Expert: Dr Ian Jackson - please note UK based - 11/4/2003

Question
Hello:

Seeing as you are an expert in regard to medications that control pain I have a question / issue for you. I apologize that this question / letter is somewhat long but I need to give you some background.

I am on Methadone, 100mg a day for pain management.  I have been on it for over 6 years with no problems or negative side effects.  Maybe I shouldn't say "no side effects".

I get kidney stones. When I do, I end up in the emergency room of the local hospital.  The first time I had a kidney stone after starting Methadone, I couldn't believe the amount of medication it took to help the pain.  The e.r. doctor that was on that night was very understanding.  He gave me 10mg of Morphine. It didn't help.  He then gave me 20mg of Morphine.  That didn't help. His next order to the nurse was "give him 10mg of Morphine every 10 minutes until his pain is under control".  Once I hit 90mg's my pain started to be manageable.   

Here is my main issue.  I had a Hydrocele removed this past July.  My doctor / surgeon didn't know what to give me for pain after the procedure.  He said that because I was so used to the Methadone, he didn't know what would help the pain.  He prescribed me Tylenol #3's.  Well, they did nothing.  The first 3 days after the surgery I was extremely swollen and in a great deal of pain. On a scale of 1 to 10, 10 being the worse I would say the pain was a 9 the first day and night, an 8 on the second day and night and an 8 going to a 7 on the third day. I don't like to complain so I put up with it. Well, the surgery didn't work and the Hydrocele is back and bigger than it was before.  I am going back in for another surgery.  This time they are going to open me in my lower abdomen and pull the hydrocele up from the scrotal sac and through the opening they make.  He will then drain the hydrocele, cut out the weak part of the vein or sac and then let it back down into the scrotum.  He said that this surgery is a bit more involved and the recuperation time may be a little longer than the last time.

He is my question.  Do you know of a medication that will "go over" the methadone and help with the pain just for the first 2 -3 days?  I have been researching this for the past week and trying to get as much information as possible to bring to him on Monday when we set up the surgery.  I don't want to go through what I went through last time.

Again, sorry this was so long as I am sure you are a busy man. Thank You for your help.

Paul


Answer
Paul

Many thanks for the challenge!

Let's see what we can do.

Firstly there is a group of drugs that are very useful as postoperative analgesia. These are called Non Steroidal Anti-inflammatory drugs. (NSAIDs) These form a very important part of postoperative analgesia (and for the treatment of pain from kidney stones!)

There are many different types but I would suggest that either good old fashioned DICLOFENAC or one of the new ones called REFOXIB would be best.

Next is to have a good dose of paracetamol as well so 1Gram 4hourly for first 24 hrs then 6 hourly thereafter.

I would then suggest good old fashioned CODEINE in a dose of 60mg 4 hourly and then reducing as time progresses.

Naturally a good dose of local anaesthetic should be given into the tissues around your wound to reduce your pain.

Above this things get difficult as I guess from the drugs used previously that you are not from the UK. So I really cannot suggest further as I have no experience of working within the USA e.g. other avenues such as PCA (patient controlled analgesia) may have a place.

Best of luck.

Ian Jackson