Worried about post-op pain
 

I am getting a first rib resection, scalenectomy, and pec minor tenotomy in about 2 weeks. I am a recovering heroin addict, and have been using opioids for about 3 years. I have been prescribed oxycodone 80mg every 4 hours, dilaudid 8mg every 2 hours, fentanyl 100mcg patch, morphine 100mg every 4 hours, and so on. Eventually, my doc stopped prescribing me opiates because of a crackdown on opioid prescription in california. I looked for other doctors, but it became so expensive that I eventually started using heroin. While heroin contains many impurities, it is diacetylmorphine - essentially a stronger version of morphine or oxycodone. I know there is a lot of taboo regarding heroin, so I don't want any judgment here. I have been through rehab, and have been almost completely clean for about 6 months.
I am worried that my doctor will not prescribe me a high enough dosage for me to even feel the medication. I plan to tell him about my extremely high tolerance, but I'm concerned that there is some kind of policy that prevents him from giving me a certain dose. This is Dr. Jeffrey Ballard, at St. Joseph's Hospital in Orange County, CA. I am really not exaggerating when I say "extremely high tolerance." At one point, the best prescription I could get was thirty 5mg vicodin pills. I took all of them, 150mg, and did not feel a thing. Hydrocodone and codeine simply do not affect me. Tramadol is even weaker. I was prescribed other drugs on top of the opioids, but they did nothing. Basically, the minimum dose that will be even noticeable for reducing my pain is 80mg of oxycodone orally, or 12mg of dilaudid IV. The amount of diacetylmorphine and morphine I was consuming would probably be enough to kill a few normal people, but it barely made a dent in my pain. I am on suboxone 8mg/day now, which does virtually nothing to my pain.
Basically, I'm concerned that whatever they prescribe me won't be enough, and I will have to go back to heroin or suffer excruciating pain for months. I have a very, very low pain tolerance, as my opioid receptors are so tolerant to my own natural endorphins. The slightest pain makes me cringe, so having muscles and a rib removed sounds horrifying to me. If I can't get a dose prescribed to me that has any effect, I don't know if I will do this surgery at all, honestly... What has me really terrified is the pre-operation medication. If I understand correctly, they give me anesthetic and dilaudid right before the surgery, so that I don't wake up or experience the pain during the surgery. The normal person would probably be fine with 2-3mg of dilaudid, but I used to use up to 36mg of dilaudid IV, and the last time I used any pain medication, my tolerance did not go down at all (since I am still on suboxone). If I tell them beforehand that I have a high tolerance, and they give me only 5mg, thinking that it's just slightly higher than normal, will I wake up during the procedure, or experience the pain of having my RIB removed? I hope this doesn't come off as overly dramatic, but it is very terrifying for me. Will they test out my tolerance beforehand, so they can see just how extreme my tolerance to pain meds actually is? And after the surgery, what regulations are in place that might prevent me from getting medication that will actually affect my pain levels? Will they do some type of analysis, to ensure that I don't spend the next couple months without any kind of pain management? I feel like they might really need to see it to believe it, but I was a hardcore heroin user, and I worry that if I bring that up, they might refuse to give me any pain meds altogether, out of concern that I might get addicted.

Thanks for your time, I appreciate any input,
Shane H.

You must tell them the truth - all of it. Otherwise they will not be able to make the appropriate decisions. You can't be the first person they have operated on that have taken to extreme drug use and developed a high tolerance to them to help eliminate extreme pain. Talk to your doctor and the hospital anesthesiologist about this problem.

I plan to be completely honest, but I am worried that there will be something that prevents them from prescribing the amount I actually need. I have read about hospitals having maximum limits, but the surgeon was not aware, and the anesthesiologist ended up prescribing only 2-3 times the normal dose. In my case, 2-3 times is nowhere near enough; my tolerance is 15 to 20 times the normal person's, for most painkillers. This is really worrying me :/

heya,
i had very little pain from surgery, if that makes you feel any better. i took the pain meds, but i don't think i needed them - was just scared not to take them. BUT, i never, even if i went long in between, felt any severe pain. i am told i am unusual in that regard. anyway, just tell this to the doctor; say you are worried about not getting them, see what they say

interesting, and yes I can see how you feel that you're in a predicament. Honestly, the situation that you're in depends on a few things- what KIND of thoracic outlet do you have? How many times have you seen your surgeon/his office/staff ect already in preparing for your eventual surgery. Would you say you have a pretty good relationship with them? Are you in outpatient rehab/therapy/AA now? Do you take methadone at the moment, or anything similar? You said that you've been mostly clean for 6 months- does that mean that you haven't taken ANY prescription medication OR other drugs? If so, your tolerance would have lessened, which is good news for your upcoming surgery.

After you've answered the above questions, I think we can help guide you a bit more. I have had the rib resection and scalenectomy bilaterally and I also didn't suffer severe/extreme pain. But I didn't have nerve involvement, and it is my understanding that patients with dominant arterial or venous TOS really have an "easy time" if you will, in the recovery/healing process. I have A/V TOS.

Good luck to you! My brother in law is a recovering heroine addict, its a tough and often misunderstood road. We're here to help, no judgement. We want you to get the surgery when you need it, and get the appropriate care. We certainly don't want to have you feel like you're going to be pushed into a corner and forced to give up your sobriety in an effort to relieve your post op pain. Cheers!

In addition to oral medication, you might also consider discussing other pain control options with your doctor -- like nerve blocks or a pain pump that drips an anesthetic into the local surgical site. These options may be able to help you get through the first few days which is often the worst...

I wish you well...

I have neurogenic TOS. My long thoracic nerve is actually severely damaged, giving me a winged scapula. And I am on suboxone (similar to methadone), and have been since I quit heroin, so my tolerance has not dropped at all.
To update, I have made an appointment for a consultation with a pain specialist, who is going to analyze my tolerance I guess. They told me that they deal with addicts or tolerant patients all the time, so I shouldn't be concerned about having pain. Really, however, I have realized that my concern is less about the pain, and more about the withdrawal. Since I cannot take suboxone while taking pain meds (the suboxone blocks the effect of the pain meds), I will have to stop taking the suboxone 3 days before the surgery. I will experience withdrawal on the 2nd and 3rd day, and then they will give me opiates immediately prior to the surgery, stopping the withdrawal. But after the surgery, they will need to prescribe me enough opiates to prevent withdrawal, which is a very large amount (larger than the amount to relieve pain) haha. 80mg of OC might relieve my pain, but I will still experience withdrawal if I do not take my suboxone. I would say it would take around 120mg to match the effect of the suboxone I take, which is very strange because suboxone does not make me high, per se. It prevents withdrawal at the same level a gram of heroin might, while providing the opiate effect of half a milligram of dilaudid. Only way I can explain it is that buprenorphine is a very strange chemical. Needless to say, it will require quite a large amount of opiates to prevent me from going into withdrawal. I am concerned that they will be legally bound to only give me enough that I am mostly pain-free, but not enough to stop the withdrawal, *edit* I wonder if they have ever been in this situation before. I suppose these are really questions for my doctor, but it is so hard to get in contact without paying for an appointment. The medical system in the US is just so unforgiving and devoid of empathy...

worrying is no good without the information. get all the information first. write down all questions and ask at doctor's appointment. ask them straight out - your concerns, etc. if you find you are not being heard, find another doctor if you can.
there are a million uncaring bad doctors out there. but there are good doctors, who care, who go out of their way to help you. these doctors are few and far between but they do exist and many have been mentioned on this forum.
Hug.

Hmm, you have experience heroin withdraw, my guess is that you have experienced the same amount of pain that the surgery will cause.

Using the oxygen mask after the surgery might help, it increases endorphines and helps relax people.

Also, try reading "Mindfulness" by Ellen J. Langer and/or Zen and the Art of Running. Those books might have some good tips for you as well.

I hate meds, and was only on them for a couple days. I switch to advil when I returned from the hospital.