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jhmitch 10-06-2005 09:22 PM

Chronic Pain and Surgery: Please Advise

Hopefully, someone who has had some experience with being on chronic pain meds and then having surgery can help me out with this dilemma.

I'm 56 years old and have chronic pain from two ('bone-against-bone') bad knees, fibromyalgia, arthritis of the spine, adhesions from 4 abdominal operations, and neuropathy from diabetes. For the past year I've been prescribed Vicodin 7.5/500, three times a day from my rheumatologist.

In late November, I'm due to have my left knee replaced by an orthopedic surgeon. Yesterday, my rheumatologist told me I'd better taper-down off the Vicodin since once I'm released from the hospital following the first knee operation, I won't get anything stronger than Vicodin for the pain. If my tolerance is still there, it won't do a darn thing for misery.

The knee surgeon's staff confirmed what the rheumatologist said and this has me more than a little worried about going through the operation at all. However, the rheumatologist said if I put-off surgery too long, I could end-up in a wheelchair.

I'm debating about whether I should go see the knee surgeon one more time to get his take on this problem or go to directly go see a pain management specialist. My concern is that even if I manage to completely taper-off Vicodin, I'll still quickly "ramp-up" to my current tolerance level once I go back on them after my knee operation. With fibromyalgia, pain is amplified a lot higher than it's normal level (which is definitely not good) so this adds even more to my 'fear factor' about this surgery.

If anyone reading this has been through this sort of a situation please give me some advice... it would be greatly appreciated. I don't mind tapering-off Vicodin half as much as the fear I feel about this upcoming surgery.

jhmitch :eek:

Shoreline 10-07-2005 05:08 AM

Re: Chronic Pain and Surgery: Please Advise
HI JH Mithch, That's some of the most rediclous thinking on opiates I have heard. If you have an ortho surgeon doing a TKR that has a flat plolicy to never prescribe anything stronger than Vicodin, I wouldn't let him touch me.

Years before long acting meds were available, when you had major surgery like back surgery or knee or hip replacements you normally wake up from surgery with IV patient controled anelgesia "PCA"
Meaning you press a button every 5-12 minutes depending on how the machine is set and the machine delivers more medication IV, It's a much better system than waiting for a nurse to bring you a pill or shot and then waiting for it to work.

When I was discharged from all 3 back surgeries I came home with 5mg percocet with orders to take 2 every 3-4 hours, That's more than twice the strength of a 7.5 Vicodin.
There is absolutely no reason to come home and suffer after surgery.
If you had been taking 8 10mg percocets a day for several years prior to surgry than the doc sort of has a point but there are still meds stronger. They make a 30 mg Oxycodone tablet without tylenol that could be used or they can prescribe oral morphine. The odds of becomeing addicted to pain meds when your only reason for taking them is pain is about 3%. It's when folks continue to take them for other reasons that problems develop.

One, you won't be able to due the PT required for a TKR without appropriate pain managent.
2 and this is the biggie, under-treated post op pain can lead to conditions like RSD or chronic regional pain syndrome because your nervous system just goes hay wire from untreatd pain and you end up with chronic pain that can barely be managed "Intractable." What is the point of making you suffer because you have been using 2-3 Vicodin a day pre op. That's minimal and absolutely absurd.

People have invasive surgery like TKR's while taking high doses of LA meds, like several hundred mgs of morphine or Oxycodone per day and they can still manage their pain post op. Why is this surgeon so against pain mnagement and using medfs for their intended purpose? Ya know what they call the doc that graduated last in his class.
The Answer is: Doctor

OxyCodone is the opiate in Percocet and OxyContin and many other products. Percocet is the standard orthopedc post op med. Even if you are just having ACL surgery you would likely get pecocet from most docs.Those few Vicodin wouldn't make a bit of difference to most people if even the standard meds are used, but should they need somthing stronger there are plenty to choose from.

Vicodin contains Hydrocodone, Percocet contains oxycodone,oxy is about 50% stronger and available in doses from 5mg to 30 mgs and even higher if he uses long acting version of oxycodone.

They have so much more to choose from now. Any doc that told me I'm going to make you suffer and not prescribe anything stronger than Vicodin after surgery wouldn't be my surgeon.

3 vicodin is minimal tolerance, nothing compared to what peopele on long acting meds take and they have surgery and their pain can be managed. IF some old school doc isn't aware he has options for better post op oral pain control once your home I flat out wouldn't have surgery by a doc that knows less than I do about Pain management.

Find another surgeon, one that says don't wory about those couple vicodin per day, we will use whatever it takes to keep you up and moving post op to do the PT required. Your more likely to end up in a wheel chair if they don't manage your pain properly because you won't be able to get the Knee working in the window you have for PT before the joint and muscles become frozen because it hurts too much to bend.
You got a doozy of a medical team working on you that's seems to be very opiate phobic.

Find a young doc that knocks out hundreds of knees a year and is used to managing pain in all different people, that jusn't just prescribe what he thinks should do the job. If a med is not working you need something stronger and a doc that will listen. What's next, surgery without any pain meds to make a man out of ya, take 2 tylenol and don't complain and do your PT ???

Rheumys are notorious for not treating pain agressively and if the surgeon has the same antiquated views, Post pone the surgery untill you meet a doc that doesn't think 3 vicodin a day makes you extremely tolerant. That's minimal compared to most folks that live with chronic pain.The risk of develping chronic intractable pain from poor post op management is very real and an uneccesary risk with all that's available. You won't be able to manage the PT if you don't have realistic pain management and most surgeons are very aware of this. What a crock.

You start PT within days after a TKR so the muscles don't become frozen, like frozen shoulders, and it's not fun. If they don't get the kneee bending stand retraining the muscles for the poition they are now in you won't be ablt to bend it . Without proper pain management you won't be able to tolerate bending it. It will hurt but nothing is gained by making you suffer.
Did they offer to do the surgery without anesthesia to make a stronger man out of you?

It doesn't make you an addict or doc shopper to find another OS and to realize this guy is a quack and doesn't know what he's talking about, a rheutmey is not a surgeon and never prescribes post op meds, so he's talking out of the wrong cheeks. What part of the country are you in and I'll bet there are some folks that can recomend PM docs and even ortho surgeons that use meds stronger than Vicodin every day of their practice. There really are ortho surgeons that know Vicodin isn't all there is when it comes to post op pain management.

Explain to a new doc that this fear was created by some doc that doesn't seem to be aware there are options stronger than vicodin. Usng something stronger and then tapering back down as you heal won't turn you into a drug addict looking to knock over a pharmacy to get your fix.

MY mom had a TKR last year and came home with 10mg percocet and then slowly stepped down to 10 mg Vicodin and then 5 mg vicodin. That's pretty standard post op care and she never had to resort to robbing pharmacies or buying stronger meds from the street. She used what she needed, when she needed it and hasn't taken a pain pill in months. She didn't become an addict and they had her on more than 3 vicodin per day for several months prior to the TKR because she had a mastectomy 4 months prior.

People have surgery after surgery sometimes and develop tolerance and they simply have to use a stroger med if your not getting relief. Why torture yourself in this day and age.:rolleyes: What they are telling you is flat out ignorant.

Good luck, Dave

feelbad 10-07-2005 06:00 AM

Re: Chronic Pain and Surgery: Please Advise
The Vicodin thing is a bunch of will DEFINITELY be getting a PCA with either MS or dad had both knees replaced one year apart and this IS pretty much the standard practice.and pretty much the standard for ANY type of a least immediately post op.There is absolutly no way in he** that any surgeon would torture you by only giving you Vicodin after any type of surgery.

My dad had his PCA for about the first week with a slow taper onto two percs every four hours.This continued when he was transferred to the rehab hospital for physical therepy for a couple of weeks too.and when he was finally sent home,it was with more percocet.At discharge I really feel would be possibly when you may be getting a switch onto vicodin.but I think most orthos tend to stick with the percs,at least for your first discharge Rx for pain.

You will also be doing at least "some" pt "like" therepy almost immediately post op.They have this little machine that they set the leg into that slowly,very slowly will move your knee back and forth.Honestly,thinking back i do believe that this was actually applied on the very first day right after his surgery was over and he was in his room.Shore is right about finding another surgeon if the one you will be seeing has the same stupid beliefs as the rheumy doc.Those types of docs (the rheumys?)really really do not like to Rx any sort of narcotics to any of their patients,honestly.I am really quite suprised that you are even actually getting the vics from him.The rhuemy that i saw for my knee did NOT use narcotics at all in his practice.Now,THAT is a little too extreme and quite a stupid way of thinking.

when you see this surgeon just tell him the little horror story you were told by some really ignorant people and that you are indeed very afraid of the pain.This would not be considered to be an odd or abnormal question to be asking any surgeon as they DO realize that most patients ARE very afraid of what is going to be there when they wake up from surgery as far as the pain,and they are more than willing to sit down and discuss the "pain plan" with you.They want you feel comfortable(emotionally) when you are going into surgery and knowing that no matter how bad the pain will get,that they will make every attempt to try and control it for you.Just make sure that this surgeon you are going to see knows about your big concerrns.I am sure he will tell you that every attempt to make you as comfortable as possible will be taken.just make sure you speak up.

if for some reason,this surgeon you see is an idiot, move onto another DO have the right to.let us know how your consult goes with this surgeon,K?make sure to write down on a piece of paper,any and all possible questions that you need the answers to from the surgeon.i actually had three full pages of questions when I was trying to decide whether or not to have a very high risk surgery done on the inside of my spinal cord.believe me, i wanted the answers to ALOT of questions and my NS really was very helpful and actually answered them all in great detail.Trust me,if you don't actually write them down,if you are anything like me, when the time comes to ask questions,your mind will just draw a blank up til you get back home and then think of all kinds of questions that you had wanted to ask but could not remember at the time.just keep a pen and paper lying out somewhere so as soon as something pops into your head,regarding something that you just suddenly wanted to know about your surgery,you can IMMEDIATLY write it down.just don't forget to grab that list when you go to the appt,lol.keep us posted on how it goes with the surgeon,good luck,Marcia

Shoreline 10-07-2005 08:39 AM

Re: Chronic Pain and Surgery: Please Advise
Maria is absolutely right, I read her post and came back, If you get the same speech from the surgeon himself, than find another surgeon, But if it wasn't the surgeon that told you Vicodin is all you will get, a lot of misinformation can be spread by staff members.

It would so unusual to find a doc that sadistic. It sounds more like your simply getting the Rheumies opinion on the use of opiates. He doesn't agree with their benefit but that's just his opinion.Everyone has one. He may very well stop prescribing Vicodin for your knee once it's replaced, thinking your cured now, But the surgeon should manage your entire recovery perriod untill discharge. That just means you need to look for a real PM doc if you still need help managing your pain.

PM docs manage arthritis very succesfully along with every other condition that the specialist in that field couldn't cure or fix.

With almost every NDSAID being taken off the market, which was the main stay of Rheumotology, aside from steroids, Rheumotology may be a dying specialty. Any internal med doc can manage arthritis and most conditions Rhuemeys manage. Understanding inflamation and auto imune responses really are not some gaurded secret only Rheumies can deal with. For some reason they have little grasp of pain management and little compassion for pain.

I wouldn't normally make such a blanket statement about a single specialty, but I have to wonder why so many folks are at the PM clinic I go to when any Rheumy should be able to help them. I've seen the benfit of PM in arthriis patients many times and it's flat out amazing. It makes you wonder why the Rheumey waited untill somone could not place their palms together or stand before giving up on steroids and Celebrex and treating the actual pain. Relieve the pain and you can stand. It's not that complicated in many cases.

I think things will go better than that doc thinks but it is a painful op and a painful recovery getting to maximum flexion of the knee. With the worries of post op pain control out of the way you can go in there without the kind of worry this doc has created.
Take care, Dave

pixiepoodle 10-07-2005 11:07 AM

Re: Chronic Pain and Surgery: Please Advise
After my last surgery a year ago, my anesthesiologist was the one who prescribed my post op pain meds after looking at all the pain meds I normall take, including having a pain pump. Anesthesiologists are more in tune with what it takes to relieve pain. While in the hospital I was given all the demoral I wanted and a shot right before I left.

I mentioned to my surgeon my concern about my pain level after I got home because of having Fibro and that its makes my pain threshold higher than a normal person. I also mentioned that I went the "Vicodin" route after a prior surgery and suffered terrribly. He asked what did I think would work for me and I told him Percodan. He was precious enough to write the script for me to taken 2 every 4 hrs. and I was comfortable.

You could try talking to him again (since you are the only one who can speak up for yourself) and explain your pain threshold is very high and Vicodin is not going to cut it. The dr. is only going to give you a script for a week or 2 anyway, so its hard to become a hard core addict. I never had any withdrawal from the Percodan. If that doesn't work, then when you call to find another dr., ask up front about post op meds so you don't make an appt, for nothing. Keep us posted if you succeed in getting results.

Rrector 10-07-2005 11:51 AM

Re: Chronic Pain and Surgery: Please Advise
Hi JHMitch: Dave, Marcia and Pixie pretty much said it all and said what you should do about the situation. I concur with pretty much everything that's been said. I can't believe a doctor of any specialty would suggest you taper off Hydrocodone to get ready for post surgery. That is totally ridiculous!

When I had my last surgery two years ago, I had beign tumors removed from my left lung. I went in prior to the surgery and talked to the surgeon. I was up front with him and told him exactly what I was taking at the time. I was on Duragesic, 100 mcg every 48 hours. I was also on BT meds, but I don't remember now what it was. While in the hospital they left the patch on and had me on the pump as well. I could also have oral meds if I needed them. When I went home, they gave my a script for 100 Oxycodone, 5 mg, two PRN for pain. This was in addition to my regular pain meds, the Duragesic patch and my BT meds.

If I were you, I would have a little talk with the surgeon and let him know what's going on with your medications and what that doc said to you. I think you'll find he will say not to worry about it and they will keep you comfy and not expect you to go home with Hydrocodone. Please let us know how you come out.

jhmitch 10-07-2005 12:32 PM

Re: Chronic Pain and Surgery: Please Advise
Dear Dave, Marcia, Pixie, and Director

Thank you all for some tremendous advice! I am feeling much less overwhelmed about all this than I was when I first posted, yesterday.

As of today, I've taken myself off the 'November knee replacement schedule' until I can get some solid answers about the surgeon's plan for pain relief (when I'm finally released from the hospital). If, ultimately, my knees have to wait a month or so while finding another orthopedic surgeon - I can live with that.

Also, in two weeks, I'll be seeing this orthopedic surgeon so I'm compiling a list of questions about post-release pain control and physical therapy to discuss with him. As you've suggested, an honest, face-to-face, conversation about my concerns makes a lot more sense than depending upon his staff (or my rheumatologist) to anticipate his actual treatment policies.

He's already told me that he orders a spinal block before surgery, and will give me a pump right after the operation (and I'll also have my leg harnessed into one of those devices that repeatedly bends the knee). Then, after a day or two, it will be off to an inpatient physical therapy place for a week.

What really worries me is what will happen when I finally leave the hospital/inpatient center since I went through something very similar following an abdominal operation last winter. The discharging surgeon prescribed exactly what I was already taking before the operation - (You guessed it, our old friend -Vicodin! :eek: ) for pain. I was one miserable pup and refused to leave the hospital until I got script for a few stronger acting meds (it may have been Percocet - but I'm not sure). They finally gave me another script for about four days worth and I felt glad to have it along with my Vicodin.

I live about 70 miles north of Phila. There are two hospitals and a number of orthopedic surgeons in this immediate area. This particular knee surgeon came highly recommended - both by former patients and a physical therapist who has worked with his post-op patients.

My husband feels I should also be seeing a pain management specialist but, from what I understand, they aren't very plentiful so it takes a long time to get an appointment with one. Still, it certainly wouldn't hurt to try to get an appointment, especially with all the opiate-phobic doctors around here. Sometimes I think we really are living in the Dark Ages of pain control.

Well, I've rambled on long enough. I'll be glad to let you all know what transpires and greatly appreciate your information and support. There is nothing like talking to people who have "been there" to learn what can be done when dealing with pain problems (though I am very sorry you all had to go through severe pain in order to gain this knowledge).

Thanks again!

jhmitch :)

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