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ProfessorTomoe

Changing Medications (Level of Trust Required)

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8 minutes ago, ProfessorTomoe said:

I just went through my pre-op "stop list" for my pain management procedure, and it's freaking spartan compared to the one that Spine Team Texas had me on. Basically, it amounts to no blood thinners and no anti-inflammatories, neither of which I take in the first place. My procedure is scheduled for two weeks from today, Friday, August 18th, at 12:20 p.m. CDT. I get to have a light meal and clear liquids 8 hours before the procedure, and I can take my other medications as usual, even on the day of the injection (including my pain medication), with a small sip of water only.

That's pretty damned liberal when you compare it to the stop list that STT gave me. Makes me wonder why STT was so worried about things.

I don't know your list, but I had a situation where ALL of my drugs were blood thinners as a side effect, which might be what the STT folks were using as their guideline, i.e., if it might be a blood thinner, don't take it.

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When you go to a new doctor for an old problem, and he says "every lab test or imaging I'd want to order, you've already had in the past two years - most of them twice - and I have no idea what they were thinking when they ordered THESE tests... and you know, they've checked for every plausible cause except this one..."

(My daughter had that experience. And the process of checking that one plausible cause happened to be the first 80% of the process of fixing it, so after struggling for over two years with the musical-chairs medical care of a medical-school-affiliated system, she spent a grand total of less than an hour over two weeks with this new doctor and the problem was gone.)

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2 hours ago, Don Edwards said:

When you go to a new doctor for an old problem, and he says "every lab test or imaging I'd want to order, you've already had in the past two years - most of them twice - and I have no idea what they were thinking when they ordered THESE tests... and you know, they've checked for every plausible cause except this one..."

Ah, yes, the referral phenomena of "all the basic grunt work is already done by first doctor, leaving second doctor with a much smaller, easier list of differentials" that lets second doctor look like a genius.  Sometimes, first doctor would have done the exact same thing as their next move, if they'd gotten the chance; other times there's just one or two things they missed.

Quote

(My daughter had that experience. And the process of checking that one plausible cause happened to be the first 80% of the process of fixing it, so after struggling for over two years with the musical-chairs medical care of a medical-school-affiliated system, she spent a grand total of less than an hour over two weeks with this new doctor and the problem was gone.)

I'm glad she's better!

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11 minutes ago, CritterKeeper said:

Ah, yes, the referral phenomena of "all the basic grunt work is already done by first doctor, leaving second doctor with a much smaller, easier list of differentials" that lets second doctor look like a genius.  Sometimes, first doctor would have done the exact same thing as their next move, if they'd gotten the chance; other times there's just one or two things they missed.

Actually, in this case it was a matter of escaping from musical-chairs medicine. My daughter happened to live near a medical school, and every medical facility near her was in some way affiliated with it. So she never saw the same doctor twice in a row (rarely saw the same doctor twice, period); rarely saw the doctor that her appointment was scheduled with; and rarely was billed having seen the doctor she had had the appointment with OR the doctor she actually saw. Seriously, over two years I think she had >50 different doctors' names in her file. Even though she kept going to the same clinic.

And if the doctors had been actually studying her file in any depth - even looking to see if a test had been done recently before ordering, she wouldn't have had so many tests ordered twice.

The doctor who looked over the entire file and fixed the problem was in another town and NOT affiliated with the medical school. She had a grand total of two appointments, saw him on both of them, and was done.

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Sometimes modern medicine can surprise us, good or bad.  McKinley Health Center was the student health center, "free" care included with tuiton.  Nicknamed McKillMe.  Yet I got some if the best health care in my life there.  They were the ones who put my symptoms together and suggested I might have PCOS.  They were the ones who, on hearing that my cough was something which had been spreading through the vet school, sent in samples for testing which identified "The Disease" as Whooping Cough, apparently brought back from a conference in Mexico by the Dean of Students!  Apparently the first physician to think to do so, she checked for zoonotic diseases I might have picked up from patients, too.  

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7 hours ago, Don Edwards said:

(My daughter had that experience. And the process of checking that one plausible cause happened to be the first 80% of the process of fixing it, so after struggling for over two years with the musical-chairs medical care of a medical-school-affiliated system, she spent a grand total of less than an hour over two weeks with this new doctor and the problem was gone.)

I was about to go through that with my podiatrist until I met pain management specialist #3 Wednesday. I would have had an MRI ordered today if it weren't for him. He told me that the "stone bruise"/"gunshot" pains on the bottom of my left foot were probably due to spinal issues. Regardless, I'm having the podiatrist fax over my operative report on my big toe and the report from the week I was given the Lyrica to the pain doctor, just as a precaution.

I still don't have all of the Lyrica out of my system. God, I hate not being able to talk coherently ...

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5:37 a.m. CDT 20170805. Feels good to be able to see what the [redacted] I'm typing again. However, it does not feel good to have my podiatrist go a step down in my eyes.

(hands /me the list and two pens in case the first pen is empty)

At the past couple of visits, the podiatrist had been touting this dry-skin cream with 40% urea. That's a lot, I'll grant you. He said "they" (guess) couldn't get the stuff stocked in local pharmacies. I was interested, because I knew somewhat of urea's effects on the skin (no, I'm not a dermatologist). At yesterday's appointment, with Mrs. Prof's full approval (she hates how my heels get dry and cracked enough to do bodily damage), I took the bait. Bought a 4oz (114g) jar for $35.

I woke up this [WAY TOO FREAKING EARLY] today and checked the internet. Decided to look up the stuff I'd bought, too. Gilden Tree Ultra Softening Cream, it's called.

I quickly learn why "they" couldn't get the stuff stocked in local pharmacies.

This product is only available to medical offices.

Then I read further along:

Suggested Cost to Patient: $26.00 each

I've been had for $9 bucks. Dishonesty and overpricing (not by much, but still ...). Not a combination I want from my doctors. This stuff damned well better do what it's supposed to do.

In any case, my "follow-up period" ended with my previous appointment, too (which they conveniently didn't charge me at that check out), so I had a balance due when I checked out this time around. Friday's appointment cost me $115.00. (Mrs. Prof made a particularly embarrassing remark about "Am I ever going to be able to retire?", for which I let my displeasure be unknown.)

Otherwise, Mrs. Prof and I decided on the way home that, if my follow-up period is done, then we're done with the podiatrist. Time to move on to the pain management doctor, as long as he gets the stone bruise pain from my foot under control.

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Now, there's something I didn't need when I was on the Lyrica: Zofran. I just drank a cup of coffee to warm up and to stay awake, and I wound up getting sick to my stomach. It seemed like I could eat anything while on the Lyrica. I'm told Lyrica is chemically related to gabapentin (another pain reliever), which made me gain weight when I was on it. That would explain much.

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I have a conundrum with which I need advice. My pain management doctor has increased my hydrocodone dose from my current four pills a day. It's now "one-to-two tablets 3x a day as needed." Basically, six pills a day if I go with the max. His reasoning is that my Roux-en-Y gastric bypass is not giving me good absorption and that I need the higher dosage.

Mrs. Prof is DEAD SET against this. Her arguments? One time, back in the early 80s, I did develop a mild dependency. My doctor cut me off. Once I got over it, I've never had another problem with dependency since (my counterargument). Also, she had horrible experiences with her father being an alcoholic and is afraid anytime I'm prescribed anything with the potential for dependency. My counterargument is that I'm following doctor's orders under supervision, and (again) that I know what dependency feels like. Her final argument is that I'm dealing with Opioid Induced Constipation already. My experience yesterday proves that it goes both ways.

My biggest self-argument is whether I'm not sure if I'm going to turn into a drug zombie on the sofa, or if I'm already one because I'm not getting sufficient relief. I have enough daily pain to knock an elephant flat, despite my hydrocodone.

Her biggest argument is that I won't be able to drive. I haven't been able to drive since early February. She says that's her ultimate goal, and I think she knows that can't be achieved on such high levels of pain medicine (at least, not legally). I've told her to make her feelings on that known directly to the doctor.

How the hell do I handle this? More than one of you, please, jump in. What do I do to deal with this situation?

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It is a serious issue and I wish I had a solution I could be sure worked. Unfortunately I do not.

My mother was an alcoholic as well. I also have issues with drug dependencies, especially as pertains to alcohol. My wife has had her own scrapes with these and we have discussed them. It is fair to say that I am terrified of this happening in my life again. But the thing is, every time there has been a danger of it, my wife has stopped herself in time. I have learned to trust her judgment. This hasn't made me less frightened but the fact that I trust her means I can manage my fear. This is, of course, between her and me. What works for us may not be the right solution for you. Still, I understand your wife and sympathise with her; it is a terrible fear to confront.

Ultimately, I feel, it will be important for you and her to find a balance, a solution where she can trust your ability to manage the drug. This will involve talking to one another on what may be difficult and painful topics for you both. Listen to her fears, respect them, even if they don't sound rational. Fear doesn't need to be rational in order to be crippling. It just needs some vaguely plausible possibility to feed on in order to grow out of control. Only through mutual understanding can a lasting solution be found.

Trust is all-important here. Try to find a basis for mutual trust. If you can achieve that, everything else will become easier. Not necessarily easy, mind, just easier.

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Saw my primary care doctor today—he recommended that I start off with 4½ pills at first and move up from there if needed.

That wasn't the real reason for the appointment, though. I've had a spot on my right ear that's been draining for about 6 months now. He saw it at my last appointment and said if it hadn't improved by now that I should come back for a freeze treatment. It hasn't improved. So, the doctor brings in this big cryo rig and sticks it up next to my ear. He blasts it a couple of times, then repeats the procedure.

I hope this works, because if it doesn't, he said it might be a basal cell carcinoma which would require a trip to a dermatologist. Yep, another doctor.

Please, no more doctors. No more doctors.

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The rule for Lasix is amusingly phrased as, "Use as much as you need and as little as possible."  Sounds like that's a good rule of thumb for opioids, too.  I agree that starting with a small increase, and only increasing more if/when you have to, sounds prudent.  Also keep in mind that bad days happen, and if you need a little extra on some days, that doesn't mean you have to increase what you take every day.

Mrs. Prof (and you) may have to come to terms with you never being able to drive in the foreseeable future.  It sucks, and it makes life more complicated, but it still might be an unhappy truth.  At least there's some hope for the future, if the new pain guy is going to be doing procedures that might bring some relief, but until that happens, driving may just not be possible.

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4 hours ago, CritterKeeper said:

Mrs. Prof (and you) may have to come to terms with you never being able to drive in the foreseeable future.  It sucks, and it makes life more complicated, but it still might be an unhappy truth.  At least there's some hope for the future, if the new pain guy is going to be doing procedures that might bring some relief, but until that happens, driving may just not be possible.

I have told Mrs. Prof to convey her goal of making me able to drive again directly to the pain doctor the next time we see him. I'll probably have to keep having her convey that goal, since he's bound to have other things on his mind on that day (like my surgery (or "procedure," as he's calling it)).

I don't know if I ever posted my CT Myelogram here. I'm just going to post the lumbar portion, which the doctor called "one of the worst he's seen." Brace yourself for a lot of medicalese:

Quote

L1-2: Mild facet arthrosis and ligamentum flavum thickening. Mild uncinate hypertrophy. No significant central stenosis.
L2-3: Mild to moderate facet arthrosis and ligamentum flavum thickening. Uncinate hypertrophy. Mild circumferential disc bulge which contacts the anterior descending nerve roots in the lateral recesses. Midline AP thecal sac 10-11 mm. Amputation of the bilateral L2 nerve root sleeves. Bilateral foraminal stenosis which is not well evaluated.
L3-4: Mild to moderate facet arthrosis and ligamentum flavum thickening. Uncinate hypertrophy. Mild disc bulge. Midline AP thecal sac 11 mm. Amputation of the bilateral L3 nerve root sleeves. Bilateral foraminal stenosis which is not well evaluated.
L4-5: Minimal disc space collapse. Moderate left and moderate-severe right facet arthrosis. Ligamentum flavum thickening. Uncinate hypertrophy. Moderate disc bulge which contacts the anterior descending nerve roots in the lateral recesses. Thecal sac measures 9.5 mm midline AP. Amputation of bilateral L4 nerve root sleeves. Bilateral foraminal stenosis which may be severe, which is not well evaluated.
L5-S1: Mild disc space collapse. Mild to moderate facet arthrosis. Mild ligamentum flavum thickening. Uncinate hypertrophy. Mild circumferential disc bulge. Midline AP thecal sac 11 mm. Partial effacement of the L5 nerve root sleeve contrast. Bilateral foraminal stenosis which is not well evaluated. No amputation of the S1 nerve root sleeves.

The words to look for here are arthrosis, thickening, hypertrophy, bulge, stenosis, collapse, and amputation. Amputation shouldn't show up at all, the doctor said. My L2, L3, and L4, nerve root sleeves are amputated on both sides. Do Google searches on the rest, especially stenosis and arthrosis. Those are really giving me hell.

This is the first pain doctor to take this myelogram seriously. The first at the STT "quack shack" (my opinion—damned liability laws) wrote it off as some intern's work. The UT Southwestern doctor, I was told (by the Baylor Scott and White doctor) was forced out of Baylor's pain program and wound up taking over UT Southwestern's program. I now have the head of Baylor Scott and White's downtown Dallas pain program treating me.

BTW, we went to drop off the new hydrocodone prescription yesterday (8/7). My last refill was 7/10. I was told by the pharmacist that I could therefore not drop off the refill before Wednesday, 8/9. I know I had at least two days leeway when I had it refilled last time. I'm glad I've got medication to make it through Wednesday and through one dose on 8/10. Stupidity. It's like the stuff will become radioactive and kill us all if it leaves the pharmacy one day early.

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Mrs. Prof got the hydrocodone refilled today, for which I am most thankful (and for which I was about to drive her crazy, she said). I've just taken my first 15mg dose. Future doses will be 15mg 3x daily (45mg daily), to be raised to 50 if that doesn't work after 3 days.

I have a bellwether against which to measure if its working: my right ear. It's hurting like hell and spotting on my pillow after the cryo treatment I got Monday. I normally sleep on my right side. The hydrocodone's going to have to make that possible again. If not, the dosage goes up.

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6:35 a.m. 20170810. I slept for about five hours with the extra hydrocodone. I don't know if it made a difference, though, because when I woke up, I was on my back and not resting on my ear. The ear is still sore to the touch.

I gave Mrs. Prof my plan for testing the dose, using the ear pain as the margin against which the dosage would be tested. Her response? "Always gotta be looking for some reason to increase the dose." I took that as an insult and told her that I had to pick something as a test. I couldn't use 15 or 16 items as tests, now could I? "I don't know," she said. I'm starting to feel like she's always looking for some reason to keep the dosage down, even if it's not working.

We are at loggerheads with each other over the issue. It's frustrating.

In any case, I took my 15mg dose at 6:00 a.m., with the next doses due at 2:00 p.m. and 10 p.m. CDT. Let's see if the new spread makes a difference.

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12:01 a.m. CDT 20170811. T minus one week, 12 hours and 19 minutes and counting until my pain management procedure. I'm still not 100% sure of what'll be happening, but I expect a full explanation on the day of the procedure. I just hope it's one where I don't have to be awake during it, because the doctor mentioned "an hour or two" as the time span. I don't think I could remain sane for that long with medical equipment inside me while conscious.

The pain medication isn't helping yet. My ear is scary looking and still hurts. I think I'm going to sleep on my left side tonight, something I hardly ever do. Then again, my left toe and foot are throbbing from the pain of the break, so I'll have to deal with that. In short, The 45mg dose has until Monday to kick in before I bump it up to 50mg.

Going to try and get more than 5 hours of sleep tonight. How I'll do it is anyone's guess.

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8:28 a.m. CDT 20170811. One thing I haven't noted during all of this is the effect of the Cymbalta, the drug that began this thread. That's because there hasn't been any effect that I can tell. What am I supposed to be watching for? There hasn't been any additional pain reduction or depression reduction. Maybe some extra sleepiness.

Oh yeah, sleep. I fell asleep between midnight and one, then woke up around three. Stayed up for another hour, then slept until seven. I think that's about five hours. Mrs. Prof wasn't up yet.

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5:59 p.m. 20170811. Lots of entries in the chronicle today. The five hours on the left side didn't cut it for me. I switched back to the right side and took a long nap. I don't know what time I laid down, but I woke up around an hour ago. Overslept my pain medicine dose by a couple of hours. I'm going to have to extend my last dose of the day to make up for it, so that I don't overdose.

Even though I overslept, it wasn't restful. My right ear especially hurts, and of course my back is sore. Damn this ear. It's going to force me to see another doctor.

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On 8/10/2017 at 6:46 AM, ProfessorTomoe said:

I gave Mrs. Prof my plan for testing the dose, using the ear pain as the margin against which the dosage would be tested. Her response? "Always gotta be looking for some reason to increase the dose." I took that as an insult and told her that I had to pick something as a test. I couldn't use 15 or 16 items as tests, now could I? "I don't know," she said. I'm starting to feel like she's always looking for some reason to keep the dosage down, even if it's not working.

I know you won't want to hear this, but I'm glad she's worrying about it.  I don't know whether it *is* a problem, but I do know that the *potential* is there, and much as I'd like to see you completely pain-free, I also don't want you to develop a dependency or addiction.  Addicts tend to come up with excuses for why they need more meds, so I can understand her worry.  Again, not saying it *is* a problem now, just saying I think her vigilance is justified.

Can't you use your back and foot as your measure of how well the pain meds are working?  Why do you need to make something else hurt?  (Not a criticism of the idea, I honestly want to know the reason!)

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1 hour ago, CritterKeeper said:

I know you won't want to hear this, but I'm glad she's worrying about it.  I don't know whether it *is* a problem, but I do know that the *potential* is there, and much as I'd like to see you completely pain-free, I also don't want you to develop a dependency or addiction.  Addicts tend to come up with excuses for why they need more meds, so I can understand her worry.  Again, not saying it *is* a problem now, just saying I think her vigilance is justified.

Justifiable vigilance is not a bad thing. I'm watching what I'm taking, and I'm staying true to my word. No increase before Monday, if an increase is warranted.

1 hour ago, CritterKeeper said:

Can't you use your back and foot as your measure of how well the pain meds are working?  Why do you need to make something else hurt?  (Not a criticism of the idea, I honestly want to know the reason!)

Well, I was using my ear (which my primary care doctor thinks is developing a basal cell carcinoma and is painful to the touch, even by a pillow) as the #1 test, since it was the easiest item to judge if I was getting relief. It's been interfering with my sleep, especially getting to sleep. As it turns out, my back and my foot are valid indicators as well. Getting up, walking, bending, other daily movements—they all hurt. I just thought it would be easier to zero in on one item rather than have 14 or 15 indicators. Doesn't look that way now.

OIC isn't a problem anymore, at least. (Anyone else, don't make me explain the acronym.)

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5:23 a.m. CDT 20170812. Here we go again. Five hours of sleep, thanks in no small part to my right ear. I'm going to stay awake until 6am and take my morning dose of hydrocodone, then try to go back to sleep.

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