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

Prevodilac: Marija Cvijic Lektor: Ivana Korom

"How much pain medication are you taking?"

„Koliko tableta protiv bolova uzimate?“

That was the very routine question that changed my life.

Ovo rutinsko pitanje mi je promenilo život.

It was July 2015,

To je bilo jula 2015,

about two months after I nearly lost my foot

oko dva meseca nakon što sam skoro izgubio stopalo

in a serious motorcycle accident.

u teškoj motociklističkoj nesreći.

So I was back in my orthopedic surgeon's office

Bio sam u ordinaciji ortopedskog hirurga

for yet another follow-up appointment.

na još jednom kontrolnom pregledu.

I looked at my wife, Sadiye;

Pogledao sam suprugu, Sadiju

we did some calculating.

pa smo počeli da računamo.

"About 115 milligrams oxycodone," I responded.

„Oko 115 miligrama oksikodona,“ rekao sam.

"Maybe more."

„Možda više.“

I was nonchalant, having given this information to many doctors

Nisam se uznemirio, s obzirom da sam na to pitanje odgovorio doktorima

many times before,

već puno puta do tada,

but this time was different.

ipak sada je bilo drugačije.

My doctor turned serious

Moj doktor se uozbiljio,

and he looked at me and said,

pogledao me i rekao:

"Travis, that's a lot of opioids.

„Travise, to je mnogo opijata.

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

Trebao bi da razmisliš o skidanju sa lekova.“

In two months of escalating prescriptions,

Za dva meseca povećanja doza,

this was the first time that anyone had expressed concern.

to je bio prvi put da je iko izrazio zabrinutost.

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

U stvari, to je bio prvi pravi razgovor koji sam vodio

about my opioid therapy, period.

po pitanju moje terapije opijatima.

I had been given no warnings,

Nisam dobio nikakva upozorenja,

no counseling,

savetovanja,

no plan ...

plan...

just lots and lots of prescriptions.

samo mnogo, mnogo recepata.

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

Ono što se sledeće dogodilo je zaista obeležilo moje celo iskustvo ove povrede.

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

Dobio sam, ono što sada znam da se zove, previše agresivan režim smanjenja doze,

according to which I divided my medication into four doses,

prema kojem sam podelio moje lekove na četiri doze,

dropping one each week over the course of the month.

izbacujući po jednu svake nedelje tokom mesec dana.

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

Posledica toga bila je pojava apstinencijalnog sindroma.

The result, put another way,

Ili drugim rečima,

was hell.

pakao.

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

Rane faze krize su po mnogo čemu ličile na teži oblik gripa.

I became nauseated,

Bilo mi je muka,

lost my appetite,

izgubio sam apetit,

I ached everywhere,

sve me je bolelo,

had increased pain in my rather mangled foot;

bol je bio pojačan u mom povređenom stopalu;

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

razvio sam poremećaj spavanja usled opšteg osećaja nemira.

At the time,

Tada sam mislio

I thought this was all pretty miserable.

da je to prilično grozno.

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

To je zato što nisam znao šta sledi.

At the beginning of week two,

Početkom druge nedelje,

my life got much worse.

moj život se pogoršao.

As the symptoms dialed up in intensity,

Simptomi su se pojačali,

my internal thermostat seemed to go haywire.

moj unutrašnji termostat bio je u totalnom neredu.

I would sweat profusely almost constantly,

Skoro stalno sam se preterano znojio,

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

a opet, ukoliko bih izašao na vrelo avgustovsko sunce,

I might look down and find myself covered in goosebumps.

pogledao bih i video da sam se ceo naježio.

The restlessness that had made sleep difficult during that first week

Nemirnost zbog koje nisam mogao da spavam prve nedelje

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

sada se pretvorila u ono što je ličilo na apstinencijalnu krizu.

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

Užasna nervoza koja je izazivala trzaje,

It made sleep nearly impossible.

učinila je spavanje nemogućim.

But perhaps the most disturbing was the crying.

Međutim, ono što je najviše uznemiravalo verovatno je bilo plakanje.

I would find myself with tears coming on

Osetio bih kako mi suze naviru

for seemingly no reason

naizgled bez ikakvog razloga

and with no warning.

ili upozorenja.

At the time they felt like a neural misfire,

Tada se to činilo kao neurološka disfunkcija,

similar to the goosebumps.

nešto slično trncima.

Sadiye became concerned, and she called the prescribing doctor

Sadija je postala zabrinuta, te je pozvala ordinirajućeg lekara

who very helpfully advised lots of fluids for the nausea.

koji je veoma uslužno savetovao dosta tečnosti za mučninu.

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

Kada ga je pritisnula i rekla: „Znate, njemu je zaista izuzetno loše,“

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

doktor je odgovorio: „Ukoliko je baš tako loše

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

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

Nije bilo šanse da se vratim na prethodnu dozu

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

jer i dalje nisam znao šta da radim po pitanju krize.

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

Odlučili smo da nastavimo i ukinuli još jednu dozu.

At the beginning of week three,

Početkom treće nedelje,

my world got very dark.

moj svet postao je veoma mračan.

I basically stopped eating,

Prestao sam da jedem

and I barely slept at all

i jedva da sam spavao

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

zahvaljujući nervozi koja bi me drmala celu noć.

But the worst --

Ali najgora -

the worst was the depression.

najgora je bila depresija.

The tears that had felt like a misfire before

Suze koje su se ranije činile kao greška u sistemu

now felt meaningful.

sada su imale smisla.

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

Tokom dana bih osećao stezanje u grudima,

where you know the tears are coming,

nakon kojeg znate da slede suze,

but I couldn't stop them

koje ne bih mogao da zaustavim,

and with them came desperation and hopelessness.

a sa kojima su se pojavile depresija i očajanje.

I began to believe that I would never recover

Počinjao sam da verujem da se nikada neću oporaviti

either from the accident or from the withdrawal.

ni od nesreće, ni od skidanja sa lekova.

Sadiye got back on the phone with the prescriber

Sadija je ponovo pozvala lekara

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

koji je sada predložio da pozovemo lekare koji su prepisali lekove

from the last hospitalization.

tokom poslednjeg boravka u bolnici.

That sounded like a great idea,

To je zvučalo kao dobra ideja,

so we did that immediately,

stoga smo to istog trena i uradili,

and we were shocked when nobody would speak with us.

nakon čega smo bili šokirani kada niko nije hteo da priča sa nama.

The receptionist who answered the phone advised us

Osoba koja se javila nam je rekla

that the pain management team provides an inpatient service;

da tim lekara koji je zadužen za kontrolisanje bola obezbeđuje terapiju,

although they prescribe opioids to get pain under control,

ali da, iako prepisuju opijate kako bi smanjili bol,

they do not oversee tapering and withdrawal.

ne nadgledaju smanjenje terapije ili skidanje sa iste.

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

Besni, ponovo smo pozvali doktora i molili ga da uradi bilo šta -

anything that could help me --

bilo šta što bi mi moglo pomoći -

but instead he apologized,

ali se umesto toga izvinio

saying that he was out of his depth.

govoreći kako ne može ništa da uradi.

"Look," he told us,

„Vidite”, kazao nam je,

"my initial advice to you is clearly bad,

„moj prvobitan savet je očigledno bio pogrešan,

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

stoga je moja preporuka da se Travis vrati na početnu dozu

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

dok ne nađe nekoga stručnijeg da ga skine sa njih.”

Of course I wanted to go back on the medication.

Naravno da sam hteo da ponovo uzimam lekove.

I was in agony.

Bio sam u agoniji.

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

Međutim, verovao sam da ukoliko ponovo počnem da uzimam lekove

that I would never be free of them,

da ih se nikada neću rešiti,

and so we buckled ourselves in,

stoga smo se spremili,

and I dropped the last dose.

te sam ukinuo i poslednju dozu.

As my brain experienced life without prescription opioids

Moj mozak je iskusio život bez prepisanih opijata

for the first time in months,

prvi put u poslednjih nekoliko meseci.

I thought I would die.

Mislio sam da ću da umrem.

I assumed I would die --

Verovao sam da ću umreti -

(Crying)

(Plač)

I'm sorry.

Izvinjavam se.

(Crying)

(Plač)

Because if the symptoms didn't kill me outright,

Jer ukoliko me tog trenutka ne bi ubili simptomi,

I'd kill myself.

ubio bih se sam.

And I know that sounds dramatic,

Znam da to zvuči dramatično,

because to me, standing up here years later,

jer i meni, koji stojim ovde godinama kasnije,

živ i zdrav -

whole and healthy --

to me, it sounds dramatic.

čak i meni to zvuči dramatično.

But I believed it to my core

Međutim, duboko u sebi sam verovao u to,

because I no longer had any hope

zato što sam izgubio nadu

that I would be normal again.

da ću ikada ponovo biti normalan.

The insomnia became unbearable

Nesanica je postala nepodnošljiva

and after two days with virtually no sleep,

i nakon dva dana bez praktično imalo sna,

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

proveo sam celu noć u podrumu na podu našeg kupatila.

I alternated between cooling my feverish head

Čas sam hladio grozničavu glavu

against the ceramic tiles

o keramičke pločice,

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

čas sam silno pokušavao da povratim iako danima nisam ništa jeo.

When Sadiye found me at the end of the night

Kada me je Sadija pronašla kasno u noć,

she was horrified,

bila je užasnuta

and we got back on the phone.

i ponovo smo bili na vezi.

We called everyone.

Zvali smo sve.

We called surgeons and pain docs and general practitioners --

Zvali smo hirurge, specijaliste i lekare opšte prakse -

anyone we could find on the internet,

koga god smo mogli da nađemo na internetu,

and not a single one of them would help me.

i nijedan od njih mi nije mogao pomoći.

The few that we could speak with on the phone

Onih par sa kojima smo uspeli da razgovaramo

advised us to go back on the medication.

su savetovali da se vratim redovnoj terapiji.

An independent pain management clinic said that they prescribe opioids

Nezavisna klinika za smanjenje bolova rekla je da oni propisuju lekove

but they don't oversee tapering or withdrawal.

ali da ne nadgledaju smanjivanje doza ili skidanje sa istih.

When my desperation was clearly coming through my voice,

Kada se u mom glasu moglo jasno čuti koliko sam depresivan,

much as it is now,

kao što se može čuti i sada,

the receptionist took a deep breath and said,

osoba sa druge strane je duboko udahnula i rekla:

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

„Gospodine Rider, zvuči kao da vam treba rehabilitacioni

or a methadone clinic."

ili metadonski centar.”

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

Nisam imao bolje rešenje, stoga sam prihvatio njen savet.

I hung up and I started calling those places,

Prekinuo sam i počeo da zovem te centre,

but it took me virtually no time at all

ali mi nije trebalo mnogo

to discover that many of these facilities

da shvatim da su mnoge od tih ustanova

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

opremljene za borbu protiv dugotrajnih zloupotreba supstanci.

In the case of opioids,

U slučaju opijata,

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

to najčešće ne uključuje skidanje pacijenata sa lekova,

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

nego ih prebacuju na bezbednije, dugotrajnije opijate:

methadone or buprenorphine for maintenance treatment.

metadon ili buprenorfin kao terapiju prevencije kriza.

Plus, gde god sam zvao, postojala je poduža lista čekanja.

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

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

Prosto nisam bio tip pacijenta za kakvog su bili obučeni.

After being turned away from a rehab facility,

Nakon što sam ostao bez rehabilitacione ustanove,

I finally admitted defeat.

konačno sam priznao poraz.

I was broken and beaten,

Bio sam slomljen i isceđen

and I couldn't do it anymore.

i više nisam mogao da podnesem.

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

Stoga sam rekao Sadiji da ću ponovo početi sa terapijom.

I would start with the lowest dose possible,

Počeo bih sa najmanjom mogućom dozom

and I would take only as much as I absolutely needed

i uzimao bih tek toliko koliko mi je trebalo

to escape the most crippling effects of the withdrawal.

da izbegnem najgore simptome apstinencije.

So that night she helped me up the stairs

Te noći mi je pomogla da se popnem na sprat

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

te sam prvi put nakon dugo vremena spavao u krevetu.

I took the little orange prescription bottle,

Uzeo sam malu narandžastu bočicu sa lekovima,

I set it on my nightstand ...

stavio je na noćni ormarić...

and then I didn't touch it.

i više je nisam dotakao.

I fell asleep,

Zaspao sam,

I slept through the night

prespavao celu noć,

and when I woke up,

a kada sam se probudio,

the most severe symptoms had abated dramatically.

najgori simptomi su se drastično smanjili.

I'd made it out.

Preživeo sam.

(Applause)

(Aplauz)

Thanks for that, that was my response, too.

Hvala, to je bila i moja reakcija.

(Laughter)

(Smeh)

So --

Stoga -

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

Izvinjavam se, treba mi malo da se priberem.

I think this story is important.

Smatram da je ova priča bitna.

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

Ne zato što mislim da sam poseban.

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

Ova priča je bitna upravo zato što nisam poseban;

because nothing that happened to me was all that unique.

zato što se meni nije dogodilo ništa jedinstveno.

My dependence on opioids was entirely predictable

Moja zavisnost od opijata je bila potpuno predvidiva

given the amount that I was prescribed

s obzirom na količinu koja je prepisana

and the duration for which I was prescribed it.

i na vreme trajanja koje sam uzimao.

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

Zavisnost je prirodan odgovor mozga na opijatsko okruženje

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

stoga je potpuno razumljivo da pomišljate na to od samog početka.

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

Bio mi je potreban dobro osmišljen plan skidanja sa lekova pod nadzorom lekara.

but our health care system seemingly hasn't decided

Međutim, naš zdravstveni sistem još uvek nije odlučio

who's responsible for patients like me.

ko je odgovoran za pacijente poput mene.

The prescribers saw me as a complex patient

Jedni su me videli kao komplikovanog pacijenta

needing specialized care,

kojem je trebala posebna nega,

probably from pain medicine.

u vidu lekova protiv bolova.

The pain docs saw their job as getting pain under control

Drugi su smatrali da je njihov posao da smanje bol,

and when I couldn't get off the medication,

a kada nisam mogao da se skinem sa lekova,

they saw me as the purview of addiction medicine.

videli su me kao problem lečenja zavisnosti.

But addiction medicine is overstressed

Međutim lečenje zavisnosti je previše usmereno

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

i fokusirano na one koji pate od dugotrajne zavisnosti.

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

Ukratko, propisan mi je lek koji je zahtevao dugoročno nadgledanje,

and then I wasn't given that management,

a onda mi taj nadzor nije pružen,

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

niti je bilo jasno čiji je to posao bio.

This is a recipe for disaster

Ovo je recept za katastrofu,

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

a svaka ovakva katastrofa je interesantna i vredna pričanja -

probably worth a TED Talk --

verovatno vredna TED govora -

but the failure of opioid tapering is a particular concern

ali neuspešno skidanje sa opijata je značajan problem

at this moment in America

trenutno u Americi,

because we are in the midst of an epidemic

jer se nalazimo u središtu epidemije

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

u kojoj je 2015. godine 33 000 ljudi umrlo usled predoziranja.

Nearly half of those deaths involved prescription opioids.

Skoro polovina ovih smrti je uključivala propisane opijate.

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

Tačnije, zdravstvena zajednica je počela da reaguje na ove uzbune,

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

ali njihov odgovor uglavnom podrazumeva propisivanje manje količine lekova -

and absolutely, that's going to be important.

što će naravno biti od značaja.

So for instance, we're now gaining evidence

Na primer, imamo dokaze koji ukazuju da

that American physicians often prescribe medication

američki lekari često propisuju lekove

even when it's not necessary

čak i kada to nije neophodno,

barem što se tiče opijata.

in the case of opioids.

And even when opioids are called for,

A ukoliko zaista jesu potrebni,

they often prescribe much more than is needed.

često se propisuju mnogo više nego što treba.

These sorts of considerations help to explain why America,

Ova razmatranja pomažu da se objasni zašto Amerika,

despite accounting for only five percent of the global population,

uprkos tome što obuhvata samo pet posto svetske populacije,

consumes nearly 70 percent of the total global opioid supply.

koristi skoro 70 procenata ukupne potrošnje opijata.

But focusing only on the rate of prescribing

Međutim, ako se fokusiramo samo na stopu propisanih lekova

risks overlooking two crucially important points.

rizikujemo da predvidimo dve ključne stvari.

The first is that opioids just are

Prva je da opijati jesu

and will continue to be important pain therapies.

i da će nastaviti da budu značajan deo terapije protiv bolova.

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

Kao neko ko je patio od jakog i dugotrajnog bola,

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

mogu da vam garantujem da ovi lekovi čine život podnošljivim.

And second:

A kao drugo:

we can still fight the epidemic while judiciously prescribing opioids

možemo da se borimo protiv epidemije dok razumno propisujemo opijate

to people who really need them

ljudima koji ih stvarno trebaju,

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

tako što ćemo zahtevati od doktora pažljivo rukovođenje propisanim lekovima.

So for instance,

Na primer,

go back to the tapering regimen that I was given.

hajde da se vratimo na režim smanjivanja koji mi je preporučen.

Is it reasonable to expect

Da li je razumno očekivati

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

da ijedan lekar koji propisuje opijate zna da su oni previše agresivni?

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

Nakon što sam objavio svoju priču u naučnom časopisu,

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

neko iz centra za kontrolu bolesti mi je poslao vodič za skidanje sa opijata.

This is a four-page document,

U pitanju je dokument od 4 strane,

and most of it's pictures.

od kojih većinu predstavljaju slike.

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

U njima uče lekare kako da smanje dozu opijata u lakšim slučajevima

and one of the their recommendations

i jedna od njihovih preporuka

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

je da nikada ne smanjujete više od 10 procenata od ukupne doze nedeljno.

If my physician had given me that plan,

Da mi je moj doktor dao taj raspored,

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

moje skidanje bi trajalo mesecima, umesto nekoliko nedelja.

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

Siguran sam ne bi bilo lako.

It probably would have been pretty uncomfortable,

Verovatno bi bilo prilično neugodno,

but maybe it wouldn't have been hell.

ali možda ne bi bio pakao.

And that seems like the kind of information

To se čini kao informacija

that someone who prescribes this medication ought to have.

koju bi neko ko propisuje ove lekove trebalo da ima.

In closing,

Na kraju,

I need to say that properly managing prescribed opioids

moram da kažem da pravilno kontrolisanje propisanih opijata

will not by itself solve the crisis.

neće samo po sebi rešiti problem.

America's epidemic is far bigger than that,

Epidemija u Americi je mnogo veća od toga,

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

ali kada lekovi postanu odgovorni za desetine hiljada smrti godišnje,

reckless management of that medication is indefensible.

nema opravdanja za neodgovorno korišćenje tih lekova.

Helping opioid therapy patients to get off the medication

Pomaganje ovakvim pacijentima da se skinu sa lekova

that they were prescribed

koji su im propisani

možda nije celokupno rešenje naše epidemije,

may not be a complete solution to our epidemic,

but it would clearly constitute progress.

ali bi definitivno pomoglo napretku.

Thank you.

Hvala.

(Applause)

(Aplauz)