The narrative arts-both fiction and nonfiction-provide fertile ground for exploring the complexities of pain and healing. Starting this month, we begin an occasional series about books, film, podcasts, and other narrative forms that can inform and inspire.
We welcome your contributions to this new feature, by way of short reviews or recommendations.
For our inaugural column, we can recommend a few excellent nonfiction books that have captivated readers this year. Both books are available in audio, read by their respective authors as well as in print and electronic format. Both authors are doctors and researchers, though only one is a physician.
A Bioethicist Writes About His Experience of Pain and Opioid Withdrawal
In Pain: A Bioethicist's Struggle with Opioids, by Travis Rieder, PhD, is an eloquent and informed account of traumatic injury, pain, and healing-but also of unintended abandonment by physicians who should have known better how to manage the tapering of the high doses of opioids they initially gave their patient.
Rieder is the Assistant Director for Education Initiatives, Director of the Master of Bioethics degree program at Johns Hopkins University (JHU), and Research Scholar at the Berman Institute of Bioethics. He is also a Faculty Affiliate at the Center for Public Health Advocacy within the Bloomberg School of Public Health at JHU.
On Memorial Day weekend 2015, Rieder was involved in a motorcycle crash that shattered his left foot. He was quickly transported to a trauma center, where he underwent a series of operations and skin grafts, with his pain managed aggressively with opioids.
By the time of his accident, Rieder and the entire country were aware of the opioid crisis, yet his treatment did not include many of the newest recommendations such as multimodal analgesia, IV acetaminophen, and evidence-based tapering regimens.
It is a nonfiction book by a uniquely qualified writer who is able to describe the large cracks that patients can slip through. As an associate at JHU of some of the most respected faculty in medicine and bioethics, he had access to information, research, and experts. But that access did not prevent him from finding himself dependent on high doses of opioids. He then faced the implication from his physicians that he should not be on such high doses, but with no good guidance on how to taper.
The hospital pain service that had treated him as an inpatient would not treat him as an outpatient. His plastic surgeon suggested a tapering schedule of 25% less each week, which Rieder carried out, despite the plan being far too aggressive. To make matters even worse-fear of shame kept him from seeking help from fellow faculty members.
Ultimately, Rieder channeled his experience into a memoir that can give physicians and other health care practitioners a strong framework for ethical discussions about pain care. For example, he describes the controversies and cost issues about multimodal analgesics such as IV acetaminophen. It was not until much later, when he was speaking at an anesthesiology conferen ce, that he learned from chatting with anesthesiologists there that the reason the hospital gave him only 3 doses of IV acetaminophen was probably the high cost, not the concern over liver damage.
Many of us who work at academic medical centers take comfort in the belief that we have access to state-of-the-art care and physicians who are going to be current with the medical literature-more access, at least, than the average person.
And so this book's effect is that of a horror story; you will not be able to rationalize that his horror could never be your horror. In particular, Rieder's mismanaged pain and opioid tapering occurred in the metro area where we both happen to work and live-Baltimore. (We have never met.)
In the book, Rieder chose not to use the real names of the hospitals and physicians who treated him, because the mistakes they made could have been made at any hospital, he writes. The city is home to at least 2 world-class academic medical centers, and several more are just a 90-minute drive in either direction in Washington and Philadelphia.
A Model for Physician Activism in Public Policy
What the Eyes Don't See: A Story of Crisis, Resistance, and Hope in an American City, by Mona Hanna-Attisha, MD, MPH, FAAP, is not about pain (although the title would be just as appropriate for a book about chronic pain). It is, instead, about the Flint water crisis, in which a whole city was unwittingly subjected to tap water poisoned with lead for more than a year.
The story will resonate with pain practitioners who are, in any way, looking for ways to effect change through public policy and legislation, and even mitigation.
The author was a pediatrician practicing in Flint and leading the pediatric residency program for Michigan State University and Hurley Children's Hospital when she learned through her best friend, an environmental scientist, about high lead levels in Flint tap water.
At the same time, she was noticing that her young patients were beginning to present with problems such as attention-deficit disorder, and extreme skin lesions and rashes after bathing. Although an activist parent and a few others in the city were beginning to mobilize, state officials assured the public that the water was safe.
The book describes an intense 28-day period starting with the barbecue where the author first learned of the problem. Although most research takes years, she and a small team of dedicated scientists and statisticians worked nearly round the clock to get institutional review board approval, collect data on patients' blood lead levels, and then convince public officials to do something about it.
Despite the data and science, they still faced political resistance and attempts by the state to discredit them as scientists.
Hanna-Attisha is Assistant Professor of Pediatrics and Human Development at Michigan State University and a pediatrician at Hurley Children's Hospital.
The book is worth reading for the way in which one physician-a young but experienced faculty member-was able to marshal forces to tackle a full offensive line of bureaucratic, financial, and political players. Considering the way pain care and opioid management can be subject to those same forces, this book can be relevant to physicians, nurses, and others who are on the front lines of the opioid epidemic and the continuing efforts to improve pain care.
One of the points made by Hanna-Attisha is that even when there is irreversible damage, such as from lead poisoning (or, if the reader will extrapolate, from opioid addiction or years of chronic pain), human resilience and the right resources and corrective steps can mitigate the damage. In Flint, for example, attempts were made at socioeconomic approaches to improve the lives of poor children and their parents, through better nutrition, jobs, a program to improve literacy and deliver new books every month to Flint children's homes.