Question: Major Panic Attack or Seritonin Syndrome.. I started Effexor xr 75 mg on Thursday May 17th. By Monday morning I noticed I was weighing in a few pounds light, thought it was great at the time. Abs were cracking more than usual so I was happy. I felt great, happy and clear until about 4pm I took 3 hits of strong marijuana and had a massive panic attack that put me in an ambulance. The attack lasted nearly an hour. The syncopy started as I stood up and I just couldn't gain my ground. I took Xanax the night before if that matters. Im ok now, but don't know how to proceed. I stopped taking the Effexor. I guess my question is, would I have had this attack if I had waited for my body to adjust to the Effexor, or is this a sign that this medicine isn't for me.

Dr. Stuart Shipko Says...:

Although drugs such as Effexor are prescribed for anxiety, it is not uncommon for the serotonin based antidepressants to precipitate serious panic attacks when they are first started.  The marijuana probably also played a role in this panic attack, as both the marijuana and the Effexor affect the autonomic nervous system.  Many people are able to use marijuana and antidepressants, but it was probably worse for you since you had just started the Effexor.  Often the serotonin based antidepressants are initiated along with a benzodiazepine such as Klonopin or Ativan to prevent the initial anxiety/panic that may occur.  It was probably a good idea for you to stop the Effexor, as you likely would have had more panic attacks.  This is a pretty common side effect.  You can still take this category of medicine.  One strategy to prevent initial anxiety/panic is to start off at a very low dose.  Another strategy is to start the medication with a benzodiazepine.  You should avoid marijuana at least until you are stable on the medication. 

Question: I quit marijuana 2 weeks ago and my tinnitus is through the roof. When will it go away?

Dr. Stuart Shipko Says...:

This is a pretty uncommon symptom, and I don't think that the phenomenon has ever been studied.  It is so uncommon that I went online to see if anyone was posting their experiences on marijuana withdrawal tinnitus.  People have reported withdrawal related tinnitus.  From what I could learn from the posts, it looks like it takes a few months for the tinnitus to resolve.  Tinnitus is an extremely common symptom and can result from a variety of medical conditions and medications.  It would probably be a good idea to see your doctor to make sure that the tinnitus is not due to an unrelated medical condition.

Question: Hello Dr. Shipko! Thanks so much for your quick answer. I got a bit of relief from just getting and answer ::-) I am still tapering off the Metoprolol. I am cutting smaller and smaller doses. It has taken me about 7-8 weeks to get from 50 mg 2x a day to about 10 mg. The sizes are progressively smaller for the 7 day container i have. I was planning to end it when it is done next week at about 6 mg. I was thinking of staying on the Lorazepam until the Metoprolol side effects are done. It has been a beast getting off and tired of thinking of having to get off another. I wish he would have told me ahead of time but i think he saw me on them for the rest of my life ( i am 54 now). I know why i have not seen a Doctor for 25 years previous. I guess they worked for the purpose he had in mind...but i am so glad to be getting my mind back. After reading everything on Lorazepam...i am starting to wonder if maybe some of the side effects have been from Lorazepam. Of course now the newest Dr. i saw ran a bunch of blood tests and i tested positive for Hashimoto's. He said it is very complicated. Yep it is but i want off the meds to see how bad the Hashimotos is. So maybe stay on Lorazepam for 3 more weeks or so and then start to wean. I will get your book. And although you live 11 hrs drive from me...are you taking new patients?

Dr. Stuart Shipko Says...:

I think that it is a good idea to wait until you are completely weaned off of the Metoprolol and stabilized on thyroid replacement before bothering to taper off of the Ativan (lorazepam).  Typically Hashimoto's thyroiditis results in low thyroid.  Often people associate high thyroid with anxiety, but I see anxiety commonly in patients with low thyroid as well.  My guess is that the reaction to tapering the Metoprolol was contributed to by the thyroid abnormalities.  You may need a bit longer than the three weeks that you mention, especially because adjusting the thyroid alone can take a few weeks.  My guess is that the Ativan is not the problem, but you are going to want to wean off of it eventually.

Question: Hello Dr. Last November i had a high blood pressure experience 230/120. Saw a Dr. and he gave me Amplodipine, Benazapril, and Metoprolol, 1mg Lorazepam as needed and a diuretic and Potassium Cloride 10 mg ER. Was a Zombie for 6 months couldnt work and saving down to about nothing. I lost weight,eating right,exercising and lost 50lbs. BP was getting better avg. 140-150/-85-95. I have to workto support my family so i weaned off of Amlodipine 2-3 weeks no problem started to think better. Then the benazapril and didnt notice much but as i started to get off the Metoprolol very slowly my anxiety went through the roof and needed more lorazepams. I initialy would take a lorazepam a few times a week...but it got so bad with the Metoprolol with anxiety and palpitations that the only thing that would help is the lorazepam. I have stablized at 12.5 mg per day of Metoprolol but my lorazepam usage has gone to 1.5 a day and i am barely making it throughout the day on that dose. I realize i am dependent and want off of them before i need more to get me through the day. The other day i felt amazing without a lorazepam until 3pm and i got a panic attack out of the blue. Took a lorazepam and i was fine. Yesterday i took 1 in the AM and it lasted all day. This morning i started to go for a walk and couldnt breath alll of a sudden and had another panic attack. took a 1 mg of lorazepam and evened out but not like it used to do for me. Not sure what to do? Maybe see if i can get a Dr. to prescribe equivelent of Valium and wean off of it using the Ashton (UK) method. I am in Ca. near Oregon Border and could use a Dr. who understands this. Any help is well appreciated. Thank You!

Dr. Stuart Shipko Says...:

These are questions that come up frequently.  I address these questions in my eBook, Xanax Withdrawal.  http://xanaxwithdrawalbook.com/  Although written primarily based on my experience with Xanax, the principles apply to lorazepam mg for mg.  I have gotten better results from a direct taper rather than Valium substitution.  Although the benzodiazepines are supposed to be cross tolerant, often there is not an 'equivalent' dosage of Valium and the transition period can be quite uncomfortable for these patients.    My approach also differs from the Ashton approach in that tapering strategies are very flexible with the patient having a lot of control over the speed of dosage cuts, and taking extra medication at times if it gets too uncomfortable.

It appears that you panic attacks related to  metoprolol withdrawal.  Palpitations can be caused by the alpha adrenergic rebound.  You don't mention exactly when you took the last dosage, but if you are still symptomatic and you are less than two weeks since your last dose of metoprolol  you might see how you feel after reinstating about half of the metoprolol and then tapering it slowly.  I don't imagine that the rebound would last longer than two weeks, so a test of the drug will not provide relief or useful information regarding the cause of your problem.

I agree that you should taper off of your benzodiazepine.  You bring the information in Xanax Withdrawal to your family physician or psychiatrist to develop a strategy for tapering.  Usually they are receptive to a reasonable plan. 

Question: Dr. I have a painkiller addiction and will abuse any controlled substance to avoid withdrawals. I know I need in patient treatment, but cannot have my employer find out. How many days is typical for in patient treatment?

Dr. Stuart Shipko Says...:

Inpatient care for opiate dependency is variable, depending on drug, dosage, duration of use, route of administration and a number of other factors.  I have had patients with the same issue you bring up:  the employer finding out, and I have seen some patients sneak in a detox while telling the employer that they are on vacation.  My opinion is that when you reach a point where you are going to need inpatient treatment, that this is primary and worry about what your employer - or anyone - might say.  My suggestion is that you find the best possible treatment program, get yourself healthy and worry about your employer later.  If you don't deal with your drug problem, it is going to end up ruining your career anyway. 

Question: Hi There, Okay I have been diagnosed with major depression and severe anxiety. I have had the same therapist for 6 years. My medications are trazodone 100mg at bedtime, Celexa 40mg in am, xanax 1mg 3 times a day. This has been working for years. Right now I'm going thru a tramatic time medically in my life. Last month my therapist left the practice to start her own. She is not up and running yet. So I'm seeing another therapist from facility. Right off without knowing me or what I'm going thru. She lowered my dosage of xanax by half. It's not working, I've been very close to going to the hospital. HELP

Dr. Stuart Shipko Says...:

What you describe is all too common.  In the process of marketing the SSRIs, such as Paxil and Prozac, the drug companies did their best to vilify the competition - Xanax.- to try to take a bite out of the Xanax market.  The dangers of the drug have been exaggerated.  Many clinicians have a knee jerk type reflex and feel this strong urge to stop a patient's Xanax whenever they see it has been prescribed.  Cutting the dosage is half is extreme and I am not surprised at your discomfort.  If you are unable to reason with your prescribing doctor, you might want to contact your long term provider and ask for some help in reinstating your usual dosage.

Question: If cocaine made my heart pound and skip beats does that mean that it almost gave me a heart attack?

Dr. Stuart Shipko Says...:

Cocaine increases the heart rate, and at the same time causes some degree of constriction of the blood vessels that feed the heart.  These are effects that occur each time it is used.  Cocaine can also cause arrhythmia at times, but this doesn't occur each time it is used.  Cocaine has the potential to cause a heart attack even in a young person who does not have heart disease.  The arrhythmia can cause an even worse problem, a cardiac arrest in which the heart stops beating entirely.  There may even be some cardiovascular damage such as higher blood pressure or thicker heart walls which persist after regular use. You definitely stressed your heart, but it would be difficult to know exactly how close you actually came to having a heart attack.

Question: Is it possible to get addicted to Ativan after only using it for 2 to 3 weeks? I had a bottle of about 50 1 mg tablets that I took over this period. I was going through a difficult break up and sleeping problems sadness are why I used them but I didn’t plan on using them after I ran out. I ran out about 36 hours ago and I have not slept and feel incredibly anxious ever since? How long will this feeling last. It is really horrible.

Dr. Stuart Shipko Says...:

In a word, yes.  You are not addicted in the classical sense, but have developed a dependency.  The rate at which this can occur is highly variable.  In your case dependency is more likely because you took a relatively high dosage.  Fifty 1 mg tablets over 20 days comes out to more than 2 mg a day.  I imagine that it made you really sedated at first.  I would have started a new patient on something closer to 0.5 mg once or twice a day - or even less.  Withdrawal symptoms tend to peak at around 48 to 72 hours.  Then it typically will remit over the next week or two.   I suggest that you call your doctor and get a prescription for a few 0.5 mg tablets and some tapering instructions. 

Question: I am 4 and a half weeks out of a 3 year Tramadol habit. I went cold turkey which was a bad idea. I was feeling pretty depressed for a while but that is slowly lifting but I still feel less positive than normal. Is there anything I can do to speed up the PAWS from tramadol? Do diets that are supposed to increase serotonin levels really make any difference? Could a long time use of tramadol permanently deplete my serotonin levels to a point where I would need to us an SSRI just to get back to baseline?

Dr. Stuart Shipko Says...:

Most people are surprised to learn that depression is not caused by a 'chemical imbalance' related to serotonin or any other neurotransmitter.  Actually, the chemical imbalance concept was originally a marketing strategy.  Chemical imbalances aside, depression that people experience when stopping opiates can sometimes be severe and may be associated with suicidality.  You describe a significant depression that has already improved.  Sometimes with severe withdrawal depression an antidepressant is needed.  If your depression has improved significantly the antidepressant is not needed.  I typically avoid prescribing any medications when people withdraw from medications because over time the prescribed medication may well become a problem.  When patients have mild to moderate depression I often recommend a supplement, SAM-e at a 400 mg daily dosage along with b-complex.  This facilitates synthesis of neurotransmitters and has a proven track record in helping depression.  

Question: We are trying to start a family and I have had 2 miscarriages in a row. My doctor says I am physically healthy in my womb so I should not worry about it too much its just bad luck. The one thing my doctor does not know is that my husband takes cocaine 3 or 4 times a week. Do you know if this can lead to miscarriage or birth defects?

Dr. Stuart Shipko Says...:

To date there is no body of scientific knowledge to support that drug use by the father will cause birth defects in the child.  In 1991 a study was done which indicated that cocaine could bind to the outside of the sperm, and that the cocaine might get into the egg at the time of conception.  This was speculative and has never been studied.  The whole area of paternal contributions to miscarriage related to toxins and substance abuse is an area that remains unstudied.  The common wisdom is that only the drug use of the mother is important, and for this reason I suspect that it is difficult to get a grant to study this problem.  While the problem remains unstudied, this does not mean that there is no problem.  It would be interesting to see how you do if your husband were to abstain.