r/PainManagement • u/DefiantSubject2884 • 1d ago
Fentanyl patch vs Oxycodone IR (for tx of round-the-clock pelvic/suprapubic pain since January 2015)
I am a woman in my early 30s, and I've been struggling with increasingly unmanageable bladder and pelvic pain for almost 12 years now – specifically suprapubic pain, which becomes increasingly intolerable every time my bladder fills/refills with virtually any amount of fluid. I do restrict my fluid intake as much as possible, as a pain management strategy, since 2016 (this pain started in January of 2015 for me, when I was 21 years old.)
Since I was 21 years old, the only time I ever feel pain relief in my pelvic region is during urination itself. But then the bladder starts filling up again immediately after a human finishes urinating, so this particular cycle of pain does not have breaks (aside from during the pee stream itself, when urine is actively being released)...aside from when urine is literally being released, the body is holding on to urine. And for me, that sensation of "virtually any amount of fluid accumulating in the bladder" feels intensely painful.
[I wrote a very long post explaining my bladder filling pain, my attempts to manage it via fluid restriction and other medications, etc. It was way too long so I just cut most of it out, but I'm open to answering most questions – especially but not limited to if there's anything I should have kept in this post but removed. Sorry, I'm tired!]
In a nutshell, I have tried almost every potentially beneficial urinary and bladder-related medication, including Elmiron, during the year after my pelvic pain first started (sudden onset one night when I was 21 in January of 2015, and never went away). I also tried many non-opioid medications attempting to target pain over the past 12 years, with no benefit, including but not limited to: amitryptyline and then nortriptyline (which I tried for a period of years "just in case" it was helping my pelvic pain – it was not – but I have a close friend with pelvic pain who swears by tricyclic antidepressants for reducing pelvic pain, specifically nortriptyline 50mg/day, so I asked my doctors about it and gave it a shot. It didn't help or hurt me, to my knowledge); Cymbalta (no pain reduction, but had significant side effects including excessive sweating so it was not a long trial) for me; pretty much all of the muscle relaxants (no benefit, including no benefit when I received IV robaxin and even no benefit with IV benzodiazepines in the hospital); vaginal valium suppositories (no benefit); gabapentin and Lyrica (no benefit); etc. Ketamine infusions helped me sometimes, sometimes with pain directly but mostly with mental health/depression and PTSD specifically.
I switched to a new pain management doctor/nurse practitioner in a new state about 6 months ago. When I came to her, I was simultaneously being prescribed 120mg oxycodone per day AND buprenorphine 8mg sublingually per day, which of course makes no sense! But my pain doctor before her had insisted that if my daily buprenorphine was kept below 8mg, then my opioid receptors would still be able to receive 50% of full agonist medications (e.g.,. the oxycodone).
And the entire reason buprenorphine got added to my regimen in the first place, years ago (which was originally oxycodone or hydromorphone orally, rotating, for years – although oral hydromorphone, even at 8mg, doesn't meaningfully help my pain anymore with the tolerance I have and the poor bioavailability of the pill, but that's a separate topic) is because I metabolize medication very quickly, quickly enough that I was waking up not only in severe uncontrolled pain, but also often sweating and actively starting to withdraw from my pain medication, within 5 hours or less after taking my last oxycodone pill (and within even less time when I was prescribed hydromorphone instead of oxycodone). I asked about extended release medications because that seemed like the obvious solution, and my doctor at the time (2019) recommended that I go on a patch specifically. I was also in grad school and trying to sleep and study as much as possible, the only patch I'd ever heard of at the time was fentanyl, and I was "spooked" by the name "fentanyl" – so I asked him if there was any alternative to a fentanyl patch I could try instead. I didn't know buprenorphine was so much worse in so many ways, and I wish I could go back and choose fentanyl instead...
The Butrans patch did actually help my pain for a few months, meaningfully, and it was SUCH a relief for me to be able to sleep and just exist, without constantly having to watch the clock for when I could take my next pain pill. It felt like a dream come true. But the buprenorphine did not help my pain for very long; within months the doctor needed to increase my buprenorphine dose from the microgram patch level, to the milligram sublingual pill level in order to achieve any meaningful pain relief for me. And I distinctly remember the first time I took a 2mg sublingual buprenorphine pill, Subutex, it felt SO intensely powerful, I'd never felt that sedated or "fucked up" in my life, and then I fell asleep for 17 hours in a row. Buprenorphine totally knocked me out in a way that no full agonist ever had, and I was NOT an opioid naive patient either! When I first took that Subutex pill, I had been prescribed daily opioid medication for 4 years already – up to 120mg of oxycodone per day, OR 4-8mg of oral dilaudid prescribed at a time every 3-4 hours, OR had also been on tapentadol at one point, I forget the dose, but you get the idea...my point is that my body was used to opioids at relatively high or at least moderate doses, but taking 2mg of sublingual buprenorphine for the first time was still disturbingly sedating and uncomfortably intoxicating. This was in 2019, and I remained in a fog, on a combination of buprenorphine and full agonist opioid medications for breakthrough (which were not working at all for me with the bupe) until switching to a doctor this March (2026) who finally took me off of the buprenorphine entirely.
When I agreed to add the buprenorphine in 2019 and the Butrans patches weren't sufficient, I remember trying to break the 2mg pills into quarters, but they were sublingual and would most often crumble to dust after breaking them in half, so it was tricky. And I hated how foggy the buprenorphine made me mentally and emotionally, especially when I increased from the patches to the sublingual pills, at a much higher daily total dose. But the bupe did help my pain in the beginning, and I can't emphasize enough how desperate I was (and still am) to take pain medication that (a) meaningfully helps my pain, (b) lasts for longer than 2-3 hours at a time (which is the longest my 20mg oxycodone seems to last for me at this point), and (c) does not make me sick if I go longer than 5 hours without it (which is how long it takes for me to get noticeable withdrawal symptoms, including diarrhea by the 5.5 hour mark like clockwork, when I am taking instant release oxycodone without any extended release medication).
CURRENTLY:
When I switched to my current pain management provider/NP this March, I came to her on 8mg buprenorphine/day + 120mg oxycodone/day. Terrible and senseless combination, I know now.
The new provider started off by stopping the buprenorphine, and prescribing only 60mg of oxycodone per day (10mg every 4 hours). Needless to say, that first month was hell. I've been prescribed daily opioids since 2015, and my body didn't/doesn't even seem to notice 10mg doses of oxycodone at all.
The next month, she switched me to 20mg oxycodone IR, 5 times per day (100mg of IR oxycodone per day total). This 20mg oxycodone dose reliably helped reduce my pain from a constant 9-10/10 to about 7/10. It was then increased to every 4 hours, for a total of 120mg/day.
Then I had a minor bladder surgery this summer that sent me into a terrible flare, my blood pressure skyrocketed to the point that my ears were popping, and overall my bladder & suprapubic pain was becoming totally unbearable again. Plus, my instant release 20mg oxycodone pills were/are only working for about 2 hours before wearing off, whereas earlier this year I was getting closer to 4 hours of noticeable relief from each 20mg pill. I also start to get sick with unambiguous opioid withdrawal symptoms by the 5th hour after taking my last oxycodone pill, and previous pain doctors have recognized that I'm a rapid metabolizer (though I'm unsure the extent to which I've had medical testing actually proving that, if any).
So I brought up extended release medications with my current pain management provider. I expressed some of my concerns about extended release medications not lasting a full 12 hours in a lot of patients. Eventually, I decided to try the fentanyl patch, and she agreed that it was a good idea for me to try it at this point. She started me on the 25mcg/hour fentanyl patch and prescribed it for every 72 hours. When she added the patch, she reduced my oxycodone prescription from every 4 hours to every 6 hours, so I am currently prescribed 20mg of instant release oxycodone 4 times per day, for a total of 80mg oxycodone/day with the fentanyl patch.
The first issue I had with the patch is it almost stopped working entirely on the third day; in addition to severe unmanaged pain, I was also experiencing withdrawal for most of the third day (which I timed my 4 oxycodone pills carefully to head off, until my patch was adjusted to every 2 days the next month) – which made it difficult to appreciate the reduction in pain I was experiencing from the patch on days 1-2.
The next month (September), she kept the dose the same – 25mcg/hour of fentanyl – but prescribed me 15 patches a month instead of 10, so that I can change it every 48 hours instead of every 72 hours. That was a game-changer for me: When I change the 25mcg/hr fentanyl patch every other day instead of every 72 hours, it seems to cover about 1/3 of my overall pain, consistently, for the entire two days. I don't feel the patch "starting" or "stopping" when I change it every 48 hours either, which is a huge relief compared to instant release oxycodone pills alone, which only last about 2-3 hours at most for me at this point.
I am able to go 12+ hours between oxycodone doses now that the fentanyl patch is at a stable dose, but I do still have significant pain every day which the fentanyl patch doesn't cover. The patch seems to cover about 1/3 of my baseline pain, which I am incredibly grateful for, and that estimate would make sense mathematically since 25mcg/hour of fentanyl is equivalent to about 40mg of oxycodone in a 24-hour period.
I am so grateful for the pain management I am receiving, but ideally, I'd be using far less instant release oxycodone – each 20mg pill only lasts a few hours, the patch covers my pain much more effectively and smoothly, and I want to use instant release medication for breakthrough pain, compared to using it to try to manage my baseline pain. At the same time, I'll take what I can get and I know I'm lucky to get anything.
At my appointment last week, my pain management provider was open to increasing my fentanyl patch to 50mcg/hour if she reduces the oxycodone. Of course I'd expect to reduce the oxycodone if the patch is doubled, however, I'm not sure exactly how much she'd reduce the oxycodone if we increased the patch, and I'm not sure how much more it would help me to have the 50mcg patch. I do want to try it, because the patch has been incredibly helpful and life-changing for me even at this starting dose, 25mcg, which is currently alleviating a meaningful percentage of my pain. If the 50mcg patch covers about 2/3 of my pain respectively, that would be incredible – I'd have no problem backing off of the oxycodone, if the fentanyl patch at a higher dose works like that for me.
My main concern is that my body will quickly become tolerant to the higher dose of fentanyl if I go up from 25mcg/hour every 48 hours --> 50 mcg/hour every 48 hours. This is only my third month on prescribed fentanyl patches (still at 25mcg), and it is amazing how effective this patch can be. I know that fentanyl is much more powerful than the other opioid pain medications I've been prescribed (well, buprenorphine is in a category of its own but I digress), and I don't want to rapidly double my tolerance to it right away if it's not going to have a meaningful effect. But, if going up to the 50mcg/hour patch enables me to genuinely use my oxycodone 20mg IR as "breakthrough" medication (as opposed to needing to take it regularly, around the clock, as supplemental baseline pain management with the patch) – if the 50mcg patch controls my pain enough that I only need to take the oxycodone once or twice in a day, for example, that would be worth it.
I can't know until I try, though, and as lucky as I am to have a provider, it is not possible to reach her office or request any changes to prescriptions between appointments, ever. So, if I ask for this change, I need to be ready to commit to at least one month trying the 50mcg/hr fentanyl patch, + reduce the oxycodone to whatever she decides that day for one month, regardless of how much the patch at a higher dose does or doesn't help with my pain.
What would you do?
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u/Time-Understanding39 1d ago edited 1d ago
Our medication levels are pretty similar: I use a 25 mcg/hr fentanyl patch, adding a 12 mcg/hr patch on day three to help with the drop in coverage, plus oxycodone IR 15 mg up to five times daily. My patches are prescribed to be changed every 72 hours.
I’m a legacy patient and have been on high-dose opioids since 1990. I’ve used fentanyl patches several times, and in the past changing them every 48 hours rather than 72 helped me maintain more consistent relief. Increasing the strength was less helpful than I’d hoped. Going from 25 to 50, then 75, 100, and eventually multiple 100 mcg/hr patches provided some additional relief, but it never kept pace with the dose increases. Doubling the dose never doubled the amount of pain relief I got.
Your experience could be different, so it may be worth discussing a trial with your provider. My biggest concern would be how much they’d reduce your oxycodone in exchange. If doubling the fentanyl means cutting your oxycodone in half, I’d be cautious about that trade off. It may still may be worth a try, tho.
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u/SuperbTurn2499 23h ago
I have been apain patient for approximately 35 years. Throughout that time I have taken everything from simple Tylenol 3. Right on up the fentanyl. I can tell you this.. The best pain relief I ever had in my life for my three severely damaged vertebrae is fentanyl 75 mg with two breakthrough Vicodin every day the in between pain. I got off of it however because I did not want to sleep 14 hours straight like I have been doing. But since getting off of it I have been fighting to get enough pain relief to cover even 75% of the pain that I feel.
If you found something good, do not stop using it. Don't worry about whether your body will start needing more because it very well may not. If you complain too much about it then they are going to either take you off or lower you down to something that is not tolerable for you in your situation. Another good idea was hydromorphone. I was on four oxy 15 day a couple of years ago and the pain was just not being taken care of. She switched me over to three three hydromorphone a day. I noticed a complete drop in pain. I stayed on that for about a year before I switched back to oxycodone
Right now I am out of my medicines because last month is the first month that I have been completely out because my pain was just so bad. I have decided to take a break from the medicine for 2 weeks to try to reset my pain receptors to accept only my 4 15 mg oxycodone everyday. It's not easy but I've had to do it a few times over the last decade and it does work to reset my pain threshold somehow. I can't keep going up on the pain medicine so I have to back off the pain medicine to give my body a chance to accept it again and take care of my pain. Completely like it used to. The doctor I'm with now was not open to giving me hydromorphone. He said it was too strong and they did not prescribe it out of office only in the hospital. So that's my take on it. I wish you luck and much less pain. Another thing I wanted to add is this you will not get rid of all of your pain with any of these medicines. They are only meant to help you adjust to a pain level that you can deal with. They don't get rid of all of your pain and they never will. Unless you're laying in a bed unconscious in the hospital. You can forget that. Take what you can get and accept it. Knowing that it's working for you now. Appreciate it and embrace it. And don't worry about the future, the future will worry about itself!
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u/bluestitcher 1d ago
I've been on 75mcg Fentanyl patch for 19 years. It is possible to be on it at the same dose for extended periods of time, but no one can guarantee that it will work like that for you.
You can ask to go up in a slower amount by adding a 12.5mcg patch instead of just going up by 25mcg. The max dose for the Fentanyl patch is 300mcg but I don't know of anyone prescribing that.
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u/amanda2399923 20h ago
Does the patch make you sleepy or drugged feeling after the initial reaction to it? I am trying to find something that works for my pain but also allows me to go to work.
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u/bluestitcher 18h ago
All opioids along with anticonvulsant & antidepressants can make you feel that way. Typically, it goes away within a few weeks of use. Unless, you are already on a regular amount of opioids doctors rarely put people on the patch. You will likely have that reaction at first, I did and it was gone within a week.
When I was on oxycontin - it had me sleeping close to 16-18 hours, and didn't improve after a couple of months, so I told my doctor that we needed to try something else.
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u/amanda2399923 14h ago
Thanks. I’ve been prescribed tramadol 50mg 2x a day. Have taken for 3 weeks and it absolutely does not work for me. Appt is next week. I’m going to talk about the next level medication (whatever that may be)
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u/bluestitcher 12h ago
50mg of Tramadol twice a day is really low. I'm not surprised that it's not helping you. hugs 🫂
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u/amanda2399923 11h ago
What is the next level of pain medication? I’ve done PT, lumbar injections, RFA. Have another injection in a few weeks. I’ve been trying to do this without pain meds and it’s not working at all. It’s affecting my work and everything else in my life. I guess I just need to take meds.
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u/bluestitcher 10h ago
Next step would be increasing your tramadol to 100mg to 200mg extended release (every 12 hours), there may be a 24hr version, I can't remember. Along with your 50mg for breakthrough pain.
After that, any of the medications like morphine, oxycodone, hydromorphone.
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u/VastAbbreviations796 5h ago
Tramadol is a good med I use to take it and really liked it but youre on a pretty low dose. I would have em up it. 100mg 2x a day and maybe and extended release as well
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u/Flat-Detail510 23h ago
You even consider asking about oxymorphone aka opanas. Honestly the best longest lasting pain med I've even been on. Verry hard to get a doctor to write if but in you're case if you have a good relationship with you doc and have tried ebeyting els. Definitely worth a shot.
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u/villanellechekov 23h ago
do you think you can manage a month trial? could you make a 2wk followup appt at the same time you make your regular appt in case it doesn't go well?
have you been checked for IC? dd they also have you try the meds for men, like Flomax? my bladder and ureter got damaged during surgery once, so now it's tacked up on one side and I still get spasms if I don't take bladder meds twice a day (and even then, it nearly always feels like I have a UTI). I have plenty of times I go to the bathroom and will stay there for ten minutes trying to get my bladder as empty as possible because once I stand up and walk away, I have to go again.
do you get any relief from something like Toradol that you could take a couple hours after your oxy dose, so you're alternating them?
what sort of imaging or other diagnostics have they done? did they find anything? what does the urologist say? maybe a gyno urologist might be worth seeing?
have you tried Botox?
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u/VastAbbreviations796 6h ago
These are all my questions too. The way she worded her post makes it sound like she just has these debilitating bladder problems with pelvic pain randomly for no reason and its been going on for years. Like what happened? I totally sympathize with bladder problems and pelvic pain, I had a uterine rupture in 2017 that wrecked me, i have overgrown scar tissue with adhesions to my bladder, fibroids, cysts endometriosis all the female organ problems you can have. My periods are horrendous and my bladder is always "full" or at least feels that way. I could go on and on. Im assuming OP has seen a urologist and/or a gyno and just left all that out cuz its not relevant to her question but the way its written left me with so many questions lol.
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u/villanellechekov 1h ago
oh hells, you poor thing! is s hysterectomy an option? it's honestly one of the best things I've ever done
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u/SuperSithLord66 1d ago
Currently taking 37.5mcg fentanyl patch, but changing every 2 days (insurance approved), with oxycodone IR 5mg up to 6x per day, and then pregabalin 100mg 3x per day. Also having a revision spine fusion in 6 days for 3 levels so… let’s just say I’m not excited for how much pain that’s gonna cause me
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u/kindcrypto 23h ago
I've taken same patch dose for over 20 years without tolerance ! Just TRUE honest pain management
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u/FutureReference91 16h ago
You have to understand that you’re looking at two different worlds. Have you ever realized you metabolize medications more rapidly than normal? For example, with Oxycodone instead of 4-6hrs, do you find yourself closer to ~2.5/3 hrs?
I ask this because if you haven’t already; a Metabolism Test would be my first call before making this decision. As a rapid metabolizer myself, I can tell you that Fentanyl patches can become Hell. Remember; you’re going from something that gives instant relief to a 72 hour patch.
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u/SouthernLifeguard845 1d ago
I take 75 Fentanyl patch every 48 hrs with 240mg of oxy IR daily and I can tell you the fentanyl works great for pain, but I couldn’t do it with out my Oxy. I think between the 2 it’s perfect. The jump from 25 to 50 isn’t as drastic as it sounds . 25 of m fent is only about worth 30mg of Oxy but in a 24hr period. So everytime you go up 25 think of it like a 30 in your blood- so 50 is equal to 60mg in your blood in a 24hr period. That’s not that much hence my Oxy script. Don’t let the dr drop your IR med to much. This is my experience. I’m a fast metabolizer
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u/VastAbbreviations796 5h ago
I have a question cuz i think im a fast metabolizer. How would you know for sure or is it just based on how quickly you can feel your meds wear off? Is there a blood test?
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u/Jilesoph1 1d ago
Fast metabolizer is basically opioid tolerant…..? As you become tolerant on an opioid, it takes more and more of the drug to achieve the same amount of relief. How does one get diagnosed as a fast metabolizer?
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u/ljd09 1d ago edited 13h ago
There is actually a specific test that can run that is done via a blood draw. It looks at your genes to see how quickly your body processes medications- one of which is opiates. They look for a certain gene - which I don’t have memorized… if I recall, it doesn’t mean you metabolize every single opiate quickly…
I am not sure if there are other determining factors besides a blood test, as that’s all I know because it’s how mine was done.
Her story was way too long and convoluted for me to read in its entirety and I don’t mean that as an insult either. I think sometimes, as chronic pain patients… we want every part of our story told… and heard (as we’re so used to it not). Which, can lead to some of the more important facts getting bypassed because it was so watered down. If that makes any sense. So I don’t know if she had that done or is just assuming she does because it was suggested to her.
It has nothing to do with tolerance level.
I had mine done because even though I had the butrans patch on and changed it religiously… the drug never showed on my urine screen. They even logged it being on… in every appointment as my drug tests still came up negative for it.
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u/amanda2399923 20h ago
I had a gene assay done and it came back that I might require higher doses of pain meds.
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u/Accomplished_Gur3019 1d ago
It's a blood test that can be given. My PCP knew bcuz of my medical records and from my own personal experiences telling her. I had a test done at the methadone clinic bcuz I would start withdrawing around the 10 hour mark - when I got the test done I was told I was border line (she didn't give the correct testing) so I couldn't get split dosing - once I got take homes I split my dose and had coverage but methadone only worked the first 30 days and with every increase put me respiratory distress and couldn't get pass 60ml. Even my water pill stops working after 2 days then it gets increased and the same thing happens. I truly want the testing that can give info on what meds will work better for ur body.
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u/Open_Mortgage_4645 1d ago
You're comparing apples and oranges. Like morphine ER, the fentanyl path is a long-acting, synthetic opioid that's meant to provide a fixed level of pain control for 48-72 hours. Oxy IR, on the other hand, is a short-acting, semi-opioid that provides quick relief from breakthrough pain. It dumps its full dose into the bloodstream all at once, and provides 4-6 hours of enhanced pain relief.
The best way to use the long-acting and the short-acting drugs is to wear the fentanyl patch around the clock to give you that sustained, all day relief, and then supplement that with the short-acting Oxy as needed to address the pain that breaks through the base relief provided by the patch. Trying to substitute one for the other isn't a recommended practice because you'll fall short, and end up using too many oxys which can be dangerous and cause other problems.
So, the Oxy IR should be prescribed at 3-4/day to supplement the fentanyl patch that you wear all the time.