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Where do Narcotics Fit in Your Overall Pain Management??

Lala329LLala329 Posts: 283
edited 06/11/2012 - 8:45 AM in Chronic Pain
I was curious about what role narcotic pain medications play in your overall pain management? I was going to put this on the pain medication board, but since I'm interested in how you guys integrate your medication use with adjuvant pain management techniques I thought it was more appropriate here.

From what I gather there are two main ways, with variations, to approach narcotics for chronic pain management:

1) PRN (as needed) approach: There seem to be a few ways to manage meds on a prn basis. The main ones that come to mind are taking the narcotic for pain spikes when the pain is intolerable, or taking a narcotic before activities that are known to provoke pain. I think the overall theme with this is that the drug is taken with respect to pain levels- either an actual pain spike, or the prediction of a pain spike. This method seems to give narcotics a relatively small role in overall pain management, with the emphasis being that other techniques are used just as much or more than medication.

2) Around the clock approach: Narcotics are taken at regular time intervals irrespective of pain levels. This method seems to put narcotics more as a cornerstone of treatment, with other techniques being used to supplement the narcotic pain control as needed (which of course they are needed since narcotics certainly don't give 100% relief).

I'm not sure which way is better. Each has its benefits and drawbacks, so I was just curious how you guys manage and which method you prefer.


  • I guess for better I have not had too much experience with it till right after the discogram. They saw me in so much pain, the just handed me two pills as soon as I was wheeled out the room.

    I took it for two days after as every footstep produced pain. The funny thing though was one of the diclofenic brought down the pain in minutes while the narcotics did nothing for the pain but what it did was make you not care.

    I knew the pain was there and felt it but honestly just did not care. It was a very strange feeling. I decided at that point that this was really not doing much and stopped on day 3.

  • Lala I haven't needed the narcotics much so far. As you point out there are two approaches. This is my experience.

    #1 - as needed. I take them once a week maybe twice in the evening if the pain is uncontrolled by the neurontin. I have some level of pain all the time but sometimes I over do it or whatever and I will take one relatively low dose to relieve the pain which lets me get a good night sleep. As JS says it doesnt so much get rid of the pain as let me not care.

    #2 - round the clock. After each of my surgeries (recently and going back over the years) I was told that it is crutial to take the medications on schedule for the first few days. After day 3 it was up to me to decide when to taper off. My understanding is that pain is expected at this time and by keeping ahead of it you heal faster and better.

    I will say that I am very confused by all the different meds and dosing that I see on this site. It seems to me that many people are left to find their own way in pain relief. I often wonder if treatments that would get to the heart of the pain are bypassed as people are handed narcs to zone them out.Although I found a PM doc that I like I still believe that many are run as for-profit businesses that are more interested in the bottom line than in patient care.

    Hope my thoughts answer your question. :)
  • My PM doc has me on Oxycontin 30mg 1 every 12hrs. and 1-2 Norco PRN as needed for pain. I am having a HORRIBLE time with this. The Oxycontin doesn't affect my pain at all and 1 Norco is unfortunately like taking a sugar pill anymore. I am in absolute misery and will definately be calling the doc in the am. I've actually considered going to the ER I am currently sitting in the recliner in tears, crap this sucks!!!!!
  • dilaurodilauro ConnecticutPosts: 9,875
    one piece of your total pain management.

    Over the past two or more years, I might have pointed to this post to try to document what total pain management control is.

    Narcotic pain medications can only do so much. Many people hope that these medications will eradicate their pain. That will not happen, even when using high dosages of Extended Release medication combined with breakthrough pain medications. Unless a person takes more than the prescribed amounts, you do need other items:

    The Blend
    Ron DiLauro Spine-Health System Administrator
    I am not a medical professional. I comment on personal experiences
    You can email me at: rdilauro@veritashealth.com
  • jlrfryejjlrfrye ohioPosts: 1,110
    Ive learned that if I just take my pain meds every 12 hrs that I can fight off a terrible flare-up. So versus taking as needed I keep my meds on a schedule.
  • I was on a schedule with my vics for 6 months after my surgery. Now I do both, I take 1 vic 7.5/500 at 8am and 9pm as scheduled. The rest of the day I take it on prn basis.I try to use the tends unit, heating pad, stretching, and relaxation techniques first before reaching for a pill. If I know ahead of time that something is going to cause pain, shopping more than a hour,baseball games, trips to zoo or water parks I must take them on schedule to avoid a trip to ER. I also take motrin in addition to the vics when pain levels are up.I really do try because I dont want all that in my system but most days Im 3 vics a day. My husband always complains because he sees me struggle with the pain and says just take the dam pills every 4 hrs because he cant stand to see me cry in pain!!!
  • Hi,
    I have had two neck surgeries a year apart (C4-7 front and back) which forced me to retire from my job, I applied for SSDI in Dec. 09 and was approved 3 wks ago. I have been on pain meds for two years, my PM doctor has me on Fentanyl 50 every 3 days and I take percocet for break through pain as needed, the 1st 2 days I only need it when I go to bed.
    My wife has been on SSDI for 8 yrs due to a stroke at age 47 and Fibromyagi and a autoimmune disease. She takes a lot of meds for pain. Until my neck problems 2 years ago I could not really relate to her pain but I do now. She has been a big help telling to keep my meds on track and the most important things she tells me everyday is to "Pace Yourself" I was always trying to do more than my body can handle and I always would pay a big price in pain, I have slowly gotten smarter and can say I can't do that (most of the time).
  • Hi Lala,
    I take my Percocet 10/350 four times a day along with my xanaflex 3 x a day...I have learned not to wait until I am in severe pain..whenever I did that the meds didn't work for about 24 hours. I have been on this dose on and off for about 2 years now. For awhile I tried a Fentonyl patch, but since the Dr. wouldn't give me anything for breakthrough pain I opted to go back to the percocet. Often I even have to take additional ibuprophen...it's awful on my stomach~
  • There are no surgical options, or PT, or anything else, so keeping it controlled with Narcotics are what I do.
  • Different narcotics work differently on different people. I was on lortab which worked great, then the pain level increased and I guess I was getting kind of used to the lortab. My doc wanted me to try ER morphine for months and I didn't want to because morphine doesn't work on me after surgery, and everyone I know that takes it, seems drifty and out of it. I finally tried it, and I was a goofball on it - couldn't stand it. She now has me on percocett and it works a ton better. I think we're gonna switch between that and lortab every few months so I won't get tolerant to either. Anyway, from my experience, maybe you just need to find the "right" medicine to work for you.. Good luck, being that miserable is just AWFUL!!! The ER might not be a bad idea..
  • people become tolerant to narcotics. you don't feel anyting becuase your body is tolerant to them. if you up your dose, you will become tolerant to the new dose also. narcotics don't get rid of the pain. they make you take your mind off the pain. one will still have pain even with morphine or another strong pain med. one will still have a measurable amount of pain with pain meds. this is a fact of life. if you think that upping your dose will get rid of your pain, you will be disappointed. i take 45 mg of oxycontin per day and 4 700 microgrms of fenatyl lollipops a day and still have pain. there is nothing i can do. the pain is manageable though with pain meds not gone. pain patients will still have pain no matter how much and what drug we take.
    I have 4 fusions from L5-3, the latest last May '12 where they fixed my disc that broke.They went through my side this time. I take 40 mg of oxycontin 4x a day and 4 fenatyl lollipops 300 micro gms 4x a day.
  • Okay so if I want to do something like the blend. Do you recommend copying that and taking it in to the PM doc? I am just wondering how to explain it to him. I need to do something different because these have been the most miserable few days I've had in a long time well maybe actually ever. Only two more days till my appointment man this is going to seem like FOREVER!!!
  • dilaurodilauro ConnecticutPosts: 9,875
    I am not a doctor so my statements regarding the "Blend" are based on what I have researched, what I have done, what I am doing, what has been advised for me to do, what prescriptions have been written for me, what my doctors have advised, what my therapists think is required, etc.

    So, yes, I dont think it would be any harm to copy that and show that as an example.

    All of the doctors that I have been dealing with over the past 10 years or so, totally agree with the concept of the "Blend". Its not a firm fixed
    packaged solution. Its a way of life and how to deal with chronic pain.

    Jon perfectly stated the problem with using narcotic pain medications. As we continue to use it, the effects wear off. Increasing the dosage, is only a short term solution. The pain will be there, its just a way of masking it.

    That is why a total approach at pain management is so very important.
    Ron DiLauro Spine-Health System Administrator
    I am not a medical professional. I comment on personal experiences
    You can email me at: rdilauro@veritashealth.com
  • I will see what he thinks of the concept regarding the blend. I am hoping that my SCS will work and I can reduce the amount of meds that I take. I know it's not the total answer but I am trying to be hopeful that I will be a success story. I don't want to take the dang meds but I have kids and a hubby so being curled upon the couch isn't a good option and it's not how I want to live!! Gosh how I hate the situation I am in!!! S^%$!!!
  • unfortunately, some people continue to be in pain with strong pain meds so they take more without dr knowledge or approval or which is worse, some will ask their pain dr to change pain meds or up the dose which unfortunately sends up a red flag with the pm. he thinks you are seeking more narctoics. what do we do? i don't know. you can up your dose 1000x's and still not get relief except a drug overdose. if your dr finds out, he can 86 you from his practice by not sticking to his contract. we are in a perdicament. my advise is to talk to your pain dr and tell him your meds are not working. the chances are is that he will think you are scamming him form more narcotics. the best thing to do is continue with your pain meds. if it is really bad, you can suggest to your pain dr that you can get an injection or thearpy. injections work well most of the time. they can be a bit painful but if done correctly they will work. people don't like them for a couple of reasons, fear of pain or they want more pain meds instead. i would get the injection and stick to my pain meds. remember, pain meds don't get rid of pain. they mask pain. if you are really hard up for pain relief, talk to dr about changing dose and type of meds. remember, pain drs see people all the time who try to scam them for narcotics. they are suspicious because of this and the fact that they are monitored by the dea and they are in danger of losing their liscense. give them a break and don't hassle them for more meds unless absolutely necessary. it is really hard to find a good pain dr now a days. so once more a bit of advice, get an injection and stick to your pain meds.
    I have 4 fusions from L5-3, the latest last May '12 where they fixed my disc that broke.They went through my side this time. I take 40 mg of oxycontin 4x a day and 4 fenatyl lollipops 300 micro gms 4x a day.
  • dilaurodilauro ConnecticutPosts: 9,875
    is a total pain management control system.
    Its not more pain medications, its not higher dosages.
    That will not give you the result you want in the long run. In the short term, it can hurt you, you might be labeled a drug seeker, an addict, which is one thing, but on the medical side, you are just increase medications to hide the pain.

    Pain does not hide.... Please remember that. Its there, it always will be..

    What we need to do is figure out how to deal and cope with that.
    Ron DiLauro Spine-Health System Administrator
    I am not a medical professional. I comment on personal experiences
    You can email me at: rdilauro@veritashealth.com
  • Sometimes it works really well for me (norco) with anti-inflam meds and other times it does absolutely nothing. Part of that I think is that my nerve pain has been getting progressively worse which the narcotics don't touch. Right now since I don't have a PCP or pain doc I am on norco and lorazepam but I am almost out of the latter with no refill. It's the only thing that has allowed me to sleep for more than 4 hours though. I went 6 months or more without more than 4 to 5 hours of sleep a night which was really affecting everything including my pain levels.

    Before this started to progress for me the narcotics in conjunction with anti-inflam meds and muscle relaxants were very effective. Now, it is barely touching my pain. I have been in bed all day and yesterday I was having serious trouble walking from the nerve pain and I just couldnt get rid of it. Today I am having real trouble with head tremor and falling over as well as neck pain, arm pain etc. and I have norco but it just does not help for this kind of pain. I am glad I have it because I have many other types of pain which it DOES help, but lately the nerve pain is taking center stage.

    Meds are just so darn difficult to get right and to keep you comfortable especially over a long period of time and if you have many different issues going on. I am also super sensitive to meds as an example I have seizures from alcohol and anything containing alcohol like dayquil; so when I take things like neurontin I can't function and I hear that is one of the best for nerve pain. I always seem to get all the possible side effects but the narcotic side effects are a lot more tolerable. Grr!
  • i've talked with my pain dr and another one before he retired about prescribing pain meds. both of them had major issues with patients upping their pain dosage without their knowledge. people who see pain dr's usually sign a contract and it is specific about how to manage your pain. all contracts state that upping your dosage without their knowledge is a major breaking of your contract and because of this the pain dr has the right to dismiss a person from their practice. mine checks insurance forms to see if his patients are double dosing from different drs or he will make sure people are not coming in early to get more meds. if people are, he can and will drop them with his famous "15 day notice" where his letter states that he will drop a patient from his practice because they didn't follow his contract. no if's and or buts. like ron and i have said, upping your dosage will not help. it is dangerous and one can over dose. and finally, one is breaking the contract that one has signed. i bet most people under a pain doctor have signed a contract or have blood tests. if not you are lucky. remember, this is one issue that will get a doctor's goat more than any other issue. he has written a dosage and time amount for a reason. he is the expert on this, we are not. if you don't like it, get another pain dr. i bet most people who have problems with their pain drs are because they want more meds than the dr has prescribed.i have been on pain meds for over 10 years and have gotten along with both of my pain drs because i follow his orders about meds and i don't up my dosage without his knowledge.
    have a pain free life
    I have 4 fusions from L5-3, the latest last May '12 where they fixed my disc that broke.They went through my side this time. I take 40 mg of oxycontin 4x a day and 4 fenatyl lollipops 300 micro gms 4x a day.
  • Jon you are right. When in long term pain management we need a partnership with one doctor.

    Another big problem is people who get meds and stock them. They do this by keeping prescriptions that were changed or by taking less than prescribed when possible so that they have extra.

    You may stop the pain by taking what you think will work for you -- of course you may stop your heart as well.....
  • I did it with tramadol and tylenol for a long time. But as my body became tolerant to tramadol and I couldn't increase the dose to do my use of antidepressants, I had to add narcotics.

    Now, narcotics are the staple of my pain control regimen. Fentanyl patch + Norco for breakthrough pain. I also take 60mg/day of Prevacid for gastrointestinal issues caused by said narcotics, and developed stage II hypertension earlier this year. I'm a wreck.

    I'm currently in the process of doctor reviewing to see if surgery is an option for me at this point (I believe the surgery I would need is called a vertebrectomy. Sounds awful, doesn't it? I finally found at least one practice that seems to have some experience with it). I'm starting to think that all of these narcotics are taking a toll on my body.

    Post edited, previous phrasing regarding is inappropriate for the context

    Sorry, Ron. The phrase seemed appropriate at the time, but is inappropriate in this forum! I am happy to have a PM doctor I have a great working relationship with, and NOT looking for another of those!

    Ron DiLauro, Spine-Health Administrator 06/29/10
  • Pain meds do mask pain. And the ability to mask pain is a great thing when you have chronic, debilitating pain that won't go away.

    I would caution people in this thread to focus on their own experience, and not discuss their opinions of what others do. Until you've walked a mile in another's shoes, etc. etc.

    Anyway, I am quite thankful to have narcotics available to me, and to be in a position in my life in which doctors are willing to give them to me. I am managing to have some sort of life because of narcotics right now.

    As for narcotic abuse- yes it exists. We all know that. But painting all users with the broad brush of abusers seems unfair. I am a model narcotic pain medication patient. But getting a life back via narcotics is a balance, you can just as easily lose a life via narcotics.
  • I have 2 PM doctors. One is an anesthesiologist who not only does "regular" pm, but specializes in injections. My other PM is a psychiatrist/PM. He is the one who prescribes all of my oral meds, has occasionally had therapy sessions with me, and is in control of all of my medications. Along with my surgeries and history of back problems/injuries, I have bipolar disorder. Both of them are wonderful. Their treatment programs are all inclusive and by that I mean that not only do I get all of my meds (narcotics/antidepressants/muscle relaxers/BP meds/ and nerve medication (topamax) ), but I have biofeedback sessions, therapy session, and injections (prior to this surgery)

    I think that each and every treatment program is or at least should be, customized to the patient and their particular problems. It took a lot of trial and error, but with a tweak here and a tweak there, I think I've found a good treatment plan. I know things will change because of this surgery, but I have every confidence that my docs will help me to figure that proper balance.
  • Why do you ask? In some ways - the question can be taken in two ways. One side can condemn those that use them and the other side can point out, how with a lot of soul searching, we have come to conclude that life without some measures of control, with ALL TOOLS available make sense to us.

    For 25 years - I was told that I had a bad back. For 25 years I was told I was too young to have anything really wrong. For 25 years, I got X-rays about every 5 years, cause that is when I could not walk. I would hobble in on crutches or get pushed in a chair.

    I used all kinds of things - exercise - stretching, Yoga, Piliates, Rieki, working out on an exercise bike, so I could drop weight - and almost always was sick when finished, because the pain would drive up so high that I would be overwhelmed for an hour or so. I kept it up-as long as I could, and in the end - I am back to it - at 15 min at a time - and just trying to keep consistent at every day or every other day. I use all of these things, every day.

    I've been on Fent75 and still gone through hell for 40 hours, cause the dosage was wrong and in me really was a mountain slope, both up and down. I started on T1's self dosing and Robax for years. When that did not work - I went to my Dr and was told that -it was all he would give me too. He told me it was all in my head.

    And years later - I kept winding up in Hosp for stabilizing and round of Narcs to drop the pain off for a bit. ER could see the pain, as you cannot hide true pain, it shows in how the body reacts.

    I went thru 2 pain clinics and had recommendations sent to my GP- on how to handle me and he never followed one idea. I have been reviewed by a surgeon twice and he sent over a list of drugs to try first, and then after looking more at the scans, said he would not touch me, until I was in a chair, cause if he messed up, that was the view.

    I rode the ctscan twice so far - and had an hour apology from my Dr, about how sorry he was that he missed all of this, and how his lack of looking after the problem - caused Chronic pain and that I was right to feel like I did, cause I was right and he was wrong. I looked at him and said - it fine, I don't care - lets fix this now! And was given meds - and told to try this and see what happens.

    I have quit 11 medications - because they don't help control pain.

    I use 4 meds - 1 extended release - and 1 short acting. Both the same med, but differing strengths. I have a total daily dose allotted and have been on the same for 3 years. I have 2 for emergencies, that put me down for 24 to 36 hours, to rest the pain level back. Yes - there are times that I feel like it should increase and then I work on things, in all kinds of ways to reduce my situation and as I do, I feel much more in control of the pain, than if I just popped a pill and expected it to do everything for me, without me figuring out how to reduce suffering.

    If I reduce resistance to zero - then I reduce the magnitude of the results of pain - suffering to zero as well. The body can take a lot of pain, it is how we interpret it.

    There are all kinds of things that I use every day, but I never distract myself from it, that just masks it, which in some ways is similar to just using a pill.

    I meditate every day and sometimes all night, and get more rest and peace in those minutes, than anyone would believe and I cannot describe it either. And I have learned to do the same with and for others. In all senses of the word - this disease has taken more than I was every willing to give up - and at the same time - given back to me more than I deserve. I still learn from it every day.

    I'll meet it head on, invite it into my guesthouse and see what it has to teach me today.
  • dilaurodilauro ConnecticutPosts: 9,875
    The PM termology can get confusing. I use the term PM many times, but in my case the doctor is really a physiatrist.

    Here is a link to an FAQ that explains this:

    Physiatrist vs Pain Management Doctors
    Ron DiLauro Spine-Health System Administrator
    I am not a medical professional. I comment on personal experiences
    You can email me at: rdilauro@veritashealth.com
  • one question answered
    i only have one pain dr. i had one who retired and referred me to another one. my first one liked me because i followed his rules and he told my new dr i was an excellent patient because i followed his rules and didn't whine or complain. i will take exception to one poster who said they cautioned posters who said not to discuss my opinions unless i have been in other's shoes. first of all, i believe it is a free country and i can state my opinions and my opinions are based on my experiences that i relate to others. i don't think i could talk about back surgery unless i experienced it so i can talk about pain meds because i have had 10 years of experience with them. what i said about pain meds are factual and not opinions. unfortunately there are a lot of abusers with respect to pain meds. that's why we sign contracts and that is why pain dr;s are uptight about prescribing them. my pain dr likes to tell stories about abusers that he comes across. he does not mention names but i believe this is the major issue pain drs have to deal with , those who abuse their meds. people come in his office and demand narcotics or demand that their dose be upped. he also deals with a lot of people who want to get on disability, so he has to be careful here. he is very strict with checking out patients. his job is on the line. and because of abuse, we who really need narcotics have harder times getting them. everyday, there are stories about famous people who o.d. on narcotics which i bet are because they take more than they were supposed to or they take them when not prescribed to them
    I have 4 fusions from L5-3, the latest last May '12 where they fixed my disc that broke.They went through my side this time. I take 40 mg of oxycontin 4x a day and 4 fenatyl lollipops 300 micro gms 4x a day.
  • Hi...Recently i have been put on a new pain regime..I know the steroids have maybe played a part in this but what i think also is working is I am taking 2-3 20 mg oxycontin every 6 or so hours and if I have twings of pain creeping up I take 5 mg oxycodone IR...This has really kept the aching away...Does anyone else use the Oxycontin ER plus the Oxycodone IR as the breakthrough? The only real side effect is sever constipation, though I'd rather deal with that instead of the spinal and nerve pain...i am also on round the clock gabapentin total 2700mg...the lyrica did nothing for me...
  • Yep, that's a common combo. I'm on MS-contin and Norco and like it, although I need him to up the MS/down the Norco. It's quite nice!

  • dilaurodilauro ConnecticutPosts: 9,875
    My pain medication makeup was:

    Oxycontin ER (Extended Release) starting at 40mg 3x day and after a long time, finally down to 10mg 1x day, to 10mg 1x week till none.

    In between, I was always using the Oxycodone IR (Immediate Release) 5mg for breakthrough pain.

    That combination always seem to keep things manageable.
    In the beginning, the ER was every 12 hours, but that eventually went down to 8 hours.

    During some recent flare ups, my physiatrist, scripted me for Opana ER (5mg) and Opana (regular) 5mg for breakthrough. The objective (even though the dosage was not high) was to reduce the amount of breakthrough and hopefully just go with the ER.

    Long term goal, was not to use any breakthrough and eliminate the ER. I am not there yet, the ER is done, but I've gone from 6 Opana 5mg a day to 2 or 3...which is progress.

    I think it is very important to combine an ER and IR medication. The combination hopefully will help you through the day, so that you don't have all the ups/downs and spikes.

    Ron DiLauro Spine-Health System Administrator
    I am not a medical professional. I comment on personal experiences
    You can email me at: rdilauro@veritashealth.com
  • Agree totally, Ron. The combo is SO much better than trying to get by on just an IR medication when your pain is 'round the clock!
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