May 29, 2023

The United States accounts for five percent of the world’s population but consumes almost 70 percent of the total global opioid supply, creating an epidemic that has resulted in tens of thousands of deaths each year. How did we get here, and what can we do about it? In this personal talk, Travis Rieder recounts the painful, often-hidden struggle of opioid withdrawal and reveals how doctors who are quick to prescribe (and overprescribe) opioids aren’t equipped with the tools to eventually get people off the meds. Travis Rieder, PhD, is the Assistant Director for Education Initiatives, Director of the Master of Bioethics degree program and Research Scholar at the Berman Institute of Bioethics.

How much pain medication are you taking that was the very routine question that changed my life it was july 2015 about two months after i nearly lost my foot in a serious motorcycle accident so i was back in my orthopedic surgeons office for yet another follow-up appointment i looked at my wife satya we did some calculating about a hundred and fifteen milligrams

Oxycodone i responded maybe more i was nonchalant having given this information to many doctors many times before but this time was different my doctor turned serious and he looked at me and said travis that’s a lot of opioids you need to think about getting off the meds now in two months of escalating prescriptions this was the first time that anyone had expressed

Concern indeed this was the first real conversation i’d had about my opioid therapy period i had been given no warnings no counseling no plan just lots and lots of prescriptions what happened next really came to define my entire experience of medical trauma i was given what i now know is a much too aggressive tapering regimen according to which i divided my

Medication into four doses dropping one each week over the course of the month the results is that i was launched into acute opioid withdrawal the result put in another way was hell the early stages of withdrawal feel a lot like a bad case of the flu i became nauseated lost my appetite i ate everywhere had increased pain and my rather mangled foot i developed

Trouble sleeping due to a general feeling of restlessness at the time i thought this was all pretty miserable but that’s because i didn’t know what was coming at the beginning of week 2 my life got much worse as the symptoms dialed up in intensity my internal thermostat seemed to go haywire i would sweat profusely almost constantly and yet if i managed to get

Myself out into a hot august sun i might look down and find myself covered in goose bumps the restlessness that had made sleep difficult during that first week now turned into what i came to think of as the withdrawal feeling it was a deep sense of jitters that would keep me twitching made sleep nearly impossible but perhaps the most disturbing was the crying i

Would find myself with tears coming on for seemingly no reason and with no warning at the time they felt like a neural misfire similar to the goosebumps sadia became concerned and she called the prescribing doctor who very helpfully advised lots of fluids for the nausea when she pushed him in said you know he’s really quite badly off the doctor responded well

If it’s that bad he can just go back to his previous dose for a little while and then what i wondered try again later he responded now there was no way that i was going to go back on my previous dose unless i had a better plan for making it through the withdrawal next time and so we stuck to writing it out and we dropped another dose at the beginning of week 3 my

World got very dark i basically stopped eating and i barely slept at all thanks to the jitters that would keep me writhing all night the worst the worst was the depression the tears that had felt like a misfire before now felt meaningful several times a day i would get that welling in my chest where you know the tears are coming but i couldn’t stop them and with

Them came desperation and hopelessness i began to believe that i would never recover either from the accident or from the withdrawal sadia got back on the phone with the prescriber and this time he recommended that we contact our pain management team from the last hospitalization that sounded like a great idea so we did that immediately and we’re shocked when

Nobody would speak with us the receptionist who answered the phone advised us that the pain management team provides an inpatient service although they prescribed opie ways to get pain under control they do not oversee tapering and withdrawal furious we called the prescriber back and begged him for anything anything that could help me but instead he apologized

Saying that he was out of his depth look he told us my initial advice he was clearly bad so my official recommendation is that travis go back on the medication until he can find someone more confident wean him off of course i wanted to go back on the medication i was in agony but i believe that if i save myself from the withdrawal with the drugs that i would

Never be free of them and so we buckled ourselves in and i dropped the last dose as my brain experienced life without prescription opioids for the first time in months i thought i would die i assumed i would die i’m sorry because if the symptoms didn’t kill me outright i’d kill myself and i know that sounds dramatic because to me standing up here years later

Whole and healthy to me it sounds dramatic but i believed it’s my core because i no longer had any hope that i would be normal again the insomnia became unbearable and after two days with virtually no sleep i spent a whole night on the floor of our basement bathroom i alternated between cooling my feverish head against the ceramic tiles and trying violently to

Throw up despite not having eaten anything in days when saudi had found me at the end of the night she was horrified and we got back on the phone we called everyone we called surgeons and pain docs and general practitioners anyone we could find on the internet and not a single one of them would help me the few that we could speak with on the phone advised us to

Go back on the medication an independent pain management clinic said that they prescribed opioids but they don’t oversee tapering or withdrawal when my desperation was clearly coming through my voice much as it is now the receptionist took a deep breath and said mr reeder it sounds like perhaps what you need is a rehab facility or a methadone clinic i didn’t

Know any better at the time so i took her advice i hung up and i started calling those places but it took me virtually no time at all to discover that many of these facilities are geared towards those battling long-term substance use disorder in the case of opioids this often involves precisely not weaning the patient off the medication but transitioning them

On to the safer longer acting opioids methadone or buprenorphine for maintenance treatment in addition everywhere i called had an extensive waiting list i was simply not the kind of patient they were designed to see after being turned away from a rehab facility i finally admitted defeat i was broken and beaten and i couldn’t do it anymore so i told sadia that

I was going back on the medication i would start with the lowest dose possible and i would take only as much as i absolutely needed to escape the most crippling effects of the withdrawal so that night she helped me up the stairs and the first time in weeks i actually went to bed they took the little orange prescription bottle i set it on my nightstand and then

I didn’t touch it i fell asleep i slept through the night and when i woke up the most severe symptoms had abated dramatically i’d made it out thanks for that that was my response to i’m sorry i have to gather myself just a little bit i think the story is important it’s not because i think i’m special this story is important precisely because i’m not special

Because nothing that happened to me was all that unique my dependence on opioids was entirely predictable given the amount that i was prescribing and the duration for which i was prescribed it dependence is simply the brains natural response to an opioid rich environment and so there was every reason to think that from the beginning i would need a supervised

Well-formed tapering plan but our healthcare system seemingly hasn’t decided who’s responsible for patients like me the prescribers saw me as a complex patient needing specialized care probably from pain medicine the pain doc’s saw their job is getting pain under control and when i couldn’t get off the medication they saw me as the purview of addiction medicine

But addiction medicine is overstressed and focused on those suffering from long term substance use disorder in short i was prescribed a drug drug that needed long-term management and then it wasn’t given that management and it wasn’t even clear whose job such management was this is a recipe for disaster and any such disaster would be interesting and worth talking

About probably worth the ted talk but the failure of opioid tapering is a particular concern at this moment in america because we are in the midst of an epidemic in which 33,000 people died from overdose in 2015 nearly half of those deaths involved prescription opioids the medical community has in fact started to react to this crisis but much of their response

Has involved trying to prescribe fewer pills and absolutely that’s going to be important so for instance we’re now gaining evidence that american physicians often prescribe medication even when it’s not necessary in the case of opioids and even when opioids are called for they often prescribe much more than is needed these sorts of considerations help to explain

Why america despite accounting for only 5% of the global population consumes nearly 70 percent of the total global opioid supply but focusing only on the rate of prescribing risks overlooking two crucially important points the first is that opioids just are and will continue to be important pain therapies as somebody who has had severe real long-lasting pain i

Can assure you these medications can make life worth living and second we can still fight the epidemic while judiciously prescribing opioids to people who really need them by requiring that doctors properly manage the pills that they do prescribe so for instance go back to the tapering regimen that i was given is it reasonable to expect that any physician who

Prescribes opioids knows that that is too aggressive well after i initially published my story in an academic journal someone from the cdc sent me their pocket guide for tapering opioids this is a four-page document most of its pictures in it they teach physicians how to taper opioids in the easier cases and one of their recommendations is that you never start

At more than a 10% dose reduction per week if my physician had given me that plan my taper would have taken several months instead of a few weeks i’m sure it wouldn’t been easy it probably would have been pretty uncomfortable but maybe it wouldn’t have been hell and that seems like the kind of information that someone who prescribes this medication ought to have

In closing i need to say that properly managing prescribed opioids well not by itself solve the crisis america’s epidemic is far bigger than that but when a medication is responsible for tens of thousands of deaths a year reckless management of that medication is indefensible helping opioid therapy patients to get off the medication that they were prescribed may

Not be a complete solution to our epidemic but it will clearly constitute progress thank you

Transcribed from video
I was in opioid withdrawal for a month — here's what I learned | Travis Rieder | TEDxMidAtlantic By TEDx Talks