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 bu