Question
Three months ago I started going to a pain management clinic due to fibromyalgia pain. The doctor was very reasonable and gave credence to what I said had worked in the past. He put me on Nucynta. In the followup visits, however, the PA keeps insisting I stop taking Lorcet (hydrocodone)completely,  and use MS Contin and/or Nucynta, both of which are class II. I do not feel I am ready for these strong meds, and told her so. I fear dependence, even though I've been on Lorcet for five years successfully. (My primary referred me to this clinic because 4 tabs per day just wasn't quite enough). I was actually hoping they would start me on Lorcet 10/500, but the PA practically argues with me when I state that it has worked well in the past and I'm just not ready for strong meds. I think Lorcet 10/500 or even Norco would be fine right now- also less Tylenol to worry about. She almost appeared angry when I said I "preferred to not take very strong meds until I reach that point where I may need them". I don't want to stop attending this practice, so can you give me some ideas on how to talk to the PA so that she won't keep giving me these strong drugs? It has been 3 months, and I already feel slight withdrawal symptoms early mornings when I wake up. This is scary to me. I am very nice, compliant, and don't want to dictate my care to her, but I also don't want morphine until I reach the point where I may someday need it. This is understandable, isn't it? Could you help me select my wording so she will see it more realistically? Thanks in advance.

Answer
Patricia - this is a really really touchy subject for pain management doctors.  They are remarkably rigid in the medications that they use normally.  There are a few reasons for this but my belief is that it usually one of two.  First, especially with a PA (who as you must know) is NOT a doctor it could be a simple matter of limited knowledge.  They may understand and trust particular medications better than other medications. Related to this is also the PA's limited authority to change from what his or her practitioner allows them to recommend without talking to them first.  Secondly, it might be worries about liability - too many practitioners are scared of using amounts of Tylenol that are accepted as safe because of unreasonable fear of adverse effects and liability related to them.

There isn't a lot that I can do to help here.  Your reasoning is sound.  I agree with you that the Morphine is more likely to make you dependent and to become abused than the hydrocodone in the other medication is (and so does the DEA - that is why Morphine is more tightly regulated).  Nucynta is a newer medication so there are still pharmaceutical reps out pushing it and keeping it in the doctor's minds and that might be an issue.  The best course of action that I can recommend is to go to your local pharmacist - where you have been filling your prescriptions all along - and ask the pharmacist there to write a letter of recommendation for you based on the argument you made above.  I may be more persuasive if your pharmacist is a Doctor of Pharmacy but it is not necessary.  If he or she can show a good pharmaceutical history of regular use of the old medication along with restating the reasonable request you make he or she may be able to sway the PA with that recommendation.  If that is still not doing the job you may want to ask them to include the written recommendation in your medical file at the clinic in case there are complications related to the use of the Nucynta in the future.  Obviously here I am trying to leverage their concern for liability - the written recommendation is a part of your medical history and has been provided to them and should be in your file but asking and mentioning the potential for complications with the use of Nucynta may serve the purpose without you  having to say it that if they do not abide by your wishes and the recommendation of the pharmacist that you will hold them accountable if something happens.  That might do it as well.

All of that might fail too.  I would say that the best thing you can do if that fails is return to your GP who reffered you with a copy of the letter from the pharmacist and explain the issue to him the same way you explained it to me.  Appeal to his sense of duty and desire to help - "I knew that if anyone would understand my history and was going to be able to help it would be you Dr. Frankenstien".  Tell him that you are concerned for your safety and quality of life on the morphine therapy and as if he would consider making an exception and handling your care with a slight increase from the previous as you described.

That might fail too.  In that case there may be no option but to use what the clinic will give you OR find a new practitioner.

It offends me that patients in need are commonly underprescribed medications for pain management and my heart goes out to you while you complete this - which is sure to be a frustrating exercise.  Best of luck.

First stop - your regular Pharmacy to see your regular Pharmacist!

Dr. J-