A doctor's case for medical marijuana | David Casarett

譯者: joya xue 審譯者: 庭芝 梁

I would like to tell you about the most embarrassing thing

我想跟你們說說， 在我擔任臨終關懷治療師的時候，

that has ever happened to me in my years of working as a palliative care physician.

曾經發生過最尷尬的一件事。

This happened a couple of years ago.

那是在好幾年前發生的。

I was asked as a consultant to see a woman in her 70s --

我受託去見一位 70 多歲的女士， 擔任她的醫療顧問──

retired English professor who had pancreatic cancer.

她是一位退休的英文教授， 罹患胰腺癌。

I was asked to see her because she had pain, nausea, vomiting ...

我被找去是因為她覺得 疼痛、噁心、想吐......

When I went to see her, we talked about those symptoms

當我去見她的時候， 我們談論了這些症狀；

and in the course of that consultation,

而在諮詢的過程中，

she asked me whether I thought that medical marijuana might help her.

她問我是否認為 藥用大麻能幫助到她。

I thought back to everything

我回想了所有在醫學院學過的， 關於藥用大麻的知識；

that I had learned in medical school about medical marijuana,

which didn't take very long because I had learned absolutely nothing.

這並不需要很多時間，

因為我完全沒學過 任何藥用大麻的知識。

And so I told her that as far as I knew,

所以我告訴她：

據我所知，藥用大麻 並沒有什麼用處。

medical marijuana had no benefits whatsoever.

And she smiled and nodded and reached into the handbag next to the bed,

她微笑並點點頭， 然後從床邊的提袋裡，

and pulled out a stack of about a dozen randomized controlled trials

拿出將近一打的 隨機對照試驗報告，

showing that medical marijuana has benefits

結果都顯示藥用大麻有助於減緩 噁心、疼痛、焦慮等症狀。

for symptoms like nausea and pain and anxiety.

She handed me those articles and said,

她把那些報告遞給我，並且說：

"Maybe you should read these before offering an opinion ...

「或許你應該先讀讀這些， 再發表意見......醫生。」

doctor."

(Laughter)

（笑聲）

So I did.

於是我照做了。

That night I read all of those articles and found a bunch more.

那天晚上，我把那些報告全讀過了，

還找到了更多的資料。

When I came to see her the next morning,

當我第二天去見她的時候，

I had to admit that it looks like there is some evidence

我不得不承認，

看起來的確有一些證據， 支持大麻具有醫療效果；

that marijuana can offer medical benefits

and I suggested that if she really was interested,

於是我建議， 如果她真的有意願的話，

she should try it.

她應該試一試。

You know what she said?

你知道她怎麼回答嗎？

This 73-year-old, retired English professor?

那位 73 歲的退休英文教授？

She said, "I did try it about six months ago.

她說：「我大約六個月前就試過了。

It was amazing.

它超級棒。

之後我每天都用，

I've been using it every day since.

It's the best drug I've discovered.

這是我所發現過最棒的藥。

我不曉得為何花了 73 年 才發現這個東西，它棒極了。」

I don't know why it took me 73 years to discover this stuff. It's amazing."

(Laughter)

（笑聲）

That was the moment at which I realized

那時我才意識到，

I needed to learn something about medical marijuana

我需要學習藥用大麻相關的知識，

because what I was prepared for in medical school

因為我在醫學院裡所學到的，

bore no relationship to reality.

已經和現實脫節了。

So I started reading more articles, I started talking to researchers,

於是我開始閱讀更多資料， 開始和研究人員交流，

I started talking to doctors,

開始和醫生們交流，

and most importantly, I started listening to patients.

更重要的是， 我開始傾聽患者的聲音。

I ended up writing a book based on those conversations,

基於那些對話，我後來寫了一本書，

and that book really revolved around three surprises --

那本書以三件 「意料之外」的事件為中心──

surprises to me, anyway.

反正對我來說是意料之外的，

One I already alluded to --

第一件事我剛剛已經提到了──

that there really are some benefits to medical marijuana.

藥用大麻的確是有一些效果的。

Those benefits may not be as huge or as stunning

或許那些藥用大麻的成效，

並不像某些積極擁護者 所希望我們相信的──

as some of the most avid proponents of medical marijuana

藥用大麻具有顯著或者驚人的效果，

would have us believe,

but they are real.

但是它真的有效。

Surprise number two:

第二個意料之外是：

medical marijuana does have some risks.

藥用大麻也具有某些危害。

Those risks may not be as huge and as scary

但那些危害並沒有嚴重或者恐怖到，

as some of the opponents of medical marijuana would have us believe,

藥用大麻的反對者 想讓我們相信的程度，

but they are real risks, nonetheless.

儘管如此，它的確具有危害。

But it was the third surprise that was most ...

但第三個意料之外，

surprising.

是最令人驚訝的。

And that is that a lot of the patients I talked with

許多我曾經接觸過，

求助於藥用大麻的患者，

who've turned to medical marijuana for help,

weren't turning to medical marijuana because of its benefits

並不是為了療效而使用藥用大麻的，

or the balance of risks and benefits,

也不是基於危害和效用的平衡，

or because they thought it was a wonder drug,

更不是因為他們覺得 那是一種特效藥，

but because it gave them control over their illness.

而是因為能給予他們 對疾病的控制感，

讓他們能用有效果、有效率、

It let them manage their health

in a way that was productive and efficient

有效益、覺得舒服的方式，

and effective and comfortable for them.

來管控自己的健康。

To show you what I mean, let me tell you about another patient.

為了表達的更清楚， 讓我來聊聊另一位患者。

我遇到羅繽的時候她 40 多歲，

Robin was in her early 40s when I met her.

She looked though like she was in her late 60s.

但她看起來像是快要 70 歲了。

She had suffered from rheumatoid arthritis for the last 20 years,

過去的 20 年，她受到 類風濕性關節炎的折磨，

her hands were gnarled by arthritis,

她的手因為關節炎扭曲，

her spine was crooked,

脊柱也彎了，

she had to rely on a wheelchair to get around.

她必須靠輪椅來移動。

She looked weak and frail,

她在外表上、身體上

and I guess physically she probably was,

看起來很虛弱，一碰即碎；

but emotionally, cognitively, psychologically,

但是在精神上、意識上、心理上，

she was among the toughest people I've ever met.

她是我所遇到過最堅強的人。

And when I sat down next to her

當我在她身邊坐下，

in a medical marijuana dispensary in Northern California

那是在加州北部 一間藥用大麻藥局裡，

to ask her about why she turned to medical marijuana,

我問她為什麼開始使用藥用大麻，

what it did for her and how it helped her,

這對她有什麼作用？如何幫助了她？

she started out by telling me things

她告訴我一些事，

that I had heard from many patients before.

那些也是我從許多患者那裡聽過的：

It helped with her anxiety;

它有助於解決焦慮；

it helped with her pain;

有助於解決疼痛；

when her pain was better, she slept better.

當疼痛減緩時，她就能睡得比較好。

And I'd heard all that before.

這些原因都是我聽過的。

But then she said something that I'd never heard before,

然而她接下來說的， 我卻從來沒聽過：

and that is that it gave her control over her life

藥用大麻讓她能掌控

自己的生活和健康。

and over her health.

She could use it when she wanted,

她可以在想用的時候就用，

in the way that she wanted,

以她想要的方式、

at the dose and frequency that worked for her.

以適合她的用量和頻率使用。

And if it didn't work for her, then she could make changes.

如果沒有效果，她可以做出調整。

Everything was up to her.

所有的事她都能自己作主。

The most important thing she said

最重要的就是，她說：

was she didn't need anybody else's permission --

她不需要得到其他人的允許──

not a clinic appointment, not a doctor's prescription,

不需要預約診所， 不需要醫生的處方，

not a pharmacist's order.

不需要向藥劑師購買。

It was all up to her.

一切都由她作主。

She was in control.

她說了算。

And if that seems like a little thing for somebody with chronic illness,

對於罹患慢性病的人來說， 這是一件小事嗎？

不是的，完全不是。

it's not -- not at all.

When we face a chronic serious illness,

當我們面對嚴重的慢性疾病時，

whether it's rheumatoid arthritis or lupus or cancer or diabetes,

不論是類風濕性關節炎、 狼瘡、癌症、糖尿病

or cirrhosis,

還是肝硬化，

we lose control.

我們都失去了控制權。

And note what I said: "when," not "if."

注意我是說「當」你患病的時候， 而不是用「如果」。

All of us at some point in our lives will face a chronic serious illness

我們所有人，到了人生的某個階段， 都要面對嚴重的慢性病，

that causes us to lose control.

這導致我們失去控制權。

We'll see our function decline, some of us will see our cognition decline,

我們看著自己的機能衰退， 有的人還會經歷智力衰退，

we'll be no longer able to care for ourselves,

我們不再有能力照顧自己，

to do the things that we want to do.

做我們自己想做的事。

Our bodies will betray us,

我們的身體終將背叛我們，

and in that process, we'll lose control.

而在那個過程中， 我們失去了控制權。

And that's scary.

這挺嚇人的。

Not just scary -- that's frightening,

不止是嚇人，簡直令人恐懼，

it's terrifying.

寢食難安。

When I talk to my patients, my palliative care patients,

我和我的病患， 也就是臨終關懷患者交流時，

many of whom are facing illnesses that will end their lives,

他們之中有許多人 正面臨將奪走他們生命的疾病，

they have a lot of be frightened of --

他們對很多事情感到恐懼──

pain, nausea, vomiting, constipation, fatigue,

痛楚、噁心、嘔吐、便秘、疲倦、

their impending mortality.

即將到來的死亡。

But what scares them more than anything else

但和其他所有事相比，

他們更恐懼的事情， 是可能在某個時候，

is this possibility that at some point,

也許是明天，或是下個月，

tomorrow or a month from now,

they're going to lose control of their health,

他們將會失去對自己健康的控制權，

of their lives,

對生活的控制權，

對醫療的控制權，

of their healthcare,

and they're going to become dependent on others,

他們變得必須依賴他人，

and that's terrifying.

這是很可怕的。

So it's no wonder really that patients like Robin,

所以像羅繽這樣的患者，

who I just told you about,

就是我剛剛告訴過你們的，

who I met in that clinic,

在診所裡遇到的那一位，

turn to medical marijuana

不意外的，她會選擇使用藥用大麻，

to try to claw back some semblance of control.

是為了試圖抓住 一些表面上的控制權。

How do they do it though?

但他們怎麼做到的呢？

How do these medical marijuana dispensaries --

這些販售藥用大麻的藥局，

like the one where I met Robin --

例如我遇到羅繽的那一間，

how do they give patients like Robin back the sort of control that they need?

他們是如何讓羅繽這樣的患者

獲得所需要的控制權呢？

And how do they do it

他們是如何做到那些，

in a way that mainstream medical hospitals and clinics,

主流的醫院和診所

at least for Robin, weren't able to?

無法對羅繽做的？

What's their secret?

他們的秘密是什麼？

So I decided to find out.

我決定要搞清楚。

I went to a seedy clinic in Venice Beach in California

我去了位於加州威尼斯海灘 一間破破的診所，

and got a recommendation

拿到一份同意書，

that would allow me to be a medical marijuana patient.

允許我成為一名使用 藥用大麻的病患。

I got a letter of recommendation that would let me buy medical marijuana.

我拿到了一份同意書， 能讓我購買藥用大麻。

I got that recommendation illegally,

我用不合法的方式拿到同意書，

because I'm not a resident of California --

因為我並不是加州居民──

I should note that.

我應該先聲明這點。

I should also note, for the record,

我還要聲明，以供紀錄，

that I never used that letter of recommendation to make a purchase,

就是我從未使用 那份同意書購買大麻，

and to all of you DEA agents out there --

以上的聲明是要給 美國緝毒局的調查員的──

(Laughter)

（笑聲）

love the work that you're doing,

要熱愛你們的工作，

keep it up.

繼續堅持下去！

(Laughter)

（笑聲）

Even though it didn't let me make a purchase though,

儘管我並沒有 用這份同意書進行購買，

that letter was priceless because it let me be a patient.

但是它仍然無比珍貴， 因為它讓我成為一名患者，

It let me experience what patients like Robin experience

讓我體驗到， 像羅繽這樣的患者所經歷的，

when they go to a medical marijuana dispensary.

體驗到她們在藥用大麻藥局 所得到的經驗。

And what I experienced --

而我所體驗到的──

what they experience every day,

就如同成百上千位

hundreds of thousands of people like Robin --

像羅繽一樣的人， 每天都在經歷的──

was really amazing.

簡直是棒極了。

I walked into the clinic,

我走進了藥局，

and from the moment that I entered many of these clinics and dispensaries,

從我走進這些 診所和藥局的那一刻起，

I felt like that dispensary, that clinic,

我感覺到，這間藥局、這間診所，

was there for me.

是為我設立的。

There were questions at the outset about who I am,

一開始的時候， 他們會詢問一些問題，

例如我是誰？我從事什麼工作？

what kind of work I do,

what my goals are in looking for a medical marijuana prescription,

我希望藉由藥用大麻處方或產品

or product,

達到什麼效果？

what my goals are, what my preferences are,

我的目標是什麼？喜好是什麼？

what my hopes are,

我的期望是什麼？

how do I think, how do I hope this might help me,

我是怎麼想的？ 我期望帶來什麼幫助？

what am I afraid of.

我擔心什麼？

These are the sorts of questions

像羅繽這樣的患者，

會不斷地被問到這些類型的問題。

that patients like Robin get asked all the time.

These are the sorts of questions that make me confident

像這樣的問題，會讓我有信心，

that the person I'm talking with really has my best interests at heart

覺得這個和我談話的人， 是從內心關注我的利益，

and wants to get to know me.

並且想要更瞭解我。

The second thing I learned in those clinics

我從這些診所學到的第二件事，

is the availability of education.

是可以獲得許多指導。

Education from the folks behind the counter,

除了從櫃台裡的人得到指導，

but also education from folks in the waiting room.

也從等候室裡的其他人得到指導。

當我坐在他們旁邊時， 這些人都很高興──

People I met were more than happy, as I was sitting next to them --

people like Robin --

他們都是像羅繽那樣的人──

to tell me about who they are, why they use medical marijuana,

他們告訴我：他們是誰， 為什麼使用藥用大麻？

what helps them, how it helps them,

什麼幫助了他們？如何幫助了他們？

and to give me advice and suggestions.

並給我意見和建議。

Those waiting rooms really are a hive of interaction, advice and support.

那些等候室就像是提供交流、 建議和支持的場所。

And third, the folks behind the counter.

第三，坐在櫃檯裡面的人，

I was amazed at how willing those people were

讓我驚訝的是， 他們非常心甘情願的，

to spend sometimes an hour or more talking me through the nuances

願意花一個小時甚至更多時間， 跟我討論許多細節，

of this strain versus that strain,

像是這個品種和那個品種的比較，

smoking versus vaporizing,

透過吸菸還是霧化方式，

edibles versus tinctures --

食用的還是酊劑──

all, remember, without me making any purchase whatsoever.

還記得嗎，這是在我還沒有 購買任何東西的情況下。

Think about the last time you went to any hospital or clinic

回憶一下你上次去醫院或診所，

and the last time anybody spent an hour explaining those sorts of things to you.

以及上一次有人花了一個小時 向你詳細解釋，是什麼樣的情況？

The fact that patients like Robin are going to these clinics,

實際上像羅繽這樣的患者， 會去這些診所，

are going to these dispensaries

會去這些藥局，

and getting that sort of personalized attention

得到這種程度的關注、

and education and service,

指導和服務，

really should be a wake-up call to the healthcare system.

真是現今醫療系統的警鐘。

People like Robin are turning away from mainstream medicine,

像羅繽這樣的人，會放棄主流醫療，

轉向藥用大麻藥局尋求協助，

turning to medical marijuana dispensaries

because those dispensaries are giving them what they need.

是因為那些藥局 能給予他們真正需要的。

If that's a wake-up call to the medical establishment,

如果那是對於現今醫療機構的警鐘，

it's a wake-up call that many of my colleagues are either not hearing

那也是針對我那些不去聆聽，

or not wanting to hear.

或是不願聆聽的同僚。

When I talk to my colleagues, physicians in particular,

當我告訴我的同僚，特別是內科醫生

關於藥用大麻的事，

about medical marijuana,

they say, "Oh, we need more evidence.

他們總是說： 「哦！我們需要更多證據。

We need more research into benefits, we need more evidence about risks."

我們需要更多關於成效的研究， 以及更多關於危害的證據。」

And you know what? They're right.

你知道嗎，他們是對的。

They're absolutely right.

他們絕對正確。

We do need much more evidence about the benefits of medical marijuana.

我們的確需要更多證據， 來證明藥用大麻的成效。

We also need to ask the federal government to reschedule marijuana to Schedule II,

我們也需要要求聯邦政府， 把大麻重訂為二類藥物，

or to deschedule it entirely to make that research possible.

甚至是完全取消限制， 才能讓研究進行。

We also need more research into medical marijuana's risks.

我們也需要針對藥用大麻的危害 進行更多研究。

Medical marijuana's risks --

關於藥用大麻的危害──

we know a lot about the risks of recreational use,

對於一般娛樂用大麻的危害， 我們了解很多，

we know next to nothing about the risks of medical marijuana.

但是對於藥用大麻的危害， 我們幾乎一無所知。

So we absolutely do need research,

所以我們當然需要進行研究，

but to say that we need research

但話說回來，我們需要研究

and not that we need to make any changes now

並不等於現在就不必做出改變，

這是完全忽略了重點。

is to miss the point entirely.

People like Robin aren't seeking out medical marijuana

像羅繽那樣的人使用藥用大麻，

because they think it's a wonder drug,

不是因為他們認為那是萬能藥，

or because they think it's entirely risk-free.

也不是因為他們覺得沒有風險。

They seek it out because the context in which it's delivered and administered

他們追求的原因， 是由於大麻被遞送、發放，

以及使用的環境，

and used,

gives them the sort of control they need over their lives.

這樣的環境給予他們所需要的── 對生活的掌控權。

And that's a wake-up call we really need to pay attention to.

而這是我們真正需要關注的警鐘。

The good news though is that there are lessons we can learn today

好消息是，今天我們能從

from those medical marijuana dispensaries.

藥用大麻的藥局學到這一課。

And those are lessons we really should learn.

而那些正是我們應該學習的。

These are often small, mom-and-pop operations

這些藥局通常是小型的、家庭式的，

run by people with no medical training.

由未曾受過醫療訓練的人士所經營。

想到就令我們感到羞愧，

And while it's embarrassing to think

that many of these clinics and dispensaries are providing services

這些診所和藥局 一直在為患者提供服務、支持，

and support and meeting patients' needs

並滿足他們的需求，

in ways that billion-dollar healthcare systems aren't --

以一種數百億規模的醫療系統 都做不到的方式──

we should be embarrassed by that --

我們應該對此感到羞愧──

but we can also learn from that.

但我們也應該向它學習。

And there are probably three lessons at least

我們能向這些小型藥局學習的

that we can learn from those small dispensaries.

至少有三個課題：

One: we need to find ways to give patients more control

第一，我們需要找到 小巧但是重要的方法，

來給予患者更多的控制權。

in small but important ways.

How to interact with healthcare providers,

例如如何與醫療人員溝通，

when to interact with healthcare providers,

什麼時候溝通，

how to use medications in ways that work for them.

如何以對患者有效的方式開藥。

In my own practice,

在我自己的診間裡，

I've gotten much more creative and flexible

我已經找出更有創意和彈性的方式，

in supporting my patients in using drugs safely

支持患者安全地使用藥物

來控制他們的症狀──

to manage their symptoms --

with the emphasis on safely.

同時能強調安全性。

Many of the drugs I prescribe are drugs like opioids or benzodiazepines

我所開立的很多處方， 是屬於鴉片類或苯二氮䓬類藥物，

which can be dangerous if overused.

這些藥物過量使用會有危險。

But here's the point.

但這就是重點。

They can be dangerous if they're overused,

當他們過量使用時，會造成危險；

but they can also be ineffective if they're not used in a way

但如果不能依照 患者的意願與需求來使用，

that's consistent with what patients want and need.

結果也是無效的。

So that flexibility, if it's delivered safely,

所以在安全使用的前提下，

can be extraordinarily valuable for patients and their families.

「提供彈性」對於患者和家屬， 具有非常重要的意義。

That's number one.

以上是第一點。

Number two: education.

第二個課題：指導。

Huge opportunities

這是個大好機會，

to learn from some of the tricks of those medical marijuana dispensaries

去向藥用大麻藥局學習

to provide more education

如何提供更多指導的技巧；

that doesn't require a lot of physician time necessarily,

這並不會佔用醫師太多時間，

or any physician time,

甚至根本不會佔用任何時間，

but opportunities to learn about what medications we're using

卻能給我們一個機會了解： 我們正在用什麼藥物，

以及為何用這些藥物，

and why,

prognoses, trajectories of illness,

如何預測判斷疾病的預後，

and most importantly,

以及最重要的，

opportunities for patients to learn from each other.

這是患者之間彼此學習的機會。

How can we replicate what goes on

我們如何複製出

in those clinic and medical dispensary waiting rooms?

在藥用大麻藥局等候室 所出現的情境呢？

How patients learn from each other, how people share with each other.

病人如何互相學習？ 人們如何彼此分享？

And last but not least,

最後但同樣重要的一點，

putting patients first the way those medical marijuana dispensaries do,

就是像那些藥用大麻藥局所做的， 把病患放在第一位，

making patients feel legitimately like what they want,

讓病患能感覺到，

我們這些醫療從業人員，

正是為了他們的期待

what they need,

is why, as healthcare providers,

和他們的需求而存在的。

we're here.

Asking patients about their hopes, their fears, their goals and preferences.

向患者詢問他們的 期望、恐懼、目標和偏好。

As a palliative care provider,

身為臨終關懷從業人員，

I ask all my patients what they're hoping for and what they're afraid of.

我會詢問所有的患者： 他們想要什麼？擔心什麼？

But here's the thing.

而這就是重點。

Patients shouldn't have to wait until they're chronically seriously ill,

病人們不該等到罹患慢性絕症，

不該等到接近生命的盡頭，

often near the end of life,

不該等到他們需要尋求 像我這類的醫師，

they shouldn't have to wait until they're seeing a physician like me

before somebody asks them,

才有人問他們：

"What are you hoping for?"

「你想要什麼？」

"What are you afraid of?"

「你擔心什麼？」

That should be baked into the way that healthcare is delivered.

這應該融入整個醫療體系的 提供項目之中。

We can do this --

我們可以做到這些──

we really can.

真的可以。

Medical marijuana dispensaries and clinics all across the country

全國各地的藥用大麻藥局和診所

are figuring this out.

都很清楚這件事。

They're figuring this out

規模更大、更主流的醫療系統

in ways that larger, more mainstream health systems are years behind.

在這方面落後他們許多。

But we can learn from them,

但我們可以向他們學習，

and we have to learn from them.

而且我們必須向他們學習。

All we have to do is swallow our pride --

我們需要做的 就是放下我們的驕傲──

put aside the thought for a minute

暫時放下我們的想法，

that because we have lots of letters after our name,

放下我們名字後面的 一大堆頭銜，

because we're experts,

放下我們的專家身份，

because we're chief medical officers of a large healthcare system,

放下我們在大型 醫療機構裡的主管權力，

we know all there is to know about how to meet patients' needs.

我們所應該知道的， 是如何滿足病患的需求。

We need to swallow our pride.

我們需要放下驕傲。

We need to go visit a few medical marijuana dispensaries.

我們需要去拜訪幾間藥用大麻藥局。

We need to figure out what they're doing.

我們需要搞清楚他們在做什麼。

We need to figure out why so many patients like Robin

我們需要搞清楚 為什麼很多像羅繽一樣的病人，

are leaving our mainstream medical clinics

會放棄主流醫療院所，

and going to these medical marijuana dispensaries instead.

轉向藥用大麻藥局。

We need to figure out what their tricks are,

我們需要搞清楚他們的秘訣，

what their tools are,

他們使用的工具，

and we need to learn from them.

我們需要向他們學習。

If we do,

如果我們這樣做了，

and I think we can, and I absolutely think we have to,

我認為我們可以， 並且我們必須做到的，

we can guarantee all of our patients will have a much better experience.

我們可以確保所有的患者 都能得到更好的體驗。

Thank you.

謝謝大家。

(Applause)

（掌聲）