Posted by matthhhh on July 22, 2003, at 16:23:37
In reply to Re: Ultram dose, posted by matthhhh on July 22, 2003, at 13:47:12
Have you ever considered taking morphine instead of Ultram. Theres been a number of research studies that indicate that one dose of morphine 20-40 mg, relieves ocd symptoms and social anxiety for a period of at least 5 days. And it also suggests that risk of addiction is very low. I found this information on morphine.
Exciting evidence recently published in the Canadian Journal of Psychiatry suggested morphine as an efficacious drug that showed dramatic effects in cases in which SSRI's, behavior therapy, and psychosurgery failed (Warnecke 1997). The author referenced several imaging studies showing a concentration of opioid receptors in the caudate nucleus, an aforementioned important region in the pathogenesis of OCD (Murin et al. 1980; Woo et al. 1985). Notably, none of the patients reported a euphoric response after each dose of morphine, which suggests that the mu subclass of opioid receptors may not be involved and the risk of addiction should be very low. Oral doses of morphine were given with doses ranging from 20 to 40 mg. Surprisingly, therapeutic effects lasted for at least 5 days following a single dose.
Another type of treatment is based on a theoretical conception of aberrant reward systems in OCD. It has been hypothesized that there is a failure of the endogenous reward system to signal satisfactory completion of an act. This reward system is under partial control of the endogenous opioids. Naloxone, a competitive opiate antagonist, exacerbates OCD symptoms. Franz and colleagues[12] randomized 8 treatment-refractory OCD patients to oral morphine (ie, MS Contin), lorazepam, or placebo. All patients received a 2-week trial of each agent in random order, in a double-crossover, double-blind design. A single dose of oral morphine resulted in a greater improvement in OCD symptoms than lorazepam or placebo, as reflected by a decrease of more than 40% in YBOCS scores. Case reports also suggest that tramadol, an opioid receptor mixed agonist/antagonist with some serotonin and norepinephrine reuptake properties, is efficacious in reducing OCD symptoms.[13,14] Double-blind studies of tramadol's efficacy in treatment-resistant OCD are currently underway.
A Possible New Treatment Approach to ObsessiveCompulsive Disorder Dear Sir: I would like to report on a possible new treatment approach to obsessivecompulsive disorder (OCD). The use of narcotic antagonists and agonists has been of great benefit in a small number of treatment-resistant cases of OCD and OCD-spec- trum disorders that have presented to the anxiety disorders clinic where I work. Two cases will be briefly discussed and the rationale for the use of narcotic agonists/antagonists also briefly reviewed.
Case 1 is a 55-year-old, divorced, unemployed female who had severe OCD since early adolescence. Her main symptoms consisted of cleaning, checking, and preoccupation with de- tail that resulted in extreme slowness. Her illness waxed and waned but had become progressively worse over the years. Response to the usual antiobsessional medication was minimal. Under the care of a previous psychiatrist, she had received bilateral cingulotomies with no benefit. Under my care for the last 6 years, the patient showed no response to trials of all of the selective serotonin reuptake inhibitors (SSRIs), alone or in combination, or to a course of intravenous clomi- pramine infusions. Electroconvulsive therapy relieved her comorbid depression only for a short period of time. Cognitive behavioural therapy provided by an experienced behavioural therapist was of limited benefit. A further psychosurgical procedure of bilateral anterior capsulotomy provided only temporary modification of symptoms. Over the last 2 years she developed a new symptom of compulsive picking that has become so severe that on admission to hospital, her face, breasts, and abdomen were severely excoriated. Demoralized, with few remaining family supports, she was being assessed for a nursing home placement because she no longer was able to cope on her own. On the basis of reports in the veterinary literature of narcotic antagonists being effective in compulsive behaviours in animals, as well as on the proven safety of naltrexone in the treatment of drug and alcohol addiction, I decided to try this approach in this patient. Naltrexone 50 mg/day was given initially and then increased to 100 mg/day. Within a few days, the compulsive picking dramatically decreased, although the patient continued to be very dysphoric. At this point, based on an anecdotal report from another patient with severe OCD that her symptoms had dramatically remissed for up to a week when given morphine following surgery, I elected to try a narcotic agonist in this particular case. After a suitable washout period for the naltrexone, morphine sulphate was given subcutaneously in a dose of 10 mg. The response was dramatic. Twenty-four hours later, the patient remained mildly euphoric and free of all OCD symptoms. This state lasted for several days. Oral morphine was then tried, and after some adjustment, a dose of 30 mg was found to be effective for 6 to 7 days, particularly diminishing the compulsive picking and the dysphoria. Other narcotic agonists, such as propoxphene and pentazocine, had no effect. The patient continued to do well on the oral morphine and entered a rehabilitation program, where the morphine was discontinued. She suffered a relapse, but now she remains much improved after the morphine was restarted at a dose of 30 mg every 5 to 6 days.
Case 2 was a 35-year-old single female who was unem- ployed but trained as an accountant. She had severe trichotillomania, which began in her early 20s; she had received extensive treatment for this condition, but all of the SSRIs, including clomipramine, had been ineffective. She had no other symptoms of OCD or depression. The trichotillomania worsened under stress and was confined to her head and eyebrows. She wore a wig because of large areas of baldness. Her life had become very restricted because of the time spent in hair-pulling activity and the embarrassment of her being bald. Repeated trials of SSRIs with augmentation remained ineffective. A trial of naltrexone was undertaken at 100 mg/day. After 2 to 3 weeks, the trichotillomania dramatically decreased, and her hair started growing back. Unfortunately, she could not afford the cost of the medication and discontinued it with a return of symptoms.
Since these 2 cases were treated, 4 other end-stage cases of OCD (the only other option was psychosurgery) have been successfully treated with oral morphine, the dose ranging from 20 to 40 mg given every 5 to 8 days. Three cases of OCD-spectrum disorder (2 with trichotillomania, one with compulsive gambling) have been treated with naltrexone with marked improvement. Morphine works primarily on the mu receptor with analgesia and/or euphoria being the result, but it has an effect on the other receptors as well. Subtypes of each receptor have also been identified, and of possible relevance to OCD is the concentration of opioid receptors found in the striatal system, particularly the caudate nuclei (16,17), which appear to be an important region in the pathogenesis of OCD (18,19). In the cases in which morphine was useful, it is puzzling why the effect lasted for at least 5 days following a single oral dose. None of the patients reported a euphoric response beyond what could be expected as a result of symptom relief. This suggests the involvement of opioid receptors other than the mu receptor. The risk of addiction, if this is true, should be very low, if it exists at all. The cases discussed are being followed very closely from this perspective, but there has been no evidence of dose escalation. The response to narcotic agonists or antagonists in a few cases is similar to that reported in the veterinary literature and reinforces the concept of a neuroethological approach to the understanding of OCD, with a possible common pathogenesis for stereotypies in animals, such as the acral lick syndrome in dogs, and similar repetitive motor behaviours in humans, such as compulsive picking or hair pulling (20,21). Although there are many useful treatment approaches for OCD, about 30% of patients do not respond to traditional therapy and continue to remain very chronically ill. The last-resort treatment is often psychosurgery, a procedure not readily available for most (22). It is hoped that this letter may stimulate other thoughts on this subject. Clearly, there is a need for research. Of interest, a recent television documentary on medical advances had a short section on OCD. A psychiatrist from Baylor Medical College in Texas was interviewed and made a brief comment about the successful use of morphine in a few cases of otherwise intractable OCD. I am in the process of trying to find the name of this individual..
poster:matthhhh
thread:243298
URL: http://www.dr-bob.org/babble/20030718/msgs/244310.html