Deco dives while on meds

[DocVikingo]

Hi Doc, Can you define tiny, and elaborate on what you think an acceptable risk for seizure underwater is?Best,DDM

Seizure incidence with tramadol use is <1% in the general pop. Risk rises slightly in those with selected comorbidities (e.g., hx of brain injury, ETOH abuse), under concomitant treatment with other drugs that may increase the risk of seizures, or taking high doses or on extended regimens of the drug.

After an adequate and uneventful topside trial I would dive while on a modest dose of tramadol, although probably would minimize alcoholic beverages on the trip.

As you well now, this tiny increase in seizure risk is not exclusive to tramadol, but has been reported across the opioid class of analgesics. Is the recommendation for all individuals on a reasonable regimen of such an agent but who are otherwise fit to dive to be, "No SCUBA until you're off the drug?"

Regards,

DocVikingo

 

[Duke Dive Medicine]

Seizure incidence with tramadol use is <1% in the general pop. Risk rises slightly in those with selected comorbidities (e.g., hx of brain injury, ETOH abuse), under concomitant treatment with other drugs that may increase the risk of seizures, or taking high doses or on extended regimens of the drug.

After an adequate and uneventful topside trial I would dive while on a modest dose of tramadol, although probably would minimize alcoholic beverages on the trip.

As you well now, this tiny increase in seizure risk is not exclusive to tramadol, but has been reported across the opioid class of analgesics. Is the recommendation for all individuals on a reasonable regimen of such an agent but who are otherwise fit to dive to be, "No SCUBA until you're off the drug?"

Regards,

DocVikingo

Doc,

Our first concern with any medication is the reason it's been prescribed in the first place. In LakerPride's case, it's a back injury... if it's bad enough that he's on tramadol, it's worthwhile to consider the risk for additional injury. Not having examined him, I can't speak to that.

The second concern is the interaction of the medication with the diving environment. One of the first questions we ask about any medication is, "does it lower the seizure threshhold?" If the answer is yes, then our answer is, "don't use it while diving". Tramadol has not been studied under pressure, so we don't know exactly how it interacts with an increased pO2. However, I do think it's reasonable to say that because the risk of seizure with tramadol is elevated in individuals with an increased likelihood of seizure from other comorbidities (TBI and others you've already discussed), the risk will also be elevated when breathing hyperoxic mixes under pressure. Because of this, I do not think that you can predict the effects of tramadol under water based on a topside trial; in fact, it's potentially hazardous to do so.

Re opioids in general: our position is that individuals should not dive while taking opioids, primarily due to the CNS depressant effects and the potential for additional CNS depression with nitrogen narcosis.

One way of evaluating the risk for seizure with tramadol, or any medication, is to compare it to another diving risk that's been quantified. In commercial diving, the acceptable risk for decompression sickness is 0.1% for mild cases and 0.025% for serious cases; in Navy diving, the acceptable risk is 2% for mild cases and 0.1% for serious cases (reference: Vann et al Lancet 2011 Jan 8;377(9760):153-64). DCS is rarely fatal, while seizures underwater are almost invariably so. When looked at in this light, what should the acceptable risk for seizure underwater be? I would contend that anything above the baseline risk for a healthy diver, who is diving within accepted parameters, is unacceptable. That's what I'm basing my recommendations on.

This got batted around here a bit and made for a lively fellowship discussion yesterday after Dr. Freiberger's fitness-to-dive lecture. I do think it's worth mentioning that Drs. Freiberger, Piantadosi and Moon are in concurrence that tramadol should not be taken while diving, especially while using hyperoxic mixes.

Best regards,
DDM

 

[jimmy71]

One way of evaluating the risk for seizure with tramadol, or any medication, is to compare it to another diving risk that's been quantified. In commercial diving, the acceptable risk for decompression sickness is 0.1% for mild cases and 0.025% for serious cases; in Navy diving, the acceptable risk is 2% for mild cases and 0.1% for serious cases (reference: Vann et al Lancet 2011 Jan 8;377(9760):153-64). DCS is rarely fatal, while seizures underwater are almost invariably so. When looked at in this light, what should the acceptable risk for seizure underwater be? I would contend that anything above the baseline risk for a healthy diver, who is diving within accepted parameters, is unacceptable. That's what I'm basing my recommendations on.

Best regards,
DDM

Could you tell me what that baseline risk is? I have not seen (nor looked) at what the baseline risk of a seizure is in a healthy diver with no history diving with O2 at or under 1.6? Any number for how the risk changes as ppo2 increases? I would love to know this info. I would also loveto know the acceptable risk of DCS sickness in non-commercial diving.

A nice link to meds that decrease seizure threshold Drugs that may lower seizure threshold : Epilepsy.com/Professionals

Thanks for the info

 

[DocVikingo]

Doc, I would contend that anything above the baseline risk for a healthy diver, who is diving within accepted parameters, is unacceptable.Best regards,DDM

Hi DDM,

Well, then, for openers we can sideline all divers on any opioid (e.g., Vicodan, Percocet/Percodan, Duragesic, Dolophine/Methadose, OxyContin, Ultram/Ultracet, Talwin, Toradol); any SSRI, SSNRI or TCA (e.g., Celexa, Lexapro, Prozac, Luvox, Paxil, Zoloft, Wellbutrin, Effexor, Cymbalta, Pristiq, Elavil, Doxepin, Sinequan, Tofranil, Pamelor, Vivactil); selected antipsychotics (e.g., Thorazine, Clozaril, Abilify); ADHD stimulant meds (e.g., Strattera, Ritalin, Concerta); overactive bladder meds (e.g., Detrol LA, Ditropan); antihypertensives of the angiotensin receptor blocker class (e.g., Capoten, Coreg, Diovan); certain antibiotics (e.g., Flagyl, IV penicillin, Keflex, Keflin, Levaquin, Cipro); selected estrogen replacement agents (e.g., Premarin); selected weight loss agents (e.g., Meridia); certain antimalarials (e.g., Lariam)--okay, my fingers are tired.

Help, I can't find a dive buddy. And, I can hear the dive industry cavalry coming and I believe they have a noose ; )

Seriously, IMHO DAN has never been very good at dealing with the realities of medications and their potential implications for SCUBA. The articles on drugs and diving that I’ve seen in Alert Diver are in my estimation simply sad, e.g., Alert Diver | I'm Taking This Medication...Can I Dive?, Alert Diver | Psychiatric Fitness to Dive. RE the latter piece, I quote: “While there is little actual data on psychiatric medication at depth, there is no data demonstrating the hazard of selective serotonin reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors, nor is there data regarding the hazards of the group of agents usually referred to as atypical antipsychotics, often prescribed for antidepression augmentation, bipolar disorder and schizophrenia. Stimulant medications used to treat attention deficit hyperactivity disorder (ADHD) show no clear risk....” Say what? (See my opening para in this post).

I of course appreciate DAN’s need for conservatism for both moral and legal reasons and the pathetic absence of research by which to guide its recommendations. Nonetheless, the fact remains that a very substantial number of divers will take a medication, either episodically or chronically, that theoretically could have an adverse impact on safe diving.

In the absence of hard data, which for nearly every medication will never exist, the diver will have to become as informed as science allows, then decide for herself or himself the level of risk deemed acceptable.

Regards,

Doc

 

[jimmy71]

Doc,
You make many valid points and the process of evaluating and determining risk is something that every diver/person must do at every step at everything. One must balance risk vs benefit. The problem arises that not everyone understands the risks, nor is there enough time in the world to become an expert at every subject in life to make your own appropriate choices.

A great mistake that intelligent people make is the assumption that most people are also intelligent. I assume you are a MD by your handle. I am sure you have had patients say and do MANY extraordinarily stupid things that make you question how they were able to get dressed that morning and make it to your office. You would also assume that when one was going to have a possibly life altering surgery or procedure, they would spend some time and work to learn as much on the subject as possible. We both know this is not the case. They show up in your office because someone told them to and say "Just tell me what I should do doc!" Try as you might to explain to them the options and rational, it is a often a lost cause.

This is life and also because medicine is just as much art as science. Try as you might to have evidence based medicine drive all your care, it can not happen at this time. Why do the dive tables, O2 limits, and recommendations change? What may have been determined to an acceptable risk a couple years ago is not now.

I agree with you that recommendations from DAN can sometimes be overly cautions and can sometimes conflict themselves. I completely understand why. They are also making such recommendations to the lowest common denominator. Almost all the dive training I received had stupid rules that were taught as LAW, not to be violated. With dry suits I was told to only use dry suit for buoyancy and wing if dry suit fails. Never use your BC to assist you in lifting an object underwater. Rules like these are in place to try to prevent stupid people from doing stupid things. I violate them all the time. If you use your brain, they will never become issues.

Look at some of our current dive knowledge or medical history in general. The vast majority of it is an idea that one person had that made sense to them at the time that everyone accepted as law. Reverse profile dives is a great example of this. I can name hundreds in the history of medicine.

Long story short, I agree with you DocV. I completely understand what you are saying. DAN's fear is that this person may be asking a simple question that receives a simple answer. For all we know he is walking around with ventriculostomy or a VAD but only THOUGHT he needed to ask about the ultram. There are more stupid people than smart ones. You will be right more often if you assume everyone you meet is stupid. WOW, now i have gone and depressed myself. Wish I could take an SSRI............. but then I would not be able to dive.

Jimmy

PS I am to lazy or stupid to proof read

 

[LakerPride]

Jimmy, I understand your point. I have no heart condition, I have three bulging discs, L3-L4, L4-L5, L5-S1. When the injury occurred a small piece of bone fractured and impinges on a nerve going to my left leg which causes severe pain. I also frequently have paraspinal muscle spasms, I was originally prescribed percocet but felt like I was constantly stoned. With Tramadol I feel no change, but the pain is reduced enough to function normally. I also take 800mg of motrin a day as an anti inflammatory. A little background, 32 y/o male, last 2 BP's 119/70, 69" 215 lbs, one mild concussion during active service due to blast proximity. No concussive symptoms since 2003. No hx of DCS, or barotrauma. Hospitalizations, 1999 ACL, MCL, meniscus reconstruction R knee, 2001 ACL reconstruction R knee w/ patellar autograft, 2001 ACL reconstruction L knee. 2009 back injury. Meds, tramadol, motrin, OTC prilosec. and a joint supplement with the following ingredients http://www.movefree.com/images/supp_MFA_MSM_D.jpg which by the way has been awesome.

 

[jimmy71]

Laker,
I am sorry but I will admit that I forgot about you in all this discussion. My Bad. This is what it all boils down to and I hope that you have already figured it out.

questions you need to ask yourself:

How important is diving to my health and well being?

What degree of risk is acceptable?

lets look at a couple of the common risks associated with diving and you need to look at the answers of how they apply. I am going to stick with the tech aspect as that is what you are wanting to get back into. Lets start with easy ones.

mobility/flexibility - You obviously had multiple injuries and need to question your flexability/ability. Remember the responsibility to self rescue that comes with tech diving. That being said, I know MANY tech divers that can not reach their valves and such. I personally have a hell of a time getting my fins on and off in full tech gear. Honestly look at your abilities. Do not be a liability to your dive team. You can also address this issue with gear configuration such as side mount and remote valves.

Nitrogen narcosis - I assume you know how ultram and your other meds effect you. You sound like you have gotten back into diving slowly and thus know how these meds effect you and how nitrogen also effects you. You can also mitigate this by adjusting your EAD to shallower if it is a problem. I would not recommend taking new or diff meds in the mix before a deep dive. Narcosis effects everyone different. I expect you to know how it effects you. Narcosis is not a problem, it is not REALIZING you are narked that is an issue. I have been around people who say "I do not get narked" or "it does not effect me." Those people scare the crap out of me because it means they have no situational awareness to know different they feel. It is not uncommon for me and many other divers to be fairly high on sea sickness meds before we even splash on a deep dive. Those meds effect your level of conciousness way more than ultram. Especially if you take ultram regularly. I do not see this as a big issue.

DCS - DCS is rarly fatal if it occurs after following a dive schedule. So we will ignore fatal DCS. For arguments sake lets assume you are an increased risk of DCS because of your history (I doubt I have any facts to back this up). This is simple to solve. Step one make sure you have dive insurance and a doctor has cleared you for diving. Step two add plus 1 conservatism to what every you plan your dives with. Make sure your team knows and accepts this. As you continue to exhibit that you are not at an increased risk, you can change your level of conservatism to what ever floats your boat. Again, not really a big issue as I see it because little harm if you guess wrong.

O2 Tox/seizures - This one takes a little more debate and only you can answer. As DDM points out, a seizure underwater usually equals death unless you are very very luckly. It is also safe to assume that you will probably not have any warning to a seizure. Are you at an increased risk of seizures of any type? The answer is yes. No one will question that. How much of an increased risk? NO ONE KNOWS. The current O2 limits already have a very large safety factor built in to them because of the assumed outcomes of one. This is the reason why some DCS is acceptable to the military and commercial divers. They get bent, you mend them and you loose a diver for a while. No big deal. I would have to imagine that the SCUBA organizations believe that ANY risk of seizure underwater is to much. If you have a .000001% risk of seizure is that to much? what about .01%? what about 1%?
I am unsure if I was taught wrong or just did not listen well, but I swear that I was taught you could run at 1.6 throughout your dive. If I am doing a 1 gas nitrox dive, I do not even have second thoughts about taking it to 1.6. I have even taken 21% beyond 1.6 but you would never hear me recommend it to someone else. I will also say that I almost never dive without sudafed and antihistamines in my systems. They both lower seizure threshold.
I would be very shocked if you could find me someone who has had a seizure at the 1.4/1.6 limits that did not have a significant seizure history. The SCUBA agencies response is = "That is exactly the point!" People sieze when they do incorrect gas switchs or fall asleep on deco and drift deep. If this concept concerns you, simple change what ppo2 you run at. Why not try 1.3/1.5 or less?

Want to ensure that you will never have a problem? Never dive again. I doubt this is an option. I know it is not for me as well. I hope this answers your questions. If not, feel free to ask some more. Please remember that doctors are people and not much different than your car mechanic. Would you let your mechanic fix something on your car if he could not explain how he believes it is related to the problem in a way that you understand? So why act any different with doctors?


Jimmy

 

[Duke Dive Medicine]

Doc and Jimmy, you both make some good points, and Doc, your ability to turn a phrase is always refreshing. First, for clarity's sake, I should differentiate us from DAN; I'm writing this from the second deck of the Duke Center for Hyperbaric Medicine and Environmental Physiology, not from the Peter Bennett Center. I work for Duke Hospital, and though we still interact with DAN on a regular basis and conduct research with them, we're no longer officially associated with them. Our advice should not be construed as coming from DAN, and vice versa.

Jimmy, I get what you're trying to say, but I think you're a bit off in some of your assessments. We don't give extra-conservative advice to save stupid people from themselves. We give advice that we consider to be appropriate based on our collective knowledge and training. If there's doubt, we would rather err on the side of conservatism. Also, your comparison of a medical professional to an auto mechanic only goes so far. DocV is an expert in the workings of the human brain, but I'll guarantee you that he couldn't take one apart and put it back together again and expect it to work. Some confusion on the part of the health care consumer is understandable because professional opinions can differ, but you seem to be implying that we're just tossing out opinions willy-nilly with the goal of minimizing our liability. I assure you that that's not the case.

Also, some of your comments about O2 toxicity are not completely accurate. For instance, it's pretty well-accepted that 1.2 ATA is a safe pO2 for back gas. However, if a diver becomes hypercapnic, perhaps while fighting a current or performing heavy work under water, it's possible to seize at that partial pressure. The limits are not padded as much as you may think.

Doc, let's get back to the OP's question for a moment. He asked if he could engage in technical diving while using tramadol. In other words, can he go underwater and breathe an inspired pO2 of up to 1.6 ATA while taking a medication that's been documented as causing seizures in those who are predisposed? The answer should be a resounding "no", and I was surprised that you took the stance that you did, especially never having laid eyes on him. Seizures under water are pretty much forever. You don't get to say "oops, let's try again".

I certainly believe in assessing each individual on a case-by-case basis, and some of the meds you mentioned carry more of a risk of seizure than others. In instances where the diver has been thoroughly evaluated and, as you advocated, has undergone a topside trial without adverse effect, it may be reasonable to recommend that the diver use a normoxic mix and stay within the depth limitiations of an open water diver; this would maintain the pO2 at a level that is highly unlikely to be problematic.

I'll reiterate that opioids are contraindicated while diving, and not because they may cause seizures. No, you shouldn't dive while you're on a Duragesic patch or Vicodin, for the same reason you shouldn't dive on Ativan, Clonopin, Valium, or Jack Daniel's. Anything that causes CNS depression should not be taken while diving. Not to be picky, but Toradol/ketorolac is an NSAID, not an opioid, and it's given IV or IM so it's unlikely that a diver will be actively using it while diving. Talwin is also given parenterally.

All that said, I think that there are probably plenty of divers out there who are using medications that we'd be concerned about, and I'd love to get my hands on some raw data so we could start filling the knowledge gaps that you mentioned. Until then, though, it's best to approach any medication with caution, especially those that carry a risk of seizure or other adverse event that could be catastrophic under water.

Best regards,
DDM

 

[DocVikingo]

Hey DDM,

First, for clarity's sake, I should differentiate us from DAN; I'm writing this from the second deck of the Duke Center for Hyperbaric Medicine and Environmental Physiology, not from the Peter Bennett Center. I work for Duke Hospital, and though we still interact with DAN on a regular basis and conduct research with them, we're no longer officially associated with them.

Of course I am aware of that distinction and its implications, and perhaps I should have nuanced my reference to DAN. This aside, as best as I am able to determine the overlap between the thinking regarding various meds and diving within the second deck of the Duke Center for Hyperbaric Medicine and Environmental Physiology and among the diving medical professionals at the Peter B. Bennett Center maps rather intimately.

Doc, let's get back to the OP's question for a moment. He asked if he could engage in technical diving while using tramadol. In other words, can he go underwater and breathe an inspired pO2 of up to 1.6 ATA while taking a medication that's been documented as causing seizures in those who are predisposed? The answer should be a resounding "no", and I was surprised that you took the stance that you did, especially never having laid eyes on him.

Actually, I rather surprised myself as I'm normally pretty conservative in my positions and recommendations on this forum. I don't regard primum non nocere lightly.In reflection, for some odd reason it was suddenly in my face that we know next to nothing about meds and SCUBA and that this ignorance will continue for many lifetimes. And that if we proceed under a tenet such as anything above baseline risk (e.g., for seizures, for inert gas narcosis) is unacceptable, we will be caught in an unceasing string of &#8220;No, no, nos&#8221;. This reality can result in divers being denied a recreation passionately important to many of them and one which may afford solace and even transient relief from the very maladies for which they are taking meds; perhaps more than medicine can presently offer. Presented in an overly cautious or unconditional format, this &#8220;No&#8221; perspective also may encroach upon the exercise of personal responsibility, an entity already woefully lacking in modern society, at least in this country.In the meantime, perhaps the quirky notion that in the absence of meaningful research findings on the effects on meds on SCUBA it behooves (1) diving medicine to freely admit its limitations and rein in conjecture and (2) the diver to gather and contemplate what information science in general, and diving medicine in particular, affords and then decide what level of risk is personally (although others obviously factor into the equation) acceptable and under what circumstances. Just saying&#8230;.Regards,DocV

 

[Duke Dive Medicine]

In reflection, for some odd reason it was suddenly in my face that we know next to nothing about meds and SCUBA and that this ignorance will continue for many lifetimes. And that if we proceed under a tenet such as anything above baseline risk (e.g., for seizures, for inert gas narcosis) is unacceptable, we will be caught in an unceasing string of “No, no, nos”. This reality can result in divers being denied a recreation passionately important to many of them and one which may afford solace and even transient relief from the very maladies for which they are taking meds; perhaps more than medicine can presently offer. Presented in an overly cautious or unconditional format, this “No” perspective also may encroach upon the exercise of personality responsibility, an entity already woefully lacking in modern society, at least in this country.

You could definitely go down a slippery slope with the medication thing. In Dr. Freiberger's excellent talk on fitness to dive, he breaks it down this way: commercial and military diving organizations tend to be more proscriptive in their approach to fitness to dive, i.e. you're taking "X" drug or you have "Y" condition, therefore you can't dive. In recreational diving, the goal is to be more descriptive, i.e. evaluate the individual diver and make specific recommendations based on the findings. We really don't like to say "no" because most of us are divers too, and we understand the pull. Still, I'm sure you'd agree that there are certain conditions and medications that are not compatible with diving.

Beyond that, there's a continuum, and as I said before, professional opinions vary widely. Asthma is a great example. As conservative as BSAC is sometimes, they're very liberal with asthma; as long as a diver hasn't wheezed within 48 hours, he/she is ok to dive. We take a more conservative approach and perform pulmonary function testing prior to signing off on an asthma patient.

In the meantime, perhaps the quirky notion that in the absence of meaningful research findings on the effects on meds on SCUBA it behooves (1) diving medicine to freely admit its limitations and rein in conjecture and (2) the diver to gather and contemplate what information science in general, and diving medicine in particular, affords and then decide what level of risk is personally (although others obviously factor into the equation) acceptable and under what circumstances.

I'm not sure you could classify our recommendations on diving and medication as conjecture. As Jimmy pointed out, sometimes medicine involves synthesizing existing knowledge and research and coming up with a recommendation despite a dearth of evidence in a particular area. For instance, we (i.e. Duke Dive Medicine, including all of our attending physicians) do not recommend diving while on anticoagulants because of the risk for uncontrollable bleeding in the event of injury, especially to the head. Has this ever happened in a diving environment? I don't know. Has it happened on land? Definitely. On the other hand, do people take coumadin and dive safely? I'm sure they do. However, most medical professionals will be more conservative than liberal in their recommendations. As you said, primum non nocere.

I'm all for divers being personally responsible for themselves, and we do our best to educate them when we evaluate them so that they can make informed decisions. I don't really want to open the PFO can, so to speak, but an example is this: if we treat a diver for sudden-onset severe neurological and/or inner ear DCS and discover a PFO, we will advise that diver to stop diving and tell him/her exactly why. We will also advise the diver that if he/she chooses to continue diving, to use nitrox, preferably on air tables, and dive very conservatively. This, I think, is a good example of giving divers the facts and then letting them decide for themselves.

Best regards,
DDM