Author Topic: Climbing the analgesic ladder  (Read 916 times)

Fiz

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Climbing the analgesic ladder
« on: July 18, 2017, 02:25:53 PM »
I went to the GP about 20 years ago when the combinations of OTC analgesics weren't touching the pain in my back. He asked me what's wrong with my back and I said I have no idea it just hurts constantly and I need better pain relief. He said before he'd give me a prescription he'd need a diagnosis and so I had xrays and scans which clearly showed advanced degenerative disc disease in three discs and the joints between them and the spurs of boney growths etc. So he gave me tramadol. That was fine for many years but in the last 2-3 years I've been getting 'electric shock' type pain in my spine where the damage is and sometimes the pain is so debilitating I can't do anything.

During this time I have been gradually increasing the analgesia. Today for example I took a 50mg tramadol, 30mg dihydrocodeine, 100mg SR tramadol and 15mg of Diazepam with the anti emetic metochlopramide and that has helped with the pain considerably and I'm functioning moving around my home. But as things are most definitely getting worse and in the last couple of years fairly rapidly, I wonder what the next step up the analgesic ladder will be for me to control my pain.

For those of you who have increased your analgesia over time how did you progress up the ladder and what medications did you add or switch to each time?

My big fear is because of my history of overdosing, they won't give me anything stronger and I'll end up in unbearable pain. Though I get my meds weekly for this reason, delivered by the chemist. I'll admit if I have a bad back pain day when I'm in a very low phase it almost tips me over the edge. Physical and emotional pain seems too big a fight.

The asda delivery driver (who I'd asked to put my shopping on worktops because I can't bend to collect shopping from crates on the floor) said the next step is oramorph but dd thinks they'd offer diclofenic suppositories first and she says they're a good pain killer.

I guess I'm wanting reassurance that there's drugs up the ladder that are effective and I will be allowed and I won't be left like this. Apologies for long post.

NeuralgicNeurotic

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Re: Climbing the analgesic ladder
« Reply #1 on: July 18, 2017, 03:55:23 PM »
Quote
My big fear is because of my history of overdosing, they won't give me anything stronger and I'll end up in unbearable pain. Though I get my meds weekly for this reason, delivered by the chemist. I'll admit if I have a bad back pain day when I'm in a very low phase it almost tips me over the edge. Physical and emotional pain seems too big a fight.

I know the feeling.  >bighugs< >bighugs< >bighugs<


Have you been tried on any anti-convulsants at all? I ask because your mention of electric shock type pain suggests there may be a neuropathic element to what you're experiencing.


ally

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Re: Climbing the analgesic ladder
« Reply #2 on: July 18, 2017, 05:53:33 PM »
So far I've had five spinal operations.  That includes a SCS trial, and a SCS implant.  I've also had various interventions, such as nerve root blocks. Steroid injections etc.  I was on codeine phosphate, then, tramadol.  However, the tramadol made me itch, so, i was given m/r OxyContin, and. Oxynorm liquid for break through pain.  I've been on that a while now.

 I've had no side effects, and, I find it an affective pain killer.  I'm also on amitriptyline.  I've tried lots of other opiates, and anti inflammatory drugs, plus pregabalin, and, gabapentin etc. It's all trial and error,  finding an opiate that's effective and suitable.  I do realise it may be difficult to get oxy prescribed, due to your past medical history.  Also, like tramadol, it's a restricted drug.  However, it may be worthwhile enquiring whether it would be suitable  for you.  Good luck X

Fiz

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Re: Climbing the analgesic ladder
« Reply #3 on: July 18, 2017, 06:44:44 PM »
Thanks Ally that's useful. I'll have two drug suggestions now.

NN, it's the bony spurs and squished discs which both protrude and when they hit the spinal cord it feels to me like an electric shock, which then sends my whole body into shock and then often I'll cry because it's all overwhelming. Obviously though the cause of the pain is my lower spine, it's sending that signal to the brain in order for me to feel it.

I think I'm going to need to discuss it with my GP but I'm really unsure as to what she'll be happy prescribing.

Silly additional question not related to meds but related to the spinal pain. How do you manage when you want a piece of furniture moved from A to B? I can't do it or even help and know no one who would help me. Lots of people here on ouch must have this problem. 

NeuralgicNeurotic

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Re: Climbing the analgesic ladder
« Reply #4 on: July 18, 2017, 07:14:47 PM »
I can also vouch for the efficacy of OxyNorm for breakthrough pain.  >thumbsup<

I take the capsules and have 5, 10, and 20mg strengths available for titrating up and down during flare-ups.

Gabapentin and Pregabalin (anti-convulsants) modify electrical activity in the brain, and therefore alter the way in which the brain interprets pain signals from the spinal cord, so might be worth discussing. I found the side effects from Gabapentin disasterous, but have fared well with Pregabalin.

Amitryptaline I cannot comment on, as it could never be prescribed (am already on a hefty dose of Dosulepin for depression).

Good luck, and I hope your GP is as helpful to you on this issue as she has been on others.  >bighugs<

KizzyKazaer

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Re: Climbing the analgesic ladder
« Reply #5 on: July 18, 2017, 09:28:39 PM »
Quote
How do you manage when you want a piece of furniture moved from A to B? I can't do it or even help and know no one who would help me. Lots of people here on ouch must have this problem. 

Our local authority subsidises a 'Handihelp' service for small repairs and jobs around the home - might be worth checking with your own council to see if they support a similar scheme?

Fiz

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Re: Climbing the analgesic ladder
« Reply #6 on: July 21, 2017, 05:21:07 PM »


Good luck, and I hope your GP is as helpful to you on this issue as she has been on others.  >bighugs<

Funny you should say that but for only the second time ever she forgot to phone me to discuss what meds I need for the week so I now have nothing at all! Good job I have nothing planned for the coming week as I can barely move. I know technically I could phone the surgery and speak to a stranger to me Doctor but I got only as far as the decision to before having a panic attack. I don't do phones well. So I'm a week without anything. If desperate I might text dd and ask if I can have some of her oramorph which is in her room. But it's a new sealed bottle so I will try not to.

NeuralgicNeurotic

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Re: Climbing the analgesic ladder
« Reply #7 on: July 26, 2017, 08:24:04 PM »
Fiz, I hope that you're doing a bit better, and that your doctor has been able to get some pain relief to you.  >hugs<

Fiz

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Re: Climbing the analgesic ladder
« Reply #8 on: August 05, 2017, 07:29:52 AM »
I haven't actually made it in to the surgery to see her yet, it's ages since I left the house now. Fortunately I haven't had any excruciating pain since the 3 days in a row which raised my anxiety hugely because I'm only allowed 4 days worth of pain relief a week due to risk and I was thinking what if I have 5 bad days in a week and imagining trying to get through one of those days with just paracetamol doesn't bare thinking about. But so far I've not had more than 4 days really bad pain because as soon as it's bad I stay vertical in bed and rest it, it just means I can't get anything done for a few days including feeding myself at times. I'm down for a phone call from her on Wednesday this coming week. This last week has been really tough emotionally because of losing the cats and dd as expected has taken it badly which makes it all harder to cope with.

I'm going to attempt to brush the stairs to remove the thick layer of dog hair today. That has the potential to trigger pain that can last days. I'm never sure whether it would be helpful to take tramadol before I start such a task. If I eat breakfast I can take naproxen which will help reduce any nerve inflammation. 

Sunny Clouds

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Re: Climbing the analgesic ladder
« Reply #9 on: August 06, 2017, 11:49:38 AM »
Perhaps I could do one of my usual "Do you also...?" things.  You've probably tried all these, but on the offchance you haven't...

Varying the doses/meds.  In other words, not taking the same every day.  Some people find rotating the meds so that you're taking different sorts can help the body not to adjust and make them less effective.  It does't work for everyone, and you'd need to be sure your doctor is ok with it.

Thinking techniques.  You've probably tried some but there's no harm in trying a variety.  For example, after years of being told to try to ignore the pain from my arthritis or make it go away, I tried focussing on it instead, letting my natural curiosity take over and the pain didn't go away as such, it was as if my brain just said "Oh, ok, so I don't need to pay attention to that then."  I don't say that will work for you, but exploring thinking patterns, whether distraction or meditation or curious examination or whatever won't necessitate shelling out any money and even if they just reduce the pain a little bit, they can top up the medication, as it were.

Pressure points.  Yes, these are usually more relevant to muscular pain, but insofar as they are, they can at least help with some of the consequential pain, i.e. your spine hurts, so your muscles around it may go rigid to protect it.  People use everything from 'pain pens' to thumbs to acupuncture needles.  Some things cost, obviously, but pressure from fingers/thumbs doesn't involve buying anything.  I had a book but I can't find it, although if I'm in pain, I just rummage around for the tender point and use some steady pressure for a few seconds, repeated at intervals.  It's trial and error to find the right spot.

Sports physical supports like weightlifter's belts.  Even if you've tried something before, it might be worth looking round to see what else there is that would minimise movement of your lower back.  What's on the market changes over time and if you're short of money, you might be able to get something secondhand or even free depending on where you look.  There may also be other activities/sports that have specialist kit to keep the lower back straight whilst moving/lifting.

Please don't take any of this as a suggestion you mightn't have thought through all the options, but more along the lines of prompting in case you haven't re-visited them recently.
(I'm an obsessive problem-solver, so feel free to ignore any suggestions or solutions I offer, even if they sound terribly insistent.)

Fiz

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Re: Climbing the analgesic ladder
« Reply #10 on: August 09, 2017, 05:00:36 AM »
The concentrating on the pain and mentally examining it I can do for moderate pain if my brain isn't needed for something else at the time and it definitely reduces the 'suffering' (emotional response) to the pain. But when I get the excruciating electric shock like pain everything like that is out of the question. I do alternate between dehydrocodeine and tramadol, finding the latter more effective. The only time I've taken the two together is when I've taken 40 Dulcolax but that's another illness altogether  >doh<

I'm down for a phone call from my GP today so we'll see what she says.

NeuralgicNeurotic

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Re: Climbing the analgesic ladder
« Reply #11 on: August 09, 2017, 06:47:53 AM »
Quote
But when I get the excruciating electric shock like pain everything like that is out of the question.


I hear you. Dealing with that level of pain is more about survival than combat. All the best for the phone call, Fiz. Here's hoping your GP can help.  >hugs<

Fiz

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Re: Climbing the analgesic ladder
« Reply #12 on: August 09, 2017, 06:13:37 PM »
Just spoken to her. She's on holiday for the next 2 weeks so will be back 3 weeks from now. She's not keen on giving me a step up in pain relief while she's away and can't monitor how it's going, side effects etc but she's noted it for discussion for 3 weeks time. It seems sensible. She's happy to give me 3 weeks worth of all my other meds which shows she thinks I will be alright with that amount at the moment.

NeuralgicNeurotic

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Re: Climbing the analgesic ladder
« Reply #13 on: August 09, 2017, 07:44:58 PM »
 >thumbsup<

Sunny Clouds

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Re: Climbing the analgesic ladder
« Reply #14 on: August 09, 2017, 08:18:52 PM »
 >bighugs<
(I'm an obsessive problem-solver, so feel free to ignore any suggestions or solutions I offer, even if they sound terribly insistent.)