Switching from One Long-Acting Med to Another?

[Eva 14]

I just wondered if anyone has experience switching from one long-acting pain med to another? Such as MS Contin to Oxycontin, or any of the other long-acting meds like Opana, methadone, Fentanyl, etc.? If so, I'd love to hear your experience, thanks.

I recently saw my pain doc and complained about the sweating that I've been experiencing with Avinza (oral morphine). I figured it was time to try something else (hopefully something that wouldn't cause the sweating side-effect).

My pain doc told me that switching from one long-acting med to another is actually a fairly complex process. I asked him if I couldn't just wake up one morning and NOT take the Avinza and take Oxycontin or something else instead. He told me that it's not that simple. I think he said I might have really bad withdrawals if I switched too suddenly.

My pain doc pretty much agreed that I might as well try something else, but I'll have to see him more frequently for the first few months that I'm switching over. (This gets expensive, but what else can a person do?).

My pain doc recommended Exalgo, the new long-acting form of Dilaudid. I think it's pretty expensive, but then so is Avinza. At least my insurance pays for most of my med costs.

My pain doc says that I would gradually lower my dose of Avinza, while simultaneously adding in the Exalgo. I never expected that trying a new long-acting med would be so complicated. I thought that it was as simple as substituting one med for the other. I know that pain docs like to start the new med at a low dose and work up, but I didn't realize that I'd still have to be taking the Avinza for a few months. If you've undergone a med switch, was this how you did it? Are there any pitfalls that I should look out for?

I'm a bit scared, as I've never switched meds before. In the past, I've tapered off of Avinza, so I'm not that scared of withdrawal. I am scared of the pain I'd feel if my meds were insufficient, but it sounds like I'd still be able to take my Avinza if the new med wasn't working well for my pain. I do worry a bit about talking two long-acting meds at once, but my pain doc has been in practice for several years, so he must know what he's doing. Also, if I'm taking two long-acting meds at once, I don't know how I'd be able to evaluate how well the new med is in terms of pain control and side effects.

Can anyone offer any advice about med changes? Is this the normal way of switching meds, or do most people completely discontinue one med and take only the new one? They are all opiates/opioids, so I wouldn't think there would be any withdrawal. I realize that some opiates may hit slightly different receptors in the brain (mu agonist, kappa agonist) but I always thought that Oxycontin could substitute for morphine or vice versa. I even thought about when heroin addicts switch over to methadone---I didn't think that was that complicated. Of course, those people aren't in physical pain, so maybe that is a different set of circumstances.

I do recall a few people on this board stating that "med changes can be rough", so I just wondered what you were referring to? What can I expect, in a very general sense?

I really want to try a different long-acting med to see if it doesn't cause sweating, but now this seems so much more complicated than I thought it would be. Any opinions, experiences, or advice is most welcome!

Best Wishes,
Eva

[Pharmacist.steve]

There is no black/white formula when switching from one opiate to another... you will have to be re-titrated on the new med. No matter if you stop one and start another or wean from one and up the other over some time frame... it can be a very bumpy ride.... virtually no way around it. The doc could give you some short acting meds of the same drug that you are working your way on to.. to fill in the gaps and break thru pain during the transition... if your doc goes this route ..it will be important that you keep track of how many extra doses you take so that doc will be able to make more aggressive dose adjustments on the new drug.

[Mark N]

I switched from Oxycontin to MS Contin and had no troubles but I was on a low dose when I made the switch. I didn't tolerate opiates very well and didn't like how irritable I felt on oxy so I was ready to do without despite pain levels of 7 and up. My OSS convinced me that MS Contin would react differently with me so it was worth a try and he was right as I felt much better on it. I don't know if my experience helps you since I was on the lowest dose of Oxy when I made the switch. Good luck as it is never easy making a change in medication as we can't be sure of the reaction we will get.

[tortoisegirl]

When I've switched meds (methadone to morphine to fentanyl to methadone) I went straight over, but my doctor used the rule of thumb that I was started on half my expected dose for the new med...ie. I was put into withdrawal and had a lot of pain. I had my short acting meds to take, but we did a quick titration up. The only safe way to do it is tough on the patient.

Tapering down on one while tapering up on the other may be a bit less likely to cause problems. My doctor had me going in every 2 weeks during this time, and I also had to put in some calls and I ended up having to come in for an emergency appointment as well. I think its well worth it though if you aren't doing well on your meds. Its also not a good idea as far as tolerance to stay on the same med indefinitely, as most folks don't have complete cross tolerance (ie. you will likely get more bang for your buck by switching meds).

However, I found this wasn't the case for me, as my required dose on morphine and fentanyl patches was actually much higher!). I was quite disappointed, but we ended up working with my methadone dose and schedule such that it is much better than it was (I was the one who originally asked to switch meds as I had never tried any other long acting ones).

Follow your doctors instructions exactly, get follow up appointments at the closest intervals you can, ensure you have some short acting meds, and tough it out. As far as your evaluating how it is working...you probably won't be doing that until you are only on the new med (or close to it). You may however have a tough time discerning between withdrawal and any new side effects, as they can overlap (nausea, sweating, etc). It helped me that I was quite familiar with the withdrawal symptoms (a couple times by accident, and once on purpose).

I think Exalgo can be a good choice. I've heard the new Oxycontin formula isn't as helpful (plus you'd have to dose it much more often than you are used to), and fentanyl may give you the sweating similar to morphine. The reason they typically must be withdrawal is for it to be safe...as the doctor doesn't know how much cross tolerance you have to the new med, nor how much your body will require for analgesia, as the conversion charts are just a rough guideline.

I've always heard the line that its better the patient is uncomfortable than dead! I'd except the weeks or months you make this switch to have some increased pain and mild withdrawal. Ensure that you have a plan in place for if it gets out of hand (such as taking short acting meds and calling to be seen earlier if needed). I wouldn't be scared though, as pain specialists do this quite often. Best wishes.

[alex44]

I Agree

With everything said. However, be VERY careful with Methadone, From personal experiance, It is MUCH harder to come down off of then Morphine. I have had the unfortunate experiance of going thru total withdrawel with both, the Morphine was much easier. I am sorry if this is not exactly the answer you were looking for but it is the truth (IMHO) - both incidents were precipitated by A. a doctor retiring (Morphine) B. Getting on Methadone until I could get a new PM Doc. Good luck.
Blessings
Alex44
Skypilot

[Leeaelle]

Hmmm ~ Thats interesting. I switched from Methadone to Opana with NO trouble whatsoever. I just stopped the Methadone one day and went directly over to Opana the next. That was that. I didn't have any symptoms or trouble at all. That's always the way I've done it when switching over from one long-acting med to another. I've had to switch several times too. I'm GLAD I didn't have any trouble, but I find it strange that I didn't if you're supposed to wean, titrate, etc.

Oh well. Good thing I never advised anyone about it. LOL. Take care everyone. Hugs, Lee

[tortoisegirl]

I've also gone straight over, but my doctor usually started me on a lower dose than suggested on the conversion chart (50% lower is typical). Without that, there is a risk of overdose symptoms as the patient's cross-tolerance to the med is typically unknown. I've had withdrawal on most switches, and on the verge of overdose on one (I was in bad withdrawal so he wasn't conservative on switching me back to my old med).

Another issue with switching straight over is accounting for the amount of med in your system...with methadone's long half life, you still have a lot in your system (even if its not being effective for your pain after 8 hours or however you react to it), so with a straight switch, a longer period of time should go by before being instructed to start the new med.

Similar to the fentanyl patch (there is still med in your skin/fat after removing the patch). Med switches are a good reason to have a pain specialist you trust. There is no one way to do it...its all about what the doctor is comfortable with and thinks is best for the patient and situation. Best wishes.

[Eva 14]

Thanks for your replies. I learn a lot on this board; it's interesting to read about people's individual experiences with different meds.

My insurance denied the Exalgo (too expensive) so now I have to wait until my next appointment to get a prescription for a different long-acting med. So I'm on the Avinza for another 2 months.

Maybe I should start a new thread and ask which long-acting med is least likely to cause sweating? I know everyone reacts to meds differently, but there must be some meds that are more or less likely to cause sweating than others.

Opana sounds interesting---I think it's oxymorphone? I need to look up exactly what that is. Is it related to oxycodone?

I suppose I should ask my pain doc about methadone. I know that it's really inexpensive, which is good. But I've also read a lot of horror stories about the withdrawal from methadone being even worse than withdrawal from heroin! Plus, there is that warning about methadone and the QT interval---something about how it can cause an irregular heart rate that could result in death. I guess that's really rare, but still scary to think about.

I have no idea how my pain doc feels about methadone or if he even prescribes it. I sure hope my pharmacist wouldn't think I'm a drug addict for bringing in a script for methadone. *I* know that people on methadone maintainance are NOT prescribed their methadone from a drugstore; they have to go to the methadone clinic every single day to get their dose. But with certain pharmacists being pretty ignorant about chronic pain, it's just one more thing to think about.

I wonder if another morphine preparation (MS Contin, Kadian, etc.) might not cause the sweating? I really would like to try some different long-acting meds, but I hate the thought of having to schedule more frequent doctor's appointments, because the appointments are expensive AND it's tough to drive in this amount of pain.

My pain doc did mention that it might be a good idea for me to try a different long-acting med, because there's always the chance that I may be becoming tolerant to morphine. I actually don't think that I am becoming tolerant to morphine, but anything is possible.

Interesting to hear that the Fentanyl patch can cause sweating, too. I tried that briefly about ten years ago. It caused really dry mouth for me, which was really annoying. I was CONSTANTLY having to drink water and thus go to the bathroom. It really was ridiculous.

I also tried Oxycontin about 8 years ago, but my dose wasn't all that high. I did okay with that, but my dose was too low to take care of my pain. (I wasn't yet seeing my pain doctor, so my dose was insufficient). It's interesting to hear that Oxy can cause the sweating, too. It sounds like ALL the long-acting opiates have the side effect of sweating? Too bad.

I know that they keep coming out with NEW long-acting pain meds, so I hope I can find one that doesn't cause the sweating AND takes care of my pain. My pain is very severe, so I'd have to be on at least a moderate dose.

Thanks for any advice or experiences about long-acting pain meds. It's always an education to hear real-life stories from people who have tried these meds.

Best Wishes,
Eva

[tortoisegirl]

I don't think withdrawal should be a factor in choosing a med as most folks stay on these indefinitely. If not, then you can switch to a different med to taper down from if necessary. Although I only did a partial taper once from methadone (I went about 2/3 down on my dose), I didn't have an significant issues. In fact, due to its long half life, I've heard in some ways it is easier to taper from, since in some ways it self tapers.

There is a lot of false info online about methadone to beware of. You also have to take into account a lot of the stats that may look bad about it are because of its use for addicts, and that doesn't appropriately reflect stats for pain patients. You are correct that some doctors just don't use it, or at least not until everything else has been tried.

As for the prolonged QT interval, its suggested to get an EKG after being on it to detect that, which is a cheap and simple test. My doctor also had me get a sleep study as sometimes even if you don't have breathing problems during the day, it can cause central sleep apnea during the night. It was especially suggested for me since I have sleep issues and hypersomnolence to begin with. It may not be the best first line opiate, but there are many folks like me who didn't respond so well to some others, and its a very good and safe choice.

Yes Opana is oxymorphone. Not really similar to oxycodone though. Its semi-synthetic and supposed to have less side effects (like euphoria and sedation) and less chance of dependance. Due to that, some folks just plain don't respond to it. I didn't. I was seeing my primary doctor at the time and he must have not known about conversion rates on it because he was letting me take a very high dose since I wasn't responding to it otherwise.

I'd just see what your doctor has to suggest next. I don't think there is any way to predict how your body will react. If you want to do your doctor a favor, look up what meds will be doable for your insurance, as its different for each insurance. Some have step programs too (you have to try & fail certain meds before being allowed the more expensive ones). Some all out deny some meds, while some just charge you a lot more for them. That way you won't go through the denial again. They should have a formulary list that says what meds are included, and at what cost (assuming you have a copay and not a percent payment).

I personally think its unlikely another morphine preparation would have less sweating, as its the same active ingredient, and I'd assume you'd be taking a lower dose. In fact, it would be likely to be even more pronounced as all the others are shorter acting...ie. the dose wouldn't be as stable in your system as it is with Avinza. It sounds like you have some good options if you've only tried Avinza and the fentanyl patches a a therapeutic dose though. Oxycontin, Opana ER, and Methadone are probably your best options if not Exalgo, Fentanyl, or morphine products.

You'd probably dose out of Nucynta ER as it has a dose ceiling of 500mg/day, and has about a 5:1 conversion ratio with oxycodone. I was considering asking my doctor about the IR form for breakthrough, but realized that I may need 300mg/dose (I'm taking 60mg oxycodone right now and since I've been on that same med/dose for years, it doesn't cut it anymore), so I'm not sure if that is a good option as two doses would hit the 600mg/day ceiling for the IR version. Interesting they pay for Avinza but not Exalgo...I would have thought they were about the same cost, but maybe not. Suboxone / Butrans patch is another option, but I'd worry about breakthrough pain on that since it blocks the effects of other opiates.

I've personally never had a pharmacist so much as give me a weird look about my meds, but I'm probably in the minority. I sure get that "you poor thing" look though. They have always been really helpful. I've also found that methadone is easy to find in stock at a pharmacy (at least in my area). One thing I thought I'd mention is that with the switch you'll likely need to be taking pills much more often then you were with the Avinza (typically dosed once a day). Although Oxycontin and Opana are said to be does every 12 hours, dosing every 8 hours (or less) is not unusual. If your pharmacist does give you trouble about that or any other med, its sign you need to switch pharmacies.

Similarly with Methadone (I take it 4 times a day and do even better with 5 times). Its not an issue for me, but can be an annoyance. Also, Methadone only comes in 5mg and 10mg pills. I take 12 of the 10mg pills a day, so that is a lot of pills per month. In fact, my doctor won't write a script for more than 200 pills (DEA flag), so I have to fill it every 2 weeks. At least its still only a monthly appointment. Best wishes.