Worsening Pain 10 Months Out

I am looking for reasons why pain would increase after GB WLS.  I am active, increasing my core strength, am still losing weight, and am getting all of my nutritional and water requirements the vast majority of days.  My pain is getting worse, to the point that I have accommodations with my employer that allow me to work extended hours during the day to make up work for having to lay down in my office.  I already have a diagnosis of being permanently disabled to pain but I'm not even 30--I'm not ready to give up being able to get out of bed yet.

In April 2012, I wa**** by a car riding by bike to work, wherein it totalled me and I totalled the car.  I had an extensive hospital stay, a stent in rehab, failed PT, an intramedullary rod, bone death, a new rod, and more failed PT.  I had never had to take prescription painkillers before and there has only been a few days in the ensuing three years that I wasn't having to take them--to the point I was having to get rides from family and friends to go to appointments, school, or just out.  I subsequently put on 50 pounds and I was assured by doctors that at 250 pounds that I was too heavy to be properly evaluated.  I had previously been biking 100 miles a week and going to the gym an additional 3 days a week--I was by no means inactive or weak. I became almost completely immobile for a few months and have suffered limited mobility since.  I can now exercise like a real human being but only--and I stress this because I have tried mind over matter--ONLY if I take prescription narcotics.

My father got me on the train for gastric bypass and I was originally going to do it with him but the Bariatric Advantage made my kidneys almost fail so I had to figure out another way to do the diet plan.  The surgeon and my PCP agreed that the weight coming off would at least ease the pain so with my father having had some success with his own ailments I spent six months figuring it out.  When I finally did get the surgery 10 months ago, I thought I was going to die--I couldn't even get out of bed to urinate.  However they put me on that slab for the surgery put my back into such spasm they had to drug me to put me out during what ended up being an extended hospital stay.  I went from 0-5 mg of Oxycodone a day pre-WLS to multiple doses of Codeine just to be able to get up.  I don't say this to be dramatic--I am very sensitive to narcotics (it runs in the family, along with the inability to produce the liver enzymes necessary to metabolize alcohol).  Del Sol refused to give me any muscle relaxers on the holiday weekend so my brother had to drive down from home to drive me the 500 miles back home without them because I couldn't afford the $1000 co-pay for the emergency room (pain is considered a PCP event under most insurance plans).  It took me less than 2 weeks to get through the medication they gave me for pain meant to last a month and I haven't been on less than 10mg of oxycodone a day since. 

In fact, if anything, my pain has increased after losing over 90 pounds and being less than 30 pounds from my medically ideal weight.  I go through a box of Salonpas (which it turns out I'm increasingly allergic to judging by the increasing number of welts and lost skin), a tube of T-Relief arthritis or three tubes of Icy Hot Advanced, 42 500 mg of Tylenol (because I've been told I can no longer take 8 of the Tylenol a day--I have to restrict it to 6), and 105 mg of oxycodone in a good week.  Honestly, I don't know that the Tylenol makes any difference but I have to be able to say that I'm taking it and doing everything I can.  Since relocating for work last month, I have access to a tub and take an epsom salt bath every other day (my landlord hates me--we're in a desert).  I get a 2-hour massage every week that provides temporary relief.  I do anywhere between 100 and 200 crunches, 15 to 20 minutes of squats, 5 minutes of leg lifts on each leg, 5 minutes of clamshells on each side, 100-200 pelvic lifts every day (spread evenly out throughout the day as I'm able every hour), at least 30 minutes of walking my dog, and stretching 30 minutes twice a day.  It hasn't produced any relief despite this being what every PT has prescribed me--six in total over the last four years.  In all, I spend well over $100 a week in attempted pain relief on a good week and about four hours of exercise a day.  I have tried going stone sober (withdrawal isn't as fun as the kids make it out on TV), I have tried restepping it by alernating doses, I move every hour, I don't strictly stand or sit for my desk job, and I alternate heat and ice twice a day (10-5-10).  I have a TENS unit that sometimes provides relief if I leave it on high for hours at a time and also have access to an e-stim machine when I visit my parents that helps temporarily.

I am extremely disheartened after this surgery.  I am constantly sick despite taking vitamins, minerals, 60-120 grams of protein, and 15 billion CFU of probiotics every day.  ON a day I can get all of the food in, I ingest about 1000 calories.  I've thrown up more in the last ten months than I did in the six years before it.  I have to take betaine hydrochloride and a host of dietary enzymes in order to be able to digest my food because even if I turn my 1/8 cup porridge into a 30 minute meal I can't break it down without it.  (It started out as 1/4 cup of porridge but now my dog eats half because I can't get through all of it in a half-hour without getting sick.)  Recently I've also begun throwing up my protein drinks as well.  The whey from the surgery has been making me throw up since a month after the surgery, which didn't seem to concern my surgeon when I went for my follow-up.  I have to take at least one box of Gas-X every week--that is, I buy the gel caps and bite them open and discard the gels because the sugars in the tablets became too much.  (I calculate it out to about $60 a week on these "remedies" but without them I get so constipated, bloated, and/or vomity that I end up going days without eating without meaning to--my days end up being pills and water.)  I tried getting off of everything digestive-producing in the two weeks betwen finishing school and starting work but I literally became so unbearable to be around between the gas and my discomfort that my mom was 90% sure I was going to have to go to the hospital.  I drink a minimum of 64 ounces of water a day and my pain medication has had no effect on my regularity.  God forbid I eat anything that isn't practically pre-digested (can't break it down), or is "off-diet" by being high in fat or carbs of any kind (there are only so many times you can pass out before people start to question).  I bring all of this up because I have seen some posts that an increase in gas/inability to pass stool can increase pain but whether or not I am full of gas or poo or food or water or am empty seems to be irrelevant--my pain is increasing every day.  I just went to my PCP and we had that heartbreaking conversation of having to increase my pain medication when the whole point of this surgery was so that I would never have to take another one again. 

I can't go back to Las Palmas because they don't take my insurance anymore, which sucks because they knew I was changing insurance when I was having the surgery and were angry to find out that I did, in fact, switch insurance.  I also got the annoyed phone call of being overdue for my appointments despite my explaining to them that I wish I would have known they weren't going to take my new insurance before having the surgery because I never would have had it because being a student not working I couldn't even afford the resulting bills from the surgery much less accruing new bills.  Their only response has been to drive 500 miles back to them and spend over $500 on a visit by the doctor, which means that I will owe more than $5000 after they get done scanning me.  (To put it frankly, even though I had an amazing insurance plan when I had the surgery, I owed $4500 because of the increased hosital stay and subsequent scans they did--I am not in a financial position to go through the gammut they want me to go through without insurance, especially if it turns out to be as fruitless as my extended hospital stay.)  My PCP has sent me for scans but being on the exchange right now I can't afford the co-pay.

I am hoping that someone has had something similar and can tell me more than "chin up."  Two of my six Tylenol a day are now Tylenol PM so I can avoid taking oxycodone to try and sleep at night.  I'm not going to lie: it doesn't always work and I can't take any more oxycodone without being completely useless.  It's to the point that I went from being drowsy at 2.5mg (because I would cut the tablets in half and take them every 8 or more hours if I needed to--in those pre-surgery days where I didn't always have to take pills) to being unable to function on less than 15 mg--2.5mg a minimum of every three hours.  I have to be drug tested every 90 days to get a new prescription and have had to report my use to the board of bar examiners just to be able to pass character and fitness to pass the bar.  I don't know what to do.  Any suggestions are welcome, just bear in mind I can't afford the medical care of going back to the surgeon.

I am a registered nurse not a doctor, so take that into consideration. Here's what I read. You are taking a **** load of opioids. The CDC is now saying that opioids are ineffective for long term pain management. You have to keep increasing them and they stop controlling pain. Plus there is a huge risk of accidental OD. You need to look at alternatives. There can be no good come out of a 30 year old taking that many opioids. 

Second: 4 hours a day of exercise is too much. Are you training for the Olympics? That in and of itself could exacerbate your pain issues. 

You have a lot going on. I would suggest a pain therapist to talk to. I can't give advice about the RNY issues, I'm too new to this myself.

Best of luck to you. 

Believe me, if it were up to me I wouldn't be taking any of it at all--I never would have had to take the first dose four years ago when that witch hit me.  Pre-GB WLS I did have days where I didn't need the pills and I had a routine of massage, chiropractic, and acupuncture on a rotating anti-inflammatory schedule wherein I would take Ibuprofen for a week, Tylenol for a week, aspirin for a week, then nothing, with oxycodone only as needed.  This way I didn't get the effects of too many of them at once and I could keep the loads down on my liver and other vital organs. Pre-GB WLS the weather would worsen the condition but I could have a lie-down or whatever because I was in law school at the time and had accommodations.  If I had to take it I took it and if I didn't I didn't.  I went through, I think 90 5mg pills in three years, always a half-tab or less at a time.

Post-GB WLS I haven't had a day without needing it my pain has been so bad.  There are days that my pain has become so severe that I can't get out of bed until I have had at least a quarter tab.  I hate these pills: they slow my mind, coming down off of them makes me cranky, and I just don't even like the connotation of having to take them.  I used to be able to make them last longer by eating fatty foods but I can't do that anymore because of how sick that makes me after the surgery.  Until the surgery I tried oral anti-inflammatory drugs but, as you know, I can't take NSAIDs anymore so I'm stuck with Tylenol and opioids.  The surgeon gave me Tramadol and Codeine for recovery but all the Tramadol (non-narcotic) did was make my nose run--it provided zero relief.  The Codeine didn't make me as drowsy but I don't even want to go down the Codeine road.  I just want to be off of all of it.  Pre-GB WLS I had tried anti-depressants with the pain relief stuff and they weren't even good for the level of pain I had before.  And, as I included in my original post, I am doing as much alternative medicine as I can afford: 2 extra-strength Tylenol every 8 hours with the last two of the day being Tylenol PM to avoid having to take more narcotics, 1 tube of T-Relief Arthritis or 3 tubes of Icy Hot Advanced a week, 1 box of Salonpas a week, 2 hours of massage a week, heating pad and ice packs everyday, TENs, e-stim,...  I have had to build to this point.  I started with all of the non-narcotic remedies but ran out of other options and sometimes I feel like the other stuff I do is really only the ritual of trying because even as I am sitting there I don't get relief.  It's not like I'm not trying to find alternative relief, it's just that for every step forward I take it seems like the pain-relieving effects wane or something because I'm still hurting or the pain returns within an hour or two.  I actually have a very high tolerance for pain--I had a broken arm I didn't realize was broken for almost a month because I brushed it off.  I set my own broken hand and iced it.  But as soon as I am reaching for that cane because I physically can't bear the weight of my lighter frame on my lower back and hip I don't have  choice.  If I have to go back to a walker or a wheelchair I'll do the honorable thing and be done with it but I can't go back to it--I won't.  As I also previously mentioned, I have tried to go completely without the oxycodone--going all the way through the lovely withdrawal period--and stayed off of it but I needed it those days.  I actually got in trouble in my clinical program at school because when I was refusing to take the medication, I couldn't do the basic office managerial component of the work because I couldn't get up from my desk and I was spending so much time at my shared desk that the other students were complaining.  It wasn't me telling me that I need it, it was the threat of having to stay in school longer because I couldn't be a productive adult that made me go back.  Not emotionally but physically: I can't do what I have to do without it.  It takes me longer to do what I have to do but I do it because at least that way it gets done.  Opiates are absolute ****e for long-term pain relief--I have that conversation every three months and the six times a day I take my half-pill I have that conversation with myself.  And, honestly, I still hurt when I take them but they're enough to take the edge off so I can do what I need to do.  My doctor will only dispense me 3 months' at a time and I have to go in for drug testing to get a new prescription so I am constantly in contact with a medical professional who is monitoring the situation. 

Do you have any suggestions, as an RN, of something else I could be trying at home?  You obviously work for a doctor or a hospital.  Is there something you have seen other patients try?  I am on a waiting list for the pain clinic but because I don't have private insurance right now the waiting list is almost six months long where I live and about 400 miles away.  I have an appointment in early November as the first time they can see me so *fingers crossed*  they have something different that 4 surgeons, 6 PTs, 2 OTs, and my doctor hasn't already sent me for.  I even mentioned that as a hopeful and prophylactic measure (since some have commented that pain can increase with poor digestion following GB WLS) I also take the aforementioned digestive aids (which I did not mention includes betaine hydrochloride, chewable enzymes, beano, and lactase) with every meal, drink a minimum of 64 ounces of water a day, take all of my necessary vitamins and minerals, and get at least 25 grams of fiber a day.  And, heck, I even moved to a place with less erratic weather trying to control that trigger--that's how far I've taken it.  Let me be very clear that I do get out of bed every day even if I am rapidly approaching that point that I don't know if I will soon want to.  I have finished school, I am working and studying for the bar, I live within walking distance of work (because it would be pretty irresponsible for me not to at this point), and I continue to do the things I need to do to be a functioning adult.  I don't cavort with people who take legal or illegal pain killers (that wouldn't look too good in my profession) outside of clients and all of the friends that I maintain regular, daily contact with are all drug-free.  I have an amazing support system of family and friends and I know how lucky I am to have them so it's not like I'm hurting for human contact or in want of distraction.  They keep me honest, too--they know how much I should be taking, my schedule, and they even do my exercises with me so I don't feel so weird about it.  (And when I'm at home, even my dog helps haha.)  I just can't do what I have to do without something to help me so what I need now is is something to fix what it is that is helping me do what I need to do.  I need and want it to be less oxycodone, and I need and want to spend less than the sometimes $1,000 I spend a month between pain relief remedies and digestive helpers.  (Thank God for Costco so I can buy most of this in bulk and save money that way.)

In response to your question about the exercise: The four hours includes up to 10, often fifteen-minute sessions of the PT breaks my PTs prescribed--crunches on the bosu to reduce the load on my lower back, vertical and horizontal leg lifts, clam shells, pelvic lifts, squats on the bosu to increase core strength--because I need to, apparently, be moving 15 minutes for every hour of stillness.  My pain does increase if I don't get up at least every hour and it will increase if I move too long.  I won't lie, most days it's not a constant movement for 15 minutes each go because it hurts too much to do it that way so I have to rest between exercises.  A ten-hour workday is really a 12-hour workday because I have to smash all of that in.  (Fortunately, I have the world's most understanding boss and even though I'm working for $10,000 less a year than I am worth, the understanding and accommodations are the only reason I am able to work.)  The other 90 minutes is the stretching (hamstrings, calves, runner's cross, quads, quadratus laborum, TI band) and walking.  I have to stretch to keep my joints moving and it's the first thing that every surgeon, doctor, PT, chiropractor, massage therapist, and OT tells me I need to be doing so I do it every day so I don't have to keep having that conversation.  Plus my dog needs to go out and it would be a pretty jerk move for me to deny her going to the park for the hour a day she's not trapped in the apartment.  (She's my rehabilibuddy--we've recovered together the last four years and I can't do her that dirty!)  I have tried doing less, I have tried doing more, I have tried doing differently, I have tried doing nothing at all.  I am trying but I can feel myself not wanting to try anymore.  To give everything a fair shake I do it a couple of weeks at a time (because you can't really tell in a couple of days, you really do have to give it an honest go) but I can tell you that different exercise routines, without or without medication, at a decreased weight in different combinations over the last 10 years hasn't yielded me better results.

The drugs cause nausea and lack of appetite.  I am sure it is harder to have weight loss surgery on top of that.  I hope you find some treatment to get off of the medicines and be able to enjoy your lighter body.

I never used to have nausea unless I took too much, which I can say hasn't occurred in at least the last six months.  (I can tell when I have had too much because my lungs start to feel pressure and I haven't had that since Christmas or before, really--it's not a pleasant feeling.)  Thank you for your well-wishes.  I really wish right now I had never done this.

I wonder if the dose that was right for you at 240 pounds needs to be lower now that you weigh less

That's what I thought, too, which is why I did a 30-day "dry out" period.  When I started going back to it (at the request of my clinic supervisor due to my decreased productivity and long hours at the office) I took it a quarter-tab at a time (1.25mg) which would have been at about the 60-pound loss mark in February.  I thought this would also help with the nausea but it didn't.  Since about mid-to-late March, then, is really where I have gone from 0 to 15 in a day (God, only 4 months).  I want to think that part of what has happened is that for the first time since taking the oxycodone, I have not really been able to stop taking it.  Before I never had a prolonged period of time to which I would habituate to the levels, if that makes sense.  There were days and sometimes even weeks where I could go without it so there was never really a time to get used to it.  (Not that I understand why people want to feel that way, blech.)  But when I needed it I needed it, and I had to report the use to my school, car insurance, my new employer... I guess Vicodin is apparently better long-term in terms of ravages to your body but I took 1 almost 10 years ago when I got all my wisdom teeth removed and was so sick I just went without.

The reason I got the surgery is my doctor and my surgeon promised me up and down that if I ever did have to take pain pills (after healing) again would be if something subsequent happened--another massive car accident, the onset of some incredibly painful disease, or what have you--because the weight coming off along with the PT was going to be enough to relieve the symptoms.  I really don't want to be on this medication--it is the worst.  I used to think that there was nothing more embarrassing than being hit by a drunk driver on your way to school and having to defend yourself as a passenger in the hit vehicle because they know you take medication like that.  Or having to test separately because it looks like I'm cheating when I'm doing my PT exercises during tests.  Or getting extra time on tests because every dose makes you drunk for an hour on the way up or down. Or having the school inspect your desk because someone stole your Schedule I medication.  It turns out having to explain it multiple times to the state and national agencies that control your licensing as to why you needed it, your continued need for it, and having no explanation as to why your remedial measures haven't been productive is worse.  Having to produce medical records from doctors who have retired or moved is just a pain--and getting affidavits is painful.  Every year that this continues I get to have this conversation in order to re-license.  I have wanted to do what I'm doing sinceI was 8 years old and seeing a future where something like this could stop me at any moment is the real worst.  I am going to be required to carry malpractice insurance even though it's not required for my state because my clients will have a prima facie case against any slip-up I make--about $5000 a year.  I don't want this to be my career, which is why I had the surgery, so I am just so heartbroken that it's been so much worse.  I pay a premium on my basic car insurance because of the medication.  These remedies that are only semi-tax deductible if you have an income are killing me.  The only thing saving me right now is that I can walk to work.  And realizing now that it's gotten so bad in 4 months...  November and insurance can't come soon enough.

Sorry, I know this is a /dump of information.  Thank you for listening.

Your initial question was why pain would worsen after WLS. You have a lot going on, but WLS is not causing your pain. If you were heavier right now, your pain would be worse.

I hope you find relief. But this really isn't a WLS issue.

What makes you think it wouldn't be?  I don't ask this to be facetious.  I have seen posts on this site and others that pain can increase if Rheumatoid Arthritis was triggered by the WLS or the connective tissues break down because the WLS malabsorption.  My pain was much, much better when I was literally twice the person--I was a 24W at 250 and am now a 12P at 148.  The ONLY thing that has changed is my weight.

There are a whole bunch of things in your post that explain your pain, but WLS is not one of them. For instance, some people have lifetime pain issues after a serious accident. And almost all of us start to develop arthritis and other pains as the years go by. Without WLS.

You've had so many tests, I'm sure they've ruled out vitamin and protein deficiencies. Except for vitamins, your malabsorption is no longer an issue at this stage.

I just think you are digging, understandably looking for answers. But I believe you are looking in the wrong place.