Adam's Updates

"In Pain is FUCKING BRILLIANT and BRUTAL.

This is my favorite kind of book about mental health issues of any sort. An educated third person “objective�� perspective (the author Travis Rieder is a bioethicist) blended with honest, vulnerable writing from the first-person “subjective�� perspective (Rieder experienced extreme acute pain due to an awful motorcycle accident, and chronic pain occurring in the months and years that followed).

Rieder describes his pain experiences from the first person (phenomenological) perspective.

And let me just tell you.

It’s very effective writing.

I didn’t literally “feel�� what he described.

But it got me about as close to that experience as reading someone’s words, and empathizing with them could.

The writing is so explicit, and so descriptive, (without being at all gratuitous) that I was literally writhing and wincing again and again.

Without knocking you over the head with it, he really makes you understand how fucking bad that experience was.

And it was FUCKING bad.

To say it was a living hell (for whatever that tired old cliché is actually worth) would be accurate.

This book is worth it just for that stuff alone.

But that is quite simply, only the vestibule at the front door of hell. Only the very beginning of a long descent into the ravages and prolonged suffering of every shade and variety that he endured.

In fact, Rieder speaks of the many varieties of pain with the expertise and specificity of a fine wine connoisseur.

Rieder’s descriptions are almost poetic at times, full of imagistic metaphor, not for gratuitous esthetic effect, but out of pure necessity, because other, more clinically “precise�� descriptions simply fail at this frontier of communication.

Although this type of writing and self disclosure is quite contrary to Rieder’s training as an academic philosopher. It is clear that if he stayed to academic form, and was as such, unwilling to “come out�� and speak honestly from his raw first person experience, it would amount to another type of intellectual dishonesty and failure via omission.

And so, he made the extremely brave decision to serve the brutal, tender, honest realness of his darkest hours, along with reasonable, modulated, thoughtful passages, without being dramatic or pedantic.

Hence the “Brutal�� and “Brilliant�� adjectives that bookend this review.

This book also contains some of the best phenomenological writing on opioid withdrawal that I am aware of.

Rieder became dependent on opioids over the course of his protracted pain management, and then was advised to abruptly discontinue them by a doctor (of all people).

Advice that was so woefully incompetent that I was LITERALLY face palming and saying NO out loud.

SNOL?

I guess?

Anyway

One of the BIG problems (probably the biggest problem) with opioids (and all drugs of abuse for that matter, but particularly opioids) is that they disable the brain and body‘s natural ability to do what the drugs do for you.

Opioids do stuff like modulate pain, slow bowel motility, enhance sleep and promote euphoria.

So another words.

Opioids:
- take away the pain
- make you feel peaceful and care free
- make you sleep like a baby
- they are a nice decongestant
- and they make it so you can’t poop (huge problem that you can die from)

In opioid withdrawal, you get the equal and opposite rebound effect.

In Opioid Withdrawal:
- you’re extremely pain sensitive (hyperalgesia)
- you feel dysphoric (suicidal even)
- you can’t sleep (often for days on end)
- your eyes and nose run like gooey rivers
- you have chronic diarrhea
- extremely painful vomiting and dry heaving

I have worked with hundreds of opioid addicts.

Many report that they would rather die than experience precipitated opioid withdrawal again.

Detoxing from any drug is rough.

Try skipping caffeine for a few days if you don’t believe me.

Detoxing from alcohol and benzodiazepines can be fucking deadly. It can literally kill you.

Withdrawing from opioids is rarely deadly.

But people do crazy stuff to avoid that misery.

Including suicide.

Kicking dope is no joke.

And the real kicker here, is that Rieder was completely unaware, and completely unprepared for any of this.

All the guy needed was a little bit of education, and a little bit of support, and maybe just a little bit of medicated assisted opioid withdrawal.

And he would’ve been spared an awful misery.

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He (under explicit directives of his doctor) made some of the most harmful, and dangerous mistakes you can make.

For instance, his primary physician advised him to taper down over the course of a week or so.

That’s the equivalent of advising somebody to jump off a 10 story building, 2 or 3 floors at a time.

NO!

Take the FUCKING stairs for fucks sake.

ONE STEP AT A TIME!

In other words, a medically indicated opioid taper takes weeks, or even months, or even longer in some cases.

Abrupt opioid discontinuation is the ULTIMATE rookie move.

And it almost killed the guy.

That’s right, he became severely depressed and suicidal.

Any addiction professional could have seen that coming a mile away.

The problem was.

Rieder wasn’t in addiction treatment.

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Rieder wasn’t an “addict��.

He wasn’t stealing from his grandma‘s purse, or turning tricks, or dealing to grade schoolers, or (insert any of the myriad dehumanizing clichés about addicts here) to buy heroin.

He wasn’t misusing the medications.

He didn’t like being on the opioids.

He desperately wanted to be off of them.

He was simply a “regular guy�� who was trying to get off of a prescribed medication.

So when his medical team suggested that his opioid withdrawals were “not their problem�� and directed him to addiction treatment, he rightfully balked.

Although, if he had gotten just a little good advice and support, his experience of withdrawal would’ve been much less dangerous and awful.

One of the benefits (if you could call it a benefit) of being a heroin “addict�� is that you are probably inside a community of people who (one way or another) understand stuff like opioid withdrawal.

In other words, junkies know how to kick dope.

At least they know how not to.

And of course, if you are engaged in good treatment (hard to find but certainly out there), your team will educate you as to what to expect in opioid withdrawal, and provide you with guidance, a taper schedule, and medications to make that experience MUCH more survivable.

The problem is, you’ll get a bunch of shitty therapy and a bunch of 12 step jammed down your throat.

And for a guy like Rieder.

None of that sounded necessary or appropriate.

And he may have actually been right.

Lots of people get strung out on prescription opioids. But that doesn’t mean that they are addicted (a terrible and completely dysfunctional word to be sure).

People like Rieder would be better described as having complex protracted opioid dependence.

But probably not substance use disorder.

So does someone like Rieder go get on methadone? Or go to residential treatment?

All the guy needed was just a little good advice.

And maybe some buprenorphine.

And perhaps a little sleep medication.

And some good support.

And we’re done.

In addition to being an amazing memoir.

This is some of the most interesting and compelling writing about the medical and social systemic aspects of the opioid epidemic and opioid use more generally, that I am aware of.

It’s a thoughtful, balanced, and fair accounting of the relative use value and risks associated with pain management.

Rieder discusses the benefits and problems with scientific and medical reductionism.

The Benefits of Reductionism:
- you can identify, isolate and control variables.

The Problem of Reductionism:
- you can’t see the forest through the trees.

The Problem With Reductionistic Medicine:
- the image of the “whole person�� in the environment gets lost.

Rieder also discusses the merits of the systems perspective, and the benefits of integral medicine, without outright referring to it as such.

Probably most importantly, Rieder describes the dangers of the stigma surrounding opioids and drug use in general. And the need for rational, evidence-based, prescribing practice, which includes medically assisted withdrawal, with the responsibility of withdrawal management placed squarely on the prescriber.

Rieder doesn’t blame medical clinicians, he has a broader more systemic view than that. But he does call for reform of the current system, and ascribes responsibility for educating and assisting clients in their detox efforts to the prescribing clinician.

��

Yes!

Additionally, Rieder advocates for better addiction treatment. Including harm reduction policies that decriminalize, and even legalize drugs like heroin, and provide clean needles and safe places for people to use, so that they don’t catch diseases and die, and so that they can get access to good information, and addiction treatment if they want/need it.

��

Yes, yes, yes, and hell yes!

This is a long review.

But this is a really fucking important book.

I’d say it’s the best one of these that I know about.

I think it is the perfect counterbalance, to Dr. Carl Hart’s Drug Use For Grownups (read my review of it here - /review/show...)

I read these two books back to back.

I highly recommend doing exactly that.

If I ever teach another course on the bio/psycho/social/systemic issues pertinent to drug use and addiction, I will make these two books required reading.

I will end this review like I started it.

In Pain is FUCKING BRILLIANT and BRUTAL.

5/5 STARS ⭐️"