Help me help my Mum

[Pharmanaut]

I'd have to look a bit deeper into it.
Thought MoA was different?

[Shwampa]

Would you rather she has a Liver Failure or Headaches? I can't believe she's taking that much Paracetamol and DHC. First of all, your mum's medical history points to a bone disease of some kind and the first thing I'd check is blood calcium. High calcium, from overactive Parathyroid for example, can explain the bone pains and increased risk of peptic ulcer. It's just my humble opinion for what's worth.
Spinal fusion doesn't involve the legs unless the surgeon got his graft from there. Chronic pain around the site where the graft was obtained is a well known side-effect of the procedure. So, I have my doubts about the operation gone wrong. Your mum need to be admitted to a "pain clinic" so a comprehensive review can be done and adjustments made under specialist supervision.

[johnep]

Excellent advice to see a consultant in the pain clinic. A referral from the GP should be requested.
johnep

[Shwampa]

What a coincidence! I just had a look at the latest bmj copy (1 May 10) and the "clinical review" article was: Management of medication overuse headache

This article was originally published in Drug and Therapeutics Bulletin (DTB 2010;48:2-6).

Here's an extract:

Stopping the overused medication
General principles of withdrawal
Guidelines from the British Association for the Study of Headache state that patients with MOH fare better if they are motivated and understand that their “treatment” is likely to be causing their frequent headache.

They should be forewarned that withdrawal initially aggravates symptoms (eg, withdrawal headache, which may be accompanied by nausea, vomiting, tachycardia, sleep disturbances, restlessness, anxiety, and nervousness).

Withdrawal should be planned in advance to avoid unnecessary lifestyle disruption, and done under
the supervision of a doctor or headache specialist nurse.

It may be necessary to arrange absence from work for 1–2 weeks.1 The guidelines also recommend a diary to record symptoms and medication use during withdrawal, and that good hydration should be maintained.

Most drugs causing MOH can be stopped abruptly; the Scottish Intercollegiate Guideline Network suggests that opioids and benzodiazepines should be withdrawn gradually.

As with other drugs that produce a withdrawal syndrome, gradual reduction in caffeine intake may be
preferable to abrupt withdrawal.

How drug type affects outcome
The duration of withdrawal headache and associated autonomic symptoms varies depending on the types of medication that have been overused.

For example, in a study involving 98 patients with MOH undergoing withdrawal as inpatients, the mean duration of withdrawal headache was 4.1 days for triptans; 6.7 days for ergots; and 9.5 days for analgesics.

Similarly, the number of days with associated symptoms (eg, nausea, vomiting, sleep disturbance) was lower for triptans than for either ergots or analgesics (1 day vs. 2.5 or 2.2 days, respectively).

Overall improvement occurs within 7–10 days when the causative drug is a triptan; after 2–3 weeks when it is a simple analgesic; and after 2–4 weeks when it is an opioid.

[bobbin]

It should be possible to reduce the paracetamol dose down to 'two tablets four times a day' without tapering. Increasing the dose of paracetamol above the maximum recommended dose does not increase its analgesic efficacy, but can obviously lead to toxicity.

Dihydrocodeine is not very useful for chronic pain because it is too short acting to provide consistent relief. Pain specialists only recommend long acting products such as MST Continus and Durogesic. A comprehensive assesment by a pain specialist would be very useful.

[bobbin]

So, does that mean that gabapentin is more potent than pregabalin?

No, pregabalin is considerably more potent than gabapentin.

[milkchoc]

Wow sorry it has taken me such a long time to get back on. Gabapentin she has tried im sure. One of the patch's the doctor gave her gave her chronic water retention and she had to come off it, iirc that was gabapentin. She went to a pain clinic where she agreed she would try the tens machine, injections, acupuncture and further medication but most certainly not further surgery. At the minute she has a cartilladge issue in her knee and has just had to have tooth out, but ill give her her do, she has knocked 4 paracetamol and 4 dihydrocodene down a day. So down to 14 each a day now, i know it's still far too much but a step in the right direction. Now something which a different doctor told us once is as she is overweight too her medication levels may need to be higher?? Could this be true at all. One doctor has given her some Buprenorphine tablet's that rest on her gum and they help but only for a short period and not consistently i.e work for 2 hours then wont work after the next tablet has been taken. So far were waiting on appointments for the pain clinic and the knee scan (MRI). Thank's for all your help and it's nice to know aswell that there is help out there.

[pharmacrat]

Bobbin mentioned morphine and fentanyl, this sounds like the type of severe genuine pain where a CD script would be okay. Buprenorphine (temgesic) is already controlled schedule 3 and in the same safe as the harder stuff in chemists.

Are you being treated appropriately for your own mental illness? First of all, let's explain the difference between addiction and chemical dependence. Addicts seek out their drug as a major part of their life and are psychologically lost without it. If she was being prescribed diazepam for muscle relaxation and sleep, and she is a sick woman who does not try to con the doctor or get more supplies through other means, that is unlikely to be addiction to the diazepam.
Second, the idea that "the pills are hurting her..." is not really true. Most medicine doesn't hurt if used in the right way- otherwise it would be poison, not medicine! 18 paracetamol 500mgs a day would NOT be prescribed by any competent doctor- it WILL damage the liver taken long term at that dose. Surely she is buying more OTC? Or you mean 8?