Posted by Elizabeth on December 27, 2001, at 0:43:27
> Hey, Elizabeth! Thanks for your third (?) posting. It was fun to read.
Thanks. :) I enjoy your posts also. I've been really busy for the holidays, and now I'm settling down with my computer to catch up on email & stuff.
> Thought you'd disappeared. Instead, I find that I don't really know how to find specific responses to my postings.
I generally check the "add name of previous poster" box (below the Subject:) when replying to someone else's posts, especially in a big cluttered thread like this one. So anytime I reply to a message of yours, it should have " > > JANNBEAU" at the end of the Subject.
> Thread is also getting long--unwieldy--sstart a new one?
Yes, good plan! I'm afraid I couldn't come up with much of a title, though -- this conversation is going all over the place, we're not just discussing one or two topics!
> Thanks for reminding me of the difficulties of communicating without visual and aural cues! Again, sorry to put you in such a position! : )
We're all in such a position, that's just how the internet is! Of course, it's really not such an excuse for me since I'm really bad at interpreting nonverbal cues IRL.
> Seems you know far more about this subject than I.
Which subject? We've covered a lot here!
> Though I've had many courses in pharmacokinetics/toxicokinetics, etc., I don't use most of it anymore.
In what context did you come to be taking courses like that? I've taken most of the basic sciences and some cognitive neuroscience stuff, but otherwise I'm mostly self-taught. (I have to credit my parents with much of my education, too. It's a shame that most parents aren't able to spend as much time with their kids as mine were with me and my sister.)
> I found in clinical drug research that most is a farce, driven entirely by the profit motive and by drug companies and researchers who seek to obey the letter of the law but not the spirit of said regulations.
Yeah, it's true. Not only that, but the drug companies basically control the FDA, the agency that's supposed to be regulating them, because so many people in the FDA have ties to drug companies. In general the government infrastructure having to do with drug regulation and/or enforcement is extremely corrupt.
To be fair, I do know some doctors who do clinical research who work for teaching hospitals, and although they often get grants from drug companies, they seem to be decent and honest by and large and genuinely want to find out what works and what doesn't (although sometimes, I think, their enthusiasm can blind them). They also seem to have about the same attitude toward drug companies as you have!
> I, too, then, am skeptical. I try to educate myself, whence some of my misinformation! (All the rest of you out there, disregard my comments and listen to E-Beth!)
Oh, nonsense. You obviously have some good knowledge to share. I bet you know more than the average psychiatrist (not that that's saying much!).
> Well, true. We've made progress. We have the "scientific method;" we have great potential to distribute our information; we know volumes more about physiology and psychophysiology than the Medievalists knew, just as we have a much better understanding of the psychopathology than we knew even fifty years ago.
Yeah, but it's amazing how many people still don't understand that the mind and emotions don't make up a "soul" independent of a body -- that was one of the Medieval attitudes I was talking about. This assumption is even built into much of our language.
> Have you ever seen the movie "The Snake Pit" or read about "Bedlam", the famous London institution? That's what I mean!
We've come a long way, and yet I still marvel at how far we *haven't* come. Psychiatric inpatients still don't have real civil rights. There's still a lot of stigma out there; many people see serious mental illness as being limited to poor people (although a lot of us are poor or even homeless). The popular media portray mental illness in all sorts of inaccurate ways. (I hope that the movie _A Beatiful Mind_ portrays mental illness more accurately. I think it's important for people to know that intelligent, educated, even brilliant people can suffer from debilitating mental illness.) We still don't get adequate medical benefits. I could go on and on....
> Bedlam is, by the way, a shortened form of the name for "Bethlehem" Asylum--interesting, yes? Ironic, perhaps?
"Insert sarcastic comment here?" :-)
> All true, especially the lack of balance between the "information for the patient" and the PI. However, I think that, if we are an educated patient, we should be able to take the information from the PI and distill it, using what pertains to ourselves and discarding extraneous information.
Even most educated patients don't understand pharmacology very well, and many also aren't aware of all the politics and a**-covering that goes into making a drug monograph.
> However, we DO need to know the PURPOSE of the PI, which is mainly to fulfil the requirements of the Code of Federal Regulations and other laws governing drug research, manufacture, and distribution, yes?
Exactly: to cover the drug co.'s a**! :-)
> The physician should make this very clear to the patient.
I think most doctors don't even realize that patients read these monographs. I always make it clear to mine that I do (and that I understand them well enough not to be scared off by rare side effects, for example).
> A patient should know his/her ability to digest and use the information.
That's hard -- knowing enough to recognize when something's over one's head -- especially for laypeople.
> It also helps to know one's pharmacist well; these folks can be really helpful with respect to side effects and drug interactions.
I haven't been impressed with most of the ones I've met, although every now and then there's an exception (Cam, you reading this? :-) ). Most retail pharmacists I've encountered seem to get everything out of a book and believe everything the drug companies tell them. (I've had many annoying experiences trying to fill my Ambien prescription as a result of this. According to the product labeling, nobody should need more than 10 mg/night, but I need 20. Although I've been taking Ambien since 1996 and know very well what dose I need, most pharmacists don't care about what I have to say. A lot of them seem more interested in being foot soldiers in the War on Drugs than in helping patients understand how to use their medicine.
> I, of course, have a PDR and another huge tome that gives the percentage of the effects in controlled trials in both placebo or comparator drug and the drug under test.
Which tome is that? My main resources besides the PDR are Goodman & Gilman and the _APP Textbook of Psychopharmacology_ (Schatzberg and Nemeroff, eds.). I have a bunch of other (smaller) books, too, of course, and the internet and medical libraries can come in handy.
> But, then, again, you must know how to interpret the numbers! What constitutes a significant difference between inactive or placebo and the medication, for instance?
Yes. I don't think most people realize that "significance" actually has a specific meaning in statistics! (Despite having majored in math, I don't have a very good grasp on statistics myself, although I do know some basic stuff.)
> Bummer! Boston would be a hard act for anyplace to follow!
I'd love to go back -- it's a wonderful city, not just a place to get good health care. Also, many of my friends from college are still there. And it would be a nice place for me to be able to look for work because there's a lot of medical research going on (I'd like to assist in clinical research, preferably psych research of course).
> > And I've been finding that medications that are considered "new" or "cutting edge" here are ones that were in use in Boston several years ago.
>
> Where in the world are you, Timbuctu?Worse, North Carolina. :-)
> Some attempt to make us feel guilty for needing opioids (I will use this term as your arguments make sense in the context of "stigmatism") and attempt to discourage their use, when, for the kind of chronic pain I have, and that I suspect you also suffer, opioids should be the drugs of choice.
Buprenorphine works great for my back pain (Soma was okay, but buprenorphine is a lot more reliable), but the reason I really need it is that it helps with aspects of my depression that no other medication has helped with.
> Talk about side effects of medications: Nonsteroidal Anti-inflammatory Drugs (NSAIDs) are LOADED with, sometimes, lifethreatening side effects, and are not even particularly effective for many types of pain for which they are prescribed.
No s***. The only thing I've *ever* found them useful for is menstrual cramps. I've tried taking large amounts of NSAIDs for the back pain -- nothing. Ditto dental pain. They don't have a lot of side effects for me, but I have a friend whose stomach started bleeding because he took too much ibuprofen (in an attempt to relieve pain for which he probably should have received opioids). Opioids have a lot of annoying side effects, but they're basically safe.
> I wish you luck in finding a physician near you who will have the knowledge and motivation to learn and to help you! I'm considering accupuncture. Have you tried it? Unfortunately, my insurance doesn't pay for it, but will pay for any drug the doc prescribes!
I tried it for a couple months one summer, back when I lived in Cambridge, mainly because of the back pain. A friend said it had helped with his sciatica, and the guy he was seeing was well-respected. But it didn't do anything for me.
> Checkmate--game to you! Opioid agonist, it will be hereafter in these conversations!
FWIW, my boyfriend (a psychopharmacologist by training) also recalls recent pharmacology texts recommending that the word "narcotic" be dropped from the medical vocabulary altogether.
You're not the only person who's had to watch a loved one die in pain because doctors and nurses wouldn't give them adequate medication. Not by a long shot.
> Good information. I am not very well up on addiction research. With regard to bioavailabiity with oral administration, would you just not take a larger dose of the morphine to get the same effect?
That's right, if you were taking it orally. With morphine there's a big difference between the oral and IM dose (compared with, say, oxycodone).
> > Anyway, kappa opioids don't have much attraction for people who prefer mu agonists.
>
> Tell me more. I don't know much about this subject.Supposedly, kappa agonists (like Stadol) are effective analgesics, more effective in women than in men. Stadol is also a mu antagonist. I don't know too many people who've tried it, and I don't know anyone for whom it was effective.
> > The other partial/mixed agonists are the partial mu agonists, such as buprenorphine and dezocine.
>
> --an addict in withdrawal is liable to be willing to take whatever s/he can get, and buprenorphine does block withdrawal symptoms.That's true. I think that the concern about "abuse" is way overblown, though. Doctors consider it such an awful thing if somebody gets opioids (excuse me, "narcotics") who doesn't need them, but they regularly give SSRIs, anticonvulsants, and even antipsychotics to people who probably don't need them. By and large, the people who are affected by restrictive prescribing practices are pain patients, not people looking for a good time. I'd rather see a few people get high on safe, legal drugs (rather than buying stuff on the street when they have no idea what it is) than see a lot of people go without pain medication (which is what is happening).
> > It can also be used to detox oneself and causes hardly any withdrawal symptoms of its own.
>
> Didn't know this.Buprenorphine withdrawal is like a shadow of full agonist withdrawal. The main symptoms I've experienced are moodiness, chills, sweating, nasal congestion, and heightened sensitivity to cold, light, and noise. The back pain and anergia might get worse too, it's hard to tell. Definitely no vomiting, diarrhea, fever, etc. The moodiness is the main thing that gets me in trouble.
> I have come to believe (personal observation) that some psychotropic or CNS active medications make permanent changes to the brain, meaning, perhaps, that the set points for the receptors may be changed, e.g., (I think, but don't quote me on this) that receptor physiology is permanently altered by some CNS medications--permanent receptor upregulation(?) or that presynaptic receptors are affected more than is realized? I refer specifically to the amphetamines and amphetamine-like medications (and there lies another whole discussion--the ability of the SRI's to alleviate depression. I have noticed that when the early "amphetamine" or NE agonist effect of the AD wears off, so does the antidepressant effect--I experienced that with Prozac, Paxil, and, NOW, just recently, with Effexor; took my first amphetamine (for weight control) when I was 19 years old (40 yrs ago) and, through the years, have felt "retarded" without them.
Do you mean psychomotor retardation, or intellectual? I found Paxil activating, but not in a pleasant way (it made me jittery); Prozac and Zoloft didn't seem to have any effect at all. I'm pretty unimpressed by the SSRIs. I'm more concerned by the overuse of anticonvulsants, especially since I started having these possible seizures. (I'm not bipolar and have never been diagnosed as bipolar.)
> Although I don't presently take stimulants, I always found small or prescribed doses to make me feel "better" and to increase my functional status. I think this is an iatrogenic (although inadvertant) effect that I'll always have to contend with--or perhaps, I was just congenitally depressed and the amphetamines treated that condition (?).
Amphetamine can do that. Stimulants are often given to depressed patients with serious medical illnesses (or at least, they used to be) because they work fast and are much safer than the tricyclics. There was a brief period when amphetamine was the main antidepressant drug (before that, opium and morphine were), before the TCAs and MAOIs were discovered.
> Anyway, I agree with your contention that illegal isn't synonymous with pathological! I have struggled with this concept. You have enunciated it beautifully.
Thank you. It's really bizarre how the government seems to think that it can create diseases by passing laws, and even more bizarre that doctors go along with it!
> Felt literally as if I was going to die!. Tremor, chilliness, cognitive deficits, memory loss, headache, "speeding", disorientation, somnolence; loss of sense of time; wildly fluctuating blood pressure (hypertension followed late in the evening by hypotension --110/62 which is much lower than my bp has been in years--dizziness; nausea--others that I cannot remember. DC's Ultram, returned to normal within 24 hours! Scared the dickens out of me. Totally out of my control until I figured out the interactive potential of these drugs.
The serotonin syndrome is very scary. Ultram is bad with most ADs; often there are both pharmacokinetic and pharmacodynamic interactions. I've had the serotonin syndrome *three* times (!), once while taking Effexor. One very common symptom seems to be chattering teeth. The labile blood pressure is also common. (I'd hardly call 110/62 a problematic BP, though -- at one point mine was something like 60/35!) I was very disoriented, kept asking the same questions I'd asked a minute before. My pupils were very dilated. The time when I was on Effexor was the most serious -- I was in a mixed manic state, and eventually I blacked out and was apparently acting very weird.
> I've recently increased my dose of Effexor to 150 qd, because it was losing it's effectiveness as an AD.
I just went up to 150, too. I'm hoping that it will help me enough that I can stop taking the buprenorphine every day and just use it on an as-needed basis.
> I've seen no further increase in pain relief, so I wonder if that effect may not occur at low doses as with the TCAs?
Effexor is pretty much an SSRI at low doses, FWIW. I'm not sure at what dose the NE effect is supposed to kick in, though.
> Elizabeth, tell us how you know all of this stuff? Your knowledge seems far greater than that of the average "Joe"!!!
Mostly I just read and pick stuff up. Also, another thing I liked about the doctors I saw in Boston was that they didn't dumb things down or treat me like I should just take their orders without question. I learned a lot from them because they treated me as an equal.
-elizabeth
poster:Elizabeth
thread:87922
URL: http://www.dr-bob.org/babble/20011222/msgs/87922.html