Moody Bitches Appendix: Selected Drugs

Naming Names:
A Guide to Selected Drugs

Antidepressants

SSRIs, Prozac, Zoloft, Paxil, Celexa, Lexapro, Luvox, and others

Specific serotonin reuptake inhibitors do just that. They specifically block the reuptake of serotonin. They don't affect any other neurotransmitters, hence the term specific. Blocking reuptake means that more ­serotonin is available to get across the synapse to the next nerve cell, or neuron. Think of it this way: There is a pitcher neuron and a catcher ­neuron. The balls are the serotonin. The pitcher can scoop up any balls that aren't caught immediately with its mitt and throw them again, or just hold on to them. If you block the pitcher's mitt, there are more ­serotonin balls available to eventually be scooped up by the catcher's mitt. This blockage results in enhanced serotonin getting across to the catcher. This is referred to as increased serotonergic tone. Now, why this ­translates into feeling happy and relaxed is complicated and not well understood. There are changes that occur long term in the number of catcher's mitts produced; the postsynaptic neuron learns to accommodate the extra serotonin in the synapse by adjusting how many receptors there are. This is called downregulation. (If there were less serotonin in the synapse, the number of receptors would increase, called upregulation.) This up- and downregulation is the neurologic basis for tolerance to a drug. If you keep on taking a drug that increases a neurotransmitter level, you will eventually develop fewer receptors for that transmitter. So there are two stages to adapting to a new antidepressant: an immediate response to having more neurotransmitter available and then a delayed, more chronic response that involves the up- or downregulation of the receptors. There may also be a lag because of neuroplasticity and BDNF needing time to do its job. The bottom line is that these are the medications used to treat depression and anxiety, and they work slightly better than placebos in many patient groups and significantly better than placebos in other patient groups.

Not everyone who is depressed, anxious, or obsessive has measurably low levels of serotonin when you look at them in research settings, so very likely there are other things going on chemically that we have yet to fully understand. SSRIs, sometimes called serotonergic medications, are good for decreasing depression, anxiety, and obsessiveness. Obsessive-compulsive disorder is treated with SSRIs exclusively. The other types of antidepressants that affect other brain chemicals really don't work that well in OCD.

Unfortunately, increasing serotonin in your brain often translates into feeling less horny and making it harder to climax. Some SSRIs can make your pelvis feel numb, with decreased sensitivity of the genitals. Zoloft is well known for causing this problem. Most of the SSRIs make it take longer to climax, and sometimes the quality of the orgasm is reduced. This side effect is worse upon initiating the medicine and gets better over time, though for some people it is a lasting problem. In my experience prescribing these medicines, the SSRI with the fewest sexual side effects is Lexapro, but there can still be decreased libido and increased time to orgasm at higher doses. Other psychiatrists prefer Prozac, the original SSRI, which they feel is less likely to cause weight gain and sexual side effects. My issue with Prozac is that it has the longest half-life of any of the SSRIs. This means that even if you stop using the medicine, it stays in your system for days or weeks. One of the main advantages to using Lexapro, because it has a shorter half-life, is that you can stop it for a day or two and markedly decrease its blood level and therefore its side effects.

Celexa was my SSRI of choice until Lexapro came along. They are chemical sisters, more alike than different. Celexa works fine for many of my patients, but Lexapro seemed to be a bit "cleaner," leaving my patients less foggy and more mentally sharp. When I give my patients a prescription for Lexapro, I tell them to break the tablet in half to start. I usually start with the 10-milligram tablets, but sometimes I'll start with 5-­milligram tablets in people who are very sensitive to medicine or have absolutely no history of taking anything that alters their brain chemistry. I recommend the half tablet for a few days (three to five) before going up to the full tablet. Also, it's better to take SSRIs on a full stomach or with food and not on an empty stomach, as nausea becomes much more likely. The presence of food protecting the stomach lining helps to diminish this side effect. (This is true for many medicines. In general, if a pill makes you feel nauseated, you should take it with food unless the bottle specifically states that you need an empty stomach for it to work, as is the case with Synthroid and some antibiotics.)

A big issue with many SSRIs is timing - when to take the pill. With Lexapro, many people find the best time to be late afternoon, three or four p.m. Sometimes taking Lexapro first thing in the morning will make you very sleepy after lunch (I call it the exaggerated siesta response), so taking it in the late afternoon will delay that sleepiness until closer to bedtime. Others get a lift from it and take it first thing in the morning after breakfast. Still others, though fewer, take it right before bed and it helps them to sleep. The only problem with taking it before bed is that it can enhance the vividness of your dreams. It doesn't cause nightmares but may give you very intense and memorable dreams that seem quite real. Also, I occasionally hear about people feeling a bit hungover in the morning if they take it before bed. It's harder to get out from under your warm blanket. So I tend to recommend "tea time" as the best time to take Lexapro; the only problem with that is remembering to take it, which is crucial in order for it to work! The bottom line with the timing issue is that you really have to experiment and figure out which of those three types of people you are. And if late afternoon works best for you, set an alarm on your cell phone or anchor it to something you do regularly that time of day, like picking up the kids from school or hiding from your boss.

As for the other SSRIs, there are a slew of them, and they all have different side-effect profiles. As there are serotonin receptors in the stomach, many of these medicines can cause nausea or stomach upset. I don't prescribe Zoloft much because when it first came out, we referred to it as "the puke drug." Nausea, vomiting, diarrhea, and stomachaches were big problems in my patients. I have a colleague I respect tremendously who uses Zoloft preferentially, though, and it is widely prescribed by many other physicians, so obviously not everyone feels the way I do. (I have a theory on how Zoloft became so popular with internists. They saw drug reps from Pfizer who gave them samples of medicines for blood pressure and threw in some Zoloft for their depressed patients.)

Paxil is another SSRI I don't typically prescribe. It tends to be sedating and makes people feel hungover the next morning when they take it at night. It has actions similar to Benadryl, an antihistamine, and can also cause increased appetite and weight gain more often than some of the other meds. Also, it is tricky to discontinue due to its short half-life. In my experience, Paxil is the SSRI that is hardest to stop, with the most significant withdrawal syndrome. There is an extended-release version, Paxil CR, that is easier to taper off.

So let's talk about that whole withdrawal issue. While it isn't as much of an issue with SSRIs as it is with the SNRIs (see the section below), it can be a bit uncomfortable to come off these medicines. It is important to slowly taper the dose over several weeks so that you can avoid the headaches, spacey feelings, and disorientation that can come from abruptly discontinuing the medicine. I have a number of patients who notice that if they miss a day or two of their SSRI they are irritable, grumpy, or angry. They have a shorter fuse than usual. Other people feel acutely depressed when they miss a few doses of their medicine.

There is some literature that shows that if someone is in the bipolar spectrum, SSRIs can aggravate rather than ameliorate some symptoms, so it is an important distinction. People with a history of manic episodes shouldn't take SSRIs, and even sometimes people with bipolar relatives would be better off with a different medication choice. (I often choose Lamictal for these folks. See below.)

SNRIs (Effexor, Effexor XR, Cymbalta, and Pristiq)

This second group of antidepressants blocks the reuptake of serotonin and norepinephrine (similar to the brain's adrenaline). These antidepressants are particularly good for anxiety and panic disorder, and they work very quickly, often relieving depressive symptoms within a week. Effexor was a popular choice at Bellevue when I was working there, because we would start to see the antidepressant effects kick in within three or four days. Like the SSRIs, they also make it difficult to achieve orgasm and can cause weight gain in some people.

Unfortunately, this group of antidepressants has more of a discontinuation syndrome than the SSRIs. Effexor withdrawal is legendary. Google it and you'll see. I have heard patients going through withdrawal complain of the following: nausea, dizziness, disorientation, extreme anxiety, agitation, electric shocks running from their head to their arms (sometimes called brain zaps), feeling their brain move inside their skull, feeling their vision lag behind their eyes, and feeling something like cold water running down their spine. I had one patient who obtained relief only by locking herself in her closet and screaming; this was a mild-mannered gal, not a screamer. When she got online, she was relieved to see that other people had taken this approach to dealing with their discomfort. I had another patient feel so out of it, disoriented, and ditsy that he almost got hit by a cab crossing the street. I have learned not to be too surprised when I hear about people's experiences trying to get off Effexor. Most important, I have been able to assist people in their attempts to get off it by starting them on an SSRI (either Lexapro or Prozac) prior to doing a slow taper of the Effexor. Cymbalta is another SNRI that is difficult to discontinue, but it isn't as legendary as Effexor in difficulty.

Cymbalta, which has received FDA approval to treat fibromyalgia, is touted as an antidepressant that also helps with pain syndromes. All the SSRIs and SNRIs can help with any types of pain, but especially neurogenic pain, the tingling that occurs from nerve pressure. Because SNRIs do things that SSRIs don't (mainly, they affect a second neurotransmitter system, norepinephrine, that the SSRIs don't affect), if you have a partial response to an SSRI, it makes sense to try an SNRI to see if you can have a more robust response.

Wellbutrin, Wellbutrin SR, Wellbutrin XL, and Zyban (Bupropion)

The makers of Wellbutrin don't give a lot of information about how it works, except to say it doesn't increase serotonin. As such, it doesn't do much for obsessiveness or anxiety, but it's great for certain types of depression. It seems to enhance dopamine function, so if you have a low-energy, foggy, can't-get-off-the-couch type of depression, Wellbutrin can be a great choice. It often increases energy, concentration, and motivation. What's even better, it reliably decreases appetite, helps with willpower (making it to the gym, sticking to your meal plan), and has no sexual side effects. Some women even find that it's easier to climax and that they have more libido on Wellbutrin.

The biggest downside with Wellbutrin is initiating the medicine. The first few days are tricky. Many people feel "speedy" when they start taking it, like they've had too much coffee. Also, it can cause difficulty falling asleep. Taking the pill after eating a meal first thing in the morning can help. Also, I have found that it helps to eat a little bit of protein throughout the day on the first few days, like a hard-boiled egg or some almonds. Eventually, the jitteriness smooths out, but it can be a tough ride in the beginning.

One caveat: if irritability and a short fuse are issues for you, Wellbutrin can make that worse, especially at the higher doses. Wellbutrin comes in immediate release, SR, and XL. In my experience, XL is the best, but it's also harder to get started on than SR because the lowest dose isn't all that low. Sometimes I'll start people on a lower dose of the SR formulation and then switch over to the XL.

Many people need only a half dose of Wellbutrin XL (150 milligrams) instead of the 300-milligram maintenance dose. If someone can't get by without the 300-milligram dose, I'll often add a small amount of Lexapro to counter the edginess. Adding a second medicine to counteract side effects of the first is never a good idea, except here. The combination of Wellbutrin and Lexapro does fabulous things. Between the two of them, they are like buckshot, knocking down every symptom of depression and anxiety. And their side effects cancel each other out, to some extent, so the low libido and potential weight gain with SSRIs can be countered by adding Wellbutrin. Also, the low motivation and lackadaisical side ­effects seen in higher doses of SSRIs can be countered by adding a bit of Wellbutrin. Many of my patients are on this combination, and I look forward to the day when some genius in the pharmaceutical industry realizes they should just make one pill with both these medicines bundled together.

Remeron (Mirtazapine)

Remeron is considered a tetracyclic, a medicine that effectively increases serotonin in multiple ways, but not by blocking the reuptake site as SSRIs do. It blocks certain serotonin receptors (5-HT2A, B, and C, and 5-HT3). It also increases norepinephrine transmission, as Effexor and Cymbalta do. It can help with anxiety and is quite sedating, making it a good choice for people with insomnia. It also can quell nausea, vomiting, and irritable bowel symptoms. The main drawback is that many people experience increased appetite and weight gain from Remeron, but in the right patient this can be a plus. (People who are chronically ill or anorectic, for instance.)

Tricyclics and MAOIs

These are older versions of antidepressants that are seldom used anymore. The tricyclics (Elavil, Anafranil, Tofranil, Pamelor, Vivactil, and many others) are quite effective at treating depression, as they raise levels of two neurotransmitters, serotonin and norepinephrine, by blocking their reuptake. The problem is the signal-to-noise ratio, or the positive effect to side-effect balance. Even though they block those two transporters, they also hit a lot of other neurotransmitter receptors, so you pay a pretty high price for efficacy with dry mouth, constipation, difficulty climaxing, and sedation. Also, they are dangerous in an overdose, as opposed to the SSRIs, which have a much wider margin of safety. There are still some psychiatrists who prescribe them, but not many. I am not among those who do. That goes for MAO inhibitors also. These medicines (Nardil, Marplan, Parnate) prevent the breakdown of many neurotransmitters, including serotonin, norepinephrine, and dopamine, thus increasing their levels, but you have to follow a strict diet and avoid many medications (including cough and cold preparations) or you risk having a marked rise in blood pressure. There are newer MAOIs that don't require much in the way of diet restrictions, including a patch called Emsam, but it's not a medication that I typically prescribe.

A word about antidepressants in general: while some increase serotonin and others enhance norepinephrine or dopamine, many have one underlying effect in common, called hippocampal neurogenesis. It turns out that the brain can grow new neurons, new connections, especially if brain-derived neurotrophic factor gets involved. BDNF is increased by many antidepressants and results in new brain cells being formed and new connections being made. But exercise does the same thing, people. Numerous studies have shown that regular cardio enhances BDNF and hippocampal neurogenesis. This is why when my patients ask me about getting off the meds, the first thing we start to talk about is an exercise regimen. Neurogenesis is a delayed effect of the antidepressants, taking weeks to fully kick in. Sometimes my patients start to feel better very quickly when we start certain medicines (Lexapro, Viibryd, and Effexor seem to kick in more quickly), but most meds need a good six to eight weeks to fully settle in and do their job.

The two medicine groups that are immediate acting, instead of taking weeks to kick in, are the stimulants and the antianxiety medicines. In some ways, it makes more sense to consider these to be drugs instead of medicines because of their near-immediate effect.

Stimulants

Amphetamines like Adderall and Dexedrine help to give energy, moti­vation, focus, and concentration. They work within an hour. The main side effects are that they are stimulating, make it hard to calm down or to sleep, and also cut appetite. These medications were used for treating depression in the 1960s, until it was discovered that they can cause tolerance and dependence and that the withdrawal can bring about a horribly depressed mood. These days they are used almost exclusively for attention-­deficit disorder, though many people try them out as appetite suppressants. (The problem here is that this effect diminishes over time, so they need to be used sporadically, if at all, for that indication.)

There is no quick and easy way to diagnose ADHD. The gold standard is a battery of neuropsychological testing that takes many hours and costs around one thousand dollars at a minimum. Many people come to my office having read an article on ADHD and feel fairly sure they have the diagnosis. There is a sense that their concentration and attention are faltering, and maybe their impulse control isn't 100 percent. Sometimes people undergo a trial of stimulants to see if they have ADHD, but the truth is, anyone who takes these medicines will experience an increased focus and less distractibility. Many of my patients who are taking stimulants have been on them since grade school and demonstrate clear signs of hyperactivity and inattention. But some of my ­patients take stimulants because they're sitting at desks in front of computers for a dozen hours a day and find that the prescriptions help them stick with their work for long stretches.

With Adderall and Dexedrine, there are tablets and capsules. The tablets come on a bit more quickly and peak and "crash" to some extent. They last about three or four hours. The capsules come on a bit more slowly and have a longer plateau with much less of a crash, lasting about six to eight hours. I often prescribe both the capsules and the tablets to my patients so that they can experiment with each and see which they prefer, though many of my patients end up using both of them throughout the week, depending on the demands on their time. Many people take a capsule earlier in the day and a tablet later on if they need more medicated time.

I usually start with the lowest dose, 5 milligrams. The tablets can be broken in half, unlike the capsules. For people who've never had stimulants before, I start with the tablet and have them break it in half, just to make sure they're not too sensitive to it and don't have some unforeseen problems with it. But most people don't really get by on 2.5 milligrams. They need either 5 or 10 milligrams. So they can start with a half, go up to one tablet, and if they need two, it's fine.

The most common side effect of stimulants is feeling a bit revved up, like you've had too much coffee. Interestingly, the people who really do have ADHD don't feel so stimulated; they feel calm and focused. (This is also their response to cocaine and speed, which can help to diagnose someone. Also, these are the people who can have a cup of coffee right before bed. Stimulants don't seem to rev them up as they do other people.) One of the many downsides of stimulant use is a headache when the crash comes (when it wears off). Also, importantly, it cuts your appetite quite a bit.

One word of advice I usually provide: eat before you take the medicine, so you won't be too ravenous when it wears off. One reason people notice the crash is that they haven't had anything to eat or drink for six to eight hours and so their stomach hurts and they have a headache. I encourage them to eat something like a salad or fruit or at least a protein bar at some point during the day, so their blood sugar won't tank. Also, don't take them too late in the day or it will be difficult to fall asleep.

There is an extended-release amphetamine medicine that lasts longer than the Adderall or Dexedrine capsules called Vyvanse, which lasts twelve hours or more. Some of my patients who have been taking stimulants for years and work very long hours appreciate what Vyvanse can give them.

You may be wondering why I haven't mentioned Ritalin, or the long-acting forms of Ritalin called Concerta or Metadate. I don't prescribe these ADHD medicines, and I don't think the medicines in this class work nearly as well as the amphetamines. When it was first introduced, Ritalin supposedly had a lower abuse potential, and it also didn't have the baggage of the amphetamines because it had a new name and was a new compound (methylphenidate). However, it really doesn't work as well as Adderall or Dexedrine in my experience (and my patients' experiences), and many psychiatrists, including me, think it actually is more likely to be abused. If someone comes to me and has tried both and is absolutely sure he or she prefers Ritalin, then I will acquiesce and prescribe it, but so far that has been a rare occurrence. Most people who come to me on Ritalin and switch over to Adderall or Dexedrine appreciate the new medicine.

Benzodiazepines

Antianxiety drugs like Valium, Xanax, Klonopin, and Ativan belong to the family of medicines called benzodiazepines, often called benzos. These medicines help to soothe and calm anxious feelings. I had a ­mentor once who called them psychic pain relievers. A smaller dose will "take the edge off" anxiety, while a larger dose will put you in a zone where you simply don't care or react much to the storm outside the window. But take too much and you are "shlogged" or just plain asleep. There's an old movie with Goldie Hawn and Burt Reynolds where Goldie takes one too many Valiums and ends up with her face in a plate of egg salad. The real danger is mixing benzos with alcohol, which can cause coma or death but more commonly causes falls down stairs or off curbs.

One big difference between the antidepressants and the benzos is how quickly they work. The SSRIs and SNRIs can quell anxiety, but they will take days or weeks to do so. The benzos are more like drugs than medicines in that they work very quickly. Once your stomach has absorbed them and they are processed by your liver (not all of them are, though; Ativan and Serax do not get broken down by the liver), they then make their way to your brain, where they increase the transmission of a neurotransmitter called GABA. This chemical is an inhibitory neurotransmitter, and higher levels result in a brain that is less excitable. In an emergency room, if a patient comes in having a seizure, the doctors will inject benzos into a muscle or vein to stop the brain from misfiring. Orally, most benzos work within twenty to forty minutes, depending on how much food is in the stomach. (One way to make them work faster is to put the pill under your tongue, thus bypassing the stomach and liver. The veins beneath your chin will drain the medicine directly to your heart which will pump it to your brain. This is particularly common to do with Ativan, called lorazepam as a generic.)

The main side effect of benzos is that they make people sleepy and unfocused. One shouldn't drive or operate machinery and should never mix them with alcohol. Another problem is interference with memory consolidation. At higher doses, benzos can turn your brain into Teflon, and things don't stick as well. New memories aren't formed appropriately and so become irretrievable. The workplace is not the best environment for these medicines, and I typically advise patients with chronic anxiety who need to stay sharp that they're better off taking an SSRI or SNRI instead. The other big caveat is addiction. These meds can cause tolerance, dependence, and withdrawal. It is possible (though rare) to have withdrawal seizures if a chronic high dose is abruptly discontinued. Also, the issue of rebound anxiety is worth mentioning. If you take benzos consistently, especially Xanax, your brain comes to expect them, and when they wear off, the anxiety you're trying to quell comes back like gangbusters, often earlier and earlier, necessitating more frequent dosing of benzos or higher doses of them. In my practice, whenever possible, I encourage only intermittent, sporadic use of benzos and stimulants, which is the key to using them. Don't get into any patterns of regular use where your brain starts to expect a certain medicine at a certain time.

The most commonly used benzodiazepines are Ativan (lorazepam), Xanax (alprazolam), Valium (diazepam), and Klonopin (clonazepam). For panic and anxiety, all these medications work, but they have different times of onset and levels of sedation, so it can be challenging to find the right medicine for the job. The sedation is a very big deal. Many of my patients can't tolerate taking a benzo at work, for instance, because they get too cloudy and spacey. The trick is to cut the anxiety without completely wiping you out so that you feel as if you have to head to bed. Some people find Ativan to be the least sedating, and others notice Klonopin is better for them. It's very hard to predict which patient will like which medicine, so sometimes there's a bit of trial and error. Also, many people notice that after they take Xanax they are depressed or otherwise feel "off" the next day.

Delayed onset is a drag when you're dealing with a fifteen-minute panic attack, so Klonopin isn't a great choice for this because it takes up to an hour to fully kick in. One nice thing about Ativan is that you can dissolve it under your tongue to work more quickly than any of the others. With Ativan, sometimes there's delayed sedation, sometimes not. The usual dose is either .5 or 1 milligram (though at Bellevue we would give either 2 or 4 milligrams, depending on how agitated the patient was, and we would give it as an intramuscular injection).

Many people use benzos for fear of flying, and, depending on the length of the flight, there are many options. Klonopin lasts the longest, with a half-life of roughly twenty-four hours, so it's too long acting for most plane rides. It's a good choice for chronic anxiety, though. Klonopin is also a good choice to take before bed if you wake up with anxiety in the morning, as there is a bit of a hangover effect due to its long half-life. Typical doses are .5 or 1 milligram.

Valium is the only benzo that also relaxes skeletal muscles, so it's particularly good if you have tension headaches or tight neck muscles, or if you have a back spasm. It's medium to long acting, with a half-life of thirty hours, but it has an active metabolite with an even longer half-life. Typical doses are 5 or 10 milligrams.

Xanax is medium length, moderate onset, but often pretty specific to the brain and less so to the body (unlike Valium). Its half-life is around eleven hours. Dosages range from .25 to 2 milligrams. Sometimes you can find a dose of Xanax that is good for planes, like .25 or .5 milligram. Taking a bit once you are at the gate and a bit more once you're settled in your seat is what I often advise. The trick is to not be so sedated that you can't carry your baggage once you get off the plane. Your balance might be affected, as well as your coordination, and remember: don't drink any alcohol if you're taking benzos. Not on a plane or anywhere else. They act synergistically and the chances of falling are markedly increased. Also, some people get disinhibited when they take benzos, the way some get when they drink alcohol. A little too loose and loopy. So it's not always the best choice to take benzos before that big presentation in the conference room just because you're nervous. (Beta blockers, like propranolol, are a much better choice in this situation.)

Mood Stabilizers

The usual treatments for bipolar disorders are mood stabilizers like lithium, Depakote, or Tegretol. Many of the mood stabilizers in the ­current psychiatric armamentarium come from the field of neurology and are actually medications used to control seizures, thus called AEDs, antiepileptic drugs. Lithium is the exception. It is not an epilepsy medication but rather a mineral, with a long history of being used as a "tonic" to soothe the nerves. Lithium was even an ingredient, once upon a time, in 7UP.

Lithium continues to be the gold standard for treating classic manic symptoms, but many people don't like the way it stifles their creativity, causes salt/water balance issues of excessive thirst and urination, and also puts their thyroid at risk. (Chronic use of lithium can often lead to hypothyroidism, for which people need to add Synthroid to their medication regimen.) Also, you need to monitor blood levels and make sure the kidneys are functioning adequately, so being on lithium means going to a lab to get blood tests. Even given these downsides, I do prescribe lithium frequently for my bipolar patients because it works. Usually, though, I use it in combination with another mood stabilizer so that the dose can remain quite low.

Depakote and Tegretol also require blood draws to check levels and make sure the liver and bone marrow are still doing their job; doctors have to monitor white and red blood cell counts, platelet levels, and liver function. Depakote can cause hair loss, acne, and swollen gums, and ­Tegretol is no picnic either, with nausea, vomiting, and blurred vision as potential side effects. These two meds are not for the faint of heart, but if you need them, you take them.

Lately, the second-generation antipsychotics are gaining traction in being used as mood stabilizers, and many are FDA-approved to treat ­bipolar disorder. These are medicines like Risperdal, Seroquel, and Abilify. (The first generation of antipsychotics, like Haldol, Prolixin, and Thorazine, don't typically have the mood-stabilizing properties of the second generation.) No need for blood draws goes in the "pro" column. In the "con" column are weight gain, sedation, and the potential for irreversible diabetes and movement disorders (tardive dyskinesia). These medications, while effective, are in no way benign. The problem is that bipolar disorder is hardly benign either. Suicide rates are very high when people are in either the manic or the depressive phases of the illness. And I've seen people ruin their marriages, their credit rating, and their children's serenity while in manic phases. Bipolar illness takes a toll on patients and families, and it is very tricky to treat. Balancing the risks and benefits of each treatment and tailoring the options to the patient's particular symptoms gets complicated; it's important to see a psychiatrist and not an ­internist if you have bipolar disorder. If you can find someone who specializes in bipolar treatments, so much the better.

Abilify (Aripiperazole)

In 2007, Abilify, a medicine formulated to treat schizophrenia, was approved by the FDA to treat depression, as an add-on medication. So if someone is on an SSRI or Wellbutrin and isn't having a robust response, she can augment her medication regimen with a small dose of Abilify. Abilify is also used as a mood stabilizer. In schizophrenics and bipolars, the typical dose is in the 15- to 30-milligram range. For depression, the range is 2 to 5 milligrams, which should lighten the side-effect burden, one would think, but in truth, Abilify can be a bit tricky to initiate due to its side effects. The drug company calls it activation, but it can feel like agitation. I warn my patients that they may feel more energetic and "antsy," and it's not uncommon to have some insomnia when starting Abilify. It has a very long half-life, so even if it's taken in the morning, it may lead to difficulty initiating sleep. Many people are better off taking it before bed, so the peak blood level comes during the day. I usually start with a 2-milligram dose and ask my patients to break it in half for the first few days. The activated feeling usually passes by the end of the first week or clears up as the dose is increased over time. I have some ­patients who end up on 5 milligrams, but many more stay in the 1- to 2.5-­milligram range.

I do have several people with schizophrenia in my practice who are doing well on Abilify and quite a few with treatment-resistant depression who require a combination of antidepressant and low-dose Abilify.

Lamictal (Lamotrigine)

Lamictal has become increasingly popular among psychopharmacologists, but is rarely considered by internists trying to treat their depressed patients. A great medication for depression or anxiety with no sexual side effects and no weight gain, Lamictal is well tolerated with minimal side effects, if you can get past one big issue: a very serious rash that is often described as life threatening. Stevens-Johnson syndrome is a dangerous potential reaction to many medications, especially mood stabilizers, including Tegretol and Lamictal. To decrease its likelihood, you need to go up very slowly on the medication; this is called a slow titration. The Lamictal titration is typically prescribed over a six-week course: 25 milligrams for two weeks, 50 milligrams for two weeks, 100 milligrams for a week, then 125 milligrams for a week, finally stopping at 150 milligrams, which is when you might start seeing some results. Sometimes people don't turn a corner until a higher dose, and it takes time to find the right one. Given the six-week titration schedule and then fishing around for where the person will remain dosewise, Lamictal isn't for those patients who are in a hurry to feel better. It's a good medication to choose when someone comes to me already on another medicine but only getting a partial response, when we have the luxury of time. Also, it's a great choice if you've been on a bunch of antidepressants and they all work well at first but then "poop out" after a year or two, or if you've tried SSRIs, SNRIs, and Wellbutrin but nothing has worked. Lamictal often works when nothing else does, and it's very subtle. With many medicines you can feel side effects, or you can somehow sense when you've taken the medicine versus when you've missed it. You feel medicated. Most of my patients don't feel like they're taking any medicine when they're on Lamictal. They just notice an absence of symptoms.

Prosexual Medicines

The short answer is that there are currently no FDA-accepted medi­cations that can reliably induce sexual arousal in women, but, rest assured, Big Pharma is working on it. However, the FDA has already shot down several prosexual drugs for women. I often wonder if the FDA won't approve any proposed sex drug that works too well because they fear these pills will turn women into impulsive, uncontrollable sex fiends, and society as we know it will break down. Or perhaps they're worried about the drug falling into the wrong hands and being used as a date-rape drug. While I sympathize with the latter concern, it doesn't explain the holdup in this approval process. (See the perimenopause chapter for more on this.)

Prosexual Meds Currently Available by Prescription

Testosterone, the hormone most responsible for sexual interest, desire, and some part of sexual response in women, is FDA approved only for use in men. Some doctors will prescribe small doses of testosterone for women, but it is considered an off-label use. Desired effects include a boosting of sex drive, clitoral enlargement, and increased frequency of sexual ­activity and thoughts. Undesirable side effects include weight gain (mostly due to muscle mass), acne, increased facial (and upper thigh) hair, and possibly liver problems if administration is oral. If you use sublingual drops or spray or a transdermal cream or patch, you bypass the liver issues. Pregnant women should never take testosterone, as it will cross via the placenta and affect the baby's development.

Normal testosterone levels in women run between 14 and 76 nanograms per deciliter, with the most common range between 20 and 50 nanograms per deciliter. The ideal dose of testosterone is between .25 and 2 milligrams per day in the pill form. For creams, it's a 2 percent cream applied three times a week at bedtime or thirty minutes before sex if the sex falls on a night when you aren't taking your dose.

Testosterone may well make you horny, engorged, lubricated, and more able to climax. It may also make you hairy, pimply, and a bit aggressive. I do have some patients who are taking testosterone prescribed by their gynecologists. It seems to work reliably in many of them, but the desire it stokes is indiscriminate. A man on the subway, your boss, and the pizza delivery boy all seem like reasonable sex partners. Remember, testosterone is not the hormone of monogamy; it is the hormone of novelty. Also, it causes more masturbatory behavior.

In women who have a primarily physical basis for their sexual dysfunction, such as female sexual arousal disorder, Viagra significantly improves sexual functioning. When taken by women, Viagra, Levitra, and Cialis do make genitals engorged and lubricated. For some women this will assist in arousal and even climax, but they do very little in terms of stoking desire. The Berman sisters researched Viagra on 48 prescreened women. It significantly increased the blood flow to the vagina, clitoris, labia, and urethra in all of them. The ability to climax increased in 67 percent of them, and more than 70 percent said they felt more sensation in the genital area during stimulation. In another of their studies, out of 202 women, 82 percent were more pleased with lubrication and sensation. Also seen were improvements in ability to orgasm, enjoyment during intercourse, and overall sexual satisfaction. It's important to note that the Berman studies eliminated women with low desire and low testosterone as well as those who would have responded better to psychotherapy. Another study, this time by Basson, showed that Viagra was no better than a placebo among 577 women who weren't screened the way the Berman studies' women were.

For Viagra, you'll need a prescription from your doctor and your insurance is unlikely to pick up the bill, though it'll pay for it for men. The dosage is 50 to 100 milligrams an hour before sex, on an empty stomach and with no alcohol on board. If you're not sure about the timing of when sex will occur, ask your doctor for Cialis, which lasts much longer. Neither of these is FDA approved for use in women yet.

Side effects can include nasal congestion, facial flushing, indigestion (possible worsening of gastroesophageal reflux disease, or GERD), and a temporary blue tinge in vision. You should avoid mixing it with nitrate medications or a dangerously low blood pressure can result. Also important, Viagra has been known to delay orgasm in men and women.

Buspirone (brand name Buspar) is a prescription serotonin agonist (5HT1A receptor). In studies with animals, the experimental serotonin agonist that works at the 1A receptor site, 8-OH-DPAT, was consistently shown to lower the threshold for ejaculation. Buspirone, which works at the same receptor site, was also shown to be effective. Clinical studies of women on SSRIs with sexual dysfunction showed that more than half improved when buspirone was added. Lybridos contains buspirone as its second ingredient, after testosterone (see below).

Cyproheptadine is a prescription serotonin antagonist (5HT2 receptor) that can mute the sexual side effects of SSRIs if taken before sex, but it's incredibly sedating, so you have to work fast.

Experimental Medicines in the Pipeline or Recently Rejected by the FDA

Lorexys is a combination of buproprion (found in Wellbutrin) and trazodone (Desyrel). These are two common antidepressants, one ­activating and one sedating, that may boost libido via dopamine enhancement. Clinical trials performed by developer S1Biopharma are under way.

Lybrido is a pill with an outer coating of testosterone and an inner core of Viagra. The testosterone enhances desire, arousal, and response, as well as triggering dopamine production for more pleasure. Viagra ­enhances blood flow, creating genital swelling, which ramps up sensation. The manufacturer (Emotional Brain) hopes to have FDA approval and distribution by 2016.

Lybridos is a pill with an outer coating of testosterone and an inner core of buspirone that slows down serotonin release, leading to short-term serotonin suppression, which improves desire and sexual response. The manufacturer (Emotional Brain) hopes to have FDA approval and distribution by 2016. Lybrido is about a year or so ahead of Lybridos in terms of clinical trials.

Flibanserin modulates serotonin in prosexual ways, thus turning down the inhibition and turning up the juice on desire. It is a 5-HT1A receptor agonist and 5-HT2A receptor antagonist (sort of like combining buspirone and cyproheptadine). It was rejected by the FDA in 2010, ten to one, due to the drug reportedly not being much better than a placebo, the side effects of dizziness, fatigue, and nausea outweighing the benefits in a study of eleven thousand women. Studies of prosexual drugs for men with fewer participants and more significant side effects have garnered FDA approval in the past, so the manufacturer (Sprout Pharmaceuticals) is resubmitting to the FDA in 2014.

Intrinsa is a testosterone patch for women developed by Procter & Gamble and rejected by the FDA in 2004. Remember the "women don't need this" line in the perimenopause chapter? The official party line is that they were concerned about "off-label use."

Libigel is a testosterone ointment that failed to sufficiently separate from a placebo in clinical testing in 2011 (Biosante). Phase III clinical trials were being conducted anew, with more than three thousand postmenopausal women enrolled, but are now at a standstill.

Luramist is a transdermal spray testosterone (developed by Vivus, then sold to Acrux ) withdrawn from consideration for FDA approval in 2004, reconsidered for submission as of 2012, and now MIA. Acrux makes Axiron, a transdermal testosterone gel approved for use in men, instead.

Estratest was a popularly prescribed pill containing estrogen and testosterone combined in dosages of either 1.25 mg estrogens/2.5 mg ­methyltestosterone or 0.625 mg estrogens/1.25 mg methyltestosterone. The brand was discontinued in 2009 for mysterious reasons. There is a ­generic available called EEMT HS (esterified estrogens and methyltestosterone.)

Apomorphine is an FDA-approved medicine for the treatment of Parkinson's disease. It is a subcutaneous injection that stimulates the release of dopamine, resulting in feelings of pleasure and erections. It was also an experimental prescription medicine in a sublingual form called Uprima, rejected by the FDA in 2000 over concerns of nausea, vomiting, and fainting. The company Nastech had a nasal-spray form of apomorphine in 2000, but the trail goes cold when trying to track down what ever became of it. E-mail me if you know.

Bremalanotide (Palatin Technologies) was the most promising medicine to enhance sexual desire ever. I even bought stock in the company when I heard about it, which I have only done one other time and that was with Pfizer's Viagra. Delivered via nasal spray and stimulating the medial preoptic area of the hypothalamus (the so-called ground zero of desire), it sent extra dopamine surging in all the right areas. The FDA shot it down, citing nausea, vomiting, decreased appetite, and increased blood pressure. An injectable version is in the works, with clinical trials proceeding nicely. Given the FDA's track record on approving drugs that actually work to enhance women's desire, don't hold your breath here.

Phentolamine is available as a prescription medicine called Vasomax (for men) or Vasotem (for women) that works faster than Viagra and is safer to take with nitrate medicines. It is a blood-flow-enhancing agent combined with an alpha-adrenergic receptor blocker. Side effects include low blood pressure, diarrhea, and nasal congestion (sound sexy?). The drug is not FDA approved in the United States but is available in other countries (Brazil and Mexico).

Appetite Suppressants

Please, start with eating whole, raw foods, more protein, and fewer carbs, and avoid flour and sugar as much as possible. If you have any sense that dairy is making you gassy, cut that out, too. Add probiotics and omega-3 fatty acids to your supplements. And move your body. If things still aren't going in the right direction, you can try the following things to boost your efforts.

Prescription Meds for Appetite Suppression (Topamax, Phentermine, and Qsymia)

Topamax can reliably cut appetite and stimulate weight loss, but you need to be careful of side effects. We doctors often call it dopamax, because it can make you stupid if you push on the dose. Cognitive complaints are common with this medication, from memory lapses to word-finding difficulties, so I usually use lower doses, typically 25 to 50 milligrams once or twice a day. It can often help with depression and headaches as well.

Phentermine is the half of Fen-Phen that wasn't taken off the market. (Fenfluramine, the other half, is a potent serotonergic medicine that can cause brain changes in serotonin nerve cells and was shown to cause heart valve disease and pulmonary hypertension.) Phentermine comes in both tablets and capsules, which are short acting and long acting, ­respectively. The tablets can be broken, so I often recommend that people start with half a tablet in case they're sensitive to its effects. I have patients who like this better than Adderall for the combination of appetite suppression and concentration.

Some doctors are combining Topamax and phentermine in their obese patients who want to lose weight. There is a brand-name pill that combines these two generic medications, called Qsymia. (Your guess on how to pronounce this baby is as good as mine, but keep in mind that you can typically take two generics more cheaply than one brand-name ­medicine.)

Adderall, Dexedrine, and Other Amphetamines

Back in the fifties, using prescription speed was the way to lose weight. Amphetamines were widely prescribed to dieting women. They do cut appetite, but this effect typically wanes over time. And if you continue to take them and increase the dose to chase that initial reaction, you run the risk of becoming psychotic or paranoid, hallucinating or thinking bugs are crawling all over you. It's rare, but if it happens to you, you're going to be hospitalized for longer than you'd like. Amphetamine-induced psychosis is notorious for taking a long time to clear - weeks, not days, which is how long cocaine- or PCP-induced psychoses take to resolve. So the best way to take these stimulants, if you're going to try them, is sporadically, with no pattern of use that your brain will adjust to, to avoid tolerance. But really, my advice is not to use them at all, unless you need them for ADHD.

Acomplia (rimonabant) is a medicine designed and marketed by Sanofi-Aventis that I was excited about when I heard it was in the pipeline. It is a cannabinoid receptor antagonist, which means it's like a pill to stop the munchies. Because it induced a depressed mood, it's not available in the United States, but my ­assumption is that there will be some other, more refined cannabinoid antagonist coming down the pike at some point that will cut appetite without making you miserable.

Belviq (lorcaserin) is a selective 5-HT2C receptor agonist. Activation of these receptors in the hypothalamus activates proopiomelanocortin production and consequently promotes weight loss through satiety.

Prescription Sleep Aids

Ambien (Zolpidem)

Ambien (zolpidem) is the most often prescribed and most requested sleep aid in my office and the most maligned in the press. It is a powerful sleeping pill with some pretty quirky side effects. Number one is Teflon brain. Once it kicks in, in twenty or thirty minutes, nothing sticks. You will not lay down new memories. This is why I tell my patients to take it IN BED once they're done with EVERYTHING. No more e-mails, texting, phone calls, or Internet purchases, unless you want to have absolutely no recollection of what was said or done. I have a patient who used to wake up in the morning and see his cell phone on his pillow. Scrolling through the list of recent calls was a waking nightmare. Numbers of his ex-girlfriends. What did he say to them? No clue. I have heard of "Ambien sex," in case you haven't. Some women find it easier to loosen their inhibitions with Ambien. If you don't mind having no memory whatsoever of the event or what was said, give it a try, but to me, that's all pretty risky. You might say things you wish you hadn't or do things you'd typically not do, with a patchy memory at best of what went down. This is best for established couples with few secrets, not for early in the relationship or with casual partners.

Then there's the sleepwalking and nighttime eating. I have a number of patients who won't take Ambien anymore because it makes them raid the fridge after it kicks in. One guy woke in the morning to find the kitchen a mess, pots and pans everywhere. He'd cooked himself a full meal and had no recollection of preparing it. Others awoke to find empty ice cream cartons and candy wrappers littering their bedsheets. And we've all heard about people sleepwalking or driving their cars in the middle of the night erratically (Patrick Kennedy, Tiger Woods), blaming Ambien for at least some of their bizarre actions.

Besides these memory-related side effects, there is the issue of Ambien's half-life. It is short. It puts you to sleep but does not keep you there. Many of my patients pop awake three to four hours later and then have trouble getting back to sleep. The joke I always make in my office is, "Ambien sings you a lullaby and rocks you to sleep, but then it slams the door on the way out." I often recommend that people take half a pill ­before bed and save the other half by their bedside for when they wake up. I call this the "poor man's Ambien CR." The controlled-release version of Ambien automatically gives you that second dose in the middle of the night, but the problem for many of my patients is that it's not sufficiently front-loaded to knock them out adequately in the beginning of the night. The upside is that after years on the market, they're both finally generic, and I do have some patients who combine a bit of immediate release with the long-acting version. But they need to be careful about the total dose. Ambien comes in 5 milligrams and 10 milligrams, but the 5s are usually right for most people. Older people should take even less. Ambien CR comes in 6.25 milligrams and 12.5 milligrams. If you break them, you lose the controlled release aspect of them, so it's not recommended.

Many of my patients notice that if they take Ambien nightly, sometimes it just doesn't seem to work. It's a bit unreliable. There may be a cumulative tolerance issue that develops, and so you need to take breaks in using it. Actually, it isn't recommended (or FDA approved) for chronic use but, unfortunately, many people are taking it that way. The other downside of Ambien is that it really doesn't work well on a full stomach, so if you're a late dinner eater, you're out of luck. There are some ­sublingual versions of zolpidem that you can put under your tongue. ­Remember, sublingual administration bypasses the stomach and the liver, so these meds will always work faster; what time you eat becomes irrelevant. The sublinguals Edluar (impossible to pronounce) and Intermezzo are both brand names and expensive for now, but they'll go ­generic ­eventually.

Lunesta (Eszopiclone)

Lunesta (eszopiclone) is like Ambien but better for many of my patients in that it works more reliably, especially on a full stomach. Lunesta lasts a bit longer, with less of the middle-of-the-night bouncing up, fully awake. And from my patients, at least, I have had no reports of night eating or "drunk dialing." One downside is its own quirky side effect. At least 10 percent of the people who take Lunesta (16 percent at 2 milligrams, 33 percent at 3 milligrams) get something called metal mouth, waking up with a horrible taste on their tongue, as if they'd slept with a few pennies in their mouth. Most things you drink or eat taste funny, and brushing your teeth makes no difference because there isn't a coating on your tongue. This is a neurological side effect, meaning it's mediated through your nervous system. It's harmless and it fades as the day progresses, but for the one out of ten who get this side effect, it's usually a deal breaker. Lunesta comes in 1-, 2-, and 3-milligram tablets. Don't break them; they taste horrible. For what it's worth, I don't get metal mouth and this is my favorite sleeping pill when I need something stronger than the herbal remedies.

Sonata (Zaleplon)

Even shorter acting than Ambien, Sonata (zaleplon) is great for people who have trouble falling asleep but not staying asleep. And it's even better for those who fall asleep fine but wake in the middle of the night and can't get back to sleep, because it clears your system in time for you to take it pretty late at night and still get up for work. It's been around long enough to be a cheap generic, and most of my patients like it. If you're a restless sleeper with insomnia that lasts all night long, it's not a good choice, but for most other people, it's worth a try. It comes in 5- and 10-milligram doses.

Benzodiazepines for Sleep

Restoril, Xanax, Klonopin, and Ativan are all potentially good sleeping pills in the benzodiazepine family. They each have a different half-life and, therefore, a different hangover potential. Klonopin lasts the longest and has a morning carryover effect, so it's particularly good if you have trouble not only falling asleep but are also waking up anxious. Typical doses are .5 to 1 milligram, but it takes awhile to kick in, so you may need to take it an hour before bedtime. Restoril is medium acting and is a good choice for most people. I usually prescribe 15 or 30 milligrams. Ativan is shorter acting and, for some, less sedating, but if all the other benzos leave you hungover, it's the one to try. A dosage of .5 or 1 milligram will help decrease nighttime anxiety to allow for sleep, but at Bellevue we would give 2 milligrams to really knock someone out. Xanax is its own special little complicated benzo. Medium to long acting, sedating for many, it's great for killing anxiety. If your insomnia is all about ­worrying, then this is the one for you. But I have many patients who feel that they're a bit depressed and "off" the day after they take Xanax for sleep, so it isn't for everybody. Doses range from .25 to 1 milligram.

I don't like to give benzos for sleep induction. People get used to their effects and need higher doses as tolerance becomes an issue. I limit their use to treating anxiety, but many other doctors prescribe them for insomnia. Also, benzos should never be combined with alcohol, and they have a higher potential for abuse, physical dependence, and withdrawal than other medicines, so you really need to watch your dosing and frequency. Being honest with your prescriber about how you're taking it is your first and best line of defense against misuse and addiction.

Trazodone

Trazodone is a medicine that's been around for a long time (and so is generic) and was originally used as an antidepressant. It has a low potential for abuse and there's no tolerance, so it's a good choice for people with addiction issues. The problem for many of my patients is that it makes them feel kind of crappy in the morning, headache-y and a bit hungover, but that typically goes away pretty quickly once they shower, have a cup of coffee, etc. Doses range from 50 to 150 milligrams to induce sleep. (Doses for treating depression are higher.)

One of the very rare side effects of trazodone, or so I was taught in medical school, is that it can induce an erection that doesn't go away, called priapism. When I was a fourth-year student at Temple, we had a brain-damaged patient who was given trazodone nightly so that he (and the nightshift) could have a quiet night. He never spoke to me, but every morning I had to go into his room and check his diaper to make sure he didn't have a hard-on. He never did. But still, I had to do my job, five days a week. One day I didn't get there until lunchtime, and when I came in to have a peek at his penis, he croaked out, "I've been waiting for you." I almost wet my pants. No one had ever heard him speak!

Rozerem (Ramelteon)

This is a prescription sleep aid that acts like melatonin, hitting the same receptor that melatonin hits (so it's a called a melatonin receptor agonist). The few times I prescribed it, my patients reported feeling strange and trippy, so I stopped. I e-mailed many of my colleagues to find out their experiences and received responses like "It doesn't work, so I stopped prescribing it" and "My patient got crazy high from it." The makers of Rozerem point out that it doesn't hit the benzodiazepine receptors and so has a low potential for abuse, but when you do a search on drug users' networks, it does come up as having a "weed-like high . . . ­especially if you've already had a good night's sleep and take it during the day." It comes in 8-milligram tablets, to be taken thirty minutes before bed.

Tricyclics

These are older antidepressants that have fallen out of favor for treating mood disorders due to side effects like sedation, dry mouth, trouble initiating urination, and constipation. But some of them are still used at nighttime to induce sleep, especially in people with pain syndromes, particularly neuropathy, or with depression or anxiety (and by older doctors who haven't learned new tricks). Elavil is a popular tricyclic used for sleep in doses that range from 10 to 100 milligrams, as are Sinequan (doxepin) and Pamelor (nortriptyline).

Remeron, Cymbalta, and Paxil

These are the more sedating antidepressants. If you're depressed, anxious, and have insomnia, these medicines might be good choices for your doctor to make for you. But all three of them can cause weight gain, so they're not too popular in my office!

Seroquel

This is an antipsychotic medicine initially formulated to treat schizophrenia and is also FDA approved to treat bipolar disorder or as an add-on in depression pharmacotherapy. Doses of 200 to 800 milligrams are used for these major psychiatric illnesses, but many doctors prescribe 25 or 50 milligrams to induce sleep. I personally don't prescribe antipsychotics unless someone is psychotic, due to serious side-effect possibilities (movement disorders, metabolic syndrome, or irreversible diabetes). But many doctors do reach for this prescription for their patients with insomnia. The most common issue with Seroquel is weight gain. I have one older gal with horrendous, debilitating insomnia who swears by her Seroquel as she pats her roll of belly fat, telling me it's the "cost of doing business," but as I want to stay in business, I don't typically prescribe this one.

Nonprescription Sleep Aids

Benadryl

Used commonly by tons of people, this one doesn't require a doctor's prescription and is cheap and plentiful at every drugstore. For most people, 25 or 50 milligrams will knock them out for the night. Downside? Dry mouth, hangover, and waking up foggy as all get-out. There are more significant cognitive complaints in some people, especially the elderly. It's definitely not good for anyone with Alzheimer's. It's great for people with allergies or a cold, as it dries you out as well as sedating you, though this can mean trouble for your sinuses, including pain and inflammation. Many over-the-counter sleeping pills, like Sominex, Unisom, Sleep Eze, and Nytol, have generic Benadryl (diphenhydramine) or doxylamine (another antihistamine) as their active ingredient.

Prescription Drug Abuse: Opiate Painkillers and ADHD Meds

A small proportion of Americans are addicted to cocaine and heroin and an even smaller percentage of those are women. Where women are gaining ground is in the painkiller department. Sales of opiates (those medicines derived from the poppy flower) like oxycodone (Percocet), hydrocodone (Vicodin) and OxyContin (a long-acting oxycodone) have ballooned, and deaths from overdoses have tripled during the past decade. Between 1991 and 2010, prescriptions for these medications in America increased from 30 million to 180 million, a six-fold increase. The manufacturing of the drug oxycodone increased from 8.3 tons in 1997 to 105 tons in 2011, an increase of 1,200 percent.

In our nation of quick-fix answers, our medicine cabinets are full. We are 5 percent of the world's population, yet we account for about 80 percent of the world's pain medicines. We have enough painkillers to keep every American adult medicated around the clock for a month.

Too many opiates and you simply stop breathing. More people are killed by prescription opiates than by heroin and cocaine combined. Emergency room visits related to the abuse or misuse of pharmaceuticals are more common than those for illicit drugs, 435 versus 378 per 100,000. Motor vehicle accidents were always the number one cause of accidental death in the past. Now, in more states, it's overdose deaths that are number one. And according to the National Institute of Drug Abuse, women are more likely to be prescribed painkillers than men, and they're more likely to use these drugs nonmedically. A CDC report (2013) showed that the use of opiate painkillers by women has quintupled since 1999 and that overdose deaths are rising faster among women than among men. Younger women in their twenties and thirties tend to have the highest rates of opioid abuse, but the overdose death rate was highest among women ages forty-five to fifty-four, where the drugs were often ­prescribed for pain.

So why are women more vulnerable to opiate use, misuse, and addiction? One reason is that women naturally somaticize, or convert ­anxiety and psychic pain into physical aches and pains. Feeling tense, put-upon, and burdened translates into backaches, neckaches, and headaches. Fibromyalgia, a syndrome of achy muscles and joints typically treated with antidepressants, is a good example. (But please consider a diagnosis of Lyme disease if you live in a tick-infested area, before you assume it's fibromyalgia.)

Sometimes we say yes to everyone's requests, piling on more responsibilities for ourselves by accommodating and gratifying others, until our bodies finally say no. Also, women with a history of childhood sexual abuse are more likely to somaticize than others, and there's no question that these women are overrepresented among the ranks of addicts.

The truth is, opiates feel great - you feel warm all over and everything seems all right. They soothe many aches and pains and offer psychic pain relief as well. It is easier to suffer the slings and arrows of everyday life with an analgesic on board, and it's very easy to hide an addiction to pills. Pinpoint pupils can give you away, but if people don't know to look for that, there's really no other outward sign that you're high on painkillers, except an easily overlooked slackening of the facial muscles and droopy eyelids. Your breath doesn't give you away as it does in alcoholism or nicotine addiction, and you don't typically stumble around or slur your speech. And when it's easy to hide, it just adds to the adrenaline charge of the duping delight.

Many treatment options are available for opiate addiction, including buprenorphine (a replacement drug similar to methadone except that it blocks the brain from getting high on your drug of choice), acupuncture, supplements like DLPA (an amino acid that helps you make endorphins), and, of course, rehabs and twelve-step programs.

As always, the first step is admitting that you have a problem and you need help. No easy feat for anyone, but especially the working mother who does it all seamlessly. While painkillers may work for some, others opt for stimulants instead. Pills like Adderall, Ritalin, and Dexedrine are typically prescribed for children with ADHD, but they are also prescribed in growing numbers for adults.

Supermoms may take ADD medicines so they can do more and last longer, all while running on empty. Between 1991 and 2010, ­prescriptions for stimulants increased from 5 million to 45 million, a nine-fold increase. High school and college-aged kids are a huge black market for study pills like Adderall, Ritalin, and Dexedrine, but it turns out moms like prescription speed, too. Like cocaine and methamphetamine (speed), ADD meds increase the amount of dopamine available in the brain, enhancing concentration, cutting appetite, and making it easier to stay awake longer. The downsides are headaches and stomachaches when the pills wear off and the need for higher doses more frequently if the use becomes long term.

Many of my patients on ADD meds notice that although they become more efficient and productive, their social skills and empathy are sacrificed in the process. One of my patients only takes her ADD meds when she has paperwork to do, not when she has clients to meet, noticing that she is unable to engage in small talk or warm eye contact. "With the Adderall, I turn into "laser-brain," wanting to cut through all required niceties to get to the knot and untangle it. I'm too intense and in too much of a hurry."

I have a patient with horrendous ADD. If she comes to my office in the morning before she's taken her medicine, it is nearly impossible for me to get a word in edgewise as she talks in circles, never quite arriving at her destination. She tells me her daughter starts many of her sentences with, "Mommy, focus!" For her, the Adderall isn't a luxury or a drug of abuse; it is truly the medicine her brain needs to function normally. What people need to understand is that everyone responds to stimulants in similar ways, with increased focus, concentration and impulse control, whether they have ADD or not. The difference between people who have ADD and those who don't is the stimulant effect. Unlike people without the diagnosis, who get jazzed and can't sleep, people with ADD can have caffeine, cocaine, speed, or Adderall and not feel very jacked up.

If you are prescribed stimulants for ADHD, stay conscious and mindful of your use; make sure you're honest with your physician about how often you're taking your medicine and under what conditions. I can help my patients who stay in touch with me about their patterns of use; it's the ones who keep the behavior hidden who miss out on my guidance. If you are abusing stimulants, it's important to seek help from a clinician who can help you wean yourself off. Abrupt cessation can cause a syndrome of very low energy and mood, not to mention a ravenous appetite bouncing back from being suppressed.

Cocaethylene

In New York City, people go out for a few drinks and end up in a bathroom stall snorting a line or two of cocaine. No big deal. Except it is. Combining cocaine and alcohol actually creates a third drug in your ­system, cocaethylene, which is more toxic to your brain and heart than either drug alone. This is the only time ingesting two drugs creates a new one in your body. We know that alcohol kills brain cells and liver cells. Cocaine constricts blood vessels, which puts you at risk for heart attacks and strokes. Cocaethylene is even more likely to cause these two catastrophic medical situations.

Just say no to this combination.

MDMA (Ecstasy, Molly)

MDMA (methylene-dioxy-meth-amphetamine) used to be known as Ecstasy, but these days, it goes by the rebranded name Molly. MDMA is a potent serotonin releaser, causing most people to feel happy and relaxed. It is also a dopamine and norepinephrine enhancer, so people are awake, focused, and euphoric. What's unique about MDMA is that it also triggers oxytocin release, creating feelings of closeness and connection. Since the 1980s, this drug has been growing in popularity. Emergency room visits reporting Ecstasy use increased from roughly 4,500 to 10,000 between 2005 and 2011. (I do feel compelled to offer, for comparison, the emergency room visits related to misuse of prescription medications, which rose from 636,472 to 1,345,645 between 2004 and 2010.) I believe the rising popularity of this drug reflects our growing need for social cohesion in our digital age. We are more connected yet less. We are all communicating like never before, yet without touch, eye contact, or closeness. On the dance floor, you get all of the physical closeness you crave, plus the intense bonus of emergence. When a flock of birds turns all at once into a new direction, a slight ripple of delay detectable, you can see the phenomenon of group cohesion. Group mind is intoxicating, and universal consciousness is a common psychedelic-induced euphoria. Many people who make dance a regular part of their lives will tell you that the sensation is better than drugs.

Because of the increased demand for this unregulated drug, there has been rampant drug substitution. Counterfeit drugs that contain no MDMA are common. In the early 2000s, tablets sold as Ecstasy often contained combinations of chemicals, none of which were MDMA. In response to this, people started selling white powder and calling it Molly instead of ecstasy, with the understanding that Molly was pure MDMA powder, not like those adulterated tablets that were going around. Unfortunately, the truth is quite the opposite. In 2013, the DEA's Miami field office reported that out of 106 samples of seized Molly, 43 contained different substances: the most common substitutes are methylone and mephedrone, more commonly known as bath salts. Nineteen substances were so obscure they were unidentifiable.

Lesson number one: buying a white powder at a concert or nightclub is dangerous and unwise, even if it now carries the name of an ­innocent, freckle-faced little girl. There is no telling what chemicals you've just purchased, and pressed tablets are also no guarantee of ­purity. Lesson two: the behavior that accompanies Ecstasy use is often a bigger risk than the drug itself. With MDMA in a warm environment, there is an increased risk of heatstroke, so dancing for hours on end can lead to serious health risks. Also, MDMA causes water retention, especially in premenstrual women, so drinking too much water is also risky. MDMA, when used in medically supervised settings at a low dose, infrequently, without overheating or water intoxication, can provide therapeutic benefits. But in the recreational setting, where you don't know exactly what you're ingesting, dancing for hours without taking breaks, or drinking too much water, the risks outweigh any potential benefits.

Cannabis

Cannabis is an ancient medicinal plant that has been used for thousands of years to decrease inflammation, nausea, muscle spasms, and chronic pain; induce sleep; and improve mood and appetite. Even if you don't smoke pot, your body uses its own cannabinoids to regulate nearly every bodily function.

Before it was rechristened marijuana, the scary Mexican slang specifically designed to conjure up frightening images of migrant workers made insane from loco weed, cannabis was known to doctors and patients alike as an incredibly useful medicine. Up until the late 1930s, it was a mainstay in the American pharmacopeia, used to treat ailments ranging from menstrual cramps to insomnia. Ignoring and even misrepresenting the AMA's request, Congress made cannabis illegal, mostly bowing to industrial interests against hemp, and renamed the well-known medicine using a smear campaign based on xenophobia. After the repeal of Prohibition, the federal machinery in place to enforce the ban on alcohol morphed into the one we have in place today, fighting the war on drugs.

America arrests and imprisons more people than any other nation on earth for nonviolent drug offenses, but it has done nothing to shrink the rates of drug abuse. We are the biggest consumers on the planet. Eighty-two percent of Americans believe we're losing the war on drugs and 78 percent believe cannabis should be legal, but our government spends more than fifty billion dollars every year invading our privacy, tearing apart families, targeting low-income communities, enriching drug cartels, and denying patients access to less toxic medicine.

In places with legal cannabis or medical dispensaries, fewer motor-vehicle fatalities and opiate overdoses are recorded. Every nineteen minutes in the United States someone else dies from an opiate overdose. Alcohol, which is associated with domestic violence, homicide, and suicide, causes 100,000 fatalities a year in the United States. Cannabis has no such associations. No one has ever died from an overdose, something you can't say about nearly any other prescription medicine or drug of abuse. Chronic pain patients can lower their use of opiates significantly and reduce their risk of overdose by adopting a regimen including cannabis, since they act synergistically. Curious about who's funding the war on medical marijuana? The makers of OxyContin and Vicodin, for starters.

If you are lucky enough to live in one of the growing number of states with medicinal cannabis laws, I encourage you to educate yourself about what this plant can do for you. (One place to start would be The Pot Book, a nonprofit book I edited, published in 2011.) What is most important with using cannabis or other drugs, or food for that matter, is if you are choosing to do it, honor the pleasure. If you are more conscious and ­conscientious, using drugs as a ritual sacrament imbued with meaning and inducing reverence, you will become less compulsive and destructive in your drug-taking behavior.

Cigarettes and How to Quit Smoking

The percentages of people who try a drug and go on to become addicted are as follows: inhalants, 4 percent; psychedelics, 5 percent; sedative hypnotics (sleeping pills and antianxiety meds), 9 percent; cannabis, 9 percent; alcohol, 15 percent; sniffing cocaine, 17 percent; smoking cocaine (crack) and heroin, 23 percent; tobacco, 32 percent. Addiction to heroin and cocaine are distant seconds to the vicelike grip of nicotine dependence. Cigarettes are the most addictive drug known to modern science, and they kill half their users.

Here's how I get my patients to stop smoking cigarettes. First, we set up a taper schedule. This does two important things: it gives your brain time to adjust to receiving less nicotine, and it gives you time to say good-bye to your friend. If you smoke a pack a day, you make a timetable for cutting down to nineteen cigarettes a day, then eighteen, and so on. You can do this over twenty weeks, twenty days, or anything in between, as long as it's a consistent step-down schedule. Some of my patients slow down the schedule as they get to the last five cigarettes or so.

Next, you learn to substitute other behaviors when you're triggered to want a cigarette. Smoking consists of two things, sucking and breathing. Sucking releases endorphins and endocannabinoids, causing pleasure (if that weren't the case, babies would not suckle and survive), and deep breathing calms you down. Some people are helped in the process of quitting by sucking on spoons, their thumbs, or their tongue. But the most important thing is the breathing. Whenever you take that first drag of a cigarette, you take a deep breath, hold it in, and then let it out slowly. I tell my patients to go ahead and do the sucking and the breathing, but without the cigarette. Take a deep breath, hold it and let it out slowly, again and again (see the breathing exercises at the end of the downtime chapter). Whenever you're anxious, fidgety, or want to smoke, take a look at what is driving the behavior and write it down, and then get to work on regulating your breathing. As with regulating all drug use and abuse, the answer starts with consciousness. Be aware and in your body, not lost in a fog.

Quitting smoking is tough and often requires multiple attempts. It will be even harder if you're living with a smoker or if your lover or friends smoke. Acupuncture involving ear stimulation can help immensely, as can hypnosis. Nicotine replacement patches can be helpful if you'd rather step down that way instead of a cigarette taper, but I've seen too many people end up addicted to nicotine gum, so I don't typically recommend that to my patients.

An interesting side effect of the buproprion-containing antidepressants (Zyban, Wellbutrin) is that they seem to make cigarettes taste awful and not give you the same rewarding experience they used to, which is why Zyban is a popular prescription for smoking cessation.

The other medicine used for smoking cessation is Chantix (varenicline). It's not recommended for people who have any sort of psychiatric history, though. Every time I've prescribed it, my patients have gotten intolerable side effects, such as acutely depressed mood, suicidality, and crazy nightmares. It may work well in others without a psychiatric history, but I have no experience with this.

dr. holland

moody bitches weekends at bellevue the pot book ecstasy guide

moody bitches weekends at bellevue the pot book ecstasy guide

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