Has this doctor mentioned when he is going to wave his magic wand and make the source(s) of your pain go away ?

I absolutely understand how difficult it is to find the right doctor to work with you to manage your pain. I also understand that they are under some pressure. Docs who over prescribe make the news all the time....they can go to jail, lose their practices and families because of one bad patient who was a drug seeker and went out and did something foolish. I understand that that can make them cautious....but damnit, it does not give them the right to treat all of us like we are just looking to get high !

I'll be honest.....I have been having trouble incorporating this next bit of advice in my own "pain story", but I'd recommend bringing a spouse, friend, parent, whomever, to your appts with you. Have them rehearsed and ready to speak up with saying "Hey, that's only 10 days worth of breakthrough meds !", "What do you expext her to do the rest of the month ?", "With current meds, she can sit up and watch tv....she can't do housework, go out with friends, or interact much with the kids !" etc

Bring a pain log to your appointments showing your pain levels each day.with meds, ice, heat, tens, laying down, and all of the other stuff we have to do to make life bearable.

If you are feeling nervy......and have a new pain doc lined up ( ), ask this joker what the maximum dose of morphine is. The answer is, there is no limit. I've had one patient who needed 1200 mg every 8 hours to control his pain while he was still on orals. I'll be honest.......I worked in hospice, so docs were more willing to prescribe higher because there was a limit to how long the patient would be taking meds. I am not trying to make light of someone being terminal, but if they can need high doses, why would a doc who treats a patient who is going to live another 10, 20, 30 or more years with chronic pain not think their tolerance will increase over time ?

As CP'ers, I do think we need to do everything we can in the non narcotic pain management area to make sure we are doing everything we can to manage our conditions. I think, for instance, if I were to ask for an increase in narcotic but also refuse to try Neurontin because I heard it makes people gain weight or it adds to brain fog, I think the doc is justified in saying no to the increase in narcotic. If the Neurontin made me vomit frequently and the narcotic did not, I think he should increase the damn narcotic

Okay....I'm done my rant now

I hope you are able to work things out with your doc....or it is time to find a new one.

Wishing you less pain

Jennelle -

Let me join the chorus on this one. You are being done wrong.

And for what it's worth, the same issue came up for me at an appointment with my pain mgt. doctor on Friday, but he handled it in a completely different way. I went in complaining that my 20 mg. Oxycontin tablets were just not enough anymore: they were lasting all of 90 minutes as opposed to the advertised 12 hours. So I asked for an increase in my prescription, which was quickly turned down on the grounds that the drug was simply not working for me anymore (I remember years ago when the same thing happened with Vicodin) and to increase the amount of the dose would be simply to invite something called Hyperalgesia or "abnormal pain sensitivity manifested as increased pain from noxious stimuli and as pain from previously non-noxious stimuli." Opioid Guidelines in the Management of Chronic Non-Cancer Pain, Andrea M. Trescot, MD, et al, Pain Physician, 2006; 9: 1-40, at 17, http://www.rsds.org/2/library/articl...sician2006.pdf

Instead, the answer according to my doctor lay in the long settled concept of "opioid rotation." See, Pharmacotherapy Principles & Practice, Marie A. Chisholm-Burns et al (McGraw-Hill Professional, 2007):

Opioid rotation is the switch from one opioid to another to achieve a better balance between analgesia and treatment-limiting adverse effects. The practice is often used when escalating doses (greater than 1 g of morphine per day) become ineffective. In some settings opioid rotation is utilized routinely to prevent the development of analgesic tolerance. [at p. 497]

See also, Opioid therapy for chronic noncancer pain: practice guidelines for initiation and maintenance of therapy, Coluzzi F., Pappagallo M., Minerva Anestesiol. 2005 Jul-Aug; 71(7-8): 425-33, at 428-29, http://www.minervamedica.it/en/freed...2Y2005N07A0425

So what my doctor suggested instead was that I switch all the way to methadone, which, in addition to being a strong relatively opioid is also an antagonist of NDMA (Nmethyl-D-aspartate) receptors, as is ketamine and Namenda (memantine), among others. [Trescot et al at p. 14.] Having said this, I understand that methadone poses unusual risks to people with cardiac arrhythmia (which I don't have) and obstructive sleep apnea, which I've got. But where the latter is well controlled with the use of a BiPAP machine (an advanced and more comfortable version of the CPAP) I am prepared to see how I react to it.

But the purpose of this post is not to extol methadone, but the virtues of opioid rotation.

Bottom line: it may not be in your best interest to ask for an increase in your prescription dose, as much it would to simply switch meds. And the list of potential choices is large, even if it winds up being something as relatively benign as Tramadol, which may be helpful to CRPS patients due to “its concomitant serotonin/norepinephrine re-uptake block.” RSDSA Complex Regional Pain Syndrome: Treatment Guidelines, Section 3 Phamacotherapy, R. Norman Harden, M.D. at p. 29, June, 2006, http://www.rsds.org/3/clinical_guidelines/index.html

Perhaps worth discussing with your doctor, or a new one.

Mike

I know some of you may have already received this e-alert but for those who don't get them and in light of the very interesting conversation here I thought I would post what I received from the RSDSA the other day. It should help to dispell some myths around this subject and help us with dealing with the medical profession.