Everything thats been confirmed for the next three months you will find on our website. If you have not already purchased tonights book i encourage you to do so. Wholeheartedly. We have a bunch behind the registers for sale and will be signing after words right here at the table so the line will go down from the register up to hear. If you can help by pulling up the chair when the talk is over and leaving them against something solid that would be great. In the meantime if you can silence your cell phone to keep everybody focused here in the room and youll see theres a camera over here. Ccn is recording the it tonight. Also, for that reason we have you will see a microphone right over here for the audience q a. When it gets to that time i encourage anybody who has a question, whoever you are, go up to the microphone there, why not and try to get as many questions as possible within the time we have. With that, im very excited to introduce tonight. Travis rieder is our offer tonight and channeled a background in philosophy into his current role on the faculty at the Johns Hopkins institute for bioethics. He served as director of the Masters Degree Program and also assistant director for education initiative. As a person whos leading a pathbreaking program in a field associated with medicine and Public Health he was at the resume be a best person to talk to what people should know about the current wave of opioid dependencies that is sweeping across vast swaths of the american landscape but as you will see in his book in pain reeder comes to the topic from his own struggles against that very dependency. After crushing his foot in a motorcycle accident about four years ago now an injury that almost necessitated invitation he underwent numerous surgeries to put his body back in place, a process with an income Principal Amount of pain in various forms. To manage that he thought for relief in a way he was prescribed of men fentanyl, morphine and more and then the question became how do you back away from those doses the time is right. That is a question that is widely debated among the medical committee, a fact that he first came to understand firsthand and needed to grapple with. With his initial notes were made while still in the hospital his book is an exceptionally vivid account of much debated and still widely misunderstood subject matter with all the more vital because its grounded in experiences that we all might undergo some day or have experienced ourselves. With that in mind please join me in welcoming Travis Rieder to politics and prose that mac. Thank you for that welcome and thanks to politics and prose for having me here and thank you for coming out. Its a little surreal. I spent several years in the dc area having done my graduate work at georgetown so to be speaking at politics and prose which is such an institution pretty wild. Thank you for being here with me. Great introduction and gives you an idea of what we will talk about. Bioethics is a strange sort of field and those of us who do it are all kinds of weirdos. Disciplinary weirdos. We all come from distinct disciplines and work on these very urgent pressing issues and i think very often we take ourselves to be doing it in an entirely scholarly way and thats how i started my work in bioethics but it turns out if youre interested in ethics and policy regarding americas Healthcare System a really good way of not finding out from huge gaps in deep chasms in the american Healthcare System is to become a patient in that system. You will find very quickly that its quite broken in all sorts of ways. Not the best way to do a Research Program but its the way i found this program so i will tell you some stories. Some of the stories are mine and other people i love and know and some of the stories are our culture and medicine. In 2015 i was in a celebratory mood and i had just gotten my First Permanent faculty position at Johns Hopkins and my partner had gone a permanent position as a Research Scientist we were feeling ecstatic. We had a one and a half yearold daughter whose gorgeous and amazing and in celebration of these things i did a really dumb thing and bought a new motorcycle. I had written for a long time and now i can afford a nice motorcycle. On memorial day weekend i took that shiny new bike out on a ride and made it about three blocks before of ban blew a stop sign and tboned the bike, crushing my left foot between the bumper of the van and the motorcycle itself. Not going to describe the gory details of my injury case at all of you are up for that but i would not describe in detail. I will give you enough of a sense of white what happened next happened and basically the first three bones in the first metatarsal the bone that connects the big toe to the angle shattered blue whole of the inside of my foot and as you heard in the introduction that put me in a salvage situation. Its one where the surgeon thanks there is a Severe Threat of reputation so their job is to see if they can salvage the limit. Thats why found myself in may 2015. The story i will tell you about to kick things off is a day, particular day that happened. It was almost one month after the accident. I had been to three different hospitals at this time and undergoing my fifth major surgery and this was the big reconstructive surgery. This is one where they pulled the shattered bones together as best as they could and the only way the doctors would say this but is if they found a way to plug the hole. This is something i had never considered before having been fortunate my life up until then that not all injuries can be stitched together. If you lose a big chunk of flesh you have to do something about that. Theres this very aggressive ambitious surgery where they made an incision from my niece to my hip on my left leg and carved out a bunch of flesh to plug that hole with. Its more than just a skin graft so they took skin, muscle, fat so the tissue would plug the hole in microsurgical agent spent an artery to vascularized the tissue and a nerve in case i wanted to feel something in that but again. That surgery took almost nine hours. It had involved three different surgical teams and when i woke up the next morning fully coming out of the anesthesia i was in excruciating pain. I had been in pain for months and i thought i knew pain and i had been under medicated at least once during the month and thought i knew about pain but i now had a new surgical site, big one and the original surgical site was also expanded and they carved away this necrotic tissue. I had never experienced anything like this in my life. The result of that was i was desperate to get relief. I had been hospitalized three different hospitals for several weeks and knew the drill and what i could have. I had morphine and fentanyl and took oral oxycontin and i asked for more and they did not give it to me. I asked lowder and they still did not give it to me. Then i started to get frustrated. I dont remember this perfectly but i imagine i stopped being quite as compliant a patient as i tend to be. I asked what people more aggressively. Finally, im in the icu and they checked this delicately flesh out the icu attended was doing rounds and she was impatient when she finally got my room im begging for more pain meds and she said yes, yes, mr. Rieder, its been noted and i will discuss it with my team. She and her flock of white coats swooped out. I had no idea what it happened at that moment. I was ashamed because she had scolded me and im a good kid and i knew enough to be ashamed when your scolded but i did not quite get it. I was traumatized at least a little bit high and they did not get it. It took me a while to pull myself together and i would later be told by lots of friends exactly what had happened. I was beating treated with suspicion. I was being treated like a drug seeker which is insane, lets be clear but i had pinned sticking out of my feet and just had my fifth major surgery. But the fact was even in that situation i just wanted the meds a little too badly. I set someones alarm bells off. Thats the first thing i want to tell you about on this day. Its the middle of june and i had recovered somehow and you will hear a lot about my partner got the rest of the stock but she had to hold the house together and take our children so this was one day by myself and i was freaking out. I pulled myself together and i pulled my privilege together. I put this fremont after words but it seemed to matter to me that the doctor i asked for was the one doctor who call the doctor reeder instead of mr. Rieder. He was a young guy who spent more time with me and asked me about my research. Thats the guy i wanted. I got him. He came to my room and i said you have to fix this. My attending, will fix you up. He kept his word and his attending called the Pain Management consults. Pain management consult came to my room and they fixed me. They gave me lots of the good stuff. I was so grateful. I faded into oblivion for the rest of my ten days of this hospitalization and remember it being hard and away the whole couple months was hard but it was fine. They hooked me up. Okay. The description of this day is i gave it to you sound like i was treated badly and treated well. I was treated like a drug seeker with suspicion and then i was given what i needed, pain relief. But i have not told you the whole story yet because that team that gave me all this medication they started a train out the station that they had no intention of looking over. They were not going to drive this further. I never saw my Pain Management doctor again. Eventually the experience that came to define this entire, was not excruciating pain or not getting my foot blown apart and not the months of the years of physical therapy learning to walk again but it was what happened next which is i eventually was told i had to go off these pain meds but they gave me a bunch of an escalating doses of on seemingly unlimited supply of and it was only when i checked in with the trauma surgeon two months after the accident that he asked me what i want and looked at the dosage and said this is not good. Its time for you to get off the meds now. Its also not his problem though. Time for you to get off the meds but the one elses job. He sent me to the surgeon who taken over prescriptions as i left in surgeon very and concertedly says sure, if youre ready to get off meds culture dose into four and in a month will be off them. Im not going to give you the long version of what comes next but a big part of what i wrote this book is i did not have to say it in public anymore. I also gave a ted talk if you want the gruesome details in 14 minutes you can do that. The short version is that advice was terrible. It was spectacularly bad. In q a if you want to know concrete stuff i spent four years researching this now and can tell you how its supposed to be done and im not an md by the way. Fourweek taper on 170 or 3milligram of opioids that i was on is phenomenally bad. It sent me into acute withdrawal and every day of that for weeks was the worst day of my life. The sick joke of tapering opioids which i hope no one in this room knows but i bet some of you do, statistically speaking, the sick joke is the further you get into the process the worse it gets. If somebody gives you a standard dose reduction like a quarter each week or even if theyre smarter and give you a 10 reduction that 10 or quarter as you get to the process becomes a bigger percentage of the dose you are taking and the severity of withdrawal symptoms is linked to the percentage after one week i thought i was miserable because i had the idea of coming. I was really sick and thought i will not make this for a month but then i dropped another dose in the second week scared me because you could all these symptoms. If you ever watch a movie or sing to the and see someone go to heroin withdrawal the symptoms look like that but are not done before commercial rate. They last everything a minute of every break and last 24 hours a day. You shake and sweat and get goosebumps cant sleep and your just miserable. The second week for me i was crying and became depressed because withdrawal is the opposite of a the drugs affect. One of the effects of opioids is euphoria. Withdrawal gives you dysphoria. I didnt know this at the time so all i think is that im dying. Slowly and excruciatingly. I go through this more and more and ask doctors for help in my partner starts calling everybody we cant get a hold of and no one will help us. None of the doctors that prescribed the meds or the surgeons who operated on a nor the pas who wrote the prescription orders practitioners and none of the general practitioners that live in the dc Baltimore Area that we got a hold of. The one that popped up a google that we just called because we were desperate. None would see us. I will review a very small selection of this book. This is a story during week four of Opioid Withdrawal and i just want to give you a sense of what this is like in a way that will not make myself feel unless i read it. 2. 5 minutes. Not long. My beautiful wonderful baby daughter gets left out of a lot of the story and thats part of the pain. I simply was not present so i barely remember her being there at all. I know that my partner manage childcare while also caring for me in running the house and i vaguely remember seeing them occasionally crawling on me on the couch where they sat inches away watching so she could jump up and grab my daughter she got too close to my foot or the surgical side of my thigh. Most of what i remember was solitude, pain and i do however, remember one particular day. It changed my view of what my one and a half daughter was capable of. I made it the whole day through Late Afternoon without crying without the depression crashing and and i dared to hope that this might mean times during a corner and then maybe i was going to get my life back. And then around four or 5 00 oclock i felt the telltale welling in my chest and the darkness circling. Feeling cause panic and despair and my partner picked up on the first ring and i learned out to the sobs i almost made it. I almost made it today. Oh god, im so sorry. Im so sorry i to call you. I started to think i could survive this but i cant. This will never get better and im so broken, baby. So broken. How can a body recover from this . She was already driving home and you will survive this she said. Your hormones and brain are between you but it will get better. Just hold on. Im about to pick up baby girl and then will be home to take care of you. I said okay and hung up. When the car pulled up the front window i find my spot on the couch i tried to stop crying but i always do my best not to let them see me like that. It was no use. The harder i tried the more explosive the sobs became aunt i eventually just gave up. When the door opened she burst into the living room singing at the top of her lungs until she saw me. She stopped babbling admitted sound in mid step in her face turned serious. She slowly walked over to where i was lying on the couch and i cried to her, so sorry, baby girl. Oh god, im so sorry. I hope you wont remember this. She did not seem upset. She seemed in control. I was lying on my side of the couch and i was about eye level with her and she walked until her face was inches from mine examining me intently with a deep, dark brown eyes she got from her mom and she asked, papa crying . Yes. Yes, papa crying i told her. Poppa hurts but it will be okay. I do not believe it and im trying to try my best to be strong for my daughter. Then she did something i did not understand and will never forget. She put her tiny little hands on my cheek and held my face firmly while she looked directly at me. She kissed my eyes. One at a time. I never had seen her do anything like that before i could hardly believe it. Maybe she learned that at daycare. Maybe one of her helpers had kissed her eyes once she fell down at one time or maybe it was just an incredible empathetic intuition by my little girl. Whatever the explanation i grabbed her and hugged her as tightly as i ever have. I told her she just hoped that he get through one more night. That was not a fun time in my life. Not great. That was during week four and the end of the story, happy one for me, i made it out. Here is something really important to know. I do not make it out because the system up to be out and i did not make it out because im strong and pull myself up by my bootstraps and muscled my way through. I was a freaking rack and i made it out because i was lucky. I had an incredible support system and i wanted to be a dad to my one and a half yearold again i wanted to be functioning partner in my health and be a faculty member at Johns Hopkins and i had the Family Support to carry me through when i was completely unable to do it myself. But i did make it out. Four weeks was hell. I gave up at the end. I filled a prescription because i was done but i managed the night for the first time in three nights and did not take any and that was the crack when i woke up in the morning and i knew i could make it out. In the wake of that i was grateful at first because i thought i would die in that i did not and that i was angry because i thought the Healthcare System was the reason i thought i was going to die and then i was deeply confused and frustrated because the more i thought about it the more i thought how in the world to get to a place where we are so bad at pain and Pain Medicine and opioids that no one filled me in one particular way and an entire group of worldclass doctors who managed to stitched together my foot with my thigh, dont forget, fill me in multiple ways that were sometimes in tension with one another. I was withheld medication when i desperately needed it because i might have been a drug seeker when drugs sticking out my foot and i was medicated to the self carelessly way and by the way, something i said all the time is going to withdraw was if i go back on the meds i will never come off of them because i would never go through this again. This is my question. How do we get here . How did we get so messed up . It turns out im a researcher. Thats what i do for living and thats what done for the last four years. I think about opioids and pain and Americas Health care system. By the way, were not the only ones. Other people are just messed up as we are but it does turn out we are number one. There is a lesson in the book i cant give you the full version of now but history teaches us a lot about this. One of the reasons were so messed up is theres a pendulum when it comes to opioid attitudes and it swings back and forth. Its done that for a lot longer than a lot of us think for about 150 years starting with the invention of morphine and heroin in hypodermic needle. We swing back and forth between radical embrace and prohibition. How are we in this really radical that place . How is Pain Medicine so broken . We are mid swing. For ten years, 15 years, 20 years depending on your read of the narrative we prescribed really aggressive and this is the key part, it might have been okay if we done it according to evidencebased and if we knew how to use the medications but we did not heres the scary part. Whole bunch of doctors still dont. Now we are terrified of opioids because read the newspaper and what is happening. Theyre killing people. Youre telling doctors to stop killing people and so were squeezing the supply in our hurting patients in another fun way. We are torturing them. Patients who been on opioids are dependent and need them for pain and are being denied them. Were failing in multiple ways and thats crazy. The next little section i will read for you is trying to figure out a little bit of just how bad we are at Pain Medicine and how much we have to improve before we do anything responsible for prescribing of opioids. This story here is about my mom and about two years after i had gone to my own medical trauma and struggle with opioids mom had to have both her knees replaced. Bilaterally replacement. Its an extra sheeting the painful surgery. She knew and i knew she would need pain medication. She was terrified and i was terrified because i had just gone through this. By then i had exploited all my access and i knew people who knew people and had a worldclass Orthopedic Surgeon advising me and request pain doctor advised me and i took that and applied it to my moms case and said heres the lesson to meet my friends and my team have drawn up and i dont care what your surgeon says but we will take ownership of this because i dont trust doctors anymore. We made a plan and stuck to it and my mom is an absolute boss. She felt like she needed to do and it was hard to watch and people but in about two weeks she was off of medication, more or less and in the third week she needed an occasional nighttime dose. After she was more coherent attacks of her inside can you count how many pills you have left because i knew shed been prescribed 120 norco, 7. 5 million can milligram hydrocodone and find out thats what shed been trust me, you will not need that. Thats four pills a day for 30 days. Thats bad news. But you might need a good amount of it and i was anxious to know how much. The reading picked up when she answered me and she texted a while after i asked writing i have 73 of 120 remaining. Shed used well under half of what she had been prescribed and i should have been surprised but by this point i began to see the data on overprescribing for surgery practitioners and all different fields of study to examine the prescribing practices. They publish with the average prescription for a given procedure and then attempting to find out how many pills patients actually end up taking. Results like my mom are not uncommon. A particularly striking result was published in 2015 by a group of researchers at the university of michigan. Looked up particular procedure, gallbladder removal and found the average postoperative prescription for this surgery was about 250 milligrams measured in morphine equivalents for the sake of standardized patient. When the researchers interviewed patients they discovered the average amount of medication taken was 30 milligrams. As a result the group produced a prescribing guideline that included an educational component informed patient they likely would need only a few pills for a handful of days and they should not take the pills unless they really needed them. In the months following the implementation of this guideline the average amount of opioid prescribed drop from 250 250275 milligrams and with no refill requests. Just because the scene is necessary in cases of surgery for severe injury does not mean that we cant make very real progress. Being exposed to opioids at all puts one at risk in the evidence suggests the length of exposure increases risk through a remarkable degree. As a result we simply cannot justify spending more opioids out into the world and cant allow doctors to routinely write prescriptions for 120 pills 160 will do or for 30 pills when threefive will do. I get to this point in my research and one thing i realized is we need to have a discussion about responsible opioid prescriptions. So, we need a discussion about appropriateness and responsibility. The conversation is happening out there during the pendulum swing and its either drugs for everybody or to export nobody because these are evil black magic. Those are both insane positions. They are completely unsupportable by the evidence. It turns out some pain really responsible to opioids for some amount of time and we should responsibly use opioids in those cases only. It sounds like its possible like duty to have a phd to say that apparently. Apparently someone does have to say that. This is about responsible opioid prescribing. Another thing i found is when you go back to my experience it was not just about the number. The number was certainly a problem and it was a problem because i had a hands off it heres an unlimited number of pills and you will be in excruciating pain so watch the clock and stay ahead of the pain. Every four hours like clockwork. What happens when you take opioids connect you become tolerant. If youre looking for the same amount of high pain relief yet take more to achieve that response. I kept upping the dose. There were problems with the amount. Had i known what i know now then my hope is that i wouldve tried to decrease the dose a lot sooner and wait the benefits of pain relief against the risk of future suffering. Did not have that information so i cannot. Theres a bunch thats happening. Number of pills is the problem and this management problem. If a physician or nurse or pa or someone with the right education isnt looking at you while you go through this no one will be there to help you when things go off the rails. If no one knows how to get you off the medication or know what he sees it as a job even if youve been prescribed while you might be in serious trouble when you try to get off of them. Then you go into withdrawal is a screw that, life is better on the pills. Quick upshot of that research. Responsible prescribing is hard. Harder than you think. It will take work. Unfortunately, nuance is hard and we dont like to do it. We have to think a lot about what it means to have clinicians actually prescribe the right amount of pills for the right amount of time in the right circumstances with the right oversight. What would be really nice at this point is if i said i figured out how to solve Pain Management. False. And so that whole thing even hear about in the news that is super scary in that Opioid Epidemic we solved that. We got fixed Pain Medicine and i fixed opioids. We didnt but suppose we did. Solving Pain Medicine wont solve the Opioid Crisis. Thats the thing i want to say five minutes worth about. Theres this really intuitive narrative and the narrative goes like this. Prescription opioids supply cause problems starting in the 1990s. From 19992010 prescription opioids increased by four 100 . In that exact same time Overdose Deaths from prescription opioids went up four 100 . Its a really bad matching trendline and so theres a spirit about their that gets backed up high q a about pharmaceutical efforts and different lobbying efforts and medicine and money and getting an idea that you can prescribe without consequence. We have a 400 increase in describing the results in 400 overdose death. Supply was the problem. Cut off supply we fix the problem. That was never going to work. It was never going to work because its a miss understanding of a whole bunch of things. You must understand the nature of dependence in addiction. It misunderstands the company the nature of the Opioid Crisis as it turns into Something Else and we started splitting the supply of prescription opioids back in 2010two to 12 and didnt solve the Opioid Epidemic but it made it worse. At the same time we did in fact start to decrease the number of prescription opioids Overdose Deaths heroin Overdose Deaths went through the roof. We drove a whole bunch of people to heroin is the conclusion we are invited to make. Once you have this huge preparation of people going into heroin the people controlling that supply are incentivized to make it more and more potent and more deadly because then they can get more and more money for the same amount and so it gets increasingly laced with fentanyl like carpets and offered its 5 50100 times more potent. We use it to tranquilize elephants and other large mammals. Its been placed into heroin. We are not going to solve the broader Opioid Epidemic like [inaudible] we should never have tried it and its supplied here or it failed here in the case of prescriptions and already failed in the case of illicit drugs and that the war on drugs. We will need a lot more than just cutting supply. The last third or so of the book is investigating what these solutions might look like. There are four categories of things that we have to talk about supply. Supply does management when you put a country with deadly drugs that are unregulated it can cause a lot of harm and if you not read the land thats black tar heroin spreading across the country but also prescription opioids and unrelated and used in pill mills and handed out without oversight and supply will be part of the problem. But we might also ask about demand and why are so Many Americans taking drugs connect that sounds like an important question to ask but could we help people and make them not want to take drugs so much . If you build community and provide healthcare and education and give people a little more prospects might they look less for pain relief because heroin and prescription opioids and fentanyl they are incredibly [inaudible] the pain does not have to be physical. It can be emotional or psychic. Supply demand and we have to treat the 2. 6 Million People who have Substance Abuse disorder already and about one in ten of them are getting specialty treatment. We have to do a massive scalable treatment for supply demand and treatment but theres this other category if you to all those things there is still the risk that in a country with terribly contaminated heroin the lot of people are using a lot of people will die before they are ready to treat to seek treatment. We need Something Else and to help people stay alive long enough that they are interested in seeking treatment and theres Harm Reduction is another category. A great slogan for Harm Reduction is that people dont recover well. You have to keep them alive long enough to go into treatment. The last thing i will read to you is about Harm Reduction because this might be a little more newer to folks here than it would be in other countries. On the north side of vancouvers Downtown Eastside is a nondescript score front along many others like it. The picture of hypodermic needle in the front door gives the appearance of a medical facility and that impression continues on the inside. Visitors come to the door but their names down at the check and asked and wait to be called into the back. Rather than the private rooms of the Standard Health clinic the back room has a dozen stalls each with privacy blinders on either side and a metal desk and mirror covering the wall and hard plastic chair across from the stalls is a long desk covered with medical equipment. The facility is called insight and while its goal is Health Promotion its not your Typical Community clinic. Its primary purpose is reducing the harms that often attained injection drug use with secondary goals including things like connecting those used trucks with healthcare, provide treatment information and offering us a space in community for people who might struggle to find either. The injection room with the 12 stalls staffed by health professionals. Each visitor is offered a clean needle, sterile cooker, filter, water and a tourniquet. Everything needed to cook and inject heroin available in a safe, supervised environment. Insight is a Safe Injection Sites. Also sometimes called the supervised drug consumption facility or Overdose Prevention site. It mitigates the risk of contracting hep c or hiv through shared needles. They are sorted by trained professionals should they overdose. There equipped with duct testing strips to test for personal allowing the user to decide whether to decrease the dose in light of that knowledge. The visitor overdose anyway the overdose reversal drug lock phone is on hand. Since opening the first injection site insight has served more than three and a half Million People intervene in thousands of overdoses and recorded not a single fatality. To the extent americans are surprised by Harm Reduction strategies we are a little late to the game. United states slowly come around to the idea of Needle Exchange programs with close to 300 across the country by 2017. That number is dwarfed by other countries. Australia has more than 3000 Needle Exchange programs and more than ten times the number in america serving up a position that is less than one tenth the size. As a result theres only one Election Program for every 3200 americans who use drugs. Theres a program for every 31 people who inject drugs in australia. Safe injection sites exist all over the world with more proposed every year because they prevent life and save suffering. They decrease burdens on Health Care System by saving money and improving public order and increasing access to addiction and other Health Services by people who use drugs. By taking drug use of the streets where its most trouble connecting those who inject and those who use injection drugs save the clinic, public space and Healthcare Information Safe Injection Sites are able to do a lot of good. Needle exchange is to prevent disease and the reversal can stop overdoses but a brick and mortar site where people can come to use drugs offers the possibility of connecting up with people and resources rather than driving them ever further into the shadows. After all, the heart of it is to see the harder it is to see some using drugs the harder it is to say that. And you around the several it becomes difficult to understand our current practices. What ive suggested here that we should take a Harm Reduction approach for the drug crisis. Whether you buy into the philosophy our current context of crisis justifies the basic strategy. We have to find a way to prevent our family members, friends and fellow Citizens Drug use from killing them. We find this eminently sensible or come to it reluctantly but either way, i thank you should come to it. I will wrap up there because i want to hear what you all have to say. I will close by noting i probably just made the sound like a dark book but the countries messed up in a bunch of ways for Healthcare System is that it Pain Medicine and theres a lot of doubt that theyre working hard to fix this and even if we did fix it it wouldnt fix the broader Opioid Crisis which might have been a sort of thought you would have had reading reports from the media and that will take a lot more but the thing i want you to leave with is on all of those accounts we need a culture change and all of us can be part of a culture change. Why did i write this book . Some people asked if it was traumatic. It was fairly cathartic but its fairly traumatic reliving it all the time and the reason i wrote it anyway is because if i can get a bunch of doctors and patients which hey, that includes all of us to think better about both sides of the pain and drug crises that intersect with it comes to opioids that will be worth doing. I invite you to think about that with me and lets chat more openly now. Oh, please, use the microphone. I have a comment in question or maybe 100 questions. But ill limit it to one. I appreciate that. [laughter] the passage you read about your daughters amazing response to your pain was one of the most emotional things ive ever heard red at the bookstore. Its a beautiful description of an amazing event. You intrigued me. He said hed be willing to talk about the protocol that should be followed coming off opioids. Im getting a lever placement surgery in september so ive got skin in the game and i imagine a lot of people in this audience have been through Knee Replacement so i should man up and not be concerned but systemically there are huge lawsuits living in maybe not as big as tobacco but almost as big, maybe, i dont know. You would think the threat of that the legal action would get people together in a room on a macro level is a talk about evidencebased whatever does that discussion happen in all these medical conferences that i would like to believe is happening back. Great question. I certainly guess those conversations are happening and sometimes its a good thing. Thats the danger here. A big part of what i write in this book is that policy response to prescription opioids so far has largely been more harm than good. The reason is you cannot get away from that pendulum. You say why isnt everybody getting together in the same room and sometimes they are i mean, loosely defined everybody but get tips from insurers and docs and Surgeon General and yada, yada, yada, cdc, fda but the risk is coming up with something that we believe doctors will actually follow and what that gets translated into is hamfisted. Hamfisted mean Something Like you get four pills after a procedure ask and if not delineated 20 individualized patients. For some people four pills will be absolutely enough which is why we need the evidencebased and for some people it wont be. Thats a decision you would want an educated Healthcare Practitioner to know the evidencebased on and respond to particularities of the patient. Yes, those discussions are happening and im grateful and fortunate to have been invited to the fact they want us there gives me hope. I wear on my sleeve my perspective and want to talk about response ability and they tend to be responsive but i am scared with too many people in power and say lets fix this thing because my fear is the response will be yeah, you know 5014milligram is the highest dosage anyone should have a negative bunch of patients on 700 milligrams equivalent and decide what to do with them and then with tapping out is there been tapered with are not ready. I just described what withdrawal is like and doing that to somebody when theyre not ready against their will is torture. Sixtysecond version of the right way. Talk about that. Second 62nd version of the right way to come off is most people who been on opioids take two weeks, three, four weeks are fairly routine but major surgeries like me replacement and hip replacement surgeries if you stay inside two weeks most people want expense withdrawal that they notice and its an interesting phenomenon that talks people who been to surgeries and asked him what it was like when they had to stop taking the pain pills. It was weird, i cannot sleep, got jittery and got goosebumps. It was withdrawal but minor. Dependence can form in a matter of days. Doctors dont know that, by the way. They will say things like dont worry about it to lamont that which is insane because you had a month to increase the severity of your dependency upon opioids. This is not me providing medical advice but this is reciting the literature. But the literature will tell you is if you have a dependence and independence is diagnosed when you go into withdrawal by trying to cut off the medication just going slow will often fix most of it for routine sorts of tapirs and going slow means reducing no more than 10 of dose reduction from your starting dose or every week and if that makes you sick go to 5 every two weeks. No reason to go fast if it will torture you. A bunch of people wont notice it. Then you get the hard cases of god for bid Knee Replacement gets infected and you do a reconstruction and you are six weeks of surgery and payments of opioids. Your case is more complicated and do you want a Pain Management team for what theyre doing . I will tell you from my own experience finding those people who know what theyre doing and willing to take you on his terrifyingly hard. Either phd and my wife has a phd and we are in the dc Baltimore Area and we spent three weeks calling people and no one would do it for us. Thats scary. Whats it like for everyone else . And jeffrey. I was taken with your compelling interview and in fact i could not stop listening. Very simply you and i are part of the same club and i came off 150 cc and i am double your age and im 72 and the doctors warned the mih the recovery is unpredictable and i shattered my collarbone and scapula, the big vote on my shoulder and had eight rib fractures so i was taken to the confidentiality by the hospital and this was between the watergate building. [laughter] and its also the hospital where Ronald Reagan was treated. This was well thought and they used a nerve block procedure which was wonderful so i had in equipped ivy medicine for 24 hours and for todays i had 11 miniature wires in my body that were guided by ultrasounds where they placed the message right into where the lectures were. After and i went through six months of recovery pt and it three grades of Pain Medicine. I do not have a Pain Management team but we had a well classed trauma team and Orthopedic Team and i spent six nights in trauma which is a long time to be in a, fed and five nights but the simple question was im not a doctor or trained in that but i have simpleminded notion that if i dull the pain i run the risk of reinjuring the scratches because i have to take care myself [inaudible] but ive stayed off the Pain Medicine and had a hydro morphine i never touched the bottle. I have it in my cabinet for the next accident. All tell you how to get rid of that left back. I tried to basically say i dont want Pain Medicine at all if i can help it but they walk in and say hows your pain today and i say its like putting and but im 95 recovered but i thank god i tried to avoid the Pain Medicine. When i asked them why did you do surgery they said injuries were too substantial but we were worried about a punctured lung and we were worried about the concussion but it was minor. But what i worry about later on is the psychosomatic stuff that will come later because i got [inaudible] waking up in the middle of the night and you just had an accident and so i wonder what you are putting in place and maybe you dont want to talk too much about that in the thought that you cant control it night. Wow. Yeah, a lot of questions in there. Let me tackle a couple. One point that is important is your doctor might have messed up when they said heres a bottle even those you say you dont want it but they might not have. Pain is dangerous to and pain can keep you from recovery. The real challenge and the reason i say Pain Medicine his heart is this is the secret. Pain medicine is hard and weve acted like its not. Weve acted like pain is the thing that can be treated by anyone just like antibiotics can be given out. One of the reasons it is hard is because exactly what you are saying. Youre worried about doubling the pain to the point where you might reinjure yourself in a totally legitimate worry and the sort of thing a doctor should warn the patient about. You need to experience and a pain that you dont reinjure yourself but you need to get enough pain relief that you can sleep and rest and get recovery. Theres just a sweet spot and thats phenomenally difficult. There is an interesting link between pain and ptsd which is getting to your last question that the group of folks i talked to in the epilogue in the final chapter which is the defense veteran center and one thing they became well known for is they were treating veterans for pain but not just because they were coming back and developing dependence and addiction but because they were coming back really traumatized and started to think some of their trauma was that they never processed anything because you get the first shot of morphine the second they hit the ground and their encore nine all the way back to walter reed to germany or wherever from afghanistan and their conclusion was if we dont fix their pain not only will we not fix the dependency of addiction rate but we will not get a handle on this crazy epidemic of ptsd we are seeing in our soldiers and they have done important work. If you not seen the documentary i highly recommend it. Its about the team i write about in the epilogue and if long before i interview them but they worked with the documentary from crew and one a bunch of rewards and its striking. Might want to check that out. Anyone else . A bunch of polite people were waiting to give other people the chance. You mentioned some of the practices and countries like australia and vancouver. Are there any jurisdictions that you found that is getting this right . If so, what explains how they got it right and are they jurisdictions we can learn from . Great question. I will say with the caveat i havent but the part of the caveat is im not an expert on everywhere so what i am told germany does Pain Medicine pretty well and the reason that im a little concerned and theres a caveat there is the pendulum swung everywhere. A lot of the country not dealing with a Drug Overdose crisis never got to kickstart with opioid overprescribing because they dont respond to pain. They dont clinically respond to pain just dont get medicine for everything. The neighbor placement surgery in some countries they give you ibuprofen after words. I watch my mom go through the replacement and i dont want to live somewhere where they give you ibuprofen after that but i learned of the horrors that are possible from opioids but not like magic. The replacements are good use for small doses of opioids for less than two weeks. Ive heard germany does things pretty well but what i will say is some of western europe is starting to freak out a little bit. The ranking of countries having this off the top of my head. America is the worst. We screw this up tragically. North americas as a whole but the marketing from pharmaceutical companies are the kind of lesson you absolutely must treat pain with opioids with others of the cost that was inclusive to america but that happened in canada two. Canada is only three years point is on the Drug Overdose trajectory. They switch to control early because bent all started happening here. Canada is in terrible straits, australia is in pretty bad situation but western europe who for a long time say how do they escape this are starting to get scared because the same prescription overdose spikes and i like we can follow america. America is the bogeyman of it. 70000 people die from Drug Overdoses in 2017. If you cant hold in your mind the skill of that theres more americans dying in the entire vietnam war. We talked about the hiv aids epidemic and was but more people die from opioids in 2017 then ever died at the height of the hiv aids epidemic in the 90s. Everyone is speaking out because america is the bogeyman but i dont know if there are places that have mailed this. Great question. You for your talk. I wondered about methadone maintenance next and what your research has shown about them and how they did not work or are they still working in what the promise is for making them work for todays problems with opioids . Connect methadone maintenance if you dont know if the opioid which means its in south and opioid and one of the ways you treat opioid is you put someone who has an addiction was an egg chaotic drug faith and burning their life down because of their addiction put them on methadone which has a half life. Because of the way it works sometimes will hear in the media that drugs like methadone and another called [inaudible] called a partial agonist but the idea is its an opioid you give to treat opioid addiction so we hear things like politician say i dont like the stuff because its replacing one addiction with another. If they say that they dont understand addiction because heres the thing. Addiction is defined by behavioral compulsions. An inability to control ones behavior. Interesting factoid if youre thinking youre listening to a story about addicted to opioids turns out knots. I had a profound opinion and went into withdrawal and maybe i was on the road to addiction the fight gone back on the spells and never to come off them but theres a difference between the behavioral sponsor so methadone great drugs to treat addiction because they replace the dependence you have the biological dependence with another one that i take that back, strike that from the record. It treats the cravings and the compulsions and evens out the brain when it doesnt work for everyone its less people give their life back and hold down a job and get one drink in the morning and comes in liquid form and do well enough to get to stay todays home and when it works well and takes their life back and a father again and mother again and sister again and it doesnt work for everybody and its a drug that specific to opioids. Im a huge fan of methadone and i want to destigmatize the heck out of it which is why i use this response to be like it doesnt replace addiction with addiction. Replace the stigma but if the next addiction crisis comes after this one is methamphetamines in the next one is benzos methadone will not help. It just treats opioid addiction does not treat addiction at large. I think we should invest the heck out of it produces all cause mortality by 15 which is Gold Standard in Public Health but its not a Silver Bullet for the addiction crisis. Thank you all. Very much. There will be copies of travis readers book at our registrar. If you like him to sign the book for me sign line to the right of the table and please pull up your chairs
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