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    A bioethicist’s personal opioid nightmare

    After receiving opioids for a motorcycle injury, Travis Rieder, PhD, was shocked to find that doctors knew little about how to manage those intense medications. The author of “In Pain” shares the details of his journey — and how we can spare others.

    Travis Rieder, PhD, rides his motorcycle at a racetrack in 2014. A year later, he suffered a devastating crash and dependence on opioids.
    Travis Rieder, PhD, rides his motorcycle at a racetrack in 2014. A year later, he suffered a devastating crash and dependence on opioids.
    Courtesy: Travis Rieder, PhD

    In May 2015, bioethicist Travis Rieder, PhD, was in a horrific motorcycle accident. The impact left bones protruding from his foot, and the wreckage required multiple surgeries to repair. He spent weeks in the hospital, faced possible amputation, and felt pain like “acid was being poured right onto my nerves” that required intense opioid treatment every day.

    But Rieder’s worst experience came two months later, when he went through opioid withdrawal.

    During the weekslong tapering process, Rieder suffered incredible physical and emotional anguish — and his doctors did little to help. Still, Rieder says he does not entirely blame them. Instead, he faults a system that too often fails to prepare physicians to handle opioids and their extraordinary power for both harm and healing.

    After his recovery, Rieder — who directs the master’s degree program at Johns Hopkins Berman Institute of Bioethics — went on to write In Pain, an NPR Best Book of 2019. In it, he describes his personal journey as well as the medical, societal, and historical factors that fuel thousands of opioid deaths in this country each year.

    Rieder will address the AAMC’s annual meeting, Learn Serve Lead 2020: The Virtual Experience, on Nov. 17. He recently spoke with AAMCNews about his own painful experiences, the current state of opioid use in America, and how we can give pain patients and those who struggle with addiction the care they sorely need.

    Editor’s note: This interview has been edited for brevity and clarity.

    After your accident, various providers reacted very differently to your desperate requests for pain medication. Why?

    Travis Rieder, PhD Courtesy: Travis Rieder, PhD

    At the time, it was incredibly confusing and very, very frustrating,

    For the most part, I had physicians throwing medication at me. But then I had interactions where I was treated with suspicion for wanting the exact same medications. I had physicians basically treating me like a "drug seeker,” which is insane since I had five surgeries over the course of a month.

    It would only be years later, after I buried myself in the research, that I realized that we've been swinging back and forth between those attitudes — between being hostile toward opioids and then embracing them warmly — for 150 years. So it’s no surprise that different clinicians have different attitudes.

    When it came time to reduce your opioids, you say your physicians abandoned you. What happened and why?

    I’d had my fifth surgery, which was really the big one since it had taken a part of my thigh and sewed it to my foot, and my pain had gone through the roof.

    The good news was that a specialty pain team got that pain under control. But the tricky part is that they didn't take any ownership of the long-term management of that regimen. They told the surgeons to increase the dose as I built up a tolerance, but that was the extent of the guidance.

    It was when I went to my original trauma surgeon months later that he said, “Whoa, you're on a really high dose of opioid painkillers. You have to get off them now.”

    Then I was given a really aggressive plan for reducing the opioids, and that was what caused all the problems that followed.

    You write in your book that you thought opioid withdrawal was going to kill you. Can you describe that experience?

    Imagine the worst case of the flu you've ever had. Multiply that by 1,000 and that’s a start. You get sweaty, you run a fever, and you get the shakes. You get nauseated, you vomit, you have diarrhea.

    Whatever pain you're medicating comes roaring back — plus your whole body hurts. You also get jittery, and it keeps you from getting any meaningful rest. At the end of my withdrawal, which lasted 29 days, I went three days without any sleep.

    I also had really crushing depression. I thought, “I'm broken beyond repair, my life is worthless. I'll never be good to my daughter, I'll never be good to my partner.” I thought that if [the depression] didn’t get better, I was going to have to find a way to check out.

    Luckily, with my family’s amazing support, I managed to survive the withdrawal.

    Opioids are such powerful drugs. How can physicians avoid undertreating pain while also avoiding overusing them?

    Now that we are scared of opioids, prescribers have internalized the message that we should prescribe fewer of them. That’s horrible advice. It says, “Prescribe fewer opioids regardless of the situation.” Instead, it’s got to be, “You use opioids for the right patient in the right circumstances.”

    We have some general ideas emerging from the research literature. For one, opioids typically should not be used as a first-line treatment for chronic pain. So, try a lot of other things first. But a whole bunch of pain is really well-treated by opioids: surgical pain, traumatic pain, and some forms of chronic pain when other modalities have basically pooped out.

    What must physicians do to provide appropriate care once they’ve decided to prescribe opioids?

    A big part of the job is knowing how to help a patient over the lifetime of the medication regimen. No one was checking on me over the course of two months as my prescription was being escalated to see whether or not this was a good arc for my treatment.

    Almost everyone who gets put on opioids is going to need to come off them. If they're on for more than a few days, then physical dependence is going to be an issue. So, all doctors who are managing patients need to learn how to taper patients off responsibly.

    It's incredibly important that clinicians recognize that abruptly discontinuing opioids is never an evidence-based response.

    Also, we have an entire population of “legacy patients” — patients who are the legacy of our past heavy prescribing behavior. A forced tapering can destabilize them, and they might be unstable in lots of ways already. They might be housing insecure or have other health comorbidities, or they’re often old. All of those things make the risk of deprescribing before a patient commits to partnering on it very serious.

    What broad, systemic changes are necessary to help physicians do all this work?

    Pain is really hard to treat, so it will take a lot of training. We need our medical students and residents to have standardized training on pain management. That’s number one.

    Also, think about how much time all the opioid-related care takes — that’s time that clinicians either can't bill or have a really hard time figuring out how to bill.

    So, insurers need to understand how to pay for pain treatment appropriately. A bottle of 60 pills can be just a few dollars, but things like physical therapy, yoga, and cognitive behavioral therapy are expensive. Payers have to make it so that a patient isn’t thinking, “Well, I could either go bankrupt trying to treat my pain, or I could take these pills. Or, because the doctor won't give me these pills and instead will only tell me to do these expensive things that I can't afford, I'll buy pills on the street.”

    More than 2 million people in the United States are already addicted to opioids. What changes do we need to better treat them?

    Anyone who's ready to recover from their addiction needs to be able to go into treatment the moment they decide. That means we need the infrastructure for treatment, and it needs to be readily available and not incredibly expensive. We fail in all these accounts. And a whole bunch of facilities don't use the gold standard of treatment, which is to include medications for opioid use disorder.

    Also, we need to help people stay alive until they're ready to enter treatment, which requires harm reduction. We need things like syringe exchanges and widespread naloxone distribution that keep people alive.

    What have you learned about racial and other inequities in the treatment of pain in this country?

    The data tell us that you are most likely to have your pain taken seriously if you are a White man. If you're a woman or a person of color, your testimony about your pain is considered less reliable. That’s a big problem.

    Also, now that we have this trend against opioids, aggressively deprescribing them can force patients who are on them into terrible withdrawal. That's more likely to happen to patients who don't have their pain testimony taken seriously — women and people of color. And that’s even more disconcerting.

    What are your thoughts on how the COVID-19 pandemic has impacted the opioid epidemic?

    It's catastrophic. Every one of the risk factors for taking drugs and every one of the components of recovery have been impacted.

    People take drugs for pain, of course, but for other predictable reasons too, like unmanaged mental health problems, poverty, joblessness, and hopelessness. Also, a huge part of many people’s recovery is human connection. They may have a group, they see their clinicians and therapists, and they’ve figured out a life that's valuable for them which might involve loved ones. Now, social distancing means we're disconnecting from other humans, and the economy has collapsed.

    It's a powder keg of everything that can undermine treatment and that drives drug use, addiction, and overdose.

    Overdose deaths are up about 13% across the states that we have data for. This data always lags, so we’re not going to know how bad this year is for a while. But I'm terrified to get the numbers.

    You had an infant daughter at home while you were going through withdrawal. What was that like?

    My baby girl and my partner Sadiye, who was a hero through the whole process, are so important to mention. I had everything to live for. When I was bawling because I thought I was going to die and my daughter climbed on my lap and kissed my eyes, she gave me strength for one more day.

    For months after I came out of withdrawal, I would go to bed at night thinking about people across the country who were going through withdrawal and didn’t have anyone to take care of them — to kiss their eyes and give them hope.

    People typically don't get free of drugs because they pull themselves up by their bootstraps. Very often, it's really easy to determine who has the supports they need to be fortunate enough to succeed. So that means for all the folks who are not so fortunate, we have to step in as a society and provide the infrastructure that can help make it more likely that they will succeed.