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By THE BALANCE
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There is no denying that mental health problems are on a rise in the world. To combat these mental health disorders there has been an influx of medicines that are used to treat these ailments. One of the medications that belong to this category is Duloxetine which is the generic name of Cymbalta – a medication used to treat depression, anxiety, and various nerve disorders. 

Duloxetine is known by the brand name Cymbalta and it is an anti-depressant that is used to treat the depressive disorder in adults and generalized anxiety disorder (GAD) in adults and children older than 7 years of age. Duloxetine is also used to treat various nerve pain disorders such as diabetic neuropathy and chronic muscle or joint pain associated with osteoarthritis. It also treats fibromyalgia. Fibromyalgia is a chronic condition that causes pain, muscle stiffness, and tenderness. 

Duloxetine is also used off-label to treat stress urinary incontinence in women, migraine, Attention Deficit Hyperactivity Disorder (ADHD), Obsessive-Compulsive Disorder (OCD), and Multiple sclerosis. Duloxetine helps to improve mood, energy levels, sleep, and decreases nervousness. Duloxetine (Cymbalta) was the seventh most prescribed drug in the United States in 2014. According to statistics 17 million prescriptions have been written for Cymbalta since 2006. 

Duloxetine belongs to the Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) class of anti-depressants. Serotonin and Norepinephrine are two neurotransmitters produced by the body to maintain the emotional state of the individual and to manage signal transmission. 

In generalized anxiety disorder and depression, there is a disruption in the levels of serotonin and norepinephrine in the body. Low levels of these neurotransmitters result in depression. Duloxetine (Cymbalta) works by increasing the levels of serotonin and norepinephrine in the brain by inhibiting or blocking their absorption by body cells. 

Duloxetine helps to improve mood, energy levels, and stamina and decreases nervousness with increased levels of serotonin and norepinephrine in the body. Apart from this Duloxetine provides analgesia in certain nerve disorders such as fibromyalgia, diabetic neuropathy, and bone pain. It is assumed that Duloxetine brings about the analgesic effect by blocking the sodium ion channel. 

Duloxetine comes in the form of an enteric-coated capsule to prevent it from degradation by the stomach acid and therefore it is an extended-release medication. It is taken orally and you should not crush or chew this medication rather you should swallow it whole. These capsules are available in 30mg and 60mg dosages for treating anxiety, depression, and nerve pain. For treating these conditions 1 capsule is to be taken in a day. Doctors usually prescribe the lowest dose initially and if the symptoms do not improve they may double the dose. 

For depression, the starting dose is 60mg and it can be increased to 120mg in a day which means 2 capsules are to be taken in a day. For anxiety and nerve pain the starting dose is 30mg and it can be increased to 60mg that is 2 capsules in a day

For urinary incontinence 20mg and 40mg of dosages of Duloxetine are available. 2 capsules are to be taken in a day and if the symptoms do not improve your doctor may recommend you to take 40mg of Duloxetine twice a day. 

The maximum dose of Duloxetine is 120mg in a day. Never take two doses at once to make up for the missed one as it increases the risk of adverse effects. You can take the medication with or without food as it shows no significant interaction with food. 

Certain individuals are not advised to use Duloxetine and they should inform their doctor if they have any of the conditions listed below:

  • Individuals who are allergic to Duloxetine and similar medicines
  • Individuals who are having kidney or liver problems
  • Individuals who have a condition called glaucoma in which the pressure inside the eyes is increased
  • Individuals who bruise easily
  • Individuals who have a cardiovascular problem or high blood pressure
  • Individuals who have a history of seizures, bipolar disorders, and manic episodes
  • Individuals who want to get pregnant, are already pregnant, or are breastfeeding
  • Individuals who have taken anti-depressants in the last 14 days

Individuals taking Duloxetine for depression should be monitored for signs of suicidal thoughts such as thoughts about killing or harming oneself. The risk is higher in children and teens who are two times more at risk of developing suicidal ideations. In addition, individuals aged 18 to 24 are 1.5 times more at risk of suicide. 

The risk of suicide is also for those who do not have a mental health disorder and those who take Duloxetine for other reasons such as nerve pain. The risk of suicidal ideation is greatest at the beginning of the treatment and every time the dose is altered whether increased or decreased. Individuals might experience symptoms such as panic attacks, new or worsening depression, and thoughts about killing themselves, restlessness, unexplained excitement, or unusual behavior. 

If you observe any of these signs in yourself or your loved one who is on the Duloxetine regime, you should immediately consult the doctor so that proper intervention can be made. 

According to medical professionals, Duloxetine is not addictive and pharmaceutical companies make it clear while wording their brochures that Cymbalta does not have addiction potential. Nevertheless, abuse and misuse of Duloxetine unquestionably occur. Duloxetine has the potential to cause both physical and psychological dependence even when used as prescribed. 

Duloxetine elevates mood and increases energy level along with improving sleep patterns. People often get accustomed to the pleasurable effects of Duloxetine. After some time of use, Duloxetine causes tolerance which means that an individual has to take increased doses of the drug to attain the original effect. After the development of tolerance, dependence follows which is similar to addiction to Duloxetine. 

Duloxetine Addiction is the state of dependence on Duloxetine by the body and brain as they become accustomed to the presence of the drug in the system. The effect of Duloxetine on the levels of serotonin and norepinephrine causes an elevation in mood. 

Even though Duloxetine does not cause the high or euphoria associated with other addictive substances it is still misused due to the benefits that come with its use. The reason why individuals continue using Duloxetine long after the prescribed duration is that they cannot tolerate the unpleasant withdrawal symptoms that follow after discontinuing Duloxetine. 

Duloxetine (Cymbalta) abuse is not common as seen with other drugs since this drug does not cause a high and does not induce euphoria but abuse is still possible. Individuals often abuse Duloxetine in conjunction with other drugs such as alcohol, or other medications to enhance the pleasurable effect of the drug.

When Cymbalta is abused with other drugs the chances of an overdose increase significantly. In addition, poly-drug abuse can make withdrawal episodes very difficult for the individual since withdrawal symptoms are intense in this setting. Therefore Duloxetine abuse should be avoided at all costs.

Duloxetine Addiction Symptoms

It is difficult to spot Duloxetine (Cymbalta) abuse since the symptoms mimic the side effects of the drug or the condition for which Cymbalta is used to treat. However, with close observation, one can notice the signs and symptoms of Duloxetine abuse. 

Following are the sign and symptoms of Duloxetine (Cymbalta) addiction:

  • Slurring of speech
  • Bloodshot eyes
  • Individuals faking their condition to manipulate doctors to prescribe them Duloxetine
  • Decreased appetite
  • Financial issues due to absent days at work or inability to concentrate
  • Increased somnolence or insomnia
  • Poor hygiene and changes in physical appearance 

As with all other medications, Duloxetine also has side effects associated with its use. Common side effects of Duloxetine are as follows:

  • Nausea
  • Vomiting 
  • Dry mouth
  • Headache 
  • Constipation 
  • Feeling drowsy 
  • Pounding heartbeat
  • Diarrhea
  • Increased urination
  • Difficulty urinating 
  • Sweating or having night sweats 
  • Dizziness
  • Stomach pain
  • Decreased appetite
  • Heartburn
  • Tiredness
  • Muscle pain or cramps
  • Weakness

Duloxetine use is also associated with serious side effects in which case a doctor should be contacted promptly and emergency medical help should be provided. 

Following are the serious side effects of Duloxetine: 

  • Swelling of the abdomen
  • Yellowing of the skin or eye
  • Unusual bleeding and/ or bruising
  • Itching
  • Decreased appetite
  • Dark-colored urine
  • Mental confusion
  • Fever
  • Sweating
  • Fast or irregular heartbeat 
  • Extreme muscle stiffness
  • Rash
  • Hives
  • Blisters on the skin
  • Difficulty breathing
  • Difficulty swallowing
  • Hoarseness 
  • Swelling of the face, throat, feet, or lower legs 
  • Pain in the upper right side of the stomach 

It has been quite a concern among people who are starting to take Duloxetine whether they can consume alcohol with the medication or not. Similar to other anti-depressants, Serotonin and norepinephrine reuptake inhibitors (SNRIs) like Duloxetine (Cymbalta) cannot be mixed with alcohol. Mixing alcohol and Cymbalta poses an increased risk to the health of an individual since mixing these two can have devastating consequences. 

Alcohol aggravates the side effects of Duloxetine. In addition, Alcohol nullifies the action of the drug which means that concomitant use of alcohol and Duloxetine will worsen the condition that Duloxetine was treating. Alcohol and Duloxetine cause physical as well as psychological adverse effects hence mixing the two substances is not advised. 

Risks of Mixing Duloxetine and Alcohol

There is great peril associated with mixing Duloxetine and Alcohol. Duloxetine is an anti-depressant and alcohol is a central nervous system depressant. Both these substances significantly alter brain functioning when used together. Duloxetine is used for the treatment of depression and when an individual consumes alcohol with the drug, alcohol blunts the action of Duloxetine such that the individual might experience worsening depression and may think that the medication is not working, oblivious to the fact that it is alcohol that has rendered the Duloxetine useless. 

Duloxetine is known to cause liver damage. Each time, individual drinks alcohol several liver cells die, and with increased drinking, the loss of hepatocytes is beyond the ability of the liver to regenerate. Taking Alcohol and Duloxetine concomitantly puts the liver at an increased risk of damage. 

Alcohol use is associated with blackouts where the individual does not remember what happened during their state of intoxication. Alcohol and Duloxetine (Cymbalta) can worsen these blackouts and impairs the memory until the effect of the drug lasts such that the individual will have no recollection of events that happened and this can put the individual’s life at risk. 

Mixing Cymbalta and alcohol results in the following side effects:

  • Vomiting
  • Confusion
  • Nausea
  • Vomiting
  • Drowsiness
  • Dizziness

Duloxetine is safe when used as prescribed and overdose is not common but it is possible when the drug is misused. Cymbalta overdose can happen if the individual takes increased doses of the drug whether intentionally or by accident such that they may consume a fatal dose. 

Secondly, Cymbalta overdose is common in settings where the medication is combined with other substances that are contraindicated to be used with Duloxetine. 

The lethal dose of Duloxetine that causes an overdose varies from person to person since it is influenced by various factors such as the route of administration of the drug, the dose of the drug, or the substance with which the individual combined the drug. Individuals abusing Cymbalta alone may require higher doses of the drug as compared to those who combine it with alcohol. 

According to various studies, 1000mg of Duloxetine is considered a sufficient dose to cause an overdose whether used alone or when combined with another substance. Considering that the maximum daily intake of Duloxetine is 120mg, there is a broad margin of safety and individuals need to take an excessively large quantity of pills to cause an overdose.  

Duloxetine overdose is associated with certain tell-tale signs that are indicative of an overdose. The symptoms and side effects of Duloxetine overdose are as follows:

  • Fast heartbeat
  • Loss of coordination
  • Auditory and visual hallucinations
  • Fever
  • Nausea 
  • Sleepiness
  • Vomiting
  • Diarrhea
  • Seizures
  • Drowsiness
  • Lightheadedness 
  • Loss of consciousness 
  • Agitation 
  • Confusion
  • Unresponsiveness to surrounding 
  • Coma

Serotonin Syndrome is also a feature of Duloxetine overdose due to increased levels of serotonin in the body as an effect of the drug. Serotonin syndrome has symptoms of restlessness, agitation, rapid heart rate, dilated pupils, heavy sweating, diarrhea, and headache.

Duloxetine Overdose is a medical emergency and prompt hospitalization is vital for survival. Duloxetine overdose in the form of serotonin syndrome, or overdose due to mixing of Duloxetine with alcohol or with benzodiazepine will vary in severity and hence a complex approach is required for treating Duloxetine overdose. 

In the hospital, the medical staff may do gastric lavage and administer activated charcoal to remove the drug from the system. Moreover, they will provide oxygenation and ventilation to the patient. Meanwhile, the vital signs are monitored and body temperature is kept under control. 

Apart from the above management, symptoms of Duloxetine overdose are treated. While managing an overdose, Cymbalta should never be stopped abruptly rather it should be gradually tapered down under the supervision of a doctor. 

Individuals who are addicted to Duloxetine should never attempt to go cold turkey when planning to discontinue the drug due to the intensity of the withdrawal symptoms. Duloxetine (Cymbalta) withdrawal symptoms are commonly encountered when individuals quit the drug which made the doctors coin a name for this condition that is ‘Cymbalta (Duloxetine) Discontinuation Syndrome’. 

According to a study it has been reported that 44% of individuals using Cymbalta experience discontinuation syndrome upon cessation of the drug. It is advised that when one plans to quit using Duloxetine they should never go cold turkey, no matter how tempted they are to do so. This is because going cold turkey intensifies the withdrawal episodes and makes the withdrawal episodes painful for the individual that is difficult to bear. The best way to discontinue Duloxetine is to taper the dose gradually and this should be done under medical supervision. 

Duloxetine Withdrawal Symptoms

There are a plethora of withdrawal symptoms of Duloxetine that makes it very challenging to discontinue the drug. Withdrawal symptoms are both physical and psychological and they are as follows: 

Physical Withdrawal Symptoms of Duloxetine 

  • Dizziness
  • Severe headaches
  • Irritability
  • Paresthesia (burning or prickling sensation in the hands and/or feet)
  • Diarrhea
  • Insomnia
  • Nausea
  • Vomiting
  • Irregular heartbeat 
  • Increased sweating
  • Fatigue
  • Seizures
  • Vertigo
  • Hypersensitivity 

Psychological Withdrawal Symptoms of Duloxetine 

  • Anxiety
  • Nightmares
  • Depression
  • Agitation
  • Irritability
  • Paranoia
  • Hypomania
  • Confusion   
  • Suicidal thoughts 

Brain zaps are commonly encountered in individuals who quit Duloxetine. Brain zaps are sudden electrical buzzing in the head and this phenomenon is not completely understood yet. Disorientation and lightheadedness are frequent findings associated with brain zaps. However, brain zaps pose no threat to the physical health of an individual 

Duloxetine Withdrawal Timeline

It is not possible to describe the withdrawal timeline for Duloxetine since the severity and duration of symptoms of Cymbalta withdrawal vary from person to person based on different factors. Some individuals may experience severe withdrawal symptoms in the initial days after discontinuing Duloxetine (Cymbalta) while others may experience these symptoms for months after cessation of the drug. 

The earliest symptoms of Duloxetine withdrawal appear 12 hours after the last dose. 24 hours after the last dose individual may experience somatic symptoms such as nausea, vomiting, restlessness, etc. The physical side effects of Duloxetine peak in 2 to 3 days after the last dose and they can last for weeks. Psychological symptoms usually last for months and they gradually fade with time.  The safest way to deal with withdrawal symptoms is to enroll in a medically assisted detox program as it helps to minimize the unpleasant withdrawal symptoms that follow after discontinuing Duloxetine (Cymbalta).

Duloxetine addiction involves a detox program at the beginning which removes all traces of drugs from the body. The detox is medically supervised to ensure the safety of the patient while weaning off the drug. Duloxetine (Cymbalta) detox is sufficient to bring a person off the drug but if an individual requires additional care in the setting of poly-drug abuse such as abusing Cymbalta with alcohol or other medication then a rehab program provide an effective opportunity to treat this condition. 

There are two types of rehab programs; an inpatient rehab program and an outpatient rehab program. Inpatient rehab program involves a stay in a residential rehab center that is designed for effective treatment of the individual by providing them round-the-clock care and support to assist them during recovery.

In-patient rehab programs are an excellent choice for individuals who prefer a sober-living environment for a dedicated period so that they do not give in to the temptations in their surroundings or at home. This program involves staying at the campus with weekly family visits. 

Out-patient rehab facility works for those who want to recover from addiction while staying in the comfort of their homes. It involves visiting the rehab clinic for certain hours a day every week.

A rehab program includes the following:

  • 12-Step Program work
  • Relapse Prevention Strategies
  • Life skills development 
  • Individual therapy
  • Group therapy

This combined approach helps an individual to safely come off addiction and an after-care program is offered to reduce the chances of relapse. 

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