Pain management and other issues for surgical patients that are long term heavy drinkers

In My Humble Opinion
1

I’m helping somebody recover from joint replacement surgery and want to be better informed and more capable regarding her pain management and some other issues. I think she may be a somewhat difficult case because she is a heavy drinker (four times the 2014 CDC limits for “heavy drinker”) and has been so for decades. She’s 70.

I’ve never known her, for 36 years, to go a day without drinking, except when she was on opioid treatment (hospitalized or at home after surgery). Her usual pattern is to start drinking mid afternoon, and she’s famous for being irritable or angry in the hours leading up to starting drinking. She very rarely gets drunk enough to fall down, or throw up, but it happens.

I was with her throughout surgical consults and hospital intake (she wants me there as she has difficulty understanding everything going on). They did ask about drinking, in what I think is a typical way, and she said something ordinary like “a couple glasses of wine in the evening”, but then they didn’t let it go, they kept asking more probing questions, specific in ways I’ve never heard before and didn’t understand. She gave minimally interesting answers. I wondered if they were keying off of some clue unknown to me. She does have slightly yellow eyes, which I think might suggest liver damage, but I don’t know if they were paying attention to that. Of course, they were looking at blood work, about which I know nothing.

This must be a pretty common issue, right? Many millions of people drink too much, and possibly have addiction to it, right? Especially in the older age groups that also get hospitalized more. I have a friend whose mother was in this category and the hospital did various special things to manage this — not giving her alcohol, but doing other medication for it. I’m trying to interpret. Are opioids interchangeable with alcohol? I mean, if somebody would have physical problems when alcohol is withheld, do opioids cancel that?

She’s 9 days post-operative and her pain pill usage is going up, not down, though she’s using the new joint more and demonstrating much improved physical capability. Her prescription (oxycodone 5 mg) is about to run out, though she has a few pills saved from an earlier hospitalization. She’s not drinking while taking these pills. Her mood is always quite variable and she gets pretty angry, and this seems worse during this whole process. She next sees her physical therapist and her surgeon in 2 days and 3 days respectively.

I have to take care of her; she’s relying on it. I can do as little as just let things unfold as I continue to care for her, or I can ask questions. I’m not the patient so I don’t have official standing for much, though I could refuse to do things for her that I thought were bad for her. I’m also trying to deal with her mood swings and figure out how to get on with my own life (for example I have to start physical therapy for my own recent surgery in a couple days and will have to plan on leaving the house more). And, just out of curiosity, I wonder why they questioned her so hard about the subject and just wouldn’t let it go (nobody has ever done that to me).

Any advice to share? Tips? Insights?

Since there are some factual questions here, but also some opportunity for speculation, with uncertainty I put this in IMHO.

Thanks!!

2

Remember that confidentiality is one way: her doctors can’t talk to you, but you can talk to them.

3

Sounds like she’s shifting her addiction to opioids rather than alcohol, not at all an uncommon occurrence. Her physicians should be made aware of her alcohol dependence. Sounds like they were already suspicious about it. They can make sure she’s on the right meds to prevent/treat alcohol withdrawal. Opioids are not the right treatment for alcohol withdrawal.

She should also be evaluated by them to see if there’s any other reason she’s needing more opioids for pain; while cross dependence is the most likely reason, there could be others such as worsening inflammation at the surgical site, infection, etc.

And as MandaJo has already noted, you are free to inform them of your concerns and observations even though they are limited in what they can tell you.

Good luck

4

Patients need to tell their doctors the truth about their alcohol consumption. Trust me, the doctor will not be shocked, and probably not even surprised, thanks to the cues mentioned in the OP’s third paragraph.

Family anecdote: I have a relative who had surgery many years ago, and he neglected to tell his doctor that his nightcap was a drinking glass full of ice, and topped off with straight vodka. That was sufficient to make him physically addicted to alcohol, and a procedure that should have had him out of the hospital in a couple days instead had him in the ICU in a medically induced coma when he had a seizure that night.

5

My husband’s grandmother was hospitalized for something, and when asked about drinking said she had “a glass of wine every afternoon”. That was true. She also had a lot more. They didn’t give her any alcohol in the hospital, and she suffered physical withdrawal and had the dt’s. It’s kind of a big deal, and something they could have managed if they’d known.

Do tell her doctor. Both her prior drinking and your current concerns. They probably can’t tell you anything, but it will help them treat her.

6

True, however the doctor then needs to document this honestly. I would answer drinking questions when my PCP (now retired) would ask. He would then tell me that sounds like a lot, how about if I put down…

His reason was that the other doctors in the group practice would give him a hard time if he recorded what I answered into the medical record. He knew I was not going to change, and didn’t want to have to explain this to his colleagues.

7

Not a doctor. I am an alcoholic, sober for many years now.

AFAIK - alcoholic withdrawal is general treated with benzodiazepines - vallium, xanax, ativan… when I was last in rehab they gave us librium.

It’s been my experience that doctors are remarkably ignorant when it comes to addiction. I was truthful with my doctors about my habit and one told me as long as I could hold a job and wasn’t getting DWI arrests, as long as my liver was okay, there was no problem.

I’ve tried to replace alcohol with opiates in the past and that’s what I would be doing if I were her.

My cynical gut tells me just let her drink. It’s probably better than her getting addicted to opiates. You’re not going to get her to change. And you’re just going to aggravate yourself if you try.

8

Don’t have time for a comprehensive post, but

1 the doctors can tell you everything if the pt waives HIPPA, it’s theirs to control.

2 the only wrong answer is the one that misleads us.

3 pain and withdrawal are adjacent symptoms, they can be controlled by a single medication at a higher dose but are better treated with a couple of modalities.

4 the entire process is unlikely to be pleasant unless high doses of opiates are used, which will have a high risk of creating new problems.

9

*HIPAA.

And the patient doesn’t waive it, rather they just sign a consent to allow the practitioner to discuss information with another specific person. All HIPAA rules remain in effect (and much of HIPAA doesn’t apply to patient confidentiality anyway. It mandates industry-wide standards for health care information on electronic billing and other processes, along with regulating how protected medical information is handled).

10

This is something I think about but don’t know how I’ll handle it if push comes to shove. My husband is an alcoholic and very doctor-avoidant. He’s 72. The time is coming when he’s going to have to see a doctor as age-related issues come on, and I’m sure he’s going to lie about how much he drinks. I want the doctor to have all the info, but didn’t know if I should say something, due to confidentiality. But I bet doctors can spot alcoholism without being told. In this case, the purple nose and shaking hands are going to be a dead giveaway.

11

Spousal confidentially matters, too. Would your husband feel betrayed if you told his doctor about his drinking? Or would he just be mildly annoyed? Or grateful that it meant he didn’t have to bring it up?

12

I don’t thonk confidentiality comes into play, from you to the doctor. Only the other direction.

13

He’d be unhappy. Hopefully the doctor wouldn’t give me away, and would just say that he can spot the signs of alcoholism.

14

This varies a LOT depending on the physician, and how far along the patient is down the road physically in their addiction.

I always appreciated a ‘heads-up’ from family members about concerns they figured the patient wouldn’t bring up; it can really help focus on what’s important. And I kept confidences all around.

15

I remember, in the pre-EMR days, seeing an order where the patient-husband’s alcohol consumption was addressed, and that his wife had interrupted him and said, “No, honey, tell the doctor the truth” and that changed the treatment plan.