Sunday, September 9, 2012

Common Drug Interactions You Don't Know About

Just a quick blog about some common drug interactions you probably don't think about.

Caffeine and Psuedoephedrine: With hay-fever season here in California, short term nasal decongestants are a way of life at this time of the year. Mixed with lots of caffeine from gallons of ice tea with the hot weather, it's easy to become wired and not even recognize it. Caffeine and sudafed potentiate each other. If you do need to use nasal decongestants, use for the short term and limit your caffeine so you can sleep and not become some wired maniac.

Melatonin with Tramadol or Antidepressants: I see this all the time; people taking over the counter melatonin for sleep with their antidepressants or Ultram. These drugs mixed together in any combination can cause a life threatening illness called serotonin syndrome. It is a very common reason why I don't see people responding to their antidepressants as they should. All antidepressants by themselves help sleep. If you are not getting relief, discuss this with your doctor before you begin self medicating.

Steroids (Prednisone, Birth Control, Testosterone): These medications should be generally taken in the morning. I see people who have various immunological diseases on these medications complaining of insomnia. I usually see this in patients who take these medications at night. All of these drugs are known to cause insomnia. In fact high doses of all these drugs can cause mania and psychosis. Keep your doses for the morning hours.

Dementia medications (Aricept) with bladder medications (Vesicare): I see this commonly as a prescribing error by most primary care physicians. The two drugs essentially negate each other. Dementia medications increase acetylcholine in the central and peripheral nervous system. Bladder agents work by blocking this chemical in the same central and peripheral nervous system. I suggest you decide which is the issue causing the most loss of function and start there first, dementia or incontinence. Incontinence medications when used by themselves can cause a drug induced dementia, and might be worth stopping in elderly patients to see if their mental status improves before adding extra medications.

NSAIDS and Antidepressants: All nonsteroidals such as aspirin and ibuprofen thin the blood. So do antidepressants. In fact I frequently tell surgeons in my pre-op evaluations that antidepressants should be stopped 5 days before surgery if they are worried about a bleeding risk. Recently a patient of mine who was on an antidepressant had a complicated outcome with her liposuction because she forgot to mention this to her surgeon. I have many career actresses and models as patients where I advise using Tylenol for pain while on their antidepressants to minimize bruising.

I always tell my patients to inform me about medication changes including OTC's and supplements. It is one of the reasons I advocate using less medications overall. People are so worried about psychiatrists over medicating them. Be careful not to over medicate yourself.

Sunday, September 2, 2012

Less is MORE

Last week at the end of our session my patient told me, "I'm glad I found you". He had earlier seen an "addiction medicine" doctor who detoxed him off of opiates, i.e., 20+ Norco's per day. This doctor used a Suboxone taper with Tramadol and detoxed him over 5 days. The Suboxone was appropriate;  the Tramadol was not. My patient then stated that for 4 to 5 months he did not feel well. He couldn't sleep, he kept having racing thoughts, and he felt quite dazed. He was probably in a manic delirium exacerbated by his "successful" detox. My patient thought that he was still having drug withdrawal symptoms. I told him, "No, although your detox was successful this most likely triggered a bipolar mood cycle". It is not necessary to wait a year of sobriety to make this diagnosis. In fact my patient was so impaired during this time he almost lost his job.

I told my patient that this "addiction specialist" he saw was not trained to recognize why he was abusing prescription drugs in the first place. His attempt at self-medicating his unrecognized bipolar disorder was the problem. An internist or any other physician who does detox but is not a trained psychiatrist is going to drop the ball.  WHY?  It is a rare person who uses drugs in a vacuum. Usually there is some underlying issue that leads to the abuse or dependency. I applaud doctors who detox patients successfully. I can tolerate physicians who miss identifying Major Depression, Anxiety, Bipolar and ADHD disorders. But when they start taking the initiative to treat these disorders, I get mad as hell because it is dangerous! 

An addiction doctor I know put a patient on Lithium after his "successful detoxification". To make a long story short, he eventually came under my care after relapse. Lithium is a serious drug that has serious side effects. I discussed this with my patient and decided to discontinue Lithium. I evaluated him later and noticed continued hyperactivity and poor attention. After starting him on Stattera (Amoxetine) his ADHD is much better. We went from "bipolar disorder" to ADHD where my patient is now happy, functional and thriving.

The moral of the story? See a psychiatrist who can perform your detox AND who will not miss a serious underlying diagnosis that would prevent your optimal recovery and health. All psychiatrists who are recently trained can perform detox and treat psychiatric disorders. More so if they are board certified. Psychiatrists are the only medical doctors who are trained and certified in the biopsychosocial approach which aims at treating the whole person and not just parts like detox, withdrawal symptoms and maintenance. Psychosomatic medicine subspecialists like myself, practice this orientation for all types of diseases including drug abuse and dependence. The moral of the story? See a psychiatrist who can perform your detox AND who will not miss a serious underlying diagnosis that would prevent your optimal recovery and health.

The intersection of all 3 circles is health and well being.

Seriously?!?  Make it easy on yourself. Start with a psychiatrist and get it all done at one time. Why see several providers? As a board certified, subspecialized psychiatrist all of this is pretty easy for me to do. Less is MORE.