News 2010
Getting through surgery
One of the major problems people with chronic pain face is when they have acute pain on top: either from an injury or due to surgery. People with chronic pain have a nervous system that is super-sensitive due to the constant alarm signal from the pain: it is a bit like one of those old-fashioned car alarms that go off when someone walks past, or sneezes in its general direction!
So having a bout of pain on top is likely to send the system into €˜overdrive€™ which can persist well beyond the incident that caused it.
I€™m afraid often their pain is inadequately managed, strong painkillers being witheld on the grounds that the patient is already on painkillers, need to manage €˜acute on chronic pain€™ much more effectively.
I€™ve had some bad experiences in the past, so I was really rather dreading the pain after my hysterectomy. I€™d been in increasing pain before the op, and started stronger painkillers in a bid to €˜pre-empt€™ the increase in pain. In addition to the usual pain everyone can have after the surgery,
I knew that my chronic pain was likely to €˜ramp up€™ a lot with surgery.
I used BuTrans 7 day patches, initially 5 microgrammes (equivalent to 60mg codeine a day) and then 10 microgrammes (120mg codeine a day). I found them relatively easy to cope with, although I did feel a bit €˜out of it€™ initially. I didn€™t have any sickness though. The constipating effects of BuTrans are somewhat less than other similar drugs like codeine, but as I already have a neuropathic bowel, this did get a bit worse. The pain was partially reduced.
The Pain Clinic doctor suggested Pregabalin and I started at 75mg at night. I must say it did improve my sleep a lot, but as I increased the dose, I noticed I was increasingly forgetful and foggy in the head.
I managed to get up to 150mg at night and 75 mg in the morning, and shortly before the op I increased as advised to 150mg twice a day. I did find it helped the pain. I also started regular Paracetamol and Arcoxia (an anti-inflammatory drug): belt and braces!
In addition, I devised a regimen of vitamins, mostly a multivitamin plus zinc, extra vitamin E and C to promote healing. I took strong cranberry supplements to reduce the risk of bladder infection which is a common problem after hysterectomy and more of a risk for me as I have a bladder that doesn€™t empty properly.
On my admission, I spoke at length to the anaesthetist, who was really aware of chronic pain because her husband suffers from it. So fortunately, she was happy to set up really good pain relief around the operation.
She agreed I should have a PCA, which is a patient-operated dose of intravenous morphine that can be used as needed (there€™s a lock-out system to ensure you don€™t overdo it). She also recommended local anaesthetic injections into the pelvic area. I made sure these wouldn€™t be anywhere near any spinal nerves!
The gynaecologist had, quite rightly, suggested that I needed a full abdominal incision, as I have too many problems to risk keyhole surgery. He wanted to ensure he had a good view to make sure he didn€™t cause me any further damage to bladder or bowel nerves.
I came through surgery really well. The PCA worked well, I was able to cope well and slept the first night. I had intravenous fluids for a while as my blood pressure dropped (it always does) but soon came off the PCA and was just on my usual medication. I was up and about and went home on the 4th day, a day ahead of schedule.
I found that although I was €˜sore€™ as one might expect, I healed quite quickly. My scar remains somewhat sensitive but I can now, 6 weeks on, wear my jeans again!
I weaned off the Arcoxia after 3 weeks, only taking it occasionally since then, and dropped the Paracetamol back to as needed (sometimes once a day, sometimes nothing). I then started reducing the BuTrans. I guess for patients, I would advise weaning off slowly using the equivalent in tablets, but I decided that with my bowel problems, I needed to avoid tablets so reduced from 10 to 5 microgrammes and then a week later stopped altogether.
The withdrawal effects after being on the patches for about 4 months were surprisingly marked: I felt as if I had flu and even 2 weeks later am still sneezing! I had a change in my bowels, but as I am normally very constipated, what would have been diarrhoea was fairly manageable. But I did have a €˜jippy€™ tummy until this week.
I have also started reducing the Pregabalin: am now down to 75mg at night. I€™ve found that my pain (arach pain that is) is no different. Fortunately the pelvic pain for which I had the hysterectomy has been reduced. I€™ve found that I feel a lot more €˜with it€™ mentally , although my sleep is worse and I€™ve had some €˜rebound€™ anxiety symptoms. I€™ve had to take a low dose sleeping tablet (Zopiclone 3.75mg) some nights.
In conclusion: I think my strategy to prevent a sustained increase in my chronic pain ( a very real risk when you have hyperpathia: increased pain response as part of a chronic pain syndrome) worked well. I had good pain relief at the time of surgery. Coming back down off the medication has been a bit unpleasant, but liveable with, and now easing off.
So if you have to have surgery, maybe this tactic would be helpful.
Best wishes for 2010
DocSarah
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