Scopolomine questions- including withdrawal?

[gbot]

Hi all-
Sorry in advance for the exhaustingly long post- am a newbie.

I get terribly sea sick. I now use Transderm Scopolomine patch- EVERY time I dive. I have tried ginger, bands, and all the behavioral approaches. Can't do Dramamine -get very very drowsy...Haven't tried non-drowsy formula or Bonine as of yet.... For the most part the patch works fine for me- although sometimes I still experience symptoms and some slight nausea... but at least I'm not retching and vomiting the entire trip -on the dock-on the boat- AND even under the water (decompression stops @15' just kill me!)

I've got an extremely sensitive system and the side effects of the patch are almost enough to ruin the vacation/experience (sleeplessness, crazy dreams if I do get sleep, extreme dry mouth, visual changes (btw- I ALWAYS wash my hands thoroughly after handling the patch as directed))... I also rarely drink alcohol when I'm using the patch because I'm so afraid of the interaction (no margaritas or mojitos or mai tais for me :depressed.

.... But I SO love the diving that I'm willing to endure...

I've seen and talked to divers who've done a variety of things with their patches such as:
1) cutting the patch in half
2) removing the patch after each dive, then replacing with a new one only a few hours before the next day/dive
3) removing the patch after each dive, saving it, then replacing it prior to next dive
etc...
I know none of the above things are recommended by the pharmaceutical manufacturer... and I know every diver's physiology is different... But is there any good factual information about any of these (or any other modified) approaches to using a Scopolamine patch?

ALSO---
I have noticed- ROUTINELY- that a week or so after I return from my dive trips and have settled back in at home (3500 elevation) that I get some incredible headaches that last 2 to 3 days, with lower grade headaches a day or so prior and a couple of days after the onset of the worst of it. (....and yes- I always wait 24 hours or so to fly)

The headaches feel sinus related- pain around brow bone/top of the nose, teeth hurting, etc. I also have a little bit of light sensitivity with these headaches

I am not prone to headaches and don't get migraines- but this is a consistent pattern and set of symptoms that only happens when I have used scopolomine. On other dive trips before I used the scopolamine I have not experienced this.

Is there such a thing as "scopolamine withdrawal"? And if so any info would be appreciated- as well as any way to mitigate or prevent the symptoms.

And finally- if there isn't such a thing as "scopolamine withdrawal"-- what else could this be?

Thanks for any help/advice.

 

[Duke Dive Medicine]

Gbot,

It sounds like the side effects of the scopolamine are almost worse than the condition it's supposed to treat. I'd suggest that you try some of the non-drowsy antiemetics, and if those don't work, speak to the practitioner who's prescribing the scop and/or your pharmacist and see what they suggest. Re removing the patch after diving and then applying a new one: scopolamine works best when applied 12 hours prior to the exposure but is effective when applied 2-3 hours beforehand, so you may be able to get away with putting it on early in the a.m. before the dive boat leaves the dock.

There is such a thing as scopolamine withdrawal, typically if it's used for longer than 72 hours. Headache is one symptom. Taking the patch off after you're back on shore and applying a new one 3 hours or so before you leave the dock the next day may help, but may also reduce the effectiveness of the medication.

 

[gbot]

Thanks Duke DM-

I might try the non-drowsy anti-emetics, but truthfully, I don't want to get stuck having to abort another dive last minute and then end up stuck on a boat vomiting for 50 minutes while everyone else is under.

Re: withdrawal- The first dive trip I used the patch with, I kept a patch on continuously for about 11 days (replacing with a fresh one every 3 days as directed). The headaches after that trip was by far worse than on my other trips where I had an intermittent day or so without a patch (bad weather and/or alternate activity prevented continuous diving each day).

If continuous use is a precursor, then my above observation seems to be another tick mark in the match-up for symptoms hinting at withdrawal problems.

I know self-diagnosis is risky, but I live quite remotely, no dive medicine practitioners, no neruologists, etc... I've spoken with 2 local pharmacists (who were less than informed), and I asked my GP for the script for the patch- there wasn't much analysis or discussion about it.

I'm just trying to educate myself at this point and have come up pretty empty with my own search methods. Can you refer me to any articles or websites that discuss withdrawal more thoroughly?

Has anyone else experienced this cluster of symptoms in the same pattern?

Thanks again.

 

[Bubbletrubble]

I'll just make a few comments about what you experienced...

• If you had those bad headaches after trips during which you were taking the scopolamine patch for 72+ hours, yes, it's entirely possible that you have been dealing with scopolamine withdrawal. It is a real phenomenon, and your symptoms are consistent with what some people have described. The Novartis website lists the following under the "Adverse Drug Experiences" section of the prescribing information page for Transderm Scōp:
  

  Drug Withdrawal/Post-Removal Symptoms: Symptoms such as dizziness, nausea, vomiting, and headache occur following abrupt discontinuation of antimuscarinics. Similar symptoms, including disturbances of equilibrium, have been reported in some patients following discontinuation of use of the Transderm Scōp system.These symptoms usually do not appear until 24 hours or more after the patch has been removed. Some symptoms may be related to adaptation from a motion environment to a motion-free environment. More serious symptoms including muscle weakness, bradycardia and hypotension may occur following discontinuation of Transderm Scōp.

• The differential diagnosis for headache is long and varied. Before jumping to a diagnosis of scopolamine withdrawal it might be wise to get evaluated by a healthcare professional. You could have an underlying medical condition which might be revealing itself in this way.
• Don't cut up the scopolamine patch. The patch is designed for the appropriate amount of drug to be released over a certain time frame through the piece of skin in contact with the patch. The time-release feature is meant to keep a relatively constant level of the scopolamine in your system. Cutting up the patch might disrupt some or all of the time-release feature and could actually release too much of the drug at once. Theoretically, this could result in a more pronounced side effect profile shortly after applying the patch, and you might not be protected against seasickness when the level of scopolamine falls off.
• There's at least one recent case report in the scientific literature of a 30-year-old woman who experienced withdrawal symptoms from the scopolamine patch. She didn't complain of headaches, but she did have severe nausea. She was able to overcome the nausea by taking meclizine at a dosage of 25 mg every 12 hours for 1 day.
• I have heard that others complaining of scopolamine patch withdrawal have been successful treating the nausea/headaches/vertigo symptoms with a meclizine tapering protocol. Anecdotal reports given by people experiencing rather severe nausea and vertigo successfully tapered with: 50 mg meclizine every 6 hours for 3 days, then 25 mg every 6 hours for 3 days, then 25 mg every 8 hours for 3 days, then 25 mg every 12 hours for 2 days, then off.
  Since your withdrawal symptoms seem to be on the milder end of the spectrum, you could probably abbreviate the taper or just start off at the 25-mg-every-8-hours stage and continue from there.
  Warning: In the future, if you ever find yourself in this situation again after a boat trip and you want to start a meclizine taper, it would be prudent not to start the meclizine too early. The reason for this is that you want to guard against having a significant amount of scopolamine in your system while adding meclizine on top of it. Both scopolamine and meclizine have anticholinergic properties, so having both on-board at the same time could cause a very strong anticholinergic effect (overdose?).
• Talk to your physician about the meclizine taper if you plan to conduct one. Make sure you know the potential side effects of meclizine. In the U.S., meclizine can be purchased over-the-counter without a prescription. Meclizine is also known by the brand names Bonine and Antivert.
• Considering your reaction to the scopolamine patches, for future diving trips, you really should give meclizine a try. Self-hypnosis is also worth a shot. Alternatively, you can plan to dive in a place that offers excellent shore diving opportunities, like Bonaire.

Good luck with everything.

 

[fab50diver]

Gbot I feel your pain! The first time I tried snorkeling and diving with a patch it washed off and I spent the rest of the trip hanging over...well you get the pic. My doc prescribed the pill form for me while snorkeling but I haven't tried that while diving and I'm not sure whether they still make the pills. I WISH the OTC meds worked for me but they never have so right now I'm diving with a patch and sometimes still have to add meclizine. I have been able to have a drink with dinner though without unpleasant side effects and don't have the withdrawal you've experienced. I do have the sensation of a rocking boat for several days afterward though.

 

[DocVikingo]

....the side effects of the patch are almost enough to ruin the vacation/experience (sleeplessness, crazy dreams if I do get sleep, extreme dry mouth, visual changes....I have noticed- ROUTINELY- that a week or so after I return from my dive trips and have settled back in at home…that last 2 to 3 days, with lower grade headaches a day or so prior and a couple of days after the onset of the worst of it.

Hi gbot,

Bummer, but adverse reactions can and do happen with all manner of drugs and scopolamine is no exception. Both the manufacturer's package insert and the PDR warn of the potential for a withdrawal syndrome after 3 consecutive days of use.

Interestingly, some individuals can use the patch for years without problem and then suddenly and inexplicably develop withdrawal signs/symptoms, some of which last for extended periods of time. I believe that such withdrawal is more common than is reported; talk to a number of cruise ship passengers who have used it and you'll hear a surprising number of complaints.

BTW, yours is far from a full-blown case (which I appreciate is little consolation ; )).

I've seen and talked to divers who've done a variety of things with their patches such as:

1) cutting the patch in half

This is unwise as the drug delivery system of Transderm Scop is predicated on an unmolested patch.

2) removing the patch after each dive, then replacing with a new one only a few hours before the next day/dive.

The patch works best when applied at least 4 and preferably 6-8 hours before diving. It also works best when the user maintains a steady-state blood level of the drug.

3) removing the patch after each dive, saving it, then replacing it prior to next dive
etc...

See #2 above. Also, the adhesive system of the patch is not designed for repeated removal and re-application. It is quite likely that after doing this even once the patch will not remain in place for very long.

But is there any good factual information about any of these (or any other modified) approaches to using a Scopolamine patch?

Not that I am aware of, but the manufacturer's cautions about such "approaches" are grounded in sound reasoning and should be followed unless otherwise specifically directed by a prescribing physician.

An alternative approach that would be worth trying is oral scopolamine (e.g., Scopace). Oral scopolamine is faster acting, the dosage is easier to adjust, it clears the body more rapidly, and it will not get dislodged or fall off from behind the ear. It also is less expensive.

If you'd like to read more about Scopace, see the below (*) article by my old friend Renée Duncan.

I might try the non-drowsy anti-emetics, but truthfully, I don't want to get stuck having to abort another dive last minute and then end up stuck on a boat vomiting for 50 minutes while everyone else is under.

This would be a good place start before getting involved in such regimens as meclizine tapers following scopolamine patch use. Many divers get excellent results from OTC meclizine (e.g., Bonine, Dramamine Less Drowsy Formula).

Regards,

DocVikingo

This is educational only and does not constitute or imply a doctor-patient relationship. It is not medical advice.


*From the March/April 2004 issue of Alert Diver magazine, reprinted with permission from the Divers Alert Network.

Scopace Tablets

Here's An Alternative to "The Patch" for Motion Sickness Relief

By Renée Duncan, Editor

We've all heard about "the patch for divers." In fact, we've profiled it a couple of times in the pages of Alert Diver.* And it works beautifully for many divers and travelers who experience motion sickness.

I'm one of those unfortunates who, given a good whiff of diesel and a quick view of a rolling horizon, will be feeding the fish off almost any boat unlucky enough to have me. Actually, I usually take it in stride, but my involuntary actions have dismayed some of my fellow dive travelers at times.

Unhappily, "the patch" is just too strong for me. I'm on the small side, 5 feet 2 inches (1.57 meters) tall, maybe 110 pounds (49.5 kilograms) without my gear. And putting on a patch practically guarantees I won't recall much of my dive, flight or boat ride (short-term memory loss is one of the side effects).

It doesn't have this effect on all small persons; and, by the same token, it may affect larger persons just as intensely - or it may not be enough. As with many medications, it simply works on each of us individually, and some days (and dosages) can be tougher than others.

What to do? Well, I've pondered. Fed some fish. Postponed dives. Or gone diving off the other side of the boat after a good spew.

Then I heard about a pill I could take for motion sickness. The best thing about it is that I can keep my dosages low rather than enduring the fixed dosage of a patch. And although, I haven't had motion sickness in a while, I almost wish I could get sick again, just to try it.

Divers and travelers who suffer from motion sickness, you have a choice: you can use the scopolamine patch or take it in pill form. For many folks, the pill is welcome news. Scopace, a medication for motion sickness, is available through your doctor - in 0.4 mg tablets.

Scopace contains scopolamine hydrobromide, described by the American Hospital Formulary Service (a drug information reference from the American Society of Health-System Pharmacists) as the "single most effective medicine to prevent nausea and vomiting induced by motion."

So, how do these tablets compare to the patch? To begin with, both have scopolamine, a drug well known for its ability to ease motion sickness.

Dosing Flexibility

The patch and the pill differ, however, in dosing flexibility. The patch delivers a fixed dose to all persons who don it. And therein lies the problem. Because a fixed dose is formulated for individuals of average weight, it may be excessive for smaller individuals and not enough for larger persons. This means a small person could encounter side effects from absorbing too much of the drug, while larger individuals may still get motion sickness because they're getting insufficient amounts.

With tablets, you can adjust the dosage to the lowest level you find effective. Granted, this may mean a couple of trial-and-error runs, but it beats the dizziness and blurring of vision if you're sensitive to the patch.

Skin Considerations

Then, there's the issue of skin. Topical absorption of a medication - such as what you find in a scopolamine patch - is dependent on certain skin characteristics. These factors include skin thickness, patch adhesion (that's why instructions tell you to apply the patch to clean skin) and blood circulation within the skin.

If the skin is too thick, the medication may penetrate too slowly. With hairy or sweaty skin, the patch may not adhere properly. If circulation is poor or if blood flow is shunted away from the skin (this can happens in cold conditions or during episodes of extreme nausea), drug levels may remain diminished because of reduced drug passage into the blood.

Ingesting the Tablets

Next, there's speed: in order to work, tablets have to melt. If you wait until you're already ill, you may get quicker relief with the patch.

Quality guidelines published by the United States Pharmacopoeia, an organization that works closely with the Food and Drug Administration (FDA), the pharmaceutical industry, and the health professions to establish authoritative drug standards, specify that scopolamine tablets must disintegrate within 15 minutes. According to Craig R. Sherman, M.D., Medical Director, Hope Pharmaceuticals (the manufacturer of Scopace), ongoing testing confirms that Scopace tablets meet or exceed this standard.

Whichever method you prefer, remember to dose yourself at least an hour before you dive, travel or go boating.

Side Effects

The incidence of side effects associated with the two dosage forms of scopolamine can differ. If you have experienced any negative effects with the patch, you may want to give the pills a try, or vice versa.

The primary side effect of scopolamine tablets at the intended doses is reduced salivation, says the manufacturer. That's dry mouth in diving terms, and it's not fun. But it's not dangerous, either. More serious side effects can always happen with any medication. The manufacturer points out, however, that the more serious side effects with the tablets tend to be infrequent because you can adjust your dose to the lowest level you need.

Another consideration is the duration of possible side effects. If a side effect occurs after you ingest a tablet, you can suspend subsequent doses while your body metabolizes the pill. In contrast, side effects associated with topically applied medicine may be prolonged after it is removed because of continued absorption into the blood from the skin.

To reinforce the drug's safety, Hope Pharmaceuticals also provided this study result for the scopolamine tablet:

A study conducted for NASA evaluated whether oral scopolamine impacted operational proficiency. Scopolamine was tested in two doses - 0.25 mg and 0.5 mg. The researchers concluded that neither dose produced any loss of proficiency performing selected tasks. Furthermore, the incidence of drowsiness and blurred vision associated with the drug did not exceed that associated with placebo.

Just like the scopolamine patch, Scopace can cause inability to urinate in men with enlarged prostate glands, and can exacerbate certain types of glaucoma (excessive pressure in the eye). It can also cause drowsiness, which could be dangerous while performing certain activities such as driving a car.

It's Your Trip

No one wants motion sickness to spoil a trip. At the same time, you don't want to over-medicate yourself: it's just as bad. If you have a tried-and-true method of dealing with motion sickness, stick with it. If you're not happy with your present solution, perhaps you'd like to discuss a prescription for Scopace with your doctor.

For other, non-medical ways to prevent motion sickness, see Dan Orr's July/August 2003 Incident Insights report on "Mal de Mer."

Pay attention to what your body's telling you about motion sickness or drugs.”

 

[gbot]

Thanks All-

Good info from both Bubbletrouble and DocVikingo (the article by Renee Duncan was quite informative- as was the meclizine tapering). ...and thanks for the comiseration fab50.

There seems to be sound justification for giving oral Scopolamine a go...

I think I'll also try some of the others (Bonine/non-drowsy Dramamine) as well- but want to do a trial for effectiveness before actually using it on a dive trip...and risking my precious dive days.

As far as sticking to shore diving- Been to Bonaire- loved it (got totally spoiled by the freedom-from-schedule aspect)- but was also sick swimming out to drop down points in choppy water, during deco stops, and sometimes even just hanging out on a pier gearing up. I guess I got it bad

Thanks again- The info and leads are truly appreciated.

 

[gbot]

OK- so another question is arising for me:

Am looking at a possible liveaboard trip in the Andamans. Needless to say, I'm quite worried about being on a boat continuously for a week at a stretch, given my history with motion sickness and prolonged Scop patch use.

Is there any protocol for alternating medications for prolonged abatement of motion sickness?

One of the earlier posts warned of the risk of using scopolamine and meclizine together as both are anticholinergics... I'm looking for more information on drug interactions like this.

Also- can anyone refer me to a dive med MD who does telemedicine?

Thanks.

 

[DocVikingo]

Am looking at a possible liveaboard trip in the Andamans.

Hi gbot,

Of course the mal de mer issue reamins no matter what liveaboard you may choose, but I'd mention in passing that I've done an Andamans liveaboard and was quite disappointed. IMHO, there are many far better itineraries at better values for the money.

RE drugs interactions, you have a number of options, all sound ones:

- consult the drug manufacturer's package insert. I will be among your best sources of reliable information.

- ask your local pharmacist about possible interactions among drugs you are taking/thinking of taking.

- check out this website --> Drug Interactions Checker | Drugs.com

Regards,

DocVikingo

 

[Damselfish]

No facts, just what I've seen with all 3 of the people I dive with who use the patch. While the manufacturer says not to cut the patch - so obviously I'm not recommending it - all 3 people have determined a whole patch is too much and leaves them feeling wonky in various ways. They always cut them, with no apparent ill effects so far. My husband has been doing this for many many years, for frequent plane travel as well as boats. (It does seem over the years he has needed to reduce the amount of patch he wears.) YMMV.

Why they don't make patches in different sizes when they say not to cut them, I don't understand. One dosage makes no sense to me.