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PostPosted: Tue Dec 06, 2011 10:07 am 
I am in the process of scheduling an elective (though necessary) surgery. It will require pain control beyond what I can get from OTC meds or upping my Suboxone dose. I have corresponded with Suboxdoc and he has sent information for me to share with my docs about large (larger then normal) doses of opiates for Suboxone patients in post-op situations. I am concerned however, that I won't be able to find a surgeon willing to do this. It seems counterintuitive for a doc to give an opiate addict MORE pain relief than he gives other patients, even though because of our tolerance/and Suboxone use, it is necessary. Have any of you had success with this method of Post-op pain control? And by success I mean were you successful in getting tho quantity of drugs in the first place, and if so who prescribed them; your surgeon, a GP, or your personal Subox doc.

Any information you can share about how you dealt with severe post-op pain would be appreciated as well.

Thank you.


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 Post subject: Lot's of Pain Meds
PostPosted: Tue Dec 06, 2011 3:23 pm 
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Hey E.R.,

That was the main problem I had with my surgeon several weeks ago. Had surgery on my tongue which causes intense pain, the Dr. didn't prescribe me enough meds to last so I called, talked to his main assistant and she told me to come in. This was on a Friday and I had the surgery on Wednesday and my pain was through the roof.

The office was closed because of the holiday and she was there to catch up on work. I told her he only gave me 30 Lortabs with instructions to take 1 every 4-6 hours + 1 refill. And yes, I tried to explain to him how Bup blocks opiate meds and that I'd need stronger or more meds. She told me his is notorious for under prescribing pain medication. She asked if I had enough to last over the weekend and I said "no, because I've had to take 2, not 1 of the meds. She understood after I told her my situation and she was kind enough to call the pharmacy and authorize an early refill. When I got there I found out she changed the amount to 100 with 2 refills. Bless her heart. What I really needed was something very strong like liquid Morphine or a Fentynal patch so I wouldn't have to swallow.

I am due for one more surgery and this time it'll be different. A week before my scheduled surgery I will go see my Suboxone doctor and explain what happened to him. Then I'm going to ask to get a weeks supply of meds ahead of time so I can stop taking the Sub and hope that the pain meds will work this time. The last time it took a week for the meds to take effect. It was either the Sub blocking the opiate or my pain was just so bad that Lortab wasn't the right drug to help lessen the pain.

If you want more information or need to talk, PM me and we'll get into the subject a little more.

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PostPosted: Tue Dec 06, 2011 4:32 pm 
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Rule, I think it was awful that you had to go through so much much pain, and I agree that surgeons should take the Sub use into account and prescribe adequate doses of meds like Dr. J recommends. That being said, I have to tell you that a recovering addict having 100 Lortabs with 2 refills concerns me. And I think you said that you were on a very low dose of Sub before the surgery (1.5mg?). I believe the blockade effect of Sub is greatly reduced at doses below the ceiling level. Do you have someone helping you keep track of your dosing so that you don't go overboard? I am in no way implying that you are doing anything wrong, I just think you are in dangerous territory and need to be very careful.
How is the healing going? Has the pain subsided? I hope you are on the mend. Let us know how you are doing.
Take care,
Lilly


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PostPosted: Tue Dec 06, 2011 6:14 pm 
Rule62,
First let me thank you for your kind and detailed reply to my question. I relay appreciate it. Also, I understand Lillyval's concern for having that many Lortabs with refills easily accessible. It could be dangerous for me, especially if I had lowered or stopped my Suboxone dose; so be careful.
My comment however is not about the quantity of narcotics you have there, but rather the quantity of Acetaminophen you will have to take for sufficient pain relief with this polls. 5mg Lortab (Vicodine) have 500mg of Acetaminophen in them (or at least 325mg). By the time you take the 60mg per day - the Subox Doc's minimum for a regular Suboxone user to get pain relief - you will have received 6 GRAMS, or 6000 mg of Tylenol! If you were to take this quantity 3 days in a row, you will have put your liver well into the toxic zone for Acetominophen overdose. The liver cannot remove the tylenol quick enough before the next dose of Hydrocodone is needed so over time, you reach a level of 6 grams, 8 has been know to be fatal.

I know because of excessive abuse in the past, that 8 grams of Tylenol is not fatal for me (obviously), but it does cause me to get severe hemorrhoid flare ups because my liver is toxic. It is probably doing even worse things to my brain, but I am not a doc so don't know about of that. Nevertheless, hemorrhoid pain is the least of the worries of a toxic liver. Liver tissue destruction is the result of this and eventually necrosis. It dies, and with no liver, there is no life.

Remember, this is just a comment for informational purposes. I am not suggesting that you ARE taking too many Lortab or taking them too often. I just want people with prescription drug issues like me to be aware that Liver toxicity and Liver failure is slow, painful, and deadly. Once liver tissue necrosis has started, there is little to nothing that can be done about it short of a transplant.

This is why we need to learn how to communicate to our doctors/surgeons that because of our tolerance we need stronger meds, not necessarily more of them.


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PostPosted: Tue Dec 06, 2011 7:08 pm 
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That's a good point. They recently lowered the maximum daily dosage of acetaminophen to 4000mg. And e.r.r. even if you survived 8g in the past you could still OD on that amount if you ever did it again (which I know you won't). But the toxicity of that stuff is very unpredictable. Rule, if you have consumed a large amount of APAP over the last few weeks, (and if you've been taking the Lortabs you have), the amino acid methionine is needed by the liver to metabolize it. The best sources are eggs (by far) and brazil nuts. I don't know if it's available in supplements. If you've been taking more than 4000mg/day, or have been taking the max. for more than a couple of weeks you need to talk to your doc. Hopefully, they can find a better way to manage your pain for the next surgery.
Hope you're doin OK,
Lilly


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 Post subject: Acetaminphen Toxicity
PostPosted: Tue Dec 06, 2011 7:46 pm 
Rule, Lilly is right, the toxic level is 4 grams not 8. I think 8 is where someone died, can't remember, I know that my children's pediatrician is who told me. In any case anything over 1 gram every 4 hours is too much. There is a supplement (aka drug) you can take to offset Tylenol over dose. It is called acetylcysteine, know under a brand name as Mucomyst. In is't pill form it is available at places like GNC, or the Vitamin store. It is a gnarly drug, smells horrible and will give you equally bad smelling gas, but it is the official antidote to acetaminophen overdose used in the Emergency Room.

This is what I used as dosing instructions 5 years ago when I needed it:

The FDA approved oral dosing regimen is 140 mg/kg as the loading dose, then 70 mg/kg every 4 hours for 17 doses starting 4 hours after the loading dose. Oral acetylcysteine is irritating to the gastrointestinal track and should be diluted to a final concentration of no more than 5% to reduce the risk for vomiting. The oral form of NAC has an unpleasant odor and taste that can also affect compliance with administration.

Now that said, if you feel that you have overdosed on Tylenol, I strongly recommend that you call poison control (it's confidential) and verify this with them. If they tell you to go to the ER then you should. If you won't, well then that's why I gave the above information. It's a yucky drug, but I suppose if the alternative is Liver failure...


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 Post subject: stop the APAP!!
PostPosted: Tue Dec 06, 2011 8:08 pm 
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For all you hydro guys, watch out as said....liver toxicity = death

now days tylenol wouldn't even get through FDA approval (I think JJ wrote it)...there is NO way I would take all those lortabs. When I broke my back, my Doc tried pulling that shite. Needless to say, he wasn't my Dr. very long. Most of those pussies have NO clue how to tackle a small medical challenge.


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PostPosted: Tue Dec 06, 2011 8:42 pm 
Lillyval wrote:
Rule, I think it was awful that you had to go through so much much pain, and I agree that surgeons should take the Sub use into account and prescribe adequate doses of meds like Dr. J recommends. That being said, I have to tell you that a recovering addict having 100 Lortabs with 2 refills concerns me. And I think you said that you were on a very low dose of Sub before the surgery (1.5mg?). I believe the blockade effect of Sub is greatly reduced at doses below the ceiling level. Do you have someone helping you keep track of your dosing so that you don't go overboard? I am in no way implying that you are doing anything wrong, I just think you are in dangerous territory and need to be very careful.
How is the healing going? Has the pain subsided? I hope you are on the mend. Let us know how you are doing.
Take care,
Lilly


Im in the process of trying to schedule (non-elective) surgery as well. My Sub doc told me that if I bring my mother in with me to take possession of the script (maybe because I am only 22?), he will write the pain meds for the surgery because I told him the doc had no idea what Sub is (and is a total asshole. That is why I am having problems, I am finding a new surgeon).

I take 1.25 mg/day and my doc told me at this dose, the problem is not the blockade; it is simply tolerance in itself. 1 mg of bupe does NOT equal 10 mg of Percocet..we wish. It is probably a good idea to stop the sub a few days before just in case (that is what I would do), but even if you wait a week, you'll still have that tolerance sticking with ya like a shadow.

Take care, and good luck with your surgery!


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PostPosted: Wed Dec 07, 2011 8:32 am 
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<snip> It is probably a good idea to stop the sub a few days before just in case (that is what I would do), but even if you wait a week, you'll still have that tolerance sticking with ya like a shadow.


I agree, and this is mainly why I went off my subs in time for my pre-surgical consult this Thursday.

Although that tolerance thing sticking with me really sucks!

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 Post subject: Thank you all
PostPosted: Wed Dec 07, 2011 11:44 am 
I take 8mg once per day and I have professional support from other doctors and documents from independent medical research (from reputable medical Journals) that tells how a surgeon should handle post-op pain for people on Suboxone. Nevertheless, it has been my experience that finding a physician, let alone a surgeon, who is sympathetic to our situation is a gargantuan task. Worse yet, the harder we try, the more that we are potentially labeled as drug seeking. I guess that this is the bed I made by being and addict, so now I am sleeping in it - so to speak. I'm sorry to be so negative, guess I'm feeling sorry for myself.


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PostPosted: Wed Dec 07, 2011 12:13 pm 
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Do you have the NIH paper about treating acute pain (including post-op pain) in patients on opiate replacement therapy? It's posted under the "Links" section of the forum (it's the first thread, a "sticky"). It might be what Dr. J sent you, but I just wanted to make sure that it's what you have.

One of the options that it talks about that often people overlook is one of taking a small amount of sub along with the full opiate agonists they take for pain relief. The key is a LOW dose. It will help the person to stay out of withdrawals if the pain meds aren't enough and can also help to get more pain relief. I know it helped with a procedure/surgery that Diary had to go through.

The paper also offers other options for getting better pain relief. Many of us share that very paper with our doctors. Good luck!

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 Post subject: Let Me Clarify
PostPosted: Wed Dec 07, 2011 1:51 pm 
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Lilly and everyone else who were concerned about the amount of Lortab I was given. Are you actually accusing an addict doing addictive behaviors???? Oh yes, you have every right to be concerned. 300 Lortabs in the hands of an addict is a prescription for trouble so let me clear this up.

During the first two weeks I was taking 2 every four to five hours. Would not take more than 8 total because of the toxicity of the Tylenol. The limit is 4,000mcg's or 4mg's. (don't quote me on that) The pills were 10/500 so the math was easy.

My plan was to go back onto Sub as soon as the pain subsided enough. Well.....once the pain went down and time had passed since my last dose of 1mg of Sub, then I could FEEL the hydrocodone and of course chased the high for a couple days until my senses came back and I'm back on the Sub again. Still have one refill left but also have one more surgery so I will save it for then.

Because of the pain I am taking more Sub than I used to. Two 2mg films in the AM and 1 more in the PM. The late evenings and nights I hurt the worst. My next goal is to get down to 4mg's total and then work my way back to 1mg before the next surgery. Did it once, can do it again.

Like I stated on my last post, I will go in and talk to my Sub doctor and see what he recommends before my next surgery. I may or may not be truthful with him about my abusing the Lortabs. It may be in my best interest to tell him because I backslided and may need to take larger amounts of Sub for awhile until my recovery gets back on track. Yea, I really fucked up. Been this way all my life. I'm starting to wonder if maybe I'd be better off staying on Sub for life. I'll talk to him about that.

The future is what I'm worried about. Radiation is the most painful part of oral cancer. Most stop eating because the pain is so terrible. From what I've read, a lot of patients are on a Fentynal patch or liquid Morphine. All those options will be discussed with my Oncologist. I will also be truthful about my addiction and how we are going to get pain relief w/o me over doing it. My wife is not a good candidate to hold them for me. She has no willpower when I ask for more. Plus I can find them where ever she hides them. An addict can SMELL the opiates in the walls!

That's the latest folks. I messed up and will be tested more in the future.

The day I went back on the Sub my wife made it clear that she prefers the man on Sub, not Lortab. I feel better too.

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PostPosted: Wed Dec 07, 2011 4:20 pm 
Rule,

You pegged it. Yes, I feared that you were "stretching" the truth, and abusing your Lortab. Nevertheless, you needn't feel any judgment from me (if you did). I can't speak for the rest of us (though I probably can), I doubt anyone was judging you. I suppose since we know what liars and minimizers we have been in our past, it's easy to assume that one of use i doing this when they start talking about access to opiates in the hundreds. I can honestly say that were I in your situation, with the big C staring me in the face, I would probably have done worse regarding the abuse of the Lortab. Remember, I was the one who knew about the Acetaminophen antidote. That said, I think that you need to separate these two issues because they are causing confusion. On the one hand, you have an additive personality and previous (maybe current) active addiction issues, that would lead me to say that you should be on Suboxone indefinitely. On the other hand, you have a genuine need for strong pain control as you go through th process of dealing with the oral cancer treatment. The second issue is all that you need to be thinking about now. Whether you stay on Suboxone for life or not is too far into the future. I hate to sound trite, but this is where "on day at a time" fits. I will give you my opinion. It's worth every penny you're paying me for it. I hope it helps though.

There is a paper from the NIH referenced on this thread. Suboxdoc just sent it to me. It discusses the way that these researchers recommend handling pain control, with Suboxone patients. Moreover, it scientifically dispels each myth that we have heard from physicians. It alone will not solve your problems, but if you can get a sympathetic doc to read it and take it to heart, maybe they can be an advocate for you with the surgeon. In brief, it suggests what you are doing, taking a small dose of Suboxone WITH a large dose of opiates. The only stung suggestion I have for your (and an issue I am dealing with as well), is that you don't need MORE pain killers as much as you need STONGER ones. (ref: tylenol overdose discussion). You need to not be forced to overdose on lortab to get the pain control you need. I don't fault you for doing this. IF you are in the kind of pain you claim to be, and I think you are; with the tolerance you have developed, and the fact that you have even a small amount of buprenorphine in your system, you need (don;t quote me) I think at least 60 mg of the opiate per day, maybe more. I think you WILL need one of those fentanyl patches or something. Maybe you will have to stop the Suboxone for a while. Do it then. Who care what "we" think. Do what you need to do to get control of your pain, so you don;t feel the need to abuse and overdose on something else. Just make sure that you have someone in your life that you can be accountable to. Is there someone who can help you stay honest with yourself through this painful process?


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 Post subject: Pain Control
PostPosted: Wed Dec 07, 2011 6:57 pm 
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Thanks E.R., or is it EX E.R.?

I believe I've learned my lesson here and will be careful about the meds next time. As far as being on both Sub and pain meds, my Sub doctor told me to stop the Sub and only take the meds, which I did. So I had no Sub for almost three weeks. Being at such a low dose helped but like you said, it was the tolerance problem.

And no, I won't worry about staying on Sub forever until all this is way over. The reason it was mentioned was that my doctor is the kind who wants all his Sub patients off of it in six months. Hopefully I'll be the exception. I doubt he'll rush me with what I'm going through.

Thanks for the 2¢, it was worth it.

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PostPosted: Wed Dec 07, 2011 7:30 pm 
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Rule. Good to hear you are doing fine. I had 2 cousins and a sister-in-law that had throat cancer and they had liquid morphine. It really helped alot dropped it in the cheek and it absorbed. I agree if you get strong enough medicine then your less likely to over take for relief. I'm sure that is a fear of a bunch of us while on subs,getting pain relief we need. In Louisiana the doctors do not like giving pain med's much less enough. Hope it all goes well for you.
Mel :wink:

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PostPosted: Thu Dec 08, 2011 8:30 am 
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You are all right - giving an addict pain meds is not what places them at risk of relapse. No, instead it's failure to adequately treat their pain that actually places them at risk of relapse. This is listed in the NIH paper as one of the common misconceptions of health providers that result in the undertreatment of acute pain in patients on bupe/methadone: "use of opioids for analgesia may result in addiction relapse."

I only hope your doctors are aware of those studies.

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