After the surgery, pill addiction?

It was my physical therapist who alerted me that I might be addicted to hydrocodone (Vicodin), a drug I have been taking for nearly three months since my hip replacement surgery.

I had told her that when I didn’t take it, I started to feel a stinging, achy feeling in all of my joints, similar to having the flu; and she said that sounded like I was addicted.

She suggested that it might not be wise to stop using it immediately. Didn’t the doctor say anything about how to wean myself from it?

He did not say a thing. Maybe he thought this 68-year old woman was not likely to get hooked. But anyone can get hooked, and many of the people who are addicted to hydrocodone are people like me, who started taking it after surgery and just couldn’t get off it.

Addiction to pain pills is rampant here in the state of New Mexico, which is now first in illegal use of these opiates that are routinely given for severe pain. Seems like any doctor ought to know how to help patients stop using it. There’s a drug that can be administered to assist in that transition; it’s called Suboxone.

Hydrocodone was first introduced in the 90s to replace codeine, allegedly to avoid codeine’s constipating effect. Turns out hydrocodone and oxycodone (Percoset) are just as constipating; all opiates interfere with the peristalsis of the stomach that accompanies digestion.

Over 50 additional side effects of hydrocodone are listed at Drug Rehabs, http://www.drug-rehabs.com/hydrocodone_side_effects.htm

Of course that list doesn’t include the much more serious side effects of taking acetominophen, which is always included in hydrocodone pills along with the narcotic. Acetaminophen in large doses causes liver damage. Warnings to that effect are now pasted on the bottle, but in the early days of hydrocodone use, patients were not informed.

This is the helpful painkiller we were given to replace codeine, and we may well ask what was so wrong with codeine that we needed a new drug with all these risks attached to it -- including that fact that it’s far more addictive, so much more addictive that it’s now in demand as a street drug?

PubMed lists only 16 side effects for codeine, which is a natural opiate, unlike the synthetic form used in hydrocodone. Codeine is still used, but if you want to get it for major pain like surgery you’ll have to practically stand on your head in the doctor’s office. Is this insistence on hydrocodone for our protection, or does it protect the market for hydrocodone? To my knowledge there are no advantages to hydrocodone over codeine.

After Julie, my PT, suggested the possibility of addiction, I found I was able to reduce the dose immediately to half a pill twice a day; but two weeks later, I am still taking that dose for the flu-like symptoms! It’s surprising how uncomfortable those aching joints can be, perhaps because my body starts thinking I have the flu and ought to be in bed.

So it’s not just the hip surgery one has to recover from – but the recovery!

Maybe medical marijuana would be a better solution. I’ve used it, it works … but that's a topic for another blog.

Through The Surgical Tunnel

  “I was very, very depressed after this fall,” R. said in her deep, soft voice – a soothing voice that must have been considered alluring during her youth, when she lived in Big Sur and worked as a server at the famous Nepenthe’s Inn.  Now she is 76. She fell one day around Christmastime last year, when walking her dog. A neighbor saw her on the street near her home in Santa Fe, unable to get up, and took her to the hospital. The hip was broken.

“I wasn’t sure I wanted to live any longer,” Sylvia added. “But little by little it’s getting better.”

I suggested that it might have something to do with the drugs. Painkillers are basically downers. Of course it’s also a shock to find that one has become so vulnerable. A tug of the leash, and the walk is over, for six months or more.

In fact, a hundred years ago, as my Buddhist friend Jay did not hesitate to point to me after my own fall, such a break would likely have been fatal.

You go to bed, and you lie in pain, waited on by unwilling relatives; and maybe the bone heals, maybe not; and maybe you “give up the ghost” (a wonderful old phrase that you don’t hear much anymore), and die.

Now you have surgery, the leg is set, you are up on your wobbly feet in two days, and then you start doing physical therapy. A few months later, you are on your feet again.

Given this illuminating historical perspective, it’s somewhat surprising that we don’t wake up after surgery stunned, but grateful. Instead of shouting, “I’m alive!” we may wish we had already died. Perhaps the nervous system, recognizing that the experience was life-threatening, does not know how to update itself.

Or this depression may be due to the ambivalence we feel, especially as we age, about the value of our lives, the death wish (thanatos, according to Mr. Freud) struggling against the life wish (libido) until, needless to say, death wins out.

But as I considered my own experience after a recent surgery, I learned that it is the anesthesia administered during surgery, more than the painkillers that follow it, which may have a very disorienting effect on many people.

There is even a name for this condition, and, naturally, an acronym: Post Operative Cognitive Decline (POCD). This decline was first identified in elders after cardiac surgery, but it turns out that orthopedic surgery can have the same result, even when it’s elective. (When surgery is mandatory, after an accident, one might expect POCD to be more common, as trauma is known to be associated with loss of control; and trauma can lead to depression.)

In any case, POCD is caused not by the drugs per se or by the trauma, but by the effect of the anesthesia on the flow of oxygen to the brain. This reduction of oxygen supply, however brief, is likely to have negative effects on cognitive ability. Now scientists are researching ways to minimize this loss, particularly in the elderly. In one study, research showed the value of “intra-operative monitoring of anesthetic depth and cerebral oxygenation as a pragmatic intervention to reduce post-operative cognitive impairment.”

That’s the scientific angle, the one likely to produce helpful surgical interventions. Now that we are living longer, it will be helpful if the various orthopedic surgeries some of us must endure do not accelerate cognitive decline! I have not had the opportunity to ask my surgeon, but I assume the cocktail used in my case was adapted for this very purpose. The nerve block I was given before going into the OR is intended to reduce the need for anaesthesia. I do know that I had no trouble breathing when I woke up, a good sign!

Even then, I definitely experienced a journey into the twilight zone that became more evident a week after the surgery and continued for about a month. Part of that experience was a curtailment of my ability to think clearly. But another part of it was more like Sylvia’s depression. I, too, wondered whether I wanted to go on living; the very question seemed to bring on a wave of hopelessness. My physical condition, though a temporary one, seemed chronic, timeless, a new state of being that I resented, that capped my ability to make up for whatever I had failed to do in this life thus far.

I had a lot of very colorful dreams, most of them bizarre and alarming.

Looking back, it feels to me as if I had entered a dark tunnel, not of cognitive decline per se, but of life review that seemed preparatory for death, even though I knew I was not dying.

It was a descents into a subconscious region, where it seemed the body itself, stirred and jumbled by the surgical intervention, released buried complexes regarding self-worth and purpose.

One morning, after a long meditation, I bumped into an old belief – that I needed to somehow be Great in order to deserve my life. That belief had been with me since childhood, an ambition passed on to me by my mother, who wanted to be a great writer herself!

Exploring this lifelong negative fantasy, I discovered that I did not have to have a justification for living – I did not have to reach for some vaunted, special goal in order to prove my worth.

I just had to set my sights on realistic, attainable goals, and try to be a good person while I carried them out.

This was quite a profound realization. Ultimately it offered great relief…but first I had to process the realization of how unattainable my goals had been all these years. I couldn’t get out of the tunnel until I had conducted this painful review.

Meanwhile, as time passed, my body continued healing. What a miracle that is! And as I regained the use of my legs and made my way into the light of day I knew the journey had fixed something more than the hip.

I had revisited an ancient complex held in the bone since childhood, when it was first discovered that my hips were out of place; and it had been released.

It had been, after all, despite the modern technology, a shamanic journey, and I had come back to life having retrieved a lost piece of my soul.