Dr. Patricia Chen

Dr. Patricia Chen took over as Dawn's primary care physician today.

The conversation went like this:

*Dawn explains the ear pain and how she thinks it's an Effexor discontinuation symptom*

Dr. Chen: I agree with you

*Dawn chokes up with relief*

We discussed Dawn's previous treatments under her previous primary-care physician, which involved quite a few looks of shock and silent groaning from Dr. Chen. She explained several things:

1. Effexor, especially after being taken for nine years, deposits itself into the tissues and takes quite some time to get used up. Though it has a short half-life, when very small amounts get into the tissues it takes some time (six to eight weeks) before it's used up.
   
2. The ear pain represents a discontinuation symptom Dr. Chen witnessed with other patients. The solution involves going back on a low dose of Effexor to get rid of the ear pain, then gradually introduce the SSRI fluoxetine (Prozac, Ladose) for about a month. Once the body accepts the fluoxetine, gradually eliminate the Effexor, then stay on fluoxetine until the body uses up all the Effexor in the tissues. Then taper off the fluoxetine gradually enough so no problems occur (that is, no ear pain).
3. Dr. Chen made the same mistakes as our previous primary care physician. The difference--she took the initiative to follow-up with a psychiatrist and pursued information on effective best-practice treatments for tapering off Effexor. Our previous primary-care physician seemed to have such a high workload that he failed to make (have?) time to do this legwork.
4. Dawn began taking the lowest dose of Effexor (37.5 mg) today and already feels reduced pain in her ears.
5. Dr. Chen said that Dawn suffers from eustachian tube dysfunction, but that dysfunction does not account for the severe pain in her ears. Typically, eustachian tube dysfunction manifests itself as reduced hearing levels, echoes of one's voice, sort of like being underwater. I didn't ask her about our uneducated norepinephrine theory.
6. If Dawn doesn't respond, Dr. Chen's more than willing to refer us to an ear-nose-throat specialist.
7. Dr. Chen failed to have an explanation for why Effexor produces this discontinuation syndrome symptom--we don't think many people do know why it does this.
8. We weren't sure why having Effexor sticking around in the tissues might cause the ear pain--wouldn't having bits of it in the tissues be a good thing in the case of discontinuation? Obviously not, but we're not sure why. There's probably a simple explanation for this.
9. Dawn will finish out the course of prednisone--it might have minor side-effects but nothing serious.
   

It really represented everything we hoped for from a first visit. I called just after 8AM, got an appointment for 10:45AM, got the prescription from Costco by 12:00PM and home by 1PM.

If everything goes as planned (and it seems reasonable to expect that it might) we will only have these SSRI/SNRI medications around until roughly the end of September.

I've found the human cost in extricating oneself from Effexor alarming. Dr. Chen argued Effexor works in some situations--for example, post-menopausal women. She mentioned it represents one of the most difficult anti-depressants to discontinue.

Even worse--paroxetine (Paxil), which exhibits many of the same problems as Effexor but for which Dr. Chen doesn't have a tested discontinuation plan. Since paroxetine represents an SSRI, using it in combination with fluoxetine (another SSRI) proves problematic. Dawn used Paxil for one year many years ago, then her doctor switched her to Effexor. So that represents one lucky break.

In my opinion, doctors exhibit reckless behavior by putting patients on SSRI/SNRI class medications without extensive knowledge of discontinuation effects and how to successfully manage them. Dr. Chen learned the hard way--doctors like our previous primary care physician of two years still don't know even after watching a patient like Dawn endure three exceedingly painful attempts at discontinuation.

Even more alarming--Dawn's far from alone. Google returns 424,000 hits for "effexor withdrawal". A sharp contrast exists between horror stories on the Internet and the level of awareness in the four out of five doctors we interacted over the last three months.