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医生观点阐述药用大麻

A doctor's case for medical marijuana | David Casarett

我想跟你们说说
I would like to tell you about the most embarrassing thing
在我当临终关怀治疗医师这些年头
that is ever happened to me
发生的最让人尴尬的事情
in my years of working as a palliative care physician.
这件事发生在几年前
This happened a couple of years ago,
我受托去见一位70多岁的女士
I was asked as consultant to see a woman
她是一位退休英语老师 患有胰腺癌
in her 70s retired English professor, who had pancreatic cancer.
我被找去是因为她疼痛 恶心 呕吐
I was asked to see her because she had pain, nausea, vomiting.
当我就诊时
When I went to see her,
咨询过程中
we talked about those symptoms
我们讨论了这些症状 她问我
and in the course of that consultation, she asked me,
是否认为药用大麻能帮助到她
whether I thought that medical marijuana might help her.
我回想了一切在医学院学过的
I thought back to everything
关于药用大麻的知识
that I’ve learned in medical school about medical marijuana,
这次并不需要很长时间 因为我根本没学过什么
which didn’t take very long because I had learned absolutely nothing.
然后我告诉她 就我所知
And so I told her that as far as I knew,
药用大麻并没有什么用处
medical marijuana had no benefits whatsoever.
她笑了并点点头
And she smiled and nodded
然后从床边的手提包里
and reached into the handbag next to the bed,
拿出了将近一沓的随机对照实验报告
and pulled out a stack of about a dozen randomized control trails,
结果都显示药用大麻有助于
showing that medical marijuana has benefits for
减缓恶心 疼痛 焦虑的症状
symptoms like nausea and pain and anxiety.
她把那些报告递给我说:
She handed me those articles and said,
“医生 或许你应该先看看这些 再发表你的观点”
“Maybe you should read these before offering your opinion, doctor. “
我照做了 那天晚上我看了所有那些文章
So I did. That night I read all of those articles
还找到了更多的资料
and found a bunch more.
第二天早上去见她的时候
When I came to see her the next morning,
我不得不说 看起来的确
I had to admit that it looks like
有一些证据表明药用大麻有治疗效果
there is some evidence that marijuana can offer medical benefits.
然后我建议如果她真的感兴趣的话
And I suggested that if she really was interested,
她可以试一试
she should try it.
你们知道她说什么吗?
You know what she said?
这位73岁退休的英语教授
This 73-year old retired English professor.
她说:“六个月前我就试了
She said, “I did try it about six months ago.
太神奇了 从那之后 我每天都要用
It was amazing. I’ve been using it every day since,
这是我发现的最好的药
it’s the best drug I’ve discovered,
我不知道为什么我73岁了
I don’t know why it took me seventy-three years
才发现它 太棒了”
to discover this stuff. It’s amazing.”
那时我才意识到
That was the moment at which I realized
我需要学习关于药用大麻的知识
I needed to learn something about medical marijuana,
因为我在医学院学到的
because what I was prepared for a medical school
已经和现实脱离了
board no relationship to reality.
于是我开始阅读更多的文章
So I started reading more articles,
开始和研究人员交流
I started talking to researchers,
开始和医生交流 最重要的是
I started talking to doctors and most importantly,
我开始倾听患者的话
I started listening to patients,
最后根据这些对话 我写了一部书
ended up writing a book based on those conversations.
这本书以3个意外事件为中心
And that book really revolved around three surprises.
反正对我来说是意料之外的
Surprises to me, anyway.
第一件事我刚刚已经提到了
One I already alluded to,
药用大麻的确有一些疗效
but there really are some benefits to medical marijuana.
或许那些疗效并不显著或者令人感到吃惊
Those benefits may not be as huge or as stunning,
也不像那些极其拥护药用大麻的人
as some of the most avid proponents of medical marijuana
希望我们相信的那样 但是他们确实会有效果
would have us believe, but they are real.
第二个意料之外的事
Surprise number two,
药用大麻存在一些危害
medical marijuana does have some risks.
那些危害并没有严重恐怖到
Those risks may not be as huge and as scary as
药用大麻反对者让我们相信的程度
some of the opponents of medical marijuana would have us believe.
然而药用大麻确实也存在危害
But they are real risks nonetheless.
第三件事是最让我惊讶的
But it is the third suprise that was most surprising.
许多我曾经接触过
And that is that a lot of the patients I talked with
求助于药用大麻的患者
whose turned to medical marijuana for help,
他们并不是因为药用大麻的药效
weren’t turning to medical marijuana
或者基于危害和效用的平衡 从而使用药用大麻
because of its benefits or the balance of risks and benefits,
更不是因为他们觉得它是一种特效药
or because they thought it was a wonder drug,
而是因为它可以给予他们对疾病的控制感
but because it gave them control over their illness.
可以更有成效的 有效率的 舒服的
It let them manage their health in a way that was productive
管理他们的健康
and effective and comfortable for them.
为了跟你们说清楚 让我来聊聊另外一位患者
To show you, I mean let me tell you about another patient.
我遇见罗宾的时候 她40岁
Robin was in her early 40s when I met her.
但她看起来都快要70了
She looked though like she was in her late 60s.
过去的20年 她一直遭受风湿关节炎的折磨
She had suffered from rheumatoid arthritis for the last twenty years,
她的手因为关节炎扭曲
her hands were gnarled by arthritis,
脊柱也弯了
her spine was crooked.
她必须依靠轮椅行动
She had to rely on a wheelchair to get around.
我觉得从身体状况来看
She looked weak and frail
她很虚弱 好像弱不禁风
and I guess physically she probably was,
但是在情感 认知 心理方面
but emotionally, cognitively, psychologically,
她是我遇见过最坚强的人
she was among the toughest people I’ve ever met.
我坐在她旁边
And I sat down next to her
那是加州北部一间药用大麻配药局里
in the medical marijuana dispensary in Northern California,
我问她为什么她要使用药用大麻
to ask her about why she turns medical marijuana,
这能起到什么效果 怎么帮助她
what it did for her and how it helped her.
她开始给我讲一些事
She started out by telling me things
这也是我之前从许多患者那听到的
that I had heard from many patients before.
药用大麻有助于解决焦虑
It helped with her anxiety.
帮助她缓解疼痛
It helped with her pain.
当疼痛减缓时 她就能睡得更好
When her pain was better, she slept better.
这些我之前都听到过
I’d heard all that before,
而接下来她所说的 我却从没听见过
but then she said thing that I’ve never heard before.
药用大麻能让她掌控自己的生活
And that is that it gave her control over her life
以及自己的健康情况
and over her health.
她可以想用的时候就用
She could use it when she wanted,
以她想要的方式
in the way that she wanted,
以适合她的剂量和频率
at the dose and frequency that worked for her,
如果药效不显著
and if it didn’t work for her,
她也可以做出调整
then she could make changes.
一切都取决于她自己
Everything was up to her.
最重要的一件事是
Most important thing she said
她不需要其他人的允许
was she didn’t need anybody else’s permission.
不需要诊所的预约 不需要医生开处方
Not a clinic appointment, not a doctor’s prescription,
不需要向药剂师订购
not a pharmacist order.
这一切她都可以自己决定
It was all up to her.
她在把控这些
She was in control.
对于患慢性病的患者来说
And if that seems like a little thing
这是一件小事么?
for somebody with chronic illness?
不是的 完全不是
It’s not, not at all.
当我们面对一个严重的慢性疾病的时候
When we face a chronic serious illness,
无论是类风湿性关节炎 还是狼疮
whether it’s rheumatoid arthritis or lupus,
癌症 糖尿病 还是肝硬化
or cancer, or diabetes, or cirrhosis,
我们都失去了疾病的控制权
we lose control.
注意我说的是“当你患病的时候”而不是“如果你患病”
And know what I said when, not if.
我们所有人 到了人生某个阶段的时候
All of us, at some point in our lives
都要面对严重的慢性疾病 这让我们失去了控制权
will face a chronic serious illness that causes us to lose control.
我们眼看着身体机能的衰退
We’ll see our function decline,
有的人还会智力衰退
some of us see our cognition decline,
我们不再有能力照顾自己
will be no longer able to care for ourselves,
做我们自己想做的事
to do the things that we want to do.
我们的身体终将背叛我们
Our bodies will betray us,
这个过程中 我们失去了控制权
and in that process we’ll lose control.
这挺吓人的
And that’s scary.
不仅仅是吓人 简直令人恐惧 寝食难安
Not just scary, that’s frightening, it’s terrifying.
我和病人交流的时候
When I talk to my patients,
也就是那些临终关怀的患者
my palliative care patients,
他们当中很多人都面临着可以夺取他们生命的疾病
many of whom are facing illnesses that will end their lives.
他们对很多事感到恐惧
They have a lot to be frightened of.
痛楚 恶心 呕吐 便秘 疲倦
Pain, nausea, vomiting, constipation, fatigue,
以及即将到来的死亡 但和其他事情相比 更让他们恐惧的是
their impending mortality, but what scares them more than anything else
可能在某个时候
is this possibility that at some point
也许是明天 或是下个月
tomorrow or a month from now,
他们就会失去自己对健康的控制权
they’re going to lose control of their health,
对生命 医疗的控制权
of their lives, of their health care,
他们必须开始依赖他人
and they’re going to become dependent on others,
这是很让人害怕的事情
and that’s terrifying.
所以这不用感到惊奇
So it’s no wonder really
就像我刚才告诉你 像罗宾那样的患者
that patients like Robin who I just told you about,
就是在诊所里选择使用药用大麻那位
when that in that clinic turned to medical marijuana
都是为了试图抓住一些表面上的控制权
to try to claw back some semblance of control.
但他们怎么做到的呢?
How do they do it though?
这些配药局 就像我遇见罗宾的那间 他们是怎么做的呢?
How did these medical marijuana dispensaries like the one where I met Robin?
他们是怎样让罗宾这样的患者
How do they give patients like Robin back
获得所需的控制权呢?
the sort of control that they need?
他们是怎样实现
And how did they do it in a way that
那些主流医院和诊所无法对患者做的呢?
mainstream medical hospitals and clinics at least for Robin weren’t able to?
他们的秘诀是什么?
What’s their secret?
所以我决定找出答案
So I decided to find out.
我去了位于加州威尼斯海滩的一间破诊所
I went to a CD clinic in Venice Beach in California
拿到了一份同意书
and got a recommendation
允许我成为一名使用药用大麻的病患
that would allow me to be a medical marijuana patient.
我拿到了一份同意书
I got a letter of recommendation that
能让我购买药用大麻
would let me buy medical marijuana.
我用不合法的方式得到了这份同意书
I got that recommendation illegally
因为我并不是加州的居民
because I’m not a resident of California.
我应该先声明这一点
I should’ve know that.
我应该声明 以供记录 此前我从未
I should also know for the record that I never used
使用过那份同意书购买药用大麻
that letter of recommendation to make a purchase.
以上的声明是要给美国缉毒局调查员的
And all of you DEA agents out there,
要热爱你们的工作
loved the work that you’re doing.
并坚持下去
Keep it up.
尽管我并没有用这份同意书购买药用大麻
Even though it didn’t let me make a purchase though,
但它仍然无比珍贵 因为它让我成为了一名药用大麻患者
that letter was priceless because it let me be a patient.
让我体验到像罗宾这样的患者
It let me experience what patient like Robin experience
她们在配药局所经历的
when they go to a medical marijuana dispensary.
我所体验的 我每天经历的事情
And what I experienced, what they experienced everyday,
就如同成百上千位 像罗宾一样的人每天体验的 太让人惊奇了
hundreds of, thousands of people like Robin, was really amazing.
我走进了药局 从我走进
I walked in with the clinic and from the moment that I entered
许多药用大麻配药局的一刻
many of these clinic dispensaries,
我觉得 这间药局 这间诊所就是为我设立的
I felt like that dispensary, that clinic was there for me.
一开始的时候 他们会问一些问题 我是谁
There were questions at the outset about who I am,
我从事什么工作
what kind of work I do,
我的期望是什么
what my goals are,
通过使用药用大麻处方 或产品想达到什么效果
in looking for a medical marijuana prescription or ehh…product.
我的目标是什么 我的喜好是什么
What my goals are, what my preferences are,
我的希望是什么 我是怎么想的
what my hopes are, how do I think,
我希望带来什么样的帮助 我的担心是什么
how do I hope, this might help me, what am I afraid of.
像罗宾这样的患者
These are the sorts of questions
总会不断被问到这些类型的问题
that patients like Robin get asked all the time.
这样的问题会让我有信心
These are sorts of questions that make me confident
觉得这个和我谈话的人 是从内心关注我的利益
that the person I’m talking with really has my best interests at heart
并且想要了解我
and wants to get to know me.
我从那些诊所知道的第二件事 是你可以从中学习
The second thing I learned in those clinics is the availability of education.
不但能从柜台里的人学习到知识
Education from the folks behind the counter,
还可以从在等候室里的病人学到知识
but also education from folks in the waiting room.
我在那里遇到的人都很开心
People I met were more than happy.
我坐在他们身边的时候 像罗宾一样的患者
As I was sitting next to them, people like Robin
告诉我他们是谁
to tell me about who they are,
为什么他们要用药用大麻
why they use medical marijuana,
什么帮助了他们 药用大麻怎么帮助了他们
what helps them, how it helps them
并给了我一些建议和意见
and to give me advice and suggestions.
那些等候室就像是
Those waiting rooms really are
提供交流 建议 支持的场所
a hive of interaction, advice and support.
第三点 坐在柜台后面的人
And third, the folks behind the counter
他们让我惊讶 他们很乐意
I was amazed at how willing those people were
有时花上1个小时甚至更长时间
to spend sometimes an hour or more,
跟我讨论这种药跟其他药的细微差别
talking me through the nuances of this strain versus that strain,
采用吸药还是雾化的方式 食用还是酊剂
smoking versus vaporizing, edibles versus tinctures,
还记得吗 这是在我还没有购买任何药物的前提下
all remember without me making any purchase whatsoever.
回想一下上次你去医院或是诊所
Think about the last time you went to any hospital or clinic
还有上次有人愿意花一个小时
and the last time anybody spent an hour
跟你解释那些事
explaining those sorts of things to you.
事实就是 像罗宾这样的患者愿意去这样的诊所
The fact that patients like Robin are going to these clinics,
打算去这样的药局
are going to these dispensaries and getting
获得这种针对个人的关注 指点以及服务
that sort of personalized attention and education and service,
这应该是对现代医疗系统的警钟
really should be a wake-up call to the healthcare system.
罗宾这样的患者会慢慢脱离现代主流医疗系统
People like Robin are turning away from mainstream medicine,
而转向这种药用大麻配药局
turning to medical marijuana dispensaries,
因为那些药局会给予他们需要的
because those dispensaries are giving them what they need.
现代医疗建设应该警醒一下了
If that’s a wake-up call to the medical establishment,
对于我的很多同事来说 这也是个提醒
it’s a wake-up call that many of my colleagues are
很多同事之前并不去听或者不想听患者的诉求
either not hearing or not wanting to hear.
我和我同事交流的时候 特别和内科医生
When I talk to my colleagues, physicians in particular
讨论药用大麻的时候 他们说:“我们需要更多的证据
about medical marijuana, they say “Oh we need more evidence,
我们需要研究它的疗效
we need more research in the benefits,
我们还需要研究它的风险”
we need more evidence about risks.”
你知道么?他们是对的
And you know what? They’re right.
他们一定是对的
They’re absolutely right.
我们需要更多的证据证实药用大麻的好处
We do need much more evidence about the benefits of medical marijuana.
我们需要要求联邦政府
We also need to ask the federal government
把药用大麻这件事重新提上研究日程
to reschedule marijuana to schedule to
或者完全取消限制 才能让研究成为可能
or to deschedule it entirely to make that research possible.
针对药用大麻的风险 我们也需要进行更多的调查
We also need more research into medical marijuana’s risks.
关于药用大麻的风险 我们知道更多的是药用大麻用于消遣的危害
Medical marijuana’s risks, we know a lot about the risks of recreational use.
但是我们对应用医疗的大麻的危害却一概不知
We know next to nothing about the risks of medical marijuana.
所以我们一定需要进行调查研究
So we absolutely do need research.
但话说回来 我们需要调查研究
But to say that we need research
但我们不需要现在做出任何改变
and not that we need to make any changes now,
这是完全不对的
is to miss the point entirely.
罗宾这样的人实际并不是想去使用药用大麻
People like Robin aren’t seeking out medical marijuana,
而是因为他们觉得药用大麻是一种特效药
because they think it’s a wonder drug
或者他们觉得压根就没什么危害
or because they think it’s entirely risk-free.
他们寻求药用大麻是因为药用大麻被派送
They’re seek it out because the context in which it’s delivered
发放以及使用的环境
and administered and used
给足他们一种所需 也就是对生命的控制权
gives them the sort of control they need over their lives.
这点也是我们需要关注的
And that’s a wake-up call we really need to pay attention to.
好消息是
The good news though is that there are lessons
今天我们能从医用大麻配药局学到一些东西
we can learn today from those medical marijuana dispensaries.
我们真的应该好好借鉴一下
And those are lessons we really should learn,
这些药局通常是小型 家庭式的
these are often small mom-and-pop operations
由未曾受过医疗训练的人所经营
run by people with no medical training,
虽然想到这点有点令我们羞愧
and while it’s embarrassing to think
许多这些诊疗所和药局正在为他们的患者
that many of these clinics and dispensaries are providing services and support
提供服务与支持 满足他们的需要
and meeting patients needs in ways that
这些是我们数百亿规模的医疗机构做不到的
billion-dollar healthcare systems aren’t.
我们应该对此感到羞愧
We should be embarrassed by that,
但是我们也可以从中学习
but we can also learn from that.
至少 我们能从这些小型药局里
They’re probably three lessons at least
学到3点
that we could learn from those small dispensaries.
第一 我们需要找到小巧但重要的方法
One, we need to find ways to give patients more control
给予患者更多控制权
in small but important ways,
比如如何与医疗人员互动沟通
how to interact with healthcare providers,
什么时候和医护人员沟通
when to interact with healthcare providers,
如何对患者采取有效的药物治疗
how to use medications in ways that work for them.
在我的诊治里
In my own practice,
我已经找到更多的创新的灵活的方式
I’ve gotten much more creative and flexible
可以让我的患者更安全的使用药物
in supporting my patients in using drugs safely
以此来治疗他们出现的症状
to manage their symptoms.
但是在强调安全性这一点上 我所开的处方中
But the emphasis on safely, many of the drugs that I prescribe
很多药物都属于鸦片类 或是苯二氮平类药物
are drugs like opioids or benzodiazepines,
这些药如果过度服用 会产生危险
which can be dangerous if overused.
所以这里就是重点 如果他们服用过多 可能就会出现危险
But here’s the point, they can be dangerous if they’re overused,
但如果不能依照患者的意愿与需求来服用
but they can also be ineffective
这种药效也发挥不了
if they’re not used in a way that consistent with what patients want and need.
所以在安全使用的前提下
So that flexibility if it’s delivered safely
“提供弹性”对于患者和其家属来说都是极其重要的
can be extraordinarily valuable for patients and their families.
以上就是第一点
That’s number one.
第二点 借鉴
Number two, education.
这是个大好的机会
Huge opportunities to learn
向那些医用大麻配药局学习一些技巧
from some of tricks of those medical marijuana dispensaries
这并不会占用许多医师必要的时间 甚至不会占用时间
to provide more education that doesn’t require
但是却会给我们提供更多的指点
a lot of physician time necessarily or any physician time.
更多的了解 我们现在正在使用什么药物
But opportunities to learn about what medications were using
为什么这样判定疾病的预后
and why prognosis trajectories of illness
这是患者之间学习的最重要的机会
and most importantly opportunities for patients to learn from each other.
我们如何复制在那些诊疗所
How can we replicate what goes on in those clinic
医用大麻配药局等候室出现的情形呢
and medical dispensary waiting rooms,
患者如何互相学习
how patients learn from each other,
人们怎样彼此分享信息
how people share from each other.
最后但同样重要一点 也是那些配药局做的
And last but not least, putting patients first,
把患者放在首位
the way those medical marijuana dispensaries do,
让患者感觉我们这些从业人员的存在
making patients feel legitimately like what they want,
就是为了满足他们需要且想要的
what they need is why as healthcare providers we’re here,
我们询问患者它们的希望 担心 目标和偏好都是什么
asking patients about their hopes, their fears, their goals and preferences.
身为临终关怀从业人员 我问我所有的患者
As a palliative care provider I ask all my patients,
他们希望的结果是什么以及他们害怕什么
what they’re hoping for and what they’re afraid of.
这就是重点 病人们不应该等到
But here’s the thing, patients shouldn’t have to wait
他们身患慢性绝症 快要走到生命的尽头时候 才被问这些事
until they’re chronically seriously ill, often near the end of life.
他们不需要等待
They don’t have to wait,
他们不应该等到直到
they shouldn’t have to wait
我这种医师医师出现
until they’re seeing a physician like me,
才有人问他们这种问题
before somebody asks them.
你想要什么? 你担心什么?
What are you hoping for? What are you afraid of?
这应该融入到整个医疗体系的提供的项目之中
That should be baked into the way that health care is delivered.
我们可以实现这点 我们真的能做到
We can do this, we really can.
全国各地的医用大麻配药局和诊所
Medical marijuana dispensaries and clinics
都清楚这一点
all across the country are figuring this out.
他们清楚在这个方面
They’re figuring this out in ways that
规模更大的主流医疗系统要落后他们好多年
larger more mainstream health systems are years behind.
但是我们可以从中学习
But we can learn from them
我们必须向他们学习
and we have to learn from them.
我们所有要做的事就是放下我们的骄傲
All we have to do is swallow our pride,
暂时放下我们自己的想法
put aside the thought for a minute
我们的名字后 有太多的头衔
that because we have lots of letters after our name,
我们是专家
because we’re experts,
我们是大型医疗系统的主要干事
because we’re chief medical officers of a large healthcare system.
我们所应该知道的全部 是如何满足患者的需要
We know all there is to know about how to meet patient’s needs.
我们需要放下骄傲
We need to swallow our pride,
我们需要去拜访新的大麻配药局
we need to go visit new medical marijuana dispensaries.
我们需要搞清楚他们在干什么
We need to figure out what they’re doing.
我们需要知道为什么有很多患者都和罗宾一样
We need to figure out why so many patients like Robin
抛弃了我们主流的医疗院所
are leaving our mainstream medical clinics
而是去了这些药用大麻配药局
and going to these medical marijuana dispensaries instead.
我们需要弄清楚他们的秘诀在哪
We need to figure out what their tricks are,
他们使用什么样的手段工具 我们需要从中借鉴学习
what their tools are and we need to learn from them.
如果我们可以这样做了 我认为我们可以
If we do and I think we can,
并且一定会做到
and I absolutely think we have to,
保证我们所有的患者
we can guarantee
都能够得到更好的体验
all of our patients will have a much better experience.
谢谢大家
Thank you.

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译制信息
视频概述

我们应该怎样看待药用大麻,他对现代医疗系统应该起到了警示作用。

听录译者

Maple

翻译译者

喋喋

审核员

审核团审核员XD

视频来源

https://www.youtube.com/watch?v=0ygtX2nyexo

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