What becoming a patient taught me about responsible opioid prescribing

In early 2015, I was a postdoctoral fellow in bioethics with a research portfolio largely focused on climate change ethics, food ethics, overpopulation and other issues related to sustainability and planetary limits. I had no particular expertise in core issues of medical ethics and spent very little time in hospitals.

Then on May 23, a motorcycle accident changed all of that. While out for a ride, a van struck me on the left side, crushing my foot before tossing me to the ground. Rebuilding my foot would require a total of six surgeries and weeks of hospitalization.

Although I don’t recommend it as a research strategy, becoming a patient is an exceptionally good way to find cracks (and sometimes gaping chasms) in the healthcare system, and over the rest of 2015, I collected insights that I wish I never learned. I’ll describe just a couple of those.

Prescribing ethics

One of the most important lessons I learned about pain medicine and ethics is that a lot of clinicians don’t seem to know how or when to prescribe opioids responsibly. As documented in my book, In Pain, I learned this both when my doctors refused to get my extreme, traumatic, post-surgical pain under control, and when a different group of doctors (in the same hospital) later gave me lots of pain meds with no long-term plan. While some doctors were so suspicious of opioids that they talked down to me when I requested more medication, others saw my trauma as an obvious justification for opioids, so they prescribed more and more without consideration for who would eventually manage those meds when they went off shift or I was discharged from the hospital.

The piece of this first lesson that really came to define my experience, though, involved not the challenge of knowing how to prescribe opioids—but rather how to deprescribe them. Although I won’t go into details here (listen to my TED Talk if you want those), the most traumatic aspect of my encounter with the healthcare system came two months after the motorcycle accident – a month after the fifth surgery – when one of my surgeons finally told me that I needed to get off my pain medication. But no one on my team knew how to deprescribe, so I was given a far-too-aggressive taper, and I spent four weeks in opioid withdrawal.

Every moment of that month was the worst moment of my life, and it was caused by doctors prescribing medication that they didn’t know how to deprescribe.

Prescription opioids and the drug overdose crisis

Because my own expertise in bioethics did not intersect much with what I was learning about pain, opioids and eventual dependence and withdrawal, I didn’t learn all the right lessons immediately.

The most important case of learning the wrong lesson involved drawing a straight line from my own experience with doctors’ inability to responsibly prescribe and manage opioids to the drug overdose crisis in North America. Given how bad my doctors were at prescribing and managing opioids, it struck me: no wonder our country is facing an addiction and overdose crisis. But the truth, I would find out, is far more complicated than such an observation implies.

While it’s true that reckless prescribing helped spark what would become “the opioid epidemic” in the late 1990s and early 2000s, by the time I was in the hospital, these problems had decoupled significantly. Opioid prescribing was down year after year, many clinicians were actually afraid to prescribe opioids because of the relationship to the addiction and overdose crisis (recall the way I would be looked down on when asking for pain meds), and yet overdose deaths were skyrocketing. When I first began to research opioids, just over 50,000 people were dying each year from overdose – enough to make it a crisis. In the most recent 12 months for which there is data, more than 110,000 people died from overdose. That mind-blowing number is courtesy of a toxic supply of street drugs, not from prescribed opioids.

The second lesson, then, is that responsible opioid prescribing will not solve the drug overdose crisis. That doesn’t mean it’s not important, of course. Patients deserve good pain care, but giving them that won’t magically fix our catastrophic problem with drugs in this country. A complete solution to addiction and overdose will require much more.

But articulating precisely what such a solution requires? Well, that’s for another blog post.

By Travis N. Rieder, Ph.D., director, Master of Bioethics Program, associate research professor, Johns Hopkins Berman Institute of Bioethics.

Want to learn more about this topic? Check out our upcoming virtual Bioethics Grand Rounds “ Responsible Pain Medicine During a Drug Overdose Epidemic” featuring Travis N. Rieder, Ph.D. on Oct. 18 at 5 p.m. CT. Register here.