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New Pain Management Patient - Possible Meds?

emellmatteemellmatt Posts: 1
edited 01/20/2016 - 6:43 PM in Pain Medications
I'm hoping someone can give me some suggestions to bring up with my PM provider.

I'm 31 & have had two back surgeries in the past six months. I dropped my motorcycle almost six years ago, two months after having my youngest son, & that was the beginning of the end. I spent a year in physical therapy before a MRI showed that I had degenerative disc disease & several bulging discs in my C & L spine. My primary sent me to pain management where I was immediately put on Fentanyl patches, which I don't think was the right option right off the bat. I had to hire a nanny for my two young children because I would fall asleep washing dishes. I asked to be put on something else & went through many meds, two that I remember are Opana & Nucynta. Later I found out I had stage one uterine cancer & was put on Dilaudid as well. Shortly after that I went through a divorce & lost my insurance, so I had to tough it out with just NSAIDS. A few months later I was in two car accidents within a six week span & my neck & back only got worse. I moved & took a job at the local hospital & was able to get insurance again, so I was put on the max dose of Ultram for several years.

Fast forward two years, I picked my five year old up in May & something popped in my back. I was in excrutiating pain & couldn't even walk on my own. I lost my job & with it went my insurance, so I couldn't get anyone to care about how bad of shape I was in. I ended up in the ER in July & was diagnosed with Cauda Equina due to a blown disc at L5-S1. Within a week I was having a laminectomy & discectomy. After surgery the surgeon came in to talk to me & I was told the disc had blown quite a while before & that it was too calcified to remove, so he was only able to do the lami. A few months later I went for coffee with a friend & when I went to stand up, I couldn't. My left leg gave out & I was having bladder issues. I managed to drive myself a few miles to the nearest ER & was immediately admitted for emergency back surgery, again. This neurosurgeon came in after & said he didn't understand how I was able to walk. He said he didn't find any calcification in the disc & removed almost all of it, as well as more of the bone, & I shouldn't have any more issues.

That was almost three months ago & I'm definitely still having problems. I ended up back in the ER a few weeks ago & a MRI of my entire spine showed the bulges on my first MRI have only gotten worse, there's now significant degeneration at almost every level in my neck, & my L4-L5 bulge is now a decently large paracentral protrusion. It also showed that I have a very significant amount of scar tissue encapsulating my nerves where they did the two surgeries at L5-S1 & that in & of itself is causing a great deal of pain. I'm looking at the likely possibility of having a two to three level fusion & I'm meeting with the neurosurgeon again in a few weeks to see if they want to a procedure on my neck as well.

In an effort to keep from having the fusion if I can help it, I was finally able to find a pain management provider who is willing to try injections & another round of physical therapy before we go the fusion route. My first appointment with him was this past Monday, & he seems to be a wonderful doctor. He's a part of the practice my primary care doc is with, so he went over all of my records & my recent blood work, which showed that my liver function is a little off. In addition to that, I have a clotting disorder that has been managed with blood thinners for several years. Because of that, I'm not supposed to take NSAIDS, which means I've eaten Tylenol like Skittles for years. I truly believe the liver issue is due to the Tylenol seeing as I don't drink alcohol & I've had all of my Hep vaccines & then some since I work in the medical field. Another issue that has to be considered is I've had seizures for the past year, which have been chalked up to a past relationship where my partner had an affinity for putting my head through whatever was close at the time, walls, doors, cabinets, ect. I had a nasty concussion after he found out I was making plans to leave him that put me in the hospital for two days with a brain bleed. So I'm on two anti-convulsants on top of everything else.

When I was at my appointment Monday, my PM doctor & I discussed the probability of the Ultram I've been on recently to control my pain lowering my seizure threshold, which I think is exactly what happened. Therefore Ultram is no longer an option. Since I'm not supposed to take NSAIDs either, my options for pain control are pretty much limited to narcotics. I've been on Percocet off & on since my first surgery in July. I feel like I've built up a tolerance, combined with my back & neck problems getting steadily worse which causes my pain to get steadily worse. I briefly touched on that during my appointment. He put me on 5mg Oxycodone (without the Tylenol since we're trying to figure out the liver abnormalities), & said that's a "baby dose" so I needed to play around with it but to try not to take more than one a day. This put me off a bit since this medication lasts four to six hours, at best. It's been a few days & it isn't really helping at all.

I have a follow up appointment tomorrow & I think he's going to do a round of steroid injections as well, even though he was hesitant about them when I brought it up due to the fact that I can't pin point an exact area where the pain originates from due to the damage at so many levels of my back & neck. He flat out said it's time to do the fusion if we're going to do it because aside from medication, there's really no options left. I think he's only going forward with the injections & physical therapy to be kind.

Since the medication he put me on isn't helping, I'd like to go in tomorrow with a few options to go over with him. As someone who has gone through all of this before, & as someone who has worked in the medical field & has some understanding of how this works, I feel like I might do best with a long acting medication & a short acting for break through pain. The issue is finding something that won't hurt my liver & won't bring on seizures, so anything with Tylenol & Ultram are out.

Any suggestions?
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  • LizLiz Posts: 7,902
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    Spinal stenosis since 1995
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  • emellmatt said:
    I'm hoping someone can give me some suggestions to bring up with my PM provider.

    I'm 31 & have had two back surgeries in the past six months. I dropped my motorcycle almost six years ago, two months after having my youngest son, & that was the beginning of the end. I spent a year in physical therapy before a MRI showed that I had degenerative disc disease & several bulging discs in my C & L spine. My primary sent me to pain management where I was immediately put on Fentanyl patches, which I don't think was the right option right off the bat. I had to hire a nanny for my two young children because I would fall asleep washing dishes. I asked to be put on something else & went through many meds, two that I remember are Opana & Nucynta. Later I found out I had stage one uterine cancer & was put on Dilaudid as well. Shortly after that I went through a divorce & lost my insurance, so I had to tough it out with just NSAIDS. A few months later I was in two car accidents within a six week span & my neck & back only got worse. I moved & took a job at the local hospital & was able to get insurance again, so I was put on the max dose of Ultram for several years.

    Fast forward two years, I picked my five year old up in May & something popped in my back. I was in excrutiating pain & couldn't even walk on my own. I lost my job & with it went my insurance, so I couldn't get anyone to care about how bad of shape I was in. I ended up in the ER in July & was diagnosed with Cauda Equina due to a blown disc at L5-S1. Within a week I was having a laminectomy & discectomy. After surgery the surgeon came in to talk to me & I was told the disc had blown quite a while before & that it was too calcified to remove, so he was only able to do the lami. A few months later I went for coffee with a friend & when I went to stand up, I couldn't. My left leg gave out & I was having bladder issues. I managed to drive myself a few miles to the nearest ER & was immediately admitted for emergency back surgery, again. This neurosurgeon came in after & said he didn't understand how I was able to walk. He said he didn't find any calcification in the disc & removed almost all of it, as well as more of the bone, & I shouldn't have any more issues.

    That was almost three months ago & I'm definitely still having problems. I ended up back in the ER a few weeks ago & a MRI of my entire spine showed the bulges on my first MRI have only gotten worse, there's now significant degeneration at almost every level in my neck, & my L4-L5 bulge is now a decently large paracentral protrusion. It also showed that I have a very significant amount of scar tissue encapsulating my nerves where they did the two surgeries at L5-S1 & that in & of itself is causing a great deal of pain. I'm looking at the likely possibility of having a two to three level fusion & I'm meeting with the neurosurgeon again in a few weeks to see if they want to a procedure on my neck as well.

    In an effort to keep from having the fusion if I can help it, I was finally able to find a pain management provider who is willing to try injections & another round of physical therapy before we go the fusion route. My first appointment with him was this past Monday, & he seems to be a wonderful doctor. He's a part of the practice my primary care doc is with, so he went over all of my records & my recent blood work, which showed that my liver function is a little off. In addition to that, I have a clotting disorder that has been managed with blood thinners for several years. Because of that, I'm not supposed to take NSAIDS, which means I've eaten Tylenol like Skittles for years. I truly believe the liver issue is due to the Tylenol seeing as I don't drink alcohol & I've had all of my Hep vaccines & then some since I work in the medical field. Another issue that has to be considered is I've had seizures for the past year, which have been chalked up to a past relationship where my partner had an affinity for putting my head through whatever was close at the time, walls, doors, cabinets, ect. I had a nasty concussion after he found out I was making plans to leave him that put me in the hospital for two days with a brain bleed. So I'm on two anti-convulsants on top of everything else.

    When I was at my appointment Monday, my PM doctor & I discussed the probability of the Ultram I've been on recently to control my pain lowering my seizure threshold, which I think is exactly what happened. Therefore Ultram is no longer an option. Since I'm not supposed to take NSAIDs either, my options for pain control are pretty much limited to narcotics. I've been on Percocet off & on since my first surgery in July. I feel like I've built up a tolerance, combined with my back & neck problems getting steadily worse which causes my pain to get steadily worse. I briefly touched on that during my appointment. He put me on 5mg Oxycodone (without the Tylenol since we're trying to figure out the liver abnormalities), & said that's a "baby dose" so I needed to play around with it but to try not to take more than one a day. This put me off a bit since this medication lasts four to six hours, at best. It's been a few days & it isn't really helping at all.

    I have a follow up appointment tomorrow & I think he's going to do a round of steroid injections as well, even though he was hesitant about them when I brought it up due to the fact that I can't pin point an exact area where the pain originates from due to the damage at so many levels of my back & neck. He flat out said it's time to do the fusion if we're going to do it because aside from medication, there's really no options left. I think he's only going forward with the injections & physical therapy to be kind.

    Since the medication he put me on isn't helping, I'd like to go in tomorrow with a few options to go over with him. As someone who has gone through all of this before, & as someone who has worked in the medical field & has some understanding of how this works, I feel like I might do best with a long acting medication & a short acting for break through pain. The issue is finding something that won't hurt my liver & won't bring on seizures, so anything with Tylenol & Ultram are out.

    Any suggestions?
  • About specific medications. Given the complexity of your medical history, your actual doctors are the only ones who should make those suggestions.
    Whatever medications he recommends, pm doctors typically start someone with short acting or immediate release meds, and increase the dosing frequency to allow the patients body to adjust to the opiates first, before adding extended release meds, due to risks of oversedation like you experienced with the fentanyl....
    Your pm doctor is aware of the various options available in immediate release and extended release meds, and aware of your various medical issues, so if I were you, I would see what he suggests as far as meds go.
    Patients who come in with suggestions for meds can be looked at funny, so while you can tell him that the once a day oxycodone isn't helping enough, I would definitely not be suggesting extended release or other meds at this point.


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