilline) and anticonvulsants (carbamazepine, pregabalin, gabapentin). But you probably need to speak to a chronic pain specialist about these things rather than a family physician who may not be uptodate with the latest in a highly subspecialised field of medicine.

[Ulthosian Stark]

Ok fair enough. There's lot of different drugs that can be used for chronic pain, both opioids and non-opioids. There is some evidence that opioid cycling appears to have a "reset" effect on the mu opiate receptors. So you could potentially substitute tramadol for other opioids and perhaps get some benefit. Then there are heaps of non-opioid drugs used in chronic pain including antidepressants (amitryptilline) and anticonvulsants (carbamazepine, pregabalin, gabapentin). But you probably need to speak to a chronic pain specialist about these things rather than a family physician who may not be uptodate with the latest in a highly subspecialised field of medicine.

The thing about chronic pain specialists in NY is there are none that will do anything BUT post operative. At least ones that'll take my insurance.

So in order to see a legit pain management place I need to get the surgery, which has 4 years of rehab time. The way I live and the things I like to do tend to border on dangerous (dangerous sports, lots of shooting, lots of setting firework displays etc) the average age for men of my family to die is around 35-40 I don't know if being off my feet from 22-26 would really be worth it if it'll only make the next decade and a half better. Especially if I can get that sort relief from medication.

Amytriprilline sounds like it would help. Gabapentan though, only person in real life I knew who was on it had cancer. He survived it and is in remission and decided to stop take the gabapentan and he said it had pretty bad withdrawal and side effects, which is contrary to what I find on the web, just as with tramadol.

I've already done loads and loads of research, I've been looking into pain medication since I was old enough to realize what I was reading what with being in pain an awful lot. I thought it was normal and everyone was like this but nope. Not at all.

I know plenty of different meds in different classes, the matter is that the ONLY ones that have ever helped have been opiates and muscle relaxers. A cornucopia of nsaids and acetaminophen preparations have only given me a hernia, I don't like taking meds that produce little result and such bad side effects.

I'll be honest, the first time being prescribed lor tab was like I got a new lease on life haha. I immediately became more active and more happy. So long as you take them as you should, and don't share with friends, there is absolutely nothing wrong with being prescribed these extremely useful medications. People have made better living through chemistry for thousands of years