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Dr. Bob is Robert Hsiung, MD,
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Posted by europerep on October 22, 2011, at 10:23:49
In reply to Re: opiates and major depression, posted by CaptainAmerica1967 on October 22, 2011, at 9:28:04
A psychiatrist in the USA needs a SAMHSA waiver if he or she wants to prescribe buprenorphine *as an opiate replacement*. Any psychiatrist (or physician) who can prescribe narcotics (that group contains almost all regular physicians) can prescribe buprenorphine off-label, for example for TRD.
Posted by CaptainAmerica1967 on October 22, 2011, at 13:30:37
In reply to Re: opiates and major depression » CaptainAmerica1967, posted by europerep on October 22, 2011, at 10:23:49
androog - there's a second answer. Hope you find one.
Posted by kirbyw on October 22, 2011, at 22:54:27
In reply to Re: opiates and major depression, posted by CaptainAmerica1967 on October 22, 2011, at 13:30:37
I have previously posted that vicodin gives me a lift when I am in a depressive episode. Even a small dose such as half of a 5/500 will give me a big lift for 6-8 hours. The problem is that I don't have a steady supply guaranteed, so I am saving the Vicodin from my last rx, in case of a serious episode. My regular meds are parnate, lithium and 2.5 mg of zyprexa. Since adding zyprexa I have put on 10 pounds, which I don't like at all. I can't determine if the zyprexa is helping or not.
Posted by CaptainAmerica1967 on October 23, 2011, at 3:39:45
In reply to Re: opiates and major depression, posted by kirbyw on October 22, 2011, at 22:54:27
> I have previously posted that vicodin gives me a lift when I am in a depressive episode. Even a small dose such as half of a 5/500 will give me a big lift for 6-8 hours. The problem is that I don't have a steady supply guaranteed, so I am saving the Vicodin from my last rx, in case of a serious episode. My regular meds are parnate, lithium and 2.5 mg of zyprexa. Since adding zyprexa I have put on 10 pounds, which I don't like at all. I can't determine if the zyprexa is helping or not.
Why don't you ask your physician straight out for Viocodin if it helps? Life is too short to have it wasted on being depression all of your life or at least that's how I feel. If you've had depression all of your life, you'll be on an antidepressant most likely the rest of your life which are also tough in withdrawal themselves. Some individuals the atypical antipsychotics work well, but they make me severely depressed and I've tried all of them for a good lenght of time. I even tried Amisulpride which in low doses is suppose to work as an antidepressant and anxiolytic, but all made me very tired, fatigued, and sleepy, depressed. Lithium I tried many times, but never felt anytime from it really although it's suppose to be a good prophylactic against depression/anxiety and increases brain derived nerve growth factor; I just worried about my kidney because of excessive workout session (sweating and ions) so whenever I tried it I used Lithium Orotate which is much more bioavailable supposedly and therefore can be used on less smaller of a dose, not sure as conflicting reports. It's over the counter.
Maybe print off a study for your physician like the Bodkin 1995 (Havard Study) or Richard Gracer, MD,President of National Alliance of Advocates for Buprenorphine Treatment, NAABT.ORG that wrote an article in March 2007 in the NAABT newletter educationg phyisician on the potential treatment of opioids (smaller doses than addiction) in general but more buprenorphine as it is currently the most potent longest acting kappa antagoinst which he thinks anyone with addiction or depression has a faulty mechanism in general of overactive kappa receptors leading to overactivity of the brain, There's even currently a clinicaltrials.org study for buprenorphine going on called "Buprenorphine For Late-Life Treatment Resistant Depression (BUILD)" where Reckitt Benckiser, Inc., the original developer of liquid buprenorphine who supplied bup. for the Harvard Bodkin 1995 study are supplying the liquid buprenorphine for this study so I wonder if this company, RB, is going to try to market a new form of buprenorphine indicated for treatment resistant depression. Again, liquid bup. given either intranally or squirted underneath the tongue in liquid like the original Bodkin study. Intranasally would be a new form if patented as companies come out with a liquid, chewable, long lasting/extended release or patch forms to hold onto patent to make more money so lets hope RB have plans on marketing bup to TRD patients with indication.
Posted by floatingbridge on October 23, 2011, at 8:24:43
In reply to Re: opiates and major depression » Aurora, posted by safire4hope on October 18, 2011, at 7:29:01
Hi Safire,
I have TRD and chronic pain. I respond fabulously well to tramadol and hydrocodine, though experienced gradual escalation. Does suboxone or bupererephrone (sp) escalate over time? If so I would probably skip. If not, I am very interested,
Is there a website to see if there is a dispensing doctor in my area? I can't say I have an addictive past. I would need t o present as TRD and chronic pain and as a very favorable
responder. Thank you.
Posted by uncouth on October 23, 2011, at 8:56:58
In reply to Re: opiates and major depression » safire4hope, posted by floatingbridge on October 23, 2011, at 8:24:43
I'm glad this thread is going. I have been looking into bupe. myself over the past few months. And I think I actually ordered some a long long time ago when I was in the worst of my horrible depression, suicidal, in 2009, when ECT didn't work. But I'm not sure I ever used them...
Anyway, I am in the process of contacting a few doctors in my area. I am not expecting much at all but will let you know at the minimum what they say.
I am wondering though, does anyone know the biology behind the opioid receptors in relationship to the other theories about depression? I mean, I get that opioids modulate pain and pleasure, but that's not the only thing wrong in depression. How does kappa antagonism, or mu agonism, or whatever, relate to the other theories behind depression or bipolar depression such as:
- monamine hypothesis
- glutamate overactivity at NMDA receptors
- increased oxidative stress and dendridit atrophy
- stress-related hippocampal atrophy
- sleep
= hormonal imbalance
- ketamine's rapid impact on depressionI mean I get that there is not one master key to fit the lock, but it seems crazy that bupe is working for even the sickest patients, who must be in a ton of pain, and seemingly fully resolving all the other symptoms. Is that true? Is it helping motivation, pleasure, positive affect, instead of just helping numb negative affect?
What are the hypotheses for the more dynamic effects that opioids have in the brain in terms of end results and neurogenesis, monamine regulation, etc....or perhaps the feelings of pleasure and numbing of pain sort of make life worth living again, and the normal parts of life that we all need to feel good are more easily attainable when one is not in a state of severe pain or severe angst or emptiness or existential despair, etc.
All I know is that when I was at my sickest, in 2009, when ECT didnt work and I wanted to die, and was actively making plans to kill myself, it is totally unconsciousable that I wasn't given opioids at that time if they could have helped. Unfortunately I wans't int eh right mind to think about that.
Uncouth
Posted by CaptainAmerica1967 on October 23, 2011, at 10:53:40
In reply to Re: opiates and major depression - Question, posted by uncouth on October 23, 2011, at 8:56:58
The biology or mechanism of action of bup being the longest and most potent kappa antagonist that has an blocking effect on the overactivity of the brain and seems to calm it down do to chronic stress. The prefrontal cortex and the limbic system, the nucleus accumbens is part of the pleasure center(dopamine)and seems to not be normal (overactive) in both addicted patient and depressed patients according to Richard Gracer, MD of The National Alliance Of Advocates For Buprenorphine Treatment or NAABT.org. I've heard that kappa antagonist also block dynorphin which is the opposite of endorphins and makes individual feel kind of lousy, and not euphoric. I personally feel buprenorphine has more anti-anxiety effect that any of the benzodiazepines.
So much of this was already covered in the below post that I will repost them; hopefully that's allowed here.
...
keeping opioid prescribers out of trouble pseudoname 11/10/05
Re: opiates and major depression Nieko 7/19/08
Re: keeping opioid prescribers out of trouble Crotale 7/21/08
Re: opiates and major depression » androog maree 7/22/08
Re: opiates and major depression Crotale 7/25/08
Re: opiates and major depression Crotale 7/25/08
Re: opiates and major depression » maree Nieko 8/27/08
Re: opiates and major depression » Aurora safire4hope 10/18/11
Re: opiates and major depression » safire4hope Chairman_MAO 10/18/11
Re: opiates and major depression » Chairman_MAO safire4hope 10/18/11
Re: opiates and major depression » safire4hope Chairman_MAO 10/18/11
Re: opiates and major depression » safire4hope CaptainAmerica1967 10/18/11
Re: opiates and major depression » Chairman_MAO safire4hope 10/18/11
Re: opiates and major depression » CaptainAmerica1967 Chairman_MAO 10/18/11
Re: opiates and major depression sigismund 10/19/11
Re: opiates and major depression » Chairman_MAO CaptainAmerica1967 10/19/11
Re: opiates and major depression » Chairman_MAO europerep 10/19/11
Re: opiates and major depression » europerep Chairman_MAO 10/19/11
Re: opiates and major depression » CaptainAmerica1967 Chairman_MAO 10/19/11
Re: opiates and major depression » CaptainAmerica1967 safire4hope 10/19/11
Re: opiates and major depression » Chairman_MAO europerep 10/20/11
Re: opiates and major depression CaptainAmerica1967 10/20/11
Re: opiates and major depression » CaptainAmerica1967 SLS 10/20/11
Re: opiates and major depression JohnLA 10/20/11
Re: opiates and major depression CaptainAmerica1967 10/21/11
Re: opiates and major depression - Question uncouth 10/23/11
Posted by floatingbridge on October 23, 2011, at 14:12:00
In reply to Re: opiates and major depression » safire4hope, posted by floatingbridge on October 23, 2011, at 8:24:43
I found two doctors in my area that treat with bupeenephrine (sp) and suboxone for both chronic pain and TRD.
I am assuming there is no escalation factor. If there is, would someone be kind enough to let me know.
I am going to check this out. Pain just limits my world. Apparently, there are a number of people on this for chronic pain. Wish me luck. Any thing I should consider, please let me know.
Posted by SLS on October 23, 2011, at 15:30:23
In reply to Looking into this, posted by floatingbridge on October 23, 2011, at 14:12:00
> I found two doctors in my area that treat with bupeenephrine (sp) and suboxone for both chronic pain and TRD.
>
> I am assuming there is no escalation factor. If there is, would someone be kind enough to let me know.
>
> I am going to check this out. Pain just limits my world. Apparently, there are a number of people on this for chronic pain. Wish me luck. Any thing I should consider, please let me know.
Go for it!
- Scott
Posted by sigismund on October 24, 2011, at 5:25:28
In reply to Looking into this, posted by floatingbridge on October 23, 2011, at 14:12:00
>I am assuming there is no escalation factor. If there is, would someone be kind enough to let me know.
I've never taken it, but I assume you would need to have lowish expectations or there would need to be dose escalation.
But it would treat the pain, and the depression, and therefore seems to the point.
Posted by floatingbridge on October 24, 2011, at 10:01:55
In reply to Re: Looking into this, posted by sigismund on October 24, 2011, at 5:25:28
Sigi, what does lowish expectations mean?
So far I have read there are two doses made. One fairly low 2mg and that is what chronic pain patients (fibromyalgia) take. The other 8mg may be given for opoid dependency.
I don't know. I have been reading about it on a fibromyalgia forum. The person on it longest has been two plus years at her starting dose.
The half life is 36 hours, so discontinuation is said to be very attenuated and unpleasant (by some).
Maybe the opoid thing freaks me out. Though could it be worse than some meds I am on or have been?
Posted by sigismund on October 24, 2011, at 10:41:23
In reply to Re: Looking into this » sigismund, posted by floatingbridge on October 24, 2011, at 10:01:55
All opioid dependence is difficult, but bupe dependence is easier than some (methadone) I feel sure.
I meant by lowish expectations that tolerance would be enough to keep any opioid feeling fairly small, and you would have to accept that. But you know all that.
I was always uneasy with you working your way through the psych drugs. If there was sense in that feeling, perhaps it was that you were in pain and sick, rather than depressed? Don't know. Or just my prejudices?
If you go on it, you know there will be a protracted withdrawal syndrome should you come off it, but nothing like methadone. Compared to hydrocodone I could not say.
But at least it makes sense.
Posted by sigismund on October 24, 2011, at 10:53:59
In reply to Re: Looking into this » floatingbridge, posted by sigismund on October 24, 2011, at 10:41:23
You made a comment (on the politics board) about hydrocodone.
What was it?
Parcelling out the pain in batches? Not quite.
With methadone what you get is a couple of nice hours and then back to normal.
I assume the kappa antagonism (if that is right) avoids the slightly depressing quality that people on methadone experience. Maybe that is where the AD effect (if there is one) will come from?
Certainly my experience with methadone was that it was a zero sum game. Those few nice hours are what you have to pay back, or so I felt.
I was reading about some herb and fibromyalgia. What can it have been? I take curcumin. It is possible to find a dose of that which does not aggravate insomnia (I think). I can't remember what it was now.
As you said, it will be no more traumatic than some meds you have been on. Not in the least in fact, until you try to stop. And even then, not so bad.
Posted by sigismund on October 24, 2011, at 11:27:38
In reply to Re: Looking into this » sigismund, posted by sigismund on October 24, 2011, at 10:53:59
That herb I was reading about would have been rehmannia.
Posted by floatingbridge on October 24, 2011, at 13:05:19
In reply to Re: Looking into this, posted by sigismund on October 24, 2011, at 11:27:38
Thanks, sigi. I think rehmannia, that is Chinese? I might be confusing it with rhodilia, which is maoi contradicted.
Yes, I think the kappa activity is the antidepressant quality. That is the sum depth of my knowledge.
So it would be more difficult to discontinue than hydrocodine?
I disliked how it set my pain clock. By the end of my use, it was every four-five hours, and I would be looking at my watch. I didn't really escalate past a certain point because more did not do more and made me very dumb. Plus I did not want to. I wanted to work within that ceiling. But the crap I took from doctors was humiliating at times.
Really, I found tramadol was superior for mood and pain.
I am still mulling this over. Gabapentin is just stupefying. My doc wanted me to take more. He still does. But I do not feel good past 900mg. But that stuff sets my pain clock, too. I don't think there is a way around that when using medication.
I took a hydrocodine two weeks ago. Five milligrams. It felt very freeing. It was easy to move, I felt peaceful, the world was tolerable. I decided to just enjoy the few hours and not try to make it last. I still have this crazy big bottle left from when I quit. I was having a crappy day and said f*ck it.
Posted by floatingbridge on October 24, 2011, at 14:42:18
In reply to Re: Looking into this » sigismund, posted by floatingbridge on October 24, 2011, at 13:05:19
sigi, oh, you said you could not say.
Sometimes I do not read things through very well the first time.
Oh well.
I imagine I would need to talk to a doctor and have all my questions written up ahead. (It's not so much my memory but my distractibility....)
Posted by sigismund on October 24, 2011, at 14:48:43
In reply to Re: Looking into this » sigismund, posted by floatingbridge on October 24, 2011, at 13:05:19
> It felt very freeing. It was easy to move, I felt peaceful, the world was tolerable.
That was exactly my attraction to opiates.
From what I read you would have a few horrible weeks withdrawing from bupe. But the intensity would depend on the dosage.
I took gabapentin (mainly 300mg/d) for a year or so without adverse effect beyond weight gain until the latest thing. But swelling of the feet is no good....you have to be able to walk. I'm suspicious of it now. And I liked it too. If you have a 14 hour flight, it is quite an escape to take 1200mg. Everything becomes so much more fun. I can even approach those in flight computer and my neighbours with some degree of calm. Not as good as hydrocodone of course. There was a time people talked to each other. Maybe that was when I was more attractive? I had a wonderful chat once to an American who lived in Bangkok and was reading Sodom and Gomorrah from Rememberence of Things Past in French. Now no one says a word.
Rehmannia is Chinese and may possibly have something to do with endogenous steroid production. At any rate it is used for adrenal insufficiency (I think) and autoimmune diseases and fibro. I was told that Tian Wang Bu Xin Wan (of which it is an ingredient) would extend my life, which I took to be their polite way of saying they didn't like my chances at that point.
Posted by Chairman_MAO on October 24, 2011, at 20:55:46
In reply to Re: opiates and major depression » Chairman_MAO, posted by europerep on October 22, 2011, at 7:19:07
> They can have their careers destroyed regardless of whether they can rationally explain in front of an investigative panel the reasons for giving buprenorphine to TRD patients.Yes, that is a huge problem and I reject the legitimacy of such panels.
>
> > It is very much like prescribing morphine or heroin.
>
> Not according to the people who have done research on this for years and years. I trust them more than internet people.
>
> > Risk to who? Overdose is difficult; TCAs are more dangerous.
>
> Ever heard of that pesky addiction thing? Buprenorphine is a drug with abuse potential, like all other opiates. (The hypocrisy about giving Adderall to anyone with ADHD but not giving buprenorphine to TRD patients is a different story.) I agree that a risk-benefit assessment for bupe in TRD can be positive, but buprenorphine is not Prozac.
>
>You are so snarky I really don't know how to respond. "Abuse potential"? You mean something that someone wants to take? No, buprenorphine is not Prozac. It is a much better drug with greater efficacy which has not been documented to induce dysphoric mania leading to suicides.
Addiction? A vast majority of people that take narcotics do not develop an "addiction"--which in and of itself is a value judgement.
Posted by Chairman_MAO on October 24, 2011, at 21:01:29
In reply to Re: opiates and major depression » europerep, posted by Chairman_MAO on October 24, 2011, at 20:55:46
>
> (The hypocrisy about giving Adderall to anyone with ADHD but not giving buprenorphine to TRD patients is a different story.)Actually, it's the same exact story. What about giving dextroamphetamine to someone with TRD? Everyone has a right to drugs, period.
Posted by europerep on October 25, 2011, at 12:31:38
In reply to Re: opiates and major depression » europerep, posted by Chairman_MAO on October 24, 2011, at 20:55:46
> You are so snarky I really don't know how to respond. "Abuse potential"? You mean something that someone wants to take? No, buprenorphine is not Prozac. It is a much better drug with greater efficacy which has not been documented to induce dysphoric mania leading to suicides.
Can you present any evidence for buprenorphine not having potentially severe side effects in psychiatric patients? I doubt it.
> Addiction? A vast majority of people that take narcotics do not develop an "addiction"--which in and of itself is a value judgement.
Addiction is a quite valid concept, and concern over it is absolutely warranted. Your "vast majority of people" is pretty vague by the way.
> Everyone has a right to drugs, period.
That's a valid opinion, however, there is this thing called "reality". In reality, you need good reasons for giving opioids to patients (including pain patients). That too is warranted.
I'm not sure whether we're not talking past each other. I have tried both buprenorphine and more "typical" opioids for my TRD, and I am thankful for the open-mindedness of my doctor who prescribed me the latter (the buprenorphine thing was a little more complicated, but that's not relevant here). So I totally think these substances have a place in psychiatry. However, *precisely because* they have a place in psychiatry, they should be used with care. Nothing is worse than a legislative backlash after some ill-informed journalist writes an article about opioid prescribing behaviors, which then makes the situation even worse for those patients in need of these drugs.
Posted by floatingbridge on October 27, 2011, at 9:29:14
In reply to Re: Looking into this » floatingbridge, posted by sigismund on October 24, 2011, at 14:48:43
>Rehmannia is Chinese and may possibly have something to do with endogenous steroid production. At any rate it is used for adrenal insufficiency (I think) and autoimmune diseases and fibro. I was told that Tian Wang Bu Xin Wan (of which it is an ingredient) would extend my life, which I took to be their polite way of saying they didn't like my chances at that point.
This is a formula I think they always give me. I need to go back. I also need to see my osteopath. He is amazing. And he only does soft tissue manipulation. He doesn't sell anything. I appreciate that. The psyiatrist who was alarmed because I said tramadol had a nice mood effect tried selling me all sorts of sh*t.
Btw, I entered (anonymously) the database for suboxone treatment. I said for fibromyalgia and that I was not taking any opoids or narcotics. I get these email messages from doctors that say things like, I have read your application and would be happy to help you with your dependency issues. It's very silly.
Posted by sigismund on October 27, 2011, at 10:20:05
In reply to Looked into this » sigismund, posted by floatingbridge on October 27, 2011, at 9:29:14
You'd have to be careful they didn't want to whack you onto a high dose.
Posted by europerep on October 27, 2011, at 10:33:41
In reply to Re: Looked into this » floatingbridge, posted by sigismund on October 27, 2011, at 10:20:05
> You'd have to be careful they didn't want to whack you onto a high dose.
Good point. In fact, even the 2mg Subutex are actually designated for opiate replacement therapy. Buprenorphine against pain starts at 0.2mg (Temgesic), and there is also an 0.4mg formulation (Temgesic forte). This is over here at least. Buprenorphine for depression can be a little higher than that, but for some people a dose around 1 mg is perfect. The Subutex 2mg can be split though, so they may be of use nonetheless.
Posted by floatingbridge on October 27, 2011, at 11:47:56
In reply to Re: Looked into this » sigismund, posted by europerep on October 27, 2011, at 10:33:41
As I read, I noticed that. I thought a 2mg starting dose would have some severe side-effects for me.
I have run into that name Temgesic here, so the States must have it.
The entire thing is on hold. I'm lucky to get gabapentin for pain at this point.
I have read two things. The first is there is supposed to be no escalation. The second, which I am not sure is true, it that I read instead of sensitizing the opoid receptors the active ingredient gives them a rest, or as one person put it, 'helps heal them'. I find this a little too good to be true myself.
Obviously, I don't know the scientific terms of this discussion....
Posted by sigismund on October 27, 2011, at 21:27:33
In reply to Re: Looked into this » europerep, posted by floatingbridge on October 27, 2011, at 11:47:56
> I read instead of sensitizing the opoid receptors the active ingredient gives them a rest, or as one person put it, 'helps heal them'. I find this a little too good to be true myself.
Just more ideology. What is the score? I forget. It is a partial agonist, an inverse antagonist or what? Anyway, after a certain point, the more you take the less it works. So the mu opiate recptors can't be maxed out, if that is what is meant.
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