Travis Rieder: The agony of opioid withdrawal -- and what doctors should tell patients about it
トラヴィス・リーダー: 医師が患者に伝えるべきオピオイド離脱の苦闘
Travis Rieder wants to help find a solution to America’s opioid crisis -- and if that sounds a bit too lofty, he’d settle for making clear, incremental progress in a responsible, evidence-based way. Full bio
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服用していますか?」
that changed my life.
ごく慣例の質問です
I nearly lost my foot
約2カ月後のことです
surgeon's office
すでに何回も訪れたオフィスに
訪れていました
oxycodone," I responded.
this information to many doctors
何回も伝えていましたから
そのオピオイド量は多いですね
about getting off the meds now."
that anyone had expressed concern.
今回が初めてでした
real conversation I'd had
私が受けていたオピオイド療法に関して
この時が初めてでした
my entire experience of medical trauma.
私の体験した医療トラウマそのものです
is a much too aggressive tapering regimen,
指示された急激な薬の減量計画では
my medication into four doses,
over the course of the month.
毎週段階的に減量することでした
into acute opioid withdrawal.
急性のオピオイド離脱症でした
別の言い方をすると
feel a lot like a bad case of the flu.
重いインフルエンザに似ています
in my rather mangled foot;
due to a general feeling of restlessness.
夜 眠れなくなりました
what was coming.
次にどうなるか知らなかったからです
seemed to go haywire.
止むことなく流れました
into the hot August sun,
8月の熱い太陽に当たると
covered in goosebumps.
気づきました
sleep difficult during that first week
不穏な気持ちは
as the withdrawal feeling.
考えるようになりました
that would keep me twitching.
筋肉をピクピクさせ
disturbing was the crying.
突然の号泣
like a neural misfire,
and she called the prescribing doctor
薬を処方した医師の「親切」な助言は
lots of fluids for the nausea.
それだけでした
"You know, he's really quite badly off,"
「症状はかなりひどい」と言うと
"Well, if it's that bad,
「そんなにひどいようなら
previous dose for a little while."
私は不安げに聞くと
医師はそう言いました
to go back on my previous dose
断固として反対でした
it through the withdrawal next time.
確実な計画がない限りは
and dropped another dose.
量をもう一段階落としました
イライラが原因で
that would keep me writhing all night.
like a misfire before
I would get that welling in my chest
desperation and hopelessness.
失望と絶望感
that I would never recover
薬の離脱症状からも
or from the withdrawal.
思うようになりました
with the prescriber
that we contact our pain management team
疼痛管理チームの担当者に
when nobody would speak with us.
誰一人として私たちに対応したがらないこと
the phone advised us
provides an inpatient service;
入院患者だけに対応できて
to get pain under control,
tapering and withdrawal.
and begged him for anything --
どうにかしてくれと訴えましたー
何でもいいとー
言いました
医師は続けて言いました
is that Travis go back on the medication
トラヴィスがとりあえず元の量の薬を服用し
more competent to wean him off."
見つかるまで待つこと」
to go back on the medication.
やまやまでした
myself from the withdrawal with the drugs
また薬に頼ると
解放されないと確信しました
without prescription opioids
オピオイドの無い状態を
didn't kill me outright,
standing up here years later,
ここに立っていると
with virtually no sleep,
on the floor of our basement bathroom.
my feverish head
despite not having eaten anything in days.
激しい嘔吐を試みました
at the end of the night
電話しまくりました
and general practitioners --
家庭医であろうと関係なくー
誰にでも
would help me.
手助けしてくれる人はいませんでした
speak with on the phone
said that they prescribe opioids
オピオイドは処方するけれど
tapering or withdrawal.
was clearly coming through my voice,
声から伝わったのでしょうかー
took a deep breath and said,
what you need is a rehab facility
リハビリ施設 或いは
と言いました
so I took her advice.
彼女の言うことを素直に受け止め
calling those places,
そのような施設に電話をしました
long-term substance use disorder.
対象にした施設であり
weaning the patient off the medication,
段階的な離脱ではなく
onto the safer, longer-acting opioids:
つまり
for maintenance treatment.
had an extensive waiting list.
長い順番待ちが必要でした
they were designed to see.
患者に当てはまりませんでした
from a rehab facility,
going back on the medication.
the lowest dose possible,
as I absolutely needed
effects of the withdrawal.
最小量を服用することを決めました
I actually went to bed.
prescription bottle,
had abated dramatically.
that was my response, too.
私も正に同じ反応でした
just a little bit.
ちょっと心を落ち着かせてください
思っているからではありません
precisely because I'm not special;
特別では無いからですー
to me was all that unique.
珍しいわけではありません
was entirely predictable
for which I was prescribed it.
全く予測通りでした
response to an opioid-rich environment
脳が自然に反応していることです
to think that from the beginning,
well-formed tapering plan,
seemingly hasn't decided
決められていません
as a complex patient
疼痛医学の観点から
as getting pain under control
彼らの役目は痛みを抑えることで
get off the medication,
離脱できなくなった段階では
of addiction medicine.
管轄だと考えました
from long-term substance use disorder.
強調されすぎています
that needed long-term management
長期の管理体制が必要だったのに
whose job such management was.
ハッキリしていませんでした
and worth talking about --
話題にされるべきですー
is a particular concern
注意が払われていない現状は
大きな問題になっています
依存症の問題の渦中にいて
from overdose in 2015.
過剰量の服用で命を落としています
involved prescription opioids.
処方オピオイドの犠牲者です
started to react to this crisis,
trying to prescribe fewer pills --
薬の投与量を制限するものです
that's going to be important.
we're now gaining evidence
often prescribe medication
多くの場合
傾向があること
much more than is needed.
help to explain why America,
先に述べたアメリカの現状ー
of the global population,
of the total global opioid supply.
上がっていることの裏付けとなります
on the rate of prescribing
問題視することで
two crucially important points.
見落としてしまう可能性があります
important pain therapies.
欠かせない薬品であるということ
severe, real, long-lasting pain,
当事者として言えることは
can make life worth living.
生きることに価値が生まれることは確かです
while judiciously prescribing opioids
慎重な処方を続けながらも
医薬品の管理に当たることを義務づけることで
manage the pills that they do prescribe.
that I was given.
再度考えてみると
knows that that is too aggressive?
期待しすぎでしょうか?
in an academic journal,
学術誌に発表すると
their pocket guide for tapering opioids.
オピオイド漸減療法のガイドが届きました
how to taper opioids in the easier cases,
オピオイド依存症の漸減療法を医師に説明し
than a 10 percent dose reduction per week.
10%以上減量しないということです
instead of a few weeks.
何カ月にも及んだことでしょう
pretty uncomfortable,
決して楽ではなかったと思いますが
the kind of information
この薬品を処方する立場の人の手元に
this medication ought to have.
prescribed opioids
オピオイド療法だけでは
is far bigger than that,
それだけでは対応できません
for tens of thousands of deaths a year,
年間何万人もの死につながるのであれば
of that medication is indefensible.
弁解の余地がありません
to get off the medication
to our epidemic,
言い切れませんが
ABOUT THE SPEAKER
Travis Rieder - BioethicistTravis Rieder wants to help find a solution to America’s opioid crisis -- and if that sounds a bit too lofty, he’d settle for making clear, incremental progress in a responsible, evidence-based way.
Why you should listen
A philosopher by training, bioethicist by profession and communicator by passion, Travis Rieder writes and speaks on a variety of ethical and policy issues raised by both prescription and illicit opioid use.
This wasn't always his beat, though. Both in his doctoral training at Georgetown University, and as faculty at Johns Hopkins University’s Berman Institute of Bioethics, Rieder published widely on a variety of topics in philosophy and ethics. His interest in opioids came about suddenly, after a motorcycle accident, when he took too many pills for too long and suddenly found himself with a profound dependency. In the wake of that experience, he became driven to discover why medicine is so bad at dealing with prescription opioids, and how that problem is related to the broader drug overdose epidemic.
Rieder's first article on the topic, in the journal Health Affairs, was one of the most-read essays in 2017 and was excerpted by the Washington Post. Since then, Rieder has co-authored a Special Publication of the National Academy of Medicine on physician responsibility for the opioid epidemic, written several essays for the popular media and spoken widely on the topic to physicians, medical students and the general public. He expands on all of this work in a new book project forthcoming with HarperCollins, tentatively titled In Pain In America.
Travis Rieder | Speaker | TED.com