"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.
「你服用多少止痛藥?」 這個非常例行性的問題 改變了我的人生。 時間是 2015 年 7 月, 兩個月前,我差點在一場嚴重的 摩托車意外中險些失去了我的腳。 我回到我的整形外科醫生的辦公室, 這是另一次後續追蹤的會面。
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.
我看著我的太太莎蒂耶; 我們做了一些計算。 我回應:「大約 115 毫克的氧可酮。」 「或許更多一些。」 我很冷靜,畢竟以前 已經告訴過許多醫生 這項資訊很多次了, 但這一次卻不同。
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."
我的醫生開始嚴肅起來, 他看著我說: 「崔佛斯,那是很大量的鴉片類藥物。 你得要考慮現在 就開始脫離這些藥物。」
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.
兩個月來,處方的藥量不斷增高, 這倒是頭一次有人表示關心。 的確,這是我第一次針對 我的類鴉片藥物治療 所進行真正的談話,沒別的。 之前都沒人給我過任何警告、 任何咨詢、 任何計劃…… 只是給我很多很多的處方。
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.
接著發生的事,真的可說是定義了 我對於醫療創傷的整個經驗。 我現在知道了,當時他們給我 太積極的漸減式給藥方案, 根據這個方案, 我將我的藥物劑量分為四份, 在一個月的期間,每週減少一份。 結果是,我開始發生急性類鴉片戒斷。 換一種說法,結果就是 像地獄一樣。 戒斷的初期, 感覺像是糟糕的感冒。 我會感到惡心, 失去食慾, 全身都疼痛, 我那隻被壓壞的腳也越來越痛; 因為總是感到焦躁不安, 我甚至開始難以入眠。 當時, 我以為這些狀況算是很悲慘。 那是因為我還不知道 後面有什麼在等著我。
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.
第二週剛開始時, 我的人生變得很糟。 症狀的強度都增加了, 我的內部恆溫器似乎在混亂暴走。 我幾乎常常會大汗淋漓, 但如果在炎熱的八月 我有辦法出門到大太陽底下, 我可能低頭就會看到 我自己滿身雞皮疙瘩。 在第一週,焦躁不安讓我難以入眠, 現在則變成了一種 我漸漸認為是戒斷的感覺。 它是一種很深刻的神經過敏感, 會讓我一直抽動。 它讓睡眠變成幾乎不可能。 但最惱人也許是哭泣吧。 我會發現自己淚流滿面, 但似乎沒什麼理由, 且毫無預警。 當下的感覺就像是神經故障, 跟雞皮疙瘩很類似。 莎蒂耶很擔心, 便打電話給開處方的醫生, 他非常有幫助, 建議了一些適用於噁心時攝入的流體。
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."
她進一步逼問他: 「他的狀況真的很不好。」 醫生回應:「嗯,如果有那麼糟, 他可以暫時恢復他之前的劑量。」
"And then what?" I wondered.
我納悶:「那接著呢?」
"Try again later," he responded.
他回答:「之後再試一次。」
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.
我絕對不可能再恢復先前的劑量, 除非我有更好的計畫 能讓我下次順利通過戒斷。 所以我們堅持要拼過這一次, 且再減少一份劑量。
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.
第三週剛開始時, 我的世界非常黑暗。 基本上我已經不再進食了, 我也幾乎沒在睡覺, 這要歸功於讓我整晚扭動的神經過敏。 但最糟的是—— 最糟的是憂鬱。 本來感覺像是故障造成的眼淚, 現在感覺有意義了。 一天會有好幾次, 我的胸口會有什麼湧上來的感覺, 你會知道眼淚馬上就要來了, 但我無法阻止它們, 和它們一起來的, 是絕望和無望的感覺。 我開始相信,我永遠不會復元了, 不論是車禍意外或戒斷, 都無法復元了。
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."
莎蒂耶再度打電話給開處方的醫生, 這次醫生建議我們聯絡 我最後一次住院時的 疼痛管理團隊。 那聽起來像是個好主意, 所以我們馬上照做了, 令人驚訝的是, 沒人願意跟我們說話。 接電話的接待人員告訴我們, 疼痛管理團隊 提供服務給住院病人; 雖然他們會開類鴉片藥物來控制疼痛, 但他們不管漸漸減量和戒斷。 我們火大了, 又打電話給開處方的醫生, 求他給我一點什麼—— 任何能幫助我的都好—— 但他卻只是道歉, 說這已經超過他的能力範圍。 「聽著,」他告訴我們: 「我一開始給你的建議 很顯然是不好的, 所以我的正式建議是, 崔佛斯應該回到先前的劑量, 直到他找到更有能力的人 來幫他戒掉。」
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.
我當然很想要回到之前的劑量。 我很痛苦。 但我相信如果我不去戒斷這些藥物, 我永遠脫離不了它們, 所以我們狠下心, 減掉最後一份劑量。
As my brain experienced life without prescription opioids for the first time in months, I thought I would die. I assumed I would die --
這是數個月來頭一次, 我的大腦能在 沒有處方類鴉片藥物的 情況下體驗人生, 我覺得我要死了。 我假設我要死了——
(Crying)
(哭泣)
I'm sorry.
抱歉。
(Crying)
(哭泣)
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.
因為如果症狀沒有徹底把我殺死, 我也會自殺。 我知道那聽起來很戲劇化, 因為對我來說,幾年後站在這裡, 完整且健康—— 對我來說,聽起來很戲劇化。 但我發自內心相信, 因為我不再抱有 我能夠再次恢復正常的任何希望。
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.
失眠變得讓人無法忍受, 在足足兩天無法入睡之後, 我整晚都待在地下室浴室的地板上。 一下子是把我發燒的頭部靠在磁磗上 讓它冷卻下來, 一下子是用力嘔吐, 即使數天都幾乎沒有吃什麼。 莎蒂耶在夜將盡時找到了我, 她嚇壞了, 我們又去打電話。 我們打給每個人。 我們打給外科醫生、疼痛醫生, 還有家庭醫生—— 任何我們在網路上能找到的人, 卻沒有一個人能夠幫我。 有少數幾個人願意 在電話上和我們說話, 建議我們再把劑量加回來。 有一間獨立的疼痛管理診所, 說他們會開類鴉片藥物的處方, 但他們不負責減量或戒斷的部分。 當我説話的聲音中 都帶著明顯的絕望時, 就像現在一樣, 接待人員深呼吸之後說: 「雷德先生,聽起來 你可能需要去勒戒機構 或美沙酮診所。」 我當時什麼也不懂, 就接受了她的建議。 我掛了電話, 開始打電話到這些地方, 但我完全沒花什麼時間, 就發現許多這類機構 適合的是與藥物濫用長期抗戰的人。 至於類鴉片藥物, 通常就是不要讓病人馬上戒掉藥物, 而是要讓他們轉換到更安全、 更長效的類鴉片藥物: 美沙酮或丁丙諾啡,以維持治療。 此外,我找的每個地方, 等候名單都很長。 我很明確就不是他們的目標對象。
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.
在被一間勒戒機構拒絕了之後, 我終於承認失敗。 我徹底被打倒了, 我沒辦法再繼續了。 我告訴莎蒂耶, 我要恢復原本的劑量。 我先盡可能從最低的劑量開始, 只取用我絕對必要的量就好, 只是為了脫離最嚴重的戒斷效應。 那晚,她扶我起來,爬上樓, 數個星期以來, 我第一次真的爬上床。 我拿了裝處方藥的橘色小瓶子, 放在我的床頭櫃上…… 我並沒有去碰它。 我入睡了, 我睡了整晚, 當我醒來時, 最嚴重的症狀已經大大減輕。 我挺過去了。
(Applause)
(掌聲)
Thanks for that, that was my response, too.
謝謝,那也是我的第一個反應。
(Laughter)
(笑聲)
So -- I'm sorry, I have to gather myself just a little bit.
所以—— 抱歉,我得要調整一下心情。
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.
我認為這個故事很重要。 並不是因為我認為我很特別。 這個故事之所以重要, 正是因為我不特別; 因為發生在我身上的事 並非獨一無二。 我對於類鴉片藥物的依賴 完全是可預期的, 畢竟我拿到的處方劑量相當大, 我吃處方藥的期間也很長。 依賴只是大腦對於富含類鴉片 藥物的環境所做出的自然反應, 所以絕對有理由可以相信, 打從一開始, 我就需要一個 受監控且合適的減量計畫, 但我們的健康照護制度似乎還沒有決定 像我這樣的病人要由誰來負責。 開處方藥的醫生 把我視為一個複雜的病人, 需要專門的照護, 可能戒除止痛藥物。 疼痛醫生認為他們的工作 是要控制疼痛, 當我無法脫離藥物時, 他們認為我屬於上癮藥物的範圍。 但上癮藥物主要是強調 和著重那些對抗長期藥物濫用的人。 簡言之,我拿到的處方藥 是需要長期管理的藥物, 但卻沒人提供我這種管理, 甚至不清楚這種管理到底是誰的工作。
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.
這注定會導致災禍, 任何像這樣的災禍 會很有意思且值得拿出來談—— 可能值得做一場 TED 演說—— 但此時,在美國, 類鴉片藥物減量的失敗 是個特別需要關注的議題, 因為我們現在正在流行期當中, 2015 年就有三萬三千人 因為用藥過量致死。 這些人當中,有近一半 和有處方的類鴉片藥物有關。 事實上,醫療圈已經開始 對這項危機做出反應, 但他們的反應大多是在試圖 開比較少的處方藥—— 當然,那是很重要的。 比如,我們現在有證據顯示, 美國醫生常在即使不必要的時候, 也會開處方藥, 如類鴉片藥物。 即使是需要類鴉片藥物時, 他們處方的劑量也比需要的多很多。 這類原因說明為什麼美國人口 只佔了世界人口的 5%, 消耗掉的類鴉片藥物 卻佔全球總供應的近 70%。 但如果只把焦點放在開處方的比率, 會有忽略兩個關鍵點的風險。 第一,類鴉片藥物目前是, 將來也繼續會是重要的止痛方式。 我自己不久前才經歷了 嚴重、真實、長久的痛苦, 我可以向各位保證, 這些藥物能讓人生變得值得活下去。 第二, 我們可以一邊對抗流行期, 一邊明智而謹慎地處方類鴉片藥物 給真正需要它們的人, 做法是要求醫生要妥當管理 他們處方的藥物。 舉例來說, 回到他們給我的劑量漸減方案。 期待處方類鴉片藥物給我的醫生 知道這個方案太積極, 這種期待是合理的嗎? 在我把我的故事初次刊登在 一本學術期刊上之後, 疾病防治中心的人寄給我一本 類鴉片藥物劑量漸減的口袋指南。 這份文件共四頁, 大部分是圖片。 在指南中,他們教醫生 如何針對比較容易的案例 做類鴉片藥物的劑量漸減, 他們的建議之一是, 就是每週減少的劑量 不要超過 10%。 如果我的醫生有給我這樣的方案, 我的劑量漸減會需要花 數個月時間,而不是幾週。 我確信不會太好過。 可能會很不舒服, 但也許不會像地獄一樣。 這些資訊似乎是 負責處方這類藥物的人應該要知道的。
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.
最後結尾, 我得要說,單靠妥當管理 處方的類鴉片藥物 不能解決危機。 美國的流行狀況嚴重到它無法解決, 但如果這種藥物 造成一年數萬人死亡, 隨便管理這類藥物是不可原諒的。 協助類鴉片藥物治療的病人戒除 他們的處方藥物 或許不是能徹底解決流行問題的方案, 但它依然可以帶來進展。
Thank you.
謝謝。
(Applause)
(掌聲)