First Do No Harm: An Ethicist’s Experience with Opioid Withdrawal

Man in despair with raised hands and bowed headd, in a low light room looking in front of mirror

By Ajay K. Singh, MBBS, FRCP, MBA
February 14, 2017

A compelling personal story by Travis Rieder, an ethicist at the Johns Hopkins Berman Institute of Bioethics, titled In Opioid Withdrawal, With No Help In Sight is definitely worth reading in full—a very personal story from someone who has been on the sharp end of opioid withdrawal.

Rieder writes about how he was treated with opioids after his left foot was crushed when he was hit by a van while riding his motorcycle. His acute pain was unbearable, requiring multiple opioid agents at high doses. He says that over a period of two months he became tolerant, gradually upping his doses of extended-release oxycodone and gabapentin until finally his plastic surgeon recommended a weaning regimen. What followed, according to Rieder, was a harrowing withdrawal experience with very little support by the medical community. He writes, ” How could it be that my doctor’s best tapering advice led to that experience? And how could it be that not one of my more than ten doctors could help?”

Rieder makes the point that education of physicians is a key problem. He says that physician’s need to be trained in dosing and weaning strategies and symptom management. He says that medical schools are not doing enough to prioritize teaching pain management in their curriculum. He talks of the Hippocratic dictum to “first, do no harm.” Says Rieder, “By prescribing a drug that has predictable harmful effects without a plan for dealing with them, a physician is at least partially responsible for causing those harms.”

Rieder concludes, “My goal is not, however, to change one doctor’s view about what he owes his patients. Instead, I want to start a broader conversation about physician responsibility for opioid-related harms, as well as the systemic forces that make it easier or harder for physicians to recognize and discharge their responsibilities. Opioid withdrawal isn’t minor. It’s not “just temporary” or “the price to be paid” for pain relief. It’s not morally innocuous. The moments that I was in withdrawal—all of the thousands of moments of genuine suffering—were the worst of my life. That kind of suffering matters, and its seriousness needs to be reflected in the way we deal with prescription opioids.”

Knowing how to rationally prescribe opioids and how to recognize and manage withdrawal seems obvious if you are a clinician prescribing powerful painkillers. But, what Rieder’s story also highlights is the importance of a support infrastructure and having in place mechanisms for patient’s to access services during their withdrawal. Generalizing one person’s story to indict the whole health system should be done cautiously, but Rieder’s experience is certainly a “wake up call,” if not a call for action.

The Opioid Use Disorder Education Program

The Opioid Use Disorder Education Program (OUDEP) is now available from HMS Global Academy. OUDEP is comprised of 3 free online CE/CME courses produced by Harvard Medical School (HMS) with scientific contributions from The National Institute on Drug Abuse (NIDA). These courses are intended for nurses, nurse practitioners, physician assistants, physicians, and other health care providers collaborating to treat patients with substance use disorders.

Ajay Singh, MBBS, FRCPDr. Ajay K. Singh is the Senior Associate Dean for Global and Continuing Education and Director, Master in Medical Sciences in Clinical Investigation (MMSCI) Program at Harvard Medical School. He is also Director, Continuing Medical Education, Department of Medicine and Renal Division at Brigham and Women’s Hospital in Boston.


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