Hidden Complications of Medications

Withdrawal has not been that kind to me lately. I’ve been going through approximately a migraine a day. On top of that is leg pain. It’s an old leg pain that I’ve had since high school and it largely went away as I got older. It would flare up now and again, but it was manageable. And by pain, I mean crippling pain that shoots through all my joints from the knee and below. My toes even hurt.

Before, it wasn’t a problem. I would take prescription levels of ibuprofen and that would take the edge off of it. Granted, it would tank my stomach and I would feel sick and have a lot of heartburn. But at least I wouldn’t be in crippling pain. And after my back injury, I was introduced to another NSAID called Ketoprofen. That stuff is wonderful. It took care of severe back pain, sciatica, and my leg pain. Also, for migraines, I could take excedrin. It wasn’t perfect, but it took the edge off and I could function again. I can no longer take these drugs. Any of them.

The reason for these is lithium. I cannot take ibuprofen, aspirin, or naproxen (aleve) because they will increase the serum levels of lithium and push me toward toxicity. In fact, besides tylenol, there are no over the counter pain killers that I can take that does not mess with lithium. But it gets worse. All NSAID class drugs do this. So no COX-2 drugs either. What I’m left with are anticonvulsants and antidepressants (and opiates).

However, anticonvulsants are not a reality because of possible complications with lamotrigine (lamictal). All of them score a moderate interaction on the Drugs.com interaction checker. Worse yet, the best ones not only take a while to work, but can decrease the amount of lamictal in my system. That could have devastating mood impacts. So anticonvulsants are pretty much out because they are slow and interact with another one of my drugs.

Finally, there are tricyclic antidepressants and SNRIs (like welbutrin). There are two problems with this. SNRIs make me suicidal and a little homicidal. Even at low doses they destabilize me. So no matter how effective they are, I simply cannot take them. As for tricyclics, like amitriptyline, they too are antidepressants with a risk of mania. This effect is exacerbated by taking olanzepine.

And there’s one other. A low level opiate, tramadol, also interacts with both olanzepine and lithium causing increased risk of seizure. This is because it acts on both the D2 and D3 receptors in the brain. So even low level opiates are off the table because of the medication cocktail that I’m on. Which is disappointing because tramadol is the least likely to get me hooked on another narcotic.

This just reveals the hidden complications of medication. Drugs like lithium and olanzepine interact with nearly everything. And once you throw in lamictal, everything goes out the window. And adding in bipolar disorder helps clear away the remaining drugs. The only things left for intermittent moderate to severe pain are powerful narcotics like hydrocodone and oxycodone. To some, that might sound nice. But after withdrawing from one drug, I’d rather not do it with another. They are also sedating, which is something I desperately want to get away from after taking clonazepam for so long.

However, I don’t advocate dismissing these drugs because of the complete lack of access to no nonsense pain killers. It would seem strange to jeopardize one’s mental health because you can’t take ibuprofen anymore. And I’m definitely not going to stop taking these drugs simply because I have days of pain. Even if right now I’m very badly medicating myself with a little alcohol and tylenol. What it means, in my opinion, is that if you have severe pain that isn’t handled by tylenol, get to a general practitioner and find out a medication right away that you can take. I was stupid and didn’t set up a primary care physician and am now in the lurch for not doing so. Instead, I’ll have to rely on my psychiatrist for pain meds until I can get into my July appointment, and that’s a position that I don’t want to put her in.

It’s also a very good reminder to double check every interaction with every drug because even common and safe drugs like ibuprofen can have relatively devastating effects. Drugs.com has a good one that lists the severity of the interactions and what it does. Also, talk with your pharmacist about these things. I’ve found several good ones and they know off the cuff what can’t be done or what little tricks can be taken to work around complications. It’s their job, and my psychologist informed me that there is a strong movement amongst pharmacists to demonstrate that they are more knowledgable than doctors about medication. Ask questions, they are more than happy to inform you about the latest research that they have read. Plus, and this is just me speculating, I think that they like the sexier drug cocktails that pose complex interactions. It’s a stretch to figure it all out. It’s like my experience with the university health clinic, where my doctor was more than willing to act as primary care after finding out that I had a herniated disk. I think it’s a break from the norm, which is always more interesting to intelligent educated individuals.

An Almost There Mania And The Allure of Pushing

I’m in an “almost there” mania right now. I’m not manic by any means, but I’m creeping in on one. I have several ideas that I want to do, biking, studying, writing, and camping with my telescope. I want to do them all, right now. Just set off and do something. But I lack that impulsivity that comes with any sort of mania. As a result, I have many things I want to do, and can’t get around to doing any of them. It’s all so close though. I can almost taste the heights that my mind could soar to if only I could push a little bit.

Part of this is definitely the side effects of the drugs that I’m on. Be it the lithium, the zyprexa, or the klonopin, one or all of them are pushing me down. It’s an odd reality to feel yourself not transitioning in anyway. In depressive periods, I call this a purgatory of moods. But that’s where I don’t feel much of anything. I’m in no mood state. Here, I’m trending into a mood state, but being resisted, heavily. Which is a good thing as my girlfriend pointed out. It keeps me sane. I’m still eccentric, but I’m very sane on these drugs. Which is a good thing over all, to be sane, but it doesn’t feel as good as being manic.

And that allure of being manic is something that I discussed with my psychologist. On these drugs, they don’t stop you from becoming manic. If I really wanted to. I could drink a six pack and load up on 2 pots of coffee and trigger the whole thing. I’d be completely gone and ready to take on the world for weeks. And in these states that I’m in right now, the need to push is so tempting. It’s like having a marvelous drug dangled in front of you and all you need is a little push in the right direction to get there. You don’t have to find some dealer, or shady access, or risk chemicals. Just a little alcohol and caffeine and I could fly as high as I wanted. It’s something I did naturally, before being medicated. I’d use those things to make me feel better and push my moods around as I wanted to. It’s almost a benefit that comes with being bipolar, while we are a slave to our mood swings, at the same time, we can push our moods around in ways that normal people cannot imagine.

Yet, as much as I want to push, I’m not going to. I’m resisting. One of the ways that I find useful is talking to my girlfriend about the things that I want to do, and have her organize it and tell me what I should do. As strange as it sounds, I cannot do that on my own. I need someone to tell me and process for me. And I’ll keep my klonopin going, even though I desperately want to end it and let my mania take hold. Instead, I’m going biking. And I’ll bike until I collapse. I’m shooting for 50 miles today. And after biking, I’ll feel relaxed and rested and ready to tackle something else. In the past, when I was slightly manic to manic, I would just bike my brains out and it felt wonderful. So I’m trying that again today. And hopefully, it’ll alleviate some of the desire to push the boundaries of what my meds can do.

Loud Music and Mood Shifts

Last night I ran a show for a group of ambient noise music. It’s a full spectrum experience where there is no beat to what is done, but there are dozens of sounds that you can listen to. If you are interested in expanding your musical horizons, getting into some noise like Add N to (x) will get you to places that most music doesn’t venture. Personally, I love it because every performance is different and unique to the space. I’m not going to hear the same folk set over and over again to the point that without hearing them, I know all the EQ settings and mixing levels. As a sound engineer, it doesn’t bore me. Additionally, with a pair of high quality speakers, the entire room becomes flooded with sound and it becomes a full body experience. Trust me, go to an avant garde showing sometime and if the sound is done properly, you’ll never have an experience quite like it.

In addition to sound, sometimes there are visuals that are projected on a wall that are responsive to the sound itself. Last night we had that too. It was amazing. Sound just flooded around me and the rapid flashing of visuals intensified all the aspects of it. But it did a lot more than just being unique, it also prompted mood shifts in me and a bizarre delirium.

I had two drinks by that time, but spread out over about 4 hours. And the sound and visuals just meshed together to alter my brain state considerably. I felt delirious and confused and thought I was going to have another psychotic episode. My body became numb and my arms felt elongated as well. I couldn’t think very well, I just reacted. What cognitive abilities did bleed through made me stop watching the visuals and plug up my ears so I wasn’t nearly as engaged. But I was clearly manic after it was done. And, more interestingly, I felt the shift happen in a matter of 5 minutes or so.

This got me thinking about cognitive loads and how they can produce manic episodes. Things like crowds of people can excite manic moods. The levels that I was dealing with were seizure levels of noise, music, and multicolored flashing visuals. So it’s no surprise that it changed me. But it changed me quickly and that’s what makes me interested in it. If it was the entire night that did it to me, that would be one thing, but to do it in a matter of minutes shows that at a certain level of intensity music and environment can really push one over the edge fast. And now it’s something that I have to watch out for. I normally bring ear plugs to protect my hearing, but it’s a must to allow me to block out unwanted noise from changing me. Especially since it could have gone a lot worse than it did.

Good news is that zyprexa again does its job. I woke up this morning and voila, mania is controlled. That stuff is amazing. It’s a bit more involved since I ride the line on dosing. Any lower and I won’t be able to control things, higher and it starts to zombie me, but right at 2.5, I only have to look out for problems at night when it starts to get low in my body. But I take it, it bumps my levels up, and I’m pretty much me again. Wonderful stuff, better than anything abilify did for me (which takes too long to act). And being at the minimal dose also allows me to have experiences like I had above. Not that I want to be manic (ok, I kinda do), but I can find my triggers really quickly and experiment in a safe way. I know the dosing to control my behaviors and that’s that. I’m learning a lot about myself as a result and that’s really fun in its own way.

Apartment Shopping, Hay Fever, and Antipsychotics

It’s that time again in Madison, time to shop for apartments. And that’s about all I have been doing in the past two days is looking at different apartments. I saw 12 in one day and over all nearly 25. It’s a lot of walking and the weather hasn’t been the greatest for it either. All wet and now slightly cold. Cold, that is, by comparison to the 85 degree heat we had previously. Thankfully though, that is all settled and the time to fill out applications is at hand. We have two, one we want and a backup, so we should be good no matter what. Hurray.

The other difficulty that has arisen is very early hay fever. I’ve been sluggish and feeling slightly ill for a few days now and it never really occurred to me that it was allergies. It wasn’t until today, where I slept in late and did nothing all day that I suddenly started sneezing after leaving the house. Allergy season has arrived and it’s not that pleasant. But, this is different from past years. Before, I used to pretty much get sick with allergies. My nose would run all the time and I would be completely out of it. When they say “fever” it’s very much like one. However, this year all that it’s done is made me sneeze, given me a small headache, and made me lethargic. My allergies have seemingly disappeared for all intents and purposes. This also goes for my dog allergies and my cat allergies (and I used to be very allergic to cats). They just vanished into thin air.

There’s a very good reason for this. Antipsychotics. Most antipsychotics, like seroquel, rispridone, abilify, and zyprexa, all act in some way on the histamine receptors, primarily H1 receptors (although some act on more). This often causes them to make you sleepy, just like benadryl does, but it’s the same mechanism of action for every antihistamine out there. This includes claritin and zyrtec. Everything acts on that receptor as its mechanism. So, while zyprexa is clearing the hallucinations from my mind, it’s also doing a fairly good job on taking care of my allergies. Actually, it’s better than just about anything else I’ve taken, far better than claritin and it’s a good margin better than zyrtec. I still have allergies, but a little sneezing and lethargy is better than being completely out of the game.

With all that said, since I’m definitely going to get hits by people who have allergies, I wouldn’t recommend taking an antipsychotic for allergies. For starters, seroquel and risperidone will knock you out cold, as in, you can’t walk after taking them until you adapt to it. And abilify, while everyone has their own experiences, it’s a drug that has a lot of phases and none of them are very pleasant. It took me a solid 5 weeks to fully adapt to it. Then there’s zyprexa. Which is fast acting, short half life, and can remove your emotions very quickly. It has the power, even at low doses, to stop a full psychotic episode in its tracks within 2 hours. I also know that there is a growing market for antipsychotics on a lot of off label uses, but these are heavy duty drugs that do a lot more than just attack your allergies. They can really mess you up and I fight tooth and nail with my psychiatrist every time she wants to raise my dose of zyprexa. I’m content with it being at 2.5mg, but not happy. It’s a necessary evil in my life that I would easily give up and go back to having allergies. The only reason that I’m thrilled is because I have to be on this drug, so it’s a perk that I get to enjoy.

Social Responsibilities and Bipolar Disorder

Yesterday was St. Patricks Day and I went with my girlfriend to one of her friend’s house to celebrate. It wasn’t the usual drunken brawl that Paddy’s Day is known for. Instead it was traditional food and some actual imported Guinness (not the Draught Guinness, the real Irish stuff). It was fun and we had a good time, and a little to drink. And there in lies the danger. Last time I drank a lot, I had an extraordinary psychotic episode. It scared my girlfriend considerably. But here, I was drinking a little.

What went wrong the last time, as near as we can figure, is that I metabolize zyprexa really quickly. So by the time that midnight rolled around and the psychosis started kicking in, I had really low levels in my body. It’s not like abilify that last for 4 days in your system, this lasts around 1 day. I must be on the short end of the half life metabolization, so I had the lower than average levels. The reason that my psychiatrist suspects this is because the psychosis went away after I took my normal dose. So I’m right on the cusp of it working. 5mg of the stuff will probably end any psychosis.

With this in mind, I did the socially responsible thing. At around 8pm, I went back to the apartment to take my meds early (I also knew that I was going to be drinking so I cut back on the klonopin earlier). That way they didn’t get too low and I’d be reasonably safe. I also didn’t drink all that much and kept them spaced apart fairly well. And surprise surprise, nothing happened. Instead, I was my usual mildly manic and slightly intoxicated self that goofed off. It was fun and relaxing, a good way to spend a saturday evening.

But while I was walking home, I was thinking about just how much more careful I’ve become and all the extra things I must take into account when having a good time. It’s not just that I’m trying to avoid having an episode and dealing with the fall out of possibly remembering it. It’s also that I didn’t want to make a scene if it did happen. One might call it a faux pas to have hallucinations at someone else’s house. Plus, it would have dramatically embarrassed my girlfriend. Honestly, I should have been carrying my zyprexa on me, but I didn’t.

It goes deeper than simply a dramatic faux pas. I’ve felt a new sense of responsibility in managing my moods. While a mania can be fun and silly, it does predispose me to being more aggressive. I’ve never acted on it, but the entire idea behind mania is that I’m not fully in control. Even hypomanias can straddle that line. And my psychotic episodes seem to be fairly benevolent and nice, if a little handsy with my girlfriend. So there isn’t any physical threat that is lurking in these episodes. That doesn’t mean that I should let them come out. With that thought in mind, I feel that I have to remain in control at all times. Even when I cut loose and have some fun, I’m still thinking about whether my meds will hold up or if I need to bring them along, or even if I should tell someone close what to do if I start getting out of hand. There’s really a social responsibility angle that I’m now seeing, where even if I don’t hurt anyone, I shouldn’t put them in a situation that they are not prepared to handle. I have been very myopic in my view of getting better, and now that I see it bleeding off on other people, I see the extra burdens that comes along with mental illness. One simply needs to be in control at all times. Which is hard, but eminently doable.

Of course, while this social responsibility is felt by me in terms of psychotic episodes and rampaging (though sometimes really fun) manias, it’s always been there for other people too. In terms of drinking, smoking pot, doing drugs, one still needs to know one’s limits and control them. Yesterday I saw a lot of people who were losing control while I was attempting to maintain it. But as mentioned before in a previous post, while part of the control is behavioral on my part, I also have drugs that I can rely on. The general public can’t pop a pill and become sober 45 minutes later before they make a total ass of themselves.

Let’s Talk About Sex

I’ve thought about writing this piece for a while. Having my mood swings, my interest in sex also fluctuates. In the low periods, I obviously don’t really care for it all that much. But during the summer highs, it means that I like sex, a lot. And I have sex, a lot. From what I’ve learned, I’m not a normal guy in that I don’t think about sex all the time, and even when I’m hypomanic I don’t. But I’m always in the mood. It comes with the territory of the highs. And now that I’m in a higher mood, I’m having a lot more sex. But it’s complicated by drugs.

It’s almost a fact that practically every drug that I’ve taken (with the exception of lamictal and lithium) has impacted my sex life in one way or another. And in reality, nearly every single one of the antipsychotics has some potential of sexual disfunction. I’m unclear about how disfunction is categorized, and I wouldn’t say that I had dysfunction, just lack luster sex. What’s worse is that reading about the side effects online gives me no insight as to what the drug does exactly. Sexual dysfunction could mean a lot of things, some I might tolerate, others I definitely would not. So in keeping with some standards of professionalism, I’ll try to keep this clean and use rather clinical terms, but be forewarned, this is going to get a bit TMI about how zyprexa and klonopin impact my sex life.

Zyprexa (olanzapine) at higher doses just strips away any sexual urge one can have, that also goes for emotional states. This isn’t surprising, but it is worrisome. Since I’m in a relationship, my girlfriend has needs and me simply not being interested is a particularly hard strain on the relationship. It’s not something that immediately comes to mind when one is thinking of side effects. After all, if you’re uninterested in sex, you don’t really care about what you’re missing, but other people do. And it’s a very selfish thing to say that I want to take care of myself over your interests without trying to find some balance. My girlfriend provides a great deal of stability as well in addition to filling emotional needs, not being able to reciprocate in a rather intimate way is unfair to her. And to be clear, when I say that it strips away sexual urges, I don’t just mean that I’m not in the mood, it means that I see her as an object that I eat dinner with. I’m thankfully off of the high doses of zyprexa and it doesn’t impact my sex drive any more, but it’s something of a conundrum where it puts pressure on relationships rather than just on yourself.

Zyprexa also has another worrisome side effect. In me at least (being male), it means that I orgasm nearly instantly. Sex lasts about 2 minutes. In terms of the history of this drug, it has been a monumental disappointment to go from no sex to lack luster sex. Especially since I was pretty good at it before all the pills arrived. Hypomanias and manias can produce incredible stamina, and that’s what my girlfriend first experienced. So zyprexa was a big let down.

Then there is klonopin (clonazepam). With my sex drive finally up and running again as my mind starts switching into more and more hypomanias, klonopin has been both good and bad. The good is that sex lasts forever now. My girlfriend loves that I can now go for an hour and that it hasn’t diminished my sex drive in the least. I actually want to have sex. It’s almost like alcohol, where I’m a little tired, but almost always in the mood. The bad news is of course that sex lasts for an hour for a reason. While zyprexa shortened the duration, klonopin has made orgasm nearly impossible. Sex is still enjoyable, but it’s just lacking in that respect. She likes it though, so I’m good with it.

I thought I’d share these things because they’re simply not reported in the side effects listing that one finds at RXList or Drugs.com. They also aren’t even mentioned by my psychiatrist when being prescribed them. And I think that these are relatively important things. Not nearly as important as remaining stable, but this is a side effect that can have damaging effects on relationships or enjoyment of life. Sex is not everything, but it’s a big one in terms of intimacy, and nearly every drug has the potential to have some impact on it. So if you like sex, ask about the side effects, because it impacts your partner as much as you.