The mystery of "Himmmm"

This is the pile of pills I knock back every morning to keep myself more or less functional.

The long white 5500 pill and the two blue ones are painkillers: 500 mg acetaminophen (paracetamol outside the US), and 440 mg naproxen sodium. This is combining analgesics from two different families with two different mechanisms of action. They're both non-selective inhibitors of cyclooxygenase, but acetaminophen, a derivative of coal tar, seems to work mainly on the central nervous system, whereas NSAIDs like naproxen have a more peripheral action that includes anti-inflammatory effects. I try to be conservative with the Tylenol, as I like my liver and I do occasionally drink. Naproxen, I am more cavalier about, as it doesn't cause me any GI issues, and I rarely exceed the '3 pills in 24 hours' box instructions. Prescription naproxen for osteoarthritis is 500 mg q8-12h, which puts my usage well within standard therapeutic range. 

Starting out with two naproxen instead of one is what's known as an 'attack dose', used because it's way harder to convince things to stop hurting than it is to keep them not hurting once they've calmed down. Being immobile for long periods of time, which ideally I have been if I've slept decently, makes my joints hurt like fuck, probably because all the pressure is on one facet of the cartilage for a long time with no breaks. The attack dose gets things under control so I can actually, you know, get up and walk around.

The small pink thing is 25 mg diphenhydramine, which is seasonal. I have appalling pollen allergies this time of year. The standard adult dose in the US is actually two pills. I appear to have a deficiency in a liver enzyme called cytochrome p450 2D6, which breaks down a lot of common medications. Some things I have to take half doses of, like the Benadryl; some things, there is no dose large enough to be effective while being low enough not to murder me with side effects (see: alpha- and beta-blockers). 

It's especially inconvenient when it comes to analgesics, because it means most of the heavy-hitters don't work. Opioid painkillers in current use are almost all prodrugs that are metabolized into the active compound by CYP2D6 in the liver, which means that they do something between jack and shit for me. I've proven this experimentally with pethidine (Demerol), hydrocodone (Vicodin) and oxycodone (Percocet), and I've decided that's all the investigation I'm going to put up with. Straight-up morphine would probably work, but I don't feel like finding out. This also means I can't pull a Kurt Cobain and resort to heroin when nobody will prescribe me things I need to function -- "Heroin" was originally a brand name for diacetylmorphine, which requires the same enzyme for activation.

[For pain control when things get truly terrible, I use dextromethorphan. While it is chemically related to methorphan, an opioid painkiller, dextromethorphan does not work under the same principles as opiates; it is instead a dissociative that functions by blocking NMDA receptors. The mechanism of action is substantially similar to both nitrous oxide, aka 'laughing gas' used for dental work, and ketamine, whose medical use is as a pediatric and veterinary anesthetic. DXM and ketamine are both used as adjunct therapies in cases like burn patients, who would otherwise require such large doses of narcotic painkillers it would risk respiratory depression and death. I would frankly keep a stash of ketamine on hand if I could get a hold of medical-grade stuff of a known purity, but I can't, so the FDA-vetted and quality-controlled Robitussin gelcaps available at my local pharmacy are the next best thing.]

The big pink thing is a multivitamin. This one happens to be a women's multivitamin, hence the obnoxious color. I just buy whatever's cheapest at CVS. I probably don't need it, but decades ago a friend who was leaving for a semester abroad told me that if I died of malnutrition while she was gone, she'd never speak to me again. I keep it up mainly out of tradition.

The big blank white pill is magnesium citrate. There's Mg in the multivitamin, but these are a much bigger dose -- 500 mg, which is more than nutritionally necessary, but has a fair amount of evidence for therapeutic uses. It's supposed to help muscle soreness after heavy activity, prevent some kinds of migraines, and treat restless leg syndrome, all of which I have issues with. Doses of magnesium citrate over 300 mg may function as a laxative in some people; the 500 mg pill is in the range usually cited for migraine prevention and seems to play well with my system, but YMMV. Use with caution.

The round white tablet is 200 mg of caffeine. I've never liked coffee, but I don't function super well without caffeine, so pills it is. I quit caffeine for a good six months at one point, on the advice of a therapist trying to lower my anxiety levels. It made me a billion times worse, because suddenly I didn't have enough executive function to do fucking anything, and my blood pressure started tanking at random. Caffeine is indicated as a symptomatic treatment for things like POTS, because it helps keep blood pressure above that critical 'I might pass out' level, and there's some evidence it raises the average volume of cerebrospinal fluid, which probably helps the hydraulics. I carry a few loose tablets for migraine prevention. It doesn't always work, but almost all of the heftier migraine prophylactics like tryptans are on the big list of CYP2D6/Do Not Take drugs, so the equivalent of Excedrin Migraine is the best I've got.

The brownish capsules are mucuna pruriens, or velvet bean supplements. Also called Dopa mucuna, velvet beans contain about 20% L-DOPA (by volume, I think), a chemical precursor to dopamine. I started taking them a while ago because, frankly, I wanted to be able to fucking wake up in the morning. I have a lot of quirks that suggest my brain has a problem either utilizing dopamine or keeping reasonable levels of it around -- executive function problems, restless leg syndrome, chronic hypotension, a history of avolia and borderline akinesis under extreme stress, a few other things. In addition to being the 'motivation' neurotransmitter, dopamine is also the 'wake the fuck up' neurotransmitter (and can be converted into the 'RED ALERT' substances epinephrine and norepinephrine, which help maintain blood pressure) and usually the 'not feeling complete emptiness instead of satisfaction when you complete something' neurotransmitter. I figured more would fix some of this, in which case problem solved, or not fix any of this, in which case I could strike one more thing off the DDx.

If you have this problem with serotonin, most doctors will be happy to throw some serotonin reuptake inhibitors, usually in the form of SSRIs (e.g, Prozac, Celexa, Lexapro, Zoloft), at you. Are there any dopamine reuptake inhibitors, you ask? Yes! They are illegal, because they are fun. Cocaine is a good one, as are amphetamines. Since that is a non-starter, and dopamine itself doesn't cross the blood-brain barrier when taken orally, I went with the readily-available source of L-DOPA, which does cross the BBB and get converted into dopamine when accompanied by adequate levels of the appropriate enzymes. Technically L-DOPA is the same thing as levodopa, and available as a prescription medication, but you try talking a doctor into giving a (reasonably) healthy and athletic 40-year-old a bottle of Parkinson's pills, and see how far you get.

The white capsules are probably going to be the most controversial here: 300 mg of phenibut hydrochloride. Phenibut is a Soviet-era anxiolytic, developed for use by cosmonauts because the standard anxiolytics then in use (barbiturates, first-generation antipsychotics, and the then-new benzodiazepines) were too sedating to be useful. It is not in clinical use in the US, and does not fall under the general definition of narcotics in American law, which makes it a generally uncontrolled substance here. (It is used clinically in a lot of Eastern Europe, where it is subject to the same controls as any other prescription medication.) A couple of states have specifically banned it, but most haven't, including mine. I get my supply from liftmode.com, a lab near Chicago, which sells several variations of the stuff, including loose powder and crystals if you need to measure out a custom dose. 

Phenibut is an analogue of a neurotransmitter called γ-aminobutyric acid (GABA), which gives it a mechanism of action similar to but much weaker than GHB (Rohypnol), and the muscle relaxant baclofen. In low doses, it is dopaminergic, which is both synergistic with the dopa mucuna I take, and what makes it less sedating than the other commonly-used families of tranquilizers. 

Do not fuck around with phenibut. I take a small dose of it because it helps limit my levels of random anxiety and muscle spasticity, both of which are common symptoms of dysautonomia secondary to Ehlers-Danlos, and both of which make my life inordinately difficult. Getting prescriptions to deal with either of those things is like pulling teeth, and no official drug or combination thereof has ever worked so well for me with so few side effects. I am on the smallest effective dose I can find, and if I forget it when I refill my pill caddy it takes me a couple days to notice. Not everyone is so tolerant to taking it or missing doses, and if you decide to give it a whirl, you need to have a lot of respect for the stuff. Be careful on a par with something like Xanax or Klonopin. Start with powder, and titrate on and titrate off for best results.

[If you check Erowid, you will discover that people apparently take much, much larger amounts of phenibut for recreational purposes. I have no idea why. I tried it once and it was nothing I would ever describe as fun. My eyes wouldn't saccade in tandem, and my brain felt like it was full of chlorinated pool water. I mostly lay as still as I possibly could, trying not to throw up. It made being catastrophically tequila-drunk feel like a mild inconvenience. I have confidence in dosing math I do while sober, so eventually I just took something for the nausea and went to sleep until it wore off. 0/10, do not recommend.]

Things not pictured that I keep around for spot treatment: 

Bronkaid MAX, which is 25 mg ephedrine sulfate. Yes, you can still get ephedrine OTC. There are probably limits on it, which I never hit. This is sold as a bronchodilator for treating mild asthma, and it's also the best decongestant I can get my hands on. For some reason it's less uncomfortable than pseudoephedrine. My asthma is not bad, but I was goddamned living on this stuff the entire time we were in masks, because an excess of hot humid air is what sets me off. Under normal circumstances, I only have issues doing heavy cardio in the hottest, squishiest part of summer, and knocking back a single Bronkaid before I leave for class takes care of it.

Secondary to that, during the Mask Times the Bronkaid didn't cut it and I had to buy a rescue inhaler. Primatine is just a straight-up bolus of more ephedrine (adrenaline), right to the bronchi. It works, but it is not all that pleasant a feeling, and the crash afterwards is so nasty it tanks my emotional state along with my energy levels. I cry a lot. I try to be home before that happens. I prefer to avoid the experience altogether.

Previous iterations of Bronkaid had 400 mg guaifenesin, which is an expectorant (i.e., makes it easier to cough the crap out of your lungs). It was reformulated without it a few years ago, so now I just have that around as a separate pill. It's usually sold as Mucinex, or generic equivalent. Guaifenesin is also a centrally-acting muscle relaxant, and may or may not have useful effects on chronic upper back and neck pain. Relaxant doses are 3-4x the expectorant dose, and while this is safe to take occasionally I can't tell if it does anything much. Trying to keep myself on a steady dose of this size would be expensive and probably hammer my kidneys more than I'm really comfortable with.

I have two small tincture bottles of thienodiazepines in propylene glycol. These are more gray market research chemicals, like the phenibut; thienodiazepines are basically benzos with the serial numbers filed off. They too are outside the narcotics laws and not FDA approved for clinical use in the US, but widely used elsewhere in the world. I got tired of having to bow and scrape and submit myself for judgement to the medical establishment just to get half a dozen Ativan at a time, so I went and bought my own. I have a bottle of flualprazolam 1mg/mL, a short-acting thieno roughly equivalent to alprazolam (Xanax), and a bottle of diclazepam 4mg/mL, a medium-to-long action thieno roughly equivalent to diazepam (Valium). 

I am not going to tell you where I got them. Do not fuck with thienodiazepines either. I take them PRN for panic, in eyedropper doses equivalent to the prescriptions I have had in the past for the corresponding benzos, only when I am useless as I am and the alternative is dragging myself to the ER for brand-name sedatives. Considering that I have whined to several doctors that I can't get the 0.5 mg alprazolam tablets to break nicely into quarters, my usage is not at a worrying level. I have had these bottles for years, I forget about them for months at a time, and they are both still nearly full. If your idea of a fun time is taking bars of Xanax, plural, I do not recommend even starting with these things. It will end badly.

I bought a little tin of CBD tea a few months ago. I went to some trouble to find stuff that is as close to CBD-only as I could. The compound in marijuana that people generally find fun is tetrahydrocannabinol (THC), which is a serotonin analogue. Most people find more serotonin more enjoyable, which is why a lot of recreational drugs (and antidepressants) bang on that particular receptor. I've learned the hard way that I absolutely do not need more serotonin, and fucking around with my levels is incredibly unpleasant. Aside from the usual sandy bloodshot eyes that everybody gets, I also suffer akathesia and sometimes parasthesias, general dysphoria, and something wacky happens to my temperature regulation -- I always feel way too hot, not like the room is too warm, but like I'm running a fever and overheating from the inside out. The most peculiar thing is what I can only describe as the feeling that all of my abdominal organs are suddenly trying to escape outward, leaving a great uncomfortable quivering hollow about where my diaphragm should be. I don't know if it qualifies as serotonin syndrome, but it's trending in that general direction. It's not at all fun or stress-relieving.

I can't actually tell if the CBD tea does anything, so it probably doesn't. I don't much like tea, but the label says it contains "natural hazelnut flavors, toasted brown rice, and licorice", which is probably as good as mulch water is going to get for me. (I do sometimes drink genmaicha in the summer, which is green tea and toasted rice grains. If you put enough sugar in it, it tastes like breakfast cereal.) I used to give the used tea bags to Tseng when he was on his way out. He seemed to enjoy them.

The evidence that tonic water is effective as a muscle relaxant is vague at best. Levels of quinine in tonic water sold in the US are capped at 83 mg/L, which would mean you'd need about three litres of the stuff to get to the dose formerly used to treat leg cramps. On the other hand, use of quinine for cramps was banned when a not-insignificant number of people developed complications from the 200-300 mg usually given. Sensitivity to the stuff seems to vary pretty widely. I happen to like tonic and lime, with or without the gin. Can't hurt.

I have very little patience for anyone who thinks I'm not "taking responsibility for managing" my medical shit. I get to do as much living as I do through a combination of complicated exercises in pharmacodynamics and sheer stupid willpower. I've spent a lot of time explaining all this to doctors only to have them shrug and go, "Don't do things that make it worse, I guess?" I have to spell "Ehlers-Danlos" every time I go to the ER/urgent care, so the attending can Google it real quick and pretend they know what it is. At this point, any physician who takes offense to me showing up with a folder full of journal articles is immediately fired.