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Old 01-12-2005, 01:34 PM   #1
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surgery denied because of pain meds

I went to see a knee surgeon, and he refused to do a knee replacement on me : he said I am too risky because of the high dose of meds. How bad is the pain after knee surgery? I am on over 300 mgs Oxycontin a day for DDD in neck and back. What can I expect after surgery?

 
Old 01-12-2005, 06:26 PM   #2
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Re: surgery denied because of pain meds

I've never heard of being denied surgery because of being on pain meds. If it would help get you of them you'd think they would want to do the surgery. Have you had any other previous surgeries on your knee? It might be worth a shot to see a different surgeon and get his/her opinion? Good luck and I hope things work out for the better for you.
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Old 01-13-2005, 04:17 PM   #3
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Re: surgery denied because of pain meds

This is exactly what I have been talking about for years. Prior to OxyC, surgeons did hip replacement, long fusions, TKR's and you had a few days of IV meds and came home with 2 5mg percs every 4 hours.

My last 6 level fusion was in 99, 12 screws and 8 rods, and I got the same meds they used for the first 2 surgeries. My NS sent me home with 2 5mg percs. Your on a dose of meds that he's never seen or prescribed and has no idea how to manage your post op pain. Your dose is 30 times stronger than anything he has ever prescribed and he's not comfy doing that and won't. He can't imagine you hurting more than someone he just fused, or did a hip replacement, or bilateral rib resecton on.

An even worse scenario that I have seen is when the doc says your on all these meds so you shouldn't need anything else, I've seen that dozens of times. So you suffer big time.

People with Virgin backs work themselves up to 300+ mgs of oxy a day, what is the surgeon supposed to do when he's never prescribed more than percocet? 50% more and take responsability for possibly ODing the patient? The anesthesia dept doesn't want that responsability. Will your PM doc manage your postop pain, does he have hospital privlidges to come in and order larger doses of opiates than the anesthesia dept has ever seen and put his malpractice insurance on the line for a bad knee.

There are docs that could work with you and your pain management doc, but how would the surgeon call it successfull, if you never come off the meds and only increase use. He doesn't see the benefit if he can't resolve your pain and get you off the meds. The surgeon has spent his entire life believeing opiates are only used short term post op in limited strength and dose. You discontinue them 6-8 weeks post op if your lucky and they call the surgery a success. He doesn't want to be part of what he believes is wrong.

The even worse scenario is when you no longer get relief from your meds, something has changed, say a bulging disc explodes and the vertabrea shifts into your spinal cord and now the patient wears depends. Patients were able to put off surgery for years with high doses of meds when they couldhave managed without meds but now it has to be fixed, then the doc wants to detox you either prior to or after surgery to see how the surgery worked or to be sure he could manage your pain because he's not willing to prescribe 50% more than the 300+ mgs a day.

The doc has the right to pick and choose patients and one that's already on a high dose of pain meds will be difficult for him to manage post op pain. In his mind he can't justify a 50% increase on a number he would never go near. PM docs and surgeons don't see eye to eye on the benefit of long term opiate therapy.Not all PM docs have the same idea. Some only prescribe as a last resort when you are bed ridden and have no quality of life. He can wash his hands and just say get more oxy for your Knee, that's how you managed whatever other problem you have.

This is very common, and we will see it more and more often. People would rather mask their pain than have surgery, but at some point fixing it will be more apealing than a life spent on opiates. When opiates no longer mask the problem, people may not be able to find a doc willing to even try to fix your problem without detox.

I'm sorry, but when opiates are used as first line instead of last line it creates huge conflicts. Now you need a doc at a hospital that has a pain management dept in it. Where the anesthesiologist is aware of your situation and knows what is safe and what's not, plus you need a surgeon that's OK with the surgery, knowing the only success rate he can count on is patient reporting. In the past, if they discontinued pain meds and you stop complaining of pain. You were a success.

I understand mechanical pain is different from other pain, but the surgeon doesn't. He sees no chance of success and great risk to you and his practice if he tries to dive into water deeper than he's ever seen.

As far as pain, It's about as invasive as any surgery, they totslly open your knee, saw the end of your femur off, saw the end of your tibia off and then drive the spike ythat holds the artificial knee up into the the core of the Femur where marrow is created and dwown into the core of the Tibia. It's major surgery and ezxtremely invasive and likelu extremely painful, whch makes pain control a larger issue and much more complicated by the present meds.

continued

Last edited by Shoreline; 01-14-2005 at 06:19 AM.

 
Old 01-14-2005, 06:28 AM   #4
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Re: surgery denied because of pain meds

If you are taking these meds for DDD which is just the beginning of a bad back, deydration of discs is very common and occurs in everyone over the age of 30. Have they tried any other modailities other than oxy to manage your back pain. If DDD is causng this much pain, what would a rupttured disc with floating fragments that impinge nerves, or stenosis or shifting of the vertabrea "retrolethsis" require to manage your pain, or would you then consider fixing the problem. I thinK PM has gone a bit overboard. If we start moving towards a society where everyone with DDD needs PM with the most potent opiates and DDD is just the beginning of back problems, half our populaton could choose to go the pain management route and be on one of these meds that should be used only when every other attempt to manage pain has failed.

THis is the result of over zealous PM docs and patients that don't want to modify their lifestyle to accommadate their changng bodies.

I've seen folks take these meds at high doses so they don't have to change a thing in their life, People have money invested in horses and love to ride, probably one of the worst things I can think of for a bad back, but folks would rather medicate and continue to ride than give up riding, just as an example. Same goes for many activities where lifestyle modification was a choice, and many other modalities may have been a choice, but it's kind of late now to expect an ESI to reproduce the pain relief of large doses of oxy does.

We live in an instant relief world, instant gratification and the patients desire outweigh the patients best interest. Even if back surgery was every an option, at this point you need very special docs and very special PM docs and very special anesthesiologist to even consider surgery. It's not that anesthesia is a problem, they can certainly knock you out safely and maintain your breathing on a vent, But having the back pain and the meds will also appear that your not agood candidate for or a full recovery where you have to push the knee and push your body.

Docs aren't going to dope you up to the point your numb and can destroy a 100k knee without the pain to let you know your pushing too hard. So your in a catch 22, Medicate even more to get through the rehab, or don't mediacte and never fully recover from the TKR because it hurts to much to do the PT and rehab work. With a TKR the rehab is extremely important and if the doc feels you won't get through the rehab, the surgery will fail. You have to walk and excercise it, are you able to with your back pain?

If you can only walk 1/10 of a mile on your present meds, how can you rehab a prosthetic Knee and make it fully functional and get through the rehab process while in extreme back pain that requires that kind of dose of meds. If they just double your dose or increase to make you comfortable, any possible damage you do do the Knee or your back during rehab will be somewhat masked and continued to be masked if you continue to use the same PM doc that uses whoping doses at the first signs of an aging back.

This surgeon just can't see the benefit in a patient that can't do the rehab. There are alternatives, like in patient rehab but again unless your PM doc has hopital privlidges at the rehab facility, he will have no control over the meds you take and they won't allow you to take your own meds and self medicate in addition to whatever they give you for the knee.

I really am sorry that every GP and surgeon sees PM as a way to pass the buck on a patient that complains and requires meds beyond their comfort level. The attitude of let someone else risk their licence on this patient is much easier to take than to deal with a patient with continued complaints of pain. What was once the final solution after everything has been tried and failed is becomeing the first line solution, and patients can shop PM docs untill they find one willing to sell their licence for repeated office visits and copays. Rather than learning to deal with the pain and trying every other modaility that's out there, the meds are the quick and easy solution, but they do have consequences that not everyone sees or looks far enough down the road to see because they hurt now and want relief now. People really don't die from being in pain.

My clincic is so busy they had to send me out to an ortho to get the pump implanted, the surgeon that did the implant assumed I had meds at home and the pump would take care of the rest of the pain. Well, the pump was set so low in the beginiing, "to be safe" 1/5 of my present dose now, and I was at the point refill wise with oral meds that I had 4 days of meds left when I was released and given nothing by the surgeon for incision pain. At my 2 week follow up with the implant doc, I explained how I had no meds when I went home, he did give me 40 percocet.

MY PM doc wanted me off the LA orals and would gladly adjust the pump every week to 10 days in the beginning, then every 2 weeks then every 3 weeks now I go a month between adjustments and refills and I'm still fine tuning things. The pump implant was really a breeze comared to back surgery, but the same thing hapens all the time, They see a patch or your med list and assume it will manage any pain their surger may create. In their eyes, their surgery will relieve your pain so you don't need anything in addition to your present meds.

IT's happened to me and happens with many CP patients that require surgery. Just imagine being in a car accident and having a compound fracture of your Femur, what would an ER doc give you that's stronger than your present meds. He will tell you the pain will be relieved once the fracture has been set and imobilized.

IF you absolutely want this knee done, look to major universities that have PM dept on premesis and can bring in a PM doc as a consultant for your after care if your doc isn't afiliated with the hospital you want surgery at. But think about the rehab process and what kind of shape you would be in and the end result of the TKR if your unable to rehab the knee due to your back pain.
Good luck, Dave

 
Old 01-14-2005, 01:57 PM   #5
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Re: surgery denied because of pain meds

Boy, Dave I never thought of all the different scenarios you explained. I just thought if there is a chance to stop the pain why not operate, now I understand. Thanks for opening my eyes!!
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Old 01-14-2005, 02:38 PM   #6
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Re: surgery denied because of pain meds

I don't know what you can expect when you have knee replacement surgery, but I know one thing for sure. You need to find a new surgeon, one who isn't afraid of a difficult surgery because he might get an increase in his malpractice insurance. There are a lot of good surgeons out there, you just have to find them. I lucked out when I had my lung surgery two years ago. I was on Oxycontin, 160 mgs TID or 480 mgs. I also had Roxicodone, 30 mgs for BT pain. I told the surgeon when I went in for a presurgery appointment what I was taking and how much. I told him I just wanted him to know, because I didn't want to lay in that bed after surgery and be hurting the whole time. Maybe I'm just lucky when it comes to this kind of stuff, but I got a wonderful surgeon and I got the best of care. He even had his own Nurse Practioner who worked in the ICU to take care of his patients.

Anyway, enough of this stuff for now. Find yourself another doc. There out there, but you need to do a little searching for them. Not everyone is lucky like I was. Good luck!
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