Posted by Elizabeth on June 8, 2001, at 14:35:56
In reply to Re: Codeine for Depression Treatment » Elizabeth, posted by shelliR on June 7, 2001, at 11:43:54
> Can't take ultram unless I discontinue the nardil, seems like.
That's true. Ultram is a mild risk, IMO, with SRI type drugs (SSRIs, Effexor, Serzone, etc.) but a serious one with MAOIs.
I'm trying Ultram right now. I think it is well suited to chronic pain (and psychiatric disorders) but is not a great choice for acute pain (or PRN use for other conditions). It takes about 3 hours to work. It has at least one long-acting metabolite (desmethyltramadol). Taking regular scheduled doses over time should result in steady-state plasma levels of desmethyltramadol, leading to a smoother effect than you'll get with typical short-acting opioids (including buprenorphine).
I've found that tramadol doesn't work well for me (even after 3 hours) in the dose range that is supposed to be safe. One might be able to use higher doses by adding an anticonvulsant. I don't know for sure that it would work well even if I went outside the accepted dose range, though.
> I am waiting to hear about a consultation at Johns Hopkins, since they have also done that small study on buprenorphine. I want to make sure opiates are a possibility or I don't think it's worth going for the consultation.
Johns Hopkins...I'm curious, where do you live? (I'm originally from the DC area, is why I ask.)
I'm planning on setting up an appointment for a consultation at Columbia. We can compare notes. < g >
> Well, I can take as much as I need to of codeine; it is easy to get over the internet, so I thought I try it.
Shhh! :-) It's true that it's possible to get a lot of medications (even some that are federal Schedule III, IV, or V controlled substances) on the net, but I expect the government to start cracking down on this. I would not count on the net as a long term source of codeine or other opioids, especially. If you start becoming pharmacologically dependent on it and then are suddenly unable to get it, you could have a very hard time (as many an addict has learned the hard way).
> I have a call in to a pain management dr. in Virginia who works narcotic protocol programs for pain.
That's cool. Some of them are reasonable and understand that tolerance doesn't mean you're abusing the drug; it's just a natural result of taking opioids. Others want to push you into "pain management" which means using non-opioid drugs like NSAIDs and nonpharmacological stuff like acupuncuture (this has become a mainstream thing now), physical therapy, TENS, cognitive-behavioural therapy, etc. -- even if it's ineffective or inadequately effective (as these therapies often are). I felt fortunate to get any medication (Relafen (NSAID), baclofen, and finally Soma after the other two failed!) when I went to a pain clinic at an academic medical centre.
> I talked to his nurse and am waiting to hear if he would accept me for depression.
Good luck...let me know what happens.
People who have pain syndromes as well as depression are most likely to be treated with opioids. I've thought about going to a pain doctor too (chronic back pain which exacerbates my insomnia).
> The other thing is how expensive he is, but since my needs are different, the nurse said he may also not charge me his usual.
Some doctors have a few places in their schedules reserved for people who can't pay the usual charge. One time I was in a partial program (day treatment) and it came out that one of the people in the program was there for free. A lot of the other people were pretty angry when they found out about it because that program was not something that private insurance would usually cover and they don't take Medicaid (as a result, the people in the program were pretty much all young white people from upper- or upper-middle class families).
> I am feeling pretty desperate, I talked to my pdoc this morning and he feels he can't help me and I need to find someone else. That in itself is not a great loss, but it is scary to be in the position that only someone both creative and with the willingness to take a risk can treat me.
I know *exactly* what you mean. I've been in that position too.
Do you want to talk over email? We seem to have a lot of the same situations and problems. I'd like the chance to talk to someone who understands what I'm going through. You know? Anyway, if you'd like to talk, I can post an address where you can reach me.
> I'm talking about such severe disorientation that I couldn't hardly even dress myself. I've had no disorientation with hydrocodone.
Which TCAs did you try? The side effects that caused me to stop TCAs without an adequate trial are similar to the opioid side effects that bother me so much (constipation, dry mouth, etc.), only milder, which is why I'm thinking of trying a TCA again.
> > Careful, you're dating yourself. ;-)
>
> That's okay. I'm much smarter than I was twenty years ago and have a triving, creative business.I'd like to think that most people get smarter as they age (although sometimes this doesn't seem to be true). It sounds like you've got a pretty good thing going -- nice (and encouraging) to hear.
> And I am very very afraid of losing that business if I can't control my depression.A legitimate fear. I'm sure you've suffered losses before as a result of depression. I know I have (which doesn't exactly help make the depression go away).
> I have a certain, I think healthy, mistrust of any doctor. A doctor is a person, not a god.
Right. But a lot of them -- especially "old school" types, but also some younger doctors who I think are trying to emulate their teachers -- think they are, at the least, superior human beings. They're the ones with the education, but they should be able to provide a convincing reason for anything they want you to do (or refuse to do for you).
> I am really good at what I do, but I make mistakes sometimes. I don't exempt doctors from the same possibility. I do tend to find pdocs a bit more arrogant than other doctors.
They work with patients who are more vulnerable and helpless-seeming than the average medical patient. Also, psychiatry is sort of ghettoised by the rest of the medical profession -- psychiatrists aren't seen as "real doctors" by a lot of other doctors. So they sometimes try to compensate for that by being more arrogant. (IMHO)
> And I do come in with everything typed up--all past medications and results, so that I don't have to spend the whole session answering questions.
I need to write up a history, too. My records are terribly confusing, and pdocs I've seen in the past often like to minimise what they put on paper (because of confidentiality concerns -- they do document things that really need to be documented for legal reasons, but they try to avoid having a lot of incriminating records for insurance companies to peruse).
> > She wouldn't even *read* them? What kind of doctor is that?
>
> A doctor that you leave after ten years.What I'm wondering, I guess, is how you stayed with her for so long.
> I haven't switched; I am trying to build in safety valves since it is such a battle to get enough hydrocodone. I wanted to see if the other would work BEFORE I ran out of hydrocodone. So far I have access to only 10 pills per month.
Ouch. 10 doses (or even 20) would not be enough for me to get by on. (Buprenorphine is really a 3x/day med, and hydrocodone and codeine are, if anything, shorter-acting.)
> I can get more hydrocodone with a consultation on the internet, but I would really like a real pdoc to work with me and support my treatment.
In the best of all possible worlds....
-elizabeth
poster:Elizabeth
thread:64320
URL: http://www.dr-bob.org/babble/20010605/msgs/65798.html