Chronic knee pain with previous history of knee replacement

Dear Ask The Doctor: Medication Hip replaced 2006 and failed knee replacement 2007. Was being prescribed 300 mg oxycodone a day for pain.Could not handle so voluntarily quit with Suboxone. Physician decided to keep me on Suboxone for pain relief of knee. I am very active (why my knee and hip fell apart), running, martial arts, hiking, climbing and biking (can no longer do most of these but do go to gym regularly and still hike. Activity causes alot of break thru pain but is important for my mental and physical health. Suboxone doctor advised Pain Management. Went to PM and they took me off Suboxone except for break thru pain and put me on Butrans patch 20 mcg. Is okay but does not last week. Also my insurance will only cover 4 patches monthly (Dr prescribed 6.) Another Doctor at Pain clinic took me off Suboxone and prescribed Tramadol for break thru. I had some issues and talked to pharmacist who said Effexor I take twice daily should not be prescribed with Tramadol or vice versa. Effexor has been very therapeutic for me. Qusetion- what do I do for break thru (daily ) pain? I do not like oxycodone or morphine and I am allergic to vicodin. Pain levels 2 to 3 until I get active...then can be as hifg as 8 after exercise. Have been diagnosed for knee revision surgery but I am 60 years old and do not want to go thru that again. In fact surgeon said it is much more traumatic than original knee surgery. Surgeon okay with postponing "as long as I can stand the pain". I am at a loss. I like the Butrans but there seems to be no options for break thru pain. Is there another patch I would not need break thru meds for? Or some other meds I could take that I have not experienced? I function okay with meds...work full-time in engineering, I am a married home-owner and I neither drink nor smoke.The only drugs I did as a youth was marijuana and LSD a few times. What I like to do is climb mountains, drive fast (especially motor cycles) and experience new things. On the reverse side of this I am a very spiritual person (will spare you the detailof my beliefs). I pray and meditate. I want to stay active until I die or die being active. Married with 2 adult sons. Please advise if you can. (photo below is me being stupidfunny) Thank you Brian Muldoon

Dear Brian: Chronic pain as you described it in your question is indeed a very annoying, difficult to manage  and one of the most expensive conditions in industrialized countries. I see that you have been consulting several specialists and trying many treatment modalities with not totally good results. Your case may be managed as chronic pain, you might benefit of Physical Therapy. Some antidepressants are useful in chronic pain to alleviate insomnia and pain. In addition, these medications may improve your ability to cope, and they may reduce depression, anxiety, or fatigue associated with chronic pain. Local anesthetics, corticosteroids, or other substances may be directly injected into painful soft tissues to produce some relief of the symptoms. On the other hand I advice you to discuss with your orthopedic surgeon the possibility of a re intervention of what you called in your question “failed” knee replacement.