Opioids and Pain: A Professor’s Story

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America’s opioid epidemic was a matter of academic interest to bioethicist Travis N. Rieder until he suffered a serious accident in 2015. That’s when, as he put it, his very “intimate run-in with the American healthcare system” left him with a “profound dependence on oxycodone,” and a deeper understanding of the painful choices faced by doctors and patients.

Rieder, a research scholar and the director of the Masters of Bioethics program at the Johns Hopkins Berman Institute of Bioethics, put his hard-won knowledge into a recently released book, “In Pain: A Bioethicist’s Personal Struggle with Opioids” that attempts to break through some of the simplistic approaches to opioids with what he says is a more “nuanced” approach.

In a recent conversation with TCR, he explains why defining opioid dependency as purely “addictive” has complicated our approach to the epidemic, why it’s placed a heavy burden on doctors who prescribe painkillers, and why public health considerations should outweigh punishment approaches taken by the justice system.

The transcript has been condensed and slightly edited for clarity.

The Crime Report: How did your own experience with surgery and pain influence your perspective on the opioid epidemic?

Travis Reider: I hadn’t really thought about it prior to my own surgery [in 2015]. Probably, the most important thing that I can identify now is that we tend to think about prescription of opioids as being risky because they are “addictive.” Which is definitely true, they have addictive potential, but we tend to think of that as the only or the major risk of these medications. What I learned is that the much more significant risk for most people is physiological dependence.

Addiction is a behavioral affliction. It’s characterized by compulsive behavior, cravings for a drug or an activity, and seeming to have no control over acting even when there are bad consequences. Whereas, physiological dependence is characterized by changes in the brain such that when you take away the drug, you go into withdrawal. The thing is, everyone who is exposed to a drug like opioids for long enough, at high enough doses, will become dependent and so will go through withdrawal.

A relatively small percentage will actually develop an addiction. The reason I think this is so important is because if you thought addiction is the only worry, you might think, “well, I don’t have an addictive personality, whatever that means, so I’m not at any risk from this drug.” But, it doesn’t matter what your personality is. You’ll develop a dependence just because that’s how brains work. The process of going through withdrawal, the fear of that process, how truly agonizing that is, that’s enough to drive people back on the medication and then promote what is genuinely addictive behavior, even if that’s not something you thought you would wrestle with.

TCR: Why was it important for you to share your personal experience?

Reider: I was incredibly lucky. I went through this terrible dependence and withdrawal, and I did make it out. A lot of my good fortune had to do with having an incredibly supportive family, a partner, a one-and-a-half-year-old daughter who I desperately wanted to be present for and to make it off the medication for. And then also, the thought that I have just a huge amount of privilege. I have middle-class lifestyle, a good job. I’m a faculty member at Johns Hopkins. I’m a white man, so I tend to have my testimony taken more seriously than a lot of other people in society. I have all of these privileges that society hands out, and still, this is how close I got to having my life just ruined by this drug.

Travis Rieder

Travis Rieder. Photo by Varsha Kumar.

What kept me awake at night afterwards was reflecting on that, and realizing if it was this hard for me and I have all of this privilege, how hard and how bad must it be for [others who aren’t as fortunate]. I happen to have a microphone by virtue of being a professor, so shame on me if I don’t tell this story.

TCR: You pointed out in the book that opioid crisis has primarily hurt white men. Why do you think this is?

Reider: That’s not actually true anymore. There was a disproportionate effect on white people in the kind of early stages of the opioid crisis. [(It was] as a kind of epidemic of privilege. The early stages of the opioid crisis were sparked by overprescribing of pharmaceutical opioids. Who gets that sort of medication? People who have access to the healthcare system, so that’s already kind of a layer of privilege. And then, two, it’s people whose testimony is taken seriously. We have a phenomenon of suspicion around pain, because a doctor can’t know for sure whether or not you’re in pain, if there’s any reason to lie, then the doctor has reason to be suspect. Opioids are drugs that can get you high and have street value.

Basically, these two things collided. (There is empirical evidence that pain reports of women, Hispanic people, and black people are taken less seriously than the testimony of white men. It’s not at all surprising that the opioid epidemic at least started in rural and suburban areas that are predominantly white. But we should be clear that there is no longer any real discrimination. All races, all classes, everybody is being decimated by the opioid crisis now, but that’s partially because of the slow move towards heroin and elicit fentanyl.

TCR: You mentioned that the pendulum has swung back and forth between the encouragement and prohibition of opioids. Where does the United States lie now between these two extremes and where should we be?

Reider: I think we’re kind of mid-swing. I hear from pain patients all the time who say we’ve already swung back towards prohibition, because they are treated with suspicion when they try to get medication from their doctor or fill medication at their pharmacy. There are still of a lot of public health folks who think that we’re still far too aggressively prescribing opioids, because we’re still at several times the rate we were in the early 1990s.

I think both things are true, which is why the problem is so wicked right now. You have generations of doctors who are still prescribing opioids pretty recklessly, because that’s how they got trained to deal with pain and that’s kind of all they know how to do. They’re often doing this in biased way. They’re often treating some people with more suspicion that others. And then, there are a lot of doctors who are saying: “This is too hard. Everyone is telling me I’m killing my patients. I’m just not going to prescribe opioids.” They are withholding opioids even when they are called for.

‘We’re getting the worst of both sides of this. We need to stop the swing of the pendulum because prohibition doesn’t work and giving opioids out like candy doesn’t work. But that doesn’t mean that we need to land recklessly in the middle. It means that we need to be at a place where we take pain seriously, we require clinicians to be educated on how to treat pain, we reimburse physicians for all sorts of integrative treatments and don’t rely on them to just write a prescription for opioids as the cheapest and quickest way to get patients out of their office. There needs to be a nuanced, educated, sophisticated view on how to treat pain. That’s just way harder than either of the two extremes, which is why there’s resistance and why it’s going to be slow.

TCR: How does the stigmatization of opioid use and addiction affect pain treatment and laws surrounding opioid use and the opioid crisis in general?

Reider: Physicians are being told by the media and by their colleagues that they are killing patients by prescribing these drugs and they just kind of put their hands up. And now, we have opioid-free emergency departments and clinicians who just put up signs in their office that say “I don’t prescribe opioids.”

There’s also a more formal policy response. One of the most harmful things that I think we’ve done is we’ve started trying to address the problem with one-size-fits-all prescribing recommendations. You get things like a 50- or a 90-morphine milligram equivalent prescribing restriction. You as a clinician just can’t prescribe more than a specific amount. Many states have adopted a number of days so that you can’t prescribe more than three days or five days or seven days. Some of these are very sensible, like a day limit, for instance.

For acute pain, it turns out that not that many people will need opioids for longer than say a week for most moderate acute pains. But, it doesn’t mean that these one-size fits all strategies are actually going to work.

They’re going to have stigmatizing and harmful effects because it’s going to make physicians more suspicious of patients who are requesting these medications. There are all sorts of vulnerable populations that are going to be hurt the worst by this: people who can’t go out to see their doctors as often, who can’t go in for refills.

Whenever you make it harder for clinicians to prescribe a certain amount, they’re just going to be less likely to do it, because hurdles are something that physicians don’t have time for. All of these things make me very worried. The answer is going to require sophistication and nuance.

TCR: What do you think the role of the criminal justice system should be?

Reider: That’s a really hard question. I tend to think that this is by and large a health care issue and not a criminal justice issue. We’ve gotten ourselves into a little bit of trouble when we have treated addiction as a criminal justice issue. But I sometimes hear well-meaning advocates for pain patients saying things like the law needs to stay out of my relationship with my doctor. That’s not true. The law has a role in your relationship with your doctor. For instance, I think it is super reasonable is that we could require physicians who are going to prescribe certain substances to be educated on certain substances.

That’s not a requirement for a pill limit. It a policy to say: “Hey we expect doctors to treat pain, maybe we should expect doctors to be educated on how to treat pain.” Again, the answer is almost always going to lie somewhere in the middle. We do need to have protection from a kind of completely unrestricted medical practice. I tend to think that criminalizing the use of a substance that somebody has an addiction to is going to do very little good.. Punishing somebody because they used heroin when they have an addiction to opioids, is probably not going to do anything. It’s not going to be much a deterrent. Remember, addiction is defined by compulsive behavior even in the face of negative consequences.

Criminal punishment doesn’t serve as a very good deterrent. It tends to have discriminatory effects. It affects differently along race and class lines, and it doesn’t help rehabilitate. People have a health condition; they have an addiction. This is a purview of medicine, mental health, behavioral health, and the criminal justice system isn’t set up to deal with that. The health care system is. In general, my prior is these are not problems for the criminal justice system, these are problems for healthcare, for public health.

TCR: Are there any other problems or solutions related to this crisis that people should be aware of?

Reider: At the end of the book, I talk about harm reduction. One question we can ask is what can we do after we have a population of people who are addicted. If we are not going to arrest our way out of the opioid crisis, if it’s a health issue not a criminal justice one, what can we do?

Well, one issue that gets us really twisted up on both moral and legal fronts is the idea that we can use harm reduction. Harm reduction strategies include anything from needle exchange programs, which are quite old school and we’re very good at but we don’t embrace real well across the states. In some places, they’re illegal. Having a needle exchange program violates drug paraphernalia laws. Here you have this practice that reduces the disease burden and the mortality of people who use drugs, but it can make us feel morally kind of icky because it feels like if we give people clean needles to shoot heroin with, we’re kind of helping them do heroin. It can be legally problematic, because we’re giving them drug paraphernalia.

Well, now you scale it up to things like safe injection sites which of course is a big conversation in Philadelphia and San Francisco. There’s tension between the justice department saying to Philadelphia if you open a safe injection site we’re going to shut it down …public health groups are saying: “Look, the evidence tells us this is one of the ways we will solve the opioid epidemic, this is one of the ways we will reduce opioid deaths when this is one of the most serious crises facing our country.”

The most interesting discussion about potential solutions when it comes to our kind of ethical and legal qualms is we could actually reduce the number of people dying from drug use if we adopted just a whole [range] of harm reduction strategies. Why do we think it’s so wrong to give people a clean safe space to inject their drugs where there’s something to relieve them if they overdose? We need to have a really loud conversation about this.

Maria Trovato is a TCR news intern. Readers’ comments are welcome.

2 thoughts on “Opioids and Pain: A Professor’s Story

  1. I recognize Dr Rieder’s good intention and desire to see nuance prevail over broad-brush policy that harms more than it helps. And I do not wish to trivialize his lived experience. However, as I have recently written with Stephen E Nadeau MD and Andrea Trescott MD, in Practical Pain Management,”Assessments of the risks of opioid treatment often conflate dependence (a common and easily managed pharmacodynamic effect of opioids), tolerance (an uncommon and readily managed consequence of chronic opioid therapy), and addiction (a rare but serious medical problem of complex origin). ”

    I have also recently noted in a June 28 2019 editorial on STAT News: “Almost the entirety of the public narrative that shapes State and Federal opioid policy is wrong. Using data published by the CDC itself, a colleague and I have shown that there is no relationship between State-by-State rates of opioid prescribing by doctors [versus] overdose-related deaths from all sources … including legal or diverted prescriptions and illegal street drugs. In other words, there is no cause and effect. Historical charting of the data reveal that hasn’t been the case in 20 years.” Many thousands of patient narratives contradict the notion that medical exposure to opioid pain relievers is inherently dangerous. Risk factors are typically less than one percent.

    So as we strive for nuance and balance, let’s first start from the medical evidence. The evidence makes clear that assigning blame for our opioid crisis to doctors prescribing for pain patients is nothing short of an urban myth. But all of drug control policy is founded on that myth.

  2. I have a non-fatal, debilitating health problem. The last time I want to the ER, the doctor on staff was shocked that I wasn’t being given adequate relief from Fibromyalgia. I am so, very, very happy for this success story that justifies the denial of appropriate pain killer for sadly justifiable usage for the afflicted. I hope the above book makes the author feels very self righteous to add his efforts to ban much needed help from sufferers of severe pain.

    I would not at all be surprised if the author of this book takes a firm stance against suicide. If this is the case, I have to ask if this man prefers for people of suffer rather than take opioids. My symptoms are not going to abate. I face the remainder of my days in insufferable pain. [‘this comment has been condensed for space]

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