Expert: William J. Walker, Pharm.D. - 1/26/2004

Question
I am a 41 yera old male.In Feb 1994 I destroyed my left knee in a motorcycle accident.The doctor put it back together.In april 1997 I had the knee replaced.In Nov, 2001 I had it replaced again.Eight total surgeries plus one for sleep apnea in Aug 2002.My pain has never really stopped, and recovery after each operation was long and exhaustive. I have been taking HYDROCONE 10.5 consistantly for greater than 5 yrs.As of Feb 2003 I was placed on a pain patch(DURAGESIC fentenal) 25mg for 3 months and 50 mg since (8months)My problem is that My entire body is now in pain.Eminating from the center of my torso and extending throughout my whole body.Extreme tireness, weakness, pain, sleepyness, and depression and shortbreathness have totally disabled me.I have been out of work 3 months-and during the past 2 years I have been tested for everything imaginable.(still waiting on results from Lyme desease test)My life has come to and abrupt end,the pain medication does nothing to help me, only mask my problem...So 7 days ago I decided that possibly the medication was adding to my problems, and I stopped wearing the DURAGESIC PAIN PATCH AND stopped taking the PROVIGAL (the wake me up medication).I've been freezing to death ever since, My body is screaming- I'm too sick to even set up- I have diarrea and terrible nausea.HOWEVER, my mind seems to be more clear, my sleepiness has decreased, depression lightened up 1 notch. I am still taking the HYDROCONE 2 or 3 times a day, but hope to stop it as well, if I can live thru this sickness.DO you have any advice as to how long I will have to endure this pain and is there anything I can do to shorten it.I know my body is screaming from narcotic withdrawal...but I have to beat it if I ever want to get well and go back to work.The company I work for will not allow one to work while on narcotic pain relievers. I have lived a lie for 6 or 7 years. NOW ITS TIME TO BE REAL ...PLEASE REPLY,,,THANK YOU C.L.B

Answer
I am not sure exactly what you are telling me.   First you describe for me a rather detailed history of substantiated pain and subsequent treatment.   Only to close with a strong plea to detox off of medications and as quickly as possible.   Then you confuse me by mentioning that you have been lying.

Now mind you I am not interested in judging you.   Nor am I interested in determining whether or not you have been in real pain at one time or another.   I am only trying to figure out what it is that you are trying to tell me here.

Yes,  you are in very real and very harsh narcotic withdrawal.    It is not only unavoidable it is totally expected.    Your opiate use at such high dosages for such long periods of time will make this a fact.    You have tried to eliminate the drugs very quickly though and that is torture.   The better way to approach this goal is to do it slowly and methodically under supervision.   There is no reason that you have to thrust yourself into severe withdrawal pain.    All of the nasty symptoms that you described are part of this withdrawal.    They are all symptoms of narcotic craving.    They will all also respond to a re-introduction of the drugs.

What we recommend for all of our patients who have been under long term narcotic therapies is to begin the reduction and taper as a slow decrease of 5% of the total daily dose.    That dose is then taken for several weeks.    The longer a period of time that you have been using these agents the longer period of time it will take to successfully make another reduction in dose.    In your case I would guess that you would need at least two weeks on a given dose before you could handle another 5% decrease.    Maybe more.    At any rate you would then take several months or more to taper all the way off.   And the last 5-15% is the absolute hardest.

Cold turkey cessation is possible.   It can be done.   But it is excruciating.   And it will take many weeks before you are through with it.

You have found out some important things though.   That these drugs have been the source of many of your other problems.   Like the depression.   And the sluggishness.   So it is going to be a major relief to know that these will lift.   But what about your real pain problems?   The knees?    What do you suppose will come of this?   Or is this the part that was the lie?    Maybe you have no longer this pain?    But if you do...then you are going to have to face this again too.

I would recommend that you seek treatment by a physician for this entire affair.   You should have a suitable pain management program.   With a pain specialist.   Who can utilize therapies other than strong narcotics.    There are other methods and other drugs that might be helpful.   And you are going to need some support in other areas.   Some medications to help soften the harshness of withdrawal.   Such as some diphenoxylate for the diarrhea and perhaps some dextromethorphan for the withdrawal pains.    Clonidine,  an alpha blocker,  will help to reduce the shivering,   the cold and heat intolerance,  and the cardiovascular side effects of withdrawal.    And some benefit from an SSRI for the depression.   And to help with the insomnia that results in withdrawal.    

Get some help.  Don't do this alone.    I applaud you for taking the step and for your courage.   But it is crucial to succeed.   And not set yourself up to fail.

I would be happy to offer any other assistance as you deem appropriate.