Last night a pharmacist saved my life

The title may be a bit melodramatic, but indulge me if you will.

We've had a trying few days around our house. Heidi's chronic pain flared up pretty badly over the weekend which saw us going to the urgent care clinic, redirected to the ER and then ultimately calling our family friend and doctor from when we lived in Washington to get some relief from what was the worst bout of pain she's had in a while. In the midst of all this, a symptom which Heidi had never exhibited prior to this weekend showed up. It started as involuntary twitching in her left leg and gradually got worse and worse until by Sunday night, she was having full body spasms. These twitches went away when she slept and could be almost "willed away" if she concentrated hard enough. But they were still undeniably there.

On Monday, we went to the physical therapist and the chiropractor. Both provided a great deal of relief, but after a few hours, the twitches were back. The chiropractor recommended following up with our regular MD, saying something about "brain stem lesions" and other such things that sent my brain which, left to its own devices will always concoct the worst case scenario, into hyperdrive. His thought was that the MD would refer us to neurology which seemed appropriate to me.

So we did just that - we visited our MD yesterday and he did just what we expected and referred us to neurology. He sent Heidi back over to the hospital for some bloodwork to rule out some of the more obvious things. I had left work to accompany her to her appointment and she sent me back to work as my presence at blood draws is not essential. I did, however, leave her in a wheelchair in the front lobby of the hospital. Jeez, what kind of husband abandons his wheelchair bound wife to go back to work? What a cad.

That was, until going back to work caused a light bulb to go on over my head.

I'll admit that I had thought of it previously, but had dismissed it. Heidi takes Effexor for the fibromyalgia-like pain that she has. She takes a mid-range dose as that's the dose where you get the effects for pain vs. the mood-elevating effects of its approved indication for treating depression and anxiety. She also takes trazodone at night, which is an old time antidepressant that we don't use anymore because the doses needed for effective treatment of depression are so sedating you end up looking like something out of The Walking Dead. However, it does have a place in treating mild insomnia which is what she'd been taking it for. She had been taking 25mg of trazodone at night, every night and had recently upped her dose to 50mg. In addition to this, she had been tweeking her dose of Effexor upward as her pain had been bad.

What's important to know is that both of these drugs affect a neurotransmitter called serotonin. What they do, in effect, is keep serotonin in the neural synapse instead of allowing it to be taken back into the neuron for reuse. This is what leads to the mood elevating effects you see with these drugs. Why the hell this works for pain is a fuck-if-I-know type thing, but it does. Sometimes, when you combine these drugs, you can get a drug interaction which leads to an excess of serotonin. Basically think Duran Duran's "Too Much Information" but instead "Too Much Serotonin."

This condition is what's known as "serotonin syndrome." When I looked up the interaction between Effexor and trazodone, I found the following:

Symptoms of the serotonin syndrome may include ... neuromuscular abnormalities such as hyperreflexia, myoclonus, tremor, rigidity, and ataxia.

It was a long shot - especially at the low dose of trazodone she was taking and there were many other symptoms she didn't have, but something easy and worth a try. I had her stop her trazodone and the doctor was already having her back her Effexor dose down to 150mg. The half life (the amount of time it takes half of the drug to be eliminated from your system) of trazodone is 3-6 hours and it's generally accepted that for a drug to completely clear your system takes 5 half-lifes. So if my theory held any water at all, about 30 hours from when she took her last dose of trazodone, her symptoms should really start abating.

We're past that point now, and her twitching is all but gone. She's gone from needing a wheelchair to get around to nearly baseline in that time. I'll never be able to prove definitively that I was right, but in my mind, I was. Nothing else changed. And as House always says, it fits. Mostly, I'm just glad that she's on the mend.

I always get ticked by the way the movies and TV portray pharmacists - you know, as nerds behind a counter without a single ounce of social skills. They are invariably balding middle age men with thick glasses that don't seem to be using their brains. Nothing could be further from the truth. I do this kind of stuff every day. Mostly, it is mundane stuff that is easy to catch and any pharmacist worth their salt will see it. But every now and then, I get something like this. And it makes all those years of fancy schooling worth every penny.

So hug your pharmacist (especially if I am your pharmacist - I like hugs) because some day, they might just save your life. Or at least stop you from twitching.

Get the point? Good. Let's dance.

Up on sugar pills, we go walking

A study published on Monday by British researchers has apparently shown that antidepressant medications are effective, but only in people that have the most severe forms of the disease. Predictably, this has been spun by the mainstream media into something that it is not. A quick Google News search turns up some of the following headlines:

Antidepressants just a placebo: study
Study concludes that antidepressants are ineffective
Antidepressants 'have no impact'

And my favorite: Antidepressants don't work.

As a health care professional, it's not the turning on the ear of commonly believed medical conventional wisdom that bothers me. That happens all the time. Case in point, when I was in pharmacy school, I was docked points on a case presentation I did because I did not recommend hormone replacement therapy to a 94 year-old female nursing home patient with severe dementia. Now, you rarely if ever see HRT given to any post-menopausal woman. (I'd like those points back, please, for being ahead of the curve.) But what does bother me is the misrepresentation of the data by news outlets that just want to sell papers, get ratings, or generate traffic to their web site.

While the caveats to the "antidepressants don't work" headline are in the articles, they are usually buried about a paragraph or two from the end. Most people don't bother reading newspaper articles past the first couple paragraphs, so for the majority of people the take-home message is "Antidepressants: They're Utter Shit."

The thing about the actual study is that it's a meta-analysis, which means that they took data from other studies and pooled them all together to create one big gargantuan study, hoping to glean new information. What the researchers did here was take clinical trials for three of the most common antidepressants (Prozac, Effexor, and Paxil) and one that does not enjoy the popularity of the other three (Serzone). All this data was pooled into one big pot and statistics applied to them. I'll be the first to admit that I'm no statistician, so I don't know much about what tests they applied to the data. When the data came out the other end of the statistics, the researchers found that there was no statistically or clinically significant difference between the antidepressants and placebos in all groups studied except for the most severely depressed patients.

This is all well and good but one thing is missing out of the mix here. Drug efficacy studies are not done by meta-analysis. They're done by randomized, double-blind, placebo-controlled clinical trials. Whenever an efficacy study fails to meet these criteria, you can bet that there will be a slew of letters written to criticize the design of the study. Now, that having been said, it is exceptionally unlikely that we'll ever see a new round of randomized, double-blind, placebo-controlled clinical trials because it is not financially advantageous to the drug companies. Sad, but true. And don't even get me started on studies that show negative results being buried by drug companies. That is truly shameful.

The other thing I will say is that, as someone who lives with depression and has a nearly 10 year history with antidepressants, the idea that the drugs will cure people is sadly misguided. They are but a component of a comprehensive treatment plan. For so many people, they have been miracle workers, yours truly included. My experiences with depression have mostly skewed toward the mild-to-moderate end of the spectrum. When I read Andrew Solomon's The Noonday Demon: An Atlas of Depression, his experience with depression made mine seem like Sunday afternoon in the park. But nonetheless, I know that I personally benefited from drug treatment. However, the drugs will only take you so far. There's work that you have to do and that does not fit in very well with our "a pill will fix you" culture. You have to do the mental work, you have to make the changes in outlook and mindset that are needed. What antidepressant medication does, in my opinion, is give you the boost out of the mud. When I was at my worst, getting dressed in the morning required incredible effort, let alone doing my job and being a functional partner and parent. To even begin to think about trying to make the mental changes in mindset required to lift myself out of the muck was more than I could bear. But once the drugs kicked in, that kind of mental effort was easier to bear. Relying on the drugs to fix everything would have been foolhardy.

We've known for a long time that the combination of drugs and talk therapy are more effective than either of the two on their own, which was conveniently ignored by the meta-analysis and the mainstream news stories that followed. In my estimation, what we need to take from this data is that folks who suffer from depression can't expect a pill to do all the work.

But they do work. I've witnessed it. I've lived it. That may be anecdotal evidence (which is held in even lower esteem than meta-analysis) but it is some of the most powerful evidence I have. They work but like everything else in life, you can't have unreasonable or unrealistic expectations regarding their abilities.

(Props to Dolly for providing the inspiration for the title of this post. I've had that damn song stuck in my head for days!)