question for nurse re fentanyl

[whiterabbit11]

I am a steady user of 2 fentanyl patches totaling 125mcgs each 3 days. I also take darvocet, bextra 40mgs daily and .50mg xanax a day.I also have a baclofn pump. Some days the pain becomes near intolerable sharp shooting pains in my side and shoulder like a broken rib towards the outwrd curvature of 55 degree scoliosis.I have some left-over 400mcg fentanyl suckers from a surgery. Would using a sucker on a bad day overdose me?WR

[duramater]

whiterabbit11,

I copied this post to the care forum, so that the sci-nurse will easily see it. Because fentanyl is a narcotic, it is wise to be very sure of correct dosages so as not to create a worse situation. I would suggest that you check with your doctor before adding anymore to your dosage. Potential side-effects of overdosing can be severe, most notably, respiratory depression.

Mary

...and she lived happily ever after...

[Wise Young]

whiterabbit,

Let me give an opinion about pain management. As you probably know better than most people, your body accomodates to opioids. The nervous system has the goal of maintaining pain sensitivity. It simply downregulates opioid receptor sensitivity and the dose of the opioids that you take becomes ineffective.

There are several strategies around this. One is to switch medications so that you are suppressing one type of pain response at one time and another at another, so that the system will come to a different equilibrium. Another is to manipulate neurotransmitters that influence pain responses. A third is to take drugs that selectively reduce the excitability of pain neurons.

The latter two strategies are now being favored for the treatment of neuropathic pain. Amitryptaline is a monoamine oxidase inhibitor and it tends to reduce the breakdown of catecholamine neurotransmitters. At relatively low doses of 20 mg per day, it seems to "blunt" the pain in some people. There have been several reports suggesting that glutamate receptor blockers, such as dextromethorphan or oral ketamine, may help. Neurontin is an anti-epileptic drug that selectively blocks bursting activity of sensory neurons that are responsible for sending pain messsages. It has been reported to be a selective phosphokinase C gamma (PKC gamma) blocker which has been shown to be important for development of neuropathic pain in animals. A number of other drugs are being tested in clinical trial but I am not an expert on these drugs and do not have much of an opinion.

Yes, taking fentanyl suckers when the pain is really bad may help but I think that it will downregulate your opioid receptors further and you may get more pain between the suckers. So, in my opinion, it is not a good long term solution. So, perhaps I can suggest several other possibilities that you may want to consider.

1. Electrical stimulation. Several studies now have suggested that spinal cord stimulation, even FES, may reduce neuropathic pain. It is popularly used for people with peripheral nerve damage and people simply turn the stimulator up or down when they need it or not.

2. Acupuncture. I have heard that electrical acupuncture likewise can reduce pain although even professional acupuncturists admit that the pain relief is temporary and it is impractical to get acupuncture every day. On the other hand, it may be possible to find the acupuncture points yourself and apply it to yourself.

3. Exercise. Exercise and particularly FES exercise can alter the excitability of the spinal cord. This may be related to sensory input that occurs when you are exercising. Have you ever tried doing arm cranking or other exercises?

I hope the above helps.

Wise.

[whiterabbit11]

Dr. Young & Mary,
Just wanted to say thanks for the help. Sometimes it helps just to complain to someone different and get good advice at the same time. WR

[alan]

If anyone tries a spinal cord stimulator, I recommend you make sure the stimulator can be placed above the level of your injury, and have it there for the trial period. Due to scarring, mine could never be pushed past the injured area, and, despite three position revisions in a year, never relieved anything, and was finally removed. Maybe it might have done some good if the stimulation was applied to an area of the cord that was actually still connected to my brain. Then again, they don't always help even non-SCIs with fairly localized pain, so it's a crapshoot, like everything else.

Whiterabbit, what about having morphine, dilaudid, or some other opiate added to the baclofen in your pump? From what I've read, pumps can dispense more than one med. You may need a different brand of pump than what you have, but you should be able to reduce your oral and patch opiates (and side effects) by going to intrathecal opiates. Take a look at the Spinal Disorders 3 forum at www.braintalk.org, (http://www.braintalk.org,) and maybe drop a note to Dr. Whitworth there.

[duramater]

WR...

You are very welcome, I am very good at hearing complaints....

please don't be shy..

Mary

...and she lived happily ever after...

[whiterabbit11]

I'm printing all the suggestions out for my doctor the next time I see him. I always feel guilty asking for pain meds and he's pretty stingy sometimes, although he said what Alan did about the Darvocet-tylenol-liver problem so he's probably right. My 1st PC DR. was anti-pain meds so you got whiskey and a bullet. next I had such a concoction that I could barely drive to work without nodding off and now I think I've got a smart one but he doesn't listen well. I like the idea of the mix in the pump and i'll send him the copy of your suggestions in the mail before my next appt. I did that with my 4-AP request and he said he'd write a scrip but the snowstorm nixed the appt.,then he got "indisposed" for 2 months according to his nurse so back to the waiting game.WR

[southerncaliboy]

my doctor suggested one of those stimulators Im having second thoughts now http://sci.rutgers.edu/forum/images/smilies/confused.gif