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

譯者: Lilian Chiu 審譯者: Yanyan Hong

"How much pain medication are you taking?"

「你服用多少止痛藥？」

That was the very routine question that changed my life.

這個非常例行性的問題 改變了我的人生。

It was July 2015,

時間是 2015 年 7 月，

about two months after I nearly lost my foot

兩個月前，我差點在一場嚴重的

in a serious motorcycle accident.

摩托車意外中險些失去了我的腳。

So I was back in my orthopedic surgeon's office

我回到我的整形外科醫生的辦公室，

for yet another follow-up appointment.

這是另一次後續追蹤的會面。

I looked at my wife, Sadiye;

我看著我的太太莎蒂耶； 我們做了一些計算。

we did some calculating.

"About 115 milligrams oxycodone," I responded.

我回應：「大約 115 毫克的氧可酮。」

"Maybe more."

「或許更多一些。」

I was nonchalant, having given this information to many doctors

我很冷靜，畢竟以前 已經告訴過許多醫生

many times before,

這項資訊很多次了，

but this time was different.

但這一次卻不同。

My doctor turned serious

我的醫生開始嚴肅起來，

and he looked at me and said,

他看著我說：

"Travis, that's a lot of opioids.

「崔佛斯，那是很大量的鴉片類藥物。

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

你得要考慮現在 就開始脫離這些藥物。」

In two months of escalating prescriptions,

兩個月來，處方的藥量不斷增高，

this was the first time that anyone had expressed concern.

這倒是頭一次有人表示關心。

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

的確，這是我第一次針對 我的類鴉片藥物治療

about my opioid therapy, period.

所進行真正的談話，沒別的。

I had been given no warnings,

之前都沒人給我過任何警告、

no counseling,

任何咨詢、

no plan ...

任何計劃……

just lots and lots of prescriptions.

只是給我很多很多的處方。

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

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。

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

我現在知道了，當時他們給我 太積極的漸減式給藥方案，

according to which I divided my medication into four doses,

根據這個方案， 我將我的藥物劑量分為四份，

dropping one each week over the course of the month.

在一個月的期間，每週減少一份。

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

結果是，我開始發生急性類鴉片戒斷。

The result, put another way,

換一種說法，結果就是

was hell.

像地獄一樣。

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

戒斷的初期， 感覺像是糟糕的感冒。

I became nauseated,

我會感到惡心，

lost my appetite,

失去食慾，

I ached everywhere,

全身都疼痛，

had increased pain in my rather mangled foot;

我那隻被壓壞的腳也越來越痛；

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

因為總是感到焦躁不安， 我甚至開始難以入眠。

At the time,

當時，

I thought this was all pretty miserable.

我以為這些狀況算是很悲慘。

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

那是因為我還不知道 後面有什麼在等著我。

At the beginning of week two,

第二週剛開始時，

my life got much worse.

我的人生變得很糟。

As the symptoms dialed up in intensity,

症狀的強度都增加了，

my internal thermostat seemed to go haywire.

我的內部恆溫器似乎在混亂暴走。

I would sweat profusely almost constantly,

我幾乎常常會大汗淋漓，

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

但如果在炎熱的八月 我有辦法出門到大太陽底下，

I might look down and find myself covered in goosebumps.

我可能低頭就會看到 我自己滿身雞皮疙瘩。

The restlessness that had made sleep difficult during that first week

在第一週，焦躁不安讓我難以入眠，

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

現在則變成了一種 我漸漸認為是戒斷的感覺。

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

它是一種很深刻的神經過敏感， 會讓我一直抽動。

It made sleep nearly impossible.

它讓睡眠變成幾乎不可能。

But perhaps the most disturbing was the crying.

但最惱人也許是哭泣吧。

I would find myself with tears coming on

我會發現自己淚流滿面，

for seemingly no reason

但似乎沒什麼理由，

and with no warning.

且毫無預警。

At the time they felt like a neural misfire,

當下的感覺就像是神經故障，

similar to the goosebumps.

跟雞皮疙瘩很類似。

Sadiye became concerned, and she called the prescribing doctor

莎蒂耶很擔心， 便打電話給開處方的醫生，

who very helpfully advised lots of fluids for the nausea.

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,"

她進一步逼問他： 「他的狀況真的很不好。」

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

醫生回應：「嗯，如果有那麼糟，

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

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

我絕對不可能再恢復先前的劑量，

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

除非我有更好的計畫 能讓我下次順利通過戒斷。

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

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,

第三週剛開始時，

my world got very dark.

我的世界非常黑暗。

I basically stopped eating,

基本上我已經不再進食了，

and I barely slept at all

我也幾乎沒在睡覺，

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

這要歸功於讓我整晚扭動的神經過敏。

But the worst --

但最糟的是——

the worst was the depression.

最糟的是憂鬱。

The tears that had felt like a misfire before

本來感覺像是故障造成的眼淚，

now felt meaningful.

現在感覺有意義了。

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

一天會有好幾次， 我的胸口會有什麼湧上來的感覺，

where you know the tears are coming,

你會知道眼淚馬上就要來了，

but I couldn't stop them

但我無法阻止它們，

and with them came desperation and hopelessness.

和它們一起來的， 是絕望和無望的感覺。

I began to believe that I would never recover

我開始相信，我永遠不會復元了，

either from the accident or from the withdrawal.

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

莎蒂耶再度打電話給開處方的醫生，

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

這次醫生建議我們聯絡 我最後一次住院時的

from the last hospitalization.

疼痛管理團隊。

That sounded like a great idea,

那聽起來像是個好主意，

so we did that immediately,

所以我們馬上照做了，

and we were shocked when nobody would speak with us.

令人驚訝的是， 沒人願意跟我們說話。

The receptionist who answered the phone advised us

接電話的接待人員告訴我們，

that the pain management team provides an inpatient service;

疼痛管理團隊 提供服務給住院病人；

although they prescribe opioids to get pain under control,

雖然他們會開類鴉片藥物來控制疼痛，

they do not oversee tapering and withdrawal.

但他們不管漸漸減量和戒斷。

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

我們火大了， 又打電話給開處方的醫生，

求他給我一點什麼——

anything that could help me --

任何能幫助我的都好——

but instead he apologized,

但他卻只是道歉，

saying that he was out of his depth.

說這已經超過他的能力範圍。

"Look," he told us,

「聽著，」他告訴我們：

"my initial advice to you is clearly bad,

「我一開始給你的建議 很顯然是不好的，

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

所以我的正式建議是， 崔佛斯應該回到先前的劑量，

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

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.

我當然很想要回到之前的劑量。

I was in agony.

我很痛苦。

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

但我相信如果我不去戒斷這些藥物，

that I would never be free of them,

我永遠脫離不了它們，

and so we buckled ourselves in,

所以我們狠下心，

and I dropped the last dose.

減掉最後一份劑量。

As my brain experienced life without prescription opioids

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，

for the first time in months,

I thought I would die.

我覺得我要死了。

I assumed I would die --

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,

因為如果症狀沒有徹底把我殺死，

I'd kill myself.

我也會自殺。

And I know that sounds dramatic,

我知道那聽起來很戲劇化，

because to me, standing up here years later,

因為對我來說，幾年後站在這裡，

whole and healthy --

完整且健康——

to me, it sounds dramatic.

對我來說，聽起來很戲劇化。

But I believed it to my core

但我發自內心相信，

because I no longer had any hope

因為我不再抱有

我能夠再次恢復正常的任何希望。

that I would be normal again.

The insomnia became unbearable

失眠變得讓人無法忍受，

and after two days with virtually no sleep,

在足足兩天無法入睡之後，

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

我整晚都待在地下室浴室的地板上。

I alternated between cooling my feverish head

一下子是把我發燒的頭部靠在磁磗上

against the ceramic tiles

讓它冷卻下來，

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

一下子是用力嘔吐， 即使數天都幾乎沒有吃什麼。

When Sadiye found me at the end of the night

莎蒂耶在夜將盡時找到了我，

she was horrified,

她嚇壞了，

and we got back on the phone.

我們又去打電話。

We called everyone.

我們打給每個人。

We called surgeons and pain docs and general practitioners --

我們打給外科醫生、疼痛醫生， 還有家庭醫生——

anyone we could find on the internet,

任何我們在網路上能找到的人，

and not a single one of them would help me.

卻沒有一個人能夠幫我。

The few that we could speak with on the phone

有少數幾個人願意 在電話上和我們說話，

advised us to go back on the medication.

建議我們再把劑量加回來。

An independent pain management clinic said that they prescribe opioids

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，

but they don't oversee tapering or withdrawal.

但他們不負責減量或戒斷的部分。

When my desperation was clearly coming through my voice,

當我説話的聲音中 都帶著明顯的絕望時，

much as it is now,

就像現在一樣，

the receptionist took a deep breath and said,

接待人員深呼吸之後說：

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

「雷德先生，聽起來 你可能需要去勒戒機構

or a methadone clinic."

或美沙酮診所。」

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

我當時什麼也不懂， 就接受了她的建議。

I hung up and I started calling those places,

我掛了電話， 開始打電話到這些地方，

but it took me virtually no time at all

但我完全沒花什麼時間，

to discover that many of these facilities

就發現許多這類機構

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

適合的是與藥物濫用長期抗戰的人。

In the case of opioids,

至於類鴉片藥物，

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

通常就是不要讓病人馬上戒掉藥物，

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

而是要讓他們轉換到更安全、 更長效的類鴉片藥物：

methadone or buprenorphine for maintenance treatment.

美沙酮或丁丙諾啡，以維持治療。

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

此外，我找的每個地方， 等候名單都很長。

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

我很明確就不是他們的目標對象。

After being turned away from a rehab facility,

在被一間勒戒機構拒絕了之後，

I finally admitted defeat.

我終於承認失敗。

I was broken and beaten,

我徹底被打倒了，

and I couldn't do it anymore.

我沒辦法再繼續了。

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

我告訴莎蒂耶， 我要恢復原本的劑量。

I would start with the lowest dose possible,

我先盡可能從最低的劑量開始，

and I would take only as much as I absolutely needed

只取用我絕對必要的量就好，

to escape the most crippling effects of the withdrawal.

只是為了脫離最嚴重的戒斷效應。

So that night she helped me up the stairs

那晚，她扶我起來，爬上樓，

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

數個星期以來， 我第一次真的爬上床。

I took the little orange prescription bottle,

我拿了裝處方藥的橘色小瓶子，

I set it on my nightstand ...

放在我的床頭櫃上……

and then I didn't touch it.

我並沒有去碰它。

I fell asleep,

我入睡了，

I slept through the night

我睡了整晚，

and when I woke up,

當我醒來時，

the most severe symptoms had abated dramatically.

最嚴重的症狀已經大大減輕。

I'd made it out.

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 --

所以——

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

抱歉，我得要調整一下心情。

I think this story is important.

我認為這個故事很重要。

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

並不是因為我認為我很特別。

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

這個故事之所以重要， 正是因為我不特別；

because nothing that happened to me was all that unique.

因為發生在我身上的事 並非獨一無二。

My dependence on opioids was entirely predictable

我對於類鴉片藥物的依賴 完全是可預期的，

given the amount that I was prescribed

畢竟我拿到的處方劑量相當大，

and the duration for which I was prescribed it.

我吃處方藥的期間也很長。

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

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，

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

所以絕對有理由可以相信， 打從一開始，

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

我就需要一個 受監控且合適的減量計畫，

but our health care system seemingly hasn't decided

但我們的健康照護制度似乎還沒有決定

who's responsible for patients like me.

像我這樣的病人要由誰來負責。

The prescribers saw me as a complex patient

開處方藥的醫生 把我視為一個複雜的病人，

needing specialized care,

需要專門的照護，

probably from pain medicine.

可能戒除止痛藥物。

The pain docs saw their job as getting pain under control

疼痛醫生認為他們的工作 是要控制疼痛，

and when I couldn't get off the medication,

當我無法脫離藥物時，

they saw me as the purview of addiction medicine.

他們認為我屬於上癮藥物的範圍。

But addiction medicine is overstressed

但上癮藥物主要是強調

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

和著重那些對抗長期藥物濫用的人。

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

簡言之，我拿到的處方藥 是需要長期管理的藥物，

and then I wasn't given that management,

但卻沒人提供我這種管理，

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

甚至不清楚這種管理到底是誰的工作。

This is a recipe for disaster

這注定會導致災禍，

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

任何像這樣的災禍 會很有意思且值得拿出來談——

probably worth a TED Talk --

可能值得做一場 TED 演說——

but the failure of opioid tapering is a particular concern

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，

at this moment in America

because we are in the midst of an epidemic

因為我們現在正在流行期當中，

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

2015 年就有三萬三千人 因為用藥過量致死。

Nearly half of those deaths involved prescription opioids.

這些人當中，有近一半 和有處方的類鴉片藥物有關。

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

事實上，醫療圈已經開始 對這項危機做出反應，

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

但他們的反應大多是在試圖 開比較少的處方藥——

and absolutely, that's going to be important.

當然，那是很重要的。

So for instance, we're now gaining evidence

比如，我們現在有證據顯示，

that American physicians often prescribe medication

美國醫生常在即使不必要的時候，

even when it's not necessary

也會開處方藥，

in the case of opioids.

如類鴉片藥物。

And even when opioids are called for,

即使是需要類鴉片藥物時，

they often prescribe much more than is needed.

他們處方的劑量也比需要的多很多。

These sorts of considerations help to explain why America,

這類原因說明為什麼美國人口

despite accounting for only five percent of the global population,

只佔了世界人口的 5%，

consumes nearly 70 percent of the total global opioid supply.

消耗掉的類鴉片藥物 卻佔全球總供應的近 70%。

But focusing only on the rate of prescribing

但如果只把焦點放在開處方的比率，

risks overlooking two crucially important points.

會有忽略兩個關鍵點的風險。

The first is that opioids just are

第一，類鴉片藥物目前是，

and will continue to be important pain therapies.

將來也繼續會是重要的止痛方式。

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

我自己不久前才經歷了 嚴重、真實、長久的痛苦，

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

我可以向各位保證， 這些藥物能讓人生變得值得活下去。

And second:

第二，

we can still fight the epidemic while judiciously prescribing opioids

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

to people who really need them

給真正需要它們的人，

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

做法是要求醫生要妥當管理 他們處方的藥物。

So for instance,

舉例來說，

go back to the tapering regimen that I was given.

回到他們給我的劑量漸減方案。

Is it reasonable to expect

期待處方類鴉片藥物給我的醫生

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

知道這個方案太積極， 這種期待是合理的嗎？

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

在我把我的故事初次刊登在 一本學術期刊上之後，

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

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。

This is a four-page document,

這份文件共四頁，

and most of it's pictures.

大部分是圖片。

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

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，

and one of the their recommendations

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

就是每週減少的劑量 不要超過 10%。

If my physician had given me that plan,

如果我的醫生有給我這樣的方案，

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

我的劑量漸減會需要花 數個月時間，而不是幾週。

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

我確信不會太好過。

It probably would have been pretty uncomfortable,

可能會很不舒服，

but maybe it wouldn't have been hell.

但也許不會像地獄一樣。

And that seems like the kind of information

這些資訊似乎是

that someone who prescribes this medication ought to have.

負責處方這類藥物的人應該要知道的。

In closing,

最後結尾，

I need to say that properly managing prescribed opioids

我得要說，單靠妥當管理 處方的類鴉片藥物

will not by itself solve the crisis.

不能解決危機。

America's epidemic is far bigger than that,

美國的流行狀況嚴重到它無法解決，

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

但如果這種藥物 造成一年數萬人死亡，

reckless management of that medication is indefensible.

隨便管理這類藥物是不可原諒的。

Helping opioid therapy patients to get off the medication

協助類鴉片藥物治療的病人戒除

that they were prescribed

他們的處方藥物

may not be a complete solution to our epidemic,

或許不是能徹底解決流行問題的方案，

but it would clearly constitute progress.

但它依然可以帶來進展。

Thank you.

謝謝。

(Applause)

（掌聲）