So if you whack your thumb with a hammer, you think pain is in your thumb. Physicians have a more sophisticated understanding. We know that it's an alarm that goes, on nerves, to your spine, where it is translated to your brain, and pain actually happens ... somewhere. It's a little vague.
當你用鐵槌敲到你的拇指時, 你會認為疼痛是在拇指裡面。 醫生對此的了解更複雜。 我們知道疼痛是一種警報, 透過神經傳到脊椎, 在哪裡被轉譯到大腦, 而疼痛實際上發生在…… 某處。 有點模糊,我們讀醫學院的整個 過程中只受過兩天的疼痛教育,
We actually only get two days of pain education throughout all of medical school, so ... In fact, the only pain lecture I remember from the '90s was in a dark room like this, after being awake for 30 hours and hungry, and finding out our noon lecture was sponsored by OxyContin. We got pens, we got great lasagna, and they had very cool slides that showed pain stopped by opioids. And we learned that home opioids aren't addictive, and if you stay ahead of pain --
所以…… 我唯一對於九○年代疼痛課的記憶 是在像這樣的暗房中, 已經三十小時沒睡覺又很飢餓, 此時發現我們中午的課 是由疼始康定所贊助。 我們拿到筆,拿到很棒的千層麵, 他們用很酷的投影片展示 鴉片類藥物如何止痛。 我們學到家中使用的 鴉片類藥物不會上癮, 且如果你能一直超前疼痛—— (笑聲)
(Laughter)
你就能讓你的病人保持無痛。
you can keep your patients pain-free.
And beyond the obviously egregious marketing, I think it was framing "pain-free" as the goal that has destroyed countless lives.
除了明顯的過份行銷之外, 我認為是把「無痛」塑造成目標 導致無數的生命被摧毀。
My friend's son Christopher started having severe abdominal pain during this "no-pain" era. Eventually, he was diagnosed with a colon disease and had surgery his senior year. They sent Christopher home with 90 OxyContin, and then 90 more, and then, as the pain started getting faster and faster ... Uncontrolled pain is terrifying. So when his ran out and his friends' medicine cabinets ran out, Christopher tried heroin. And Christopher Wolf lost his battle with substance use at age 32.
我朋友的兒子克里斯多夫 在這個「無痛」時代 開始有嚴重的腹痛。 最後他被診斷出一種結腸疾病, 在大四時接受手術。 他們讓克里斯多夫回家, 給了他九十顆疼始康定, 然後又給了九十顆, 接著,隨著疼痛變得越來越快…… 無法控制的疼痛很讓人害怕。 所以當克里斯多夫的藥用完了, 他的朋友的藥櫃也空了, 他就去嘗試海洛英。 克里斯多夫‧沃夫因物質濫用 過世,享年三十二歲。
So did we misunderstand pain? What if pain isn’t an alarm to silence but a learning system for survival? TED pose.
所以,我們誤解了疼痛嗎? 如果疼痛並不是要消除的警報, 而是生存的學習系統呢? TED 姿勢。
(Laughter)
(笑聲)
(Cheers and applause)
(歡呼及掌聲)
Pain is every organism's primary learning system for survival. I mean, it's like, "Ouch. Don't touch that." Or, to paraphrase "The Princess Bride," "Life is pain, Highness." "Pain-free" was marketing, and it made physicians think that one pill could solve pain. It still makes people feel like you can't be happy if you have some pain, and we now know that if you want to move past pain, it takes work. Setting the bar at "pain-free" was too high. Plenty of people could have been more comfortable, but they gave up because pain-free was out of reach.
疼痛是所有生物的 主要生存學習系統。 就像是:「唉喲,別碰那邊。」 或者,引述《公主新娘》: 「人生就是痛苦,叞下。」 「無痛」是行銷,讓醫生認為 一顆藥丸就能解決疼痛。 它仍然會讓大家覺得如果 你有些疼痛,就不可能快樂, 我們現在知道 如果你想要超越疼痛,就需要努力。 把標準設在「無痛」是設得太高了。 很多人本來可以「更舒服一點」, 但他們放棄了, 因為達不到「無痛」。
We have really good new information that I'm going to share, and so from now on, I want you to think about pain as a Venn diagram, with physiology, fear and control. I'm going to tell you how each of these can give you power over pain.
我等下要分享一些很棒的新資訊, 所以接下來,我希望大家 用文氏圖來看待疼痛, 三個圓分別是生理學、 恐懼,和控制。 我會說明這三者分別如何能 給你處理疼痛的力量。
Right now, I'm translating these, in my research, into a low-back pain device to reduce opioid use. But 20 years ago, I just wanted to have a fast cure for needle pain, for IV access and my kids' shots. I was driving home one night after a graveyard shift, and my hands were vibrating on the steering wheel, because we needed to get the tires balanced. I was ignoring that to think about pain, and when I got home and reached for the door in my house, my hand was numb. Vibration. So I burst in, my Boy Scout husband grabbed some frozen peas, and we had ourselves a genuine eureka moment, where cold and vibration blocked pain. Over the next decade, I found the right frequency to block pain, I got a grant, and I created Buzzy, which is vibration plus ice ... in a bee shape. And you put it on your arm when you’re getting an injection. And to date, 45 million needle procedures had decreased pain, and over 80 randomized controlled trials, independently, all around the world, have been published. But ...
現在我在做的研究,是將這些 轉化為一種下背疼痛裝置 來減少鴉片類藥物的使用。 但二十年前, 我只希望有辦法可以快速治好 針痛、靜脈通路,和我孩子的注射。 有一天晚上,我在夜班 結束後開車回家, 我的雙手在方向盤上震動, 因為我們得讓輪胎保持平衡。 我沒在意它,只是想著疼痛, 當我回到家要開家門時, 我的手都麻木了。 震動。 我衝進去,我的童子軍丈夫 拿了一些冷凍豌豆, 我們經歷了一個真正的突破時刻, 冰和震動可以阻擋疼痛。 在接下來的十年,我找到阻擋 疼痛的正確頻率,取得補助金, 我創造了 Buzzy, 它結合了震動和冰, 外形是蜜蜂。 當你要接受注射時, 把它放在手臂上, 至今,有四千五百萬次的 針刺程序都減少了疼痛, 且有超過八十個獨立進行的 隨機對照試驗在世界各地發表。 但…… (歡呼及掌聲)
(Cheers and applause)
在做了大約三十次隨機對照試驗時,
At about 30 randomized controlled trials in, one of my colleagues came to me and confided that he was in opioid recovery. And he asked whether or not Buzzy could let him get through a total knee replacement drug-free. I'd never thought about it. It's the same pain nerve for knees as for needles, so I said maybe. And he did it. Vibration plus cold replaced OxyContin.
我的一位同事來找我,向我透露 他正在戒除鴉片類藥物。 他問我 Buzzy 有沒有可能幫他 度過全膝關節置換手術, 不用藥物。 我從來沒想過這點。 膝蓋和針所連結的 疼痛神經是相同的。 所以我說,也許吧。 他就做了。 震動加上冰冷,取代疼始康定。
(Applause)
(掌聲)
So at that point, I went all in, to figure out why. And here is what we know. So the reason that vibration decreases pain is because the physiology of the nerves of light touch, pressure, stretching and motion all races pain to the spine. Now people have tried electricity to trigger the light-touch nerves, but we now know that motion, shown in green, is what's most effective at shutting the gate on sharp pain. This is called gate control, and the exact right frequency of vibration triggers the nerves that decrease pain.
那時起,我就全力投入 去搞懂為什麼。 我們所知的如下: 震動能減輕疼痛的原因 是因為輕觸、按壓、伸展, 和動作的神經生理學 都會把疼痛訊息傳遞到脊椎。 有人試過用電力來觸發輕觸神經, 但我們現在知道,綠色的動作神經 對於阻斷劇烈疼痛是最有效的。 這稱為門控。 對震動頻率可以觸發 減輕疼痛的神經。
The physiology of ice is different. So the cold goes up to the brain, where the conductor goes, "Obnoxious, but not dangerous. I will decrease sensations coming from everywhere." And it decreases pain everywhere.
冰的生理學則不同。 冰冷會向上到達大腦, 在那裡,總指揮會說: 「很討厭,但不危險。 我會減低來自各處的感覺。」 它就會減輕各處的疼痛。
If a child was so freaked out from previous experiences that even the swab hurt ... physiology wasn't as helpful. So we added distraction, like a monkey poster. And what we discovered was combining counting plus making a decision cut pain in half. So, for example, "How many monkeys are actually touching the bed?" activates the decision switchboard. I know what you guys are doing. It's five.
如果孩子被之前的經驗嚇壞了, 怕到連擦拭都會痛…… 那生理學就不那麼有用。 所以我們加上了分心元素, 比如猴子海報。 我們的發現是, 結合計數和做決策, 能讓疼痛減半。 比如,問:「有幾隻猴子 真正碰到了床?」 就能啟動決策交換板。 我知道你們在算,是五隻。
(Laughter)
(笑聲)
Here is your pain hack for the day, though. If you do not have monkeys on hand, then find any sentence and count how many of the letters have holes in them. Counting, deciding. So, like, you've got a g-hole, o-hole, a ... hole.
以下是今天的疼痛密技。 如果你手邊沒有猴子, 隨便找個句子, 算算看有幾個字母 是中間有洞的字母。 計數、決策。所以會有 g 的洞、o 的洞、 a 的洞(音近:屁眼)……。
(Laughter)
(笑聲)
(Laughter and applause)
(笑聲及掌聲)
I guarantee you and your family will use this.
我保證你和你的家人會用這招。
(Laughter)
(笑聲)
The biggest hack, though, is understanding why distraction works. And now, through functional MRI, we can actually see pain happen. And it's not one place. Pain is a symphony of connections, from the sensation area to the conductor, to the decision switchboard, and then to fear, memory, meaning, control. So if the decision switchboard is occupied sorting monkeys, it can't notify fear and meaning, and you feel less pain. What you feel is mostly what you expect to feel.
不過,最大的秘技, 是了解為什麼分心會有用。 透過功能性磁振造影, 我們可以真正看到疼痛發生。 不只發生在一處。 疼痛是連結的交響樂, 從感知區,到總指揮, 到決策交換板, 接著到恐懼、記憶、意義、控制。 所以如果決策交換板忙著分類猴子, 它就注意不到恐懼和意義, 你感受到的疼痛就減少了。 你所感覺到的 大部分是你預期會感覺到的。
Stay with me. If you're a kid, the same punch hurts more from a bully than from your buddy. And if you're an adult and you feel something, the second you think it's cancer, it hurts more and more, until you find out it's not. And those same kids who had horrible shot experiences can tolerate all kinds of needle pain ... to look cool.
別分神。 如果你是孩子, 惡霸打你一拳會比好兄弟 打你同樣的一拳更痛。 如果你是成人,你有某種感覺, 一旦你認為那是癌症, 就會越來越痛,直到 你發現並不是癌症。 而有恐怖打針經歷的那些孩子 為了看起來很酷,卻能 忍受各種針刺的疼痛。
(Laughter)
(笑聲)
Because it is a different context. These patterns, called connectomes, are very personal, because experiences lay down more of the same sensation. And we now know that people who have certain areas in the brain connected feel more pain than people with different areas connected. And more importantly, untreated pain or intense pain can lay down heavier connections, so that even when your body is healed, you will still feel more pain. It's this very plasticity and personalization which makes the physiology, fear, control matrix so useful. Because choosing physiologic options that you can layer, that work for you, decreases pain, like heat, cold, vibration, deep relaxation, acupuncture, capsaicin, exercise, meditation ... There's more. Christopher probably had 10 of these around his house and just didn't know it. Having control over your options decreases pain. Deep breathing increases control. Choosing what to focus on increases control.
因為情境不同。 這些模式叫做連結組, 是非常個人化的。 因為經驗會建立比較多同樣的感知。 我們現在知道,大腦中 某些區域有連結的人, 會感覺比較多疼痛, 連結區域不同的人, 疼痛感覺就相對少。 更重要的是,未治療的 疼痛或強烈的疼痛 可能會建立比較密切的連結, 所以即使你的身體已經癒合了, 你仍然會感到更多疼痛。 正是這種可塑性 以及個人化,讓這個生理學、 恐懼、控制模型如此有用。 因為, 選擇你能建立的、 對你有效的生理學選項 就能減輕疼痛。 比如: 熱、冷、震動、深度放鬆、 針灸、唐辛子、運動、冥想…… 還有更多。 克里斯多夫的家中 可能就有十種這類選項 只是他不知道。 控制你的選項就能減輕疼痛。 深呼吸能增加控制。 選擇把焦點放在哪裡也能增加控制。
Fear and control are the volume knobs for pain. Fear controls so many of our sensations, this shouldn't be unusual, but we don't practice it for pain. So if you're home alone and you hear a clunk ... your hearing becomes hypersensitive. But when you remember your kid's home from college, your fear dials down and your brain overrides it and says, "Don't worry about it." Saint Augustine called pain the greatest of evil. But if it is a survival system, it cannot be all evil. So instead, think of pain as your nagging, safety-obsessed, exaggerating friend who’s sometimes wrong. And it’s OK to ignore or override your friend if you know that you're safe.
恐懼和控制是疼痛的音量旋鈕。 恐懼控制很多種知覺, 這並非不尋常, 但我們沒有針對疼痛做練習。 如果你獨自在家,聽到哐啷一聲…… 你的聽覺就會變得超敏感。 但當你想起你的孩子從大學回家了, 你的恐懼就減低了,你的大腦 會推翻它,說:「別擔心。」 聖奧古斯丁把疼痛稱為最大的邪惡。 但如果它是種生存系統, 就不可能全是邪惡的。 所以, 把疼痛改想成是一位 嘮叨、過份強調安全、 誇大的朋友,且他有時會犯錯。 且如果你知道 你是安全的,要忽略 或推翻你的朋友都沒關係。
This takes practice. On a flight that was turbulent, I had an entire cup of scalding-hot coffee dumped straight on my ankle. Electric jolt through my scalp. I ripped off my sock; it was already red. It was going to blister. There was no way I could get my foot into that little sink to get cold water on it. And then I remembered. Physiology hack. I had an unopened cold beer.
這需要練習。 有回我搭飛機遇到亂流,我把一整杯 熱騰騰的咖啡直接灑在我的腳踝上。 電流穿過我的頭皮。 我扯掉我的襪子,腳踝已經紅了。 接著會起水泡。 我不可能把我的腳放到 小水槽裡去泡冷水。 接著我想起來了。 生理學秘技。 我有一罐還沒開的冰啤酒。
(Laughter) Medical-grade cold beer went on my ankle, stat.
(笑聲) 馬上把醫療級的冰啤酒 敷在我的腳踝上。
(Laughter and applause) I had a vibrator in my carry-on, because I would. On my ankle. And then --
(笑聲和掌聲) 我的隨身行李有個震動 按摩器,因為我會帶。 放在腳踝上,接著——
(Laughter and applause) The pain kind.
(笑聲及掌聲) 是疼痛用的震動按摩器。
(Laughter)
(笑聲)
And then my fear hack. I'm like, "There's a barf bag that has holy letters, but I'm going to put it in the pocket pouch and save it, because then, I have increased control." And, pain , I was no longer that concerned.
接著用我的恐懼秘技。 我說:「有個嘔吐袋, 上面有神聖的文字, 但我要把它收到口袋裡,保留下來, 因為這樣我就能提升控制。」 而疼痛,我已經不那麼在乎了。
(Cheers and applause)
(歡呼及掌聲)
Although then, I realized I'm that guy, with my bare foot sticking out in the aisle on a plane, with a beer on it.
不過,接著,我發現我就是那個 在飛機上打赤腳還把腳伸到 走道的傢伙, 腳上還有啤酒。
(Laughter)
(笑聲)
Power over pain isn’t always pretty, but it is possible and it is absolutely critical. Because there’s one more misconception we have not talked about. I honestly thought that opioids turned off some pain switch. They turn on our reward system. So some people feel amazing, but most people just still feel pain, but don't care. Now, this is a godsend for people with chronic pain diseases. We should not take them away. And in the trauma bay, the more morphine in the first 24 hours after a burn or a wound, the less post-traumatic stress, the less chronic pain later. But studies show that recovery after surgery is just as well accomplished with coaching and physiologic options. And if you're one of the people who feel amazing with opioids, it's too risky. A study in 2019 found that one in 15 young adults who got opioids for their wisdom tooth removal had substance-use disorder within a year. Ibuprofen works better.
掌控疼痛的力量不見得都會很好看, 但,是有可能做到的, 且絕對是非常重要的。 因為,還有一種誤解我們還沒談到。 我真心認為鴉片類藥物 會關閉一些疼痛開關。 它們會啟動我們的獎勵系統。 所以有些人覺得棒極了, 但大部分人仍然會感受到 疼痛,只是不在乎。 這對有慢性疼痛疾病的人 而言是天賜之物。 我們不該奪走這些。 且在創傷區, 在受到創傷或燒傷之後的 二十四小時之內用越多嗎啡 創傷後壓力就會越少, 後續的慢性疼痛也越少。 但研究顯示,手術後的恢復 同樣可以透過輔導 和生理學的選項來達成。 如果你屬於用了鴉片類藥物 會覺得棒極了的人, 風險太高了。 2019 年有一項研究發現 因為拔智齒而使用鴉片類藥物的 年輕人,十五位中就有一位 在一年內會有物質濫用障礙的問題。 布洛芬的效果比較好。
So what do we do? Well, in my dream world, we have health-care systems -- paid-for options and coaching -- for Christophers everywhere. And we quit giving double-digit prescriptions for opioids for home recovery. In the real world, 80,000 people died in the US last year from opioid overdoses, and 80 percent of substance-use disorders start with a pill prescribed for pain ... Usually taken from your friend's medicine cabinet. People can’t afford options. Doctors, 20 years later, still don't know them. But you do. You all now know to throw away the opioids in your medicine cabinet. You now know that there are options you can use to decrease pain, and you know that "pain-free" should be ditched for "more comfortable." And whether you dump scalding coffee or pain wakes you and exhausts you every day ... Options that are in your control ... can allow you to reframe pain.
所以,我們該怎麼做? 在我夢想的世界裡, 我們有健康照護系統—— 付費選項和輔導—— 供各地的克里斯多夫使用。 我們不再開大量鴉片類藥物的 處方給在家恢復的病人。 在真實世界裡,去年美國就有 八萬人死於鴉片類藥物過量, 且八成的物質濫用障礙 都始於疼痛處方藥…… 通常是直接從朋友的 藥櫃裡面拿取的。 大家負擔不起其他選項。 二十年後,醫生仍然 不知道這些選項。 但各位知道。 各位現在都知道要把 藥櫃裡的鴉片類毒品丟掉。 各位現在都知道可以用 其他選項來減輕疼痛, 且各位知道,應該把「無痛」扔掉, 換成「更舒適」。 不論你是打灑了熱咖啡, 或者每天你會痛醒 且因為疼痛而精疲力竭…… 你能夠控制的選項…… 可以讓你重新詮釋疼痛。
Thank you.
謝謝。
(Cheers and applause)
(歡呼及掌聲)
Whitney Pennington Rodgers: Amy, thank you, it's amazing. So how do you think that pain scales have set us back from this work that you're doing, and how is the NIH treating pain and addiction differently now?
主持人:艾咪, 謝謝你,很棒的演說。 依你所見,疼痛分數如何 阻礙你現在在進行的工作? 國家衛生研究院現在對疼痛 和成癮的治療又有什麼不同?
Amy Baxter: So in one of the 120 versions of this talk, I talked about how the thing is, in the '90s, if we wanted to “disease-ify” pain, it meant we had to be able to measure it. So that was where the FACES scales come from, and they're actually very useful in the emergency department to tell whether or not a medicine is working. In fact, we were one of the first ones that showed, with sickle cell, that the patient's report, based on those scales, was what was most indicative of whether they needed to be admitted, rather than any biologic marker. But what we're doing now is we're using something called the PROMIS scales, so it’s how intense pain is on five-point scales, how much it interferes, so there's pain interference, pain intensity. And the way we're looking at pain is much more on the impact for the person, rather than trying to pretend there's any kind of objective pain measurement.
講者:在這場演說的 一百二十個版本之一, 我談到在九○年代的狀況, 我們想把疼痛視為是一種疾病, 那就表示得想辦法測量它。 那就是臉譜量表的由來, 在急診部其實非常有用, 可以知道藥物是否有效果。 事實上,我們很早就用 鐮狀細胞來說明病人回答 那些量表的結果最能顯示 他們是否需要住院, 比任何生物標記都還適合當指標。 但我們現在則是在用應用個案 自陳資訊系統(PROMIS)量表, 量表把疼痛強度分為五級, 還有對生活的干擾程度, 所以有疼痛干擾程度和強度。 我們看待疼痛的角度會更 著重在它對當事人的影響, 而不是試著假裝有某種 客觀的疼痛測量存在。 主持人:好。你也提到你現在 在投入 Buzzy 的新應用,
WPR: OK. And you mentioned that you're working on some new applications for Buzzy, specifically for back pain. What are some of the possibilities that we have here for what this could do for us in the future?
明確來說是背痛的應用。 有什麼樣的可能性? 未來對我們可能有什麼幫助? 我的墓碑上會有一隻震動蜜蜂。
AB: On my tombstone, there's going to be a vibrating bee. It's actually called DuoTherm, not Buzzy. But what we've learned is that there are harmonics of interaction between the specific frequencies that cancel out the pain. So there’s one particular nerve called the Pacinian that has a very specific frequency range, and by causing them to interact, we're starting to explore more about the pain that's coming from the fascia between the skin and between the muscles, but that area is where we're unexplored, and so by interacting with different frequencies and then layering heat or cold, pressure options, giving people the choice of so many different ways to do it, it's really engaging all the different areas of the brain from which pain comes.
它叫 DuoTherm,不是 Buzzy。 但我們發現,有些特定頻率之間 交互作用的諧波可以抵消疼痛。 有種神經叫巴齊尼氏, 有非常明確的頻率範圍, 透過促使它們進行交互作用, 我們開始進一步探究疼痛, 來自筋膜和皮膚間 以及肌肉間的疼痛, 這個區域尚未被探索, 用不同的頻率進行交互作用, 接著再加疊上熱或冷、壓力選項, 讓大家有各種不同的做法選擇, 會用到大腦不同的區域, 都是和疼痛有關的區域。 主持人:非常謝謝你,艾咪。
WPR: Wow, OK. Well, thank you so much, Amy.
講者:不客氣。
AB: Welcome.
謝謝大家。
Thank you, all.