Thursday, February 26, 2009

Help in Small Doses

(excerpt from a talk given in Waterloo, Ontario, February 26 2009)

About drugs I have only one thing to say. It is a very recent insight, but it offers a glimpse into a wealth of possibilities. It's not about drugs per se, but about dosage. Over the years, I've tried a huge spectrum of drugs–from phenothiazine tranquilizers to antidepressants to various mood stabilizers–but all of them, even the ones that seemed to help, had side effects I couldn't tolerate. So I've become very wary of drugs. My psychiatrist doesn't push them–“I'm here to advise; the decisions are yours,” she says, which is one of the reasons I trust her–but she does sometimes suggest, especially when I get backed into a particularly bad corner, that there might be a drug that could help. Last fall, I got backed into such a corner and she suggested quetiapine (or Seroquel, its brand name). But when I tried it, at the lowest standard dosage of 25 mg, it zonked me out so thoroughly and for so long–the familiar “zombie” effect–that I realized I could not possibly function in any normal way on it. I cut the pills in half, then into quarters; though better, it still knocked me too far under. So I dropped the trial. But my doctor happened to mention that she knew a couple of people who were helped by extremely small doses of this drug. And then my wife's doctor said the same thing, that she'd heard of people who were aided by a mere “whiff,” as she put it, of quetiapine. So my doctor wrote me a prescription for 1 mg–we would start from that baseline. The trouble came when I tried to fill the prescription at Shopper's, only to be told by the pharmacist, very insistently, that the lowest dose sold was the 25 mg tablet and it was unobtainable in 1 mg strength. “But that's the prescription my doctor wrote,” I said, pointing at the slip. “You might try a compounding pharmacy,” he muttered, then looked past me and said, “Next?” To make a long story short, in all of Toronto I found only two old-fashioned compounding pharmacies who could make up the prescription in the lower strength. I have been trying it for a few weeks shows promise. But my point is (or rather, my two points are): 1) Cui bono? Who stands to gain if drugs are only sold in higher-strength amounts? You don't have to be a conspiracy theorist to see that drug companies would not want it widely advertised that minute portions of their brands might help some people. Would any drug seller want it known that some buyers got by on a “whiff” of his product? Would he want to pay for the tests to discover such a possibility? 2) Which of my many failed drug trials over the years might have stood a chance of success at a dosage of one half, one sixteenth...of the normal range? A “tincture of this, a tincture of that,” as the old saying went.

A bit of this...a bit of that. Even tiny pieces can have an important place in the mosaic.

“Alle Ding sind Gift und nichts ohn Gift; alein die Dosis macht das ein Ding kein Gift ist” [all things are poison and nothing is without poison; only the dose makes a thing not a poison]. Paracelsus's famous dictum usually receives a negative stress, i.e. Many things are poisonous except in small amounts. I have been reminded lately of its more positive face: Some things are beneficial precisely in small, even minuscule, amounts.

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