The WAITING ROOM => GENERAL KNEE QUESTIONS and comments (good for new threads) => Topic started by: subwayknees on August 04, 2011, 06:36:35 PM

Title: Post operative plan for Opiate dependent chronic pain patient
Post by: subwayknees on August 04, 2011, 06:36:35 PM
I am new here and already gotten some good advise, but I would like to hear from anone who is opiate dependent from pain management who has undergone major knee surgery.
I have cancelled several surgeries at the last minute and been turned down by a few surgeons because of concerns over adequate pain management (post operative) due to my high opiate dependence.  For over five years I have been taking under strict medical control between 300 to 400 mg of morphine er daily and an additional 90mg morphin ir, for breakthrough pain.
Several local orthopedic surgeons have said they would not even consider doing my needed revision total knee and reconstruction because of the difficulties in managing my post operative pain due to high opiate needs.
I have been referred to several major teaching hospitals and finally after two cancelled surgeries I am trying to get a positive outlook on the upcoming revision and reconstruction.
The surgeon who is also an NFL team physician and works out of a major teaching hospital said that upon arrival the day of surgery he will have the hospitals pain management program director meet with me to plan a post operative plan.  That sounds wonderful, but it does not give me specifics other than I am a difficult case and he wants their top pain doc to manage me.
I have been to enough pain doctors and orthopedic surgeons to know that while some do provide adequate post operative pain control others underuse.  In my case just on a day to day basis I am taking as much as many post operative painents use the first few days after surgery, and I am still in major pain.
I can't see how even doubeling my intake could cover what I will need the first week out of surgery.

The body can easily get use to high doses of opiates and with some days taking up to 500mg morphine and methadone , I know I have a very high tolerance for opiates.  One 60mg morphine is like a baby aspirin to me. If anyone has faced this delima please let me know how your docs handeled it and if it was successful.
I cannot cancel this again but am very concerned that I will not get the needed post operative pain coverage after a revision with allograft.
Title: Re: Post operative plan for Opiate dependent chronic pain patient
Post by: amoler on August 04, 2011, 08:16:54 PM
I thought one of the standard postop-ish options was an epidural or a local anesthetic thingy that continuously tops off the local for something like 48-72 hours. But then maybe that's just something I read as experimental. It might be worth asking, because neither of those would conflict with opiate dependence.

I can't even get a dr to so much as offer me anything better than an NSAID for my knee pain. I have been told repeatedly that it is irrelevant how much pain I suffer, beacuase I am fat and old and just need to suck it up and learn to live with the pain. (One OS said that almost word for word)

Oh 'nother idea... is it remotely possible to wean you down just a bit the week before the surgery? I know that makes for some real misery but maybe it's a thought??
Title: Re: Post operative plan for Opiate dependent chronic pain patient
Post by: subwayknees on August 04, 2011, 08:43:46 PM
AMOLER, thank you.  I have spoken to my pain doctor and discussed cutting back before surgery, he said that since my opiate tolerance is so high I would have to start tapering off several months before surgery and with the damage to my knee and leg he felt that the pain would be too great to deal with.
I have, since I posted made a call to my new orthopedic surgeons office and asked to speak to his nurse or physicians assistant if not him directly so I can discuss this entire matter, I may have to simply make another appointment to see him personally and ask for a specific plan for post op pain control rather than wait till the morning of surgery to deal with the issue.
The pump I think you are speaking about is used to deliver pain medication, usually morphine, or fentanol (sp?) through an IV directly but the dosage is simply set at a level ordered by the doctor.  Most joint replacement units have pre determined protocals for post op pain management, I have to be 100% sure that they fully understand my level of tolerence before getting to the or, as I do not want to be fighting with docs about proper pain control when I wake up in recovery, it is a little late then.  Thanks
Title: Re: Post operative plan for Opiate dependent chronic pain patient
Post by: amoler on August 04, 2011, 08:50:36 PM

NOT a morphine pump

Have look at this. Might be helpful.
Title: Re: Post operative plan for Opiate dependent chronic pain patient
Post by: Kimberly 77 on August 04, 2011, 08:54:36 PM
The nerve block, spinal, or epidural shouldn't work any less because of the amount of meds you are currently on. This is where they put a needle in your spin and block the nerves from pain. I would think because it is not ingested it would work fine on you even with a very high tolerence. The issue would be more of managing your pain after they remove the epidural. Weaning down before surgery may be worth the extra pain you will suffer while waiting. Amoler, your not alone my OS has never prescribed me anything for pain except for right after my surgery.
Title: Re: Post operative plan for Opiate dependent chronic pain patient
Post by: subwayknees on August 04, 2011, 09:02:31 PM
kimberly, thank you, that was a great link,  i will reference as soon as i speak to my surgeon.  again, thank you
Title: Re: Post operative plan for Opiate dependent chronic pain patient
Post by: subwayknees on August 04, 2011, 09:03:52 PM
amoler, your info was also excellent,  you guys are great   thanks
Title: Re: Post operative plan for Opiate dependent chronic pain patient
Post by: starpolisher on October 04, 2011, 08:05:17 PM, I am very concerned and upset about the amount of morphine I'm on.....I am on 180 mg of morphine sulfate (long term pills) and 32 mgs of hydromorphone for short term pain a day.  I did cut back from 48 mgs of hydromorphone and wanted to cut back an additional 8 mg but my pain doc said no....not while I'm having PT.  At one time I only took 120 mg of the long term but had a complication when I had a strep infection in my toe and was in awful pain since I couldn't wear my special shoes and wish I could cut that in half.  It is only because I had Astym for my AF that I could cut back on my short term.  I am so fearful of what this morphine does to our body.....but my pain docs have been insistent and before my Astym, (wish it would help all problems but sadly it doesn't) I still had so much pain, even with the morphine.  I dread the thought of surgery and I hate how this morphine makes me feel.

I know an epidural and nerve block would take away all pain when you have surgery.  I have always had that (I went to Hospital for Special Surgery in NYC) and David Wang was my pain doctor.  He was just wonderful and very compassionate.  I remember a woman in the waiting room who had come from South Carolina to see him and you could see how she was in truly horrible pain.....she told me she was literally dying from her pain....she looked like a skeleton.  When i saw Dr. Wang I asked him if he could help her and he said he could!  I don't know where you live.....but hopefully a wonderful pain doc could help you.  I had an epidural for several days and a nerve block when I had my operations there.  You could email Dr. Wang.  If you go to the Hospital for Special Surgery site, you can find his could email him and ask him if he could give you any advice!  I so hope you can be helped.  My heart goes out to you!  I was really feeling upset about the morphine I'm on but seeing what you are going through......I sincerely hope you will find help and at least know we all care very much about you and I will pray for you (if that helps at all).  There are some outstanding pain mgt. doctors......I hope with all my heart you can find one. 

I was able to cut back somewhat on my morphine....very slowly....because my Astym helped my pain!  I would extend it an hour and after several weeks, I would be taking one less pill.  It's a slow process....but my pain was better!  I know that if you add more, it doesn't work that long and then you need that higher dose.  So I wish I could just get as low as possible or find something not so strong.  Unfortunately I dont do well with a lot of pain meds and I can tolerate morphine.  Let us know how you make out!