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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 15 of 15. This is the beginning of the thread.
Posted by Philip Burke on November 17, 2007, at 16:39:33
I would appreciate input regarding different drug regimes for the treatment of Degenerative Disc Disease, "Failed Back Surgery Syndrome", radiculopathy and various neuropathies associated with this illness. I have been suffering from lower back and leg pain for over 10 years. I've had discectomies X 2 @ L4-5, 1998 & 2000. I had a spinal cord stimulator implanted in 2002, but the efficacy of this device is greatly compromised by "postural problems", rendering it practically useless to me unless I am lying supine, motionless on my bed. I am trying to achieve the best balance of antidepressants, painkillers, anti-seizure medications and any other medication that is effective, for pain relief and mood improvement. I currently see a Pain Management specialist and a psychiatrist to treat chronic pain and depressed mood. I've tried several different antidepressants, and have, at this point in time, settled on a combination of two - Remeron, 30 mgs at bedtime, and Zoloft, 100 mgs in the morning. I also take 100 mgs of Lyrica three times a day and one tablet of Vicoprofen as needed up to 3 times a day. I cannot tolerate Cymbalta. Practically every doctor I have been to recommends this drug, but I have tried twice (over 6 weeks of 60 mgs) and found that although it helps with pain, I could not stand feeling like a brain dead zombie. I keep trying to find the best combination of medications, without the use of narcotics or opiates, to get the relief I need. Any input, suggestions, comments, etc. will be greatly appreciated.
Posted by Sigismund on November 17, 2007, at 17:45:56
In reply to Degenerative Disc Disease and Psychiatric Meds, posted by Philip Burke on November 17, 2007, at 16:39:33
Congratulations on being able to type that out.
I know what it's like, having ruptured a disc 20 years ago.The best thing for me has not been meds but really good physiotherapy, the sort that is very hard to find.
Basically it's a combination of Feldenkrais and Pilates with elements of Horvath (http://www.gyrotonic.com/), taught by pysiotherapists.
One doctor who was kind enough to write me narcotics once said (correctly, IMO) 'Mate, NOTHING works for nerve root pain'.
Every available (only) slightly useful drug is way to toxic/inapropriate for me, though I find Boswellia useful for arthritis and hope it helps with the back and leg pain I get. But I'm lucky...it's not too bad.
Posted by Philip Burke on November 17, 2007, at 17:54:06
In reply to Re: Degenerative Disc Disease and Psychiatric Meds » Philip Burke, posted by Sigismund on November 17, 2007, at 17:45:56
> Congratulations on being able to type that out.
> I know what it's like, having ruptured a disc 20 years ago.
>
> The best thing for me has not been meds but really good physiotherapy, the sort that is very hard to find.
>
> Basically it's a combination of Feldenkrais and Pilates with elements of Horvath (http://www.gyrotonic.com/), taught by pysiotherapists.
>
> One doctor who was kind enough to write me narcotics once said (correctly, IMO) 'Mate, NOTHING works for nerve root pain'.
>
> Every available (only) slightly useful drug is way to toxic/inapropriate for me, though I find Boswellia useful for arthritis and hope it helps with the back and leg pain I get. But I'm lucky...it's not too bad.Thanks for the "gyrotonic" physical therapy suggestions; I found a gym fairly close that has that equipment.
What is "Boswellia"? Will it help "nerve pain" as well as arthritis?
Posted by Sigismund on November 17, 2007, at 18:09:21
In reply to Re: Degenerative Disc Disease and Psychiatric Meds » Sigismund, posted by Philip Burke on November 17, 2007, at 17:54:06
>I found a gym fairly close that has that equipment.
Excellent. That's what you need. And a good teacher who is also a physio.
Where I go (core stability stuff) lots of people have injuries.
>What is "Boswellia"? Will it help "nerve pain" as well as arthritis?
This is what I take for my arthritis.
http://www.lef.org/newshop/items/item00620.html(The boswellia is frankinsense, I think, which may have been the NSAID of Jesus' time.)
Will it help with nerve pain?
Maybe a little, I'm not sure at all.Do you have arthritis?
It's brilliant for that.
Posted by Philip Burke on November 17, 2007, at 18:53:07
In reply to Re: Degenerative Disc Disease and Psychiatric Meds » Philip Burke, posted by Sigismund on November 17, 2007, at 18:09:21
> >I found a gym fairly close that has that equipment.
>
> Excellent. That's what you need. And a good teacher who is also a physio.
>
> Where I go (core stability stuff) lots of people have injuries.
>
> >What is "Boswellia"? Will it help "nerve pain" as well as arthritis?
>
> This is what I take for my arthritis.
> http://www.lef.org/newshop/items/item00620.html
>
> (The boswellia is frankinsense, I think, which may have been the NSAID of Jesus' time.)
>
> Will it help with nerve pain?
> Maybe a little, I'm not sure at all.
>
> Do you have arthritis?
> It's brilliant for that.
>
> For a 54 y/o man, I suppose I do, but the nerve pain is by far the most bothersome. I have not come across anything about a natural supplement or herb that reduces that type of pain.
Posted by Jay_Bravest_Face on November 17, 2007, at 19:14:51
In reply to Degenerative Disc Disease and Psychiatric Meds, posted by Philip Burke on November 17, 2007, at 16:39:33
> I would appreciate input regarding different drug regimes for the treatment of Degenerative Disc Disease, "Failed Back Surgery Syndrome", radiculopathy and various neuropathies associated with this illness. I have been suffering from lower back and leg pain for over 10 years. I've had discectomies X 2 @ L4-5, 1998 & 2000. I had a spinal cord stimulator implanted in 2002, but the efficacy of this device is greatly compromised by "postural problems", rendering it practically useless to me unless I am lying supine, motionless on my bed. I am trying to achieve the best balance of antidepressants, painkillers, anti-seizure medications and any other medication that is effective, for pain relief and mood improvement. I currently see a Pain Management specialist and a psychiatrist to treat chronic pain and depressed mood. I've tried several different antidepressants, and have, at this point in time, settled on a combination of two - Remeron, 30 mgs at bedtime, and Zoloft, 100 mgs in the morning. I also take 100 mgs of Lyrica three times a day and one tablet of Vicoprofen as needed up to 3 times a day. I cannot tolerate Cymbalta. Practically every doctor I have been to recommends this drug, but I have tried twice (over 6 weeks of 60 mgs) and found that although it helps with pain, I could not stand feeling like a brain dead zombie. I keep trying to find the best combination of medications, without the use of narcotics or opiates, to get the relief I need. Any input, suggestions, comments, etc. will be greatly appreciated
>
>Hi...
I am really sorry you have had to live with so much pain. (physical and mental) Myself, although I've never experienced the horrible painful situation you are in, have lived with a chronic, scarred deep sinus cavity infection that flares up out of the blue, (it puts pressure on the bone) for the past 10 years. I tried surgery without sucess. Pain management really became the focus once I realized how this pain was affecting my mental health. I have some good doctors who have helped me.
You say you do not want to turn to narcotics. I understand, greatly, your concern. I recall going to a support group for people with pain management issues, and I saw a few things that scared me a bit. But, afterwards, I immediately went to my doctor, with a list of about 40 questions. I did not want to feel 'doped up', because I always knew that with those 'good' feelings comes the 'crash'. But, interestingly enough, it wasn't until he prescribed Oxycodone to take PRN, giving me only 7 doses in 14 days, that I finally felt better with my pain threshold...but..most importantly, I snapped out of my depressions easier. I didn't use the Oxycodone FOR my depression, but it was this relief that, if the really bad, big HURT came (a flare up), I had help. And honestly, I use on average 2 Oxycodone a week, sometimes even less. The reason my doc picked Oxycodone is because it got the job done fast, and it didn't leave me feeling 'high', like say if I took Tylenol#3, 4x a day, everyday. I take a few different NSAID's more regularly, to prevent inflammation from the start, and this has worked well. Oh, I also forgot to mention, apparently in pain management, benzodiazepines are contraindicated, but again using them in extreme moderation, they seem to calm the Central Nervous System. I do not take them everyday, and every night, and that is the key, I believe. It keeps me, I think, from getting the "brain fog" that some get from chronic use of both benzos and narcotics.
For your antidepressant choice, I am not really sure what to say. I was on Effexor as it supposedly had pain-reducing properties, but the stuff drove me nuts! I've been on Prozac for 5 years, and am looking at tapering down, either switching or coming off. I briefly tried Remeron, but it didn't cut it for me. A friend of mine takes Remeron as part of his pain management for back problems. Maybe that is an option to think about. Neurontin did nothing for me.
So, I hope that maybe gives you a different perspective on your options. Please take good care...and any questions please let me know. Thanks...Jay.
Posted by Phillipa on November 17, 2007, at 19:36:38
In reply to Re: Degenerative Disc Disease and Psychiatric Meds » Philip Burke, posted by Jay_Bravest_Face on November 17, 2007, at 19:14:51
I also ruptured a disc at L4 and 5 and had the pain going down my leg. I just let it heal on it's own as Pt made it worse. But Percocet l tab relieved depression for me with a broken arm but the doc said leads to addiction but have been on benzos over 30 years so what is the difference. Good luck. Phillipa
Posted by Epiphanie on November 17, 2007, at 21:43:29
In reply to Re: Degenerative Disc Disease and Psychiatric Meds » Philip Burke, posted by Jay_Bravest_Face on November 17, 2007, at 19:14:51
it wasn't until he prescribed Oxycodone to take PRN, giving me only 7 doses in 14 days, that I finally felt better with my pain threshold...but..most importantly, I snapped out of my depressions easier.
****Me too, I needed 20 mg for Sciatica, but after my initial prescription no one would give me Oxycontin again and I too was referred to Pain management. I was soooo NOT depressed when I finally felt relief from the pain.
I didn't use the Oxycodone FOR my depression, but it was this relief that, if the really bad, big HURT came (a flare up), I had help. And honestly, I use on average 2 Oxycodone a week, sometimes even less.****Me too, but the days in between were excrutiating. I became homebound. Since no one would give me more Oxycontin, I used what I had left only for emergencies, like when I had to get my prescriptions, groceries and go to Doctor appointments.
Pain Management wants to inject Steroids into my spine but I have an infection so I can't do it now.I've been on Prozac for 5 years, and am looking at tapering down, either switching or coming off.
****Why do you want to stop Prozac? I made a big mistake going off Prozac. I just recently went back to it. Have you considered lowering the dosage? I have read many places that by lowering the dosage or skipping days can make Prozac work again if you have Poop-out.
>
Posted by Philip Burke on November 17, 2007, at 22:27:01
In reply to Re: Degenerative Disc Disease and Psychiatric Meds » Philip Burke, posted by Jay_Bravest_Face on November 17, 2007, at 19:14:51
> > I would appreciate input regarding different drug regimes for the treatment of Degenerative Disc Disease, "Failed Back Surgery Syndrome", radiculopathy and various neuropathies associated with this illness. I have been suffering from lower back and leg pain for over 10 years. I've had discectomies X 2 @ L4-5, 1998 & 2000. I had a spinal cord stimulator implanted in 2002, but the efficacy of this device is greatly compromised by "postural problems", rendering it practically useless to me unless I am lying supine, motionless on my bed. I am trying to achieve the best balance of antidepressants, painkillers, anti-seizure medications and any other medication that is effective, for pain relief and mood improvement. I currently see a Pain Management specialist and a psychiatrist to treat chronic pain and depressed mood. I've tried several different antidepressants, and have, at this point in time, settled on a combination of two - Remeron, 30 mgs at bedtime, and Zoloft, 100 mgs in the morning. I also take 100 mgs of Lyrica three times a day and one tablet of Vicoprofen as needed up to 3 times a day. I cannot tolerate Cymbalta. Practically every doctor I have been to recommends this drug, but I have tried twice (over 6 weeks of 60 mgs) and found that although it helps with pain, I could not stand feeling like a brain dead zombie. I keep trying to find the best combination of medications, without the use of narcotics or opiates, to get the relief I need. Any input, suggestions, comments, etc. will be greatly appreciated
> >
> >
>
> Hi...
>
> I am really sorry you have had to live with so much pain. (physical and mental) Myself, although I've never experienced the horrible painful situation you are in, have lived with a chronic, scarred deep sinus cavity infection that flares up out of the blue, (it puts pressure on the bone) for the past 10 years. I tried surgery without sucess. Pain management really became the focus once I realized how this pain was affecting my mental health. I have some good doctors who have helped me.
>
> You say you do not want to turn to narcotics. I understand, greatly, your concern. I recall going to a support group for people with pain management issues, and I saw a few things that scared me a bit. But, afterwards, I immediately went to my doctor, with a list of about 40 questions. I did not want to feel 'doped up', because I always knew that with those 'good' feelings comes the 'crash'. But, interestingly enough, it wasn't until he prescribed Oxycodone to take PRN, giving me only 7 doses in 14 days, that I finally felt better with my pain threshold...but..most importantly, I snapped out of my depressions easier. I didn't use the Oxycodone FOR my depression, but it was this relief that, if the really bad, big HURT came (a flare up), I had help. And honestly, I use on average 2 Oxycodone a week, sometimes even less. The reason my doc picked Oxycodone is because it got the job done fast, and it didn't leave me feeling 'high', like say if I took Tylenol#3, 4x a day, everyday. I take a few different NSAID's more regularly, to prevent inflammation from the start, and this has worked well. Oh, I also forgot to mention, apparently in pain management, benzodiazepines are contraindicated, but again using them in extreme moderation, they seem to calm the Central Nervous System. I do not take them everyday, and every night, and that is the key, I believe. It keeps me, I think, from getting the "brain fog" that some get from chronic use of both benzos and narcotics.
>
> For your antidepressant choice, I am not really sure what to say. I was on Effexor as it supposedly had pain-reducing properties, but the stuff drove me nuts! I've been on Prozac for 5 years, and am looking at tapering down, either switching or coming off. I briefly tried Remeron, but it didn't cut it for me. A friend of mine takes Remeron as part of his pain management for back problems. Maybe that is an option to think about. Neurontin did nothing for me.
>
> So, I hope that maybe gives you a different perspective on your options. Please take good care...and any questions please let me know. Thanks...Jay.
>
> Jay,
Thanks for your input. I have this fear of "addiction" when it comes to narcotics, yet pain management docs don't hesitate to give me MSContin, oxycodone or both. I suppose that if you get it from medical doctors who monitor you closely, it is not addiction. If you get it off the streets and take it for fun, it is addiction. Semantics. I have an appt. with my PM doc on 12/3 and will probably get an Rx for some strong painkiller because the pain I feel is zapping all the fun out of life. I really don't want to take the "time release" painkillers on a regular basis, although that seems to be what they always recommend. I think that taking oxycodone p.r.n. is best. I just simply want to stop hurting so much. The two antidepressants I take work well enough, but I would like to take just one that will help reduce pain, improve my mood, help me sleep, calm me down a bit - all in one. I was hoping someone out there may have this same syndrome of pain and takes just one effective antidepressant. What works best? I am always open for suggestions.
>
>
>
>
Posted by kaleidoscope on November 18, 2007, at 15:13:04
In reply to Degenerative Disc Disease and Psychiatric Meds, posted by Philip Burke on November 17, 2007, at 16:39:33
Hi
It's interesting that you're taking Remeron and Zoloft since neither of these drugs are generally used to treat neuropathic pain. SSRIs such as Zoloft are considered to be ineffective in the treatment of neuropathic pain whereas Remeron has not been studied for this indication. It is important to bear in mind that although some antidepressants have a clear role in the treatment of neuropathic pain (eg. amitriptyline), others show no efficacy at all.
The tricyclic antidepressants are often the most effective drug treatment for neuropathic pain. Amitriptyline (Elavil) is the best established. The usual initial dose is 10 or 25mg at night increasing to 50-75mg. Nortriptyline can be used as an alternative - starting with 10mg at night and increasing up to a usual maximum of 75mg. Nortriptyline is considerably less sedating than amitriptyline and causes a lower incidence of adverse effects overall. Other tricyclic antidepressants such as imipramine and desipramine are also sometimes used to treat neuropathic pain. Desipramine is much less sedating than amitripyline.
SSRIs show very little efficacy in the treatment of neuropathic pain and should not generally be prescribed solely for this purpose.
Among the newer antidepressants, venlafaxine (Effexor) and duloxetine (Cymbalta) can be effective in the treatment of neuropathic pain, most notably diabetic neuropathy. Duloxetine (Cymbalta) is officially approved for diabetic neuropathic pain. The usual dose is 60mg per day. Effexor and Cymbalta both cause a high incidence of side effects and are much more expensive than tricyclics.
Among the antiepileptics, gabapentin (Neurontin) and pregabalin (Lyrica) are similar in effectiveness and have received the most study. Carbamazepine (Tegretol) may also be effective, although it is not as well proven. If necessary, the dose of pregabalin can be increased up to a maximum of 600mg per day in two or three divided doses. Side effects are dose-dependent.
Tramadol, a weak opioid with additional properties, has shown effectiveness in the treatment of certain types of neuropathic pain. Tramadol can be tried before considering potent opioids.
Posted by Philip Burke on November 21, 2007, at 14:04:09
In reply to Neuropathic pain » Philip Burke, posted by kaleidoscope on November 18, 2007, at 15:13:04
> Hi
>
> It's interesting that you're taking Remeron and Zoloft since neither of these drugs are generally used to treat neuropathic pain. SSRIs such as Zoloft are considered to be ineffective in the treatment of neuropathic pain whereas Remeron has not been studied for this indication. It is important to bear in mind that although some antidepressants have a clear role in the treatment of neuropathic pain (eg. amitriptyline), others show no efficacy at all.
>
> The tricyclic antidepressants are often the most effective drug treatment for neuropathic pain. Amitriptyline (Elavil) is the best established. The usual initial dose is 10 or 25mg at night increasing to 50-75mg. Nortriptyline can be used as an alternative - starting with 10mg at night and increasing up to a usual maximum of 75mg. Nortriptyline is considerably less sedating than amitriptyline and causes a lower incidence of adverse effects overall. Other tricyclic antidepressants such as imipramine and desipramine are also sometimes used to treat neuropathic pain. Desipramine is much less sedating than amitripyline.
>
> SSRIs show very little efficacy in the treatment of neuropathic pain and should not generally be prescribed solely for this purpose.
>
> Among the newer antidepressants, venlafaxine (Effexor) and duloxetine (Cymbalta) can be effective in the treatment of neuropathic pain, most notably diabetic neuropathy. Duloxetine (Cymbalta) is officially approved for diabetic neuropathic pain. The usual dose is 60mg per day. Effexor and Cymbalta both cause a high incidence of side effects and are much more expensive than tricyclics.
>
> Among the antiepileptics, gabapentin (Neurontin) and pregabalin (Lyrica) are similar in effectiveness and have received the most study. Carbamazepine (Tegretol) may also be effective, although it is not as well proven. If necessary, the dose of pregabalin can be increased up to a maximum of 600mg per day in two or three divided doses. Side effects are dose-dependent.
>
> Tramadol, a weak opioid with additional properties, has shown effectiveness in the treatment of certain types of neuropathic pain. Tramadol can be tried before considering potent opioids.
>
> I was taking the synthetic opiate Ultram ER 300 mg. (tramadol), the maximum dose, for about 3 months with mirtazapine, 30 mg. at bedtime. It help reduce the neuropathic pain considerably, but I began to have insomnia, headaches and increased sweating. I was told by others I looked "red in the face". Just by chance, I took my blood pressure at my pharmacy in one of those set ups for the public. It read 148/118. Since I am a trained First Responder and have a sphygmomanometer and stethoscope, I took my BP again at home and found the same high BP. Typically, my BP is ~128/86. I found a PDR, looked up Ultram and found that the most common side effects are an increase in BP and insomnia AND I read that it should be prescribed with caution if an antidepressant is being taken. I stopped it immediately and went through a week of hellish withdrawal. Curiously, the withdrawal symptoms were almost exclusively mental - dysphoria, difficulty concentrating, anergia and fatigue. My BP dropped to a more normal reading of ~118/78, the headaches stopped and I stopped having trouble getting to sleep. I caution anyone who is considering taking Ultram while taking an antidepressant, especially one that potentiates both seratonin and norepineprine in synaptic transmission. I thought that I had found the best and safest painkiller for my neuropathy, but obviously not.I have found that Remeron helps with pain. It is a tetracyclic, potentiates both seratonin and norepinephrine and does not have the troublesome anticholinergic side effects of the tricyclics. But, I have gained over 25 lbs since I started taking it, something you do not want to do when you have polyneuropathy due to "failed back surgery syndrome" (discectomy X 2 @ L4-5). Which antidepressant can help my neuropathic pain, does not cause weight gain and other bothersome side effects, and also is effective in treating my unipolar affective mood disorder? I am having a very difficult time trying to find out. I tried Cymbalta twice, over 6 weeks on 60 mgs. each time, but felt absolutely awful. Every doctor I have been to recommends Cymbalta, but I cannot take it.
The pain I experience is radicular, due to nerve damage from nerve root compression at L3-4-5, but seems to respond to the type of drug therapy that is used for diabetic neuropathy. Paroxetine and sertraline have been shown to be somewhat effective in diabetic neuropathy, and therefore I have found these drugs to help my condition. I was taking MSContin, 30 mg. every 12 hours, with mirtazapine. Paroxetine was added, and after about 2 weeks my pain decreased and I was able to decrease the MSContin 50%.
I take 100 mgs. of Lyrica three times daily and find it very helpful. I find it better than Neurontin due to its longer half-life.
Apparently, save for Wellbutrin, practically every antidepressant I have looked into can cause weight gain. In most cases, though, it is not clear whether it is due to the drug, or to the syndrome of depressive illness. Has anyone out there LOST weight after taking a particular antidepressant other than Wellbutrin? I am looking for one that will help with pain, not make me gain weight, and is effective in relieving the symptoms of depression.
I am hopeful that with the right antidepressant, at the best dosage, along with the Lyrica, I can go without taking a powerful painkiller. The trick is finding the drugs with side effects that are tolerable.
Posted by Sigismund on November 21, 2007, at 18:13:31
In reply to Re: Neuropathic pain, posted by Philip Burke on November 21, 2007, at 14:04:09
I'm wondering if the ADs that help with pain also tend to cause weight gain?
(I don't know at all.)But keeping the weight down would have to be a priority for you, at least long term.
Posted by Philip Burke on November 21, 2007, at 23:07:05
In reply to Re: Neuropathic pain » Philip Burke, posted by Sigismund on November 21, 2007, at 18:13:31
> I'm wondering if the ADs that help with pain also tend to cause weight gain?
> (I don't know at all.)
>
> But keeping the weight down would have to be a priority for you, at least long term.That's the challenge I have . . . getting my weight down (at least 30 lbs), while being on an antidepressant that helps with pain, but does not cause weight gain. I wonder if Effexor causes weight gain? Can anyone who takes Effexor tell me if weight gain is a problem?
Posted by kaleidoscope on November 25, 2007, at 13:34:44
In reply to Re: Neuropathic pain, posted by Philip Burke on November 21, 2007, at 14:04:09
>Which antidepressant can help my neuropathic pain, does not cause weight gain and other bothersome side effects, and also is effective in treating my unipolar affective mood disorder?
Have you tried nortriptyline or desipramine? Both of these drugs sometimes cause weight gain, especially nortriptyline, but neither of them are anywhere near as bad as Remeron.
>I am hopeful that with the right antidepressant, at the best dosage, along with the Lyrica, I can go without taking a powerful painkiller
The thing is, for some people, antidepressants can cause more side effects than conventional analgesics.
Posted by Philip Burke on November 25, 2007, at 20:35:53
In reply to Re: Neuropathic pain » Philip Burke, posted by kaleidoscope on November 25, 2007, at 13:34:44
> >Which antidepressant can help my neuropathic pain, does not cause weight gain and other bothersome side effects, and also is effective in treating my unipolar affective mood disorder?
>
> Have you tried nortriptyline or desipramine? Both of these drugs sometimes cause weight gain, especially nortriptyline, but neither of them are anywhere near as bad as Remeron.
>
> >I am hopeful that with the right antidepressant, at the best dosage, along with the Lyrica, I can go without taking a powerful painkiller
>
> The thing is, for some people, antidepressants can cause more side effects than conventional analgesics.I couldn't agree more, but conventional analgesics provide very little relief for my neuropathic pain. Although, I may end up taking some type of opiod in a moderate dose to make living with the pain tolerable. It is somewhat of a dilemma or "Catch 22" for me since I am currently not working due to this painful condition. If I get on strong medication, the pain will be substantially reduced, making it possible to do a job and do it well, but who is going to hire someone on strong pain medication? Is there a law that protects people like me, prohibiting an employer from discriminating against me?
This is the end of the thread.
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