Tolerance to opiates (fentanyl & morphine)

ger715 · 12-20-2011, 10:28 AM

MSIR and MSER. Help - what do these initials represent?
Ger

Dr. Smith · 12-20-2011, 10:55 AM

Quote:

Originally Posted by ger715

MSIR and MSER. Help - what do these initials represent?
Ger

Two forms of Morphine pills used for pain.
MSIR = Morphine Sulphate - Immediate Release
MSER = Morphine Sulphate - Extended Release

Doc

12-21-2011, 02:26 PM

Hi, ger715:

Quote: "Recently, I asked my doctor about frequently having difficulty lasting 6hrs because the pain will get too bad."

Between hour 48 and hour 72 (on the third day) of my fentanyl patches, my chronic pain does increase somewhat, so I take a capsule of MSIR to prevent this pain from getting stronger and to prevent breakthrough pain from showing up.

You really have a lot of courage talking to your doctor about your withdrawal symptoms. I would never be able to do such a thing because my biggest fear is that my primary care doctor (the only doctor willing to prescribe strong narcotic painkillers for me) will prefer weaning or cutting me off of my fentanyl patches rather than dealing with the withdrawal problem. These withdrawal symptoms might give him the perfect "excuse" to wean or cut me off of my fentanyl patches without my consent, because he is being harassed by the French Polynesian public health insurance company for the very high cost of the fentanyl patches this insurance has to cover (70% for the insurance company and 30% for me). I am also afraid my doctor will consider me a druggie (confusion between "physical tolerance" and "psychological dependence [addiction]").

Quote: "First of all, he said I was evidentially reaching "end of doseage" sooner; but didn't feel I had reached an amount to do "rotation" (meaning a change in a different narcotic)."

I think I also reached "end of dosage" sooner (lucky me!

). So you have not started "opioid rotation" yet. If you and your doctor do decide someday to change your opioid, I wonder if your doctor will have to find an opioid at least as strong as Oxycontin so you do not feel increased pain or the same withdrawal symptoms. I am so used to my fentanyl patches (and to the convenience of having to change them every 72 hours instead of taking a pill twice a day) that I do not know if I could do opioid rotation. Besides that, I kind of feel "attached" to my fentanyl patches because they have helped me for over nine years. Without them, I would not have a life worth being called a "life".

Quote: "There has been a couple of times when i was an hour or two late and the pain in my legs and body was awful."

When I change my patches late, I feel withdrawal symptoms, while waiting for the fentanyl in my patches to kick in.

Quote: "I cannot imagine anyone taking a holiday from the meds. This could be very dangerous and you will still need to start up at a high dosage fairly quickly."

If I may ask, how could this be dangerous? What do you mean when you say I would "still need to start up at a high dosage fairly quickly"?

Quote: "It is a vicious circle that none of us asked for; but have to deal with this to get thru each day."

This is so, very true. I could not have said it better.

Thanks for your help and information.

12-21-2011, 02:58 PM

Hi, Dr. Smith:

Quote: "All your body knows is that it's not getting enough medication to maintain a certain constant level, and it responds by presenting withdrawal symptoms."

So, when our body knows it is not receiving enough medication to maintain a certain constant level in our blood, our body responds to this lack of medication by using withdrawal symptoms? I wonder if withdrawal symptoms just happen with opioids or if they can occur with any medication.

Quote: "When your health conditions have worsened, it may feel like the pain is getting worse, or the medication is no longer addressing the pain (as well as it used to), without withdrawal. However this can also indicate an increase in tolerance."

So, if my health conditions have worsened, causing my pain to get worse, it means the pain medication is no longer controlling the pain as well as it used to. I thought an increase in tolerance to a pain medication, responsible for withdrawal, could happen or not happen, even if my health conditions have worsened.

Thanks for your information and help.

12-21-2011, 03:11 PM

Hi, Dr. Smith:

Quote: "Sometimes rotation is forced upon a patient with the same results."

Does this mean a doctor can force a patient to have opioid rotation even if the patient does not agree? Of course, this patient might benefit from opioid rotation, but it might also not help him/her, especially if the opioid the doctor wants to give this patient has already been tried by this patient and has not worked. The worst case is when the doctor does not believe the patient. I know so many of them, to whom this happened.

Quote: "She switched to MSER as a less expensive alternative, and found that she needed only 2/3 of the "equivalent" dose of oxy she had been taking."

Was this person then tolerant to MSER since she needs only 2/3 of the "equivalent" dose of Oxycontin she had been taking before?

Thanks.

12-21-2011, 03:15 PM

For ger715, I just wanted to add that morphine sulfate extended release can also be called morphine sulphate sustained release.

Sloane · 12-21-2011, 07:05 PM

Quote:

Originally Posted by kittycapucine1974

Hi, Sloane:

I do not know how you were able to convince your doctor (pain management doctor, primary care doctor...) to prescribe for you a dosage of 400 mcg of fentanyl patches. On the one hand, I would like to stay on my 125 mcg fentanyl patches dosage to prevent the return of the nausea and vomiting caused by my fentanyl patches, nausea and vomiting which no medications could control. On the other hand, I would like to increase my fentanyl patches dosage to 150 mcg to control my increased pain and prevent my withdrawal symptoms, but I am afraid the doctor will refuse this increase and I fear the return of the nausea and vomiting caused by a higher dosage of fentanyl patches.

Quote: "It is possible that the medicine is delivering at a faster rate than 72 hours due to various factors such as heat, humidity, sweating, exposure to hot water, etc."

I do think my fentanyl could really be delivered to my body at a faster rate than 72 hours because, where I live, it is very hot and humid, so I sweat almost daily, even late at night.

Quote: "I would recommend you either go up 25 mcgs on your patch or change your current dosage to every 48 hours, if possible."

I will try to convince my present primary care doctor or try to find a new one. There is only one pain management doctor in French Polynesia and he is no good. According to him:
1) my pain is in my mind even though I have proof I have RSD and
2) he believes only cancer patients have pain strong enough to deserve the use of fentanyl patches.

Even though it happened (rarely) to me to forget changing my fentanyl patches, I have never yet taken a "drug vacation". Like you, I do not know what a fentanyl holiday would do to my RSD, epilepsy, and asthma. Maybe some of my doctors or other people and doctors from the Internet would have the response.

Quote: "Furthermore, with rsd, in particular, the current theory of resetting the brain's tolerance is to use ketamine by coma or inpatient or outpatient infusion without coma. This is the ultimate treatment for rsd."

My public health insurance does not pay for it. It is my dream to try the inpatient RSD ketamine coma procedure, if only I had the at least U.S. $ 50,000 it takes, plus the costs linked to the complications this treatment might cause. I must admit I envy the rich people who can afford this treatment. I am not one of them, but the woman who injured me and caused my RSD and epilepsy is; she even owns a store and two houses. Unfortunately, my lawyer, very likely a "scheister lawyer", lost my case. Who knows!?!? Maybe the woman's insurance company "bought" him. I do not think this impossible.

What is Fentora? Is it the fentanyl lollypops? I never heard of Fentora.

Quote: "As for your question about the MSIR helping the withdrawal symptoms from the patch, yes, the MSIR should abate the symptoms; however, you may need to take more than your prescribed dosage for it to do so."

I will try this technique the next time fentanyl withdrawal happens to me. It cannot hurt; it can only help.

The other medications I take for pain are Tambocor extended release 200 mg (one capsule per day) and Inderal immediate release 40 mg (one tablet twice daily). I do not know if Tambocor and Inderal are similar to clonidine.

Quote: "Ultimately, I think you will find you will feel best and experience less pain if you up the patch either in dosage or by changing it every other day or 48 hours...it works out to be the same either way."

I will try to convince a doctor about this, but with doctors being afraid of insurance companies' doctors, it will be quite hard.

Quote: "The other thing I mentioned was to test the patch to see if it is not releasing too much medicine too quickly due to the factors I mentioned above."

How to do these tests? As mentioned earlier in this post, where I live, it is very hot and humid, so I sweat almost daily, even late at night. I do not see a way to prevent this because the electricity in French Polynesia is the most expensive in the world. If the electricity was cheaper, I could have air conditioning.

Quote: "I do best using mylan generic brand which does not have gel in the patch. The medicine is in the adhesive."

I seem to be different. Fentanyl patches containing a reservoir of gel seem to stick better to my skin than non-reservoir types of fentanyl patches.

Quote: "Make sure you are applying the patches correctly according to the manufacturer's instructions."

I use tape (not waterproof tape, which cannot be found where I live) all around the edges of my fentanyl patches. Sometimes the tape sticks; sometimes it does not.

Quote: "Frankly, fentanyl is known not to give any mental high to the patient unlike the MSIR. It does not seem like you are asking for much by needing the extra 25 mcgs or one less day on the current dose. It is not to get high. If you wanted to increase the MSIR, I could see where a doctor would be more concerned from an addiction point of view."

I totally agree with you. I never got high with my fentanyl patches whereas I sometimes (rarely) get high with my MSIR capsules.

Thank you for sharing all your information and ideas.

hello kitty...

as for my fentanyl patch dosage of 400mcgs. it has gone from 150 to 400 mcgs over twelve years with new pain problems coming on along that continuum of time. I never convinced the doctor to do it. it just rose as the pain got more severe. I know it is a high dose that will not be able to be increased.

as for testing the patch, change it at 48 hours one time and compare it to a patch that was used for 72 hours. is there any gel left in the patch at the 48 hour period patch. is it the same as the 72 hour period patch? given where you live, the climate is probably impacting the patch delivery system. I have an aunt in Arizona who changes her patch every 48 hours during most of the year. in the winter she can go longer. the weather is the problem for her as she sits outside in the hot sun. no doubt, I bet you have the same problem. explain it to the doctor that way and bring the paper leaflet from the package in with you that state heat will cause patch to accelerate delivery.

as for your question about fentora. it is a tablet that you put in back of your cheek inside your mouth to dissolve. it is different that the lollipops as they are loaded with sugar which rots your teeth with repeated use, and they are not as potent. (i.e. if someone uses a 400 mcg lollipop, they would need a 200 mcg fentora buccal tablet as much of the lollipop is swallowed compared to the buccal tablets).

as for clonidine, it is an alpha-agonist hypotensive whereby it acts to decrease the heart rate and help the blood flow more easily by relaxation of the vessels. inderol is a beta-blocker which helps a variety of heart related anomalies. as for tambocor, it is an antiarrythmic which helps with irregular heartbeats of various origins. they are three different drugs all used for the heart and other things sometimes, but none of them work the same as each other. therefore, the inderol will not help with the withdrawal symptoms like clonidine will. sorry for that bad news for you. nonetheless, you understand the differences.

as for the r-lipoic acid and other meds dr. smith suggests, go to the nutrition store. they are vitamins. mostly, they are vitamin b types like b-6 or b-12. also, to check your adrenal glands is a blood test. if your cortisol is high, you may benefit from pregnalone and a host of other hormonal-related supplements. I believe he referred to Dr. Forrest Tennant's, Intractable Pain Guide. I am a patient of Dr. Tennant's. I highly recommend you googling his name and the name and "intractable pain" as there is valuable information in his guide. if you want to know more about his regimen, just private message me. I will give you all the meds he recommends as supplements. all but one are available from the nutritional/vitamin store.

i noticed you questioned if withdrawal symptoms only occur with opiates. no, there are different types of withdrawals for various types of medicines. they may differ in symptoms, but they are never pleasant.

I think I got all your questions. good luck trying to convince the doctor to change the patch timing or dosage. you are clearly in need of a change.

finally, I am flattered by the Joshua Sloane that may come to be soon. good luck with that. take care and be well.

sincerely,
sloane

Dr. Smith · 12-22-2011, 12:36 AM

Quote:

Originally Posted by kittycapucine1974

So, when our body knows it is not receiving enough medication to maintain a certain constant level in our blood, our body responds to this lack of medication by using withdrawal symptoms? I wonder if withdrawal symptoms just happen with opioids or if they can occur with any medication.

Withdrawal occurs when a body is deprived of any substance it has become physically dependent upon. This includes opioids, and can include many other drugs (and types of drugs) but it does not occur with any/all drugs.

Quote:

So, if my health conditions have worsened, causing my pain to get worse, it means the pain medication is no longer controlling the pain as well as it used to. I thought an increase in tolerance to a pain medication, responsible for withdrawal, could happen or not happen, even if my health conditions have worsened.

That is also possible. I think it's important that all pain patients understand these terms and the differences between them.

http://www.erowid.org/psychoactives/...finitions1.pdf

Doc

Dr. Smith · 12-22-2011, 01:28 AM

Quote:

Originally Posted by kittycapucine1974

Hi, Dr. Smith:

Quote: "Sometimes rotation is forced upon a patient with the same results."

Does this mean a doctor can force a patient to have opioid rotation even if the patient does not agree?

That is not what I meant, but it can work that way. The example I gave explained what I meant. My friend was on one medication that was working fine for her, but when she lost her insurance, she could no longer afford that medication, so the change was "forced" upon her by economic considerations.

There are times when a doctor may feel that a medication change is in the best interest of the patient, and may insist upon the change. Here in the U.S., a patient has the right to refuse treatment, so that patient could refuse the change. But a doctor also has the right to refuse to treat a patient (in a non-life-threatening situation), or to stop prescribing pain medications if s/he feels that is justified.

I do not know what the practice/policy is in other parts of the world.

Quote:

Was this person then tolerant to MSER since she needs only 2/3 of the "equivalent" dose of Oxycontin she had been taking before?

She was still opioid tolerant, yes, but she is less tolerant of the MSER than she was to the Oxy. This is one reason rotation is done.

Once a person has become opioid tolerant, they remain tolerant until their bodies adjust to having less/no opioid present. This can occur slowly over a long time by slowly reducing the amount of opioid present, or suddenly, in which case they go through withdrawal.

When a doctor changes a patient's opioid medication, it is usually done by titration. They start with an intentionally low dose (often about 1/2 of the equivalent dose of the original opioid), and increase as needed until they find the lowest dose necessary to provide the desired effect. Some temporary withdrawal symptoms may occur, but not nearly as severe as if the patient stopped abruptly.

Even more care must be taken when rotation/switching to methadone - titrating more slowly - because of the potential for adverse reactions. This has been discussed on other threads re: methadone.

Doc

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