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What Causes Persistent Back Pain Despite Taking Medication?
Question: Re: 88 yr old 87 pound widow with severe chronic pain. Started Fentanyl 25 patch 12/24 AM. 12/26 took her to ER with uncontrollable pain. Dr. said to take 1/2 Oxycodone 20mg for breakthrough pain. She has taken 2 to 3 1/2 Oxycodone 20mg tabs per day since and still has severe pain. Back pain has moved to hip and knee joints. 4th patch is due to be put on 1/2/16 AM. Is t safe to not use patch anymore and go back to Oxycodone 20 mg tabs for the pain?
Brief Answer:
There are several considerations.
Detailed Answer:
First, it is much more appropriate to have discussions with one's own physician(s) than internet ones unable to prescribe, diagnose, nor treat the particular patient in question.
Then, I am not quite certain of the narcotics being given but it seems as if it is 10 mg three times a day.--a reasonable dose.
There is also the question of why someone has new, severe pain. Arthritis is very UNlikely to hit multiple places suddenly and severely. A more catastrophic illness (disk collapse, bone fracture, cancer) is more consistent with a catastrophic pattern and the diagnosis has to be made to know what to do.
Then, if someone is on two narcotics (fentanyl AND oxycodone) if you take away one,you have less. Less drug is NOT going to give MORE pain relief.
Safety from drug overdose of course is more safe the least drug one is taking. So, from a drug overdose point of view, dropping narcotics will NOT produce overdose. But it will produce less pain relief. It MIGHT produce withdrawal BUT this is unlikely at the doses and durations the quesiton seems to indicate (lowest doses for under a week).
There are several considerations.
Detailed Answer:
First, it is much more appropriate to have discussions with one's own physician(s) than internet ones unable to prescribe, diagnose, nor treat the particular patient in question.
Then, I am not quite certain of the narcotics being given but it seems as if it is 10 mg three times a day.--a reasonable dose.
There is also the question of why someone has new, severe pain. Arthritis is very UNlikely to hit multiple places suddenly and severely. A more catastrophic illness (disk collapse, bone fracture, cancer) is more consistent with a catastrophic pattern and the diagnosis has to be made to know what to do.
Then, if someone is on two narcotics (fentanyl AND oxycodone) if you take away one,you have less. Less drug is NOT going to give MORE pain relief.
Safety from drug overdose of course is more safe the least drug one is taking. So, from a drug overdose point of view, dropping narcotics will NOT produce overdose. But it will produce less pain relief. It MIGHT produce withdrawal BUT this is unlikely at the doses and durations the quesiton seems to indicate (lowest doses for under a week).
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Dr. Wachsman, the purpose in asking for your advice is because it will be two and 1/2 more days before we can see her doctor and she is living with severe pain. My question was can the fentanyl patch be discontinued tomorrow morning and have her start taking Oxycodone 20mg tabs 3 times a day as she was taking before using the fentanyl patch.
We would much prefer to have discussions with her physician, but that it not possible until Monday and this is Friday.
In other words, she started using the patch on Dec. 24 and stopped taking any Oxycodone tabs. We took her to the ER on Dec. 26 because of the severe pain she was having. The ER doctor told her to take 1/2 Oxycodone 20mg tabs to control the break through pain, which is not helping.
Again, my question is can the fentanyl patch be safely discontinued in the morning and can she go back to taking the 20mg Oxycodone tabs at 8AM, 2PM and 8PM as she was before starting on the patch?
It is 11:30PM on Friday and we cannot make an appointment with her doctor until Monday morning and she is in constant pain.
We would much prefer to have discussions with her physician, but that it not possible until Monday and this is Friday.
In other words, she started using the patch on Dec. 24 and stopped taking any Oxycodone tabs. We took her to the ER on Dec. 26 because of the severe pain she was having. The ER doctor told her to take 1/2 Oxycodone 20mg tabs to control the break through pain, which is not helping.
Again, my question is can the fentanyl patch be safely discontinued in the morning and can she go back to taking the 20mg Oxycodone tabs at 8AM, 2PM and 8PM as she was before starting on the patch?
It is 11:30PM on Friday and we cannot make an appointment with her doctor until Monday morning and she is in constant pain.
Brief Answer:
the drugs have some safety range.
Detailed Answer:
Thank you for the question.
Yes, good question. The fentanyl still goes into the system even after the patch is removed. It is somewhat long acting. BUT, the dose of the fentanyl is relatively small.
"Fentanyl plasma concentrations are not measurable until 2 hours after patch application and require 8 to 16 hours until full effects are observed. Steady-state serum levels of fentanyl are maintained for as long as the patches are applied. The patches are re-applied after 72 hours, but the effects are prolonged because fentanyl continues to be absorbed from the skin reservoir. Because of its long delay and decay times, the fentanyl transdermal system is unsuitable for the routine management of short-duration, acute pain state"
XXXX
It's effects are all over the place in the elderly. The results vary tremendously in how much gets in, how fast, what lag til it works (but hours to a day) and how long it sticks in the skin.
But 25 is the lowest dose. It didn't do that much. Pain is a very very good indicator of whether the drug is having an effect. So... you can skip doses until the pain increases and then restart the 20 mg. 24 is a bit on the long side for the fentanyl to still be there; 8 hrs is a bit on the short side. Mostly, the drugs have a decent safety margin. Drowsiness, decline in breathing are serious signs.
Restarting oxycodone with a 24 hr lag or at 12 hr if there is increased pain is very likely safe in most people on the lowest dose of fentanyl. Age, liver failure (you'd know), and small size are risks for more drug being in the body and more danger.
the drugs have some safety range.
Detailed Answer:
Thank you for the question.
Yes, good question. The fentanyl still goes into the system even after the patch is removed. It is somewhat long acting. BUT, the dose of the fentanyl is relatively small.
"Fentanyl plasma concentrations are not measurable until 2 hours after patch application and require 8 to 16 hours until full effects are observed. Steady-state serum levels of fentanyl are maintained for as long as the patches are applied. The patches are re-applied after 72 hours, but the effects are prolonged because fentanyl continues to be absorbed from the skin reservoir. Because of its long delay and decay times, the fentanyl transdermal system is unsuitable for the routine management of short-duration, acute pain state"
XXXX
It's effects are all over the place in the elderly. The results vary tremendously in how much gets in, how fast, what lag til it works (but hours to a day) and how long it sticks in the skin.
But 25 is the lowest dose. It didn't do that much. Pain is a very very good indicator of whether the drug is having an effect. So... you can skip doses until the pain increases and then restart the 20 mg. 24 is a bit on the long side for the fentanyl to still be there; 8 hrs is a bit on the short side. Mostly, the drugs have a decent safety margin. Drowsiness, decline in breathing are serious signs.
Restarting oxycodone with a 24 hr lag or at 12 hr if there is increased pain is very likely safe in most people on the lowest dose of fentanyl. Age, liver failure (you'd know), and small size are risks for more drug being in the body and more danger.
Note: For further queries, consult a joint and bone specialist, an Orthopaedic surgeon. Book a Call now.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Answered by
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