Question
Hi, I have a question about pain management. I have been on Morphine for quite some time. I've been taking Morphine Sulfate ER 60mg every 8 hours, and Morphine Sulfate Immediate Release 30mg for breakthrough pain.

On Saturday morning I tried to fill my script for the Extended Release Morphine, and it was not available. We tried all the local pharmacies, and they were all out, and the pharmacists all said it was a manufacturing issue and they have ordered it but have not been receiving shipments. I called my doctor and was advised to go to the ER because I had taken my last Morphine ER around 11pm Friday evening and was completely out and unable to have my script filled.

The ER doctor contacted my doctor and he advised them to give me clonidine and a fentanyl patch until I could get a script for fentanyl from my doctor on Monday (since he was unable to phone in a fentanyl script for me, even as a one time emergency script).

The doctor at the ER, from what I was told, ordered the 75mg fentanyl patch which my doctor had suggested from the hospital pharmacy, but the pharmacist said that's very high, and it seems like they allowed the pharmacy to make the decision, and so they ended up only giving me a 12mg fentanyl patch (not a script, but just 1 patch which they applied right then), and one clonidine pill.

They made me wait an hour to observe me after applying the patch, and my pain was only worse, not better, but they said they don't usually get involved in chronic pain cases and I was lucky to have gotten even what I did. I came home and called my doctor and he wasn't happy, and said that was a wasted trip to the ER because the 12mg fentanyl patch wouldn't be enough to help me, so he called in some hydrocodone and some clonidine for me and said if that wasn't helpful enough I'd just have to be admitted for pain management.

I survived the weekend (barely) and Monday afternoon I saw my doctor. He wrote me a script for 75mg fentanyl, and I still have the Immediate Release Morphine for breakthrough pain. I got the script filled and applied the first patch (and removed the 12mg patch I'd had on since Saturday morning) around 4pm Monday. It's now 6am Tuesday, so I've had it on for about 14 hours. It is helping, but my pain is still much worse than it had been prior to Saturday when my Morphine ER ran out.

I don't want to be impatient and complain that it's not effective before I even give it a chance, but to be honest I've been unhappy with my doctor for a while now and I question whether I am getting the right care. In your opinion is the fentanyl the best option for me to replace the Morphine ER, or would nothing work as well as the Morphine?

How long would I need to wait before being able to tell if the fentanyl is as effective? On Wikipedia it says, "Full benefits of pain relief from patches may take 4 to 10 days, although "relief" can be felt within hours." Would you agree with that? Like I said, I am feeling much better with the patch on, but I am definitely in more pain than what I have been prior to running out of Morphine ER on Saturday morning. Should I just be patient and count on this fentanyl kicking in more over time or is this not going to help me as much as the morphine?

Answer
Bethany,
I am familiar with Fentanyl patches. If I understand correctly, aren't they supposed to be used for 72 hours? I could be wrong. Anyway, from what you are telling me, it is my OPINION that you experienced a break or interruption in your pain medication, therefore it put your body off balance. That's the best explanation I can give. You should have experienced relief at least within 8 hours after the hospital applied the patch. I am glad to hear that your doctor was unhappy with the service you received in the ER, but you say you have not been happy with him for a while. You wouldn't believe how often I hear that from pain patients. For whatever reason, pain mgmt doctors seem to develop a lackadaisical attitude over time. I know it isn't easy to care for patients day after day who are complaining of pain, but they chose this field.

Is it possible to request a different physician in your group? Or, do they have PAs (physician assistants)? Sometimes PAs are very good to work with, and they are always under a doctor in case  they come against something they have a question about.

In priase of your doctor, though, I am impressed that he did speak to the hospital and to the hospital pharmacy about the Fentanyl. He also called you in some Vicodin, which shows he cared. Believe it or not, I've heard stories in which patients were left "on their own" on  weekends and holidays! If they had a problem with breakthrough pain, or a problem came up such as yours where they couldn't get their meds filled, I've heard of doctors just saying the patient had to wait until Monday. THAT is ridiculous! First of all, these patients are in chronic pain. Secondly, they begin having withdrawals within hours if their meds are not taken. So, all in all, I think your doctor at least attempted to help you. Whatever the reason is that you're not happy with him is for you to decide what to do. I have heard of patients being left in the cold for several days just because it is a weekend or holiday. This is wrong, in fact bordering on negligence.

I wonder what the doctor said about your increased level of pain when you got in to see him? Did he seem to think it had to do with an interruption in your pain med schedule? Because that is what I think it is.

You asked about strength of morphine vs Fentanyl. That is subjective and varies from patient to patient. It may be that oral morphine tablets would work better for you, the extended release which lasts 12 hours. I will tell you that there is a fairly new patch on the market by the name of Butrans which is supposed to work wonderfully for chronic pain. I have not spoken to anyone who has used it, but I have spoken to two pharmacists, and they both said it was a wonderful patch. One said that it worked better for pain than morphine or Fentanyl, yet strangely enough, it is not on the same control level as morphine. Morphine and Fentanyl are Class 2 narcotics, and Butrans is only a class 3, which is the same level as Vicodin or Tylenol 3. The pharmacist I spoke to said that was good because it is more effective with pain, yet less addictive. It is very new, and therefore expensive without insurance, but would be worth discussing with your pain doctor. I would be very interested in seeing how patients with chronic pain like the Butrans. (Please don't' think I'm endorsing any product; I don't do that, ever! I'm just trying to suggest something to help)! Basically, Fentanyl would work wonders for one person, yet another might do better on morphine tablets and visa versa. We are all individuals with our own body chemistry, so sometimes it is a "trial and error" situation. But, as long as you have a good, compassionate doctor who LISTENS to you and you can develop a good rapport with a knowledgeable pharmacist you are in good hands, plus you must be your own advocate and stay informed and educated. It seems you are doing a fine job of that.

A tip for future use: I know you must use the same pharmacy at all times since you are under contract with the pain clinic. Speak to your pharmacist a week or so before each new prescription is due. Request that they order your med and keep it, to prevent this from happening. The pharmacist should do this anyway. I understand that occasionally there are manufacturing issues that the pharmacies cannot control. If you develop a good relationship with the same pharmacist you should be able to use him/her as an advocate. I have a pharmacist that is almost as good as my doctor; I trust him implicitly. I drive out of my way just to have him handle my medications. Sometimes pharmacists do know more about medications and reactions than our doctors and nurses do; they studied for almost as many years as MDs, so its their job. I often use pharmacists when I have a question about a patient or a medication; they are valuable resources.

Finally, I am including  a website from the National Institute of Health, a governmental agency. They give all kinds of information about drugs and meds. Stay clear of Wikipedia. They are usually filled with errors. The NIH site is written by professionals for citizens like you and me to refer to. It is below. I wish you much luck in navigating this tricky area. I would love to hear back from you, especially if your doctor decides to try you on the Butrans patch, or no matter what. I always like to hear back from those who write in to me. The NIH website is below. You can look up any drug or chemical and receive good, sound info.

http://www.nlm.nih.gov/medlineplus/druginfo/meds/a601202.html