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Pain Management Notes

I saw the pain doc yesterday, so I'm going to scribble down my notes here. I'll combine my notes from last time (which I wrote in this journal piecemeal when my brain was working even more poorly than it is right now), in order to try to get everything better organized.

So here's our current thinking:

Neurontin

At my first appointment, Pain Doc had suggested that I increase my dosage of Neurontin (a med I've taking for a couple years to help with mood and anxiety stabilization), because it is also commonly prescribed to treat nerve-related headaches. I had therefore—with the approval of meds doc and pain doc—increased the dosage from 300 mg/day to 600 mg/day.

Unfortunately, my body is eternally funky, and so this dosage increase apparently resulted in something like hallucinations, which became apparent while I as actually at the Pain Doc's office for my 8/19/14 appointment (when Shannon was, thank god, accompanying me).

Pain Doc suggested the following Neurontin dosage course:
  1. 400 mg/day for a week, then
  2. 500 mg/day for a week, then
  3. 600 mg after that (as long as the hallucinations don't return).
Unfortunately, I ended up messing this up: I took 400 mg/day for a week, then 500 mg/day for a few days (until my weekly pill case was empty & I had to refill it for the following week), then flubbed up in the wake of my gum surgery & accidentally fell back into mindless habit & just filled my pill cases with my longtime dosage of only 300 mg/day. I didn't notice the mistake until yesterday, but I'm back on track now: I'm on 400 mg now, will up to 500 mg on Sunday, then will up to 600 mg the following Sunday, and we'll see how things go.

Codeine

Tylenol #4 contains 2 active ingredients: acetaminophen (Tylenol) and codeine. When we say that we're reducing my Tylenol #4 dosage, what we really mean is that we're reducing my codeine dosage. The codeine has been being delivered to my body by the Tylenol #4 tablets, and so we are reducing my Tylenol #4 dosage as a means to establish the goal of weaning my body off the opioid. The Tylenol (acetaminophen) component of the Tylenol #4 tablets is actually irrelevent.

At my 8/19/14 appointment, we kept my max Tylenol #4 dosage steady at 5 tabs/day due to the pain expected as a result of my gum graft surgery and recovery, but yesterday—since my mouth pain is now mostly gone—we reduced my max Tylenol #4 dosage to 4 tabs/day. Since each Tylenol #4 tablet contains 60 mg of codeine, I believe I'm now down to a max of 240 mg of codeine/day. (In addition, this brings me down to a max of 1,200 mg of acetaminophen from Tylenol #4, which I'll discuss more in a moment.)

Butrans

The next step in the codeine/opioid weaning process, which we will discuss further when I see the Pain Doc on 9/24/14, is to abandon the Tylenol #4 altogether as the opioid delivery system & switch to the Butrans patch. This would be a much better way to conduct the weaning process, since the patch could provide a much more consistent level of medication in my system, resulting in fewer rollercoaster problems & therefore, probably, fewer headaches as we continue ... as long as the patch works. The problem is that Butrans is not effective for everyone, and there is a very distinct possibility that it will do nothing at all for my pain, but would nevertheless restrict me from taking the Tylenol #4 ... thereby leaving me essentially defenseless against the headaches. This is a frightening prospect, but I'm willing to give it a try. Come September 24, I expect a new medication adventure to begin.

Acetaminophen

As I mentioned above, as we go about reducing my daily amount of codeine via Tylenol #4 tablets, we are also reducing my acetaminophen dosage, which is entirely unnecessary. It's therefore perfectly fine for me to get more acetaminophen from other sources to help supplement the amount contained in the decreasing number of Tylenol #4 tablets:
  • 1 Tylenol #4 tablet = 300 mg acetaminophen
  • 1 regular strength Tylenol (RST) tablet = 325 mg acetaminophen
  • 1 extra-strength Tylenol (EST) tablet = 500 mg acetaminophen

Currently, I can only take 4 Tylenol #4 tablets per day in order to limit my amount of codeine, but that only gives me 1,200 mg of acetaminophen. I can supplement those Tylenol #4 doses with RST and/or EST in whatever configuration works best for me, as long as I don't exceed 2,500 mg TOTAL of acetaminophen in any one day. So currently I can take 4 additional RST tablets each day, which might potentially help a lot. I just have to keep track.

Also ...

There are other things I can do that might possibly help with the pain. Pain Doc recommends:
  • stretches: The periodontist insisted in no uncertain terms that I stop all stretching while my gum grafts were healing, but it's now time to get back to those physical therapy exercises! I started again last night & this morning.
  • acupuncture: Pain Doc attempted to refer me, but his office phoned to tell me that my insurance doesn't cover it. I'm still working on figuring this out—since my info from my insurance company seems to indicate differently—but I haven't been quite on top of things lately, for obvious reasons. I'm hoping to dive back into this & start making bureaucratic phone calls on Monday re: the whole acupuncture question.
  • caffeine: Pain Doc has no problem with my using coffee (or No-Doze or whatever) to help treat the headache symptoms, as long as I don't go all crazy with it.


Pain Doc had also previously mentioned the possibility of a nerve injection to help with the base issue of the occipital neuralygia, but he's reluctant because I don't show the classic symptoms of occipital neuralgia (i.e., he would expect light tapping on the back of my head to cause me excruciating pain, but it doesn't). I'm not tremendously torn up that we aren't going to stick a big needle in my neck.


Terrible headache last night kept me up until around 4 a.m., at which point I was still in excruciating pain but so exhausted that my need for sleep was able to overwhelm me. I'm going to phone my Meds Doc to ask about the advisability of sleep aids to help me fall unconscious when I just need to escape the headaches, especially during this period of dosage reduction & accompanying withdrawal effects. It would be nice to have some way to just decide to go to sleep & be able to do it & therefore not have to deal with the headache for a little while. I'm not thinking of prescriptions, but maybe OTC sleep aids, maybe something herbal, not sure. I'm going to ask him.

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