![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 5 to 29 of 29. Go back in thread:
Posted by floatingbridge on April 16, 2010, at 14:52:47
In reply to Re: ultram, really..., posted by ed_uk2010 on April 16, 2010, at 14:42:01
Well, this one has effexor-like properties. That's why I would consider it--my pdoc suggested it as an option. I'd jettison my pristiq.
I still don't know....
Thanks for weighing in Ed!
> I agree. Opioids can certainly produce euphoria in the short term but they are not antidepressants in the long term.
>
>
> > I don't think you're nuts. I have only second hand knowledge on this so take that FWIW.
> >
> > I know of two folks who have tried the opioid route to improve mood and functioning. Both had great results.... INITIALLY - around three months. After that, a tolerance issue came into play and the opioid use became chasing the original great results which were never achieved again even at higher more frequent dosings.
> >
> > I think it's a slippery slope for some. The idea of one individual over another being an opioid responder is an idea that is difficult for me to grasp. I believe the human brain - which we all have - IS opioid responsive.
> >
> > I don't want to rain on your idea but I think caution is advised and my opinion is the use of these compounds should be monitored even when used in chronic pain management because their "road use" is likely filled with potholes that just add to problems. Big problems.
>
>
Posted by bulldog2 on April 16, 2010, at 15:35:56
In reply to Re: ultram, really... » ed_uk2010, posted by floatingbridge on April 16, 2010, at 14:52:47
> Well, this one has effexor-like properties. That's why I would consider it--my pdoc suggested it as an option. I'd jettison my pristiq.
>
> I still don't know....
>
> Thanks for weighing in Ed!
>
> > I agree. Opioids can certainly produce euphoria in the short term but they are not antidepressants in the long term.
> >
> >
> > > I don't think you're nuts. I have only second hand knowledge on this so take that FWIW.
> > >
> > > I know of two folks who have tried the opioid route to improve mood and functioning. Both had great results.... INITIALLY - around three months. After that, a tolerance issue came into play and the opioid use became chasing the original great results which were never achieved again even at higher more frequent dosings.
> > >
> > > I think it's a slippery slope for some. The idea of one individual over another being an opioid responder is an idea that is difficult for me to grasp. I believe the human brain - which we all have - IS opioid responsive.
> > >
> > > I don't want to rain on your idea but I think caution is advised and my opinion is the use of these compounds should be monitored even when used in chronic pain management because their "road use" is likely filled with potholes that just add to problems. Big problems.
> >
> >
>
>Ultram doesn't offer much in the way of euphoria as oppossed to some of the full agonists. It also has some true ad features. You have to learn not to chase the high on any opiate or stimulant and they still can do their job. Some people use these drugs responsibly over a long period of time. You have to monitor drug dosage. If one is constantly escalating the dose than it is time to get off the med.
Posted by ed_uk2010 on April 16, 2010, at 16:18:01
In reply to Re: ultram, really... » ed_uk2010, posted by floatingbridge on April 16, 2010, at 14:52:47
> Well, this one has effexor-like properties. That's why I would consider it--my pdoc suggested it as an option.
I know, but I wouldn't generally recommend taking it as an AD. Opioids can elevate mood in the short term but I don't believe that they benefit depression in the long run. Even though tramadol may be different, I can't imagine that it would be better than Effexor in the long term.
If you suffer from chronic pain, I would consider tramadol. Otherwise, I think it would be sensible to avoid it.
Posted by floatingbridge on April 16, 2010, at 19:04:53
In reply to Re: ultram, really... » floatingbridge, posted by ed_uk2010 on April 16, 2010, at 16:18:01
Hi Ed, I do have chronic pain, sad to say--not as bad as many, so I'm not complaining. I don't know. I think that tramadol might mess with my pain mechanisms for lack of any techniqcal understanding--that maybe I would end up with a shortage of whatever they are, endorphins?. I am also looking into LDN as well, though my pdoc has not heard of that. That's why I'm seeing a specialist next week--for assessment and possible treatment plans. Then we'll see. OTC stuff doesn't touch the increasing flare-ups. Thanks again--it's a big idea for me to even entertain. In many ways, I'm in disbelief that I could be really ill.
Thanks for writing.
> > Well, this one has effexor-like properties. That's why I would consider it--my pdoc suggested it as an option.
>
> I know, but I wouldn't generally recommend taking it as an AD. Opioids can elevate mood in the short term but I don't believe that they benefit depression in the long run. Even though tramadol may be different, I can't imagine that it would be better than Effexor in the long term.
>
> If you suffer from chronic pain, I would consider tramadol. Otherwise, I think it would be sensible to avoid it.
Posted by Phillipa on April 16, 2010, at 21:41:02
In reply to Re: ultram, really... » ed_uk2010, posted by floatingbridge on April 16, 2010, at 19:04:53
FB I had saved an article on LDN and there was a reason decided not for me. For some reason I think it had to do with autoimmune? Goggle alternative. Love Phillipa
Posted by bulldog2 on April 17, 2010, at 8:32:00
In reply to Re: ultram, really... » ed_uk2010, posted by floatingbridge on April 16, 2010, at 19:04:53
> Hi Ed, I do have chronic pain, sad to say--not as bad as many, so I'm not complaining. I don't know. I think that tramadol might mess with my pain mechanisms for lack of any techniqcal understanding--that maybe I would end up with a shortage of whatever they are, endorphins?. I am also looking into LDN as well, though my pdoc has not heard of that. That's why I'm seeing a specialist next week--for assessment and possible treatment plans. Then we'll see. OTC stuff doesn't touch the increasing flare-ups. Thanks again--it's a big idea for me to even entertain. In many ways, I'm in disbelief that I could be really ill.
>
> Thanks for writing.
>
> > > Well, this one has effexor-like properties. That's why I would consider it--my pdoc suggested it as an option.
> >
> > I know, but I wouldn't generally recommend taking it as an AD. Opioids can elevate mood in the short term but I don't believe that they benefit depression in the long run. Even though tramadol may be different, I can't imagine that it would be better than Effexor in the long term.
> >
> > If you suffer from chronic pain, I would consider tramadol. Otherwise, I think it would be sensible to avoid it.
>
>Yes any opiate or stimulant causes your body to release less of the associated neurotransmitter. Less endorphins when taking an opiate and less dopamine when taking a stimulant. Also when you stop meds the body will gradually recover to its former levels. However when you're in pain your body is already not releasing enough endorphins or you would not be in pain. Tramadol is considered the milder of the opiates. It is not even a full agonist at the opiate receptor. Chronic pain is very debilitating. It certainly does take away from quality of life. Unfortunately decisions are rarely black and white or the perfect decision. I remember last year I resisted taking opiates for the longest time. So I sat in an easy chair all day gritting my teeth and being miserable. Finally went to the doc and asked for real pain meds. I did not take it for euphoria but so I could function. It was nice being able to not feel pain and walk around again. When I had to get off of them I did not find it that awful. A half a pill a week until I was off. Not really bad at all.I've talked to others who also did not have a hard time. People who end up chasing the high and get addicted will have a more difficult time.
You have a lot of options. Stay on your current pain med and antidepressant if that's working. I saw one study where tramadol was added to effexor for a double whammy.
I think quality of life is indicator for me. I find nothing noble about people who won't take pain meds and are so righteous about their ability to endure pain. Stupid maybe? God put the poppy on this earth for a reason. Maybe a gift to mankind to be used judiciously.
Posted by ed_uk2010 on April 17, 2010, at 12:08:03
In reply to Re: ultram, really... » ed_uk2010, posted by floatingbridge on April 16, 2010, at 19:04:53
>Hi Ed, I do have chronic pain, sad to say--not as bad as many, so I'm not complaining.
Hi FB,
What is the cause of the pain and what have you tried so far?
Tramadol can be useful for certain types of chronic pain, at least for a few weeks to cover exacerbations. Its long term efficacy is often reduced by the development of tolerance. The extent to which tolerance develops is variable. Stopping tramadol after long term treatment can sometimes lead to significant withdrawal symptoms, which may represent a mixture of SSRI/Effexor-like withdrawal symptoms and opioid withdrawal symptoms.
Posted by bulldog2 on April 17, 2010, at 13:38:28
In reply to Re: ultram, really... » floatingbridge, posted by ed_uk2010 on April 17, 2010, at 12:08:03
> >Hi Ed, I do have chronic pain, sad to say--not as bad as many, so I'm not complaining.
>
> Hi FB,
>
> What is the cause of the pain and what have you tried so far?
>
> Tramadol can be useful for certain types of chronic pain, at least for a few weeks to cover exacerbations. Its long term efficacy is often reduced by the development of tolerance. The extent to which tolerance develops is variable. Stopping tramadol after long term treatment can sometimes lead to significant withdrawal symptoms, which may represent a mixture of SSRI/Effexor-like withdrawal symptoms and opioid withdrawal symptoms.
>
>
>
>
>
If withdrawal is done correctly there should not be significant withdrawal symptoms. It should not be done suddenly.I don't understand people doing cold turkey. It is also a milder opiate so it should not be as bad as stronger opiates.
I was on 60 mg on percocet for a long time and many people in the hip replacement rehab unit had also been on strong pain meds for a long time.I was on 6 10 mg pills a day. I was withdrawn 1/2 pill a week. The withdrawal went very smoothly.
I agree that some tolerance will develope with long term use. Again I must reiterate that proper slow withdrawal should not be significant.
I have read that benzo withdrawal is much worse.
Times are changing in terms of opiate use. People in chronic pain may need long term use for pain and life quality maintenance. If managed carefully tolerance should be slow. Also some that are older may require opiates the rest of their lives and therefore withdrawal may not be an issue.Things are usually not simply black or white so we have to make the best decision. The nsaids and actetimoniphen while not addictive are really hard on the stomach, liver and kidneys. So life time maintenance on opiates may be appropriate for some.
Posted by ed_uk2010 on April 17, 2010, at 17:20:26
In reply to Re: ultram, really... » ed_uk2010, posted by bulldog2 on April 17, 2010, at 13:38:28
I understand what you're saying. My point is that opioids are not generally a first-line treatment for chronic non-malignant pain.
Also, acetaminophen at recommended doses does not damage the stomach, the liver or the kidneys. Acetaminophen causes very few adverse effects. NSAIDs such as ibuprofen can be more effective than acetaminophen but they do cause more side effects, especially stomach ulcers.
> > >Hi Ed, I do have chronic pain, sad to say--not as bad as many, so I'm not complaining.
> >
> > Hi FB,
> >
> > What is the cause of the pain and what have you tried so far?
> >
> > Tramadol can be useful for certain types of chronic pain, at least for a few weeks to cover exacerbations. Its long term efficacy is often reduced by the development of tolerance. The extent to which tolerance develops is variable. Stopping tramadol after long term treatment can sometimes lead to significant withdrawal symptoms, which may represent a mixture of SSRI/Effexor-like withdrawal symptoms and opioid withdrawal symptoms.
> >
> >
> >
> >
> >
>
>
> If withdrawal is done correctly there should not be significant withdrawal symptoms. It should not be done suddenly.I don't understand people doing cold turkey. It is also a milder opiate so it should not be as bad as stronger opiates.
> I was on 60 mg on percocet for a long time and many people in the hip replacement rehab unit had also been on strong pain meds for a long time.I was on 6 10 mg pills a day. I was withdrawn 1/2 pill a week. The withdrawal went very smoothly.
> I agree that some tolerance will develope with long term use. Again I must reiterate that proper slow withdrawal should not be significant.
> I have read that benzo withdrawal is much worse.
> Times are changing in terms of opiate use. People in chronic pain may need long term use for pain and life quality maintenance. If managed carefully tolerance should be slow. Also some that are older may require opiates the rest of their lives and therefore withdrawal may not be an issue.Things are usually not simply black or white so we have to make the best decision. The nsaids and actetimoniphen while not addictive are really hard on the stomach, liver and kidneys. So life time maintenance on opiates may be appropriate for some.
Posted by bulldog2 on April 17, 2010, at 17:59:57
In reply to Re: ultram, really..., posted by ed_uk2010 on April 17, 2010, at 17:20:26
> I understand what you're saying. My point is that opioids are not generally a first-line treatment for chronic non-malignant pain.
>
> Also, acetaminophen at recommended doses does not damage the stomach, the liver or the kidneys. Acetaminophen causes very few adverse effects. NSAIDs such as ibuprofen can be more effective than acetaminophen but they do cause more side effects, especially stomach ulcers.
>
> > > >Hi Ed, I do have chronic pain, sad to say--not as bad as many, so I'm not complaining.
> > >
> > > Hi FB,
> > >
> > > What is the cause of the pain and what have you tried so far?
> > >
> > > Tramadol can be useful for certain types of chronic pain, at least for a few weeks to cover exacerbations. Its long term efficacy is often reduced by the development of tolerance. The extent to which tolerance develops is variable. Stopping tramadol after long term treatment can sometimes lead to significant withdrawal symptoms, which may represent a mixture of SSRI/Effexor-like withdrawal symptoms and opioid withdrawal symptoms.
> > >
> > >
> > >
> > >
> > >
> >
> >
> > If withdrawal is done correctly there should not be significant withdrawal symptoms. It should not be done suddenly.I don't understand people doing cold turkey. It is also a milder opiate so it should not be as bad as stronger opiates.
> > I was on 60 mg on percocet for a long time and many people in the hip replacement rehab unit had also been on strong pain meds for a long time.I was on 6 10 mg pills a day. I was withdrawn 1/2 pill a week. The withdrawal went very smoothly.
> > I agree that some tolerance will develope with long term use. Again I must reiterate that proper slow withdrawal should not be significant.
> > I have read that benzo withdrawal is much worse.
> > Times are changing in terms of opiate use. People in chronic pain may need long term use for pain and life quality maintenance. If managed carefully tolerance should be slow. Also some that are older may require opiates the rest of their lives and therefore withdrawal may not be an issue.Things are usually not simply black or white so we have to make the best decision. The nsaids and actetimoniphen while not addictive are really hard on the stomach, liver and kidneys. So life time maintenance on opiates may be appropriate for some.
>
>acetaminophen is starting to get another look for side effects. The milligrams have been downed in the states to 2000 for safety. Apparently a lot of people were ending up with liver failure. Also acetaminophen does not get great ratings for anything other than mild pain.
But I agree with you that if you can control your chronic pain with low dose acetaminophen than go for it.
Right now I am experimenting with clomipramine for depression and pain relief. I will see if I can go up to 50 - 75 mg tops. Add some neurontin in and see what happens. Some get good pain relief with tcas especially with neuropathic pain.
Posted by floatingbridge on April 17, 2010, at 18:50:57
In reply to Re: ultram, really... » floatingbridge, posted by ed_uk2010 on April 17, 2010, at 12:08:03
Hi Ed,
It sounds like you might have some experience with pain issues--hope they are resolved....
I have lower spine issuses confirmed by an MRI a few years ago--damage and some osteoarthritis. The pain & range of motion issues have increased and now involve the upper back, neck, and head. I see a psyatrist next week for an evaluation.
I also have severe fatigue from undetermined source. Have had the basic string of diagnostic tests.
Life has never been a piece of cake since day one--I can hear the violins playing--like many babblers, unfortunately. I mention this because I have accepted discomfort unquestioningly. Now my ability to compensate has seemingly diminished--and the pain increased. My pdoc noticed my issues over time--I didn't really realize, hadn't been to doctors, avoided tylenol, etc. So pain management is a new term. Apparently preventing pain flares can decrease a future eruption's intensity and duration. I'm sure you know that.
Through my reading, I'm compiling a list of possibilities. Some first line meds--savella, cymbalta, say--might be contraindicated for me--I reacted badly to strattera (caused an unremitted raynauld's presentation & head and body aches).
Effexor I tolerated years ago--. Most tca's might exacerbate fatigue, except for what Bulldog is currently trying.
Anyhow, I'll see what the physiatrist says--I'm sure a multi-pronged approach is needed.
O.K. Enough of me. Thanks for inquiring! If anything has worked for you, I'd be curious to hear your experience.
fb
Posted by ed_uk2010 on April 18, 2010, at 8:19:53
In reply to Re: ultram, really..., posted by bulldog2 on April 17, 2010, at 17:59:57
>Acetaminophen is starting to get another look for side effects. The milligrams have been downed in the states to 2000 for safety. Apparently a lot of people were ending up with liver failure.
Minor elevation of liver enzymes (notably alanine aminotransferase) seem to be quite common in patients on long term acetaminophen but this does not represent liver damage. Many drugs cause minor elevations.
http://www.ncbi.nlm.nih.gov/pubmed/17076974
Acetaminophen causes far fewer adverse effects at recommended doses than any other oral analgesic. The recommended dose in the UK for chronic pain is 1000mg four times a day. Thousands of people take it on a daily basis. It can take the edge off the pain, even if it is not strong enough on its own. Tolerance does not develop, which is a major bonus. For severe pain, it is usually combined with other pain relievers for enhanced efficacy.
Problems with acetaminophen are normally related to:
A. Deliberate overdose
B. Taking several acetaminophen products together without realising that they all contain the same drug. This is most common with opioid combination medicines.
Posted by ed_uk2010 on April 18, 2010, at 8:44:00
In reply to Re: ultram, really... » ed_uk2010, posted by floatingbridge on April 17, 2010, at 18:50:57
Hi FB,
It's interesting that you mentioned the psych meds which are also used for pain relief eg. Cymbalta. What have you tried in terms of standard pain relievers eg. non-steroidal anti-inflammatory drugs?
Back pain can be an entire speciality in its own right. It's often difficult to treat but there are numerous options.
In terms of medication, the following are normally tried in (approximately) this order....
1. Regular acetaminophen - four times per day
2. Non-steroidal anti-inflammatory drugs (NSAIDs) eg. naproxen, Celebrex. A medication is often given to protect the stomach from the NSAID.
3. Combination analgesics eg. acetaminophen + a low potency opioid such as tramadol or codeine. An NSAID is often taken as well.
4. Potent opioids (oxycodone, morphine) for severe pain, if appropriate.
Muscle relaxants can be useful is spasm is a problem, at least in the short term. Interestingly, cyclobenzaprine (Flexeril) is related to the tricyclic antidepressants.
If nerves in the back are damaged or compressed, amitriptyline or nortriptyline are often prescribed. The TCAs can be quite sedating but some are worse than others. Nortriptyline is less sedating than amitriptyline. As you know, other TCAs are also used. As well as being used for nerve damage, TCAs are also used for chronic pain of other causes if standard pain relievers haven't worked, especially if sleep is impaired or if depression is a problem.
If TCAs are not tolerated, Cymbalta is sometimes helpful. It can cause side effects of its own, however.
Pregabalin (Lyrica) is prescribed mainly for nerve damage or compression. The mechanism of action and the side effects are different to the TCAs so it is often useful as an alternative.
A variety of other treatment are used by pain specialists. Some people have steroid injections into the back. This is not a pleasant procedure.
Physical therapists, osteopaths and chiropractors can all offer treatment for back pain. I have heard that some people who don't benefit from medication have found considerable relief. Some doctors offer acupuncture and I know someone who finds it very helpful.
Posted by bulldog2 on April 18, 2010, at 9:09:37
In reply to Re: ultram, really... » ed_uk2010, posted by floatingbridge on April 17, 2010, at 18:50:57
> Hi Ed,
>
> It sounds like you might have some experience with pain issues--hope they are resolved....
>
> I have lower spine issuses confirmed by an MRI a few years ago--damage and some osteoarthritis. The pain & range of motion issues have increased and now involve the upper back, neck, and head. I see a psyatrist next week for an evaluation.
>
> I also have severe fatigue from undetermined source. Have had the basic string of diagnostic tests.
>
> Life has never been a piece of cake since day one--I can hear the violins playing--like many babblers, unfortunately. I mention this because I have accepted discomfort unquestioningly. Now my ability to compensate has seemingly diminished--and the pain increased. My pdoc noticed my issues over time--I didn't really realize, hadn't been to doctors, avoided tylenol, etc. So pain management is a new term. Apparently preventing pain flares can decrease a future eruption's intensity and duration. I'm sure you know that.
>
> Through my reading, I'm compiling a list of possibilities. Some first line meds--savella, cymbalta, say--might be contraindicated for me--I reacted badly to strattera (caused an unremitted raynauld's presentation & head and body aches).
>
> Effexor I tolerated years ago--. Most tca's might exacerbate fatigue, except for what Bulldog is currently trying.
>
> Anyhow, I'll see what the physiatrist says--I'm sure a multi-pronged approach is needed.
>
> O.K. Enough of me. Thanks for inquiring! If anything has worked for you, I'd be curious to hear your experience.
>
> fb
>My doc put me on the opana-er because he said the current trend in pain management is time released opiates. That may work better than immediate release. It is easier to keep pain under control with a constant flow of meds as opposed to immediate release when there is a flare up and than large doses may be needed. Once you get the correct dose of the time released product pain will be well controlled and should free your life of constant pain worries. For some reasons the doc said that sometimes some actually lower the dose. So for constant chronic pain time released may be the way to go. There are now many good time released products on the market.
I also tolerated chronic pain for a long time. But when I just wanted to be asleep to escape pain or sit in the easy chair gritting my teeth and thinking about pain all the time I knew something had to be done.
Tylenol just doesn't cut it for me. Maybe for mild pain and maybe others respond well to it. Look for a time released product without acetimoniphen. There was an article in the Life Extension magazine that that med is truely toxic and will damage your organs. Personally I would rather take an opiate long term than a nsaid or acetimoniphen.
By the way they make an extended relief ultram product that works 24 hours.Can't think of its name. I know one lady on it and she really likes its pain relief properties and calls it her happy pill.I think she has been on it 6 months without a dose increase.
No perfect solutions only a best solution.
Posted by ed_uk2010 on April 18, 2010, at 9:59:31
In reply to Re: ultram, really... » floatingbridge, posted by bulldog2 on April 18, 2010, at 9:09:37
>My doc put me on the opana-er because he said the current trend in pain management is time released opiates. That may work better than immediate release. It is easier to keep pain under control with a constant flow of meds as opposed to immediate release when there is a flare up and than large doses may be needed.
Definitely. IR opioids are not generally appropriate for chronic severe pain because they are much too short acting.
>There was an article in the Life Extension magazine that that med is truely toxic and will damage your organs.
Well it will, if you overdose on it. Therapeutic doses are almost always free of side effects, which makes it rather unique. I appreciate that it doesn't help your pain however, and so there is no point in taking it :)
>By the way they make an extended relief ultram product that works 24 hours.
We have one here called Zydol XL. Most doctors prescribe the 12 hours brands though. Not sure why.
There are plenty of difficult decision to make when treating chronic pain. Opioids cause adverse effects frequently, but they are sometimes the only meds that help. In men, hormonal disturbances and sexual dysfunction are very common side effects in the long run. Hopefully, we will have more effective and safer pain relievers in the future. Analgesics are very profitable for pharmaceutical companies because pain is such a massive problem. Lets hope that they are doing plenty of research into new treatments.
Posted by bulldog2 on April 18, 2010, at 10:30:13
In reply to Re: ultram, really... » bulldog2, posted by ed_uk2010 on April 18, 2010, at 9:59:31
> >My doc put me on the opana-er because he said the current trend in pain management is time released opiates. That may work better than immediate release. It is easier to keep pain under control with a constant flow of meds as opposed to immediate release when there is a flare up and than large doses may be needed.
>
> Definitely. IR opioids are not generally appropriate for chronic severe pain because they are much too short acting.
>
> >There was an article in the Life Extension magazine that that med is truely toxic and will damage your organs.
>
> Well it will, if you overdose on it. Therapeutic doses are almost always free of side effects, which makes it rather unique. I appreciate that it doesn't help your pain however, and so there is no point in taking it :)
>
> >By the way they make an extended relief ultram product that works 24 hours.
>
> We have one here called Zydol XL. Most doctors prescribe the 12 hours brands though. Not sure why.
>
> There are plenty of difficult decision to make when treating chronic pain. Opioids cause adverse effects frequently, but they are sometimes the only meds that help. In men, hormonal disturbances and sexual dysfunction are very common side effects in the long run. Hopefully, we will have more effective and safer pain relievers in the future. Analgesics are very profitable for pharmaceutical companies because pain is such a massive problem. Lets hope that they are doing plenty of research into new treatments.
>
>Yes sexual problems seem common and also on the ssris. I'm trying to determine wether it is basically a raised prolactin issue. That seems to be the problem with ssris and may also be the issue with opioids. In that case dopamine agonists may be of some help. Dostinex seems effective for that but now I read there is some problem with heart damage. I don't know wether it is dose related and may be safe at lower doses.
yes better pain relievers with less sides. Also better ads with less sides.
BUT I wish docs would like into ways of helping people with sides. If we know that raised prolactin is causing sides how about some creative doc looking into meds that lower prolactin. Most docs just shrugg their shoulders and say oh well you just have to deal with that.
Posted by floatingbridge on April 18, 2010, at 10:52:45
In reply to Re: ultram, really... » floatingbridge, posted by ed_uk2010 on April 18, 2010, at 8:44:00
Hi Ed,
Your list is really quite helpful--seeing it all lined up--like the first time I looked at the STAR chart for depression.
In answer: I have no experience in the second category--celebrex and the like. Maybe that's a possibility.
I have taken 4,000 daily of tylenol and on seperate days of ibuprofen. Neither provided noticeable relief--and alarmed my pdoc. He thinks that is above standard U.S. dose recommendations. (Well, my grandmother was from the UK.)
My pdoc expressed concern over muscle relaxant--that they could have cognitive effects. (We've worked long and hard to get my mood levels up and stable....)
After your posts, I feel better prepared for my phyiatrist visit next week. Knowing the treatment protocol helps immensely. I'll do some reading about other nsaids.
I mention the psych meds such as cymbalta because I seem to need one, but I suspect difficulty tolerating most snri's which are the ones usually given patients with chronic pain--however, there is renewed interest in effexor and pain treatment. I tolerated that years ago....
Thanks again! And a good day to you.
Posted by floatingbridge on April 18, 2010, at 11:53:17
In reply to Re: ultram, really... » floatingbridge, posted by bulldog2 on April 18, 2010, at 9:09:37
Hey Bulldog, thought Ultram was the XR (or is it CR). At any rate, it was the once a day pill my doc mentioned. No peaks and valleys for me! Can't handle any more.
cheers!
I feel much more prepared for next week's appt. Thanks!
Posted by bulldog2 on April 18, 2010, at 11:59:32
In reply to Re: ultram, really... » ed_uk2010, posted by floatingbridge on April 18, 2010, at 10:52:45
> Hi Ed,
>
> Your list is really quite helpful--seeing it all lined up--like the first time I looked at the STAR chart for depression.
>
> In answer: I have no experience in the second category--celebrex and the like. Maybe that's a possibility.
>
> I have taken 4,000 daily of tylenol and on seperate days of ibuprofen. Neither provided noticeable relief--and alarmed my pdoc. He thinks that is above standard U.S. dose recommendations. (Well, my grandmother was from the UK.)
>
> My pdoc expressed concern over muscle relaxant--that they could have cognitive effects. (We've worked long and hard to get my mood levels up and stable....)
>
> After your posts, I feel better prepared for my phyiatrist visit next week. Knowing the treatment protocol helps immensely. I'll do some reading about other nsaids.
>
> I mention the psych meds such as cymbalta because I seem to need one, but I suspect difficulty tolerating most snri's which are the ones usually given patients with chronic pain--however, there is renewed interest in effexor and pain treatment. I tolerated that years ago....
>
> Thanks again! And a good day to you.Hi Floating
The tylenol dose has been lowered to 2000 mg in the states because some were getting liver failure on the 4000 mg.
While celebrex is safer on the stomach it has been implicated in sudden heart attacks because it does thicken the blood.
The tcas have been rated as the best ad's for pain relief. Amitriptyline and clomipramine maybe being the best. I am on 25 mg of clomipramine at this moment for only several days and can't say that has helped my pain. However that is a low dose and maybe I will get better results on 50 mg. But I have gotten a nice ad response at this low dose! So this may be a very good ad or very powerful. It is a bit sedating but your stimulant may very well counter that.
There are some studies that tcas seem to potentiate the action of the opiates which is a good thing if you go the way of the opiates.Of course one has to be able to tolerate the tcas.
So tylenol might be to weak for your chronic pain and the nsaids to toxic to the liver, and kidneys for chronic use.
So you have the ads for chronic pain of which the tricyclics seem to have the best pain relieving attributes. Some however don't get enough pain relief from them and combine them with a time released opiate. There are some good time released morphine products.
You have savella which is new but is more for the pain of fibromyalgia. Some do get pain relief from cymbalta but that seems as hard to get off of as the opiates for some.
You haven't mentioned the anti convulsants which are good for neuropathic pain but not as good for arthritic type pain. Again some combine it with an opiate.
Of course my p-doc is trying to kill two birds with one stone. So he is prone to the opiates and he strongly monitors dosage. He has found that benzo withdrawal is far worse than opiate withdrawal. Opiates are on a par with stims in that there are tolerance and withdrawal issues.
You are going to a phyiatrist next week. Did you mean psychiatrist or do you mean some other type of doctor.
It is up to you and your p-doc which way you go. I think you mentioned he was okay with the tramadol so at least he/she has an open mind.
I think opiates by themselves are not complate ads or at least not for me. But they are nice adjuncts.
This is my feeling on using tramadol as your ad and bumping pristiq. I think you would get more out of a strong and standard ad such as effexor or any you can tolerate and adding in a time released opiate to the ad. That is if you go the way of an opiate. A strong ad plus a time released opiate would give you a better pain and ad combo than the tramadol.
By the way I saw studies where they combined effexor and tramadol. That was interesting.
Posted by ed_uk2010 on April 18, 2010, at 13:33:25
In reply to Re: ultram, really... » ed_uk2010, posted by bulldog2 on April 18, 2010, at 10:30:13
> > >My doc put me on the opana-er because he said the current trend in pain management is time released opiates. That may work better than immediate release. It is easier to keep pain under control with a constant flow of meds as opposed to immediate release when there is a flare up and than large doses may be needed.
> >
> > Definitely. IR opioids are not generally appropriate for chronic severe pain because they are much too short acting.
> >
> > >There was an article in the Life Extension magazine that that med is truely toxic and will damage your organs.
> >
> > Well it will, if you overdose on it. Therapeutic doses are almost always free of side effects, which makes it rather unique. I appreciate that it doesn't help your pain however, and so there is no point in taking it :)
> >
> > >By the way they make an extended relief ultram product that works 24 hours.
> >
> > We have one here called Zydol XL. Most doctors prescribe the 12 hours brands though. Not sure why.
> >
> > There are plenty of difficult decision to make when treating chronic pain. Opioids cause adverse effects frequently, but they are sometimes the only meds that help. In men, hormonal disturbances and sexual dysfunction are very common side effects in the long run. Hopefully, we will have more effective and safer pain relievers in the future. Analgesics are very profitable for pharmaceutical companies because pain is such a massive problem. Lets hope that they are doing plenty of research into new treatments.
> >
> >
>
> Yes sexual problems seem common and also on the ssris. I'm trying to determine wether it is basically a raised prolactin issue. That seems to be the problem with ssris and may also be the issue with opioids. In that case dopamine agonists may be of some help. Dostinex seems effective for that but now I read there is some problem with heart damage. I don't know wether it is dose related and may be safe at lower doses.
>
> yes better pain relievers with less sides. Also better ads with less sides.
>
> BUT I wish docs would like into ways of helping people with sides. If we know that raised prolactin is causing sides how about some creative doc looking into meds that lower prolactin. Most docs just shrugg their shoulders and say oh well you just have to deal with that.Opioids may reduce luteinizing hormone and hence sex hormones eg. testosterone.
Posted by ed_uk2010 on April 18, 2010, at 13:55:04
In reply to Re: ultram, really... » ed_uk2010, posted by floatingbridge on April 18, 2010, at 10:52:45
>I have taken 4,000 daily of tylenol and on seperate days of ibuprofen. Neither provided noticeable relief--and alarmed my pdoc. He thinks that is above standard U.S. dose recommendations. (Well, my grandmother was from the UK.)
I believe you often give 650mg four times a day, although the maximum dose is still 1000mg four times a day. The FDA considered reducing the maximum dose to 650mg four times a day to reduce the risk of liver damage if people took multiple acetaminophen products together. The maximum dose has not been reduced to 2000mg per day.
We only have 500mg tablets here and the recommended dose is 1000mg four times a day, except for mild pain which can be treated with 500mg four times a day. Doses are given every four to six hours.
Therapeutic doses do not cause liver damage. Reduced doses are only recommended for heavy drinkers, alcoholics and patients with established liver disease.
I am aware that the FDA is concerned about the risk of liver damage due to acetaminophen overdose. They are mainly concerned about how a lot of people take more than the recommended dose of products such as Vicodin, and also that some people take multiple acetaminophen products together eg. Vicodin + Percocet + flu meds.
Posted by ed_uk2010 on April 18, 2010, at 14:08:38
In reply to Re: ultram, really... » ed_uk2010, posted by floatingbridge on April 18, 2010, at 10:52:45
>In answer: I have no experience in the second category--celebrex and the like. Maybe that's a possibility.
It could be. Ibuprofen is an NSAID although its anti-inflammatory properties are not very strong. It is very useful for headaches and dental pain though.
For chronic pain and inflammation, long acting NSAIDs are often used. Naproxen (up to 500mg twice a day) is believed to be safe for the heart and cardiovascular system although it frequently irritates the stomach. As a result, it is usually combined with a proton pump inhibitor (a PPI, such as omeprazole) to protect the stomach. This combination is getting very popular in the UK. It is not very expensive.
Celecoxib (Celebrex) seems to be safer than other COX-2 inhibitors such as Vioxx and Arcoxia. Arcoxia is a very potent NSAID which is widely used in Europe but it does elevate BP and cannot be used in those susceptible to heart disease. Celecoxib is less potent and probably quite a lot less harmful to the cardiovascular system.
>I have taken 4,000 daily of tylenol and on seperate days of ibuprofen. Neither provided noticeable relief.
It doesn't sound like Tylenol will be adequate, at least not on its own.
> My pdoc expressed concern over muscle relaxant--that they could have cognitive effects.
There are quite a variety on the market with different properties. They are not all the same.
Best regards
Posted by floatingbridge on April 18, 2010, at 16:52:43
In reply to Re: ultram, really... » floatingbridge, posted by ed_uk2010 on April 18, 2010, at 14:08:38
Thank you both so much--knowledge helps me me maintain an open mind. I appreciate being able to air my concerns.
I imagine any changes may be delayed. I might need diagnostics.
Wish me the best!
Cheers,
fb
Posted by ed_uk2010 on April 18, 2010, at 17:00:18
In reply to Ed and Bulldog » ed_uk2010, posted by floatingbridge on April 18, 2010, at 16:52:43
> Thank you both so much--knowledge helps me me maintain an open mind. I appreciate being able to air my concerns.
>
> I imagine any changes may be delayed. I might need diagnostics.
>
> Wish me the best!
>
> Cheers,
>
> fbI hope your appointment goes well :)
Posted by bulldog2 on April 19, 2010, at 8:35:43
In reply to Ed and Bulldog » ed_uk2010, posted by floatingbridge on April 18, 2010, at 16:52:43
> Thank you both so much--knowledge helps me me maintain an open mind. I appreciate being able to air my concerns.
>
> I imagine any changes may be delayed. I might need diagnostics.
>
> Wish me the best!
>
> Cheers,
>
> fbThe best to you and now you are an expert in these matters.
Regards
bulldog2
This is the end of the thread.
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