March 15, 2011

Mark Foster, DO
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Bob–

I want to share with you a success story that has played out over the last three months.

I have been working with a woman in her mid-fifties who is wheelchair bound due to crippling arthritis and obesity. She is about one-hundred and fifty pounds overweight and suffers from all the accompanying serious medical problems, including diabetes, high cholesterol, high blood pressure and heart disease. Less than a year ago, she survived a heart attack and had a coronary stent placed. She is a simple and sweet woman, grateful to be alive, gentle towards her husband, and she trusts completely her doctors’ advice.

She and her husband are in a tragic and all-too-common situation. He makes too much to qualify for Medicaid, and yet they can’t afford insurance. She has been prescribed seven medications by her specialists and me, some of which are essential for her, like diabetes and heart medicines. However, she doesn’t take them regularly because she can’t afford them. The total monthly bill for her pills would be over $400, which is impossible for her. I have been able to help keep her afloat with samples and generics, but there is one medicine that she has been unwilling to go without: Effexor XR, at a cost of $150 a month. She has continued to take this preferentially over everything else.

I raised this concern several months ago and suggested we switch Effexor XR to something generic, or stop it altogether. This worried her, because she had been on it for twelve years, and the one time she had tried to come off of it, she had a horrible withdrawal reaction. Eventually, I helped her understand that due to cost, side effects, and inefficacy, it didn’t make sense to continue Effexor XR at the expense of her worsening diabetes or heart disease, which if not controlled could lead to her death. She chose to try to wean off of Effexor XR over a four-to-six week time period, a plan supported by her husband.

We decreased her dose in increments week by week, and she handled these adjustments fairly well. But when the time came to stop completely, she began to have difficulty. At first, her complaints were physical: nausea, dizziness, blurry vision, headaches. These symptoms were expected, and we treated them with temporary pain, nausea, and anxiety medicines. I offered her the chance to resume the medicine at the lowest dose and slow down the withdrawal, but she declined. By this time, she was committed to weathering the storm and getting through it sooner rather than later.

Then things got worse. About a week after stopping, her emotional state dramatically declined. At a follow up visit, I walked into the room and was startled by her appearance, disheveled and scowling. She snapped at her husband, who had a frightened look on his face, like he didn’t recognize this person anymore. She began sobbing within seconds of my greeting. She expressed anger, despair, wanted to vaguely “run away” and get divorced, and said passively that she wished she could die.

This was very concerning to me. Part of me felt like we were at the peak of the withdrawal, and if we could just hold on, things would get better soon. But another part of me thought that we had gone too far, too fast, and that without tying her into additional resources, I had set her up for failure. She couldn’t afford counseling or inpatient care, and basically, she had only her husband and me to rely on for support. I feared that she was a person who had been on meds too long, who had too many strikes against her and would never successfully wean off. After careful discussion with her and her husband and determining that she was not at risk for suicide, I advised her that I thought we should resume a generic SSRI, take some benzos for anxiety and sleep, and then reassess the situation in a few days from a more stable vantage point.

Then an interesting thing happened. Slouching in her wheelchair, she looked at me through bleary eyes, peering from a depth of soul through the fog of despair, searching for any glimmer of sunlight. She said she didn’t want to give up yet. She hated that a medicine could have this kind of control over her. She asked desperately, “You said this part would only last a few weeks. Do you think I’ll ever be well again?”

I considered how to respond, knowing that she would cling to whatever I said, wanting to help her both now and in the long-run, wary of being wrong or overly-optimistic, equally wary of being pessimistic and giving up too soon, right before the moment of victory. There was no guidebook for this moment, no protocol for this decision. I was taking a step into the dark, and I knew that she would be following my lead. That was a lot of responsibility, and a pivotal moment in her life, so I had better be right. I thought of what I knew of her from all of our previous interactions, what she would have wanted me to say in this very moment if she could have foreseen it, and I decided to reach for hope, for her and for myself.

“Yes,” I said carefully, “this part will be over soon, maybe tomorrow, maybe next week. But yes, you will feel well again. If you promise me you will be safe, then I want you to go home, take this valium, and sleep. See me back in three days. If you are still willing to fight through this, then I will fight with you. I think you are very brave. Your brain is resetting after years on this chemical, and you will get better. There are brighter days ahead, I promise you.”

She nodded through tears and said, “Okay, Doctor. I trust you, I trust you.” Her husband agreed to this plan, and we established some emergency protocols. They made a follow-up appointment, and he wheeled her out of the clinic.

That was two Mondays ago. I am happy to report that when I saw her back the following Thursday, she looked like a brand new woman. She was smiling. She felt physically well and emotionally stable. She had hope in her eyes and voice. Her husband looked relieved. He had watched over her while she slept for most of a day, and when she awoke he said it was as though the fog had lifted. Now, she was herself again.

I was relieved, too. I am going to continue to follow up with her weekly for the foreseeable future. With the money she is saving, I hope to have her visit with a counselor at least a few times. We are working to get her other health problems under control. We will surely face more obstacles going forward. But that is life, is it not? Obstacles, challenges, failures, triumphs.

It seems to me that she is a person who was originally medicated because it was assumed by well-meaning medical professionals that she lacked the aptitude or desire to cope with life on her own terms. I wasn’t involved in that decision, so I don’t want to judge, and maybe their approach served a purpose in its time. But I think they underestimated her. I almost did, too. She is resilient, and has a glowing fire of resolve and toughness within her that is now shining through. She has just completed a very difficult thing, this Effexor withdrawal, and I believe her victory will bolster her self-concept and sense of inner strength. That bodes well for her future mental and emotional wellness, no medicines required.

Mark