Tolerance to opiates (fentanyl & morphine)
 

Hi, everybody:

I use Duragesic (fentanyl patches) 125 mcg (one 100 mcg patch and one 25 mcg patch every 72 hours) for intense chronic pain caused by generalized internal chronic RSD and I take MSIR (morphine sulfate immediate release capsules) 30 mg (one capsule once or twice daily as needed) for breakthrough pain.

I have been using Duragesic, starting first with the 25 mcg dosage and then going all the way up to the 125 mcg dosage, since September 2002. I have been taking MSIR since May 2007.

I would like to know when physical tolerance (not dependence) will occur, because I guess it is only a matter of time before it happens, unless there are cases when it never happened.

Are there medications to help reverse this tolerance? What about other techniques?

For example, my fentanyl patches (dosage of 125 mcg every 72 hours since August 2010) are supposed to last 72 hours, but they seem to last only about 48 hours. Between hour 48 and hour 72, I sometimes have withdrawal symptoms but I always have my pain come back. My primary care doctor, who is the only one willing to prescribe strong opiates for me, will not prescribe fentanyl patches in a higher dosage for me (even though it is advised by Janssen Pharmaceutica in their doctor's medication notice, before switching to a change every 48 hours.) Anyway, knowing my doctor so well (he has been my doctor for about six years), I know for sure he will refuse a change of my fentanyl patches every 48 hours. Maybe he just does not like or want to do it; maybe it is not legal in France and in its overseas territories to change fentanyl patches other than every 72 hours; maybe he is afraid of the public health insurance company harassing him because me changing the fentanyl patches every 48 hours would cost them more than me changing the fentanyl patches every 72 hours (because they would have to pay for 15 patches of 100 and 25 mcg instead of 10 patches of each). They already harass me and my doctor now, so what would it be if the fentanyl patches were changed every 48 hours instead of every 72 hours, like now.

By the way, do you know if a MSIR capsule can stop fentanyl patches withdrawal besides stopping pain?

Thanks a lot for all the information you could give me.

Hi Kitty,
My first thought when I read this post is that it looks as tho you have been experiencing a drop in tolerance, just by the mere fact that you've tapered up to this higher dose over the years. And now your body is telling you that the 72 hrs isn't enough anymore.
I can surely relate to this! I can barely stretch my patches to last even 60 hrs, and I start going into withdrawal. My doctor doesn't want me to go from 72 hrs down to 48 hrs, and neither do I.

My doctor is big on the term known as 'Drug Holidays' but it requires strong perseverance and it can become VERY uncomfortable.
A drug holiday is when you taper back to a weaker strength in your med and stay there for several days or longer. This gets your tolerance to go back to the way it was when you were able to take the lower doses and the patches used to last the full 72 hrs.
It can be quite a roller coaster ride and of course you'd eventually end up back where you are now. At least it buys you some time tho. And of course you need your Dr's supervision to do this - don't try it on your own.
That's one technique anyhow. I've also heard that low-dose Naltrexone can help, but I don't know enough about this to make any claims.

Sorry I don't know anything about MSIR, but there should be others along with more knowledge than I.

Rae
:grouphug:

fentanyl patch and MSIR question
 

hello there...

I am also on a fentanyl patch for rsd along with other pain problems that existed prior to the onset of the rsd. in the 11 years since I have been on the patch I have gone from using 150 mcgs to 400 mcgs. currently I am on a 72 hour change which I prefer. my previous dose to the current one was 350 mcgs every 48 hours. the doctor upped the dosage, so I could return to a 72 hour dosage as 48 hours comes too frequently for me. 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 guess it is different here in the U.S. wrt doctors changing dosages as we have private healthcare. I would recommend you either go up 25 mcgs on your patch or change your current dosage to every 48 hours, if possible. is there another doctor you can go to who has expertise in pain management and would be willing to work with you not at you?

I have never taken a medication holiday as the previous poster mentioned. with rsd, I could not imagine what that would do. 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. I have not done it as I feel I am doing well enough with the fentanyl patch and the fentora (fentanyl) breakthrough pain meds as ketamine treatments are complex, involved, expensive, and not always well tolerated during and immediately after. You are not nearly as highly dosed as myself, and it sounds as though you have fairly good pain control notwithstanding the issues you present here. it does not seem like ketamine is the best choice for you right now. if things get drastically out of control from where you are now, perhaps you should think about ketamine in the future.

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. you may want to ask your doctor for clonidine which can help the withdrawal symptoms. it is a heart medicine, but it helps with withdrawal symptoms quite well. I do not think the clonid one is the answer as ultimately, you are experiencing withdrawal due to your patch running out on you which occurs every few days. it is a band aid solutIon. 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.

as I mentioned, if you cannot discuss the issues with your doctor and get the results you need, you may have to see a specialist about it. many people change their patch one day earlier than the 72 hours with excellent results. I certainly have throughout the years. it is only nature rail that you develop a tolerance. 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. if you use a heating pad near the patch, that will do it. if you live in a warm environment that can do it. same is true with hot baths or hot tubs (whirlpools). perhaps yOu can try another fentanyl patch than the brand you are using. I do best using mylan generic brand which does not have gel in the patch. the medicine is in the adhesive. they work far superior to the other gel dispensed types that are the usual method of delivery. make sure you are applying the patches correctly according to the manufacturer's instructions. I had problems once due to that. 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 25mcgs 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. so, go talk with your doctor armed with the knowledge you gain here from other's experiences. I wish you the best of luck in getting a result that benefits you. take care and be well.

:hug::hug:
Sloane

If you were on a dose that worked for some time, and then needed an increase, tolerance is very likely the reason - i.e. it's occurred.

Doc

Hi, Rrae:

Thanks for your answer and information.

Quote: "My first thought when I read this post is that it looks as though you have been experiencing a drop in tolerance, just by the mere fact that you've tapered up to this higher dose over the years. And now your body is telling you that the 72 hrs isn't enough anymore."

I think you are right. Unfortunately for me, I have had absolutely no success in convincing my doctor to have my fentanyl patches changed every 48 hours instead of every 72 hours. It is not that I absolutely want to do this, but I do not see any other solution.

I have heard of the term "drug holidays", but I fear this might cause epilepsy or asthma attacks, or both at the same time. I remember Emergency Room doctors telling me that withdrawal from narcotic, especially strong narcotic, painkilers lower the seizure threshold or the asthma attack threshold. I do not know if this is true or not. I also fear that CPS will use these epilepsy or asthma attacks as an excuse or opportunity to steal my two-year-old baby boy.

By the way, how can I tell if the narcotic withdrawal symptoms are a way for my body to tell me I need a drug vacation to lower my narcotic tolerance or a way for my body to tell me my health conditions (especially my generalized internal chronic RSD) have aggravated, hence the need for a higher dosage of narcotics?

I will talk to my doctors about the ideas mentioned in your post to find out if they are compatible with my health problems.

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.

Hi, Dr. Smith:

Quote: "If you were on a dose that worked for some time, and then needed an increase, tolerance is very likely the reason - i.e. it's occurred."

I agree with you. Thanks for giving me your opinion.

I am on Oxycotin for the past 3 years, as well as Percocet for breakthru pain. I started with 20mg's Oxycotin 3 times a day. I am now up to 60mg's every 6 hrs. for a total of 240 mgs daily. I am going to a Pain Specialist. They are usually the only ones that are more likely to deal with pain management and prescribe accordingly.

Recently, I asked my doctor about frequently having difficulty lasting 6hrs because the pain will get too bad. 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). 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. I also asked him is it possible to feel "withdrawal" this soon. His answer was a definite "yes". 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. I hate having to take this amount of narcotics; but have done the injections, trial stimulator (failed). While still having quite a bit of pain; at least I am able to have some quality of life. It is a vicious circle that none of us asked for; but have to deal with this to get thru each day.

You still will have a better chance with a Pain Specialist in prescribing pain meds. Wish you the best in your efforts. By the way, never get a high. When we have this kind of pain, we are dependent; but a high - not likely.

It doesn't work quite like that. Your body can't/doesn't "tell" you that you need a medication vacation. 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.

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.

For another technique used by some PM doctors to address tolerance, Google: opiate rotation or opioid rotation
Like the "vacation", its efficacy and duration may be different for individuals.

Doc

I didn't know any specific amount had to be reached (Thanks). Sometimes rotation is forced upon a patient with the same results. I know a patient who recently lost her insurance, and could no longer afford the oxy she had depended on for years. 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. Needless to say she and her doctor were pleased.

Doc

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

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.

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.

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.

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

more answers to your questions
 

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

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.

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

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.

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