Posted by Elizabeth on November 19, 2001, at 16:54:20
In reply to Re: Morphine for depression. » paxvox, posted by shelliR on November 18, 2001, at 22:42:34
> There were accusations and attacks that those of us investigating narcotics were nothing but addicts in depressive disguise. It was
> not a very supportive time on this board.Dr. Bob did intervene, if you recall, and I think that, while the subject is alive and well on p-b, the people who were being abusive have calmed down or stopped posting on the subject.
> Anyway, you've asked a tough question. I completely lucked out, if you consider lucking out working with a doctor who sees me five minutes, won't return phone calls, and was making me come see him every other day.
The question that immediately arises in my mind is: how much does he charge you (per 5-minute session)?
> I was already using vicodin as an adjunct to my AD premenstrually, then my AD pooped out and nothing else seemed to work.
For me, opioids are very hard to use because of their side effects (*very* bad constipation, dry mouth, itching, amenorrhea, etc.) and also because they're so short-acting (well, most of them are, buprenorphine included), which can result in a lot of ups and downs in mood and energy level throughout the day. Although regular ADs by themselves were never adequate for me, I need to take one "in the background" to smooth things out.
A friend has been trying to convince me to try complicated combinations of ADs, but I haven't seen anything that gives me much hope for stuff like that. I'm considering trying Provigil again: the one time I tried it, I was taking Parnate and the combination was too activating, but it did help with my main residual depression symptoms (anhedonia, anergia, dulled concentration). And other than the jitters (nervousness, exaggerated startle response, exacerbation of tremor), I didn't notice any side effects from it. It didn't even cause much of a BP increase with the Parnate, and practically every other stimulant I tried with Parnate did, even in very small doses (like, 1.25 mg of Adderall).
> Buprenorpine has the most information on the board and is probably the easiest opiate to get from a doctor (and it still is not easy).
A problem with buprenorphine that makes it harder to get if you live in the USA is that the only formulation available is a solution for injection. It can be taken intranasally (that's what I do), but it's very inconvenient and the doctor will still have to entrust you with syringes. I got it from a doctor who I'd known for several years, who I'd seen regularly (not just 15 minutes once a month). Because I had always been honest and forthright with him and because he had known be for a long time, I think that he felt certain enough that I was a reliable person and that if I started having any troubles I would let him know about it.
Before making the decision to prescribe it to me, my pdoc spoke about it with Dr. Alexander Bodkin, a researcher at McLean (which is a teaching hospital affiliated with HMS) who he knew from residency. A couple of years earlier, my pdoc had sent me to Dr. Bodkin for a consultation because I was having trouble finding something that would work for me, and buprenorphine had first come up as a possible treatment for me during that session although I didn't try taking it until much later. Dr. Bodkin has quite a bit of familiarity with buprenorphine and its use in the treatment of depression; he was the primary author of a paper reporting the results of a small pilot study. (The paper, in case you're interested, is "Buprenorphine Treatment of Refractory Depression," by Dr. Bodkin, Gwen Zornberg, Scott Lukas, and Jonathan Cole. It was published in the Journal of Clinical Psychopharmacology, vol. 15 no. 1, pp. 49-57. A guy posted it on the web, at http://balder.prohosting.com/~adhpage/bupe.html.)
It probably also helped that my doctor was generally very experienced and had plenty of confidence in his own judgment and skill. He'd been involved in academic medicine for a long time before leaving to focus on his private practice, and he had been in charge of one of the general adult units at McLean, so he was very experienced not just with outpatients but with more severely ill inpatients. He had also already been treating another depressed outpatient with morphine (30 mg five times a day), and that patient had not abused the medication. So my doctor had plenty of firsthand experience that made him feel confident that it would be safe for him to try treating me with buprenorphine.
> Its selling point to pdocs is that there is a very small study study out of the McLean Harvard Group in Boston (It will come up if you do a search on Google, Yahoo, etc.). They are a very respected group within the psychopharmacology community.
(There are a lot of psychiatric research groups at various sites affiliated with Harvard. Take a look at http://www.hmcnet.harvard.edu/psych/redbook/)
This actually isn't much of a selling point to most doctors. If you can convince them to actually *read* the paper, though, they'll learn about some of the advantages buprenorphine has compared with other opioids, and this may convince them it's safe to prescribe. Because buprenorphine is only a partial agonist, there is a ceiling on its intrinsic effect. As a result, you can't get high on it. It's also virtually impossible to kill yourself by ODing on it (a legitimate concern that doctors may have about prescribing opioids to severely depressed patients). The article goes into some detail about the pharmacology of buprenorphine. This information, more than the results of the study, is liable to quell doctors' objections to prescribing buprenorphine as an antidepressant.
(I believe that a lot of the evil in the world arises out of ignorance, so spreading accurate information can be effective in combating evil.)
> I am on the east coast and am very uncomfortable in my position of knowing just one pdoc.
FWIW, I've been able to convince pdocs outside the tight-knit Harvard community (< g >) to prescribe it for me because I was already on it, after talking to the doctor who originally prescribed it (and, in some cases, Dr. Bodkin). Pdocs who might not be willing to *start* you on opioids can often be much more receptive to the idea of *continuing* you on them.
> He is not easy to get along with and I am always in fear that he'll cut me off if he gets angry at me and decides he doesn't want to work with me.
Can you talk to him about this? (Be diplomatic, of course -- like, leave out the part about his difficult personality, or at least try to put a less judgmental spin on it! :-} )
> Before I found him, I was going to research pain clinics and ask them if they would consider giving me opiates for pain, because my experience with vicodin was so positive.
Pain clinics are not all alike, but they have a general reputation for pushing people to agree to a "pain management" program (i.e., no medication -- "management" pretty much rules out "treatment"). Possibly a pain medicine specialist in private practice would be willing to help you, though. I think it would be nice if I could find someone like this to supervise my buprenorphine, because psychiatrists usually have no real experience with chronic opioid therapy.
> BTW, I have had to go up several times on oxycontin and it is still a question whether my body will finally get to a level and settle in so I don't have to go up and up and up. So there is the real possibility of developing an opiate habit. I guess you would have to decide how bad your depression is to take that chance.
I'd be much more worried about the possibility of one day having to "detox" if I were taking oxycodone, personally. Another advantage of buprenorphine is that the withdrawal symptoms are pretty mild, certainly not worse than what I experienced going off MAOIs! In contrast, oxycodone discontinuation could be extremely difficult.
-elizabeth
poster:Elizabeth
thread:84007
URL: http://www.dr-bob.org/babble/20011113/msgs/84687.html