Post-operative Pain in Taiwan - Beware

[Lord Lucan]

[EDIT: Obviously this is a tongue-in-cheek post. I would like to point out that my experience with opiates for pain relief - which is the only reason I've ever taken them - is that the whole experience is pretty unpleasant, but that it sorts out the pain. The side effects of nausea, sedation, fullness of the stomach and general grogginess are pretty unpleasant. I can't imagine how people take these for fun or get addicted to them. I certainly would not be mucking around with them. Yuk.]

This what I'm trawling the internet for now. Did you see that 40mg OxyContin tablet? Phwooar! And that bottle of Percocet? I would happily give NT$5,000 for a week's Percocet right now. I know it's rude, and not fair on the other members who are not spending these fine spring days in relentless agony, but here are some corkers I found today on the internet:

WARNING! NOT SAFE FOR THE TAIWANESE MEDICAL PROFESSION! DOCTORS! CLOSE YOUR EYES! YOUR CHILDREN WILL BECOME HEROIN JUNKIES! YOU HAVE BEEN WARNED!



What can you say? The full range of Oxycodone/Acetaminophen(Paracetamol) combinations. Beautiful colours and nicely differentiated geometrics. Have the added advantage of dual action with the opioid and paracetamol, using two different but effective ways to provide that post-operative analgesia that I need, but am not getting. One does have to frown though at the waste in pairing up a almost perfectly safe narcotic with the scary frightening paracetamol preparation which is sometimes fatal at 6gms.* Do not take more than the prescription recommendation - when they say this about paracetamol products, they really mean it. It's called a narrow therapeutic index (the lethal does is not much more than the therapeutic dose.)

Let's move on.



A lovely pair. No dangerous-in-overdose paracetamol to worry about here, just pure pnr analgesia. This is the pill that most frightens America (and the UK and all). This is more or less the strongest oral analgesic on the market, apart from oral morphine, which frankly I wonder about. (If you need morphine you need it perenterally. That's a word you learn by the way if you've been in serious pain for ten days with internet access.) Yes, anyway, this one is all opioid. You can take this one right up until the pain goes away, no "oh shit I can't take any more until next Tuesday but it still hurts like fuck" with this baby. Obviously if you push it beyond the bounds of what's sensible you'll fall asleep. Er, and that's about it. (No mulitple organ failure or dissolved stomach syndrome as with those very expensive new drugs like paracetamol or NSAIDs). Yes, you have to be either suicidal or, no, suicidal AND out in the back of beyond to die from this one. Why? Every hospital, and every ambulance in The World, has the antidote: Naloxone. That's the bit in Trainspotting when he falls down the hole, and then is sucked back up. I could go on. But for those planning to go out and eat a heroin factory this weekend, it's the depressed breathing that kills you. But as a painkiller taken in small doses, there's little to beat it for efficacy or safety. Well, I say "efficacy" - I wouldn't know of course would I? God it makes me mad to think there are daft fuckers out there addicted to painkillers when I can't even get them for a medical condition that indicates "analgesia at the opioid level, Bones! I need everything you've got!" ["My Gaaad Jim, they're still using Junior Disprin! This isn't the Stoooone Age!"]



Very well turned out threesome in a very tastefully-lit arrangement. And lovely to see these three beauties displaying their wares all over the table. Rubbery Jubbery. Enough analgesia there to make even the most chronic old wheezebag giggle like a spring chicken. On the other hand, it could make you want to buy a gun and run amok in the nearest hospital. Probably easier to buy a gun actually... Probably do more time for the painkillers, too....



One for the vintage afficianados. Not exactly wowing them on the catwalks of, er, Boots the Chemist, but still providing relief to those requiring medium-term post-operative analgeisa. But hey, any port in a storm of crippling and debilitating pain, eh sailors?



Rare foreign edition. Doesn't exactly set your world on fire, but those dusky maidens from far away shores sure know how to give a guy 15mg of Codeine phosphate and 325mg of paracetamol! Hint: Try Tijuana. Another hint: Tried eleventy billion milligrammes of codeine the other night for me pain and I might as well have shove... Ahem. Next!

And when it's time to go... dim the lights please gentlemen... the one you hope you never have to take... but kind of know you will someday....

WARNING! NOT SAFE (OR FUNNY) FOR PEOPLE WHO HAVE RELATIVES WITH CANCER OR WHO HAVE JUST DIED OF CANCER AND THAT SORT OF THING!



Remember kids... Drugs are bad. Stay away from them. I have, and look at the fucking miserable twisted git I've turned into.

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*The irony of course of these combination opioids and paracetamols is that it is always the paracetamol that kills you. No, sorry, the real irony is that the company that licences OxyContin (no paracetamol) is probably going to lose that licence in favour of the combination product because, now get this, people are more likely to die by taking the combination drug (bear with me) and are therefore "less likely" to overdose on it!!! Now, I'll run that by you again: People are less likely to fuck with the really dangerous pill (the one with paracetamol) because that will kill you. Therefore, we licence the really dangerous one, and ban the pure opioid one, which if doctors were honest with you about, you would puke up (because of the tablet filler) long before you could take enough to kill you. In the US they are just about to take the licence of the pure opioid away because there is less liklihood of abuse of the combination drugs because painkiller addicts say "gee, I'll not chug this one or grind it up and blow it up my ass [or whatever] because it's got paracetamol in it". Yeah right. Emergency rooms all over the shop are full of people being told "I'm sorry Mrs Jones, if only he'd overdosed on morphine or heroin or something we could have saved him, but he went bananas with the Percocet." Is Rush Limburgh stupid? No. He knew the OxyContin would never kill him. I rest my fucking case Mr Doctor-poo. And your mother was an amster.

[Huang Guang Chen]

On the other hand, it could make you want to buy a gun and run amok in the nearest hospital. Probably easier to buy a gun actually... Probably do more time for the painkillers, too....

Oh dear. You're probably right. Television is the new opiate of the masses, and you need to be alert in order to get your fill.

BTW, sadly those panadol codeine combos are also no longer available in Thailand.

HG

[Mr He]

Can't you have it send it a discreet package?

An alternative would be to get your missus to go and see the doctor twice per day, or you do that yourself.

[Lord Lucan]

Thanks to the help of a fellow Forumosan, I have been able to find a doctor who specialises in pain. I will post up his details later. Unfortunately his medication is beginning to kick in and I need to lie down. I will also have some advice for people facing surgery so they don't have to go 10 days without food and end up with NSAID-induced GI bleeding like me.

Eating real food for the first time in 10 days. Wonderful feeling. I went for succullent Southern Fried Chicken. Will follow up with some hot buttered toast made with freshly baked bread out of the bread machine. Wow. Now to put back on those 15 pounds I lost this week.

[Tigerman]

Lord Lucan,

Ugh... I feel your pain! Seriously, hope you get feeling better very soon. And I hope the surgery was successful, notwithstanding the level of pain to which you have been needlessly subjected.

That's nothing. I had a kidney operation and post the operation I went 3 hours without a single painkiller until I was eventually given 20milligrams of morphine. That worked like a charm. And the best part about it was I didn't need the operation. It was a miss diagnosis.

So long as were telling war stories...

I have a 16 inch scar that runs from just above my willy, passes through my belly button, and ends just below my sternum. I received this scar the last time a had a second section of my colon removed... During pre-op, the anesthesiologist came to see me and to discuss options for post-op pain relief. I told him that I remebered feeling lots of pain after my last surgery, and that I understood and expected to feel pain again this time. But, the guy waved his hand and asserted that they had become much improved over the past 15 years. He asked me if I wanted to have an epidural... I remembered that my wife had been awake during her c-section and she never felt anything... so, I replied that yes I would like to try the epidural.

The problem with epidurals is that they are hit or miss. When my wife was awake, the docs could test whether or not the epidural was working, simply by touching her from toes to upper legs and asking her if she felt anything. The funny thing was, she was so frightened that she kept answering in the affirmative, up until the doc pulled Zack out and showed him to us!

My epidural didn't work. It had missed. That's the story of my life... so, when I woke up in the recovery room, I was in really acute pain, and shivering from the cold that many people feel after surgery.

I stayed like that for 12 hours, until the night nurse came on duty and said, "WTF! The epidural either works or it doesn't. If you are in pain, its because it didn't work and you must be in loads of pain." She started me on morphine, which I only used for a day, IIRC. I hate pain... really hate it... and pain inhibits recovery. But, after I started to hallucinate again... nasty hallucinations... I rejected the morphine and took some simple pain relievers such as Tylenol (not so effective for a 16 inch cut through the abdominal cavity... but, no hallucinations.

BTW, my father always said that there is very little chance that one could become addicted to pain-killers if one took them only while in pain.

[Huang Guang Chen]

Modern pain thinking is basically that pain is a fucker and it need not happen, which to me smacks of sweet mercy.

In my previous life as nurse Ratchett, aside from holding the keys to the asylum, fortunately, I also worked for 6 years in operating theatres in Sydney. Great weekend job when I was studying Chinese - no routine operations, emergencies only and oodles of overtime pay if we came in out of hours.

Here's some tips from that time and other experience should you ever face an operation or pain:

Anaethetists are the smartest doctors and recognised as such by the medical hierarchy. They are responsible for your life, pain and whether you say good things about the surgeon. Most people never remember their anaethetist. I would prefer to elect an anaethetist than a surgeon, who should be a mere monkey trained by the repetitive practice of relatively simple hand movements.

You talk to your anaethetist about pain management. They specialise in the neurological interaction of various drugs and other interventions and define the limits of what can and will be used. Also speak to your surgeon. It's better to have them both think you're a woos than a Spartan.

Careful about sounding too keen with the nurses about your post-op pain management, unless you strictly use that very term. Start with something like, "Ripper, I'll get a morphine drip out of this" and alarms go off in their heads. Time wasters seeking treatment and pain relief to feed prescription drug problems are a tedious reality in the health system. They are often also violent. Nurses don’t like violent people; they see too much violence - usually at home.

Be that as it may, nurses are some of the most twisted, fucked up, evil alcohol/prescription drug popping and passively aggressive people on the planet. Do not piss them off!

Nurses are your unfortunate conduit to someone with brains and hopefully sense. They are also translators, with one foot in the heady hierarchy of the quacks and another in the bogs of their lowest patient. They have to speak all languages in between.

Nurses have outrageous power for such fucked up people, the keys to the Scheduled drug cabinet, for example. They are responsible, and god knows why, of ensuring every amp of anything deemed too fun for the free market is accounted for. The red key chain accesses pure medical grade cocaine and opiates, amongst other things. Special K, a disassociative anaesthetic and now a party drug, was never accountable; there were shelves lines with it.

Obviously the temptation is too much for many. Some are caught and sent off elsewhere to work, or are that sneaky they're still doing it and not been caught. Anaethetists are also the more frequent freaks among the doctors. If you're lucky, the parties can be fantastic! Anaethetists also tend to kill themselves. As the most knowledgeable doctors, they usually only try once, and of course, it works. None of this pussy-footing wrist scratching for these boys.

At the end of an operation that involved cutting or burning, they usually insert local anaesthetic - lashings of it. People like to go home after work, not come back and sort you out cos you're gibbering in pain - there's your leverage! As such, the anaethetist, NOT the surgeon, writes you up for post op pain relief. This is usually, even on the most simple operations, more than enough to deal with what is expected. The problem is, that it is almost inevitably written as a PRN (pro re nata), or as required. Now since the quacks are not going to be there when that local wears off, the nurse is in control of your happiness. That evil witch doles out the "as required, or pro re nata, pain killers.

Your leverage is to be a decent human being, or at least one a wizened, husband loathing, all life's opportunities slipped me by, I got doctors thrusting their outrageous pay discrepancy in my face as my mortgage is killing me, prescription drug wrecked invariably hungover loather of life can empathise with. I'm not kidding and I really have no axe to grind.

Your other option is to be a nurse, but not one that's worked with anyone you deal with, and especially so if you are even vaguely considered an arsehole.

You can, however, get between the nurse's malice and the penchant for a smooth shift - she really does not want to call the anaethetist saying you are screaming in agony but she hasn't given the "as required" drugs. Exploit that. T
The trick is to make sure she doesn't call and say something like, "yeah, but I think he really just wants the juice," cos they might just give you an injection of salt water. Doctors are generally indebted to nurses as they tend to spot and alleviate a doctor's mistakes. When doctors are training, nurses literally save their patients' lives and the quacks' careers.

All true.

HG

[Lord Lucan]

I will also have some advice for people facing surgery so they don't have to go 10 days without food and end up with NSAID-induced GI bleeding like me.

1. Discuss the post-op analgesia with your doctor. Think about whether you would have the operation at all if the post-operative analgesia were to be poor. Ask him who will be responsible for pain control after the op. I am assuming it is an out-patient procedure. You will need to find out whether is one of these doctors who knows nothing and cares less about pain control. If it happens to me again I will ask for the names of the drugs and their classification. If he doesn't want to talk about it that means you will be given panadol. I went to see a specialist the other day and he was quite happy to talk about the range of pain control measures available and which would be most suited to me. If you are the sort of person that needs a lot of pain control then tell the doctor that. If you have stomach ulcers or a history of that you must tell the doctor so he won't give you NSAIDs. You will also need to discuss what medication you will be taking to provide a base level of pain control, and what you can take on occaision for breakthrough pain. For example, my new doctor prescribed a certain long-acting drug "A" and advised that in the event of sudden excruciating pain that I could crush up the tablet before swallowing it so that it would enter my system quicker. And the doctor will tell you how much as a maximum you can take in any 24 or 12 hour period. If you need more pain control you need to go back to him, and he should provide a number you can call him on, or some way to get in touch with someone who will understand your pain history and responses to previous drugs. If you have previous prescriptions which did not work, bring them with you.

2. The Taipei Medical University Hospital (http://www.tmuh.org.tw or http://www.tmch.org.tw) has a Pain Clinic (疼 痛 科). The address is: 台北市信義區吳興街252號 (Wu Xing Jie) and the nearest MRT is the City Hall (市政府) stop. Then get a taxi.

The phone number for appointments is 2738 0032 and the surgeries are on Tuesdays. They take the Jian Bao card, as would be expected. I have no idea if he speaks English, but the doctor I saw (Dr Li) listens carefully and prescribes treatment based upon your history and what you tell him, not any preconceived notions. Again, you have to be clear about what has and has not worked for you in the past. And also be clear about other medication you are taking, or might take, or any side effects you have experienced in the past or which may worry you. Don't forget, these guys do not have your medical history. If this is your first visit, he doesn't know you from Adam. For example: Are you allergic to asthma? Breathing problems? Ulcers? Adverse reactions in the past?

I recommend you get your doctor, or a sympathetic doctor to write a "zhuan zhen" (?) letter or whatever it's called to the doctor at TMUH. I'll call it a "referral" for the sake of argument. This may enable you to get to see him if it's a Monday evening for example, and you are urgent. And if you're in this much pain you are urgent.

3. Worth remembering that small clinics do not have access to opiates and that paracetamol is almost always what you are given for any degree of pain. Remember also that it is cheaper to buy paracetamol from a chemist (in bulk) than to wait ages for a doctor to prescribe you two days' worth.

4. Remember that doctors here are paid by the number of patients they see in a day, and are planning to give you 2.54 minutes of their time. They probably do not have the time for the long discussion and investigation into your medical history that is necessary before prescribing strong painkillers. Prescribing controlled drugs is just too much "mafan" for most. Find out what the exact name of the drug the doctor wants to give you, and if it's Smarties, just say no thanks, and leave. All haggling will do is make you look stupid, make you feel cheap, and result in the grudging prescription of an un-named NSAID with a billion side effects.

5. If you get a white round tablet, it is probably paracetamol/acetaminophen. Remember not to take more than the prescribed dose of this as it is very close to the fatal dose. It will not be labelled with its real name.

As an additional note, the TMUH has patient-controlled pain relief machines for post-op inpatients. I don't know whether this is available for Jian Bao patients or not.

I strongly recommend international medical insurance for long-term expats. It is a lot cheaper than you might think. The Jian Bao is going to hell in a hand basket and when you need that big op do you really want to be sitting in one of those Apple Daily beds with fifty billion strangers at your side? Or do you want to be in your own private en-suite room in the new wing at Tai-Da? The other benefit is that for elective surgery most firms will pay for the treatment anywhere in your area of cover, but you pay the flights. Meaning you could go home for that Big Op and go private and have the family there. For me, some of those private hospitals in Thailand look superb both in terms of their 5-star hotellishness as well as their private-only level of treatment (Thailand and Singapore are where most Asian medivac patients end up because that's where the best treatment is), and a week's recuperation in Thailand might be just the thing. Anyway. HTH.

[Fox]

HG,

At one time I worked in a surgery at the Howard Florey Institue in Melbourne. It is a medical research facility where they do a lot of testing on animals. I was a medical science student and my job was to prep the animals for surgery. The surgeons would always point to the anaethisist saying he was the most important man in the room.

My epidural didn't work. It had missed. That's the story of my life... so, when I woke up in the recovery room, I was in really acute pain, and shivering from the cold that many people feel after surgery.

Tigerman,

That is very similar to what happened in my case. Except that seconds before the surgery the anethisist asked me if I'd ever had a back injury, in which case he wouldn't give me an epidural. Because I do have a back injury he gave me a general anaesthetic. When I came round my chart showed I'd had an epidural, but infact besides being knocked out I'd had nothing to manage the pain. I thought my experience was probably just particular to Taiwan, but these days I've come to realize that medical bungles are totally common place.

[spark]

so basically Taiwanese are nazis with prescription pain meds like the rest of the world.


Thank you George and Laura.

[Eros]

Just to add my two cents, I busted my hand up quite badly a few years ago. Prior to surgery there was no discussion of post-operative pain management. Honestly, I never thought of even asking - I knew it would hurt and I probably assumed I would be given a pain reliever.

Well to confirm what others have said, I received no pain reliever aside from Panadol (acetaminophen). I never even received anti-inflammatory medicine.

I was later told that this was to aid in the healing process. I don't know about that. I have read some reports that support this claim but the pain was really almost unbearable. I think I would have sacrificed a week of healing time in order for less pain.

But it is what it is, and it was what it was. I'll know better (if there's a) next time.