![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 7 to 31 of 83. Go back in thread:
Posted by kazoo on May 7, 2001, at 1:56:57
In reply to Re: Whats the best opiate? PACHA, posted by kazoo on May 7, 2001, at 0:51:30
As always, I'm having second thoughts about my previous post re. the use of opiates to relieve depression.
Conventional wisdom, as it is, dictates that opiates, and the synthetic narcotic analogs, are specifically and concisely indicated, via the PDR, for physical "pain" such as a toothache, bone fracture or cancer. With that being the case, one could say that depression is a form of mental anguish, and mental anguish is just as painful as physical pain. So it would follow, then, that opiates would be good for this painful mental anguish called depression. I realize that I'm mixing realities with metaphors, but I *can* understand why someone would use a narcotic to relieve the terrible anguish associated with depression. Morphine has this wonderful quality of not only relieving physical pain, but also providing a "lift" in spirits, whether from the absence of pain or the presence of those chemicals which induce this sense of well-being. So, if we did not use morphine to relieve physical pain, but used it for just this sense of "wellness," is this still a justifiable reason to use type of drug?
The logic (if any) skates on thin ice, and I'm flip-flopping back and forth, which I dislike doing.
I do know that one can build up a tolerance to opiates very quickly, and if you should need them for a terrible physical pain, such as a third degree burn, they don't work as well, if at all, so there goes the "justification."
Opiates may provide a "quick-fix" to relieve the despair in any mental state, and is this so wrong to do? Yes and no, and vice versa. However, the medical community doesn't view it this way, and it is through this very same medical community that any chance of changing their common, status-quo thinking is just as futile as asking the original question.
I'm stumped on this one.
(a flip-flopping, stumped) kazoo
Posted by Elizabeth on May 7, 2001, at 7:48:54
In reply to Re: Whats the best opiate for depression ? » Pacha, posted by shelliR on May 6, 2001, at 18:08:18
Of the ones you mentioned, buprenorphine or tramadol would be my choice.
Buprenorphine has the advantage that it can be combined safely with classic monoaminergic antidepressants, which is somewhat risky with Ultram (MAOIs, in particular, are absolutely contraindicated). A disadvantage is that there is no pill form available in the U.S. at this time. People in other countries who've tried the sublingual formulation -- known by the brand names Subutex and Temgesic -- say that it doesn't work very well by that route, which is consistent with my experience attempting to take Buprenex (the solution) sublingually. (Dr. Bodkin, the researcher Shelli mentions, confirmed that this has been his experience as well, BTW.)
Tramadol has the advantage that it is available in the U.S. in pill form (also it is not a controlled substance (YET), so you're more likely to be able to get a prescription for it). It may be toxic if you raise the dose too high.
Darvon is rather toxic and very weak. Oxycontin is very expensive, and oxycodone is more likely to produce tolerance rapidly than buprenorphine or Ultram.
Methadone might be a good choice, as it is extremely long-acting (so tolerance will develop relatively slowly). A disadvantage is that if you become unable to obtain it, the withdrawal syndrome is incredibly long-lasting (although not as intense as withdrawal from shorter-acting opioids).
Certain opioids, such as morphine and hydromorphone, are not well-absorbed orally and therefore probably not the best choice.
I agree with Shelli that if you haven't tried MAOIs, they are very much worth a go.
> Before I would try opiates for depression, I would definitely try MAOIs. Also, I think next month, the selegiline patch will be available, an MAOI that will (I believe) cause no food/drug interactions.
The selegiline patch can cause drug-drug interactions (e.g., with Sudafed or Demerol) but, because it bypasses the GI tract, it won't interact with foods. Shelli -- where did you hear that it will be available that soon? That'd be pretty neat.
> You have to really plan out taking opiates for depression. You don't want to start unless you have a way to continue, i.e., be able to keep getting prescriptions.
Yes. This is a disadvantage of full agonists in particular, because they have extremely intense withdrawal syndromes compared with partial agonists. People develop tolerance at different rates, and some experience seems to suggest that many who take opioids for depression can continue indefinitely on the same dose (my therapist, in particular, has found this to be the case on the few occasions when he has used morphine as an AD).
> I just e-mailed (Friday) questions to a doctor who participated in a study using buprenorphine, which if I understand correctly, is an opiate antagnonist which does not create a high but can help depression.
That would be Dr. Bodkin. It's true that buprenorphine does not create a high, but it is a partial agonist rather than an antagonist. (It is supposedly an antagonist at kappa opioid receptors, but I haven't actually seen any data to support this idea. Anyway, kappa agonists, such as Stadol, are apparently rather unpleasant for depressed people who respond to opioids; the mu receptor is probably the one responsible for their antidepressant effect.)
> Incidently, he is also part of the group which developed the selegiline patch--at McLean Hospital in Boston. His secretary suggested the e-mail; if I get any insight from him I'll share it.
McLean is in Belmont, actually. :-)
> I'm just amazed, however, how many people on this board say they have tried everything and have not tried nardil, parnate, or some of the reversable MAOIs. They are very different from all the other antidepressants and they did the job for me for fifteen years.
Yeah, they sure are (although I think that the reversible MAOIs are probably not as effective for people who've failed to respond to other ADs).
Shelli -- let me know what Dr. Bodkin says. I spoke to him a few days ago (about a referral) but he didn't have much time to talk so I refrained from asking him how his research was going.
Posted by shelliR on May 7, 2001, at 11:15:59
In reply to Re: Whats the best opiate for depression ?, posted by Elizabeth on May 7, 2001, at 7:48:54
Hi Elizabeth.I talked to Dr. Bodkin for about three minutes and he's the one who told me that the selegiline patch was due to come out. He said he'd talk to me again when he got back from being out of town, but so far no luck.
So I called Dr. Lukas (same hospital, same studies) and it was his secretary that told me to e-mail him. I asked him about opiates and also exactly when the patch was due out. IF I hear from him, I'll let you know what he says.
Do you think Bodkin is worth having a consultation with? (I'd have to come up from Washington, D.C.).
It seems, though, that the information you are giving me is probably the same that he would.I don't have anyone to try different optiates with me here. I will look up tramadol, because I don't know anything about it. But even if that's what Bodkin would recommend, I'm not sure he'd write me prescriptions (since I'd only be going for a consult), and my pdoc down here (who I never see--just renews my prescriptions) is okay with me taking a small dose of hydrocodone, but won't prescribe it.
So basically, I feel like I am my own pdoc now. Sometimes that feels scary and lonely, but at other times it is a relief not to hear all the time from my last pdoc how codeine is not an anti-depresssant, how I will become an addict etc. Your clarification on habituation vs addition led to my doing a lot of reading on the subject. Basically, I ended up feeling a lot better about the whole thing. So thanks.
One question I asked Dr. Lukus was, besides eliminating food interactions, if there was any anti-depressant advantage to the patch. Selegiline is a reversible MAOI, right? So I was curious to know how it compares to nardil or parnate orally in terms of anti-depressant value for treatment resistent depression. My guess is that I would not be a good candidate for it, but I'm curious what he will say, if I do indeed get an answer.
Shelli
Posted by mikes on May 7, 2001, at 12:37:59
In reply to Re: Whats the best opiate for depression ?, posted by JahL on May 6, 2001, at 11:49:09
"anti-opiate brigade"....LMAO.
> Hopefully this thread won't get hijacked by the anti-opiate brigade...
>
> J.
Posted by JahL on May 7, 2001, at 12:50:47
In reply to Re: Whats the best opiate for depression ?, posted by mikes on May 7, 2001, at 12:37:59
> "anti-opiate brigade"....LMAO.
'Scuse my ignorance, but what does LMAO stand for?
Posted by JahL on May 7, 2001, at 12:53:42
In reply to Re: What? » mikes, posted by JahL on May 7, 2001, at 12:50:47
> > "anti-opiate brigade"....LMAO.
>
> 'Scuse my ignorance, but what does LMAO stand for?Laugh My Ass Off???
Posted by jimmygold70 on May 7, 2001, at 15:48:13
In reply to Whats the best opiate for depression ?, posted by Pacha on May 6, 2001, at 7:30:27
Pacha,
Did you try ECT ? (Electroconvulsive Therapy). That's more effective than most drugs.
Jimmy
> Lately i've been seeing a lot of talk about opiates being used successfully in treating depression.
>
> I am unresponsive to all ssri and usual antidepressants. And would like to try one of the following: Tramadol, Darvon, Buprenorphine, Oxycontin, other ?
>
> What are your views
Posted by mikes on May 7, 2001, at 21:56:53
In reply to Re: What? » JahL, posted by JahL on May 7, 2001, at 12:53:42
yes, laughing, to be exact. any idea what "SWIM" means? I've been trying to figure it out for months.
> > > "anti-opiate brigade"....LMAO.
> >
> > 'Scuse my ignorance, but what does LMAO stand for?
>
> Laugh My Ass Off???
Posted by mikes on May 7, 2001, at 22:07:50
In reply to Re: Whats the best opiate for depression ?, posted by jimmygold70 on May 7, 2001, at 15:48:13
The lengths you will go to to avoid a high...jeez. I wouldn't mind losing some of my memories, but why bother if opiates can do the job?
> Pacha,
>
> Did you try ECT ? (Electroconvulsive Therapy). That's more effective than most drugs.
>
> Jimmy
>
Posted by kazoo on May 8, 2001, at 1:01:09
In reply to Re: Whats the best opiate for depression ?, posted by jimmygold70 on May 7, 2001, at 15:48:13
> Did you try ECT ? (Electroconvulsive Therapy). That's more effective than most drugs.
> Jimmy^^^^^^^^^^
Jimmy, me lad, one does not "try" ECT like "trying" a new brand of toothpaste. ECT is serious business and I can't imagine any patient confronting their doctor with this idea. It's up to the doctor to evaluate you to determine if you are a candidate, not the other way around.As I have stated in previous posts about this subject, ECT is not a walk in the park, or something that can be performed willy-nilly at the Office on just anybody who walks in the door, much less requesting it. There are a series of steps and tests that are mandated by sound (and sane) medical practice, not to mention law, before ECT is to be even considered.
ECT is the last resort for mental illness. It is done usually in a hospital setting and when everything (and I mean EVERYTHING) else fails.
And as far as ECT's efficacy goes, the jury has been out for the longest time on this topic, and, quite frankly, I think it will always be out. This is the most troubling thing (for me) about ECT: the fact that there are still (after all these decades) so many questions and doubts about its effectivenss.
All other routes and alternatives should be and must be exhausted before this sort of thing is to be even considered. If you search the archives, you can find such alternatives.
I don't know why the posters in this group so casually suggest ECT as the golden way-out from drug-resistant depression. It is not.
kazoo
Posted by Elizabeth on May 9, 2001, at 15:07:05
In reply to Re: Whats the best opiate for depression ? » Elizabeth, posted by shelliR on May 7, 2001, at 11:15:59
> I talked to Dr. Bodkin for about three minutes and he's the one who told me that the selegiline patch was due to come out. He said he'd talk to me again when he got back from being out of town, but so far no luck.
Yeah, he's been super-busy lately (he's not even taking any new patients except experimental subjects). So he's hard to reach. I spoke to him for just a couple minutes becuase I needed a referral.
> So I called Dr. Lukas (same hospital, same studies) and it was his secretary that told me to e-mail him.
Scott Lukas? I know him! He teaches a class on substance dependence. I think he's actually a PhD -- a *real* pharmacologist. < g >
> I asked him about opiates and also exactly when the patch was due out. IF I hear from him, I'll let you know what he says.
More perspectives are always welcome!
> Do you think Bodkin is worth having a consultation with? (I'd have to come up from Washington, D.C.).
I don't know if he'd even have time to see you! He's quite busy, as you've noticed.
> I don't have anyone to try different optiates with me here. I will look up tramadol, because I don't know anything about it. But even if that's what Bodkin would recommend, I'm not sure he'd write me prescriptions (since I'd only be going for a consult), and my pdoc down here (who I never see--just renews my prescriptions) is okay with me taking a small dose of hydrocodone, but won't prescribe it.
The idea of a consultation is, you go see the consultant, and the consultant speaks to your regular psychiatrist and makes recommendations as to your treatment. Yes, given your situation, I think a consultation (with Bodkin or, if he's too busy, with another doctor -- I'm sure he can make a good referral) would be worthwhile.
> So basically, I feel like I am my own pdoc now.
I know...I've had that feeling many times...like, nobody's there to help me so I have to just do my best to help myself.
> Your clarification on habituation vs addition led to my doing a lot of reading on the subject. Basically, I ended up feeling a lot better about the whole thing. So thanks.
You're welcome! I'm glad it had the desired reuslt.
> One question I asked Dr. Lukus was, besides eliminating food interactions, if there was any anti-depressant advantage to the patch.
It's supposed to start working quite fast.
> Selegiline is a reversible MAOI, right?
No. It's an irreversible one, preferentially inhibiting type B (but becoming nonselective at higher doses).
> So I was curious to know how it compares to nardil or parnate orally in terms of anti-depressant value for treatment resistent depression. My guess is that I would not be a good candidate for it, but I'm curious what he will say, if I do indeed get an answer.
I did try high-dose oral selegiline (for 6 weeks or so), but the results were less than stellar. It made me jittery, that was about it. (Kind of like Wellbutrin.) Maybe I wasn't taking enough.
Elizabeth
Posted by Elizabeth on May 9, 2001, at 15:12:40
In reply to Re: Whats the best opiate for depression ?, posted by jimmygold70 on May 7, 2001, at 15:48:13
> Pacha,
>
> Did you try ECT ? (Electroconvulsive Therapy). That's more effective than most drugs.It's extremely effective for certain types of depression, mania, and catatonia. However, it's got serious risks; also, as I noted, it is only effective for certain very specific types of depression.
I have not tried ECT, even though I do have one of the types of (treatment-resistant) depression that are known to respond well to it. (The type of depression I have is called melancholic depession.) This was my personal choice, of course, but it was based on seriously weighing the risks and possible benefits of ECT verus alternatives.
Posted by shelliR on May 11, 2001, at 12:20:31
In reply to Re: Whats the best opiate for depression ? / ETC, posted by Elizabeth on May 9, 2001, at 15:12:40
Elizabeth. I talked to Dr. Bodkin briefly today, and I had it wrong about the selegiline patch. It's not due out for a year.
He will do a consultation, but will not proscribe codeine because of a prior law suit. But he definitely seems very knowledgeable and gave me the name of someone in my area, who he admits is probably "less creative" in prescribing for depression than he is.
Shelli
Posted by dougb on May 11, 2001, at 17:05:54
In reply to Re: Whats the best opiate? PACHA, posted by kazoo on May 7, 2001, at 0:51:30
> Opiates for depression? That's like a trans-orbital lobotomy for a headache. It just doesn't make any sense, but, then again, none of these drug combinations do, and I'm amazed (and baffled) as to how (and why) they do.
Are you a doctor? or how do you arrive at above supposition?
> Remember, doctors use the PDR as their Bible, so unless you can rewrite the indications for the drugs you mention to include depression,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
>you may want to consider shellR's good advice before being labled as one with "drug seeking behavior" (Gasp! Gasp!)
Do you mean, withdrawal, constantly seeking better alternatives, inability to get off of meds, constant increase of dosage and rapidly acquired tolerance?
Posted by kazoo on May 12, 2001, at 0:13:38
In reply to Re: Whats... and Drug Seeking Behavior » kazoo, posted by dougb on May 11, 2001, at 17:05:54
> Are you a doctor? or how do you arrive at above supposition?
^^^^^^^^^^^^^^^^^^^^^^^^
A definition is needed here: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.
Pay particular attention to the word "deadening" then ask yourself how "deadening" the senses can, or would, lift someone from depression, which does a fine job of deadening the senses on its own.
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.
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." I then asked him, "Even if the patient requested this giving sound reasons?" And his answer was "*Especially* if the patient requested this, reasons or not, it's just NOT DONE."
> 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
^^^^^^^^^^^^^^^^^^^^^^^^^
What drugs are you talking about? Using RETIN-A as an anti-wrinkle cream instead of its indicated use for 'acne vulgaris'? You don't say which drugs he does this with? 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?
> Do you mean, withdrawal, constantly seeking better alternatives, inability to get off of meds, constant increase of dosage and rapidly acquired tolerance?
^^^^^^^^^^^^^
Does the term "doctor shopping" mean anything to you? Those ADDICTED to optiates have to CHASE FOR DOPE via DOCTOR SHOPPING and with the right amount of cash, there are plenty of them out there more than willing to oblige the hopelessly addicted, BUT DEPRESSED (!), individual.Opitates are not used for depression. To even think such a thing is an insult to the medical profession.
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.
kazoo
Posted by SalArmy4me on May 12, 2001, at 0:28:47
In reply to Re: Whats... and Drug Seeking Behavior, posted by kazoo on May 12, 2001, at 0:13:38
I'm willing to bet that the people endorsing opiates for depression have not tried every more convential treatment for depression.
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.
--The Salvation Army A.R.C. Command: Changing the world, one life at a time.
Posted by shelliR on May 12, 2001, at 14:46:33
In reply to Oy Vey: Opiates » kazoo, posted by SalArmy4me on May 12, 2001, at 0:28:47
One of the main reasons I use this board is to both pick up information on new depression treatments AND to discuss my use of opiates to control my depression. I have gotten both support, suggestions, and warnings concerning various opiates. I have also gotten insight into the difference between tolerance and addiction.
I have been to the best known psychopharmagologists in my area (a large eastern city). My psychiatrist is aware that I am using opiates to combat my depression; (I am not keeping secrets from my pdoc.) He agrees that I have tried enough drug combinations in the past few years that a respite is in order.
I also have strongly recommended MAOIs for people who have treatment resistent depression, before they enter into the opiate world. I think MAOIs can help people when all other meds have failed. And I try to help others realize that starting opiates to help depression has to be a well-thought out plan, and will not be successful for everyone, perhaps not even for most people.
That having been said, it is becoming increasingly tiresome to try to exchange information re opiates on this board among the posters who feel the necessity of sharing their own pedestrian outrage of such treatment for depression. I suppose all that can be done is to ignore your posts and not get into a defense of opiate use.
But I did want to say to you, that before you offer us your unsolicited consultations, perhaps if you read through the threads you will find that most of the posters using opiates to treat depression ...
have been to many doctors--doctors expert in treating medication resistent depression; Physicians who just might have more information than your MD father, or your MD mother, or the MD sitting next to you at a dinner party.
have tried many many medications and many combinations of medications over many years;
are using opiates WITH the knowledge of our
psychiatrists.and,
do not recommend that all depressed persons should use opiates as a treatment.It seems to me that most of you don't even read the whole thread before you rush in to save our opiate souls.
Shelli
Posted by SalArmy4me on May 12, 2001, at 18:25:20
In reply to Re: Opiates for depression, posted by shelliR on May 12, 2001, at 14:46:33
Here's what Dr. Richelson, one of Dr. Bob's colleagues wrote about opiates in depression:
"Long before the established antidepressants were available, opiates and opioids were used to treat depression. However, for various reasons today, I would not use this class of compounds to treat depression. The mechanisms of tolerance to a drug is very complex and not well understood for most drugs. Some mechanisms involve increased metabolism of the drug and adaptive changes at the cellular level. The theory about tolerance to opioids is that there are adaptive changes at the level of receptors for these compounds. Why tolerance would not develop in some patients, but not others is a mystery." --http://www.dr-bob.org/babble/20010411/msgs/59892.html
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_{!}."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.
Posted by Elizabeth on May 12, 2001, at 19:57:44
In reply to Re: Whats the best opiate for depression ? / ETC » Elizabeth, posted by shelliR on May 11, 2001, at 12:20:31
> He will do a consultation, but will not proscribe codeine because of a prior law suit. But he definitely seems very knowledgeable and gave me the name of someone in my area, who he admits is probably "less creative" in prescribing for depression than he is.
He is very knowledgeable; I think the world of him. He also knows a lot of people -- he referred me to a young pdoc who was a student of his. (I've only seen the guy once so far but he seems very bright, and I trust Dr. Bodkin's assessment of him.)
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.
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
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
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