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Tuesday, June 11, 2013
When someone is severely depressed, immediate action is essential. That’s because without help or hope, a suicidal person may do himself irreversible harm.
The trouble is that most antidepressant treatments do not act quickly. It can take up to six weeks for medication to kick in. That may not be soon enough for someone with overwhelming depression.
In such situations, patients may be admitted to a psychiatric ward (voluntarily or involuntarily), where they can be observed and protected. Many such facilities are overwhelmed, however, and may not offer a healing environment.
An old medicine in new form may offer unexpected hope for such patients. Ketamine has been used as an anesthetic during surgery since the early 1970s. During the Vietnam War, it was called the “buddy drug,” since it could be administered on the battlefront by another soldier.
Ketamine continues to be prescribed for surgery on children and in veterinary medicine. The problem keeping it from being used more widely as a surgical anesthetic is that ketamine creates “dissociation.” Users may feel disconnected from their environment and may experience distorted perceptions or even hallucinations.
While the dissociative experience posed problems in surgical recovery rooms, it made ketamine appealing as a club drug. Known as “Special K,” ketamine is used around the world during raves or dance parties.
Researchers are rediscovering the fascinating pharmacology of this medication. Unlike conventional antidepressants such as fluoxetine (Prozac) and venlafaxine (Effexor), ketamine impacts the brain in a completely different way. Some small studies have uncovered remarkable effects against hard-to-treat depression.
Instead of taking weeks to change brain chemistry and relieve suicidal thoughts, ketamine goes to work rapidly. One pilot study compared a ketamine injection to placebo. The active drug produced a “robust and rapid antidepressant effect” within two hours that lasted nearly a week (Archives of General Psychiatry, August 2006).
A disadvantage of such therapy, however, is the intravenous administration. It is inconvenient for many depressed patients to return to the doctor frequently for injections.
That is why there is such interest in a new formulation called esketamine, developed by the Johnson & Johnson pharmaceutical company. This medication can be used as a nose spray. Preliminary results are promising.
Other companies also are pursuing compounds that work on the same brain chemicals. GLYX-13 is being developed by Naurex. A study published in the journal Neuropsychopharmacology (April 2013) found antidepressant activity without ketamine’s dissociative side effects. The company is working on an oral version that could be used for treatment-resistant depression. These new drugs are likely to be submitted for FDA approval within the next several years.
In the meantime, however, some psychiatrists are already using ketamine injections for selected patients. Doctors can do this legally because ketamine is an FDA-approved anesthetic drug.
Such off-label prescribing has unknown drawbacks. We don’t know how long-term use will affect brain function, but in a suicidal emergency, the short-term benefit might outweigh the risks.
Q: I’ve heard about a therapy in which a sugar solution (no steroids) is injected into an injured joint. The theory is that it irritates the joint into repairing itself or something. Is there anything to support this approach?
A: You are describing prolotherapy, a treatment that was pioneered in the 1930s. It involves the injection of dextrose (sugar), glycerin or other substances such as platelet-rich plasma or stem cells into the affected area. Prolotherapy injections are thought to stimulate healing.
Recent research supports this approach in osteoarthritis. Scientists at the University of Wisconsin recruited 90 people with knee pain. They were randomly assigned to receive injections of dextrose or saline (as a placebo control), or to do specified physical-therapy exercises (Annals of Family Medicine, May/June 2013). Injections were administered at least three times in five months, and the volunteers were assessed at one year. Those who had been given dextrose injections had significantly more improvement in their knee pain than those in the other treatment groups.
To learn more about prolotherapy or to find an expert in this treatment, you might consult the American Association of Orthopaedic Medicine (www.aaomed.org).
Q: When I was a kid in the early 1960s, if I had a sore throat, Mom would put a glob of Vicks VapoRub on the back of my tongue and tell me to swallow it.
I understand now that it’s for external use only. Has the formula changed since then? I honestly can’t remember if it helped get rid of the sore throat, but I do remember the horrible taste.
A: We’re not aware of any change in the Vicks VapoRub formula. It contains camphor, eucalyptus oil, menthol, cedarleaf oil, nutmeg oil, thymol and turpentine oil along with petrolatum (petroleum jelly). Camphor is somewhat toxic when ingested, which is why the makers of Vicks warn that it is for external use only.
Q: My husband takes blood pressure medicine (lisinopril, carvedilol, clonidine and amlodipine). In addition, he takes amiodarone and Plavix for his heart.
I believe that some of these drugs are wiping him out. He can barely keep his eyes open by 10 a.m. after taking his pills at breakfast. He used to garden, take walks and play doubles tennis twice a week. Now he spends most of his time in the recliner because he has no energy. If he took his pills at bedtime, would that be better?
A: It is unlikely that taking all these meds at night would solve the problem. Instead, he should have his medications reviewed by his cardiologist. Several of them (amiodarone, amlodipine, carvedilol, clonidine) can interact badly with each other to aggravate his heart condition.
Perhaps the doses he was placed on years ago need adjustment. As people age, their susceptibility to side effects can change.
We are sending you our Guide to Drugs and Older People and Drug Safety Questionnaire for details on how to keep medicines from contributing to cognitive decline and other complications. Anyone who would like copies, please send $3 in check or money order with a long (No. 10), stamped (66 cents), self-addressed envelope to: Graedons’ People’s Pharmacy, No. OQH-883, P.O. Box 52027, Durham, NC 27717-2027. They also can be downloaded for $2 from our website: www.peoplespharmacy.com.
“The People’s Pharmacy with Joe and Terry Graedon” airs Saturday at 7 a.m. on WVTF (89.1 FM) and at 4 p.m. Saturdays and Sundays on RADIO IQ (89.7 FM). Joe and Teresa Graedon’s column runs in Tuesday’s Extra.
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