We’ve made some (arguable) progress in dealing with my neck problems, along with some setbacks. The first setback was that about four days after I started the painkiller and muscle relaxant, I broke out in hives all over. That was no fun at all, and I’m not completely over them till yet. I immediately stopped the Flexeril (cyclobenzaprene, muscle relaxant) and Ultram (tramadol, opioid), since they were the two drugs I’ve never taken before and hence the first suspects for causing the hives. When I didn’t get better in a few days, I also stopped the Voltaren (diclofenac, anti-inflammatory). By today, two weeks down, most of the hives have gone away but I still have occasional bouts of itching, plus lots of small sores and scabs from clawing at myself, scratching.
I had my MRI done, although it was a struggle. I was set up to go in at 9:00 PM, the last patient of the night at the radiology center. (I was astonished to find they worked that late.) I went in without being on medication, so whatever pictures they got would be what I was actually experiencing. Now I think that was a mistake.
The block the techs wanted me to rest my neck on pressed directly on the ruptured disc, and trying to lie still was, frankly, agonizing. I just couldn’t do it. After a bunch of unusable pictures, one tech said “Why don’t we prop up your head on a pillow and give your neck a rest, and take the pictures of your lumbar spine.” And we did that, and the pain relief was ineffable. Once we were done with that, he had another go at the neck pictures but this time put a small pad under the back of my skull, which lifted my neck just enough to take pressure off the bad place, and I was able to lie still and he got his pictures.
The following week I went back to the neurologist, and we looked at the MRI images. They were pretty ugly. They showed the C5/6 disc clearly invading the spinal cord space and impinging on the C6 neural foramen, with the C6/7 disc also herniated but not invading as badly. She also pointed out places where it appeared the vertebral bone was over-growing, making the disc displacement worse. All that fits exactly with the kind of pain and nerve problems I’m having; it’s just confirmation of the diagnosis, and confirmation that we have to do something.
Next we tossed around various pain-relief modalities that might not give me hives again. She didn’t think the Voltaren was involved, and extended that script, and prescribed Soma (carisoprodol) in place of the Flexeril for muscle relaxation. Soma has worked really well for me, which is a damned good thing, given the conversation on painkillers.
The first painkiller she suggested was Butrans (buprenorphine), a transdermal patch system that lasts a week at a time. I wasn’t really charmed by that, because Butrans has a warning about caution using it in people with compromised respiratory systems. (I learned later that ANY opioid at all has cautions about using it in people with compromised respiration.) Then we talked about other opioid possibilities, and eventually she wrote me a prescription for Nucynta (tapentadol), a relatively new drug on Schedule II of the Controlled Substances Act. (Butrans, which we talked about earlier, is on Schedule III and Ultram, which I tried at first, is on Schedule IV.)
I think I ought to explain how controlled substances work, since it becomes important to the discussion. The Controlled Substances Act has five lists, or schedules, of drugs. Schedule I contains the drugs with “high potential for abuse and no recognized medical use.” That contains heroin, cocaine, methamphetamine, various designer drugs, and marijuana (without a lot of justification for its presence). Schedule II contains drugs with a medical use, but still with high potential for abuse and addiction. That’s where morphine and all its relatives live. Schedules III through V contain drugs with decreasing potential for abuse.
Schedule II drugs are a lot of trouble to deal with. A doctor isn’t allowed to phone or fax a Schedule II prescription; he has to write a paper prescription every single month, the patient has to go get the paper prescription every single month, and physically carry it to the pharmacy, then present photo ID to receive the actual drug, even if he stood there and waited for the script to be filled, and that’s completely aside from the “high potential for abuse and addiction” part of it. Schedule II is scary. And that’s what the doctor and I were talking about.
As I said, Nucynta is Schedule II. It’s one of the big boys. It’s also still under patent, which means there is no generic equivalent for it, and my insurance company reflexively fights paying for any brand-name drug. So I was annoyed but not surprised to find they refused to pay for the Nucynta prescription ($300 a month) unless the doctor called and fought them about it. To know what I’m up against, I called the insurance and asked what they considered an equivalent drug they would pay for. They told me their formulary included hydromorphone (Dilaudid), oxymorphone (Opana), and … wait for it … morphine sulphate. That’s right. Morphine. I asked about Butrans (remember, that one is on the less restrictive Schedule III). No, they wouldn’t cover that either. Well, what was their formulary equivalent for that? Oh, the equivalent for that one is fentanyl (Duragesic), also a schedule II drug. Fentanyl is roughly 80 times stronger than morphine. And this is their “equivalent” for a Schedule III? No thank you, ma’am.
So at this point I’m not taking any painkillers. I’m not taking any anti-inflammatories either, since I haven’t absolved Voltaren of guilt, regardless of what the neurologist thinks. I’m managing thing with Soma alone, and fortunately that’s working pretty well. I’m not having the horrible spasms and pain, although I’m still getting lots of pins and needles all down my arm, and I’ve lost some feeling in the balls of my left forefinger and thumb. I have an appointment to meet a neurosurgeon on the 25th, to which L is coming as well. I’m still of a mind that this is going to have to end in surgery; I don’t have faith in much less.
