Pain and Other Things

Other thing : Bladder stones

Absolutely no clue why I have had bladder stones since BC started. NOT kidney stones Bladder stones. Probably better described as bladder glass shards. Started in Sept 2009, last to date was Sept 2015. Will update. This post was to a gal going through a similar scenario, but her's were kidney stones. Posting it here in a bit of an abridged version in case I have to retrieve it for doc work.

I'm pretty sure I didn't tell you I had 6 bladder stone passing's. They ranged from 4 hours to 7 days.

The first passed intact(4 hrs). I caught it on tissue. I looked at it for many minutes with a magnifying glass.

Okay, this gets kinda bizarre with the first stone, I was in birth type pain, used Lamaze. spasms were about 5 minutes apart over 4 hours. I didn't go to the hospital b/c as a nurse, I new they would confine me to a bed. I was pretty sure what I was dealing with. Knew that just like childbirth walking and moving -------doing whatever the chit you wanted was important.

None of the docs have even given a passing glance that this has happened. The only doc that cared for a fleeting moment was the doc that I told about the intact stone. His comment "I so would have liked to have seen it I've never seen one". Well, me neither in 40 years.

Considering, I have Aunt Mary's gallstones from 1972.. Strained urine for patient stones for years. I had a perfect stone. Studied it for about ten minutes and then...flushed it. I have no clue why. Other than I hated it.

But I can tell you it was beautiful. It was varying shades of Fushia, spiculated, with and imbedded thing that looked like the icon tool. The icon tool had the sheen of alalbaster. It was one of the most unique things I've seen in my life.

How with my science history and my collection of old things, how I got rid of something so unique, plagues me to this day. Other than I hated it b/c of the pain. OH well.

Other thing: Chest pain.

For those that have a history of chest pain or new onset chest pain, it's important to understand the difference between them. I stated at the end that New Onset chest pain should always be treated by activating EMS. I'll ad a bit more here on that. I say activate EMS b/c the medics have all the necessary things on the squads to start interventions. Jumping in your own car and going to your doc's office or to ER may actually delay lifesaving treatment.

Have a chat with your PCP on your next visit regarding whether you should take an aspirin 325 mg with new onset chest pain. It should be chewed and swallowed. This has been in the Advanced Cardiac Life Support (ACLS) guidelines for several decades. But, please, talk with your doc about this

Some folks have an established chest pain history. There are two terms used to describe this Stable Angina and Unstable Angina. Stable angina is a situation that a patient has a known history of chest pain and is under a doc's care for it. Unstable Angina has two definitions 1. New onset i.e never occurred before, or 2. pre-infarct chest pain(before a heart attack). The way too manage each type is very different. Knowing the difference between the two can save your life.

Use a phrase DIFERR to determine the difference between stable angina and unstable angina.

1. Stable angina is generally treated with drugs under the direction of a cardiologist that has determined the best course of treatment after a cardiac workup.

2. Unstable angina is nothing to be messed with. It means that there has been a change. It can be the precursor signals to a heart attack. Ignoring the changes between stable angina and unstable angina can mean the difference between life and death. If their has been a prolonged period between bouts of angina, don't think that this is the old stable angina.

Chest pain: Stable angina..................................................Unstable angina

Duration .......predictable...................................................... unpredictable

Intensity.......generally the same type and radiation.............unusual

Frequency.....occurs usually with the same activity..............increasing freq. & at unusual times

Exercise.....generally, brought on by the same amount........may occur with exercise, but may

of activity............................................................... .................come on at rest (not good)

Radiation.. follows a usual pattern.........................................pattern changes

Relief.......relieved by rest or nitro..........................................no response to rest or nitro

For those folks with a history of chest pain and or Nitro taken at the prescribed 5 minute intervals without relief after the last nitro plus 5 minutes should activate EMS.

Those that have symptoms of NEW ONSET chest pain should activate EMS. Those that understand the DIFERRence between stable and unstable angina will know when to activate EMS.

Chest pain has a predictable radiation pattern. Fairly predictable. Not absolutely predictable. I wrote it that way for a reason. You will see too many web sites that say descriptions. Makes heart problems sound predictable. Stable Angina can be predictable. Unstable angina is not predictable. The definition of radiation means that the pain moves away from the original site of the pain. Chest pain can radiate to the left or right arm. The shoulders. The elbows, the neck, the jaw. Women present differently than men. (reason is unknown) Women can present with radiation to the back. Substernal chest pain with or without radiation for both men and women without radiation is serious if it lasts more than 20 minutes.

This was written as a response to another member. I haven't explained this in years and I did add a couple things to it.

Other thing: Bladder control

On a mission regarding bladder control hope I don't get banned b/c of spamming. Love ya'll

Repost from Warm and Fuzzies. not appropriate to the site , but there were a couple of bladder leaking meme's. But this is a serious story has to do with the funny one about bladder leaking. All the docs will tell you about kegels. WELL, I inadvertently found a solution if you are a swimmer.

There is a swim stroke that I can't find the name for which I learned as a kid. It's meant to be a stroke to reserve energy if lost in the water and have to swim a long distance. I have been using it more frequently b/c I had a shoulder injury and was working the deltoids.

LOANDBEHOLD. The stroke increases bladder control. Takes maybe 2-4 weeks, but dependent I'm thinking on how often you use the stroke. I vary 3 strokes for particular reasons. Then I noticed better bladder control.

It's a back stroke. You bring up the arms from the side to the top. At the same time you bring up the legs in a frog position. Then you snap them down and glide. I kept working the movement harder, to get the work out of the deltoids. Then TADA, head slap moment, I noticed I didn't have the run for the bathroom after the pool or the hitting of the air conditioning. It was AMAZING. I know this isn't a funny on a funny page, but I'm posting this in as many places as I can. So, hahahaha. Leaking is no fun hope it helps, spread the word.

Rosieo, as always, I'm not shooting from the hip, I went looking and found an excellent article, but still looking for some stuff. I have lots of thoughts for you. Sorry, you have this new thing to deal with, HHUGS. I likely will put the links here as I find something that I want to discuss and share. Then I'll put stuff in sequence. SO, if you want to start reading the links that's your choice. But I suggest waiting till I get the entire post done.

http://www.nidcr.nih.gov/oralhealth/Topics/CancerTreatment/HeadNeckRadiation.htm

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3376368/

http://www.tooth-pain-relief.com/trigeminal-neuralgia.htm

http://www.newhealthadvisor.com/Best-Painkiller-for-Toothache.html

https://us.sensodyne.com/online-checkup/

https://community.breastcancer.org/forum/6/topics/834699?page=1#post_4784830

Rosieo I think I've gather what I want on your question, going to put the post together in the next open box.

Other thing: Jaw radiation, jaw pain, and management. All info can apply to any head and neck cancer.

Rosieo, As you have likely been told already, your mets is rare. But just as with any cancer diagnosis, we the blessed (sarcasm), know that the treatment can cause many other problems that are as bad or worse than the cancer. So my approach here is to cover the whole gamut. I may do it over several posts and I will be saving as I go. Eventually, I'll post an "I'm done" thingy.

Each section will have the reference material which is evidence based. There will be some anecdotal information.

This link is to a pamphlet that identifies the overall approach to radiation of the head & neck. It covers the main topics. It is well presented. What I'm guessing is that you have not had time to do the dentist check up. Please, ask your RO for a dentist referral, to a dentist that has experience dealing with radiation patients. You can, also, call your dentist to see if they feel comfortable working with you. Then have your dentist consult(talk with) your RO before any work on your mouth would be done. Even re: something as a simple teeth cleaning.

Recommendations re: Mouth care, foods, brushing are all solid info, but latter links will have even more info. I've chosen this link to be first b/c it "keeps it simple". Basically, it's presented in an outline form without lot's of verbiage.

http://www.nidcr.nih.gov/oralhealth/Topics/CancerTreatment/HeadNeckRadiation.htm

https://community.breastcancer.org/forum/6/topics/834699?page=1#post_4784830

This thread I did some time ago. Regretfully it hasn't gotten much viewings. It's a short thread. It's shocking how many drugs cause mouth problems. The reason I added it here is b/c not many are aware how many drugs can cause mouth problems. With the addition of radiation, I doubt anyone has studied how any of these drugs can impact the mouth.

That's why I asked for your drug list. But you can review the list on the thread and see if you are on any of the medications.

Hi Rosieo, Hugs sweetie, chit, it's always something. I'm going to finish the mouthcare section while I'm on a roll Then I'll get to your next two questions.

Breaktrhough thought that I have to follow up on-------do you have someone that can take care of your drugs and helping you track them in the pain diary and administration?

BBL

Rosieo I didn't find the old post on Benzo's, but I did find an old post on fentanyl. Has lot's of stuff in it. I'm happy I found it. Fits perfectly here.

Jan 11, 2015 04:12PM sas-schatzi wrote:

Fentanyl.(repost from another thread I was working on)

I'm including the black box warning in it's entirety. Not sure as yet, how I will annotate it. But will reinforce the last paragraph regarding heat sources since you will be using the heating pads. The statement at the very end is very well written. If you start using Fentanyl, you would have to discontinue the total body warm moist heat. But if the trade off is better pain control, it doesn't matter how you get there as long as you get there.

Not sure what your MO knows about the drug, if he thinks it only works for a small area. All Opiods work by affecting the opiod receptors in the brain which positively affects the whole body. Plus, Fentanyl has a positive serotonergic affect. That means it mimics the positive affect of increasing serotonin availibility( mechanism I'm not sure of). The antidepressants SSRI's & SSNRI's(see fentanyl thread for list if questions) increase serotonin. Fentanyl is the only opiod that has a positive serotonergic affect. It's two for one drug.

What's different about fentanyl from the other opiods is it doesn't space you out unless the dose is too high. My pain was the entire musculoskeletal system. Post polio & fibromyalgia induced by the Aromatase inhibitors. The day I started, I was a pain scale of 10. Like you the tears were flowing. I was WORN out by pain. It was heaven as the drug started to take effect.+- 18 hours. The pain melted away. Memory on pain scale with it on, is sketchy. I was so used to living my life with a 5-7(predominantly 5). For the duration that I was on Fentanyl, pain control was effective enough that I rarely took meds for breakthrough. I had an OXY script of 120 pills prescribed to be taken every 4-6 hours for breakthrough. If you calculate that out, it was enough for a month. That script lasted 18 months versus 1 month.

The lovely positive serontonergic effect was one of mellow well being for the duration. Not High. Not spacey. With Oxy 10 mg, I'm spacey without great pain control and a bit spacey on 5 mg. I much preferred Fentanyl over Oxy.

In the Duragesic monograph below you will see the discussion regarding 3A4. All opiods go through 3A4. My 3A4 is a intermediate metabolizer which means I process it slowly. At the time I was using it, we didn't know that. You've read the "Panicking about Pain" thread. I developed a 7 day plan. I won't restate it here. What it means for you is that you should have your genetics done. I'm taking an educated guess here that you are a rapid metabolizer at 3A4, b/c you are taking high dose without relief but are symptomatic with negative s.e.'s. Doesn't matter if I'm wrong or right. Testing of your 3A4 is critical to your pain control. Depending if there is an aberration in the metabolism, dosing of anything going through 3A4 should be adjusted. Likely hood if I hadn't developed my 7 day plan, I would have been overdosed if I had changed the patch every 3 days

With Genelex testing for the panel is as cheap as testing for one.(see Fentanyl thread). For completeness her the panel includes 2D6, 2C9, 2C19, 3A4, 3A5, Vkroc1.

Dosing: Ask for the 25 mcg patch to start.. They come in a box of 5. If after one week of use pain is not in target range and s.e's none to minimal discuss using 50 mcg. But as you go up in dose s.e's will become more prominent as is the case with all drugs. Once they screwed up my script and gave me 50 mcg. I used them , but was spacey.

Skin prep: Wash application site with non oily soap and dry well. Patch will fall off if the skin is oily. Avoid cleaning skin with alcohol before application. Might set you up for skin irritation. Application site should be moved around to avoid skin from becoming irritated from the adhesive. If a patch comes off, it's designed to not be able to be reapplied.

Skin site selection: Most practioners recommend the upper back area. I recommend anterior upper chest. Reason is if you become unconscious for any reason the upper chest area is exposed by EMT's/doc's to evaluate breathing. In an unconscious state the patch would be identified and removed. If the patch is on the back it may be missed. Long term use, consider a Medic Alert bracelet.

Initiating drug: Ask for a HomeHealth Referral for "Evaluation of Medication" change. There's an ICDM-9 code for it that the HHA will use. It's covered by insurance. The importance of this is that the nurse will evaluate how you are responding to the drug. It's necessary to be done in your surroundings versus going to the docs office. This evaluation is usually done over 1-2 weeks. Should be repeated if there is a dosage change. review the monograph to educate yourself about the drugs workings.

Storage and disposal: Keep in a secure area from children and pets. Dispose of in the trash that is then secured. Disposal is controversial as it is with all drugs now. Drugs used to be recommended to be put done the toilet. Drugs were affecting the environment. In the trash it goes to the landfill. Communities have developed drug disposal plans.

/////////////////////////////////////////////////////////////////////////////////////////////////////////

Drug Monograph

Black box warning for Fentanyl( black box warnings means that these are serious considerations regarding a drug).

DURAGESIC^® (fentanyl transdermal system) CII contains a high concentration of a potent Schedule II opioid agonist, fentanyl. Schedule II opioid substances which include fentanyl, hydromorphone, methadone, morphine, oxycodone, and oxymorphone have the highest potential for abuse and associated risk of fatal overdose due to respiratory depression. Fentanyl can be abused and is subject to criminal diversion. The high content of fentanyl in the patches (DURAGESIC^®) may be a particular target for abuse and diversion.

DURAGESIC^® is indicated for management of persistent, moderate to severe chronic pain that:

• Requires continuous, around-the-clock opioid administration for an extended period of time, and
• Cannot be managed by other means such as nonsteroidal analgesics, opioid combination products, or immediate-release opioids

DURAGESIC^® should ONLY be used in patients who are already receiving opioid therapy, who have demonstrated opioid tolerance, and who require a total daily dose at least equivalent to DURAGESIC^® 25 mcg/hr. Patients who are considered opioid-tolerant are those who have been taking, for a week or longer, at least 60 mg of morphine daily, or at least 30 mg of oral oxycodone daily, or at least 8 mg of oral hydromorphone daily or an equianalgesic dose of another opioid.

Because serious or life-threatening hypoventilation could occur, DURAGESIC^®is contraindicated:

• In patients who are not opioid-tolerant
• In the management of acute pain or in patients who require opioid analgesia for a short period of time
• In the management of post-operative pain, including use after out-patient or day surgeries (e.g., tonsillectomies)
• In the management of mild pain
• In the management of intermittent pain (e.g., use on an as needed basis [prn])

(See CONTRAINDICATIONS section of the full Prescribing Information for further information.)

Since the peak fentanyl concentrations generally occur between 20 and 72 hours of treatment, prescribers should be aware that serious or life-threatening hypoventilation may occur, even in opioid-tolerant patients, during the initial application period.

The concomitant use of DURAGESIC^®with all cytochrome P450 3A4 inhibitors (such as ritonavir, ketoconazole, itraconazole, troleandomycin, clarithromycin, nelfinavir, nefazodone, amiodarone, amprenavir, aprepitant, diltiazem, erythromycin, fluconazole, fosamprenavir, grapefruit juice, and verapamil) may result in an increase in fentanyl plasma concentrations, which could increase or prolong adverse drug effects and may cause potentially fatal respiratory depression. Patients receiving DURAGESIC^®and any CYP3A4 inhibitors should be carefully monitored for an extended period of time and dosage adjustments should be made if warranted. (See CLINICAL PHARMACOLOGY-Drug Interactions, WARNINGS, PRECAUTIONS, and DOSAGE AND ADMINISTRATION sections of the full Prescribing Information for further information.)

The safety of DURAGESIC^®has not been established in children under 2 years of age. DURAGESIC^®should be administered to children only if they are opioid-tolerant and 2 years of age or older. (See PRECAUTIONS - Pediatric Use section of the full Prescribing Information.)

DURAGESIC^® is ONLY for use in patients who are already tolerant to opioid therapy of comparable potency. Use in non-opioid tolerant patients may lead to fatal respiratory depression. Overestimating the DURAGESIC^® dose when converting patients from another opioid medication can result in fatal overdose with the first dose (see DOSAGE and ADMINISTRATION – Initial DURAGESIC^® Dose Selection - section of full Prescribing Information for further information). Due to the mean elimination half-life of approximately 20-27 hours, patients who are thought to have had a serious adverse event, including overdose, will require monitoring and treatment for at least 24 hours.

DURAGESIC^® can be abused in a manner similar to other opioid agonists, legal or illicit. This risk should be considered when administering, prescribing, or dispensing DURAGESIC^® in situations where the healthcare professional is concerned about increased risk of misuse, abuse, or diversion.

Persons at increased risk for opioid abuse include those with a personal or family history of substance abuse (including drug or alcohol abuse or addiction) or mental illness (e.g., major depression). Patients should be assessed for their clinical risks for opioid abuse or addiction prior to being prescribed opioids. All patients receiving opioids should be routinely monitored for signs of misuse, abuse, and addiction. Patients at increased risk of opioid abuse may still be appropriately treated with modified-release opioid formulations; however, these patients will require intensive monitoring for signs of misuse, abuse, or addiction.

DURAGESIC^® patches are intended for transdermal use (on intact skin) only. Do not use a DURAGESIC^® patch if the seal is broken or the patch is cut, damaged, or changed in any way.

Avoid exposing the DURAGESIC^® application site and surrounding area to direct external heat sources, such as heating pads or electric blankets, heat or tanning lamps, saunas, hot tubs and heated water beds, while wearing the system. Avoid taking hot baths or sunbathing. There is a potential for temperature-dependant increases in fentanyl released from the system resulting in possible overdose and death. Patients wearing DURAGESIC^® systems who develop fever or increased core body temperature due to strenuous exertion should be monitored for opioid side effects and the DURAGESIC^® dose should be adjusted if necessary.

I found an old post of Bestbirds that 's excellent. I have her permission to repost her post's as needed. This also, tie's into todays work

Apr 19, 2015 04:21PM Bestbird wrote:

I am so sorry you are dealing with acute pain, and would suggest that you consider speaking with your doctor about engaging a Palliative Care (PC) team. Palliative care differs dramatically from hospice, as you can still be treated for your disease. The purpose of PC is to manage all your symptoms as well as possible, including pain.

In addition, perhaps you might engage the services of a patient advocate or social worker at your place of treatment who may make recommendations that will assist you with everyday items.

Below are my notes on pain medications. Please forgive the formatting, as it tends to get a bit messed up when I copy and paste from other sources. This information is from my MBC Therapies Guide, and you and others are welcome to request a complimentary copy by following instructions at:

https://community.breastcancer.org/forum/8/topic/828391?page=1#idx_11

I hope you find something that makes you feel much better very soon!

Over the Counter Drugs (OTC)

Weak Opioids·
Strong Opioids·
Antidepressants
Anti-seizure Medication
Nerve Blocks

PAIN PLAN: BASIC AND BREAKTHROUGH

1.Pain diary, document per directions from previous posts. Identify what your acceptable pain maintenance scale is_________(Range 0-10)

2.Consider Fentanyl patches, 12.5 mcg. they come in a pack of 5, changed every 3 days. If okay with doc you can add another patch to make 25 mcg after 24 hrs to see how you respond. Then work it from there

3 OXy or hydrocodone or morphine or codeine or other for breakthrough. Dose appropriate to drug i.e OXy 5 mg tabs 1 tab q 4-6 hrs prn for breakthrough. Can work higher, but try getting the fentanyl dose right first and you shouldn't need as much oral med.

4. Ativan for anxiety 1mg 1-2 tabs q whatever span he writes

5. Melatonin 3 mg for sleep. work to a higher dose. May take a while to start kicking in. When I first started it was 1-2 hours. Then after a couple of weeks it was 15 minutes. Can go as high as 20 mg. I was on 10 mg at my highest.

6. NSAID choose between Ibuprofen and naproxyn. start at OTC dose and then move to prescription dose-----doc will advise. Rosieo the dose you are taking now is not good for the liver or kidney's. You should get better control with a whole plan in place. Basic NSAID plan is schedule for 24 coverage, then a breakthrough dose just as with the narcotic breakthrough dose. Avoid acetaminophen if possible.

7. Add Neurontin/gabapentin or Lyrica if symptoms of neuropathy occur.

8. Constipation daily documentation in pain diary, daily dose of whatever you use.

9. Antidepressant plan if applicable. I recommend Savella/ milnapricin. it's a SNRI that is similar to Cymbalta, but has less side effects.

10. Exercise

11. Get that palliative care doc appointment made. The ideal, but they may not be available in your locale. Only one doc should be managing your controlled substances prescribing and pain plan.

Pretty basic plan, allows for upward mobility without gorking you out to begin with. Important to start lower and work up. Pain management should never be without ability to change. The plan should be fluid enough to respond to usual pain levels and then allow the patient a stepwise plan to respond and "rescue" themselves from an acute change.

This will be the basic and rescue plan for this thread. I will tweak as we go.

Rosieo, It makes it more difficult without a Palliative care doc. But your docs seem willing to work with you on drugs.

Get that pain diary going okay

ovy---OXY typo. Amazing not more typo's I am wearing 1.25 strength glasses and I need 3.25 LOL

My experience with Xanax is patient based. I have never had it. I have had only one patient addicted to Ativan out of thousands. BUT plenty that were hooked on Xanax. I learned over time to very intensely dislike seeing it in the patient admission histories. I always evaluated for last dose very quickly and signs of withdrawal. Also, I have seen more patients with drug seeking behaviors re: Xanax. than any other Benzo. I'm completely disrespectful of the drug. There aren't that many drugs that I'm that opinionated about.

Constipation, let's take that to the constipation thread. Recently, dsgirl posted a recipe that sounded very good. But there are many suggestions and lot's of discussion there.

I knew it was information overload yesterday. The intent was to give you everything you needed to know in one place. But then also the summary of what to ask for. I have finished it this afternoon. So, please, take a relook

The drug plan is basic. The intent is to give you the ability to move up on each one. It will take at least a week. The ideal is it's balanced. I call it a smorgasboard.a' A little of this, a little of that" If you get the balance right at the lowest dose possible that controls your pain , you will experience less side effects. But if your pain level changes commonly referred to as breakthrough, than you can add the appropriate drug, if the plan is written right.

Another accepted medical term is a "rescue" drug. i.e what do I use in case I have a sudden change in pain--breakthrough. That should be part of the basic plan. Let me give you two different examples that many are familiar with. Asthma, a person is frequently on a basic medicine plan, then they have an Inhaler for acute breathing change needs. It's commonly referred to as their "rescue inhaler". Another example, is high blood pressure. A person may be on a regular daily dose. But for some reason they have an unusual sustained spike. If they have planned well with their doc, they know which drug to take to regain control. I'll use me as an example, when I was first put on my two BP pills, I asked the doc which one was my rescue drug.

Pain management should never be without ability to change. The plan should be fluid enough to respond to usual pain levels and then allow the patient a stepwise plan to respond and "rescue" themselves from an acute change.

Absolute necessity in the plan is the pain diary. If the pain diary is documented well, you can see based on your numbers when you have pain spikes. For example, after you keep it for say a week, you see that you spike everyday when you shower at 10 am. Then take one of the breakthrough drugs at 9:am. This allows coverage for the active time that produces more pain.

Another important example, say your diary shows that you wake up every morning at a pain level of 8. You may build into your plan to set the alarm 2-4 hours before your normal wake time and take a breakthrough drug. In this case, I recommend that that single dose be kept in the bedside drawer with a glass of water so you don't have to get out of bed. In the drawer if possible so it can't be knocked on the floor.

Plus, say you have followed your basic & breakthrough plan, but your pain scale report shows that you are not below your target maintenance point i.e less than 4. The doc can adjust meds on "data". versus it "hurts and uncomfortable".

Zero pain is wonderful, but the trade off is side effects. Myself, I accept a level 3-5 as my maintenance range. That may seem high, but I'm used to it and like to avoid drugs. But I have a plan and manipulate it as needed. I, also, have in my plan 2-5 pain free days a month. Generally, Sunday. The trade off is I'm then constipated for about the next day or so. I use them judiciously.

Roseio, I have now scared the bejebbers out of folks about taking Valium or other Benzo's with an opioid. It's utilized all the time in hospital settings. In the home setting it can be safely taken. I mentioned it in my last post, but feel I must expand. All drugs have consequences. Used with understanding everything can be done safely. A small dose of Valium i.e. 2.5 mg-5 mg can be taken with the lowest dose opioid. In fact they can work synergistically i.e really well by complementing each others action.

If on a fentanyl patch, I wouldn't try a Benzo until I was on the maintenance dose of fentanyl. Then I would only use it in the low dose.

With Valium at 10mg concern is that being mixed with anything else it may suppress respirations.

The posts were directed at your particular unique scenario of jaw radiation. Seriously, no clue if TMJ spasm is going to be a problem. I have a serious life long physician caused TMJ problem. I know what it takes to break a tight propeller type spasm. Physicians aren't used to the dose needed in the worst case scenario. I won't even mention the dose, for fear someone might try self medicating.

If I were in the worst case spasm scenario and a fentanyl patch on, I would removed the patch and figure out with the doc how long before I could take the Valium. It's a very unique pain scenario. So, let's leave it for now.

Taking Ativan low doses and Valium low doses with a patch on can be done in a well established pain plan.

Is that a better explanation?

Working on a post with Mari about Tramadol. I'm posting the PM here b/c I can't afford to loose the info. Tramadol has some unique characteristics very different than other pain relievers. This post is done now, but likely more discussion on Tramadol will occur.

////////////

OH Mari, Now I have to tweak my response to you about Tramadol. Actually, this would have been much better done on the pain thread as Tramadol has become such a widely used drug as docs are refusing to prescribe higher scheduled narcotics.

Which since you are taking this to your doc. My statement is "Shame on the medical profession for not meeting the pain management needs of their patients". "Cancer causes pain". "A patient has the right to proper pain management as evidenced by the choice of the Agency on Health Care Policies and Research as one of three first Guidelines for Practice published in 1989". The other two were diabetes and incontinence.

Tell him to read my entire thread and it will teach him allot on pain management.

////////////////////Retweaking, but cutiing and pasting to thread can't loose this

Hi Mari, I tweaked the pain plan and formalized it more. Please, take a relook and make any suggestions. I want to get it to a point that members can take it with them to their docs.

Consider Savella/milnapricin. in place of Cymbalta. Greatest reason is Savella is not metabolized by the CYP450 (liver metabolism). Therefore, not to worry about genetic abnormalities of that system.

Tramadol has a unique effect different than other pain relievers. " Metabolism. Following oral administration, tramadol is extensively metabolized by a number of pathways, including CYP2D6 and CYP3A4, as well as by conjugation of parent and metabolites. Approximately 30% of the dose is excreted in the urine as unchanged drug, whereas 60% of the dose is excreted as metabolites." Since most docs don't test for CYP abnormalities this can be a problem.

Tramadol , also has a " weak inhibition of norepinephrine and serotonin reuptake by the parent drug to enhance inhibitory effects on pain transmission in the spinal cord [Articles:19180260, 15509185, 19496778"

https://www.pharmgkb.org/pathway/PA165946349

Tramadol/Ultram is generally good. I take it, BUT start very slowly and low dose for a few days to a week. I have found a common complaint that the first few doses can make you feel weird. IT certainly did me. I put them aside for maybe a year, but found when I totally quit oxy after a few months I had to have something.

Since Tramadol has a weak effect on the same neurotransmitters that are affected by SSRI's and SNRI's, it can play a little havoc with those which is the likely cause of the weirdness at the beginning.

Then I went through a period I was taking Tramadol daily for about 3 months for the very reason I identified above about the neurotransmitters. I quit the daily b/c of constipation. Now maybe a 1-3 times a week. Rarely, more than that.

Usual starting dose is 50 mg. I suggest 25 mg. and not every 6 hours like it suggests till you see how your head likes it.