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

翻译人员: Tianji (Homer) Li 校对人员: Yuanqing Edberg

"How much pain medication are you taking?"

“你使用了多少止痛药？”

That was the very routine question that changed my life.

那曾是一个改变过我生活的 例行公事般的问题。

It was July 2015,

2015年7月，

about two months after I nearly lost my foot

在经历了一场严重的 摩托车事故的两个月以后，

in a serious motorcycle accident.

那次事故差点让我失去了双脚。

So I was back in my orthopedic surgeon's office

我回到骨科医生的办公室

for yet another follow-up appointment.

等待复查。

I looked at my wife, Sadiye;

我看着我的妻子，塞耶；

we did some calculating.

我们计算了一下。

"About 115 milligrams oxycodone," I responded.

“大约115毫克氧可酮，” 我回答。

"Maybe more."

“也许还不止。”

I was nonchalant, having given this information to many doctors

我有些漫不经心，我已经对很多医生

many times before,

重复过这个说法了，

but this time was different.

但是这一次情况不太一样。

My doctor turned serious

我的医生表情严肃地

and he looked at me and said,

看着我说：

"Travis, that's a lot of opioids.

“特拉维斯，这剂量可不轻啊。

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

现在你需要考虑戒掉这种药物了。”

In two months of escalating prescriptions,

两个月内我的处方药剂量不断增大，

this was the first time that anyone had expressed concern.

但这是第一次有人开始表示担心。

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

的确，也是在那个时期， 我开始了第一次关于

about my opioid therapy, period.

自己阿片治疗的谈话。

I had been given no warnings,

我没有收到过警告，

no counseling,

没有接受过咨询，

no plan ...

也没有任何戒断计划.....

just lots and lots of prescriptions.

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.

接下来发生的事，就是我的 整个创伤治疗经历的真实写照。

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

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，

according to which I divided my medication into four doses,

根据这个方案，我把药物分成了四个剂量，

dropping one each week over the course of the month.

在一个月内，每周降低一个剂量。

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

结果我出现了急性阿片戒断的症状。

The result, put another way,

换句话说，这个过程让我

was hell.

痛不欲生。

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

戒断的早期阶段感觉像得了急性流感。

I became nauseated,

我感到恶心，

lost my appetite,

食欲不振，

I ached everywhere,

浑身疼痛，

had increased pain in my rather mangled foot;

受伤的脚的状况更是雪上加霜；

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

这种坐立不安的感觉让我难以入睡。

At the time,

当时，

我就觉得这简直太痛苦了。

I thought this was all pretty miserable.

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

这是因为我还不知道接下来会发生什么。

At the beginning of week two,

第二周刚开始，

my life got much worse.

我的生活变得愈发痛苦不堪。

As the symptoms dialed up in intensity,

当症状向更深的程度蔓延，

my internal thermostat seemed to go haywire.

我身体内的恒温计似乎开始变得混乱。

I would sweat profusely almost constantly,

大量流汗成为了家常便饭，

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

然而，如果我好不容易 在8月的烈日下出了门，

I might look down and find myself covered in goosebumps.

却在低头时发现自己浑身是鸡皮疙瘩。

The restlessness that had made sleep difficult during that first week

现在我意识到，让我在第一周

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

彻夜难眠的那种坐立不安， 正是戒断的症状。

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

这是一种深入骨髓的 坐立不安，让我不停颤抖。

It made sleep nearly impossible.

入睡几乎是不可能的。

But perhaps the most disturbing was the crying.

但最令我一筹莫展的是哭泣。

I would find myself with tears coming on

我发现自己会无端地，

for seemingly no reason

没有任何预示地

and with no warning.

开始流泪。

At the time they felt like a neural misfire,

就像神经错乱了一样，

similar to the goosebumps.

类似起了鸡皮疙瘩的感觉。

Sadiye became concerned, and she called the prescribing doctor

塞耶也忧心忡忡，她替我 给开处方的医生打了电话，

who very helpfully advised lots of fluids for the nausea.

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,"

她在催促他的时候说： “他现在的状况十分糟糕。”

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

医生答道，“如果真是这样的话，

他可以暂时按原剂量服药。”

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

"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

但那时，我根本不可能倒退至原剂量了，

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

除非下一次戒药之前 我能做个更好的计划。

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

之后我坚持原计划，又降了一个剂量。

At the beginning of week three,

在第三周开始的时候，

my world got very dark.

我的世界陷入了黑暗。

I basically stopped eating,

我基本上已经无法进食，

and I barely slept at all

也几乎不能睡觉，

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

坐立不安使我整夜都在不停颤抖。

But the worst --

但最糟糕的是——

the worst was the depression.

最糟的是那种压抑的感觉。

The tears that had felt like a misfire before

原本感觉像是无端涌出的泪水，

now felt meaningful.

现在有了意义。

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

一天几次，我感到胸腔的喷涌感，

where you know the tears are coming,

意识到马上就会开始流泪，

but I couldn't stop them

但我无法抑制，

and with them came desperation and hopelessness.

随之而来的还有绝望和无助。

I began to believe that I would never recover

我开始认为我永远不会康复了，

either from the accident or from the withdrawal.

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

于是塞耶再次联系了开药方的医生，

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

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。

from the last hospitalization.

That sounded like a great idea,

这听起来是个好主意，

so we did that immediately,

因此我们立即行动，

and we were shocked when nobody would speak with us.

接着我们傻眼了，没有人与我们沟通。

The receptionist who answered the phone advised us

电话那边的接待员告诉我们，

that the pain management team provides an inpatient service;

疼痛管理团队提供的 服务是针对住院病人的；

although they prescribe opioids to get pain under control,

尽管他们开了控制疼痛的阿片药方，

they do not oversee tapering and withdrawal.

却并不负责药方减量和戒药症状。

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

盛怒之下，我们又联系了 那个开药方的医生——

anything that could help me --

向他寻求任何能帮助我的方法——

but instead he apologized,

然而，他只是深表歉意，

saying that he was out of his depth.

表示他已尽了全力。

"Look," he told us,

“听着，”他对我们说，

"my initial advice to you is clearly bad,

“我一开始对你的建议很明显是错的，

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

所以我的官方建议是 让特拉维斯恢复原先的剂量，

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

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.

当然，我愿意恢复当初的剂量。

I was in agony.

我早已痛苦不堪。

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

但我认为，如果就这样放弃了戒药，

that I would never be free of them,

我将永远受制于它们。

and so we buckled ourselves in,

因此我们决定破釜沉舟，

and I dropped the last dose.

放弃了最后的剂量。

As my brain experienced life without prescription opioids

当我的大脑在几个月来第一次经历着

for the first time in months,

没有阿片处方的日子时，

I thought I would die.

我认为我会死去。

I assumed I would die --

我觉得自己必死无疑——

(Crying)

（抽噎）

抱歉。

I'm sorry.

(Crying)

（抽噎）

Because if the symptoms didn't kill me outright,

因为即使疾病不会完全致我于死地，

I'd kill myself.

我也会自我了断。

And I know that sounds dramatic,

我知道这听起来很夸张，

because to me, standing up here years later,

因为对几年后站在这里的健全且健康的

我来说——

whole and healthy --

to me, it sounds dramatic.

这听起来的确很夸张。

But I believed it to my core

但当时，我发自内心地相信，

because I no longer had any hope

正因为我不再抱有任何希望，

that I would be normal again.

所以我会恢复正常。

The insomnia became unbearable

失眠变得让人无法忍受，

and after two days with virtually no sleep,

在连续两天彻夜未眠后，

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

我在地下室的卫生间待了一晚。

I alternated between cooling my feverish head

我时不时地将发热的头颅

against the ceramic tiles

靠着瓷砖降温，

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

并且强制自己呕吐， 尽管我已经连续几天滴米未进。

When Sadiye found me at the end of the night

当塞耶在黎明之初发现我时，

她惊恐万分，

she was horrified,

and we got back on the phone.

于是我们回到了电话旁。

We called everyone.

我们打给了所有人。

We called surgeons and pain docs and general practitioners --

我们给外科医生，疼痛医生 和全科医师都打了电话——

anyone we could find on the internet,

所有我们能在网上找到的人，

and not a single one of them would help me.

然而没有一个人愿意帮我。

The few that we could speak with on the phone

少数我们通上电话的，

advised us to go back on the medication.

都建议我恢复原剂量。

An independent pain management clinic said that they prescribe opioids

一个独立的疼痛管理诊所 说他们可以开阿片药方，

but they don't oversee tapering or withdrawal.

但他们不负责减少剂量或戒药。

When my desperation was clearly coming through my voice,

当我的声音完全透着绝望时，

much as it is now,

差不多像现在这样，

the receptionist took a deep breath and said,

接待员深吸了一口气，说道：

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

“里德先生，听起来你需要的是康复机构，

or a methadone clinic."

或者一个美沙酮诊所。”

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

鉴于当时我没有更好的主意， 于是遵循了她的建议。

I hung up and I started calling those places,

我挂了电话，打给了她所说的地方，

but it took me virtually no time at all

但我很快就发现，

to discover that many of these facilities

事实上，许多这样的机构

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

都是为了长期戒毒的需要而设立。

In the case of opioids,

而在阿片的事例中，

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

这牵涉的不是让患者戒药，

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

而是帮助他们过渡至 更安全，更长效的阿片：

methadone or buprenorphine for maintenance treatment.

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。

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

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

显然我也不是它们所期待的患者。

After being turned away from a rehab facility,

当被一个康复机构回绝时，

I finally admitted defeat.

我最终认输了，

I was broken and beaten,

我被击溃了，

and I couldn't do it anymore.

无法再继续坚持下去了。

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

因于是我告诉塞耶，我想恢复原剂量。

I would start with the lowest dose possible,

尽可能从最低剂量开始，

and I would take only as much as I absolutely needed

并且只有在必须的时候才服用，

to escape the most crippling effects of the withdrawal.

以此来避开戒药中最恐怖的影响。

So that night she helped me up the stairs

那晚，她扶我上了台阶，

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

几周以来，我第一次真正上床了。

I took the little orange prescription bottle,

我拿起橘色的小药瓶，

I set it on my nightstand ...

放在了床头柜上...

and then I didn't touch it.

接着我就没再碰它。

I fell asleep,

我睡着了，

I slept through the night

我睡了一整夜，

and when I woke up,

当我醒来时，

the most severe symptoms had abated dramatically.

最严重的症状已奇迹般地减轻了不少。

I'd made it out.

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 --

因此——

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

抱歉，我不得不稍理一下思路。

I think this story is important.

我认为这是个重要的故事。

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

并不是因为我认为我很特殊，

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

而恰恰是因为我并不特别；

because nothing that happened to me was all that unique.

因为那些事不仅只发生在我身上。

My dependence on opioids was entirely predictable

我对阿片的依赖是完全可预见的，

given the amount that I was prescribed

医生给多少，我服多少，

and the duration for which I was prescribed it.

并且还有规定的时长。

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

依赖只是大脑对富含阿片环境的自然反应，

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

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，

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

but our health care system seemingly hasn't decided

但我们的健康护理系统似乎并未准备好面对

who's responsible for patients like me.

谁该对我这样的病人负责的问题。

The prescribers saw me as a complex patient

那个开药的医生认为我是一个复杂的患者，

needing specialized care,

需要特殊照顾，

probably from pain medicine.

甚至是止痛药。

The pain docs saw their job as getting pain under control

而疼痛医生认为他们的工作是控制疼痛，

and when I couldn't get off the medication,

当我无法摆脱药物时，

they saw me as the purview of addiction medicine.

他们认为我已经发生了药物上瘾。

But addiction medicine is overstressed

但是成瘾药主要是强调

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

和针对那些面临长期药物使用障碍的患者。

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

简而言之，医生给我开了一种 需要进行长期管理的药物，

and then I wasn't given that management,

但我并没有得到接受监管的机会，

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

我甚至不清楚这种管理性措施归谁负责。

This is a recipe for disaster

这一整个过程堪称灾难，

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

任何这样的灾难或许 都值得关注和分享——

probably worth a TED Talk --

或许值得一个TED演讲——

but the failure of opioid tapering is a particular concern

但阿片减药的失败仍然应该引起重视，

at this moment in America

特别是在当今的美国，

because we are in the midst of an epidemic

由于我们生活在这样一类的流行病中，

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

仅在2015年因用药过度 致死的人数就达到了33000人。

Nearly half of those deaths involved prescription opioids.

而这些人中，有近一半 与处方阿片类药物上瘾有关。

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

医疗群体事实上已开始 对这类危机做出反应，

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

但他们的措施无外乎是开更少的药——

and absolutely, that's going to be important.

那的确十分重要。

So for instance, we're now gaining evidence

举个例子，我们有证据证明

that American physicians often prescribe medication

美国医生会主动为病人开药，

even when it's not necessary

即使在阿片的例子中，

in the case of opioids.

这并不是必须的。

And even when opioids are called for,

甚至当患者需要阿片时，

they often prescribe much more than is needed.

医生们也会经常开出过高的剂量。

These sorts of considerations help to explain why America,

这类情况解释了为什么美国，

despite accounting for only five percent of the global population,

尽管只占世界人口的5%，

consumes nearly 70 percent of the total global opioid supply.

却消耗了全球总阿片用量的近70%。

But focusing only on the rate of prescribing

但如果仅关注开药的速率风险，

risks overlooking two crucially important points.

会忽略两个至关重要的因素。

The first is that opioids just are

其一，阿片无论是现在

and will continue to be important pain therapies.

还是未来，都会是重要的疼痛疗方。

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

如果有人承受着十分严重的慢性疼痛，

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

我向你们保证，这些药能够 支撑你继续活下去。

And second:

其二：

we can still fight the epidemic while judiciously prescribing opioids

我们仍需与流行病搏斗， 同时明智地将处方阿片

to people who really need them

留给确实需要它们的人，

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

这就需要医生在开药时正确管控剂量。

So for instance,

举个例子，

go back to the tapering regimen that I was given.

回到我的减药经历中。

Is it reasonable to expect

合理的情况是，

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

任何开阿片处方的医生都能 意识到病人是不是用药过猛。

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

在我在一篇学术期刊上发表我的故事后，

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

就有CDC（疾病防治中心）的人 给了我他们减药的袖珍指南。

This is a four-page document,

这是一份4页的文档，

and most of it's pictures.

大多数内容都是图片。

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

这些图片会指导医生 如何针对简单病例减少阿片剂量，

and one of the their recommendations

其中有条建议是

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

每周减少的剂量不得多于10%。

If my physician had given me that plan,

如果当初我的医生让我遵从了这个计划，

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

我的减药周期将会持续几个月，而不是几周。

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

我确信那样会更容易一些，

It probably would have been pretty uncomfortable,

有可能还是会感到十分不适，

but maybe it wouldn't have been hell.

但也许不至于让人痛不欲生。

And that seems like the kind of information

而且那似乎也是

that someone who prescribes this medication ought to have.

医生开药时应该考虑的信息。

In closing,

最后，

I need to say that properly managing prescribed opioids

我要说，仅靠正确使用处方阿片

will not by itself solve the crisis.

并不会彻底解决危机。

America's epidemic is far bigger than that,

美国的流行病治疗任重道远，

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

但当一类药物要为每年 几万生灵的逝去负责时，

reckless management of that medication is indefensible.

对用药的鲁莽处理就十分不可取。

Helping opioid therapy patients to get off the medication

帮助阿片治疗患者摆脱

that they were prescribed

对处方药物的依赖，

may not be a complete solution to our epidemic,

对于我们的流行病治疗来说 也许不是一个万全之策，

but it would clearly constitute progress.

但它显然是一种突破。

Thank you.

谢谢。

(Applause)

（掌声）