Pain Medication Guide - FAQ

Ive decided to compile information from all our discussions about pain medications; available medications, effectiveness etc. etc. along with some basic medical info. There is a list of abbreviations in the Lounge for any abbreviations that you may not know. Many times threads start with very vague questions from new members who are not familiar with pain management. This is fine, there are many people here that are happy to help you and provide well thought out input. However, I have noticed a trend that many beginning threads that are vague require several posts from regular members asking for more detailed information. My goal is to provide newbies with a generic baseline to start out with so that when they post their question they are little more informed and can get faster, easier responses.

A couple things to remember: Give at least a partial history of your pain condition, medications, strengths, how often you take them, and be specific in your question.

One main point to remember is that everyones body has different metabolisms, processes meds differently and respond to medications differently. You can use the sticky thread Opioid Comparison by Rawoody as a guide to see the potentcies of medications and how they relate to other meds in their strength. Then dig in further to find out others experiences. Many times you can find similarities; you may find that a couple of medications you have used successfully, another member has also used successfully. It may be time to increase so you are looking for input. The person you have similarities with will possibly respond similarly as you will so they are a great person to talk to.

Those looking for pill ID's should post the shape, color, and imprints in the title. You can provide a picture if possible, but usually the regulars can ID your pill with the description alone. I have noticed that when the thread is detailed, members (specifically Goat & Kirby) are lightening fast at ID'ing your pill.

Many pain management plans are composed of two main medication types,

• A baseline medication that is a long acting around the clock medicine (ER/CR) to keep your daily pain at bay

1. OxyContin - Oxycodone with a biphasic controlled release mechanism, usually dosed BID or TID depending on the person, sometimes dosed QID
2. MS Contin - Morphine with a controlled release mechanism
3. Kadian - Morphine extra extended release capsule
4. Avinza - Morphine extra extended release capsule, dosed Q 12-24H depending on the person
5. Opana ER - Oxymorphone with a controlled release mechanism
6. Ryzolt - Tramadol with a controlled release mechanism. Other names: Ultram ER.
7. Duragesic - Fentanyl Transdermal System 72hr continuous transdermal release patch, can be rx'ed for 48hr as well. Fentanyl is the strongest narcotic.
8. Palladone - Hydromorphone extended release capsules (not available in the US) (Members: Solo 5150)
9. Methadone - This medication has a long half life and can be a tool in pain management or addiction management

General Consensus: ("Members:" after each description refers to members who can provide more feedback & or find the drug effective in pain management.)

• The majority seem to find that OxyContin works the best for their baseline medication. (Members: Myself)

• Duragesic, for those who can get it, is tops. However due to the higher rx'ing of OC, there are much more people taking OC than Duragesic, otherwise it may come in first. Although we may see this change as Purdue Pharma who makes OC now has sole distribution rights and the cost as astronomical. Those whose insurance will not cover it or have high co pays or the uninsured continue to change from OC. (Members: Myself, Quincy, A Mom, htmom, Str8updude)

• MS Contin, Kadia, Avinza seems to follow the previous two, judging by the number of members reporting its effectiveness. (Members: Goat, Woodstock)

• Opana comes next and is a relatively new drug and is not yet widely prescribed. This leaves feedback on it very black and white. Members either love it or hate, there are few inbetween, however more people find that it does not help their pain than those who feel it is an effective pain management tool.  (Members: Patches_NY, 3red3red)

• Methadone is less common than all the medications above, although some are rx'ed it and find it to be effective.

• Tramadol is hands down the worst pain medication there is. It is a poor excuse for a pain med and is often rx'ed as a first step or by doctors too afraid to rx narcotics. Some feel that Tramadol is useful in easing withdrawl symptoms.

• An instant release medication (IR) for break thru pain flare ups to treat pain that "breaks thru" the baseline medication

1. OxyIR - Oxycodone in immediate release form
2. MSIR - Morphine in immediate release form
3. Norco - Hydrocodone/APAP, multiple dosages 10/325, Lortab 10/650, Vicodin 5/500, Vicodin HP 7.5/750, all immediate release.
4. Percocet - Oxycodone/APAP. Multiple dosages, all immediate release.
5. Ultram - Tramadol immediate release
6. Dilaudid - Hydromorphone immediate release form
7. Opana IR - Oxymorphone in immediate release form (member: 3red3red)
8. Actiq* - Oral Fentanyl Transmucosal Citrate x*#&er immediate release, quickest acting medicine, approved for cancer pain but also used off label for CP
9. Fentora* - Fentanyl Effervesent Buccal tablet immediate release, quickest acting medicine, approved for cancer pain but also used off label for CP
10. Demerol - Meperidine

*Note: Actiq & Fentora are not bioequivalent/interchangeable. Actiq 400mcg would not be a substitute for Fentora 400mcg.

General Consensus:

• Results are too widely varied to go into great detail on each one, members can provide info on specific IR meds.
• Most members agree that Dilaudid is a poor choice as it is not absorbed very well orally. IV use of Dilaudid many report is excellent, in a hospital setting, and IM administration I have seen no feedback other my own which it is not at all effective when administered IM.
• Oxycodone (Oxy IR, Roxicodone) seems to be the most widely used BTP med in more tolerant patients and almost all find it effective until they are on very high dosages. Members: Quincy
• In less tolerant patients hydrocodone (Vicodin, Norco, Lortab) seems to be widely used and generally very effective.
• Actiq and Fentora, both fentanyl BTP meds are the strongest available, although the results are mixed, some people get no relief from them and others find them excellent for BTP. Members: Myself, Quincy
• Again tramadol is hands down the worst medication even with moderate pain, except for easing withdrawl symptoms.
• Tylenol is very tough on the liver so most try to avoid the APAP combos all together. Most on APAP combos try to keep the APAP levels down, IE taking a limited amount of Norco 10/325
• Opana IR, I have not seen much information on this yet. (members: 3red3red)

Other common medications that apart of a regimen are:

• Medications that work on nerve pain

1. Neurontin - Gabapentin, relievs nerve related pain like sciatica etc.
2. Lyrica - Pregabalin, relieves nerve pain associated with sciatica, shingles, diabetes, fibromyalgia etc. Not an A/D.
3. TCAs - Tri Cyclic Antidepressants (Member: htmom)

• NSAID's (non steroidal anti inflamatory drugs)

1. Motrin - Ibuprofen, relieves pain, inflamation etc., multiple dosages up to 800mg. Processed by the kidneys; common misconception is that its bad for the liver.
2. Voltarin - Diclofenac
3. Indocin - Indomethacin
4. Naprosyn - Naproxen
5. Relafen - Nambumetone
6. Vioxx - Rofecoxib
7. Daypro - Oxaprozin
8. Mobic

Muscle relaxants

1. Soma - Carisoprodol
2. Robaxin - Methcarbomal
3. Zanaflex - Tizanidine
4. Flexeril - Cyclobenzaprine
5. Skelaxin - Metaxalone
6. Valium - Diazepam, a benzodiazapine that can help relax skelatal muscles

• Benzodiazepines

1. Serax
2. Klonopin
3. Xanax
4. Valium
5. Ativan
6. Halcion

• Anti Depressants

1. Paxil
2. Luvox
3. Prozac
4. Wellbutrin
5. Cymbalta
6. Zoloft
7. Deseryl

• Sleep Aids

1. Ambien
2. Lunesta
3. Deseryl
4. Vistaril
5. Benadryl

General Consensus:

• Both nerve pain medications are extremely effective
• Many find adding an NSAID boosts the effectiveness of their narcotic pain med
• Most find effectiveness in all the muscle relaxers, with Flexeril being the least effective. Different muscle relaxants can be used in different situations. Most members find Soma to be the most effective muscle relaxer. Most also agree that Soma needs to be used in conjuction with a narcotic to get the most results out of it.

Getting the most out of your insurance & prescription coverage.

Many people at one time or another have had to deal with their health insurance company not wanting to cover particular medications, or they have restrictions that make getting your rx more difficult. For some of you there is a solution. Some insurances will allow a prior authorization to get approval, and some have a process known as a PER. Let me give you the rundown on this excellent bit of information.

PER stands for Pharmacy Exception Request. It is a request made by the pharmacy on behalf of the doctor that is sent to the insurance pharmacy department. For example OxyContin is a formulary drug, but they only cover it for cancer patients. I use it for CP. My pharmacy faxes a paper to my doctor who says I need that medication for chronic pain signs it and sends it back. Its then sent to the insurance and they determine if they agree with the doctor and for how long the PER is good for. Since Ive been on either fentanyl or OC for so long they approve my PER on OC and its valid for 3-4 months, which means during that time I dont need a new PER and they just fill it. When the PER expires, the pharmacy takes the PER on file, sends it to the insurance and gets a new apporval. This also applies to qty limitations, I have a PER to get 120 Soma, as they only cover 90 at a time in the formulary, and applies to drugs not even in the formulary or brand names. My particular plan states that they wont disagree with my doctor, whatever he deems necessary, they will approve it, but it still has to go through the works. I hope to have this insurance forever. They approve everything, I have no co pay, and they go out of their way to help. A STAT PER can be filed if Im running low on meds and need quick approval. I am assigned a case manager that helps me with anything from PERs to making sure referrals are done in a timely manner. She also provides me with resources for my conditions and is very friendly and genuinely seems to care about my well being. Also, many insurance companies have nurses on their staff. If you ask to speak to the nurse, she can help the approval process along by contacting the insurance pharmacy department, as they do not take calls from members. You can also get a supervisor involved which will help as well. Bottom line is that sometimes you have to work at getting what you need, especially chronic pain patients. Dont take no for an answer, and exhaust all resources.

Dangerous Interactions

Grapefruit causes the body to have a higher concentration of medication in the bloodstream. It can be dangerous, and there are several medications that it affects. The reason is that our small intestine has an enzyme that destroys part of the medication we take preventing full absorption. When that natural process happens less medication is used in the body than we took. Now grapefruit juice destroys that natural enzyme. The same way that lemon destroys the pepsin enzyme that helps digest meat. (making lemon on fish & seafood a complete contradiction digestively speaking, although tasty) With that enzyme blocked more of the medication is absorbed into the body, and can rise to toxic blood levels. Since many people take pills in the AM, the same time many eat or drink grapefruit for breakfast, its even worse.

Here are some of the medications you have to be careful NOT to have grapefruit with:

• Cordarone
• Benzodiazepines
• BuSpar
• A/Ds
• Immuno Suppressants
• ED meds, that little blue pill   ED meds are vasodialators, and opens up constricted arteries & veins, allowing better blood flow to the lower regions, but to everywhere else too. Too much flow can cause your blood pressure to drop dangerously low.
• Pain medications, especially methadone with its already long half life
• Allergy Meds
• Lovastatin......actually all the statins.

Non traditional, non pharmaceutical pain relief. Many DO's are more open to these than MD's.

1.  Chiropractic treatment 
2.  Physical therapy 
3.  Medications
4.  Injections: ·         Trigger point injections  ·        Epidural steroid block 
5.  Moist heat/cold to affected areas
6.  TENS unit
7.  Magnet therapy
8.  Conditioning (strengthening under supervision)
9.  Massage therapy
10.  Pain management
11.  Dietary supplements (Glucosamine, chondroitin sulfate, etc)
12.  Accupuncture 
13.  Yoga/transcendental meditation

 (1-13 Courtesy of BeavisMom, to see the full thread read below)

This is a work in progress, and I will continue to update as I read through new & old posts. I hope some can find this post useful. Last update 11/30/09