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Dr. Bob is Robert Hsiung, MD,
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Posted by paxvox on October 18, 2001, at 16:26:21
In reply to opiates and major depression, posted by androog on October 16, 2001, at 16:49:58
Ultram is not an opiate, actually. It does show affinity, and does bind with opiate receptors. It behaves very much like an opioid, even to the extent of cravings and physical and psychological dependence. I guess it is similar to meds like Wellbutrin, that while not true stimulants like the amphetamines, present with very similar characteristics. Ultram is not an FDA controlled substance.
NOW, to try to answer your question. Yes, I believe some people respond paradoxically to the sedative effects of opiates and their cousins. Personally, I have this type of reaction. The long-term use of opiates as AD med treatment would probably not be found in too many mainline docs. However, some docs will try certain meds if nothing else helps. I would think, however, that chronic opiate use would quickly lead to tolerance, and addiction that ultimately would kill you (or make you wish you were dead). Perhaps this is why heroin is so popular? I clearly have not given you a very scientifically sound answer, but a subjective one. Take from it what you will.
PAX
Posted by androog on October 18, 2001, at 18:33:01
In reply to Re: opiates and major depression » androog, posted by Elizabeth on October 16, 2001, at 18:33:46
Hi Elizabeth, and everyone else who has been kind enough to respond to my original posting-
Elizabeth had asked what drugs I had been on in the past that were related to my depression. Here they are (or at least the ones I have documentation for):
Klonopin, Risperdal, Zoloft, Revia, Lamactal, Serzone, Zyprexa, Celexa, Imipramine, Nortriptyline, Pamelor, Prozac, Buspar, Remeron, Wellbutrin, Sinequan, Effexor, Nardil (that one landed me in the emergency room hooked up to an EKG and eating nitroglycerine).
As is often the case, my depression brings with it much anxiety. That's why some of the names on this list are not strictly antidepressants.
It's interesting to note that I actually was taking Ultram as prescribed by my previous psychiatrist in Indiana. I had forgotten that, as I have forgotten many things, due to the ECT. My wife, however, had obtained a complete list of my medical records going back many years, and the evaluation of the psychiatrist who had me on Ultram was that I was responding favorably to it.
Today I tried contacting a number of doctors to see if they could help me out. I said to their representative (I never did talk to an actual doctor) that I would like to know if prescribing Ultram for the treatment of depression was an option before I spent $150 to find out it was not. Only one rep said that her doctor would likely think of doing it, but I'd have to plunk down $345 to see if I qualified. I can certainly understand having to pay for an office visit, but yikes! I don't even have health insurance!
I'll let those of you who are interested in my situation know of any developments, and I thank you for the constructive advice.
P.S. To Elizabeth:
I would NEVER recommend ECT as a treatment for anything. I keep telling my current doc that I wish I'd never had it done because I can't remember so many things. He said there was nothing else to do given the severity of my depression, and that it helps thousands of people. This may be so, but here is just a partial list of things I don't recall (as related to me by my wife):
-My wedding
-My honeymoon
-Selling my house in Indiana
-Moving to Chicago
-Gutting & re-habbing our kitchen and many other rooms in the house
-The names and faces of our neighbors who say "Hello, Peter (my real name) to me.
-Two visits from my dad after moving here
-Several visits from friends from out-of-state
-All sorts of furniture we have around the house
-How to get the keys out of my ignition (a friend has since shown me how to do that.)One last thing that's somewhat humorous: My wife and I were recently in the grocery store. I was in the candy aisle, as usual, when I ran into a face I knew that I'd encountered in the past, but couldn't even remotely recall. He didn't see me, so I scrambled out of his view, coward that I am. I found my wife, pointed out this man, and said "Who is that guy and why am I so scared of him?" She replied, "That's the doctor who gave you the ECT."
Nuff said.
PPS to Elizabeth-
May I ask where you get the Buprenorphine from? Do you have to inject it? I read that it's an opiate agonist/antagonist which sounds contradictory to me.
Posted by judy1 on October 18, 2001, at 20:10:15
In reply to Re: opiates and major depression » judy1, posted by Neal on October 18, 2001, at 1:12:27
Hi Neal,
I wish I could give you a name, my shrink who is affiliated with UCLA told me this. There is a mood disorders clinic there (I have bipolar disorder) that you can call- best of luck and let me know how it goes- Judy
Posted by Peter S. on October 18, 2001, at 20:58:19
In reply to Re: opiates and major depression, posted by androog on October 18, 2001, at 18:33:01
Hi Androog,
Just wondering what your current regimen is: how much Ultram are you taking per day and how many times per day? How long have you been taking it? Have you noticed any sign of tolerance-have you had to increase the dose?
Thanks!
Peter
> Hi Elizabeth, and everyone else who has been kind enough to respond to my original posting-
>
> Elizabeth had asked what drugs I had been on in the past that were related to my depression. Here they are (or at least the ones I have documentation for):
>
> Klonopin, Risperdal, Zoloft, Revia, Lamactal, Serzone, Zyprexa, Celexa, Imipramine, Nortriptyline, Pamelor, Prozac, Buspar, Remeron, Wellbutrin, Sinequan, Effexor, Nardil (that one landed me in the emergency room hooked up to an EKG and eating nitroglycerine).
>
> As is often the case, my depression brings with it much anxiety. That's why some of the names on this list are not strictly antidepressants.
>
> It's interesting to note that I actually was taking Ultram as prescribed by my previous psychiatrist in Indiana. I had forgotten that, as I have forgotten many things, due to the ECT. My wife, however, had obtained a complete list of my medical records going back many years, and the evaluation of the psychiatrist who had me on Ultram was that I was responding favorably to it.
>
> Today I tried contacting a number of doctors to see if they could help me out. I said to their representative (I never did talk to an actual doctor) that I would like to know if prescribing Ultram for the treatment of depression was an option before I spent $150 to find out it was not. Only one rep said that her doctor would likely think of doing it, but I'd have to plunk down $345 to see if I qualified. I can certainly understand having to pay for an office visit, but yikes! I don't even have health insurance!
>
> I'll let those of you who are interested in my situation know of any developments, and I thank you for the constructive advice.
>
> P.S. To Elizabeth:
> I would NEVER recommend ECT as a treatment for anything. I keep telling my current doc that I wish I'd never had it done because I can't remember so many things. He said there was nothing else to do given the severity of my depression, and that it helps thousands of people. This may be so, but here is just a partial list of things I don't recall (as related to me by my wife):
> -My wedding
> -My honeymoon
> -Selling my house in Indiana
> -Moving to Chicago
> -Gutting & re-habbing our kitchen and many other rooms in the house
> -The names and faces of our neighbors who say "Hello, Peter (my real name) to me.
> -Two visits from my dad after moving here
> -Several visits from friends from out-of-state
> -All sorts of furniture we have around the house
> -How to get the keys out of my ignition (a friend has since shown me how to do that.)
>
> One last thing that's somewhat humorous: My wife and I were recently in the grocery store. I was in the candy aisle, as usual, when I ran into a face I knew that I'd encountered in the past, but couldn't even remotely recall. He didn't see me, so I scrambled out of his view, coward that I am. I found my wife, pointed out this man, and said "Who is that guy and why am I so scared of him?" She replied, "That's the doctor who gave you the ECT."
>
> Nuff said.
>
> PPS to Elizabeth-
> May I ask where you get the Buprenorphine from? Do you have to inject it? I read that it's an opiate agonist/antagonist which sounds contradictory to me.
Posted by Elizabeth on October 19, 2001, at 12:44:17
In reply to Re: opiates and major depression, posted by JohnL on October 18, 2001, at 2:27:48
> ... I went and did some research on Ultram. As it turns out, it is a lot more than just an opiate. It apparently is similar to Effexor, in that it inhibits the reuptake of serotonin and norepinephrine.
Ultram isn't really much of a monoamine reuptake inhibitor at safe/accepted doses. It's basically just a weak opioid that has been plugged as something "different." (Don't tell the FDA.)
> There were a surprising number of cases of serotonin syndrome when patients combined antidepressants with Ultram.
Also true of Demerol.
> I saw one study where a patient with refractory major depression was treated successfully with Ultram monotherapy.
It can also help with OCD and social phobia.
> Simply tell a potential doctor that you are experiencing success with Ultram and that all you need is someone who will provide maintenance prescriptions and monitoring of progress.
Frankly, I think it'd be better to say that you had Ultram for pain once and it really helped improve your mood, and leave out the part about self-medicating (which would most likely get you labelled an "abuser").
-elizabeth
Posted by Elizabeth on October 19, 2001, at 12:50:37
In reply to Re: opiates and major depression » androog, posted by paxvox on October 18, 2001, at 16:26:21
> Ultram is not an opiate, actually.
"Opioid" is the correct term, technically -- it's neither a natural constituent of opium nor a semisynthetic derivative of one.
> Ultram is not an FDA controlled substance.
Yet.
> I would think, however, that chronic opiate use would quickly lead to tolerance, and addiction that ultimately would kill you (or make you wish you were dead).
There have been a number of case reports of people taking opioids for depression, social anxiety, etc., *without becoming tolerant*. This is after long-term use. (I haven't had problems with tolerance, myself.)
Also: people develop tolerance to the respiratory depression from opioids *before* they become tolerant to the mood elevating effects, so it is possible to continue increasing the dose of an opioid agonist without dying from respiratory depression. Some opioids, such as Demerol and Ultram, can cause seizures which would probably become a problem (a potentially lethal one) at higher doses.
-elizabeth
Posted by Elizabeth on October 19, 2001, at 13:06:26
In reply to Re: opiates and major depression, posted by androog on October 18, 2001, at 18:33:01
> Klonopin, Risperdal, Zoloft, Revia, Lamactal, Serzone, Zyprexa, Celexa, Imipramine, Nortriptyline, Pamelor, Prozac, Buspar, Remeron, Wellbutrin, Sinequan, Effexor, Nardil (that one landed me in the emergency room hooked up to an EKG and eating nitroglycerine).
Some remarks and questions:
What did Revia do to you, and why did you think to try that one?
Nortriptyline is the generic name of Pamelor.
I notice that Effexor isn't on your list.
How long were you taking the Nardil, and was the hypertensive (?) reaction linked to a food or drug interaction?
> It's interesting to note that I actually was taking Ultram as prescribed by my previous psychiatrist in Indiana.
If it's been prescribed by a previous pdoc and you can get him/her to endorse it, a new doc will be much more open to prescribing it than they would otherwise. Do you still have that doctor's phone number?
I sympathize with your frustration in trying to find a doctor. I'm temporarily living somewhere I don't plan to stay, and I'm having a terrible time just finding a doctor who's willing to speak to me (*not* through a secretary). The best I've been able to do so far was speaking to a nurse.
> I would NEVER recommend ECT as a treatment for anything. I keep telling my current doc that I wish I'd never had it done because I can't remember so many things. He said there was nothing else to do given the severity of my depression,
Obviously, he was lying. Jeez. I'm really sorry about all your memory problems (although that one about the car keys is kind of amusing).
> One last thing that's somewhat humorous: My wife and I were recently in the grocery store. I was in the candy aisle, as usual, when I ran into a face I knew that I'd encountered in the past, but couldn't even remotely recall. He didn't see me, so I scrambled out of his view, coward that I am. I found my wife, pointed out this man, and said "Who is that guy and why am I so scared of him?" She replied, "That's the doctor who gave you the ECT."
*chuckle* That's pretty funny!
> May I ask where you get the Buprenorphine from?
Eckerd's, usually.
> Do you have to inject it?
You can take it that way. The formulation available in the USA is intended for IV or deep IM injection. It's not very effective orally. I take it intranasally. Since it's not an aerosol, I have to lie down hyperextending my neck in order for it to be absorbed adequately through this route. The dose I take is probably about the same as I would need if I were using it IM. It can also be used sublingually, but I think the dose required would probably be greater.
I don't know if there's a problem with having frequent IM injections over a long period of time (frequent IV use is definitely problematic!) but that might be feasible too.
> I read that it's an opiate agonist/antagonist which sounds contradictory to me.
It's really a partial agonist: it has limited intrinsic activity, so past a certain dose it has no more effect and can act as an antagonist, preventing full agonists from having any effect, too.
-elizabeth
Posted by androog on October 19, 2001, at 23:26:35
In reply to Re: opiates and major depression, posted by Peter S. on October 18, 2001, at 20:58:19
Hi Peter,
Initially I started with the normal dose of 4oomg per day. I have taken four times that much in a day and it didn't seem to make much of a difference one way or the other in terms of my level of depression.
I really should mention that I am non-practicing alcoholic who stopped drinking in 1985. I hate the term "recovering alcoholic" because it implies that an alcoholic will one day be free of the disease, which I don't think ever happens, otherwise I'd've figured out how to swing that a loooong time ago.
When I was in the middle of my ECT treatments this past February, I started drinking again. This is something I never thought I'd do because I have absolutely no doubt that alcohol is something I have no control over. I don't even remember any of the drinking, but according to my wife I was going at it pretty hard. I somehow managed to quit again, but don't really remember that, either. I can't stress how much the ECT affected my memory. Well, that and the booze. It's kind of interesting that I'd show up at the hospital legally drunk, and they'd go through with the ECT regardless. Especially since they start you off with an IV of valium. Sounds like fun. Wish I could remember it.
Anyway, I think the point I'm trying to make is that I'm an addictive person prone to substance abuse. It's not surprising to me that I was taking far more tramadol than I needed. When it gets right down to it I need about 800mg, or twice the recommended amount, daily to maintain an even keel. I should repeat that I told nobody but my wife that I was taking the tramadol (kind of a blind taste test), and all I heard from family and friends was how good it was to see me back to my old self. I guess what I'm getting is that i haven't become some drooling, nodding out junkie. Just a motivated and happier one.
There's no doubt in my mind that my depression is at the root of my substance abuse, not the other way around. It's just a guess, but I'd say a good majority of substance abusers are suffering from some form of depression. I further believe that the reason we abuse certain substances is that we're trying to make up for something lacking in our brain chemistry - something that occurs naturally in others. I know all the talk is about serotonin, but I'd bet the house that what we substance abusers are lacking in are endorphins.
Anyway, I just got a call back from the one doc I'd called earlier who sounded as though he might be willing to give the tramadol a try. In his return call he said he couldn't find enough evidence to back up my claim that opiates have been successfully used in the treatment of depression. I found this odd because it took me only a few minutes on the internet to find a study conducted by the Harvard School of Medicine that supported my claim.
If anybody out there knows of any respectable websites whose findings are pro-opiate in the treatment of major depression, please let me know. I know way down deep that I'm right, at least to some degree, on this one. Of course, I've said that before and been wrong, but hey: you can't blame a feller for trying.
Thanks much,
Androog
Posted by Neal on October 20, 2001, at 0:49:52
In reply to Re: opiates and major depression, posted by androog on October 18, 2001, at 18:33:01
> It's interesting to note that I actually was taking Ultram as prescribed by my previous psychiatrist in Indiana. I had forgotten that, as I have forgotten many things, due to the ECT.Couldn't you go back to this pdoc? Isn't Indiana fairly close to Chicago?
-Neal
Posted by Peter S. on October 20, 2001, at 16:48:31
In reply to Re: opiates and major depression, posted by androog on October 19, 2001, at 23:26:35
> Hi Peter,
>
> Initially I started with the normal dose of 4oomg per day. I have taken four times that much in a day and it didn't seem to make much of a difference one way or the other in terms of my level of depression.
>
> I really should mention that I am non-practicing alcoholic who stopped drinking in 1985. I hate the term "recovering alcoholic" because it implies that an alcoholic will one day be free of the disease, which I don't think ever happens, otherwise I'd've figured out how to swing that a loooong time ago.
>
> When I was in the middle of my ECT treatments this past February, I started drinking again. This is something I never thought I'd do because I have absolutely no doubt that alcohol is something I have no control over. I don't even remember any of the drinking, but according to my wife I was going at it pretty hard. I somehow managed to quit again, but don't really remember that, either. I can't stress how much the ECT affected my memory. Well, that and the booze. It's kind of interesting that I'd show up at the hospital legally drunk, and they'd go through with the ECT regardless. Especially since they start you off with an IV of valium. Sounds like fun. Wish I could remember it.
>
> Anyway, I think the point I'm trying to make is that I'm an addictive person prone to substance abuse. It's not surprising to me that I was taking far more tramadol than I needed. When it gets right down to it I need about 800mg, or twice the recommended amount, daily to maintain an even keel. I should repeat that I told nobody but my wife that I was taking the tramadol (kind of a blind taste test), and all I heard from family and friends was how good it was to see me back to my old self. I guess what I'm getting is that i haven't become some drooling, nodding out junkie. Just a motivated and happier one.
>
> There's no doubt in my mind that my depression is at the root of my substance abuse, not the other way around. It's just a guess, but I'd say a good majority of substance abusers are suffering from some form of depression. I further believe that the reason we abuse certain substances is that we're trying to make up for something lacking in our brain chemistry - something that occurs naturally in others. I know all the talk is about serotonin, but I'd bet the house that what we substance abusers are lacking in are endorphins.
>
> Anyway, I just got a call back from the one doc I'd called earlier who sounded as though he might be willing to give the tramadol a try. In his return call he said he couldn't find enough evidence to back up my claim that opiates have been successfully used in the treatment of depression. I found this odd because it took me only a few minutes on the internet to find a study conducted by the Harvard School of Medicine that supported my claim.
>
> If anybody out there knows of any respectable websites whose findings are pro-opiate in the treatment of major depression, please let me know. I know way down deep that I'm right, at least to some degree, on this one. Of course, I've said that before and been wrong, but hey: you can't blame a feller for trying.
>
> Thanks much,
> Androog
Posted by Elizabeth on October 22, 2001, at 11:43:48
In reply to Re: opiates and major depression, posted by androog on October 19, 2001, at 23:26:35
> It's just a guess, but I'd say a good majority of substance abusers are suffering from some form of depression.
Me too; depression or anxiety, anyway. A *lot* of opioid addicts have major social anxiety, which I very much identify with. One guy said that when he's around lots of people, he feels like they look like gargoyles. And I knew what he meant (although he said it much more concisely and more clearly than I ever could).
> I know all the talk is about serotonin, but I'd bet the house that what we substance abusers are lacking in are endorphins.
I suspect it's a little more complicated than that, but yes, the endogenous opioid system is undoubtably involved in our problems. (I'm not an addict, but I think that my troubles aren't all that different from those of many -- most? -- opioid addicts, and perhaps alcoholics too.)
> Anyway, I just got a call back from the one doc I'd called earlier who sounded as though he might be willing to give the tramadol a try. In his return call he said he couldn't find enough evidence to back up my claim that opiates have been successfully used in the treatment of depression. I found this odd because it took me only a few minutes on the internet to find a study conducted by the Harvard School of Medicine that supported my claim.
A lot of the research on the subject seems to come out of Harvard, yes. Take a look at http://www.hmcnet.harvard.edu/psych/redbook/15.htm
Here are some other sites and cites:
http://www.addict.f2s.com/medarticlemenu.html
"An Addict's View -- Medical Articles." Great site. A selection of research (basic and clinical) articles relating to opioids and psych disorders.Stoll AL, Rueter S. Treatment augmentation with opiates in severe and refractory major depression. Am J Psychiatry. 1999 Dec;156(12):2017.
A clinical case series in which oxycodone and (get this) oxymorphone were used successfully as antidepressants for patients who hadn't responded to conventional treatments.Bodkin JA, Zornberg GL, Lukas SE, Cole JO. Buprenorphine treatment of refractory depression.
J Clin Psychopharmacol. 1995 Feb;15(1):49-57.
Another case series, this one using buprenorphine. You can read this one on the web: http://balder.prohosting.com/~adhpage/bupe.htmlCallaway E. Buprenorphine for depression: the un-adoptable orphan. Biol Psychiatry. 1996 Jun 15;39(12):989-90.
And here's some stuff on Ultram (some pro, some anti):
Shapira NA, Verduin ML, DeGraw JD. Treatment of refractory major depression with tramadol monotherapy. J Clin Psychiatry. 2001 Mar;62(3):205-6.
Goldsmith TB, Shapira NA, Keck PE Jr. Rapid remission of OCD with tramadol hydrochloride. Am J Psychiatry. 1999 Apr;156(4):660-1.
Spencer C. The efficacy of intramuscular tramadol as a rapid-onset antidepressant. Aust N Z J Psychiatry. 2000 Dec;34(6):1032-3.
Halfpenny DM, Callado LF, Stamford JA. Is tramadol an antidepressant? Br J Anaesth. 1999 Mar;82(3):480-1.
Markowitz JS, Patrick KS. Venlafaxine-tramadol similarities. Med Hypotheses. 1998 Aug;51(2):167-8.
Rojas-Corrales MO, Gibert-Rahola J, Mico JA. Tramadol induces antidepressant-type effects in mice. Life Sci. 1998;63(12):PL175-80.
I know there's been an article or letter somewhere that describes a case of Ultram treatment of social phobia (it might be the OCD one).
HTH
-elizabeth
Posted by androog on October 24, 2001, at 21:17:42
In reply to Re: opiates and major depression » androog, posted by Elizabeth on October 22, 2001, at 11:43:48
hi folks,
well it's been an interesting week. the pdoc who said he couldn't find enough evidence supporting my claim that ultram really eased my depression, referred me to another doc he thought might be more willing to go out on a ledge. I called this doc, but he charged $500 just to walk in the door and, of course, said he couldn't guarantee he'd try me on anything like ultram.
i got on the internet and went to my walgreen's account and discovered that prior to january 2001, two pdocs had prescribed ultram for me. this was before i had ECT and i had no recollection of it. one of the two who had previously prescribed it for me was a referral that i had gotten from my current pdoc (doc 1). i don't know if i mentioned it before, but doc 1 is strictly by-the-book, and very methodical. i had asked him about ultram numerous times before, but my request fell upon deaf ears.
anyway, i called the doc (doc 2) who had prescribed the full dose of 400mg in the past, and asked if he could give it another try, this time in conjunction with my current anti-depressants. he didn't want to go around doc 1 and suggested i give doc 1 another try and if there were any problems, to have doc 1 call him, doc 2.
confused yet? i'm not done.
i called doc 1, told him of the conversation i had had with doc 2, and much to my surprise, doc 1 said he had recently come across evidence supporting my claims about ultram.
exonerated at last! maybe.
doc 1 won't prescribe any ultram for me without my first coming in to see him. this guy has no clue as to how awful major depression is. if i had a broken leg, would he have me come in to see him in a month (that's when his next opening is)? i don't think so. i find that very few people who have never had it can appreciate the full intensity of major depression. they seem to think it's sadness, and will just eventually go away of its own accord. i think of it as being handcuffed 24 hrs a day to a terrorist. the terrorist is the voice in my head that keeps saying, "i ain't going anywhere, so you might as well just kill yourself. it'll only get worse, and anyone you tell this to will be incapable of understanding the seriousness of this threat. so just do it."
well, i've managed to get an appointment with doc 1 tomorrow by explaining the whole predicament to his very-understanding receptionist. won't he be surprised to see me so soon? he looks at the floor a lot when i talk about stuff that he's not comfortable with, such as my depression.
i'll let you all know the results of tomorrow's appointment. i'm not giving it a lot of hope. i can already see him giving me a script for 100mg a day, which just doesn't cut it. i know - i've tried. it'll take at least the full 400mg to get me back to the point where i can finally start making a living again. and, after awhile, it'll take more than that. tolerance to this type of medication is inevitable, so i'm going to keep trying to get my tramadol (ultram) overseas. it's a lot cheaper, is every bit as effective, and doesn't leave me dependent on someone who doesn't have a clue, other than an intellectual one, to the severity and relentlessness of this beast. book knowledge, yes. street smarts, no.
also, i'm going to try to get out from underneath doc 1 and start seeing doc 2 instead. it's a political quagmire since they know each other, but i think doc 2 is more tuned-in to the nastiness of major depression
thanks once again for hearing me out. i know that my whining to my wife about this eventually just starts to get her down. she's stood by me throughout this ordeal and has helped me immensely. but after awhile even the strongest of people get tired of hearing about all of this negativity. that's where a dicussion group like this can really help. thanks to you, too, dr. bob for providing this forum.
i look forward to the day when i can shutup and get back to the things i once enjoyed. and at this point, i have no qualms whatsoever about being dependent on drugs to get me there.
best of luck to all of you,
androog
Posted by Kristi on October 27, 2001, at 20:35:10
In reply to Re: opiates and major depression, posted by androog on October 24, 2001, at 21:17:42
Hi,
I'm curious how your appt. went. Did you get a prescription? Of more than 100 mg???I take Ultram myself, for pain... never really realized it was used for depression, but I guess that explains why my depression has been slightly relieved in the past few months.
Take care, Kristi
> hi folks,
>
> well it's been an interesting week. the pdoc who said he couldn't find enough evidence supporting my claim that ultram really eased my depression, referred me to another doc he thought might be more willing to go out on a ledge. I called this doc, but he charged $500 just to walk in the door and, of course, said he couldn't guarantee he'd try me on anything like ultram.
>
> i got on the internet and went to my walgreen's account and discovered that prior to january 2001, two pdocs had prescribed ultram for me. this was before i had ECT and i had no recollection of it. one of the two who had previously prescribed it for me was a referral that i had gotten from my current pdoc (doc 1). i don't know if i mentioned it before, but doc 1 is strictly by-the-book, and very methodical. i had asked him about ultram numerous times before, but my request fell upon deaf ears.
>
> anyway, i called the doc (doc 2) who had prescribed the full dose of 400mg in the past, and asked if he could give it another try, this time in conjunction with my current anti-depressants. he didn't want to go around doc 1 and suggested i give doc 1 another try and if there were any problems, to have doc 1 call him, doc 2.
>
> confused yet? i'm not done.
>
> i called doc 1, told him of the conversation i had had with doc 2, and much to my surprise, doc 1 said he had recently come across evidence supporting my claims about ultram.
>
> exonerated at last! maybe.
>
> doc 1 won't prescribe any ultram for me without my first coming in to see him. this guy has no clue as to how awful major depression is. if i had a broken leg, would he have me come in to see him in a month (that's when his next opening is)? i don't think so. i find that very few people who have never had it can appreciate the full intensity of major depression. they seem to think it's sadness, and will just eventually go away of its own accord. i think of it as being handcuffed 24 hrs a day to a terrorist. the terrorist is the voice in my head that keeps saying, "i ain't going anywhere, so you might as well just kill yourself. it'll only get worse, and anyone you tell this to will be incapable of understanding the seriousness of this threat. so just do it."
>
> well, i've managed to get an appointment with doc 1 tomorrow by explaining the whole predicament to his very-understanding receptionist. won't he be surprised to see me so soon? he looks at the floor a lot when i talk about stuff that he's not comfortable with, such as my depression.
>
> i'll let you all know the results of tomorrow's appointment. i'm not giving it a lot of hope. i can already see him giving me a script for 100mg a day, which just doesn't cut it. i know - i've tried. it'll take at least the full 400mg to get me back to the point where i can finally start making a living again. and, after awhile, it'll take more than that. tolerance to this type of medication is inevitable, so i'm going to keep trying to get my tramadol (ultram) overseas. it's a lot cheaper, is every bit as effective, and doesn't leave me dependent on someone who doesn't have a clue, other than an intellectual one, to the severity and relentlessness of this beast. book knowledge, yes. street smarts, no.
>
> also, i'm going to try to get out from underneath doc 1 and start seeing doc 2 instead. it's a political quagmire since they know each other, but i think doc 2 is more tuned-in to the nastiness of major depression
>
> thanks once again for hearing me out. i know that my whining to my wife about this eventually just starts to get her down. she's stood by me throughout this ordeal and has helped me immensely. but after awhile even the strongest of people get tired of hearing about all of this negativity. that's where a dicussion group like this can really help. thanks to you, too, dr. bob for providing this forum.
>
> i look forward to the day when i can shutup and get back to the things i once enjoyed. and at this point, i have no qualms whatsoever about being dependent on drugs to get me there.
>
> best of luck to all of you,
> androog
Posted by androog on October 28, 2001, at 14:35:18
In reply to opiates and major depression, posted by androog on October 16, 2001, at 16:49:58
Hi All,
My recent trip to my current pdoc did, indeed, yield some results. After rapping me on the knuckles for my "deceit" (not telling him that i was taking ultram on my own) he proceeded to write a script for 400mg of ultram a day. he was very angry that i had been self-medicating. of course, my telling him about my self-medicating would be akin to telling the warden that i had a nice little tunnel from which to escape my impending death sentence.i told him that i had walked the straight and narrow for over 15 years, taking only those medications prescribed to me by a doctor. after shelling out thousands of dollars seeking a solution to my problem with no results, i decided to take matters into my own hands (and will continue to do so). i told him that i felt like i had reached the end of a long corridor and was faced with 2 doors: one marked "suicide", the other "drug dependency". i told him i didn't have to think long before selecting the "drug dependency" door. he didn't care much for my analogy, probably because it only left him with the "suicide" door to recommend.
at any rate, he said he would only write the ultram prescription once a month upon my seeing him, and that there would be no refills. if he found that i was deceiving him in any way, the game was over - he was taking his ball and going home.
this was interesting to me in two ways: 1) he was writing a prescription based on MY recommendation while at the same time chastising me for taking said drug and 2) he was treating me as a common criminal for having a history of substance abuse.
i've found over the years that although major recurring depression and substance abuse have been found to have strong physiological ties, many doctors acknowledge this only superficially. inwardly they harbor the same antiquated images of a bowery bum as do many other unenlightened people.
having had a substance abuse problem for many years, i've given a lot of thought as to what might be the best course of treatment. not once has a doctor asked me what makes my natural state of conciousness so awful that i need to self-medicate. and that's basically what it gets down to. address that problem and the rest will likely take care of itself. the catch is, at least in my case, that treatment would involve the use of opiates, and that doesn't sit well with most docs. i have tried countless antidepressants over the years to no avail. opiates work almost immediately on me and leave me perfectly capable of going about my everday duties. i've tried opiates in the past without telling anyone, and have received only positive feedback concerning my ability to get things done, to socialize and to have a pleasant, sunny disposition. i don't stagger, nod out, drool, dress only in black and come out at night, or any of the other pre-conceived notions of how a drug addict behaves. there's a reason we have opiate receptors.
it is SO frustrating to me to know that there is something out there that will free me, but that our society has placed such powerful sanctions against it that one needs to become a criminal to obtain it. why should society care what i put in my body? we can place liquor. tobacco and double cheeseburgers with fries into our systems anytime we want, and well we should. but when it comes to opiates the attitude is stick 'em in prison or refer 'em to another doc.
Kristi, if taking 100mg of ultram a day relieves your depression slightly, i'd guess that 2, 3, or even 4 times that much would almost entirely eradicate it. of course, i'm not a doctor. but i have had more personal experience with the drug than do most docs. additionally there are now studies that back up my layman's hypothesis.
well, i've spewed forth yet another manifesto in defense of the more liberal use of opiates for those who find that their minds and well-being crave it.
best of luck to all who live in the pit of despair.
androog
Posted by Ed O`Flaherty on October 27, 2002, at 16:47:49
In reply to Re: opiates and major depression, posted by androog on October 18, 2001, at 18:33:01
I came across this thread to-day when I was trying to get a report on Stoll`s article on opiates in depression in the American Journal of Psychiatry published in 1999.
Ultram was mentioned in the thread and I wonder is anybody using it.It is an opiate with a reckoned low likelihood of dependence.It is widely use all over the woprld as an analgesic (tramadol),being a bit stronger than ibuprofen.
Posted by androog on October 27, 2002, at 20:04:14
In reply to Re: opiates and major depression, posted by Ed O`Flaherty on October 27, 2002, at 16:47:49
I'm the fellow that posted the initial thread concerning tramadol and depression. I've been taking the tramadol for almost a year and have been greatly helped by it. Why I had to go and do all the research and twist my doctor's arm before he findly relented to prescribing it, I'll never know.
I realize that I'm prosletyzing, but it is inconceivable to me that the stigma of addiction outweighs the likliehood of suicide in the treatment of the severely depressed. That anyone can sit on their high horse and dole out useless drug after useless drug, all the while telling the patient to come back in three to six weeks, is nothing short of malpractice in my book. If I were to go to my doctor with a compound fracture and he gave me a couple of aspirin and told me to be on my way, he would certainly be guilty of negligence. This situation is hardly different. I would expect somebody who was trained in a specialty such as psychiatry would have some sort of clue as to just how dangerous depression can be. I had repeatedly told three different psychiatrists that opiates worked for me, and got the same dull stare every time. Nobody batted an eye when it came to giving me ECT 17 times, often when I was drunk. Nobody cared much when the ECT did nothing for me other than wipe out years of memories ("there was nothing else we could do" i was told). But eyebrows certainly shot up when I brought up the subject of opiates!
It's been about a year since I posted the original thread (seems much longer than that) and I'm happy to say that tramadol has saved my life. I started taking it on my own when nobody would prescribe it for me, and would continue to do so even if I didn't have a valid prescription. My psychiatrist only prescribed it when I asked him for a referral to someone with a more open mind concerning the subject. To this day he shows little interest in it and doesn't even know what dosage it comes in. Why do I continue to go to him? Tramadol, pure and simple. I've long since given up the notion of anybody in the business (and I mean business) of psychiatry actually being useful (pardon me Dr. Bob). I'm sure there are many out there, but I haven't the time or money to go seeking them out. I pay $150 every month to get a prescription written -- a prescription I had to instruct my shrink to write. In return, I get to stay alive.
That said, I can tell you for a fact that tramadol works for at least one person with refractory depression. I have not built up a toerance to it, the side effects are negligible and increased dosages (yes, i've tried it) only make me dizzy. I would suggest its use for anybody with treatment-resistant depression.
Sorry for spewing forth like this, but as you can see, I'm very bitter about the whole experience. Major depression is a force to be reckoned with and sometimes you have to pull out the big guns to do it. Better sooner than later. Sometimes you only get one chance.
Posted by utopizen on October 27, 2002, at 21:01:58
In reply to Re: opiates and major depression, posted by Ed O`Flaherty on October 27, 2002, at 16:47:49
So, um, was I the only one freaked out after reading Confessions of an Opium Reader?
Posted by Dr. Bob on October 28, 2002, at 8:07:03
In reply to Re: opiates and major depression, posted by utopizen on October 27, 2002, at 21:01:58
> So, um, was I the only one freaked out after reading Confessions of an Opium Reader?
I'd just like to plug the new double double quote feature. But I don't mean to be pushy. Did you deliberately not use it to link to Amazon? If so, I'd be interested in why, over at PBA:
http://www.dr-bob.org/babble/admin/20020918/msgs/7717.html
Thanks,
Bob
Posted by Blah on January 21, 2003, at 10:12:54
In reply to Re: opiates and major depression, posted by androog on October 28, 2001, at 14:35:18
I'm in a similar possition to Androogs. I am 28 and have had depression/dysthymia my entire life (probably have a mix of personality disorder traits too). I started deep psycoanalasys 3 times a week when I was 5. Since high school I have tried: a triciclycate, prozac, serzone, paxil, wellbutrin, rameron, trazidone, zoloft, nardil (an MAOI), effexor, adderal, ritalin, and maybe others as well; I can't remember them all. All of these drugs not only didn't help but made things worse, and I had full trials on most of them (the side effects were just too much, most I stuck it out for 3 months to a year just to find myself deteriorating). Most times a drug doesn't work the frustrated pdocs will blame me for the failier. Once a pdoc said the drug wasn't working because I wasn't execising regularly, I explplained that because of my depression I didn't have the energy to cook meals everyday let alone exercise. Her responce was, "You have to make the energy," truely science at work.
My parents were very emotionaly abusive in weird and a typical ways. I have always had terrible problems concentrating, but have only been critisized for it, even by pdocs and some therapists. I made it through college with few friends, and no one would hire me. I now live on SSI, and my symtems are becoming worse. I haven't had a relationship in over a decade, and even masterbation means nothing to me anymore, just fills me with more hopelessness. I just fired another useless pdoc (a second year resident) who couldn't undersatand that after 23 years of useless treatment I wanted some control. Like most she cared more about her ego than me: "but I'm the Dr. I'm the one with the Phd!" At this point I feel an opioid analgisic is the only thing that will work for me. I'm always dissociating cause everything, EVERYTHING, is so painfull, I also have terrible hypervigulance. To this day I still can't ride a bicycle. I got my father to pay for a mood dissorder specialist. They said on the phone they do rx opiates. I have never done heroin or other hard drugs, I don't drink or smoke, only smoke marijauana occassionaly, and didn't do anything till I was 24; so I have no addiction history unless you want to infantalize me by claiming that using any drug at anytime is addiction, which many pdocs often do. I'll write back later to tell you all how it went.If you write back:
-no mention of ECT. It is a temporary and barbaric practice with perminant damage, and I would sooner commit suicide. Many pdocs and therapist have said it wouldn't work for me anyway.-no mention of other SSRIs I haven't tryed like Celexa. It is obvious this class of drugs is harmful for me, and I see no reason to enter into it again.
Sorry if this sounds rude but I am tired of the same useless advice being doled out by the robots of psychiatry.
-Blah
Posted by BrittPark on January 21, 2003, at 11:14:05
In reply to Re: opiates and major depression, posted by Blah on January 21, 2003, at 10:12:54
I'm sorry you're having a rough time. Before you see your new psychiatrist, do some research on opioids and depression both on the web in general and in the PB archives. The research on opioids for treating depression is sparse but there. The two opioids for which there is some research are buprenorphine and tramadol.
I'm a strong believer in the use of opioids for depression. If it weren't for the spectre of tolerance opioids would be perfect ADs for many people (including me).
Good Luck and Feel Better,
Britt
Posted by androog on January 21, 2003, at 13:29:13
In reply to Re: opiates and major depression, posted by Blah on January 21, 2003, at 10:12:54
Hi All,
Androog here. I wanted to let you know some interesting things about tramadol and how it has worked with my depression. Bear in mind that my memory has some gaping holes in it from the ECT I had done 2 years ago. I still don't retain info very well, so I apologize if I repeat myself in this post.
First, I should mention that I am a recovering alcohoic ( I hate that term -- sounds like I'll recover some day and be able to drink resonsibly). I have also been through the drug ringer with regards to my chemical dependency.
Second, the fact that I have this history of chemical dependence has raised a red flag with every pdoc I have ever seen. They shudder at the thought of giving someone like me a potentially addictive drug. They don't shudder at the mention of suicide, which is apparently preferable to chemical dependence, as is frying your brain with ECT.
That said, I 'm happy to report that in the almost two years that I have been taking tramadol my intake has actually dropped. In fact, I am taking only about half of what I was taking a year ago.
This is interesting to me because addiction usually (always?) involves an increased tolerance of the addictive substance. This has not been my experience with tramadol.I must admit that in the past I have tried taking more tramadol than I really need. Once an addict always an addict. The result of the excessive tramadol intake on me has been negative -- dizziness and disorientation rather than the euphoria I would have expected. This has worked in my favor because I no longer take more than I need. The tramadol seems to have a fail-safe mechanism built into it to foil my addictive tendencies. It's a great relief to me to know that I won't have to keep increasing my dosage -- not because I'm that concerned about addiction, but because of the lack of availability of the tramadol. Addiction can be reversed, suicide cannot.
With regards to Blah's experience with pdocs, I have had the same thing happen over and over. It has become clear to me that the vast majority of those who treat major depression have never experienced it. They say "Take this drug and see me in 3 weeks". This is akin to saying "Take aspirin for 3 weeks and we'll see if that relieves the pain of your compound fracture". It's nothing short of cruelty, but in an ignorant sort of way.
Blah, people like us have to accept the fact that the severity of our disease is something most pdocs only read about. Problem is, words don't begin to describe the horror of major depression, so unless they've experienced it firsthand, they'll only know what they read in a book or hear from their patients. Try describing sight to a person who has been blind since birth. It's not much different than what we go through with our pdocs.
I have no idea, of course, if tramadol will work for everyone. It probably won't. I also don't know what kind of pysical toll, if any, it has taken on my body. Only time will tell.
What I do know is that if it had not been for the tramadol I would probably not be here to write this. I figure I have lived at least a year longer than I would have without it, so any injurious effects I've experienced from it are, in my mind, offset by my increased longevity and quality of life.
I'm not a physician and I 'm operating solely on the basis of my experience, but ignorance coupled with experience is better than ignorance alone, and the treatment I was receiving involved only ignorance.
Blah, don't do something rash while there are still options open to you, even if those options are unorthodox. I never thought I'd feel okay again when I was in the pit of despair, yet here I am writing this post when I should be working ;>)
I know how awful you feel and how scared you can get when you start to believe that suicide is the only answer. Words ring hollow when you're hurting like you must be, but I'll use 'em anyhow. Something will work for you, and your depression is NOT your fault. Call around and see if there is a pdoc in your area that is willing to use tramadol or opiates to treat depression. That's what I did, and I was surprised at the response.
Hang in there, Blah!
Androog
Posted by juanantoniod on January 22, 2003, at 1:27:44
In reply to Re: opiates and major depression » Blah, posted by androog on January 21, 2003, at 13:29:13
Hi, Androog!
I agree with almost everything you've said and been through. I would just like to know if you take your Ultram in divided doses and if so, how often, or in one daily dose?
Best wishes,
Antonio
Posted by djmmm on January 22, 2003, at 8:42:35
In reply to Re: opiates and major depression , posted by juanantoniod on January 22, 2003, at 1:27:44
For what it's worth, tramadol's major pharmalogical effects are mediated through serotonin and norepinephrine reuptake. It only has minor effects on the opioid system. It is very similar to Effexor.
Posted by BrittPark on January 22, 2003, at 11:11:49
In reply to Re: opiates and major depression , posted by djmmm on January 22, 2003, at 8:42:35
> For what it's worth, tramadol's major pharmalogical effects are mediated through serotonin and norepinephrine reuptake. It only has minor effects on the opioid system. It is very similar to Effexor.
IIRC, tramadol's analgesic effect is about 50/50 opioid/catecholamine. In animal studies naloxone reverses about 50% of its analgesic effect.
Tramadol itself binds very poorly to opiate receptors but it 0-desmethyl metabolite binds much more strongly, though still relatively weekly.Now as to its mechanism as an AD it may well be NE/5-HT that's the key. But I'm betting that it is also the opiate receptor activity.
Cheers,
Britt
Posted by androog on January 22, 2003, at 13:37:17
In reply to Re: opiates and major depression , posted by juanantoniod on January 22, 2003, at 1:27:44
Hi Everyone,
I need to correct a statement I made on my last post. In that post I said that I didn't develop a tolerance to tramadol. My wife reminded me that when I first started taking tramadol for my depression about 2 years ago I only needed 150 mg. I DID develop a tolerance to normal doasages of the tramadol. I kept taking more to get the desired effect. When I got up to 800 mg I hit a plateau. That was back in late 2001, and I still respond to that amount. I realize that that is twice the recommended daily dose, but that's what it takes to get me out of my pit, and the pit is somewhere I'm not going to again, if I can help it.
I take an initial dose of 600 mg and then spread the other 200 mg out over the rest of the day.
About 50 minutes after I take the initial dose I start to feel the depression lift.
About 1 hour after I take my first dose, I get a brief feeling of euphoria or something close to it. This lasts perhaps 5-10 minutes, after that I just feel ok -- no euphoria, no depression. I have to wonder if the euphoria part is really just a feeling of normalcy that seems exaggerated because it eradicates the hell of depression so quickly. Or maybe it's the weak opioid mechanism at work. Could be that's why it takes so much to get me there. But that doesn't explain why the same dose every day has the same effect it did over a year-and-a-half ago.
It's certainly possible that a pure opiod would stop my depression with a smaller dose, but the very word "opioid" elicits a knee-jerk response from the docs I mention it to. I'd like to give opioids a go, but I can't find a doc that'll go that route.
One more thing I neglected to mention is that I also take 200 mg of the tricyclic doxepin a day. This alone doesn't do anything, but it probably enhances the effect of the tramadol. I've read that tramadol can increase the serotonin-raising effects of antidepressants.
I think that's it for now.
Take care, and don't give up the ship.
androog
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