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12/17/2008 09:40 AM

Intractable Pain Patient's Handbook for Surviva #3



If Step One opioids fail to adequately control

pain, an IP patient will have to resort to Step Two

opioids. They are much more potent than Step

One opioids. They are usually required if pain is

severe and constant – meaning it never goes away

during the entire 24-hour day unless the patient is

asleep. Patients with the "cardiac-adrenalsyndrome"

will usually require Step Two opioids. Unfortunately, these opioids may cause constipation, hormone changes, and weight gain. Patients who must take them must learn and practice measures to minimize complications. Some Step Two opioids are often referred to as long-acting, since they remain in

the blood and control pain for several hours.

Long-acting opioid products, including morphine, methadone, oxycodone, and oxymorphone, are to be

taken on a regular, fixed schedule. Depending on the opioid, the time interval will be every 6, 8, 12, or 24 hours. IP patients should discipline themselves to take their long-acting opioid on a fixed, regular schedule such as when they first awake, noon, late afternoon, and just before bedtime. They are NOT to be

taken as needed, and when patients attempt to take them this way, they soon find that their pain is not

well-controlled. Many patients will also need to use Step One opioids during pain flares or breakthrough



Hydrocodone Vicodin®, Lortab®, Norco®

Propoxyphene Darvon®, Darvocet®, Darvon-N®

Tramadol Ultram® Codeine Empirin®, Fiorinal®

Dihydrocodeine Panlor® Pentazocine Talwin®

Nalbuphine Nubain® Butorphanol Stadol®


Methadone Methadose®, Dolophine®

Morphine Kadian®, Avinza®

Oxycodone OxyContin®

Fentanyl Duragesic®

Levorphanol Levodromoran®

Oxymorphone Opana ER®

Some of the above are now produced in very innovative formulations. Fentanyl is a skin patch and the

morphine formulations listed in the Table act like a pump in the intestine providing pain relief for as long as 12 to 24 hours.


Some Step Two opioids are long-acting and

prescribed to suppress pain and possibly prevent

pain from even occurring. Unfortunately,

they may not totally do the job, and pain will

flare or "breakthrough" the barrier of the longacting

opioid. A severe breakthrough or flare episode can disable you and send you to bed or worse – to the emergency room. If your pulse rate or blood pressure rises too high during a breakthrough episode, you may even have a heart attack or stroke that could be fatal. Consequently, most severe IP patients will

need to master the use of a long-acting opioid and one or more breakthrough opioids. Rapid breakthrough pain relief within 5 to 15 minutes is the goal of the use of a breakthrough opioid medication. To achieve this rapid action, breakthrough opioids should be taken as a liquid, lollipop, injection, or suppository. They are commonly referred to as "short-acting" opioids because they may only act for 1 to 3 hours.


One of the biggest mistakes an IP patient makes is to get too dependent on a favorite opioid such as

fentanyl, meperidine, or oxycodone or the way it is delivered, such as an injection or lollipop. Why? You

may eventually get tolerant to the opioid and have to switch. Also, many are extremely expensive and

health insurance plans simply will not pay for them. Their position is that the older generic opioids such as morphine, methadone, hydrocodone, meperidine, and hydromorphone are good enough for pain control.

You must identify several opioids that are effective for you. Do not plan on getting the one you most

want. Cost factors have simply ushered in a situation that has priced some of the Step Two and breakthrough

opioids out of range. You should immediately look at the lists of opioids in this Handbook and determine which ones you have and have not tried. At a minimum, you should identify four that you can take and which are effective. Also, do not get your heart set on route of administration such as a lollipop or injection. For survival, you must learn what your health plan will pay for. Do not expect your health plan to give you a special exception to their usual opioids and costs policy. It is usually a bad idea to take brand name opioids. Why? Sooner or later your health insurance will likely disallow brand names.


In addition to opioids, there are additional medications that almost all IP patients will require. One is a sleeping aid, and the other is a muscle relaxant. Hormone replacement of adrenal hormones, thyroid, estrogen, testosterone may also be required as pain and/or opioid medications may deplete them. You may also need mediation for nausea, constipation, or weight control.


Fentanyl Transmucosal

("lollipop" or buccal tablet) Actiq®, Fentora®

Hydromorphone (liquid, injection, or suppository) Dilaudid® Meperidine (liquid or injection) Demerol®

Oxycodone (liquid) Oxydose® Morphine (liquid, injection, or suppository) Roxanol® Oxymorphone (tablet) Opana® Hydrocodone (liquid) Tussionex®


IP and its accompanying high pulse rate keep IP patients awake. You will likely need a sleep aid, and several of the favorites of IP patients are listed in the Table. Some antidepressants, which activate serotonin are liked by patients and physicians because they assist sleep and depression at the same time. Furthermore, serotonin may promote neurogenesis or healing of nerves. IP patients all expect 6 to 8 hours of sleep like a normal person. DO NOT expect this. You will likely not be able to sleep more than about 4 hours at a time. Many IP patients cannot sleep over 2 to 3 hours at a stretch. This is particularly true if you have damaged your spine, hips, knees, or nerves in your arms or legs. Why? If you sleep too long on these damaged tissues, you may crush them and produce more pain. Your body wants you to awake frequently so you avoid sleeping in one position and crush tissues which may increase your pain. IP patients need to take their last daily opioid dose within 1 hour before bedtime. When you awake in the night, you should get out of bed, stretch, and use the restroom before returning to bed. If you have pain during the night, take a dose of your breakthrough opioid.


The severe pain and high pulse rate of IP causes

anxiety and muscle contraction. A high pulse rate may

make you feel jittery or nervous. In addition, you may

have an injury that may cause muscle contraction. Most

IP patients find that a muscle relaxant provides considerable additional pain relief and comfort. For reasons that are not particularly clear to me, some muscle relaxants are not effective in IP patients. Although pharmacologically classified as anti-anxiety agents, some are effective in reducing high pulse rates and muscle spasms. Those muscle relaxant-anti-anxiety agents that have proven to be popular with many IP patients are listed in the Table. Do not take more than one of the agents in the Table on the same day. The # 1 cause of sedation, falls, and accidents in IP patients is overdose of this group of agents.


There are new drugs for pain relief that act by blocking the electricity in nerves. Pain that is caused by nerve damage in the legs, arm, chest wall, abdomen, or pelvis is often called

"neuropathic pain." These agents can be used with opioids, and many patients can use these with a Step One opioid and avoid the necessity of Step Two opioids. In milder forms of chronic pain, these agents may work so well that opioids are not even necessary. IP patients can sometimes reduce their opioid dosage with these agents.



Chloral Hydrate Somnote®

Triazolam Halcion®

Temazepam Restoril®

Zolpidem Ambien®

Amitriptyline Elavil®


Carisoprodol Soma®

Cyclobenzaprine Flexeril®

Methocarbamol Robaxin®

Diazepam Valium®

Clonazepam Klonopin®

Lorazepam Ativan®


Duloxetine Cymbalta® Pregabalin Lyrica®

Some of the older antidepressants and anti-seizure drugs are nerve blockers, and they have

been extensively used for pain relief. The two newest on the market, however, are generally superior, and

they are the only ones I now recommend.


IP patients must all take some nutritional and hormonal agents. IP depletes the body of certain nutritional substances and hormones. If these are depleted, pain worsens, and the patient will experience more fatigue, insomnia, and depression. IP patients should read about various dietary supplements and try ones that have an appeal. At this time, there is no marketed vitamin, mineral, herb, or amino acid that I restrict or condemn. Here are my minimal recommendations, for all IP patients.

1. Daily multiple-vitamin-mineral tablet or capsule.

2. Calcium, magnesium, and vitamin D. for osteoporosis prevention.

3. Pregnenolone 50 to 100mg a day. This is the basic adrenal hormone and nerve healer.


To achieve better pain relief and promote healing, IP patients may find one or more topical medications,

which are rubbed into the skin over painful areas, to be effective. These agents are known as "topical"

because they go on top of the skin. Since IP patients have tissue damage and scarring, internal

medications may not always reach the damaged nerves because blood vessels in the damaged tissue

area may also be damaged. Consequently, topical medications may be able to penetrate into damaged

areas by diffusion.

The list of topical medications being used and researched throughout the country is too long to fully list here. IP patients are encouraged to ask their pharmacist or other IP patients if they recommend a specific topical medication. Then try it. Topical medications have essentially no permanent side effects, so you can experiment safely. The most consistent topical pain relievers in my experience have been morphine and carisoprodol. The formula is to crush tablets of medication and dissolve one or two tablets in one ounce of cold cream. Apply as often as necessary for pain control.

An excellent topical pain reliever is lidocaine, which is classified as a topical anesthetic. It is available as a patch (Lidoderm). This patch produces excellent pain relief for about 12 hours. It can be placed on the neck, back, hip, knee or other body area that is painful. Unless an IP patient has pain deep in the body such as abdominal adhesions, they can usually get good relief from the lidocaine patch. These patches are particularly effective if there is a pain flare or you have "overdone" it and caused some additional discomfort in a joint, back, or spine area by over-exercise.


This troublesome problem often results from opioid drugs and inactivity. To help prevent it, drink 6 to 8

glasses of fluids a day and take some fiber supplements which can be purchased over-the-counter at any grocery or drug store. Many over-the-counter laxatives are effective. I have not observed that one fiber product is superior to others. Therefore, it is a personal choice. I have surveyed patients repeatedly to determine a consensus on laxatives, but there is no agreement among IP patients as to which ones are best. If fluids and non-prescription, over-the-counter laxatives do not do the job, there are a number of prescription laxatives. Simply ask a physician to give you a prescription. You may have to try several to settle on one you find most effective. I have found that my IP patients with severe constipation almost always respond to polyethylene glycol (GlycoLax®, MiraLax®, GoLYTELY®), or a licorice product called Evac-UGen.


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