Prescription drugs

After harrowing opioid experience, Hopkins bioethicist says doctors must do more to help patients through withdrawal

After a month of white-knuckling his way through the nausea, sweating, shivering, and depression of opioid withdrawal, Travis Rieder finally gave in and refilled his prescription.

But he put that bottle of pills—which he'd been prescribed in the aftermath of a motorcycle accident and several foot surgeries—on his nightstand and didn't touch them. When he got to sleep that night without them, it was his first true rest in days.

In 2013, medical providers in the U.S. wrote nearly a quarter of a billion prescriptions for opioids. That's enough for every American adult to have their own bottle of pills.

"I had come out on the other side," Rieder, a bioethicist at Johns Hopkins, writes in an article published today in Health Affairs.

For many patients who are prescribed opioids for pain, Rieder says, this is not the outcome. Instead of passing through the gauntlet of withdrawal, a large number of patients who start with prescriptions for opioid painkillers end up with chronic pill addictions, or turn to heroin for a cheaper fix.

In 2013, according to the Centers for Disease Control and Prevention, medical providers in the U.S. wrote nearly a quarter of a billion prescriptions for opioids—drugs such as oxycodone, hydrocodone, morphine, and methadone. That's enough for every American adult to have their own bottle of pills. The CDC estimates that 91 Americans die every day from overdosing on opioids, including both prescriptions and heroin. Deaths from prescription opioids have more than quadrupled since 1999.

A Washington Post/Kaiser Family Foundation survey published last month found that one-third of of Americans who had taken prescription opioids for at least two months became addicted to or physically dependent on the painkillers. Moreover, almost all long-term users said they were introduced to the drugs by a doctor's prescription—yet six in 10 said doctors offered no advice on how or when to stop taking the drugs.

Fortunately for Rieder, the potent medley of pills he was taking after his May 2015 accident failed to create a psychological addiction.

"I was kind of revulsed by the drugs," he said in an interview last week.

But the biological dependence was there—the unavoidable physiological consequence for any opioid user who's built up a tolerance. Rieder powered through his withdrawal with willpower and family support, but he received little competent guidance from medical professionals as he weaned himself off the drugs. The more than 10 doctors he sought out during his withdrawal offered conflicting advice, many suggesting he simply return to the pills. After being turned away from a pain management clinic, he called a methadone clinic but couldn't be accommodated for five days. When he protested the wait, he was referred to the emergency room, where it was likely he would be prescribed the very drugs he was trying to quit.

Travis Rieder

Image caption: Travis Rieder

Post-withdrawal, Rieder found himself reeling with anger that he'd navigated through that experience without a rudder. When he shared his personal story with colleagues at the Johns Hopkins Berman Institute of Bioethics, where Rieder is assistant director of education initiatives, they reaffirmed his instinct to probe the opioid issue more deeply—from an ethical standpoint.

In his article in Health Affairs, Rieder calls the medical community's inadequate training and resources for treating opioid withdrawal a moral failure—and one that's especially glaring as America faces what experts agree is an opioid epidemic.

In Health Affairs, he writes:

If a physician prescribes a highly addictive medication for pain management, with serious and predictable withdrawal effects, then he or she has a duty to see that patient through the weaning process as safely and comfortably as possible. Or, alternatively: He or she has a duty to refer the patient to someone who will be able to see the patient through that process.

Rieder's recovery didn't end where his article leaves off. He walked with a cane until recently, and he underwent another foot surgery last winter. For that process, Rieder became his own health care advocate, consulting the Blaustein Pain Treatment Center at Johns Hopkins for expert advice on how he could prevent another opioid tailspin. Though avoiding the drugs entirely wasn't an option, he pressed doctors for the lowest and shortest doses possible.

"I was in a lot of pain from that surgery, but I wasn't willing to fully medicate the pain," he said in the interview. "I didn't want to risk it."

Rieder recognizes that the route he took to recovery was cultivated by the advantages of his own research and personal connections at Johns Hopkins.

"There's something wrong with the system when it's a privilege" to access such options, he said.

Michael Erdek, a pain treatment specialist who works at the Blaustein Center, said though Rieder's initial experience isn't necessarily the norm for patients on opioids, his story is "not shocking."

Broadly, the cultural tide is shifting, Erdek said, against the "knee-jerk" prescriptions for opioids of the early 2000s as the public better understands the risks of tolerance and addiction.

"It's reached a level of societal awareness now," Erdek said.

But the medical community at large, Erdek suggested, still hasn't grappled successfully with the complications of withdrawal. A lack of specialized expertise on these issues can lead to passing the buck among different physicians, as Rieder experienced.

"There's a bit of a mystery about who is going to deal with these types of patients," Erdek said.

For Erdek, who recently joined the Berman Institute of Bioethics as an affiliate faculty member, the most resonant angle of Rieder's story is its call for better education of medical professionals.

Johns Hopkins recently started offering a pain curriculum for first-year medical students, he said, but such training is still far from mainstream. According to a 2013 survey in the American Medical Association's Journal of Ethics, the overall picture for pain management is "one of inadequacy and dissatisfaction on the part of practitioners," with only 3 percent of U.S. medical schools dedicating any part of their curriculum to pain education until recently.

"As physicians, as ethicists," Erdek said, "what we need to do is come up with a responsible, ethically sound way of dealing with this education."

For Rieder, who hopes to focus on policy solutions in his future work, the issue is a moral imperative.

"Opioid withdrawal isn't minor," he writes in his article. "That kind of suffering matters, and its seriousness needs to be reflected in the way we deal with prescription opioids."