What are the guidelines for maximal narcotic dosing?

The current guidelines state patients should avoid taking more than 90 MME of narcotics/day. MME means “morphine mg equivalents”.  This is a way to compare any narcotic to morphine so we can compare the strength of the other narcotic. 

For example, we all know what $100 is, but how much are 100 euros?  Or how much are 100 pesos?  Much like different country currency, the MME calculators will standardize narcotic dosing so we can figure out how much of any narcotic is in morphine doses. 

For example, oxycodone has an “exchange rate” of 1.5 mg to morphine.  So, 10 mg of oxycodone is actually equal to 15 mg of morphine.  (10 x 1.5= 15).  After converting your narcotics to morphine, you add up all the doses.  This total amount should not be more than 90 mg of morphine/day. 

If you are taking more than 90 MME /day, you are potentially putting yourself at risk for future challenges. You should discuss your long term goals about narcotics with your prescribing doctor. 

Maximum Daily Dose of Tylenol

how much Tylenol to take
Did you know the maximum daily dose of Tylenol is 4000 mg/day?  The maximum dose of ibuprofen (Advil) is 3200 mg.  But these are in patients with no other medical concerns such as kidney disease, liver disease, or GI concerns.  Ask us!  We are happy to help.
All short-acting narcotics should only be taken “PRN” which means as needed.  You should only take your narcotics as needed by your pain, never on a set schedule such as every morning, every lunch, every dinner and every night before bed.  If you’re doing better from therapy, non-narcotics, interventions, or other causes, you may not need your narcotics….so don’t take them.  There is much research showing long term narcotics make your situation worse.  You should strive to always try to get off of narcotics or decrease your requirements.

Why is my Neurontin (gabapentin) Not Working?

Many times we have patients that have tried neurontin and reported it does not work.  However, they dont realize the normal minimal dose needed to get a benefit is 1200 mg/day. 

On occasion patients try it and only go to 300 or 600 mg /day and then think it doesn’t work.  Make sure you give your meds a chance to work and follow the prescriptions before stopping. 

Please inform your doctors why the medicine was not working and what dose you were taking.  Many times, we just need to increase the dose more before a benefit comes.

Why Decadron Is Our Drug of Choice

Many people ask me injections.  And just like there are hundreds of ways to make a pizza, there are hundreds of ways to do injections! 

Variables include:

 -The approach or direction of the injection

-The technique or how the physician performs the procedure

-The mixture of medicines in the injection

-The local anesthetic used

-The volume of injection meds

-The imaging technique or the way the x-ray machine is used

 -The type of injection (we have already learned there are over 85 different injections just in the low back)

– And the choice of steroid 

In considering our choice of steroids, we prioritize patient safety over everything else.  Therefore, the steroid we routinely use is decadron, also called dexamethasone. 

There are many different types of steroids, each with its own characteristics.  Some last longer than others, some are safer than others, some are faster acting, some are cheaper, and they have different sizes.  Decadron is very small and non-particulate.  Therefore, it can be used IV, or injected directly into a vein, and not cause any problems, making decadron one of the very safest steroids to use during injections. Furthermore, it is one of the longest acting steroids, maximizing the benefit for the patient.  
When you are considering steroid injections, make sure you discuss with your physician their choice for which steroid they use and why.  Empower yourself with knowledge.  

What Does The Term “10/325” On My Narcotic Prescription Mean?

This is the way your meds are made. The first number is the dose of narcotic.  The second number is the dose of the other medicine, usually Tylenol.

For example, if you are taking Percocet 10/325, every single pill has 10 mg of oxycodone and 325 mg of Tylenol.

If you are taking Norco 5/325, every single pill has 5 mg of hydrocodone and 325 mg of Tylenol.  If you are taking Vicoprofen 10/200, every single pill has 10 mg of hydrocodone and 200 mg of ibuprofen.

Always ask your doctor if you have specific questions on your medications.

Keeping Medicine Safe At Home

You should treat all your medicines as dangerous, especially if you have children at home. Or even frequent visitors such as friends, relatives, neighbors, or even house cleaners.  Anyone that sees your prescription bottle can easily take a handful without you noticing until later.  You should always keep your controlled substances/medicines in a secure, locked location. You wouldn’t leave cash lying around your house or car or workplace, treat your medicines like cash!  Keep them away for safety.

What do I do with unused or expired medicines?

The current guidelines are to dispose of any unused or expired meds in non-palatable waste such as kitty litter, grease, or coffee grinds.  Additionally, you can call your pharmacy and ask if they have or know of any “medication take-back” programs.

What do I do if my medicines cause sedation?

Many times we will prescribe medicines that can have a side effect of sedation.  In fact, we like to use possible side effects for treatments!  For example, if you have muscle spasms and problems sleeping due to spasms, we could provide a muscle relaxant that has sedation as a side effect to help with your insomnia.  Generally, we suggest taking medicines that cause sedation at night so the sedation peaks when you should be sleeping.  You should be careful using any medicines that can cause sedation and operating any heavy machinery or cars/vehicles.

My spouse has terrible pain, can I give them one of my pain pills?

This is very dangerous.  We only prescribe narcotics after a full evaluation of symptoms, other medical problems, and exams.  Giving anyone a narcotic or controlled medicine that does not come from a physician can be deadly.  Furthermore, giving narcotics to anyone for whom they are not prescribed, even a spouse, is a federal offense.  Don’t do it. Have them call us for evaluation or go to urgent care/ER for evaluation.

What should I do when I pick up my prescription?

First, make sure it’s yours!  Verify the medicines, dose, frequency, and number of pills.  Next, especially if you have narcotics, you may want to verify all this in the store.  I have had patients say they picked up their prescription, got to their car, counted their pills, and then realized they were shorted.  Unfortunately, there is nothing we can do in this situation as the pharmacy will simply say you got the right amount.  You should verify your medicines and address any questions before leaving the pharmacy.  Also, feel free to ask your pharmacist if you have any questions.  They are a wealth of knowledge!

Medicines And Their Side Effects: How to Know When to Change

This depends on the severity of the side effect.  For example, If you start to have swelling in your throat, you should stop immediately and seek physician evaluation as we don’t want the swelling to affect your breathing.  On the other hand, if you start to notice some mild nausea or sedation that is not very bothersome, it’s probably okay to continue your medicine and simply monitor for progressing symptoms.  Many medicine side effects will improve after 24-48 hrs.  If you can make it through the mild side effects, you might find the side effects go away and then you only have the benefit.  Just communicate with us so we can follow up and monitor as well.

Options Aside from Narcotics

There are many non-narcotic options to help with the pain.  Basically, you can take muscle relaxants to help with muscle spasms; or anti-inflammatory meds to help with inflammation or arthritis pain, or nerve-calming medicines to help with nerve pain.  Just because you don’t want narcotics does not mean we can’t provide medicines.