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toe
Pooh-Bah
Reged: 10/09/02
Posts: 1419
Loc: MidWest USA
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Okay, I have a problem. My PM doc is not a PM specialist. I had to explain to him that MS Contin is available in generic and I believe it was news to him that methodane is prescribed for pain. I also had to explain that morphine poorly metabolized" which expains why the oral dosage appears to be so high.
Even thought the 60x2 I'm at noe doesn't really give the relief I need I want to keep my dose as low as I can. That way I have more options for when my pain increases. Already I can't use codiene. . . 400mg and *nothing*
It (MS Contin)definitely doesn't last 12 hours. And I have to wait 3 hours to starting feeling relief after I take it. And on bad days, it's still close to nothing. Do these situations constitute breakthrough pain?
People talk about it all the time, but I still don't understand what it is or how it works. How many tablets/,pmth does a doctor give you for breakthrough pain? Does it have to be just the instant release form of the time-release med you are taking? (I asked because I cannot fathom 15 mg MSIR helping to bring me through this. The breakthrough meds seem like they would HAVE to be a stronger med. than the SR med, or it wouldn't work.
I really need to get some concrete info on the use of break through pain and links, if possible. This is a doctor who is willing to listen. He made me sign a contract last week when he upped me from 30mg Morphine to 60mg. Like when they brought me up to 30 from 15 I felt woozy for a day or two but that went away. The 30mg were knocking out maybe 10-15 % of my pain. When I first started on the 60mg twice a day I felt great but maybe I was just having a run of good days. Imean, it's only been 2 weeks on the 60's but I am definitely hurting again. Don't get me wrong, it's better than the 30mg but not the miracle I thought they were at first.
So, I got my doctor to raise my MSContin a bit by telling him I had educated myself about it. Perhaps if I can tell him I have also educated myself about "breakthrough pain medication," I can get some if that, too. 60mg 3 times a day would defeat my point, as would raising me to 100x2.
Please, tell me everything you know about breakthrough pain and how the meds are prescribed.
I sure would appreciate it.
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"It's the end of the World as We Know it. . ."
-REM "and I'm seeking asylum in Canada"-toe
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Reel_X_4U
Enthusiast
Reged: 04/24/03
Posts: 255
Loc: Queens, New York City
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From what are hear
Fentanyl (a synthetic heroin-like drug, metric unit used to measure it's dosage is "Micrograms" "Mcg") is an excellent med for break-through break. It usually comes in patch that delivers the drug slowly or it also comes in the form of Actiq lollipops, which can sucked on slowly and the drug will absorbed transmucusolly or sublingually. But I'm not sure whether you should take it since you already are on Morphine 60mg twice a day. Fentanyl is short-acting, that's why it used for breakthrough pain. But it can also be used as the primary med for intractable pain, that's how the patches are utilised. For break-through pain, the lollipops are utilized for people, who are already on narcotics for pain, but on occasion, the pain breaks through the narcotic pain-killer, and pain is "FELT!!" from the user. An exceptionally strong and short-acting analogue of fentanyl is "Sufentanil" or "sufenta", it fifteen times stronger then Fentanyl, and Fentanyl is 80 times stronger then Morphine. Another Fentanyl analog, which is exceptionally strong is "Alfentanil" or "Alfenta". Do a Metacrawler (my favorite search engine) search, find the most informative site that explains Fentanyl and how it is used, print it out and read through it, highlight those features that explain it's used for "break-through pain", and bring it to your doc on you next visit, if he's not familiar with the med, then make sure you also bring along with the varying dosages it comes in, as well as how the doctor should prescribe it, like how often one can use the lollipop and it's varying methods of delivery. Find a site that tells doctors on how to prescribe it and print it out. I'm happy you found a doc that is willing and "open-minded" with treating your pain. Don't mess it up, docs like that are hard to find. Good Luck Friend. 
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Some men see things as they are and say "WHY"!!
Some men see things as they are and say "WHY"!!
I've dreamt of things that never were, and say "WHY NOT"!!
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toe
Pooh-Bah
Reged: 10/09/02
Posts: 1419
Loc: MidWest USA
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Well, he's prescribing the Morphine SR on the insistence of my spine doctor, and with the agreement that as soon as I get on medicaid I will transfwr to a PM clinic. . . The stuent center is free and I would be billed for co-pay every visit to the pain clinic. I'm in line for SSI right now, and I get a certain level of disability medical assitance from the state for prescriptions, but it's not much. . . 115 dollars doesn't even cover my morphine, let alone my psych meds.
I take 120mg of morphine a day, but that's not really a lot. It's intended for twice a day dosing and only one notch above the average adult starting dose. Maybe my body metbolizes opiates more wastefully.
I will look into fentanyl and it's cousins and see if their are any fast acting generics out there. . .it has to be generic. I'm nore than a little concerned about his possible reaction if I were to go in and ask for fentanyl. That was one of the spine doc's suggestions (aka duragesic, along eith methadone and the morphine above I mentioned). But he is not very familiar with pain meds: when I first brought him these suggestions he said, "I think you have to go to clinic to get mehtadone."
Actiq is *defnitely* out of my price range, as was Duragesic.
And it's all one of those meds marked :cancer patients only,"
CPer's on long acting opiates, please help me!
I'd really like to know more about *breakthrough pain* its self and people's experiences with it, as someone here once posted that no doctor should prescribed a long-acting opiate without something for breakthrough. But I was think about something more traditional, like plain oxycodone or
something.
If you are on a long acting oiate analgesic can you tell me if your experiences are like mineThe knee problem is actually becoming worse than the back problem I came in for and my back still troubles me almost every day, but fentanyl seems like a big, expensive leap. . .what is commonly prescribed for chronic pain patients (without cancer) already on long-acting analgesics? Are the symptoms I described in my first post indicative of a need to change my MSCOntin dosing, need for breakthrough meds, or what? I searched this entire forum for all of history and there has never been a topic devoted to Breakthrough Pain. Let's get one going!
I have to hobble ito the other room now and take 800mg ibuprophen 60mg MSContin 10mg of flexeril and my Ca/Mg supplement so my fiancee (we are going to Toronto to get married next month) and I can watch "Brain Candy."
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"It's the end of the World as We Know it. . ."
-REM "and I'm seeking asylum in Canada"-toe
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Farmer
Enthusiast
Reged: 12/23/01
Posts: 202
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This will sound strange, but I don't belive what you are feeling is the "classic definition" of breakthrough pain, yet you do still need breakthrough pain medication.
What breakthrough pain is, is a sudden, uncommon and excrutiating pain that generally comes with no warning to users of long-acting opioids. Cancer is nearly always the cause. If you take your long-acting meds and say three or fout hours later they stop working, that is not brealthrough pain. That is just medication failure. If you long-term medication is simply not strong enough and you feel pain when you shouldn't that too is not breakthrough pain.
Breakthrough can best be described as a sudden flare or searing pain that completely overwhelms long-term pain meds. Let's look at it in the case of Fentanyl. This is given in a long-term patch with one dose being 100mcg/hour. A common med for breakthough of that medication would be the 600mcg Atiq lollipop. What that means is for a cancer patient with painful cancer such as bone cancer, her pain is generally held in check with 100mcg per hour. When this flares or breaksthrough she may need 600mcg in 15 minutes. That is alot of medicine and even someone terminal and used to strong meds, they could not handle that high of a dose over time. This type of pain could be called suicide pain because it's so bad and so quick, so it must be treated very hard and very fast.
Now you still need a "breakthrough med" when you are being prescribed long-term pain meds, even if you don't have the classic breakthrough pain. Say you take 80mg oxy once every 12 hours. If you have a lot of pain one day and it's just not cutting it, you can't just double up and take another, for one thing the dose is released over 12 hours and you're just worried about a few hours. Another thing is your doc and your prescription company will assume 60 tabs will always last a month so if you double up when the pain gets bad you will run out. In this case you simply need a shorter acting pain med, yet you would not need the super strength med used for cancer breakthrough.
If you are taking 40mg of oxy every 12 hours, your doc should write for 30 oxy-IR per month as well. This would give you 5mg of oxy (and no fillers) in an immediate release (IR) form. When you are taking a 40mg oxy that gives you 3.5 mg every hour, when you need a little extra, you take a IR which basically doubles your dose for one hour only (not the full 12 hours).
Since your pain cannot possibly be constant over 12 hours, or with the patch over 72 hours, you will always need access to meds to help when the pain breaks through.
Good luck. As usual, sad as it seems, we need to educate the Docs because they just don't understand.
Farmer
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TLT
Board Addict
Reged: 10/21/02
Posts: 358
Loc: loc. usa
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toe, farmer is exactly correct. It sounds like you may need to increase your long-acting meds up 50%, BT pain is usually treated with a short acting med, and should be equivalent to 25-30%of reg. long-acting med.
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"RUDENESS IS THE WEAK MANS IMITATION OF STRENGTH"
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china020
Stranger
Reged: 02/25/03
Posts: 6
Loc: East Coast
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Farmer, I just want to say great explanation of breakthrough pain meds!!! I am on the Pain patch and I take 30 mg MSIR for my breakthrough pain and it hardly takes the edge off. I am open to any suggestions.I am trying to get my Doctor to see me early this month so I can switch to something else.
Again, EXCELLENT work. 
China020
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prettyday
Threadhead
Reged: 02/09/03
Posts: 905
Loc: Coastal Sage Scrub
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That was the best and clearest explanation I ever got; now I understand so much better! Farmer 
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First they ignore you, then they laugh at you, then they fight you, then you win.
- Mahatma Gandhi
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toe
Pooh-Bah
Reged: 10/09/02
Posts: 1419
Loc: MidWest USA
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I wasn't sure. I feel so uncomfortable going in and asking for a higher dose when he just raised it to 120mg/day two weeks ago. MS-Contin and the family of generics come in15, 30, 60, 100 and 200 mg.
I think there are two things going on, One is that this dose simply isn't strong enough. Because of the doses it comes in, everytime it is raised, it is effectively doubled. And I feel great for a couple of days because I have *half* as much pain but my tolerance seems to build rather quickly. I would say about 50 percent of the time, I am still hurting, sometimes so badly I dread having to get up from a chair or from the bed. And there is always a dull ache in my lumbar and upper thoracic. The knee problem is almost certainly arthrtic--yesterday it Impossible to get relief from it, I even tried putting my tens unit on my knees, to no avail.
The other problem is that the slow release morphine doesn't last long enough. It simply doesn't last 12 hours.
So it sounds like I need both a raise in the mg and in the dosage. How can I go int there and tell the doctor that I think I need to take this 3 times a day and mydosage needs to be raised again?
Maybe I can ask him to have me take it three times a day, but I'm still not sure what kind of "breakthrough" med I should ask for. Farmer says 5mg of oxy for a person on 80mg a day, others say 30-40% of your daily dosage. But I'd rather take something else other than morphine for that.
Frankly I just want to get on methadone so I don't have to worry about the price so much, but my doctor doesn't know that methadone is prescribed for pain, so I can hardly see him knowing the bioequivalance between these drugs.
I can certainly tell him that the dosage doesn't last 12 hours. . . that's quite common and the length of relief is inversely proportionate to the the length of timeon opiate therapy. I've said myself that on good days the minimal relief I get from it is fine, but on bad days that relief is pretty useless. So a fast acting med to take in addition to my scheduled meds.
But what should it be? If I will be taking 180 mg MS Contin ('n 120 now) What would be the best, most efficent med to take on the days when my body refuses to be content with the meds it's on now. I don't have alot of options: it *has* to be something cheap. Right now 60 60mg tablets of generic MS Contin costs almost 200 dollars and I have to pay 10 percent of that. For a brand name, of would be %20. I have a medical card for 115 dollars a month and maybe 300 dollars of my university prescription insurance left.
I know the company that makes MSContin has a program for the "indigent." I'm going tolook it upm but for now, I have an appoitment with my doctor in 2 days. I want to ask him to give me the 60mg 3 per day and ask for a "breakthrough"med. Please give me your suggestions on what I should ask for. My tolerance is high, high, high and I wish there was something other than morphine I could add on the really bad days.
Please help. For once, by jeeves, I am without an answer. 5mg oxycodone IR wouldn't do a thing for me. I tell the doctor that I get my information from a chronic pain board pn the web, and he listens to (you).
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"It's the end of the World as We Know it. . ."
-REM "and I'm seeking asylum in Canada"-toe
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TLT
Board Addict
Reged: 10/21/02
Posts: 358
Loc: loc. usa
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toe, here is a link on how BT medications should be calculated. BT Pain
Actually I worded my previous post wrong. Each BT dose, should be 10-15%, of your total daily dose of long-acting med, so if you took 30mg 2xday, Long-acting med,each BT dose, should be between 6-10 mg.
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"RUDENESS IS THE WEAK MANS IMITATION OF STRENGTH"
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toe
Pooh-Bah
Reged: 10/09/02
Posts: 1419
Loc: MidWest USA
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The only thing I regret is that oral morphine is so poorly metabolized it could easily be ineffective . . .
I take 120mg, so my breakthrough dose would be 12-18 msir.i.e 15mg MSIR tablets.
But I am hoping he will hcange it-- I timed it lastnight and my MS Conin wears off after less than 9 hours, my dose would be 180, do my breakthrough dose would be 18-27mg msir.
Thee;s a liquid that can be prescribed for this sort of precise dosing, right?
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"It's the end of the World as We Know it. . ."
-REM "and I'm seeking asylum in Canada"-toe
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TLT
Board Addict
Reged: 10/21/02
Posts: 358
Loc: loc. usa
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toe, I believe the liquid form,is called Oxyfast.
The amount of BT dose, that you calculated is accurate. I am currently taking a total of 300 mg of oral ER morphine, and my BT doses of percocet are 30 mg. Sometimes I take only 20mg, but 3 times a day, instaed of 2, as prescibed.
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"RUDENESS IS THE WEAK MANS IMITATION OF STRENGTH"
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toe
Pooh-Bah
Reged: 10/09/02
Posts: 1419
Loc: MidWest USA
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Wow, he's going to love this suggestion.
Iknow for fact that MS Contin only lastes 8, at the most, mime hours. Like I said before that the dosage level is okay on a good day, but when the weather is changing or I sleep funny or try on clothes, The pain in the thracic comes back like female cat in heat. I've also had a constant dull ache in the lumbar area, presumably where the degeniation is, So can you prescribe me to yake the 60mg pills 3 times a day, so I don't have to wory about waiting the hours of interlude until the next dOSE?
I've also been reading about breakthrough pain in cancr sifffererrs and how some of the same effects are gfelt in the chronic pain paopulation. Most of the people I have chatted with vouldn't believe I didn't have a brakthrough pain medication for those days when the pain is bad I can't leave my bed. According to a website refence I got, the breathrough mecidation should equal 10-15 % of the patient's daily maintain ence dose. One patient said that his breakthrough dose for 300mg MSContin was 30mg of plain ocycodone with no tylenol. There is also a liquid form of morphine I could use if I would need a breakthrough dose that isn't available in pills.
So, can I please have a script for 120 60mg MS-Contin and 3 15 mg pill of oxyfast?
Of yeah, and how did that autimmune disease and nuclear0whats its blood test from last visit go?
I may have to spiff that up a bit.
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"It's the end of the World as We Know it. . ."
-REM "and I'm seeking asylum in Canada"-toe
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Farmer
Enthusiast
Reged: 12/23/01
Posts: 202
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Toe: I have some concerns with your current medication. Morphiene is not well metabolized by anyone via oral administration. In fact over 70% is generally lost in pill form. So when you start dosing you are guessing at how well you will metabolize it. If you are a perfect candidate you may actually use 30%, but suppose your GI is not working right or your liver function is poor, well then it will work very poorly for you.
I think rather than trying to up the dose (yes I'm sure you are fairly tollerant) you ought to see if another med works better. There are several choices. To me the best choice is Oxycontin as the dosing is very similar in that it will last 8-12 hours but it is much more effective orally. In fact you could likely drop your dose and get better relief. You could try 40mg 2x day and it may work well for you. But, it is expensive. Methadone is considerably cheaper, but it is likely harder to have a GP prescribe it because of the connotations even though it was created to reduce the "pleasant" effects. It also takes quite a bit longer to take effect.
My recommendation is, if you feel you need to stick to the MS, is to try a different med for "breakthrough". You said you thought 5mg of oxy would be way too low. Is that from actual experience or simply due to the dosing with MS? If you haven't tried Oxy, you may be surprised at how well even 5-10mg would work. So let me suggest you simply ask of oxyfast or Oxy-IR. if it works great - then suggest moving away from the MS. If it doesn't work, then maybe it is a tollerance thing and you should think about the patch or something else.
Good luck - Farmer
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toe
Pooh-Bah
Reged: 10/09/02
Posts: 1419
Loc: MidWest USA
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I can't afford brand-name medication. Maybe when I am on full medicaid.
He wouldn't give me BT--has not heard of that for pain. He did agree to raise my M.S. Contin to 180. . . 60x3.
My rheumatoid factor came back as 87, almost four and a half times the max. normal range. So maybe the rheumatologist he is sending me to will have a better idea of how to treat my pain. I am pretty bummed about the RA. From all I've read on it, the blood test seems to have been no mistake. My grandfather has it, too. And unlike those that get it when they are 60 or something (I'm 27), my prospective quality of life is pretty bad.
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"It's the end of the World as We Know it. . ."
-REM "and I'm seeking asylum in Canada"-toe
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quincy
Board Addict
Reged: 11/07/02
Posts: 333
Loc: pacific northwest
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Toe;
Im sorry to hear that you are having so much pain. I just went through the same thing, trying to find a BT med. I was on 20mgs per day of methadone, a really low dose. I also got Norco for breakthrough. At a certain point I was taking up to 12 per day for pain, which is not acceptable for breakthrough. My methadone wasn't a high enough dose, and didn't work. I was overcompensating with the Norco and I was really scaring myself about how much I was taking and how tolerant I got. When I finally saw the PM doctor, he solved the problem by increasing my methadone by three times and cutting out the Norco. While I like to have them on hand as a safety net, I have to admit that I really don't think I need them now. For me, that is just as well as I feel like my use of Norco was starting to get out of control. That means a little holiday is in order. I find that just going from 5mgs to 15mgs four times a day works just as well as taking 2 different narcotics. I also find that I am not so tolerant now to the methadone. With the norco on board, I couldn't "feel" the methadone at all, normally I get kinda dizzy from it.
I guess it just depends on the person. I thought that having a BT med was necessary if you took long-acting meds, just to have a back up plan. But if the doctor gets it right the first time, you might not need them. It also depends on your condition. If you have RA, I am really suprised that you are having luck getting narcotics at all. I used to work for a rheumatologist and I thought RA looked very painful and crippling. I was so suprised that she almost never gave out narcotics for this. She used things like methotrexate and Enbrel instead. I could never understand this reasoning. She was willing to use drugs that could potentially cause real harm to the patient. I mean methotrexate is used for early abortions and to as a neoplastic drug (cancer) Enbrel is expensive and has to be injected. They also overuse Vioxx and other things like gold salts, sulfathalazine and other NSAIDS that people generally couldn't tolerate. In fact the doctor was once frustrated how so many people couldn't take methotrexate or Vioxx, that it made them sicker. She also sarcastically mentioned that these same people could, however, take "massive amounts" of narcotics. My God!! A whole 30 vicoden only lasted a week for people whos' fingers were slowly turining into claws!! Sadly her attitude is so common. And among doctors who specialize in treating painful conditions like RA or fibromyalgia or arthritis ets. Pathetic.
Sarah
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woody
Newbie
Reged: 01/07/02
Posts: 42
Loc: Pacific Northwest
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I was prescribed Oxycontin, a narcotic that is supposed to give 12 hours of pain relief. I never have gotten more than 8 hours. I worried also about my increasing tolerance and lived in more pain than I needed to for a couple of years. What happended for me was that my wife called my PM Dr. and told him that I was in more pain than I was telling him. He had me come in and told me that there was no reason for me to be in pain, as I responded to the opiates pretty well. He told me not to worry about the tolerance. He said eventually it would level off. He was almost pissed because he said that he had patients that NOTHING works to relieve their pain and I should trust him and let him treat me. I let my Dr. prescribe me more pain meds until I was pain free most of the time. My tolerance eventually leveled out - far from the end of the scale. I have plenty of room for more tolerence should my pain become more severe.
I currently take 3 80mg Oxycontins, 6 Dilaudids and a 50mcg Duragesic patch every 2 days.
As I take Oxycontin and Duragesic(another time released med), I was give oxycodone and then Dilaudid for break through pain and to cover the 4 hour gaps between the Oxycontin. The trick is to get the pain meds in your system before the pain gets bad. Numerous studies have shown opiates are more effective if you use them before the pain gets bad. For me, once it gets bad, no amount of drugs will relieve it. Thats what the BT is supposed to be for, to give you a turbo boost past the pain so you can get ahead of it. There are times when I don't need the BT meds, but by the end of the month I've usually almost exhausted all of the BT meds.
I've found the Dilaudid to be the best BT drug for me, but the oxycodone usually worked too.
I don't know if this helps and forgive me if I've told you what you've already learned.
Best of luck and never give up.
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