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Old 09-19-2006, 12:07 PM   #1
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Arrow Useful Sites & Resources

This thread is here for all to add useful sites and/or resources which have helped them and that they want to share.


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Old 09-23-2006, 04:04 PM   #2
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Post Data-base of State Laws, Regulations: Pain Management


CLick on your US State for information. If we carried a copy of these, maybe ERs and others would pay better attention to us! One can hope. TC. JD
Your conscious mind may not be able to understand what I'm telling you, but I trust your unconscious mind to use that part that is most relevant.

Last edited by JD; 09-23-2006 at 04:07 PM. Reason: Make the link work!
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Old 09-27-2006, 12:56 PM   #3
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I remembered that David (username C4quad.inc) from OBT had a great list of helpful links that he had posted in the useful websites sticky. There were so many helpful links, so I hope David doesn't mind that I found the google cache to copy them here.

I hope all the links still work.

Americans with Disabilities Act


Government/Soc Sec:

U. S. Food and Drug Administration
Recalls, Market Withdrawals, and Safety Alerts

Disability Rights Resources

Guidelines,and laws for the Use of Controlled Substances for the Treatment of Pain,for each State


State Medical Boards

American Medical Association

Federation of State Medical Boards

Doctors Disiplined by State and Federal Governments.


The College of Physicians and Surgeons of Ontario




Spinal Chord Injury Information

Animinated Spinal Procedures

APA Spinal Cord Injury Hotline, 800-526-3456
American Paralysis Association, 800-225-0292
National Spinal Cord Injury Association, 800-962-9629



Spine Solver.com For Back Pain Answers

American Academy of Minimally Invasive
Spinal Medicine and Surgery


Spinal Disorders

Dermatome Chart

Top-Picks Spine Links

Resources for Pain Management;


Chronic Pain Association of Canada

Pain World Australia

New York State Physician finder


Doctor Database

North American Chronic Pain Society

American Society for Action on Pain

The National Pain Foundation

Society For Pain Practice Managment

Pain Related Links


Partners Aginst Pain:

Hugs/n/Pain http://groups.yahoo.com/group/Hugs-N-Pain/



Multiple Sclerosis





Chronic Fatigue,Syndrome,and Fibromyalgia,Good Dr. List



Chronic Fatigue Syndrome

Reflex Sympathetic Dystrophy

RSD Puzzle List

CRPS Type 1

PARC: Promoting Awareness of RSD in Canada

RSD Syndrome of America

The RSDHope Group


Information About RSD

Access to Free Medicine

Glaxo Smith Kline
Express Scripts They Administer Purdue's Oxycontin pgrm. http://www.express-scripts.com/
PROVIGIL N.O.R.D. 800-675-8415

Physicans Desk Reference,Medicine Information,Description,and Identification



Potential Adverse Drug Interactions Data Base

Common Medical Abbreviations

Gray's Anatomy Reference

Emergency medical information

Living Will Registry,and Organ Donor Information

National Library Service for the Blind and Physically Handicapped (NLS)

Spelling Check and Correction Pgrm.

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Old 09-28-2006, 11:50 AM   #4
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Post Critical Methadone warnings:

I had this information up on the chronic pain board, at OBT.
So I am moving it here as well.

In the news just this week is the tragic death of Anna Nicole Smith's 20yr old
son. 2 days ago I saw the Cyril Wecht who was hired by Ms Smith to do the
autopsy reported on Court TV that the death is being called a Torsade de Pointes or in English a Prolongation of QT and sudden cardiac death.
Daniel Smith had Zoloft, Lexapro (why both is confusing) and METHADONE in
his tox screen results. Methadone is the only opiate to cause this interaction and effect on the heart. So patients who are using this opiate for pain
management need to be aware that 1) they should be evaluated for prolongation of QT with an EKG before treatment is started, and 2) use of
drugs that appear on the lists for causing this could be additive with methadone.

Some new papers have surfaced in the medical community warning physicians to screen their patients for cardiac risk.
But not all doctors read the newest findings. So I am putting them here
for readers on this board.

Pharmacotherapy. 2005 Nov;25(11):1523-9. Related Articles, Links

Effects of Methadone on QT-Interval Dispersion.

Krantz MJ, Lowery CM, Martell BA, Gourevitch MN, Arnsten JH.

1. Department of Medicine, Denver Health Medical Center, Denver, Colorado.

Study Objective. To evaluate the effects of methadone on QT-interval dispersion. Design. Single-center, prospective, cohort study. Setting. Methadone maintenance treatment facility. Patients. One hundred eighteen patients who were newly admitted to the facility. Intervention. Twelve-lead electrocardiograms (ECGs) were performed in patients at both baseline and 6 months after the start of methadone therapy. Measurements and Main Results. The ECGs were manually interpreted, and investigators were blinded to time interval and methadone dose. At least eight discernible ECG leads were required for study inclusion. Mean differences between baseline and follow-up rate-corrected QT (QTc) interval and QT dispersion were compared. Multivariate associations between clinical characteristics and magnitude of change in QT dispersion were assessed using linear regression. Mean +/- SD baseline QT dispersion was 32.9 +/- 12 msec, which increased to 42.4 +/- 15 msec (+9.5 +/- 18.6 msec, p<0.0001) after 6 months of therapy. The QTc increased by a similar magnitude (+14.1 msec, p<0.0001). No QT dispersion value exceeded 100 msec. The only variable associated with a greater increase in QT dispersion was antidepressant therapy (20 vs 8.5 msec, p=0.04). Conclusion. Methadone modestly increased both QTc interval and QT dispersion. Increased QT dispersion reflects heterogeneous cardiac repolarization and occurs with nonantiarrhythmic agents, such as synthetic opioids. However, the magnitude of this effect appears to be substantially less with methadone than with antiarrhythmic drugs.

PMID: 16232014 [PubMed - in process]
Tidsskr Nor Laegeforen. 2005 Aug 11;125(15):2021-2. Related Articles, Links
Click here to read
[Methadone-induced heart arrhythmia]

[Article in Norwegian]

Ostvold C, Topper M.

Hjerteseksjonen, Medisinsk avdeling, Sykehuset Telemark, 3710 Skien.

There is an ongoing debate over whether it is necessary to screen patients with an ECG before and during therapy with methadone. We present two patients who developed QT prolongation and sustained ventricular arrhythmias during treatment. Our experience as well as a literature survey indicate that an ECG should be performed before and during long-term methadone treatment.

Publication Types:

* Case Reports

PMID: 16100543 [PubMed - indexed for MEDLINE]
Swiss Med Wkly. 2005 May 14;135(19-20):282-5. Related Articles, Links
Click here to read
Methadone-induced Torsade de pointes tachycardias.

Sticherling C, Schaer BA, Ammann P, Maeder M, Osswald S.

University Hospital Basel, Div. of Cardiology, Basel, Switzerland. csticherling@uhbs.ch

Methadone is a synthetic opioid frequently used in drug maintenance programs for heroin addicts. It prolongs the QT-interval and is mainly metabolized by the isoenzyme CYP3A4 of the hepatic cytochrome-P450-system, which is used by numerous other QT-prolonging agents. Its most severe side effect is the development of life-threatening Torsade de pointes ventricular tachycardia in the setting of a prolonged QT-interval. Since drug addicts are prone to concomitant medical conditions requiring additional medication as well as to continued abuse of cocaine, they are at higher risk for developing this major complication of methadone therapy. Before subjecting patients on methadone to other drugs, the QT-interval should be determined and it should be ascertained whether the new agent has the property to prolong the QT-interval or is metabolised by the cytochrome-P450 system.

Publication Types:

* Review

PMID: 15986265 [PubMed - indexed for MEDLINE]
At risk are people who are magnesium deficient or low in potassium, who genetically inherited this trait, who use multiple drugs that can cause this in an additive or synergistic manner, anorexics or who are poor metabolizers (this is genetic also).

It is difficult to find illustrations of the electrocardiogram that illustrate the QT tracing. I used to have a good link here, but it closed.
Most people watch TV and see doctor shows, which show this tracing on the monitors. All of the separate parts of the graph have labels, from Q, R, S, T, and the timing for this can be measured. When the timing gets prolonged, the heart cannot maintain its built in rhythm and the ventricles begin to beat independently, and may go into a fib condition (trembling) and the heart must be reset with a shock, using the paddles.

The University of Arizona keeps a good up to date list on four categories of drugs involving QT issues. Here is their new website:
The 4 lists of drugs are on PDF files and don't have links.

Anyone on Methadone should print out what I have posted here and take to their doctor, if cardiac concerns have not been discussed. Not all doctors understand the new methadone data or have read it. There is still a general
assumption that all opiates are not QT risks. And that is no longer true.

Adding a link here:
This link discusses the common use of proton pump inhibitors (Prilosec, Nexium, Aciphex, Prevacid, Protonix) and how these
drugs affect other medications and absorption. Listed is methadone, which is enhanced by these drugs. So people on methadone for pain could have dosage problems if taking a PPI at the same time. Be careful

adding a link re FDA warning on Haldol and QT

This link is to a site that explains the genetics of drug metabolism.
People who are "slow metabolizers" are at greater risk for drug interactions or negative responses to certain drugs:
All truths are easy to understand once they are discovered; the point is to discover them.-- Galileo Galilei


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These forums are for mutual support and information sharing only. The forums are not a substitute for medical advice, diagnosis or treatment provided by a qualified health care provider. Always consult your doctor before trying anything you read here.

Last edited by mrsD; 05-21-2009 at 04:51 AM. Reason: fixing old links
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Old 02-17-2007, 02:51 PM   #5
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Definitions provided below for Charite, PLIF, ALIF, TLIF, discectomy, IDET
PLIF, ALIF and TLIF Procedures


Spinal fusion is a surgical procedure in which two or more vertebrae are joined or fused together. Fusion surgeries typically require the use of bone graft to facilitate fusion. This involves taking small amounts of bone from the patient’s pelvic bone (autograft), or from a donor (allograft), and then packing it between the vertebrae in order to “fuse” them together. This bone graft, along with a biomechanical spacer implant, will take the place of the intervertebral disc, which is entirely removed in the process. Spinal fusion surgery is a common treatment for such spinal disorders as spondylolisthesis, scoliosis, severe disc degeneration, or spinal fractures. Fusion surgery is usually considered only after extensive non-operative therapies have failed. Three common fusion surgeries available at our practice include PLIF, ALIF and TLIF.

PLIF stands for Posterior Lumbar Interbody Fusion. In this fusion technique, the vertebrae are reached through an incision in the patient’s back (posterior). The PLIF procedure involves three basic steps:

Pre-operative planning and templating. Before the surgery, the surgeon uses MRI and CAT scans to determine what size implant(s) the patient needs.
Preparing the disc space. Depending on the number of levels to be fused, a 3-6 inch incision is made in the patient’s back and the spinal muscles are retracted (or separated) to allow access to the vertebral disc. The surgeon then carefully removes the lamina (laminectomy) to be able to see and access the nerve roots. The facet joints, which lie directly over the nerve roots, may be trimmed to allow more room for the nerve roots. The surgeon then removes the affected disc and surrounding tissue and prepares bone surfaces of adjacent vertebrae for fusion.
Implants inserted. Once the disc space is prepared, bone graft, allograft or BMP with a cage, is inserted into the disc space to promote fusion between the vertebrae. Additional instrumentation (such as rods or screws) may also be used at this time to further stabilize the spine.


TLIF stands for Transforaminal Lumbar Interbody Fusion. This fusion surgery is a refinement of the PLIF procedure and has recently gained popularity as a surgical treatment for conditions affecting the lumbar spine. The TLIF technique involves approaching the spine in a similar manner as the PLIF approach but more from the side of the spinal canal through a midline incision in the patient’s back. This approach greatly reduces the amount of surgical muscle dissection and minimizes the nerve manipulation required to access the vertebrae, discs and nerves. The TLIF approach is the preferred method at our practice for interbody fusion as it is generally less traumatic to the spine, is safer for the nerves, and allows for minimal access and endoscopic techniques to be used for spinal fusion.

As with PLIF and ALIF, disc material is removed from the spine and replaced with bone graft (along with cages, screws, or rods if necessary) inserted into the disc space. The instrumentation helps facilitate fusion while adding strength and stability to the spine. We currently use many state of the art cage technologies including those made of bone, titanium, polymer, and even bioresorbable materials.


ALIF stands for Anterior Lumbar Interbody Fusion. This procedure is similar to PLIF, however it is done from the front (anterior) of the body, usually through a 3-5 inch incision in the lower abdominal area or on the side. This incision may involve cutting through, and later repairing, the muscles in the lower abdomen.

At our practice, a mini open ALIF approach is available that preserves the muscles and allows access to the front of the spine through a very small incision. This approach maintains abdominal muscle strength and function and is oftentimes used to fuse the L5-S1 disc space.

Once the incision is made and the vertebrae are accessed, and after the abdominal muscles and blood vessels have been retracted, the disc material is removed. The surgeon then inserts bone graft (and anterior interbody cages, rods, or screws if necessary) to stabilized the spine and facilitate fusion.

Minimal Access
We routinely do several types of spinal procedures utilizing minimal access techniques. The development of these techniques originated with the application of endoscopy during microdiscectomy surgery for herniated lumbar discs. It has now been applied to fusion surgeries. Ask a member of our clinical team to see if this might be right for you.

After Fusion Surgery
Recovery time is different for every patient. However, most patients are up and walking by the end of the first day after surgery. Most patients can expect to stay in the hospital for 3-5 days depending on their condition. Once released from the hospital, patients who have undergone a PLIF, ALIF, or TLIF procedures are given a prescription for pain medications to be taken if needed, as well as a detailed post-operative activity plan to help ease recovery and return to a healthy life.

Case Example of Degenerative Spondylolisthesis treated with TLIF

This 58 year old woman had degenerative spondylolisthesis at the L4/5 level as shown on the x-ray and MRI above. She had difficulty walking distances and back and leg pain. She was treated with laminectomy and fusion with instrumentation.
4/06 - Lumbar Fusion - L1, L2, L3, L4, L5, S1
Anterior with cages and Posterior with rods and screws.

8/17/05 - Cervical Fusion - C4-5, 5-6, 6-7 - Anterior and Posterior Fusion with plate in front and rods and screws in the rear - Corpectomy at C-4 and C-5 and microdisectomy at C6-7.

1/4/05 - Lumbar Laminectomy -L3, L4, L5, S1, S2 Obliteration of Tarlov Cyst at S2. Failed surgery!
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Old 02-17-2007, 02:54 PM   #6
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Total Disc Replacement—Charite™ Artificial DiscThe Charité Artificial Disc is a total disc replacement technology that uses two metal alloy endplates and its unique sliding core. This offers the theoretical advantage of allowing the spacer to shift dynamically within the disc space during spinal motion, moving posteriorly with flexion and anteriorly in lumbar extension. Some experts feel this may improve the segmental rotation and decrease the possibility of facet impingement at extremes of motion. This has not yet been clinically demonstrated.

Figure 14: Charité artificial disc

Figure 15a and 15b: Charité Artificial Disc design to mimic normal disc motion

The Charité Artificial Disc was designed to restore disc space height, to restore motion segment flexibility, to prevent disc degeneration at adjacent segments, to reduce or eliminate pain from motion or from nerve compression, and to improve the patient's functional activities. It was designed to be biocompatible and durable. It has a life span of 40 years (85 million cycles).

The Charité Artificial Disc has kinematics that mirror the segmental motion of a normal spine. It is designed to allow anatomic alignment in lordosis, and to allow normal facet joint loading and unloading.

Wear debris, a concern with polyethylene implants in the peripheral joints, has been studied in the Charité, given the implant's proximity to the spinal canal and nerve roots. In a long-term laboratory test of cyclical motion simulating >11 years of use, no wear debris particles were identified. There is minimal deformation of the core, with less than 8% height loss expected in 10 years of use.

Meticulous attention to implantation is required to ensure that the articulating surfaces of the endplates are parallel in order to restore normal biomechanics. Angled prosthetic endplates are available and were designed to produce parallel surfaces while accommodating lumbar lordosis. Different size endplates are available to the surgeon, so the largest size possible can be used to minimize the chance of subsidence into the bone. Care must be exercised by the surgeon to place the implant centrally in both the sagittal and antero-posterior planes.

Figure 16: Charité Artificial Disc is centralized, front view

Figure 17: Charité Artificial Disc is centralized, side view

Rotation must be controlled by the surgeon during implantation. The endplates are inserted , and the polyethylene core placed into position as the disc space is distracted. Core dislocation is a rarely reported complication.

The surgical approach is typically through an anterior retro-peritoneal route. Patient positioning is important so that radiographic confirmation of the implant position can be seen easily by the surgical team. Factors critical for a good result using the Charité are proper patient selection, selecting the correct prosthesis size, and proper prosthesis positioning with the CentreLine Instruments

Several clinical studies have been published documenting the European experience with this disc since 1987. Worldwide experience with this unconstrained anatomic disc replacement is now greater than 10,000 cases.

Cinotti reported on 46 Italian patients in 1996, with 2-5 year follow-up. He saw no implant failures, but did report reoperation in 19% for continued pain and one case of implant dislocation due to wrong size selection. Overall patient satisfaction was 63%.

LeMaire reported his French series in 1997, following 105 patients a mean of 51 months with 79% good outcomes and no device failures.

Zeegers reported 50 patients in 1999 in a Dutch series. He showed 70% good results with 2 year follow-up, but he did report 24 reoperations in 12 patients, none due to device failure.

The US FDA study was launched at the Texas Back Institute with the first US implantation in March 2000. Since that time, 294 patients have been enrolled in the FDA multicenter (14) study. The study was completed in December 2001, and the FDA approved the Charite for single-level L4-5 and L5-S1 implantation as of October 2004.

The study protocol called for a 2:1 randomization of Charite:BAK threaded fusion cages with autogenous bone graft. 196 patients received the Charité Artificial Disc as part of the randomization, with another 71 non-randomized patients receiving the disc as part of the experience portion of the protocol, so that a total of 267 discs were implanted.

Inclusion criteria were age 18-60, single-level L4-5 or L5-S1 symptomatic degenerative disc disease confirmed by discography, Oswestry score >30, VAS score >4/10, failed >6 months of nonoperative care, back and/or leg pain without nerve compression, <3 prior abdominal surgeries, and compliance with the follow-up schedule.

Exclusion criteria included previous fusion, multilevel degeneration, prior fracture in the lower lumbar spine, non-contained HNP, osteoporosis or metabolic bone disease, spondylolisthesis >3 mm, positive straight leg raise, scoliosis >11 mm, spinal tumor, infection, facet joint arthrosis, psychological disorder, and morbid obesity.

Additional exclusions were metal allergy, bone growth stimulator elsewhere in the spine, participation in another study, arachnoiditis, pregnancy, chronic steroid use, or presence of an autoimmune disease.

Figure 18: Front view of implanted Charité Artificial Disc

Figure 19: Side view of implanted Charité Artificial Disc
4/06 - Lumbar Fusion - L1, L2, L3, L4, L5, S1
Anterior with cages and Posterior with rods and screws.

8/17/05 - Cervical Fusion - C4-5, 5-6, 6-7 - Anterior and Posterior Fusion with plate in front and rods and screws in the rear - Corpectomy at C-4 and C-5 and microdisectomy at C6-7.

1/4/05 - Lumbar Laminectomy -L3, L4, L5, S1, S2 Obliteration of Tarlov Cyst at S2. Failed surgery!
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Old 02-17-2007, 02:55 PM   #7
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Anterior cervical decompression (discectomy)
A cervical disc herniation can be removed through an anterior approach to relieve spinal cord or nerve root pressure and alleviate corresponding pain, weakness, numbness and tingling. This procedure, called a cervical discectomy, allows the offending disc to be surgically removed.

The anterior approach to the cervical spine (from the front of the neck) can provide exposure from C2 down to the cervico-thoracic junction. Spine surgeons often prefer it because it provides good access to the spine through a relatively uncomplicated pathway. All things being equal, the patient tends to have less wound pain from this approach than from a posterior operation.

After a skin incision is made, only one thin vestigial muscle needs to be cut, after which anatomic planes can be followed right down to the spine. The limited amount of muscle division or dissection helps to limit postoperative pain following the spine surgery. The main trouble that patients have after surgery is a sore throat and difficulty swallowing, which produces a sense of a ‘lump in the throat’ caused by the surgical manipulation of the area.

The general procedure for the decompression surgery includes the following:

1. Surgical approach

The skin incision is one to two inches and horizontal, and can be made on the left or right hand side of the neck.

The thin platysma muscle under the skin is then split in line with the skin incision and the plane between the sternocleidomastoid muscle and the strap muscles is then entered.

Next, a plane between the trachea/esophagus and the carotid sheath can be entered.

A thin fascia (flat layers of fibrous tissue) covers the spine (pre-vertebral fascia) which is dissected away from the disc space.

2. Disc removal

A needle is then inserted into the disc space and an x-ray is done to confirm that the surgeon is at the correct level of the spine.

After the correct disc space has been identified on x-ray, the disc is then removed by first cutting the outer annulus fibrosis (fibrous ring around the disc) and removing the nucleus pulposus (the soft inner core of the disc).

3. Dissection

Dissection is carried out from the front to back to a ligament called the posterior longitudinal ligament. Often this ligament is gently removed to allow access to the spinal canal to remove any osteophytes (bone spurs) or disc material that may have extruded through the ligament.

The dissection is often performed using an operating microscope or magnifying loupes to aid with visualization of the smaller anatomic structures.

Possible risks and complications of anterior cervical discectomy surgery may include:

Inadequate symptom relief

Failure of bone graft healing (a.k.a. non-union or pseudarthrosis)

Persistent swallowing or speech disturbance

Nerve root damage

Damage to the spinal cord (about 1 in 10,000)



Damage to the trachea/esophagus

Also, the small nerve that supplies innervation to the vocal cords (recurrent laryngeal nerve) will sometimes not function for several months after neck surgery because of retraction during the procedure, which can cause temporary hoarseness. Retraction of the esophagus can also produce difficulty with swallowing, which has usually resolved within a few weeks to months.

There is little chance of a recurrent disc herniation because most of the disc is removed with this type of surgery.

An anterior cervical fusion is usually done as part of a cervical discectomy. The insertion of a bone graft into the evacuated disc space serves to prevent disc space collapse and promote a growing together of the two vertebrae into a single unit. This ‘fusion’ prevents local deformity (kyphosis) and serves to maintain adequate room for the nerve roots and spinal cord.

By: Peter F. Ullrich, Jr., MD

xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx

IDET - IDET (Intradiscal Electrothermal Therapy) back surgery animation
IDET is a minimally invasive outpatient back surgery to treat patients with chronic low back pain that is caused by tears or small herniations of their lumbar discs. This animation walks you through the steps involved in an IDET back surgery.

Click on link to see animation...

4/06 - Lumbar Fusion - L1, L2, L3, L4, L5, S1
Anterior with cages and Posterior with rods and screws.

8/17/05 - Cervical Fusion - C4-5, 5-6, 6-7 - Anterior and Posterior Fusion with plate in front and rods and screws in the rear - Corpectomy at C-4 and C-5 and microdisectomy at C6-7.

1/4/05 - Lumbar Laminectomy -L3, L4, L5, S1, S2 Obliteration of Tarlov Cyst at S2. Failed surgery!
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Old 09-16-2007, 03:43 PM   #8
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Post Drug interactions with Methadone:

Here is a good monograph on Methadone/Metabolism/drug interactions:

All truths are easy to understand once they are discovered; the point is to discover them.-- Galileo Galilei


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Old 11-29-2007, 01:03 PM   #9
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Post opiate conversion tables...

I am putting these up for reference only. Sometimes people need to look up this information.
Not all conversions listed in tables work for everyone equally either...there is variation. So make
sure you have an experienced doctor when an opiate adjustment is needed.


for fentanyl:


Fenfanyl is hard to convert either way.
And Methadone has special requirements too.
Since Methadone can stop the heart in sensitive people, you should insist
upon an EKG before starting it. Converting high doses of other opiates to methadone gives a high starting dose which can be dangerous. I have a post
earlier in this thread about that risk.
All truths are easy to understand once they are discovered; the point is to discover them.-- Galileo Galilei


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Old 09-24-2011, 12:24 AM   #10
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Default concussions and chronic pain

concussions can cause serious chronic headahces, neck, and back pain.
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