Re: Q Question About My Morphine Dose????
- From: LooseCannon <lambchop.LC@xxxxxxxxx>
- Date: Wed, 31 Aug 2005 14:40:37 -0700
Frank wrote:
A year ago my doc put me on methadone 20mg per day which increased to 70 mg per day in about 3 months. This stuff made me drowsy and inattentive all day, so I got myself off it. It took me 2-1/2 weeks of misery to detox, so I wasn't real ready to try anything else. My doc urged me to try morphine, which I did and it doesn't seem to affect me the same way the methadone did. I started at 60mg per day 6 months ago and have increased to 150mg(5-30mg) which I take throughout the day.
My question is .......is this a large daily dose of morphine? I have leveled out for about 4 months, but now feel that I should add another 30mg dose per day. I perceive my doctor is being very cautious with me because, prior to my increased morphine dosage, she had also prescribed percocet for breakthrough pain. When I increased from 3 to 5 30mg doses of morphine she told me that since I was taking so much morphine I didn't need the percs. I want to request an increase, but I am afraid she will think I'm over the edge. TIA for any knowledge on this.
I think I may be able to help you on this matter, Frank. First of all despite your detoxing on the methadone, when you start on another opiate, your tolerance shoots right back up to where it used to be. It doesnt reset to the old tolerance unless mebbe 10 years passes between when you detox off one med and when you start on the new drug.
So when you started on the morphine at 60mg/day, you rapidly needed to go up cuz your old tolerance was rearing its ugly head. Its a freakin' shame that your doc doesnt know this, but its certainly NOT surprising. Opiate ignorance is common with doctors. It shouldnt be, but it is.
Also, why you are taking morphine throughout the day makes no sense. There are a bunch of differnt long acting morphine meds, from OramorphSR, which is prolly the cheapest off the bunch and lasts anywhere from 8-12 hrs between doses, to MSContin, also about 8-12 hours, to Avinza and Kadian, which last up to 24 hrs between doses. That keeps a much more steady dose of pain medicine in your system, cuz when you take the short acting stuff, its levels go up and down in your system, leaving you with uneven pain control. Using short acting pain meds is a piss poor way to manage pain! If you have any insurance coverage at all, getting the long acting meds is much more effecient and effective at treating your pain!
Now as to your current dosing. When you are first put on meds like morphine, the doc is SUPPOSED to start you on a low dose and evaluate your response to it every few days, raising or lowering it till you hit on the dose thats right for you. Sounds like this wasnt done, so when your body was trying to find the dose it needed, your doc was getting uptight about you needing more medication. Now that alone would be happening, even if you hadnt been on the methadone, but witth your old tolereance still quite fresh in your system, you had a double whammy going on with the tolerance issue. Whats happening is what they now call "pseudoaddiction", where your tolerance keeps going up and the resulting issues are being misinterpreted by your doc and it sounds like shes getting scared to do anything more for you cuz she thinks you are going up too soon. If she knew ANYTHING more than the bad info she has picked up on opiates, she wouldnt be concerned over your situation at all! Do a web search on "pseudoaddiction", and youll prolly learn allot that you may even be able to print out and share with your doc to ease her concerns some.
I started out with an opiate-dumb doc too. My tolerance went up fast and he just didnt get it. Sent me to an addiction counselor to find out if I was abusing the meds and fortunately, that addiction specialist was perty smart on the subject and luckily he "schooled" my doc on the proper way to prescribe these kinds of meds. His method of handling what he thought was blossoming drug abuse turned out to be the best help I couldve received, and it helped save me and prevented a bad situation. A few years later when I ended up with a real expert on pain management and opiates, I was treated even better. The first doc didnt wanna prescribe breakthru meds either, like your doc is doing, esp. cuz of my morphine dosage, so I do understand your situation. What I learned from my 2nd doc was that no amount of base medications can prevent breakthru pain, and that breakthru meds should ALWAYS be made available to pain patients being treated with opiates and the use and dose of them is a secondary issue to what your base meds are doing.
Keep in mind that abuse/addiction for pain patients occurs at less than 1 to 3 percent of the opiate-using pain patient population (which figure really applies depends on which study you are reading), but either figure is really, really low and much lower than most docs would tend to believe! Your dose is well within normal limits, and your need for breakthru meds is normal and prolly much needed. I can suggest 2 ways to handle this situation...either try to educate this doc as best you can. There is a pain management journal for doctors and the subscription is free for doctors too, and the journal is great. The articles cover all these types of subjects and the journal is great at dispelling myths that so many docs have come to believe about opiates. You can subscribe too, altho its $36/year to ppl who arent doctors (altho Ive heard of some ppl applying for a subscription as "Dr. <your name here>, Ph.D., and actually getting it at no cost!). Try checking out the journal's website at www.ppmjournal.com. They have summaries of back issue articles and youll see that there are MANY articles that apply to the kinds of issues you are experiencing with this doc of yours. You can also find all kinds of articles elsewhere on the internet to educate your doc with. Or, you can try to find a good doctor who really knows about prescribing pain meds who will help you better. I really doubt any doc who would prescribe you short acting meds UNLESS its cuz you have no insurance and thats the only kind you can afford. That would be understandable, but to be honest, its so ineffecient to do it that way that I would try looking into the lowest cost of the long acting morphines, either one of the generic versions of MSContin, or the OramorphSR (they are similar, but have totally different ways of making the morphine last up to 12 hrs in your system).
If you live in CA, I can prolly refer you to a good doc, depending on how far you are willing to drive. Otherwise, mebbe you could just look around and find a better pain doc than youve currently got.
I just changed pain docs and when I went in for my first visit to see this new doc, I took the most recent issue of Practical Pain Management Journal with me, cuz it had an article that was so pertinent to my situation (high tolerance opiate patient cuz of so many years being on morphine), and much to my surprise, the new doc already subscribed and had read the articles that month! I knew right then that I would be in good hands, and now 5 months later, I've had that belief confirmed. I am quite happy with the new doc! I just learned that one of the ppl who got dismissed along with me and many other pain patients of our former pain doc (he did it cuz he didnt want patients on Medicaid, even tho we didnt use our Medicaid to see him...we paid cash!) just learned from her new pain doc that hes losing almost all of his breakthru meds and the doc is just expecting that upping his Oxycontin will solve the problem. That is rarely the case. I feel just terrible for the guy, cuz he is in SO much pain. Being forced to ride out this situation, even for a month as an experiment seems really cruel to me. I am sure glad that I didnt end up with that doc!
So theres allot of info out there that you can use to try to educate yourself and your doc with. Your situation is not unusual, and your dose is not high at all. Youd be shocked to hear what my tolerance is, but I have over a decade on morphine under my belt, plus Ive been lucky enuf to have some really great docs who either knew already how to properly prescribe opiates or they were willing to learn so the patients they treated would get the best possible relief. I do not believe in automatic high dose opiates, but I DO believe in doctors prescribing what a patient needs to control the pain!
There is one more thing you might wanna suggest to a nervous doctor. How about periodic drug testing by contract? My doc did surprise testing about 2-3 times a year, and he not only tested for street drugs, he also tested for the medications he prescribed, and for the levels of those meds. If we pissed clean or light, so that meds we were prescribed didnt show up in our system or were in levels way below what we were being prescribed, or if we tested positive for street drugs (marijuana is ok with some docs, but it wasnt with him) he could and did dismiss us as patients. But as long as the tests came out as they were supposed to AND there were no problems with requests for early refills, lost medications, etc., then the doctor knew that he didnt have to really worry about the meds being abused or diverted (sold to others). Of course, an overwhelming majority of patients pissed exactly what they were supposed to, and that helped the doc to feel more confident about prescribing for his patients.
Sorry for the long post, but you had several questions and I wanted to answer them thoroughly. I hope that what Ive posted helps in some way. You are welcome to email me if you have questions you dont wanna post here too. My email addy is lambchop.lc@xxxxxxxxx
Good luck...
Frank
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