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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 16 of 16. This is the beginning of the thread.
Posted by A0102 on March 21, 2002, at 7:59:54
Hi everyone...
I am getting more and more interested in the use of opioids for TRD. After around 7 years of being depressed, I'm starting to feel like it's about time I find something that works sooner rather than later. I'm taking 60mg/day of Nardil along with 400mg/day Provigil currently. About the only real difference I can see with this is that my "good" days are a little better, however my bad days are are just as bad and no less frequent. I've been on Provigil for quite a while now and Nardil for about the past month. I've had my fair share of SSRIs (3 of them), TCAs (3 of them also), Remeron, Wellbutrin, Effexor, and now Nardil. For the first week or so, SSRIs make me feel great. No sleep, nearly photographic memory, infinte energy, and a little getting myself into trouble. Just from that I would conclude that I'm bipolar III. Pretty soon, though, they all leave me feeling tired and emotionally numb. TCAs just make me feel like crap in general, even at tiny doses. The most prominent effects I get are a feeling of being dumb, dry eyes, body aches, and a feeling of being half awake when I want to be awake and when I'm trying to sleep as well. The other antidepressants are a mixture of irritating side effects and a lack of effectiveness. Of course I've tried several combinations of the various meds I've taken, but to no avail.
The only time in my life that a medication actually felt like it helped me deal with depression effectively was when I was on a steady diet of hydrocodone for pain after a girl going in the wrong direction on the road gave her best shot (successfully, I might add) at totaling my car. I did not experience a *total* remission with hydrocodone, but I was much more able to deal with life in general. I never took larger-than-prescribed quantities of it or attempted to increase the dose over the entire time I was on it (about 6 months). I found that depression-wise it maintained its effectiveness and, contrary to most people's experience, boosted my energy. I did not suffer the dumbing effects that are caused by a lot of ADs, in fact my grades actually improved during that time. I also have IBS (digestive problem where my stomach releases too much acid and I occassionaly get a pins n needles/hurts like feeling). Hydrocodone also solved that problem, but that's not too surprising seeing as how opiods like Paragoric and Lomotil are used to treat similar conditions.
On my last visit to a pdoc, I asked if he had a plan from here since I'd already been through 10 ADs without much luck. He actually mentioned opioid therapy. My concern with this is that since it does seem to be such a miracle med for me, is that just begging for an addiction? Then again, who would want to give up an effective treatment? Would someone in remission brought by Prozac want to give that up? Also, I think it would be quite a waste to simply disregard the one medication that has helped over the years because of social stigma or the risks of mismanagent.
I would love to hear from the few of you who have experience with this. I am interested to know how long anyone has been on a similar treatment and what measures pdocs take to handle these concerns as well as protect their own backsides.
Jeez! I think this one's long enough for now. Anyway, looking forward to your responses...
Adam
Posted by shelliR on March 21, 2002, at 20:35:21
In reply to opiate/opioid therapy, posted by A0102 on March 21, 2002, at 7:59:54
Adam,
You might do a search on opiates and buprenorphine.
I was on oxycontin for depression and I definitely developed a tolerance for it. I really didn't have a hard time, though, detoxing from it in a couple of days. But my depression returned full force. Now I am on buprenorphine and seem also to be developing a tolerance. Yet it's definitely worth it to me because my depression is very physical and painful and nothing else seems to work. On the other hand Elizabeth has been on buprenorphine for quite a while (along with effexor) and has not developed a tolerance to it. BTW, I am also trying lamictal which I hope will stop my need to keep going up on buprenorphine.Anyway, there's a lot of threads about it through the years, in fact even this year.
Shelli
Posted by cisco on March 22, 2002, at 18:59:13
In reply to opiate/opioid therapy, posted by A0102 on March 21, 2002, at 7:59:54
Adam:
Hell yes, Opioids have a quick, and very effective, anti-depressant effect.
Unfortunately, due to the rapid build up of tolerance, you will find yourself in a geometric progression of dose increases.
In my opinion, you will be better off taking 'Long-acting' Opioids (Dolophine, Buprenorphine, LAAM) to avoid the mood swings inherent with the 'Short-acting' Opioids (Morphine, Oxycodone, Hydrocodone).
Buprenorphine is very good at saturating the brains Opioid receptors. Mixed agonist/antagonist at the Mu, it is a potent Kappa antagonist.
Dolophine (methadone) is a very simple, open chain molecule, opioid. It is a potent Mu agonist, that is prized for its slow onset, and long duration. These same qualities are said to make withdrawals difficult. It is also the most controlled drug in the world. Which can make it a PITA.
Anyway, I say go for it. Read up on candidate meds, make a choice. Feel good!!
Cisco
Posted by Elizabeth on March 22, 2002, at 21:52:36
In reply to opiate/opioid therapy, posted by A0102 on March 21, 2002, at 7:59:54
Hi Adam.
I've been taking buprenorphine for more than a year. Regular ADs (MAOIs, TCAs, Effexor) have helped me, but only partially. I'm doing a lot better on the combination. I've known a few doctors who treated other patients with opioids (even full agonists like OxyContin and MSIR) and observed no tolerance or abuse. One way that doctors can reassure themselves is to have you get urine screens every so often to make sure that you're taking the medication as directed. Starting the medication in an inpatient setting might also help. My pdoc had me sign an informed consent; I'm not sure what that's worth, but it seems to be standard (for people being treated for chronic pain with opioids). Anyway, if there's anything in particular that you'd like to know, I'm happy to answer your questions.
I noticed a couple of things from your post that I wanted to ask you about.
The hypomanic stuff you get when you start on SSRIs is very suggestive, as you recognized. You didn't mention whether you've ever tried taking an anticonvulsant (or lithium) and then adding an AD. I think this can make a lot of difference in bipolar depression (even "bipolar III").
Also, can you say more about your depression? Like, what kind of symptoms do you have and how did the hydrocodone help with them? Have you been diagnosed with anything else besides depression?
Have you ever taken a benzodiazepine? (In particular, Xanax.) What about Parnate? ECT? Can you list any augmentation strategies you've tried (thyroid hormones, stimulants, lithium, antipsychotics, etc.)?
The stuff that hydrocodone did for you sounds pretty much like the typical experience of opioid-responsive depressed people. Tolerance is the biggest concern, I think: I'm not sure how common it is, but I think that it's probably frequent (although not universal). Taking buprenorphine rather than a full agonist might reduce the risk of tolerance (buprenorphine also has much milder withdrawal symptoms than the full-agonist opioids).
Opioids won't help with excess stomach acid; I'd suggest Maalox for that. They will eliminate any diarrhea you may be having, though!
> My concern with this is that since it does seem to be such a miracle med for me, is that just begging for an addiction?
You know yourself best. Do you think you're the type of person who'd become addicted, or be tempted to abuse it? (impulsive, thrill-seeking, etc.) It's a hard question, and you can't know for sure; you just have to use your judgment.
-elizabeth
Posted by shelliR on March 22, 2002, at 22:05:26
In reply to opiate/opioid therapy, posted by A0102 on March 21, 2002, at 7:59:54
Adam,
Just as an aside, I took nardil successfully for many years. It took over 5 weeks for me to feel it and when I did, it made a huge difference. My depressons after that never lasted more than a day or so. But then it pooped out after about 15 years. And that may be due to several things including hormones and some form of FMS and severe inflammation in my chest. So I wouldn't give up on it yet.
Shelli
Posted by Zo on March 24, 2002, at 3:53:55
In reply to opiate/opioid therapy, posted by A0102 on March 21, 2002, at 7:59:54
I was almost *exactly* in your shoes late last summer. And have been trying meds and med mixes for about fifteen years. All over this board about my TRD. I had an appendectomy in August and felt soooo well on all that Vicodin, my pdoc put me on Bupe (troches). . .And the first few days, maybe a week, felt sooo nice, it's very persuasive--and then I went into a dark, agitated, determined mania the likes of which I'd never seen before. The upshot was, this *absolutely* cleared up for us the question of was I Bipolar II, he put me on Lamictal (on top of same Dex and Effexor for years). . .and, snap!
Everything clicked. I've never been this long without depression in my whole life--and nary a suicidal thought.The moral of the story being. . .something about the *enourmous* difficulty of tracking down Bipolar II, in part because hypomania feels just plain good. . . I don't doubt for a minute there are TRDs! I was about ready to think about ECT. . .and look what happened.
Hope this is of some use,
Zo
Posted by katrina smith on March 24, 2002, at 13:48:26
In reply to Re: opiate/opioid therapy » A0102, posted by Elizabeth on March 22, 2002, at 21:52:36
I am lookin for an MD that will consider using the opiates in treating my resistant depression. I live in the Boston area. Any ideas? Please reply
Posted by shelliR on March 24, 2002, at 14:02:17
In reply to Re: opiate/opioid therapy (nm), posted by katrina smith on March 24, 2002, at 13:54:34
Katrina,
There are several pdocs right outside Boston who did studies on buprenorphine and depression. I talked to both of them and they are not giving opiates to patients for a fear of a law suit. They may change their minds when bupe comes out in the US as sublingual. They are both at McLean Hospital and if you go to them already on opiates (from a pain doctor, etc.), they may take you. I don't want to give out their names unless you are able to get opiates from another source, because I have called them so much this past year, that I feel guilty passing on their names when I know they won't prescribe it. I seem to remember Adam is in Boston, but I could be wrong. Anyway, if that's the case, he might be able to refer you, but really you must have tried every AD and mood stabilizer out there, if you are even considering opiates.
Shelli
Posted by katrina smith on March 24, 2002, at 14:12:03
In reply to Re: opiate/opioid therapy » katrina smith, posted by shelliR on March 24, 2002, at 14:02:17
Shelli, Thanks for your reply. I do have the names of a couple of docs. What other sources are out there for obtaining meds? I know of the online pharmacies, but are they legal? It seems very expensive and maybe dangerous. How are some patients getting these meds? I just want to feel better. When I mentioned this to my pdoc and my psychiatrist, they laughed basically. I live in a city where there are many heroin addicts, and even asking for opiates is suspicious. What are you doing for your treatment{if that is not to personal?}. Anyway thak you for your prompt response. Take care
Posted by katrina smith on March 24, 2002, at 15:47:38
In reply to opiate/opioid therapy, posted by A0102 on March 21, 2002, at 7:59:54
I have never heard of a pdoc who was willing to go the opiate route. Another post mentioned your name? Do you live in the Boston area? Just curious? Have you tried MAOI's? Any succcess?
Posted by katrina smith on March 25, 2002, at 16:36:46
In reply to Re: opiate/opioid therapy » A0102, posted by Elizabeth on March 22, 2002, at 21:52:36
Elizabeth, I am looking for a pdoc in boston who will consider using opiate agonists in the Boston area? Do you know of any. Is it inappropriate to ask this on this post? You seem very knowledgable in this area? Please help?
Posted by Elizabeth on March 26, 2002, at 22:02:39
In reply to Re: opiate/opioid therapy, posted by katrina smith on March 25, 2002, at 16:36:46
> Elizabeth, I am looking for a pdoc in boston who will consider using opiate agonists in the Boston area? Do you know of any.
I can't guarantee that anyone will prescribe them to you in particular, but Dr. Bodkin at McLean recommended the idea to me (he had done some research on buprenorphine). I'm not even sure if he's seeing patients anymore, though.
-elizabeth
Posted by katrina smith on March 27, 2002, at 4:44:08
In reply to Re: opiate/opioid therapy » katrina smith, posted by Elizabeth on March 26, 2002, at 22:02:39
Thank you Elizabeth in taking time to answer my questions? Take care. Hope your doing well.
Posted by jay beck on June 2, 2003, at 14:45:10
In reply to opiate/opioid therapy, posted by A0102 on March 21, 2002, at 7:59:54
HAHAHA
opiate therepy, good one. I wish i could have told the judge that i was shooting up for theraputic effects for my deppresion/anxiety.
no serously, a little backround info from where im coming. i am a drug addict and i am quite deppresed and have bad anxiety.
Obvously the perfect solution for this, back in about 1910, was heroin. Unfortunatly, thanx for the damn FDA and DEA, we cant just self medicate ourselves with opeates anymore. but honestly its a really crappy solution to a serious problem. you basicly just cover up your deppresion/anxiety temparaly, complete with STRONG addiction and (for me personaly) horrid withdrawl. I started using painkillers to fix my issues but it lead me to a pretty shitty place. they were the ultimate answer to my imperfect mentality, and if were to take a stab in the dark, i bet "almost" every single deppresed/anxious person in this world would get a quick fix using opiates.
the way your talking about using opiates is what the law now states as abuse.(the law is bullshit) Mental pain does not count as a reason to prescribe opiates in year 2003. (although i wish t was, i could have avoided all the money i lost in the black market and never been charged with possesion).
very fast tolerence and dependence
bad withdrawl if you have been using a decient amount for a while. which you will be because of that very fast tolerence. and this is "pretending" your not one of those many addictive personalitys (for which im lucky to be one) and arnt abusing them at all. if you are abusing them they will "eventualy" lead u somewhere around where i was about 6 months ago.now i do think if you have serious treatment resistant chronic deppresion. opiates could be used until your other meds start working. im talking about i dont want to leave my bed suicidal type. not my ups are great and my downs are melencholy type.
as an alternative you could use ADDERAL XR (amphetimine time-release) augmented to your daliy meds. Thats what i use, although i'v been abusing them every now and then becacuse i have a problem. if i take adderal daily it greatly enhances my mood and productivity untill the crash.
well thats my 2-cents
(dont respond to this claiming that technicly in some fucked up clause you can get a script of opiates legaly for emotional pain, all i have to say is if you want to get opiates for emotional pain contact the FDA, and thell laugh at your ass)
Posted by SteveB on June 2, 2003, at 18:16:38
In reply to Re: opiate/opioid therapy , posted by jay beck on June 2, 2003, at 14:45:10
Hi,
From my experience opiates should really be used as the very last line of defense. I've been depressed & anxious for as long as I can remember (my teens at least), and have in the past self-medicated using a long list of recreational drugs - from pot, to amphetamines, morphine and finally heroin.
And yes, morphine and smack were the only drugs that ever made me feel... happy. I tried to only take the good from my life as a junkie, keeping my relationship with family and friends intact, holding a job, etc, but smack does take its physical and emotional toll. So once buprenorphine came on the market here in France (first as Temgesic then as Subutex), I switched over and took it for almost 2 years.
Buprenorphine is a relatively clean opioid, in that it's only a partial agonist, so it has the analgesic properties of a traditional opiate without much of the narcotic effect of heroin or morphine. It does however retain some of the opiates' AD qualities (feeling of mental well-being & relaxation, etc). I was pretty happy and productive on Subutex, and having to pop just one pill a day was no inconvenience. Then again skipping my daily dose was NOT AN OPTION, because dependence meant I'd be sick as a dog without my morning pill. Also note that buprenorphine comes with all the classic inconveniences of the other opiates - constipation, pin-prick pupils, itchy skin, etc.
I quit Subutex three years ago to remind myself what I was like without medication. Withdrawal was an absolute nightmare, even for someone who knows all about opiate withdrawal. I was sick for a month, followed by several months of severe depression.
Anyway, to cut a long story short, buprenorphine is an opiate and as such will end up doing you more harm than good if you take it for a long period of time. All opiates de-regulate your natural production of endorphine, so they don't "augment" your body's ability to make you happy, they replace it. Take the drug away and you'll come crashing down big time.
Oh yes, I was happy on Subutex so I can't knock it completely. In fact, besides the other opiates I've tried, buprenorphine is the only drug that ever gave me a true sense of well-being. But don't try it unless you're chronically depressed and have exhausted absolutely all other avenues. Opiates/opioids ALL will result in tolerance, dependance and withdrawal - not fun!
Posted by Dr. Bob on June 2, 2003, at 20:08:02
In reply to Re: opiate/opioid therapy , posted by jay beck on June 2, 2003, at 14:45:10
> (dont respond to this claiming that technicly in some f*cked up clause you can get a script of opiates legaly for emotional pain, all i have to say is if you want to get opiates for emotional pain contact the FDA, and thell laugh at your *ss)
I'd like people to feel comfortable here, so please don't use language that could offend them, thanks:
http://www.dr-bob.org/babble/faq.html#civil
Bob
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