America is still in pain
In 2015, a distracted driver blew a stop sign and changed my life forever. When his van impacted my motorcycle, my left foot was crushed between the two before I was thrown to the ground. The six reconstructive surgeries that followed never fully gave me my foot back, though that‘s not what had the most lasting impact. The most defining moments of my life came from the opioids I was prescribed for months. And then my doctors’ inability (or unwillingness) to help me off of them.
The result was a traumatizing withdrawal that left me violently ill, deeply depressed, and eventually suicidal. The withdrawal was so bad that I thought it would kill me outright, and it went on for weeks as I completed an ill-advised, bumbling taper. Although I made it out the other side of that experience, I was haunted by a sense that I had been abandoned by the healthcare system, left to my own devices to fix a problem that they, themselves, had caused.
In 2019, I published “In Pain: A Bioethicist’s Personal Struggle with Opioids,” in which I shared my story and examined the failures that led to it. In the years since, while speaking about the book, I’ve often been asked whether things are changing. The accident is ever further in the past. Aren’t things getting better?
In some ways they are. I’ve spoken at medical conferences, hospitals, and healthcare systems, and the audiences are receptive. I give continuing medical education talks that teach clinicians about the importance of knowing how to taper the medications that they prescribe—among the most sensible ideas I can imagine, but one that somehow still isn’t universally endorsed.
But in many ways, America’s problems with pain and opioids are getting worse. The COVID-19 pandemic supercharged the already catastrophic drug overdose crisis, leading to more than 100,000 people dying each year, the majority of them from opioids. And while you might think that this would incentivize clinicians to do better at using opioids, the opposite has too-often been true. That’s because the presence of “an opioid crisis” as a cultural bogeyman has led to sometimes-unreflective prohibitionist attitudes about opioids— the idea that these drugs are evil black magic and so must never be used.
The problem with such a view is that opioids are still important pain medications, and so should be used in some contexts. Thus, trying to solve the problem by simply not prescribing opioids leads to multiple bad outcomes. Most obviously, patients in pain sometimes don’t get the medication they need. Less obviously, but crucially, if clinicians think that restricting opioids is the only aspect of responsible prescribing, then they may not learn other important aspects, such as managing the medication over the long term, and safely tapering when the cycle is complete.
Finally, an entire generation of patients are already on opioids—sometimes on very high doses that have been prescribed for years or decades, beginning in the ‘90s or early 2000s during the heyday of aggressive opioid therapy. A focus on restricting opioids can, and has, led to these patients being abruptly tapered and even abandoned, resulting in catastrophic withdrawal. The problem has become so serious that the FDA and HHS have warned that such abandonment can lead to devastating outcomes, such as patients switching to the toxic illicit market, or even committing suicide.
So I’m afraid the answer is ‘no’: we haven’t gotten all that much better in recent years. Which is why we must keep talking about opioids. My own pain recedes as time goes by, but America’s continues.
IN PAIN: A BIOETHICIST’S PERSONAL STRUGGLE WITH OPIOIDS
By Travis Rieder Harper Paperbacks ($17.99)
Travis Rieder is an associate research professor and director of the Master of Bioethics degree program at the Johns Hopkins Berman Institute of Bioethics. This essay is adapted from his book, “In Pain: A Bioethicist’s Personal Struggle with Opioids.” He will appear at Alphabet City on March 14th at 7 p.m. as a part of “Healthcare & Humanity Reading Series: The Truth of Opioid Addiction.” The event is free and tickets are available via City of Asylum.