C L O S L E R
Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

Book Review of “In Pain”

Takeaway

Clinicians need to understand that patients' pain is real to build rapport and reassurance, which will help patients be open to the full range of treatment options.

“In Pain,” is bioethicist Dr. Travis Rieder’s candid narrative about his pain experiences and struggles with opioid dependence following a motorcycle accident in 2015. Dr. Rieder had five surgeries within one month. After each surgery his opioid dose escalated. Two months later, one of his doctors recommended that he taper off his opioids. Dr. Rieder, with the support of his wife, attempted to find a provider to guide him through opioid weaning; yet despite reaching out to each of his former providers, as well as substance use treatment facilities, he found himself suffering through opioid withdrawal without guidance.

 

His gripping recollections of all-consuming pain, personal suffering, and abandonment, reveal the limitations of our medical training and clinical responsibilities, as well as the flaws of our fractured medical system. Dr. Rieder could have solely focused on his repugnant and unacceptable experiences as a patient. Instead, he wove a contextual historical narrative and used his expertise as a medical bioethicist to acknowledge the racial discrepancies, stigma against addiction, and clinical negligence that contributed to our current opioid epidemic.

 

He advocates that we solve an overwhelmingly complex problem – how to responsibly manage pain without causing iatrogenic addiction – by changing our medical practice, addressing our personal biases, and advocating for policy changes. A few examples of changes that clinicians can make are shared below with a few quotations from the book:

 

The goal is not to eliminate pain.

Patients often expect that pain be eliminated. Understanding and managing these expectations is important. Consider telling patients, ” I cannot make your pain go away, but I can help you function despite your pain.”

 

Opioids are powerful reinforcers.

“ . . . the incredibly dangerous nature of opioids is that taking them makes the brain very, very happy, while taking them away makes it miserable.”

Most patients who take opioids for more than two weeks will become dependent; discontinuing opioids will induce withdrawal. The increased pain during withdrawal will diminish over time. I often tell patients short term pains for long-term gains.

 

It’s easy to let patients fall through the cracks

“The challenge here is systematic, baked into the way our healthcare is structured. The doctors who prescribed my medication somehow didn’t see it as their job to help me get off that medication.”

Prescribing opioids has consequences. Patients benefit from longitudinal follow-up to monitor for addiction. If you will not be following a patient longitudinally, then provide a warm handoff to their primary care or chronic pain management provider.

 

Pain can be over-treated and under-treated in certain populations.

“ . . .the doctor had disrespected me in a very specific way, by not taking my words – my testimony – seriously.”

A common unconscious bias that some clinicians hold is that Black and Hispanic patients experience less pain and are more likely drug-seeking compared to white patients.  Black and Hispanic patients then receive less aggressive pain management.

 

There is no magic bullet for pain treatment.

“If a physician recommends [cognitive behavioral therapy (CBT)] to a chronic pain patient, the response may well be some version of ‘What? So you think this is all in my head? You think my pain isn’t real?’”

Acknowledging that you understand that your patient’s pain is real builds rapport and reassurance, and may help a patient to consider non-pharmacological treatments such as exercise, physical therapy, yoga, massage, CBT, and mindfulness.