Opiod Tolerant? Welcome to the Torture Chamber. . .

Opioid-dependent patients may fear the risks of under-treatment due to prejudices, . . /. . Patients should be reassured that . . . effective pain control is an achievable goal. 

Ther Clin Risk Manag. 2017; 13: 1163–1173.Published online 2017 Sep 5. doi: 10.2147/TCRM.S141332

Today is Day. . .let me think. . .Day 13. Thirteen days since I had total knee replacement, right knee. It was messed up pretty bad. My doctor thought, going in, that I might be a candidate for a partial knee replacement. Nope, not even.

The surgery went pretty well by all accounts and I am now officially “on the mend.” No doubt this is going to be a slow and painful process, but if I want to walk without a limp, and drive, and sit cross-legged on the floor with my kitty (which I hope to do again some day), I have to keep working that knee which, right now, is swollen and TIGHT, and a challenge to bend beyond what I guess is 100/110 degrees.But this pain, which is caused by swollen and damaged tissue coupled with aggressive scar tissue formation, is nothing —NOTHING — compared to the absolute torture I endured in the days right after surgery because I am “opiod tolerant.”

 Acute pain in patients with opioid tolerance makes pain management a challenge, and perhaps one of the greatest risks associated with pain management in this population is the risk of undertreatment due to stigma and bias. Further, data on pain management in this patient population are limited.

https://www.uspharmacist.com/article/acute-pain-management-in-patients-with-opioid-tolerance

My husband and I both warned the surgeon, anesthesiologist, and hospital staff beforehand that, because of previous ‘failed’ lumbar surgeries as well as a severe Lisfranc injury of my left foot, I have been taking Tylenol 3 for years now, under the care of a pain specialist. While I take between 2 and 4 pills every day, my usual dose is 3: one when I wake up, one in the middle of the day, and one before I go to sleep. Sometimes I have to take an extra one during the day. Once in a great while I manage to get by with two pills. I never ever take more than four in a day.The upside of taking Tylenol 3 daily is that the pain I experience is tolerable, for the most part. Even though I still can’t walk too far or stand too long, or lie in one position for too long, or do a myriad of other things I used to do without a second thought, I can make it through the day (usually) without agony, which is a blessing.But because I’ve taken Tylenol 3 with codeine for so long, I have developed a tolerance to opiods. The biggest challenge has been getting and keeping post surgical pain under control, esp. in those first few days. After surgery of any kind,  pain management for me is a challenge because the usual drugs/dosages don’t work effectively. The pain quickly rises from moderate to severe to excruciating, leaving me writhing in a state of agony, seemingly without end.This knee replacement surgery was no different. Even though my surgeon injected multiple pain blocks in my knee before closing me up, and even though I had an intervenous line in my elbow for some injectable pain med, and een though I was given something strong by mouth–Norco, I think–and even though I had a pain block thing in my thigh above that knee, I was in agony. And once again, the hospital staff was either scrambling to find something that would work without stopping my breathing, or they insisted I “wait and let the *drug of choice* ‘kick in.’ Let them say that after experiencing total and complete torture for 10 minutes, 20, 30, 40 . . . I can’t tell you how many times I lay there bawling, nor how many times I called my husband in the middle of the night crying and crying because it hurt so fucking bad–Even now, back at home, pain control is an issue. I have 3 Norcos left right now and I am saving those for just before bed. I have been trying to do my exercises with the help of over-the-counter Motrin and ice packs, neither of which is adequately cutting that deep  pain around my knee, nor the shallow fire-like pain in my lower leg. When the Norco runs out, I will be back to my 2-4x/day Tylenol 3, the Motrin, and ice packs, unless those don’t cut it, in which case I don’t know what I’m going to do, especially when my outpatient physical therapy starts in earnest 3x/week. They say to be sure to take pain medication an hour before because they are going to work the patient hard, and it’s going to hurt, and I don’t mind telling you I’m afraid what I have available to me isn’t going to cut it.When I say I’m afraid, I mean that literally.Research shows that pain management for opiod tolerant patients is a challenge on multiple fronts, including bias of medical professionals, and the fact that folks like me need stronger pain meds more often after surgery to get the same effects as opiod naive patients (those who do not take opiods on a regular basis). The research is out there, guidelines are out there, my husband and I put it out there most emphatically and still I suffered mightily post-surgery. My goal, I told everyone, was to reach a 4/10 on the pain scale. Most days I hovered between 6 and 8. Those 9s were almost too much to bear.When will the medical profession take action based on the research of their own cohort? Because right now, it’s SSDD for people like me, who dread any kind of surgery and who can blame us? It’s fucking torture after and it shouldn’t be. Couple that with the nurse who came into my room after, accusing me of not icing my leg enough, which is why the pain was as bad as it was–was she effing serious? Yes, as serious as the nurse who came into my room after my last surgery, accusing me of overzealousness, or of being a drug addict or I don’t know what when she said: “Do you know that yesterday you pushed the PCA button over 400 times, and today you only pushed it four times?” Hell yes I know, you idiot. YESTERDAY my pain was OUT OF CONTROL. I knew that PCA pump wouldn’t allow me to dose myself more than x times per hour, but as soon as that dose was available I wasn’t fucking going to miss it. And YES I know I only pushed that button four times today because finally, FINALLY, they found a cocktail of drugs/treatment that got my runaway pain under control–Almost too much to bear and it shouldn’t be. It shouldn’t be.