Question: Hello Dr. ,
I have been seeing doctors at Pain Management Clinics for over 6 years. I have CNS pain caused by multiple conditions: Adrenal Adenoma, Chiari 1 Malformation, Ehlers-Danlos Syndrome, osteo arthritis, degenerative discs, detached patella and knees need resurfacing, weak muscles and muscle pain, etc.
I have been using Morphine Sulfate ER 30 mg. 3x a day, and Morphine Sulfate IR 15mg. as needed or 2 x a day. This has been my SAME dosage for over 5 years. My newest Pain Clinic Doctor recently tried to switch me a new opiate, called Nucynta. He did not plan any type of tapering off program for the Morphine, I was just supposed to switch them. I also take Clonazepam 0.5mg 3x day; Fluoxetine 30mg. 3x day, Gabapentin 200 mg. 3x day, and Tizanadine at night, with150 mg. Ranitidine 1-2 x day. His reason for switching my medication, he said, was because of his concerns about my taking Clonazepam and the potential for excess opiate to be in my system. I have taken Clonazepam for eight years, with Gabapentin, as my first line of medication for Fibromyalgia Pain. I also have a history of child abuse and anxiety and depression, which is addressed very well by the Clonazepam and Fluoxetine. This group of medications works well for me and I do not get any euphoria or mental side effects from the opiates or clonazepam. Last year, after my Orthopaedist confirmed my own diagnosis of Ehlers-Danlos (my bowed knees and double joints helped), I realized I finally had a reason for Fibromyalgia.
When I went to purchase the Nucynta, I had just become a Medicaid patient. The Doctor had given me a coupon (from the pharmaceutical company) for $25.00 off on my co-pay. The price of the prescription, at a Kroger Pharmacy, was $545.00, with insurance compensation applied! I am on Medicaid because I have no income and can't work very well. I could not afford the prescription and told the Doctor how much it cost. He wrote prescriptions for my regular opioids. But then, he wanted me to stop taking Clonazepam, and switch to Buspirone. He also did not discuss or implement any type of a tapering-off or step therapy for stopping the Clonazepam and starting the Buspirone. I am on 0.5 mg Clonazepam, and he prescribed 7.5 mg Buspirone.
I started by substitution of 1 tablet of Clonazepam, the first week, with 1 tablet of Buspirone. The first week my side effects included increased anxiety, restlessness, insominia, myoclonic jerks all over, and increased sweating, hot flashes, agitation, anger, and the feeling of a weight bearing down on my chest.
THe 2nd week I was taking 2 Buspirone and 1 Clonazepam per day. I started to experience restless legs (a previous symptom from 3 years ago) as well as the other symptoms, and increased anger and agitation. I also started to go into a darker mood, and having tried many different SSri'S and other medications for depression, anxiety, and pain, I realized I was not doing well. I discussed the situation with my Pharmacist, who advised me that after 6 years on Clonazepam I could expect/need a longer time to taper off the medication than just a month, and that the Buspirone would not be strong enough to take care of my symptoms and conditions.
I called the Pain Doctor's office and spoke to his assistant, asking to refill the rest of my prescription for Clonazepam (since I had only a partial fill and I wanted to stop taking th Buspirone). She relayed this information to the Pain Doctor, and he replied by telling me to take 2 tablets of 7.5mg Buspirone in place of the Clonazepam. I explained to her my symptoms and the troubles I was having, with the increased anxiety over becoming uncontrollable really being my number one concern. She again relayed this information to the Doctor, (who at no time spoke directly to me) and she said, "he will fill the remainder of your Clonazepam, but this is the last refill. You will have to get it somewhere else.
I picked up the rest of the Clonazepam and went off the Buspirone, but the symptoms did not resolve for six weeks, and I am still having some symptoms of excess anger and depression. When I went to the Pain Doctor for my regular monthly 15 minute medication appointment, he informed me that he would no longer be able to service me as a patient, because I refused to stop taking the Clonazepam, and because I was on Medicaid and the entire practice was no longer accepting Medicaid patients.
I would like to ask the following questions:
1. DO Morphine and Clonazepam attach to the same Opioid receptor in the brain or CNS?
2. What is the daily recommendation for a Chronic Pain patient for Morphine dosage?
3. What does Nucynta offer that would be superior to the Morphine Sulfate?
4. Considering I was having no side effects or problems with my current regime, other than needing a refill every month, can you explain why the doctor felt the need to change my medications?
5. Are there any studies that compare the results of Clonazepam versus Buspirone?
6. Are there any charts or guidelines I can refer to to show dispensing instructions for my meds?

When I began taking each drug I am on, I started at a lower dose, which was increased or decreased by each doctor until I felt better. I still have pain all day and in my knees as I walk, I have migraines from my Chiari, I am not completely treated. But I am satisfied with the results of the current medications I take and only had to switch doctors because my prior one left her practice to go to XXXXXXX

There is a crisis in XXXXXXX of doctors who do not want to accept Medicaid. I can see, from comparing my bills, that they do not allow the Doctors to XXXXXXX as much, and they adjust the claims so they don't make as much money. They also can't slip bogus charges through the system to an Insurance Company. My first visit to the most recent Pain Doctor was billed at $694.00. Medicaid paid $295.00.
The second visit was about $250.00, and Medicaid paid $150.00. I have called over 5 different doctors to ask if they will accept me as a Medicaid patient, and they will not. Excuses are: we are full of Medicaid patients, or we only take 1 to 3 per month by referral, and appointments for Medicaid patients follow last in line behind those with private insurance, so you may have to wait 3=6 months, or up to a year, to be seen by the doctor, if he accepts you. How do I get monthly refills approved? Also, there was no exception for the fact that I had previously seen a doctor when I had private insurance, and could get an appointment the next day. Also, I could not come in as a cash patient and pay $150.00 for an appointment, if I had Medicaid as my insurance.
I would like to allow you to reply anonymously if you like, due to the nature of my situation.
If you have any other resources you can refer me to I would be very grateful. Such as advocates or support groups, or departments who regulate the medication amounts and types that can be prescribed together, and dosages. I am working on my XXXXXXX disability claim and need all the help I can get. I am 56 yrs old, female. I started searching for a diagnosis in 1997. The Chiari was found in 2009, and I diagnosed (and had confirmed) the Ehlers Danlos in 2014. The adrenal adenoma was found by incident, of a ct scan of my kidneys because I had protien in my urine. It is about 1.6m or 10mm in size and is secreting adrenalin/nor-adrenaline but my cortisol levels are low. My estrogen is low (menopausal). My eGF is elevated. I am having trouble finding doctors who will continue to see me now that I have Medicaid. My private insurance was $541.00 a month with Cigna. I received a credit of $400.00 from the Healthcare act, but I had to make at least $16,900 a year to qualify for it. I cancelled it after 6 months and went onto Medicaid. The Pain Doctor charged a $33.00 copay and my prescriptions are $1.00. My prior co-pays were $40.00 and prescriptions were 10-15.00 each. I have more than six conditions that need to be monitored or addressed, potential surgeries need to be done. I have recently been told, "just go to this hospital, they have to take you". My ER experience has shown me that they are only there to stabilize me and send me to a specialist, and I will spend 3 to 8 hours having my vitals monitored before being sent home with no treatment.
I hope you will review my letter with compassion and empathy, and please try to help me figure out what to do next.
Best Regards,
XXXXXXX XXXX
YYYY@YYYY
zip code 0000
0000, dob.
P.S. I am also B- and RH- blood types, and am half French.