Withdrawal, Part 2

A few weeks ago I wrote about my first experience attempting to stop taking the painkiller Tramadol that I had been using in my recovery from a total knee replacement. I had been assured by my health professionals that it was not habit forming, but I found that, at least for me and many others, that was not the case.

Before that attempt I was taking 4–50mg tablets a day. I called my surgeon's office to ask for some advice, and spoke to one of the nurses there. When she heard my question, she replied dismissively along the lines of "oh, don't worry - you can just stop taking it whenever you don't need it anymore". I told her that that was certainly not true, and recounted what I had gone through when I tried to do just that. She was shocked, and said she had never heard of anyone having withdrawal symptoms like that. I mentioned that a quick Google search would show that I was not alone in this regard. But we did discuss a plan to slowly wean myself off of it, and that's what I began doing. Six-hour intervals between doses became 12 for a few days, then 16 for the next few. After that I started cutting the tablets in half, and taking half a pill every 12 hours, and after a few days increased that to 16 hours. Note that all this time I was continuing to do my physical therapy exercises and walk 30+ minutes a day, without any pain at all. Last Sunday I was out of the house when my next dose was due, and didn't get back until 4 hours after that. I figured I was at such a low dose that I could now stop taking it without going through as horrible an experience as I had earlier.

Sunday evening I did have some difficulty falling asleep, as my muscles weren't able to easily relax, but eventually I did get some sleep. Not much, but enough to function on Monday. When I got up I felt fine: no pain, and none of the runny nose, coughing, or sneezing that I had had last time. But by the time night came, I could definitely feel my muscles getting tense, and I knew I would have trouble laying still. It was now about 40 hours since my last dose. I knew that this night would be tough, so I made a plan. I was going to stay up as late as I could, so that I would collapse from exhaustion and fall right asleep! I even took a couple of sleep aid pills to ensure that I would go out like a light!

Well, it was a good plan, but it didn't work. The sleep aids did their thing, and I got really drowsy. I knew if I tried laying down in our bed that I would end up keeping Linda awake, too, so I laid down in the guest room and tried to rest there. Every time I tried to get in a comfortable position, though, my muscles would get tense and my joints would hurt, and I'd have to move. It felt as though I was twitching uncontrollably. I thought about walking it off, but I felt too drowsy to even sit up! It continued to get worse, tossing and turning repeatedly, never staying in one position for more than 5 seconds or so. At a few points in the night it got so bad that I had to sit up and flail my arms around wildly to get them to feel OK. I would start to doubt the wisdom of continuing - maybe I should take another pill and wean myself even further before stopping. But I figured that I had come this far, and I really wanted to see it through. Besides, I didn't have any critical meetings or anything at work the next day, so I could take it off to recover.

I would look at the clock every now and then, and remember the time passing midnight, then 1:45am, then 3, then 4:30am, then...

The alarm went off! I had set it for 6am because my wife had to get up early for work. But that meant that I had finally fallen asleep! I got up, went to our bedroom, woke her, gave her a quick summary of the night's events, and then crawled back into bed. I slept until almost 11am, and though my body felt a whole lot better than it had before, my brain was still pretty fuzzy. I wasn't able to focus on any task for very long. I'm not sure if it was from sleep deprivation or another symptom of withdrawal. I tried reading Twitter but had to put the phone down after a minute or so. Same thing when I tried to play some games. I started writing this post that afternoon, but after about 2 sentences I gave up. So I watched some TV, laid in bed, walked around our garden, watched some more TV, and generally was a blob all day. When Linda came home that evening, she saw the state I was in, and knew what I needed: a big bowl of homemade ramen, with lots of veggies and hot chilis! It actually seemed to wake my brain up, and I was once again able to focus on things.

Later that evening I was walking to the kitchen, and I noticed that my surgical knee felt... different. It was sore! When I bent it, I could feel the muscles and tendons and everything pressing together painfully in the still-swollen interior of the knee. It had now been 8 weeks since the surgery, and I was told that although the swelling would diminish in the first few weeks, that it wouldn't be gone for about 6 months! So it appears that the Tramadol was helping to control that low-level pain, even if it wasn't much help when, say, the physical therapists would force my knee to bend further than it wanted to – that was still extremely painful! But now that this low-level pain is present, I kind of like having it, as it reminds me that I need to keep working on getting it stronger and more flexible.

I'm writing this two days after that difficult night, and the only odd symptoms I've had are some strange visual effects. They started later in the evening both days, and it looks like there is a curved band of kaleidoscopic distortion in my right eye. It goes away when I close my eyes, so I'm not sure what it could be. If it keeps happening I'll get it checked out, but for now, it's a minor annoyance.

I now have a much greater appreciation of what addicts go through when they try to get clean. My addiction was tiny compared to most, and yet it left me feeling horribly uncomfortable and unable to lay still. It's a small price to pay for the privilege of having a new knee, but it's one that I didn't expect. It's great to finally be done with the painkillers! I really needed them to make the progress I've made, but I didn't want to be addicted to them any longer than absolutely necessary.

Withdrawal

So this week was the big post-op appointment with my surgeon following my total knee replacement. Six weeks: that was the first big milestone, where my progress would be assessed to make sure that I was recovering well. It was also the point where some of the more annoying things that I had to do would end (assuming I had progressed well): no more compression stocking; no more sleeping only on my back with my foot in a foam block to stretch the knee, and no more walker. Full disclosure: I hadn't used the walker at all since about 2 weeks after the surgery, but the doctors insisted on it as a safety measure, so... 😉

I wasn't too concerned about the exam, as I had been doing the physical therapy religiously all this time, and had a gotten a good deal of flexibility and strength back. And that's exactly how the exam went: I was given a proverbial gold star, moving me ahead to the next phase. Joy!

One thing that has always concerned me was my use of pain medication. After surgery they start you on Hydrocodone, a strong opiod painkiller, and boy, did I need it! But as I healed the severe pain diminished, and I really only needed it when doing some of the more painful PT exercises. So two weeks later they switched me to Tramadol, a non-opiod pain medication. Since it's not an opiod, it is supposedly not as addictive, nor as difficult to stop using once you no longer need it.

So, given my progress on the healing front, and my missing being able to share a glass of wine with my wife at dinner, I decided to stop taking the medication. Sure, it would be uncomfortable for a day or two, but after that I'll be clean!

So my last dose was this past Tuesday at 11am. Wednesday morning I awoke with what appeared to be a cold: runny nose, congestion, watery eyes, sneezing, and a dry, hacking cough. Oh, great – now I have to deal with a cold on top of everything else!

Towards the end of the afternoon, I started to feel lethargic. OK, I thought, this is the drug withdrawal, and I have to tough it out. I was also feeling chilled, but I didn't know if that was the cold or the withdrawal causing that. My wife took good care of me, and made a delicious ramen to warm me up, with lots of chili to clear my sinuses, and lots of kale and other veggies to keep me strong.

I went to bed, trying to relax enough to fall asleep, but I just couldn't get comfortable. I had taken some Tylenol to help ease any knee pain, but my knee wasn't really bothering me that much. No matter how I tried to position myself, I could feel the muscles in my legs twitching, making it impossible to lay still. I didn't want my constant movement to keep my wife awake, so I got up. Maybe walking around a bit would calm my legs down, so I walked around the house for a while. That helped a little, but I still didn't feel like I could rest, so I sat down at the computer, and figured I'd see if there were any tips I could find on dealing with Tramadol withdrawal.

Well, it wasn't hard to find that information! And man was there a ton of it! The first page I read was a message board where different people described their experiences, and it was like a slap in my face! They described everything I had been feeling; even my "cold" wasn't a cold, but just some of the symptoms of withdrawal!

I continued reading a variety of sites, and it reinforced all of the anecdotal reports of the first site I read. What was worse, though, is the timeline they described for these symptoms: they would peak after 72 hours without the medication, and continue for 10 days or so! I was barely 36 hours into my withdrawal, and I wasn't going to be able to handle this without locking myself in a padded room for the duration. Every single site recommended the only way to stop is to gradually wean yourself by slowly reducing your dosage, so that's what I decided to do. I felt defeated: I had been kicking ass on this whole knee-replacement thing since the beginning, and now I finally ran into something that kicked mine. So I reluctantly took a Tramadol pill at 11:30pm, and an hour or so later I was feeling better enough to attempt sleeping. I did manage to get a few hours, so this morning I'm a little sore and grouchy. My (revised) plan is to go with taking it at 12 hour intervals for a few days, then increase it to 16 hour intervals for another few days, and adjust that as needed until I'm off it completely. No heroic cold turkey for me anymore!

Let me close with a current photo of how my knee is progressing. The swelling continues to diminish, but it's still there. The scar is looking fine, thanks to the Vitamin E oil I rub in it daily.

6 week knee photo
6 weeks after surgery

Dry

One month ago today I had Total Knee Replacement surgery for my left knee. Before undergoing the procedure, I did as much research as I possibly could. I knew the risks. I knew the timeline I could expect for recovery. I knew the range of outcomes. I knew that the more work you do in physical therapy, the better the outcome. I knew that the physical therapy would be very painful. I knew that I would need to rely on pain medication in order to be able to do what needed to be done.

And all of that information has been spot-on. But there was one bit of information that I probably should have known, but didn't make the connection: while I was recovering from this surgery, I couldn't drink alcohol. Opioids and alcohol do not mix!

It's now been a month since I've had any sort of alcoholic beverage. Before the surgery, my wife and I would split a bottle of wine with dinner, and then later I'd maybe enjoy a bourbon later in the evening as the day wound down. Not anymore! I feel as though I should get my 1 month sober chip from AA (well, except for the minor detail that I'm taking opiods!).

I know this sounds a little crazy; after all, I have a brand-new knee! But it's just one of those things that you really don't think about ahead of time.

knee replacement at one month
Left knee, one month post-surgery

Here's a shot of the knee today: the staples have been removed, and all but one of the little bandage strips have fallen off. Compare it to the photo I took 2 days after surgery in this post! I'll have a nice Frankenstein-like scar on it, but other than that it's amazing that I can walk and move around almost normally already. I still lack some flexibility, but I'm working on that!

So while I'm happy that the new knee is healing well, I'm longing for the not-to-distant future when I can be off pain meds and enjoy a nice glass of wine once again!

Post-op

As I mentioned earlier, on Monday I had surgery for a total replacement of my left knee. Long story short: it went better than I could have ever imagined.

The first thing I was to say is how wonderful the staff at the hospital was. Everyone there seemed to focus on making sure that a) I knew what was going on around me and b) that I was feeling OK. To illustrate this, I took a pano of my view from my bed:

Hospital wall charts
Hospital wall charts at the foot of my bed

The charts have most of the information I needed. The leftmost chart shows what I should expect for my progress after the surgery until I am discharged; the center chart has the name of my doctors and nurses, along with notes on what I had already done; and the chart of the right lists all the medications I was on, what they were for, and what other effects they might have. When a new shift came on, the first thing the nurses did was introduce themselves and write their names down. This was very helpful to my drug-addled brain!

Speaking of drug-addled, I don't remember anything from when they wheeled me into the operating room until when I was back in my room. However, my wife spoke with me as soon as I came out of recovery, and said I told her about several things that happened as they were prepping me for surgery, as well as some comments about waking up in the recovery room. I don't remember any of that! Apparently whatever sedative they gave me didn't interfere with short-term memory, but prevented long-term memories from forming. It's so odd to have someone talk about things that you told them, and you have no clue!

I got precious little sleep that night. First, there is the problem with being awakened every few hours for blood pressure / heart rate measurement. But the main problem was that I had to put my surgical leg into this foam block that elevated my heel an inch or so above the bed. That may not sound like much, but the effect is to force my leg to stretch, as there was nothing supporting my knee. That constant stretching is essential to getting the full range of motion back, but oh man was it painful, even after taking the opioid painkillers! However, after 3 nights of using the block, it feels fine. Making progress like that is always encouraging.

The day after surgery they got you out of bed early to do some physical therapy, and then later had classes for "The Joint Club": all the people who had had joint replacements the previous day. The nurses and physical therapists went over all of the exercises we would need to do for the next 6 weeks, making sure that everyone was doing them correctly. They also answered all the questions people had about what they should expect. I left there feeling that I knew just how things would progress. Boy, was I wrong! But in a good sense – my progress has been even better!

I've gotten a good range of motion back, although I still have a ways to go. I can walk without using my walker, but always use it for safety reasons: one fall and I could undo everything. I do the physical therapy exercises 3 times a day, and they can be very painful! When I'm doing them I keep reminding myself that this short-term pain will result in a much healthier knee in the long run.

And no post-operative report would be complete without a shot of the scar! Well, it's not a scar yet, but yesterday when the nurse came to inspect the wound and replace the dressing, I managed to get a shot of it: 32 meticulous staples that look like I have a zippered knee!

Post-surgery knee with staples

You can also see the compression marks on my skin. Apparently blood clots are a potential complication of this type of surgery, so besides exercises to keep the blood flowing, I have to wear compression stockings on both legs for 6 weeks. It ain't pretty, but if it keeps me healthy, so be it.

I'll try to post one more follow-up in a few weeks with my continued progress. Until then, back to the PT!

The Night Before

My knee replacement surgery is tomorrow. I have to be at the hospital at 5:30 AM, which will be difficult enough in itself!

On Friday I decided to give my knee one last fling, so that I have a clear memory of how much I was limited by the arthritis. I did 15 minutes on the elliptical machine at the gym, and then later in the afternoon I hit a bucket of balls at the driving range. Well, I made it about 2/3 of the way through the bucket when I started to feel a twinge in my knee, so I gave the rest to the guy next to me and headed home.

For the past decade or so, I've dealt with my knee, as well as my other painful joints, by taking Aleve (naproxen sodium). If I knew I would be doing something active, I would take it ahead of time prophylactically, and always took it afterwards. This would keep the inflammation to a minimum. However, when you are having surgery, they make you stop taking all drugs a week ahead of time, as they can increase your chances of blood clots during surgery. So after my exertion during the day, my knee was throbbing pretty badly at night. The pain continued through the weekend, and it's still present as I'm typing this. Obviously I had relied on Aleve to mitigate the pain in my knee so much that I had forgotten just how bad it could be.

I probably won't be able to add to this blog for a few days, but I'll try to remember as much of the experience as I can so I can write about it later.