And august we have printed calendars by the information desk. Everything thats been confirmed to ththe last three months you l find there. If you havent already purchased two nights but i would encourage you to do so. There are a bunch behind the registers for sale and there will be a signing afterwards write here at this table. So, the line will go down from the register up to here. If you could help by folding up the chairs when the talk is over and leaning them against something solid, that would be great and in the meantime if you could silence your cell phone to keep everybody focused in the room and also you will see there is a camera over a year, cspan is recording of the talk and you dont want to be the person whose phone goes off in the middle of a broadcast. Also for that reason, we have a microphone right over here and that is for the audio qanda when it gets to that time i encourage anybody that has a question whoever you are to just go up to the microphone and line up and we will try to get to as many questions as possible channel a background in philosophy into his current role on the faculty at the Johns Hopkins institute for bioethics as a person who is awaiting a pathbreaking program in the field associated with medicine. As we will see in his book he 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, almost necessitated amputation reader underwent numerous surgeries that put his body back in place and as i managed that they craved relief in the form he was prescribed the question then becomes how do you back away from the doses once the time is right. He was still in the hospital documenting the shape of the bodily sensations readers book is an exceptionally vivid account it is grounded in experiences that we all might undergo some day so with that in mind please join me in welcoming Travis Rieder to politics and prose. [applause] its a little bit surreal i spent several years in the area having done my graduate work at georgetown to be speaking at politics and prose which is such an institution its a great while so i appreciate you being here with me in th these urgent pressing issues and i think very often its in an entirely scholarly way and that is how i started my work in bioethics and it turns out that if you are interested in ethics and policies regarding americas healthcare system, a really good way although not a recommended way of finding out huge gaps you will find it very quickly that its quite broken im going to do tonight is tell you some stories of people i love and know and some stories are those of our culture and medicine. In 2015, i was in a celebratory mood and i got my First Permanent faculty position of George Hopkins and my partner had gotten a permanent position as a researcher scientist and we were feeling quite ecstatic and we had a one and a half yearold daughter who was gorgeous and amazing and in celebration of all of these things i did a geta really dumb thing and bought a new motorcycle. I had read in for a long time but i dislike now i can afford a really nice motorcycle and on memorial day weekend i took the shiny new bike out on a ride and made it about three blocks before going through a stop sign and crushing my left foot between the bumper of the van and motorcycle itself. Im not going to describe the details of my injury in case you are not up for that tonight. Im not describe i could descrin detail. I will give you enough of a sense of why what happened next happened and so basically the first three bones, the first that connects to the ankle shattered and blew a hole in the inside of my foot and as you are heard in the introduction that the end a limb salvage the situation and that is one where the surgeon takes her to be severthere to besevere for the f their job is to see if they can salvage said thats where i found myself in may of 2015 and a story that im going to tell you about to kick things off is a particular day that happened almost a month after the accident. I had been to three different hospitals at this point. I was undergoing my fifth major surgery and this was a big Reconstructive Surgery so this is one where they dealt with the shattered bone, pulled them together as best they can but maybe the doctor was going to save this boosay this but as ifa way to plug the hole. Its something i never considered before having been considered fortunate until then. Not all can be stitched together. If you lose a chunk of flesh, you have to do something about that so there is a very aggressive surgery where they made an incision on my left leg and carved out a bunch of flesh to plug that hole so it is more than just a skin graf graft so y take skin, muscle, fat and then they wont mike rowe surgically transplant the nerve in case i ever want to feel anything in that again. It took almost nine hours. It involved three different surgical teams and when i woke up the next morning kind of fully coming out of anesthesia, i was in excruciating pain. I had been in pain for a month. I had been under medicated at least once during that month and i thought i knew about pain, but now i had a surgical site, a big one and the original surgical site was also expanded. I never experienced anything like this in my life. I was desperate to get relief. I have had morphine, i had until, i asked for more and they wouldnt give it to me. I asked a lot of people a little bit more aggressively until finally when someone was attending the icu as they check this out they are doing the rounds on me and she is very impatient and finally gets to my room and im begging for more Pain Medicine and she says yes, you have a repeated request that has been noted. I will discuss it with my team and she and her flock go out. I had no idea what happened at that moment it was she had escorted me and im a good kid. I knew enough to be ashamed that i didnt quite get it. I was traumatized, at least a little bit high and it took me a while to kind of pull myself together. I would later be told exactly what happened with suspicion i had been treated as a drug speaker which is insane lets be clear because i had pins sticking out of my feet and i had my fifth major surgery but the fact was even in that situation, i just wanted the medicine a little too badly. That is the first thing i want to sell you about. In the middle of june and i had recovered somehow and you will hear a lot about my partner, throughout the rest of this talk she had to hold the house together and this is one day that i was by myself and i was freaking out. So i had to kind of pull myself together and i told my privilege together. I put this on afterwards but it seemed to matter to me the doctor that i asked for is the one who called me doctor rieder instead of mr. Rieder. He spent a little more time with me and asked me about my research. My attending surgeon will fix you up and he kept his word and his attending called a Pain Management consult and they came to my room and fixed me. They gave me lots of good stuff and i was so, so grateful i faded into oblivion for the rest of my ten days of hospitalization and i remember it being hard in the way that the whole couple of months was hard but it was fine. They hooked me up. So the description of this day as i just gave it to you sounds like i was treated badly like a drug speaker with suspicion and then i was given what i needed, pain relief. But i havent told you the whole story yet because this team that gave me all this medication, they started a train out of the station that they had no intention of looking over. They were not going to drive this any further. Eventually the experience that came to define this entire drama wasnt excruciating pain and it wasnt getting my foot blown apart. Its what happened next which is i was told i had to go off the Pain Medicines. They gave me a bunch and escalating doses seemingly unlimited supply of and it is only when i check in with the surgeon two months after the accident he says this is not good. Its time for you to get off of the medicine now. Also not his problem. He sent me to the surgeon who have taken over the prescriptions and that surgeon said sure if you are ready to get off of the medicine cut your dose into four and in a month you will be off of them, taper down each week. Im not going to give you the long version of what comes next. A big part of why i wrote this because i didnt have to stay in the public anymore. I gave a tabletalk if you want the details but the short version that advice was terrible. It was spectacularly bad. If you want to know some concrete stuff i can tell you how this is supposed to be done and i am not an m. D. By the way but on the 170 equivalents if was phenomenally bad and every day of that for weeks was the worst day of my life. And the sick joke of tapering off of opioids which i hope that nobody in this room knows but i guess some of you do statistically speaking it is that the further you get into the process, the worse it gets if somebody gives you a standard dose reduction or even if they are smarter and give you a 10 , to 10 or quarter as you get through the process becomes a bigger percentage of the dosage that you are taking and the severity of the withdrawal symptom so one week i thought i was miserable but that is because i have no idea what was coming. I thought im not going to make this for a month and then i dropped another dose into the second week scared me. They look like that but they are not done for commercial break and you stopped being able to sp so the last 24 hours a day. And you shake and sweat and get goosebumps and cant sleep if you are just miserable. The second week i started crying and became depressed. It is the opposite of the drugs affects and one of the effects is euphoria so the withdrawal gives you dysphoria. I didnt know this at the time my partner started calling everybody and nobody would help us. None of those that wrote the prescriptions were for nurse practitioners, none of the general practitioners in the dc Baltimore Area that we got ahead of. The ones that popped up that he called because we were despera desperate. But im going to do now is read a small selection of this book. This is a story during week number four of the Opioid Withdrawal and i just want to give you a sense of what this is like in a way i wont be able to do unless they make myself do it. My beautiful, wonderful baby daughter gets left out of a lot of the story and that is part of the pain. I simply wasnt present so i barely remember her being there at all. Crawling on me on the couch while she sat on the ottoman just inches away watching so she could jump up and grab her if she got too close to my foot. Most of what i remember, solitude and pain. I do, however, remember one particular day that changed my view of what my daughter was capable of. I have made it the whole day over god im so sorry. Im so sorry that i had to call you. I started to think i could survive this but i cant. This will never get better. Im so broken. Im just so broken. How can anybody possibly recover from this. She was already driving me home. Yohe will survive this, she sai. I said okay and hung up. When the car pulled up outside of the window behind my spot on the couch i tried to stop crying so i do my best not to let her see me like that. But it was no use. She enters the house like a Freight Train into this day was no exception. When the door open she burst into the living room singing at the top of her lungs until she saw me. She stopped babbling and her face turned serious as she walked over to where i was laying on the couch i said i am so sorry. I hope you will not remember this. She didnt seem upset though. She seemed in control. I was lying on my side on the couch about eye level with her. She walked into her face was inches away examining me with her deep dark brown eyes that she got from her mom if she asked are you crying yes, i told her. It will be okay. I didnt believe it, but i was trying my best to be strong for my daughter. And then she did something that i didnt understand and i will never forget. She put her little hands on my cheeks and held my face firmly while she looked at me and then she kissed my eyes one at a time. I had never seen her do anything like that before and i could hardly believe it. Maybe she learned about at daycare. Maybe one of the helpers kissed her eyes after she fell down 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. And i told her that she just helps me get through one more night. So it wasnt a fun time in my life, not great. The end of the story was a happy one for me. I didnt make it out because im strong and pulled myself up by my bootstraps. I was a wreck. I needed out because i was lucky and in an incredible support system and because i wanted to be a benefit to my one and half yeahalfyearold againahalf yeara functioning partner in my house and i had the Family Support to kerry me through when i was completely unable to do it myself. But i did make it out. For weeks without. I gave up at the end actually. I filled a prescription and managed to sleep that night for the first time in three nights if i didnt take any and when i woke up in the morning i knew that i could make it out. In the wake of that, i was grateful at first because i thought i was going to die and i didnt than i was angry because i thought the reason was the reason. Then i was deeply confused and frustrated because the more thai thought about it the more i thought how do we get to a place that we are so bad in Pain Medicine at opioids but no one failed me in one particular way that an entire group of worldclass doctors failed me in multiple ma ways. I was withheld medication when i needed it because they may have been a drug seeker and then i was medicated in a careless way that led to this profound suffering that so easily could have led to be going back on the beds. By the way something nice at all the time when i was going through withdrawal if i go back on the meds i will never come off of them because i will never go through this again. We are not the only ones it turns out a bunch of other people were just as messed up as we were in this instance. One of the reasons we are so messed up as there is a pendulum when it comes to opioid attitudes and it swings back and forth and its done it a lot longer than we think. About 150 years starting with the invention of orpheum and heroine and hypodermic needle and we swing back and forth between the radical embrace so how are we in this data place how is Pain Medicine so broken, because we are made to swing for ten, 15 years depending on the narrative they prescribe really aggressively. Here is the scary part now we are terrified because read the newspaper about something they are killing a bunch of people. The next section im going to read is trying to figure out a little bit just how bad we are in Pain Medicine and how much we have to improve before we do anything like responsible prescribing opioids. She knew and i knew i was going to need a lot of pain medication. She was terrified and i was terrified because i had just gone through this so then i had exploited all of my access. I had worldclass orthopedic surgeons and pain documents advising the. I took that and applied it answered here is the lesson. I dont care what your surgeon says, we are going to take ownership of this because i dont trust doctors anymore. We stuck to it and my mom is an absolute boss. It was very hard to watch and very painful but in about two weeks she was off of medication more or less and she occasionally needed a night time does. Bad news is what that is. I was interested to know how much. I should have been surprised by this point i had begun to see the data on overprescribing and practitioners in all different fields are starting to examine the prescribing practices for the average for a given procedure and then attempting to find out how many pills patients actually end up taking. These results are not uncommon. Particularly striking result was published by a group of researchers at the university of michigan. The studies looked at a particular procedure, gallbladder removal and found that the average postoperative description for the surgery was about 250 milligrams measured in morphine equivalent for the sake of standardization. When the researchers entered into the average amount taken with 30 milligrams. As a result of the group produced a guideline that included an educational component and informed patients they would need only a few bills for a handful of days and they shouldnt take them unless they really needed them. In the months following the implementation of the guideline of thguidelines, the average amt of opioids prescribed dropped from 250 to 75 milligrams. There was no increase in the refill requests. Just because they were seen as necessary in cases of surgery it doesnt mean we cant make very real progress. Being exposed at all is a risk. The evidence suggests the length of exposure increases to a remarkable degree and as a result we cannot justify sending more opioids out into the world and are needed. We cant allow doctors to write prescriptions for 120 pills when 60 will do it for 313 to five will do. I get to this point in my research and one of the things i am realizing is we need a discussion about responsible prescribing and responsibility, hammer, nail. We needed a discussion about the appropriateness and responsibility because the competition that is happening during this pendulum swing is either drugs for everybody because they have pain and drugs to be given or drugs for nobody because these are evil black magic. But those are both insane positions. They are completely unsupported by the evidence. It turns out some respond to you for some amount of time it sounds plausible but do you need a phd to say that, apparently someone does have to say that. So this is about responsible prescribing and one thing that t kind of interesting go back to my experience and it wasnt just about the number. The number was almost certainly a problem and the reason is because i got a hands off by the way you will be in excruciating pain watch the clock and stay ahead of the pain every four hours is like clockwork happens when you take opioids come you get a tolerance to them, a physiological response. You will need more to achieve the response. I just kept upping the dose and there were problems with the amount. Had i known what i know now, my hope is i would have tried to decrease the dose of a sooner and waved the benefits of pain relief. Theres alsthere is also a manat problem if a physician or nurse or pa someone with the right education isnt looking at you while you go through this no one is going to be able to help you when things go off the rails. To say life is better on the pil