Navigating Detox, Chronic Pain and Addiction

David Condos: Hi guys. Welcome to this episode of Recovery Unscripted. I’m David Condos. This podcast is powered by Foundations Recovery Network. Today, my guest is Dr. Melissa Lee Warner from Black Bear Lodge, a residential treatment program in north Georgia where she serves as a medical director. She joined me to discuss how they use a symptom-based approach to help each patient face the unique challenges that various substances present during detox.

She also illuminates the complex intersection of chronic pain, addiction, mental health and the non-intoxicating techniques that can set patients up for long term recovery. Now, here’s Dr. Warner.

David: I’m here with Melissa Lee Warner. Thank you for your time today.

Dr. Warner: Glad to join you David.

David: Well, let’s start by having you tell us a bit about your personal story, and how you got started in the world of medicine.

Dr. Warner: I’m an addiction medicine specialist. That means all of my time, and my career is about treating addiction, and different aspects of things that go along with addiction. I was actually in the Navy for a brief period of time. I always want to thank the taxpayers, because back in the early ’80s, taxpayers’ dollars paid for a scholarship for me to go to medical school. Then from there, I did work in the Navy for a few years.

After that, I was in a family medicine residency and realized that family medicine was not going to be the job for me. At least not in a family practice office. I hadn’t figured out what I would do, but in my last year, some synchronicity came together. I had some extra elective time, because I had done an internship while I was in the Navy. I went to a family medicine colleague for a rotation in addiction medicine at an addiction treatment center. I didn’t know anything about it prior to then. It was quite fascinating and interesting.

While I was there, they asked would I like to do their fellowship? Since I knew I didn’t want to do family medicine, and I didn’t have any other plans–

David: Might as well give it a try, yes.

Dr. Warner: Right. That was it. I did that fellowship. Then actually I worked there for several years. It’s been addiction medicine and working in residential addiction treatment centers for over 25 years now.

David: For anyone who’s not familiar with Black Bear, how would you sum up the overall philosophy or the mission you have there?

Dr. Warner: It’s to do evidence-based best practices of addiction medicine to develop lifetime relationships for long-term recovery. We meet people where they are without judgment. We know that anybody can get sober. It doesn’t matter how many times they’ve tried or not tried in the past. We work towards internally motivating them to see why they like to do it. Recovery is definitely possible.

David: Whenever someone is starting their recovery journey in treatment, physically cleansing the body through detox is the first step. From a medical perspective, could you tell us about how you approach detox at Black Bear? How you meet the different challenges that different types of drugs can present during that phase?

Dr. Warner: Sure. Treating alcohol withdrawal for many medical providers who aren’t even addiction medicine specialists is probably not all that complicated or difficult to do. On the other hand, treating benzodiazepine withdrawal really does involve some expertise. The benzodiazepines are more commonly today we see Xanax or Klonopin. Other medicines that are similar to that, Ambien is one a lot of people become addicted to. Back in the olden days, it was Valium, Librium they’re all benzodiazepines.

The withdrawal from these medicines isn’t just over in a few days like alcohol withdrawal or prescription pain pill withdrawal, but can linger on for weeks and months and be fairly debilitating. Knowing the significance, taking an approach that allows the adequate use of long-acting sedatives in the beginning period of time, phenobarbital is the name of the sedative that we use primarily.

Adding to that, medications that can help once they’re off of the phenobarbital. Over the ensuing number of months to reduce the withdrawal symptoms, these kinds of things can be interesting and complicated and a problem for people who aren’t aware of that.

David: They maybe don’t expect it to be that long of a process?

Dr. Warner: Yes. Most medical providers would have no idea. Sometimes, even addiction medical providers don’t recognize what some folks are at risk for.

David: What about when someone is detoxing from opioids, how do you approach that at Black Bear?

Dr. Warner: For a long time, even though we use sedative for sedative withdrawal, we have not in medicine been technically allowed to use an opioid for opioid withdrawal. You can give someone with opiate addiction an opiate to treat pain, but you can’t treat opioid withdrawal with an opioid. That left pretty much methadone as the only opioid that could be used for withdrawal. To have methadone at your treatment center, you have to have all kinds of special things and special arrangements and special dispensing.

Very few centers in the country had or have methadone in their addiction treatment center. That meant that all of us that are old enough, grew up using a symptom-based approach. That symptom-based approach often included the blood pressure medicine, Clonidine, because it’s very helpful for withdrawal, particularly opioid withdrawal, and also tobacco withdrawal for that matter, combined with a sedative like phenobarbital. Another one we will use sometimes would be Valium, some combination of those two medicines and then other medicines that help.

David: You’re doing that in response to the symptoms that they’re showing?

Dr. Warner: Right. That’s the symptom-based approach. In addition, muscle relaxants for restlessness and muscle spasm. Stomachs for abdominal cramping, diarrhea, vomiting nausea, anxiety, all those different sorts of things.

David: What does the blood pressure medicine do?

Dr. Warner: Clonidine? It literally helps the withdrawal. The Clonidine is what we call centrally acting. In other words, the way it helps blood pressure is in the brain itself, because of that, the fact that it’s centrally acting that it also offers a benefit for withdrawal. It also has an anti-anxiety benefit. We use it sometimes for that, not as a long-term solution for anxiety, but short term. It also has analgesic properties, which means pain relieving properties. Clonidine might also become part of a treatment strategy for someone with chronic pain. It has a variety of benefits.

David: Those are all just kind of side benefits of this blood pressure medication?

Dr. Warner: Yes. We’re almost never using it for blood pressure actually in addiction medicine.

David: I’ve read that another one of your specialties is the intersection between chronic pain and addiction. Let’s have you start this part of the conversation by defining what chronic pain means and describing some of its components.

Dr. Warner: Chronic pain has a fairly simple definition. It’s general. It can apply to anything. Essentially, if someone is having ongoing pain, the source of the pain often is not as important as the chronic nature of it. The idea, when we call something chronic pain, is that any other remedy that might have been tried to resolve the pain, it is not going to work. Whether that was surgery or that sort of thing.

The idea is that this is going to be an ongoing situation for someone in which case the treatment of chronic pain tends to be more about increasing function and participation. It would be unrealistic to think that someone with chronic pain that what was going to happen is their pain would go away.

David: I saw in the presentation that you gave on this at the Recovery Results conference, you described some of the broader factors that can influence how the body and mind perceive pain. What are some of those factors? How do they affect chronic pain?

Dr. Warner: Probably, the top two things that affect the experience of pain, and, of course, they again have to do with the central nervous system, because even if you’ve cut your finger, the place you experience that is in your brain. Two things that we reach for first to address when someone has chronic pain or sleep. Inadequate sleep is a major factor that’s going to magnify the pain experience. A lot of what we’re going to do is work towards getting good sleep. Second factor coming in right after that is mood, anxiety, depression, irritability, those things also dramatically magnify the experience of pain, but the idea is that you’re not going to get anywhere with chronic pain generally if someone has addiction active and ongoing. The active addiction in a variety of ways really interferes with the ability to successfully treat chronic pain. In fact, we’ve seen over and over and over again that when people get into recovery from whatever kind of addiction they had, that some of the very same pain management modalities that had truly offered them no benefit whatsoever, and again, it could be any number of things from an interventional thing, or a medication that absolutely did not work while addiction was active, the very same thing is effective once they are in recovery as part of a pain management program.

David: Do we know why that is?

Dr. Warner: I think it relates to the factors, again, in the central nervous system, and what’s happening in the brain. When someone’s in active addiction, there’s withdrawal, there’s anxiety, there’s sleep. There are just many, many, many, many things that are almost eclipsing the nervous system’s ability to take care of other things.

David: As you brought up, addiction can often come into play, because people are naturally looking for some relief from their pain. Could you describe why chronic pain, and drug dependence are often so intertwined, and how that plays out?

Dr. Warner: All of the compounds that people could be addicted to which I use the term, intoxicating compounds, offer that euphoria or that high whether they are a stimulant or a sedative, or an opioid which all act differently, but the other thing they have in common is anesthesia. They are numbing. People will reach for — human beings. Not just people with addiction. Human beings might reach for beverage alcohol to help numb the pain of their depression. Alcohol is a depressant, [chuckles] but the fact that it at least gives some temporary pain relief to the pain of depression. We see people reaching for alcohol for that reason.

For chronic pain, people may have inadvertently begun using intoxicating compounds to get relief. The factors that often are at play when someone develops addiction are underlying genetics. Very, very, very large factor. Somewhere in their family tree and their own personal genetics, they have some sort of vulnerability to develop addiction. We are not able to tell if we take a family of people with addiction, who’s going to have a higher or lower vulnerability. We just know that they’ll have probably three times the vulnerability of people that don’t have addiction in their family tree. Then, some sort of a stressor. Obviously, if we are talking about pain, pain is a very significant stressor, and then have intoxicating medications been prescribed, benzodiazepines or an opioid.

That’s the recipe right there. The intoxicating compound, the stressor, and the genetic susceptibility.

David: Yes, and as you said, once the active addiction takes hold, it can really alter the experience of pain. It can block out a lot of the ways that you otherwise would try to help.

Dr. Warner: Right. It’s going to both magnify and interfere with treatment.

David: Could you describe a specific example of that?

Dr. Warner: Opioids, for people that don’t have a susceptibility to addiction. Opioid pain medication is a pretty typical and acceptable choice for acute pain. You had your appendix out, you are going to need something to help for a few days. When it comes to chronic pain, opioids, sometimes, can actually magnify the pain. You may have heard that’s called hyperalgesia.

Opioids are not actually a good choice. There are a number of other reasons they are not, but literally we’ve had folks who, it was as simple as getting them off the opioids without instituting any other pain management approaches. It’s never that the pain, or the source of the pain wasn’t real, or wasn’t true pathology. It’s about the body’s ability to mediate it with the person’s own neurotransmitters and that sort of thing.

David: Related to this, as you mentioned, opioids not only don’t help the chronic pain, but of course can lead to addiction, and in some cases even make the pain worse like you said. What are some of the non-addictive, or non-intoxicating options for managing chronic pain that you’ve seen success with?

Dr. Warner: We are going to start with things like optimizing sleep, and treating mood and that sort of thing. Then there are other medicines that can be helpful for chronic pain even though you wouldn’t think of them as pain medicines. You may have seen Cymbalta on television, serotonin and norepinephrine reuptake inhibitor. They are medicines that can treat anxiety and depression, because of the norepinephrine component that it affects in your body that’s helpful for chronic pain. Cymbalta can be helpful for pain even if someone doesn’t have a mood disturbance. The vast majority of our patients at Black Bear do have a mood disturbance so we are regularly using one medication for two or three benefits when we are choosing medications.

We may be getting a mood benefit, a sleep benefit, a pain benefit, or withdrawal benefit, so that’s part of the art and science of the practice of addiction medicine. Wellbutrin, which is a medicine that only treats depression. It’s also a medicine that can treat tobacco addiction and Willbutrin can be helpful for pain management also, even if someone wasn’t suffering with depression. Again, many benefits depending on the medication.

David: Cool. What are some other non-medicinal, maybe more holistic ways that you can help someone with chronic pain?

Dr. Warner: I will tell you that the number one thing that is incredibly effective for pain management is ice.

David: Wow, really?

Dr. Warner: Not kidding. If you put some ice on something for 20 minutes, it will become completely numb. It actually can bring helpful blood flow to the area. It can reduce inflammation if that’s part of what’s going on. Generally, we are using a lot of non-medication approaches. We do trigger point injections right at Black Bear Lodge. People with chronic pain, depending on where it is, and if it has a musculoskeletal component, will have areas of muscles spasms and irritation in connective tissue distress, and trigger point injections can relax that.

There are things like E-stim which is an electrical stimulation where you out those pads on. Those things could be incredibly beneficial. Usually, or actually all that someone needs, because once you are trusting the addiction, and looking at some of these other things, I would say, 85% of the time, patients we’ve treated [music] with true, serious and significant chronic pain don’t need much more than that. Then, there’s a subset of 15% who may need additional more specific or intensive modalities, but very much the exception to the rule. The huge piece is getting into recovery from addiction that begins to bring the pain relief.

David: I assume it all comes back to the mind too in someone’s mental health, and I know you guys do some experiential therapies at Black Bear. Have you seen some of those options help?

Dr. Warner: Yes. Mindfulness as an approach, and meditation or mindful meditation are very potent for pain management as well as a number of other things that they are helpful for. It brings you into the reality of what is simply happening from a pain standpoint in the moment as opposed to all the overlying things of fear, and projection, and that you let them go away, and you just become in the moment where the discomfort is manageable.

David: All right. Well, I just have one last question. Everyone who serves in this filed has their own reasons for wanting to further the cause of behavioral mental health. Could we end by having you sum up why helping people find recovery is important to you?

Dr. Warner: First of all, because it is so possible. Second of all, because so many, many, many people are affected. This is over — leaving out tobacco addiction, just the other drugs addictions — we are talking about over 10% of the population. Even worse than that is the fact that in the United States anyway, we’ve taken an incredibly ineffective approach which is criminalizing addiction. I’m not sure if you are familiar, but the statistics have been very clear that 75 to 85% of people in our criminal justice system are really people with addiction, and that incarceration and those sort of things do not help people get sober.

Drug court helps, treatment helps. Drug court helps people get into treatment so my heart is in it for a lot of those reasons. I think my spirit is in it, because part of what we see is that some incredibly broken, near death individuals, when they get into recovery, and get into long-term recovery, [music] often go on to have a better quality of life than they have ever had. There’s no other chronic progressive, genetically mediated, potentially fatal illness in medicine that I’m aware of where that is the case.

David: That’s cool. Even thinking about it in a strictly medical perspective, it still has better potential. When you say recovery is possible, you really mean that even compared to other medical conditions?

Dr. Warner: Sure. Of course, we’re not resourced anywhere where we need to be. It is possible that 95% of people who need addiction treatment are not getting it, because they don’t have the resources.

David: All right. Well, Dr. Warner, thank you for your time.

Dr. Warner: Thanks for asking me. It was a nice surprise.

David: Thanks again to Dr. Warner for joining us. Now, I get to welcome back Stephanie Spann, National Race Director for the 6K Run Walk series put on by heroes in recovery. A grassroots movement that brings together communities across the country to celebrate life in recovery. Welcome, Stephanie.

Stephanie: Thank you, David.

David: How are you doing today?

Stephanie: I’m doing good. How are you doing?

David: Very well. Thank you for joining us again. As we often do, talking about Heroes in Recovery. Let’s first, let’s have you start by summing up the overall mission of Heroes and what they’re all about.

Stephanie: Our mission at Heroes in Recovery is to break the stigma associated with addiction and mental health disorders. We do host 6Ks around the country, and that’s our celebration; celebrating those that have come through recovery and also bringing awareness to the industry, and also that we’re here as a message of hope.

David: Yes, absolutely, and bringing everyone together for these 6K races, and I know you have two big ones coming up this month in California starting with this weekend in San Diego. Can you tell us about that race?

Stephanie: This weekend is our fourth annual Heroes in Recovery in San Diego, and it’s hosted at De Anza Cove Park. It’s a gorgeous run right along the water. We’re so excited to be back this year. We’ve moved it to April this year as the kickoff for our Innovations in Recovery conference.

David: Yes, absolutely. We had Jordan Young on the show talking about the conference a couple of weeks ago. That’ll be awesome. I know San Diego is beautiful this time of year. Then you have another race in Orange County coming up a couple weeks after that.

Stephanie: April 21st, we have the third annual Orange County Heroes in Recovery 6K and that one is at Mile Square Park. It’s a very flat course, a very beautiful course right through the park there. Partly paved, partly grass, but it’s a gorgeous course, and we’re so excited to be going back this year.

David: Cool, yes, that sounds awesome. I know you guys have launched the virtual runner option that you talked about last time you were on the podcast. Anyone, no matter where they live, no matter if they can make it to a actual race, can be a part of this? Tell us more about that now that it’s officially launched.

Stephanie: Yes, so now that we’ve launched it, we can talk more about it. We’re so excited. If you go to heroesinrecovery.com, if you click on the Hero 6K, there’s a virtual 6K button. You click on that to register. We have six different levels that people can participate at. They are welcome to participate no matter where they live, and they have up until the end of 2018 to actually get those miles in. We do mail the packets at the end of each month.

People can participate whenever it’s convenient for them, but definitely it can help us break that stigma and share the word. The prices range for virtuals from $20 to $110. The $110 package is amazing where you get a full lineup of a medal, a bib, a bag, a magnet, you get your race shirt, some brand new performance socks that we just got this week, branded tumbler, a hat, headband. We do have a limited edition tank in there too. That’s what we call the ultimate hero package.

David: All right. That sounds great. Thank you again for joining us today.

Stephanie: Thank you for having me.

David: This has been the Recovery Unscripted podcast. Today, we’ve heard from Melissa Lee Warner of Black Bear Lodge. If you’d like to talk with an admissions coordinator about the treatment options at Black Bear and other Foundations programs, please call any time at 855-823-2141. They can answer your questions and help you get started. See you next time.