 Happiness Isn't Brain Surgery with Doc Snipes. This podcast was created to provide you the information and tools Doc Snipes gives our clients so that you, too, can start living happier. Our website, docsknipes.com, has even more resources, videos, and handouts, and even interactive sessions with Doc Snipes to help you apply what you learn. Go to docsknipes.com to learn more. I'd like to welcome everybody to today's special presentation of Happiness Isn't Brain Surgery with Doc Snipes, practical tools to improve your mood and quality of life. In this presentation, we're going to talk about something called serotonin syndrome. And it is really very timely, if you will, because it's starting to affect more and more people. But a lot of people don't really understand what it is, what causes it, or even the symptoms. So they set themselves up for potentially being in a life-threatening situation. We're going to define serotonin syndrome, explore the drug interactions that often cause it, look at some risk factors for it, and you'll briefly learn about treatment for serotonin syndrome. Now serotonin syndrome, like I said, can be life-threatening. So this isn't something that you want to self-treat. But I'm going to give you some information about the treatment course looks like. So it's not so scary to you if you have to go to the emergency room or if you have to go to your physician because you think you might be developing it. So serotonin syndrome is increased when the level of serotonin in the brain gets too high. How do we do this? Well, certain medications and drugs and herbs act in different ways on the neurotransmitter system. One way you can do it is increasing the amount of serotonin that's made. Now serotonin is made from an amino acid called tryptophan. Eating tryptophan in foods, there are no known cases of it causing serotonin syndrome because tryptophan is in there with a bunch of other amino acids and they all compete and jockey to get into the brain. When you start taking supplements or it's pure tryptophan, it's a lot higher dosage than you would normally get in food, plus it doesn't have anything else competing against it, then it can become a problem. So supplementation with tryptophan has been implicated or is suspected in certain cases of serotonin syndrome. And at the end of this presentation, there are a bunch of journal articles if you want to go through and read the actual technical research. Another way to increase serotonin in the brain is reduce the breakdown of serotonin. When serotonin is in the brain, it's released into the synapse, it's broken down, it's reabsorbed and the process goes on again. But we can reduce the breakdown of serotonin through medications called MAOIs. Most people are not on MAOIs anymore unless they've tried other antidepressants and those antidepressants haven't worked. If you are on one, you know you're on one because you have a lot of dietary restrictions. Yet another way to increase serotonin is by increasing the release. So you have the two nerve endings and you have the pre-synaptic nerves and the post-synaptic nerves. Now, these medications tell the pre-synaptic nerves to send out a whole lot more serotonin than they normally would. Amphetamines and MDMA do this. Anorectics, your appetite suppressants including dexadrine will also increase serotonin. Now, your prescription anorectics are going to be a lot stronger than your over-the-counter weight loss drugs that contain dexadrine or dexadrine derivatives. But it's important to understand that will increase or can increase your serotonin. Anti-migraine medications are also known to increase serotonin release. So if you've got migraines and you're on something like Amitrex or Tegretol or Depakine, it's important to understand increases your serotonin. Now, in the big scheme of things, you may need your serotonin increased. The key is not getting too much. More ways to increase serotonin is to stimulate the post-synaptic receptors. Remember I said there's the pre-synaptic receptors. They squirt all the serotonin into the space between the two nerve endings. You've got the post-synaptic receptors. So if you get these post-synaptic receptors, they start taking more in. So you stimulate them and basically they're serotonin receivers and they get more active and they start sucking up, if you will, more serotonin. Drugs that are thought to do this include Busbar, Busbarone, Lithium, and your pain medications. Yep, not just antidepressants, your pain medications, especially your opioid pain medications, including something as, quote, mild as codeine or as strong as fentanyl or demoral. So knowing this, if you're taking prescription painkillers, even if you're taking them as prescribed, but you also are on other medications that increase your serotonin, you could be at risk for serotonin syndrome. So make sure your doc knows all the medications and herbs you're on. A final way that you can increase serotonin is by preventing the reuptake of serotonin. So it's squirted into the synapse, the post-synaptic receptors take it up. Sometimes these guys are a little bit slow. The best analogy I can give you is think of it like a bouncer at a nightclub. Most of the time when the nightclub's full, there's nobody else being left in, you tell everybody who hasn't gone, gotten into the club, just go home, try again tomorrow. Well serotonin reuptake inhibitors are the bouncers of the door that are there and keeping people in line and saying, just wait a second. I'll get you in pretty soon. Just wait a second. I'll get you in pretty soon. So it keeps little serotonin molecules hanging out, waiting to get through the door to the other side. Your SSRIs are serotonin reuptake inhibitors, Paxil Prozoxoloft, any of those typical first line antidepressants that are prescribed now. Ultram, which most people think of as a painkiller, also prevents serotonin from being taken back up. If you're on pain medication, whether it's a strict opiate or an SSRI, you do want to make sure that you're aware that it does impact serotonin levels. Trasidone is a serotonin agonist, so it increases serotonin and it also prevents its reuptake. So, you know, it has a double whammy for increasing serotonin. Tricyclic antidepressants, pretty much any medication that's characterized as an antidepressant, is likely going to increase serotonin to some extent. Serotonin and norepinephrine reuptake inhibitors, they're called SNRIs, such as Cymbalta and Afexor, increase serotonin. And a lot of your nicotine addiction medication, such as Welbutrin and Zypan, there are norepinephrine dopamine reuptake inhibitors, but they also act to increase the levels of available serotonin. The Mayo Clinic and WebMD has a full list of the most dangerous, if you will, medications in terms of increasing serotonin and potential for causing serotonin syndrome. Other drugs that raise serotonin, so we just went through a bunch of, for the most part, prescription medications, but there are other things that raise your serotonin, too, including illicit drugs like LSD, ecstasy, cocaine, and amphetamines. So if people are taking these and suddenly they spike a high fever, a lot of times you can look and that is serotonin syndrome. I can't say every time because I'm not seeing these people, but one of the key features of serotonin syndrome is a high fever. So when you see that caused by illicit drugs or right after somebody takes illicit drugs, that's going to be one of the first things you think about. Research is unclear about the ability of cannabis to trigger serotonin syndrome in combination with other drugs. If you're really sensitive and you use marijuana in addition to other serotonin increases, potentially it could cause problems, but like I said, the research is really unclear right now. Herbal supplements, there are a lot of herbs out there that are touted to be natural antidepressants. That is your clue again that it's probably going to increase serotonin levels. St. John's wort, 5-HTP, Sammy are three of your most prominent ones. When you take these, you don't even have to take them with a prescription medication. If you take them and they increase your serotonin levels too high for you, and it's all very individual, you can precipitate serotonin syndrome. Cava, ginseng, nutmeg, and pre-workout supplements that have stimulants in them. You can get pre-workouts that are stimulant free, but most people use the ones that have stimulants. All of these are things that you can buy at Walmart, Target, GNC, whatever. So you'd think, well, they're over the counter, they're harmless. No, that's not the case. If you're taking pre-workout supplements with stimulants plus something like 5-HTP, then you're increasing the likelihood that the two of those are going to have an additive effect and cause a serotonin problem. Over-the-counter cough and cold medicines containing dextromethorphan, Delcham is one that's really popular in terms of a cough medicine. But a lot of people are starting to abuse dextromethorphan. I don't know how much longer it's actually going to be available as an independent medication. Any of your cough and cold medicines, especially those that end in DM, probably have dextromethorphan in them, which can raise serotonin levels. I have heard anecdotal evidence about people who have been abusing dextromethorphan, using it recreationally, who have caused serotonin syndrome in themselves. Antinazia medications, such as Reglan or Zofran. These can be medications you might take for motion sickness or if you have nausea because you're undergoing cancer treatment. There's a lot of reasons people may be on antinazia medications. Remember, over-the-counter medications as well as prescription medications will raise serotonin levels. There's one antibiotic called XIVOX that has been shown to raise serotonin and one antiretroviral, which is used to treat HIV and AIDS. It's called Norvier that has also been implicated as one of those drugs of concern in terms of it can potentially cause a serotonin crisis. Why am I spouting out all these things to you? Because think about how many times you may have been sick and taking cough medicine, but decided you wanted to go to the gym anyway. You took your pre-workout supplement and you've been toying with depression and trying to self-medicate using over-the-counter natural antidepressants. You've got three things that you're taking that potentially raise serotonin levels. Generally, when you take medications like that, it's not a one plus one plus one equals three. It's one plus one plus one equals seven because they work in an additive and exponential capacity. Does it mean you shouldn't ever take any of these? That's between you and your doctor and, you know, however you make your decisions about what supplements you take. But it is important to be aware if you start taking these or if you take something and you start feeling wonky, it's important to be aware of the signs of serotonin syndrome. Can, can identify. C stands for cognitive changes and cognitive means thinking. So if you start getting agitated, confused or have extreme euphoria, I know some people love shooting for that extreme euphoria, but it can also be a warning sign that you've gone too far. Insomnia, hypomania, you can't sit still, you're feeling 10 foot tall and bullet proof and nobody can tell you any different and hallucinations. All signs of an impending problem. A stands for autonomic changes. Now, autonomic means those things that your body does without you thinking about them, such as your heart beating and breathing and regulating your body temperature. So tachycardia, if your heart rate, if your heart starts beating really fast, fever, especially a really high fever that spikes suddenly after you take a medication or a drug, arrhythmias, irregular heartbeats, sweating, you know, we all sweat, but all of a, if all of a sudden you start sweating profusely and you're not running a marathon, something's going on there. And if your pupils are dilated, which means really, really big, your body is responding to something and it's important to pay attention to that. The last sign are your neuromuscular changes. So the way you think, the way your body just naturally functions, the things you don't normally think about, and then neuromuscular changes, including tremor, you know, shakiness or being excessively rigid, you know, not being able to move very well in coordination, getting really clumsy all of a sudden seizures, diarrhea, nausea and vomiting. Serotonin is involved. There's about 80% of your serotonin is actually in your digestive tract. And when you have serotonin syndrome, everything speeds way up. So you may have extreme stomach cramping, diarrhea, nausea, vomiting. Those are potentially signs that you've got too much serotonin going on. Now, obviously some of these things, some of these symptoms are, you know, common. If you get the flu, you're going to have a high fever, diarrhea, nausea and vomiting. So I'm not saying you want to get freaked out every time you feel this way. The key is to say, did you recently take some kind of medication or supplement that is known to increase serotonin? Other symptoms to pay attention to and just kind of keep an eye on are if you have a headache or you start getting shivery and goosebumps for no apparent reason. In severe cases, serotonin syndrome can be life threatening. If you experience any of these symptoms, you or somebody with you should seek medical attention immediately. If you're not able to do it, they need to take your happy little butt to the hospital. If you have a high fever, especially one that spikes really, really suddenly, this can cause brain and organ damage. You need to get to the hospital. Seizures, that's pretty self-explanatory. You need to get to the hospital. Irregular heartbeat or loss of consciousness. I do want to caution you, though. Don't wait until you get to this point before you seek medical attention. If you are feeling extremely poorly after taking a medication that increases serotonin, probably a good idea to seek medical consult. So what are the risk factors? What do you need to consider to figure out, well, do I have the flu or food poisoning or what? If you recently started taking or increased the dose of a medication or substance known to increase serotonin levels, your body may not be reacting well to it. If you take more than one drug known to increase serotonin, remember I said it's not one plus one equals two, it's like one plus one equals seven. If you take herbal supplements known to increase serotonin levels, whether it's in addition to other medications or by themselves, many herbal supplements are not regulated by the FDA, which means the amount in one pill could be very different than the amount in another pill. So you could potentially get a whole lot more one time than you were expecting. And or if you use any illicit drugs known to increase serotonin levels, so if you're using ecstasy, you know, you go to a rave, you go to a party, you try something, maybe, maybe you're not a drug addict, you just try to do the party and you start having any of those symptoms of serotonin syndrome, cognitive changes, high fever, tremors, sweating, dilated pupils, nausea, vomiting. There's a problem, there's something going on and you need to get evaluated. Serotonin syndrome may appear after one dose, it's not something that has to build up. So if you just took it for the first time, if you just experimented for the first time with a drug at a party, that doesn't mean you're safe. It, you know, serotonin syndrome could happen. Being aware of the symptoms, you can get medical treatment, it generally resolves within 24 hours of the removal of the serotonin enhancing drugs, which again is something your doc needs to do, you don't want to self-medicate here. 60% of patients present within one to six hours after the initial administration. So if you take a medication or you increase your dose and within one to six hours you start feeling really poorly, having those symptoms, present, go to a walk-in clinic, go to your doctor, go to the emergency room if you think you need to and get evaluated because, you know, unfortunately, 60% present within one to six hours, that means the other 40% don't. Now, whether it's because they don't become symptomatic for more than six hours or because they just don't present, we don't really know. But generally, the majority of people who actually seek medical treatment for serotonin syndrome recover almost completely. Most people recover completely if you let that fever get too high and to the point where it starts causing organ and brain damage, you know, that's a lot of times irreversible, which is why you want to get evaluated and treated quickly and not just kind of wait and waited out. Serotonin syndrome is very real and very dangerous. The amount of any drug necessary to cause serotonin syndrome varies greatly between people, not only based on your body's experience with the drug and tolerance to the drug, but also on your individual, you know, physical makeup and any other drugs that you might be on. So what may be problematic for you may not be a problem for somebody else. Many over-the-counter drugs and herbs can cause serotonin syndrome, which is why it's important to tell your doctor about all over-the-counter medications and herbs you're taking, including pre-workout supplements. Opiates, even when taken as prescribed, can, if combined with certain herbs, pre-workout supplements or over-the-counter medications, cause or contribute to serotonin syndrome. So, you know, maybe you're taking 5-HTP, you go in, you have your wisdom teeth taken out, they give you a prescription for 20 hydrocodone and you're taking them as prescribed, but you're already taking enough 5-HTP that your serotonin levels are already pretty high, it could cause a problem, it could send you over the edge proverbially. Even if you aren't on an antidepressant, you may be at risk for serotonin syndrome by combining over-the-counter medications and or illicit drugs. Be careful, be cognizant, be aware. Abuse of dextromethorphan can put you at risk of serotonin syndrome, there's just no two ways about it, we know there have been people who have died from serotonin syndrome because of ODing on dextromethorphan. Alcohol, which we didn't talk about a lot, also increases serotonin levels. So, if you're on the brink of serotonin syndrome, you've already got as much as your body can handle and you go and you start drinking, you can precipitate a crisis. This is also the same reason why people who are on antidepressants aren't supposed to drink, because it is dangerous. It's not just, you know, please don't, it's not advised, it's dangerous. So, be aware of what you're taking, be aware of how your body acts, be aware of the symptoms of serotonin syndrome and please, if you have any doubt in your mind about whether you have those symptoms, seek medical attention immediately. As I said, there are a bunch of references you can get in and look at about the causes, consequences, yada-yada of serotonin syndrome. They're all here, so feel free to look those up. If you like our podcast, you can subscribe on your favorite podcast app, join our Facebook group at docsknipes.com slash Facebook, or join our community and access additional resources at docsknipes.com.