"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.
“你使用了多少止痛药?” 那曾是一个改变过我生活的 例行公事般的问题。 2015年7月, 在经历了一场严重的 摩托车事故的两个月以后, 那次事故差点让我失去了双脚。 我回到骨科医生的办公室 等待复查。
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.
我看着我的妻子,塞耶; 我们计算了一下。 “大约115毫克氧可酮,” 我回答。 “也许还不止。” 我有些漫不经心,我已经对很多医生 重复过这个说法了, 但是这一次情况不太一样。
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."
我的医生表情严肃地 看着我说: “特拉维斯,这剂量可不轻啊。 现在你需要考虑戒掉这种药物了。”
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.
两个月内我的处方药剂量不断增大, 但这是第一次有人开始表示担心。 的确,也是在那个时期, 我开始了第一次关于 自己阿片治疗的谈话。 我没有收到过警告, 没有接受过咨询, 也没有任何戒断计划..... 有的只是越来越多的处方药。
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.
接下来发生的事,就是我的 整个创伤治疗经历的真实写照。 我现在才明白,自己当时所采用的 是一个过于激进的缩减方案, 根据这个方案,我把药物分成了四个剂量, 在一个月内,每周降低一个剂量。 结果我出现了急性阿片戒断的症状。 换句话说,这个过程让我 痛不欲生。 戒断的早期阶段感觉像得了急性流感。 我感到恶心, 食欲不振, 浑身疼痛, 受伤的脚的状况更是雪上加霜; 这种坐立不安的感觉让我难以入睡。 当时, 我就觉得这简直太痛苦了。 这是因为我还不知道接下来会发生什么。
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.
第二周刚开始, 我的生活变得愈发痛苦不堪。 当症状向更深的程度蔓延, 我身体内的恒温计似乎开始变得混乱。 大量流汗成为了家常便饭, 然而,如果我好不容易 在8月的烈日下出了门, 却在低头时发现自己浑身是鸡皮疙瘩。 现在我意识到,让我在第一周 彻夜难眠的那种坐立不安, 正是戒断的症状。 这是一种深入骨髓的 坐立不安,让我不停颤抖。 入睡几乎是不可能的。 但最令我一筹莫展的是哭泣。 我发现自己会无端地, 没有任何预示地 开始流泪。 就像神经错乱了一样, 类似起了鸡皮疙瘩的感觉。 塞耶也忧心忡忡,她替我 给开处方的医生打了电话, 这位医生贴心地针对我的 恶心症状建议了许多种流质食物。
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."
她在催促他的时候说: “他现在的状况十分糟糕。” 医生答道,“如果真是这样的话, 他可以暂时按原剂量服药。”
"And then what?" I wondered.
“然后呢?”我问。
"Try again later," he responded.
“过段时间再试一下,”他答道。
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.
但那时,我根本不可能倒退至原剂量了, 除非下一次戒药之前 我能做个更好的计划。 之后我坚持原计划,又降了一个剂量。
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.
在第三周开始的时候, 我的世界陷入了黑暗。 我基本上已经无法进食, 也几乎不能睡觉, 坐立不安使我整夜都在不停颤抖。 但最糟糕的是—— 最糟的是那种压抑的感觉。 原本感觉像是无端涌出的泪水, 现在有了意义。 一天几次,我感到胸腔的喷涌感, 意识到马上就会开始流泪, 但我无法抑制, 随之而来的还有绝望和无助。 我开始认为我永远不会康复了, 无论是从那场意外事故,还是戒药过程。
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."
于是塞耶再次联系了开药方的医生, 这次他建议我们联系上次住院的 那家医院的疼痛管理团队。 这听起来是个好主意, 因此我们立即行动, 接着我们傻眼了,没有人与我们沟通。 电话那边的接待员告诉我们, 疼痛管理团队提供的 服务是针对住院病人的; 尽管他们开了控制疼痛的阿片药方, 却并不负责药方减量和戒药症状。 盛怒之下,我们又联系了 那个开药方的医生—— 向他寻求任何能帮助我的方法—— 然而,他只是深表歉意, 表示他已尽了全力。 “听着,”他对我们说, “我一开始对你的建议很明显是错的, 所以我的官方建议是 让特拉维斯恢复原先的剂量, 直到找到医术更加精湛的人帮助他戒药。”
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.
当然,我愿意恢复当初的剂量。 我早已痛苦不堪。 但我认为,如果就这样放弃了戒药, 我将永远受制于它们。 因此我们决定破釜沉舟, 放弃了最后的剂量。
As my brain experienced life without prescription opioids for the first time in months, I thought I would die. I assumed I would die --
当我的大脑在几个月来第一次经历着 没有阿片处方的日子时, 我认为我会死去。 我觉得自己必死无疑——
(Crying)
(抽噎)
I'm sorry.
抱歉。
(Crying)
(抽噎)
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.
因为即使疾病不会完全致我于死地, 我也会自我了断。 我知道这听起来很夸张, 因为对几年后站在这里的健全且健康的 我来说—— 这听起来的确很夸张。 但当时,我发自内心地相信, 正因为我不再抱有任何希望, 所以我会恢复正常。
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.
失眠变得让人无法忍受, 在连续两天彻夜未眠后, 我在地下室的卫生间待了一晚。 我时不时地将发热的头颅 靠着瓷砖降温, 并且强制自己呕吐, 尽管我已经连续几天滴米未进。 当塞耶在黎明之初发现我时, 她惊恐万分, 于是我们回到了电话旁。 我们打给了所有人。 我们给外科医生,疼痛医生 和全科医师都打了电话—— 所有我们能在网上找到的人, 然而没有一个人愿意帮我。 少数我们通上电话的, 都建议我恢复原剂量。 一个独立的疼痛管理诊所 说他们可以开阿片药方, 但他们不负责减少剂量或戒药。 当我的声音完全透着绝望时, 差不多像现在这样, 接待员深吸了一口气,说道: “里德先生,听起来你需要的是康复机构, 或者一个美沙酮诊所。” 鉴于当时我没有更好的主意, 于是遵循了她的建议。 我挂了电话,打给了她所说的地方, 但我很快就发现, 事实上,许多这样的机构 都是为了长期戒毒的需要而设立。 而在阿片的事例中, 这牵涉的不是让患者戒药, 而是帮助他们过渡至 更安全,更长效的阿片: 美沙酮或者丁丙诺啡来维持治疗。 除此之外,我打过电话的每一个 地方都有着一大串的等候名单。 显然我也不是它们所期待的患者。
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.
当被一个康复机构回绝时, 我最终认输了, 我被击溃了, 无法再继续坚持下去了。 因于是我告诉塞耶,我想恢复原剂量。 尽可能从最低剂量开始, 并且只有在必须的时候才服用, 以此来避开戒药中最恐怖的影响。 那晚,她扶我上了台阶, 几周以来,我第一次真正上床了。 我拿起橘色的小药瓶, 放在了床头柜上... 接着我就没再碰它。 我睡着了, 我睡了一整夜, 当我醒来时, 最严重的症状已奇迹般地减轻了不少。 我做到了。
(Applause)
(掌声)
Thanks for that, that was my response, too.
非常感谢,我当时亦有同感。
(Laughter)
(笑声)
So -- I'm sorry, I have to gather myself just a little bit.
因此—— 抱歉,我不得不稍理一下思路。
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.
我认为这是个重要的故事。 并不是因为我认为我很特殊, 而恰恰是因为我并不特别; 因为那些事不仅只发生在我身上。 我对阿片的依赖是完全可预见的, 医生给多少,我服多少, 并且还有规定的时长。 依赖只是大脑对富含阿片环境的自然反应, 就是这样,每个人都认为从一开始, 我就需要一个受监督的,合理的的减药计划, 但我们的健康护理系统似乎并未准备好面对 谁该对我这样的病人负责的问题。 那个开药的医生认为我是一个复杂的患者, 需要特殊照顾, 甚至是止痛药。 而疼痛医生认为他们的工作是控制疼痛, 当我无法摆脱药物时, 他们认为我已经发生了药物上瘾。 但是成瘾药主要是强调 和针对那些面临长期药物使用障碍的患者。 简而言之,医生给我开了一种 需要进行长期管理的药物, 但我并没有得到接受监管的机会, 我甚至不清楚这种管理性措施归谁负责。
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.
这一整个过程堪称灾难, 任何这样的灾难或许 都值得关注和分享—— 或许值得一个TED演讲—— 但阿片减药的失败仍然应该引起重视, 特别是在当今的美国, 由于我们生活在这样一类的流行病中, 仅在2015年因用药过度 致死的人数就达到了33000人。 而这些人中,有近一半 与处方阿片类药物上瘾有关。 医疗群体事实上已开始 对这类危机做出反应, 但他们的措施无外乎是开更少的药—— 那的确十分重要。 举个例子,我们有证据证明 美国医生会主动为病人开药, 即使在阿片的例子中, 这并不是必须的。 甚至当患者需要阿片时, 医生们也会经常开出过高的剂量。 这类情况解释了为什么美国, 尽管只占世界人口的5%, 却消耗了全球总阿片用量的近70%。 但如果仅关注开药的速率风险, 会忽略两个至关重要的因素。 其一,阿片无论是现在 还是未来,都会是重要的疼痛疗方。 如果有人承受着十分严重的慢性疼痛, 我向你们保证,这些药能够 支撑你继续活下去。 其二: 我们仍需与流行病搏斗, 同时明智地将处方阿片 留给确实需要它们的人, 这就需要医生在开药时正确管控剂量。 举个例子, 回到我的减药经历中。 合理的情况是, 任何开阿片处方的医生都能 意识到病人是不是用药过猛。 在我在一篇学术期刊上发表我的故事后, 就有CDC(疾病防治中心)的人 给了我他们减药的袖珍指南。 这是一份4页的文档, 大多数内容都是图片。 这些图片会指导医生 如何针对简单病例减少阿片剂量, 其中有条建议是 每周减少的剂量不得多于10%。 如果当初我的医生让我遵从了这个计划, 我的减药周期将会持续几个月,而不是几周。 我确信那样会更容易一些, 有可能还是会感到十分不适, 但也许不至于让人痛不欲生。 而且那似乎也是 医生开药时应该考虑的信息。
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.
最后, 我要说,仅靠正确使用处方阿片 并不会彻底解决危机。 美国的流行病治疗任重道远, 但当一类药物要为每年 几万生灵的逝去负责时, 对用药的鲁莽处理就十分不可取。 帮助阿片治疗患者摆脱 对处方药物的依赖, 对于我们的流行病治疗来说 也许不是一个万全之策, 但它显然是一种突破。
Thank you.
谢谢。
(Applause)
(掌声)