America’s Other Opioid Problem

I remember what it felt like when the van ran straight into the left side of my motorcycle. It felt like pressure—like space-time was being warped as the energy transferred from one vehicle to the other. Time slowed to a crawl while I noticed the bike being kicked away from underneath me. I remember being tossed through the air like a rag doll, eventually landing on my back, my bike momentarily sliding onto my leg before flipping off and skidding to a stop.

It was brutally fast: Five minutes before, I had left home on my brand-new bike, out for a celebratory Memorial Day ride. With an 18-month-old daughter at home, I had just received news of my permanent faculty appointment at Johns Hopkins. Life was going so well.

That moment changed everything. The impact of the van blew my foot open inside my armored boot, and it took weeks, multiple surgeries, and a minor medical miracle before the doctors could tell me I would keep my mangled extremity. But this story is not about my foot injury. It’s about what that injury led me to discover about an inconspicuous but destructive slice of the opioid crisis.

This was my first brush with serious medical trauma, and the pain was unbearable. Sometimes it was like a sharp knife slicing through skin, muscle, and tendon; other times, I was consumed by fire. I learned to distinguish between the deep, throbbing bone pain, the sharp tissue pain, and the electric nerve pain. The only escape from these terrors was the medicine, flowing from an IV directly into my veins. Morphine was good, hydromorphone was better, and fentanyl was the stuff of gods.

On the first night in the hospital, and again after the most invasive surgery, my pain was undermedicated, leading to true panic. I moaned and begged, willing to try any drug that would distract me from the unrelenting agony. Those moments taught me never to get behind my medication regimen—a lesson my doctors and nurses echoed—and I never questioned my impulse to pop more pain pills every four hours.

I was heavily medicated on opioids, around the clock, for more than 60 days. The tolerance that built up meant that at the end of those two months, I was taking approximately 170 morphine milligram equivalents per day—nearly double the maximum suggested dose.

And then, suddenly, I was told to stop. From my first dose of morphine through the two months following, I received no information, no counseling, and no long-term pain management plan. But my meds were now a serious concern. “That dose is much too high,” my trauma surgeon sternly advised me. “Time to get off the meds.”

Helping me to do so, however, was not his job, so he sent me to my plastic surgeon, who had prescribed my medication after the last surgery. He was less concerned, nonchalantly suggesting that I taper off in a month. Divide my daily dose by four, he offered, and drop one-quarter each week.

That plan turned out to be spectacularly bad. After lowering my first dose, I was thrown into withdrawal. I would later describe the early stages to friends and family as “the worst flu you can imagine, multiplied by about a thousand.” But that first week was minor compared to what followed.

When I dropped my second dose, every symptom got worse—nausea, jitters, runny nose, sweats, goosebumps, pain. I was genuinely and profoundly miserable, unable to move thanks to both my still-mangled foot and the withdrawal. The jittery feeling came to define my experience, as it kept me from getting almost any sleep. I would sit or lie on the couch, shaking, nauseated, sweating, in pain that I couldn’t medicate, trying not to think of the fact that I had weeks of this hell to endure.

It turned out, however, that these physical symptoms were not the worst of it. During that second week a new, disturbing symptom arrived: crying, which welcomed the depression that became my companion for the foreseeable future. I mourned my lost function, my seemingly broken body and mind, and began to think that I would never recover. I slept less and less. I found myself spiraling into darkness, sobbing, and wondering what I would do if this were my new normal.

That’s when my partner, Sadiye, and I started calling doctors, asking them to help. Surgeons, nurses, and general practitioners directed us to pain management for specialty treatment. Pain docs said they prescribe opioids but don’t manage tapering, so we should try addiction medicine. Addiction specialists said they don’t handle routine tapering, as they are focused on patients suffering from life-threatening addiction. Sadiye was furious, and I was defeated. She would call any doctor she could find, dressing them down for their insensitivity to my suffering, and I would lie on the couch, often crying, not surprised at their indifference.

We were coming to terms, in our own, very different ways, with a shocking truth: None of the doctors who prescribed me these medications were going to help me escape them. I had fallen through the cracks, and no one saw me as their problem.

The only advice I got was from the plastic surgeon who had given me the tapering plan. He suggested that I go back to my previous dose to mitigate the symptoms. But there was no way I would reverse course without a better plan to eventually get off the meds entirely, so I forced myself to continue riding it out.

The last two weeks of withdrawal made the first two look like child’s play. I slept less and descended further into desperation. When I started to have suicidal thoughts, Sadiye and I reluctantly decided that I should go back on the meds. We knew what this meant. I had told her: “If I don’t quit now, I’ll be on them forever. Because I’ll never put myself through this again.” But we felt it was our only option. She picked up a new bottle of oxycodone and put it on my nightstand.

That night, I decided to try to fall asleep one more time, to see if the symptoms might subside. I nodded off for the first time in three days and stayed that way for several hours. When I woke up, I knew I had turned a corner, and I was confident that I could finish detoxing. I never opened the new bottle of pills.

As I continued the long, slow process of recovery, I thought about what had happened to me. Sadiye and I shared the experience with close friends and family. Slowly, our private trauma became a more distant object of concern, and we started to ask questions. The one that haunted me was: If this happened to me, and I have virtually all of the privileges handed out by society, in addition to an incredible support system, what is happening to everyone else? And while there doesn’t seem to be data on how common experiences like mine are, after talking to doctors and patients around the country, I can assure you: It happens a lot.

Conceptual distinctions regarding the risks of opioid use are important in this landscape. Through conversations with family, friends, colleagues, and doctors, many people referred to my experience as “battling addiction.” But that’s not what happened, and it took me a long time to figure out precisely why this description is wrong.

The result of my taking so many opioids for so long was that I formed a dependence on them. My brain adjusted to the presence of such high doses of the drug that, when it was taken away, I experienced the opposite of the drug’s effects—I went into withdrawal. Virtually everyone will develop dependence on opioids if taken long enough at high doses, and so everyone will experience withdrawal if they stop taking the medication abruptly.

Not everyone, however, will develop an addiction upon exposure to high doses of opioids for an extended period. In fact, only a relatively small percentage of people will. What the language of addiction captures is the behavioral component of problematic drug use: Someone is addicted to opioids if they crave the drug and compulsively take it, despite harmful consequences. I had a house full of pills that I was choosing not to take, so this didn’t seem to be my problem.

I don’t say this to be defensive. Accuracy in describing my situation is important because dependence and addiction are different challenges that call for different solutions. A patient who shows signs of addiction needs the full suite of resources available; in the case of opioids, this could include medication-assisted treatment with methadone, buprenorphine, or naltrexone in addition to counseling and other behavioral health services. But recall that this is relatively rare in patients exposed to opioids for pain. Dependence and withdrawal, however, happen as a matter of course.

Medical schools don’t require training in pain medicine, and many students graduate with somewhere between no and very little formal instruction on pain and opioids. But even if they do become skilled at prescribing opioids, stigma pervades pain medicine. Finally, our health-care system is siloed and fractured, with deep chasms between hospitals and care teams. Handing off a patient multiple times makes it easier for clinicians to declare “not it” and feel justified in writing a prescription but never following up.

Medicine is failing to solve the problem of dependence.

To be sure, it also doesn’t deal with addiction very well. Addiction medicine is still stigmatized, under-resourced, and able to serve only a fraction of those who need it. But that failure is at least recognized, whereas the inability or unwillingness to deal with dependence seems to have escaped notice.

Given medicine’s generosity with opioids, millions of patients have been given enough medication to suffer withdrawal, and yet we haven’t figured out who is responsible for managing that process. This has undoubtedly led to unnecessary suffering, but also to a funneling of some patients into the opioid crisis, as fear of devastating withdrawal symptoms forces them to continue taking their pills long after they should have tapered off.

We need, then, to talk about responsible opioid use. This means moving beyond such simplistic notions as calling for “fewer prescriptions” or “eliminating opioids.” Some pain calls for opioids, but that doesn’t mean doctors should write prescriptions and then abandon patients. Every opioid therapy patient deserves continued management of that medication, including counseling on appropriate use, a long-term plan, and an exit strategy. We can encourage this through better education of physicians, but there must also be a widespread shift in values—medicine and society need to hold physicians responsible for complete patient care.

Doing so will take real effort, but it’s necessary. If we don’t, more patients will fall through the cracks. And many won’t be as lucky as I was.

Travis Rieder, Ph.D., is a bioethicist at Johns Hopkins University and the author of In Pain: A Bioethicist's Personal Struggle with Opioids.