I heard the interview on NPR with Travis Rieder about a book he wrote called - In Pain: A Bioethicist's Personal Struggle With Opioids. (I have copied the transcript of the interview highlights at the end of this entry.) He is a bioethicist at Johns Hopkins University who sustained a serious injury to his foot that caused severe chronic pain. He was treated with opioids, but then could not find a doctor who could effectively and humanely taper him from them.
Unfortunately I have not yet had a chance to read his book. I’m very sorry to hear about his difficulties in obtaining effective treatment. I thought that as a doctor who specializes in treating comorbid chronic pain and chemical dependency I might share some of my insights into some of the structural obstacles to doctors providing good treatment. He mentioned that he felt that a lack of knowledge about pain treatment and chemical dependency was the root cause and posited that better education on the subjects would mitigate it. I believe that this is true to a certain extent, but it ignores the overpowering context in which medical practice takes place.
I am reminded of a quote from Upton Sinclair: “It is difficult to get a man to understand something, when his salary depends on his not understanding it.” The pervasive and deeply misguided application of manufacturing principles to achieve “efficiencies” and razor thin margins have forced doctors to see a volume of patients that preclude them from having a thoughtful approach to a patient’s problems. Combined with the ever expanding administrative burden placed on them, they cannot entertain time consuming issues. This is not because doctors are greedy or uncaring. They try to do the best that they can within the constraints forced upon them. Currently most doctors are employees of large entities that impose patient quotas on them and they have little control over the structure of their practice. This has degraded care to the point of total inadequacy for people with complex problems like chronic pain and/or chemical dependency.
The alternative to situations like this is for doctors, like I have done, to go into boutique private practices that do not accept any insurance payments. While this permits the space to practice high quality/low volume medicine, it is unaffordable for most people.
I believe that as long as these types of structural obstacles are in place, no amount of education will improve these things. It may only end up serving to reinforce the reductionist narratives that seemed to drive some of the experiences that he described.
Motorcycle Crash Shows Bioethicist The Dark Side Of Quitting Opioids Alone
July 8, 2019 3:44 PM ET Heard on Fresh Air
In 2015, Travis Rieder, a medical bioethicist with Johns Hopkins University's Berman Institute of Bioethics, was involved in a motorcycle accident that crushed his left foot. In the months that followed, he underwent six different surgeries as doctors struggled first to save his foot and then to reconstruct it.
Rieder says that each surgery brought a new wave of pain, sometimes "searing and electrical," other times "fiery and shocking." Doctors tried to mitigate the pain by prescribing large doses of opioids, including morphine, fentanyl, Dilaudid, oxycodone and OxyContin. But when it came time to taper off the drugs, Rieder found it nearly impossible to get good advice from any of the clinicians who had treated him.
"We called everybody, and a bunch of them wouldn't even talk to me," he says. "And this includes the pain management team. They would not speak with me, and the message they sent through a nurse was, 'We prescribe opioids but we don't help with tapering.' "
Rieder likens his experiences trying to get off prescription pain meds to a game of hot potato. "The patient is the potato," he says. "Everybody had a reason to send me to somebody else."
Eventually Rieder was able to wean himself off the drugs, but not before receiving bad advice and going through intense periods of withdrawal. He shares his insights as both a patient and a bioethicist in a new book, In Pain: A Bioethicist's Personal Struggle With Opioids.
On what happened when he tried tapering opioids after an ill-advised consultation with a plastic surgeon, who recommended abruptly reducing his dosage
He didn't know what he was talking about; that wasn't his area of expertise. He just tried to think of something that was reasonable — and he would eventually admit this, so this isn't too much editorializing — but we went home and the next day we dropped the first dose and it immediately sent me into withdrawal. ... It got worse over the first few days, and so we start to get really freaked out, because I feel like I've got the worst flu I've ever had multiplied by some order of magnitude. And I'm thinking, I have an entire month of this to get through. And so [my partner and I] get pretty freaked out.
On why it was so hard to find a doctor to help him taper opioids
I asked myself that question every day, every hour for a very long time. And once I transitioned from being an opioid patient to being an opioid researcher the answer I came to was something like "a lot of doctors don't know, so this is just a knowledge gap." So this is probably the best description of my plastic surgeon. He just had no idea how to do this. And that's understandable, because clinicians — doctors — don't get a lot of pain education in medical school. It's not required — a bunch of them get zero — and, on average, you only get a handful of hours. So there's a knowledge gap for sure.
On being sent to an addiction clinic
We called addiction clinics and they very nicely and very gently said, "Boy, you are not our job. We're dealing with people who might die from a heroin overdose anytime they get turned away. We're triaging here. You just took too many pain meds. You just need your prescriber to get you off them."
On the ways in which money plays a role in opioid use
Opioids are dirt cheap, because a bunch of them have been off patent for decades, and these other sorts of therapies can be really expensive. ... A lot of what I was supposed to do to help that pain was physical therapy. Physical therapy stopped getting coverage by my insurance when I turned over the new year. And I no longer hit my deductible, so it was too expensive. So I stopped. Because I was a relatively new faculty member — I couldn't afford it. And so I keep thinking, well, surely a bunch of other people would also struggle to pay for this.
So there are all of these different methods for handling pain that they could be arrows in the quiver of medicine, but they're hard. They get covered less. They're expensive. And so what do we know about opioids? Well, they're incredibly cheap. Morphine is a couple cents per dose. And they are easy. You give them to the patient, the patient feels better immediately. You give pills to a patient who comes in complaining about pain, they leave happy. So this really led me to investigate this, like, deep system of perverse incentives that have pushed us toward just prescribing opioids instead of doing something more integrative and holistic.
On how opioid dependence is treated as a medical issue, but heroin addiction is treated as a criminal issue
Now we're all very concerned about the opioid epidemic — when there have been people of color dying from heroin disproportionately for a really long time, and we just don't talk about it. And we treated them like criminals. That's a travesty. It's absolutely tragic. It's a stain on our response to drugs in this country. My story is not the only one that matters. Stories that look like mine aren't the only ones that matter. People take drugs for a reason. And whether you started with oxycodone or with heroin, if you were medicating something and it hurt you, and you ended up dying from overdose, your life matters. And we need to just kind of announce that loudly every time we have this conversation.