Posted by ed_uk on April 11, 2005, at 11:24:05
In reply to The Duragesic Patch (fentanyl) Xyrem=Happiness, posted by lunesta on April 10, 2005, at 11:50:40
Hello :-)
>I am now both floating on the air.....
Lunesta, you do sound rather euphoric, it sounds like one or more of your doses may be too high.
I have to disagree with certain things that Matt said. I do believe that fentanyl can be safely combined with other sedating drugs under certain *specific* circumstances.
If an opioid-naive patient was given fentanyl in combination with another respiratory depressant drug, respiratory depression or even apnea would be likely. However, tolerance to the respiratory depressant activity of opioids is rapid and profound, palliative care patients frequently take huge doses of opioids in combination with benzodiazepines and other 'sedatives' while breathing quite normally. It would be very dangerous to initiate treatment with GHB and fentanyl in an outpatient *at the same time*. Nevertheless, it is not unusual to prescribe 'sedatives' such as lorazepam to outpatients who are already established on long-term opioid treatment.
>I must say however, that the combination sounds rather haphazard in terms of long term risks vs. benefits.
Long-term use of opioid/gabapentin combinations is frequenly useful in the treatment of chronic severe pain, I would guess that the same would also be true of the opioid/pregabalin combination. I don't know much about the long-term efficacy of GHB.
>I also suspect that it must be hard to function alike with so many narcotics used concurrently.
Lunesta, do you feel euphoric? If you do, your doses are too high. A carefully titrated dose of fentanyl should not be euphoric. In the short term, opioids are often quite sedating, making it difficult to function. Many patients who suffer from chronic pain eventually reach a stable dose of fentanyl on which they are not sedated. Tolerance to the sedative properties of opioids often develops quite quickly, tolerance to the analgesic properties tends to develop more slowly or sometimes not at all.
>not to mention that all of the forementioned are likely the most potent of each class......
Although transdermal fentanyl is more potent than oral morphine, it is no more likely to cause sedation or respiratory depression. Potency is important only in the sense that it influences the dose which is given. The word 'potent' is often misused; fentanyl is one of the most potent opioids yet it is no more effective in the treatment of chronic pain than less potent opioids such as morphine. We say it is 'potent' only because it is effective at lower doses than other opioids- it's maximal efficacy is the same. It is more potent because it has a higher affinity for opioid receptors; other opioids could produce the same analgesic effects at higher doses.
AFAIK, the side effects of gabapentin and pregabalin are similar, but the dose of pregabalin is lower.
>unavoidable dependence and potentially fatal withdrawal.......
Long-term opioid treatment almost inevitably results in physical dependence ie. withdrawal symptoms will occur if the medication is abruptly discontinued, the same could be said of many drugs used in psychiatry- although pdocs may deny it! True opioid 'addiction' only occurs in people who take excessive doses of their medication in order to get 'high'. If you're euphoric- the dose is too high. I hope that Lunesta will be careful. Be careful Lunesta! Euphoria leads to bad things!
The withdrawal would not be fatal unless the drugs were withdrawn abruptly. The taper must be flexible- taking the patient's symptoms into account. It is very important that people on long-term opioid treatment do not run out of their medication!!!
Regards,
Ed.
poster:ed_uk
thread:482353
URL: http://www.dr-bob.org/babble/20050408/msgs/482773.html