Manic Episode after Surgery & Hydrocodone
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Q:  Manic Episode after Surgery & Hydrocodone 

Dear Dr. Phelps,
My husband has been diagnosed with Bipolar.  He had been given Zoloft and seemed to be doing quite well.  Unfortunately, he was injured at work and had to have othorscopic knee surgery.  After the surgery he was prescribed hydrocondone for pain.  He almost immediately suffered a severe manic episode.  Could these medications (particularly the anesthesia or hydrocodone contributed to his episode?  He lost his job as a result of the mania.  I remember reading somewhere that one needs to quit taking Zoloft 6 weeks prior to surgery, but I can not find the source of the information.  Currently he is taking Oxcarbazepine which seems to be helping.  I have been unsuccessful in my research concerning these drug interactions.  Any information you might provide would be appreciate.

Thank you,

Dear Ms. B' -- 
Of course, it sure would help in trying to answer questions like this if we knew more about the actual causes of bipolar disorder.  For example, there is clear evidence that stress is associated often with the first episode of mania or depression in someone with bipolar disorder.  So, supposedly a surgery like this could represent a stress, certainly a physiologic one.  

Or, perhaps there was an interval without Zoloft, at least a few days?  There is a phenomenon called "antidepressant-discontinuation induced mania" (if that wasn't such a mouthful, maybe it would be more widely recognized...).  Perhaps a few days could be enough, particularly in someone who's not taking a mood stabilizer. 

Now, how about the oxycodone?  Well, the problem is, we see a fair number of folks who are known to have bipolar disorder and who are on medications for it, who then go on oxycodone or some other narcotic medication for pain, who don't seem to experience destabilizing effects from it.  Generally speaking, I think most of my colleagues and I worry a lot more about alcohol, and perhaps even marijuana, than about pain meds.  We don't, for example, routinely tell people to avoid them as much as possible if they're going for a procedure like your husband's.  We let the orthopedist treat pain just as she/he usually would.  We pay attention, mind you, as folks can get hooked on that stuff, but that's more the level of concern, not the destabilizing potential.  I worry more about steroids, for example -- speaking of which, you might check to see if he got one as part of the procedure, even if it was only injected into the knee and not his general circulation (anything ending in "-asone", as in dexamethasone, etc.). 

Should he have quit 6 weeks before?  Generally if things are going pretty smoothly and I know someone has bipolar disorder, I'd take more like 4 months to go off (because of that "antidepressant-discontinuation induced mania" thing), so that may not have helped, except if he really did just go without for a week or so, maybe a taper would have been better.  As you can see, looking backwards it's easy to wonder about lots of "shoulda's", but hard to be conclusive about anything.  

Dr. Phelps

Published March, 2003


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