Hallucinations and constipation

Almost ten months after the accident, I ended up in front of a neuroplastic surgeon specialising in hands and arms. Finally, my pain was understood.  At that time I could not button up my own trousers, had to work out how to put socks on one-handed and could not handle shirt buttons at all.  My wife, at times, had to dress me, an exercise that was as frustrating for her as it was humiliating for me.  I was positive danger in the kitchen, unable to carry pans or wield a knife.

The situation had deteriorated such that lifting my arm above my head produced agonising screams of pain all up my arm and numbed my fingers.  Walking and trips anywhere almost produced blackouts as the jogging in my torso and shoulder generated so much pain.  Only two people, my wife and one friend, could ever drive carefully enough to minimise my pain[1].

The trouble is, when asked to do any exercise by a specialist I did so, immediately, irrespective of impact. Perhaps I could not understand the suggestions ‘if possible without too much pain’: to my, perhaps literal, mind the word ‘possible’ included any low probability and ‘too much pain’ suggested actually blacking out.

This misunderstanding probably made diagnosis more difficult (see the Important Principle on describing pain and sticking to your guns on the description, earlier!) as the severity of my problems could not be identified.  Perhaps I was too compliant with the specialists, doing what they said to do and just swallowing the immediate agony in order to be compliant.

I still have problems with such instructions today. Is it just me, I wonder?

That time, though, and much to my shame, I finally could not withhold the tears of pain when the surgeon examined me. He suggested a number of diagnoses, all including some form of nerve impingement (trapping) and scheduled the first two procedures in what was to become several operations. He also put me on tramadol, ‘a nice, strong pain-killer’, he said, and I left to wince my way back home in the care of my wife’s considerate driving.  I collapsed for several, sleepless days.

Finding a dose for the tramadol proved as difficult as any other opioid. The slow-release versions, sometimes called tramaset or tramadol mr (for modified release), just did not work for me and the fast-acting versions only worked in larger doses. The maximum dose of tramadol per day is 400mg, but I found I had to take almost half a day’s dosage at once, 150-200mg, in order to find any relief from pain.

From discussions with those at the clinics and others, side effects of tramadol vary widely: one friend of mine has extremely vivid visual hallucinations, another acquaintance seems to have no side-effects at all, whilst I hallucinate very detailed, imaginary conversations and find my memory goes to pot. I would swear to friends that I spoke to them about a topic only to find that witnesses to the time when the discussion was supposed to take place were as confused as those I supposedly spoke to.

I am now a little more cautious in claiming I have spoken to anyone when on tramadol.  I am not sure that my family didn’t take advantage of this side effect, though!

On top of tramadol’s aural hallucinations, I become extremely talkative, high as the proverbial kite, and have very detailed memories, vivid daydreams that flood into my mind when I rest.  Sleep and concentration at such times is impossible.

Whilst these occur for me with tramadol, such hallucinations may occur with any of the opioids.  Further, such is their effect that driving or going anywhere is really not advisable.  This can mean that regular use of opioids adds another problem to a pain sufferer’s life: that of increased isolation.

After a week of being on tramadol or morphine, I discovered yet another side effect of their usage that I, and many others, really do not like: constipation.  All the opioids, tramadol included, induce real constipation issues[2].  Even when taken intravenously or via syringe drivers, constipation sets in and can be really uncomfortable, even painful, adding yet more to any Chronic Pain problem!

The recommended solutions to constipation are to drink lots and eat substantial amounts of fibre. However, I found this does not often work.  The next step to resolve the problem is something like lactulose that is supposed to make your stools softer but takes a day or two to kick in.  Again, I found this is also rarely effective. After that, so the recommendations go, bowel stimulants such as bisacodyl or senna should be tried, both of which are supposed to take around 6-12 hours (overnight).  Personally, I find it takes two days of taking normal senna tablets before I gain any relief and, frankly, things are still not pleasant at this stage – but it works.

The relief when the constipation is resolved is tremendous.

Important Principle: Multiple pillars of practice

I think that this is where we see an important element of Pain Management coming into play: a practitioner cannot rely on any single component of the solutions available.  My stubbornness prevents me from taking painkillers as often as perhaps I should but this is simply because I know that other techniques I have learnt are more effective at reducing my pain to a manageable level. At such times it frustrates me that I had missed a trick, a chance to stop the pain before it had escalated.

With all these drugs, it should go without saying that alcohol should be avoided.  Many of the pain killers can cause stress on a liver and the extra stress of alcohol is not helpful to good health. The advice with some pain killers is even to have regular liver check-ups.  Speaking to other sufferers, I have heard some say that taking alcohol can potentiate (enhance) the effect of opioids. However, doctors continually warn against such behaviour as being far, far too risky, especially with the cocktail of drugs many Chronic Pain sufferers are on, so it cannot be advised.

Important Aside: Facts about opiod prescriptions

It might also be appropriate to point out that opioid-only use for pain relief is increasingly being seen as a problem in the USA and UK. Studies have been carried out on the huge increase in prescription rates of between 500-800% in 10 years for drugs like oxycodone (a poppy-derived opioid, of which OxyContin is an extended-release form), hydrocodone (a codeine derivative, often mixed with paracetamol such as in Vicodin) and fentanyl. Though short-term opioids use can be effective, these studies highlight longer-term problems such as the need for increasing dosage, accidental death and concerns that opioids may even increase Chronic Pain in some cases[3].

Continued in Antidepressants? I needed them by now

References in this section:

[1] I have thanked Lloyd loads of times for this, but I do so again: your driving was much appreciated, my friend.  Both he and my wife consciously tried to avoid potholes, excessive swerves, sudden braking and accelerating or rough roads. Love you, guys.

[2] An article recommended by the ACPA is Panchal S.J., Müller-Schwefe, P., Wurzelmann, J.I.,  2007, ‘Opioid-induced bowel dysfunction: prevalence, pathophysiology and burden’ in International Journal of Clinical Practice, Jul 2007; 61(7): 1181–1187 (available online at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1974804/). Last accessed 30th December 2014.

[3] Manchikanti L., Helm II S., Fellows B., Janata J.W., Pampati V., Grider J.S., Boswell M.V., 2012,  ‘Opioid epidemic in the United States’ in Pain Physician, 15(3 Suppl), ES9-38 (available online at http://www.painphysicianjournal.com/linkout_vw.php?issn=1533-3159&vol=15&page=ES9).