MANAGING RECOVERY
Post-surgery pain can raise concerns of addiction relapse
The pain in Gary Emes’ hip was excruciating, but the fear of relapsing into addiction was stronger. He suffered for five years before he finally decided to pursue joint replacement surgery.
“The hip at that time was about 60-70% deteriorated,” Emes said an X-ray done early in 2023 showed. “I could hear the grinding and popping, and the pain was continuous, causing me to get only two to three hours of sleep per night for at least a year. All this had my head spinning.”
His chiropractor, who told him years ago he should consider replacement, said it was time to get the hip addressed by a surgeon.
“I tried everything I could because I didn’t want to have the operation,” Emes said.
Emes, 63, celebrated 26 years of sobriety on Jan. 1.
“I was most afraid, because I have such an addictive personality, that I would easily start using again, once any narcotics would be in my system,” he said. “Addiction owned me for many years, even though I hated myself for it and was killing myself, it defined me. So I was most afraid the world would not understand and I would once again be owned by the craving.”
Emes said his addiction began right out of high school.
“It was everything, anything I could get my hands on — drinking, coke, pot, any kind of pain medicines,” he admitted.
Finally the fear of re-entering the grasp of addiction was not able to compete with the bone grinding pain in his hip
“The days I was really in pain leaving work, I just remember the nights I dreamed I believed I was going to commit suicide, that is how dark it was for me,” Emes said. “The whole mess, the whole dark abyss. Not knowing who to trust and if they would respect my wishes for remaining clean; not knowing really if anyone would say it was possible or that they would do it.”
He did not want that darkness to envelop him any longer.
Emes got second opinions and even entered an online cognitive behavior therapy class for pain management offered through Lehigh Valley Hospital that is part of a five-year research project at
Stanford University.
“I’ve been meditating for many, many years, but this was a whole other kind of binaural beats,” Emes said. “That was helping me to focus on the good things in my day and try not to pay attention to the pain.”
Binaural beats is an auditory “illusion created by the brain when you listen to two tones with slightly different frequencies at the same time,” according to Webmd.com. Basically, your brain hears a third tone, which enhances brainwaves.
The American Academy of Audiology states “this enhancement of brainwaves has been studied to determine their effectiveness at reducing stress, anxiety, help in sleep, and increased focus” and there is still debate
about its effectiveness.
Emes finally connected with Dr. Stephen Longenecker at the Bone & Joint Care Center in West Reading.
“Dr. Longenecker just looked at me, held my hands and said, ‘If you want to do this pain-medicine free, I am onboard with that,’ ” Emes recalled. “I felt his spirit. I knew he was the one. I had gone to Lehigh to get a second opinion; that guy felt way off for me, didn’t understand what I was after. I just felt it with Dr. Longenecker.”
When he awoke after surgery on July 5, Emes said the only area he felt pain was around the stitches.
“It was so much pain before, I knew it couldn’t be much more pain after,” he said. “At that point I didn’t feel anything inside, it was such a blessing.
“Immediately afterward,
the pain was gone. When they got me up at the hospital, I stood — I get a little choked up — because I stood in the middle of the hallway with the physical therapy guy and I started to cry a little bit because the pain inside my bones wasn’t there any more.”
Emes was given prescription medication to take home, just in case he could not stand the pain. He said he didn’t need any of the pills. He managed just fine with Tylenol.
In addition to his physical therapy Emes said he got up every 45 minutes to an hour and walked around the whole yard, an acre in Ruscombmanor Township he shares with his husband, Gordon Weiss. That was something he hadn’t done in a year.
“One of our dogs, she’s a bird dog, and she was my nurse the whole 6-8 weeks,” he said. “It was crazy. She laid right by my side, on
my righthand side, she’d do her silent growl at any of the other dogs that came up like she was protecting that part of me.”
Bailey was a constant source of comfort for him during his healing process.
Emes was off work for two months to recuperate. When he returned to the Amazon warehouse in Upper Bern Township in September, he was given accommodative duties for the month. Now he is back to his regular duties.
Another perspective
Rocky S. 66, of Wyomissing, who asked that his full name not be used, has been in recovery for 12 years.
“I’ve actually had two joint replacements to the same shoulder,” Rocky said. “I also had a joint removed from my hand because they couldn’t repair it.”
His addiction recovery was well established by the time he needed the surgeries, he said.
“I immediately told my doctors that I was in recovery and that any type of narcotic may be an issue for me,” Rocky said. “I wanted them to be aware that I was in recovery and that we had to be very sensitive to that.
“When I had my first shoulder replacement done, it was a partial replacement and I worked with the doctor and he told me that basically, at that time, there was very little chance that I would be able to get through the recovery stage without any type of narcotic medication.
“We went into the surgery knowing ahead what the plan was as far as what the narcotic medication was going to be and we stuck to that plan. I was somewhat surprised when I got home at how many pills he actually did prescribe.”
Relapsing was certainly on his mind heading into surgery.
“I’ve always struggled with drug addiction, but frankly what really took
me down was my alcoholism,” Rocky confessed.
He said anyone in a good recovery program would be foolish to say they were not concerned about relapsing.
“Just like I can tell you I haven’t had a drink today and I haven’t had a drink in the past 12 years, that’s no assurance that I’m not going to have one tomorrow,” Rocky said.
“What I found extremely helpful was that I told every single person that I was close to,” he said. “I was extremely close to three other guys who were in my recovery network. So I told them what was going to happen, I told them after the surgery what was happening and I talked to them every single day throughout that initial phase of medication.
“So although I wasn’t able to go out and be social at my recovery meetings initially, I did stay in touch with my friends in recovery and my parents, my family, everybody.”
He credits physical therapy with being the key to his pain diminishing quickly.
Rocky’s second shoulder replacement surgery, about three years after the first one, didn’t go quite as smoothly.
“I can’t exactly tell you why,” he said. “When I had that surgery, it was the same physician, we had the same conversation. He prescribed the same medications, but I started thinking differently when I had that second recovery process.
“I can remember thinking to myself, ‘I’m still in pain, a second pill would probably help.’”
That was enough for him to turn over his medications to someone he trusted to dole out the medication as prescribed.
“Unfortunately, in addiction, there’s not always a concrete answer as to why something works one time and the next time it doesn’t,” he said. “The overriding factor throughout those recoveries was continuing
to work my recovery program, continuing to stay in touch with my sponsor on a daily basis, continuing to stay in touch with my recovery friends every day and then getting back to meetings as soon as I was able to.”
For his third joint surgery, he was adamant about only using over-thecounter medications. His doctor told him that would be virtually impossible, but he wanted to try it anyway.
“I tried, and within 48 hours I was on the phone with that physician telling him, ‘Oh my God, I had no idea,’ ” Rocky recalled.
“His response was, ‘Rocky I tried to explain this to you, I literally had to cut your thumb off and put it back on.’ He explained to me that there are so many more nerve endings in your hands than most other regions in your body.”
Again, Rocky gave the pain meds to a trusted friend to dispense to him, and things went smoothly.
“I would never tell anyone to avoid surgery while they are in recovery,” Rocky said. “What I would do is to emphasize to them the importance of being open and honest with your surgeon, your physician. I would emphasize the importance of continuing with your recovery routine on a daily basis. I would encourage them to tell their family and their friends in recovery what they are about to go through and what they are going through.”
Preparing
Joint replacement is an invasive procedure, no matter which joint is affected.
“Certainly within orthopedic surgery, joint replacement surgery is kind of a maximally invasive type of surgery because we need the adequate exposures in order to place the components of the implants,” said Dr. Brett Campbell, an orthopedic surgeon at Penn State Health St. Jo
seph Medical Center in Bern Township. “Typically, we’re using saws and hammers and those types of instruments, so that kind of has that reputation.”
Campbell, who is fellowship-trained in hip and knee replacement, has been in practice since August and said that while performing surgery on patients in recovery is not something he often encounters, he has been taught about it over his years of training.
Treating patients who have an addiction history requires a candid conversation, he said.
“It’s a discussion about how long they have been in recovery, if they’ve had relapses in the past and kind of where their overall comfort is in terms of whether opiates are a reasonable option, even in the short term,” Campbell said. “Another big part of it is the support structure the patient has.”
According to the American College of Rheumatology, there are about 790,000 total knee replacements and more than 450,000 hip replacements performed annually
in the U.S.
Dr. Ming R. Wang, associate medical director at Caron Treatment Centers and medical director of the older adults program at the organization’s South Heidelberg Township facility, said a need for joint replacement is common in the population he treats.
“Not everyone in recovery is the same, and we’re talking about people who may be in their early recovery versus someone who might be in solid long-term recovery,” he said. “That’s a very, very different group as far as how they may engage in surgery planning.”
Wang said patients new to addiction recovery may want to jump right into a surgery because they feel better and have completed treatment.
“Establish your recovery first and then think about having an elective surgery, that’s usually what I tell them while they’re with us,” he said.
“One of the big things we do is making sure that we set expectations from the front about how much pain is to be expected and sort of what to expect with the surgery,” said Dr. Kenneth J. McAlpine Jr., an orthopedic surgeon at the Bone & Joint Center and medical director of Reading Hospital’s hip fracture program.
McAlpine said returning
patients have it a little easier because the fear of the unknown causes a lot of anxiety and is a stressor that can add to the overall experience of pain associated with surgery.
“If the patients are adamant that they don’t want opioids, at any point, even in the hospital or the acute post-operative setting, then we have to rely on this multimodal pain control in order to provide them with relief,” Campbell said.
Multimodal pain relief
“The first step is typically the use of spinal anesthesia over general anesthesia to provide some additional pain relief and easier recovery,” Campbell said. “Neuraxial anesthesia is kind of the fancy word.”
That involves placing local anesthetic in or around the central nervous system, according to the National Institute of Health’s National Library of Medicine.
“The next step is with the use of peripheral nerve blocks, and those can be done before surgery or after surgery,” Campbell said. “And those provide sensory relief around a knee replacement for some patients. In some patients we can actually leave catheters in place, or like a pump system, that delivers that medication over several days. That can be a better option for anyone who is trying to avoid any kind of opioids.”
Wang said the willingness to discuss those alternatives is a sign of a good surgeon.
“A surgeon who really doesn’t want to talk about that, doesn’t seem to know much about it and says, ‘Oh, we’ll just give you some Dilaudid and you’ll be OK,’ that’s a red flag,” Wang said.
McAlpine said he probably has one patient a month who is in recovery. More often he encounters patients who are just very scared to even start opioids. He attributes that fear to the media attention on opioids or worries about a family history of addiction.
Surgical technique also can affect pain levels, he said.
“One thing that is different is that Dr. Longenecker and I both do more of an anterior approach versus posterior or anterior/lateral,” McAlpine said. “That’s been shown in studies to have much less pain and much quicker recovery in the early postoperative period.”
“Sometimes pain management is needed,” Wang said. “Sometimes it’s unavoidable, just because we are in recovery does not mean that we are denied those medications. If we need it, we need it.”