Can’t You Give Me Something Else?
When Nicole showed up for a routine colonoscopy, she was shocked when the anesthesiologist planned to give her fentanyl. She reflects on how close she felt to losing the sobriety she fought so hard for. Can you refuse opioids as a patient in recovery? What other options are out there for treating chronic pain? And does “all-natural” really mean “all-safe?” Nzinga answers these questions and more about pain, alternative medicine, and the rights you have as a patient.
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[00:01] Nicole: I can’t even imagine what the point of giving that to me was. And it scared me so much. It would have just undone a lot of the things that I had accomplished. And they’re just giving it out so freely and not knowing that that little thing could really send somebody off the path that they’re on.
[00:31] Dr. Nzinga Harrison: Good morning. Good afternoon. Good evening. Good middle of the night, depending on what time you’re listening. This is Nzinga, and you’re listening to In Recovery. Today, we’re talking about pain. But before we get into today’s episode, let me give you just a quick high-level on me, on the show, for those who might be new. In Recovery is about all things addiction, drugs, alcohol, heroin, marijuana, you name it. But also addictions that we don’t typically talk about, like work, sex, exercise, relationships. And what we’re really trying to do here is answer your questions in a way that is based in the medical science and the evidence. But more importantly, in compassion and breaking down these artificial barriers that we draw between people who are addicted and the rest of us, because in reality, it is just all of us.
[01:19] Dr. Nzinga Harrison: So I’m your host because I have a decade and a half plus of medical expertise taking care of people with addiction. I’m a physician, psychiatrist, addiction expert. I believe in this so much that I co-founded my own company where I’m also chief medical officer. It’s called Eleanor Health, and if you’re in North Carolina or New Jersey, we can take care of you. Check out the website. Shameless plug there. Importantly, I’m a human. Wife, mom, sister flying by the seat of my pants just like the rest of everybody. And so all of those roles that we play in life keep us tethered in health with relationships being that thread. And so I want a relationship with you. Send me your questions. We’d love to get your voicemails. Our phone number is 1-833-4Lemonada. That’s 833-453-6662. And I promise literally nothing is off-limits. Now, if you’re not a voicemail kind of person, you can tweet me @NAHarrisonMD. If you do tweet me, please make sure you tag @LemonadaMedia. They’ll make sure that I don’t miss your question. So with that crazy long introduction that Claire asked me to give, today’s show is about pain and addiction.
[02:45] Dr. Nzinga Harrison: So, Claire, I know I’ve been talk talk talking, but before we get into the email that we’d receive from a listener that prompted us to make this show, I wanted to share something super exciting that actually relates. So I recently celebrated 16 years of wedded bliss.
[03:07] Claire Jones: Wow. Congratulations!
[03:11] Dr. Nzinga Harrison: Thank you. So for our anniversary — Joel is my husband — he bought me this amazing contraption that turns you upside down to stretch out your back and your neck pain, which I suffer from pretty chronically. And it is so cool. So I could feel the difference that it was making almost immediately. So I’m gonna be jumping on that thing like all day everyday if I can get my 14 year old Zahir off of it because he got on in like never got off. But amazing, when your wedding gift has everything to do with pain. And then we got this email from this listener and I was like, yes, kindred spirit. Let’s jump into this.
[03:49] Claire Jones: Yeah, I’m excited for this episode because I, too, suffer from chronic pain. I herniated disc three years ago and then promptly six months right after that, broke my foot and had to get three screws in it. I’ve pretty much since then have been trying to manage back pain. So I’m really excited for this episode. I think it’s going to be informative for everyone. So our first voice mail comes from a woman in recovery from opioid use disorder. She went to get a colonoscopy and was almost given fentanyl for this relatively routine procedure, which really scared her. And it made her think about how easily it would have been for her to say yes. So let’s play a little part of her voicemail.
[04:42] Nicole: Hi, my name is Nicole, and I’m in recovery. So the anesthesiologist comes over and was just going to administer the fentanyl without even asking me. I had to stop her and be like, hey, listen, I’m in recovery. I don’t want that. She said are you sure? Are you sure? And I said, no, I’m good. Like, I don’t want any painkillers. Like, I can’t have any painkillers. So she didn’t give it to me, had the colonoscopy, woke up, was totally fine. I can’t even imagine what the point of giving that to me was. And it scared me so much. It would have just undone a lot of the things that I had accomplished. And they’re just giving it out so freely, not knowing that that little thing could really send somebody off the path that they’re on. I think about it all the time. I’m like, damn, I could have gotten high. But then I also think I was very close to going back.
[05:50] Dr. Nzinga Harrison: Oh, man. So I can hear in your voice in that voicemail how scary this was for you, so I’m sorry that it happened. But I’m really glad that you sent in this voicemail, because I know there are tons of people listening that have either already had or will have the same experience. Before we jump into that, first things first, congratulations on your ongoing recovery from opioid use disorder! That is huge and to be celebrated every single day. I do not want anybody to under appreciate what a big deal that is, because to the point of your story, every single day you’re minding your own business and triggers come out of the blue when you least expect it. So you’re like, let me go get this colonoscopy. The last thing you’re thinking is that this doctor is even going to say the word fentanyl to you. So to your point, it is actually one of the common ways that we sedate people for routine colonoscopies. And I can hear the fear and the uncertainty that brought up for you. But I hope you’ll let me push back on you just a little bit, because you have been day-after-day working this road of recovery. And I heard you say how easy it would have been to just undo everything you had accomplished if this anesthesiologist had given you fentanyl during your colonoscopy. And I want you to know that would not at all have been able to undo everything that you’ve accomplished. What you’ve accomplished is huge and way bigger than one dose of fentanyl. That said, I get it. I totally, totally get it how scary that moment was, because it is a slippery slope. And it is a part in your brain that would get tapped getting that fentanyl, and you’re like, I have worked too hard to have that part of my brain be tapped. My sobriety is too important to me. Complete and utter abstinence is too important to me. And so the conviction that you have around that, I am just celebrating it and I am lifting it up because it is remarkable.
[08:09] Dr. Nzinga Harrison: But part of staying healthy is knowing what those triggers are and avoiding those triggers. So some of the people I see do best with opioid use disorder sound exactly like you, with that passion, that vigilance, vigilance, vigilance for putting your commitment to complete abstinence in every single moment in your life. And so to the point of your question, I want to spend just a second talking to my fellow physicians who are listening. We also have to do a better job of being vigilant on behalf of the people that we’re taking care of, on behalf of the patients that are coming to us. We don’t think that just saying the word fentanyl or mentioning that I may give you fentanyl during a procedure could cause her so much fear and so much anxiety. But it does. And there are a lot of people who are in recovery from opioid use disorder who are going to have this exact same reaction. And so maybe it is for us as physicians — and this is talking specifically about anesthesia, but I think as docs, we can kind of take a bigger concept around this — in thinking about the number of people we’re seeing with opioid use disorder, the havoc that it’s wreaking on people’s lives, the effort that people are spending to get that illness in remission, that may be anytime we’re going to talk about an opioid, instead, we start with a question. Which is at times we use opioids for these surgeries, is there any reason I need to try to completely and utterly avoid that for you? So it’s the same information, right. Which is like we typically use fentanyl for colonoscopies, or I might give you fentanyl for your colonoscopy, which sent her into this procedure critically, critically afraid and anxious, and just re-language that to we often use opioids as part of this procedure, I can avoid that for you if we need to. Talk to me if we need to.
[10:11] Dr. Nzinga Harrison: We actually in medical school don’t necessarily get a lot of training around language. Like we learn medical language and we speak medical language, which is the most common anesthetic we use for this procedure is fentanyl. I mean, that’s just a statement of fact. But we don’t necessarily spend a lot of time thinking about how our words are landing, although my listeners know that I spend a lot of time thinking about that. We’re not necessarily trained into that, or even thinking about how our medical language can create anxiety in the people we’re taking care of, which is not at all our intention.
[10:48] Claire Jones: Because then it’s like you’re not directly asking that person, like, is this going to be a problem? It’s more of just like — because I think even I don’t know if I would feel comfortable having opioids as an option for a procedure, as a person who’s never used them recreationally. And so I think that’s good that it doesn’t have to single out people who are in recovery from substance use disorder and opiate use disorder.
[11:15] Dr. Nzinga Harrison: I love it. I love it. Universally applied. Excellent.
[15:26] Dr. Nzinga Harrison: So the second question that she asked was, is there any point if I said absolutely no opioid said all, that an anesthesiologist could give me opioids during a procedure, even though I had said no. And so I wanted to get to the right evidence-based answer to this question. So I accessed my network of doctor friends. And there are tons of anesthesiologists in the network. And I just posed then this question, is there ever a time where you emergently have to use an opioid to save somebody’s life during a surgery that even if they told you no opioids, period, you have to make that decision because it’s a life and death decision. And the answer was yes, but almost never. So for the biggest procedures, what my anesthesiology colleagues told me is that they can get through most surgeries, even major surgeries without opioids.
[16:22] Dr. Nzinga Harrison: So they went down through a whole bunch of alternatives and strategies that they have, from nerve blocks to regional blocks to premedication with I.V. Tylenol to all of this sort of thing. The one example they did give me is that pain actually exerts a lot of pressure on your cardiovascular function, so your heart rate, your blood pressure and your breathing. And so the point at which the answer to that becomes yes is like there is something so critical about your heart rate and your blood pressure and your oxygenation and your breathing that is being caused by pain during that procedure, that they have to use the opioids so that you don’t actually have negative consequences, the ultimate one being like dying in the surgery because your vital signs are out of whack. But again, like very uncommon. And so I would encourage you, yes, if you want absolutely zero opioids, make that very clear. Have that whole conversation with the anesthesiologists before, “even though I’m saying 100 percent no, is there a situation,” and let your anesthesiologist explain that to you within the context of the surgical procedure that you’re going to have. Now, where they said it’s more difficult is after this surgery. There are also risks — so just like the opioid pain medications create some risk for relapse to opioid use disorder, uncontrolled pain creates risk for relapse of an opioid use disorder. And so we really have to be very intentional and thoughtful to make sure that we are controlling pain in the post-surgical period. Like the anesthesiologists said, I can usually get away with it from the surgery, but the surgical recovery sometimes it can be hard to get away without having an opioid on board for that. And so, again, this is initiating that conversation that will usually be with your surgeon, not the anesthesiologist, before you have the surgery. Making a plan for your pain control after that surgery, trying to make that plan be as opioid-free as possible. Or hearing from your surgeon it is unlikely you’re going to get through this post-surgical period without an opioid. And so then the conversation becomes, “and so how do I do that safely without putting pressure for a relapse on my opioid use disorder?”
[19:01] Claire Jones: Is that part of a medical history form that you fill out pre-surgery to talk about any kind of previous or current substance use disorders?
[19:10] Dr. Nzinga Harrison: It should be, yes. So usually the way you’ll see the question, which is very lightweight language, is like, do you use any alcohol or drugs? If so, how much? It’s a very lightweight question. And if you mark no, often doctors are not going to do the second double click on that. If you mark yes. Often the double click is still, like, very shallow because it’s not something that a lot of doctors have confidence or skill set to really talk deeply through. But what your doctor does, your surgeon and your anesthesiologist absolutely are experts in opioid pain medications. They are the experts and how to use those safely. And so what we need from our listeners is that you raise your voice. So even if you’re currently using any substance, alcohol included, that has implications for how your anesthesiologist needs to safely make decisions during your surgery, and how your surgeon needs to safely make decisions with you after your surgery. So I want you — I know it’s risky and I know there’s stigma and I know for sure that people get mistreated. But I need you to take that risk. I need you to take the risk to just be open and honest, like, this is what I’m using. This is how much I’m using. This is the last time I used it. This is what I have been addicted to. This is what I’m currently actively addicted to. Even if they don’t ask you those questions, for you to be proactive about sharing that information, because it really does affect our ability to keep you safe during surgery and in the post-surgical period.
[20:51] Claire Jones: Right. And if you’re in this situation where using an opioid is the only option, that doesn’t count as a relapse, does it?
[21:00] Dr. Nzinga Harrison: No. So let me give you the definition of relapse. So, you know, when we make a diagnosis of substance use disorder, we have 11 diagnostic criteria. And you have to meet two criteria to get diagnosed with a mild substance use disorder. When you have met one or less of the diagnostic criteria for at least three months, then we say your substance use disorder is in early remission. Using once, even if you go on the street and buy it and use it once, does not equal a relapse by the medical definition of relapse. The definition of relapse is that you had a period of time where you met zero to one diagnostic criteria, and now you meet two or more diagnostic criteria. So just using in and of itself — so in the abstinence based world, just using one time, it’s like you relapsed. But from a medical perspective, think of it the same way I always talk about diabetes. When your blood sugar is in control, your diabetes is in remission. If you get one blood sugar reading that’s out of range, we don’t say your diabetes relapsed. We say, oh, let’s check another blood sugar. Let’s look at this for about a week and see what we’re dealing with. So that same exact concept flows to substance use disorders, which is like just one use does not add up to diagnostic criteria. And so to our listener here — thank you for asking the question this way, Claire, because what I was trying to say earlier to her is that even if that anesthesiologist had given her fentanyl during the colonoscopy, yes that creates risk for relapse of opioid use disorder. But that is not a relapse. That does not undermine all of the work she’s done. Now, afterwards she went and she got fentanyl, and then she started using more than she intended, and then she started having negative consequences, and then she met two or more criteria, that’s when medically the definition of relapse happens. Everything prior to that is relapse prevention.
[23:16] Claire Jones: Got it. So what are steps that some folks can take if they have to take opioids, there’s not really a great alternative for pain management either during the surgery or after the surgery. What are resources or steps that people can take to make sure that it doesn’t lead to a relapse or other negative consequences?
[23:35] Dr. Nzinga Harrison: So support system, support system, support system and prior planning. So the prior planning is that conversation you have with your surgeon before the surgery, where you quantify the chance that you might need opioids, and the surgeon is like, you’re gonna need opioids. Then it’s like, OK, we recognize what we’re doing is balancing the risk of inadequately controlled pain, which drives the risk of relapsed opioid use disorder, and using opioid pain medicines, which drive the risk of relapse to opioid use disorder. We can plan for it. And so the way you plan for it is maybe for this surgery, your surgeon would typically give a person a prescription for a one-month supply. But because we know you’re at risk, we’re not going to give you a prescription for a one-month supply. I’m going to give you a prescription for a one-week supply. Then I’m gonna have my nurse call you and see what your pain is and see if we can bring the dose down. Or see if we don’t need to give another prescription. That’s one way: minimizing the dosing, minimizing the number of tablets you have. Number two: engage your support system. Don’t keep that bottle of pain meds on your nightstand, OK? Don’t do it. Let somebody else lock that up for you. Have accountability, so keep a log of how you’re taking them. So your pain has to be this out of this before you take this medication. And I’m keeping a log, this is what my pain was, and this is the dose that I took. Whether it’s the visiting nurse or somebody you know in your support system, let them do your pill counts. So they can make sure the number of pills that should be in that bottle are in that bottle. If you have a sponsor, tell your sponsor in advance so your sponsor can be calling you. If you go to AA or NA or other support meetings, increase the number of support meetings you’re going to. If you have depression, anxiety and you have a therapist, tell your therapist in advance. If you’re in a relationship, let your partner know, don’t be stressing me out because I need my stress as low as possible. Like, take a 360-degree and like, actually write it down. Before you have that procedure, write out your safety plan, and who the support system is for helping you stay responsible for that element of the safety plan. It’ll be your surgeon. It’ll be your spouse. It’ll be your therapist. It’ll be your primary care doctor. It’ll be your best friend. It’ll be some app that you joined. Write it all the way out.
[27:45] Claire Jones: So our next question comes from a caller who started experiencing chronic pain after giving birth to her first child nine years ago. She started taking oxycontin to help with her pain management, but didn’t really want to stay on it. So instead, she started going to physical therapy and using nerve blockers. But it was like every six months or so, the pain would just come back, so now she found something called Kratom. And let me just play the last part of her voicemail.
[28:12] Caller: A couple years ago, I heard about Kratom. And I believe, you know, you’ve talked about some of the partial agonists that, you know, might replace some of the stronger narcotics. And that does help me, it’s kind of increased over the last couple of years, but it’s really the thing that’s getting me through the day. I wouldn’t say that I have negative consequences from it, it doesn’t really give me any side effects. Maybe I’m answering my own question, but I just wondered if there was anything I should be aware of. I’m on my second year taking it daily.
[28:59] Dr. Nzinga Harrison: Thank you for leaving us the voicemail with this question. I see these Kratom/CBD stores popping up everywhere. And it’s actually making me a little worried because Kratom and CBD do not at all have the same safety profile. So first, let me just start by acknowledging the stress and the emotional burden that comes with chronic pain. It is so, so much. And I really want to emphasize that pain has two dimensions: there’s the physical dimension of pain and then there’s the emotional dimension of pain. And even in between those two dimensions, when the physical pain is not there — when you’re dealing with physical pain so chronically in your life, when the pain is not there, the anticipation of the pain coming back creates its own stress and its own type of emotional pain. And so it’s like today’s a good day, but will tomorrow be a good day, or will tonight even be a good day? And even when you have sensations of discomfort that are probably within the realm of normal, they carry so much more implication because you can already, like, envision the path of that normal kind of like twitch, like, oh, I got a twitch in my back, to that debilitating pain that you have to deal with. And so that starts to steal the things from you that bring you joy, that steals being able to just be free and carefree and be with people. It steals your physical activities, steals your exercise, it steals your comfort when you’re just laying around watching Netflix and chillin. And so the debilitating pain emotionally and physically is intolerable.
[30:50] Dr. Nzinga Harrison: Moving on to Kratom. A lot of people are getting into it. So just a little educational, what Kratom is. Kratom actually comes from a tree in Asia, and the chemical in Kratom is called mitragynine. And it actually works very similarly in your brain, in your body as heroin. It works on the opioid receptors. The reason this is important to know is because people get a false sense of security for substances that are marketed as “natural.” And I don’t want you to have a false sense of security about Kratom because it comes from a tree instead of coming from a lab. Kratom has the same risk to you as do the pain pills. And so you can use Kratom safely, but I also want you to hear me say Kratom has its own risk for addiction. Some of the hardest opioid detoxes that I’ve helped people through have been from chronic everyday high-dose Kratom use. And so what I want to talk about is how do you know when your use of Kratom is moving from safe use to risky use? And it’s actually the exact same early warning signs that you would use for any other drug addiction, heroin included. And so if you’re needing more and more and more and more and more Kratom, that’s a sign. If the amount of Kratom that you’re using is starting to put financial strain and you’re letting other things go, like you’re prioritizing the Kratom over food, bills, paying off people that you owe, that’s another sign. If people start to notice a difference in you, and they’re like, “since you’ve been using this Kratom…,” that’s a sign. And I hope that you can take a look at the way you’re using Kratom, but you can also have the people in your support system take a look at the way you’re using Kratom and just make sure it’s safe use. And then be proactive about putting some safety around the Kratom. So this is how much I use, this is how much I’m gonna buy at one time. If I see myself using more, if I see myself buying more, if I see negative consequences coming, this is how I’m going to get support for myself.
[33:18] Dr. Nzinga Harrison: So last is that I will say, from a physical health consequences, Kratom does have some physical symptoms that you need to watch out for, because that was your question, is there anything I need to be watching out for? Overwhelmingly, people don’t have a negative reaction to Kratom. If you have a negative reaction to Kratom, it’s usually because the use has escalated to addiction. But outside of addiction, when people do have negative reaction to Kratom, it’s hallucinations. So hearing and seeing things that other people don’t see. And then this next part sounds a little scary because it is — I don’t mean to be scary — but liver damage and death. And so if you are developing liver damage from the Kratom on the way, you will know that because maybe your eyes start to turn yellow, maybe your skin starts to turn yellow. We call that jaundice. That’s when your liver is really, really being damaged. Maybe you actually feel some tenderness — so your liver sits right underneath your rib cage on the right-hand side. So if you start feeling some aching. Or if you start bruising easily. So your liver has a lot to do with your platelets and your platelets are what keep you from bruising. So if you like, just start noticing bruising out of nowhere, definitely go to your doctor, say I’ve been taking this Kratom. Your doctor will draw some labs, will be able to see if your liver is in trouble or not. The reason I went through all of that is not to be like super scary mom, don’t use Kratom. It’s to say just because it’s natural doesn’t mean it’s safe. Because arsenic is natural. That’s going to kill you. The poppy flower is natural. That’s where heroin comes from. So just because it is natural does not mean it’s safe. So hopefully with this information that I shared with you today, you can be using Kratom safely as your pain management strategy. If you see any of those red flags, please get some support to help you get into a safer strategy for managing your pain.
[35:29] Claire Jones: What’s like a quick list of other ways to help with pain management?
[35:35] Dr. Nzinga Harrison: Yes. So non-medication pain management has to address both the physical and the emotional aspects of pain. So, you know, if I get out of one episode without telling people to get a full comprehensive evaluation, then I have not done my job. So if you have chronic pain, I want you to see a therapist because you need an evaluation for anxiety, depression, trauma, other psychiatric needs, whether they were there before the pain, or whether they came as a result of the pain. Chronic pain is debilitating emotionally. And so I want you to have that support in place, because we need to be thinking about getting your emotional fortitude built up also. There is of course, acupuncture has official medical data. There is, of course, massage. There’s, of course, physical therapy. There are TENS units. So electrical nerve stimulation units. Stretching. Exercise. All of these have good medical data to say they make a difference in pain. But very importantly, is life meaning and social connectedness. So that’s another thing. If I get out of an episode, without saying life meaning a social connectedness, then I need all of y’all to send me an email and say, what’s your problem? Life meaning and social connectedness literally underlies every single facet of our health. And so I need you to make sure that you are doing something in life that makes you feel like you’re meaningfully contributing to this world getting better, because pain steals that from us, right? Pain makes us stay in the house. Pain keeps us disconnected from people we used to go out and hang with. Pain keeps us from volunteering where we used to volunteer. Pain keeps us from exercising. Pain basically keeps us from doing all the things we need to do to be healthy.
[37:32] Dr. Nzinga Harrison: And so, like I said to our listener earlier, for some people, the pathology, the underlying illness, is such that pain is never gonna go completely away. And so sometimes we have to reorient ourselves away from the goal being no pain, to the goal being meaningful life despite pain. We’ll minimize the pain, and I’m going live. You know what pain? I’m gonna live my life despite this pain. And that can be really hard to get to. but the first step to getting to that is resetting the goal from no pain to meaningful living despite pain.
[38:14] Claire Jones: That was the turning point for me with my back pain. For two years, it was just like I couldn’t do anything because I was either in pain or so scared that if I tried to exercise or move in a certain way or sit for too long, the pain was going to come back. And it always did. There’s no silver bullet for pain, and the best thing that you can do for yourself is just keep moving. And also exactly what you’re saying is to have purpose and connection. And so I just started going on walks every day, and let go of the fact that, like, yes, it hurt and like maybe it made things feel worse, but it did give me a little bit of purpose. Going outside is something that’s really important to me, and I could do that. And a year later now, I’m definitely not pain-free, I’m still going to physical therapy. I feel I’m in pain all the time. But it’s like I think switching that mindset on it has made a big difference for me.
[39:12] Dr. Nzinga Harrison: Yeah. And I guess to wrap it back around, the way we have conceptualized addiction in this country, like I said earlier in the show, using once does not rob you of being in remission. But we have this concept for substance use disorders that is complete and utter abstinence is the only meaningful recovery. Just like with pain, complete and utter absence of pain cannot be the only way we define a meaningful recovery, or we’re going to never get there for the majority of people.
[39:50] Dr. Nzinga Harrison: In Recovery is a Lemonada Media original. The show is produced by Claire Jones and edited by Ivan Kuraev. Music is by Dan Molad. Jessica Cordova Kramer and Stephanie Wittels Wachs are our executive producers. Rate and review us and say nice things. And follow us @LemonadaMedia across all social platforms, or find me on Twitter @naharrisonmd. If you’ve learned from us, share the show with your others. Let’s help destigmatize addiction together.