![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 26 to 50 of 83. Go back in thread:
Posted by Elizabeth on May 12, 2001, at 20:07:10
In reply to Re: Whats... and Drug Seeking Behavior » kazoo, posted by dougb on May 11, 2001, at 17:05:54
> My GP told me that he prescribes 'off-label' every day, He says that many off label uses of meds do not make it into the PDR due to economic reasons
Yes. The only AED that was ever labeled for bipolar disorder, for example, is Depakote. Tegretol never made it, and Lamictal is being studied. Lithium augmentation for unipolar depression is off-label. So is the use of psychomotor stimulants such as Ritalin, and, similarly, of antidepressants such as Wellbutrin for ADHD. MAOIs are some of the most effective drugs for panic disorder and social phobia, but they're only labelled for nonmelancholic depression (they work for melancholia too, BTW!). Imipramine, the first drug ever used for panic disorder (and the drug that was used to "pharmacologically dissect" panic disorder from other types of anxiety disorders), is not labeled for this use. Meridia, which is both chemically and pharmacodynamically similar to Effexor, is marketed as an antiobesity drug (of all things). SSRIs have a variety of FDA-approved indications, but they all are probably about equally effective for depression, panic disorder, bulimia, PMS, etc. Luvox and Anafranil aren't even labeled for depression or panic disorder (only for OCD), although both have been used for depression and PD for years in Europe.
-elizabeth
Posted by Elizabeth on May 12, 2001, at 20:36:43
In reply to Re: Whats... and Drug Seeking Behavior, posted by kazoo on May 12, 2001, at 0:13:38
> An "opiate" is any set of various SEDATIVE narcotics which dulls the senses and induces relaxation or torpor; inducing sleep or sedation; soporific; causing dullness or apathy; deadening.
You seem to be using a very outdated definition, perhaps one that was used before the opioid receptor was discovered. The effects you describe are more characteristic of barbiturates than of opiates.
"Opiate" is a term that refers to drugs that act as agonists at a particular receptor. Often it is used to include synthetic drugs, although technically I believe that only the active components of opium (morphine and codeine) are "opiates" ("opioids" is the more inclusive term).
Opioids are not simply "sedatives" or CNS depressants and have different effects on different people (just like any drug). They have both excitatory (increasing the rate of neuronal firing; CNS stimulant) and inhibitory (decreasing the rate of firing; CNS depressant) properties. Once again, they are defined by their chemical and pharmacological activity, not by their observed effects -- which, again, vary.
I have taken several drugs of the opioid agonist type, all of which were primarily activating rather than sedating. Sedation is not necessarily a bad characteristic for an antidepressant, in any case: most people find tricyclics such as amitriptyline, imipramine, and clomipramine sedating, but they have been recognised as effective antidepressants for more than 40 years (and yes, they do have CNS depressant activity). (Opioids, incidentally, were known to be effective ADs long before the tricyclics, amphetamines, or even barbiturates were discovered.)
"Narcotic" is mainly a legal term today and has (appropriately) been all but dropped from medicine.
> If you thought unconventionally, you may fool yourself into believeing that the soporific effect may "lessen" the doldrums of depression, but that's not a judicious or wise approach given the addictive nature of the opiate family.
It takes an addictive personality and addictive behaviour to produce addiction -- an addictive drug won't make an addict by itself.
> Over dinner the other night, I asked a psychiatrist from the Yale Psychiatric Clinic (YPI) whether he would prescribe an "opiate" to relieve depression. Without looking up, he said "No, that's ludicrous."
He should consult the literature, then, rather than speak without thinking.
> I've yet to encounter a doctor who does this, so you must be one of the lucky ones who has a doctor who does this sort of off-beat thing. How lucky can you get?
Lucky enough to live near a major medical centre where research into novel treatments is common?
> Opitates are not used for depression. To even think such a thing is an insult to the medical profession.
This is incorrect.
> I will tell you one other thing: if you do get optiates to treat your so-called depression, and then you're shut off, you will experience the REAL depression you faked to begin with to get them. So who's fooling whom here? Not me.
Oh jeez -- the conclusion that anybody who you disagree with isn't "really" depressed? *Please.* This is simply uncalled for.
I have been diagnosed with major depressive disorder (severe with melancholia) for more than 10 years, by multiple psychiatrists. (I do not "doctor shop," though I'm sure you'd love to make that accusation; I have moved several times during the last decade and every one of my pdocs has had access to my records and has consulted with the previous one.) I have responded to opioids after failing to respond fully to every class of conventional antidepressant as well as stimulants, anticonvulsants, lithium, etc. For the last two years I have taken a synthetic opioid partial agonist called buprenorphine which was recommended by a well respected physician-researcher at a Harvard-affiliated hospital whose credentials and experience are enough to permit him the opportunity to go against convention and whose intellect permits him to think outside the box. It really doesn't matter if you assume I am a drug addict who is just faking depression. You are a non-professional with no relevant formal education and an apparent political agenda, and you have demonstrated quite clearly that you are perfectly comfortable ignoring the facts of any situation if they are inconsistent with your prejudices.
-elizabeth
Posted by judy1 on May 12, 2001, at 21:08:52
In reply to Drug Seeking Behavior » kazoo, posted by Elizabeth on May 12, 2001, at 20:36:43
Just read your well written response, I'm glad you have had access to such knowledgeable pdocs. Another effective use for opiates is for treatment resistant panic disorder; my pdoc has also prescribed them for depression. And he also is part of a well-respected reasearch program. Take care, judy
Posted by Elizabeth on May 12, 2001, at 21:10:52
In reply to Oy Vey: Opiates » kazoo, posted by SalArmy4me on May 12, 2001, at 0:28:47
> I'm willing to bet that the people endorsing opiates for depression have not tried every more convential treatment for depression.
"Every?" You mean, like, every one of the 10 or so tricyclics, 5 SSRIs, 4 MAOIs (more in some countries), 6 or so miscellaneous atypical ADs, and augmentation with every mood stabilizer, lithium, BuSpar, pindolol, every antipsychotic, all available psychostimulants, high-dose alprazolam, ECT, folate, total and partial sleep deprivation...do I have to go on? Or do you get the idea?
I've taken pretty much all of the above. Here are the exceptions:
- only tried 3 TCAs (desipramine, nortriptyline, and amoxapine) and didn't tolerate them due to typical anticholinergic/antihistaminic TCA side effects that are known to be *worse* with other TCAs
- only tried a couple antipsychotics (Zyprexa most extensively, also Seroquel, Risperdal, Moban, Mellaril) and only, except for Zyprexa, in augmentation doses (Mellaril and Moban knocked me out at minimal doses, Risperdal caused unacceptable exacerbation of my RBD)
- only 3 SSRIs (Prozac, Paxil, and Zoloft)
- skipped Tegretol, Topamax (but other AEDs were useless)
- ECT is, in my judgment, less safe than buprenorphine (which I know first-hand to be safe and effective), so I never bothered with it
- never took antidepressant doses of trazodone for more than a couple days
- didn't bother trying to order Manerix from overseas because it has such a lousy rep, especially compared with the traditional MAOIs which I did try (Nardil, Marplan, Parnate, *and* high-dose selegiline)
- haven't tried taking high-dose Xanax around the clock
- haven't tried some of the weaker stimulants that are marketed for weight loss (e.g., phentermine) or Desoxyn (did try modafinil)
- never tried high-dose (60-90mg) buspirone
- I am absolutely uninterested in St. John's wortSo there's your counterexample. I think that it's unreasonable to expect me to try a RIMA when irreversible, nonselective MAOIs didn't work, or to keep trying SSRIs or TCAs. Also please bear in mind that I'm not bipolar or psychotic.
I have a minor interest in trying Aricept or Desoxyn, but it's nontrivial to convince a pdoc to prescribe either of these (Aricept because of my REM sleep parasomnia, Desoxyn because, well, it's methamphetamine -- although it might be safer with MAOIs than Dexedrine or Adderall). I would also consider high-dose buspirone, or possibly Meridia (Effexor is out due to a life-threatening ADR).
> I maintain that if one writes a list of psychotropic medications one has taken, I can always find 10 other viable and legitimate medications to try.
Please, by all means. Me-too drugs (like other SSRIs, TCAs, stimulants, or neuroleptics) don't count. Anything that has to be ordered from overseas is only marginally "viable." Anything that is only available through premarketing trials is out of the question (I usually don't qualify for clinical trials because they require you to be off all AD meds, which my doctor and I both feel is an unacceptable risk in my case).
So, there are the rules. I think they're quite fair given the grandiosity of your claim. Go for it.
-elizabeth
Posted by Elizabeth on May 12, 2001, at 21:23:55
In reply to Re: Opiates for depression, posted by shelliR on May 12, 2001, at 14:46:33
Just a "me too!" to Shelli. I share your frustration with constantly being put on the defensive about the medication I take, medication which was legitimately prescribed in consultation with a true expert. I think it is only to be expected that one would be resentful of being treated like a liar by well-meaning but self-righteous people who appear to think they know what's best for others and who ignore the clearly-stated details of one's situation.
> It seems to me that most of you don't even read the whole thread before you rush in to save our opiate souls.
Indeed. The anti-opiate movement on this board seems to share many of the qualities of a fundamentalist religious crusade!
Thanks for saying it, all of it. To me, this quality of support represents the best that this board has to offer (because even though you're speaking for yourself, I know you're aware that others of us have been subject to the same offensive and ignorant accusations and generalisations as you have).
best,
-elizabeth
Posted by shelliR on May 12, 2001, at 21:27:54
In reply to Re: Whats the best opiate for depression ? / ETC, posted by Elizabeth on May 12, 2001, at 19:57:44
>
> Codeine isn't the best choice for an AD anyway, IMO -- if you need a full agonist, a longer-acting one with fewer adverse effects relative to desired effects would be preferable.Like Ultram?
> I've heard many stories of people suing their doctors over some pretty absurd things. Dr. Bodkin takes particular risks in that he is willing to work with patients who may be personality-disordered (which often is associated with a tendency to blame other people for one's problems -- e.g., a patient misuses or overdoses on medication, then blames the doctor). I take Dr. B's willingness to work with these "difficult" patients as a sign of exceptional compassion.Elizabeth, yes, I believe the scenario with the law suit is very close to what you described above, and I didn't take it that Dr. Bodkin had done anything wrong. If I don't find someone around here that I highly respect to consult with, I may fly up to Boston. I also have an old friend living in Somerset. Still, in the long run it would be best to find someone in my immediate area. He did make the suggestion of going up very high on selegiline, but I'm not really anxious to go off the nardil and start again with a new MAOI, unless perhaps it was the patch.
Shelli
Posted by Elizabeth on May 12, 2001, at 21:53:09
In reply to Re: Opiates for depression » shelliR, posted by SalArmy4me on May 12, 2001, at 18:25:20
> Here's what you wrote pertaining to a doctor who wouldn't prescribe opiates for depression:
> "Elizabeth. I talked to Dr. Bodkin briefly today...He will do a consultation, but will not proscribe codeine because of a prior _law suit_{!}."See my response concerning patients who sue their doctors (certain types will do so at the drop of a hat). I know Dr. Bodkin, and in fact he first recommended buprenorphine to me. He's not a quack by any means.
> Here's what the facts say:
> •As many as 900,000 Americans are dependent on
> heroin or other illicit opioids.
> *3-8% of opiate users die of trauma or overdose.Opiate *abusers*, not *users*. This has nothing to do with medical use; your facts are irrelevant facts. Please restrict this discussion to medical use of opioids (which is vastly different from illicit use). Nobody asked about how to find out where they can buy dope in their town.
Posted by SalArmy4me on May 12, 2001, at 21:53:43
In reply to Re: Oy Vey: Opiates » SalArmy4me, posted by Elizabeth on May 12, 2001, at 21:10:52
I am hopeful that you will still be able to find an effective pharmacological treatment, despite having tried so many of them. I got some nice ideas for you:
1) Mirapex - proven as effective as imipramine in depression:
Corrigan MH, Denahan AQ, Wright CE, Ragual RJ, Evans DL. Comparison of pramipexole, fluoxetine, and placebo in patients with major depression. Depress Anxiety. 2000;11(2):58-65.
DeBattista C, Solvason HB, Breen JA, Schatzberg AF. Pramipexole augmentation of a selective serotonin reuptake inhibitor in the treatment of depression. J Clin Psychopharmacol. 2000 Apr;20(2):274-5.
2) Pindolol - it once was a wonder drug for me that I took without an antidepressant, (but most people will need one). Pindolol is a beta-blocker, the only one of its class known to speed up and augment the action of antidepressants. The main studies done (found on Medline) have used it most effectively with sertraline, although it has been tried and proven effective with most of the SSRIs, tranylcypromine and moclobemide, and a few of the tricyclics. See Dr. Bob's
Psychopharmacology website (uhs.bsd.uchicago.edu/~bhsiung/tips/tips.html) and look up pindolol for more information.
New York University Psychiatry Augmentation website: http://www.med.nyu.edu/Psych/aug/index.html3) Definitely try Tegretol XR if you get a chance.
Its very tolerable.4) Ludiomil (MAPROTILINE) - that's a good one that few have heard about since it came out around the time Prozac came out and was overshadowed by Prozac. It is a tetracyclic with efficacy comparable to SSRI's and no sexual side-effects.
5) Geodon (ziprasidone) - works on serotonin and norepinephrine with little weight gain or sedation.
6) BuSpar - only effective in depression at higher doses according to the last study done on it and depression.
7) Serzone - I was on it for a month with no side-effects.
Thyroid Hormones T3 + T4 - pioneered by Dr. Whybrow at UCLA.
Foreign drugs: *Reboxetine, *Moclobemide (I can prove that it is effective, albeit not more than irreversible MAOI's), *Mianserin, *Tianeptine, *Modafanil, Brofaromine, *Amisulpride, *Adrafanil. Others: Bromocriptine, Ropinirole (another dopamine agonist), Norvasc(?), Pemoline(?) (a stimulant), *Seroquel, Tamoxifen(?), Doxepin, Yohimbine, the new Depakote _ER_, Nomifensine.Please ask me about any of these if you have questions. I've been on them all.
Posted by Cecilia on May 13, 2001, at 0:04:45
In reply to Re: Whats the best opiate for depression ?, posted by ElizabethNeedsTogetShocked on May 12, 2001, at 22:51:11
To Eric (under his new handle): Believe me, depression IS pain. Depression can be the worst pain there is. I haven`t tried opiates and doubt they work for most people, but they do work for Elizabeth. Why does that bother you so much?
Posted by Michele on May 13, 2001, at 0:19:20
In reply to Re: To Eric, posted by Cecilia on May 13, 2001, at 0:04:45
> To Eric (under his new handle): Believe me, depression IS pain. Depression can be the worst pain there is. I haven`t tried opiates and doubt they work for most people, but they do work for Elizabeth. Why does that bother you so much?
>
>
Celia,
There is pysical pain, and there is mental pain. They are different. I believe that's why they probably make different drugs for each. :-)
Posted by Cecilia on May 13, 2001, at 0:50:29
In reply to Re: To Eric » Cecilia, posted by Michele on May 13, 2001, at 0:19:20
> > To Eric (under his new handle): Believe me, depression IS pain. Depression can be the worst pain there is. I haven`t tried opiates and doubt they work for most people, but they do work for Elizabeth. Why does that bother you so much?
> >
> >
> Celia,
> There is pysical pain, and there is mental pain. They are different. I believe that's why they probably make different drugs for each. :-)I find that when I`m in the worst depression I do hurt physically as well as mentally-it`s like I`m just one overwhelming ball of pain. I wouldn`t take opiates for it though-I know it`s not the kind of pain they can fix. (Not that the many different antidepressants I have tried have helped either). But I don`t see anything wrong with Elizabeth choosing to take medication prescribed and supervised by a respected researcher and it`s annoying to see Eric pop back with his insulting attacks on her.
Posted by Michele on May 13, 2001, at 1:01:12
In reply to Re: To Eric-Michele, posted by Cecilia on May 13, 2001, at 0:50:29
I know what your saying..... but I guess I'm talking more about the physical pain of saying like your back hurts or something. Physical pain such as what comes from cancer.... or muscle deterorations, or whatnot.... really aren't the same as mental pain. I've tried AD's before.. and tho they may have worked in making me feel better emotionally... they didn't touch my pysical pain. Unfortuanely. I agree.... Eric(?) is out of line.... but don't concern yourself with it too much... as soon as Dr. Bob sees it, he'll be blocked. For him to express himself in that way.... means he is having some really horrible mental anguish of some sort.... I know, when I first read his stuff I felt horrible for Elizabeth.... and tho I may not agree with some of elizabeths posts either... she doesn't deserve that kind of attack. So if your reading this elizabeth..... he'll be gone soon. Take it with a grain of salt.
Posted by Cecilia on May 13, 2001, at 3:15:52
In reply to Re: To Eric-Michele, posted by Michele on May 13, 2001, at 1:37:55
Actually AD`s (tricyclics in particular) are often prescribed for patients with chronic physical pain (though who knows if they really help the pain or merely help the patient cope with it better because he`s less depressed). It`s hard to separate the mind and body. Physical pain is definitely a lot easier to treat than mental pain, though, if the doctor is willing to treat it, which many are not for fear of addiction, even if the patient is terminally ill. Wheras there are a lot of people whose depresssions haven`t responded to any of the available meds or to therapy.
I just wish the drug companies would spend less money on TV commercials extolling the virtues of the drugs already available and more on researching new ones.
Posted by shelliR on May 13, 2001, at 13:07:06
In reply to Re: To Eric-Michele » ElizabethNeedsTogetShocked, posted by Michele on May 13, 2001, at 10:36:10
Elizabeth, I just got to the board and I'm really sorry that there is this attack going on. It seems bad, but remember the attack only involves two people, two repetitive people. So, I imagine it should be over soon.
Please, I hope you do not feel the need to defend yourself. Yesterday you wrote posts to people doing that, and I wonder whether that's where you really want to spend your energy. It's your call, but I wouldn't bother.
Mostly I hope it doesn't get in the way of the posts we (you, and I and Cecilia,Scott and others) have been exchanging. They have had useful information and support. I suppose this will ride over fairly soon and I don't intend to censor my thoughts or my medications on the board because of others' bullying.
So hang in there, and know that you have done all you can to find a way to beat your depression. It's a beautiful, beautiful mother's day sunday on the east coast, and I hope you are out, away from all this negativity.
Shelli
Posted by SLS on May 13, 2001, at 15:13:55
In reply to Elizabeth....................., posted by shelliR on May 13, 2001, at 13:07:06
> Elizabeth, I just got to the board and I'm really sorry that there is this attack going on. It seems bad, but remember the attack only involves two people, two repetitive people. So, I imagine it should be over soon.
>
> Please, I hope you do not feel the need to defend yourself. Yesterday you wrote posts to people doing that, and I wonder whether that's where you really want to spend your energy. It's your call, but I wouldn't bother.
>
> Mostly I hope it doesn't get in the way of the posts we (you, and I and Cecilia,Scott and others) have been exchanging. They have had useful information and support. I suppose this will ride over fairly soon and I don't intend to censor my thoughts or my medications on the board because of others' bullying.
>
> So hang in there, and know that you have done all you can to find a way to beat your depression. It's a beautiful, beautiful mother's day sunday on the east coast, and I hope you are out, away from all this negativity.
>
> Shelli
Me too.Actually, Elizabeth, I find your behavior in the midst of this nuisance enviable. When I grow up, I want to be just like you.
- Scott
Posted by gen on May 13, 2001, at 15:34:58
In reply to Re: Elizabeth..................... Me too., posted by SLS on May 13, 2001, at 15:13:55
I came on to say exactly what Scott just said. I admire your composure tremendously. And Shelli, you hang in there, too. Glad the weather is as lovely where you are as it is here.
Gen
Posted by JahL on May 13, 2001, at 15:52:35
In reply to Re: Elizabeth..................... Me too., posted by gen on May 13, 2001, at 15:34:58
If it works, it works.
@ this point I wld like to refer to my 1st post on this thread...
j
Posted by Michele on May 13, 2001, at 16:23:54
In reply to and me..., posted by JahL on May 13, 2001, at 15:52:35
Shelli,
Are you referring to me as one of the two who is attacking Elizabeth?????? I never once wrote anything directed at her... or anything of that manner. In fact.... I have had at least 2 posts.... that quotes where included... that I was basically being yelled at for writing...WHEN I DIDN'T EVEN WRITE THEM. If you look closer... me and another person are getting confused. I think I'm getting attacked here.... and by things I didn't even say. I even wrote a post to "elizabeth needs to be shocked" saying that was harsh.... and should rerain from it. I may not agree with her.but I don't think I have to.Because I don't agree... does not mean that I'm attacking her.... by any means..... and when it comes to saying stuff like that.... refer to my post at the bottom..... where you are angry at me!! And for what?
Posted by gen on May 13, 2001, at 16:52:04
In reply to Re: and me.Shelli, posted by Michele on May 13, 2001, at 16:23:54
> Shelli, thought I should give you your own admiring post, not just tack yours onto Elizabeth's, so here it is. Your restraint has been truly remarkable, and I'm glad to have your example before me! (I've admired many of your posts in the past, as well.)
Gen
Posted by shelliR on May 13, 2001, at 18:19:20
In reply to Shelli, posted by gen on May 13, 2001, at 16:52:04
> > Shelli, thought I should give you your own admiring post, not just tack yours onto Elizabeth's, so here it is. Your restraint has been truly remarkable, and I'm glad to have your example before me! (I've admired many of your posts in the past, as well.)
> GenI think the more angry people get about something that doesn't involve them, and the more redundant they begin to sound, the easier it is for me to show restraint. Anyway, that's how I felt this weekend. It's sort of like being aware of trying to remain as clean as possible in a highly polluted environment. Just because it feels so much better not to be covered with soot.
Thanks for the compliment and the support.
Shelli
Posted by gen on May 13, 2001, at 21:01:27
In reply to Re: Shelli » gen, posted by shelliR on May 13, 2001, at 18:19:20
Yes, yes! That's what I admire, and what I need to hold before me as an example. To not get covered in the soot, mired in the hysteria. You've got so much going for you: you are brave and true (gee, I sound like a medieval romance poem), articulate, informed, reasoned, and yet passionate. Without even knowing it, you've given me support and encouragement over the months (I know you're not "new"), and I want to
thank you for that.
Gen
Posted by shelliR on May 13, 2001, at 22:29:32
In reply to Re: Shelli, posted by gen on May 13, 2001, at 21:01:27
> Yes, yes! That's what I admire, and what I need to hold before me as an example. To not get covered in the soot, mired in the hysteria. You've got so much going for you: you are brave and true (gee, I sound like a medieval romance poem), articulate, informed, reasoned, and yet passionate. Without even knowing it, you've given me support and encouragement over the months (I know you're not "new"), and I want to
> thank you for that.
> GenThanks. and I wish I could just be gracious and just accept your kind words. But I have to say, I have spent my share of time in soot, and wouldn't be surprised if I slip at times and end up there again (hopefully temporarily). So you may well be disappointed that I do not always live up to my own standards (or yours).
But thanks so much for telling me that my posts have had an influence on you. And I don't recall you posting under "gen" (sorry if I've just missed them), but I'm sure if you decided to join in the posting, I'd have a lot to learn from you also.
Now, no more compliments, please! shelli
Posted by Dr. Bob on May 13, 2001, at 22:34:47
In reply to Re: Whats... and Drug Seeking Behavior, posted by kazoo on May 12, 2001, at 0:13:38
> I will tell you one other thing: if you do get optiates to treat your so-called depression, and then you're shut off, you will experience the REAL depression you faked to begin with to get them.
Please don't accuse others of faking anything (unless you can substantiate that claim). Thanks,
Bob
PS: Any follow-ups regarding civility, if not redirected to Psycho-Babble Administration, may be deleted.
Posted by mikes on May 13, 2001, at 23:24:18
In reply to and me..., posted by JahL on May 13, 2001, at 15:52:35
"Hopefully this thread won't get hijacked by the anti-opiate brigade..."
You really called this one JahL, I didn't think it was going to get this bad.
> If it works, it works.
>
> @ this point I wld like to refer to my 1st post on this thread...
>
> j
Posted by MorganW on May 14, 2001, at 1:16:19
In reply to Re: and me.Shelli, posted by Michele on May 13, 2001, at 16:23:54
I have read all these threads from beginning to end and I don't see that you have done anything wrong. Don't get angry tho... I have read a lot of your posts form the archives and what not and you seem like such a caring person, I feel bad that these people seem to be after you. Just like people are sticking up for other individuals, I want to go on record as sticking up for you. Good luck, and hang in there.
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