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PostPosted: Mon May 11, 2009 9:25 am 
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Hi -
I am a mid-forties single mom, post laminectomy/diskectomy at L5-S1, who has had chronic back and leg pain for about 10 years now.

I was the type of person who didn't even like taking aspirin when I was in my teens & twenties. Even when I herniated a lumbar disk, I didn't take the prescribed narcotics - instead, I took a ton of Aleve and Tylenol. After my surgery, I still didn't touch the pain meds that sat in my medicine cabinet. I was SO proud of full of myself and actually had the audacity to judge other people who needed pain medication. KARMA came around pretty quickly on me.

The back surgery went well, PT followed, and for about a year I was doing better. Then gradually I realized the surgery was not the miracle cure, and the pain in the buttocks and legs came back. The MRIs that followed showed bulging disks in the lumbar & cervical levels, with central herniations. Fusion was not an option because frankly, I had never heard one success story & I thought if I were careful, really careful, the rest of the disks would not go out.

A nurse practitioner started me on hydrocodone + antidepressants. I finally took them about 5 years ago and they made a huge difference in the quality of my life. The irony is that the NP who prescribed these meds actually became addicted to them and was arrested later on for writing her own prescriptions.......some of her patients were accused of being addicts, at the local ER - me included - because of withdrawals and lots of us sought help after being cut off from so many medications. I was still just physically dependent on hydrocodone at that point. I tapered off and stayed off them despite the physical pain that returned. I honestly cared more about what people thought of me than being out of physical pain.

So, fast forward.....I eventually found another doctor to help me. I think my addiction started when my mom was diagnosed with cancer. I was her caretaker & was so grateful to be there for her, but I began using the hydrocodone for emotional reasons, too. My maximum usage was about 7-8 per day - never bought off the street or stole them, always prescribed, but I overused them almost every single day. It took care of the pain and depression. Mom died and I realized I needed help to stop.

About 10 months ago, I found a suboxone physician. I was stable on a dose of 2 mg per day - and now I'm down to 0.5 mg per day.

What I'm having a very hard time with is the chronic physical never went away. I re-injured my back last month, making things even worse, but I'm deathly afraid to get an MRI. I do not want any more surgery! I've been through rounds of facet injections in the past and I'd rather have a root canal without anesthesia than do that again. They were pure torture. No numbing shots first, nothing to relax me, just these huge needles fishing around in my back. Oh Lord, never again.

So right now, I feel STUCK. I was ready to go off the suboxone soon, according to my doctor, but I can really tell it has helped with depression & anxiety symptoms. The lower I go on the suboxone dosage, the more anxious I feel. My heart pounds, I sweat uncontrollably at times, etc.

I do need HELP for my back pain, but I'm afraid I have now blacklisted myself from ever getting adequate pain management again. I don't want to be in this physical pain 24/7 and unable to work. I pay for my own health insurance and it's already costing me several hundreds every month. I also help pay for my daughter's college. I feel like I'm dog paddling financially.......I've been employed all along, but I can't push my body much longer.

I love to walk every day and swim (well, float is more like it) in the pool. I've been taking 4 nabumetone (sp?) daily and Tylenol prescribed by my sub doctor and it takes the edge off the worse pain. That's all he can offer, though.

I'm feeling very despondent right now..........any advice will be appreciated. Sorry this is so long.
Thank you!

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PostPosted: Mon May 11, 2009 7:08 pm 
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Your situation is a tough one-- and also quite common. There are several different issues to address, some more acute, others longer term.

It sounds like you will be having back problems to some extent for the rest of your life. It is important that you keep that fact in mind as you plan for the future. The most important thing long-term is that you maintain function as best you can; that means that you must find a way to avoid further injury. If you are overweight, the most important thing you can do is lose weight. You wouldn't be in the group of people who 'should think about losing weight'; you would be a person who MUST lose weight-- otherwise you will be bedridden way too early in life. You must avoid doing the things that aggravate your injury-- and I mean totally avoid them. One lift of something that is too heavy will do as much damage to your quality of life as a car accident! So you MUST recognize your limits-- and respect them.

I would expect your current injury to heal eventually; a number of studies have shown that for lumbar strain, all of the treatments are equally effective-- including epidural steroids, manipulations, physical therapy, and bedrest. The main thing is to avoid re-injury, while at the same time trying to keep some amount of conditioning. It usually takes a long time to recover-- as long as a year.

I was at a meeting over the weekend with other docs who prescribe Suboxone-- see my blog for details. We talked about what each of us does for acute pain treatment. The suggestions I am about to make are pretty 'mainstream' compared to the other opinions I have heard about pain treatment.

While the euphoric and respiratory effects of buprenorphine max out at around 4 mg per day, the analgesic (pain fighting) effects increase as the dose is increased--- or at least that seems to be the case. So one option, perhaps the first thing I would do, is to increase your dose of buprenorphine (Suboxone) to 16 mg per day. I usually recommend dosing only once per day, but again for pain I might suggest 8 mg twice per day. The med you are currently taking, nabumetone (relafen), is an 'NSAID' like ibuprofen, and has no narcotic effects. You will probably get increased pain relief from increasing the Suboxone, particularly if you optimize absorption (go to Suboxone talk zone and search 'optimizing absorption').

A second option would be to add an opiate agonist at a higher-than-usual dose. You are taking a low dose of Suboxone; there is not a huge amount of blocking activity at such a low dose. Some people at the meeting said that they have succes adding even vicodin to Suboxone; I would probably choose Dilaudid, as it is a more potent opiate and I have had some positive reports from people using it.

The third option would be to stop the Suboxone and then take oxycodone or another agonist. Unfortunately you DO have a high tolerance from being on Suboxone; you would need about 50 mg of oxycodone (per day) just to 'break even' and prevent withdrawal. So to treat pain, you would need about 15-30 mg of oxycodone every 4-6 hours.

It would be a good idea, whatever you do for the pain, to take an SSRI to help with the stress you are feeling. Pain is always worse in the presence of a depressed mood-- plus it isn't any fun being depressed!

I guess the easiest thing would be to take your Suboxone dose higher-- that is something that almost all Suboxone prescribers would recognize as a good idea. Hang in there; try to take things as they come and avoid guessing the future. Feel free to vent here anytime!

Jeff J

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Fond Du Lac Psychiatry
Dr. Jeffrey Junig, M.D., Ph.D.

  • Board Certified Psychiatrist
  • Asst Clinical Professor, Medical College of Wisconsin

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