long term use of meds

[artsprite]

I see a lot of contraindications for diving associated with the meds I take. I take them for the various problems that go along with my chronic illness Fibromyalgia. A lot of the warnings are about side effects that I've never experienced in 6 years of taking the meds. My husband is a pharmacist, and says that the problems usually occur when someone just starts out taking the medicines, and the chance for the side effects dramatically decreases with long term use. I'm speaking of drugs like Wellbutrin, Depakote (for headaches, not seizures), bedtime doses of muscle relaxers, and pain meds. I am well aware of the effects the medicines have on me, and how I function while taking them, so I don't feel I would have any problem, and neither does he. He has had 20 years experience as a pharmacist, and is an extremely educated in chemistry. I have already checked with one of my doctors, who dives himself and he sees no reason why I shouldn't be just fine. I just would like to know if you would agree with this assesment. Also, I would like to know if you know of anyone who dives with Fibromyalgia, and whether or not the pressure at depth adds to problems of joint paint, and muscle spasms associated with Fibromyalgia? Thank you for any info you can give me.

 

[John Reinertson]

1. the chief concerns regarding medications is how they will affect your ability to respond to an emergency or stressful situation, and/or the risk that these drugs can create an emergency situation. When an adverse event happens underwater, it can be much more serious and stressful than on land.

2.Wellbutrin carries a very slight but definite risk of seizure. This could lead an individual to either abandon diving (an extremely cautious approach) or to carefully assess seizure risk and dive very conservatively.
Seizures on land are usually an annoyance with no lasting harm. Underwater, they are very likely to kill a diver.
I certainly would not recommend anyone taking Wellbutrin to push the limits, particularly the depth limits with Nitrox, where seizure potential is real, and predisposing factors are probably additive.

3. Depakote should protect somewhat against seizures, but cannot be trusted to do so completely. Mental concentration effects of Depakote are minor for some people and major for some. You will have to test your own reaction and cognition.

4. Some pain meds affect alertness and some don't, and the response is very individual. See above re testing and knowing individual limits.

In individual cases, I usually suggest that you personally test your reaction to medications in two ways; Check for decreased ability to think clearly.. the easiest way I know to do this is to spend $10 for one of the programs that has an IQ test on a disk, and take the test both on and off the medication if possible. Then check reaction time alteration by playing a simple video game requiring reaction speed, such as Tetris, space invaders, etc. After a dozen games, you'll have a baseline. If performance is poor at baseline or worse on the medication, that is one more piece of information to add into the decision.

This is the best way I know of for individuals to test their reaction to a medication. It provides a readily available and fairly reproducible self-test of cognition and reaction time.

There is no good way to test for seizure risk.
If you want to dive deep or dive Nitrox near the limits, have a Heart to heart talk with a neurologist exoerienced in dive medicine regarding Wellbutrin. I've heard lectures saying the seizure risk is way overblown, but I've also watched one of my patients have a seizure in front of me from the med.

The methods above are also good ways to test for individual reaction to sea-sickness meds.

If the tests above suggest any impairment, you will have to decide for yourself whether to dive or not.. Just remember the environment is not necessarily forgiving, and you risk endangering not only yourself, but your buddy and any rescuers.

Diving is fun as long as we're all careful and responsible.


John Reinertson

 

[artsprite]

Thank you so much for your reply to my question. I think I have already done the things that you suggest to make the decision if I am capable of performing on the meds I take. First, I do not plan to do deep dives, or use nitrox, so I think the risk of being on Wellbutrin is one that I will take. As far as the IQ tests, I have actually done this recently. Before my diagnosis of Fibromyalgia, and before being on the meds, I scored 141 on a supervised, written IQ test. Just a few months ago I got one from Mensa to see if I would still score as well. It was one that I got off the internet. The tv was on when I was taking it, so I probably wasn't concentrating as much as on the one I took a few years ago. On this one, on the medications, I scored 135. Since this is still well above average, I feel I have the mental ability to handle diving. (I had taken my pain meds when I took the test.) And although I don't play arcade games, I regularly play mahjong on the computer in which you match tiles for speed, and I normally win in under 5 1/2 minutes. My best scores are under 3 1/2 minutes. Is this a good enough indication of my reaction time? I would appreciate hearing from you about whether you think I need to do any other tests of my mental abilities or ability to concentrate. Thank you again.

 

[DocVikingo]

Hi artsprite,

The issue of self-assessment psychometrics is a very complicated one, but let me endeavor to clarify a few points for you.

Self-administered IQ tests generally are not the best way to detect changes in cognition as a result of medications such as those you are taking. For openers, these tests tend to be heavily weighted with items tapping fund of information, vocabulary range, abstract reasoning, and other mental abilities that are not especially sensitive to the effects of such drugs.

Additionally, these instruments are subject to test-retest practice effects, meaning that your exposure to the device in and of itself will give you an advantage the next time you complete it. In other words, even if your cognition deteriorates somewhat as result of medication, it may not be reflected in your obtained test score.

In an attempt to get around the test-retest phenomena, you may use another IQ device, but intertest differences then complicate interpretation. For example, you almost certainly took two different IQ tests with the pre-medication "supervised, written IQ test" & the latter, post-medication, Mensa Internet test. The difference in your scores, i.e., 141 v 135, could very well be accounted for by measurement differences/normal error variability between the two devices rather than any real change in intelligence. Your 6-point drop almost surely has no implications for fitness to dive. BTW, your scores are very well above average and place you at the 99th percentile.

If IQ measures are to be repeated, the best approach is to apply one that comes in alternate forms and take a different form before & after medication. However, I doubt that as a layperson you will have access to these.

In any event, as I said earlier self-administered IQ tests are not the best way to assess changes in cognition as a result of medications such as those you are taking. Much more sensitive will be tests assessing immediate & short-term memory, attention & concentration, mental flexibility, psychomotor speed & reaction time. The problem with these is that they by and large do not lend themselves to self-assessment, but require administration by a trained professional. While I am not familiar with the mahjong computer game you described, at which you report winning in very respectable times, I strongly suspect it taps many of these factors.

I would also note you report:
1. Feeling cognitively fit to dive;
2. Receiving the okay of an experienced pharmacist with a vested interest in your welfare who has longitudinal observation of your mentation.
3. Having already checked with one of your doctors, who dives himself, who sees no reason why you shouldn't be just fine.

I leave you to consider the above discussion in the aggregate in arriving at a decision about whether you need to receive any other tests of your mental abilities or ability to concentrate. If it is your conclusion that additional cognitive examination is prudent, your doctor can arrange for appropriate referral, which in this case would be a neuropsychologist.

This is educational only and does not constitute or imply a doctor-patient relationship. It is not medical advice to you or any other individual, and should not be construed as such.

Best of luck.

DocVikingo

 

[John Reinertson]

I agree with Doc V.. The only valid point in the IQ testing is they do require concentration and ability to focus, which is often impaired by meds..

The computer games test reaction time (and focus) and are universally available.

these are not the same as careful neuropsychologic testing, but they are better than the usual trial of taking a med and saying.. "I don't feel stoned, so I must be OK"

It's a combination I'd be comfortable with as a crude measure in myself or a buddy.

It sounds like you've done a fairly careful assessment and feel comfortable with your decision, and are planning prudent limits.
I'm always glad to welcome a cautious and conscientious diver to the fold.

Dive safe and enjoy the sights

John

 

[scubadoc]

OK - I'm going to be the 'doom and gloomer' with this discussion.

This is an excellent discussion about cognition and testing by two real pros! However, this begs the issue since this would be anecdotal information and not valid clinical data that would stand the scrutiny of a good RCT.

Often the question about diving or not on medications should be about the underlying condition for which the drugs are being given.

Fibromyalgia comes and goes, migrates, gets better and worse and is a difficult condition to treat and to try to get a baseline of severity. This needs to be done, however, as you need to know as much as possible the degree and location of your pain for comparison in case of a decompression accident. You should write down all signs and symptoms that are present immediately before diving so that you won't have the tendency to blame a painful shoulder or knee on the disease, rather than DCS.

The seizure causing effect of Buproprion (Wellbutrin, Zyban) (1% across the board) is definitely dose related in individuals with predisposing factors,with seizures occurring in only approximately 0.4% of patients receiving dosages not exceeding 450 mg daily of bupropion as conventional tablets.

This is a small risk; but you must take into consideration the fact that a seizure underwater has almost 100% risk of death from drowning or severe injury from gas embolism if rescued from depth without breathing.

 

[artsprite]

Ok, I understand your points completely. I'm satisfied with all the discussion about cognitive ability, short term memory problems, etc., associated with the meds and the Fibromyalgia itself. I am all too familiar with how it affects me. I had one of those days today, when my cognitive abilities were compromised. I know exactly when it happens, and understand what is happening to me at the time that it is happening. I would not have dived today if given the chance, because I know today would not have been a safe dive. I am also keenly aware of the location of pain, and the level of the pain from the Fibromyalgia. I have lived with it every day for six years, and I am well aware of my limits. I'm sure I would be able to distinguish between FMS pain, and the joint pain associated with decompression sickness because my pain is around joints and in muscles and the fascia on and through the muscles, but is usually not in the joint spaces themselves. I have had knee surgery twice on one knee and once on the other, elbow surgery, and rotator cuff surgery. I know what joint pain is, and it is different than what I live with every day. By the way, my surgeries were successful and I have full use of all joints, so don't go off on that subject please. They were all from injuries, and the problems corrected. I just saw another of my internal medicine doctors 3 days ago, and ask him what he thought about me diving, and he said it would be good for me. I didn't ask him specifically about the Wellbutrin, but he is aware of my medications. He did not think the FMS itself would keep me from being able to do it. I still think I'm willing to the chance with Wellbutrin. Utimately every diver risks injury or death. It is working so well for me, that I don't want to go through the trial of another anti-depressant. I have taken so many different ones, and it is difficult to find one that works so well for me. I have taken some that have made me very ill. I do appreciate all the advice I have been given, and I am not taking this lightly. Obviously I have been considering all the problems I could have. I will probably ask my doc specifically about the Wellbutrin. Thank you for being the doom and gloomer. I need to know as much as possible about my special risks. I am always interested in anything anyone has to add.

 

[artsprite]

Scubadoc, I want to apologize for sounding so harsh before. I really didn't intend to. Sometimes I have those kinds of days. Like I said, that day I was having bad fms symptoms. I really did appreciate all your advice, as well as everyone elses. I know you all have my best interests at heart. I really think I've assessed the situation pretty well, but if there are any more questions, feel free to post them too. I'm not upset about what you said. It's just that a lot of times, doctors think that fms only flares up some of the time for us, but for some of us it is a daily thing. And, I really do understand what is happening to me at any given time. I'm sure from your observations that you understand a lot about Fibromyalgia, but there are a lot of doctors who don't, and they tend to think we exagerate symptoms, and whine about things needlessly. Believe me, the pain is very tractable to those of us who experience it. We are not just overly sensitive. In fact a lot of the people I know who have FMS are able to function remarkably well with an extreme amount of pain in our daily lives. But, there are those who's mental processes are greatly affected and they do not function so well. So, I understand your worries about some people not being able to distinguish between different types of pain. You would have to know me personally to decide that I can really make a decision about how I feel on the day of a dive. I will find out soon when I do my open water dive. As I said before, I am taking all of this seriously. Thank you all on this message board for helping me so much. I'll let you know how I do in the water.

 

[KimmieR]

I too consulted two physicians before deciding to dive. I have a history of respiratory problems and still require medication for prophylaxis although my pulmonary function is normal. I am in no way equating this to your situation. I just wanted to offer my two cents, and say that I too was concerned about diving with my medical history.

I called the DAN hotline number and was referred to the diving physician in charge of the hyperbaric chamber at one of the local hospitals. He went through my PFT's, medical history, and recent chest X-ray and gave me a through, honest assessment of my risks. It made me feel much better and much more informed.

I do not mean to insult your physician, or the excellent physicians on this forum that have responded to you thus far. In my case, I figured the more opinions the better, which sounds like what you're saying.

Kimmie

 

[artsprite]

Thanks kimmie, It's nice to hear someone else say they've struggled with similar problems. I had my pool class today, and the only problem I had was being soooo nervous. I didn't think I'd be so nervous, but trying to remember everything the first time is difficult. I did fine, though, so I'm going ahead with the lake dives, and then I'll see how I feel. Thanks for all the great advice everyone.