"How much pain medication are you taking?" That was the very routine question that changed my life. It was July 2015, about two months after I nearly lost my foot in a serious motorcycle accident. So I was back in my orthopedic surgeon's office for yet another follow-up appointment.
„Koliko tableta protiv bolova uzimate?“ Ovo rutinsko pitanje mi je promenilo život. To je bilo jula 2015, oko dva meseca nakon što sam skoro izgubio stopalo u teškoj motociklističkoj nesreći. Bio sam u ordinaciji ortopedskog hirurga na još jednom kontrolnom pregledu.
I looked at my wife, Sadiye; we did some calculating. "About 115 milligrams oxycodone," I responded. "Maybe more." I was nonchalant, having given this information to many doctors many times before, but this time was different.
Pogledao sam suprugu, Sadiju pa smo počeli da računamo. „Oko 115 miligrama oksikodona,“ rekao sam. „Možda više.“ Nisam se uznemirio, s obzirom da sam na to pitanje odgovorio doktorima već puno puta do tada, ipak sada je bilo drugačije.
My doctor turned serious and he looked at me and said, "Travis, that's a lot of opioids. You need to think about getting off the meds now."
Moj doktor se uozbiljio, pogledao me i rekao: „Travise, to je mnogo opijata. Trebao bi da razmisliš o skidanju sa lekova.“
In two months of escalating prescriptions, this was the first time that anyone had expressed concern. Indeed, this was the first real conversation I'd had about my opioid therapy, period. I had been given no warnings, no counseling, no plan ... just lots and lots of prescriptions.
Za dva meseca povećanja doza, to je bio prvi put da je iko izrazio zabrinutost. U stvari, to je bio prvi pravi razgovor koji sam vodio po pitanju moje terapije opijatima. Nisam dobio nikakva upozorenja, savetovanja, plan... samo mnogo, mnogo recepata.
What happened next really came to define my entire experience of medical trauma. I was given what I now know is a much too aggressive tapering regimen, according to which I divided my medication into four doses, dropping one each week over the course of the month. The result is that I was launched into acute opioid withdrawal. The result, put another way, was hell. The early stages of withdrawal feel a lot like a bad case of the flu. I became nauseated, lost my appetite, I ached everywhere, had increased pain in my rather mangled foot; I developed trouble sleeping due to a general feeling of restlessness. At the time, I thought this was all pretty miserable. That's because I didn't know what was coming.
Ono što se sledeće dogodilo je zaista obeležilo moje celo iskustvo ove povrede. Dobio sam, ono što sada znam da se zove, previše agresivan režim smanjenja doze, prema kojem sam podelio moje lekove na četiri doze, izbacujući po jednu svake nedelje tokom mesec dana. Posledica toga bila je pojava apstinencijalnog sindroma. Ili drugim rečima, pakao. Rane faze krize su po mnogo čemu ličile na teži oblik gripa. Bilo mi je muka, izgubio sam apetit, sve me je bolelo, bol je bio pojačan u mom povređenom stopalu; razvio sam poremećaj spavanja usled opšteg osećaja nemira. Tada sam mislio da je to prilično grozno. To je zato što nisam znao šta sledi.
At the beginning of week two, my life got much worse. As the symptoms dialed up in intensity, my internal thermostat seemed to go haywire. I would sweat profusely almost constantly, and yet if I managed to get myself out into the hot August sun, I might look down and find myself covered in goosebumps. The restlessness that had made sleep difficult during that first week now turned into what I came to think of as the withdrawal feeling. It was a deep sense of jitters that would keep me twitching. It made sleep nearly impossible. But perhaps the most disturbing was the crying. I would find myself with tears coming on for seemingly no reason and with no warning. At the time they felt like a neural misfire, similar to the goosebumps. Sadiye became concerned, and she called the prescribing doctor who very helpfully advised lots of fluids for the nausea.
Početkom druge nedelje, moj život se pogoršao. Simptomi su se pojačali, moj unutrašnji termostat bio je u totalnom neredu. Skoro stalno sam se preterano znojio, a opet, ukoliko bih izašao na vrelo avgustovsko sunce, pogledao bih i video da sam se ceo naježio. Nemirnost zbog koje nisam mogao da spavam prve nedelje sada se pretvorila u ono što je ličilo na apstinencijalnu krizu. Užasna nervoza koja je izazivala trzaje, učinila je spavanje nemogućim. Međutim, ono što je najviše uznemiravalo verovatno je bilo plakanje. Osetio bih kako mi suze naviru naizgled bez ikakvog razloga ili upozorenja. Tada se to činilo kao neurološka disfunkcija, nešto slično trncima. Sadija je postala zabrinuta, te je pozvala ordinirajućeg lekara koji je veoma uslužno savetovao dosta tečnosti za mučninu.
When she pushed him and said, "You know, he's really quite badly off," the doctor responded, "Well, if it's that bad, he can just go back to his previous dose for a little while."
Kada ga je pritisnula i rekla: „Znate, njemu je zaista izuzetno loše,“ doktor je odgovorio: „Ukoliko je baš tako loše neka još neko vreme bude na prethodnoj dozi.“
"And then what?" I wondered.
„I šta onda?“, pitao sam se.
"Try again later," he responded.
„Pokušajte ponovo kasnije“, odgovorio je.
Now, there's no way that I was going to go back on my previous dose unless I had a better plan for making it through the withdrawal next time. And so we stuck to riding it out and dropped another dose.
Nije bilo šanse da se vratim na prethodnu dozu jer i dalje nisam znao šta da radim po pitanju krize. Odlučili smo da nastavimo i ukinuli još jednu dozu.
At the beginning of week three, my world got very dark. I basically stopped eating, and I barely slept at all thanks to the jitters that would keep me writhing all night. But the worst -- the worst was the depression. The tears that had felt like a misfire before now felt meaningful. Several times a day I would get that welling in my chest where you know the tears are coming, but I couldn't stop them and with them came desperation and hopelessness. I began to believe that I would never recover either from the accident or from the withdrawal.
Početkom treće nedelje, moj svet postao je veoma mračan. Prestao sam da jedem i jedva da sam spavao zahvaljujući nervozi koja bi me drmala celu noć. Ali najgora - najgora je bila depresija. Suze koje su se ranije činile kao greška u sistemu sada su imale smisla. Tokom dana bih osećao stezanje u grudima, nakon kojeg znate da slede suze, koje ne bih mogao da zaustavim, a sa kojima su se pojavile depresija i očajanje. Počinjao sam da verujem da se nikada neću oporaviti ni od nesreće, ni od skidanja sa lekova.
Sadiye got back on the phone with the prescriber and this time he recommended that we contact our pain management team from the last hospitalization. That sounded like a great idea, so we did that immediately, and we were shocked when nobody would speak with us. The receptionist who answered the phone advised us that the pain management team provides an inpatient service; although they prescribe opioids to get pain under control, they do not oversee tapering and withdrawal. Furious, we called the prescriber back and begged him for anything -- anything that could help me -- but instead he apologized, saying that he was out of his depth. "Look," he told us, "my initial advice to you is clearly bad, so my official recommendation is that Travis go back on the medication until he can find someone more competent to wean him off."
Sadija je ponovo pozvala lekara koji je sada predložio da pozovemo lekare koji su prepisali lekove tokom poslednjeg boravka u bolnici. To je zvučalo kao dobra ideja, stoga smo to istog trena i uradili, nakon čega smo bili šokirani kada niko nije hteo da priča sa nama. Osoba koja se javila nam je rekla da tim lekara koji je zadužen za kontrolisanje bola obezbeđuje terapiju, ali da, iako prepisuju opijate kako bi smanjili bol, ne nadgledaju smanjenje terapije ili skidanje sa iste. Besni, ponovo smo pozvali doktora i molili ga da uradi bilo šta - bilo šta što bi mi moglo pomoći - ali se umesto toga izvinio govoreći kako ne može ništa da uradi. „Vidite”, kazao nam je, „moj prvobitan savet je očigledno bio pogrešan, stoga je moja preporuka da se Travis vrati na početnu dozu dok ne nađe nekoga stručnijeg da ga skine sa njih.”
Of course I wanted to go back on the medication. I was in agony. But I believed that if I saved myself from the withdrawal with the drugs that I would never be free of them, and so we buckled ourselves in, and I dropped the last dose.
Naravno da sam hteo da ponovo uzimam lekove. Bio sam u agoniji. Međutim, verovao sam da ukoliko ponovo počnem da uzimam lekove da ih se nikada neću rešiti, stoga smo se spremili, te sam ukinuo i poslednju dozu.
As my brain experienced life without prescription opioids for the first time in months, I thought I would die. I assumed I would die --
Moj mozak je iskusio život bez prepisanih opijata prvi put u poslednjih nekoliko meseci. Mislio sam da ću da umrem. Verovao sam da ću umreti -
(Crying)
(Plač)
I'm sorry.
Izvinjavam se.
(Crying)
(Plač)
Because if the symptoms didn't kill me outright, I'd kill myself. And I know that sounds dramatic, because to me, standing up here years later, whole and healthy -- to me, it sounds dramatic. But I believed it to my core because I no longer had any hope that I would be normal again.
Jer ukoliko me tog trenutka ne bi ubili simptomi, ubio bih se sam. Znam da to zvuči dramatično, jer i meni, koji stojim ovde godinama kasnije, živ i zdrav - čak i meni to zvuči dramatično. Međutim, duboko u sebi sam verovao u to, zato što sam izgubio nadu da ću ikada ponovo biti normalan.
The insomnia became unbearable and after two days with virtually no sleep, I spent a whole night on the floor of our basement bathroom. I alternated between cooling my feverish head against the ceramic tiles and trying violently to throw up despite not having eaten anything in days. When Sadiye found me at the end of the night she was horrified, and we got back on the phone. We called everyone. We called surgeons and pain docs and general practitioners -- anyone we could find on the internet, and not a single one of them would help me. The few that we could speak with on the phone advised us to go back on the medication. An independent pain management clinic said that they prescribe opioids but they don't oversee tapering or withdrawal. When my desperation was clearly coming through my voice, much as it is now, the receptionist took a deep breath and said, "Mr. Rieder, it sounds like perhaps what you need is a rehab facility or a methadone clinic." I didn't know any better at the time, so I took her advice. I hung up and I started calling those places, but it took me virtually no time at all to discover that many of these facilities are geared towards those battling long-term substance use disorder. In the case of opioids, this often involves precisely not weaning the patient off the medication, but transitioning them onto the safer, longer-acting opioids: methadone or buprenorphine for maintenance treatment. In addition, everywhere I called had an extensive waiting list. I was simply not the kind of patient they were designed to see.
Nesanica je postala nepodnošljiva i nakon dva dana bez praktično imalo sna, proveo sam celu noć u podrumu na podu našeg kupatila. Čas sam hladio grozničavu glavu o keramičke pločice, čas sam silno pokušavao da povratim iako danima nisam ništa jeo. Kada me je Sadija pronašla kasno u noć, bila je užasnuta i ponovo smo bili na vezi. Zvali smo sve. Zvali smo hirurge, specijaliste i lekare opšte prakse - koga god smo mogli da nađemo na internetu, i nijedan od njih mi nije mogao pomoći. Onih par sa kojima smo uspeli da razgovaramo su savetovali da se vratim redovnoj terapiji. Nezavisna klinika za smanjenje bolova rekla je da oni propisuju lekove ali da ne nadgledaju smanjivanje doza ili skidanje sa istih. Kada se u mom glasu moglo jasno čuti koliko sam depresivan, kao što se može čuti i sada, osoba sa druge strane je duboko udahnula i rekla: „Gospodine Rider, zvuči kao da vam treba rehabilitacioni ili metadonski centar.” Nisam imao bolje rešenje, stoga sam prihvatio njen savet. Prekinuo sam i počeo da zovem te centre, ali mi nije trebalo mnogo da shvatim da su mnoge od tih ustanova opremljene za borbu protiv dugotrajnih zloupotreba supstanci. U slučaju opijata, to najčešće ne uključuje skidanje pacijenata sa lekova, nego ih prebacuju na bezbednije, dugotrajnije opijate: metadon ili buprenorfin kao terapiju prevencije kriza. Plus, gde god sam zvao, postojala je poduža lista čekanja. Prosto nisam bio tip pacijenta za kakvog su bili obučeni.
After being turned away from a rehab facility, I finally admitted defeat. I was broken and beaten, and I couldn't do it anymore. So I told Sadiye that I was going back on the medication. I would start with the lowest dose possible, and I would take only as much as I absolutely needed to escape the most crippling effects of the withdrawal. So that night she helped me up the stairs and for the first time in weeks I actually went to bed. I took the little orange prescription bottle, I set it on my nightstand ... and then I didn't touch it. I fell asleep, I slept through the night and when I woke up, the most severe symptoms had abated dramatically. I'd made it out.
Nakon što sam ostao bez rehabilitacione ustanove, konačno sam priznao poraz. Bio sam slomljen i isceđen i više nisam mogao da podnesem. Stoga sam rekao Sadiji da ću ponovo početi sa terapijom. Počeo bih sa najmanjom mogućom dozom i uzimao bih tek toliko koliko mi je trebalo da izbegnem najgore simptome apstinencije. Te noći mi je pomogla da se popnem na sprat te sam prvi put nakon dugo vremena spavao u krevetu. Uzeo sam malu narandžastu bočicu sa lekovima, stavio je na noćni ormarić... i više je nisam dotakao. Zaspao sam, prespavao celu noć, a kada sam se probudio, najgori simptomi su se drastično smanjili. Preživeo sam.
(Applause)
(Aplauz)
Thanks for that, that was my response, too.
Hvala, to je bila i moja reakcija.
(Laughter)
(Smeh)
So -- I'm sorry, I have to gather myself just a little bit.
Stoga - Izvinjavam se, treba mi malo da se priberem.
I think this story is important. It's not because I think I'm special. This story is important precisely because I'm not special; because nothing that happened to me was all that unique. My dependence on opioids was entirely predictable given the amount that I was prescribed and the duration for which I was prescribed it. Dependence is simply the brain's natural response to an opioid-rich environment and so there was every reason to think that from the beginning, I would need a supervised, well-formed tapering plan, but our health care system seemingly hasn't decided who's responsible for patients like me. The prescribers saw me as a complex patient needing specialized care, probably from pain medicine. The pain docs saw their job as getting pain under control and when I couldn't get off the medication, they saw me as the purview of addiction medicine. But addiction medicine is overstressed and focused on those suffering from long-term substance use disorder. In short, I was prescribed a drug that needed long-term management and then I wasn't given that management, and it wasn't even clear whose job such management was.
Smatram da je ova priča bitna. Ne zato što mislim da sam poseban. Ova priča je bitna upravo zato što nisam poseban; zato što se meni nije dogodilo ništa jedinstveno. Moja zavisnost od opijata je bila potpuno predvidiva s obzirom na količinu koja je prepisana i na vreme trajanja koje sam uzimao. Zavisnost je prirodan odgovor mozga na opijatsko okruženje stoga je potpuno razumljivo da pomišljate na to od samog početka. Bio mi je potreban dobro osmišljen plan skidanja sa lekova pod nadzorom lekara. Međutim, naš zdravstveni sistem još uvek nije odlučio ko je odgovoran za pacijente poput mene. Jedni su me videli kao komplikovanog pacijenta kojem je trebala posebna nega, u vidu lekova protiv bolova. Drugi su smatrali da je njihov posao da smanje bol, a kada nisam mogao da se skinem sa lekova, videli su me kao problem lečenja zavisnosti. Međutim lečenje zavisnosti je previše usmereno i fokusirano na one koji pate od dugotrajne zavisnosti. Ukratko, propisan mi je lek koji je zahtevao dugoročno nadgledanje, a onda mi taj nadzor nije pružen, niti je bilo jasno čiji je to posao bio.
This is a recipe for disaster and any such disaster would be interesting and worth talking about -- probably worth a TED Talk -- but the failure of opioid tapering is a particular concern at this moment in America because we are in the midst of an epidemic in which 33,000 people died from overdose in 2015. Nearly half of those deaths involved prescription opioids. The medical community has in fact started to react to this crisis, but much of their response has involved trying to prescribe fewer pills -- and absolutely, that's going to be important. So for instance, we're now gaining evidence that American physicians often prescribe medication even when it's not necessary in the case of opioids. And even when opioids are called for, they often prescribe much more than is needed. These sorts of considerations help to explain why America, despite accounting for only five percent of the global population, consumes nearly 70 percent of the total global opioid supply. But focusing only on the rate of prescribing risks overlooking two crucially important points. The first is that opioids just are and will continue to be important pain therapies. As somebody who has had severe, real, long-lasting pain, I can assure you these medications can make life worth living. And second: we can still fight the epidemic while judiciously prescribing opioids to people who really need them by requiring that doctors properly manage the pills that they do prescribe. So for instance, go back to the tapering regimen that I was given. Is it reasonable to expect that any physician who prescribes opioids knows that that is too aggressive? Well, after I initially published my story in an academic journal, someone from the CDC sent me their pocket guide for tapering opioids. This is a four-page document, and most of it's pictures. In it, they teach physicians how to taper opioids in the easier cases, and one of the their recommendations is that you never start at more than a 10 percent dose reduction per week. If my physician had given me that plan, my taper would have taken several months instead of a few weeks. I'm sure it wouldn't have been easy. It probably would have been pretty uncomfortable, but maybe it wouldn't have been hell. And that seems like the kind of information that someone who prescribes this medication ought to have.
Ovo je recept za katastrofu, a svaka ovakva katastrofa je interesantna i vredna pričanja - verovatno vredna TED govora - ali neuspešno skidanje sa opijata je značajan problem trenutno u Americi, jer se nalazimo u središtu epidemije u kojoj je 2015. godine 33 000 ljudi umrlo usled predoziranja. Skoro polovina ovih smrti je uključivala propisane opijate. Tačnije, zdravstvena zajednica je počela da reaguje na ove uzbune, ali njihov odgovor uglavnom podrazumeva propisivanje manje količine lekova - što će naravno biti od značaja. Na primer, imamo dokaze koji ukazuju da američki lekari često propisuju lekove čak i kada to nije neophodno, barem što se tiče opijata. A ukoliko zaista jesu potrebni, često se propisuju mnogo više nego što treba. Ova razmatranja pomažu da se objasni zašto Amerika, uprkos tome što obuhvata samo pet posto svetske populacije, koristi skoro 70 procenata ukupne potrošnje opijata. Međutim, ako se fokusiramo samo na stopu propisanih lekova rizikujemo da predvidimo dve ključne stvari. Prva je da opijati jesu i da će nastaviti da budu značajan deo terapije protiv bolova. Kao neko ko je patio od jakog i dugotrajnog bola, mogu da vam garantujem da ovi lekovi čine život podnošljivim. A kao drugo: možemo da se borimo protiv epidemije dok razumno propisujemo opijate ljudima koji ih stvarno trebaju, tako što ćemo zahtevati od doktora pažljivo rukovođenje propisanim lekovima. Na primer, hajde da se vratimo na režim smanjivanja koji mi je preporučen. Da li je razumno očekivati da ijedan lekar koji propisuje opijate zna da su oni previše agresivni? Nakon što sam objavio svoju priču u naučnom časopisu, neko iz centra za kontrolu bolesti mi je poslao vodič za skidanje sa opijata. U pitanju je dokument od 4 strane, od kojih većinu predstavljaju slike. U njima uče lekare kako da smanje dozu opijata u lakšim slučajevima i jedna od njihovih preporuka je da nikada ne smanjujete više od 10 procenata od ukupne doze nedeljno. Da mi je moj doktor dao taj raspored, moje skidanje bi trajalo mesecima, umesto nekoliko nedelja. Siguran sam ne bi bilo lako. Verovatno bi bilo prilično neugodno, ali možda ne bi bio pakao. To se čini kao informacija koju bi neko ko propisuje ove lekove trebalo da ima.
In closing, I need to say that properly managing prescribed opioids will not by itself solve the crisis. America's epidemic is far bigger than that, but when a medication is responsible for tens of thousands of deaths a year, reckless management of that medication is indefensible. Helping opioid therapy patients to get off the medication that they were prescribed may not be a complete solution to our epidemic, but it would clearly constitute progress.
Na kraju, moram da kažem da pravilno kontrolisanje propisanih opijata neće samo po sebi rešiti problem. Epidemija u Americi je mnogo veća od toga, ali kada lekovi postanu odgovorni za desetine hiljada smrti godišnje, nema opravdanja za neodgovorno korišćenje tih lekova. Pomaganje ovakvim pacijentima da se skinu sa lekova koji su im propisani možda nije celokupno rešenje naše epidemije, ali bi definitivno pomoglo napretku.
Thank you.
Hvala.
(Applause)
(Aplauz)