According to Travis Rieder, there isn’t one opioid crisis. There are three crises:

- The overprescription of opioids by physicians
- The long-standing heroine epidemic in the inner cities among the poor
- The epidemic use of heroine laced with fentanyl

There are a few things I read in this book that I don’t want to forget:

- Drs aren’t trained much if at all in pain management. Vets get more training.
- Drs get no training in how to get their patients off opioids after they’ve prescribed them and kept them on them for months, sometimes years.
- Medicine isn’t organized to maintain accountability for who prescribes opioids and whose job it is to get patients off them.
- An alternative and sometimes very effective alternative to opioids for some forms of acute pain is IV APAP, essentially Tylenol through an IV drip, isn’t prescribed even though it carries less of a risk of drug dependency because opioids are so much cheaper and covered by the health insurance companies.
- Alternative lifestyle treatment for pain is also avoided not because it doesn’t help but usually because health insurance doesn’t cover it
- Social stigma to drug taking includes individuals with drug dependencies, drug addiction, and overdose. They are lumped into one basket. Millions of people in the US and elsewhere are dependent on a substance through no fault of their own, but that is not how they are viewed by their peers. And their only treatment is for addiction, whether or not they are addicts.
- Physicians, like the rest of us, have a business to run. People expect them to prescribe pills. If they don’t, they run a big risk of bad reviews on social media. So there’s a big disincentive to suggesting alternatives.
- Drs are incentivized by the drug companies to prescribe pills with free lunches, free training and conferences.
- In the hospital environment, doctors simply don’t have the time to spend explaining alternative therapies to patients (even if they actually know about them which many don’t).
- Multimodal pain therapy is difficult, time consuming, and expensive.
- Ideally, the medical system needs doctors to be allowed to exercise more and better judgment when prescribing pain treatment therapies.
- The answer isn’t to stop prescribing the pills to legacy patients who have been on opioids for years. They will just find the drugs elsewhere on the street cheaper and be at risk when using the cheaper heroine and often fentanyl-laced heroine.
- Physicians, like it or not, are the ones people trust with the prescription pad

Drug dependencies weren’t always seen as a disease, and even today it is controversial to treat people as though a drug dependency is a medical problem. Some see it as a problem of unlearning, or re-learning more constructive behaviours.

It the old days (maybe not so old) drug addicts were immoral, or irreligious, or defective.

It’s high time we change directions. For one thing, that we stop locking people up for drug use tied to pain abatement. I also think that de-stigmatizing mental health issues would also help many people avoid taking wrong turns into drug addiction.

If I have one criticism of the book it’s that it doesn’t help me understand why withdrawal from opiates affects the body — for example with stomach pain and heaving — and not just the reward receptors in the brain. ( )

This is probably the best book I have read about the modern opiate epidemic. The author presents his own story as a trauma patient who was prescribed increasing dosages of opiate pain meds after a terrible motorcycle accident, and then left to suffer through withdrawal without any meaningful help from the doctors who prescribed those pain meds to him in the first place.

The reason I appreciate this book so much is that the author looks at the nuances of opiate usage. I liked his metaphor of a pendulum swinging from too-liberal opiate use (see: the late 90's and early 00's) to total prohibition (not where we are now, but where the pendulum is swinging). Both of these pendulum positions are equally bad for different reasons.

The author talks about responsible opiate usage in legacy pain patients and how prohibition is leading those folks to seek out pain relief on their own, even if it means turning to the black market and heroin. The author describes that our epidemic is so bad right now because people ignored it when Black people were the ones suffering from opiate use. He explains how the image of the junkie is racist. He explains how alternative treatments to opiates are usually not covered by health insurance. There's a lot more than I'm not remembering, but this book is so good because it covers so many overlapping areas of policy-crappiness that got us to where we are right now.

The author also does a great job of explaining how dependence on opiates can lead to addiction. His background as a bioethicist also helps to understand why we should feel compassion for people who became addicted not through use of irresponsibly prescribed pain meds, but through black market heroin. It shouldn't matter how people became addicted; harm reduction should be the way forward for anybody who is suffering.

Without this wholistic look at pain treatment, this country will continue to fumble through coming up with solutions. We will continue to let people needlessly suffer. This needs to change. ( )