The agony of opioid withdrawal — and what doctors should tell patients about it | Travis Rieder

Translator: Sara Fandiño Reviewer: Serv. de Norm. Lingüística U. de Santiago de Compostela

"How much pain medication are you taking?"

Cantos analxésicos tomas?

That was the very routine question that changed my life.

Unha pregunta rutineira que me cambiou a vida.

It was July 2015,

Era xullo de 2015,

about two months after I nearly lost my foot

dous meses despois de case perder o pé

in a serious motorcycle accident.

nun grave accidente de moto.

So I was back in my orthopedic surgeon's office

Atopábame na consulta do meu traumatólogo

for yet another follow-up appointment.

para outra revisión.

I looked at my wife, Sadiye;

Mirei a miña muller, Sadiye;

we did some calculating.

e calculamos.

"About 115 milligrams oxycodone," I responded.

“Ao redor de 115 miligramos de oxicodona”

"Maybe more."

"Quizais algo máis", engadín.

I was nonchalant, having given this information to many doctors

Xa lles dera esta información previamente a varios doutores,

many times before,

polo que respondín con indiferenza,

but this time was different.

pero esta vez foi distinto.

My doctor turned serious

O médico púxose serio, miroume e dixo:

and he looked at me and said,

"Travis, that's a lot of opioids.

"Travis iso é unha morea de opioides,

You need to think about getting off the meds now."

é hora de deixar a medicación".

In two months of escalating prescriptions,

Durante dous meses aumentando a dose,

this was the first time that anyone had expressed concern.

esta foi a primeira vez que alguén se preocupou.

Indeed, this was the first real conversation I'd had

De feito, esta foi a primeira conversa que tiven

about my opioid therapy, period.

sobre o meu tratamento con opioides.

I had been given no warnings,

Ninguén me advertira,

no counseling,

asesorara,

no plan ...

ou propuxera un plan.

just lots and lots of prescriptions.

Só receitas e máis receitas.

What happened next really came to define my entire experience of medical trauma.

O que pasou despois, foi un verdadeiro trauma.

I was given what I now know is a much too aggressive tapering regimen,

Programáronme unha redución de dose moi agresiva,

according to which I divided my medication into four doses,

segundo a cal tiña que dividir a miña medicación en catro tomas,

dropping one each week over the course of the month.

baixando unha por semana no transcurso dun mes.

The result is that I was launched into acute opioid withdrawal.

O que me levou a padecer unha crise de abstinencia a opioides.

The result, put another way,

Noutras palabras,

was hell.

un inferno.

The early stages of withdrawal feel a lot like a bad case of the flu.

Ao principio,

[1ª SEMANA]

asemellábase a unha gripe grave.

I became nauseated,

Tiña náuseas,

lost my appetite,

perdín o apetito,

I ached everywhere,

doíame todo

had increased pain in my rather mangled foot;

e o meu pé esnaquizado doíame cada vez máis.

I developed trouble sleeping due to a general feeling of restlessness.

Comecei a ter problemas para durmir xa que me atopaba inquedo.

At the time,

Daquela,

I thought this was all pretty miserable.

pensei que era horrible.

Non sabía o que me esperaba...

That's because I didn't know what was coming.

[2ª SEMANA]

At the beginning of week two,

Ao principio da segunda semana,

my life got much worse.

a miña vida foi a peor.

As the symptoms dialed up in intensity,

Tódolos síntomas intensificáronse,

my internal thermostat seemed to go haywire.

o meu termóstato interno toleou.

I would sweat profusely almost constantly,

Suaba abondo e decontino

and yet if I managed to get myself out into the hot August sun,

e aínda así, cando conseguía saír ao quente sol de agosto,

I might look down and find myself covered in goosebumps.

poñíaseme a pel de galiña.

The restlessness that had made sleep difficult during that first week

A inquedanza que me impedira durmir durante a primeira semana

now turned into what I came to think of as the withdrawal feeling.

converteuse na típica sensación de abstinencia.

It was a deep sense of jitters that would keep me twitching.

Era un desasosego que me provocaba constantes espasmos,

It made sleep nearly impossible.

impedíndome durmir.

But perhaps the most disturbing was the crying.

Pero o que máis me alteraba era o pranto.

I would find myself with tears coming on

As bágoas brotaban

for seemingly no reason

sen motivo aparente

and with no warning.

e sen aviso previo.

At the time they felt like a neural misfire,

Daquela, asemellaba un fallo nervioso

similar to the goosebumps.

semellante aos arrepíos.

Sadiye became concerned, and she called the prescribing doctor

Sadiye preocupouse e chamou ao médico,

who very helpfully advised lots of fluids for the nausea.

quen, dilixentemente, recomendou moito líquido contra as náuseas.

When she pushed him and said, "You know, he's really quite badly off,"

Cando ela insistiu, dicindo: "Atópase moi mal"

the doctor responded, "Well, if it's that bad,

O doutor respondeu, "se tan mal está,

he can just go back to his previous dose for a little while."

sempre pode reintroducir a medicación durante unha tempada"

"And then what?" I wondered.

"E despois que?" preguntei.

"Try again later," he responded.

"Téntao de novo", dixo.

Now, there's no way that I was going to go back on my previous dose

Pero eu non concibía volver á miña dose anterior

unless I had a better plan for making it through the withdrawal next time.

agás que tivese un plan mellor para lidar coa síndrome de abstinencia de novo.

And so we stuck to riding it out and dropped another dose.

Así é que proseguimos co acordado e baixamos outra dose.

[SEMANA 3]

At the beginning of week three,

Ao comezo da terceira semana,

my world got very dark.

o meu mundo ensombreceuse.

I basically stopped eating,

Deixei de comer,

and I barely slept at all

de durmir,

thanks to the jitters that would keep me writhing all night.

todo grazas ao desacougo que me tiña retorcéndome toda a noite.

But the worst --

Pero o peor...

the worst was the depression.

o peor foi a depresión.

The tears that had felt like a misfire before

As bágoas que antes asemellaban un mal funcionamento,

now felt meaningful.

agora tiñan significado.

Several times a day I would get that welling in my chest

Varias veces ao día podía sentir esa presión no meu peito

where you know the tears are coming,

que vaticinaba que as bágoas estaban a chegar,

but I couldn't stop them

pero non as podía controlar,

and with them came desperation and hopelessness.

e con elas viñan a desesperación e a desesperanza.

I began to believe that I would never recover

Comecei a crer que nunca me recuperaría

either from the accident or from the withdrawal.

nin do accidente, nin da síndrome de abstinencia.

Sadiye got back on the phone with the prescriber

Sadiye volveu a chamar ao doutor

and this time he recommended that we contact our pain management team

e desta vez aconsellounos que contactásemos coa unidade de dor

from the last hospitalization.

que nos atendera na hospitalización.

That sounded like a great idea,

Semellaba unha boa idea,

so we did that immediately,

polo que chamamos decontado,

and we were shocked when nobody would speak with us.

e asombrounos que ninguén nos quixese atender.

The receptionist who answered the phone advised us

A recepcionista que contestou a chamada informounos

that the pain management team provides an inpatient service;

de que a unidade de dor só trata a doentes hospitalizados.

although they prescribe opioids to get pain under control,

Aínda que prescriben opioides para controlar a dor

they do not oversee tapering and withdrawal.

non supervisaban reducións nin abstinencias.

Furious, we called the prescriber back and begged him for anything --

Anoxados, chamamos de novo ao doutor e suplicámoslle por calquera cousa...

anything that could help me --

que me puidese axudar...

but instead he apologized,

pero, en vez diso, desculpouse

saying that he was out of his depth.

e admitiu que non sabía que facer.

"Look," he told us,

"Mirade", dixo,

"my initial advice to you is clearly bad,

"o meu consello inicial foi un erro,

so my official recommendation is that Travis go back on the medication

así que a miña recomendación é que Travis volva á medicación,

until he can find someone more competent to wean him off."

ata que atope a alguén máis competente para reducirlle a dose.

Of course I wanted to go back on the medication.

Por suposto que quería tomar a medicación.

I was in agony.

Sentíame moribundo.

But I believed that if I saved myself from the withdrawal with the drugs

Pero cría que se evitaba pasar pola abstinencia

that I would never be free of them,

nunca podería deixar a medicación.

and so we buckled ourselves in,

Polo que nos mantivemos firmes

and I dropped the last dose.

e deixei a última dose.

[SEMANA 4]

As my brain experienced life without prescription opioids

Cando o meu cerebro sentiu como era a vida sen opioides

for the first time in months,

por primeira vez en meses,

I thought I would die.

pensei que ía morrer.

I assumed I would die --

Asumín que ía morrer.

(Crying)

Síntoo.

I'm sorry.

(Chora)

(Crying)

Because if the symptoms didn't kill me outright,

Se os síntomas non me mataban,

I'd kill myself.

faríao eu mesmo.

And I know that sounds dramatic,

Sei que soa drástico,

because to me, standing up here years later,

porque para min estar aquí, anos despois,

whole and healthy --

san e salvo...

to me, it sounds dramatic.

é extraordinario.

But I believed it to my core

Pero estaba totalmente convencido,

because I no longer had any hope

non tiña esperanza ningunha

that I would be normal again.

de volver á normalidade.

The insomnia became unbearable

O insomnio fíxose insoportable

and after two days with virtually no sleep,

e despois de dous días sen apenas durmir,

I spent a whole night on the floor of our basement bathroom.

pasei unha noite enteira tirado no chan do baño.

I alternated between cooling my feverish head

Alternaba entre pegar a cabeza ás baldosas para baixar a febre

against the ceramic tiles

and trying violently to throw up despite not having eaten anything in days.

e tentar trousar, pese a que non comera nos últimos días.

When Sadiye found me at the end of the night

Cando Sadiye me atopou ao final da noite,

horrorizouse,

she was horrified,

and we got back on the phone.

e chamamos outra vez.

We called everyone.

Chamamos a todo o mundo,

We called surgeons and pain docs and general practitioners --

chamamos a cirurxiáns e médicos da dor, a médicos de familia.

anyone we could find on the internet,

Calquera que atopamos en internet,

and not a single one of them would help me.

e ninguén podía facer nada para axudarme.

The few that we could speak with on the phone

Os poucos cos que puidemos falar,

advised us to go back on the medication.

recomendaron volver á medicación.

An independent pain management clinic said that they prescribe opioids

Unha clínica privada da dor díxonos que prescribían opioides

but they don't oversee tapering or withdrawal.

pero que non supervisaban a redución ou a abstinencia.

When my desperation was clearly coming through my voice,

Cando a desesperación podía ouvirse na miña voz,

much as it is now,

como agora,

the receptionist took a deep breath and said,

unha recepcionista suspirou e dixo,

"Mr. Rieder, it sounds like perhaps what you need is a rehab facility

"Señor Rieder, quizais o que precise sexa un centro de desintoxicación

or a methadone clinic."

ou unha unidade de drogodependencia"

I didn't know any better at the time, so I took her advice.

Non se me ocorría nada mellor, así que seguín o seu consello,

I hung up and I started calling those places,

colguei e empecei a chamar a eses centros.

but it took me virtually no time at all

Pero non tardei nada en descubrir

to discover that many of these facilities

que están centrados en quen leva anos loitando coa súa adicción a substancias.

are geared towards those battling long-term substance use disorder.

In the case of opioids,

No caso dos opioides,

this often involves precisely not weaning the patient off the medication,

normalmente isto non implica que os deixen,

but transitioning them onto the safer, longer-acting opioids:

senón que os substitúan por outros máis seguros a longo prazo:

methadone or buprenorphine for maintenance treatment.

metadona ou buprenorfina, para o tratamento de mantemento.

In addition, everywhere I called had an extensive waiting list.

Amais, tódolos sitios aos que chamei tiñan unha longa lista de espera.

I was simply not the kind of patient they were designed to see.

Non era o tipo de paciente que están acostumados a tratar.

After being turned away from a rehab facility,

Despois de ser rexeitado polos centros de desintoxicación

I finally admitted defeat.

aceptei a miña derrota.

I was broken and beaten,

Estaba desfeito e frustrado,

and I couldn't do it anymore.

non podía continuar.

So I told Sadiye that I was going back on the medication.

Díxenlle a Sadiye que ía volver medicarme.

I would start with the lowest dose possible,

Comezaría coa dose máis baixa posible

and I would take only as much as I absolutely needed

e tomaría soamente o necesario

to escape the most crippling effects of the withdrawal.

para escapar dos efectos demoledores da abstinencia.

So that night she helped me up the stairs

Esa noite, axudoume a subir as escaleiras,

and for the first time in weeks I actually went to bed.

e por primeira vez en semanas fun á cama.

I took the little orange prescription bottle,

Collín o bote laranxa das menciñas,

I set it on my nightstand ...

apoieino na mesa de noite...

and then I didn't touch it.

e non o toquei.

I fell asleep,

Adormecín,

I slept through the night

durmín toda a noite

and when I woke up,

e cando espertei,

the most severe symptoms had abated dramatically.

os síntomas máis graves case desapareceran.

I'd made it out.

Lográrao.

(Applause)

(Aplausos)

(Suspira)

(Aplausos)

Thanks for that, that was my response, too.

Grazas, esa foi a miña reacción.

(Laughter)

(Suspira aliviado e ri)

So --

I'm sorry, I have to gather myself just a little bit.

Síntoo, teño que recompoñerme un pouco.

I think this story is important.

Creo que esta historia é importante,

It's not because I think I'm special.

non porque me crea especial.

This story is important precisely because I'm not special;

Isto é importante precisamente porque non son especial,

because nothing that happened to me was all that unique.

nada do que me aconteceu foi inusual.

My dependence on opioids was entirely predictable

A miña dependencia aos opioides era totalmente predicible

given the amount that I was prescribed

dada a cantidade que tomaba

and the duration for which I was prescribed it.

e durante o tempo que o fixen.

Dependence is simply the brain's natural response to an opioid-rich environment

A dependencia é a resposta innata do cerebro a un medio rico en opioides.

and so there was every reason to think that from the beginning,

Polo tanto, era evidente dende o comezo que ía precisar

I would need a supervised, well-formed tapering plan,

un plan supervisado de redución de dose.

but our health care system seemingly hasn't decided

Pero aparentemente, o noso sistema sanitario aínda non decidiu

who's responsible for patients like me.

quen é o responsable de pacientes coma min.

The prescribers saw me as a complex patient

Os médicos víanme coma un paciente complexo

needing specialized care,

con necesidade de coidados especiais para o control da analxesia.

probably from pain medicine.

The pain docs saw their job as getting pain under control

Os especialistas en dor entendían que a súa función era controlar a dor

and when I couldn't get off the medication,

e cando non logrei deixar a medicación,

they saw me as the purview of addiction medicine.

pasaron a verme como un caso de especialistas en adiccións.

But addiction medicine is overstressed

Pero esta especialidade está colapsada,

and focused on those suffering from long-term substance use disorder.

e centrada en doentes cunha longa historia de abuso de substancias.

In short, I was prescribed a drug that needed long-term management

En resumo, receitáronme unha menciña que precisaba unha prolongada supervisión

and then I wasn't given that management,

que non me ofreceron,

and it wasn't even clear whose job such management was.

nin quedaba claro quen a tiña que ofrecer.

This is a recipe for disaster

Esta é a receita dun desastre

and any such disaster would be interesting and worth talking about --

do que sería interesante falar

probably worth a TED Talk --

inclusive nunha charla TED.

but the failure of opioid tapering is a particular concern

O fallo no manexo dos opioides

suscita unha gran preocupación na actualidade nos EE. UU.

at this moment in America

because we are in the midst of an epidemic

porque nos atopamos no medio dunha epidemia

in which 33,000 people died from overdose in 2015.

na que en 2015 houbo 33000 mortes por sobredose.

Nearly half of those deaths involved prescription opioids.

Case a metade desas mortes, debéronse a opioides receitados.

The medical community has in fact started to react to this crisis,

A comunidade médica comezou a actuar contra esta crise

but much of their response has involved trying to prescribe fewer pills --

pero a súa resposta consistiu en prescribir menos pílulas.

and absolutely, that's going to be important.

Por suposto que é importante.

So for instance, we're now gaining evidence

Por exemplo, sabemos

that American physicians often prescribe medication

que os médicos estadounidenses a miúdo prescriben fármacos

even when it's not necessary

que non se precisan.

in the case of opioids.

No caso dos opioides,

And even when opioids are called for,

aínda cando son necesarios,

they often prescribe much more than is needed.

prescríbense máis do que cumpriría.

These sorts of considerations help to explain why America,

Este tipo de feitos axudan a comprender por que os EE. UU.,

despite accounting for only five percent of the global population,

a pesar de ter o 5% da poboación mundial,

consumes nearly 70 percent of the total global opioid supply.

consume o 70% da produción total dos opioides.

But focusing only on the rate of prescribing

Non obstante, se nos centramos só na porcentaxe de prescrición

risks overlooking two crucially important points.

podemos estar esquecendo dous feitos importantes.

The first is that opioids just are

Para comezar, os opioides son

and will continue to be important pain therapies.

e serán fármacos necesarios para o tratamento da dor.

As somebody who has had severe, real, long-lasting pain,

Como doente que sufriu dor intensa, real e constante,

I can assure you these medications can make life worth living.

podo afirmar que poden facer que pague a pena vivir.

And second:

Por último,

we can still fight the epidemic while judiciously prescribing opioids

podemos loitar contra esta epidemia sen deixar de receitar opioides

to people who really need them

a aqueles que de verdade os necesitan,

by requiring that doctors properly manage the pills that they do prescribe.

obrigando aos médicos a que supervisen todo o que prescriban.

So for instance,

Por exemplo,

go back to the tapering regimen that I was given.

volvendo ao meu réxime de deshabituación.

Is it reasonable to expect

Non é razoable esperar

that any physician who prescribes opioids knows that that is too aggressive?

que calquera médico que prescriba opioides saiba o potentes que son?

Well, after I initially published my story in an academic journal,

Despois de publicar a miña historia nunha revista científica,

someone from the CDC sent me their pocket guide for tapering opioids.

alguén do CDC envioume a súa guía para a redución gradual de opioides.

This is a four-page document,

Era un documento de 4 páxinas

and most of it's pictures.

cheo de imaxes.

In it, they teach physicians how to taper opioids in the easier cases,

Nel ensínaselles aos médicos a reducir a dose nos casos máis sinxelos

and one of the their recommendations

e unha das súas recomendacións

is that you never start at more than a 10 percent dose reduction per week.

é que nunca se paute unha redución superior ao 10 % por semana.

If my physician had given me that plan,

Se o meu médico me aconsellara ese plan

my taper would have taken several months instead of a few weeks.

a miña deshabituación ocorrería en meses, en vez de en semanas.

I'm sure it wouldn't have been easy.

Estou seguro de que non ía ser sinxelo,

It probably would have been pretty uncomfortable,

seguramente fose molesto

but maybe it wouldn't have been hell.

pero quizais non sería un inferno.

And that seems like the kind of information

Asemella que ese tipo de información

that someone who prescribes this medication ought to have.

deberíaa ter calquera que prescriba opioides.

In closing,

Para rematar,

I need to say that properly managing prescribed opioids

teño que dicir que o manexo axeitado dos opioides

will not by itself solve the crisis.

non resolverá por si mesmo a crise.

America's epidemic is far bigger than that,

A epidemia nos EE.UU. é máis grande que iso.

but when a medication is responsible for tens of thousands of deaths a year,

Pero cando un fármaco é responsable de decenas de miles de mortes

reckless management of that medication is indefensible.

un control inadecuado non é admisible.

Helping opioid therapy patients to get off the medication

Axudar a estes doentes a suspender

that they were prescribed

o que lles prescribiron

may not be a complete solution to our epidemic,

pode non ser a solución completa á nosa epidemia,

but it would clearly constitute progress.

pero sería un adianto.

Thank you.

Grazas.

(Applause)

(Aplausos)