Tuesday, June 1, 2010

Vicodin in the news

Vicodin, Vicodin everywhere but not a drop to drink...

If I have seen it once in the news, I've seen it 50 times in the past week or two. Of course, there is the horrid case of Sean Payton and the Saints. We've been reminded about Brett Favre's Vicodin thing. Then there was Kevin Ellison. Then there was the former Miss Russia Anna Malova. NFL bust Ryan Leaf got hammered for Vicodin possession recently. Then we were all reminded that Dr. House M.D. loves Vicodin. I just saw Bad Lieutenant, Port of Call New Orleans. For the Bad Lieutenant, it all began with a back injury and a prescription for Vicodin.

Then they dropped the bomb-shell: the mixture of 5mg hydrocodone and 500mg of acetaminophen (Vicodin) is the most prescribed drug in the United States of America. Surprised the hell out of me. Then again, I was not surprised.

I heard a lot of people were using this shit. For the life of me, I can't understand why. This always goes back to the narcotic resistant thing. I have a nice red laminated 8x5 inch card in my medical file at Dr. Bachner's office. On that card, you can read the words printed in large bold black letters "Narcotic Resistant Patient".

Resistance does not equal tolerance. Tolerance develops over a long period of abuse. Resistance is genetic, and it means you flat-cold don't respond to narcotics the way others do, and you never will. I have a different Mu receptor than you do. My DNA encodes a different amino acid sequence there. That is all there is to it.

Vicodin didn't work well for me at all. I was in a hell of a lot of pain after my first surgery. It struck immediately as I came out of the Propofol. On the surgical table I could feel the burning, itching, throbbing, swollen, cut pain in my right knee. My anesthesiologist was stunned. He though the Demerol he had given me would be sufficient. It didn't work.

He ordered another dose of Demerol. As the nurse injected me, she asked me if I could feel it. That seemed like a strange question. "Nope" I answered. She was shocked. She expected to see my eyes roll up in the back of my head and hear me let out a grunt of ecstatic pleasure like "Ahhhhhhh..." This is how most people respond to narcotics injected into their blood stream. Not me.

She asked me a moment later if the pains was gone. "Nope, I can still feel it throbbing and burning. It hurts a lot." Unbeknownst to me, that was my second shot of Demerol. She was amazed. I withstood a second shot of Demerol with little or no effect shown. Eventually, about 15 minutes later, the pain began to die down.

That is perfect example narcotic resistance for you. No head rush. No euphoria. No immediate relief. Delayed onset of the analgesic effect. Shorter duration of that effect. The doctors cannot control post-surgical pain using the weakest narcotics, which is the normal convention. Demerol and Vicodin weren't worth poop-squat to me.

Vicodin didn't do much for me after the surgery. I was in a lot of pain a few hours after than Demerol shot. I slept like crazy, partially to get away from the pain. It was a troubled sleep. It was not a restful sleep. I would be awakened many times by eruptions of 'break through' pain. I would take the Vicodin. It didn't do much for me. It made it a little better. I still felt plenty of pain.

For me Vicodin = weak and infective.

The second time around was entirely different. The Doc knew what he was up against. When I came out of the surgery the second time, Dr. Bachner ordered a double-dose of Dilaudid (dihydromorphinone). Dilaudid is 10 times more powerful than morphine. Demerol has only about 20% of the strength of morphine. Dilaudid is 50 times stronger than Demerol. He rolled out the big guns. He wasn't fucking around.

Dilaudid worked. I was comfortable after the second surgery. I didn't feel much or any pain. I still didn't feel "high". I had no delusions of godhood. I didn't feel sheer bliss. I was happy that I wasn't in pain, but that is not the same thing as euphoria and sheer bliss.

The surgical nurse monitored my pulse and breathing very closely after shooting me with two doses of Dilaudid. She had to make sure my respiration and heart rate weren't suppressed. There was no problem. My heart rate was between 65-68. My O2 saturation was at 97%. I was breathing fine.

This is another example of narcotic resistance for you. A resistant patient can take a double shot of Dilaudid, not get high, and not experience suppressed heart rate or respiration. If Marlin Perkins of The Wild Kingdom shot me with one of his famous narcotic tranquilizer darts, it might not work on me.

The Doc prescribed Norco for me the second time around. This is also hydrocodone and acetaminophen, however, the fuel mixture is different. Vicodin is 5mg hydrocodone and 500mg of acetaminophen. Norco is 10mg of hydrocodone and 325mg of acetaminophen. It did work better. I still experienced some pain, but not much. I was comfortable.

Incidentally, both times I stopped taking them cold-turkey. I didn't like feeling the pain again, but there were no flu-like symptoms. About two weeks after quitting the Norco, I caught a cold, but that was a fully-authentic cold. It was mostly about coughing and snot running out of my nose. This was not a case of withdrawal symptoms.

One of the advantages of being narcotic resistant is that I will probably never know the agony of withdrawal symptoms others suffer. My body doesn't like the stuff the way yours does. 97% of the people are like you. Only about 3% of the people are like me. I am a member of tiny minority.

With all that in the rear-view mirror, you can understand why Vicodin addiction is a mystery to me. I don't like the shit at all. Acetaminophen is worthless crap that hurts my liver. I don't want 500mg of that. 5mg of Hydrocodone doesn't come close to getting the job done. If a doctor were going to write me a prescription for Vicodin to control the pain of my arthritis, I might just say "thanks but no thanks, can you prescribe something else for me?"

Ask for Vicoprofen by name. 7.5mg of hydrocodone and 200mg of ibuprofen. I think 2 of those will produce the perfect analgesic effect.

With that said, I would like to say a word or two again those who recommend an FDA ban on Vicodin. The dirty little secret that the medical profession keeps in the closet is that there is only one way to control pain: block the Mu receptors on your nerves.

Despite billions of dollars in research thrown at the problem, we still have one and exactly one class of drugs that block Mu receptors. That is the opiates, or narcotics. Both terms refer to the same thing. These are chemicals that come from poppies, although a couple of patents have been granted to firms that can synthesize these agents from raw crude oil. (!!!)

This is where I have bitch-slap Mr. Matthew Herper of Forbes magazine. He recently suggested that Bextra (a chemical cousin of Vioxx) should be the FDA recommended replacement for Vicodin.

Bah! What drivel! What ignorance! He's obviousness never had arthritis.

Bextra is an NSAID. It is a Non-Steroidal Anti-Inflammatory Drug. There are many NSAIDS. Aspirin, acetaminophen, ibuprofen, naproxen sodium, and other drugs are members of the NSAID class. NSAIDs work by blocking two enzymes COX-1 and COX-2 which form prostaglandins. Prostaglandins are hormonal chemical messengers often responsible for fever and swelling.

Bextra is a so-called COX-2 inhibitor. This means it works by blocking COX-2, but not COX-1. In stark contrast, you plain old aspirin and acetaminophen block both of them. Is there any advantage in blocking COX-2 but leaving COX-1 alone?

Once upon a time, the theory said there would be. However, life is a beautiful theory ruined by an ugly fact. Years of use say there is no advantage. There may be serious disadvantages, like greatly increased risk of heart attack and stroke. Dr. Bachner will not prescribe these drugs. He doesn't believe in them. He thinks ibuprofen works best. So do I.

It is better to block COX-1 and COX-2. We should remember that common aspirin reduces the risk of heart attack and stroke. It's good for you.

EVEN IF COX-2 inhibitors like Bextra worked better than aspirin, which is not true, Bextra still does nothing to replace the Mu-blocking power of Hydrocodone. COX-2 inhibitors don't block the Mu receptors as narcotics do. If you don't block the Mu receptors, you don't kill pain. Ergo sum, Bextra can never replace the role Hydrocodone plays.

You might put hydrocodone together with Bextra, but I would rather not. Give me Vicoprofen instead, if I have to have something.