I Am Allergic to Codeine. Any Suggestions for Pain Control After Mommy Makeover?

For patients who are allergic to Codeine, it is first important to know what type of reaction the patient has.  In many cases, it would be acceptable to use Vicodin or Percocet as alternatives. Ultram is another alternative for patients who have had severe reactions to Codeine.  My favorite, however, is the new local anesthetic called Exparel that I inject along the incision lines at the end of a surgical procedure. This new anesthetic last for three days rather than a few hours.  It is extremely helpful at diminishing the need for oral analgesics and is associated with fewer side effects.

We discuss pain management in clinic before the surgery in details . If you are allergic to codeine, the anaesthetist will discuss your options and might prescribe you tramadol type of pain killers in conjunction with paracetamol and ibuprofen. For good pain relied, you need to take regular painkillers.

Great question. Post operative pain is one of the most important comments of a successful surgery. When pain is well controlled patients feel better, they get better sleep, feel more rested, they move around more easily, and get back to every day life more quickly. It also has been shown to decrease complications! As such we take pain control very seriously.
We utilize a concept called enhanced recovery protocol. Narcotics (such as codeine) only represent on small aspect of pain control, and fortunately there are many alternative available if we encounter patient allergies. This multimodal approach treats pain at several different targets within the body.
We start in the OR by performing a nerve block on the abdominal wall with a long acting numbing medication. This will provide on average 3 days of pain relief and it starts before the surgery is even done. It has been a total game changer for our patients! We then add Tylenol and a nonsteroidal anti-inflammatory (think of ibuprofen or Advil). These help reduce inflammation and add a baseline of pain control. Next we use gabapentin, which directly affects the nerves to decrease the level of pain. Then we add in a muscle relaxer, especially for patients that have the abdominal wall muscles tightened. As this is often an under appreciated cause of pain. Finally, we use a narcotic for any “breakthrough” pain. Our patients have generally been off narcotics within the first few days of surgery.
This whole concept steadily gained popularity for a couple reasons. First and foremost, many clinical studies have shown improved patient outcomes and decreased complications. So good pain control can help make our surgeries even safer! But secondly, our patients have been wanting to minimize the amount of narcotics they take. This approach has also been shown to decrease amount of narcotics patients take after surgery. The opioid epidemic has really made this more important for our patients.
So whatever the reason for avoiding narcotics, (allergies, fear of addiction, unpleasant side effects) we have been able to treat post operative pain with great success while also minimizing or eliminating narcotics!

Sensitivities and allergies are very common when dealing with patients who are scheduled for surgery.

I often have multiple medication's that I prescribe that help in giving different type of therapeutic solutions to patient's pain. This is called multimodal therapy.

Multimodal therapy often allows you to decrease the amount of narcotics that you take especially in the early postop. Which also helps and decreasing the side effects of narcotics such as: constipation & nausea

And example of this would be to prescribe extra strength Tylenol, Celebrex, gabapentin and Hydro morphone.
Depending on the initial reaction that you had with codeine a different narcotic class such as hydromorphone may help as it is similar to codeine but may be better tolerated in some patients.
There are numerous other narcotic class to mention as well, but it goes well beyond the scope of this question.

Its always recommended to discuss these issues with your surgeon at the pre-op visit and hopefully this will allow you to have the smoothest recovery possible!

best of luck

First, let your plastic surgeon know about your drug allergies and the type of reaction you get from them. For example, some people get mild itching that is tolerable, while others have much more severe reactions.

There's many ways to tackle pain control following surgery. Narcotic alternatives to codeine include: (Norco) hydrocodone/ (Percocet) oxycodone/ Nucynta (tapentadol). Flexeril is a muscle relaxant that may help with muscle spasms (if the breast implant is placed under the muscle, or if the 6-pack muscles are tightened during the tummy tuck). Some surgeons use a "pain ball" that slowly releases a longer-lasting local anesthetic over several days after surgery, while others directly inject the local anesthetic during time of surgery.

Overall, an allergy to codeine shouldn't prevent you from having surgery. But it is important to discuss it with your plastic surgeon prior to surgery to map out the best pain regiment for you. Hope this helps!

There any many different options available if you have an allergy to a particular drug. Dr Ngan works with highly qualified Specialist Anaesthetists who will contact our patients prior to surgery to discuss any allergies or reactions they have had previously to particular drugs. We will ensure you are given the appropriate pain relief suitable to you following your procedure.

Regarding any drug allergy, it's important to know if you have a true allergy or just sensitivity. A real allergic reaction usually causes a rash, especially hives (raised, red, itchy welts). More serious reactions can lead to anaphylaxis (facial and airway swelling, a decrease in blood pressure, and other symptoms). Patients who have true allergic reactions need to make sure all health care providers are aware. Sensitivity may include nausea, vomiting, head ache, itching (without rash), or similar symptoms. Patients should avoid these medications because of these symptoms, but this is not an allergic reaction and therefore not dangerous.Sometimes patients may not be sure of what their reaction was, or even what the causative medication was, because the episode happened in the distant past. Explain this to your doctor.Finally, codeine more commonly causes sensitivity than allergy, but if you had an allergic reaction, other narcotics can still be used with care. There is a low incidence of cross-reactivity, but all narcotics are morphine derivatives and therefore similar. Discuss with your surgeon and pharmacist.Good luck.

There are a few good options for pain control for those who are allergic to codeine.  There is an injectable anesthetic called Exparel that can be used in the OR which helps to decrease pain for the first 24-48 hours in the areas that were injected.  In addition to this, there are medications in pill for such as Norco, Percocet, or tramadol which are often well tolerated even with your allergy to codeine.  You should discuss these options with your surgeon to determine the best options. 

Discuss your specific reaction with your doctor.    Most patients who have a bad reaction to codeine can still take hydrocodone or oxycodone.      As others have mentioned, the use of Exparel has decreased the need for narcotic medication, and over-the-counter pain relievers or tramadol might be sufficient for you as well.     Also, more physicians are using tylenol (can be used orally) before surgery, gabapentin, celebrex and other non-narcotics rather than opioids.

Thanks for your question. I use a lot of local anesthetic for immediate pain control at the beginning of the surgery and then inject Exparel during the surgery. This provides immediate pain control and then extension for a few days. It allows early ambulation and a speedier recovery. I feel like this combination along with TissuGlu helps a lot and minimizes the need for narcotics. Nausea and/or rash to codeine in the past doesn't mean you can't take hydrocodone or oxycodone. If you are sensitive to those, Ultracet is helpful but just not as strong. All of my patients also take ibuprofen immediately after surgery for the firs week or so. 

Many patients have had a bad reaction (such as severe nausea or itching) with the use of narcotic pain medicines. This would include drugs like codeine, morphine, oxycodone (percocet), or codeine. Fortunately, we will now have many strategies to reduced the need for narcotic pain medicines after surgery. These include:
- Injection of a long-acting local anesthetic such as Exparel at the time of surgery. This can provide pain relief for the first 3 days and really help patients get over the initial hump of recovery.
- Preoperative administration of gabapentin (which helps with nerve pain), celecoxib (a non-steroidal anti-inflammatory that does not increase the risk of bleeding like other NSAIDS), and tylenol. This is part of an ERAS (Enhanced Recovery After Surgery) protocol, which has been shown to aid recovery after many types of surgery
- Postoperative celecoxib and tylenol
- I also give all my patients odansetron (Zofran) as needed for nausea after surgery. This can make it much easier to tolerate the few doses of narcotics that may be required.
With these alternative strategies for pain control, I find many patients can drastically reduce, and often eliminate, the need for narcotics after surgery.
Emile N. Brown, MD
Johns Hopkins & Harvard Trained Plastic Surgeon