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Suggest Medication For Severe Back Pain

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Posted on Mon, 14 Dec 2015
Question: I currently am on a pain contract for back issues. I have Fentanyl 25 mug and a 12.5 mug patch q 72 hours and can take Hydrocodone 5/325 tab. Can take 1 tab up to 2x per day for breakthrough pain PRN. What is your expertise thought between Fentanyl management. As my back will worsen I will not be able to increase dosage due to risk of respiratory depression. Do you have any other thoughts on an alternative pain management regimen? It has been brought up before by my psychiatrist the use of Methadone. Please let me know your thoughts and opinions Thank You. I am also interested in alternative pain management such as psychotherapy, meditation and yoga. But the pain in my back is severe and I am unable to do any daily functions without the medication. I have back spasms that causes me to fall to my knees and unable to walk. Injections, physical therapy have been done but all have been unsuccessful.
doctor
Answered by Dr. Dr. Matt Wachsman (57 minutes later)
Brief Answer:
several good questions.

Detailed Answer:
Don't go there on methadone.
Methadone has a tendency for a decreasing positive effect over time (tolerance) that seems the worst of all narcotics. On the one hand, it's use in people NOT wanting narcotic positive effects (addicts in treatment) has been beneficial. On the other hand it had the highest percentage risk of fatality of all narcotics used in pain management. This led to the removal of high dose (> 10 mg) methadone pills from the US market (and the removal of many pain management clinics!). Unless you want to undergo narcotic addiction treatment, in which case it gets tricky with the pain issue but very closely supervised methadone treatment in an addiction paradigm makes sense.

The lowest dose of fully active short acting narcotics is 5 mg; the lowest dose of fentanyl is 12.5. Lower doses have both less positive and negative consequences. People on the lowest doses are less likely to have addiction issues. The short acting drugs tend to start working in 30 to 60 minutes. Immediate release (IR) pills closer to 30, the rest closer to 60.

All the alternative pain management techniques would easily pass the FDA. they all work and have no risk. I can find the articles to support this, but I don't think we need to. More interesting is HOW they work. Everywhere. 1) physical therapy increases the function of the supporting structures around the broken parts and increases flexibility and everything else I will mention; chiropracty overlaps a lot with physical therapy. 2) Yoga has several of the benefits of physical therapy with body awareness. there are two big big important features of this that aren't in the the medical (but are in the engineering! literature)--> unbalanced / harsh/ ungraceful / sudden movement puts increased weight (active load) onto PART of the damaged area. The unbalanced nature of it means that the weight is all on ONE part and the force is huge/sudden and not compensated on a small surface area. BAD. Also, you learn to have the pain but not the suffering. This was the original entire purpose of Yoga as spiritual exercise (along with Dervish dancing, meditation, cognitive behavioral therapy, fasting, etc.). 3) psychotherapy, not so much as cognitive behavioral therapy in the context of pain issues is that last one. 4) Ballroom dance also has the benefit of yoga.

Nobody's noticed the ballroom dance association with pain management but me. While nobody in pain management does ballroom dance, everybody in my ballroom dance group has (PRIOR TO BALLROOM) chronic pain issues. We're all old.

"I am unable to do any daily functions without the medication" says it better than I do and the issue is that. Modalities involving increase in daily function would seem the key issue and those would be non-medication based. Physical therapy, OCCUPATIONAL therapy, chiropracty if the practioner is exceptionally good, and ballroom, directly involve daily functions. Yoga and meditation might.
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Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Answered by
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Dr. Dr. Matt Wachsman

Addiction Medicine Specialist

Practicing since :1985

Answered : 4214 Questions

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Suggest Medication For Severe Back Pain

Brief Answer: several good questions. Detailed Answer: Don't go there on methadone. Methadone has a tendency for a decreasing positive effect over time (tolerance) that seems the worst of all narcotics. On the one hand, it's use in people NOT wanting narcotic positive effects (addicts in treatment) has been beneficial. On the other hand it had the highest percentage risk of fatality of all narcotics used in pain management. This led to the removal of high dose (> 10 mg) methadone pills from the US market (and the removal of many pain management clinics!). Unless you want to undergo narcotic addiction treatment, in which case it gets tricky with the pain issue but very closely supervised methadone treatment in an addiction paradigm makes sense. The lowest dose of fully active short acting narcotics is 5 mg; the lowest dose of fentanyl is 12.5. Lower doses have both less positive and negative consequences. People on the lowest doses are less likely to have addiction issues. The short acting drugs tend to start working in 30 to 60 minutes. Immediate release (IR) pills closer to 30, the rest closer to 60. All the alternative pain management techniques would easily pass the FDA. they all work and have no risk. I can find the articles to support this, but I don't think we need to. More interesting is HOW they work. Everywhere. 1) physical therapy increases the function of the supporting structures around the broken parts and increases flexibility and everything else I will mention; chiropracty overlaps a lot with physical therapy. 2) Yoga has several of the benefits of physical therapy with body awareness. there are two big big important features of this that aren't in the the medical (but are in the engineering! literature)--> unbalanced / harsh/ ungraceful / sudden movement puts increased weight (active load) onto PART of the damaged area. The unbalanced nature of it means that the weight is all on ONE part and the force is huge/sudden and not compensated on a small surface area. BAD. Also, you learn to have the pain but not the suffering. This was the original entire purpose of Yoga as spiritual exercise (along with Dervish dancing, meditation, cognitive behavioral therapy, fasting, etc.). 3) psychotherapy, not so much as cognitive behavioral therapy in the context of pain issues is that last one. 4) Ballroom dance also has the benefit of yoga. Nobody's noticed the ballroom dance association with pain management but me. While nobody in pain management does ballroom dance, everybody in my ballroom dance group has (PRIOR TO BALLROOM) chronic pain issues. We're all old. "I am unable to do any daily functions without the medication" says it better than I do and the issue is that. Modalities involving increase in daily function would seem the key issue and those would be non-medication based. Physical therapy, OCCUPATIONAL therapy, chiropracty if the practioner is exceptionally good, and ballroom, directly involve daily functions. Yoga and meditation might.