N-acetyl Cysteine…New Miracle for Bipolar

N-acetyl Cysteine… New Miracle for Bipolar?

Hello, people… hope everyone is well! In last week’s blog, I introduced you to N-acetyl cysteine, or NAC, an amino acid supplement that’s garnering some serious attention in shrinky circles, as it has shown major potential to help treat multiple psych conditions. Recall from last week that NAC is most renowned for its ability to replenish levels of the body’s strongest antioxidant, glutathione, while it also regulates the very important neurotransmitter, glutamate, acta as an anti-inflammatory, and assists the body’s detoxification system.

The rationale for administering NAC for psych conditions is based on those roles: being a precursor of glutathione, as well as its action as a modulating agent of glutamatergic, dopaminergic, neurotropic, and inflammatory pathways. Those are the mechanics of NAC, the how and why it’s beneficial for brain function: NAC helps to produce glutathione, which, being the chief free radical scavenger, takes up all those nasties, reducing cellular damage. NAC also acts as an anti-inflammatory, so it decreases the blood levels of molecules that cause inflammation in the body and brain, such as interleukin-6, which incidentally may play a role in the pathogenesis of schizophrenia, bipolar disorder, and depressed mood. A third mechanism of action that has been proposed for NAC involves the stimulation, increased synthesis, and release of the neurotransmitters glutamate and dopamine. Let’s talk about those two for a moment.

As the most abundant neurotransmitter in the brain and CNS, glutamate plays an important role during brain development, as well as helping with learning and memory. Glutamate is an excitatory neurotransmitter. What is that? Excitatory neurotransmitters have excitatory effects on the neuron, meaning that they increase the likelihood that the neuron will fire a signal- called an action potential- in the receiving neuron. Because neurotransmitters can increase action potential, you can then probably imagine why neurotransmitter levels are very important. At high concentrations, glutamate can overexcitenerve cells and cause more neuronal firing. Prolonged excitation is toxic to nerve cells, and causes damage over time. So having excess glutamate, as an excitatory neurotransmitter, causes more neuronal firing, and you can actually damage cells this way. In fact, you can excite cells to death… a process referred to as “excitotoxicity.” Having too much glutamate in the brain has been associated with neurological diseases such as Parkinson’s disease, multiple sclerosis, Alzheimer’s disease, stroke, and ALS, amyotrophic lateral sclerosis or Lou Gehrig’s disease. Problems in making or using glutamate have also been linked to a number of mental health disorders, including autism, schizophrenia, depression, and obsessive-compulsive disorder, OCD. Glutamate is also a metabolic precursor for another neurotransmitter called GABA, gamma-aminobutyric acid. GABA is the main inhibitory neurotransmitter in the central nervous system- the flip-side of the coin- which decreases the likelihood that the neuron it acts upon will fire. That’s why glutamate is so important, it’s the dominant neurotransmitter used for neural circuit communication, and it’s estimated that well over half of all synapses in the brain release glutamate. 

Dopamine is the “feel good” neurotransmitter that’s strongly associated with pleasure and reward. It’s a contributing factor in motor function, mood, and decision making, and is also associated with some movement and psychiatric disorders. Dopamine is released when your brain is expecting a reward; when you come to associate a certain activity with pleasure, just the anticipation alone can be enough to raise dopamine levels. It could be a specific food, sex, shopping, or just about anything else that you enjoy. If your go-to comfort food is homemade chocolate chip cookies, your brain may increase dopamine levels when you smell them baking or see them come out of the oven. Then when you eat them, the flood of dopamine you receive acts to reinforce the craving, causing you to focus on satisfying it in the future. Dopamine is all about the cycle of motivation, reward, and reinforcement. Now imagine that you’ve been jonesing for those cookies all day, but your co-workers scarfed them all down while you were sidetracked by a conference call. Your disappointment might well lower your dopamine levels and dampen your mood. It might also intensify your desire for chocolate chip cookies, making you want them even more. Dopamine plays the main role in all of that, but keep in mind that dopamine doesn’t act alone. It works with other neurotransmitters and hormones, things like serotonin and adrenaline. Aside from its “feel good” function, dopamine is involved in many body functions, including blood flow, digestion, memory and focus, mood and emotions, motor control, pain processing, sleep, stress response, heart and kidney function, pancreatic function, and insulin regulation. Once again, as with all neurotransmitters, levels are important… theright amount of dopamine generally equates to a good mood. Ultimately, dopamine contributes to feelings of alertness, focus, motivation, and happiness, and a flood of dopamine can produce temporary feelings of total euphoria.

Those mechanisms I mentioned- glutathione reducing cellular damage, anti-inflammatory action, and the stimulation, increased synthesis, and release of the neurotransmitters glutamate and dopamine- are the proposed how NAC works, but why does NAC help people with varying psych diagnoses? Why might it work across so many conditions? This is the most intriguing thing to me. First and foremost, it seems to target biological pathways that are common across many mental disorders. For example, we know that patients with bipolar disorder have significantly higher levels of oxidative stress, and higher glutamate concentrations in their brains, especially during acute mania. It’s been suggested that people with schizophrenia may have the same, and that this may predispose them to changes in neuronal cell membranes and mitochondrial function that later manifest as symptoms of schizophrenia. It appears that NAC supplementation, by increasing CNS glutamate levels and reducing overall oxidative stress, may reduce the severity of these psychotic symptoms. 

A meta-analysis and systematic review of placebo-controlled studies on NAC as a stand-alone treatment of depressed mood in people diagnosed with major depressive disorder, bipolar disorder, and other psychiatric disorders, found evidence for “moderately improved” depressed mood and improved global functioning. In a four-month, double-blind study, individuals treated with NAC plus their usual antidepressant improved more than individuals taking a placebo with their antidepressant medication. 

In a large, six-month, double-blind study, individuals with schizophrenia who had failed to respond to multiple trials on antipsychotics were treated with 1,000 mg NAC twice daily versus a placebo, while also taking their usual antipsychotic medication. Those taking NAC experienced moderate improvements in symptoms of apathy and social withdrawal, the so-called “negative” symptoms of schizophrenia, as well as improvements in day-to-day functioning, and fewer of the abnormal involuntary movements that are commonly caused by some antipsychotic meds. 

NAC has also been investigated as a treatment for substance use disorders, with promising results. The findings of small, placebo-controlled studies suggest that NAC helped heavy Cannabis users to reduce their use, and that it may reduce the intensity of withdrawal and cravings in people in early stages of cocaine recovery. As in mood disorders, the beneficial effects of the NAC may be related to its role in restoring neurotransmitter activity that has been affected by chronic substance abuse. 

In addition to its mood-enhancing benefits, there is evidence that NAC may reduce trichotillomania (compulsive hair pulling) and other impulse control disorders, like nail-biting, skin picking, and pathological gambling. There was one eight-week, open-label study on pathological gamblers, and over 80 percent of them responded to NAC. They were then subsequently enrolled in a six-week, placebo-controlled trial, and continued to report “significant reductions” in gambling.

As for potential treatment targets, a systematic review of all of the evidence suggests that NAC may be effective at treating major depressive disorder, bipolar disorder, drug addiction, obsessive-compulsive disorder, impulse control disorders, autism, schizophrenia, Alzheimer’s disease, and even certain forms of epilepsy, specifically progressive myoclonic seizures. NAC has also been shown to potentially reduce the severity of mild traumatic brain injury in soldiers, and animal studies show that it can improve cognition after moderate traumatic brain injury. Other disorders such as anxiety and ADHD have some interesting preliminary evidence, but require larger studies.

The jury’s still out as to the mechanism, whether NAC’s benefits are the result of glutathione reducing cellular damage, the anti-inflammatory action, or the actions on glutamate and dopamine. Even though we don’t know exactly why yet, on a clinical level, NAC seems to help with ruminations, the difficult to control, extreme negative self-thoughts. These thoughts are very common in depression and anxiety disorders, and also in eating disorders, schizophrenia, and OCD. NAC seems to help some patients when other modalities, even meds and psychotherapy, haven’t helped much. It doesn’t always work, but when it does, irrational thoughts seem to gradually decrease in intensity and frequency. Negative thoughts, like “I’m a bad person,” “Nobody likes me,” or ruminations about other people or other issues that can’t seem to be quieted by reasonable evidence to the contrary- those really pesky negative thoughts that keep intruding on someone’s awareness, hour after hour, day after day, despite all efforts to control them- seem to decrease with NAC. If they do continue to occur, they’re less distressing, and can be observed from more of a distance, and are less likely to trigger depression or other negative effects.

Overall, NAC seems pretty special. Its ability to successfully cross the blood-brain-barrier to increase CNS glutathione levels, while reducing glutamate and overall oxidative stress, in addition to its anti-inflammatory properties- all conditions linked to depression and other mental health disorders- makes it an interesting treatment candidate for many psych conditions. If you take NAC, you’re basically giving your body an efficient way to soak up excess glutamate, an excitatory neurotransmitter that’s not good in excess concentrations. You’re also reducing oxidative stress and inflammation by giving it glutathione. As a result, this seems to help alleviate a number of different mental health conditions: depressed mood, schizophrenia, impulse control disorders, and substance use disorders. Studies indicate that people benefit from taking anywhere between 250 mg to 500 mg daily. Lower doses are better because high doses of NAC can sometimes redistribute heavy metals into the brain… this is not a good thing, so you obviously want to avoid that. You can take NAC with leucine, another amino acid, as taking leucine with it prevents mercury from being reabsorbed into the central nervous system. As always, please bear in mind that large placebo-controlled studies are needed to confirm the beneficial effects of NAC in mental health care, and to determine safe, optimal dosages for standalone or adjunctive treatment. But if you think it might be helpful, talk to your physician to determine if NAC is a good supplement choice for you. 

I hope you enjoyed this blog and found it to be interesting and educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in office and on Amazon. 

Thank you and be well people!

MGA

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N-ACETYL CYSTEINE

N-Acetyl Cysteine

Hello, people! Last week, we finished up our discussion on the darker side of OCD and talked about the most difficult subtype to deal with, the pure hell of pure obsession OCD, aka Pure O. As promised, we’re back this week with a new topic, N-acetyl Cysteine, or NAC. NAC is an amino acid used by the body to build antioxidants. Antioxidants are vitamins, minerals, and other nutrients that protect and repair the body’s cells from damage, usually referred to as oxidative stress. Historically, NAC has been used mainly in emergency rooms to treat people who overdose on acetaminophen… I’ve ordered it innumerable times for this very purpose. These days, it can be purchased as a supplement OTC, and new studies have begun investigating its effectiveness as both a stand-alone and adjunctive treatment for depressed mood associated with depression, bipolar disorder, schizophrenia, OCD, and trichotillomania, as well as abuse and dependence on nicotine, Cannabis, and cocaine. And it has shown some promising results. 

Before we get to that, let’s talk about some things NAC does in the body. 

1. NAC is essential for making the body’s most powerful antioxidant, glutathione. Along with two other amino acids- glutamine and glycine- NAC is needed to make and replenish glutathione, which helps neutralize free radicals that can cause oxidative stress- damage to cells and tissues in your body. It’s essential for immune health and for fighting cellular damage, and some researchers believe it may even contribute to longevity. Its antioxidant properties are also important for combatting numerous other ailments caused by oxidative stress, such as heart disease, infertility, and some psychiatric conditions. More on those later.

2. NAC helps detoxify the body to prevent or diminish kidney and liver damage, helping to prevent deleterious side effects of drugs and environmental toxins. This is why doctors regularly give intravenous NAC to people with acetaminophen overdose. It’s usually organ failure that gets you in acetaminophen overdose, and NAC helps to prevent or reduce damage to the kidneys and liver, increasing the chances of survival. NAC also has applications for other liver diseases due to its antioxidant and anti-inflammatory benefits.

3. NAC helps regulate levels of glutamate, the most important neurotransmitter in your brain, and this may improve some psych disorders and addictive behavior. While glutamate is required for normal brain function, excess glutamate paired with glutathione depletion can cause brain damage. This state- excess glutamate with glutathione depletion- is commonly seen in certain psych disorders; specifically, it’s thought to contribute to bipolar disorder, schizophrenia, obsessive-compulsive disorder, and addictive behavior.

For people with bipolar disease and depression, NAC may help decrease symptoms and improve overall ability to function, and research suggests that it may also play a role in treating moderate to severe OCD. In addition, an animal study implied that NAC may minimize the so-called negative effects of schizophrenia, such as social withdrawal, apathy, and reduced attention span. NAC supplements can also help decrease withdrawal symptoms and prevent relapse in cocaine addicts, and preliminary studies show that NAC may decrease marijuana and nicotine use and cravings. Many of these disorders currently have limited or ineffective treatment options, so NAC may be an effective option for individuals with these conditions. More on this in a moment.

4. NAC can help relieve symptoms of respiratory conditions by acting as an antioxidant and expectorant, loosening mucus in the air passageways. As an antioxidant, NAC helps replenish glutathione levels in your lungs, and reduces inflammation in the bronchial tubes and lung tissue. People with chronic obstructive pulmonary disease (COPD) experience long-term oxidative damage and inflammation of lung tissue, which causes airways to constrict, leading to shortness of breath and coughing. NAC supplements have been used to improve these COPD symptoms, leading to fewer exacerbations and less overall lung decline. In a one-year study, 600 mg of NAC twice a day significantly improved lung function and symptoms in people with stable COPD. But those with chronic bronchitis can also benefit from NAC. Bronchitis is the term for when the mucous membranes in your lungs’ bronchial passageways become inflamed, restricting airflow to the lungs. Not much fun. By thinning the mucus in the bronchial tubes, while also boosting glutathione levels, NAC may help decrease the severity and frequency of wheezing and coughing in respiratory attacks. In addition to relieving COPD and bronchitis, NAC may improve other lung and respiratory tract conditions like cystic fibrosis, asthma, and pulmonary fibrosis, as well as symptoms of garden variety nasal and sinus congestion due to allergies or infections. Ultimately, NAC’s antioxidant and expectorant capacity can improve lung function in everyone by decreasing inflammation and breaking up and clearing out mucus.

5. NAC boosts brain health by regulating glutamate and replenishing glutathione. The neurotransmitter glutamate is involved in a broad range of learning, behavior, and memory actions, while the antioxidant glutathione helps reduce oxidative damage to brain cells associated with aging. Glutamate levels are subject to the three bears law: you need some, but too much isn’t good, as it’s an excitatory neurotransmitter. Because NAC helps regulate glutamate levels and replenish glutathione, it may benefit those with brain and memory ailments. The neurological disorder Alzheimer’s disease slows down a person’s learning and memory capacity, and animal studies suggest that NAC may slow the loss of cognitive ability in people with it. Another brain condition, Parkinson’s disease, is characterized by the deterioration of cells that generate the neurotransmitter dopamine. Oxidative damage to cells, and a decrease in antioxidant ability, contribute to this disease, and NAC supplements appear to improve dopamine function as well as disease symptoms, such as tremor.

6. NAC may improve fertility in both men and women. Approximately 15% of all couples trying to conceive are affected by infertility, and in nearly half of these cases, male infertility is the main contributing factor. Many male infertility issues increase when antioxidant levels are insufficient to combat free radical formation in the male reproductive system, leading to oxidative stress and cell death, culminating in reduced fertility. In some cases, NAC has been shown to combat this, improving male fertility. One condition that contributes to male infertility is varicocele. This is when veins inside the scrotum become enlarged due to free radical damage; surgery is currently the primary treatment. In one study, 35 men with varicocele were given 600 mg of NAC per day for three months post-surgery. The combination of surgery and NAC supplement improved semen integrity and partner pregnancy rate by 22% as compared to the control group with surgery alone. Another study in 468 men with infertility found that supplementing with 600 mg of NAC and 200 mcg of selenium for 26 weeks improved semen quality. Researchers suggested that this combined NAC/ selenium supplement should be considered as a treatment option for male infertility. In addition, NAC may improve fertility in women with polycystic ovary syndrome (PCOS) by inducing or augmenting the ovulation cycle which is altered by the condition. 

7. NAC may stabilize blood sugar by decreasing inflammation in fat cells. High blood sugar and obesity contribute to inflammation in fat tissue. This can lead to damage or destruction of insulin receptors, which puts you at a much higher risk of type 2 diabetes. When insulin receptors are intact and healthy, they properly remove sugar from your blood, keeping levels within normal limits. When the insulin receptors are damaged, blood sugar levels are more difficult to control. Animal studies show that NAC may stabilize blood sugar by decreasing inflammation in fat cells, keeping receptors happy, and thereby improving insulin resistance. That said, human research on NAC is needed to confirm these effects on blood sugar control.

8. NAC may reduce heart disease risk by preventing oxidative damage. Oxidative damage is caused by free radicals, and this type of damage to heart tissue often leads to heart disease, causing strokes, heart attacks, and other serious cardiovascular conditions.

NAC may reduce heart disease risk by reducing oxidative damage to tissues in the heart. It has also been shown to increase nitric oxide production, which helps veins dilate, improving blood flow. This expedites circulation and blood transit back to your heart, and this can lower the risk of heart attack. Interestingly, a test-tube study showed that when combined with green tea, another well recognized antioxidant, NAC appears to reduce damage from oxidized “bad” LDL cholesterol, another bigtime contributor to heart disease.

9. NAC and its ability to boost glutathione levels appears to increase immune function, boosting immune health. Research on certain diseases associated with NAC and glutathione deficiency suggests that immune function might be improved, and potentially even restored, by supplementing with NAC. 

This has been studied mostly in people with human immunodeficiency virus (HIV). In two studies, supplementing with NAC resulted in a significant increase in immune function, with an almost complete restoration of natural killer cells, the main patrol cells. High levels of NAC in the body may also suppress HIV-1 reproduction. A test-tube study indicated that in other immune-compromised situations, such as the flu, NAC may hamper the virus’s ability to replicate; this could potentially reduce the symptoms and lifespan of the associated viral illness. Other test-tube studies have similarly linked NAC to cancer cell death and blocked cancer cell replication. Great news, but more human studies are needed. 

This is a short blog, but that’s a good place to stop for this week. Next week, we’ll talk about how NAC may alleviate the symptoms of multiple psychiatric disorders, as well as reduce addictive behavior; and we’ll talk about some preliminary study findings as well. I hope you enjoyed this blog and found it to be interesting and educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in office and on Amazon. 

Thank you and be well people!

MGA

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Xanax Withdrawl

Xanax Withdrawal

Welcome back, people! Last week we continued our foray into all things Xanax and talked about dependence and use disorder. The next step in the chain- withdrawal- can be a special kind of beastie, definitely deserving of its own blog, so this week will be all about Xanax withdrawal.

As I mentioned last week, some folks can take their bit of Xanax a couple of times a day as directed for umpteen years, and never develop a tolerance or pathological dependence. Others start out taking it as directed, but develop a tolerance and maybe start to abuse it- take too much too often- and then begin to develop a more pathological dependency. Others may abuse it recreationally on occasion, to netflix and chill, find they really like it, then develop a severe addiction. It may not sound like these people have much in common, but they do. When they stop taking it, they’re all going to go through withdrawal.

They won’t do so alone, though. In 2017, doctors wrote nearly 45 million prescriptions for Xanax, so it’s no surprise that these prescribing practices have contributed to thousands of cases of abuse and dependence. With those numbers, there has been all sorts of research and stats examined on benzos, and I read that in 2018, an estimated 5.4 million people over the age of 12 misused prescription benzodiazepines like Xanax. That’s a lot of people, people.

To many patients that take their Xanax exactly as prescribed, it seems to come as a surprise that they’re facing a withdrawal experience, but Xanax doesn’t discriminate- so anyone taking enough of it for more than a few weeks will develop a physical dependence. Once you have become physiologically dependent on a drug, you will experience withdrawal symptoms when you stop or reduce your dose. Simple as that.

Withdrawal is different for everyone. Depending on the dose and how often you’ve been using it, the withdrawal experience typically ranges from uncomfortable to very unpleasant, but it can also be medically dangerous. The only safe way to quit is to slowly taper down the dose under the direction of a physician, or in an in-patient treatment center setting, depending on the situation. If you’ve been taking high doses of Xanax several times a day, then quitting is going to take a great deal of time, patience, and determination. Please note that quitting cold turkey can cause extremely dangerous withdrawal symptoms. This can include delirium, which is a state characterized by abrupt, temporary cognitive changes that affect behavior; so you can be irrational, agitated, and disoriented- not a good combo. Sudden withdrawal can also cause potentially lethal grand mal (aka tonic-clonic) seizures. These are like electrical storms in the brain, where you lose consciousness and have violent muscular contractions throughout the body. It’s not a risk you want to take, people- so don’t do this on your own! Even if you’ve been taking Xanax illicitly, that doesn’t mean you have to go it alone. Just fess up to a physician and tell them exactly how much you’ve been taking so they can design a taper schedule for you, or help you find a treatment center. There is a lot of help available if you make the effort.  

Tapering your dose is the best course of action for managing withdrawal symptoms, but that doesn’t mean it’s a picnic in the shade. While you taper down the dose, you’ll likely experience varying degrees of physical and mental discomfort. You may feel surges of anxiety, agitation, and restlessness, along with some unusual physical sensations, like feeling as though your skin is tingling or you’re crawling out of your skin. But keep in mind that these are all temporary. 

Signs and Symptoms

The major signs and symptoms of Xanax withdrawal vary from person to person. Research indicates that roughly 40% of people taking benzodiazepines for more than six months will experience moderate to severe withdrawal symptoms, while the remaining 60% can expect milder symptoms. It’s very common to feel nervous, jumpy, and on edge during your taper. And because Xanax induces a sedative effect, when the dose is reduced, most people will experience a brief increase in their anxiety levels. Depending on the severity of your symptoms, you may experience a level of anxiety that’s actually worse than your pre-treatment level. Support from mental health professionals can be very beneficial during and after withdrawal, as therapy and counseling may help you control and manage the emotional symptoms of benzo withdrawal.

Physical Withdrawal Symptoms

As a central nervous system depressant, Xanax serves to slow down heart rate, blood pressure, and temperature in the body- in addition to minimizing anxiety, stress, and panic. Xanax may also help to reduce the risk of epileptic seizures. Once the brain becomes used to this drug slowing all of these functions down on a regular basis, when it is suddenly removed, these CNS functions generally rebound quickly, and that is the basis for most withdrawal symptoms. Symptoms can start within hours of the last dose, and they can peak in severity within 1 to 4 days. The physical signs of Xanax withdrawal can include: headache, blurred vision, muscle aches, tension in the jaw and/ or teeth pain, tremors, nausea, vomiting, diarrhea, numbness of fingers, tingling in arms and legs, sensitivity to light and sound, alteration in sense of smell, loss of appetite, insomnia, cramps, heart palpitations, hypertension, sweating, fever, delirium, and seizures.

Psychological Withdrawal Symptoms

Xanax, as a benzodiazepine, acts on the reward and motivation regions of the brain, and when a dependency is formed, these parts of the brain will be affected as well. When an individual dependent on Xanax then tries to quit taking the drug, the brain needs some time to return to normal levels of functioning. Captain Obvious says that whenever you stop a benzo, because it acts as an anxiolytic, you’re going to experience a sudden increase in anxiety levels. While there are degrees of everything, the psychological symptoms of Xanax withdrawal can be significant, as the lack of Xanax during withdrawal causes the opposite of a Xanax calm, which is to say something akin to panic. At the very least, that can make you overly sensitive, and less able to deal with any adverse or undesired feelings. Withdrawal can leave people feeling generally out of sorts, irritable, and jumpy, while some individuals have also reported feeling deeply depressed. Unpredictable shifts in mood have been reported as well, such as quickly going from elation to being depressed. Feelings of paranoia can also be associated with Xanax withdrawal.

Nightmares are often reported as a side effect of withdrawal. I included insomnia in physical symptoms, but trouble sleeping can also be a psychological symptom, as it is both mentally and physically taxing. People can be overtaken by anxiety and stress during withdrawal, and that may cause this trouble sleeping at night, which then contributes to feelings of anxiety and agitation, so it’s a cycle that can be tough to break free of. Difficulty concentrating is also reported, and research has found that people can have cognitive problems for weeks after stopping Xanax. Ditto for memory problems. Research shows that long-term Xanax abuse can lead to dementia and memory problems in the short-term, although this is typically restored within a few months of the initial withdrawal. Hallucinations, while rare, are sometimes reported when people suddenly stop using Xanax as well. Suicidal ideation is sometimes reported, as the anxiety, stress, and excessive nervousness that can occur during withdrawal can lead to, or coexist with suicidal thoughts. Finally, though rare, psychosis may occur when a person stops using Xanax cold turkey, rather than being weaned off of it.

Xanax Withdrawal Timeline

Xanax is used so commonly for anxiety and panic disorders because it works quickly, but that also means it stops working quickly and leaves the body quickly. Xanax is considered a short-acting benzodiazepine, with an average half-life of 11 hours. As soon as the drug stops being active in the plasma, usually 6 to 12 hours after the last dose, withdrawal symptoms can start. Withdrawal is generally at its worst on the second day, and improves by the fourth or fifth day, but some symptoms can last significantly longer. If you go cold turkey and don’t taper your dose, your withdrawal symptoms will grow increasingly intense, and there really is no way to predict how bad they may get, or how you’ll be affected. 

Unfortunately, five days doesn’t signal the end of withdrawal for some people, as some may experience protracted withdrawal. Estimates suggest that about 10% to 25% of long-term benzodiazepine users experience protracted withdrawal, which is essentially a prolonged withdrawal experience marked by drug cravings and waves of psychological symptoms that come and go. Protracted withdrawal can last for several weeks, months, or even years if not addressed by a mental health professional. In fact, these lasting symptoms may lead to relapse if not addressed with continued treatment, such as regular therapy.

Factors Affecting Withdrawal

Withdrawal is different for each individual, and the withdrawal timeline may be affected by several different factors. The more dependent the body and brain are to Xanax, the longer and more intense withdrawal is likely to be. Regular dose, way of ingestion, combination with other drugs or alcohol, age at first use, genetics, and length of time using or abusing Xanax can all contribute to how quickly a dependence is formed and how strong it may be. High stress levels, family or prior history of addiction, mental health issues, underlying medical complications, and environmental factors can also make a difference in how long withdrawal may last for a particular individual and how many side effects are present. 

Coping with Xanax Withdrawal

The best way to avoid a difficult and potentially dangerous withdrawal is to slowly taper down your dose of Xanax, meaning to take progressively smaller doses over the course of up to several weeks. By keeping a small amount of a benzo in the bloodstream, drug cravings and withdrawal may be controlled for a period of time until the drug is weaned out of the system completely. It may sound like designing a taper would be a no-brainer, but it’s definitely not recommended to taper without a physician’s guidance. Why? Because Xanax is a short-acting drug, your body metabolizes it very quickly. Controlling that is challenging because the amount of drug in your system goes up and down with its metabolism. To help you avoid these peaks and valleys, doctors often switch you from Xanax to a longer acting benzo during withdrawal, as it may make the process easier. And believe me, that’s what you want. If the physician goes this switch route, once you’ve stabilized on that med, you’ll slowly taper down from that a little bit at a time, just as you would with Xanax. 

Another reason not to play doctor on this one is if you start to have breakthrough withdrawal symptoms when your dose is reduced, your physician can pause or stretch out your taper. It’s up to him or her, through discussion with you, to design the best tapering schedule for your individual needs. Sometimes it’s a fluid and changing beastie.

In addition, adjunct medications like antidepressants, beta-blockers, or other pharmaceuticals/ nutraceuticals may be effective in treating specific symptoms of Xanax withdrawal, and you’ll need a physician to recommend and/ or prescribe those as well. 

Alleviating Symptoms of Withdrawal

An individual may notice a change in appetite and weight loss during Xanax withdrawal, so it’s important to make every attempt to eat healthy and balanced meals during this time. It may sound obvious, but a multivitamin including vitamin B6, thiamine, and folic acid is especially helpful, as these are often depleted in addiction and withdrawal. There are some herbal remedies that may be helpful during withdrawal, such as valerian root and chamomile for sleep. Meditation and mindfulness are very useful for managing blood pressure and anxiety during withdrawal, so be sure to check out my March 15 blog for more on mindfulness. Considering the insomnia and fatigue that may occur during withdrawal, it may seem counterintuitive to commit to exercise, but it has been shown to have positive effects on mitigating withdrawal symptoms and decreasing cravings. Exercise stimulates the same pleasure and reward systems in the brain, so it stands to reason that it can also help to lift feelings of depression or anxiety that may accompany physical withdrawal symptoms.

Xanax Withdrawal Safety

Some of the things I’ve mentioned are so important they bear repeating. Xanax should not be stopped suddenly, or cold turkey, and vital signs like blood pressure, heart rate, respiration, and temperature need to be closely monitored during withdrawal. This is because these may all go up rapidly during this time, and this can contribute to seizures that can lead to coma and even death. 

People with a history of complicated withdrawal syndromes and people with underlying health issues should work very closely with their physician during withdrawal, as should the elderly and people with cognitive issues, as there can be unique risks involved. If you have acquired your Xanax illicitly, you can still work with a doctor to taper down your dose. Start by visiting a primary care physician or urgent care center and tell them that you are in, or are planning to be in, benzodiazepine withdrawal. If you don’t have insurance, visit a community health center. If you plan to or have become pregnant, you will need to discuss your options with your prescribing physician and OB/GYN about the risks and benefits of continuing versus tapering Xanax or other benzos. Some women continue taking them throughout their pregnancy, while others follow a dose tapering schedule.

The key to achieving the goal of getting off of Xanax is to follow the tapering schedule to the very end. By the end of your taper, you might be cutting pills into halves or quarters. Note that some individuals may be better suited for a harm reduction approach, in which the taper leads to a maintenance dose rather than abstinence. If you’re very concerned about the risks involved in Xanax tapering for any reason, discuss these concerns with your physician, because you may be better suited for inpatient detoxification. While this is more expensive, it is covered by many insurance plans.

No matter how you slice it, quitting Xanax takes time, patience, and determination. If you’ve been using it for longer than a few months, quitting can be hard, and there will be days where you want to give up and give in. But with medical supervision and support, you can be successful, and in the long-term, the health benefits are considerable. Withdrawal isn’t a picnic, but if Xanax is both the alternative to it, and a problem for you, it beats that alternative hands down. 

I hope you enjoyed this blog and found it to be interesting and educational. If you did, let me know. If you didn’t, let me know that too!

Please feel free to share the love! Share blogs and YouTube videos with family and friends. 

Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, and share those vids too! 

And if you like what you see and want more of it, or if you want a specific topic, leave it in the comments- I love reading them! 

As always, my book Tales from the Couch has more educational topics and patient stories, and is available in the office and on Amazon. 

Thank you and be well people!

MGA

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Alprazolam Use Disorder

Alprazolam Use Disorder

Helll-ooo people! I hope everyone had a great holiday weekend, maybe bit the head off a big bunny- a chocolate one of course. We’ve been talking about alprazolam, trade name Xanax. Last week I warned you about the dangers of buying it off of the street. If you’ve forgotten why it’s dangerous, it’s because it’s nearly always counterfeit crap made in some moron’s basement with fentanyl and heaven knows what else, and you don’t want that. If you think I have a pretty clear opinion on fake Xanax, or any fake pharmaceutical for that matter, Captain Obvious says you’d be right. 

If you read the first blog in this series a couple of weeks ago, you already know that Xanax, generic name alprazolam, is a member of the class of anxiolytic drugs called benzodiazepines, and very commonly prescribed for anxiety and panic disorders- mainly because it’s very effective and works quickly. But it also has serious addiction potential and is a common drug of abuse, and this is something that patients and their families must be aware of up front. With that in mind, this week’s blog will focus on the signs and symptoms of Xanax abuse, and how that progresses to the diagnosis of sedative use disorder, or more specifically Xanax use disorder. 

Some people who are prescribed Xanax for anxiety or panic disorders can take their prescribed dose twice a day for years and never experience an issue, unless or until they stop taking it. They become dependent upon it, but only in that their body becomes used to having the drug in their system- it’s not a pathological dependence. Upon stopping it, they’ll still experience withdrawal symptoms, but they don’t develop Xanax use disorder, because their use is quite literally not disordered. Incidentally, I’ll be focusing on withdrawal from Xanax next week. In contrast, far too many people develop a pathological dependence upon Xanax. Even if they have a genuine anxiety disorder and start out taking it only as prescribed, they begin to abuse it by taking too much and/ or too often, and they develop a use disorder, which progresses to what we colloquially call an addiction. 

This is a process that generally starts because they begin to develop a tolerance to the drug and require more of it to achieve the desired effect, whether that is to quell their symptoms of anxiety, or to get high. Tolerance is a phenomenon that occurs with many drugs, but it is especially dangerous in a drug like Xanax, as it’s a closed circuit- the more you need, the more you take, and the more you take, the more you need. Ideally, a patient informs their prescribing physician if they feel that their current dose is no longer adequate. But that doesn’t always happen, and patients may choose to increase the dose on their own; and at that point, they’re abusing the drug. 

Some of the most common physical signs and symptoms of Xanax abuse include slurred speech, poor motor coordination, confusion, blurred vision, drowsiness, dizziness, difficulty breathing, loss of consciousness, and an inability to reduce intake without symptoms of withdrawal. Beyond the physical symptoms, when a person begins to abuse Xanax, there will likely be noticeable changes in their behavior as well. Some of the most common behavioral signs of Xanax abuse include the following:

-Taking risks in order to buy Xanax: some people may do things they wouldn’t have previously considered in order to obtain it. For instance, they may steal, often from loved ones, in order to pay for Xanax.

-Losing interest in normal activities: as Xanax abuse takes a firmer hold in a person’s life, they commonly lose interest in activities they formerly enjoyed.

-Risk-taking behaviors: as Xanax abuse continues, the person may become more comfortable taking big risks, such as driving while on Xanax.

-Maintaining stashes of Xanax: to ensure that they will not have to go without Xanax, they will attempt to stockpile it.

-Relationship problems: Xanax abuse invariably leads to interpersonal problems and social issues, but this often isn’t enough to motivate the person to stop.

-Obsessive thoughts and actions: the person will spend an inordinate amount of time and energy obtaining and using Xanax. This may include activities like doctor shopping or looking for alternate sources of it, or asking friends, family, and/ or colleagues for it. 

-Legal issues: this can be related to illegally obtaining Xanax, being arrested/ incarcerated for drugged driving, or for other disturbances as a consequence of use. 

-Solitude and secrecy: when abusing Xanax, it’s very common for people to withdraw from friends and family to protect their use.

-Financial difficulties: to pay for Xanax, a person may drain their financial resources and/ or those of family and friends.

-Denial: this includes setting aside valid concerns about Xanax abuse to protect ongoing use of the drug. For example, minimizing or refusing to recognize the dangers of buying it on the street.

As Xanax abuse progresses, it reaches what most people would term an addiction. But the actual diagnosis recognized in the psych nerd’s bible, the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th edition) is termed use disorder. If the person is using Xanax, we call it sedative use disorder or Xanax use disorder, but there is opioid use disorder as well- essentially anything that is abused can fill in the blank. In order for a person to be diagnosed with a sedative use disorder, they must exhibit a certain number of signs and symptoms within a one year period. The more symptoms that are present, the higher the grading the sedative use disorder will receive, and this places the severity of the disorder on a continuum, be it mild, moderate, or severe.

Paraphrased versions of the assessed symptoms of Xanax use disorder are as follows:

-Repeated problems in meeting obligations in the areas of family, work, or school because of Xanax use.

-Spending a significant amount of time acquiring Xanax, using it, or recovering from side effects of use.

-Continued Xanax use despite hazardous circumstances.

-Continued Xanax use despite the complications it causes with social interactions and interpersonal relationships.

-Continued Xanax use despite experiencing one or more negative personal outcomes.

-Using more Xanax or using it for longer than recommended or intended.

-An inability to stop using Xanax despite an ongoing desire to do so.

-Obsessive craving for Xanax.

-Ceasing or reducing participation in work, social, or family affairs due to Xanax use.

-Building tolerance over time, necessitating the use of increasing amounts of Xanax to achieve desired effect.

-Experiencing withdrawal symptoms upon decreasing the dose of Xanax.

These last two signs- building tolerance that requires continual dosage increases, and experiencing withdrawal symptoms when dosage is decreased- are indicative of physical dependence and ultimately addiction. These are natural body processes that occur when the brain and body habituate to drug use over time. Once the body becomes accustomed to having the drug, a sort of new normal is established in its presence. Thereafter, when the drug use stops, the body will issue its demand for more of the drug in the form of withdrawal symptoms. And that’s exactly where we’ll pick up next week. 

I hope you enjoyed this blog and found it to be interesting and educational. If you did, let me know. If you didn’t, let me know that too!

Please feel free to share the love! Share blogs and YouTube videos with family and friends. 

Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, and share those vids too! 

And if you like what you see and want more of it, or if you want a specific topic, leave it in the comments- I love reading them! 

As always, my book Tales from the Couch has more educational topics and patient stories, and is available in the office and on Amazon. 

Thank you and be well people!

MGA

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CounterfeitDrugs:Fake Xanax

Counterfeit Drugs: Fake Xanax

For this week’s alprazolam blog, I want to know if I can fake you out. We’re going to talk about fake Xanax. Look at the picture above. Can you tell which Xanax are fake? Are you certain? Enough to roll the dice with your life on the pass line? Because, make no mistake- if you get your Xanax from anywhere other than a licensed pharmacy, you are absolutely, positively doing so every single time you take it. By the end of this blog, you’ll definitely know the answer to the first question. As to the second, I’d hope you already know the answer, because even Captain Obvious won’t bother with that one, people. 

When you think of counterfeit drugs, you may not be too concerned if you consider them to be just weakened copycat versions of the real thing, made with a bunch of essentially harmless junk. Probably the worst that could happen is it won’t work, right? Wrong! Obviously, the main problem with counterfeit drugs in general is that they’re clearly illegal and therefore unregulated, so you don’t know what you’re getting. I mean, with counterfeit drugs, there’s no truth in advertising. And helll-ooo, they’re produced in somebody’s gnarly basement, so there sure as hell isn’t any quality control. While they can be cut with innocuous things like baking soda or baby powder, they can also be laced with extremely harmful substances, things like rat poison, bleach, and formaldehyde. Unfortunately, many drug users don’t know, or don’t care, how dangerous it is to ingest substances like these. But there are cases where counterfeit drugs are especially dangerous, and fake or counterfeit Xanax is at the top of that list. In late 2015, the entire country learned this lesson the hard way when in three months, there were nine documented cases where people in San Francisco suddenly overdosed from “Xanax.” To be clear, it wasn’t Xanax at all. That number included a baby, who had picked a tab of it up off the floor and put it in their mouth. It also included one person who didn’t even get to live to regret it. I think we got off pretty easily in that singular event, but obviously more have followed. 

By the Numbers… Without Numbers (?)

Again, since production and sale of fake Xanax is illegal, underground, and unregulated, there aren’t national or global databases to collect information or statistics as there are with other drugs. But I found some reports from various global sources that were interesting. And by that I mean frightening. Some highlight snippets include a report citing that 25% of 2018 drug overdose deaths in Northern Ireland were caused by counterfeit Xanax. Another report from U.S. Customs and Border Protection stated that in the first four months of 2020, during unspecified smuggling attempts, their CBP officers seized 27 shipments of fake Xanax, totalling over 35 pounds. I also listened to part of a podcast on the subject that featured an officer from Portland, Oregon talking about a spate of teenage overdoses on fake Xanax, and the subsequent investigation. They apparently did a round up of all the street dealers they could find, and busted down doors and did everything they could to clean up the area. The goal was to get every Xanax pill off the street, and he stated that of all the “Xanax” pills they recovered, not a single one was legit. He didn’t say exactly how many that was, but it seemed like a lot. Every pill in the area was fake. That’s huge. And very scary. 

Fake Xanax: Beyond the Obvious

“Good” counterfeit Xanax pills look exactly like the real thing. And clearly, by “good” I don’t mean that in the traditional sense. That means they have the same color, size, shape, and pharmaceutical markings, aka imprints, on the pills as the bonafide prescription versions do. While the difference isn’t obvious to the naked eye, there is one huge difference between real and fake Xanax that makes it especially scary: the latter usually contains fentanyl, an extremely potent opioid that is responsible for countless accidental overdoses in numerous counterfeit and legal preparations. In fact, it’s estimated that many thousands of U.S. citizens ingest a deadly dose of  each year without ever even realizing it. How horribly tragic and senseless is that?  

Fentanyl is a schedule II synthetic opioid that is 50 to 100 times stronger than heroin and morphine, respectively. It is typically prescribed by a specialized physician strictly for patients struggling with severe or chronic pain, and it is such a potent and dangerous drug that the DEA has advised officials to take extra protective precautions, like gloves, even just when handling it, to avoid accidental death. This is because it is easily absorbed through the skin, and takes so little to be lethal. While other opiate doses are measured in milligrams, fentanyl is dosed in micrograms, and an amount equal to two grains of salt is lethal to nearly all individuals. Clearly, a drug that is 100 times stronger than morphine is no joke, and it officially now kills more Americans annually than any drug in history.

People who take fentanyl accidentally will be unaware of what they have taken, or how much, so they face an even higher risk of an opioid overdose. In the case of fake Xanax exposure, if or when a person does overdose on it, in the unlikely event that they’re lucky enough to make it to a hospital, it presents a unique problem. As a physician, I can tell you that when a person’s symptoms present differently from what is expected, it delays treatment, and Xanax overdose and fentanyl overdose present very differently. So when it’s reported that a person took “Xanax,” or some pills are found on their person, but their symptoms don’t look like a benzodiazepine overdose, those few minutes a medic or doc takes to assess the situation may be the few that end up costing them their lives. But that can be the case fake percocet or oxycodone as well, because fentanyl is commonly used in producing counterfeit versions of all of those. Even cocaine- maybe especially so because of the cost differential- fentanyl is so much cheaper that it’s very commonly used to cut it. And talk about presenting differently: cocaine and fentanyl overdose are not even remotely similar to one another. Even if users are aware that fentanyl is in the product, and aren’t that concerned about it, there’s still no way to know how much fentanyl is in it, or exactly how potent that fentanyl is. As a result, it is extremely easy to overdose after consuming any counterfeit product. 

Since the pills look exactly like the real thing, it’s nearly impossible to tell the difference. But, if someone consumes counterfeit Xanax made with fentanyl, there will be noticeable symptoms and side effects that wouldn’t ordinarily be present with genuine Xanax. The side effects of fentanyl include excessive itching, slowed breathing, nausea and vomiting, flushed skin, and constricted pupils. These can quickly progress to overdose, and those signs and symptoms are progressively shallow breathing, usually followed by gurgling or choking sounds, or sounds like “snoring,” pale, blue, cold, or clammy skin, limp body or unresponsiveness, and finally suppressed breathing. People often report that they didn’t recognize that someone was overdosing, even though they literally sat there watching it. They usually think they’ve nodded out and are snoring, and then just stop snoring. In reality, they’re really choking, then their breathing is severely suppressed, and when they stop making noise, they’ve simply stopped breathing. Fentanyl also yields some dangerous psychological effects, such as depression, hallucinations, difficulty sleeping, and nightmares. These are all signs to be aware of if you ever take a drug from a questionable source.

Fake Xanax: How it’s Done

Counterfeit Xanax is made using a pill press, which is exactly what it sounds like: it’s a device that is used to press powders together with a binding agent, to make the substance into a solid pill form. Pill pressing devices can be smaller than the size of a person’s palm, or large enough to need a small room for storage. Pill molds are added to the pill press to press the pills into certain sizes and to make markings or indentations. Sometimes they’re called “stamps,” and manufacturers use these to customize the appearance of the pill and mimic the exact imprint used by the legit pharmaceutical company. Currently, it’s not illegal to own a pill press, and in fact, some people use them to make their own vitamins or supplements at home. But it is illegal to own a pill mold that is used in a pill press. As a result, counterfeit pill molds are usually designed in other countries and sold to the U.S. as “spare parts” or “equipment.” This allows street dealers and manufacturers to purchase their supplies without gaining attention from the police, and continue to make fake drugs in their gnarly basements.

Fake Xanax: Why it’s Done

Helll-oooo! People who sell drugs don’t do so because they enjoy it, they do it to earn a profit. It behooves them to find a way to make their drugs cheaper and more potent, because that’s the best way to generate more profit from a smaller amount of product- that’s just common business sense. Believe it or not, many street-level dealers can get their hands on fentanyl very cheaply, either through theft, or through overseas production of cheap, sketchy fentanyl look-a-likes, so they commonly use it to cut their drugs, and this actually makes their products cheaper and more potent. To be clear, these fake products may not even contain the actual primary component. But in cases of fake Xanax, if it does contain actual alprazolam, the combination makes it even more dangerous-  but the fentanyl alone can just as easily provide or mimic the effects the user is looking for. The result is a product that looks and feels pretty much like real Xanax, but is infinitely more dangerous; sold at a fraction of the price, as compared to the real thing, brought to you by your friendly neighborhood street thug. 

Fake Xanax: How to Avoid It

Clearly, the easiest way to avoid purchasing fake Xanax is to never purchase the drug on the streets in the first place. In fact, the only reason anyone should ever take Xanax in the first place is if they have a prescription for it and are instructed to by their doctor. Unfortunately, some people who are prescribed the medication seek out cheaper ways to fill their prescription, such as purchasing it from shady online pharmacies or from overseas stores. But you’d be surprised how enterprising some dealers are, and a “pharmacy” selling counterfeit drugs is certainly not unheard of. So kids, the take home lesson is that if you have a Xanax prescription, you should always get it filled at a licensed pharmacy.

Fentanyl: The Masked Killer

As a final word of caution, I just wanted to include a short synopsis of three stories I read about counterfeit drugs containing fentanyl. None of them have happy endings. 

A 28-year-old smoked “a powdery substance” at his mother’s home, where he was living at the time. His mother found him unresponsive in the living room, and having no idea of what had happened, called 911. He was pronounced dead on arrival. The death investigation determined that the substance had been given to him by a friend, who stated they both thought it was cocaine. Toxicology confirmed that while he had a non-lethal level of cocaine in his system at the time of death, the cause of death was acute fentanyl intoxication- he died of a fentanyl overdose.

A 20-year-old college student suffering from undiagnosed anxiety was panicking about a test the following day, so consumed a single oxycodone pill he had obtained illegally before going to bed. His roommates found him dead the next morning. Toxicology confirmed that he died from a fentanyl overdose.

A 19-year-old purchased two Percocet from a friend. He consumed both pills and subsequently died from an overdose. His friend confirmed the purchase, but then toxicology showed the presence of lethal levels of fentanyl. His friend swore he didn’t know they were fake and was very distraught. That friend was also later found dead of an overdose. It was confirmed that it was also due to fentanyl, but it wasn’t clear if it was suicide or accidental. 

These are cases where four individuals died of fentanyl overdose, with all of them consuming a different drug, and three of them never even realizing they were consuming fentanyl. On that note, have you decided which group of Xanax in the picture were fake? I’ll tell you now: both are fake. Guess it’s a good thing you couldn’t actually choose. Get my point?

I hope you enjoyed this blog and found it to be interesting and educational. If you did, let me know. If you didn’t, let me know that too!

Please feel free to share the love! Share blogs and YouTube videos with family and friends. 

Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, and share those vids too! 

And if you like what you see and want more of it, or if you want a specific topic, leave it in the comments- I love reading them! 

As always, my book Tales from the Couch has more educational topics and patient stories, and is available in the office and on Amazon. 

Thank you and be well people!

MGA

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When Home Becomes Work:Challenges of Working Remotely

When Home Becomes Work: Challenges of Working Remotely

Captain Obvious says that while coronavirus is responsible for thrusting us (with IT people kicking and screaming) into working remotely as a necessity, it was already a fairly common practice BR (before ‘rona). In fact, a statistic I read indicated an overall global trend toward remote work long BR, with a global increase of 159% between 2005 and 2017. As far as US stats on remote work go, 17% of US employees report that they worked from home five days or more per week BR, but that jumped to 44% DR (during ‘rona). As for the future, polls indicate that totally AR (after ‘rona) a minimum of 16% of American people who had previously worked outside the home BR will switch to working remotely from home at least two days per week AR. In addition, more than one-third of US firms that had employees switch to remote work DR believe that it will remain more common at their company AR. Globally, polls now predict that 25% to 30% of the earth’s workforce will work remotely multiple days per week by the end of 2021. In short, the genie is out of the bottle, and it’s not likely to go back in.

Many employers and business leaders think that going remote is as simple as sending an employee away from the office with a laptop and a to-do list, but unfortunately, it’s not that simple. In truth, there are real life consequences associated with working remotely. It may sound like a dream come true, but from where I’m sitting, it’s become more like a nightmare. A lot of people have gone back to their outside offices now, but many are still working from home. This is either because they- or their employers- are still too reluctant to make the switch and return, or have found it beneficial enough that it behooves them to continue remote operations. Regardless of why you may find yourself doing so, working remotely does present its own set of challenges, not the least of which is that companies were essentially forced into it overnight, without benefit of true preparedness and system checks. 

But in any event, if you are still working remotely at this point, you may find yourself continuing to do so indefinitely. I find that most of my patients enjoy lounging in their pajamas all day as they work from home, never leaving their house because it’s such an effort to get dressed; though they fail to understand why they’re so anxious, irritable, and depressed. The good news is that there is a way to do this work from home deal effectivelyand happily, and even excel at it, while still having a personal life and functioning appropriately. The bad news is there are some not-so-nice ramifications and consequences associated with the routine, and a lot of people are starting to recognize this after far too long being “trapped” at home. Spoiler alert: most people actually are not. The bottom line is that your whole world doesn’t have to change just because you’ve eliminated a commute. Out of necessity DR, it did change for a time, but at this point, it’s time to get out and reclaim some normalcy. Some of the issues that come up with working remotely are more rooted in the personal realm, and deal with basic self care and psychological health, while others center more on professional matters. But don’t kid yourself, there’s a lot of overlap and cross reactivity betwixt and between them. So this blog marks the beginning of a series dedicated to identifying the issues surrounding working remotely, and discussion on how to address them appropriately, with some tips and tricks and coping methods thrown in for good measure.  

Today’s blog will deal with some problems that I’ve noted in video calls and appointments with my patients. I sometimes call them “duh!!” issues, because a lot of you are going to be like, “Duh, Dr. Agresti, we all know that!” Well, what some people know and what they do are two very different things. If you’re depressed, and you haven’t brushed your hair or gotten dressed for a week straight, then you might hear me say, “Duh, go brush your hair and get dressed, you’ll feel better.” I suppose you could also call them “helll-ooo!!” issues, as in, “Helll-ooo… you really need to take a shower!!” That’s a real thing, people. Not all of the things I’ll discuss are quite that extreme, but my list of remote work must-do’s includes some personal care requirements that must become- and remain- second nature to you; they must be part of a regular routine, regardless of the fact that you may be all alone, with nobody even there to see (or smell) you. So that’s where we’re starting; with just some very basic, very simple recommendations for a better life and more success in a remote work situation. Most of these you probably already know, but you may not be doing them. Allow this to be your kick in the can if that’s the case.

-Sleep in your bed, but then get out of said bed when you get up in the morning. Don’t just wake up and roll over to reach for your laptop to start your day. I cannot tell you how many patients I talk to while they’re working in bed; they’re literally in bed 24/7. Get out of bed!

-Create a dedicated office, preferably with a door you can close to keep things quiet and help you avoid distractions. If you don’t have a spare room, then at least create a dedicated work space. Even a corner of a room will do if that’s all you can spare. You really just need room for a table or desk large enough to hold a computer and whatever supplies you need, and a chair. Try to make it as comfortable- and functional- as possible.

-Make a schedule and stick to it. And be sure to keep an accurate account of the hours you work. I’ll be discussing supervisory micromanaging in the next blog, but if you keep a regular schedule and good records of your hours, you’ll have all the info you need if you are questioned by a micromanaging supervisor.

-Now that you aren’t commuting to and from the office, you’re going to be physically moving a lot less. So you must make time each day for exercise. So many of my patients that have switched to working remotely have gained a fair bit of weight and almost all of them have lost serious muscle tone. When you’re working from home, it’s easy to get comfortable and complacent, and turn into a flabby flaccid couch potato. Do something to move your muscles every day. 

-Eat three square meals each day, and no more 24/7 snack attacks. Just because your refrigerator is mere steps away doesn’t mean you should make the trip every 30 minutes. A small midmorning, midafternoon, or late night snack is okay, but that’s it. Note my word choice: or not and. Three decent meals and one small snack each day is acceptable- just try not to go too crazy- and try to make it reasonably healthy, maybe a yogurt, cottage cheese, or piece of fruit. Like, a box of girl scout cookies is not a snack, people. 

-Because you aren’t commuting to and from the office, you’re also rarely going to be required to go outside. So you must make a special point to go outside every day, even if it’s just for 15 minutes after lunch. Human bodies require vitamin D, and nothing’s a better source than sunlight. Try taking a walk around your neighborhood after you have lunch, just something where you’re exposed to the sun. 

-A lot of my patients are complaining of decreased intimacy and a lack of sexual energy since they started working remotely. So my next suggestion is to do whatever you can to be close to your partner. Emotional and physical intimacy are important, so have sex, but maybe don’t combine this suggestion with the one above it, unless you have an excellent privacy fence. 

-When work is over, stop working. It can be tempting to work more hours when you’re at home. This may sound counterintuitive, but it’s true. To avoid this trap, work the same schedule and number of hours each day at home as you would if you were commuting to an office. Don’t try to cram jam in four16 hour days days a week in order to take a 3 day weekend, unless it’s an unavoidable situation, and/ or you receive permission or clearance from a supervisor if applicable.

-Make sure to get adequate sleep. Go to bed at a reasonable time, get up at a reasonable time, and try to stick to a sleep schedule. And remember to avoid blue light exposure for at least two to three hours before you go to bed, otherwise you’ll have a hard time falling asleep. 

-Keep your regular grooming routine- you’ll feel better about yourself. If you didn’t get the hint, shower every day. Brush your hair, and your teeth. Shave and put on makeup if you’re about that life. Work is not a pajama party, so get dressed in appropriate clothing. You don’t have to wear a suit or heels, but make an effort to be presentable, even if there’s no one to present yourself to. 

This isn’t rocket science, people. Basically, you should follow the same routine you always have, and do everything you would do if you were going to an actual outside office or workplace: go to bed at a reasonable and regular time on work nights, get up at a reasonable and regular time each morning, and resist the urge to hit snooze 97 times. Shower, shave, get dressed in decent clothing, and eat breakfast. Then go to work in your in-house office space, just as you would if you were going to commute to an office. Avoid distractions and get your work done. Take a one hour lunch break maximum, and make sure to actually eat something reasonable, but avoid eating at your desk. Think about taking lunch outside for some fresh air, vitamin D, and a change of scenery, and you can kill multiple birds with a single stone. After lunch time is not nap time- and it hasn’t been since kindergarten- so after lunch, go back to work until it’s time to stop at the end of the day. Make sure to put in a full day’s work, while also being careful not to overwork. Behave as if you owned the company and were paying employee salaries. Supervisors will be less likely to micromanage you to death if you give them no reason to mistrust you or doubt your motivations.  

No Nearly Naked Zooming

Captain Obvious says that videoconferencing has become a big part of our lives DR, and will continue to be long AR. Here’s a fun fact for you, Zoom saw phenomenal growth in 2020, and ended the third quarter of 2020 with an astounding report of 367% year-over-year revenue growth. If you had stock in Zoom Video Communications BR, which I did not, that’s a very fun fact for you. And get this… Zoom hosted an average of 300 million meeting participants per day throughout 2020. That’s 300 million people that don’t need to see you in your underwear, people. Same goes for gnarly, used-to-be-white, ripped t-shirts with yellow pit stains. Get it? If you didn’t, here’s the simple concept: put on a shirt. One with at least two buttons at the top. 

Drinks, not Zinks

Even if you dress appropriately for video conferencing calls, there’s really no replacement for real deal interaction, because shockingly, humans are hardwired for human connection. Even Captain Obvious wouldn’t bother with that one. It’s just not possible to simply erase our evolutionary zeitgeist and replace millions of years of in-the-flesh interactions with technologically mediated virtual communications. While Zoom and its brethren have helped us in our attempts to recreate a certain degree of face-to-face experiences, that’s really as much thanks to the power of human imagination as it is to technology; and nothing stifles human creativity and imagination like isolation and loneliness. As a society, we spend a lot of time creating tech to replicate real-life experiences, but it’s a cheap substitute. In most situations, we’re better off spending a larger portion of that time experiencing real-life personal experiences. If you live alone and work from home, you could literally spend days without any human contact. You should make an effort to socialize, but remember to do so responsibly and wear your mask, people. Call a friend and suggest you meet for dinner, coffee, or lunch, or go on a date night. Drinks are hands down better than Zinks, so arrange to meet a friend IRL. 

Loneliness or isolation is one of the most commonly reported issues that remote workers and digital nomads face, along with anxiety, stress, and depression. Next week, in part deux of this remote work blog, I’ll talk more about those, as well as some professional issues that can come into play when working remotely, and I’ll make some suggestions on how to deal with them. Then in part three, I’ll talk about some specific anxiety and stress busting techniques you can incorporate into your routine during the day, as you need them, and they won’t complicate or derail your work schedule, or negatively affect your productivity. In fact, they’ll do just the opposite.

I hope you enjoyed this blog and found it to be interesting and educational. If you did, let me know. If you didn’t, let me know that too!

Please feel free to share the love! Share blogs and YouTube videos with family and friends. 

Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, and share those vids too.

And if you like what you see and want more of it, or if you want a specific topic, leave it in the comments- I love reading them! 

As always, my book Tales from the Couch has more educational topics and patient stories, and is available in the office and on Amazon. 

Thank you and be well, people!

MGA

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The Skinny On Psychostimulants

The Skinny on Psychostimulants

Happy 2021 people! Are you as happy as I am that 2020 is finally in the rearview?! Weirdest. Longest. Year. Ever. 

That actually makes me think of a new and hilarious commercial I just saw for a big online dating site. It starts out with Satan bored out of his mind in hell, and then he gets a text message from the site saying he’s been matched with a girl, and he’s very intrigued. When they meet, it’s obvious that they’re both instantly smitten. Then the starry-eyed girl introduces herself as 2020. They fall in love. And they live happily (?) ever after… apparently in hell. Unless they stay at her place I guess. Anyway, 2020 is over, even though unfortunately, we’re still schlepping some of its covid baggage, but hopefully not for much longer. 

Considering the euphoria surrounding the new year and the stimulation of resolutions, I thought it very fitting that I start with a three part blog series on pharmacological central nervous system stimulants, aka psychostimulants. One of the main compounds in this class of drugs are the amphetamines, and that will be today’s blog topic. 

As psychostimulants go, amphetamines are very strong ones; they are a group of very tightly controlled and well monitored schedule II drugs. Add a little carbon atom, bind some hydrogens to it, and you’ve got a methyl group; and that makes it methamphetamine, which everyone’s heard of. When prescription methamphetamine is (very) illegally altered…tah-dah…you’ve got crystal meth, aka speed, ice, crank, etc. Other examples of psychostimulants include caffeine, nicotine, cocaine, and other prescription compounds that I’ll cover next week. 

Because of their stimulant activity within the central nervous system, prescription amphetamines are used in the treatment of several disorders, including narcolepsy, obesity, binge eating disorders, and very commonly, ADHD, or attention deficit hyperactivity disorder. They can also be used recreationally in certain populations to get high, to stay awake for long periods of time, and/ or to improve focus and study for exams. In fact, it’s those last two that make amphetamines very popular party favors among college students.

Structurally speaking, amphetamines are drugs that are related to catecholamines, which are chemical messengers that help transmit a message or signal across neural synapses in the central nervous system, from the terminal end of a transmitting nerve cell to the receiving end of a target nerve cell. In an over-simplified explanation, when a signal gets to the end of one neuron, catecholamines help the signal jump to the beginning of the next neuron, hence the name “neurotransmitter.” That message is repeated billions upon billions of times, as there are billions upon billions of neurons in the central nervous system. These neural signals activate emotional responses in the amygdala of the brain, such as fear in a “fight or flight” situation. At the same time, catecholamines also have effects on attention and other cognitive brain functions. Examples of catecholamines include the neurotransmitters dopamine, epinephrine, and norepinephrine. Pharmacologically speaking, amphetamines increase levels of the specific neurotransmitters dopamine and norepinephrine in the neural synapses, which helps the message to make the jump from one neuron to the next. In a way of thinking, amphetamines “speed” the transmission of the message by increasing the levels of these neurotransmitters. Amphetamines increase these dopamine and norepinephrine levels through three different mechanisms of action, at least that we know of: 1) they reverse the direction of the transporter pumps that would normally divert dopamine and norepinephrine away, 2) they disrupt cellular vesicles, thereby preventing the storage of excess dopamine and norepinephrine, which frees them up, and 3) they also promote the release of dopamine and norepinephrine at nerve cell terminals, making them readily available in the synaptic cleft. These three mechanisms combined ensure that there are very high concentrations of dopamine and norepinephrine in the synapses of the central nervous system. The “catecholaminergic” (try that one next time you play scrabble) actions of increasing the levels of dopamine and norepinephrine result in the very strong psychostimulant effects that amphetamines produce.

You’ll notice that I keep saying amphetamines, plural. Why? Because like the neurotransmitters dopamine and norepinephrine it effects, amphetamines are chiral molecules; this is a fancy way of saying that in their three dimensional world, they can exist in different forms called enantomers (more scrabble points!) that are mirror images of each other. I know this sounds complicated, but it’s really not. Think of it as “handedness.” Your left and right hands are mirror images of one another: they look similar, except the placement of the fingers and thumbs are mirror images, and they can do pretty much the same things, like hold a fork or a pencil, but the way they do so differs slightly. The same is true of amphetamines. The two enantiomers of amphetamines are usually referred to as dextroamphetamine (also denoted as d-amphetamine) and levoamphetamine (also denoted as l-amphetamine). All prescription amphetamines boil down to four variations of the amphetamine molecule, which have markedly similar, but potentially slightly variable effects: dextroamphetamine, aka dexadrine; lisdexamphetamine, which is a precursor or pro-drug of dextroamphetamine; methamphetamine, aka methamphetamine HCL, which has that methyl group I mentioned before; and mixed amphetamine, which is essentially a mixture of dextroamphetamine and levoamphetamine at a specific ratio. 

Of those four active forms of amphetamines, there are several brand name drugs on the market, some of which have generic forms available. They are all oral formulations that may be immediate-release, which are typically taken twice a day, or extended-release, which are obviously released more slowly and taken once a day. 

Adderall XR (generic available)

Dexedrine (generic available)

Dyanavel XR

Evekeo

ProCentra (generic available)

Vyvanse

Methamphetamine (Desoxyn)

The desired effects of amphetamines include: stimulation (thank you Captain Obvious), increased alertness, cognitive enhancement, euphoria, and mood lift. Amphetamines have been around for a long time and when taken as prescribed, they’re fairly safe, but there are potential negative side effects. These can include insomnia, hyperfocus, GI irritation, headache, anxiety, slight increase in heart rate and blood pressure, and anorexia. There is addiction potential associated with amphetamines, and there is a short and fairly mild associated withdrawal period where one might feel some fatigue, sleep a lot, and experience strange dreams. 

When taken as directed, and by mouth, usually 20mg – 40mg per day, amphetamines are fairly safe. However, when smoked, injected, or snorted, they are decidedly UNsafe; especially in large doses. I’ve seen people take up to 1000mg per day… though not for long. Why? Because they usually end up dead of overdose. What happens if you choose to use amphetamines in large quantities and/ or via routes other than oral? Hallucinations, delusions, psychosis, seizures, cardiovascular collapse/ arrest, stroke… the bottom line is it ain’t pretty, people, so don’t do it. 

Because amphetamines have multiple mechanisms of action and thereby are very strong psychostimulants, I generally restrict their use to adults only, and choose to use another type of psychostimulant in children called methylphenidate. And that will be the topic next week in psychostimulants part 2 of 3. 

I hope you enjoyed this blog and found it to be interesting and educational. If you did, let me know. If you didn’t, let me know that too!

Please feel free to share the love! Share blogs and YouTube videos with family and friends. 

Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, and share those vids too! 

And if you like what you see and want more of it, or if you want a specific topic, leave it in the comments- I love reading them! 

As always, my book Tales from the Couch has more educational topics and patient stories, and is available in the office and on Amazon. 

Thank you and be well people!

MGA

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Kratom:Panecea or poison?

Kratom: Panacea or Poison?

What is Kratom?

Kratom (scientific name: Mitragyna speciosa) is a tropical evergreen tree in the coffee family that is native to the jungles of Southeast Asia; specifically found in Thailand, Myanmar, and Malaysia. It is also found in Papua New Guinea. Other names for kratom include thang, kakuam, thom, ketum, and biak. Whatever it’s called and wherever it may be found, this tree, or at least the leaves on it, has been causing quite a commotion in recent years.

The Scientific Scoop

Mitragyna speciosa leaves contain multiple active components, referred to as alkaloids, with properties ranging from stimulant-like energizing and uplifting to opiate-like drowsiness and euphoria, so this makes it difficult to characterize kratom as one particular type of drug, i.e. as “stimulant” or “opiate.” Kratom’s two main alkaloids are mitragynine and its active metabolite, 7-hydroxymitragynine, which has strong activity at the µ-opioid receptors (where µ is pronounced like ‘you’ but with an m: mu). This is the main opioid receptor, the same one that is the primary binding target of opioids like heroin and oxycodone. Why is this so important? Why do we need to know exactly where kratom binds and what effect that has? Well, so we know how it may be used. Here in America, the government isn’t so good with just accepting that this ancient Asian secret does xyz just because they said so. Because kratom binds to µ-opioid receptors just like heroin etc, opponents say that it must be categorized as a narcotic and therefore, it must be addictive just like heroin etc. But Narcan/ naloxone is also categorized the same way, and obviously it’s not addictive; in fact, it’s used to save people in cases of opioid overdose. 

There is a great deal of supportive scientific evidence from many independent laboratory studies using mouse models and multiple human cell lines that confirms that kratom’s alkaloid metabolite 7-Hydroxymitragynine is in fact a key mediator of the analgesic effects of kratom, through its agonistic binding to the µ-opioid receptor. This has also been confirmed by the finding that in the presence of the opioid receptor antagonist naloxone, the pharmacological blockade of the analgesic effect will occur. In plain language: they’ve clearly shown that kratom binds specifically to the µ-opioid receptor in human cell lines, and demonstrated that this binding produces analgesic effects by giving it to a specific type of live mouse that essentially models the human system. So after the mice were given kratom, they exhibited analgesic effects from it– through previously established and accepted behaviors that I’m totally not going into here– just trust people. And then, as if that’s not enough, to further prove that this analgesic effect the mice were having was definitely the result of kratom’s binding to the µ-opioid receptor, they then gave the kratom-dosed mice Narcan, aka naloxone, which is a µ-opioid receptor antagonist. What does that mean? Think of it this way: the Narcan “antagonizes” the µ-opioid receptor; it basically bullies anything already bound to that µ-opioid receptor, pushes it off, and then it binds to it and blocks it so that as long as it’s parked there, nothing’s getting by it to bind to those µ-opioid receptors. That’s how and why Narcan saves people from overdose: it pushes all the opioids off all of the µ-opioid receptors and then sits on them, and hopefully that happens soon enough that the person survives the overdose. If they do, and if they then ingest more opioids for several hours after being given the Narcan, they won’t feel the effects of the drugs for as long as the Narcan is present there on those receptors, because the drug’s opioids won’t be able to bind to the µ-opioid receptors, as the Narcan will be sitting there. So there’s been a lot of work done in various labs all over the globe to elucidate kratom’s form and function. But despite all of this work, there’s much more to be done! I’ll talk more about that later.

None of kratom’s uses are clinically proven, as it has not been studied in the human clinical trials that the FDA requires to allow a drug compound to be legally available on the open market. Clinical studies are very important for the development of new drugs, as they help to identify consistently harmful effects, harmful interactions with other drugs, and dosages that are effective, yet not dangerous. That said, there have been many legitimate published laboratory studies with clear demonstrable findings in mouse models and human cell lines that do allow us to at least extrapolate the effects of kratom in humans with some accuracy and relative safety. Most findings have been positive, and there is a large vocal community of kratom supporters with numerous anecdotal testimonials of kratom’s effectiveness in treating various conditions. But despite this, because treatment practices using kratom have not been rigorously studied as either safe or effective, the DEA staunchly maintains that it has no valid medical uses or benefits. In fact, several years ago, the FDA threatened to make kratom a Schedule 1 narcotic, meaning it would be grouped with marijuana, LSD, and ecstasy, among others, and this elicited a huge backlash… tens of thousands of kratom proponents complained vociferously, signed endless petitions and all that yada yada, and the FDA caved, dropping the issue, at least for the time being. But that’s not going to be the end of that story people… not when the government’s involved. So for now, kratom’s status should be listed as “to be continued.”

What is Kratom Used For?

In its native regions of Southeast Asia, kratom has been known to be used as a traditional medicine for more than a century, but has likely been used for multiple centuries. There in Southeast Asia, the leaves of the kratom tree are typically chewed directly from the tree or consumed as a tea, and they induce stimulant and opioid-like analgesic effects, depending on the amount used. This is because the effects felt from ingesting kratom have been found to be dose-dependent: at low doses, which is generally considered 1 to 5 grams, kratom has been reported to work like a stimulant, imparting feelings of being more energetic, more alert, and more sociable. At higher doses, considered to be 10 to 15 grams, kratom has been reported as being more sedating, dulling emotions and sensations while producing euphoric effects. Anything over 15 grams is considered risky.

The stimulant type effects have traditionally made kratom popular among Southeast Asian agricultural workers especially, who use it to aid them in their long hours of hard labor. But for generations there, kratom has also been used successfully in its native regions for several other purposes: as an aphrodisiac to increase sexual desire, as an energy booster, to ameliorate withdrawal symptoms following cessation of opioid use, and for treating cough, diarrhea, and chronic pain. More recently, here in the US, there has been an uptick in the use of kratom by people who are self-treating chronic pain and managing acute withdrawal from opiates, while seeking alternatives to prescription medications. While some people claim to have success using kratom to treat depression and anxiety, and others say that kratom can also be used to treat muscle aches, fatigue, high blood pressure, diarrhea, and post-traumatic stress disorder (PTSD). Some studies report that kratom possesses anti-inflammatory, immunity-enhancing, and appetite-suppressing properties, but obviously more research is needed to confirm these benefits.

Kratom: Processing and Forms

The psychoactive compound referred to as kratom is found in the leaves of Mitragyna speciosa, and the processing seems pretty straightforward: after the plant’s large dark green leaves are harvested, they can be prepared in several ways: fresh leaf, dried leaf that is pulverized and powdered, dried leaf that is simply crushed, and concentrated liquid leaf extract. Kratom can typically be purchased in multiple forms, including paste, capsule, tablet, gum, tincture, and extract. In certain forms it is often combined with added sweetener to overcome its harsh bitterness. Kratom can be brewed into a tea as well, a form that is offered in kratom tea houses present in a few US states. Kratom can also be smoked or vaporized, though this is not very common.

While the use of Mitragyna speciosa is certainly not new, the alkaloid extraction and refinement methods to turn the alkaloids from the plant into kratom has certainly evolved, and now purity is said to be higher. I’ve read that now there are also fortified kratom powders available, and these contain extracts from other plants in a nod to the nutraceutical angle. In the United States, kratom is usually marketed as an alternative medicine, and often found in stores that sell supplements. Kratom can also be found in gas stations and paraphernalia shops in most parts of the US, except in the handful of states and cities that have banned it. Many people purchase kratom over the Internet, where it may be sold for “soap-making and aromatherapy,” a lot like what happened with synthetic marijuana or spice; that’s in an effort to circumvent the FDA’s 2014 ruling that made it illegal to import or manufacture kratom as a dietary supplement in the US.

Is Kratom Legal?

Although kratom is technically legal at the federal level, some US states and municipalities have chosen to ban it, making it illegal to sell, possess, grow, or use it. Other states have imposed age restrictions. In the states of Alabama, Arkansas, Indiana, Rhode Island, Vermont, and Wisconsin, kratom is illegal to buy, sell, possess or use. There are special cases in some states: while kratom is legal in California, it is banned in San Diego. While it’s legal in Colorado, in Denver it’s considered illegal for human consumption. Kratom is legal in Florida, except for Sarasota Country, where it’s banned. Kratom is legal in Illinois for those over the age of 18, except in the city of Jerseyville, where it is banned. Kratom is legal to use in Mississippi, except in Union County, where it’s banned. In New Hampshire, kratom is only legal for those over the age of 18. Please don’t quote me on these people- make sure to double check if you’re wanting to purchase- not that I’m encouraging that or even saying it’s acceptable btw. 

As far as countries around the globe go, kratom is illegal in: Australia, Denmark, Finland, Israel, Japan, Latvia, Lithuania, Myanmar, Malaysia, New Zealand (unless prescribed by a doctor), Poland, Romania, Russia, Singapore, South Korea, Sweden, Thailand, and Vietnam. Note that most places where native Mitragyna speciosa grows, it’s illegal… funny! Speaking of that, the country of Thailand has recently reconsidered the status of some illegal substances, so kratom might not remain illegal there.

In countries like Ireland, Italy, and the United Kingdom, the rules may vary from one city to the next. It’s also important to note that the status of kratom legality isn’t widely known for some countries. For example, it isn’t clear whether it is legal in China, or in many of the African nations. However, as the drug kratom becomes more widely known, countries, counties, and cities that don’t currently ban kratom may choose to do so at any point.

Is Kratom Safe?

Proponents say kratom is an amazing compound, a game-changer and lifesaver. Opponents, like the FDA, say it has no viable medicinal properties. How the US DEA, medical professionals, and millions of regular kratom users can have such divergent views of the same plant is hard to fathom. The overarching “company line” seems to answer this question “No!!” They state that kratom is considered addictive, that people can develop a physical dependence on it, and that in and of itself indicates that it’s not safe. There are some anecdotal reports of people becoming dependent on kratom, but there are more reports of people successfully using it to recover from opioid addiction; not to mention successfully treating chronic pain, fibromyalgia, anxiety, depression, on and on. So in my book, the jury’s out people. 

The question of kratom’s safety comes down to two factors: the lack of regulation and the interactions with other drugs or substances, whether endogenous or exogenous. 

Lack of Regulation

Any time a substance, including herbal supplements, isn’t regulated by the FDA, there are potential safety hazards. This is because there is no standardization when a substance isn’t regulated. That means that companies, particularly if they’re operating online, can market the product however they want. There are no official drug warning labels for kratom, and people may take it without knowing what other substances it contains. A buyer never knows what level of potency a kratom product could have or whether it’s pure. In addition, the active ingredient in kratom varies widely by plant species. As with marijuana strains, different kratom strains have slightly different effects; there are multiple species of the tree, so this makes kratom’s effects unpredictable. This unpredictable nature leads to a risk of overdose and other serious side-effects, including seizures, hallucinations, chills, vomiting, liver damage, or even death.

Kratom Interactions

Because there is little research currently available on how kratom interacts with other substances, the breadth and severity of effects are yet unknown. This unpredictability adds to the dangers of using kratom in combination with something else, because you’ll have little idea what it could do to you. Potentially negative effects can be even more severe when kratom is combined with other drugs and prescription medicines. Some of the kratom chemicals have been shown to interact with how the liver metabolizes other drugs, which can lead to dangerous interactions. Another risk is presented when people buy commercial versions of kratom that have been combined with other drugs or substances, especially if they too work on the same opioid receptors. The potential consequences of many drug interactions can range from seizures to liver damage.

Various Points on the Kratom Controversy

Depending on what you read and who you believe, kratom is a dangerous, addictive drug with no medical utility and severely deleterious side effects that include overdose and death, or it is an accessible pathway out of undertreated chronic pain and opiate withdrawal, as well as being useful in treating many other health issues. There are great physicians and impressive institutions with interesting facts on both sides of this issue.

Recent increased kratom use in the United States, combined with concerns that kratom represents an uncontrolled drug with abuse potential, has highlighted the need for more careful study of its pharmacological activity. The major active alkaloid found in kratom, mitragynine, has been reported to have opioid agonist and analgesic activity in vitro and in animal models that are consistent with the purported effects of kratom leaf in humans. However, preliminary research has provided some evidence that mitragynine and related compounds may act as atypical opioid agonists, meaning they induce their therapeutic effects like analgesia, while also limiting the negative side effects that often accompany classical opioids. One such side effect that is absent in kratom is constipation. A chronic pain medication like kratom that doesn’t cause constipation like current opioids all do sounds like a good thing, but as I said before, it’s a long way from here to there, especially considering the FDA’s current opinion. And something tells me they won’t be changing their collective mind any time soon. 

As it stands now, there is little to no control or reliable information on growth, processing, packaging, and/ or labeling of the kratom currently sold in the US; and all of this adds to the already considerable uncertainty of its health risks. In 2018, the FDA instituted a mandatory recall of all kratom containing compounds over concerns about Salmonella contamination in these products. More recently, the DEA placed kratom on its “Drugs and Chemicals of Concern” list, but as I mentioned before, it has not yet labeled it as a controlled substance, though not for lack of trying. Time will tell how long that lasts.

Kratom can be addictive due to its opiate-like qualities, and a small minority of users may end up requiring addiction treatment. The CDC claims that between 2016 and 2017, there were 91 deaths due to kratom; but this claim should be met with healthy skepticism, as all but seven of these casualties had other drugs in their system at the time of their deaths, and that makes it totally impossible to uniquely implicate kratom.

A patient wishing to use kratom to treat chronic pain or to mitigate opioid withdrawal symptoms could expect to encounter several problems with doing so, not all of which even have anything to do with the intrinsic properties of the kratom itself.

A patient that wants to use kratom to treat a legitimate illness or condition will likely face four problems for the foreseeable future:

-The first problem is that the DEA still occasionally threatens to make it a Schedule 1 controlled substance, along with drugs like heroin and ecstasy. This would make kratom very difficult to access, and would likely make the supply as a whole even more dangerous than it is now. Generally, it’s not a good idea to use something to treat chronic pain or addiction that may soon become less available and less safe: you want to know it’s going to be readily available, and that as a cure, it won’t cause more problems than the illness it’s being used to treat!

-The second problem is that the complete lack of oversight and quality control in the production and sale of kratom makes its use potentially dangerous.

-The third problem is that kratom has not been well studied for any of the uses its proponents claim it has an affinity in treating! Maybe the FDA hasn’t heard the saying that goes, “Absence of evidence of benefit isn’t evidence of absence of benefit.”

-The fourth and final problem is that kratom doesn’t show up on drug screens. I like kratom’s potential, but I can argue that adding another potentially addictive opiate-like substance while an opiate epidemic is already going on may not be the best course of action. 

Is there a sensible path forward with kratom?

I’m not sure that anyone has the answer to that question, but at a bare minimum, the safety of kratom could be improved through:

-Regulation: it would be safer if people knew the exact dosage of kratom they were truly consuming, and that it was totally free of contamination.

-Education: educated consumers who know all of the potential benefits and dangers of the compound they are consuming are far less vulnerable to misleading claims.

-Research: if kratom does in fact have the benefits that have been demonstrated in the laboratory for treating either addiction or chronic pain, we should absolutely know it and make it known: accurately defining the risks of using kratom is critical, as is making all medical personnel and laypersons informed.

If all four of these points could somehow be accomplished by scientists and public health specialists, without: overdue distortion from corporate interests, anti-drug ideology, and romanticism by kratom enthusiasts, then we should have enough clarity to answer the basic questions about kratom, including the most important question of all…is it harmful or helpful?

Effects of Kratom: Good, Bad, Ugly

The Good

Recall that the expected effects from kratom are dose-dependent: that smaller doses will produce a stimulant-like effect, while larger doses will produce sedative or opioid-like effects. 

A small dose of kratom to produce stimulant effects would be up to just a few grams, and these effects would be felt within 10 minutes after ingestion and can last up to 90 minutes. These expected stimulant effects include increased energy, alertness, and sociability, increased sex drive, decreased appetite, and giddiness.

A larger dose of kratom, between 10 and 25 grams, can have a sedative effect, imparting feelings of sedation, calmness, euphoria, pain reduction, and cough suppression, which last for much longer periods of time, potentially up to six hours.

The Bad

Potential unsafe and negative effects of regular kratom use, even at low doses, can include: agitation, tachycardia, drowsiness, vomiting, confusion, anxiety, tremors, itching, sweating, insomnia, lack of appetite, tremor, coordination problems, and withdrawal symptoms.

There can also be negative effects of high dose kratom, including: addiction, nausea, itching, constipation, and withdrawal symptoms of tremor and sweating.

There can be negative side effects of taking any dose of kratom at irregular times or random intervals as well. Many users of kratom have reported something called “The Kratom Hangover” the day after taking it, the symptoms of which can include irritability, anxiety, nausea, and headaches.

Because kratom can cause problems with coordination and sleepiness, it’s dangerous to drive or operate machinery while using it. For this same reason, pregnant women are also advised never to use kratom. 

The Ugly

There can be grave side effects from taking kratom, which can include seizures and respiratory and/ or cardiac arrest.

If a person takes a high dose of kratom and falls asleep, they may vomit and choke while asleep.

Kratom Overdose

There are numerous calls into the CDC poison centers for kratom overdose every year.

The risk of overdose increases when kratom is taken with another substance, especially opioids.

Recent studies have found evidence of fatal kratom-only overdoses involving severe and negative side effects that can occur when someone takes too much. Some of the symptoms of taking too much kratom can include: impaired motor skills, lethargy, slurred speech, either shallow or very heavy breathing, tremors, listlessness, aggression, delusions, and hallucinations.

Long-term and heavy use of kratom can lead to liver problems, as kratom tends to make it more difficult for the liver and kidneys to process and filter toxins out, contributing to the potential for this type of organ damage.

Signs of liver damage include dark-colored urine and yellow skin and eyes.

Kratom: Necessary Evil or Just Plain Evil?

Kratom is currently considered a dietary supplement, as it is not approved nor regulated by the US FDA. That said, there are anecdotal reports of beneficial effects of kratom use, though there is no clinical evidence yet to support them. In the future, with the proper supporting research, kratom may indeed have proven potential. 

But without this research, there are a lot of unknowns with kratom, such as effective and safe dosage, possible interactions, and possible harmful effects, including death. These are all things that you should weigh before taking any drug, but for kratom, they’re all question marks. In the final analysis, going by laboratory findings, kratom holds great potential. But if you’re thinking about using kratom to treat chronic pain or opioid addiction, or anything else… exercise extreme caution people.

I hope you enjoyed this blog and found it to be interesting and educational. Sharing means caring, so please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in office and on Amazon. 

Thank you and be well people!

MGA

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Opiate Addiction and Detox: Buprenorphine vs Methadone

Opioid Addiction and Detox: Buprenorphine vs Methadone

Last week, I went over the history of opioids, and it really highlighted the trend of addiction that has always been linked with them. According to the World Health Organization, more than 15 million people are suffering from opioid dependence today. It’s clear that the opioid epidemic isn’t a new phenomenon; for as long as the opium poppy has been in existence, so has addiction. Historically speaking, what is relatively new is that physicians and pharma companies are recognizing the need for more effective ways to combat this epidemic, whether through prevention or treatment. As a result, we have some novel compounds that present different options for people who are addicted to these drugs; these include non-narcotic options for pain relief to prevent addiction, as well as medications to help addicted people on their road to recovery from opioid dependence. In a future blog, I’ll talk about a non-narcotic compound currently in patient trials that is showing a great deal of promise in the chronic pain arena. If you’re interested now, I posted a video on it on my YouTube channel, so check it out. But for today, I’m going to talk about the latter: two drugs, one relatively new and one not so much, that are being used to detox opioid addicts and give them a shot at a clean life. These two drugs are buprenorphine and methadone, and one of these is definitely not like the other. I’m going to compare and contrast them: the good, bad, and the ugly. By the end, you’ll not only know my opinion on the matter, but why I’m passionate about it. 

What is Buprenorphine?

On the market for nearly twenty years, buprenorphine is a Schedule III drug used to help treat the physical ramifications of opioid withdrawal. Given as a simple medicine that dissolves under the tongue, buprenorphine satiates the opioid receptors that cause dependent people to crave opioids. It can be prescribed in its solo form, or as a branded compound product with naloxone, which is the familiar ‘resurrection’ drug Narcan. It is the most strictly regulated drug by DEA, and available only from physicians that have been specially certified in its use, a fact that has been the nexus of some controversy. Why? Some physicians and policy makers feel that the hoops that physicians must jump through in order to receive the ‘X Waiver’ required to prescribe it present a barrier to its use; that if certification requirements were relaxed or eliminated, more opioid-dependent people would have access to this option for detox. The objective of someone taking buprenorphine is to help them remain safe and comfortable as they go through detox from opioids so that they can focus on treatment and recovery. While some data claims that buprenorphine may create some feelings of well-being when a person takes it, it does not cause a euphoric high. It’s also worth noting that while it can be used safely long term, the duration of use of buprenorphine tends to be more short-term, which clearly verifies the absence of a high and it’s low potential for addiction. Buprenorphine’s binding action to opioid receptors in the brain blocks the narcotic effects of traditional opioids, so if a drug-dependent person takes buprenorphine and an opioid together, there’s still no “high,” thus eliminating the reason for taking said opioid. And, buprenorphine also has a ceiling effect, meaning that beyond a specific dose, its effects remain unchanged. This essentially does away with the “if one is good, four are better” phenomenon, so overdose is very rare. 

What is Methadone?

Methadone is a drug that some physicians believe can be used to “help” opioid-dependent people as they try to stop using drugs. But that’s about where the similarities end. Old as the hills, methadone is a Schedule II opioid medication that’s been used for detox for 60 years. Methadone has a similar chemical structure to morphine; as such, methadone can, and does, make someone feel high. In theory, methadone doesn’t make people “as high” as some other opioids, and it can take longer for that high to occur, which proponents say translates into less potential for abuse. I say this is total bullshit. Why? Because we’re talking about drug-dependent people here, people! We’re dealing with people that, despite any good intentions they may have, their brains and bodies tell them they must get high. Remember that “if one is good, four are better” phenomenon I mentioned? Yeah. Bottom line is that methadone is a very strong opiate, so when a dependent person takes it, their addicted brain gets a taste of that high, and it’s like a tease…it tends to make them want more. Helllooo! There’s almost nothing that will stop a drug addicted brain from getting what it wants. There’s no blocking action and no ceiling with methadone, so overdoses are not unusual. Regardless, for over sixty years, methadone has been given as a “short-term” treatment to help people stop using opioids. That’s bad enough, but what’s worse is that it’s even more often used as a long-term maintenance drug for the “management” of opioid addiction. In reality, it’s replacing one bad drug with an even worse one. In fact, methadone is also known as “liquid handcuffs” by the people who have managed to successfully get off of their methadone “management” programs. 

While the general objectives of buprenorphine and methadone use may be similar to one another, there are clearly many significant differences.

Methadone is almost exclusively dispensed by clinics on a per diem basis, meaning that people have to head to the clinic every day and line up to get their “medicine.” In contrast, a physician with an X waiver can write for a 30-day supply of buprenorphine. It is less problematic than methadone, largely because it’s less dangerous and less addictive than methadone, thanks to the ceiling effect precluding overdose, and the fact that it doesn’t cause a high. That said, people must keep in mind that buprenorphine is a powerful drug, and not one to be taken (or prescribed) lightly. Saying that it’s less dangerous than methadone, while absolutely true, is sort of like saying that rattlesnake bites are less dangerous than cobra bites. Me personally, I’d just rather not be bitten…but if I have to be bitten, bring on the freaking rattlesnake. 

Buprenorphine vs. Methadone

It’s Science, People!

Both humans and animals have opioid receptors in the brain and spinal cord. Biologically speaking, these receptors facilitate the binding and effect of naturally produced pain-relieving chemicals. Externally sourced opioids like methadone belong to the opioid agonist class of drugs. They work by binding to these specific receptors in the brain and mimicking the effects of those naturally produced pain-relieving chemicals. As a result, the perception of pain is blocked, producing feelings of well-being and euphoria, but also side effects such as nausea, confusion, and drowsiness. While opioid drugs are often very effective in treating pain, people can eventually develop a tolerance, so they require higher doses to achieve the same effects. It’s a vicious cycle, so people become dependent, and will experience symptoms of withdrawal if they decrease or stop opioid dosing. That means that when it comes time to taper off of methadone, it’s intrinsically difficult, and withdrawal is unavoidable. Symptoms of opioid withdrawal can include anxiety, muscle aches, irritability, insomnia, runny nose, nausea, vomiting, and abdominal cramping. It’s seriously un-fun at best.

Buprenorphine belongs to the opioid agonist-antagonist class of drugs, and it is a partial opioid agonist. As such, it activates only a portion of an opioid receptor, so it only causes a portion of the effects of an opioid, specifically eliminating the euphoric effects of opioids like methadone. It has lower potential for causing respiratory depression than methadone, and that translates to little potential for overdose death. And it also effectively blocks the effects of other opioids, including heroin and prescription pain medications like fentanyl and oxycodone, so it’s much more likely to discourage relapse in recovering patients. Buprenorphine prescriptions can be filled and taken home, eliminating the need to go line up at a nasty clinic every single day. And because it’s much longer acting than methadone, buprenorphine doesn’t need to be taken every single day anyway, so patients aren’t tied to it; they have the freedom to spend more time doing activities that are more positive for their recovery. When it comes down to tapering off of buprenorphine, it’s far easier than methadone, with essentially zero physical withdrawal symptoms. All of these factors make a big difference, people.  

Buprenorphine Pros vs Methadone

Newer, safer, more effective 

Long acting, easy taper

Safe for use during pregnancy

Low overdose potential

Prevents opioid usage- blocks euphoria

Covered by most insurance carriers

Typically excluded from employment drug screening

Buprenorphine Cons vs Methadone

Can be more expensive out of pocket

Unpleasant taste sometimes reported

Requires specialized physician

In my practice, I treat a fair number of opioid addicted people, and I do not and will not ever use methadone to treat them…it makes zero sense, when there’s an alternative that is more effective, safer, and easier to use. Methadone doesn’t solve a problem, it creates a bigger one. If I have a new patient that is on methadone, I switch them to buprenorphine as a matter of course. It’s not easy on them, but I use every weapon available in my arsenal. 

Methadone to Buprenorphine

In order to start taking buprenorphine, a patient must be in withdrawal, another un-fun fact. This is because buprenorphine is a bully. When you take it, it preferentially binds to those opioid receptors we talked about before. That means it kicks the true opioid off the receptor and replaces it. Doesn’t sound so horrible in theory, but it’s a very different thing in practice. The opioid addicted brain without its favorite thing- opioids- leads to a brain in withdrawal, which leads to a body in physical withdrawal…shakes, sweats, nausea, vomiting, diarrhea, muscle aches, and joint pain, just to name a few of the symptoms to be expected. 

The patient must be in a state of withdrawal for a proscribed amount of time before you can dose them with buprenorphine, because it can be dangerous to give it sooner. The longer they can tolerate that withdrawal prior to dosing buprenorphine, the better the buprenorphine will work and the easier the process will be. The length of the ideal withdrawal time is based on the half-life of the opioid the patient is addicted to. The half-life of a drug is roughly the amount of time it takes for half of the drug to be metabolized by the body, ie that 50% of it is left. For most opioids, 24 to 36 hours is the ideal withdrawal time. But methadone’s half-life is crazy long; in some people, it can be between 88 and 59 hours. But wait…it gets worse. That’s just for half of the drug to be metabolized. It generally takes six or seven half-lives to fully metabolize out a drug so it is no longer biologically active, so in methadone you need to have ten days off before you can safely introduce buprenorphine. Again, this is because that buprenorphine is a bully, and if you introduce it too soon, when methadone is still parked on the opioid receptors, it’s going to kick that buprenorphine off and throw the person into instant, severe withdrawal, which is not only dangerous, but intolerable to patients. Coming off of methadone requires high doses of buprenorphine for the first 24 to 48 hours, even after waiting for it to metabolize out. Otherwise, you can precipitate major withdrawal where that person starts kicking their legs uncontrollably, sweating, flinging sheets off the bed, and having terrible muscle spasms and cramping- it’s a horror to watch, let alone experience. I had a new patient that had become addicted to strong opioids secondary to chronic, severe pelvic pain and a series of several consecutive pelvic surgeries for ovarian tumors. The whole thing lasted for years and culminated in a hysterectomy. Immediately upon release from the hospital after the hysterectomy, she checked herself in to rehab to detox, and they put her on buprenorphine way too soon. Her withdrawals were very severe, to the point where she vomited so hard that she tore 19 of her abdominal sutures open and had to be taken back to the operating room emergently. Needless to say, she wasn’t too keen on the possibility of that ever happening again.  

So what’s a guy like me to do when a methadone-addicted patient comes in? If they’re committed, there are a couple of ways to handle it. Neither is fun nor risk free. One, you can step down from methadone to another opioid substitute like oxycodone in an incremental ratio for three days or so, stop the substitute for 24 hours, and then start buprenorphine. Or two, stop the methadone, wait as long as you can, which is usually two days, three max, of total misery, while using ancillary drugs like clonidine, benzodiazepines (like Klonopin, Ativan, and Xanax), muscle relaxants like Robaxin, and Mirtazapine to sleep. Basically using every drug possible to make the patient more comfortable, hold off on the methadone for as long as possible, and let the methadone metabolize out. Then put them on high dose buprenorphine for 48 hours, then drop to moderate dose for whatever time period is required. 

In addition, there are some dietary type changes that are helpful. Taking high-dose vitamin C acidifies the urine, enhancing the secretion of methadone out of the system. Taking 1000 mg of vitamin C twice a day, drinking slightly less water if possible, and eating a lot of protein will help further acidify the body and constipate the system, which sounds like hell, but is actually a good thing for withdrawal. 

The best way to deal with the situation is not to, meaning avoid becoming addicted in the first place. But, if you do find yourself addicted, do not choose a methadone detox, and definitely do not choose a methadone maintenance program. There’s just zero reason to do that when we have buprenorphine fairly readily available. 

The clear consensus is that buprenorphine is the gold standard treatment for patients suffering from opioid addiction. As a provider, I’ve had the privilege of seeing patients reclaim their lives with the help of a buprenorphine detox regimen; it allows them to focus on their jobs, their families, and their own well-being, instead of physically, mentally, and emotionally battling their addiction every minute of every day, to the exclusion of all happiness.

So boys and girls, the moral of the story is…

Coming off methadone is not fun, and I have had patients who are still depressed, anxious, and unable to sleep- six months, eight months, even a year- after transitioning from methadone to buprenorphine, to the point where they still require medications to deal with it. Xanax and methadone are my two least favorite pharmaceuticals in the entire world, each for their own specific reasons. Clearly, for patients looking to switch from methadone to buprenorphine, it’s a tough row to hoe; the symptoms can be excruciating, especially if mismanaged, but don’t let that stop you from making the switch. My first and best advice is to avoid becoming an addict, but if you do become one, never go on methadone, for any length of time, ever. It’s a trap, pure and simple. 

I hope you enjoyed this blog and found it educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in office and on Amazon. 

Thank you and be well people!

MGA

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Opiates:History,Use,Abuse,Addiction

Opioids: History, Use, Abuse, Addiction

How Did We Get Here?

Anchored in the history, culture, religion, mythology, biology, genetics, and psychology of the earliest civilizations to the societies of present day, humans have long tried to balance the positive medicinal properties of opioids with the euphoric effects that have so often led to their use and abuse.

Before we get into their history, first a quick fyi lesson in the semantics of the terms opiates vs opioids vs narcotics. While the terms are often used interchangeably, they are technically different things. 

The term opiate refers to any drug that is derived from a naturally occurring substance, ie from opium alkaloid compounds found in the poppy plant. Types of opiate drugs include opium, codeine, and morphine. The term opioid is broader, and refers to any synthetic or partially synthetic drug created from an opiate. Examples of opioid drugs include heroin, methadone, oxycodone, and hydrocodone. Narcotics is an older term that originally referred to any mind altering compound with sleep-inducing properties.

For the general public, only the term opioid is really necessary, as it includes all opi- substances. In my practice and in my blogs, I sometimes make a distiction between the terms, but if you’re looking for a safe bet, or maybe a trivia win, the term opioid is the best and most accurate choice. Regardless of the word used, one is not any safer than the other; any opiate or opioid has the potential to treat pain, to be abused, and to cause dependence.

Following are some of the most common opioids and their generic names, listed in order of increasing strength.

Codeine

Hydrocodone (Vicodin, Hycodan)

Morphine (MS Contin, Kadian)

Oxycodone (Oxycontin, Percocet)

Hydromorphone (Dilaudid)

Fentanyl (Duragesic)

Carfentanyl (Wildnyl)

History of Opiates

A long, long time ago, opiate use began with Papaver somniferum, otherwise known as the opium poppy. Native to the Mediterranean, it grew well in subtropical and tropical regions fairly easily, a fact that contributed to its historical popularity. Unripe poppy seed pods were cut, and the milky fluid that seeped from the cuts was scraped off, air-dried, and treated to produce opium. 

In case you’re wondering… today, legal growing of opium poppies for medicinal use primarily takes place in India, Turkey, and Australia. Two thousand tons of opium are produced annually, and this supplies the entire world with the raw material needed to make the medicinal components. Papaver somniferum plants grow from the very same legal and widely available poppy seeds found in today’s many seed catalogues. But, planting these seeds is less legal, with the DEA classifying them as a Schedule II drug, meaning that technically, they can press charges against anyone growing this poppy variety in their backyard. You can ask this one dude in North Carolina about it, as he was busted for having one acre of these big blooming beauties behind his house. At about 9 feet tall and topped with big red blooms, they’re not exactly inconspicuous. Another grow was discovered after an Oregon state patrol officer stopped to look at a field of beautiful “wildflowers,” wanting to cut a bouquet for his wife… a story that I personally find totally hilarious. Evidently, when he cut the first one, he was surprised by the sap that got all over his hands, so instead of taking some home to his wife, he took one to a fellow cop friend that was big on horticulture, and she enlightened him on what it was. Good thing too, because he had even thought about how cool it would be to dry the “wildflowers” to seed and plant them in his side yard! You just can’t make this stuff up.

Archaeologists have found 8,000 year-old Sumerian clay tablets that were really the earliest “prescriptions” for opium. The Sumerians called the opium poppy “Hul Gil,” meaning the “Joy Plant,” which was regularly smoked in opium dens. Around 460-357 B.C. Hippocrates, known as the “Father of Medicine” acknowledged opium’s usefulness as a narcotic, and prescribed drinking the juice of the poppy mixed with nettle seed. Alexander the Great took opium with him as he expanded his empire- it’s surprising that he was so great, because some accounts seem to suggest that he was a raging addict. Arabs, Greeks, and Romans commonly used opium as a sedative, presumably for treating psychiatric disorders. In the 15th and 16th centuries, Arabic traders brought opium to the Far East. From there, opium made its way to Europe, where it was used as a panacea for every malady under the sun, from physical ailments to a wide variety of psych issues. Biblical and literary references, and opium’s use by known and respected writers, leaders, and thinkers throughout history, including Homer, Franklin, Napoleon, Coleridge, Poe, Shelly, Quincy, and many more, made opium use perfectly acceptable, even fashionable. 

19th Century Opiates to Opioids

There was a lot of unrest and violence around the globe throughout the 1800’s. Wounded soldiers from the American Civil War, British Crimean War, and the Prussian French War were basically allowed to abuse opium. And sure enough, beginning in the 1830’s, one-third of all lethal poisoning cases were due to opium and its opiate derivatives, and this really marked the first time that a “medicinal” substance was recognized as a social evil. Yet, most places around the world still really turned a blind eye to opium and opiate use. But, so many soldiers developed a dependency on opiates that the post-war addiction state was commonly known as “soldier’s disease.”

In 1806, German alkaloid chemist Friedrich Wilhelm Adam Sertürner isolated a substance from opium that he named “morphine,” after the god of dreams, Morpheus. The prevailing wisdom for creating morphine was to maintain the useful medicinal properties of opium while also reducing its addictive properties. Uh huh, sure. In the United States, morphine soon became the mainstay of doctors for treating pain, anxiety, and respiratory problems, as well as consumption and “female ailments,” 

(that’s old-timey for tuberculosis and menstrual moodiness/ cramps) In 1853, the hypodermic needle was invented, upon which point morphine began to be used in minor surgical procedures to treat neuralgia (old timey for nerve pain). The combination of morphine and hypodermic needles gave rise to the medicalization of opiates.

Well, morphine turned out to be more addictive than opium, wouldn’t ya know it. So, as with the opium before it, the morphine problem was “solved” by a novel “non-addictive” substitute. Of course… I mean, what could possibly go wrong? Your first clue is that this novel compound was the first opioid, and was called heroin. See where this is going? First manufactured in 1898 by the Bayer Pharmaceutical Company of Germany, heroin was marketed as a cough suppressant, a treatment for tuberculosis, and a remedy for morphine addiction. Well, as you can probably guess, that worked great, until heroin proved to be far more addictive than morphine ever thought of being. So what to do? Hmmm… what…to…do… I know! Let’s make a “non-addictive” substitute for the heroin! That’s the best plan, definitely. 

20th Century: Opiates to Opioids

By the dawning of the 20th century, the United States focused on ending the non-medicinal use of opium. In 1909, Congress finally passed the “Opium Exclusion Act” which barred the importation of opium for purposes of smoking. This legislation is considered by many to be the original and official start of the war on drugs in the United States. Take that, Nancy Reagan! In a similar manner, the “Harrison Narcotics Tax Act of 1914” placed a nominal tax on opiates and required physician and pharmacist registration for its distribution. Effectively, this was a de-facto prohibition of the drug, the first of its kind.

In 1916, a few years after Bayer stopped the mass production of heroin due to the dependence it created, German scientists at the University of Frankfurt developed oxycodone with the hope that it would retain the analgesic effects of morphine and heroin, but with less physical dependence. Of course they did, because this worked out so swimmingly before. What could possibly go wrong? 

Well, we know how this story turns out.

First developed in 1937 by German scientists searching for a surgical painkiller, what we know today as methadone was exported to the U.S. and given the trade name “Dolophine” in 1947. Later renamed methadone, the drug was soon being widely used as a treatment for heroin addiction. But shocker… unfortunately, it too proved to be even more addictive than its predecessor heroin. Captain Obvious says he’s sensing a trend here.  

In the 1990’s, pharmaceutical companies developed some new and especially powerful prescription opioid pain relievers. They then created some equally powerful marketing campaigns that assured the medical community that patients would not become addicted to these drugs. Gleefully, docs started writing for them, and as a result, this class of medications quickly became the most prescribed class in the United States- even exceeding antibiotics and heart medications- an astounding statistic. Well, we now know that the pharma co’s were full of crap: opioids were (and still are) the most addictive class of pharmaceuticals on the planet… and so in the late 90’s, the opioid crisis was born. 

Opioids: True and Freaky Facts

The real fact is that 20% to 30% of all patients who were/ are prescribed opioids for chronic pain will misuse them. Further, studies on heroin addicts report that 80% of them actually began their addiction by first misusing prescription opioids. That’s a big number people, but I think it’s actually higher. Food for thought for all the pill poppers out there saying ‘I’ll never use a street drug like heroin.’ And speaking of that, by the turn of the 21st century, the mortality rate of heroin addicts was estimated to be as high as twenty times greater than the rest of the population. Twenty times, people.

Opioid Addiction and Overdose

Opioids produce a sense of wellbeing or euphoria that can be addictive to some people. Opioids are often regularly and legitimately prescribed by excellent, well-meaning physicians when treating patients for severe pain. The problem is that even when taken properly, many people develop tolerance to these opioids, meaning they need more and more to get the same effect and relieve their pain. That’s just one factor that makes them so insidious. In addition, we cannot predict who will go down this tolerance and potential addiction path, because it can happen to anyone who takes opioids. However, there are some factors that make people more susceptible to addiction, such as the presence/ prevalence of mood disorder(s) and especially a genetic/ familial history of addiction, which contributes to nearly 50% of abuse cases.

When people become addicted to opioids, they begin to obsessively think about ways they can obtain more, and in some cases they engage in illegal activities, such as doctor shopping, stealing prescriptions from friends and family, and/ or procuring them on the street. 

Another insidious facet of tolerance is that the tolerance to the euphoric effect of opioids develops faster than the tolerance to the dangerous physical effects of taking them. This often leads people to accidentally overdose as they chase the high they once felt. In this attempt to get high, they take too much and overdose, dying of cardiac or respiratory arrest. Drug overdose is the leading cause of accidental death in the United States, and there are more drug overdose deaths in America every year than deaths due to guns and car accidents combined. According to the CDC, 2019 drug overdose deaths in the United States went up 4.6% from the previous year, with a total of 70,980 overdose deaths, 50,042 of which were due to opioids. 

There’s a kahuna in Opioidland that’s so big and so bad that it bears a special mention… fentanyl. Referencing the above statistics, of the more than 50,000 opioid overdoses, fentanyl is specifically indicated in more than 20,000 of those fatalities. Again, I think it’s way higher than that. Regardless, I think we can all agree that it’s deadly. Fentanyl is so crazy dangerous because it is 50 to 100 times more potent than morphine, so it takes the teeny tiniest amount to overdose. A lethal dose of fentanyl for adults is about two milligrams- that’s the equivalent of six or seven grains of salt people! 

Obvi, there are tons of chilling statistics about fentanyl, but here’s another one for you: in one-third of fentanyl overdoses, the individual died within seconds of taking it. Get this- they died so quickly that their body didn’t have enough time to even begin to metabolize the drug, so no metabolites of fentanyl were found on toxicology screens at the time of autopsy. The moment you ingest or inject any drug/ pharmaceutical, the body immediately begins to break it down into components called metabolites. After a certain period of time (which varies according to many different factors) the drug is completely metabolized by the body, so a toxicology screen will pick up those metabolites rather than the complete molecule(s) of the drug. Every drug has a known rate of metabolism, so tox tests can tell how long ago a drug was used or ingested. This data is saying that in one-third (33%) of fentanyl overdose deaths, tox screens pick up zero metabolites, because the body had no time to even begin to start the process of making them. The screens detected the presence of the full complete molecule(s), but no breakdown products. It’s a very significant and scary hallmark of fentanyl use/ abuse/ overdose: the fact that you may not live long enough to regret using it.  

How did fentanyl become such a big part of the opioid epidemic? Around 2010, docs were getting smart to the use and abuse of opioids and the ensuing crisis, and many stopped prescribing them. This left a lot of addicted people, including many who legitimately required relief from pain, unable to get prescriptions and SOL. At the same time, buying prescription drugs on the street was crazy expensive due to increased demand and decreased supply. But also, heroin had became so abundant that it suddenly became cheaper than most other drugs, so addicts started to switch to heroin. In one survey, 94% of people in treatment for opioid addiction said they used heroin only because prescription opioids became much more expensive and harder to obtain. 

Next, to make things exponentially worse, drug cartels discovered how to make fentanyl very cheaply, so huge quantities of fentanyl started flooding the market. Because fentanyl is easier to make, more powerful, and more addictive than heroin, drug dealers recognized the opportunity, and began to lace their heroin with fentanyl. People taking fentanyl-laced heroin are more likely to overdose, because they often don’t know they’re taking a much more powerful drug. Fentanyl can be manufactured in powder or liquid forms, and it can be found in many illicit drugs, including cocaine, crack, and methamphetamine. And let’s face it folks, the people making this garbage aren’t exactly rocket scientists, so all of these drugs can (and usually do) contain toxic contaminants and/ or have different levels of fentanyl in each batch, or even varying levels within the same batch. These facts just add to the lethal potential of this stuff. 

Now fentanyl has found its way onto the street in yet another form: pills. When fentanyl pills are created for the street, they’re pressed and dyed to look like oxycodone. Talk about insidious! If you go looking to buy oxy’s on the street and the dealer is selling them dirt cheap because they don’t know any better, or care is probably more accurate, you’ll probably think ‘Wow- these oxy’s are cheap! Let me get those!’ If your body is accustomed to using real oxy’s and you unknowingly take fentanyl, you will absolutely overdose. Like see ya later, bye overdose.

But believe it or not, it gets worse… A new variation of fentanyl is finding its way into the drug trade. Carfentanil is 100 times stronger than fenatanyl, which makes it 10,000 times more potent than morphine. While it was originally developed as an elephant tranquilizer (hel-looo??!!) the powdered form of carfentanil is now commonly used as a cutting agent in illicit drugs like heroin, cocaine, and methamphetamine.

Opioid Withdrawal

Opioid withdrawal can be extremely uncomfortable. But an important thing to remember is that opioid withdrawal is not generally life threatening if you are withdrawing only from opioids and not a combination of drugs. This is because each drug class is pharmacologically different, so withdrawal is different for each one. FYI, the most dangerous withdrawls are from benzodiazepines (Valium, Xanax, etc) and alcohol, even though alcohol isn’t technically a drug, it reacts, is metabolized, and physically withdraws from the body like any drug. Individually, either can be lethal in withdrawl and require medical supervision. 

Opioid Withdrawal Symptoms

Withdrawal typically includes the following symptoms to varying degrees:

Low energy

Irritability

Anxiety

Agitation

Insomnia

Runny nose

Teary eyes

Hot and cold sweats 

Goose bumps

Yawning

Muscle aches and pains

Abdominal cramping

Nausea

Vomiting

Diarrhea

Stages of Opioid Withdrawal

-The first phase (called acute withdrawal) begins about 12 hours after the last opioid use. It peaks at around 3 – 5 days, and lasts for approximately 1 – 4 weeks. This acute stage has mostly physical symptoms.

-The second phase (post-acute withdrawal) can last for a long time, with some references documenting up to two years. The symptoms during this phase are mostly emotional, and while they are considered less severe, they last longer.

Symptoms include mood swings, anxiety, variable energy, low enthusiasm, variable concentration, and disturbed sleep.

But, don’t let concern over withdrawl symptoms keep you from getting off of opioids. There are medications that can significantly decrease all of these. Two of the most common are methadone and buprenorphine. Being that drug detox is one of my specialties, in next week’s blog, I’ll outline both of these and tell you my reccommendations.

Until then…

Now that we’ve covered the history and background on opioids, if you think you might have an opioid addiction, I have a separate quiz that will bring some clarity to you on that question. I will upload a more detailed assessment as a separate blog, but for now, here’s a short generalized screen to take first. 

Do You Have an Opioid Addiction?

Answer yes or no to each of the following questions. If you answer yes to at least three of these questions, then you are likely addicted to opioids and should definitely take the detailed addiction self-assessment test which follows. I also suggest that you print the assessment and answers and take them with you for a professional evaluation.

Addiction: Basic Screen1) Has your use of opioids increased over time?2) Do you experience withdrawal symptoms when you stop using?3) Do you use more than you would like, or more than is prescribed?4) Have you experienced negative consequences to your using?5) Have you put off doing things because of your drug use?6) Do you find yourself thinking obsessively about getting or using your drug?7) Have you made unsuccessful attempts at cutting down your drug use?

Again, if you answered yes to at least three of these questions, then you are likely addicted to opioids and should take the detailed addiction self-assessment test which follows as a separate blog. Be sure to print both with you for a professional evaluation. 

I hope you enjoyed this blog and found it to be interesting and educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in office and on Amazon. 

Thank you and be well people!

MGA

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Pedophilia:Predators in Your Back Yard

*Sensitive Content*

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Pedophilia: Predators in Your Back Yard

Pedophilia has become a topic of increased interest, awareness, and concern for both the medical community and the public at large. In my nearly thirty years of practice, I am sad to say that I have treated far too many victims of pedophilia and sexual predation of every unimaginably horrific kind; those narratives are indelibly etched into my memory. In the last decade or so, increased media exposure, new sexual offender disclosure laws, web sites listing the names and addresses of convicted sexual offenders, and increased investigations of sexual acts with children have increased public awareness about pedophilia. That’s definitely a good thing. The passing of laws, like Megan’s Law in 1996, authorizes local law enforcement agencies to notify the public about convicted sex offenders living, working, or visiting their communities, and has helped expose pedophiles living amongst us, and this allows parents to better protect their children.

But in the age of the internet, cyber predators can stalk their victims from a safe distance before ever suggesting they meet. They can be very cunning, and they often lie about their age/ gender/ status/ likes/ dislikes; they play online team video games to attract children, and they make up customized stories, tailor made to lure specific victims. Because of these realities, it’s important for everyone to understand pedophilia, its rate of occurrence, and the characteristics of both pedophiles and sexually abused children. 

In recent years, the law has taken a tougher stance on dealing with pedophiles and sexual predators, and exposure is often the order of the day for the media, as these cases play out in the wide open. You need only note the allegations of sexual predation in the priesthood or in the Boy Scouts to realize that predators are everywhere, even in some unlikely places. Who can forget Jared Fogle, the smiley faced Subway spokesman who lost 200-plus pounds, supposedly by eating only sub sandwiches? Who would’ve ever guessed that he was actually a predator, targeting children of middle school age, a demographic he often found himself in the company of during his well paid and nation wide lectures about healthy eating habits. That age group was his preference, but he wasn’t discriminatory by any stretch of the imagination. He made that quite clear in the surreptitiously taped conversations he had with a “friend” who was actually working undercover for the FBI. I was physically repulsed when I heard those recordings, and even as I remember them now, I can actually taste and feel the bile rising in my throat. Ultimately, in 2015, Fogle was adjudicated as guilty of charges of child pornography and having sex with minors, and was sentenced to more than 15 years in prison. He apparently passes the time by filing frivolous lawsuits against the Feds and Donald Trump, all without the aid of his attorney. 

A name synonymous with sexual predation since the millennium, especially here in Palm Beach County, is of course Jeffrey Epstein. This multimillionaire financier dirtbag was a predator incarnate, who, over a period of at least 15 years, lured a procession of girls as young as 14 to his Palm Beach mansion to perform nude bedroom massages for money; massages that often ended with Epstein groping or sexually assaulting the girls. All told, investigators found evidence that Epstein preyed on at least 80 girls total, here and in New York. 

One of my patients, I’ll call her Dominique, was one of at least 15 girls from Royal Palm Beach High School alone, who Epstein sexually exploited in that aforementioned bedroom 15 years ago, and she will live with those memories forever. At the time, it was a not-so-well-kept secret among RPBHS students, teachers, and administrators that girls were being sexually exploited in return for gifts of cash, expensive cars, trips, and shopping sprees courtesy of their Sugar Daddy; but nobody reported their concerns to authorities at the time. Epstein masterminded an underage sexual assault scheme, paying girls $200 for each new victim they recruited, instructing them to target vulnerable girls, often on the verge of homelessness and desperately needing money, and “the younger the better.” 

Dominique drove a convertible Mercedes, courtesy of Epstein, flew in his jet to travel on trips with him to Mexico and the US Virgin Islands, and met some very famous and influential people, including a former POTUS, a ridiculously wealthy computer nerd, and one particularly slimy smarmy one that calls Britain’s monarch “Mummy.” Dominique told me that she and the other girls would skip school, hang out at his house, float around in the pool, go out on the boat, or head to Worth Ave for lunch, followed by black card shopping. The girls also drank alcohol and did drugs, made available by Epstein, of course. Consumption of alcohol and drugs is a way that predators groom their targets, to seduce them, make them more comfortable and less inhibited, and hamper their ability to resist. 

The girls traded sexual favors in exchange for all of the cash and material gifts he gave them, and Dominique said that oral sex and intercourse were just an acceptable part of the deal; it was very much a simple transaction. The better the girls were, the more they pleased him, the more money and gifts he would give them. It was a calculated and infinitely alluring arrangement, all by Epstein’s diabolical design, and before she knew it, Dominique was in over her head, but yet unable to cut ties. Thankfully, the law intervened and cut those ties for her, for once and for all. Now she’s moving on with her life and looking forward to the future, all while still dealing with the extreme damage done in the past.

When any of his girls became nervous or ever questioned activities, Epstein had a remedy for those circumstances as well. He used his “assistant” Ghislaine Maxwell as a beard to make the girls feel more comfortable; sort of an older sister vibe, a figure for them to look up to and emulate. She played a key role in the scheme, and she’s currently awaiting trial on sex trafficking charges and who knows what else. In his first two charges here in Palm Beach County (soliciting a minor for prostitution and procuring minors for prostitution) Epstein made a sweetheart deal with the Florida DA’s office, spending 13 months (of an 18 month sentence) in a private wing of the Palm Beach County Jail on Gun Club Road, but he was still allowed to go to “work” on Palm Beach Island six days a week for twelve hours each day. I consider that incomprehensible. Then after he served his tiny time here, he was facing more charges in New York for sex trafficking of girls as young as 14 and conspiracy to commit sex trafficking. Apparently, the Feds also had a lot more charges up their sleeves, and were investigating every single thing in his life. At his arraignment in New York, Epstein pleaded not guilty to all charges. If convicted, he would have faced up to 45 years in prison. But, evidently, he couldn’t take the heat. He was found hanging in his cell by the guard that may have been too busy sleeping to guard him. The coroner’s manner of death was listed as suicide, but his family and other conspiracy theorists say he was murdered. Either way, he’s gone, as is the opportunity for his victims to face him in open court and tell their truths. 

Below, I define pedophilia and associated terms, and discuss a generalized profile of a typical pedophile or sexual predator, and go over what you can do to protect children from such predators. 

Pedophile, Hebephile, Ephebophile, Predator, or Child Molester?

I want to clarify some terms related to pedophilia. A pedophile is a person who is primarily attracted to prepubescent children, usually defined as under the age of 12. A common mistake is to define a pedophile as anyone attracted to another person that is below the age of majority; but this definition would include people attracted to teens, which is incorrect. Even a late adolescent (like 15 or 16 years old) can be a pedophile, if they have sexual interest in prepubescent children. A hebephile is a person who is primarily attracted to others in their young to mid-teens, while an ephebophile is a person who is primarily attracted to others in their mid-to-late adolescence. Captain Obvious says that a child molester is anyone who molests a child, but without regard to their sexual attractions or preferences. Their act of molestation is not typically linked to sexual desire or interest. In the interest of time for this blog, I will not divide or differentiate the term predator into hebephile or ephebophile, and the terms pedophile, predator, and molester will be used interchangeably.  

Pedophilia is a psychiatric disorder in which an adult or an older adolescent is sexually attracted to young children. Pedophiles can be anyone: rich or poor, young or old, of any race/ creed/ color, educated or not, and professional or not. Despite this wide array of potentially inclusive characteristics, pedophiles do often demonstrate similar attributes. Please note that these are just possible indicators, and you should never automatically assume that individuals with these indicators or characteristics are pedophiles. But noticing these characteristics in a person, in combination with questionable behavior, could be a red flag that someone may be a pedophile or sexual predator.

All parents want to protect their children from predators, but how do you do that when you don’t know how to spot one? Anyone can be a pedophile/ predator/ child molester, so identifying one can be difficult, especially because most of them are initially trusted by the children they abuse. Below, I’ll go over which behaviors and traits are red flags, what situations to avoid, and how to deter predators from targeting your child.

Understand that there is no one physical characteristic, appearance, profession, or personality type that all child predators share. They may appear to be charming, loving, and totally good-natured, while also adept at harboring predatory thoughts. That means that you can’t just dismiss out of hand the idea that someone you know could be a child predator. Anyone can turn out to be a pedophile or predator.

Most pedophiles are known to the children they abuse. Thirty percent of children who have been sexually abused were abused by a family member; that can include mother, father, grandmother, grandfather, aunts, uncles, cousins, stepparents, and so on. Sixty percent of children who have been sexually abused were abused by an adult that they knew, but who was not a family member. That means that only ten percent of sexually abused children were targeted by a total stranger. In most cases, the child predator turns out to be someone known to the child through school or some other common everyday activity, such as a neighbor, teacher, coach, clergy member, tutor, music instructor, or babysitter.

Traits of Pedophiles or Sexual Predators

-Majority are men over 30 years of age, regardless if victims are male or female

-Heterosexual and homosexual men are equally likely to be child molesters

-Notion that homosexual men are more likely to be child molesters is completely false

-Female child predators are more likely to abuse boys than girls

-Often single and/ or with few friends 

-Some have mental illness, such as a mood or personality disorder

-Many have a history of physical and/ or sexual abuse in their own past

Behaviors of Pedophiles or Sexual Predators

-Display more interest in children than adults -May have a job or volunteer in a position allowing them unsupervised access to a child 

-Will contrive other ways to spend time with children (act as helpful neighbor or coach)

-Tend to talk about or treat children as though they are adults 

-May refer to a child as they would refer to an adult friend or lover

-Often say they love all children or feel as though they are still children

-May prefer children nearing puberty who are curious about sex but sexually inexperienced

-Common for the pedophile to be developing a long list of potential victims at any one time

-Many believe their proclivities aren’t wrong: it’s healthy for the child to have sex with them

-Almost all pedophiles have a pornography collection, which they protect at all costs

-Many predators also collect “souvenirs” from their victims, which are also very cherished 

Other Noteworthy Characteristics

Look for signs of grooming. The term “grooming” refers to the process that the child predator undertakes in order to gain a child’s trust, and sometimes the parents’ trust as well. Over the course of months, or even years, a pedophile will become an increasingly trusted friend of the family; they will likely offer to babysit, take the child shopping or on trips, or spend time with the child in any number of ways. Many child predators won’t actually begin abusing a child until full trust has been gained; this exhibition of patience and restraint is unnerving in the grand scheme of things. 

Child predators look for children who are most vulnerable to their tactics, whether they are shy, withdrawn, handicapped, lacking emotional support, come from a broken, dysfunctional, and/ or underprivileged home, come from a single parent home lacking supervision, or just aren’t getting enough attention at home. Pedophiles work to master their manipulative skills and unleash them on these vulnerable children by first becoming their friend; this quickly builds the child’s sense of self-esteem and brings them closer to the predator. The pedophile may refer to the child as special or mature, which appeals to their need to be heard and understood. They basically strive to give the child whatever is lacking in their home. This sounds altruistic, but in reality, it’s just another empty ploy, used by the predator to distance the victim from their family and draw them nearer to them. Often, the next step is to entice them with adult activities, like looking at sexually explicit pictures and magazines and watching x-rated movies. 

Pedophiles and predators don’t only need to earn the trust of their mark; they must also work very hard to convince parents that they are a nice, responsible person and capable of supervising their child or children in their absence. They may make it seem like they’re doing the parent(s) a favor by watching them or taking them out, “Oh, I don’t mind taking little Johnny to get an ice cream cone and then to the park, that way you can just relax and put your feet up for awhile.” This is how a child predator manipulates parents, instills a false sense of security, and gains their trust. Pedophiles will foster a close relationship, and even forge a friendship, with the parent(s) of a mark in order to get close to that child. That friendship with the parent(s) is just the ticket to get the predator through that front door. Once inside the home, they have many opportunities to manipulate the children and use guilt, fear, and love to confuse them. If the child’s parent(s) works, they may offer after school babysitting or tutoring, and this gives them the private time needed to abuse the child.

Pedophiles often refer to children in angelic terms; they use descriptive words like innocent, heavenly, divine, angel, pure, and other words that may describe children, but seem inappropriate and/ or exaggerated. They may also fixate on a specific feature on a child’s face or body, and talk incessantly about it, making unusual and age inappropriate comments like, “Oh, that baby girl has the prettiest lips I’ve ever seen, they look so soft, and they’re the perfect shade of pink,” or “Wow…she’s going to be really hot when she grows up and fills out,” or “I’ll bet she’s going to grow up to be a real tease, ya know what I mean?” These are examples of how pedophiles and predators sexually objectify children, by speaking to or about them in a way that is not age appropriate and is not acceptable. 

A pedophile will often use a range of games, tricks, and activities to gain the trust of and/ or deceive a child. One of the predator’s main goals is to make sure the child won’t tell anyone about the inappropriate contact. What they do or say to ensure this silence depends on the age of the victim. For younger children, they may suggest a pact of secrecy; secrets are valuable to most kids, because they’re seen as something very “grown up” or “adult” and a source of power as well. For older children, the predator may threaten their victim, warning them that nobody would believe them if they told, and that people would make fun of them, and that they would lose all their friends if they told. In rare cases, the predator may even threaten bodily harm. Some predators just don’t care if the world knows what they’re doing; they feel above everyone else, like nobody and nothing can touch them, a la Jeffrey Epstein. As the relationship progresses, they incorporate some sexually explicit games and activities like tickling, fondling, kissing, and touching. The predator will behave in a sexually suggestive way, and have no issue exposing a child to pornographic material, bribing the target child, flattering them, and then worst of all, showing them affection and love. Be aware that all of these tactics are ultimately used to confuse your child and isolate them from you. 

Now that you know some general traits of pedophiles and predators as well as some behaviors to be aware of and look out for, let’s move on to protecting your child from predators.

How to Protect your Child(ren)

One of the first things you can and should do is find out if, and how many, sex offenders live in your neighborhood. There are subscription services that show you everything about the offenders and then send you updates with alerts when new sex offenders are released from jail and/ or if a registered sex offender moves near you. But, unless you need all the bells and whistles for some reason, you can always go to one of several free sites that will allow you to search a sex offender database by zip code, neighborhood, and by offender name if you suspect someone specific of being a sex offender. Here is my disclaimer: while it’s good to be aware of potential predators, realize that it is illegal to endeavor to take any kind of action against registered sex offenders.

Dru Sjodin National Sex Offender Website

https://www.nsopw.gov/

The Florida Department of Law Enforcement Sexual Offenders and Predators Search https://offender.fdle.state.fl.us/offender/sops/home.jsf

Another way to protect your child is to supervise their extracurricular activities. Being as involved as possible in your child’s life is the best way to guard against child predators. They will look for a child who is vulnerable and who isn’t getting a lot of attention from his or her parents, and they will cozy up to them, and then will do everything in their power to convince the parents that they are of no danger to their child. Show up at sporting games, practices and rehearsals, chaperone field trips and all other trips out, and spend time getting to know the adults in your child’s life. Make it obvious to everyone that you’re an involved and present parent. If for some reason you can’t be there for a trip or other outing, make sure that at least two adults you know well will be chaperoning the trip. Don’t ever leave your child alone with adults that you don’t know well. Remember that rule even goes for relatives too, as they can also pose a threat. The key here is to be as present as possible.

Set up a nanny cam if you hire a babysitter. Obviously, there will be times when you won’t be able to be present, so use other tools to make sure your child is safe. Set up hidden cameras in your home so that inappropriate activity will be detected. No matter how well you think you know someone, you always need to take precautions for your child’s safety.

Teach your child about staying safe online. Make sure your child knows that predators often pose as children or teenagers in order to lure children in. Monitor your child’s use of the internet, keeping rules in place to limit their “chat” time. Have regular discussions with your child about whom he or she is communicating with online. Be sure your child knows to never ever give out your address or phone number, or send any pictures to a person they met online; and that they must not ever meet someone in real life that they’ve only communicated online with. As a parent, you must know that children are often very sneaky and secretive about online behavior, especially when encouraged by others to keep secrets, so you’ll need to be vigilant about staying involved in your child’s online activity.

Make sure your child is feeling emotionally supported. Since children who don’t get a lot of attention are especially vulnerable to predators, make sure you are spending a lot of time with your child and that he or she feels supported. Take the time to talk to your child every day and work toward building an open, trusting relationship. Child predators will always ask, or demand, that their marks keep their secrets from their parents. Ensure that your children understand that if a person has asked them to keep a secret from you, it’s because they know what they’re doing is wrong. Express ongoing interest in all of your child’s activities, including schoolwork, extracurriculars, and hobbies; and let your child know that he or she can tell you anything, and that you’re always willing to talk.

Teach your child to recognize inappropriate touching. Many parents use the “good touch, bad touch, secret touch” method. It involves teaching your child that there are some appropriate touches, like pats on the back or high fives; there are some unwelcome or “bad’ touches, like hits or kicks; and there are also secret touches, which are touches that the child is told to keep a secret. Use this method to teach your child that two types of touches aren’t good, and if and when these touches happen, he or she should tell you immediately, even if the person touching them tells them that they can’t or shouldn’t tell. Teach your child that no one is allowed to touch him or her in private areas, and that they are not to touch anyone in their private areas. Many parents define private areas as those that would be covered by a bathing suit. Children also need to know that an adult should never ask a child to touch their own private areas or to touch anyone else’s private areas, and if someone tries to touch them or tells them to touch someone else, tell your child to say “no” and walk away. And again, reinforce the directive of telling them to come to you immediately if someone touches them the wrong way.

Recognize when something is out of sync with your child. If you notice that your child is acting differently for no obvious reason, pursue the issue to find out what’s wrong. Regularly asking your child questions about their day, including asking whether any “good,” “bad,” or “secret” touches happened that day, will help open the lines of communication and create an important daily dialog. If your child tells you that he or she was touched inappropriately or doesn’t trust an adult, never summarily dismiss it. Always trust your child first. Along those same lines, never dismiss a child’s claims just because the adult in question is a valued member of society or appears incapable of such things. That’s exactly what a predator or pedophile wants, it’s their stock in trade. They’re counting on adults not listening to child victims so that they can continue to get away with molesting them. 

By age 12, kids should already have gotten basic sex education explained by their parents, including what everything is called, what it does, and how it works. Parents explaining it all to their kids themselves will prevent a predatory teacher or friend from misleading them about sex for their own nefarious purposes. Make sure your child already knows everything they need to know about what’s what and what is and isn’t acceptable behavior, before they are taught very different lessons and definitions through rumor and innuendo discussed on the monkey bars or over ham and cheese sandwiches in the cafeteria. 

A child aged 14 and under may not recognize that there’s a difference between a grumpy teacher giving extra homework and a strange acting teacher that insists on kissing them on the cheek before leaving the room. They can’t really differentiate, because at this age, they simply file both of these things in their brain under ‘annoying.’ So if your child tells you vague stories about the teacher making sex jokes or touching them, or being ‘annoying’ and asking all kinds of ‘private stuff,’ you must consider the possibility that there might be something hinky going on. When and if a child mentions that their teacher is acting strangely, asking about their family and siblings, making them uncomfortable by grilling them for private information, and/ or is pushing for pictures, you must guide that child, and tell them how to react to, and deal with, these ‘annoying’ things. 

But I cannot stress enough that you must be realistic in your approach! Telling your kids to run away screaming bloody murder if the teacher touches their back, or telling them to yell ‘no!!’ and smack the teacher’s hand away if an innocent touch grazes a shoulder as the teacher walks down the rows of desks in the classroom. Those reactions will not help the situation for several reasons. First of all, chances are that they won’t hit a teacher under any circumstances, but they surely won’t do so if that teacher is actually and truly grooming them, all while filling their head with smooth assurances that they’re a good guy, on their side, and only there to help them. 

So, what’s a parent to do if they suspect something’s hinky, but have no concrete proof? If the child is age 14 and under, there are a couple of possibilities to consider. The first one is to instruct the child that if this person touches them, or asks questions or makes suggestions that makes them feel uncomfortable, that they should tell this person that they have told their parents about this issue (of inappropriate touching or making them uncomfortable with questions or whatever the case may be) and that their parents weren’t happy to hear about it. This would definitely take some serious chutzpah on the child’s part, but I think it would also empower them, and that’s never a bad thing. The second option would be to have the child deliver a message to the person that touches them, or asks questions and makes suggestions that makes them feel uncomfortable. One of the parents would create the message by getting a piece of paper and jotting a quick note on it; it should simply say ‘Stop touching my son/ daughter, Johnny Smith/ Jenny Smith’ or ‘Please stop asking my son/ daughter, Johnny Smith/ Jenny Smith so many questions, as they make him/ her very uncomfortable’ or whatever the issue may be. Then finish the note with the date and the parent’s autograph. Then the parent can put the signed note in an envelope and give it to their child, and instruct them that they are to give the envelope to the person who is touching them inappropriately, at the time they are touching them inappropriately, despite being asked to stop; or give the envelope to the person who is asking them questions and making suggestions that make them uncomfortable, at the time they are making them uncomfortable, despite being asked to stop. It is important to make sure the child gives the note to this person when they are red handedly doing what they have asked them to stop doing. This can be a very tricky situation, so make sure to give this a lot of thought. Keep in mind that employing one of these two tactics will only have a positive effect if you are absolutely sure that this person is ignoring a child’s personal boundaries and going too far with touching inappropriately or asking questions and making suggestions that make the child uncomfortable, all despite being asked to stop. You must be sure that this is a deliberate act of a magnitude that is unacceptable. One impulsive hand on the shoulder doesn’t meet the criteria to qualify here. 

Remember that the most important thing you can do to protect your child is to pay attention to them and really listen when they speak. Keep the lines of communication open, let them know you’re on their side, assess their needs and desires, talk to them, and basically, just be the best parent you can possibly be. The bottom line is that if you don’t pay attention to your child, someone else will.

These days, it seems like pedophiles and predators really have the odds stacked in their favor; they get away too easily due to lack of evidence, and even when they are caught and jailed, they get out early for good behavior. One factor that works against the pedophile is that eventually, the children they molested will grow up and recall the events that occurred, and hopefully they will report them. Often, pedophiles and predators are not brought to justice until such time occurs, and even then, they get off far too lightly. That makes victims even angrier, as they feel like they are victimized twice- first by the predator, and then again by the justice system. More than anything, victims of pedophiles and sexual predators want to protect other children from the same fate that befell them. 

Don’t forget to check out my YouTube channel for tons of interesting lectures, and be sure to hit that subscribe button. If you liked this blog and found it insightful, please pass it along to family and friends, especially if they care for children. And as always, my book, Tales from the Couch has lots of patient stories and great information; you can find it on Amazon.com.

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10 Secrets to Sleeping Better

10 Secrets to sleeping Better

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​1.) Get on a schedule and go to bed at the same time every night. Do the same thing before bed every night.

2.) Sleep in a dark, quiet and cool room.

3.) Sleep on your back with a pillow under your feet.

4.) No eating or drinking 2 hours before bedtime.

5.) No caffeine 14 hours before bedtime. No alcohol or nicotine 4 hours before bedtime.

6.) No sugar 2 hours before bedtime.

7.) No blue light from computer, I pad screens 1 hour before bedtime, no bright light of any kind 1hour before bedtime.

8.) Calm your mind before sleep.

9.) Get enough Vitamin D3, Vitamin E, Magnesium, Iron,  B complex vitamins and calcium.

 10.)      Valerian root, Chamomile, L-Theanine and Lavender ​help you sleep.

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How To Determine If Someone Is Suicidal

A Coronavirus PSA

Before we get to this next blog on suicide, I must say something related to Coronavirus transmission, because I’m tired of yelling it at my television when I see people doing it or talking about it, how “safe” it is. What is it? It’s “elbow love,” bumping elbows with someone to say hello, goodbye, good job, whassup, whatever. Think about this, people: during this viral outbreak, what have we been asking people to do when they sneeze or cough? Ideally, to do so in a tissue, but that’s not realistic, it rarely happens, so we ask them to sneeze or cough into their bent arm, at the elbow. Get the picture? The droplets they expell during that sneeze or cough are deposited everywhere surrounding that area, including the part you bump, so if your “bumpee” has Coronavirus, even if they have no symptoms, you, the “bumper” get those bijillions of virions on your elbow, and you can take them home with you. Then maybe your spouse or partner welcomes you home by putting their hands on your arms to give you a kiss… and now half a bijillion virions may be on one of their hands, just waiting to be deposited everywhere. Bottom line: for as long as this virus is around, use your words, not your body, to say whassup. So pass this knowledge on…not the virus. 

Suicide Assessment

Suicide is always a very difficult topic for every family, and in thirty years as a psychiatrist, it’s never gotten much easier to broach this subject. What motivated me to write this blog is a recent conversation I had with the father of one of my young patients, a fourteen-year-old named Collin, who in fact had just made what I believed was a half-hearted suicide attempt; the proverbial ‘cry for help.’ Understand that half-hearted does not mean it’s totally safe to blow it off, but we’ll get to an explanation about that later. His father, Lawrence, who prefers to be called Law, was a single parent, a widower after metastatic melanoma devastated the family of three about eighteen months before. Shortly after the mother, Sharon, passed away, Law brought Collin to my office. It was clear from the first appointment that Collin was depressed, and had been for some time. Psychotherapy was difficult with him, and it took about five appointments to establish more than a tenuous relationship and for him to begin to open up to me. I had tried him on a couple of medications, but they never seemed to do the job. I strongly suspected that it was due to a compliance issue. Actually, I’m certain that it was. He just didn’t take them regularly or as directed. That always mystifies me, patients who are miserable, anxious and depressed, but they take their meds haphazardly, at best; meds that could turn their worlds around…not because they’re inconvenient, and not because of side effects, just because. So, the tenuous connection made for less than optimal psychotherapy sessions, and that, combined with the absence of appropriate meds, put Collin on a path that led here, my office, 22 hours after his attempt. I was a little shocked by his attempt, but very shocked at how effectively, how deeply, he was able to hide the monumental amount of pain that he had obviously been feeling. His father Law looked exhausted, shellshocked, and was having such difficulty talking about it for a number of reasons, but he told me that one of the main reasons was shame. He was ashamed that Collin was so ill, and even ashamed that he was ashamed of it. He was ashamed that he could do nothing to help him, and ashamed that he had possibly caused or contributed to his son’s illness. I told him repeatedly and in several different ways that I understood, that his feelings weren’t unusual among parents of children like Collin, that he absolutely was helping him, and that while mental illness does have a familial component, he was not responsible in any way for his sons illness or attempt. Unfortunately, I don’t think he really heard a word I said. In my experience, suicidal ideation, thoughts of suicide, suicide attempts, and the actual act of suicide affects everyone it touches in a way that no other psychiatric illness does. But in this situation, I think Law was thinking about what his life would be like if Collin tried again and succeeded. It would be very sad, alone, and lonely.

Facts and Figures

Suicide is the 10^th leading cause of death in the United States, claiming 47,173 lives in 2019. Montana and Alaska have the highest suicide rates, which is interesting because both of those states have very high gun ownership rates. Believe it or not, New Jersey is the lowest. I have no clue why that would be the case. There were 1.4 million suicide attempts last year in the US. Men are 3.54 times more likely than women to commit suicide.  Of all the suicides in the United States last year, 69.67% were white men; they don’t seem to be doing so well. The most common way to commit suicide is by firearm, at about 50%; suffocation is 27.7%, poisoning is 13.9%, and other would be the rest, things like jumping from a tall building or bridge, laying on train tracks or jumping in front of a subway car or a bus. Among US citizens, depression affects 20 to 25% of the population, so at any given point, 20% of the population is a bit more prone to suicide, as obvi people must first be depressed (chronically or acutely) before attempting suicide. There are 24 suicide attempts for every 1 completed suicide. The most disturbing statistic is that suicide rates are up 30% in the past 16 years, with a marked increase in adolescent suicides, and suicide is now the second leading cause of death in people ages 10 to 24.

You would think the US would have the highest suicide rates in the world, but in fact, Russia, China, and Japan are all higher. 

Suicide Risk Factors

What are some factors that may put someone at higher risk of suicide?

–  Family history of completed suicide in first-degree relatives

–  Adverse childhood experiences, ie parental loss, emotional/ physical/ sexual abuse

–  Negative life situations, ie loss of a business, financial issues, job loss

–  Psychosocial stressors, ie death of loved one, separation, divorce, or breakup of relationship, isolation

–  Acute and chronic health issues, illness and/ or incapacity, ie stroke, paralysis, mental illness, diagnoses of conditions like HIV or cancer, chronic pain syndromes

But, understand there’s no rule that someone must have one or more of these factors in order to be suicidal.

Mental Illness and Suicidality

In order to make a thorough suicide risk assessment, mental illness must be considered. There seem to be 6 mental health diagnoses that people who successfully complete suicide have in common: 

–  Depression

–  Bipolar disorder

–  Mania

–  Schizoaffective disorder 

–  Schizophrenia

–  Post-traumatic stress disorder

–  Substance abuse 

Suicidal Ideation

Suicidal ideation refers to the thoughts that a person may have about suicide, or committing suicide. Suicidal ideation must be assessed when it is expressed, as it plays an important role in developing a complete suicide risk assessment. Assessing suicidal ideation includes:

– Determining the extent of the person’s preoccupation with thoughts of suicide, ie continuous? Intermittent? If so, how often?

– Specific plans; if they exist or not; if yes, how detailed or thought out?

– Person’s reason(s) or motivation(s) to attempt suicide

Assessment of Suicide Risk
Assessing suicide risk includes the full examination/ assessment of:

–  The degree of planning 

–  The potential or perceived lethality of the specific suicide method being considered, ie gun versus overdose versus hanging

–  Whether the person has access to the means to carry out the suicide plan, ie a gun, the pills, rope

–  Access to the place to commit

–  Note: presence, timing, content

–  Person’s reason(s) to commit suicide; motivated only by wish to die; highly varied; ie overwhelming emotions, deep philosophical belief

–  Person’s motivation(s) to commit suicide; not motivated only by wish to die; motivated to end suffering, ie from physical pain, terminal illness

–  Person’s motivation(s) to live, not commit suicide

What is a Suicide Plan?

A suicide plan may be written or kept in someone’s head; it generally includes the following elements: 

–  Timing of the suicide event

–  Access to the method and setting of suicide event

–  Actions taken toward carrying out the plan, ie obtaining gun, poison, rope; seeking/ choosing/ inspecting a setting; rehearsing the plan 

The more detailed and specific the suicide plan, the greater the level of risk. The presence of a suicide note suggests more premeditation and typically greater suicidal intent, so an assessment would definitely include an exploration of the timing and content of any suicide note, as well as a thorough discussion of its meaning with its author.

I spent years teaching suicide assessment to other physicians, medical students, nurses, therapists, you name it. It all seems super complicated when you look at all the above factors written out, but as I always taught, it becomes clearer when you put it into practice. What are we doing when we embark on a suicide assessment? We’re determining suicidality, the likelihood that someone will committ suicide. You’re deciding how dangerous someone is to themselves using the factors discussed above. You’re either looking at how lethal they could be, how lethal they are at this time, or how lethal they wereduring a previous episode of suicidal ideation or previous suicide attempt. 

When we put this all into practice, we look at statements and actions to determine how dangerous a person is. Did someone say, ‘if so and so does this, I’ll kill myself’ or, did someone act but just scratched their wrist? Those would be low level lethality, and they would not be very dangerous. Did someone buy a gun, load the ammunition, learn how to shoot it, go to the place where they planned to kill themselves at the time they planned, and then practice putting the gun to their head…essesntially a dry run? That would be the most lethal; that person would be the most dangerous. Those are the two poles of lethality and danger, but there are variant degrees and many shades of gray, so you really have to discuss it very thoroughly with each individual. 

Let’s say a 15-year-old is in the office after taking a big handful of pills in a suicide attempt. I ask him if he realized that taking those pills could have actually killed him, and he says no. He’s not that lethal, not that dangerous, because even though his means (pill overdose) was lethal, he didn’t know it was, so lacking that knowledge mitigates the risk, making him less dangerous. Example: acetominophen is actually extremely lethal. People who truly overdose on it don’t die immediately, but it shuts down the liver, killing them two days later. A person that takes a bunch of it thinking it’s a harmless over the counter drug is not that dangerous, because even though their method was lethal, they didn’t know it. In a similar manner, I’ve had people mix benzos with alcohol, which is another very lethal method. It’s a very successful way to kill yourself, but a lot of people don’t realize it, so it’s not that lethal to them. In the reverse case, people who know about combining alcohol and benzodiazepines, who know how dangerous it is, are dangerous, highly lethal to themselves. 

People who play with guns, like Russian Roulette-type stuff; or people who intentionally try asphyxiating or suffocating themselves, as for sexual pleasure; or people who tie a rope to a rafter and then test their weight…these people are very dangerous, very lethal, very scary to psychiatrists.   

Where someone attempts suicide is also very telling, very instructive in determining their lethality, how suicidal, how dangerous they are. If they do it in a place where there is no chance of being found, of being interrupted, they are very suicidal, very dangerous. Contrast that to doing it in a place where there are people walking by, or in a house where someone is, or could be coming home, then they are not as suicidal, not as dangerous. As an exaple, let’s say someone leaves their car running in a garage when they know that no one will be around for 2 days. That is very dangerous, they are very suicidal. If someone takes an opiate overdose at night when everyone’s in bed so they won’t find them for many hours, they are dangerous. If someone takes the overdose during the day, when people are awake at home, they are less dangerous. 

A change in somone’s behaviors and/ or outlook can also help determine lethality. When people start giving away their possessions, that is a sign that they are very lethal, very dangerous. Another factor that can be informative is if an unnatural calm comes over them, and they say that they have no more problems, and everything is great. That is an indicator of serious lethality, major danger. These people have a sense of ease because they know that they’ll be dead very soon, and they don’t have to worry about things anymore. These are ominous signs.

Giving information about an attempt also informs a person’s level of lethality. If someone makes a statement of intent to commit suicide, they are not very dangerous. For example, a spouse saying ‘if you leave me, I’ll kill myself’ or ‘you broke my heart, I can’t live without you, I’m going to kill myself’ those statements alone do not indicate a very dangerous person. Not telling anyone and hiding when they plan to attempt is much more dangerous. There are many cases when people don’t come out and tell, but they aren’t being very secretive, intentionally or not, possibly even subconsciously. They leave clues, almost giving people a road map. This is very common, and these people are typically discovered. The discovery can either totally abort the act before it’s attempted, or can abort after the attempt, but in enough time to get the person help. This is why for every 1 “successfully” completed suicide, there are 24 failed suicide attempts. Similarly, someone who says ‘if this thing (interview, event) goes my way, I’ll be good, but if it doesn’t, I swear I’ll kill myself’ is not that dangerous, not very suicidal, because they’re bargaining, which means they’re still living in the real world. But, someone who does not want to negotiate, doesn’t care to affect things one way or another, may not be living in the real world, and they’re dangerous, they may be high risk to enter the world of the dead.  

There are a couple other things to be considered in assessing risk of suicide, determining how dangerous someone might be. If someone is impaired, using drugs and/ or alcohol when they attempt or consider suicide, and if they are not suicidal when they’re clean and sober, they are generally not that suicidal, not that dangerous, they just have a drug or alcohol problem. When they get clean and sober for good, the risk is essentially zero, barring anything else. In a similar way, if someone is suffering from a mental illness when they attempt or consider suicide, but when you correct that mental illness they are not suicidal, they are not a huge danger. 

So during suicide risk assessment, you can be looking at someone having a nebulous thought and/ or making a statement that a lot of people may have or make, and you know that they’re not very dangerous; or looking all the way to the opposite side, someone who thinks about it, formulates a thorough plan, picks the place and time, aquires all the things needed to commit the act, writes a suicide letter, and practices the complete act soup to nuts, and you know that they are very, very dangerous. And all the shades in between. 

So that’s my primer on suicidal thinking and assessing suicide risk. There are lots of factors to keep in mind, and sometimes it’s a little like reading minds, but you get more proficient as the years go by…it’s easier to tell when someone is misleading or being honest and open. If you enjoy a humorous approach to character studies in all sorts of diagnoses, you would enjoy my book, Tales from the Couch, available on Amazon. I mean, most of you are isolating, sheltering in place anyway, right? Might as well entertain yourself! Check it out. – Dr. Mark Agresti

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In Isolation…Now what

You’re in Isolation… Now What?

I regret that I even have to make this blog. The situation we find ourselves in is so surreal, but here we are, so we have to rock and roll with it. Covid-19 is a respiratory virus, a particularly nasty one. In recent years, scientists have tried to prepare for a long-feared hypothetical pathogenic disaster they called Disease X, and defined it as: any unknown disease that springs suddenly into our species and races ruinously through it. Covid-19 is the first Disease X to arise since the terminology was coined, but it certainly won’t be the last. The climate is warming, we’re hacking down forests, our population is expanding faster than the earth can keep up with, and our skills at waging biological warfare are expanding and improving. The odds that we’ll keep encountering more and more Disease X’s are increasing. We will need all the vaccines we can make for this, and future, Disease X’s. Right now, there are at least 40 research groups around the globe working on Covid-19, and there are 43 Covid-19 vaccines in various stages of development around the world. One potential vaccine has just started a small human trial. While it sounds promising, with Covid-19, both the viral contagion itself and the vaccine type (using novel DNA/ RNA tech) are so new that there’s no telling what human trials will reveal, or how long they will take. Most of the scientists researching Covid-19 say that we’ll be lucky to have a vaccine for human use within 12 – 18 months.    

Yes, we’re in a pretty precarious state, but there are ways to make it less uncomfortable, less disturbing. An ounce of prevention is worth a pound of cure. The best defense is a good offense. These cliches were not popularized by accident, they’re true. In the case of Covid-19, the best preventative measure and the best offense is…stay home! It may not be fun and it may not be easy, but if there’s any possible way to stay home, do so. The only thing worse than isolating to prevent contracting the virus is to be quarantined withthe virus! I want to talk about some things you can and should do to maintain your sanity while waiting Covid-19 out. For general information, I’ve found that Unicef has great intel broken down into manageable units. They detail handwashing, using hand sanitizer, and behavioral ways to help stop the spread of Covid-19. You can navigate through the entire site from:

https://www.unicef.org/coronavirus/everything-you-need-know-about-washing-your-hands-protect-against-coronavirus-Covid-19

After talking with so many patients about Covid-19, listening to their fears and anxiety, I’ve come up with 10 things you should pay attention to while you’re isolating or you’re in quarantine.  

1. Consider anyone who is living with you in isolation, under quarantine, or simply in your shelter, as family. Everyone must function as a family, ie as a group, a “covid family” if you will. A few weeks ago, our world changed forever, and you must work together and be in it for the long haul, because we don’t know how long this is going to last. Make a decision to be good to each other, to respect each other. You must get along, because now we have an enemy that is far greater than us. It is a virus, not a natural disaster like a hurricane, flood, tornado, or fire, nothing that we are accustomed to dealing with. It is not a war, but make no mistake…we are under attack. So you need to treat the people in your “covid family” the way that you want to be treated. Talk to each other (no yelling or demeaning language) in a positive manner; this won’t always be easy, because the uncertainties linked to this pandemic will cause stress, which generally leads to shorter fuses. Decisions have to be made in a thoughtful way; if you have several people in your “covid family,” that may mean voting on important issues. Whatever you do, make every effort to keep the peace in your “covid family.”

2. Hygeine is everything when it comes to transmissible disease, andeveryone living in the house must participate in it. Wash your hands often, and just as important, wash them properly! I’ll discuss ‘the how’ below. First, let’s talk about ‘the when’. Your mama taught you to wash after using the toilet, before and after eating, after changing diapers or helping children use the toilet, after touching animals and pets, after touching garbage, and whenever they are obviously dirty. Those rules still apply of course, but with Covid-19, we’ve stepped it up a bit to include a few more “after’s”:

– After coughing, sneezing, and blowing your nose
– After visiting public spaces/ places: public transportation, markets, banks, drive-thrus, and places of worship
– After touching any of the surfaces outside of the home, including money, ATM machines, credit/debit checkout machines and stylus pens
– Before, during and after caring for a sick person, regardless of their Covid-19status
Those are minimum hand washing requirements. I suggest you wash at least every 1 – 2 hours, even if you haven’t done any of the above things. Ritualize your hand washing, especially if anyone in your “covid family” is high risk and/ or still venturing out of the home. If you touch the doorknob, wash your hands. If you touch a faucet, wash your hands, stove, wash. You get the idea. In this situation, there’s really no such thing as washing too much; you cannot be too careful, because this virus does live on surfaces for an extended period of time. FYI, that includes Amazon boxes. One of my very high risk patients actually “quarantines” her deliveries for five days and then opens the boxes with gloves on. Overkill? Hard to say. We all have to gauge our personal risk level and then behave accordingly.

As promised, here is ‘the how’ of proper handwashing. There are five simple steps to proper handwashing:

 1: Wet hands with running water (water temperature doesn’t matter)

 2: Apply soap liberally- don’t skimp- use enough to thoroughly cover your hands.
 3: Scrub all over the hands for 20 – 30 seconds with lots of sudsy lather: every surface, back and front of hands, between all fingers and under fingernails. Pretend you’re a surgeon. We’ve all seen surgeon’s scrubbing in. Do that vigorous, thorough scrubbing for 20 – 30 seconds. And yes, sing the ‘Happy Birthday’ song twice to ensure you wash for 20 seconds minimum…it’s so easy to stop early if you don’t sing, because 20 seconds is a fair chunk of time. Don’t short yourself! 

 4: Rinse well under running water

 5: Dry with a paper towel or clean cloth. 

IF YOU’RE OUT OR WHERE THERE’S NO SOAP OR RUNNING WATER, USE HAND SANITIZER. Use it basically the way you would soap. Put a generous amount into the palm of one hand and rub briskly but thoroughly all over both hands: front, back, between fingers, and under nails. If necessary, use another dose of it to act as a sort of rinse, especially if your hands have contacted multiple surfaces. 

Some other hygeine tips:

– Do not touch your face.  

– Make hand sanitizer and tissues like the American Express card…don’t leave home without it.

– Sneeze into a tissue. Some say it’s okay to sneeze into the crook of your elbow, but only as a last resort if you don’t have a tissue; your best bet is to keep a tissue handy. 

– If you must leave your home, limit outings to once a day.

– If you do leave your house, when you come back home, go straight to the bathroom and bathe before you interact with the house. Then use pre-moistened antibacterial cleansing cloths or a bleach solution to clean everything you touched on the way in. 

3. Do everything you can to boost your immune system, especially if you are higher risk. Take vitamins, 50 mg Zinc Gluconate per day, 1000 international units of Vitamin D3 per day, and 1000mg Vitamin C each day. If Vitamin C upsets your stomach, look for liposomal Vitamin C, because it is better digested.  

4. Take care of yourself. I’m embarassed to say that I have a friend from Pennsylvania who found ridiculously cheap plane tickets to Florida, $28 round trip, for he and his wife to take a quick trip about a month ago, just before travel was prohibited. Guess who got sick with coronavirus? Both of them! Guess where they are now? Quarantine! I mean, duh! File that under “Don’t be a moron!” I can’t believe I’m friends with someone that stupid. Anyway, back to taking care of yourself. This isn’t rocket science. 

– Eat healthy, limit bad things. You’re likely to have more time on your hands; don’t spend it drinking more alcohol, smoking more cigarettes or more weed, or eating your way through the pandemic. Fresh fruits and vegetables are the best, but you may not have access to them, so frozen fruit and veg are better than no fruit and veg. Every restaurant has delivery now, but try to not give in and order carb, fat, sugar crap delivery. Eating healthy also helps boost your immune system. Google “foods that boost the immune system” and see what you like and what you can get your hands on.    Blueberries, raspberries, nuts, eggs, leafy vegetables, lean meat, fish. 

– You must exercise every day. Obviously you should not visit a gym or use community gym equipment, but it’s fine if you own it and it’s inside your home. If you share gym equipment with your “covid family” be sure to clean it between uses and wash your hands thoroughly after using it. If you don’t use equipment, go for a walk or bike ride. Look On-Demand or YouTube for workout videos to do at home. Move your body everyday. 

– Keep to your regular work day sleep-wake schedule. Go to bed at a certain time, get up at certain time. Sleep deprivation and/ or exhaustion compromises your immune system, so it compromises you.  

– Get dressed. If you dress like a bum, you’re more likely to feel like a bum. Try for the sake of the people that may be in your “covid family”. Don’t wear your pajamas all day, get dressed and look a human being please. Shower, shave, brush your teeth, wash your face, yada yada. Fine, if you’re working from home and want to wear sweats for a day or two, that’s fine, but doing it every day for a long period of time tends to  undermine the sense of self-esteem and degrade the community around you, aka your “covid family” 

– Learn to relax. These are trying times. Do things to help deal with anxiety. Try aromatherapy, music, gardening, yoga, meditation. Google meditation videos, and look on YouTube as well and give it a try. For some people, a pet is the best anxiolytic in the world; think about getting a fish or a little mammal. If that’s not for you, try getting a little plant to take care of, just something you can nurture. It helps a great deal psychologically.  

– Meals become a bigger deal now, because it will probably be the most face to face interaction you’ll have, assuming you’re not going out. I suggest you schedule one big meal a day- usually dinner- and everyone pitches in. Some people prep, some cook, and some clean up. Working together is good for the mind and the soul, because it gives everyone a sense of belonging. 

5. Be frugal. If that is foreign to you, learn to stop spending. Figure it out. You must conserve all resources and manage the resources you have in the most efficient way, so you are not wasting food, goods, or money. You don’t know how long this is going to last, or the effect on the economy once it’s gone, so think before you spend a penny. 

6. Limit news exposure. You’ll go crazy watching it all day. Don’t leave the news station on as white noise either. Remember that some people, like politicians (ahem), have a secondary agenda that you can’t even begin to imagine, so you can’t really believe everything you’re hearing. Take everything with a grain of salt until you hear the same news from multiple sources who have conflicting interests. Then you can put more stock into what you’re being told.

7. How to entertain yourself or others in your “covid family”? The key here is to keep changing it up. Movies, binge watching tv shows, virtual reality systems, Gameboys, puzzles, board games, cards, reading, art. Try some hobbies you’ve never had the time to try before: planting a garden, sewing, knitting, painting, drawing, writing, tie-dye, whatever rocks your boat. You’re not going to be able to do the same thing day after day, because you’ll be bored out of your skull; remember that we’re probably looking at months before it’ll be safe to return to life, but likely a year minimum before things even start to get back to normal. Months to a year is a long time to be bored. 

8. You must maintain a high level of socialization. Use Facetime rather than just phone calls. Email or text, however you can stay in touch with people. Anyone who’s read my book, Tales from the Couch, available on Amazon (shameless plug) or reads/ watches my blogs/ vlogs, will laugh at this next bit. I suggest that you use social media, Facebook, Instagram, etc to facilitate interactions with people and get ideas from the outside world and really stay in tune with what’s going on. Normally I harp on the evils of social media, but it’s a brand new world people! Try very hard to stay in touch with friends and family during this isolated state.

9. Have structure, especially if there are kids in the house. You must establish special rules for the special circumstances we are in. If you have school-aged kids, are they “out of school?” This isn’t summer, and most schools have a curriculum for students during this time at home. So, the kids must wake up in the morning, shower, have breakfast, brush the teeth, and boom…school is in session! Make a schedule for them for every day, Monday to Friday, and stickto it religiously. I ran a school for 10 years, and I know how important this is. This isn’t punishing or being mean to the kids; kids are happier on a schedule, because they know exactly what to expect and when to expect it. The key here is to break the day up into separate topics/ sessions: reading time (or lecture, depending on age), discussion/ questions on the reading or lecture, outside activity, snack time, art, creative play time, lunch time, nap time (if applicable), puzzle time, special project time. The key to success is tailoring the subjects, activities, and the length of each session to the age of the kids. Young kids have a short attention span, so spend no more than 20 minutes on each session. Older children can usually handle 45 minutes, but adjust the time according to your child. Special projects could include maybe making homemade kites and racing them, or having a cookie day, where you make cookies and talk about the origin of ingredients and/ or their purpose in the recipe. For instance, when you add the chocolate chips, explain that chocolate actually starts as a big pod grown on a tree, called cacao (pronounced ka-kow), and google a picture of it along with how the process goes, from the pod to the chocolate chips in the cookies. As for lecture subjects, you can google lectures or ‘educational topics for ____ graders’ and find cirriculum and lesson plans. And it really is worth it for you to order stuff online to keep them entertained and learning and productive. You can even get topic or lecture ideas from everyone sitting around the dinner table. Understand that kids feel the stress of this situation too, so engaging them in positive and productive activities will take their minds off the fear and uncertainty while improving their skills and expanding their education. The bottom line is that if you don’t engage the kids, they’ll be idle and bored, a perfect prescription for the house to descend into chaotic madness.

10. Think! Think really hard before doing anything. Ask yourself, ‘Is it worth my money?’ and ‘Do I need it?’ Stop with the panic buying! Really, how much toilet paper do you actually need? Buy the things you need, but think before you do in order to conserve your resources.  Think wisely about what your family will eat, and what items will last for a long time: rice, pasta, jarred sauces, frozen fruit and veg, granola, protein bars, shelf stable milk, etc. Don’t do anything stupid like my friend in Pennsylvania did, taking a quick vacay to Florida…now he and his wife are on a Covid-19 quarantine vacay, a bummer place to be. And think how idiotic they’ll look when they have to answer friends and family’s questions on how and where they got the virus! Also, don’t panic. There’s really nothing to panic about. Prepare the best you can, take good care of yourself, be smart, and wait it out. Always keep your wits about you. 

Do you know the answer to the question ‘How long can you do this?’ I’ll tell you. The answer is… as long as we need to. Look, this will surely pass, but probably a lot like a kidney stone. That is to say, it’s going to be a long, rough ride that will involve some pain. But we’ll get through it, because we are nothing if not resilient. One day, hopefully sooner than later, we’ll have a treatment and even a vaccine for Covid-19, and eventually this virus will only exist in the perpetually frozen and hermetically sealed specimen libraries of the CDC, WHO, NIH, and whatever other acronym’d organizations keep stuff like that, filed under V– not for Virus- but for Vanquished.

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How Alcohol Kills You

How Alcohol Kills

Too much of anything, no matter how pleasurable it may be in the beginning, can lead to harmful effects. Anything that you might enjoy- eating chocolate, shopping, playing cards, even exercising- may cause harm if it is overindulged in. The negative effects or the consequences of overindulgence are well known- obesity, bankruptcy, harm to the body, etc. The same can certainly be said about alcohol. Ethyl alcohol is a highly toxic substance that can cause serious damage, both physically to the body and psychologically to the mind. An occasional drink is not the issue. But if drinking takes on a substantial role in one’s life, the effects can ultimately be devastating. You drive recklessly, you have poor coordination so you fall on your head, your inhibitions are down, so you get mouthy in a bar and get yourself stabbed or shot. 

Let’s talk numbers. Excessive drinking remains a leading cause of premature mortality nationwide. Alcoholism is a widespread problem in the US, with nearly 90,000 deaths attributed to alcohol each year, according to the Centers for Disease Control. They have established guidelines to help determine what constitutes excessive drinking.

First: A “drink” is defined as a 12-ounce beer, 8 ounces of malt liquor, 5 ounces or wine, or 1½ ounces of liquor. Remember that some cocktails contain multiple types of liquor, so they may have more than 

1½ ounces each.

Excessive drinking is considered 8 or more drinks in a week for women, and 15 or more drinks in a week for men.

Binge drinking is considered 4 or more drinks in a single occasion for women, and 5 or more drinks in a single occasion for men.

Binge drinking is the most common form of excessive alcohol consumption, and is responsible for more than 50% of the deaths from excessive drinking. Binge drinking is a major cause of alcohol poisoning, and is a pattern of heavy drinking: in males, binge drinking is the rapid consumption of five or more alcoholic drinks within two hours; in females, binge drinking is the rapid consumption of four or more alcoholic drinks within two hours. These numbers may be lower, depending on a person’s weight and body composition. An alcohol binge can occur over a period of hours or last up to several days.

Binge drinking can cause alcohol poisoning. Alcohol poisoning is a very serious- and sometimes deadly- consequence of drinking large amounts of alcohol in a short period of time. Drinking too much too quickly can affect your breathing, heart rate, body temperature, and gag reflex, and potentially lead to coma and death.

Most people can easily consume a fatal dose of alcohol before passing out. Even after losing consciousness, or after stopping drinking for the night, alcohol continues to be released from your stomach and intestines into your bloodstream, and the level of alcohol in your body continues to rise. Unlike food, which can take hours to digest, alcohol is absorbed quickly by your body- long before nutrients are. Most alcohol is processed or metabolized by your liver, and that’s why the liver is so damaged by alcohol. 

Captain Obvious says that the more you drink, especially in a short period of time, the greater your risk of alcohol poisoning. There are several ways thatbinge drinking and alcohol poisoning kill you: 

Choking: Alcohol may cause vomiting. And because it depresses your gag reflex, the risk of choking on vomit if you’ve passed out is very high. If you don’t die from that directly, you can also die from aspiration pneumonia. Aspiration pneumonia often results when you breathe in vomit, and you are not able to cough up this aspirated material, so bacteria grow in your lungs and cause an infection. Yucky! And deadly!

Stopping breathing: Accidentally inhaling vomit into your lungs can also lead to a dangerous, fatal interruption of breathing, called asphyxiation.

Severe dehydration: Vomiting can result in severe dehydration, leading to dangerously low blood pressure and fast heart rate.

Seizures: Heavy alcohol consumption can lead to seizure in multiple ways, including trauma to the head from falling or auto accident, a sudden drop in blood sugar, and even upon withdrawl from heavy drinking. 

Hypothermia: Your body temperature may drop so low that you become hypothermic, leading to cardiac arrest.

Irregular heartbeat: Alcohol poisoning can cause the heart to beat irregularly, called arrhythmia, or even stop, called cardiac arrest.

Brain damage: Heavy drinking may cause irreversible brain damage. This can happen intrinsically or as a result of head trauma from falling or car accident, etc. 

Death: Any of the issues above can lead to death.

If right now you’re thinking you’re safe because you don’t binge drink, think again. If you have “just a few” drinks every night, that is considered excessive consumption, so those few drinks each night are killing you, make no mistake. 

When you think about the ways alcohol kills, some obvious ways spring to mind: trauma from car accidents, trauma from falls from being drunk, and general stupidity from being drunk, such as things that happen when alcohol lowers inhibitions to the point that you pick a fight you can’t hope to win (and you don’t) or you get lost and walk drunkenly into a bad neighborhood and get yourself killed. For the lucky people that avoid a trauma-related death from alcohol, the negative effects of excessive alcohol consumption may not be apparent for some time, but at some point there will be obvious signs that alcohol is killing them.

Ways Alcohol is Kills

It is mind boggling just how destructive alcohol is to the brain and body. The signs alcohol is killing you may creep up slowly, with a symptom here or there, or hit you all at once with a liver that has stopped functioning, as happens in late stage alcoholism. 

Signs and ways alcohol kills:

Cardiac issues: Long-term heavy drinking takes a heavy toll on the heart. Signs of serious cardiac issues that could result in death include atrial fibrillation and ventricular tachycardia, two signs of heart arrhythmia, ie abnormal heart beat. Alcohol can also lead to a heart condition called alcoholic cardiomyopathy, which is when the heart muscle weakens and cannot pump enough blood to the organs. This can result in organ damage or heart failure.

Cognitive dysfunction: Alcohol use can lead to brain damage, which shows up first as a reduction in cognitive functioning and problems with memory. Alcohol use often leads to Thiamine (B1) deficiency, which leads to significant brain damage. Alcohol also destroys the   hippocampus, the part of your brain involving memory and reasoning.  You get confusion, memory loss, and muscle coordination problems. You also interfere with the body’s ability to repair and build new nerve cells, called neurogenesis; it is much less effective. So without a sober brain, without a clear memory, and without thinking clearly, you will put yourself in very dangerous situations that may end with you dying. Or maybe you have so much confusion and memory loss that you take the wrong dose of medication or the wrong medication completely? Or you have such impairment that you drive and cause an accident or drive and get lost. It happens every day. I had a long time patient named Rona. She was a severe alcoholic; I don’t even remember how many times she went to detox and/ or treatment. She tried to quit drinking so hard and so many times. Back then, my office was in West Palm. One day she had an appointment with me, and I could tell she had been drinking, but she didn’t seem wasted. I told her for the eighteenth million time that she had to quit drinking, and Rona dutifully replied that she knew. I made sure that she hadn’t driven to the office and she said she would be taking the bus home, so I let her go. The next day I got a visit from two sheriff’s detectives, and they told me that  Rona was dead, and did I think that she had been suicidal. I told them she had not been suicidal and explained my assessment and protocol for suicidal patients asked how she had died. They said that she was downtown and walked out into the street and right in front of a car. Her whole left side and head were destroyed by the hood of the car, and she was Trauma Hawk’d to the trauma center. Unfortunately, she had massive internal injuries and severe head trauma and she died about 3 hours later. Rona’s story is an example of the kind of trauma that happens when people drink. I had another patient, a 36 year old man named Jennings, that had very poor coordination from drinking, but he didn’t think so. Jennings had this false illusion that he was as capable as everyone else, if not more so, and when he drank he thought he was invincible. His wife had divorced him about a year earlier so he lived alone. He either did really well for himself or had family money. I always suspected a combination of the two. One Saturday afternoon, he was sitting on his porch, drinking of course, looking at his boat at the end of the dock. While continuing to drink, he apparently got the bright idea that he wanted to take the boat out. He went and got it down from the lift and into the water, and then stepped from the dock into the boat to crank the engine. Then he got out and walked inside to get a cooler together, and he stepped again from the dock to the boat to load it in. He then evidently got out of the boat to get something else, and once he got it, he was stepping from the dock into the boat for the third time. But then his run of luck ran out. That third time, he didn’t quite make that step from the dock into the boat, and he slipped, hit his head on the side of the boat, and slipped unconscious into the water, where he drowned. It was a sad end to his life. 

Gastrointestinal problems: Alcoholism can cause acid reflux and excess acid in the stomach, which can lead to gastritis. It also causes irritation and inflammation of the stomach lining, which can cause painful ulcers and internal bleeding. Alcohol hampers blood clotting, so the loss of blood from these can be extreme, leading to anemia and causing extreme fatigue, or worse. Excessive drinking can also lead to stomach pain that may indicate chronic cholecystitis, a very serious gallbladder condition. 

Liver disease: Alcohol is incredibly toxic to the liver. The problem with liver disease is that the signs of it may not be detected until later stages, such as when cirrhosis occurs. At that point, the eyes will appear yellow, along with other signs of jaundice. Also, one loses their appetite so there will be sudden weight loss, as well as intense itching, weakness, and fatigue, and easy bruising. Cirrhosis of the liver, which often begins as fatty liver disease, is ultimately fatal, unless a liver transplant is successful. But before you die of cirrhosis, you are prone to die of fun things like esophogeal varices. These varices are abnormally dilated veins that develop beneath the lining of the esophagus as a result of the pressure from cirrhosis. The more severe the liver disease, the more likely esophageal varices are to bleed, and alcohol further thins the lining of the esophagus, which contributes to variceal growth, but also makes the varices more likely to bleed. And to top it off, alcohol thins the blood by wrecking clotting factors. So what does that mean? Ruptured varices. Which means all of a sudden, with no warning, blood gushes deep in the throat from all directions, choking you as you breathe it in and cough it up and eventually, you die. It is a painful, bloody, and terrible death, I promise. I have had many patients with very sick livers over the years succumb to esophageal varices. 

Pancreatitis: Alcohol causes severe pancreas issues and pancreatitis. The pancreas controls blood sugar by producing natural insulin. Alcohol interrupts this process, so the pancreas doesn’t secrete the insulin. Without the pancreas secreting insulin, your blood sugar sky rockets and you get diabetic ketoacidosis. This means that you have sugar in your blood, but you cannot get it into your cells without the insulin, and that leads to a host of metabolic issues and could easily end in you dead. 

Cancer: Excessive alcohol causes inflammation of the tissues, and this inflammation predisposes you to cancer. Types of cancer associated with heavy alcohol consumption include oral, throat, esophageal and voice box cancers, colon cancer, rectal cancer, pancreatic cancer, liver cancer, and breast cancer. The symptoms that may indicate cancer vary depending on the type of cancer, but symptoms generally begin with weight loss, fatigue, and pain in some area in the body. 

Absorbtion Syndromes: Alcohol also causes absorption syndromes. A big one is B12. Alcohol prevents you from absorbing B12 in your small intestines, and that leads to all sorts of muscular, brain, and central nervous system issues, causing confusion, memory problems, and eventually death. Alcohol also prevents you from absorbing folate. Folate is a neuroprotectant, so lacking folate causes memory issues. There are also anemias associated with lacking folate. 

Poor/ Lacking Sleep: Alcohol causes sleep disturbances. It causes snoring and sleep apnea, so you don’t sleep well and have inadequate sleep. And guess what? People who do not sleep have a shortened life span and a much higher incidence of accidental death. I had a patient named Richard. I don’t know if I would label him as an alcoholic, but he did drink at night and was a heavier weekend drinker. He had a really good job driving heavy machinery on construction sites. One day, there was an accident on the site. Richard had actually fallen asleep and he somehow hit a guy working on site. The injured guy was actually a friend of Richard’s. He was injured with a compound tibial fracture and was going to be fine after surgery, but Richard was sick about it. As a matter of course, the company tested Richard and found no drugs or alcohol in his system. After he told me about it, he admitted that he had fallen asleep on the job and that’s how the accident had happened. I asked him how he slept and he said he thought okay, but je was always tired during the day. I explained how drinking can interrupt sleep and the consequences of that and that I had the cure. He was excited until I told him the cure was to quit drinking. I told him that this time, he’d “only” hurt a friend and co-worker, that next time it might be worse. He said he’d think about it and left. Three days later, he was back, asking me to detox him. Hallelujah! That was almost three years ago, and Richard is doing well. He managed to keep his job and his friendship, and he’s a much happier guy, proud to look in the mirror again. So not sleeping can kill you, or maime you…or someone you care about.

Infections: Alcohol suppresses your immune system, which predisposes you to infections. These may be viral or bacterial infections. Both can kill you, especially if you’re in a physically weakened state from excessive alcohol consumption.

In addition to physical effects and consequences of alcoholism, life-altering impairment can be caused in many other ways as well. There are psychosocial issues, and these include legal problems due to DUIs, loss of a job, divorce, custody battles, and financial problems. There are so many signs…physical, mental, and psychosocial…that alcohol is devastating a person’s life. Make no mistake- the most devastating way alcohol affects lives is to end lives. If you drink, be aware and beware…it happens in far more ways than you could ever imagine. 

For more information and stories about alcohol use and abuse, please check out my book, Tales from the Couch, available on Amazon.com.

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How Cocaine kills You

How Cocaine Kills

Cocaine is a potent, illegal stimulant that affects the body’s central nervous system. It is extracted from the green leaves of the coca plant, and people in South and Central America have chewed these leaves and used them in teas medicinally and as a mild stimulant for thousands of years. But somewhere along the line, these people learned that this humble leaf could be processed in a way that extracted and concentrated its active components to create a substance called cocaine, a white powder stimulant that is anything but mild. 

Cocaine goes by a lot of different slang terms and street names, mostly based on its appearance, effects, or drug culture: C, blow, coke, base, flake, nose candy, and snow are some examples. At the peak of its use here in the 1970’s and 1980’s, cocaine began to influence many aspects of American culture. Glamorized in songs, movies, and throughout the disco music culture, cocaine became a very popular recreational drug. It seemed everyone was using it, from celebrities to college students to suburban moms looking to turn up at the disco on Saturday night. It was so popular in the disco scene that people openly snorted it on the dance floor at Studio 54. But powder cocaine would soon take a back seat to its trashy cousin from the wrong side of the tracks: crack cocaine, or crack. Crack is an off-white crystalline rock made by cooking down powder cocaine with God knows what else for bulk, and the crack rock is then smoked in a pipe. This form of cocaine created a scourge of epidemic proportions and ruled the streets throughout the 1980’s and early 1990’s. Crack is whack and crack was king then, and it’s still around today. It’s actually named for the cracking sound the crack rock makes when it’s smoked. While it’s the same drug as powder cocaine and has the same effects, smoking crack gives a more immediate high than snorting powder cocaine. But it doesn’t last long, so to stay high, crack users have to “hit” the pipe over and over, constantly, 24/7, for hours and ultimately days on end. Crack also has street names: rock, gravel, sleet, and nuggets to name a few. And combined drugs also have street terms, like speedballs, which are a mixture of cocaine with heroin or other opiate. Every illegal drug and drug combination you can imagine has a list of street names…Cocoa Puffs, Bolivian Marching Powder, Devil’s Dandruff…Every time I think I’ve heard them all, a patient uses one that’s new to me.

So, what’s the attraction? What does cocaine do for you? Captain Obvious says… it gets you high. Cocaine creates a strong sense of exhilaration. You feel invincible, carefree, alert, and euphoric, and have seemingly endless energy. It makes you more sensitive to light, sound, and touch. It makes you feel confident, competent, and increases performance and output. For intense Type A individuals, cocaine is a requirement, on par with oxygen. These individuals want maximum performance, maximum fun, maximum sales…maximum everything. Period. And cocaine delivers. It works by increasing the  feel good neurotransmitters dopamine, serotonin, and norepinephrine by blocking their reuptake. No reuptake equals more feel good neurotransmitters equals more feeling good. To be candid, when just starting to use, and in small amounts, people can actually do fairly well using cocaine. They feel great and are more productive, and that’s how smart people get involved with it. At first, it seems there’s no down side, it’s up up up….on top of the world. But as they say, what goes up must come down. Whether you snort, smoke, shoot, or suck on it, using cocaine is a very sharp double-edged sword. I’ve seen people go six, eight months, using every day, and for a short time, for all appearances it works for them; they feel great, they’re focused, performing well. But then without warning, they’re not. They crash, their performance sinks into the abyss. They go into an impaired state, a mental fog, and their neurotransmitters betray them. They become paranoid, confused, disorganized, hopeless, and lost. 

Using cocaine even once can lead to addiction. As with many drugs, the more you use it, the more your body gets used to it, and that creates the need for a larger dose and/or using the drug more often in order to get the same effect. Cocaine is a potent chemical, and both the short-term and long-term effects of using are dangerous to physical and mental health. Riddle me this: how many old crack addicts are out there? I can tell you, not too many. Why? Because they’re all dead of heart attack, stroke, arrhythmia, respiratory failure, seizures, and sudden death. Whether you use cocaine once, use on occasion, or you’re a habitual user, the risk of seizure, stroke, cardiac arrest, respiratory failure, and even sudden death, is equal. Equal. No matter how little you use or how rarely you use. And the first time you use can also be your last chance.

So exactly how can you kill yourself with cocaine? Let us count the ways….cocaine’s potency and molecular makeup causes serious physiological consequences. No matter what form you use it in, it increases your blood pressure, increases your heart rate (aka your pulse), and it constricts the arteries that supply blood to your heart, all at the same time. So now, you’re asking the heart to pump faster and harder (because it has to pump against your increased blood pressure), and without as much blood flow (and therefore not as much oxygen and energy) as it was getting before the cocaine was in your system, and tah-dah! What can you get? Arrhythmias. Simply put, that’s when your heart can’t keep good time, it beats erratically and sporadically. Without conversion, you have a heart attack. Your heart basically stops beating and you die. And just remember, as you get older, your body is not as resilient. You may or may not have a lethal heart attack at 20, but you sure will at 50. How else can you kill yourself with cocaine? Using can cause you to go into a state where you’re unable to control your temperature, so it gets very high, you get restless, have tremors, dilated pupils, nausea, vomiting, complete disorientation, and mental confusion. If the fever gets too high, you can have seizures, which can lead to death. It happens every day. You also have to take into account potential accidents resulting just from being high, without your normal faculties, and being unable to take care of yourself. Freak accidents while high can be deadly. Remember too that cocaine is cut with crazy stuff- ground glass can cause internal bleeding, and diuretics and laxatives can cause electrolyte imbalance, both of which can kill you. And these days, cocaine is often cut with fentanyl- an opiate 50 times more powerful than pure heroin- which causes hundreds of overdose deaths each day. If you freebase cocaine or smoke crack, the chemicals used to cut it can cause sudden acute respiratory failure where you stop breathing and die, or they can damage the lungs over time and cause respiratory failure and the same result- death. If you use IV (intravenous needle injection) and share needles, you expose yourself to all sorts of potentially lethal infections, including Hepatitis, HIV and AIDS. If you choose to suck on crack, the chemicals used to cut it may be caustic and potentially damage the throat and/ or stomach and cause bleeding, or they may cause intestinal death and decay; these can potentially lead to death. 

So in the beginning of your cocaine career, you’ll feel great- super powerful, confident and competent. High. But shortly into your cocaine career, you’ll find that the magic is gone. The genie is out of the bottle. The high just isn’t the same, no matter how much you use or how you use it. So you chase that high…and you’ll chase it for the rest of your life, but to no avail. The high is replaced with the craving for the high. I’ve never seen a drug with cravings as powerful as cocaine. They’re just unbearable cravings, and they can last indefinitely. I’ve seen many, many cases where they last for years. I see patients now who have had these horrendous cravings for years, and I expect they’ll have them for the rest of their lives. They were lured in by the shiny bauble that is cocaine, and cocaine showed them a great time. Then cocaine turned on them, closed the door and threw the bolt, leaving them to want/need/crave what they had, likely forever. It’s just not worth it. I treat addictions of all kinds: heroin, alcohol, marijuana, benzodiazepines, you name it. For the most part, people with these addictions comply with treatment and come to their follow-up appointments. But cocaine addicts are a different story. They’ll come to my office once, all committed to stopping the cocaine, but you never see them again. They vanish…poof! They don’t do well in treatment, because the cravings are so strong that they can’t resist, so they take off and use again. The cocaine cravings are bar none the strongest I’ve ever seen. Now, the withdrawal from cocaine isn’t bad at all. It’s not like an alcohol withdrawal or withdrawing from Xanax or heroin. Those are gnarly, even potentially dangerous. With cocaine withdrawal, you can get depressed, you sleep a lot, you get vivid dreams, you want to eat a lot, you can’t think super clearly for let’s say three to seven days, but there is no real treatment needed for it, just comfort measures- keep the person cool, keep them hydrated, keep them fed, and allow them to rest- and they’ll bounce back. Now, one thing that sure does come up is that, because the cravings for cocaine are so intense, as soon as they’ve slept and ate and they’re back on their feet, it’s sayonara sucka! They bolt. They’re out again, they’re using, they’re smoking, they’re shooting, they’re shoving it up their nose, they’re putting it in their mouth, wherever and however they can use it. If they had a decent time period of not using, they may get that first super awesome high; but then they’ll inevitably spend the rest of the binge chasing that high, but they won’t find it.   

Now, you might ask how intelligent, successful, type A people get involved with cocaine when they know it will lead to their eventual mental and physical collapse and  possible death? Because these people know that in the short term it will increase their work performance, their ability to think, their social acumen, and their confidence. I always ask my patients what price they’re willing to pay for this temporary condition. Most don’t have an answer. I think that’s because they think nothing bad will come of their using, but I know different because I’ve seen different.

A true story from when I worked in the emergency department at Roosevelt Hospital: there was some sort of summer festival in Central Park, and evidently a guy locked himself in a portajohn so he could smoke crack. It’s summer, there’s no ventilation in the portajohn, and crack causes an increase in body temperature, so this guy had to be hot. But he was also high, so he was confused as to where he was and how to get out. People reported hearing him freaking out in the portajohn, kicking the walls and pounding on the door, but they couldn’t get past the locked door and he couldn’t follow their instructions to unlock the door and open it. So he was all worked up on top of being overheated, so his muscles heated his body up even more. Eventually, NYFD came and got him out of the portajohn, and he was brought to the ER, where I saw him. He was very hot and very dehydrated and very high. I started cool IV fluids and ordered an alcohol bath, but the damage was done. In short order, he developed something called rhabdomyolysis, where the muscles begin wasting away and all the muscle fibers enter the blood stream and shut the kidneys down. Despite our best efforts, he died. The family was very upset. They knew he was smoking crack, but couldn’t stop them. Every attempt to put him in treatment ended with him running away to use. And he was no slouch, no crack bum; he was a regional manager for Ace Hardware, in charge of like 20 stores. And he wound up basically killing himself in a portajohn. What a waste.

When I think about the stereotypical Type A individual doing cocaine to excel in the workplace, I think of a  Wall Street broker. I had a patient, a broker who worked on the Exchange floor. This guy was 40 when he first came to me, said he was on the fast track, that he wasn’t going to make $700,000K a year for much longer. He said he had to be sharp, had to be quick at all times and at all hours, no complacency, so he’d been using cocaine. I warned him about the potential dangers of piling cocaine on top of such a high stress job, but no matter what I said, he wouldn’t give it up. His motto was “Damn the torpedoes- full speed ahead!” He was getting away with using. Six months, seven, gaining on eight, he worked constantly, but he was the man, top trader, taking home fat 6-figure bonuses. After just over eight months on the cocaine, the piper insisted on his payment. He had a heart attack at 41, and when the ER doctor took his history, he readily admitted to using cocaine for eight months. With further questioning, he also reported having periods of confusion over the previous six months. His solution was to use more cocaine in an attempt to regain the sharpness it had once brought him in the beginning, but it didn’t work. What the cocaine did do was really keep him up at night. His solution for this was to drink four martinis every night in order to come down and get some sleep. He was doing this every day of the week for about seven months: cocaine throughout the day and martinis in the night. The cardiologist ordered a whole bunch of tests and it soon became clear that the heart attack that sent him to the ER was not his first. And unfortunately it wouldn’t be his last. His heart muscle was quite damaged from the ups and downs of the cocaine and alcohol fueled roller coaster he had boarded months before. I suspect that he never totally got off that ride, despite having another three heart attacks. Each one was progressively worse and made more obvious his mental and physical decline. At the age of 43, a massive fourth heart attack punctuated his life with a period. The man that burned the candle at both ends had burned himself out. 

No tales of caution would be complete without mentioning the models and the housewives. They like cocaine because it helps them lose weight and stay thin. And because the cocaine stimulates them, they like to take Xanax and drink alcohol at night to come down. I can spot the cocaine/alcohol/Xanax Barbies at 50 yards, because they actually turn gray. I’m serious- their skin turns gray and they get too thin. The whole program makes them look like victims of concentration camps. And they wind up forgetting normal daily activities- forgetting to pick the kids up, forgetting when dinnertime is, forgetting how to do the homework with the kids, forgetting how to accomplish simple banking transactions- everything gets screwed up. In my career, I have lost count how many husbands have sincerely asked me if I think that their cocaine/alcohol/Xanax Barbie wives are: A. Going crazy, B. Exhibiting symptoms of early onset Alzheimer’s disease or dementia, or C. Showing signs of having a brain tumor.

I’ll tell you this one last quick story about a patient I saw a few days ago. Her name is Julia, and she is a 33-year-old out, loud and proud lesbian. She’s very intelligent, a paralegal, and lives with her girlfriend of several years, Paola. She was introduced to cocaine after coming out and getting involved in the lesbian scene at age 21. She used cocaine daily- and in increasing amounts- for ten years, because she said it stimulated her libido and helped her reach orgasm. She stopped using cocaine when she had a heart attack at age 31. Unfortunately, the heart muscle was significantly damaged, and now she is unable to tolerate even mild exertion, such as that which happens during sex. So…the cocaine she used for ten years to increase her libido and help her reach orgasm has caused her current inability to have passionate sex with her girlfriend. How’s that for cruel irony? 

Cocaine is relentless and seductive…initially it can feel amazing, a ladder that lets you climb to the top of the world. Then cocaine is vicious, it sinks its hooks into you, which very few people manage to completely free themselves from. The perceived benefits aren’t worth the cost, which, as with some of my former patients, can be your life. It’s simply not worth it. I hope you get the take home message of all the many ways that cocaine can kill you, and that you understand how smart people find themselves tangled up in using cocaine, but also how even smarter people manage to stop using cocaine. 

For more details and stories about addictive drugs like cocaine, check out my book, Tales from the Couch, available in my office and on Amazon.com.

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Obesity:What Causes it and How to Combat it

We’re nearly six weeks into the new year, and this is right about the time that most people toss their new year’s resolutions out the window. Many of them had resolved to lose weight: surveys have shown that, of the people who make new year’s resolutions, an average of 45% of them resolve to lose weight and get in better shape. So that means that nearly half of resolution-makers are overweight at least. That number seems high, but given that obesity has reached epidemic status, I guess it’s not that surprising. 

Obesity is broadly defined as the state of being well above one’s normal weight. Obesity often results from taking in more calories than are burned by exercise and normal daily activities, aka ‘eating too much and moving too little.’ A person has traditionally been considered to be obese if they are more than 20% over their ideal weight. That ideal weight must take into account the person’s height, age, sex, and build. Obesity has been more precisely defined by the National Institutes of Health (NIH) by utilizing a person’s BMI, body mass index. The BMI is a key index for relating body weight to height, and it is formulaic. The imperial BMI formula is weight (in pounds) multiplied by 703, then divided by height (in inches²). If you don’t feel like dealing with the math, you can google a BMI calculator. Having a BMI of 30 and above is considered obesity. Over 70 million adults (35 million men and 35 million women) in the U.S. are obese, while 99 million (45 million women and 54 million men) are overweight and at risk for becoming obese.

What are the causes of obesity? Obesity can be complex, going beyond eating too much and moving too little. Following are some other factors that cause or contribute to obesity.   

Genetics

Obesity has a strong genetic component. Genetic predisposition means that children of obese parents are much more likely to become obese than are children of lean parents. Genetics also affect the rate at which the body uses energy (burns calories) when at rest, which is called the basal metabolic rate. People with higher basal metabolic rates naturally burn more calories than other people, so they are less likely to gain weight. The opposite is also true: people with lower basal metabolic rates burn fewer calories, so they are more likely to gain weight. But these facts don’t mean that obesity is completely predetermined, that there’s no way to change it. What you eat can have a major effect on which genes are expressed and which are not. This is demonstrated when people of non-industrialized societies come to the U.S., begin a western diet, and then rapidly become obese. Obviously, their genes didn’t change, but their diet did; that changed the signals they sent to their genes, which then changed the expression of the genes. Changing the expression of the genes resulted in obesity. The bottom line is that genetics do play a key role in determining susceptibility to gaining weight and obesity, but that is only one factor of many; it is not all genetically predetermined. 

Diet: What and How You Eat

Obviously, eating an unhealthy diet is a major contributing factor in obesity. Overeating at meals and snacking throughout the day can also lead to obesity. An unhealthy diet would be high in complex carbohydrates, bad fats, and sugar, and low in fresh fruits, vegetables, and high protein lean meats. There are social factors that affect diet and therefore weight. If you spend a lot of time with overweight friends and family who eat too much of an unhealthy diet, the odds are that you’ll be overweight as well. Economic factors also play a role in obesity. If you can only afford cheap, ready-made packaged foods or fast foods from the dollar menu, you are much more likely to be obese. Economics may force you to eat a diet high in complex carbs like pastas, breads, potatoes and rice just to fill yourself up, because that is all you can afford. That type of diet greatly increases the risk of obesity. Unfortunately, eating unhealthy foods and overeating are easy in our culture today. Many things influence eating behavior, including time with family and friends, the low cost of unhealthy but filling foods, and the access to and expense of healthy foods.  

Lifestyle

If you have a lifestyle that centers on eating and/ or drinking, this can contribute to excess weight. A chef, bartender, or baker, something that requires tasting various dishes and trying new recipes for example. Also, someone who travels a lot for their job so always eats at restaurants, which are notorious for hidden calories and fat; they are more likely to be overweight and at risk for obesity. A sedentary lifestyle, where there is little to no activity or exercise is a huge contributing factor in being overweight or obese. Our modern conveniences- elevators, cars, remote controls- have cut activity out of our lives. The problem is that the less you move, the less active you are, the more likely you are to be obese. Being active helps you stay fit. And when you’re fit, you burn more calories, even when you’re resting, so you’re less likely to be overweight or at risk for obesity. 

Medical Conditions

There are a host of medical issues that can cause or contribute to significant weight gain. Some examples are hypothyroidism, diabetes, Cushing syndrome, polycystic ovarian syndrome (PCOS), menopause, depression, and endocrine dysfunction. Some medical issues don’t cause weight gain in and of themselves, but make weight gain more likely because they limit the person’s activity. Some examples would include conditions like osteoarthritis, uncontrolled rheumatoid arthritis, and chronic pain syndromes.

Medications

The list of medications that can cause weight gain is a long one. Everyday medications like corticosteroids (Prednisone, Celestone), diphenhydramine (Benadryl), hormone replacements/ birth control, and even insulin are among the culprits. Sometimes it’s not the drug itself causing weight gain, it’s a side-effect from the drug. Some drugs stimulate your appetite, and as a result, you eat more. Others may affect how your body absorbs and stores glucose, which can lead to fat deposits in your body. Some cause calories to be burned more slowly by altering your body’s metabolism. Others cause shortness of breath and fatigue, making it difficult to exercise, while some drugs cause you to retain water, which adds weight but not necessarily fat. Some medications don’t cause you to gain weight outright, they just make it more difficult to lose excess weight you may already carry. A lot of psychiatric medicines cause weight gain. The worst offenders generally include mirtazapine (Remeron), paroxetine (Paxil), risperidone (Risperdal), aripiprazole (Abilify), and quetiapine (Seroquel). With the exception of Wellbutrin, essentially all classes of psychiatric meds can be associated with serious weight gain. As a psychiatrist, I have to prescribe meds that may cause an unwanted side effect like weight gain. I have to weigh the cost to benefit with each patient. Unfortunately, I have patients who are trapped; they must take certain medicines to remain stable, so they have to severely alter their food intake and diet every day of their lives in an effort to avoid weight gain if possible. That’s the cost to benefit ratio- they pay the cost of a severe diet in order to get the benefit of being stable psychologically.   

Why should you care about your weight? What health issues does being overweight cause? The answer is many. Obesity leads to type 2 diabetes. It causes high blood pressure, which can cause strokes. Obesity can increase cholesterol levels and cause coronary artery disease, which is where deposits line the blood vessels that feed the heart and partially or totally block them, so the heart does not get adequate blood supply; this results in a heart attack, aka a “coronary” and this can easily be fatal. Being overweight puts excess weight on the human body, and this commonly causes osteoarthritis of major joints like the knees, the hips, and the ankles. All parts of the body are stressed and strained because they are not designed to carry around that much weight, and this limits the range of motion, mobility, and ability to walk. Obesity increases the risk of cancer to several organs and body parts: the breast, colon, gallbladder, pancreas, kidney, prostate, uterus, cervix, endometrium, and ovaries.  Another common medical issue from being overweight is sleep apnea. All the weight on the chest and throat causes you to temporarily stop breathing when sleeping, until you finally noisily gasp for air. Sleep apnea is serious, and very disturbing for anyone that you share your bed with. Obesity causes a fatty liver, which then leads to liver disease and the potential to cause the liver to shut down. Obesity can cause gallstones as well as kidney disease, which can cause your kidneys to stop functioning. Obesity can also cause fertility problems in both men and women. As a psychiatrist, I get obese patients referred to me because obesity can directly cause, or indirectly lead to, various syndromes and other issues, including chronic pain syndromes, depression syndromes, isolation syndromes, social problems, self esteem issues, and difficulty dating. People who develop obesity, especially when it is the result of something beyond their control, like from a medical issue such as hypothyroidism, have all sorts of social interaction issues and work problems, and I can treat them and help walk them through it with psychotherapy. 

We defined obesity, discussed the risk factors and what can cause it, and then the issues it can cause. Now let’s discuss how we can lose weight and prevent obesity.  

Food Diary

To offset weight gain or to help work off excess weight, consider keeping a food diary tracking what you eat and when you eat. Becoming a mindful and aware eater is a great first step to managing weight. 

Eat Slowly

Another factor which helps with weight loss is eating slowly. It takes some time for your stomach to tell your brain that you’ve had enough to eat. If you mindlessly shovel huge amounts of food into your mouth, you’ll miss your cue and overeat, and that obvi will cause you to put on weight and increase the risk of obesity. Eating slowly also has the added benefit of reducing the chances of having indigestion. 

Get Physical

Become more active whenever possible. Instead of meeting someone for coffee or a movie, meet them at a park, beach, or green space and go for a walk. Ideally, you want aerobic activity; that means getting your heart rate up, when it’s harder to breathe. Aerobic activities mean constant motion, like running, biking, swimming, soccer, basketball, anything where you’re moving constantly. Constant activity is aerobic activity, and daily aerobic activity will raise your basal metabolic rate and you’ll burn more calories, even when you’re at rest.  

Resist It

Resistance training is good for targeting fatty areas on the body. Resistance training involves moving a specific muscle against resistance, either using your own body weight or using standard weights. Other activities like lifting weights, doing push-ups, and doing squats are good for reducing body fat. 

READ LABELS! 

…and make sure you understand them. If you don’t understand them, do some research, get a library book on nutrition, ask a friend if they understand, or ask your doctor what the values all mean and how much of the various components should be included in a healthy balanced diet or when dieting in an effort to lose weight. Pay close attention to calorie count, fat grams, protein grams, sugar grams, and carbohydrate count. Just because something says “light” doesn’t mean it should be included in your diet. So many people are ignorant about nutrition information on food packaging. Be sure to know what those values mean and how much you should have of each every day.

Know the Fats

Trans fats- Bad fats!

Historically, trans fats are an evil on par with Satan himself, to be avoided at all costs. The worst type of dietary fat, trans fat is a byproduct of the industrial process of hydrogenation, which turns healthy oils into solids to prevent them from becoming rancid. Eating foods rich in trans fats increases the amount of harmful LDL cholesterol in the bloodstream while reducing the amount of beneficial HDL cholesterol. Trans fats create inflammation, which is linked to heart disease, stroke, diabetes, and other chronic conditions. They contribute to insulin resistance, which increases the risk of developing type 2 diabetes. Even small amounts of trans fats can harm health: for every 2% of calories from trans fat consumed daily, the risk of heart disease rises by 23%. Mind blowing. Though they have no known health benefits, trans fats were found in most pre-packaged garbage foods and were the main component in margarine type spreads. I say ‘were’ because recent science found there is no safe level of consumption of trans fats, and as a result, trans fats have been officially banned in the United States and several other countries.

Monounsaturated fat- Good fats!
Evidence has shown that consuming monounsaturated fats has several health benefits, including reducing general inflammation in the body. Studies have also shown that a high intake of monounsaturated fats can reduce triglycerides, decrease the risk of heart disease, and lower bad LDL blood cholesterol while increasing good HDL cholesterol. A diet with moderate-to-high amounts of monounsaturated fats can also help with weight loss, as long as you aren’t eating more calories than you’re burning. These fats are liquid at room temperature. Good sources of monounsaturated fat include avocados, almonds, cashews, peanuts, cooking oils made from plants or seeds like canola, olive, peanut, soybean, rice bran, sesame, and high oleic safflower and sunflower oils.

Polyunsaturated fat- Good fats! 

The two types of polyunsaturated fats (omega-3 and omega-6) are essential fats, meaning they’re required for normal bodily functions, but your body can’t make them, so you must get them from food. 

Omega-3 fats are a type of polyunsaturated fat that, like other dietary polyunsaturated fats, can help to reduce your risk of heart disease. Omega-3s can lower heart rate and improve heart rhythm, decrease the risk of clotting, lower triglycerides, reduce blood pressure, improve blood vessel function and delay the build-up of plaque in coronary arteries.

Omega-6 is a polyunsaturated fat that lowers bad LDL cholesterol. Eating foods with unsaturated fat, including omega-6, instead of foods high in saturated fats helps to get the right balance for your blood cholesterol (ie lower bad LDL and increase good HDL). Sources of polyunsaturated fats include oily fish (like salmon, mackerel, sardines), tahini (a sesame seed spread),
linseed (flaxseed) and chia seeds,
soybean, sunflower, safflower, and canola oil, margarine spreads made from those oils, pine nuts, walnuts, and Brazil nuts.

Follow these easy ideas for getting the balance of blood cholesterol (LDL and HDL) right.

– Go nuts! Nuts are an important part of a heart-healthy eating pattern. They’re a good source of healthier fats, and regular consumption of nuts is linked to lower levels of bad (LDL) and total blood cholesterol. So, include a handful (30g) every day! Add them to salads, yogurt, or your morning cereal. Choose unsalted, dry roasted or raw varieties.

– Go fish! Include fish or seafood in your family meals 2 – 3 times a week. Fish are great sources of the good omega-3 fats. If you don’t eat fish, you can take an omega-3 supplement.

– Use healthier oils! Choose a healthier oil for cooking. For salad dressings and low temperature cooking, choose olive, peanut, canola, safflower, sunflower, avocado or sesame oils. For high temperature cooking, especially frying, choose olive oil or high oleic canola oil, as they are more stable at high temperatures. Store oils away from direct light and heat and don’t ever re-use oils that have been heated before.

Eating polyunsaturated fats in place of saturated fats or highly refined carbohydrates reduces blood pressure, raises good HDL cholesterol, reduces harmful LDL cholesterol, lowers triglycerides, and may even help prevent lethal heart rhythms.

Saturated fat- OK in strict moderation

Saturated fats are common in the American diet, and they are solid at room temperature- think along the lines of cooled bacon grease. Common sources of saturated fat include red meat, whole milk and other whole-milk dairy foods, cheese, coconut oil, and many commercially prepared baked goods and other foods. A diet rich in saturated fats can drive up total cholesterol and tip the balance toward more harmful LDL cholesterol, which can prompt heart disease from blockages formed in arteries in the heart and elsewhere in the body. For that reason, most nutrition experts recommend limiting saturated fat to under 10% of calories a day. Replacing excess saturated fat with polyunsaturated fats like vegetable oils or high-fiber carbohydrates is the best bet for reducing the risk of heart disease. 

Diet Do’s

– Eat plenty of fiber. Fiber fights belly fat. When ingested, fiber goes into your system, binds to and then forms a sort of gel with the food, which slows down the absorption of food in the gut.  

– Eat a high-protein diet. Eggs are eggsellent…high in protein and low in fat. Avoid red meat. All meats should be lean and high in protein, like chicken or turkey. Nuts are also good for a protein snack.

– Eat fish, as often as 2-3 times per week for good omega-3’s. As discussed above, oily fish like salmon, mackerel, and sardines are high in omega-3’s which are good for the brain, help to decrease weight, and have numerous other health benefits. If you don’t eat fish, take a good omega-3 supplement.

– Drink green tea; there are reports that it helps with weight loss, and it’s generally just good for you.    

Diet Don’ts

– Don’t eat sugary foods or anything with sugar in it: sodas, candies, cakes, cookies, doughnuts; those are the main culprits. It’s a major bummer, but to avoid weight gain in your life, much less to try to lose weight if you’re already overweight, you must avoid sugar like the plague. Wah wah wah… 

– Cut out the carbs! To lose weight or just to avoid putting weight on, anything with white flour must go, so say syonara to pasta and most breads. You have to cut way down on starches, if you’re allowed them at all, so there goes rice and potatoes. And while most people consider corn a vegetable, you must count it as a starch when dieting. 

– Get on the wagon! If you drink alcohol, you won’t lose weight and keep it off. Won’t happen. When you consume booze of any sort- beer, wine, liquor- the alcohol is immediately converted to sugar, and if you’ve forgotten, see Diet Don’t 1 above. There’s no point in restricting calories, fats, etc by following a diet and also drinking alcohol at the same time, even a small amount.  

Go to Bed!

Sleep is critical if you want to lose weight, so aim to sleep at least 7-8 hours each night. If you do not get proper sleep, it will be very difficult (if not impossible) to lose weight, and you will likely gain weight. This is all thanks to brain chemistry and hormones, which get all fouled up with sleep deprivation. 

Stress Less!

You have to reduce stress if you want to lose weight. When you are stressed, your body produces the stress hormone cortisol, and cortisol increases appetite and increases belly fat by selectively placing fat deposits around the stomach and middle of the body.  

A Fast Fast

We’ve always been told that starving ourselves will not result in weight loss, and that it will even result in weight gain because the body goes into ‘starvation mode.’ Well, there are some recent studies out there that conclude that intermittent fasting, 24 hours without eating, once or twice a week, actually helps with weight loss. Very interesting. 

So that’s all about obesity: what causes it, what it causes, and how to combat it. We are a fat society, and the number of cases of obesity goes up every day. It’s disturbing because it’s essentially a preventable issue. 

For more information and interesting stories on other diagnoses, check out my book, Tales from the Couch, available in my office and on

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Your Brain On The Holidays

Your Brain on the Holidays

Your brain is always busy, but it feels busier during the holidays, and rightly so. There’s a lot for it to think about during the holiday season: what to buy, for whom, and how much to spend, how to make time to visit family as well as friends, how to dodge certain co-workers at the office Christmas party, and hopefully how to squeeze in holiday naps in between eating some good home cooking. Because holiday time tends to pile on the stress, researchers are fascinated with the subject of what is happening in our brains while we’re trading time wrapping presents and plastering on a smile to spread genuine holiday cheer. 

Researchers believe that not only does the brain actually change over the holidays, but that they even know what culprit is: nostalgia. Essentially, nostalgia is that bittersweet feeling of love for what is gone, and the longing we feel to return to the past. The holidays lead to a special feeling of nostalgia that is unlike any other. Reminiscing with family, watching old holiday movies, eating favorite dishes, smelling the familiar smell of your grandparent’s house, and maybe even sleeping in your childhood bed….the holidays are a heady mix that induce nostalgia on steroids. But even more than this, therapists actually say that we should basically “expect to regress” during the holiday season. Who doesn’t want to be a kid again, to look forward to going home for the holidays? While “home” means different things to different people, I think even Ebenezer Scrooge can relate to the notion that when we celebrate the holidays with loved ones, something in us changes; it feels different. There is a child-like nostalgia, a forward-looking feeling of anticipation. Research suggests that’s because there are some serious changes in our brains during the holidays. Here are some examples of things that you might experience as a result of nostalgia:

1. You Want to Eat All of the Food

That’s pretty much what happens when you’re back in your mom’s or grandma’s kitchen, eating a meal with your siblings, is it not? You’re not just eating a meal, you’re living a memory, so you want it all! Eating a lot during the holidays is totally a real thing, and science says it’s largely because aromas trigger vivid memories, just like the smell of your grandparent’s house takes you right back to being seven years old. And socially, the same thing happens. Just because you and your siblings or cousins are grown-ups doesn’t mean you’ll act that way. Remember, if you’re regressing over the holidays, so are they. But just remember to be an adult and use your manners around the dinner table.

2. You Want to Drink All the Alcohol

There are many reasons that people drink more during the holidays. Studies have shown that the average American sees a 100% increase in their alcoholic drinking habits between Thanksgiving and New Year’s. Along with the holly jolly holidays comes an increase in social functions, holiday parties and dinners out, which inevitably leads to more alcohol consumption for most adults. Many of us look forward to celebrations during the holidays, but it’s amatuer hour when it comes to drinking… a time when some people who don’t normally drink actually drink far beyond their limits. Some of these people will suffer adverse consequences that range from fights and falls to traffic crashes and deaths. Sadly, people often put themselves and others at great risk just for an evening of celebratory drinking. So please, get a clue and get an uber. There is no reason to drive after drinking…remember: more than two means an uber for you!

3. You Want to Buy All of the Things

Holiday shopping, for most of us, feels pretty miserable. The music is loud, the mall is crowded, and you’re half way to the checkout before you realize you don’t actually know your uncle’s shirt size and you didn’t double check if your office Secret Santa recipient has any allergies. What’s worse? Apparently, shopping during the holiday season changes our brain, and even the most self-controlled shoppers can fall victim to marketing masters. That cheerful holiday music? Those festive colors? Those free samples around every corner? The bright cheery lights? Marketing. Allllll marketing. And, all pretty much intended to get you to relax, have a good time…and loosen that hold on your wallet and kiss that money goodbye. And not even any misteltoe!

4. Maybe You Don’t Want to Get Out of Bed

Not everyone enjoys the holidays. For some people, it can trigger serious battles with mental health, depression and anxiety. Between 4 and 20 percent of people experience a form of Seasonal Affective Disorder, otherwise known as SAD, which is a depression that generally sets in during early winter and fades by spring or early summer. Even people who are not diagnosed specifically with SAD may still experience depression and anxiety over the holidays. Why? Well, we postulate that people’s desire for perfection can become crippling during holiday time. People see more of each other and have more than the usual amount of time to compare themselves to others during the holiday season, in terms of what they can or cannot afford to spend on gifts or where they may travel for vacation. People often try to do too much and end up over-extending themselves. 

The holidays are meaningful to people for many different reasons. For some it is a religious holiday, for others a time to spend with family and friends, and even a time of sadness and loneliness for some. Whatever the holidays mean to you, you really need to make it a point to take good care of yourself during this busy season…it’s the best gift you can give yourself.  

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Is Marijuana For You

Given the legalization of marijuana in many states, I wanted to have an open discussion on the ramifications and repercussions of its legalization, and why choosing to use might not be the best choice for everyone.

Marijuana is so readily accepted everywhere now, in both legal and illegal states and in any and every social circle; regardless of its legal status, its use is suggested by so many people for everyone and everything under the sun…it’s a revolution that makes Woodstock look like a quilting circle. Grandmas and grandpas, CEO’s, lawyers, actors, the butcher, the baker, and the candlestick maker….everyone’s using marijuana, legal or not, and they’re not afraid to tell the world. And the marijuana of today ain’t yo mama’s marijuana…today many people prefer to smoke marijuana wax rather than the green herbacious stuff, because wax is a minimum of 90% pure THC, miles away from the 15% green stuff.

The legalization of marijuana has created a slippery slope. Now it’s basically off the radar for police, meaning that most officers will give a pass for possessing up to a certain amount of it, even in illegal states. The police officers have discretion in the field, and most just confiscate it and maybe write a fine ticket for it, or maybe not…it’s not worth the time or effort for them to fight it any further, even in illegal states. If they just wrote every possessor a fine ticket for marijuana possession, they’d be buried in tickets, so imagine the paperwork if they arrested them all. I watch a live police program on weekends, and the first question an officer asks the driver they’ve pulled over is if they have any weapons or drugs in the car. They then emphasize that “honesty goes a long way” when it comes to their decision-making process in drug possession. Sometimes they’ll employ a K-9 officer to find drugs, and I swear that at least 85% of the cars they pull over contain drugs of some sort. And most times (after the officer makes it clear that they can’t get in trouble for it) a driver will readily admit that they have smoked within the last hour or minutes before getting behind the wheel, or even just smoked while driving. This is apparently due to a general consensus that marijuana doesn’t cause impairment, which is debatable; more recent studies are suggesting otherwise.   

Because marijuana has essentially vacated its spot in the illegal drug hierarchy, the next “least worse” drugs, meaning cocaine and methamphetamine, have moved up, becoming “less illegal” in a way. Now officers even have some discretion when it comes to the possession of cocaine and meth; if the possessor only has a small amount, they may not necessarily go to jail. As hard as it is to believe, I have seen it on the live police program, people issued a ticket for possessing a small amount of coke or meth. The only difference is the type of ticket issued: while a marijuana ticket is just for a steep monetary fine, the ticket for coke or meth possession is essentially an order to appear before a judge, who then decides if the offender goes to jail or gets off with just a steep monetary fine and/ or probation, community service, etc. I wonder if lawmakers ever imagined that the legalization of marijuana in some states would lead to the near decriminalization of even minute amounts of drugs like coke and meth, but it seems it has. Similar to marijuana, I think it’s likely due to the amount of time and effort it takes to haul every coke and/ or meth possessor to jail: small amounts are permissible when weighed in the face of 100% rule of law…it’s certainly faster, easier, and more profitable to fine someone through the nose (no pun intended) than to house them in our overcrowded and expensive jails.  

Enough of the legal ramifications. Of course as a physician, I see the more personal, medical side of the legalization of marijuana. I am literally asked about it by patients every day, and I am a medical marijuana prescribing physician- I jumped through all of the state’s many hoops so that I can prescribe marijuana. I believe that used properly, marijuana has definite value as a drug. The key is for whom. I think it’s good for someone with cancer, with brain tumors, for AIDS, for neurologic disease like ALS (Amyotrophic Lateral Sclerosis), for Crohn’s disease, irritable bowel syndrome, for post-traumatic stress disorder, for specific types of chronic pain, and for certain seizure types. While I don’t prescribe marijuana willy-nilly, I definitely do prefer prescribing marijuana over other controlled drugs like opiates. But as I tell patients, just because it’s legal doesn’t mean it’s useful for everyone or even reasonable for everyone to use it. In fact, I think that for a subset of the population, up to age 30-ish, marijuana is counterproductive at best and damaging at worst. I call marijuana “the nothing drug.” If you give marijuana to a young developing mind, let’s say someone aged 14, the person belonging to that mind has their life course altered. From the day they start smoking marijuana, nothing happens. Their motivation drops off. They think a lot of good thoughts about what they can do or would like to do, but they do nothing. So nothing gets done. That’s what alters their life course. Dreams are great, but the key is to act on them. I tell my patients that when they use marijuana, nothing happens. Nothing bad, but nothing good. Nothing scary, but nothing awesome. Just nothing. Users do nothing, and if they continue to use habitually, they may amount to nothing. They may not fail, but they definitely will not excel. When you ask that marijuana-smoking 14-year-old what they’ve been up to, they’ll say ‘’nothing.’’ When you ask what they did in school that week, they’ll say ‘’nothing.’ When you ask them what they did over the weekend, they’ll say ‘’nothing.’ When you ask them what happened at the football game, they’ll say ‘’nothing.’’ When you ask them what they do when they get high, they’ll say ‘’nothing.’ Now you get the picture. Marijuana… The Nothing Drug. There’s a PSA campaign for ya’.

Using marijuana is mostly about being alone, being high, and being out of touch. You cause no problems. As a matter of fact, the last thing you want is conflict…it would harsh the mellow. My patients who smoke tell me that when they use it, they just want to keep using it, because it makes them feel so good. But there are qualities to marijuana that make people prone to isolation, where they don’t communicate with others as much. Think about it. When was the last time you went to a wild, raging party with people smoking only marijuana? Do you hear a lot of meeting and greeting, talking and laughing? Nope. But you do hear the sounds of lots of lighters striking and water bongs gurgling. And some muffled coughing- that wierd upper throat/ nasal cough that comes from people holding their breath and trying hard not to cough up the hit they just took. You may hear a woo-hoo or two, but that’ll come from the direction of the couch, which will be replete with reclining stoners. In my experience, people who smoke pot waste a lot of time doing so. It’s the kind of drug that can be used constantly, for hours and days on end, because there’s no concern of overdose. There’s a lot of time wasted, no pun intended, on thoughts not thought through and things left undone. When I warn patients about isolation, I often hear back from them that they do spend time with people, that in fact, they get high with people. I tell them that they may think they’re spending time with friends, getting high with their buddies, but that most of the time they’re getting high and playing video games or listlessly bobbing their heads to music and they just happen to all be in the same room. There’s no real interaction…it’s a very solitary pursuit, but in the presence of others, a mental masturbation marathon.

Obvi, I have many patients that complain that their lives aren’t going well, that they’re depressed and generally unhappy, and many of them smoke marijuana to “relax.” When I ask the marijuana users why they’re unhappy, they seem completely devoid of any insight as to what’s going on. I have a list of questions I ask, and it starts with “How much do you smoke?” I can probably count on one hand the number of people who tell me the truth, that they smoke a lot of marijuana; they always say they smoke “a little” marijuana. When I ask what form they use and how much “a little” is, some admit to using wax, and many tell me they use “only at night, never during the day” like that makes all the difference in the world, given that there are basically 12 hours of night in a 24 hour day.  

The best “medicine” I can dispense to these marijuana-using patients is education. I have given a version of the same talk at least a thousand times, tailored to the patient’s age and condition. It basically goes something like this: “You’re unhappy because marijuana alters you. It makes it so you’re just going through the motions of life; when you’re directed to do something, you can do it, but you never do anything of your own volition. You have no original thoughts or ideas or insight into your life, because you don’t bother to examine it. You don’t have any meaningful interactions with other people. You spend your time playing video games and eating junk food. You never see the sun, unless you have to venture out in daylight for a marijuana-related errand. You’re lacking a creative outlet, because marijuana isn’t conducive to creativity. Marijuana is robbing you of motivation, memory, ambition, desire, and energy. It blunts your emotions so that you feel nothing, so you smoke more to feel high because that’s better than feeling nothing. It’s a vicious cycle. You’re just like a rat on a wheel in a cage.” These facts are why marijuana is most damaging for people up to about age 30, because by this time at the latest they should be expending great effort trying to establish themselves and their lives, deciding where they want to go and setting goals to get there. Instead, they use marijuana and all that goes out the window. For an 80-year-old woman with cancer or rheumatoid arthritis, marijuana isn’t going to affect her life nearly as much as a 20-something-year-old looking for a job or deciding what career path they want to take.

As an example to show that using marijuana is not exclusively for the young, take my patient Frederick, who is 68 years old. He started smoked marijuana at ten and basically smoked all day, every day since. Consequently, he did nothing his whole life, so 58 years. That’s 58 years completely wasted, again no pun intended. Somehow he got on disability years ago. As far as I could tell, his only disability was that he wanted to smoke all day, that he liked to be high. I have another patient, a 23- year-old named Skylar. He’s basically a trust fund baby, living in his parents’ Palm Beach mansion full time while they spend 48 weeks of the year living up in Massachusetts. Skylar’s “job” as caretaker of the mansion, supposedly overseeing a staff of six, has always left him with more than ample time to do, well, nothing…except smoke wax. And he was a hard case, because he was able to afford the strongest wax and he smoked a lot of it- one of the handful that admitted to doing so. I saw him in my office a couple of months ago, and he told me he had wasted enough time using marijuana, he wanted off, and would I help him? Once I recovered from the shock and picked myself up off the floor, I of course told him that I’d be glad to, and I explained the deal. Most people think there’s no withdrawl from marijuana, but that’s not true. There is about a ten day withdrawl period that typically includes insomnia, restlessness, and irritability. It then takes six weeks for green marijuana to eight weeks for wax for all traces of THC to leave the body. I use medications like clonidine and trazodone to minimize the effects of withdrawal, and they make it much easier. At the two-week mark, the four-week mark, the six-week mark and the eight-week mark, patients are amazed at how they feel clearer and clearer at each point. They’re able to see how impaired marijuana was actually making them- they were totally unaware of their impairment at the time, how slow they were, how dopey and lazy. Once it’s completely out of their systems, they tell me how they’re more active, how they’re getting up in the morning and showering and getting dressed, how they’re going outside and exercising, and how things are happening in their lives. I’m happy to report that Skylar was no exception. His withdrawl from marijuana wax was uneventful, and after eight weeks, he was shocked at how different he felt, describing it as like being awake after years of being asleep. For the first time in recent memory, he was thinking, he was weighing his options (now that he had some) and he was planning his future. When I asked his greatest revelations, he said, “I have to make things happen. I have to be proactive. I have to look for and seize opportunities. No one can do that for me.” I really couldn’t have said it better than that. 

Re-reading this, I noticed that I said that marijuana is ‘robbing you’ of this and ‘taking away’ that, but really, marijuana doesn’t take things away from you, you give those things away when you choose to use. Marijuana has its place in treating certain illnesses and diseases; but remember that just because something is legal to use doesn’t make it reasonable to use it. If you’re faced with a choice to use, just think about Frederick, with 58 years wasted, no pun intended, and Skylar, who got a late start in adulting but has an unlimited future…now that he’s no longer letting marijuana limit his present.  

For lots more entertaining stories and information about marijuana and other drugs, check out my book, Tales from the Couch, available on Amazon.com. It makes for a great read and an ever better gift!

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Secrets For Surviving Panic Attacks

Well, it’s another Saturday. My avid blog readers might know what that means…I’m at the carwash again for my Inside-Out Wash and Hand Wax. And yes, I know I’m pretty particular about the state of my car, thank you very much, but in my professional opinion there’s no pathology there whatsoever. Anyway, I’m stuck for a minimum two hour sentence at this joint. It’s always the longest two hours of my life, and if I don’t find something to occupy my mind I might just lose it. I usuallly sit inside for the A/C, but the weather was beautiful, so I sat outside on what barely passed as a patio: two of those round concrete table jobbies with the rough curved benches encircling them, surrounded by tall but sparse hedges on three sides. I wasn’t the only one with the bright idea to sit outside- Floridians get very excited in November when the temperature dips below 75 for a second and the cooler breezes make it onshore- we flock to outdoor spaces like Aztecs worshipping the sun. I spied a concrete bench that was empty and sat down with my coffee from my fave place on US-1. There was a dude at my table on the bench across from me, and he didn’t so much as acknowledge my presence when I sat, so engrossed in his phone was he. Fine by me. As I surveyed my company, what struck me was that there were literally zero words being exchanged among the other waiters, even those that were clearly there together. It was like a freaking monestary- if the monestary was right next to a carwash with its particular “music” of Inside-Out Washes and Hand Waxes in the background. I don’t know why I still find the lack of communication, especially in the very most basic sense, to be so alarming, almost disturbing even. I know I’ve gotten into this in so many different blogs and videos, and of course in my book, but it seems like no one talks to anyone anymore. People talk more to Alexa and Siri these days than other people. Anyway, what were my fellow waiters doing while they weren’t talking? They were of course on their phones, just like everyone always is, always on freaking cell phones. I wasn’t the least bit shocked to see what looked like a ten-year-old girl buried in a phone. These days, young kids, I’m talking like age three and up, have phones to play games on, because moms can’t bear to give up their phones to allow the kids to play on them, and if the kids don’t have phones to play on, they’ll drive their moms crazy and make it impossible for the moms to be on their phones. So the obvious solution, nay, the only solution, is to get your four-year-old a phone. I wonder what Dr. Spock or Mr. Rogers or Bert and Ernie would say about the Romper Room set having phones, or even worse, needing phones. 

Anyway, as I sat on the hard and scratchy concrete bench on the “patio” surrounded by the sparse hedges, a woman entered the scene. She walked up and asked if anyone was sitting next to me, to which I said no. The way these benches are curved and situated, it makes it a little awkward to sit at one with a stranger, but she smiled and took a seat next to me. She looked about 40 or so, medium height and weight,  with jet black hair. I guessed she had more than a little Latin blood in her. She was not dressed Saturday casual like the rest of us waiters: she wore a nice black skirt suit with a bright pink blouse, and I assumed she was on her way to work. At where or doing what I had no clue, but realtor was at the top of my guess list. I noticed she wore no wedding ring, though that doesn’t really mean anything these days. She looked like a woman of means, and she was fairly attractive, but something was off. She looked kind of shocked for lack of a better term, like psyche shocked, and she nearly visibly vibrated, like she was plugged into a light socket. She was clearly very unsettled by something, or maybe several somethings, and it or they were simmering just below the surface. I could see she was accustomed to the valiant effort to keep them there, but they were clear as the day to me. Your average person on the street wouldn’t see any of this in her, but I’ve made my living watching and listening to people as they lay bare their pain and fear, and this woman had plenty of both. 

She said her name was Pilar, and that and her slight accent confirmed my previous guess that she was of Latin descent. I knew damn well that something was wrong with Pilar, something that I might be of help with, but also that I might not. My mental machinations continued. She could be in denial, and she could be offended if I offered an opinion. I mean, how many people want to be analyzed by a shrink they just met while waiting at the carwash? I decided that I would not open Pandora’s box. Not going there. I’m just going to sit here in the sun and be polite, but be surface. Mind my own business. Polite, surface. After a moment sitting at the little concrete table, she asked me how long the carwash takes. I dutifully explained that the Inside-Out Wash and Hand Wax took a bare minimum of two hours, especially on a Saturday morning, but that it was well worth the wait. At this, she blew her bangs out on a long resigned sigh. Then motioning to my cup, she asked where she could get good coffee. I gave her directions to my fave spot, which was just up the street on US-1 and told her to ask for “Bailey the Barista, the best barista in the Easta” I had given this name to a barista named Bailey at my fave place because she really is the best barista ever in the vast history of baristas. (ADD side note: what the hell did we call the people who made our coffee prior to the advent of Starbucks?) Pilar laughed and said she’d be back; right after she left, even the guy across from me stood up and said that with my glowing recommendation, he just had to go for a cup as well. How to win friends and influence people…with coffee…who knew, I mused. Maybe the next book? I filed that under ‘Later’ in the grey matter. 

I took Pilar’s absence as an opportunity to remind myself not to get involved, to not play the curious shrink role. No matter how bored to tears, how desperately in need of a distraction I became, I would be strong. I would not go there. Be polite, be surface. You may be wondering why I don’t just announce my profession and delve into stuff with people at every opportunity. First, that would mean I’d have to be ‘on’ and wearing my Dr. hat a lot when I’m at social events and such, when I’d really prefer to be chill. But it goes beyond that. Here’s the thing. Unless someone asks me straight up what I do, I don’t usually tell random people I’m a psychiatrist, because invariably I end up spending a lot of time listening to a story about someone’s Aunt Edna from Des Moines who has 53 cats and hasn’t left her home in 12 years because she’s purposely hoarded it with old newspapers, jars full of pee, and her old fossilized poopy diapers, all as an excuse to never leave, and do I think that maybe she’s depressed and can I give her a prescription for Prozac? There’s a lot of that kind of thing. Another issue that can happen is someone tells me their story, and in my opinion they may actually need help, but when I tell them they should seek that help, they get all pissed off at me. Plus, when I talk to people when I’m out and about, they don’t know that they should have no expectation of privacy because they aren’t patients and we aren’t in my office, and they may tell me some deeply private things, and it just gets messy for me that way. So, for those reasons, and a lot more, I don’t generally just announce that I’m a psychiatrist. But there is a flip side. It’s no secret that I hate to do nothing. I hate waiting for my car to have its Inside-Out Wash and Hand Wax because I have nothing to do while I wait. And remember: I hate doing nothing. So sometimes, like during my interminable wait for my car, when I’m bored out of my skull and climbing the walls, I might be less averse to telling people I’m a psychiatrist, because 100% of the time, it starts what might be an interesting conversation, one that might help pass the time until my car is ready. All I have to do is introduce myself and my profession, “Hi, I’m Dr. Mark Agresti, I’m a psychiatrist. What’s up?” and we’re off to the races. People spill their guts. Other times, I don’t use my last name or announce my profession, but I still engage in the conversation. So it’s kind of like the little cartoon with the angel on one shoulder and the devil on the other and do I dive in or mind my own business? It’s an internal tug-of-war I’m familiar with. Earlier, I had simply introduced myself to Pilar as Mark. In this case, I knew that Pilar was genuinely troubled, but if I told her that I was a psychiatrist, I wasn’t sure how she would take it; she seemed fragile to me. All the more reason for me to be polite but be surface. But on that flip side, I did have time to kill, and Pilar seemed very nice, and maybe I could help her just as another human rather than as a physician. So much for polite and surface. Maybe she wouldn’t even want to open up to me. But maybe she would. I had the feeling it could get deep on this carwash patio. Guess I’d find out. 

With time to kill, I decided to be like everyone else and get on my phone to check my Facebook, or Fakebook as I like to call it. They recently refused to boost one of my posted blogs. Interestingly, it was called “Carwash Psychiatrist” and was all about a different Saturday morning conversation with a steroid-raging mountain-sized man. Fakebook refused to boost it citing inappropriate content. I call total bs on that. I thought it was really informative and interesting, if I do say so myself. It’s on my website if anybody wants to read it and decide for themselves. I re-read it again as I sat there, and still I didn’t think it was inappropriate. I wished I could figure a way to get around Fakebook to boost it. As I considered that, Pilar returned and sat down next to me with her cup of coffee. Her expression was more open than it had been. I think she was more comfortable with me because now we had this coffee connection. Somehow, sitting next to each other drinking coffee together set a mood to talk, a vibe like we were old friends catching up. Glancing at my watch, I saw that I still had an hour until my car would be ready. More than enough time for a conversation, if one arose. I had given up the mental jujitsu match and decided to be polite and open. I could feel Pilar’s dis-ease, referring to her uneasiness, not illness, though she always kept it hidden…or tried to. She looked at her watch and sort of tisked the time, saying that she hoped her car would be done soon because she had to get to work. When I asked her what she did and if she usually worked weekends, she said that she designed and sold high end kitchen cabinetry, and that no, she didn’t normally work weekends, but she was behind because she’d missed a lot of days recently because she’d been sick. This was it. This was the turning point. I could be in or out. Polite and surface or open. I know something’s going on with her, maybe there’s something I can do to help her, so I go there, unable to resist the psychiatrist in me, but at this point still unwilling to tell her there was one. So I went there, I asked her the obvious question that her answer had begged: what was wrong?

She answered, “I thought I was dying.” Okay, I’m looking directly at this woman, and while she looks troubled, she is definitely not dying. I’ve seen dying. I know dying. I decided to take the light-side approach and gave a little non-committal laugh as I said she’d have to narrow that down with some details. She began, “A month ago, I had to go to the emergency room.” I expressed surprise and asked what happened to land her in the ER. She replied, “I woke up one morning and I had this tightness in my chest. I couldn’t breathe, and my heart was racing. I was sweating buckets, and I was so uneasy, like something awful was happening. I thought for sure I was having a heart attack. I had this sensation of pins and needles in my fingers. I didn’t know if I was losing my mind or really actually dying, because I felt like I didn’t know who I was or where I was…I felt like it wasn’t real. Crazy, right?” Before she had even finished her second sentence, I knew that Pilar was describing anxiety, maybe a panic attack, so I said, “Let me take a wild guess, when you went to the ER, they took your vitals, started an IV, drew blood for labs, did a chest x-ray and an EKG and when the results came in, they told you everything was normal, that you just had anxiety.” Surprised, she said yes. When I asked if she’d had other similar episodes, she said, “You know, I have been getting these attacks in the middle of the night when I’m sleeping. When it happens, I wake up and I’m sweating, I can’t breathe, my heart’s hammering, and I feel like I’m honestly losing my mind, because I can’t calm down. I really feel like I’m dying, like I’m having a heart attack, and I’m sure I’m going to die.” When she followed up with her family doctor, he repeated the same tests that the emergency room doctor did and came up with the same conclusion of anxiety, so he gave her 2mg Xanax and told her to break them in half and take a half twice a day. She said it helped a lot, but that she had been living on them for the past 3 weeks, and she was very worried about becoming addicted, because she had read that they are very addictive. She was definitely right on that count. Xanax is very effective at treating anxiety and panic disorders, but it’s a dual edged sword at best and not good as a long term solution. Then she told me that about two weeks ago, she had another attack, and she wanted to try to avoid going to the ER if possible, but she wanted to be close in case she needed them. So she decided to drive to the ER but not go in. She parked and sat in the lot for about 90 minutes, waiting for the attack to subside, but she didn’t go in. She did that same thing twice. Then, she said that she had plans to go out with her friends about a week ago, and she had an attack in her house. She was just about to get in her car to meet them, and she had an another attack. She said that this one was the same deal: shortness of breath, sweating like crazy, feeling like she isn’t real, like she is losing her mind, like she’s having a heart attack and that she’s going to die. It seemed that this had been going on for about a month. Then she said that she was living in a constant state of fear, always scared that she was going to have an attack. And that was why she was working this weekend, because she had called out of work so many times in the past 4 weeks that she was really behind on some projects. I asked her how things stood now, and she said she had stopped all social engagements. She was pretty much confined to her house, only leaving for necessities like going to her office, grocery store, and gas station. It seemed like that was pretty much it, and she needed a Xanax just to do those few things. She was living in constant fear of having the attacks, but now that fear had expanded; now she had fear of getting in her car, fear of driving, fear of being out in public, and even fear of meeting up with her friends. She’s pretty much stuck in her home, only leaving if she absolutely must. So a month into her anxiety and panic attacks, that’s where she stood. It wasn’t good. She’d have to get help to get it under control.

Keep in mind, Pilar doesn’t know what I do, but I kind of needed to push the envelope a little. I asked what her family practice doc’s diagnosis was, and she said he had told her that it was just plain old anxiety. That didn’t jive for me; this wasn’t garden variety anxiety. When I told her that I didn’t think it was just anxiety, she kind of freaked out, eyes wide, asking if she could die from it, if she would be like this for the rest of her life, and if there was a cure for it. And only then did she finally think to ask what it was. I told her with a smile, “I think you’re going to live. I’m pretty sure you have something called panic disorder. I’ve read about it. You should see a psychiatrist, because there are ways to treat it without using addictive drugs like Xanax.” She looked relieved as she asked what panic disorder was. I explained that it’s not a physical illness, it’s a psychiatric illness with attacks exactly like she was describing, and that Xanax works, but that there were other medications for it, and that’s why she should see a psychiatrist. When she asked how I knew about all this, I told her that I had read up on it a lot because I had a sister who was diagnosed with panic disorder. I went on to say that her doctor gave her Zoloft, and that seemed to work really well for her. After two weeks on it, her attacks had basically stopped, and it wasn’t addicting at all like Xanax. When she asked if I knew what caused the attacks, I told her that I’d read that the panic attacks were the result of a false alarm going off in the brain, a suffocation alarm. You think you’re suffocating, you think you’re about to die, but you’re really not. She said she never imagined that something in her brain could cause her to feel like she was really dying, but that she was glad that it was treatable. I told her that when she got on the right medicine, the attacks should go away, just like they had for my sister. She thanked me profusely and assured me that she would see a psychiatrist. Then she lifted her coffee cup, took a big sip, and said she was so relieved. I told her that by the way, caffeine wasn’t the best idea, that my sister had to give it up because it encouraged more attacks. She said she understood, but that between waking up with attacks and taking the Xanax, she was exhausted and needed the boost, but that she would make the effort to stop the caffeine. I reiterated that she should get off the Xanax asap, that it was just a very temporary fix, and she smiled and gave me a funny salute and an “Aye aye, Captain!” 

We continued to talk, and she said that she was glad she had sat down next to me. I kind of felt badly about my little white lies, not telling Pilar that I was a psychiatrist while telling her that I knew about anxiety and panic disorder because I’d read up on it when my sister had been diagnosed with it. The next thing I knew, I heard two last names called, mine being one. The other actually turned out to be Pilar’s. We stood up simultaneously, laughed, and then shook hands as she thanked me again. I told her no problem and to be well. And that’s how it was left. As I got into my freshly Inside-Out Washed and Hand Waxed car, I assuaged the bit of guilt I felt by reminding myself that there is risk in telling people you’re a psychiatrist these days. I didn’t tell Pilar. Maybe I should have, I don’t know. I think I helped her despite holding back the truth, and I felt good about that. I was sure that she would see a psychiatrist and make the effort to stop the Xanax. How weird would it be if she actually came to me, to my office to see me? It could happen. If it did, she might be angry. I’d have to cross that bridge when and if I came to it.

Pilar’s panic disorder is not at all uncommon, unfortunately. By some estimates, approximately two million adults in the United States suffer with panic disorder each year. There are two types of panic disorder: with agoraphobic features and without. Agoraphobia is defined as an extreme or irrational fear of entering open or crowded places, of leaving one’s own home, or of being in places from which escape is difficult. Most people with panic disorder start off without agoraphobia, but if the condition persists without adequate treatment, it can progress to include agoraphobia, where people find it almost impossible to leave their homes. It can be very debilitating, but it doesn’t have to be. Emma Stone, Amanda Seyfried, Sarah Silverman, Oprah Winfrey, John Mayer, Kristen Bell, and Caitlyn Jenner… What do these people have in common? They’re just a few of the many notable people that have panic disorder. That just goes to show that having a psychiatric illness like panic disorder isn’t the end of the world, and it doesn’t have to hold you back. You just need to make the choice to seek appropriate treatment if you suspect that you have it or have been told that you have it. Don’t make the mistake of ignoring it with the hope that it’ll just go away, because it won’t…it’ll only progress.

For more “psych stories,” check out my book, Tales from the Couch, available on Amazon.com.

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