Shoreline, and anyone else. Best way to get off Norco?? - Pain Management Message Board

sandollar · 01-20-2005, 09:11 AM

Hi,
I am down to 7.5mg Norco 1-2 times a day, but my fusion surgery is in 12 days and the surgeon wants me off everything. But I get a weird feeling like I want a cigarette, yet stronger. So I end up taking 5mg Norco and a Skalaxin to help. But I still feel really yucky all the time, not to mention, my back slipped out on Monday and is still out 4 days later. He said it might not get better this time, until he does the surgery due to PM doing injections in the same area, causing the back to go out AGAIN! So I am in constant pain and he doesn't want me taking anything.
Any words of wisdom?
Thanks,
Stardust

Shoreline · 01-20-2005, 11:23 AM

Hey Stardust, Sounds like you have a very opiate phobic doc. There is nothing in Norco "hydrocodone and Tylenol" that could possibly prevent a fusion from being succesful. Anti inflamatories and a few other meds, including smoking, can cause problems with fusions being succesful. I also can't think of anything an injection could possibly do that would cause any kind of slippage, If anything, you develop more scar tissue in the area and the scar tissue may prevent slippage from spondy if that's why your having a fusion, instability.

It sounds like anything that goes wrong, unmanageble pain, falure of surgery, slow progress in PT , He's already decided will be the fault of whatever pain management treatment you have had.

A couple Norco per day, wouldn't make normal post op meds they used 10 years ago on me innefective. I've said it a few times but every surgery I had, 3 back surgeries, 2 of which were fusions, the last a 6 level. I got the same pain meds. 2 5mg percs every 4 hours, after several weeks or so they dropped me down to the lortab 7.5, didn't have Norco back then either. But if he used the standard post op regemin for fusions, 5mg percs or tylox, It would be a signigficant increase over the meds your presently taking which barely manage the pain. So I can't even imagine why he wants you off all opiates. Is he going to do a UA and refuse surgery if he finds a trace of Hydro? Your present dose doesn't even create any extra challange as far as anesthesia.

Personally this would scare me to death at this point. If your in such bad shape that you need a fusion, and he thinks you can live without any type of pain control, what is he going to do post op? Say your fixed and shouldn't need anything? If he's uncomfortable with two 7.5 norco a day, what's his comfort level going to be as far as post op pain meds? Will you even have PCA when you wake up with IV meds, or will you jus get a couple 5mg Vicodin? This would have me looking for another surgeon today!!!!!

He sounds like he's more interested in you being off meds than he is in helping you in any other way. If the fusions not succesful, It will be because your a drug addict or something the PM docs did, If you complain of pain post op when he believes he fixed you, same thing.

You need proper pain control post op in order to heal. That's absolutely well documented. You need proper pain control to do the walking you need to do to prevent wasting of muscle and to be upright putting weight on the fusion to cause it to fuse. Without meds, you won't be verticle for weeks or months. If he leaves you laying in bed for 3 months because you hurt to much to move, you will be in bad shape when it's time for the brace to come off and start PT.

I'm sorry, but there is no reason related to a succesful fusion that you can't have minimal pain control weeks prior too and even more scarry weeks post op. Poor post op pain control can result in chroncic pain because the pain becomes imprinted into the nerve tissue and even with a succesful fusion, your post op care could leave you months behind anyone else or debilitated, weak, exhausted from no sleep with pain that's permanantly imprinted into nerve tissue. There is this concept that nobody evr died from pain, but t's just a concept. CP atients are 700 times more likely to commit suicide, I had a heart attack at the age of 36 with a cholesterol level of 102 and no family history of heart disease. My heart attack was from High BP from years and years of untreated pain.

It makes no sense whatsoever. Epidurals, and nerve blocks and trigger point injections are all part of the process of deciding that a fusion is neccesarry. If those things don't help and your spine is so unstable you need surgery, why would a doc complain about you trying other methods before diving on to the OR table and begging him to operate. Even with the DX's I had, where fusions seemed innevatable, all the opiate phobic PM docs did these procedures, used meds like anti inflamatories and skelaxin/felexerill and anti-depressants.

Something sounds terribly wrong and I wouldn't be comfotable with this surgeon. He's more interested in detoxig you from a redicoulously low dose of meds than helping you. Did he even tell you not to take Advil or aspirin or anti-inflamatries because they can prevent fusions from occuring.

What other meds were you on at PM, did it take months to taper you off high doses of LA opiates for this guy to become comfortable operating on a totally clean patient?

Bad Bad vibes,

Even if changing docs delayed the fusion a few weeks, I can't imagine a surgeon thinking your in such bad shape you need surgery and not at least givng you some means to manage the pan untill surgery, even if it was darvecet or Tylenolk 3, 4-6 times a day.

Sorry, that's just the impression I get when you tell me he wants you off all meds because I can't think of a single reason other than he's not even comfortable with 7.5 norco. What is his idea of post op pain control, 2.5 mg Vicodin, Ultram, take two tylenol and don't call and complain or I'll send you to drug rehab??

What levels are you having fused, what type of doc, NS or OS is doing this. IS there no other doc in town or doc outside of his loop that you can get a second opinion from now. Either someone, somehwere has given him info to make him believe you have an opiate problem although your only using them for the most severe pain or this guy is just a screwball.

With my first fusion /second surgery, I had my NS from the first surgery do the nerve work and an ortho who I thought had the worst bed side manner I had ever met do it together. I allowed this guy because he had a great rep as a great surgeon and great technician. I figured I could put up with the rudeness, him spending more time stareing at my wife than actually looking at me and the rediclous comments abut my med use. Like having a drug problem when I hadn't had pain meds in 2 years. I guess I was a dry addct? But he was suposed to be the best.

I had surgery in the morning, he came around at about 3pm to check on me because he was heading to the Bahamas the next day and said we have to get you off this PCA "Patient controlled anesthesia. " A macine that delivers a continous dose of IV pain meds and has the abilty to deliver bolus doses every 3-15 minutes depending on how they set it. I thought getting off the IV meds, 4 hours post op was crazy? Was this guy nuggin futz. Fortunately when he left for the Islands, MY NS took over and didn't DC the IV meds untill 2 days later when they discharged me.

I would normally say I would rather have a great technical surgeon than any old surgen with a great bedside manner, but there are cases where even the best technical guy has to have some type of understanding of healing and pain control. I honestly fear for you.

One of my old neighbors had a fusion done in the Navy at a navy hospital, They had him on PCA Morph or Dilaudid for 3 days and sent him home with darvecet, That night I saw him being taken to the local ER By ambulance simply because his wife couldn't get his pain under control and the guy was out of is mind in pain. I can see that happening in the military, but not in private practice.

You have choices, and this guy doesn't sound lke the right choice, I wouldn't care if he's supposed ot be the greatest spine surgeon in he world and works at MGH or Mayo or the Texas spine institute, something sounds very wrong and seems like he's sending you a very clear message as far as what to expaect post op.

I'm sorry, I don't mean to freak you out 10 days prior to surgery, but post fusion pain will reset your entire pain scale without proper management, what you once thought was unimaginable, may be what you get to deal with daily once this guy cuts on you.

MY advice is find a new doc, A NS that has done a felowship in spine surgery and does nothing but spines, there are plenty out there , you may have to travel to a larger city, but this is really archiac and I would hate to even imagine what his post op pain phylosophy is. The pain from surgery will release enough endorphins and enkephlins that you won't need medecine????????
No way, no how.
Good luck, Dave

sandollar · 01-20-2005, 12:56 PM

HI Dave,
Thanks for your input. First of all I have had this back problem for several years, until last year when I couldn't pick up my grandbaby, when I tried my back went out, Thank God the safety belt was on him, my 4 yr old Granddaughter had to help him. Since then it goes out all the time.
My Diskogram showed the S1 & L5 is rubbing bone to bone, the L4 is leaking fluid into the spinal column, but only a very tiny bit.
He is going to fuse the S1 & L5, 2 cages, 2 rods and 4 screws.but leave the L4 alone, he says there is a 50% chance it will get better on it's own after the fusion below it.
He is an Orthopedic Specialist and only does spines. He is very strict. His way or no way.
I ask about the meds. He said Post op, he is going to use the PCA pump with Dilaudid for the first 24 hours. Then he wants me up and walking the next day, he said I will be in the Hospital for 3-5 days and will be able to do most everything on my own before I am released.
I just put in a call and reminded him I am on 5mg of Xanax a day for Severe Panic Disorder and wanted to make sure he was going to order my Regular meds as well? Due to my Gallbladder surgery a new surgeon fresh out of med school decided I didn't need them and would not allow me any, the nurses were doing everything they could to keep the seizures down from being off my Xanax, until she finally approved (1).
BUt that is a different Doctor.
Anyway, this one is fusing the S1 & L5, leaving the L4 alone, and just told me he will be giving me the Dilaudid by PCA when I go to recovery. I informed him I had emergency surgery last year and was on 4mg of Dilaudid 4 times a day and it did nothing for me, but he did not reply.
He did tell me to go ahead and keep taking what I have left, from PM which is about 10=5mg Norco and a bottle of about 10=7.5mg of Norco, he said I could continue with that for now. (just since i had written you). But he also said he will not prescribe anything before the surgery. (That's PM's job until he does the actual surgery), then it's his problem to deal with.
BUt said he will make sure my pain is under control, after the surgery.
PM threw my back out this time, like when I had my Diskogram an hour North of here, it took Morphine to get it under control, the ESI & Facets I had on Monday, she did the injections in the same area, thinking she was helping, but instead she threw out my back.
A needle won't even fit between S1 & L5, they tried twice at the Diskogram.
My Emergency surgery (someone else) gave me morphine in the Hospital and 4mg Dilaudid at home every 4 hours which worked great. BUt he is going to start me with Dilaudid instead of Morphine.
If I specifically ask for better pain management, I am sure he will do whatever it takes. As I do not like the idea of starting off on Dilaudid. Come to think of it, I think he said 2mg????
I'm going to put in another call. I'll keep you posted and make sure I heard him right.
Thanks,
Stardust

sandollar · 01-20-2005, 03:51 PM

Hi Dave,
I spoke to my Surgeon again. He gave me the go ahead to keep taking the Norco 3-4 times a day or as needed.
He likes to start people off with Dilaudid, for most people it is pretty strong, however not for me. So he can and will make sure I have what I need, I see him in his office the day before surgery. At that time, he will put on my chart to begin with the Morphine, then to Dilaudid.
By the way, due to severe abdominal adhesions and 2 adhesion surgeries, he cannot do this Anterior, so he is doing a TLIF AND Posterior Lumbar Fusion.
Still having bad vibes?
Stardust

Shoreline · 01-21-2005, 04:26 PM

How does an epidural through you back out? Or do you mean just caused increased pain. And yes very bad vibes about using cages with a posterior aproach. Not the way they were designed or aproved for use, It's difficult to remove the entire disc from the back, and placement is difficult. It would require a huge laminectomy to gain acess. They clip the posterior spinous process off from L5 and S1 but to get the cages in and the discs out he may have to do a lami on L4 too. If the disc at L4-5 is compromised in any way, the stress from the fusion will make it go even faster.

You may need to decide to tell him if you see L4-5 has detierorated to go ahead and fuse it at the same time.. I wouldn't want to wake up only to be told I will have to have the fusion lengthened at some future date. He may change his mind about the cages once he gets in and sees what is going on.

I would also refer a NS doing work on my spine, I know they take greater caution not to damage or stretch nerve roots where OS can be great mechanics, Put a drill and a hammer to drive a spike into someones bone and they are in their eliment, but when it comes to nerve work or surounding nerve work, I would prefer a NS. Just my personal choice when it comes to nerve work.

There is so much out there and so many options, you never really know if your doc is taking the best aproach. But inserting cages from the back is a big no no and he knows it.

OS tend to be a little rougher and stretching nerve roots to position a cage that's not designed to be implanted from the back doesn't make sense and could cause problems.

If the cages slip you would likely have a viable law suit and I'm not a litigous person, but throwing hardware in from the wrong aproach will require opening the gap far enough to insert the widest part of a tapered cage into the disc space.

Bone on bone doesn't mean there isn't any disc left. Vertabrea may look concave, kind of like pinching a marshmellow and the edges are what's touching and the remaining dehydrated /damaged disc has to be completely removed for cage insertion, this is why they do an anterior aproach. A disc can be completely removed without working around the facets and the remaining lamina, spinous process, and the actual cord. Yur spinal cord runds up the back side of the vertabrea and this is the proach he's taking for disc removal and cage insertion. He may even have to do a partial lami on L4 simply to make room for what he's trying to do.

Vertabrea are much denser bone than the sacrum, this is why an anteror aproach with cages is the better mechanical choice, The sacrum is softer and doesn't hold screws aswell so you need something solid like a cage in there to prevent to much torqe on those screws or you end up with toggling screws in large holes created by the motion of non union and no fusion, Like me.

Instead of working around adhesions, he's working around nerves. How far can he pull things out of position to insert a cage backards without strethcing nerve roots. I feel a little better about the meds.

People usually do better on PCA dilauadid as far as stomach upset and side effects because it's synthetic, so that doesn't worry me, But oral dilaudid has a very short half life and barely gives 3 hours of relief.

But keep things in perspective, I'm not a doc , I just play one on TV.

I would still get a second opinion about posterior insertion of cages. There was a post just weeks ago about cages slipping where another doc did the same aproach. They are aproved for anterior aproaches for a reason. Mainly they don't have to do a lami or remove any part of the vertabrrea to insert a cage from the front.

I think were all guinea pigs when it comes to spine surgery so I guess this really isn't anything unusual.
I wish you the best, I'm not sure what you meant by the PM doc.

I really do wish you the best and a speedy recovery.
Take care and keep us posted when your up to sittng comfy for a few minutes. Dave