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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 16 to 40 of 55. Go back in thread:
Posted by SLS on May 28, 2009, at 23:16:03
In reply to Re: Need an alternative to Abilify » SLS, posted by jerrypharmstudent on May 28, 2009, at 20:46:22
> > My vote is for Geodon.
> >
> > If you have already tried Geodon and Seroquel, you might consider getting your hands on amisulpride.
> >
> >
> > - Scott
>
> Do you know Geodon's mechanism of action?It has quite a few. It is the most antidepressant-like of the neuroleptics.
DA2 antagonist ++
DA3 antagonist ++
5-HT1a agonist ++
5-HT1d antagonist
5-HT2a antagonist +++
NE reuptake inhibition
5-HT reuptake inhibition
> Any tough side effects like restlessnessPerhaps some insomnia. I don't think it produces akathisia at the same rate as does Abilify.
> weight gain/etc.?
Geodon is perhaps the only truly weight-neutral atypical neuroleptic. Of the older drugs, I am pretty sure that Stelazine, is weight neutral.
The dosage range for Geodon in the treatment of depression seems to be 40-80mg.
- Scott
Posted by desolationrower on May 29, 2009, at 0:53:13
In reply to Re: Need an alternative to Abilify » jerrypharmstudent, posted by SLS on May 28, 2009, at 23:16:03
Pramipexole.
-d/r
Posted by Sigismund on May 29, 2009, at 18:17:20
In reply to Re: Need an alternative to Abilify, posted by garnet71 on May 28, 2009, at 23:01:30
>The RN there wouldn't scribe it for me--she said "that's worse!"
I know what she means, almost. There's a logic there somewhere. But what is it?
Posted by garnet71 on May 29, 2009, at 19:22:27
In reply to Re: Need an alternative to Abilify » garnet71, posted by Sigismund on May 29, 2009, at 18:17:20
I thought I was asking you? lol
> >The RN there wouldn't scribe it for me--she said "that's worse!"
>
> I know what she means, almost. There's a logic there somewhere. But what is it?
Posted by Sigismund on May 29, 2009, at 21:31:09
In reply to Re: Need an alternative to Abilify, posted by garnet71 on May 28, 2009, at 23:01:30
Maybe if you had told her how unpleasant but necessary dex was she would have felt better about it?
Or maybe if you had said 'I'm glad we have people like you to stop all those drug seekers out there'?
There was a treatment for depersonalisation that comprised methamphetamine plus ECT. You could have offered to have that.
As in 'Can I have ECT with that?'
Posted by garnet71 on May 29, 2009, at 22:14:21
In reply to Re: Need an alternative to Abilify » garnet71, posted by Sigismund on May 29, 2009, at 21:31:09
lol Yeah, and if I asked for *Abilify*, they'd get right on it! lol
Hmm..if this trend keeps up, maybe someday I'll become the first patient to sue for NOT being prescribed an "addictive" drug, rather than the other way around. 8| Maybe others have done that?
Can you sue a doctor for providing treatment according to his malpractice insurance rather than your well-being? It seems unethical to me. Had I not researched my own treatment, I'd still be on an xxRI. In fact, if I didn't find this site about 6 months ago to figure out what was wrong, I would have failed out of grad school-guaranteed. I couldn't sue my last PDoc though, he really was a nice guy. I hate to say that, because it's really not a good reason, but I could not get myself to do that to him.
I feel for them, the system sux, but still...I'll just have to ask my new PDoc's i'm shopping for about the level of malpractice insurance they carry before who I decide to see, I guess.
Posted by jerrypharmstudent on May 29, 2009, at 22:19:11
In reply to Re: Need an alternative to Abilify, posted by garnet71 on May 29, 2009, at 22:14:21
> lol Yeah, and if I asked for *Abilify*, they'd get right on it! lol
>
> Hmm..if this trend keeps up, maybe someday I'll become the first patient to sue for NOT being prescribed an "addictive" drug, rather than the other way around. 8| Maybe others have done that?
>
> Can you sue a doctor for providing treatment according to his malpractice insurance rather than your well-being? It seems unethical to me. Had I not researched my own treatment, I'd still be on an xxRI. In fact, if I didn't find this site about 6 months ago to figure out what was wrong, I would have failed out of grad school-guaranteed. I couldn't sue my last PDoc though, he really was a nice guy. I hate to say that, because it's really not a good reason, but I could not get myself to do that to him.
>
> I feel for them, the system sux, but still...I'll just have to ask my new PDoc's i'm shopping for about the level of malpractice insurance they carry before who I decide to see, I guess.I think the "Oh I can't prescribe that because of my insurance" line is bullcrap. I'd been on hydrocodone for depression for over 3 years with no problems and he one day decides his insurance won't cover him? I don't get it.
Posted by garnet71 on May 29, 2009, at 22:40:24
In reply to Re: Need an alternative to Abilify » garnet71, posted by jerrypharmstudent on May 29, 2009, at 22:19:11
I'm suspecting my PDoc was recently sued for scribing "controversial" meds. He always was a pretty resonable guy. I mean, if he didn't want to prescribe me d-amp, he wouldn't have done it-he could have easily said no. Instead, he asked me why I wanted it, I told him and he listened carefully; then he let me have it for a month and referred me to malpractice insurance guy-friend of his. I was going to talk to him about this in more detail, about malpractice, but never really found a good opportunity to.
Plus, they have the DEA breathing down their back. It's insane. I also think last PDoc was the same-thinking he was sued, or maybe even lost his license temporarily, sanctioned by a medical board, or almost lost his license. Just guessing...There's was never any other patient in his office, the phone never rang, and could get an appt. w/him any day, anytime I wanted. It could be that he just moved here for all I know, but he had that cynicism about him, with my treatment--the same new attitude I noticed with the other PDoc.
When my PDoc asked me who i tried for a second opinion, I told him the name of empty office guy-he got real quiet like he immediately knew why....and nodded and paused for a long time..it was the one i tried for a few months before going back to that one. He would only give me SSRIs or Wellbutrin. When I told him they made me depressed and unable to function, and almost totally nonfunctional due to amotivation, he said 'what do you want me to do?" This was after I asked for Wellbutrin and found out it didn't work anymore. Meanwhile, I find out a few months ago there's tons of other stuff that can be prescribed to make me better. There were very few doctors who wanted to be on my insurance list, and I wonder why these particular doctors wanted to go through all the red tape to be approved.
I also think doctors who would be willing to prescribe these drugs that work for people like me would appear to be suspicious by the DEA. Say, if one Doc was prescribing d-amp to 10 patients, while others only prescribe it to 1. You'd wonder if they'd get investigated. I'm going to ask some of the doctors I'm shopping for about that, because I'm really curious. Not fact, just my intuition/suspicion.
Plus all states are different with medical malpractice laws. Maybe I live in one of the worst states for that.
I'm really curious now about all this, will have to find out more and "report" back. I thought I was the only one who experienced this, sorry you had to as well.
Posted by garnet71 on May 29, 2009, at 22:42:39
In reply to Re: Need an alternative to Abilify » garnet71, posted by jerrypharmstudent on May 29, 2009, at 22:19:11
Hmmm. Maybe new federal laws with the Obama admin? That's strange after 3 years, he'd refuse. or check your state laws. If I get around to it, I'll check mine...
Posted by greywolf on May 29, 2009, at 23:00:10
In reply to Re: Need an alternative to Abilify, posted by garnet71 on May 29, 2009, at 22:14:21
>I'll just have to ask my new PDoc's i'm shopping for about the level of malpractice insurance they carry before who I decide to see, I guess.You might as well just say goodbye to those pdocs right now.
Greywolf
Posted by garnet71 on May 29, 2009, at 23:03:53
In reply to Re: Need an alternative to Abilify » garnet71, posted by jerrypharmstudent on May 29, 2009, at 22:19:11
Well, not too many bills were passed by the 111th Congress yet, and nothing about controlled substances; could only find something about drugs in the newest appropriations bill:
http://thomas.loc.gov/cgi-bin/query/F?c111:18:./temp/~c111EUHvbW:e372419:
But it doesn't tell you much in context of what was done in the past, could be just the same type of funding. Did find out there is a U.S. "Anti-Doping Agency" though. lol!
There is too much to look through, there could be something else in here, but I can't search through it all:
http://thomas.loc.gov/cgi-bin/query/D?c111:18:./temp/~c111EUHvbW::
Posted by garnet71 on May 29, 2009, at 23:09:08
In reply to Re: Need an alternative to Abilify, posted by greywolf on May 29, 2009, at 23:00:10
Lol-there's a methampheatmine log book act that passed last year:
http://thomas.loc.gov/cgi-bin/query/D?c110:45:./temp/~c110Y5iXyN::
Maybe it is for wholesale purchases/pharmacy deliveries...hmmm. I'm in investigation mode now.
Posted by jerrypharmstudent on May 29, 2009, at 23:19:08
In reply to Re: Need an alternative to Abilify, posted by garnet71 on May 29, 2009, at 23:09:08
> Lol-there's a methampheatmine log book act that passed last year:
>
> http://thomas.loc.gov/cgi-bin/query/D?c110:45:./temp/~c110Y5iXyN::
>
> Maybe it is for wholesale purchases/pharmacy deliveries...hmmm. I'm in investigation mode now.i wonder why pdocs can prescribe amphetamines but when it comes to opiates they get all uncomfortable?
Posted by garnet71 on May 29, 2009, at 23:30:54
In reply to Re: Need an alternative to Abilify » garnet71, posted by jerrypharmstudent on May 29, 2009, at 23:19:08
Well doctors might be getting sued-maybe a case went thru recently that had a lot of significance for doctors who prescribe these types of drugs, something we don't know about.
But Hang on, still searching...
There was a lot of new drug regulation passed at the end of October 2007:
http://thomas.loc.gov/cgi-bin/query/D?c110:126:./temp/~c110bVsr6A::
I don't know what the implications are for PDocs though, but there is way too much to read thru.
Posted by garnet71 on May 29, 2009, at 23:43:17
In reply to Re: Need an alternative to Abilify » garnet71, posted by jerrypharmstudent on May 29, 2009, at 23:19:08
Jerry,
I just noticed your drug was a schedule III, while mine is a schedule II. yeah I wonder about that.
This isn't what I was looking for, but they actually post some of the doctor's names who violate the Controlled Substances act. That's brutal!
http://www.deadiversion.usdoj.gov/crim_admin_actions/admin_2007.htm
Posted by garnet71 on May 29, 2009, at 23:45:54
In reply to Re: Need an alternative to Abilify » garnet71, posted by jerrypharmstudent on May 29, 2009, at 23:19:08
Maybe this is why-could be that the DEA is giving doctors a hard time recently.
"The DEA is currently reviewing a petition to increase the regulatory controls on hydrocodone combination products from schedule III to schedule II of the Controlled Substances Act (CSA)."
http://www.deadiversion.usdoj.gov/drugs_concern/hydrocodone/hydrocodone.htm
Posted by garnet71 on May 29, 2009, at 23:51:52
In reply to Re: Need an alternative to Abilify, posted by garnet71 on May 29, 2009, at 23:43:17
Oh! the horror! a drug that enhances mood and energy for the depressed!
"Methamphetamine is chemically and pharmacologically similar to amphetamine although it has more potent effects on the CNS that can last for 6 to 8 hours. Methamphetamine increases the release of the neurotransmitter, dopamine, which stimulates brain cells, enhancing mood and energy."
http://www.deadiversion.usdoj.gov/drugs_concern/meth.htm
lol I have to stop this. I have way too much to do, but this topic got me interested.
Posted by jerrypharmstudent on May 29, 2009, at 23:56:12
In reply to Re: Need an alternative to Abilify, posted by garnet71 on May 29, 2009, at 23:51:52
> Oh! the horror! a drug that enhances mood and energy for the depressed!
>EXACTLY. I've been severely depressed and anxious the past month. today was the worst. Luckily I found two Vicodin. I took one hours ago and am feeling back to normal. I see a new pdoc next month, I wonder how he'll react when he sees in my chart that I'd been prescribed hydrocodone for DEPRESSION for the past 3-4 years.
Posted by garnet71 on May 30, 2009, at 0:10:43
In reply to Re: Need an alternative to Abilify, posted by garnet71 on May 29, 2009, at 23:51:52
There's tons of these cases, and for Vicodin, but they don't show 2008 or 2009. I wonder if the DEA has been investigating doctors or if there has been a large increase in prosecutions. Wouldn't being investigated, alone scare them away? I would think so.
I don't know what "good faith" in determining medical necessity of a controlled substance would be for some doctors, esp. PDocs. There really aren't that many tests to do for pain and psych symptoms; seems they'd have to rely on the patients' self-reporting. That must be a tough position to be in.
In some of these cases, what the doctors were accused of doing was f-ed up, but some of them I wonder...if they are just cracking down on doctors who are liberal at prescribing these types of drugs. The DEA did indicate on their web site that they were currently changing the enforcement regarding Vicodin...that might be your answer.
http://www.deadiversion.usdoj.gov/crim_admin_actions/crim_actions.htm
Name:
BILYEU, Stuart W., DO
City, State:
Southfield, MI
Date of Arrest:
07/20/2005
Date of Conviction:
04/12/2006
Judicial Status:
Pled Guilty
Conviction:
Unlawful Distribution of a Controlled Substance
DEA Registration:
Expired 07/31/2006
Remarks:
Stuart W. Bilyeu, DO, age 46, of Southfield, MI, pled guilty to the unlawful distribution of hydrocodone, a Schedule III controlled substance. According to court records, the defendant admitted that he prescribed without medical necessity or justification quantities of controlled substances to patients. For example, in October, 2004, the defendant wrote a prescription for #120 Vicodin to an individual, without any good faith attempt to determine the legitimate medical needs of the patient. From January 2003 until May 10, 2005, Bilyeu prescribed without medical necessity or justification 100 dosage units of oxycodone 80mg; 100 dosage units of Dilaudid, 20,000 Schedule III drugs, and 40, 000 Schedule IV drugs.Bilyeu was sentenced to five years imprisonment, followed by three years of supervised release.
Posted by garnet71 on May 30, 2009, at 0:40:04
In reply to Re: Need an alternative to Abilify » garnet71, posted by jerrypharmstudent on May 29, 2009, at 23:56:12
They really seem to be focusing on vicodin.
On one web page, the DEA said they are taking action due to the proliferation of prescription drugs to non-patients, yet on another, they say there is no "crackdown" on physicians.
I'd def. check your state laws though to see if something has recently changed. That might explain your doctors recent behavior. I even feel bad for them they have to deal with this. Of course I feel bad for us, too.
----------------
http://www.deadiversion.usdoj.gov/fed_regs/notices/2006/fr09062.htm
Another source of data presented by SAMHSA is that collected by the Drug Abuse Warning Network (DAWN), which provides national estimates of drug related visits to hospital emergency departments. According to DAWN, for 2004:
Nearly 1.3 million emergency department (ED) visits in 2004 were associated with drug misuse/abuse. Nonmedical use of pharmaceuticals was involved in nearly half a million of these ED visits.
Opiates/opioid analgesics (pain killers), such as hydrocodone, oxycodone, and methadone, and benzodiazepines, such as alprazolam and clonazepam, were present in more than 100,000 ED visits associated with nonmedical use of pharmaceuticals in 2004.\5\
A measure of the problem among young people is the 2005 Monitoring the Future (MTF) survey conducted by the University of Michigan.\6\ The MTF survey is funded by the National Institute on Drug Abuse (NIDA), a component of the National Institutes of Health (NIH), and measures drug abuse among 8th, 10th, and 12th graders. NIDA stated: "While the 2005 survey showed a continuing general decline in drug use, there are continued high rates of non-medical use of prescription medications, especially opioid pain killers. For example, in 2005, 9.5 percent of 12th graders reported using Vicodin in the past year, and 5.5 percent of these students reported using OxyContin in the past year.'' \7\ In announcing the latest MTF survey results, NIH Director Dr. Elias Zerhouni said that "the upward trend in prescription drug abuse is disturbing.'' \8\
DEA also wishes to dispel the mistaken notion among a small number of medical professionals that the agency has embarked on a campaign to "target'' physicians who prescribe controlled substances for the treatment of pain (or that physicians must curb their legitimate prescribing of pain medications to avoid legal liability).The reason this document focuses on the prescribing of controlled substances for the treatment of pain is that there has been considerable interest among members of the public in having DEA address this specific issue.
Each State also has its own laws (administered by State agencies) requiring that a prescription for a controlled substance be issued only for a legitimate medical purpose by State-licensed practitioners acting in the usual course of professional practice.
The Supreme Court has long recognized that an administrative agency responsible for enforcing the law has broad investigative authority,\33\ and courts have recognized that prescribing an "inordinately large quantity of controlled substances'' can be evidence of a violation of the CSA.\34\ DEA therefore, as the agency responsible for administering the CSA, has the legal authority to investigate a suspicious prescription of any quantity.
---------------------------------------------
\33\ Morton Salt, 338 U.S. at 642-643 ("an administrative agency charged with seeing that the laws are enforced'' may "investigate merely on suspicion that the law is being violated, or even just because it wants assurance that it is not.'').
\34\ United States v. Rosen, 582 F.2d at 1036
Posted by garnet71 on May 30, 2009, at 2:35:02
In reply to Re: Need an alternative to Abilify » garnet71, posted by jerrypharmstudent on May 29, 2009, at 23:56:12
Jerry, I'd suggest you read your state's guidelines for opoid prescribing, and see whether or not your doctor is in line. States apparently have the power to define the medical necessity that govern controlled substances and for establishing stricter policies. I don't know if there is anything about using them for non-pain reasons.
Well I see that you go to pharmacy school-maybe you have or haven't learned about this yet, so just disregard if you already have this info. Maybe someone else could use it here.
http://www.medscape.com/resource/opioid
A Guide to State Opioid Prescribing PoliciesSelect a State...CLOSE [X]
Alabama
Alaska
Arizona
Arkansas
California
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Connecticut
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District of Columbia
Florida
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Hawaii
Idaho
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Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
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New Mexico
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North Carolina
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Ohio
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Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
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Washington
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West Virginia
Wyoming
Additional state policies coming soon
Opioids are frequently prescribed to treat pain in patients in the United States. Still, many patients continue to receive inadequate pain relief. This may be due to the fact that physicians are concerned about opioid addiction, tolerance, and organ damage for the patient, and possible prosecution for themselves. Federal and state policies govern the use of opioids and other controlled substances This Resource Center addresses the states' policies that are in place to regulate professional practice and prevent drug abuse. In order to achieve the clinical goals of fair and just pain treatment for all, individuals who are licensed to prescribe, order, dispense, or administer opioids must be fully conversant in the laws and regulations that govern those substances.Legal Disclaimer: The purpose of these summaries is to inform and educate clinicians on the various legal/regulatory materials that govern the use of controlled substances to treat pain. The information contained within these summaries is not intended to serve as specific legal advice, and you should review the source material and consult your local attorney and/or state licensing board to determine the relevance to your practice.
In Focus
Ask the Experts - Withholding Opioids From PatientsOpioid therapy is an accepted treatment; prescribing opioids appropriately will not result in disciplinary sanctions.
Posted by Sigismund on May 30, 2009, at 2:41:19
In reply to Re: Need an alternative to Abilify » garnet71, posted by jerrypharmstudent on May 29, 2009, at 22:19:11
>I'd been on hydrocodone for depression for over 3 years with no problems and he one day decides his insurance won't cover him? I don't get it.
And if I remember correctly, it worked.
Posted by garnet71 on May 30, 2009, at 2:41:58
In reply to Re: Need an alternative to Abilify » garnet71, posted by jerrypharmstudent on May 29, 2009, at 23:56:12
Oh-one more thing that might be relevant for you. Just in February, some professional group of pain managers codified the use of opoids...but everything I've seen only applies to pain; not depression. That may also be significant. I didn't read this, but you may want to. Good luck, hope you feel better soon.
AAPM 2009: New Opioid Clinical Practice Guidelines Published
Allison GandeyAuthors and Disclosures
February 12, 2009 (Honolulu, Hawaii) A panel of pain-management experts has published the first comprehensive clinical practice guidelines on opioids for the treatment of chronic noncancer pain. The guidelines, which were 2 years in the making, are from the American Pain Society and the American Academy of Pain Medicine and appear in the February issue of the Journal of Pain.
"The expert panel concluded that opioid pain medications are safe and effective for carefully selected, well-monitored patients with chronic noncancer pain," cochair Gilbert Fanciullo, MD, from the Dartmouth Hitchcock Medical Center, in Lebanon, New Hampshire, said in a news release.
The guidelines were first presented January 28 at the American Academy of Pain Medicine 25th Annual Meeting. Medscape Neurology & Neurosurgery spoke with presenter and cochair Perry Fine, MD, from University of Utah Medical Center, in Salt Lake City.
"This is the first time these issues have been codified in this way," Dr. Fine said. "Of the many issues we tried to confront, key points include the importance of a therapeutic trial, justification for long-term therapy, and continuous reevaluation."
The panel made 25 specific recommendations and reportedly achieved unanimous consensus on nearly all. The group reviewed more than 8000 published abstracts and nonpublished studies to assess clinical evidence.
Weighing the Benefits and Risks
"Decisions about chronic opioid therapy must weigh the benefits of these medications against the risks, which include side effects and adverse outcomes associated with abuse," Dr. Fine said.
Opioids such as morphine, oxycodone, oxymorphone, and fentanyl are potent analgesics. They traditionally have been used to relieve pain following surgery, from cancer, and at the end of life. Today, opioids are used widely to relieve severe pain caused by chronic low-back injury, accident trauma, arthritis, sickle cell, fibromyalgia, and other painful conditions.
"Regular monitoring of chronic opioid therapy patients is warranted because the therapeutic benefits of these medications are not static and can be affected by changes in the underlying pain condition, coexisting disease, or in psychological or social circumstances," Dr. Fanciullo said.
American Pain Society President Charles Inturrisi, PhD, called the work a milestone collaboration between 2 leading organizations representing pain management.
"This was a big concerted effort," Ajay Wasan, MD, from Harvard Medical School and Brigham and Women's Hospital, in Boston, Massachusetts, said during an interview. Dr. Wasan moderated the session where the guidelines were first presented. "The committee should be commended on an outstanding job."
Dr. Fanciullo reports that he has financial relationships with Medtronic, Janssen, Teva Pharmaceuticals, and Pfizer. Dr. Fine reports that he has financial ties to Alpharma, Cephalon, Endo Pharmaceuticals, GlaxoSmithKline, Lilly, Merck, Ortho-McNeil, Purdue, and Wyeth.
J Pain. 2009;10:131-146. Abstract
[CLOSE WINDOW]
Authors and Disclosures
Author(s)
Allison Gandey
is a senior journalist for
[ CLOSE WINDOW ]
Information
Authors and Disclosures
Allison Gandey
is a senior journalist for
Posted by Sigismund on May 30, 2009, at 2:43:28
In reply to Re: Need an alternative to Abilify » garnet71, posted by jerrypharmstudent on May 29, 2009, at 23:19:08
>i wonder why pdocs can prescribe amphetamines but when it comes to opiates they get all uncomfortable?
Because you are from the USA.
It's not like that here.
If anything, opiates are easier to get here, though not, of course, for depression.
Posted by garnet71 on May 30, 2009, at 4:15:02
In reply to Re: Need an alternative to Abilify, posted by greywolf on May 29, 2009, at 23:00:10
Not necessarily. I already talked to the one about it, briefly, and the other one I have an appt. with already knows I was sent to him for that reason. They are not oblivious to the reasons you are switching doctors, are suspicious to begin with considering their responsibililty, and they talk among one another. I'm sure any new PDoc I'd see would call the former one. If anyone here thinks their doctor doesn't talk to another on the phone about you, for whatever reason, think again.
Last doctor who prescribed me a benzo, outside of PDoc, was when I was having bronchial spasms from Adderall. I decided to talk to her about drug seeking behavior and told her my PDoc had prescribed me .25 xanax. We had a nice little discussion about the so-called drug-seeking behavior, and she told me a story about one of her patients who was actually drug seeking, and how she got screwed. I walked out of there with .5 Xanax.
If you come across as a sincere person, I found doctors are pretty open and like to talk about other things besides your care. I always talk to my OBGYN about dating, for example, as strange as that may sound. I know what your saying, appreciate it, but honestly, I come across very genuine and its obvious that I'm a very open person because of the things I say, out loud, thinking of some of the conversations I have provoked in the past. I'd rather just say what's on my mind and discuss it in the open, well most of the time, rather than them thinking it, and me thinking it; that creates tension and uncomfortableness that you can sense/feel. When there is comfort and ease in the room, people perceive you as honest and warm.
People like to talk about controversial topics when they feel at ease, and will be more receptive to your bringing up controversial topics when they feel comfy.
Some people are just mean though.
But I guess I'm too much of a chatterbox sometimes, like tonight. lol
ps like your screenname
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Dr. Bob is Robert Hsiung, MD,
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