A Country Doctor Writes:

I must say I was a little surprised to see my post on doxepin generate well over 6,000 views in three days. I guess there is interest out there in using old drugs for some of their less well known therapeutic effects.

So here are some other pearls I have collected since I graduated from medical school in 1979. Some may be more well known than I think they are, so please skip over the obvious ones:

SEX: TOO SLOW, TOO FAST, TOO LITTLE OR TOO MUCH

SSRIs like fluoxetine, sertraline, citalopram and escitalopram can cause delayed ejaculation. Citalopram was falsely marketed as having fewer side effects than other SSRIs, but actually had the most. The new version, escitalopram, is better than the others, but can still cause this frustrating side effect. There is a long list of drugs that can counter this. I personally have had the best luck with periactin, an antihistamine, taken PRN for hot dates or even with supper every night for steadier relationships. I have also had good luck with adding daily Wellbutrin (bupropion). This drug can also restore female libido suppressed by SSRIs.

Some men just can’t help themselves and climax way too soon. I give them an SSRI and take advantage of the side effect that others try to counteract.

Men with dementia and frontal lobe brain injuries can have inappropriate sexual desires and behaviors. A desperate 80 year old wife lead me to ask my esteemed colleague, Dr.Google, for advice. With his help I achieved great success with low dose buspirone for her husband, who admitted to me that he felt restless most of the time. My prescription took care of both his restlessness and his outsized libido.

FOOD, ALCOHOL AND BEDTIME RUMINATIONS

Topiramate is an also-ran as seizure medicines go, and it is the weakest of mood stabilizers. But it’s a pretty good migraine prophylactic. It has won FDA approval as a weight loss drug and I have had huge success using it for alcohol cravings: One dose right after work can eliminate the need for that first drink walking through the door and another dose by suppertime is a common dosing time. A bedtime dose often works really well for people who can’t fall asleep because their mind keeps churning about the day’s events, what went wrong, what they should have done or said and so on. Remember that a history of kidney stones is a relative contraindication.

THIS IS YOUR BODY ON STEROIDS

Prednisone is truly a multipurpose miracle drug. Here are some of the indications I use it for:

Gout attacks: Safer than indomethacin, better tolerated than colchicine, can be used independent of kidney function and hardly ever affects warfarin’s effect on INR.

Asthma flareups, COPD exacerbations, hives and allergic reactions.

Nasal polyps and rhinitis medicamentosa (nasal decongestant overuse).

Status migrainosus (protracted migraine): 20 mg twice daily for 10 days almost always works.

Acute back pain with sciatica or cervical radiculopathy. The literature suggests oral steroids work 30% of the time. In my experience they work most of the time.

AN OPIOID DRUG TO CONSIDER

Buprenorphine, the main ingredient in Suboxone, is a good pain medication with less euphoria and lower addiction potential than traditional opiates. This is because of its different affinity for the Mu receptor, less effect on the Kappa receptor and so on. But the best thing of all is that the only approved pain version of it is as a once-a-week skin patch. Four patches per 28 days makes “pill counts” pretty straightforward and removes the temptation to take more than prescribed. And if someone were to try to get a buzz from taking other opiates, their effect is blunted by buprenorphine’s strong binding to the Mu receptor.

A PECULIAR APPETITE STIMULANT

Mirtazapine is a powerful appetite stimulant. It is also an antidepressant, increasing serotonin receptor activity. It can be used by itself or as an adjunct to combat “serotonin burnout” from long term SSRI use. As a sleep aid, it has the peculiar property of being more effective in its lowest dose than in higher doses. I still can’t wrap my head around that one.

These are some of the pharmaceuticals that come to mind right now. I might be back with more some day. I haven’t thought of cataloguing my Black Bag like this before; I’ve just tossed things in over time without keeping inventory, so to speak. They just come to mind when I need them. But now I’ll try to be more organized.