![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 103 to 127 of 131. Go back in thread:
Posted by FredPotter on August 20, 2007, at 15:50:14
In reply to Panadeine Plus » FredPotter, posted by Paulbwell on August 20, 2007, at 1:47:50
Thanks Paul how's it going? I got some Nurofen Plus and took it with ordinary Panadeine but didn't notice anything. Partly I want to alleviate painful muscles but they don't seem to respond. I'm pretty undepressed at the moment so perhaps that's why I had no AD response Fred
Posted by Paulbwell on August 21, 2007, at 4:08:03
In reply to Re: Panadeine Plus, posted by FredPotter on August 20, 2007, at 15:50:14
> Thanks Paul how's it going? I got some Nurofen Plus and took it with ordinary Panadeine but didn't notice anything. Partly I want to alleviate painful muscles but they don't seem to respond. I'm pretty undepressed at the moment so perhaps that's why I had no AD response Fred
Hi,
Looking good, feeling good thanks. I hope you find a satisfactory remedy for your muscles, i wonder what treatments you have tried. Good to hear your feeling well-keep it up!
Cheers
Posted by FredPotter on August 21, 2007, at 15:20:37
In reply to Re: Panadeine Plus » FredPotter, posted by Paulbwell on August 21, 2007, at 4:08:03
Thanks Paul. I'm glad to hear you're well. Where in NZ are you? Nice weather we're having
Posted by Larry Hoover on August 27, 2007, at 20:52:19
In reply to Re: Getting Doctors to prescribe opiates, posted by confuzyq on August 16, 2007, at 20:59:38
I don't know where else to put this, but I need to vent.
My son, 15, has the sad luck of having chronic ingrown toenails. I cannot understand how he can even wear shoes. The swelling. The bleeding. The infections.
He's had doctors take the nails off three times already, so I have some idea of his pain tolerance. He handles pain better than I do. I doubt I'd be able to wear shoes with those toes.
For some reason known only to the doctors, they've refused up until now to permanently block the regrowth of the offending nails. Finally, we got a doctor to do this for him. (Their argument: "He's so young!" Uhhh....so?)
They send him home with 18 Tylenol 3s. It soon became apparent that he's got his dad's 2D6 capacity. Your liver uses 2D6 to convert some codeine to morphine, and he's getting no relief. My son was screaming through the night, banging his head on the wall to block his sensation of the pain. He chewed a hole through his blankets, clenching them in his teeth. The doctors would not prescribe anything for his pain. They didn't want to make him into an addict!
What is wrong with these doctors? 1 out of every 10 Caucasians gets no (or limited) analgesia from codeine. Asking for something else is not drug seeking. You can't get better when you're in that kind of pain.
I drove 2 hours to bring him some Percocets, and within 20 minutes his face relaxed. Another 10 and he was asleep. When he awoke a couple hours later, I had my son back.
Lar
Posted by Paulbwell on August 27, 2007, at 21:30:53
In reply to Re: Getting Doctors to prescribe opiates, posted by Larry Hoover on August 27, 2007, at 20:52:19
> I don't know where else to put this, but I need to vent.
>
> My son, 15, has the sad luck of having chronic ingrown toenails. I cannot understand how he can even wear shoes. The swelling. The bleeding. The infections.
>
> He's had doctors take the nails off three times already, so I have some idea of his pain tolerance. He handles pain better than I do. I doubt I'd be able to wear shoes with those toes.
>
> For some reason known only to the doctors, they've refused up until now to permanently block the regrowth of the offending nails. Finally, we got a doctor to do this for him. (Their argument: "He's so young!" Uhhh....so?)
>
> They send him home with 18 Tylenol 3s. It soon became apparent that he's got his dad's 2D6 capacity. Your liver uses 2D6 to convert some codeine to morphine, and he's getting no relief. My son was screaming through the night, banging his head on the wall to block his sensation of the pain. He chewed a hole through his blankets, clenching them in his teeth. The doctors would not prescribe anything for his pain. They didn't want to make him into an addict!
>
> What is wrong with these doctors?I'm sorry for your son-and he was in real physical pain! imagine the nightmare TRD patients go through when they have only found pain meds to help to work.
It's because authorities will bar an MD to practice if they discover they have scripted/more of, a pain med than the law deems acceptable, whether they're doing well or not, the laws the law, it's not medicine. It's this threat that causes Docs to withhold pain meds-even to thoes with chronic pain, the Doc is simply too scared to script them.
> I drove 2 hours to bring him some Percocets, and within 20 minutes his face relaxed. Another 10 and he was asleep. When he awoke a couple hours later, I had my son back.
>
> LarGood you were able to help him out, interesting that you were able to aquire something effective for him when he wasn't.
Cheers
Posted by Phillipa on August 27, 2007, at 21:37:00
In reply to Re: Getting Doctors to prescribe opiates, posted by Larry Hoover on August 27, 2007, at 20:52:19
Lar one of the first things they teach in nursing is that you will get written up in a hospital if you withold pain meds from a patient. This is gross and horrible for your son. I wouldn't worry about addiction as he heals his need for the pain meds will diminish. Phillipa
Posted by Quintal on August 27, 2007, at 22:06:28
In reply to Re: Getting Doctors to prescribe opiates, posted by Larry Hoover on August 27, 2007, at 20:52:19
I'm sorry to hear about your son Lar. I had a similar experience when I had cellulitis - the codeine I was given had no effect, then I figured out that might be because of the SSRI I was taking. I was given tramadol and that worked a charm, not sure if that uses 2D6 but it worked anyway.
Q
Posted by FredPotter on August 27, 2007, at 23:44:30
In reply to Re: Getting Doctors to prescribe opiates » Larry Hoover, posted by Paulbwell on August 27, 2007, at 21:30:53
I've got a friend who's a brilliant sax player who's also an amputee. They keep chopping extra bits off at the knee. He drinks to help take his mind off the pain because they won't prescribe him any pain control (oh take some paracetamol etc). And when he drinks he can can get a bit nasty. They presumably know he drinks so assume he'll abuse painkillers. Actually recently they prescribed tramadol and he seems much happier and doesn't need drink
Posted by Larry Hoover on August 28, 2007, at 19:01:19
In reply to Re: Getting Doctors to prescribe opiates » Larry Hoover, posted by Paulbwell on August 27, 2007, at 21:30:53
> Good you were able to help him out, interesting that you were able to aquire something effective for him when he wasn't.
>
> CheersI've got a good supply of oxycodone. I've got causalgia a.k.a. reflex sympathetic dystrophy a.k.a. complex regional pain syndrome. He accidentally grabbed my pill bottle by mistake, I believe.
The war on drugs mentality should not pervade in the realm of acute pain relief. E.g. my friend's mom, dying of bone cancer, denied opiates because of their addictive potential. It was near unbearable to be near her, towards the end. But what else could you do?
Lar
Posted by Larry Hoover on August 28, 2007, at 19:03:14
In reply to Re: Getting Doctors to prescribe opiates » Larry Hoover, posted by Phillipa on August 27, 2007, at 21:37:00
> Lar one of the first things they teach in nursing is that you will get written up in a hospital if you withold pain meds from a patient. This is gross and horrible for your son. I wouldn't worry about addiction as he heals his need for the pain meds will diminish. Phillipa
Oh, I'm not worried about addiction. He's just like me. He barfs if he takes too much. That was the excuse the doctor's office gave for not providing 3 day's worth of pain relief. Unbelievable.
Lar
Posted by Larry Hoover on August 28, 2007, at 19:04:55
In reply to Re: Getting Doctors to prescribe opiates » Larry Hoover, posted by Quintal on August 27, 2007, at 22:06:28
> I'm sorry to hear about your son Lar. I had a similar experience when I had cellulitis - the codeine I was given had no effect, then I figured out that might be because of the SSRI I was taking. I was given tramadol and that worked a charm, not sure if that uses 2D6 but it worked anyway.
>
> QThanks, Q. You're right, some SSRIs can inhibit 2D6. Kind of an iatrogenic (doctor-caused) form of what I have, genetically. Same outcome, though.
Lar
Posted by Larry Hoover on August 28, 2007, at 19:07:18
In reply to Re: Getting Doctors to prescribe opiates, posted by FredPotter on August 27, 2007, at 23:44:30
> I've got a friend who's a brilliant sax player who's also an amputee. They keep chopping extra bits off at the knee. He drinks to help take his mind off the pain because they won't prescribe him any pain control (oh take some paracetamol etc). And when he drinks he can can get a bit nasty. They presumably know he drinks so assume he'll abuse painkillers. Actually recently they prescribed tramadol and he seems much happier and doesn't need drink
Just what I'm talking about.....they refuse to adequately address pain, and turn someone towards self-medication.....then blame him for self-medicating, in the void they've created.
I hope your friend is luckier than most. Tramadol doesn't have a history of prolonged action. It's pretty well known for poop-out.
Lar
Posted by Cecilia on August 28, 2007, at 21:19:54
In reply to Re: Getting Doctors to prescribe opiates, posted by Larry Hoover on August 27, 2007, at 20:52:19
Larry, is hydrocodone metabolized by the same enzymes as codeine? I was prescribed Vicodin for pain but one does nothing except make me itch and two made me sick as a dog. (I find it impossible to believe that people actually take these drugs for pleasure). Anyway, if I happened to be the one in 10 who gets no relief from codeine would hydrocodone be the the same? Cecilia
Posted by Larry Hoover on August 28, 2007, at 21:41:20
In reply to Re: Getting Doctors to prescribe opiates » Larry Hoover, posted by Cecilia on August 28, 2007, at 21:19:54
> Larry, is hydrocodone metabolized by the same enzymes as codeine?
Yes, it is. Hydrocodone metabolizes to hydromorphone, using the 2D6 enzyme. That's Dilaudid.
> I was prescribed Vicodin for pain but one does nothing except make me itch and two made me sick as a dog. (I find it impossible to believe that people actually take these drugs for pleasure). Anyway, if I happened to be the one in 10 who gets no relief from codeine would hydrocodone be the the same? Cecilia
Yes, you got it right. All the side effects, but none of the good stuff.
Lar
Posted by Cecilia on August 29, 2007, at 2:34:37
In reply to Re: Getting Doctors to prescribe opiates » Cecilia, posted by Larry Hoover on August 28, 2007, at 21:41:20
Thanks Larry. Is there a blood test to determine if I'm one of the people who don't metabolize the 2D6 enzyme properly and what pain meds (and other meds, i.e. antidepressants) don't use this enzyme? (Not, of course, that I'm likely to get my HMO to order the test even it is exists, they already know I'm anxious, and are likely to just laugh at the neurotic woman bringing in info from the internet. Do you have a link to some authoritive type source I could bring in on this topic?)
Posted by Cecilia on August 31, 2007, at 2:06:45
In reply to Re: Getting Doctors to prescribe opiates » Larry Hoover, posted by Cecilia on August 29, 2007, at 2:34:37
I've been trying to find more info on this CYP2D6 enzyme, and it seems like pretty much all the pain meds and most antidepressants are metabolized by it. Which may explain why I've had no depression relief from any of the many many antidepressants I've tried and bad side effects from most. Interestingly the two that had no side effects (though no benefits either) one, celexa, doesn't appear to use CYP2D6, the other trazodone, does. The ADs with the worst side effects for me were Effexor, Cymbalta, various tricyclics and all the MAO's, Effexor, Cymbalta and tricyclics all use CYP2D6, couldn't find any info on the MAO's. As for pain meds, oxycodone, also appears to use CYP2D6, but you say it still works for people with a deficiency in this enzyme? I'm confused. I guess the 1st thing is to see if I can convince my doctor to figure out if I really am deficient in this enzyme, though it sure sounds like it from my reaction to Vicodin. I've given up hope of ever finding anything that would work for depression, but it sure would be nice to be in less pain from my severe arthritis. Cecilia
Posted by Deus_Abscondis on September 2, 2007, at 1:29:14
In reply to Getting Doctors to prescribe opiates » Quintal, posted by FredPotter on August 14, 2007, at 15:30:08
This thread is quite topical for me especially at the moment.
I'm going to make a long contribution (some may say rant) and make no apologies for this. It is an opportunity to put down some of my ideas and to perhaps connect with other sufferers.
Without delusions of grandeur I've read quite widely (for a lay person) on opioid use for "non-cancer pain" analgesia. I haven't yet read the Elle article but will after this post.
One question I haven't answered for myself is what harm occurs if you accidentally (short term memory problem) take 4 tablets of 500mg paracetamol and then 2 tablets every 4 hours thereafter? Would anyone like to comment?
There are a few questions I'd like to raise on this board - one of which I will start in a new thread - it relates to the stimulant properties of Oxycodone.
Anyway, to go back to the initial indication - pain due to ingrown toe nail. I'm a little surprised that this couldn't be dealt with without permanent removal of the nail perhaps with orthotic/biomechanical investigation - but I will take it at face value that it is the only remedy for some. Back to opioids.
The use of opioids in medicine is restricted primarily for political reasons rather than for rational scientific/medical reasons. The historical development of "opiophobia" in medicine would be worthy of a Phd topic, book or long research article.
The main driving force against rational opioid use today is lead by the USA and the zeal with which 'anti-opioidists' pursue their 'cause' is mixed up with the irrational, ineffectual manufactured 'war on drugs' and in the pandemic of religious fundamentalism that dominates US culture. The anti opioid medical lobby has manufactured misinformation on the role of opioids. The US is not entirely to blame as the British used opium to devastating economic effect as a weapon against the Chinese after which medical opinion started to change and certainly after soldiers started to use morphine in the first and second world wars. The impact of substances on a culture requires more than just analysis of the bio-chemical/physiological/psychological basis of action.
Unfortunately, Australia is a client state of the US but in some ways we here are more conservative. The consideration of appropriate use of opioids is in the Dark Ages.
The upshot of all of this is that there are vast numbers of people who suffer needlessly. Many chronic pain conditions can be successfully managed with little risk through the rational use of opioids in a broad pain management plan. I'm being generous here to pain management 'holistic' folks as I believe that most pain can be managed by opioids and opioid agonists and antagonists. There are other positive health benefits that come out of multidisciplinary approaches to pain management but it is surreptitious to leverage these benefits on the basis of pain management. I'd even be prepared to go as far as to include so called 'psychic' pain in rational opioid use. It is all a matter of rational, educated management.
I recently was offered and attended a four day (eight half days over two months) pain education program at taxpayers expense because the physician believed that while I may have been in the category of those with chronic pain who might benefit from opioid use I also might not, so rather than finding out and trialing an opioid first I went through the pain education program - the real cost of which was probably well over A$5,000.
Many if not most local physicians (we call them General Practitioners - GPs - here in Australia) don't know the difference between addiction, pseudo-addiction, tolerance and dependency. Rather than learning how to manage their patients pain patients are sent of to pain management centres (PMCs) some of which are set up as commercial operations. While there is good evidence that some people benefit from multidisciplinary pain management approaches and many people benefit to some degree it is irrational to exclude opioid use.
One reason opioids don't get used here is that it requires the doctor to register their use - they are monitored once their use exceeds a certain amount. There are different requirements in different states in Australia. Part of the reasons for restriction is that some doctors were self administering opioids, some (were talking of a handful over many decades) were also diverting them. Doctors hate being monitored. There is little justification for them to fear that their appropriate substantive use would lead to questioning let alone any disciplinary action. All is required is that they phone a number and register the use (diagnosis, dose, duration) - they receive a code that is used by the pharmacist to validate the script to help prevent forgeries. There were attempts to enforce doctors to obtain a second opinion whenever they wished to use opioids. This was ludicrous and on this I am sympathetic with doctors - this level of interference by bureaucracy is unjustified.
Some of the promotion of PMCs is ludicrous. In one "news" story recently (in fact a covert ad for a PMC) a patient sitting behind her work desk advocated the PMC she stated - "I once suffered from migraines - now I just don't think about them - I still get them - I just don't think about them, I get on with my job". Clearly whatever this woman experienced as a migraine is not what I experience - in absence of other indictations I think the trail of vomit and diarrhoea across the office floor might give the game away that there was more going on for me than just a headache. While I know there are means to lessen the incidence of migraine I have yet not been offered (except Cafergot with one GP) any drug treatment options beyond paracetamol.
Two doctors I visited had extreme views about opioids.
Listen to this story. It didn't occur to me when I was experiencing protracted dry vomiting due to a stomach bug why one particular doctor stated when I asked for the antiemetic Stematil "I probably shouldn't be giving you this". I don't think it was due to possible side effects. Years latter I approached this doctor for an opioid. I was armed with information. I suggested Oxycontin (Oxycodone slow release - I had the opportunity to try a limited quantity and found it effective). His response was dramatic and in an agitated manner he stated waving his finger "Do you use narcotics?" I replied "no just paracetamol, even paractemol/codiene doesn't work well for me...." then he stated "I don't turn my patients into addicts - I don't prescribe narcotics to any of my patients - If I prescribed you a narcotic and you told someone my waiting room would be full of drug addicts". I asked what alternatives there were to paracetamol and non steroidal anti-inflamatories and he suggested I go to a PMC. Then it clicked as to why years earlier he made the statement about Stematil - he was thinking that I could be using it to offset opioid nausea/emises. Wow - this doctor was mad with suspicion. In yet another visit when he refused Zyban (bupiopion) as a quit smoking aid - after initially mis-classifying the drug and looking it up on screen he said one of the side effects was a risk of seizure - he had never prescribed it.
Another doctor refused to see me again after I asked for opioid pain relief(without telling me at the time - on a subsequent visit the administrator at the counter said she - the Dr - "didn't want to see me and I should go elsewhere). I visited my regular doctor (in another state whilst on holidays - I had moved) who was more amenable - he had entrusted me with Rohypnol (Flunitrazepam) on one occasion. His response was that he only used opioids with his cancer patents and wrote my request into his records.
These experiences have happened over the course of years. I am now about to consult a Dr who is an expert in addiction and dependency and specialises in the treatment of 'street' addicts. First indications is that he says he may not be able to help in pain management outside of his limited field. It is ironic that if I was 'hooked' on street heroin I would probably receive better health care than I do as a well informed middle class patient with a chronic pain condition. I have come close to trying to procure illicit opioids. The risk of apprehension is too great, I have a dependent whom I'm responsible for - such is my luck I expect that my attempted first deal would be with a under cover law enforcement officer. I don't fancy my chances trying to explain to a magistrate the reasoning behind my actions. In any case I can't afford to purchase illicitly.
All in all the state of rational use of opioids in "non-cancer" pain in Australia is PATHETIC. There are a few champions in the literature but I have yet to meet them let alone get access to opioids through them.
That a painful degenerative condition that is not life terminating should be distinguished on the basis of terminating with death verses ongoing life debilitating is irrational.
From an economic viewpoint billions are lost through non productivity. During the one 4-6 week period I had access to Endone (5mg) and Oxycontin (10mg) I was able to return to paid employment - albeit in a friends business. Untreated I am a liability - I wouldn't employ me! The prospect of lying to an employer doesn't sit well with me - I have a hard enough time dealing with my anxiety of workplaces.
Chronic pain has been shown to impact on hippocampal structure and function - evidence of dendritic retraction and cell death has been presented. This could account or contribute to my recent diagnosis of adult ADHD (inattentive type) verified independently with QEEG (for what it is worth - I have little knowledge of the efficacy of QEEG although my psychiatrist believes she can see evidence of ADHD on EEG traces). While I haven't had my memory tested yet my subjective opinion is that it is poor. Some putative models of ADHD put working memory at the core of the condition. This makes a lot of sense to me. I am now a registered user of dexamphetamine - any doctor (an perhaps other agencies) in the country can find this out about me. Dex helps considerably with attention and also helps with the profound fatigue I experience - it's not a perfect treatment. In Australia there is a statutory limit to 30mg a day - I'm on 15mg and would like to trial a larger dose but my psych is against it.
There should be but is not a right to pain mitigation. Opiophobia in chronic pain is unjustifiable and not evidence based. This is a non technical forum but I would be prepared to go head to head with anyone in terms of a literature review/analysis who would be prepared to argue that opioids have no place in chronic pain management.
It has been argued by one doctor as part of my pain education program that opioids lose their effectiveness if used continuously (tolerance) and are not effective against neuropathic pain. This doctor knew well that my condition was nociceptive and to possibly a lesser extent 'neuropathic', he just wanted to obfuscate and avoid my questions. The distinction in pain management terms is questioned by some experts. It may well be the case that I do develop tolerance at the levels I am comfortable taking (I have reasons to think not and that an effective maintenance dose for me is quite small and this only contributes to doctors suspicion). There may be a level where the cognitive effects are problematic - I suspect so. Other side effects may limit opioid use - nausea, constipation. My experience is that codeine is far more constipating for me than Oxycodone. I get a daily headache with codeine/paracetamol compound - indeed two doses (20mg Codeine/500mg Paracetamol at 4 hour interval) will give me a rebound like headache particularly if I take it in the evening - I can guarantee waking with a headache.
So I take 4 grams of paracetamol every four waking hours. Am I dependent on paracetamol - by some criteria yes. It is some but limited help, I know if I stop taking it pain will increase. I do wish to avoid pain - pain avoidance is a conditioned response. Do I get irritable and seek out my paracetamol - sometimes yes - especially if I go out and forget to take a supply or run out and search my house for misplaced supply. Sometimes I'm not timely with taking it, sometimes I forget if I've taken it - it is so ineffective you don't know if you've taken it or not. I've asked about the risk and harm of accidental double dosing paracetamol - there is no risk with the levels of opioid I expect I need. Respiratory depression would require a much larger dose.
Has having done the pain education program helped? Yes, I have restarted doing meditation - it has thrown up some other psychological issues that I'm dealing with - for the hour I do it, provided I am seated properly or lying down I experience less pain. Does meditation have ongoing pain reduction effects? - I think not. Does exercise help? - yes but not as much as is suggested. I have been 'super fit' before - provided I have extensive periods to rest afterwards I can exercise hard. Do I get a lasting endorphin effect - probably not. I cramp up regardless of whether I do exercise. I need to do yoga stretching regardless of aerobics. I also find hard exercise precipitates the frequency and depth of migraines, I am advised the more exercise I can do the better but find moderate gentle exercise and rest helps more. Do I think appropriate analgesia and all of the other stuff together works better than either alone? - yes but I'm not afforded 'appropriate' analgesia. Would you exercise more with better analgesia? - probably.
Addiction leading to abuse is a real phenomenon although I would probably characterise it differently than the mainstream. Paradoxically attempting to with hold addictive substances can increase the depth of substance seeking and interfere more with the quality of the persons life and the community around them than if they were allowed supervised access. That there are some who are addicted or have the potential to become addicted to opioids is no justification to with hold analgesia. Those in chronic pain are less able than most addicts at achieving access to analgesia. There is scant unreliable evidence that opioid use by chronic pain sufferers leads to addiction.
My experience with Endone/Oxycontin was profound not only from a pain perspective but also from a cognitive and mood perspective. I will however post this up in another thread "Oxycodones stimulant effects and ADHD".
That's all
D
Posted by Larry Hoover on September 3, 2007, at 15:19:40
In reply to More questions for Larry, posted by Cecilia on August 31, 2007, at 2:06:45
> As for pain meds, oxycodone, also appears to use CYP2D6, but you say it still works for people with a deficiency in this enzyme? I'm confused.
You're right, oxycodone (Percocet, Oxycontin) can be metabolized to oxymorphone (Numorphan). The latter is a very powerful analgesic, generally administered intravenously. Oxycodone, however, is no slouch, either. It is quite active in its parent form, prior to any enzymatic/metabolic actions. That stands in contrast to the codeine/morphine pair, with the former having less than 1% of morphine's affinity at mu opioid receptors.
> I guess the 1st thing is to see if I can convince my doctor to figure out if I really am deficient in this enzyme, though it sure sounds like it from my reaction to Vicodin.
I'm a little surprised by that, honestly, as hydrocodone should be analgesic in its parent form, too. It is much less potent than hydromorphone, but like oxycodone, its not generally thought of as being a weak analgesic. Nonetheless, the typical user of oxycodone and hydrocodone experiences some substantial extra effects from the desmethylated forms. Absent that bonus-round kick, it really isn't fair, is it?
> I've given up hope of ever finding anything that would work for depression, but it sure would be nice to be in less pain from my severe arthritis. Cecilia
Amen to that. I wish you success.
Lar
Posted by Larry Hoover on September 3, 2007, at 16:25:05
In reply to Re: Getting Doctors to prescribe opiates, posted by Deus_Abscondis on September 2, 2007, at 1:29:14
> So I take 4 grams of paracetamol every four waking hours.
There's a whole lot more in your post than this sentence worth commenting on, but I wanted to jump to this issue....that amount of acetominophen/paracetamol is very likely to be above your liver's capacity. The daily intake limit is 4 grams, and chronic use at even that level can be hepatotoxic.
In small doses, paracetamol is metabolized by conjugation, but those pathways are easily saturated. In large doses, one molecule of paracetamol requires one molecule of glutathione to detoxify a toxic intermediate called NAPQI, but there is a limited supply of glutathione. Once glutathione is depleted, liver cells are programmed to die, a process called apoptosis. If you are going to maintain that level of liver stress, you must supplement proportionally with glutathione precursors. Hospitals administer N-acetyl cysteine in cases of paracetamol toxicity, and you can do the same. Paracetamol and NAC have roughly the same molecular weight, so if you're taking 4 grams of paracetamol, I'd recommend 4 grams of NAC, taken at the same time.
Lar
Posted by Cecilia on September 4, 2007, at 1:46:43
In reply to Re: More questions for Larry » Cecilia, posted by Larry Hoover on September 3, 2007, at 15:19:40
Now I'm even more confused. I thought your earlier post said that if I lacked this enzyme hydrocodone wouldn't work for me and the 2nd one said you were surprised it didn't. It definitely doesn't help, but I can't see paying the crazy price for that Amplichip test, I guess I'll just have to see if anything else helps that they're willing to prescribe. The only other alternate is total knee replacement, and I'm just too scared. Cecilia
Posted by Larry Hoover on September 4, 2007, at 10:46:29
In reply to Still confused-Larry, posted by Cecilia on September 4, 2007, at 1:46:43
> Now I'm even more confused. I thought your earlier post said that if I lacked this enzyme hydrocodone wouldn't work for me and the 2nd one said you were surprised it didn't.
I'm sorry if I'm contributing to the confusion. The enzyme issue and binding affinity are in the statistical realm. They are useful for prediction, but individual experience trumps the stats. Looking at the tabulated data for mu opioid receptor binding, it would appear that hydrocodone should offer some analgesia, even with zero function at 2D6. Your experience was that you got no pain relief from it, but still experienced the expected side effects. That would make a dose increase impractical, and does suggest that a painkiller with -morph- in its name might be necessary, in your case. I share your experience to a large degree, but oxycodone does work for me. I have never tried hydrocodone.
Lar
Posted by Deus_Abscondis on September 4, 2007, at 13:09:40
In reply to Re: paracetamol/acetominophen hepatoxicity » Deus_Abscondis, posted by Larry Hoover on September 3, 2007, at 16:25:05
Thanks Larry that needed to be corrected in print.
> > So I take 4 grams of paracetamol every four waking hours.
OOps, errr, 1 gram ever 4 hours. Thanks for correcting that.
>The daily intake limit is 4 grams, and chronic use at even that level can be hepatotoxic.
Dr says it's safe and not to take it only when you start to experience pain. Pdoc says it isn't so safe. Hence I'm trying to get an opioid. Codeine drys me out, esp bowel - I expect constipation is not simply effect on peristalsis. In large doses (30mg) I feel hot. It also tires me - especially around the eyes. Oxycodone stimualtes and clarifies - brain fog lifts. The clarification is somewhat like cocaine but overall less dramatic - I tried it, small amounts on two occasions 25 years ago. I've never felt better than on Oxy (see my post on Oxy and ADHD). I haven't tried Oxy since I started Dex. I really hope the stimulant effect doesn't fade as tolerance develops - if it would on lowish dosages. It has puzzled me that I haven't noticed tolerance develop to Dex.
I'm wondering where the stimulant effect comes from with Oxy. If IIRC pethidine metabolises to norpethidine which has a stimulatory or "exitatory" effect.
There's more going on than just receptor binding - the regulation of the pain pathways change. I've noticed with Oxy that I feel better for days after a dose. I hypothesise that pain sensitisation is a derangement of the dynamics of nerve networks and that opioids break the viscious cycle (or postive feedback/forward that sets in).
Anyway I only a month or so with Oxy and that was some time ago now. I just wish I could trial it to see if it really does the things I recall.
Apart from irresponsibly ramping up the dose I just can't see where the danger is. Even if tolerance develops as much as some doctors suggest - even if I took it and had breaks then I would be overall better off.
One doctor said "if I prescribed it to you and you suicided on it my name would be on the label" to which I replied "it is on the label of the box of bulk paracetamol - at least you'd be able to visit me before my liver finally packed in". I get frustrated.
D
Posted by FredPotter on September 4, 2007, at 15:30:37
In reply to Re: paracetamol/acetominophen hepatoxicity » Deus_Abscondis, posted by Larry Hoover on September 3, 2007, at 16:25:05
Thanks Larry - great information. I've only heard rumours uo to now Fred
Posted by misslucrezia on October 15, 2007, at 22:24:21
In reply to Re: Getting Doctors to prescribe opiates, posted by Deus_Abscondis on September 2, 2007, at 1:29:14
Paracetomol is not ideal, long term.
A wise move would be to address the root of the problem that is sustaining that level of pain. My sympathies.
Posted by Deus_Abscondis on October 16, 2007, at 5:28:48
In reply to Re: Getting Doctors to prescribe opiates » Deus_Abscondis, posted by misslucrezia on October 15, 2007, at 22:24:21
Thanks MissL,
- funny I knew another MissL (different spelling though). While I try not to wallow in self pity having and showing sympathy is helpful, so thanks again.
The warmer weather is helping.
I'm looking into possible latent virus issues that could account for transient bouts of horrible malaise/sickness and possible antibiotic treatment for the osteoarthritis (which is evident on scans only - no blood indicators of inflammation), possible autoimmune factors also should be investigated.
The problem with chronic pain of musculo-skeletal origin is that neural pathways change not only in function (increased excitability) but also morphologically (nerves sprout extra dendrites and connectivity changes).
Opioids provide symptomatic relief and in absence of changing the underlying neural changes they are useful if used properly. Indeed opioids may allow re-conditioning of peripheral neural networks by, simplifying it, - giving them a rest and possibly resetting thresholds and together with lifestyle changes e.g., increased exercise may have long term benefit.
Cheers
D
> Paracetomol is not ideal, long term.
> A wise move would be to address the root of the problem that is sustaining that level of pain. My sympathies.
>
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