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Re: Effexor an opiate? Probably not. Elizabeth

Posted by JANNBEAU on December 19, 2001, at 14:32:05

In reply to Re: Effexor an opiate? Probably not. JANNBEAU, posted by Elizabeth on December 13, 2001, at 20:06:59

Hey, Elizabeth! Thanks for your third (?) posting. It was fun to read. Thought you'd disappeared. Instead, I find that I don't really know how to find specific responses to my postings.--Thread is also getting long--unwieldy--sstart a new one?

--I think it's easy to misinterpret stuff over the net---

Thanks for reminding me of the difficulties of communicating without visual and aural cues! Again, sorry to put you in such a position! : )

Seems you know far more about this subject than I. Though I've had many courses in pharmacokinetics/toxicokinetics, etc., I don't use most of it anymore. I'm still "cocky" sometimes, however. You've set me straight!!

I found in clinical drug research that most is a farce, driven entirely by the profit motive and by drug companies and researchers who seek to obey the letter of the law but not the spirit of said regulations. I, too, then, am skeptical. I try to educate myself, whence some of my misinformation! (All the rest of you out there, disregard my comments and listen to E-Beth!)

--I actually enjoyed your second posting.

I enjoyed yours, too. That's why I'm back!
--My response to you also responded to his comments in greater depth---

We can forget that posting, I think!
--Anyway, credentials don't mean much to me (especially since they're generally unproven on this forum

Well said!

--I think our approach differs greatly from that of the Middle Ages,

Of course!

>although some attitudes expressed by a lot of people (including medical and even scientific professionals) bear a disturbing resemblance to aspects of the Medieval world-view.
Well, true. We've made progress. We have the "scientific method;" we have great potential to distribute our information; we know volumes more about physiology and psychophysiology than the Medievalists knew, just as we have a much better understanding of the psychopathology than we knew even fifty years ago. Have you ever seen the movie "The Snake Pit" or read about "Bedlam", the famous London institution? That's what I mean!
Bedlam is, by the way, a shortened form of the name for "Bethlehem" Asylum--interesting, yes? Ironic, perhaps?

-- The trouble with the PI is the reverse: it includes every reported "side effect," even some which probably don't have anything to do with the drug. This can scare patients, to say the least, even making them unwilling to try the drug. It's misleading because most of these "side effects" are rare (especially the most serious ones), and *nobody* gets all or even most of them. I think that showing these lengthy lists to patients can do more harm than good. Unfortunately, the "patient information sheets" that pharmacies often keep are condescendingly lacking in real information.

All true, especially the lack of balance between the "information for the patient" and the PI. However, I think that, if we are an educated patient, we should be able to take the information from the PI and distill it, using what pertains to ourselves and discarding extraneous information. However, we DO need to know the PURPOSE of the PI, which is mainly to fulfil the requirements of the Code of Federal Regulations and other laws governing drug research, manufacture, and distribution, yes? The physician should make this very clear to the patient. A patient should know his/her ability to digest and use the information. It also helps to know one's pharmacist well; these folks can be really helpful with respect to side effects and drug interactions. I, of course, have a PDR and another huge tome that gives the percentage of the effects in controlled trials in both placebo or comparator drug and the drug under test. But, then, again, you must know how to interpret the numbers! What constitutes a significant difference between inactive or placebo and the medication, for instance? I could go on and on--

> I recently moved from Boston, and now I'm in, well, a place where there's not so much psychiatry research (to euphemize).

Bummer! Boston would be a hard act for anyplace to follow!

And I've been finding that medications that are considered "new" or "cutting edge" here are ones that were in use in Boston several years ago.

Where in the world are you, Timbuctu?

As a result I've grown very pessimistic about finding a doctor here who'll be willing (or even knowledgeable enough) to prescribe the things that have worked best for me (opioids, which are still stigmatized in most places)--

How true it is! Some attempt to make us feel guilty for needing opioids (I will use this term as your arguments make sense in the context of "stigmatism") and attempt to discourage their use, when, for the kind of chronic pain I have, and that I suspect you also suffer, opioids should be the drugs of choice.

Talk about side effects of medications: Nonsteroidal Anti-inflammatory Drugs (NSAIDs) are LOADED with, sometimes, lifethreatening side effects, and are not even particularly effective for many types of pain for which they are prescribed. NSAIDs give me asthma, stomach pain and bleeding, severe gingivitis, to name but a few! The COX-2 inhibitors seem especially insidious for these effects.

--or to try new things which may help me and which I haven't tried already (because they don't know anything about any drugs that I would consider "new").

I wish you luck in finding a physician near you who will have the knowledge and motivation to learn and to help you! I'm considering accupuncture. Have you tried it? Unfortunately, my insurance doesn't pay for it, but will pay for any drug the doc prescribes!
> But I'm still wondering -- how is it that ODT is 200 times as potent a mu agonist as tramadol, but only 6 times as potent an analgesic? That's the mystery to me.

I had an hypothesis about that, but it slips my mind at the moment! I'll get back to you when I remember it. (Oh, Lord, sometimes I'd give any thing to be drug-free so I could figure out whether I'm also getting Alzheimers!)
> I don't agree entirely. While I understood that you meant "opioid agonists" by "narcotics," your use of the word "narcotics" suggested a political bias which I've heard called "opiophobia." I don't believe you have this bias, though, so I suggest that you use the more modern and less politically loaded term.

Checkmate--game to you! Opioid agonist, it will be hereafter in these conversations! I certainly don't have this bias. I rely on hydrocodone and propoxyphene to keep my life bearable. I have attempted for many years to educate those close to me that the use of opioid agonists for severe acute or chronic pain is not only appropriate, it is the only HUMANE thing to do. (a personal experience watching my father die in agony brought me to this conclusion).

Those of us who use these medications for real pain do NOT generally abuse them. For
> > For instance, OxyContin (extended-release hydrocodone)--etc--

> OxyContin is sustained-release oxycodone, not hydrocodone.

Right--another slip of the fingers!

--The media have portrayed it (OxyContin) as some new drug, when in fact it's just Percocet without the Tylenol and in a slow-release formulation. Its potential for abuse is greater than that of MS Contin because oxycodone has greater bioavailability than morphine when taken orally. Injecting the sustained-release drugs is pretty difficult and dangerous, BTW, because they contain so many binders. Hard-core addicts have been known to do it, but it's not trivial and the risk is significant.
Good information. I am not very well up on addiction research. With regard to bioavailabiity with oral administration, would you just not take a larger dose of the morphine to get the same effect?

> I think that it's most likely that the people "abusing" these drugs were not hard-core addicts, but young people who were going through a phase of "experimenting" with drugs, and that the attraction of the drugs to these people lay in their "forbidden" status (since they had been identified as opioids or "narcotics").
I agree completely with this statement. I alluded to this phenomenon in my earlier posting!--the psychology of the "fad" drugs, etc.

> Anyway, kappa opioids don't have much attraction for people who prefer mu agonists.

Tell me more. I don't know much about this subject.

The other partial/mixed agonists are the partial mu agonists, such as buprenorphine and dezocine.

--an addict in withdrawal is liable to be willing to take whatever s/he can get, and buprenorphine does block withdrawal symptoms.


It can also be used to detox oneself and causes hardly any withdrawal symptoms of its own.

Didn't know this.

--is that using a drug to feel better does not necessarily constitute abuse, even if the drug use is illegal. This is but one of many ways that the government has invaded the doctor's office: by leading doctors to believe that the legal status of a drug defines whether its use is pathological or not.

How true! Also, I have come to believe (personal observation) that some psychotropic or CNS active medications make permanent changes to the brain, meaning, perhaps, that the set points for the receptors may be changed, e.g., (I think, but don't quote me on this) that receptor physiology is permanently altered by some CNS medications--permanent receptor upregulation(?) or that presynaptic receptors are affected more than is realized? I refer specifically to the amphetamines and amphetamine-like medications (and there lies another whole discussion--the ability of the SRI's to alleviate depression. I have noticed that when the early "amphetamine" or NE agonist effect of the AD wears off, so does the antidepressant effect--I experienced that with Prozac, Paxil, and, NOW, just recently, with Effexor; took my first amphetamine (for weight control) when I was 19 years old (40 yrs ago) and, through the years, have felt "retarded" without them. Although I don't presently take stimulants, I always found small or prescribed doses to make me feel "better" and to increase my functional status. I think this is an iatrogenic (although inadvertant) effect that I'll always have to contend with--or perhaps, I was just congenitally depressed and the amphetamines treated that condition (?). Anyway, I agree with your contention that illegal isn't synonymous with pathological! I have struggled with this concept. You have enunciated it beautifully.
> > I used it for about a week with Effexor before developing what I assume was serotonin syndrome; at no time did I get any significant pain relief.
> What symptoms did you have?

Felt literally as if I was going to die!. Tremor, chilliness, cognitive deficits, memory loss, headache, "speeding", disorientation, somnolence; loss of sense of time; wildly fluctuating blood pressure (hypertension followed late in the evening by hypotension --110/62 which is much lower than my bp has been in years--dizziness; nausea--others that I cannot remember. DC's Ultram, returned to normal within 24 hours! Scared the dickens out of me. Totally out of my control until I figured out the interactive potential of these drugs.

Like I said, I never found Ultram to be worth using for pain -- or for depression, for that matter -- and the evidence (high measured TCA levels, odd reactions to dextromethorphan) suggests that I'm deficient in CYP 2D6. This lends credence to your hypothesis that most of the analgesic activity of Ultram is due to ODT.
Makes sense to me!

I'll let you know if I get any pain relief from Effexor; my back pain continues so far (mainly in the morning, when I haven't recently taken buprenorphine), but I'm only taking 75 mg/day of Effexor.

I've recently increased my dose of Effexor to 150 qd, because it was losing it's effectiveness as an AD. I've seen no further increase in pain relief, so I wonder if that effect may not occur at low doses as with the TCAs? However, I've also not seen a return of the antidepressant activity of Effexor so would like to drop back to 75 mg qd. Let me know how this goes for you.
> > Nightmares or "vivid" dreams have been associated with oxycontin. Why would one not expect the same from other drugs of like action?
> I wasn't aware that vivid dreaming was associated with any opioid. They tend to suppress REM sleep, if anything, and they don't have the peculiar effects on REM sleep that are seen with SSRIs and Effexor (where REM density is increased -- this is thought to lead to the vivid dreaming often seen as a side effect of SRI antidepressants).
> I'm not going to question somebody's claim of credentials, although in this case I'm not sure what the credential means.

It's British, I believe.

But as I said above, I've seen too many cases where people didn't live up to their credentials -- and many cases of lay-people having surprising knowledge that they attained by themselves -- to pay much attention to a person's credentials or lack thereof.

Very true.
> > Generally what we've seen with Effexor has suggested that its original marketing as "Prozac with a punch" was pretty accurate: it can have nastier side effects than SSRIs (but the same general *type* of side effects), and it also can work in situations where SSRIs aren't so effective (e.g., severe or melancholic depression). The NE reuptake inhibition is likely responsible for the hypertension sometimes caused by Effexor (most TCAs block alpha1-adrenergic receptors, which may tend to lower blood pressure, canceling out this effect; Effexor, like the SSRIs, doesn't have the antagonist effects at histaminergic, cholinergic, and noradrenergic receptors that are seen with most of the TCAs).
> > > The list from the Effexor PI is pretty exhaustive. That's not surprising since the PIs typically list every reported side effect and could be expected to do the same with withdrawal symptoms.
> >
> Then you're aware that this list of withdrawal symptoms should not be taken as a list of symptoms all of which anyone discontinuing Effexor is liable to experience! Only a few of them are all that common.

--I would hate for people to avoid Effexor (a pretty good AD, though it often has nastier side effects and w/d symptoms than the SSRIs) for fear that they might become opioid-dependent!

Oh, of course! I tend to forget this is a public forum. Sorry, again, folks, E-beth is absolutely correct about Effexor.

Elizabeth, tell us how you know all of this stuff? Your knowledge seems far greater than that of the average "Joe"!!!





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