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A bioethicist’s harrowing encounter with prescription painkillers highlights systemic health care problems

In Pain: A Bioethicist’s Personal Struggle with Opioids

Travis Rieder
Harper
2019
320 pp.
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Imagine having your foot pinned between a moving van and a motorcycle and subsequently undergoing five surgeries to restore function to your mangled limb over a 1-month period. In order to endure the debilitating pain, you are prescribed high doses of opioid analgesics, only to discover that your care team has no exit strategy. Feeling abandoned by the medical establishment, you decide to subject yourself to a process of aggressive self-tapering and subsequently experience a gruesome withdrawal. Travis Rieder tells such a story—his story—in his new book, In Pain: A Bioethicist’s Personal Struggle with Opioids.

In Pain situates Rieder’s traumatic experience within the context of North America’s “triple wave” opioid overdose crisis (1). As he explains, high prescribing volumes and aggressive marketing of opioids such as OxyContin initiated the crisis in the 1990s and 2000s. When their opioid prescriptions stopped or were scaled back, some patients turned to illicit sources. Most of the tens of thousands of overdose deaths that occurred in the United States and Canada within the past several years were due to a toxic street supply of heroin and fentanyl analogs.

Although opioid prescribing rates have fallen in recent years, the ethics of how and when these drugs are administered is still relevant. As Rieder shows, patients on long-term opioid therapy may be harmed when subjected to forced opioid tapering. And not prescribing an opioid when one is needed can be harmful as well.

Rieder’s story exposes how the U.S. health care system is not designed to deal with chronicity and complexity. He argues that the errors in his care were systemic and offers a useful reframing: His physicians, he writes, were “part of a system that didn’t help them properly identify or live up to their responsibilities.” The difficulty of dealing with complicated pain cases is further intensified by additional challenges, such as physician reimbursement structures, financial conflicts of interest, and direct-to-consumer advertising of pharmaceuticals.

As an academic bioethicist, Rieder provides a philosophical lens to his lived experiences. It is this contribution where In Pain departs from other published narratives on pain and substance use, in which a discussion of the ethical issues tends to be implicit rather than at the forefront.
In “Pain and drugs,” “Dependence and addiction,” and “What doctors owe patients,” Rieder discusses moral philosophy concepts such as first- and second-order desires, as well as duties and obligations, in digestible prose that is as profound as it is engaging. In chapter four, for example, he describes what it was like to experience the epistemic injustice of having the credibility of his testimony downgraded. His physician, it seems, thought his pain was not as severe as he claimed and believed that he was trying to secure drugs. This is a common experience among people who consume opioids (2).

Extending his analysis to the current overdose crisis, Rieder argues that the United States has a moral imperative to urgently adopt evidence-based harm reduction strategies (such as expanded access to naloxone and supervised consumption sites) that have been successful in other jurisdictions. These programs are based on values such as compassion and nonjudgment and have demonstrated effectiveness in the reduction of overdose deaths as well as infections such as HIV and hepatitis C. A harm reduction philosophy is counter to the “war on drugs” approach in the United States, which criminalizes people who use drugs and contributes to further harm. Given the scale of the crisis, Rieder submits that “It’s time…to abandon the idea that we will arrest our way out of drug use and addiction.”

Despite his many privileges, Reider experienced tremendous suffering during his recovery and faced a number of challenges in accessing the care he needed. Those who are less privileged are often left far worse off.

In Pain is an invitation for compassion for the millions of people around the world suffering with pain and substance use disorders, but it is also a call to action, not just for more responsible opioid prescribing but for a fundamental change to how pain management is delivered. As Rieder argues, no advances in medical technology will solve the public health problem of pain. What he believes is required is a change in attitude toward “a pill for every pain” culture in North America and more sustained funding structures for evidence-based nonpharmacological treatments.

Pain patient advocacy groups and people on the front lines of the overdose crisis have been calling for action for decades. Rieder’s thoughtful book joins their growing chorus

References

  1. 1. D. Ciccarone, Int. J. Drug Pol. 10.1016/j.drugpo.2019.01.010 (2019).

  2. 2. Z. Buchman et al., Bioeth. Inq. 4, 1 (2017).

About the author

The reviewer is at the University Health Network, the University of Toronto Joint Centre for Bioethics, and the Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.