ABOUT THE SPEAKER
Travis Rieder - Bioethicist
Travis Rieder wants to help find a solution to America’s opioid crisis -- and if that sounds a bit too lofty, he’d settle for making clear, incremental progress in a responsible, evidence-based way.

Why you should listen

A philosopher by training, bioethicist by profession and communicator by passion, Travis Rieder writes and speaks on a variety of ethical and policy issues raised by both prescription and illicit opioid use.

This wasn't always his beat, though. Both in his doctoral training at Georgetown University, and as faculty at Johns Hopkins University’s Berman Institute of Bioethics, Rieder published widely on a variety of topics in philosophy and ethics. His interest in opioids came about suddenly, after a motorcycle accident, when he took too many pills for too long and suddenly found himself with a profound dependency. In the wake of that experience, he became driven to discover why medicine is so bad at dealing with prescription opioids, and how that problem is related to the broader drug overdose epidemic.

Rieder's first article on the topic, in the journal Health Affairs, was one of the most-read essays in 2017 and was excerpted by the Washington Post. Since then, Rieder has co-authored a Special Publication of the National Academy of Medicine on physician responsibility for the opioid epidemic, written several essays for the popular media and spoken widely on the topic to physicians, medical students and the general public. He expands on all of this work in a new book project forthcoming with HarperCollins, tentatively titled In Pain In America.

More profile about the speaker
Travis Rieder | Speaker | TED.com
TEDxMidAtlantic

Travis Rieder: The agony of opioid withdrawal -- and what doctors should tell patients about it

Filmed:
1,354,385 views

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.
- Bioethicist
Travis Rieder wants to help find a solution to America’s opioid crisis -- and if that sounds a bit too lofty, he’d settle for making clear, incremental progress in a responsible, evidence-based way. Full bio

Double-click the English transcript below to play the video.

00:12
"How much pain medication are you taking?"
0
760
2040
00:16
That was the very routine question
that changed my life.
1
4120
2840
00:19
It was July 2015,
2
7880
1496
00:21
about two months after
I nearly lost my foot
3
9400
2376
00:23
in a serious motorcycle accident.
4
11800
1600
00:26
So I was back in my orthopedic
surgeon's office
5
14400
2496
00:28
for yet another follow-up appointment.
6
16920
2000
00:31
I looked at my wife, Sadiye;
7
19560
1376
00:32
we did some calculating.
8
20960
1240
00:35
"About 115 milligrams
oxycodone," I responded.
9
23000
3360
00:38
"Maybe more."
10
26960
1656
00:40
I was nonchalant, having given
this information to many doctors
11
28640
4055
00:44
many times before,
12
32720
1896
00:46
but this time was different.
13
34640
1360
00:48
My doctor turned serious
14
36840
1576
00:50
and he looked at me and said,
15
38440
1416
00:51
"Travis, that's a lot of opioids.
16
39880
2376
00:54
You need to think
about getting off the meds now."
17
42280
2520
00:57
In two months of escalating prescriptions,
18
45520
2056
00:59
this was the first time
that anyone had expressed concern.
19
47600
2880
01:03
Indeed, this was the first
real conversation I'd had
20
51120
2736
01:05
about my opioid therapy, period.
21
53880
1760
01:08
I had been given no warnings,
22
56520
2016
01:10
no counseling,
23
58560
1616
01:12
no plan ...
24
60200
1200
01:14
just lots and lots of prescriptions.
25
62000
2400
01:17
What happened next really came to define
my entire experience of medical trauma.
26
65960
4296
01:22
I was given what I now know
is a much too aggressive tapering regimen,
27
70280
4856
01:27
according to which I divided
my medication into four doses,
28
75160
2920
01:30
dropping one each week
over the course of the month.
29
78920
2480
01:34
The result is that I was launched
into acute opioid withdrawal.
30
82720
4080
01:39
The result, put another way,
31
87960
2496
01:42
was hell.
32
90480
1200
01:45
The early stages of withdrawal
feel a lot like a bad case of the flu.
33
93520
5096
01:50
I became nauseated,
34
98640
1776
01:52
lost my appetite,
35
100440
1736
01:54
I ached everywhere,
36
102200
1936
01:56
had increased pain
in my rather mangled foot;
37
104160
2560
01:59
I developed trouble sleeping
due to a general feeling of restlessness.
38
107760
4280
02:05
At the time,
39
113680
1376
02:07
I thought this was all pretty miserable.
40
115080
1920
02:10
That's because I didn't know
what was coming.
41
118000
2096
02:13
At the beginning of week two,
42
121640
2336
02:16
my life got much worse.
43
124000
1240
02:18
As the symptoms dialed up in intensity,
44
126160
2960
02:22
my internal thermostat
seemed to go haywire.
45
130080
2896
02:25
I would sweat profusely almost constantly,
46
133000
2856
02:27
and yet if I managed to get myself out
into the hot August sun,
47
135880
3936
02:31
I might look down and find myself
covered in goosebumps.
48
139840
2800
02:35
The restlessness that had made
sleep difficult during that first week
49
143537
3239
02:38
now turned into what I came to think of
as the withdrawal feeling.
50
146800
3320
02:42
It was a deep sense of jitters
that would keep me twitching.
51
150800
5016
02:47
It made sleep nearly impossible.
52
155840
1600
02:50
But perhaps the most
disturbing was the crying.
53
158560
3760
02:55
I would find myself with tears coming on
54
163760
5016
03:00
for seemingly no reason
55
168800
1736
03:02
and with no warning.
56
170560
1240
03:05
At the time they felt
like a neural misfire,
57
173040
2416
03:07
similar to the goosebumps.
58
175480
1400
03:09
Sadiye became concerned,
and she called the prescribing doctor
59
177960
3976
03:13
who very helpfully advised
lots of fluids for the nausea.
60
181960
3200
03:18
When she pushed him and said,
"You know, he's really quite badly off,"
61
186480
3336
03:21
the doctor responded,
"Well, if it's that bad,
62
189840
2176
03:24
he can just go back to his
previous dose for a little while."
63
192040
2880
03:28
"And then what?" I wondered.
64
196200
1880
03:31
"Try again later," he responded.
65
199160
2080
03:34
Now, there's no way that I was going
to go back on my previous dose
66
202120
4056
03:38
unless I had a better plan for making
it through the withdrawal next time.
67
206200
3480
03:42
And so we stuck to riding it out
and dropped another dose.
68
210320
3880
03:47
At the beginning of week three,
69
215720
1640
03:50
my world got very dark.
70
218200
1680
03:53
I basically stopped eating,
71
221000
3016
03:56
and I barely slept at all
72
224040
1776
03:57
thanks to the jitters
that would keep me writhing all night.
73
225840
2840
04:01
But the worst --
74
229800
1936
04:03
the worst was the depression.
75
231760
1381
04:06
The tears that had felt
like a misfire before
76
234480
4056
04:10
now felt meaningful.
77
238560
1200
04:12
Several times a day
I would get that welling in my chest
78
240640
3256
04:15
where you know the tears are coming,
79
243920
1720
04:18
but I couldn't stop them
80
246480
1656
04:20
and with them came
desperation and hopelessness.
81
248160
3920
04:24
I began to believe
that I would never recover
82
252880
2936
04:27
either from the accident
or from the withdrawal.
83
255840
2360
04:31
Sadiye got back on the phone
with the prescriber
84
259680
2255
04:33
and this time he recommended
that we contact our pain management team
85
261959
3257
04:37
from the last hospitalization.
86
265240
1696
04:38
That sounded like a great idea,
87
266960
1576
04:40
so we did that immediately,
88
268560
1310
04:42
and we were shocked
when nobody would speak with us.
89
270640
2429
04:45
The receptionist who answered
the phone advised us
90
273760
3136
04:48
that the pain management team
provides an inpatient service;
91
276920
3936
04:52
although they prescribe opioids
to get pain under control,
92
280880
2736
04:55
they do not oversee
tapering and withdrawal.
93
283640
2080
04:59
Furious, we called the prescriber back
and begged him for anything --
94
287320
5240
05:05
anything that could help me --
95
293360
1696
05:07
but instead he apologized,
96
295080
1600
05:09
saying that he was out of his depth.
97
297440
2256
05:11
"Look," he told us,
98
299720
1376
05:13
"my initial advice to you is clearly bad,
99
301120
2496
05:15
so my official recommendation
is that Travis go back on the medication
100
303640
3616
05:19
until he can find someone
more competent to wean him off."
101
307280
2720
05:24
Of course I wanted
to go back on the medication.
102
312840
2256
05:27
I was in agony.
103
315120
1960
05:30
But I believed that if I saved
myself from the withdrawal with the drugs
104
318920
6816
05:37
that I would never be free of them,
105
325760
1667
05:40
and so we buckled ourselves in,
106
328560
2136
05:42
and I dropped the last dose.
107
330720
1334
05:46
As my brain experienced life
without prescription opioids
108
334080
3136
05:49
for the first time in months,
109
337240
1400
05:52
I thought I would die.
110
340360
1240
05:54
I assumed I would die --
111
342680
1256
05:55
(Crying)
112
343960
1056
05:57
I'm sorry.
113
345040
1216
05:58
(Crying)
114
346280
1920
06:04
Because if the symptoms
didn't kill me outright,
115
352840
2240
06:07
I'd kill myself.
116
355920
1200
06:10
And I know that sounds dramatic,
117
358360
1856
06:12
because to me,
standing up here years later,
118
360240
2736
06:15
whole and healthy --
119
363000
1856
06:16
to me, it sounds dramatic.
120
364880
1280
06:19
But I believed it to my core
121
367240
1480
06:23
because I no longer had any hope
122
371000
2840
06:27
that I would be normal again.
123
375360
1381
06:33
The insomnia became unbearable
124
381480
2976
06:36
and after two days
with virtually no sleep,
125
384480
3000
06:40
I spent a whole night
on the floor of our basement bathroom.
126
388280
4000
06:45
I alternated between cooling
my feverish head
127
393240
3376
06:48
against the ceramic tiles
128
396640
1680
06:51
and trying violently to throw up
despite not having eaten anything in days.
129
399120
4080
06:56
When Sadiye found me
at the end of the night
130
404960
2096
06:59
she was horrified,
131
407080
1296
07:00
and we got back on the phone.
132
408400
1400
07:02
We called everyone.
133
410240
1296
07:03
We called surgeons and pain docs
and general practitioners --
134
411560
3816
07:07
anyone we could find on the internet,
135
415400
2536
07:09
and not a single one of them
would help me.
136
417960
2040
07:13
The few that we could
speak with on the phone
137
421120
2280
07:16
advised us to go back on the medication.
138
424480
2160
07:21
An independent pain management clinic
said that they prescribe opioids
139
429000
4216
07:25
but they don't oversee
tapering or withdrawal.
140
433240
2200
07:29
When my desperation
was clearly coming through my voice,
141
437160
3296
07:32
much as it is now,
142
440480
1280
07:35
the receptionist
took a deep breath and said,
143
443520
2816
07:38
"Mr. Rieder, it sounds like perhaps
what you need is a rehab facility
144
446360
3256
07:41
or a methadone clinic."
145
449640
1240
07:43
I didn't know any better at the time,
so I took her advice.
146
451680
2816
07:46
I hung up and I started
calling those places,
147
454520
2376
07:48
but it took me virtually no time at all
148
456920
2416
07:51
to discover that many of these facilities
149
459360
2816
07:54
are geared towards those battling
long-term substance use disorder.
150
462200
3416
07:57
In the case of opioids,
151
465640
1376
07:59
this often involves precisely not
weaning the patient off the medication,
152
467040
3616
08:02
but transitioning them
onto the safer, longer-acting opioids:
153
470680
4216
08:06
methadone or buprenorphine
for maintenance treatment.
154
474920
3056
08:10
In addition, everywhere I called
had an extensive waiting list.
155
478000
2960
08:13
I was simply not the kind of patient
they were designed to see.
156
481680
3040
08:18
After being turned away
from a rehab facility,
157
486240
2856
08:21
I finally admitted defeat.
158
489120
1520
08:23
I was broken and beaten,
159
491840
1320
08:26
and I couldn't do it anymore.
160
494320
1520
08:29
So I told Sadiye that I was
going back on the medication.
161
497560
2880
08:33
I would start with
the lowest dose possible,
162
501680
2056
08:35
and I would take only as much
as I absolutely needed
163
503760
2429
08:38
to escape the most crippling
effects of the withdrawal.
164
506213
2600
08:41
So that night she helped me up the stairs
165
509680
1976
08:43
and for the first time in weeks
I actually went to bed.
166
511680
2975
08:46
I took the little orange
prescription bottle,
167
514679
2856
08:49
I set it on my nightstand ...
168
517559
1441
08:52
and then I didn't touch it.
169
520559
1321
08:55
I fell asleep,
170
523120
1256
08:56
I slept through the night
171
524400
1936
08:58
and when I woke up,
172
526360
1256
08:59
the most severe symptoms
had abated dramatically.
173
527640
2320
09:03
I'd made it out.
174
531680
1256
09:04
(Applause)
175
532960
5440
09:14
Thanks for that,
that was my response, too.
176
542440
2056
09:16
(Laughter)
177
544520
1800
09:19
So --
178
547960
1200
09:24
I'm sorry, I have to gather myself
just a little bit.
179
552080
2480
09:27
I think this story is important.
180
555920
2256
09:30
It's not because I think I'm special.
181
558200
2256
09:32
This story is important
precisely because I'm not special;
182
560480
3056
09:35
because nothing that happened
to me was all that unique.
183
563560
2880
09:39
My dependence on opioids
was entirely predictable
184
567680
3296
09:43
given the amount that I was prescribed
185
571000
1896
09:44
and the duration
for which I was prescribed it.
186
572920
2640
09:48
Dependence is simply the brain's natural
response to an opioid-rich environment
187
576360
4816
09:53
and so there was every reason
to think that from the beginning,
188
581200
3816
09:57
I would need a supervised,
well-formed tapering plan,
189
585040
2720
10:00
but our health care system
seemingly hasn't decided
190
588840
4096
10:04
who's responsible for patients like me.
191
592960
2240
10:08
The prescribers saw me
as a complex patient
192
596120
3576
10:11
needing specialized care,
193
599720
1496
10:13
probably from pain medicine.
194
601240
1456
10:14
The pain docs saw their job
as getting pain under control
195
602720
3736
10:18
and when I couldn't
get off the medication,
196
606480
2056
10:20
they saw me as the purview
of addiction medicine.
197
608560
2696
10:23
But addiction medicine is overstressed
198
611280
2136
10:25
and focused on those suffering
from long-term substance use disorder.
199
613440
3240
10:29
In short, I was prescribed a drug
that needed long-term management
200
617400
3760
10:33
and then I wasn't given that management,
201
621960
2016
10:36
and it wasn't even clear
whose job such management was.
202
624000
2840
10:39
This is a recipe for disaster
203
627920
1560
10:42
and any such disaster would be interesting
and worth talking about --
204
630600
3656
10:46
probably worth a TED Talk --
205
634280
1360
10:48
but the failure of opioid tapering
is a particular concern
206
636960
4336
10:53
at this moment in America
207
641320
1440
10:56
because we are in the midst of an epidemic
208
644160
2280
10:59
in which 33,000 people died
from overdose in 2015.
209
647280
4040
11:04
Nearly half of those deaths
involved prescription opioids.
210
652640
3520
11:09
The medical community has in fact
started to react to this crisis,
211
657680
5256
11:14
but much of their response has involved
trying to prescribe fewer pills --
212
662960
4536
11:19
and absolutely,
that's going to be important.
213
667520
2616
11:22
So for instance,
we're now gaining evidence
214
670160
2256
11:24
that American physicians
often prescribe medication
215
672440
3976
11:28
even when it's not necessary
216
676440
1536
11:30
in the case of opioids.
217
678000
1216
11:31
And even when opioids are called for,
218
679240
1976
11:33
they often prescribe
much more than is needed.
219
681240
2280
11:36
These sorts of considerations
help to explain why America,
220
684320
5176
11:41
despite accounting for only five percent
of the global population,
221
689520
3616
11:45
consumes nearly 70 percent
of the total global opioid supply.
222
693160
4080
11:50
But focusing only
on the rate of prescribing
223
698680
4496
11:55
risks overlooking
two crucially important points.
224
703200
3320
11:59
The first is that opioids just are
225
707760
4856
12:04
and will continue to be
important pain therapies.
226
712640
2920
12:08
As somebody who has had
severe, real, long-lasting pain,
227
716200
5016
12:13
I can assure you these medications
can make life worth living.
228
721240
3720
12:18
And second:
229
726480
1696
12:20
we can still fight the epidemic
while judiciously prescribing opioids
230
728200
4936
12:25
to people who really need them
231
733160
2576
12:27
by requiring that doctors properly
manage the pills that they do prescribe.
232
735760
3560
12:32
So for instance,
233
740200
1616
12:33
go back to the tapering regimen
that I was given.
234
741840
2320
12:36
Is it reasonable to expect
235
744920
2096
12:39
that any physician who prescribes opioids
knows that that is too aggressive?
236
747040
3840
12:43
Well, after I initially published my story
in an academic journal,
237
751880
3776
12:47
someone from the CDC sent me
their pocket guide for tapering opioids.
238
755680
4160
12:52
This is a four-page document,
239
760640
1936
12:54
and most of it's pictures.
240
762600
1240
12:57
In it, they teach physicians
how to taper opioids in the easier cases,
241
765200
4776
13:02
and one of the their recommendations
242
770000
1736
13:03
is that you never start at more
than a 10 percent dose reduction per week.
243
771760
4240
13:09
If my physician had given me that plan,
244
777360
2736
13:12
my taper would have taken several months
instead of a few weeks.
245
780120
4920
13:18
I'm sure it wouldn't have been easy.
246
786440
2136
13:20
It probably would have been
pretty uncomfortable,
247
788600
2360
13:23
but maybe it wouldn't have been hell.
248
791840
1800
13:26
And that seems like
the kind of information
249
794720
2056
13:28
that someone who prescribes
this medication ought to have.
250
796800
2720
13:33
In closing,
251
801080
1240
13:35
I need to say that properly managing
prescribed opioids
252
803200
5416
13:40
will not by itself solve the crisis.
253
808640
2160
13:43
America's epidemic
is far bigger than that,
254
811640
3360
13:47
but when a medication is responsible
for tens of thousands of deaths a year,
255
815960
5056
13:53
reckless management
of that medication is indefensible.
256
821040
4200
13:58
Helping opioid therapy patients
to get off the medication
257
826640
3296
14:01
that they were prescribed
258
829960
2016
14:04
may not be a complete solution
to our epidemic,
259
832000
2440
14:07
but it would clearly constitute progress.
260
835320
2120
14:10
Thank you.
261
838240
1216
14:11
(Applause)
262
839480
2840

▲Back to top

ABOUT THE SPEAKER
Travis Rieder - Bioethicist
Travis Rieder wants to help find a solution to America’s opioid crisis -- and if that sounds a bit too lofty, he’d settle for making clear, incremental progress in a responsible, evidence-based way.

Why you should listen

A philosopher by training, bioethicist by profession and communicator by passion, Travis Rieder writes and speaks on a variety of ethical and policy issues raised by both prescription and illicit opioid use.

This wasn't always his beat, though. Both in his doctoral training at Georgetown University, and as faculty at Johns Hopkins University’s Berman Institute of Bioethics, Rieder published widely on a variety of topics in philosophy and ethics. His interest in opioids came about suddenly, after a motorcycle accident, when he took too many pills for too long and suddenly found himself with a profound dependency. In the wake of that experience, he became driven to discover why medicine is so bad at dealing with prescription opioids, and how that problem is related to the broader drug overdose epidemic.

Rieder's first article on the topic, in the journal Health Affairs, was one of the most-read essays in 2017 and was excerpted by the Washington Post. Since then, Rieder has co-authored a Special Publication of the National Academy of Medicine on physician responsibility for the opioid epidemic, written several essays for the popular media and spoken widely on the topic to physicians, medical students and the general public. He expands on all of this work in a new book project forthcoming with HarperCollins, tentatively titled In Pain In America.

More profile about the speaker
Travis Rieder | Speaker | TED.com