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.

Eustachian Tube Dysfunction

Dawn's suffering from eustachian tube dysfunction right now. It's an awfully painful condition where the middle ear fills up because the eustacian tube closes due to inflammation (see above image).

A healthy eustachian tube (named for Eustachius) opens to equalize pressure in the middle ear. That popping feeling when you gain or lose altitude? That's the eustachian tube opening to equalize pressure in your ear. See this EarDoc advertisement for an explanation of what happens: http://youtube.com/watch?v=XdqrGaUF5EQ (I love the duck).

Dawn tapered off of the anti-depressant Effexor on Wednesday, July 16th and began experiencing symptoms on Thursday, July 17th, with the pain gradually increasing in severity. Dawn experiences the ear pressure pain each time she tapers off Effexor, this being the third time. It's not listed as a common side-effect on the Effexor patient information leaflet. Since she's experiencing considerable, chronic pain, we visited her primary care physician on Friday, July 25. He assured her there's no danger of rupturing of the eardrum and noticed a bulge in her right eardrum (where most of the pain occurs).

Since we don't have a good track record with her primary care physician, we're switching doctors immediately to a highly-rated female doctor closer to home, Dr. Patricia Chen. On Saturday, July 26, we visited Med7 and got another opinion. He prescribed prednisone, a steroidal decongestant, and recommended seeing an ear-nose-throat specialist if it didn't work.

Well, it's not really working, two days in--though seven days remain, the bulk of the prednisone is taken in the first three days. So, we're guessing that we'll have to see an ENT specialist as soon as we can.

Our latest theory here takes into consideration the fact that Effexor acts as an SNRI (seratonin-norepinephrin reuptake inhibitor) boosting the levels of norepinephrin in the body.

Since pseudo-epinephrine aids in reducing swelling, we theorize that increased levels of norepinephrine (adrenaline, basically) possibly aided with reduction of swelling in Dawn's ears (caused by allergies, most likely, the Central Valley being the allergy capital of the world), thus keeping the eustachian tubes open and draining/equalizing the pressure in her middle ear. This theory has the support of some empirical evidence--each time Dawn goes back on Effexor (even temporarily) the pain diminishes immediately. Dawn's a bit skeptical, since she felt even worse pain when she tapered the first time--she thinks it might be a possible side-effect.

We guess that once the boosted levels of norepinephrin disappear (as Dawn ceases taking the SNRI), the swelling increases, shutting the eustachian tubes, filling the middle ear with fluid and causing the painful pressure on the eardrum.

Thoughts? I'm pretty ignorant in this area but have been reading as much as I can. We may be completely off-base. The doctors we've talked to have no clue about the correlation between Effexor discontinuation and the ear pain though, so perhaps our opinions make at least a bit of sense.

If worse comes to worse, an ENT can perform a myringotomy--but obviously we're hoping it doesn't have to go that far. There seem to be some devices on the market (like the EarDoc, http://eardoc.info, and the EarPopper) but they're expensive and we're skeptical without knowing more. On Monday we make an appointment (hopefully for as soon as possible) with Dr. Chen. We're hoping that we can get an immediate referral to see an ENT specialist ASAP.