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tv   Travis Rieder In Pain  CSPAN  August 18, 2019 4:15pm-5:15pm EDT

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them to express their love of the land. [applause] >> thank you. >> you're watching booktv on c-span2. booktv, television for serious readers. [inaudible conversations] >> good evening, everybody. can you hear me okay? aisle jonathon wollen, the deputy direct or of event heard at politics and prose. thank you for coming out tonight. i if you haven't already picked up a calendar full of the rest of our events scheduled for july and august, we have print calendars by the information desk and we have a full list of events on our web site, that's
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politics -- he everything confirmed for the next three months you'll fine there, and if you have not already purchased tonight's book, i encourage you to do. so we have bunch behind the registers for sale. there will be a signing afterward to table and the line will go from the register up to here, and if you can help by folding up the chairs when tea talk is over and leaning then against something solid that would be great. if you can silence your cellphones just to keep everybody focused on the room and there's a camera. c-span is recording the talk tonight and you don't want to be the person whose phone goes off in the middle of a broadcast. also, for that reason, we have microphones. that's for the audience q & a. i encourage anybody who has question, whoever you are, to just good up 0 he microphone there line up and we'll try to get to as men questions as possible within the time we
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have. with that, i am very excited to introduce tonight's event. travis rieder, our author, as channeled a background in philosophy into this current roll on the faculty at the johns hopkins bedrooman institute for bioethics and he is director of the masters degree program and is also assistant director for education initiatives. as a person who is leading a path-breaking program in a field associated with medicine and public health, he would obviously by force of the resume be one of the best foam talk to in order to understand what miami know but the current wave of opioid dependency that is sweeping across the vast swaths of the american landscape, but as you'll see in his book, in pain, rieder 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
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almost necessitated amputation, rieder underwent newman how surgeries to put his body back in place, a lot of pain involved and various forms and to manage that rieder crazed relief in the form that the was prescribed of morphine, fentanyl, dedelaud did and more. the question ohio do you back away from doses once the time is right and that's a question that is widely debated among the medical community, fact that rieder came to experience first hand and needed to grapple with as best as he. could with his initial notes forming while he was still in the hospital, documenting the shape of his bodily sensations, rieder's book is an exceptionally vivid account of much debated and still widely misunderstood subject matter, all the more vital because it's grounded in experiences that we all might undergo some day or have experienced ourselves.
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so, with that in mind, join me in becoming travis rieder to politics and prose. [applause] >> well, thank you for that welcome, and thank you no politics and prose for having me here. thank you all for coming out. a little surreal. spent several years in the d.c. area, having done my graduate work at georgetown and to so be peek at politics and prose which is such an institution, it's pretty wild. it's a grow introduction, little idea of what i'm going to talk about. bioethics is a strange sort of field. those who do it all kind of weirdoes from distinct disciplines and work on very urgent, pressing issues and i think very often we take ourselves to be doing it in an entirely scholarly way. that's how i started my work in baio ethics. but it turns out if you're
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interested in ethics and policy regarding america's healthcare system, really good way of finding out some huge gaps and very deep champ cass. s in the american health care system is to become a patient and you'll fine quickly that it's quite broken in all sorts of ways. so not the best way to fine a research program but the way i found this research program and i'm going to tell you some stories, some are mine, some are people i love and know, and some over stories are the stories of our culture and our medicine. so, in 2015, i was in a very celebratory mood. i had just got minimum first permanent faculty possession at johns hopkins, and my partner had gotten a permanent position as a research scientist and we were feeling quite ecstatic. a one and a half-year-old daughter who is gorgeous and amazing and celebration of all of these thing is did a really
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dumb thing i bought a new motorcycle. i had ridden for a long time but now i was could really afford a nice motorcycle, and on the memorial day weekend i took the niney new book out on a ride and i made it about three blocks before a van blew a stop sign' t bened the pick, crushing my left foot and i'm not going to describe the gory details of my injury in case not all of you are up for that tonight. i'm not going to describe it in detail. give you enough of a sense of why what happened next happened, and so basically the first throw bones the the metatarsal this ben that connects the big to to the ankle, shatter and blow a hole out to the inside of my first and that put me in what is called a limp salvage situation where the surgeon takes there to
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be severe threat of amputation so they see if they can salvage the limb. that's where i found myself in may of 2015 and the story i'm going to tell you to kick things off is a day, particular day that happened, actually almost a month after the accident. i'd been to three different hospitals at this point, i was undergoing my fifth major surgery, and this was the big reconstructive surgery. this is one where tray debt with shatter bens and pulled them together but the an way the doctors could save this foot if is they found a way to plug he whole something i just never considered before, having been fairly fortunate, that nat owl injuries can be stitched together. if you lose a big chunk of flesh you have to do something about that, and so there's this very aggressive, very ambition surgery where i made an insignature from the knee to hi hip on my left leg and carved out a bunch of flesh to plug the
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hole with. it's a free flap surgery. it's more than skin forecast. they take skin, muscle, fat, and plug the hole and thens transport an artery and a nerve just in case ann i ever want to feel anything in that foot. that surgery took almost nine hours. it's -- had involved three different surgical teams, and when i woke up, the next morning, kind of fully come ought of the anesthesia i was in excruciating pain. i'd been in pain a month, thought i knew but pain i'd been unindicated and i thought i knew about pain but i now how a new surgical site, big one and the original surgical site was expanded and they everybody if a all this met trottic issue and never -- in the carrottic neck carrottic tissue and i had been hospitalize and knew the drill.
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aid hood morphine and fentanyl i was taking oral oxysew down and asked for me and they didn't give it to me so i asked a little louder and they still didn't give it to me. and then i started to get a little frustrated, and i don't remember this perfectly but i imagine i stopped being quite as compliant a patient is a tend to be and ask a lot of people more aggressively until film my when the icu attending -- they check the dill cat new flesh out, the ic attending rounds on me and is very impatient and finally gets to me rhyme i'm begging former pain mets and she said, yes, yes, mr. rieder, your repeated requests for more medication has been noted. ry school us with my team and she and her atlantic of white coats swoop out i had no idea what happened at that moment. i was like ashamed because she scold he me and i'm a good kid, like i knew enough to be ashamed
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when you're scolded. but i didn't quite get it. i was traumatized, ate least a little bit high and i didn't get it. so took me a while to pull memphis together if would late he be told be a lot of friend what happened. been trite with suspicion i've been treated like a drug seeker which is insane, let's be clear, because i had pins sticking out of my feet and just had my fifth major surgery, but the fact was that even in that situation, i just wanted the mets a little too badly. i set someone's alarm bells off. so, that's the first thing i want totle you about on this day. the middle of june, and i had to recover somehow. you are going to hear a lot out partner, sadia but city she had to hold the house going go other a job and take care of our children so one dave i was by myself and i was freaking out. so i kind of pulled myself
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together, and i pulled my privilege together and like i put this frame on afterwards but seemed to matter to me that the doctor i asked for was the one doctor who called me -- rieder instead of mr. rieder am young guy who spent a little more time with me and asked me about my research. that's the guy i wanted and i got him. and i got him to come to my room and said you have to fix this. said i will. my attending the surgeon, not the icu, my attending women fix you up and kept his word and his attending called a pain management consult, and the pain management consult came to my room and they fixed me. they gave me lots of the good stuff. and i was so, so grateful. i faded into oblivion for the rest of my ten days this hospitalization and i remember it being hard in the way this whole couple of months wars hard but it was fine. they hooked me up. okay. so the description of this day as i just gave it to you sound
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like i was treated badly and treated well. i was treated like a drug seeker with suspicious, and then i was given what i needed. pain relief. but i haven't told you the whole story yet because that team that give me all of this medication, they started to train out the station that they had no intention of looking over. they weren't going to drive this any further i never saw my pain management docs again. and eventually the experience that came to define this entire trauma was not excruciating pain, not getting my foot blown apart, not in the months and years of physical therapy and learning to walk again. i it its what happened next, which is i eventually was told they'd go off the pain meds they gave me a bunch of and escalating doses, seemingly unlimited supply of and only when i check in with the trauma
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surgery he asked he what i'm on and looks at the doses and says this is not good it's time for you to get off the meds now. also nothings his problem, though. like time for you no get off the meds but someone else's job. so he sent me to the surgeon who has taken over prediscriminations since i left and that surgeon very unconcernedly says, sure, if you're ready to get off the meds, cut your dose into four and in a month you'll be off. the. taper, drop one dose each week. i'm not going to give you the long version of what comes next. a big part of why i wrote this book is so i didn't have to say it in public anymore. also gave a ted talk if you want the gruesome details details in4 minutes you can watch that. but the short version is that advice was terrible. it was spectacularly bad and in q & a a issue spent for years research dismission tell you how this is spelled to begun i'm not
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an m.d. but four week taper on 170 morphine milligram equivalents of opioids which is what's was on, is phenomenally bad. and it sent me cute withdrawal, and -- acute withdrawal and every day of that four weeks was the worst day of money life. and the sick joke of tapering opioids which i hope nobody in this room knows but i'll bet you too statistically speaking -- the sick joke of tapering opioid is that 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 they're smarter and give you 10% dose reduction, that 10% or that quarter as you get through the process backs a bigger percentage of the dose that you're taking, and the severity of the withdrawal systems linked to the percentage dose reduction so after one week i thought i was miserable and that's because i inside idea what was coming. i was really sick and thought i won't make this for a month and
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then i dropped another dose and the second week scared me because you get all these symptoms, ever watch a movie, seen tv, see someone going through heroin withdrawal the symptoms look like that but they're not done before commercial break, you stepbeing able to sleep they last 24 hours a day and you shake and you sweat and get goose bumps and canned sleep and you're just miserable. and then the second week for me start crying and back depressed because withdrawal is the opposite thereof drug others effects and one effect of opioid is euphoria, so withdrawal gives you dysphoria. i didn't know any of this at the time so all i think is i'm dying. slowly. excruciatingly, and i go through this more and more, i ask doctors for help. my partner starts calling everybody, everybody whos get ahold of and nobody will help us. none of the doctors who
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prescribees meds, none 0 the surgeons none of the pas, none therefore the nurse practitioners, none of the general practitioners that live in the d.c. baltimore area that we got heeled of, the ones that pound up on google that wi just called because we were desperate. none of them would see us. i'm going to read you a very small selection of this book, and 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 i won't be able to make myself do unless i read so it. two and a half minutes. won't be long. my beautiful wonderful baby daughter gets left out 0 a lot of this story and that's part of the pain. i simply wasn't present. so i barely remember her being there at all. i know that my wife was hasn't egg child chair caring for me and thing house and i vaguely remember seeing them occasionally crawling on me on
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the couch wheel she sat on the another mon inchesway watching so she could jump up and grab her if she got too close to the moot for thigh. most of what i remember is sallitude and pain. i do however remember one particular day. as it changed my view of what my daughter was capable of. i made it the whole day how to late afternoon without crying and wow to the depression crashing in. i dared to hope that this might mean i was turning a corner and then maybe i was going to get some of my life back. and then around 4:00 or 5:00, i felt a tell tell welling in my chest and the darkness circling. i feeling immediately caused panic and then despair, she pick up on the first ring and i blurted out i almost made it. met it today. seem sorry. so sorry i had to call you. sorry to think i could survive this but i can't. this will never get better. i'm so broken, baby, i'm just so
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broken. how can a body possibly recover from this? she was already driving home. you will survive this. she said. hour hormones and brain are bow traying you but it will get better and just hold on. i'm about to pick up baby girl and then we'll be home to take care of you. said okay and hung up. when the car pulled up outside the front window right behind hi spot on the couch i trade stop crying, i always did my best not so let the daughter see me like to but it was no use. the harder i trade the more explosive the sobs became and i just gave up. he entered the house lie freight train. when the door opened she burst interest the living room, singing at the top of her lungs. until she saw me. she stopped basketballing mid-sound and mid-step and he fairs turned serious and she slowly walked over to where i was lying on the coach and just cried to her, so sorry, baby
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girl, oh, god, i'm so sorry. and i hope you won't remember this. and he didn't seem upset. she seemed in control. i was lying on my side on the couch and i was eye level with her and she walked until her face was inches from musician examining me with a deep, dark brown eyes she got from her mom, and she asked, baba crying? yes, baba crying, i told her. baba hurts. but it will be okay. i didn't believe it. but i was trying my best to be strong mr. my daughter. and then she did something i didn't understand. and will never forget. she put her tiny little hands on my cheeks and held my face firmly while she locked directly at me, and then kissed my eyes one at a time. and i never seen her do anything like that before and i could hardly believe it. maybe she learned that at daycare. maybe miss mary or one of her
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helps are kissed her eyes after she fell down one time. or maybe it was just an incredible empathetic intuition by any little girl. whatever the explanation, i grabbed her and hugged her as tyingly as i ever have and i told her she had just helped daddy get through one more night. that yes 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's something really, really important to know. i didn't make it out because the system helped me out. i didn't make it out because i'm strong and pulled myself pitch my boot straps and muscled my way through. i was a freaking wreck and i made it out because i was lucky because i had an incredible support system, and because i wanted to be a dad to my one and
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a half-year-old again. wanted to be a functioning partner in my house, wanted to 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. for weeks was hell. i game up at the end actually. filled a prescription because i was done, but i managed to sleep that night for the first anytime three nights and i didn't take any and that was the crack when i woke up in morning and i knew i could make it out and in the wake of that, i was grateful at first because i thought i was going to die and then didn't and then i was angry because i thought the healthcare system was the around thought i would die. and then i was deeply, deeply confusioned and frustrated, because the more i thought, the more i thought how in the world did we get to a place we're so bad at pain and pain medicine and opioids that no one failed me in one particular way.
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an entire group of world class doctors who managed to stitch together my foot with my thigh, failed me in multiple ways that were sometimes intention in tension win with another. was withheld medication needed because i might be a drug singh he with pins in my foot and then med indicated in a careless way that led to profound suffering and could have led to me going bang october the meds and something i said all the time when i was going through withdrawal if i go back on he meds i will never come up a of them because i'll never go through this again. so this is my question. how in the world did we get here and get so messed up? turns out i'm a researcher, so that's what i've done the laos four years i used to work on a bunch of other stuff and i don't do that anymore. i think but opioids and pain and i think but america's healthcare system. we're not the only ones other, people are just as messed up as we are, but we're number one in this instance.
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so, there's a lesson in the book that it can't give you full version of now but history type ofs us a lot about this. one of the reasons we're so messed up there's a pendulum when it comes to opioid attitudes and i its swings back sporting. it's downer for about 150 years, start withing the invention of morphine and heroin and hypodermic needle and we swing back and forth between radical embrace and prohibition. so how-we in this really radically bad place, hough is pain medicine so, so broken? because we are mid-swing. for ten years, 15 years 20 years, depending on your read of the narrative we prescribe ready aggressively and here's the key part. maybe prescribing a aggressively would have been okay if we had done it according to any evidence base and knew how to use the medication but he didn't. and whole bunch of docs still don't. now we're terrified of opioids because read the newspaper, what
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is happening, they're killing a bunch of people and we're telling doctors to stop killing people and we're squeezing the supply, and now we're hurting patients in another fun way, we're torturing them. patients who have been on opioids, who need them for pain or excruciating pain or being denied them, we're failing in tension and that's crazy. so, the next little section 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 like responsible prescribing of opioids. this store is my mom and but two years after i had gone through my own medical trauma and i mom had to head both knees replaced. bilateral knee replacement. a very painful year, getting one knee replaced very painful. getting both at the same time is excruciating. he she knew and i knew she would need a lot of
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pain medication, she was terrified and i was terrified because i had just gone through this. so by then i had exploit all of my access being at hopkins, knew miami knew people, a world class orthopedic surgeon, world class pain doc and i took all of that and applied it to moneys case and says here the less than me and my friends and team have drawn up. we're going to take ownership of this because i don't trust doctors anymore. and so we made a plan, we stuck to it, my mom is an absolute boss and she did what she felt like she needed to do it and was very hard to watch, very painful. but in about weeks she was off the medication, more or less in the third week she need he occasional nighttime dose and after she recovered and a little more coherent and a little less pain i texted her and said can you count how many pills you have left because i knew she had been prescribed 120noco, a
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175 -- when i found out -- you won't knee thad. just f that's four pills a day for 4030 days. bad news. but -- for 30 days you might need. i was interested to know how much. so the reading pick us when she answers me. she tensed a little while every asked, writing, i have 73 of 120 remaining. she used well under half of what she was prescribe. i should have been surprised but by this point i'd begun to see the data on overprescribing for surgery. prayer in all different fields are starting to -- publishing what average prescription and is then attempting to fine out how many pills patients actually end up taking. results pledge mom's north uncommon. a striking result was published in 2017 by a group eve researcher at the university of michigan, look at particular procedure, gallbladder removal and found the average post operative prescription was
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250-milligrams, measured in morphine equivalent ford the sake of standardization, when the researcher interviewed patients they discovered that the average amount of medication taken was 30-milligrams, as a result the group produced a prescribing guideline that included an educational kole potential inept that informed parents that would likely need only a few pill for a handful of days and shouldn't take the pills unless they real need need. he. in the months fool the implementation of the guideline the average opt on opioid prescribed drop from 250 to 75-milligrams and no increase in refill requests. just because opioids are seen as necessary in cases of surgery or severe injury, does not mean that we can't make very real progress. being exposed to open identities at all puts one at risk, and the evidence suggests the length of expect sure increases risk to remarkable degree. as a result we cannot justify sending more opioids out into the world than he need and can't
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aplow doctors to rite prerings associated 120 pills when 6 60. so i go this point in my research and one thing i'm realizing is, we need a discussion but responsible opioid prescribing and responsibility -- hammer, nail, right? and so we need a discussion about appropriateness and responsibility because the conversation that's happening out dug the pendulum swing is either drugs for everybody because they have pain and drugs should be given, or drugs for nobody because these are evil black magic. but those are both insane positions. they're completely unsupportable by the evidence. some pain really responds well to opioids for some amount of time, and we should responsibly use opioids in those cases only. sounds like really applause able do you indiana to have a ph.d to say that? apparently someone does have to say that. so this is about responsible opioid prescribing and then another thing found was go back
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to my experience, it wasn't just about the number. the number was almost certain lay problem and the reason it was a problem because i got a hands off, here an unlimited number of pill and you'll be in shoe saiding pain, watch the clock and stay aid of the pain. when you take opioids you get tolerant to them, so if you're looking for the same amount of pain relief you have totake near achieve that response. so i just kept upping the dose. brock. hes with the amounts. had i known what i know now then, my hope is that i would have tried to tee crease the dose sooner, weigh the benefits of pain relief against the risks of future suffering. right? but didn't have that information so i couldn't. so there's a bunch of stuff happening the number of pills a problem and also management problem. i if physician or nurse or pa isn't looking at you while you go through this, no one is going
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to be there to help you when thing goes off the rails. if no win knows how to get you off the medication or sees it as their job, then even if you have been prescribed well you might be in serious trouble when you try to get off. don't do it well go into withdrawal say, screw. that life is better on the pills. so, quick upshot of the research, responsible prescribing harder than we think. can't just do all or nothing and take as lot of work. unfortunately nuance is hard and we don't like to do it and we have to think a lot out who it means to have clinician prescribe the right number of pill in the right circumstances below at the right amount of time with the right kind of oversight. what would be really nice at this point is if i said, i figured out how to solve pain management -- false -- and that whole thing you been hearing not new in the eye union emepidemic
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we solved that because i fixed pain mid and is affectioned opioid which i didn't, but suppose. a big problem with that. solving pain medicine won't solve the opioid crisis and that's the last thing i wanted to say five minutes worth about. there's this really intuitive narrative. prescription opioid supply caused a lot of problem in the 1990s. so from 1999 to 2010, prescription opioids increase bid 400%. and that exact same time, overdose deaths from prescription opioid went up 400%. the really bad matching trend line and so there's this narrative that gets back up by a lot of stuff about pharmaceutical efforts and lobbying efforts and medicine and money and getting an idea that you can prescribe without consequence. but we have a 400% increase in prescribing that results in a
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400% increase in overdose death and the idea that supply was the problem. so supply is the answer. cut off supply and we fix the problem. that was never going to work. never going to work because miss in understand the entirety or dependence and addiction, the complicated that's tour of then edcrisis, and so we started squeezing the supply of prescription opioids back in 2010 to 2012, and did it solve the opioid enhome and . no it made it worse. he at the same tie witness in fact start to decrease the number 0 prescription opioid overdose deaths, heroin overgoing deathed went through the roof. we drove people to heroin is the conclusion we're invited to make. once you have this huge population of people going on to heroin, the people controlling
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that supplier are incentivized to make it more point tent and more deadly because they can get more and more money for the same amount and increasingly laced with fentanyl and that is 50 to 100 times more potent than morphine, car fentanyl we use to tranquilize elephants and other large al-malikis and it's being layingsed into heroin. so we are not going to solve the broader opioid epidemic by cutting the supply of prescription obamaoids and failed in in the -- opioids. and so we're going to need a lot more than just cutting supply and the last third or so of the book is investigating what the solutions might look like. there are lead four categories of things. we have to talk about supply. supply mary wheny flood a country with deadly drugs that are unregulated it can cause a
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lot of harm. if you have not read the dreamland, that's one of central lessons black tar heroin but also prescription ooidded when they were unregulated and honed it out without oversight. so supply is part of the possible. he it but might also ask about demand. why are so many americans taking drugs? that's a really important question to ask. could we help people and make them not want to take drugs so much? if you build commune and provide health care and education and give people a little bit more prospects, might they look less for pain relief? because heroin and prescription opioids, fentanyl, they're incredibly good analgesics for some of the time and some pain and the pain doesn't have to be physical. can he emotional, psychic. so, supply, demand, oya, also have to treat the 2.6 million people who have substance abuse disorder already and about one in ten of them are thankfully getting specialty treatment.
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so we have to to massive scaleup of treatment. the supply, demand, treatment. but there's another category because if you do all of those things, there's still the risk that an n a country with terribly contaminated heroin that a lot of people are using, a lot of people are just going to die before they're ready to seek treatment so we need something else. he we need to help people stay alive long enough that they're interested in seeking treatment. so there's harm reduction is another category great slogan for harm reduction is dead people don't recover well. you have to keep them alive long enough to into into treatment. the last the thing i'll read is harm reduction. might be nower to folks here -- newer to folks here than other countries. on the north side of east haying great vancouver's esideways nondescript storyfront. the picture of a heap determine mick need in the front door gives appearance of a medical facility and that impression
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continues on the inside. visitors come through the door, put the name odd check when desk and wait to be called inch rather tan private room as a standard health clinic the back room has a dozen stalls with privacy blinders on either side, metal desk, mire roar covering the wall and hard plastic chair. across the stalls is a long defense covered with medical equipment. the fail it called insight and it's goal is health promotion it is not your typical community clinic. its primary purpose is reducing the arms that attend injection drug use with secondary goal is including things connect thes. >> drugs with health care, provide treatment information some offering a safe space and community for people who might struggle to find either the injection room with the 12 stalls he satisfied by health professional and full of sterile injecting supplies, each visitor is offer a clean needing a sterile cooker, filter, water and tournament, everything needed to cook and inject heroin available in a safe, supervised
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environment. insight is a safe injection site. also sometimes call supervised drug consumption facility or overdose prevention site. consumers injection drugs can inject with sterile equipment, minimizing in the chance of getle help c and they're surrounded by trained profession aals. staphers equipped with drug testing strip to test the supply for the openad fend national allowing the user to decide whether to decrease dose in the light of me knowledge. the overdeers reverse drug naloxone is on hand. insigh has send more than 3-1/2 million people intervened in thousands of overdoses, and recorded not a single fatality. to the stenthat americans surprised by harm reduction strategies we're a little late to defame. united states is slowly come around to the idea of needle
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exchange programs with close to 300 open across the country by 2017. that number is absolutely dwarf evidence by other countries. australia has more than 3,000 needle exchange programs, more than 10 times the number in america. serving a population that is less than one tenth the size. as result they're only one needle exchange program for every 3200 americans who use iv drugs and australia, there's a program for every 31 people who inject drugs. safe injection sites exist in dozens of cities with more being proposed all the time including win the u. the reason is simple. they save lives lives and prevet suffering. an added bonus they also safe money through decreased burdens on the health care system and inproving public order and increasing access to addiction and other health services by people who use drugs of by taking drug use off the streets it's most harmful and connecting those who injection -- >> host: injection drugs to safe equipment, public space and
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health care-and, save injection sites do a lot of good needle exchanges can prevent disease and but a brick and mortar site where people can come to use drugs offer this possible of connecting them with people and resources rather than driving them ever further into the shadows. after all, the harder to see the person using drugses the harder to save them. of course if you go counsel this rabbit hole very far it becomes very difficult to understand our current practices. what i've been suggesting here alongside many in the field of public health is that we should take a harm reduction approach to injection drug crisis. whether cow buy into a festival philosophy, we have to find a way to prevent our family members, friends friends and faw citizens drug use from killing them. you may find this sensible or you may come it to reluctantly, but either way, i think you should come to it. i'm going to wrap up there because i want to hear what you
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have to say. i will close noting i made she is sound like a really dark back. the country is messed up, the health care systems bad at pain, pain medicine, and there's a lot of doubt that they're working very hard to fix this, and even if we did fix it, it wasn't pass to the broader opioid crisis might hey ben the sort of thoughtow whoa have had reading orders from the media. fate together take more but the thing want you to leave with is, on all of those counts, we need a culture change, and all of us can be part of a culture change. so why did i write this book? some people ask he if i was dramatic. i actually fairly cathartic. the reason i wrote is anyway is because if i can get a bunch of docs and a bunch of patients, which those two groups include all of us, to think better about both sides of the pain and drug
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crises that intersect when it comes to opioids, that will be worth doing. so i invite you to think but that with me and let's chat a little bit more openly now. thank you. and please use the microphone. >> i have comment and a question. or maybe 100 questions. so, i'll limit it to one. >> i appreciate that. >> my comment is that the passage that you read about your daughter's amazing response to your pain was one of the most emotional things i've ever heard read at the become store so it was a beautiful description of an amazing event. >> thank you. >> so my question -- so you intrigue me. you said you'll be willing to talk about the protocol that should be followed coming off of opioids. so i'm getting a knee replacement surgery in september so i have some skin in the game. would imagine a lot of miami in is audience have been through
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knee replace. so i should man up and not be concern but so systematically, there are huge lawsuits looming, maybe not as big tee back co but almost as big, maybe -- i don't know. so you would think that the threat of that legal action would get people together in a room on a macro level and say, let's talk but evidence-bearingsed whatever. is that discussion happening in all these medical conferences that i like to believe are happening? >> it's great question. i certainly -- yes, those conversations are happening. sometimes it's a good thing. so that's 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 and the rope is we cannot get away from that pendulum. so you say whysen everybody getting together in the same
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room. sometimes they are. if you loosely enough defind everybody. you get groups from insurers and docs and the surgeon general and yadda, yadda, the cdc, fda. the risk is coming up with something that we believe doctors will actually follow and what that gets translated to is ham-fisted and that means something like you get four pills after procedure x, and that's not delineated to any individualized patient. so for some people four pills will be absolutely enough which is why we need the evidence based and some people won't be and a decision you want an educated healthcare practicer to know the evidence and respond to the tick alerts of the patient -- the pickaired of the patient imi've been invited to them and the fact they want ethicists there gives me open. i ware on me sleeve my perspective. want to talk about responsibility and they tend to
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be responsive but i'm scared when too many people in power, let's fix this thing because my fear is that the response will be, yaw, 50 morphine eeye question help and then you have patients on 700 or 1200 and we have to decide what to do with enemy and they're being tapered when they're not ready i just describe what withdrawal is like, and doing that to somebody when anywhere not ready, against their will, is torture. >> 60 second version of the right way to come off these. >> the 60 second version of the right way could come if. by and large, most people who have only been on opioid for tweaks, three weeks, four weeks from fairly routine be major surgeries, knee replacement and hip replacements, if you stay inside two weeks most people won't experience withdrawal that anyway notice. ealy interesting phenomenon talk to people who have been surgery tchen asked white supremacy what is like to stop taking pain
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pill. i couldn't schliewe and jittery and goo bumps. they're in withdrawal you start withdrawing quickly because to pen dense can norm a few days. doctor says things like you don't have to worry about it until in month out which is inbecause at a month dependence can be severe... >> a bunch of people won't notice it; right? then you get the really hard cases, god forbid, a knee replacement gets infected, you
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have to do a reconstruction. you are in six weeks of energy and then three months of opioids. your case is a lot more complicated, and you really want a pain management team that knows what they are doing and sometimes people with an addiction medicine team because they are more familiar with the tools and the tapering protocols. from my own experience finding those people who know what they are doing and willing to take you on is terrifyingly hard. i have a phd. my wife has a phd. we are in the d.c. baltimore area at world class hospitals and we spent three weeks calling people and no one would do it for us. that's scary, right? what is it like for everybody else? what is it like for those who have less access than us? >> i was taken with your compelling interview with terry gross. in fact, i couldn't stop listening. >> thank you. >> very simply, you and i are
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part of the same club. i'm double your age. i'm 72. and the doctors warned me at my page recovery is unpredictable. i shattered my collarbone, my scapula, the big bone on the shoulder, and i had eight rib fractures down my left side. so i was taken to the -- with confidentiality you don't identify the hospital. between the watergate building and water side, and also the hospital where ronald reagan was treated. [laughter] >> they used a nerve block procedure which was wonder. . i had liquid iv medicine for 24 hours and then for ten days i had wires in my body that were guided by ultrasound where they placed the medicine right into where the fractures were. after -- and i went through six months of recovery, pt. i had three grades of pain
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medicine. i didn't have a pain management team. i had a world class i think orthopedic team and a world class trauma team. i was six nights in trauma, which is a long time to be in a trauma bed and then five nights in a -- the simple question was, i'm not a doctor like you or trained in that, but i had a simple minded notion that if i dull the pain, i run the risk of reinjuring these fractures because i had to shower, i had to take care of myself, my wife helped like yours did for you, but i stayed off the pain medicine. i had morphine. i never touched the bottle. i still have it in my medicine cabinet for the next accident. >> you need to get rid of that. [laughter] >> i tried to just basically say i don't want pain medicine at all if i can help it. how's your pain today when they walked in? i said on a scale of 0 to 10, i think it is 15, but i'm 95%
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recovered. but i thank god i tried to avoid the pain medicine. so when i asked them why didn't you do any surgery, they said your injuries were too substantial. we were worried about a punctured lung, and we were worried about massive concussion. it turned out the concussion was minor. so what i worry about later on is the psychosomatic stuff that will come later because i've had that too, waking up in middle of the night and you've just had an accident. i wonder what -- you're putting in place and maybe you don't want to talk too much about that of what comes later in the thoughts that you can't control at night. >> wow, yeah, i mean, so there are a lot of questions in there. let me tackle a couple. you know, one point i think that's really important is your doctors might have messed up when they said, you know, here's
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a bottle even though you say you don't want it. but they might not have, right, because pain is dangerous too. pain can keep you recovery. the real challenge -- like i said, pain medicine is hard. this is the secret; right? pain medicine is hard and we have acted like it is not. we've acted like pain is the sort of thing that can be treated by anyone just like antibiotics can be given out by anyone. one of the reasons it is hard is exactly you are saying you are worried about dulling the pain to the point you might reinjure yourself, totally legitimate worry and sort of thing doctors should warn a patient about; right? so you need to experience enough pain that you don't reinjure yourself. but you need to get enough pain relief that you can sleep and you can rest. you can get some recovery, right, because your body needs to heal and that requires resting. there's a sweet spot. it's phenomenally difficult; right? there is an interesting link between pain and ptsd, which is
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getting to your last question. the group of folks that i talked to in epilogue in the final chapter, the defensive veteran center for integrated pain medicine, one of the things 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, which at lot of them were, but because they were coming back really really traumatized and they started to think that some of their trauma because they never processed anything. you get the first shot of morphine into them the second they hit the ground and they are completely on cloud nine all the way back to walter reed, through germany, wherever, from afghanistan, from iraq. and so their conclusion was if we don't fix their pain, not only are we not going to fix the dependency and addiction rate, we are not going to get a handle on this crazy epidemic of ptsd that we are seeing in our soldiers. they have done some important work. if you haven't seen the documentary escape fire, i recommend it.
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it is about the team i write about in the epilogue. long before i interviewed with them, they worked with the documentary film crew for "escape fire". won a bunch of rewards. it is really striking. you might want to check that out. anyone else? >> i have a question. >> a bunch of polite people were waiting to give other people a chance. >> you mentioned some of the practices in other countries, like australia and vancouver, are there any jurisdictions that you found that's actually getting this right, and if so, kind of what explains how they got it right, and are they jurisdictions that we can learn from? >> that's a great question. i'm going to say with a caveat that i haven't, but part of the caveat is that i'm not an expert on everywhere. so from what i'm told, germany does pain medicine pretty well. the reason that i'm a little concerned -- the reason there's a caveat there is the pendulum
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swung everywhere; right? and so a lot of the countries that are not dealing with the drug overdose crisis never got the kick-start with opioid overprescribing because they don't respond to pain -- they don't clinically respond to pain. they just don't give medicine for anything. so the knee replacement surgery, right, in some countries, you have that and they give you ibuprofen afterwards. i watched my mom go through a knee replacement, i don't want to live somewhere where they give you ibuprofen after that. i learned about some of the horribles that are possible from opioids but they are not black magic. some of western europe is starting to freak out a little bit. some of the ranking counts -- countries having trouble, off the top of my head. america is the worth. we screwed this up tragically.
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but north america as a whole got everything. the marketing from pharmaceutical companies, the kind of lesson that you absolutely must treat pain with opioids regardless of the cause. that wasn't exclusive to america. that happened in canada too. canada's only about three years behind us on their drug overdose trajectory. they switched over to fentanyl really early because it started happening here. so canada is in terrible straits. australia is in a pretty bad situation. but western europe who for a long time people in my circles are saying how did they escape this are starting to get scared because they are seeing some prescription overdose spikes and they are like we can't follow america. america is a boogieman. if you can't hold in your mind, the scale of that, more americans died from drug overdoses from the entire vietnam war. we talked about the hiv aids epidemic and it was, more people died from opioids in 2017 than ever died at the height of the
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hiv aids epidemic in the 90s. everyone is freaking out because america is the boogieman, but i don't know if there are places that have really nailed this. right? that's a great question. >> thanks for your talk. i wondered about methadone maintenance clinics, what your research has shown about them how they didn't work or are still working and what the promise is for just making them work for today's problems, with the opiates. >> methadone maintenance for anybody who doesn't know, it is an opioid -- it is itself is an opio opioid. one of the reasons you treat it is you put somebody in an addiction, who is burning their life down because of their addiction, you put them on methadone which has a long half life and evens their brain chemistry out. because that's the way it works, you will sometimes hear in the media like drugs like methadone, there's one that's slightly
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different, the idea is the same, it is an opioid that you give people to treat the addiction. you will hear things like politicians say i don't like this stuff. it is replacing one addiction with another. if they say that, they don't understand addiction. here's the thing, addiction is de defined by behavioral compulsion, craving and an inability to control one's behavior; right? interesting factoid if you were thinking you were listening to a story about the professor who got addicted to opioids, turns out not. maybe i was on a road to addiction if i went back on those pills and vowed never to come off of them, but there's a difference between physiological response and behavioral response. methadone, great drugs to treat addiction because they replace the dependence that you have, the biological dependence with another one that cure -- doesn't cure. take that back. strike that from the record. that treats the craving and the come -- compulsions evens out
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the brain chemistry. when it works, it doesn't work for everybody, it lets people get their life back. they can hold down a job. they go in the morning, they take it in liquid form. when it works well, they can get their life back, a father again, mother again, sister again. it doesn't work for everybody, and it is a drug that's specific to opioids. i'm a huge fan of methadone. i want to destigmatize the heck out of this which is why i used this response it doesn't replace addiction with addiction. replace the stigma. but if the next addiction crisis that comes after this one is methamphetamin methamphetamines, methadone isn't going to help. it just treats opioid addiction. it reduces all cause mortality by 50% which is gold standard in
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public health. but it's not a silver bullet for the addiction crisis. anything else? [applause] >> thank you all very much. >> there will be copies of his book available at our register. if you would like him to sign your book, please form a sign line to the right of the table and please fold up your chairs. thank you. tonight at 9:00 p.m. eastern, after words, with journalist natalie wexler, author of "the knowledge gap". >> one reason kids often score well on those tests is they don't have the background knowledge to understand the reading packages in the first place. it is not that they can't make an inference. they make inferences in their
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lives all the time. toddlers can make an inference. that's not the problem, so much as they lack the background knowledge and vocabulary to understand the passage. that has been a big problem that's been overlooked. >> watch after words tonight at 9:00 p.m. eastern on book tv, on c-span 2. here's a look at some books being published this week. new york times reporter looks at immigration through three generations of a family, in "a good provider is one who leads". an author offers a critical look at the book a people's history of the united states. also america's social movements have been examined following the civil war. in the outlaw ocean, pulitzer prize winning journalist explores the world that exists at sea where he reports traditional policing does not
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exist. also being published this week is former army ranger's memoir, thank you for my service. in the assault on american excellence, former dean of yale law school weighs in on the current state of campus politics and argues that students are not being prepared to engage in civil discourse after graduation. and in the secret library, the world affairs correspondent mike thompson reports on a makeshift library on the outskirts of damascus that provide an escape for its patrons throughout a four year siege during the syrian civil war. look for these titles in bookstores this coming week. watch for the authors on book tv, on c-span 2. tonight we're so pleased to welcome sarah rose for her new book "d-day girls", helps win world war ii. she draws on recently declassified files,


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