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Friday, September 30, 2011

The Elvis Cocktail --- a guide

Sometimes, in my blog, I refer to the "Presley cocktail", or the "Elvis cocktail"; having nothing else to write, I will try to explain what this means.  Due to possible interactions, and due to the habit-forming effect of some of the ingredients, these drugs, including those obtainable over the counter, must be reported to your doctor.

The principal raison d'ĂȘtre of this drug cocktail is for chronic pain; the various components of this cocktail treat the physical and mental effects of pain, although only the opioids (opiates, or narcotics) described below, are indicated specifically for pain.  Because some of these drugs pre-date the introduction of the metric system into Europe, their dosages are occasionally written in grains, or fractions thereof; one grain is sixty-four milligrammes, often rounded down to sixty.

Severe chronic pain reduces the patient's attention; one becomes so fixated on the pain that it becomes hard to focus on a task.  Accordingly, the first ingredient in a Presley cocktail is a psychostimulant; Presley himself used dextroamphetamine, usually sold as Dexedrine, and racemic (half-and-half) amphetamine, then known as Biphetamine and now (in a slightly different formulation) known as Adderall.  Here is a list of psychostimulants most used in Canada, Great Britain, and the United States, along with my recommendations:

  • 50:50 Amphetamine (Benzedrine) - not recommended, because it is too mild
  • 75:25 Amphetamine (Adderall/Biphetamine)
  • Lisdexamphetamine (Vyvanse) - time-released form of Dexedrine.  Multiply by 2.5 to get the Dexedrine Spansule dose.
  • Dextroamphetamine (Dexedrine) - double the dose of Benzedrine, or multiply the dose of Adderall by 1.35.  Recommended by psychiatrists, Elvis, and me.
  • Methamphetamine (Methedrine or Desoxyn) - the undisputed best, but also highly abusable.  Used to come in many formulations, now comes in only one: the 1/12 gr. (5 mg) instant-release form.  The blue ribbon goes to this one; by far, it's the best amphetamine out there.
  • Methylphenidate (Ritalin) - chemically not related to any of the above, but can also be used to good effect.  Not to be combined with any of the above.

The pain itself must also be treated; the drugs most common for treating pain are what I have termed the typical opioids (these include those naturally harvested from poppies with no modifications, those modified in the laboratory, and fentanyl, which is completely synthetic but behaves like the natural and semi-synthetic opioids).  Atypical opioids (most synthetic ones) are also used, but these have some very different, and sometimes unpleasant, side effects.  Presley himself preferred hydromorphone; I entirely agree with his recommendation.  Because these drugs are very old (possibly the oldest class of drug in existence), no brand names will be listed except for certain drugs that are mostly known under their (usually American) brands.
  • Codeine - 1/10 the strength of morphine; very mild and not recommended for moderate-to-severe chronic pain.  Over the counter in almost every country.
  • Dihydrocodeine - See codeine.
  • Morphine (Sevredol, MS Contin, and many others) - The gold standard.  Used for everything from headaches to terminal cancer.  Also very mild, and over the couwritten some countries, as a result.  This drug is nine times the strength of morphine; the dosages Browne's Chlorodyne, Kaolin and Morphine Mixture, and Diocalm.
  • Morphine diacetate (Heroin) - This is a form of morphine used mostly in the United Kingdom, but also elsewhere.  It works just as morphine sulphate and morphine hydrochloride do, with one exception: it is twice as potent by injection than other morphine salts.
  • Dihydromorphine - Most commonly used in Japan.  Dosages and effects are roughly equivalent to morphine.
  • Dihydrodiacetylmorphine - Just as dihydrocodeine is codeine with two atoms of hydrogen bound to it, and dihydromorphine is morphine with two atoms of hydrogen bound to it, the same is true of dihydrodiacetylmorphine; the duration of action and doses are slightly different (unlike oxycodone versus hydrocodone.)
  • Oxycodone (OxyIR, Percocet, Percodan, Percolone, Supeudol, and OxyContin) - Oxycodone is an odd drug from its family.  Unlike every other opioid, oxycodone has stimulant qualities; for those suffering from pain together with fatigue, oxycodone is a blessing.  This 
  • Dihydromorphinone/Hydromorphone/Dilaudid - Different names for the same drug; Dilaudid is a trade name that in America has almost become the generic name and written with a small 'd' as a result.  This drug is nine times the strength of morphine; the dosages available are 1/30, 1/15, 2/15, 4/15, 8/15, and 1 gr.  Because of its strength, the higher dosages are available only as slow-release tablets.
  • Buprenorphine (Butrans, Buprenex, Subutex, Suboxone) - An excellent drug; ounce-for-ounce and pound-for-pound the most potent semi-synthetic opioid used in humans.  Butrans is a one-a-week patch; the others are twice-a-day tablets.   As a result of its potency, it is measured in microgrammes, not milligrammes or grains (patch only).  Subutex sublingual tablets are available in 1/32 and 1/8 gr. strengths.  The one-eighth-grain tablet is equivalent to 240 mg. (over four grains) of morphine at once; it is less sedating, but it still packs quite a punch for pain.
  • Fentanyl - Entirely synthetic; comes in many strengths, but must be placed under the tongue or on skin, just like buprenorphine.  It's far shorter-acting; the instant-release fentanyl is for breakthrough pain only, and the patch lasts for three days only.  The patch can leak, which can be deadly.
For sleep, there are essentially six options, as outlined below.  Due to the extreme variety of drugs available (there are far more sleeping powders and pills than pain medications), two drug groups will be covered only as such.  Each hypnotic loses effectiveness over time, so it is important to rotate them for chronic sleeplessness.
  • Benzodiazepines - These are the most commonly-used prescription drugs for sleep.  There is a great variety of them, but all of them are controlled drugs, and for good reason: once benzodiazepine dependence forms, withdrawal (unlike the pain drugs above) can be deadly.  It parallels alcohol withdrawal (delirium tremens and seizures being very common).  However, benzodiazepines are safe in overdose unless combined with alcohol (which is highly contraindicated when on a benzodiazepine).
  • Barbiturates - These are prescribed more rarely, but remain a valid option; these have most of the advantages of benzodiazepines, but many more disadvantages.  Barbiturates are extremely deadly in overdose, whether combined or not; the withdrawal usually is deadly (although substitution therapy works well), and addiction sets in earlier than with benzodiazepines.
  • Chloral hydrate (trichloroacetaldehyde) - Very safe, as it is used in large amounts; however, this drug is uncommonly prescribed, and mostly used with children and seniors.  This drug is available as a liquid which tastes rather like acetone; (very large) gel capsules are available as well.  The main problems with chloral are a hangover effect, as well as stomach irritation (nausea, vomiting, ulcers).  Chloral addiction is uncommon, but can result, and is extremely uncomfortable, but rarely fatal.
  • Quetiapine (Seroquel) - This is an antipsychotic often used also as a sleep aid, but this use is not suggested.  Should be used as a last resort only.
  • Melatonin - An over-the-counter hormone that induces sleep; my own preferred sleep aid, aside from chloral and diphenhydramine.  Available in 3 mg and 5 mg.  Gently nudges you to sleep.
  • Antihistamines - These are used for the relief of allergies and side-effects from pain medication far more than for sleep, but this remains a valid option.  The antihistamines to use for sleep are generally the older ones: diphenhydramine (Benadryl) and dimenhydrinate (Dramamine), both over-the-counter, work well.  The usual dose for sleep is 50-100 mg of Benadryl, or 100-200 mg of Dramamine.  THESE DRUGS ARE VERY DANGEROUS IN OVERDOSE (DELIRIANTS).    
These drugs must be properly spread out.  The most common practice is to take the opioid four times a day, the stimulant twice or three times, and the hypnotic once.  Some examples of the Presley cocktail in practice:

8:00 AM:  Hydromorphone 8 mg; dextroamphetamine 15 mg. 12:00 AM: Hydromorphone 8 mg.  4:00 PM: Hydromorphone 8 mg; dextroamphetamine 15 mg.  8:00 PM: Hydromorphone 8 mg; diphenhydramine 100 mg.  10:00 PM: Bedtime.

9:00 AM: Morphine 60 mg; one large coffee (caffeine 120 mg).  1:00 PM: Morphine 60 mg.  5:00 PM: Morphine 60 mg; one small coffee (caffeine 120 mg).  9:00 PM: Morphine 60 mg; one large glass of grapefruit juice (to make the morphine last out the night!); 1.2 g chloral hydrate.  12:00 PM: Bedtime.

This can be simplified with modified-release tablets, as well:

8:00 AM: Jurnista 64 mg; one large coffee.  Patient drinks coffee and grapefruit juice throughout the day.  8:00 PM: 600 mg of chloral hydrate is taken.  10:00 PM: Bedtime.  Patient wakes up at 8:00 AM with no pain.

My own Elvis cocktail (all drugs are instant-release):

9:00 AM: Oxycodone 10 mg; one large coffee; dexamphetamine 15mg.  Liberal amounts of nicotine throughout; Sativex (dronabinol spray) as needed.  5:00 PM:  Oxycodone 5 mg.  9:00 PM: Diphenhydramine 100 mg; melatonin 20 mg; chlordiazepoxide 25 mg; oxycodone 5 mg.

Thursday, September 29, 2011

Welcome to Canuck politics.


As you may or may not know, I live in a large city in Ontario, a province of Canada.  The provincial election is coming up, which means that the three major parties of Ontario (the Conservatives, the labour-centric New Democrats, and the Liberals) are campaigning... and so is the Green "Party".  Those who know me personally already know that I agree with the Conservative stance on issues of economics and culture, and with the New Democrats on labour law and foreign policy.  The Liberals were once a hulking giant; in recent years, however, their federal leaders have been, for lack of a better word, morons.  This, perhaps, is what led to their crushing defeat last election, after which Chief Moron Michael "Iggy" Ignatieff made a non-resignation speech, followed almost immediately by his resignation.  The separatists of Quebec lost official party status, and the Queen Cow of the federal Greens, Elizabeth May, finally got a seat to put her withered, flatulent arse on (I think she's personally responsible for 95% of the greenhouse gasses in the atmosphere today).

Despite these major changes (and they truly were major), almost nothing has changed in the political climate with the exception of the fact that the Conservatives now form a simple majority (more than half, in other words) of Commons.  When it comes to politics, I almost never deal in facts and figures; those are for the historians to review and argue over.  I deal in accuracy: a verbal photograph, if you will, of the political scene, right here, right now.  What happened last federal election is also going to happen this provincial elections... mostly.  Ontario, particularly the provincial capital of Toronto, leans left-of-centre; this means that many of our recent Premiers have been affiliated with the Liberal Party.  For those of us that don't see past the Great Wall of Bullshit, the eighth Wonder of the World, the Liberals are a left-wing party.  They might paint themselves as centrist, but the reality is that they are left-wing in all areas, with the exception of organised labour, the part that counts.  By harmonising the federal and provincial sales taxes, Mr McGuilty effectively punished rich and middle-class alike.  No handouts or tax reductions were given to Canada's heart and soul: people who work (for a living or otherwise).  Instead, the unemployed and the unemployable now live like kings.  I seem to recall that it is more financially advantageous to be unemployed than it is to be employed earning less than a certain amount, which I do not remember.

Rant over.  Now, back to your scheduled programming: before the Canadian federal election, the leaders of the four political parties had a debate, which was televised (on numerous channels, actually).  Present were Prime Minister Stephen Harper (Conservative), Mr Ignatieff, Gilles Duceppe (Bloc Quebecois), and John Layton (New Democratic Party, God rest his soul).  The "leader" of the federal Green "party", Mrs May, was not invited for one reason, and it is not the one she claimed (i.e. the Canadian government does not care about the environment).  The simple reason that the Greens were not represented at the debate was that the debate examined each party's agenda (that is, their stance on various issues and their future plans).  These issues fell into realms as wide as foreign policy, taxation, and cultural diversity.  The Greens have only one agendum: the environment.  Therefore, asking Mrs May questions in reference to, for example, the war in Mesopotamia, would not represent the agenda of the Greens collectively; the answer would only be representative of Mrs May's personal agenda.  Furthermore, until the last federal election, the Greens had not a single seat in Parliament.  Taking into consideration these two facts, only an idiot would be indignant that his or her loose association of independent candidates (because that's what the Green "Party" is) would not be represented at a debate.

Mrs May, therefore, quite clearly is an idiot.  She did get her seat, though; it was inevitable, and it is crucial to have a diverse parliament.  I would have enjoyed the added diversity in Parliament if it had been anyone but Mrs May.  Beyond being an advocate for nucular power, I am not an environmentalist, just as I am not an advocate for euthanasia with the exception of assisted suicide (by a physician or otherwise).  However, if there weren't people in Parliament that disagreed with me, it wouldn't be a democracy, would it?  The problem is not Mrs May's environmental activism, or her independent views; it is the blatant flaws in her character and personality.  Political views aside, Elizabeth May is a cell-for-cell clone of Sheila Copps (or Hilary Clinton if you're American). Dear Lord, you can have both Mrs Copps and Mrs Clinton, just please, please, please give us back our Jack!

Now, I hate to tar a whole group of people (again, I hesitate to say "party" because they really aren't one) with the same brush, but I'm beginning to think they're smoking the same thing they're hugging.  As I alluded to before, history repeats itself.  There was a debate yesterday, in which the New Democrats, the Liberals, and the Conservatives were represented by Andrea Horwath, M.L.A., Premier Dalton McGuilty, and Timothy Hudak, M.L.A., respectively.  The Ontario Greens, led by Michael Schreiner (not an M.L.A.), were not, coincidentally (or not), represented.  Mr Schreiner staged a (very public) protest, contemporaneously with the debate, and, once again, that old and hoary maxim was proven to be right: it is better to be silent and thought a fool than to open one's mouth and remove all doubt.  "The debate is happening down the street, and we need to shout to show them we're here, and that the [Ontario Greens] will not be silenced!"  the Green Party was just plain irrelevant; it would be more accurate to say that Mr Schreiner was absent.  Mr Schreiner "addressed the Green Party policy initiatives he would have raised," Mrs Grainger wrote, "including the creation of a carbon tax [like we don't have enough taxes already], freezing tuition rates, lowering energy costs [for who?!] by reducing energy usage, and controlling healthcare costs [you are speaking from a position of ignorance, mate!]... by... improved access to healthy food."  First of all, if you want to put in a carbon tax, you'd better lower some other taxes!  Second of all, just whose energy costs do you want to lower?  There is only one way to consistently reduce energy usage, and this is to make it less convenient (in other words, more expensive).  This would hit the consumer hard, and that was when Mr Schreiner put his foot in his mouth.  The people who vote Green are generally part of what is called the counter-culture; they may be stoners, anarchists, hippies, or something entirely different, but it is safe to say that many people who vote for the Greens are anti-government, anti-regulations, and anti-establishment. Making energy expensive, or hard-to-get in some other way, would make Mr Schreiner very unpopular with his voter base.  I agreed with his mention of making healthy, nutritious food easier to get; however, Mr Schreiner, where are your medical credentials?  That's right; nowhere.  I understand there's a loose association between healthy eating and healthy bodies... but coming right out and saying that healthcare costs will be lower because of easy access to nutritious food is a logical fallacy.  I forget which; I'm too stoned to tell.

See that big thing up in the sky, though?  That's the flying fuck Ontario doesn't give about the Greens.  Sure, okay, Mrs May has a seat in Parliament.  At this point, though, Mrs May has no political clout; she is far from the fly in the ointment she says she is.  She is more like a mosquito: invisible, stupid, and very hard to finally swat.  Thankfully, you can wear ear plugs for a mosquito, and that is, essentially, what the M.P.'s have been doing till now with Mrs May.  I see no reason why this will turn out any different from the federal election.  Schreiner will get his seat, nobody will give a shit.

Friday, September 9, 2011

Technology Then... and Now


As we live in what has been called the Information Age, it is only logical that the greatest improvements during the last sixty-odd years have been in the office.  In fact, the changes in office technology were so great that this can not be called an evolution, but a revolution.

My uncle worked, and still works, in the corporate and tax division of Clifford Chance, a great monster of a British law firm with offices around the globe.  The environment in such a firm is almost stereotypically corporate; the job is fine, the money is great, but the atmosphere just drains your life away with all its fluorescent lighting and rat-racing.  He began work in the 1970s; 1974, I believe.

In 1974, or thereabouts, there were no mobile phones, much less smartphones, flat-screen televisions, or internet.  Even though there was no internet, there were computers; great, big, hulking machines in glass enclosures with raised flooring that were used in factories for inventory control and in offices like this one for number crunching, which was done by a specially-trained computer operator at night, as the lawyers leaving work gave her jobs to do.  Word processing and computers did not mix; in fact, the slang for the one computer the London head office owned was "expensive calculator".  For word processing, there was the electric typewriter; not the electronic, but the classic IBM Selectric that had a whirring engine and plugged into the wall.

At great expense, the management of Clifford Chance saw fit to purchase what would now be called  fax machines for the offices in London, Paris, Prague, and elsewhere; they were then called telecopiers (this is still the case in French), or telefax boxes.  Regardless, the slang was then, and is now, "Mojo Wire", although what faxing has to do with morphine (mojo) I can't fathom.  Back then, the Mojo Wire was a olive drab-coloured box with a spinning drum around which a flimsy sort of paper called thermofax would be placed.  A vintage Mojo Wire would print at the blazing fast speed of seven minutes per page and would fill the office with the smell of burning plastic.

The xerox was, mercifully, common by this time; as it was very much in demand, the xerox at Clifford Chase was a very large autocollating model that required a trained operator.  I'm unsure how the boys at that company could possibly have managed without a xerox machine.  It was quite easy to mimeo a document if one prepared a stencil for it when he was making it; otherwise, he was out of luck.  In a law practice with a mimeo, you'd be more often out of luck than in it.

Ten years later, the landscape had changed.  Mobile phones had been invented; about as large and heavy as a brick, they required a briefcase-sized wet battery to be held in the other hand.  These telephones were very expensive at the time (costing as much as a small car), but they were evidently worth the price for the lawyers, young and old.

The real player, however, in the 1980s, was not the mobile phone; too early for that.  The real player was the computer.  In 1981, IBM, the maker of the large computer in Clifford Chance's basement, came out with the Personal Computer; soon, each paralegal and secretary had his or her own Personal Computer, and the huge mainframe was taken to the rubbish dump, despite being technically superior in every possible way (but less convenient).

Even the venerable Mojo Wire (fax) changed, although the name for it didn't.  Gone was the awkward drum and the acrid smell; now, the Mojo Wire transmitted at the speed of one page per three and a half minutes, odourlessly and on standard paper that fed itself into a slot.

In 1995, the internet arrived; it was a primitive thing compared to the internet of today, and logging on to the internet would tie up the phone and the Mojo Wire, if they didn't have separate lines.

The smartphone also arose from two independent concepts during the era: the miniaturised mobile phone and the personal digital assistant.  In fact, the personal digital assistant of ten years ago did not look all that much different from today's iPhone, with the exception of the monochrome touch screen and the lack of a telephone feature.

Here we are in 2011, wondering how the hell our forefathers managed to even think about doing business, what with the lack of office devices and all.  I am myself amazed at how we went from a machine that copies paper (the xerox) to a machine that sends copies by phone (the Mojo Wire) to personal mobile phones and computer technology.

Thursday, September 1, 2011

On Driver Design

I am growing sick and tired of the way companies design CDs for drivers (management software for printers and the like).  Does there have to be a useless programme that slows the computer down to 10% speed included on the CD?!  Answer: there doesn't.  Usually, the programme will pretend to do something useful, such as reporting the level of toner still left in the printer, or letting you write macros for the keys on the keyboard; this makes it even more confusing.  At least the drivers that are installing spyware (Do you agree to the terms and conditions of Google Toolbar?) let you give informed consent (Hell no!).

The worst company for this seems to be Hewlett-Packard... yet I like them most of all for hardware.  Several days ago, I needed to install a multifunction printer/scanner/fax on my Windows drive.  This thing is wireless, so I'm thinking I'll need to install the damn support bloatware with the driver, too.  I grit my teeth, make a restore point just in case, and start the bloatware installer.  Get this: the software is so huge that it comes on two CD's.  The install, predictably, takes over an hour (that's longer than Windows itself took).  You must restart your computer in order to proceed, yada yada.

Ten minutes later... What.  The.  Hell.  My CPU usage widget is showing 80% usage, my free memory widget is showing zero free memory, and my computer is running about as fast as a turtle... on Valium. The install took 200 MB of disc space.  Seriously, what the hell? I don't even bother trying to print.  I start up my system restore application, restore to the last checkpoint... takes another hour.  By this point, I'm sweating and my patience is about as existent as six-headed unicorns.

While the restore is happening, I grab the manual and start thumbing through it.  There's a hard-to-find section on how to make the multi-function box join a network.  Sounds promising.  Turns out, no PC required, you can hook the box up to a network.  I try it; takes me two minutes flat.  Well, how was I to know?  It wasn't in the quick start!  By this time, the restore is done.  I check my router to see at which IP address the multi-function box lives, and I navigate there.  The box has the nicest admin Web page I've ever seen.

With a practiced hand, I go through every folder on the two CD's to find the drivers directory.  No, not the bloatware; the bloody drivers.  You try explaining that to HP's support people.  I find the directory, finally, and I copy it over to my desktop.  I go through the Add Hardware wizard, finally get the damn printer installed, and restart into Linux.  On Windows, the whole experience took me over five hours: installing, venting, restoring, swearing, drinking beer, reading, setting up printer, setting up network, venting some more, another beer, installing just the driver, and one more beer.

In Linux, I spend half an hour on the Internet trying to find the HP printer driver kit.  I finally find it, download it, run it.  The driver kit asks me what printer protocol I use.  This could have been made a lot easier by having the choices: wired directly to pc, in wired network, in wireless network, wired to print server.  Instead, it uses all sorts of acronyms none of which I can understand, since I am not a network guru (no, the acronyms aren't wifi and 802.11b, I know what those are!).  I spend a little time trying, and erring, and trying again, till I finally get it.  Total time, one hour, despite some truly indecipherable acronyms.

HP's "quick and easy" driver and bloatware installation programmes are anything but.  The Linux ones are easier... and yet Linux has a reputation for being completely indecipherable.

Next time I will follow, yet again, my set-in-stone directions for installing drivers; you should too.  If you follow the steps below, you will never run into the kind of frustration that I ran into yesterday.

1.  Open the CD that came with your product.  Search for the string "*.inf".  Open every folder that has a file that ends in .inf in it and copy them to your Desktop.

2.  Run the Add New Hardware wizard.  When possible, click the "Have Disk..." button on the bottom: a dialogue box should appear.  Enter the path to the .inf folder, click OK.  If there are multiple folders, find the one that is compatible with your operating system and/or product.

3.  Your driver should now install, with no "support software".  If you want support software, download some, or buy some.

Addendum: if you want to be shocked, select all the .inf files (sometimes they're all in one big folder called DRIVERS), right-click, and click Properties.  The size should be no more than a few megabytes.  Now take a look at the other stuff... next time you say that drivers slow your computer down, think long and hard about what you mean by drivers, and do you need them.