When terror follows the surgery

Opiates: Post-operative patients left to administer painkilling medicines should be clearly informed by hospital staff of the risks and mind-altering side effects some drugs can carry.

January 21, 2001|By Richard M. Cohen

IT WAS LIKE WAITING for a bus. The holding area for surgery, which doubles as the recovery room, was packed. Family members were sprawled on plastic chairs as stretchers moved in and out. A sea of green scrub suits rushed around directing traffic.

"Hello. I'm from pain control." I was startled as this doctor pulled back the curtain. "I am an anesthesiologist, and I'm here to discuss your options for handling the pain after surgery."

So began my most extraordinary drug trip, the most intense since controlled substances carried a generation of goofballs like me into the darkness or light or wherever it was we were traveling in any given moment so long ago.

My choices this time: an epidural block, familiar to anyone who has spent time in labor and delivery rooms, or a peculiar device for self-administering a liberal dose of morphine every six minutes.

That was it. The epidural was ruled out because I have multiple sclerosis, and this block could mask the M.S. symptoms likely to kick in after surgery.

Morphine it would be, though I did not know what I was in for.

"Morphine and the other opiates are powerful drugs," Dr. Richard Friedman, director of the psychopharmacology clinic at the New York Weill Cornell Center in Manhattan, later explained.

"Most people think opiates are just analgesics, but the opium receptors are distributed widely throughout the brain and they can have deep effects on cognition," he said.

In my case, those effects took me on a wild ride.

"It is called an agitated delirium that is drug induced," said Dr. Kathleen Foley, a neurologist and pain specialist at Memorial Sloan-Kettering Cancer Center.

"Hallucinations are one of the common side effects we see in a postoperative setting. They are transient, and they're frightening," she said.

Nobody told me to watch out, however.

The doctors said nothing. I do not remember any pain after this successful operation for colon cancer.

Three blurred days of numbness would pass before I would begin to realize that something in my head was going wrong.

I just kept pressing that button for morphine. No doorbell rang or elevator arrived. I felt no sensation. I was not convinced the button was connected to anything.

It was, and a disabling confusion was slowly replacing this phantom pain.

The walls were moving and they were changing color. Full-length curtains, where there were simple white walls, lined the large suite, until, it seemed moments ago, only a small hospital room.

These pastel curtains billowed in the breeze as warm, tropical air blew softly through an open window.

Not bad for the weekend before Thanksgiving.

Suddenly, the fabric turned to marble columns. They felt cold and foreboding.

Then I was lying comfortably enough on the floor, propped up against the wall.

A friend, the social critic Todd Gitlin, arrived for a visit, and I wondered darkly what he wanted. Todd carefully stepped over me.

"Not only does that not jibe with my memory, it doesn't jibe with reality," Gitlin said, pointing out that he never saw me out of bed. He added: "You were focused deeply inward, as if you were in some inner state of wrestling with yourself. You rolled over and back a few times. You would get out a few words, as if you were straining to get words to come as you wanted them. You did say that you were hallucinating."

Very true. The television on the wall had become a seething, menacing device. It was breathing. Fog emerged from somewhere, surrounding the tube as it moved about the wall. The TV leaned forward from its mooring, leering and somehow threatening me. I was frightened.

"You become incredibly paranoid," Foley said afterward, "and restless, thrashing about in the bed. You can leap out of bed, or call your wife and say the craziest things to her."

I did phone my wife and asked her to come back to the hospital and talk me down. "You were trying to sort things out. You seemed very scared. You wanted reassurance that the walls were not closing in," she recalled. "You spoke specifically about the television looming, that it was looking at you maliciously. You said: `I'm so nauseated. I don't think I can do this much longer.'"

By then, I knew it was the morphine. I rang for a nurse and asked to be disconnected from the apparatus feeding me the drug, even to have it taken from the room. I vomited wildly, and the crisis was over. The pain snuck back slowly. I did not care. I had my head back.

"You had a psychotic reaction, in the sense you had a perceptual disturbance," according to Friedman. "You were literally hallucinating. I have heard this before, these reactions to opiates."

What is apparent is that such reactions, though unusual, are not unheard of, especially with patients left to administer morphine to themselves with no supervision or monitoring.

"This device assumes people won't administer more than they should. It's not being controlled, and brains are totally different in sensitivity." Friedman said.

He said some people worry that such devices "could potentially be unsafe if they are not monitored carefully in a delirious patient."

"I totally agree with that concern," he added. "We don't want a confused or disoriented patient pushing any buttons."

Some hospitals have a standard assessment for postoperative patients that, among other concerns, monitors pain medication.

Patients are asked several times per day about complications including hallucinations and behavioral changes.

As far as I remember, there were no such sessions.

I now know to ask questions. Patients do not understand the world of drugs and palliative care.

We deserve full disclosure, not some harried doctor who throws a couple of pain management choices our way moments before we head for surgery.

We need to be warned.

Richard M. Cohen wrote this article for Science Times and it was distributed by the New York Times News Service.

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