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Reader feedback and discussion
Here you'll find reader suggestions and other feedback I've received since the beginning of 2011.
Vanda from Nova Scotia, Canada, writes:
I realize that I am off by a few years but hope you are still receiving comments. I found your article very interesting.
Yes, I am a very sensitive to painful events, my own and others as well. I am looking for a solution to ridding myself of so much pain and how constant it is and how it has taken over my life and made me lose who I really am. All you have said rings very true, except in order to be well, I have always remained true to what has caused my pain. No embellishments or to heal from something false would not work (just my personality).
That is not to say my pain hasn't kept me from isolating myself from other's emotions and how selfish it makes me. But because I try to stay true to the causes, the monsters are real. It is the way they were handled afterwards that caused more of the trauma. Hence the event wasn't as bad as the result.
Your comment at the end about, if you are surrounding yourself with people who [not trigger] bring on emotions that I have felt in my past, is where I am at now. I know there are personalities out there that totally make me feel terrible fear, rage, distrust etc. I have not figured out what draws them to me and how to keep them away. I do not accept their inability to respect life but my efforts to battle the demons makes me an ongoing target.
LOL Sorry for laughing but that last bit did sound like it was making a mouse out of a mole hill. I respect everything you have pointed out and will certainly take your advice. Sincerely, Vanda
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Dear Vanda,
Thanks for your comments, and yes, I am still receiving and posting comments as they come in.
Sincerely,
Jim Gagne, MD
A reader asks:
Does Clarithromycin stop a cough? How long should it take before it starts to work? (1000 mg a day) And if you crush a pill does it ruin its effectiveness?
And Lisa from Cardiff, England:
Hi, I found that article on tricyclics very informative, what I would like to know is can you take them if you have COPD, and should you be monitered closely when first taking them?
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Dear Folks,
These questions are about specific medical issues. I can't answer these online. Please ask the physician who knows you.
---Jim Gagne, MD---
Jim from Yucaipa California says,
Great site, very informative. Please e-mail me when you can. I'm very interested about treatment.
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Dear Jim,
I don't email prospective patients because it's not secure. Please call the office if you have any questions or if you would like to make an appointment.
---Jim Gagne, MD---
A reader from Dublin, Ireland writes:
I found your article on PSA excellent. It's pretty tough being a committed skeptic with persistently high PSA and two negative biopsies.
I found this very convincing -- 1410 men would have to be screened -- and 48 men would have to undergo the rigors of treatment -- to prevent one prostate cancer death.
I am due to go to see my consultant shortly and I feel much better prepared after reading your article.
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Dear Sir,
THANKS for the feedback. Some experts in the U.S. are now saying the PSA is a bad idea for men more than about age 65 years old, but it may be useful in men in their 40s and 50s. There's no data to support this contention, but it's an area of intense controversy.
---Jim Gagne, MD---
Courtney from Fort Lauderdale, Florida says,
Loved your site, and enjoyed the green elephant exercise.
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Dear Courtney.
THANKS!!
---Jim Gagne, MD---
Maria from Laguna Nigel, California, writes:
You sound like the doctor I need. I am on 300mg of effexor xr and 50 mg seoquel he claims he is using as an adjunct to effexor. i have been on effexor for 5 months and nothing is working. I am not bi-polar or manic, I am depressed, i am seeing a therapist where we are working things out but i need the chemicals in my brain to work. can you help me. I wii gladly travel to glendale. please can you help me.
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Dear Maria,
As you'd expect, there's no way to tell if I can help unless we meet and I get to know you. I'd love to see you and discover whether I can help.
One thought -- I may not be exactly the right specialist for you. It sounds like your problem involves medications for depression. My experience in this area is that while I'm familiar with almost all of these medications and use them extensively, my psychiatric colleagues get better results with the same drugs. So while I'm better than a bad psychiatrist, a good psychiatrist can get better outcomes than I do. I do have good people I refer to. (Note: many of the good people don't take insurance, so it may cost you more money out of pocket.) I would guess I refer my patients with depression to a psychiatrist about 30% of the time.
If you're interested, call my office and set up an appointment.
---Jim Gagne, MD---
Angela from Burbank writes:
I'm a current patient of Dr. Gagne and I've been trying to login to the secure email section but everytime I've tried this I receive a Service Temporarily Unavailable. Is this still working?
Thanks, Angela
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Dear Angela,
The bad news is that I had a falling out with my previous ISP (internet service provider), who was hosting the secure email service. So it hasn't worked for about a year. Also, though I do have a complete database of users and their messages, that's current only as of January 2010. New email users and messages from February through June 2010 have been lost (although I kept hard copies in everyone's charts). The previous ISP decided one day in June just to delete everything, and he never responded to my messages asking if there were an up-to-date database.
The GOOD NEWS is I have a new ISP, and yesterday I completed the work of upgrading the secure email so it will run on the new server. (It's a LOT of work.) Everything is there up to January 2010. I hope the secure email service will be up and running today! Everyone previously registered on the service through 1/10 will get an email when it's up and running again, assuming their email address on the system is still current.
Warmest regards,
---Jim Gagne, MD---
Suzanne from Glendale says,
I just stopped by the site for a visit and so enjoyed reading a number of your articles. Although I am stuck in an HMO with my current employer and disillusioned with my PCP, when I change jobs I will be putting a high priority on a benefits package that allows me the option of paying extra for an "out of network" physician. I never felt so safe as when you were my doctor and look forward to the opportunity to be your patient once again.
In the interim, I can visit this website and read your thoughts and recommendations. LOVED the article about health care reform. I had wondered what you thought about it all. Your articles really help keep your readers informed.
By the way, I still work in Workers' Comp law and delight in telling my associates about my WC injury in the 90's in which you were my PTP. The defense doctor wanted to rate my Permanent Disability. You said, "Let's take a different approach than rating the PD. Let's get the patient well." You did it. Zero PD and I couldn't be happier.
Thanks for keeping this website going. And please give my best to your wonderful and gifted "other half". Boy, was that a terrific one-two punch when you practiced together! Please feel free to print part or all of this as you feel it is appropriate for the website.
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Dear Suzanne.
THANKS!! I definitely look forward to working with you again when you can do so.
Warmest regards,
---Jim Gagne, MD---
Karen from Los Angeles writes:
At the end of your article in the section "Antidepressents for Pain" you mention that "In an upcoming discussion, I'll describe a promising new pain-relieving antidepressant medication, Cymbalta." However, I cannot find where you wrote about Cymbalta. Can you please let me know where it's at on your website.
Can you also share your thoughts on the newer fibromyalgia pain/fatigue medications Lyrica & Savella?
My main question is, if someone takes an ongoing daily medication like Cymbalta, Lyrica, or Savella for pain and fatigue, how does the patient know if they are getting better? For example, if the medicine works positively, and allows the patient to get some relief from the symptoms, and then (for example) they are able to start exercising more, perhaps their body would begin to heal from the pain & fatigue. Can subtle changes in health be felt while on these types of medications? If so, do you have any thoughts about how long the patient should take them (before stopping them to see if their body feels okay without them)?
It can be intense for patients with chronic pain & fatigue, and I know that assistance from medication can help. But I wonder how a patient can keep track of their actual state of health if the symptoms are masked by the medicine. Especially with these types of medications that you have to take daily.
I also read in your "Fibromyalgia" section that you feel that pain killers like Vicodin are the "wrong medications" for treatment. I agree, in that they are just band-aids and a short-term approach. However, since medications like Vicodin can be used on an "as needed" basis, doesn't the patient have more control in assessing how their body actually feels on a day-to-day basis? (As opposed to medicine like Cymbalta which needs to be taken daily and is, therefore, constantly masking symptoms.)
Sorry for the long-winded question(s). I hope I am articulating this okay. Just wanted to get your perspective on these things!
I was so glad to find your website and see how open you were to discussing all different types of healing modalities including meditation and the mind-body-spirit approach. As someone navigating a healing journey myself, it was refreshing to read.
Thanks for your help!
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Dear Karen,
THANKS for your feedback, and I'm glad you find the site helpful. You're right, I need to bring this discussion up to date.
I'm using Cymbalta extensively for treating fibromyalgia and other types of chronic pain. It's not a panacea, but often it's incredibly helpful. One can usually avoid troubling "start-up" side effects like nausea or diarrhea by starting with a low dose and then gradually increasing it. Overall, side effects from Cymbalta are much less than with tricyclic antidepressants, and it may work better.
Lyrica (pregabalin) works best in treating "neuropathic pain" -- pain due to injured or sick nerves. There's no convincing scientific evidence it is more effective than Neurontin (gabapentin), although often individual patients will respond better to one or the other. Lyrica's effect on fibromyalgia is less impressive, although certainly there are those who do well on it.
I have little experience with Savella.
You ask how long people should be on Cymbalta, Lyrica, or Savella. This is a highly individual decision, because every person's situation is so different. Indeed, some people find relief lasts for a few months and then diminishes. I agree that the best treatment for fibromyalgia is vigorous physical rehabilitation ("functional restoration"), taking care not to overdo it or cause flare-ups. I don't agree that these medications typically mask symptoms or the ability to perceive your underlying health, although on occasion any antidepressant can cause one to feel emotionally "numb." This is a dose effect and can usually be resolved by cutting back on how much one takes.
Emotional dysregulation (i.e., often feeling emotionally overwhelmed) is an important aspect of chronic pain in many patients. All of these medications help people manage painful feelings, which is one of the reasons they can be so helpful.
One can cure fibromyalgia and similar painful conditions by gradually becoming fit, flexible, and strong on the one hand and mastering self-management and self-soothing techniques on the other. This takes time.
Short-acting opiates like Vicodin often worsen emotional dysregulation and frequently exacerbate the pain cycle.
---Jim Gagne, MD---
Lori from Cocoa Beach FL writes:
Hi. What a great page! I went online to find out some information about high blood pressure and this was really informative and helpful. Thanks for putting it out there since it is good valid info (there is a lot of strange stuff out there)
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Dear Lori,
THANKS!
---Jim Gagne, MD---
Paul from Ohio writes (lightly edited):
I am quite intrigued by your varied and holistic approach to the health of the individual in general and your insights into addictions in particular. The videos on the site: "Extaordinary Maturity" I found rather interesting and brought to mind much that I could identify with. As an alchololic/addict I was graced with sobriety and fellowship. In 1989 at the age of thirty two-I was an active member engaged in the process of recovery and growth for nearly 11 years.
However, I became complacent. With a back injury (knowing better), I started on a prescription pain medication addiction, which took me into a darker more isolated and pathetic state than I was in at age 32. Had the doctor that prescribed the Oxycontin, Diluaded and Valium not lost his license, I would not be alive today.
Even if I was a co conspirator, I am grateful that he did.
After acute narcotic withdrawal-induced psychosis and a subsequent stay in a psychiatric ward of the hospital, I am grateful to say that I am able to participate in my own recovery today -- even more than before -- and give back. I am able to share the message so freely given to me now in local psych wards and treatment facilities.
In the videos you mention the disowned parts of self and "radical acceptance." Might I recommend The Spirituality of Imperfection by Enest Kurtz & Katherine Ketcham ? And as to the parts of self what about Jungian notions on archetypes, William James Varieties of Religious Experience etc...?
As to culture and religion, my latest work on healing has to do with my indoctrination into Catholicism and subsequent religious experiences in Christianity. I am coming to grips with the cognitive dissonance so prevelant in the core of that religious segment, at least with respect to "orthodoxy." I found that love resulting from fear of punishment or seeking reward is inauthentic and impotent. Ultimately I am intrigued with mindfulness that you mention and the distinction between self (observer) and ego.
I found it critical to my own recovery to understand that recovery isn't about becoming "adjusted." Let's face it, the biggest illusion in this life is the game itself. I realized that much of what is taught, promoted, consumed and idealized in our patriarchal society demeans the individual, creativity, and imagination. It pits the individual against himself/herself. Since I have had the tendency to compare my insides with the outsides of others, I enjoyed your reference to the book by Julia Cameron, The Artist's Way and the revelations of the subconcious/unconscious though I must admit it is daunting to dilegently ascribe to the process (for me). Finally, are you familiar with Alan Watt's, particularly Psychotherapy East and West or Nature, Man and Woman?
I wish to thank you for your work in this area and encourage your further efforts. peace, Paul
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Dear Paul,
THANKS for your kind words. I am familiar with the books you mention and agree they are highly worthwhile. I recommend them.
---Jim Gagne, MD---
A reader in Charlotte NC writes (regarding What Your Mother Didn't Tell You):
What a great article! Here's my question:
As a caregiver of a chronic pain patient (daughter) would it be wise for me to say these things out loud to her? It seems she can pick and choose went to "accept" and push through the pain and when not to.
Thank you for a great website.
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Dear Ma'am or Sir,
Thanks for your kind words. I would think that most people with chronic pain would not be receptive to being told they're attached to their pain. A more helpful perspective is that often, people with pain get trapped in a downward spiral and don't have the skills or resources to stop. Improper medications can worsen being stuck. Addiction and depression can play a role, too.
You might want to share with your daughter the pages on my website you found especially compelling. Ask her what she thinks.
The most important understanding of chronic pain is that it is usually a complex and difficult problem. There is no simple, one-size-fits-all answer. You have to find what's happening with that individual patient. Yet many patients with pain have a lot of things in common, which is what I was trying to get at here.
I despair that much of what passes for treating chronic pain deals only with the physical aspects of pain -- and then focuses on approaches that pay well.
Hope this helps,
---Jim Gagne, MD---
Ed from Beaumont, CA, asks:
I was wondering if you had experience with or ever heard of Procardia XL being prescribed for social anxiety disorder. I was recently switched to this medication after Toprol XL did nothing to help me besides reduce sweating slightly.
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Dear Ed,
It's news to me; haven't heard anything one way or the other. Procardia dilates small arteries and lowers blood pressure, so biologically it's not something I would expect to help ("biologically implausible").
---Jim Gagne, MD---
Ellen from Toronto, Canada writes:
I found your article very interested since my doctor has suggested me to add Wellbutrin to boost the Effexor XR. Something that is unclear to me is the difference between the generic and the brand names. I was on the generic Effexor XR for four weeks and doing better and better (225mg) and I switched to the brand name (225mg), and I felt much worse for two weeks. It is now my fourth week on the brand name and I'm still not any better (anxiety, irritable, some insomnia). I didn't any of those side effects with the generic when I started at low dose and got to 225mg in the third week. So why this is happening? It's supposed to be the same medication. Dealing with anti-depressants is very hard, and once you find that something is helping you, and after getting a brand name and paying even more, and you feel worse, you just get so disappointed and frustrated.
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Dear Ellen,
This is yet another example of how it's impossible to know what's really going on without seeing the patient in person. What I can say is there's little if any difference between brand name drugs and generics in the U.S., because the Food and Drug Administration mandates equivalence. That said, it's certainly true that generic versions of some extended-release medications may have different absorption characteristics than the brand name -- in other words, you absorb the same amount of the drug but the time curve may be different.
If you felt better on the generic...
But that may not be the problem. The difference may be time: antidepressant medications have different effects for the first few weeks than they do once you've taken them for a while.
Discuss this with your doctor. A recent NIH-funded study showed that patients with depression have complete remission of their symptoms only about a quarter of the time with the first drug they're given. Expert antidepressant treatment increases the rate of complete remission to 50%, but that doesn't include the many patients who feel substantially but not completely better. These drugs work well, but sometimes they require expertise in their use. Also, remember that while drugs alone are effective, you get substantial added benefit from psychotherapy, particularly cogntive behavioral therapy. CBT is training in how to stop yourself from augmenting and amplifying anxiety and depression.
---Jim Gagne, MD---
Nancy from Edmonton in Alberta, Canada writes:
I recently read your receipe for a meal replacement shake. Most people talk about having them for breakfast and lunch, but I was wondering if I could have one for supper. I have the Costco whey, and it has 39 grams of protein. Can I have that much protein in one sitting and around 5.30 at night without being hard on the kidneys or disrupting my sleep?
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Dear Nancy,
I have two thoughts. First, the meal replacement shake has relatively good nutrition and can certainly replace two meals a day, but you should have something else for the third meal, preferably with more fresh vegetables. It doesn’t matter which two meals you replace.
Second, if you have diabetes, hypertension, or kidney or liver problems, you should check with your doctor to see if that much protein is okay. Usually high protein is a problem only in people with advanced kidney or liver disease.
---Jim Gagne, MD---
Kent from Illinois asks:
For an 8-year-old that had infection that passed through the nasal passages lodged behind eye. This child had to have surgery to remove the infection. How long should Dr use Flonase therapy to prevent inflamation while the child matures?
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Dear Kent,
There are two problems with your question. First, as an internist, I don't treat children. Second, I cannot address how to treat a specific problem in someone without seeing that patient in person.
---Jim Gagne, MD---
Marla from Texas writes:
I have been taking Wellbutrin at 100 for about a week and at first I felt ok then kind of flattened out. Added another dose 5 hours later. I have been on this regimen for several days and feel extremely tired and foggy with 2nd dose. I need something to get my brain energy and firing right.. Please help
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Dear Marla,
I'm afraid this is just the sort of personal medical issue I can't answer at a distance. If you'd like my help I would need to see you in person.
---Jim Gagne, MD---
A reader from San Diego asks:
What's the highest blood pressure ever recorded on a person at rest?
What are the numbers at the high end of the "severe" blood pressure range -- not the world record in just one person, but numbers that a lot of people have reached in the severe stage?
Can severe high blood pressure cause a brain aneurysm, or an aortic aneurysm, in a person who does not have a preexisting defect?
It was discovered recently (due to chest pains, slow pulse and difficulty breathing) that my 47 year old, 5'5", 130 pound Chinese friend's blood pressure was 230 over 112. I'm very worried about her.
Can severe high blood pressure (230/112 for example) be brought down to into the normal range, or only into the "not as bad" range?
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First, blood pressure can vary enormously throughout the course of the day. The reading that counts is the "resting" blood pressure -- when you're just sitting there feeling comfortable and relaxed and haven't just done anything strenuous or upsetting.
There is a syndrome of "malignant" hypertension in which prolonged and extremely elevated blood pressure hasn't been diagnosed or treated. Physicians rarely see malignant hypertension except in medically underserved populations. This condition can cause brain swelling, coma, and death. It's a medical emergency. Prolonged systolic blood pressures of 220 or more and diastolic readings of more than 110 can cause this condition.
Aneurysms are strongly associated with hypertension, though I don't know if anyone could tell if there were a "preceding defect."
It's impossible to tell for sure just from your description, but I also would be concerned about your friend. Just guessing, I would expect that she was having hypertensive heart disease with congestive heart failure. Vigorous treatment can restore her blood pressure to normal, although it's possible her heart has sustained permanent damage. Kidney damage is another concern, and severe kidney disease can produce the picture you describe.
---Jim Gagne, MD---
I've just fixed the feedback system, so now I can now receive reader comments. (I hadn't realized Feedback was broken.) I'll post pertinent comments in this space.
---Jim Gagne, MD---
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Last updated Sun, Jun 19, 2011
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©2011, James Gagné, MD