Posted by kingcolon on July 12, 2007, at 10:15:05
In reply to Re: Heroine as atnidepressant, posted by revaaron on July 11, 2007, at 15:08:39
> I think it's a shame that the words for dependence are so fuzzy and inaccurate. Dependency vs addiction vs habituation; withdrawal vs stoppage syndrome, etc. It'd be nice if we had a strict vocab that folks knew and stuck with.
>
> Don't get me wrong, bupe is quite unabusable compared to methadone (though not as unabusable as using loperamide as a maint med), but I've known my fair share of opiate users who still found a way to abuse bupe. The quality of 'high' might not be like heroin or morphine, but the usage patterns and intent were the same. Not saying everyone does this, but opiate have a knack at finding a way...A QUOTE FROM ARTICLE BELOW:
"....There are reports of the drug being abused, but then some substance abusers will abuse almost anything. We were told that San Quentin stopped using white scouring powder because substance-abusing inmates were injecting it into themselves!"
True, addicts do "find a way" to abuse!!! It's a shame we seem to have lost Babek since my post was to try to help him/her find an alternative to heroin as a treatment for his intractable depression with anhedonia. I got the impression that Babek was not looking for a "high" at all, but unfortunatey found he became addicted (craving the high)and thus got into a cycle of abuse that led nowhere good as far as the a way to treat his depression. I really think BUP is a way out for people who want to avoid the addictive effects of heroin or other opioids to deal with helping them with their basic problem of depression. As I said, it produces little if any euphoria or craving, and the evidence is very pro excellent antidepressant effects. A withdrawal syndrome pales in comparison to the benefits of treating the depression and can be managed much more easily since there is no reward of a high as one withdraws resulting in drawing one back into using again. And if the depression is under control, and one doesn't want to get high, one isn't likely to relapse into heroin or other opiate abuse.
Obviously, this applies to this type of problem only--not the typical opiate abuser.
But you're right that any opiate carries with it a risk of abuse (in BUP's case, almost entirely with IV use). Here's an article from a previous post that has a comment about the effects of BUP on depression, together with mention of fears of using it by the public in general, mostly based on the "intent" and "patterns of use" you mention in abusers. The quote above says it all. But let's not forget the sufferers from severe depression. It's been a life saver for me so far. I hope I don't become tolerant, but it seems that even that is unlikely with this drug. And for dual diagnosed people, BUP carries the distinct advantage that you really can't get a high any more easily by increasing the dose (celing effect).I'd be interested in re-focusing the topic to opiates for depression--especially for people's experiences with buprenorphine.
--------------------------------------------------------------------------------Buprenorphine for Treatment-Resistant Depression
Posted by Rudiger on June 25, 2001, at 17:47:12The following are excerpts from an editorial in the June 15th, 1996 issue of the journal Biological Psychiatry. The editorial outlines the (irrational) reasons buprenorphine is not used more often in cases of clinical depression that has not responded to every other available treatment.
Buprenorphine for Depression: The Un-adoptable Orphan
Buprenorphine [BPN] in low (circa 0.3 mg qid) transmucosally (under the tongue or by nose drops) can be dramatically effective in cases of treatment for refractory depression. Its safety and efficacy are not secrets, yet it has received little study and currently receives little clinical use.
Early in BPN's history, Emrich et al (1982) found it a potent antidepressant in drug-refractory depressives. Sporadic supporting reports have appeared in the literature from time to time since then. Most recently, Bodkin et al (1995) reviewed the literature and reported an open trial of 10 cases to further document BPN's value as an antidepressant. When the drug works, it works quickly. Bodkin et al say they see results within several days. We have found that most patients experience benefits of an adequate dose within three hours. The only intolerable side effects are nausea and dysphoria. The effects are seen in 10% to 20% of patients and are quickly obvious....
We have personally treated five patients with BPN in whom the results were impressive. Three were more or less typical cases of depression who had failed adequate trials with various treatments, including, in one case, a thorough course of ECT. Of the two less typical patients, one was a case of panic disorder with onset in childhood and what could better be called dysthymia rather than typical depression.... All five patients were followed for several years while good results were maintained.
Given BPN's availability and demonstrated efficacy, why is it so rarely used in treating depression? Therein hangs a tale. Reckitt and Colman Pharmaceuticals, Inc. [R&C] received their NDA to market BPN as a parenteral analgesic more than a decade ago. It appears that their grand strategy was to get BPN approved as an over-the-counter analgesic. It does indeed have a remarkable safety profile. At high doses, it produces less respiratory depression and cognitive obtunding than morphine, perhaps due to its antagonist action....
Addiction and tolerance are not serious problems. Patients who abruptly stop the drug complain of fatigue, dysphoria, upset stomach, and sometimes piloerection. This pallid imitation of narcotic withdrawal is generally not associated with craving, and indeed patients do not usually associate their symptoms with having stopped the drug until they experience the relief occasioned by restarting their treatment. There are reports of the drug being abused, but then some substace abusers will abuse almost anything. We were told that San Quentin stopped using white scouring powder because substance-abusing inmates were injecting it into themselves!
One handicap BPN has had as an antidepressant was the absence of any interest in that application on the part of the manufacturer. The idea of selling BPN as an OTC analgesic was not an unreasonable one, but it did not lead R&C to pursue work on the psychotropic properties of their drug.
It appears tha BPN can be used much as methadone is used in maintaining opiate addicts. While doses of up to 32mg have been used, doses in the order of 6 to 12mg seem best. Compare this to the 0.15mg to 0.3mg doses that are effective in depression. Several studies have reported that BPN is indeed effective in treating opiate dependence, although less so than methadone (Kosten et al 1993 and Strain et al 1994). However, BPN's use in treating addicts, plus the ominous "-norphine" suffix in its name, have been even more of a deterrent to BPN's exploitation as an antidepressant than has R&C's narrow focus on its analgesic applications.
Comparing BPN with classic mu agonist opiates is unfair. BPN is a derivative of thebaine, which has partial mu agonist and kappa antagonist activities. As a partial agonist, it seems to act as a mu antagonist at higher doses, and this provides some protection against it being used in escalating doses by substance abusers. In addition, in low doses it produces minimal or no euphoria. We have a little packet of reprints to send out to pharmacists who call accusingly and question why we are prescribing such a "dangerous narcotic."...
We have continually been frustrated by the resounding lack of interest our colleagues have shown in BPN as an antidepressant. In spite of some promising pilot work, Veterans Administration workers treating post-traumatic stress disorder have declined to study BPN because so many of their clients are substance abusers, and BPN is "narcotic-like."
We discovered that someone had contracted with Cygnus, Inc. to develop a BPN patch. That was accomplished, but the contracting company dropped the project. The developed BPN patch now sits on their shelf. However, after a few cordial lunches, Cygnus indicated they would need a million dollars up front to reactivate production of the patch for a clinical trial. Small business grants are limited to $100,000 to start, so that would not get Cygnus back into the BPN patch business. Also, treatment-refractory depression does not sound like an appealing market to business types. We are not sure the market is so small, and it has been suggested that as many as 20-30% of depressed patients may be treatment-refractory. But certainly, for a single physician, patient accrual is slow. While the patent on BPN has run out, orphan drug status might allow a company to be protected against competition while it recoups its investment and more. But so far there is little interest from industry.
Academia has been similarly uninterested, but with better reason. It's too bad that substance abuse takes a hight priority than depression in congress, but then what is one to expect. And our wildest fantasy does not have the National Institutes of Mental Health approving the trial of such an oddball drug for treatment-refractory depression. In our mind's eye we can see the pink sheet: Reviewer No. 1 says: "We already know that BPN works in depression, so why do it again?", while reviewer No. 2 says: "It's too much of a long shot in these times of short money."...
Research is the art of the possible, and none of us these days can afford to espouse lost causes. But your local pharmacist can dispense BPN without a triplicate, and even supply a syringe and needle so the patient can withdraw the drug form the vial and squirt it under the tongue. You will find it in the Physician's Desk Reference under the trade name "Buprenex" injectable, 0.3mg/ml. So even if the orphan remains un-adoptable, you might want to try BPN on an occasional drug-refractory depressive, and so keep it alive, at least in the lore of those who do tertiary psychopharmacology.
Enoch Callaway
University of California-San Francisco
Tiburon, CA
References:Bodkin JL, Zornberg GL, Lucas SE, Cole JO. (1995): Buprenorphine treatment of refractory depression. Journal of Clinical Psychopharmacology, 16:49-57.
Emrich HM, Vogt P, Herz. (1982): Possible antidepressive effects of opioids: action of buprenorphine. Annals of the New York Academy of Sciences, 398:108-112.
Kosten TR, Schottenfeld R, Ziedonis D, Falcioni J. (1993): Buprenorphine versus methadone maintenance in opioid dependence. J Nerv Mental Dis 181:358-364.
Strain EC, Stitzer ML, Liebson IA, Bigelow GE. (1994): Buprenorphine vs. methadone in the treatment of opioid-dependent cocaine users. Psychopharmacology 116:401-406.
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poster:kingcolon
thread:767449
URL: http://www.dr-bob.org/babble/20070710/msgs/769142.html