![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 16 to 40 of 121. Go back in thread:
Posted by shelliR on November 18, 2001, at 17:26:25
In reply to Re: Morphine for depression. » shelliR, posted by SLS on November 18, 2001, at 12:43:22
> Anyway, I'm interested to know in what ways oxycodone helps you. Does it help with concentration and memory? Does it make it easier for you to read? Does it help you think clearer and smarter? How about energy and level of activity?
>
> Thanks.
>
> I hope methadone does the trick for you.
>
> Take care.
>
>
> - Scott
Hey there. (I bet you hate it when people call you Scottie, but I like it.)< Anyway, I'm interested to know in what ways oxycodone helps you. Does it help with concentration and memory? Does it make it easier for you to read? Does it help you think clearer and smarter? How about energy and level of activity?
The main thing that oxycontin does for me is to take that huge brick of depression out of my chest. It's quite amazing--takes about a hour.Lets see, I haven't read a book since I've been on the stuff, but that has more to do with time than medication. I am still the bright ;-) but very spacey person that I was pre-oxy. It is possible that I am even more spacey, I'm not sure.
Seriously, focusing had not been a problem, transitioning was though. And opiates have not helped or hurt with that, expect that of course it is harder to focus when depressed. I don't think that it has made me "smarter or think clearer."Opiates have always given me a lot of energy, although I still have a bit of a let down in the late afternoon.
I am also taking 400mg wellbutrin, (well, usually I forget 100mg), and 54mg concerta a day, as well as 30mg of nardil. I don't understand why I am on so many drugs, especially so many stimulents. I don't feel any difference with or without the nardil and concerta. You would think I'd have asked my pdoc why and I have, but you wouldn't believe what I have had to tolerate to get my opiate prescription.
I will probably switch to methodone either Tues or Wednesday. I have to admit I'm nervous about the possibility that it won't work. My pdoc takes no calls ever and Thursday is Thanksgiving, so I wouldn't be able to go down and see him if necessary.
If it doesn't work, I'll have to go back to oxy. I'm pretty sure that the oxy people will supply it to me; it will just take some time.
Scott, I truely felt that I had wasted enough time in pain (two years) and the worst that can happen to me is that eventually I'll have to detox. That is not nearly as scarey to me as my depression full force, the horrible med trials that I went through with my last pdoc, and the possibility of ruining my business.
Our types of depression are very different, so I don't think my experience with opiates are all that helpful as a predictor for you. Maybe you should have tried that vicodin--if it made you feel nauseated and wierd, you would probably know it wasn't even worth the debate.
How does you pdoc explain your lack of any enduring response? Has he run into this pattern before? We've definitely run into it with other people on this board. I know it's really hard for you (you've said that) to confront your pdoc, but I think he owes it to you to look into any unconventional treatment that
possibly might help. Can your family be of any help to you in consulting with other doctors or talking to this one?
Take care,
Shelli
Posted by judy1 on November 18, 2001, at 19:25:27
In reply to Re: Morphine for depression. » SLS, posted by shelliR on November 18, 2001, at 17:26:25
Hi Shelli,
My prayers will be with you next week. Do you have a back-up supply of oxy in case there's a problem? Actually I feel optimistic for you, it's a drug my pdoc had considered for me also. I think quite a few of us are hoping this will be a winner. Take care- judy
Posted by paxvox on November 18, 2001, at 20:29:09
In reply to Re: Morphine for depression. » paxvox, posted by shelliR on November 17, 2001, at 20:43:04
Indeed, Shelli, I won't step on your toes. It is just that I have only recently seen cogent discussion of what I had independently concluded from my own experience. My question is, how does one approach their Pdoc about such treatment?
PAX
Posted by shelliR on November 18, 2001, at 20:41:53
In reply to Re: Morphine for depression. » shelliR, posted by judy1 on November 18, 2001, at 19:25:27
> Hi Shelli,
> My prayers will be with you next week. Do you have a back-up supply of oxy in case there's a problem? Actually I feel optimistic for you, it's a drug my pdoc had considered for me also. I think quite a few of us are hoping this will be a winner. Take care- judyHi Judy,
You know, it never occurred to me to have back-up oxy; I'll get a script from my pdoc tomorrow. Thanks for the idea.
It feels strange to have taken oxy for five months now and now overnight switch over to methadone. My doctor did a conversion of how much methodone I would need based on my dose of oxycontin. My guess is that although I would feel more comfortable with an overlap of half oxy/half methadone for the first day, it's not going to fly with him. He's worked with pain meds a lot, so he should know what he's doing. (I hope). I didn't even know that methadone is a pain reliever.
How is your detox going? Are you going to have a Christmas baby, or is that too soon?
Thanks again for the suggestion, and I'll keep everyone up to date.
Shelli
Posted by shelliR on November 18, 2001, at 22:42:34
In reply to Re: Morphine for depression. » shelliR, posted by paxvox on November 18, 2001, at 20:29:09
> Indeed, Shelli, I won't step on your toes. It is just that I have only recently seen cogent discussion of what I had independently concluded from my own experience. My question is, how does one approach their Pdoc about such treatment?
>
> PAXHi Pax,
You're weren't stepping on my toes, but if you look back at some of the threads on opiates then you will understand why I didn't want to go through that again. There were accusations and attacks that those of us investigating narcotics were nothing but addicts in depressive disguise. It was
not a very supportive time on this board.Anyway, you've asked a tough question. I completely lucked out, if you consider lucking out working with a doctor who sees me five minutes, won't return phone calls, and was making me come see him every other day.
I was already using vicodin as an adjunct to my AD premenstrually, then my AD pooped out and nothing else seemed to work. I was then in the position of wanting to use vicodin on a regular basis.
Buprenorpine has the most information on the board and is probably the easiest opiate to get from a doctor (and it still is not easy). It's a partial opiate, has helped several people on the board. Its selling point to pdocs is that there is a very small study study out of the McLean Harvard Group in Boston (It will come up if you do a search on Google, Yahoo, etc.). They are a very respected group within the psychopharmacology community.
So there is a possiblity that armed with some posts from PB on buprenorphine and that study, you may be able to convince a pdoc to try it. Otherwise, the only doctors that I have heard of that are prescribing opiates are in California.I am on the east coast and am very uncomfortable in my position of knowing just one pdoc. He is not easy to get along with and I am always in fear that he'll cut me off if he gets angry at me and decides he doesn't want to work with me. I'm sure he would arrange for detox, but that is not what I'm looking for.
Before I found him, I was going to research pain clinics and ask them if they would consider giving me opiates for pain, because my experience with vicodin was so positive. I don't know what the outcome of that would have been, but potentially they may have been able to hook me up with a psychiatrist that they know or work with.BTW, I have had to go up several times on oxycontin and it is still a question whether my body will finally get to a level and settle in so I don't have to go up and up and up. So there is the real possibility of developing an opiate habit. I guess you would have to decide how bad your depression is to take that chance.
Sorry I can't be of more help, but several people on the board are asking the same question you are and I don't know any real answers. My previous pdoc thought I would end up in the gutter and we terminated over vicodin.
Shelli
Posted by nightlight on November 19, 2001, at 8:05:31
In reply to Re: Morphine for depression. » SLS, posted by shelliR on November 18, 2001, at 17:26:25
Scott wrote:
> Anyway, I'm interested to know in what ways oxycodone helps you. Does it help with concentration and memory? Does it make it easier for you to read? Does it help you think clearer and smarter? How about energy and level of activity?Thanks.
(snipped)From shelli:
Hey there. (I bet you hate it when people call you Scottie, but I like it.Does it heelp you think clearer and smarter? How about energy and level of activity?
>
>
> The main thing that oxycontin does for me is to take that huge brick of depression out of my chest. It's quite amazing--takes about a hour.
>
> Lets see, I haven't read a book since I've been on the stuff, but that has more to do with time than medication. I am still the bright ;-) but very spacey person that I was pre-oxy. It is possible that I am even more spacey, I'm not sure.
> Seriously, focusing had not been a problem, transitioning was though. And opiates have not helped or hurt with that, expect that of course it is harder to focus when depressed. I don't think that it has made me "smarter or think clearer."
>
> Opiates have always given me a lot of energy, although I still have a bit of a let down in the late afternoon.
>
> I am also taking 400mg wellbutrin, (well, usually I forget 100mg), and 54mg concerta a day, as well as 30mg of nardil. I don't understand why I am on so many drugs, especially so many stimulents. I don't feel any difference with or without the nardil and concerta. You would think I'd have asked my pdoc why and I have, but you wouldn't believe what I have had to tolerate to get my opiate prescription.
>
> I will probably switch to methodone either Tues or Wednesday. I have to admit I'm nervous about the possibility that it won't work. My pdoc takes no calls ever and Thursday is Thanksgiving, so I wouldn't be able to go down and see him if necessary.
>
> If it doesn't work, I'll have to go back to oxy. I'm pretty sure that the oxy people will supply it to me; it will just take some time.
>
> Scott, I truely felt that I had wasted enough time in pain (two years) and the worst that can happen to me is that eventually I'll have to detox. That is not nearly as scarey to me as my depression full force, the horrible med trials that I went through with my last pdoc, and the possibility of ruining my business.
>
> Our types of depression are very different, so I don't think my experience with opiates are all that helpful as a predictor for you. Maybe you should have tried that vicodin--if it made you feel nauseated and wierd, you would probably know it wasn't even worth the debate.
>
> How does you pdoc explain your lack of any enduring response? Has he run into this pattern before? We've definitely run into it with other people on this board. I know it's really hard for you (you've said that) to confront your pdoc, but I think he owes it to you to look into any unconventional treatment that
> possibly might help. Can your family be of any help to you in consulting with other doctors or talking to this one?
>
>
> Take care,
> ShelliDear Shelli~
I am following your case w/great interest. (Altho I cd. certainly be fuzzy on some of the details). I have rarely posted, due to (what else?) depression and a chronic pain problem and caretaking a parent who recently passed away. My energy was zilch. But, more pertinently, the only way I have gotten thru the past many years was thru the use of an opiate/barbiturate drug that I was prescribed for chronic pain from a herniated cervical disc.
Ihave known for probably known s/t was wrong w/me for years, but, I tried one pdoc 15 yrs. ago who blew me off as a bored whining do-nothing who didn't know just how 'fine' I was (bullshit!)Your reply to Scott, about the burden of depression, that hooded cape that weighs ten thousand pounds, simply lifting from your shoulders within hours is what I wd. feel. And, I wd. have 10 x's the energy as I did w/o the drug in my system.
But, I couldn't use it daily, supply and side-effect problems. However, knowing that I wd. have a few days (maybe 8-9) that I wanted to rise from my bed helped me 'go on' & keep the faith that I wd. eventually find what was right for me.
I tried many, many antidepressents in the past sev'l years. Had pos. response to Wellbutrin that lasted about 6 days-but, that's it.Stayed on it intermittently, b/c I was afraid I wd. really spiral downward w/o, but, often I was A-D void and just limped along.
I will not give my entire history here, this is mostly to let you know Shelli, that I am rooting for you. I am now on a very low-dose narcotic, 60 mgs. stimulent, 2 mgs. klonopin and apotent muscle relaxer. I dropped the narc/barb drug that had made me feel too dependent and sometimes gave me 'cravings' (or what I interpreted as such).I haave only recently been diagnosed ADD w/endogenous depression, and found 2 wonderful (so far) drs. Stimulents are what I have needed all along, but, couldn't seem to convince docs why (another story).
The good news is, I feel at least 50% better on a daily basis, I am working 3 mornings a week, and I have HOPE, s/t I thought I had lost 3 months ago.
Sounds like you need you need a lot of help balancing your dopamine and endorphins, as do I.
But, it can work, I think.And, methadone is a powerful painkiller, often used in 'drug cocktails' at pain clinics. If you do a search on methadone maintenance treatment or MMT, you'll find info on, not only opiate detox, but, on patients who have remained on meth for years, due to the fact that they believe it alleviates the depresiion that caused them to become opiate habituated in their former lives. Many are quite satisfied w/staying on meth 'forever'.
Anyway, this is long-winded, and I relate strongly to you,Shelli, & Scott, and all the many, many T.R.D. patients out there.
I still suffer from chronic fatigue and rarely post, but, I will try to more often, as this board can be a lifesaver.
I haave recently added Zoloft to my regimen, so, who knows, I may improve more, and I believe I need more 'stimulent' action in my med combo too.Best of luck "transitioning'. I admire u working & dealing w/all this crap on top of it. You are strong and brave, and that is what it takes to be depressed and not give up (SOOOO much easier said than done!!!).
Best of luck~nightlight
p.s. if u don't mind me asking, what is ur daily dosage of oxy now & what will u start with on the methadone? Do u really think ur doc will give u back-up oxy?? He better, it is a holiday weekend, as u said.
p.s.s. Not all opiates/opioids alleviated my depression. Only the one 'combination' drug I mentioned. So, I am very curious about ur new plan. But the Vics helped u,as did the oxy, so that may be a good sign.
Posted by Lorraine on November 19, 2001, at 9:12:48
In reply to Re: Morphine for depression. » Lorraine, posted by shelliR on November 17, 2001, at 19:26:11
Shelli:
> >I've read good things about methodone though. Let's hope it affects you the same as the Oxy. (Isn't it cheaper?--Is that what the med switch is all about:-(
>
> Thanks, I am hoping so hard that it works. It's very very cheap; yes that's what the med change is about. If your doctor and mine are supporting opiates for TRD, it's a good sign that they may be coming to the forefront again.I don't know about forefront, my pdoc is a bit out there generally. He is apparently using Methadone with a patient with good response. He also is using Naltraxone (sp?), an opiate blocker, with another patient, with success. If we go that route (I think it is too early to be there, though), his preference would be for me to try Naltroxone (which I am not wild about because there seems to be little research to support it) and then Methadone. It's nice to know that he is thinking this way (and I have been bringing him in articles from time to time--just because that's what I do generally). He's retesting me today with a QEEG to see if he can detect why I am having these sublevel panic attacks and to see if he can figure out why my meds aren't working. His first testing said that amphetamine and mood stabilizer ought to work. I maintain fairly well on Adderall and Neurontin--of course it's only been 10 days since I stopped the Nardil, so I may not have "fallen off the cliff" into depression yet. I maintained well on Adderall and Neurontin during my Parnate washout as well. Aside from the panic attack stuff, I only seem to be lacking mood support. But I can think and act with just the Adderall and Neurontin. I have more mood lability and I can dip pretty low.
> Is methodone one of the opiates that you are considering? I wish I had more time to read about it.
Do you want me to send you the link to the info that I found?
>
> Let me know your next strategy. Either the adderall and neurotin are keeping you afloat, or you are the most patient person I know. Maybe both.I've never been hospitalized. I hate hospitals (bad experiences when a child) plus I have never been suicidal and I think a lot about the impact of my illness on my children so I don't think I'll go that route (on the other hand, that's easy to say as I don't have suicidal ideations as a symptom--the thing that happens is just that all the lights go out in me and I hybernate, slumped in a chair).
You take care too Shelli. I think that you are on the right track though because you have found a med class that works for you:-)
Lorraine
Posted by SLS on November 19, 2001, at 10:59:55
In reply to Re: Morphine for depression. » SLS, posted by shelliR on November 18, 2001, at 17:26:25
Hi Shelli.
> Hey there. (I bet you hate it when people call you Scottie, but I like
it.)Scottie is OK (if you must) :-), but I'm afraid Scottie Pottie is out.
> The main thing that oxycontin does for me is to take that huge brick of depression out of my chest. It's quite amazing--takes about a hour.
How do you deal with the roller-coaster ride every day? It must be difficult to have your state of being be so immediately tethered to a drug? It's not like taking a regular antidepressant where you can miss a few doses or take it at your convenience without feeling significantly worse. I'd be grateful to take it and have it work, though. It must be emotionally taxing just the same.
> Lets see, I haven't read a book since I've been on the stuff, but that has more to do with time than medication. I am still the bright ;-) but very spacey person that I was pre-oxy.
< smile >
> Seriously, focusing had not been a problem, transitioning was though. And opiates have not helped or hurt with that, expect that of course it is harder to focus when depressed. I don't think that it has made me "smarter or think clearer."
Gosh. I can't even begin to describe what this illness does to me. It's like I'm mentally retarded - only without the ability to experience bliss. When I have experienced brief improvements in my condition, my brain power increased by several orders of magnitude. Actually, it has scared the sh_t out of me. It might not really be such a big deal, but it is still very foreign to me. The last time I had that occur was in January, 1997. I had been taking Parnate for just over a week when I began to respond to it. It lasted for three or four days. Although I was but 50% improved, I could read, learn, and remember. I could figure things out. I remember taking home from my doctor an issue of the American Journal of Psychiatry. I was interested to read an article about the potential for pindolol to accelerate the action of antidepressants. I ended up reading the whole journal in 45 minutes. About the only thing I didn't understand was the statistical stuff. I never took a class in it. Anyway, I have not read a single full-text article since. I have become a proficient skimmer, though.
> Opiates have always given me a lot of energy, although I still have a bit of a let down in the late afternoon.
What is your dosing schedule during the day?
> I will probably switch to methodone either Tues or Wednesday. I have to admit I'm nervous about the possibility that it won't work. My pdoc takes no calls ever and Thursday is Thanksgiving, so I wouldn't be able to go down and see him if necessary.
>
> If it doesn't work, I'll have to go back to oxy. I'm pretty sure that the oxy people will supply it to me; it will just take some time.That's good.
> Scott, I truely felt that I had wasted enough time in pain (two years) and the worst that can happen to me is that eventually I'll have to detox. That is not nearly as scarey to me as my depression full force, the horrible med trials that I went through with my last pdoc, and the possibility of ruining my business.
I can certainly understand your decision. I would do the same thing without much deliberation.
> Our types of depression are very different, so I don't think my experience with opiates are all that helpful as a predictor for you.
I'm glad you pointed this out to me. I guess it's still worth a try, though.
> Maybe you should have tried that vicodin--if it made you feel nauseated and wierd, you would probably know it wasn't even worth the debate.
Actually, I would have had my friend not run out of it before I left. I should have grabbed one right away. I really was interested to see what would happen. It would have provided valuable information. Maybe I should go in for some unecessary surgery.
Do you think nausea or feeling wierd are predictors of non-response? I found something on the Internet that described that most people using methadone for depression begin to experience improvements by the end of the first week. Some took two weeks.
> How does your pdoc explain your lack of any enduring response?
He doesn't. My last two doctors have been reluctant to conjure theories. I think I'll make a point of asking next time.
> Has he run into this pattern before?
You know, I have not asked him this question specifically. I guess I just assumed that he had.
> We've definitely run into it with other people on this board. I know it's really hard for you (you've said that) to confront your pdoc, but I think he owes it to you to look into any unconventional treatment that possibly might help.
At my last visit, I was happy to see that he was somewhat receptive to the possibility that opioids might be worth considering. I mentioned oxycodone and buprenorphine. I didn't know about methadone at the time.
> Can your family be of any help to you in consulting with other doctors or talking to this one?
People in my family have been sympathetic, but not motivated to help me so directly. I have never discouraged it, however. They provided me with transportation during a course of ECT, but that's about it. I guess they have always felt that I am independent enough to take care of things on my own. I'm tired of this whole thing. I know you are familiar with this. I have no motivation to research stuff anymore. Right now, I don't give a damn about the field of medicine anymore. I never thought that would happen. I just want someone to fix me so that I can get a job and find a mate.
Thanks for replying.
- Scott
Posted by mair on November 19, 2001, at 12:24:50
In reply to Re: Morphine for depression. » shelliR, posted by Lorraine on November 19, 2001, at 9:12:48
> Lorraine - excuse my intrusion here but what's a "Qeeg" and what is it supposed to measure?
Thanks
Mair
Posted by Elizabeth on November 19, 2001, at 13:02:38
In reply to Re: Morphine for depression » Elizabeth, posted by shelliR on November 12, 2001, at 22:20:18
> I'm sorry, I got so mixed up. It's methodone he's written the prescription for: methadone 10mg tabs; 4 tabs three times daily.
That's a **lot** of methadone! Then again it might be the right amount, since you do have some tolerance from taking the oxycodone.
> Thanks for responding. It was so good to known you were both around and I appreciate your response.
Sure! I'm often distracted from p-b by other stuff that's going on for me, but I do my best to keep up, especially with people like you who I've gotten to know personally somewhat.
> I'm upset enough to mix up methadone with morphine.
> Have you ever known anyone on that?No, but I bet opioid combinations are often used to control pain for dying patients (cancer, etc.). But methadone binds very tightly to opioid receptors (like buprenorphine, only methadone is a full agonist), and as a result it tends to prevent other opioids from doing anything. (This makes it particularly useful for people with heroin dependence.)
> He'd rather me stay on oxycontin if the company will provide it (and I think I have a good shot because they don't know about my assets.)
I won't tell! < g >
> And I think you are right either way about the bracelet. He said the methodone has to be for pain, so that's what he's written.
That's right -- unlike every other legal drug in clinical use, methadone must be prescribed specifically for pain unless it's given in a methadone maintenance clinic. I suppose you could rationalize your use of it by saying that depression is just emotional pain (and honestly, I don't think that depressive pain and nociceptive pain are all that different). It's weird (since methadone isn't supposed to be much of a high), but it's the most tightly regulated legal drug in the U.S. (again, I mean drugs that are in clinical use).
> Do you know how it works for pain ...
Sure, it's an opioid agonist, like morphine, etc.
> ... and works for withdrawal from heroin?
It's a long-acting synthetic opioid. It's just like switching to Klonopin to wean off Xanax. The withdrawal symptoms don't hit as hard if the drug is longer-acting.
> Thanks again, and sorry I was so off.
No need to apologize. Best wishes to you, as always!
-elizabeth
Posted by Elizabeth on November 19, 2001, at 13:13:29
In reply to Re: Morphine for depression., posted by paxvox on November 17, 2001, at 19:45:29
> OK, I'm dropping into this discussion late, though I have made other posts RE:opiates as mood stabilizers. I have had that effect from opiates. As opposed to the "normal" sedative effects, I actually get a rather smooth lift in mood. I guess one would suggest that is why some people become heroin addicts, though I see that as a more complex issue.
Addicts get f---ed up on heroin -- nodding, general indifference to just about everything, etc. It's usually sedating, if anything.
For me, opioids are stimulating. They don't make me feel indifferent at all; instead they *increase* the range of emotions that I can experience. I don't think that the antidepressant effects I get are the same thing people are experiencing when they get high on opioids (having had the opportunity to observe a few people in the "high" state < g >).
BTW, some of the literature suggests that they do have both AD and mood-stabilizing effects.
> However, I do not know of any main-stream Pdocs that would be handing out scripts for schedule II narcotics as pyschotherapeutic meds.
Buprenorphine isn't C-II, FWIW -- as a partial agonist, it's only C-V. But there certainly are plenty of doctors who have prescribed morphine, oxycodone, etc. as antidepressants for certain patients. Before amphetamine was discovered, opium was the *only* antidepressant.
-elizabeth
Posted by Elizabeth on November 19, 2001, at 16:54:20
In reply to Re: Morphine for depression. » paxvox, posted by shelliR on November 18, 2001, at 22:42:34
> There were accusations and attacks that those of us investigating narcotics were nothing but addicts in depressive disguise. It was
> not a very supportive time on this board.Dr. Bob did intervene, if you recall, and I think that, while the subject is alive and well on p-b, the people who were being abusive have calmed down or stopped posting on the subject.
> Anyway, you've asked a tough question. I completely lucked out, if you consider lucking out working with a doctor who sees me five minutes, won't return phone calls, and was making me come see him every other day.
The question that immediately arises in my mind is: how much does he charge you (per 5-minute session)?
> I was already using vicodin as an adjunct to my AD premenstrually, then my AD pooped out and nothing else seemed to work.
For me, opioids are very hard to use because of their side effects (*very* bad constipation, dry mouth, itching, amenorrhea, etc.) and also because they're so short-acting (well, most of them are, buprenorphine included), which can result in a lot of ups and downs in mood and energy level throughout the day. Although regular ADs by themselves were never adequate for me, I need to take one "in the background" to smooth things out.
A friend has been trying to convince me to try complicated combinations of ADs, but I haven't seen anything that gives me much hope for stuff like that. I'm considering trying Provigil again: the one time I tried it, I was taking Parnate and the combination was too activating, but it did help with my main residual depression symptoms (anhedonia, anergia, dulled concentration). And other than the jitters (nervousness, exaggerated startle response, exacerbation of tremor), I didn't notice any side effects from it. It didn't even cause much of a BP increase with the Parnate, and practically every other stimulant I tried with Parnate did, even in very small doses (like, 1.25 mg of Adderall).
> Buprenorpine has the most information on the board and is probably the easiest opiate to get from a doctor (and it still is not easy).
A problem with buprenorphine that makes it harder to get if you live in the USA is that the only formulation available is a solution for injection. It can be taken intranasally (that's what I do), but it's very inconvenient and the doctor will still have to entrust you with syringes. I got it from a doctor who I'd known for several years, who I'd seen regularly (not just 15 minutes once a month). Because I had always been honest and forthright with him and because he had known be for a long time, I think that he felt certain enough that I was a reliable person and that if I started having any troubles I would let him know about it.
Before making the decision to prescribe it to me, my pdoc spoke about it with Dr. Alexander Bodkin, a researcher at McLean (which is a teaching hospital affiliated with HMS) who he knew from residency. A couple of years earlier, my pdoc had sent me to Dr. Bodkin for a consultation because I was having trouble finding something that would work for me, and buprenorphine had first come up as a possible treatment for me during that session although I didn't try taking it until much later. Dr. Bodkin has quite a bit of familiarity with buprenorphine and its use in the treatment of depression; he was the primary author of a paper reporting the results of a small pilot study. (The paper, in case you're interested, is "Buprenorphine Treatment of Refractory Depression," by Dr. Bodkin, Gwen Zornberg, Scott Lukas, and Jonathan Cole. It was published in the Journal of Clinical Psychopharmacology, vol. 15 no. 1, pp. 49-57. A guy posted it on the web, at http://balder.prohosting.com/~adhpage/bupe.html.)
It probably also helped that my doctor was generally very experienced and had plenty of confidence in his own judgment and skill. He'd been involved in academic medicine for a long time before leaving to focus on his private practice, and he had been in charge of one of the general adult units at McLean, so he was very experienced not just with outpatients but with more severely ill inpatients. He had also already been treating another depressed outpatient with morphine (30 mg five times a day), and that patient had not abused the medication. So my doctor had plenty of firsthand experience that made him feel confident that it would be safe for him to try treating me with buprenorphine.
> Its selling point to pdocs is that there is a very small study study out of the McLean Harvard Group in Boston (It will come up if you do a search on Google, Yahoo, etc.). They are a very respected group within the psychopharmacology community.
(There are a lot of psychiatric research groups at various sites affiliated with Harvard. Take a look at http://www.hmcnet.harvard.edu/psych/redbook/)
This actually isn't much of a selling point to most doctors. If you can convince them to actually *read* the paper, though, they'll learn about some of the advantages buprenorphine has compared with other opioids, and this may convince them it's safe to prescribe. Because buprenorphine is only a partial agonist, there is a ceiling on its intrinsic effect. As a result, you can't get high on it. It's also virtually impossible to kill yourself by ODing on it (a legitimate concern that doctors may have about prescribing opioids to severely depressed patients). The article goes into some detail about the pharmacology of buprenorphine. This information, more than the results of the study, is liable to quell doctors' objections to prescribing buprenorphine as an antidepressant.
(I believe that a lot of the evil in the world arises out of ignorance, so spreading accurate information can be effective in combating evil.)
> I am on the east coast and am very uncomfortable in my position of knowing just one pdoc.
FWIW, I've been able to convince pdocs outside the tight-knit Harvard community (< g >) to prescribe it for me because I was already on it, after talking to the doctor who originally prescribed it (and, in some cases, Dr. Bodkin). Pdocs who might not be willing to *start* you on opioids can often be much more receptive to the idea of *continuing* you on them.
> He is not easy to get along with and I am always in fear that he'll cut me off if he gets angry at me and decides he doesn't want to work with me.
Can you talk to him about this? (Be diplomatic, of course -- like, leave out the part about his difficult personality, or at least try to put a less judgmental spin on it! :-} )
> Before I found him, I was going to research pain clinics and ask them if they would consider giving me opiates for pain, because my experience with vicodin was so positive.
Pain clinics are not all alike, but they have a general reputation for pushing people to agree to a "pain management" program (i.e., no medication -- "management" pretty much rules out "treatment"). Possibly a pain medicine specialist in private practice would be willing to help you, though. I think it would be nice if I could find someone like this to supervise my buprenorphine, because psychiatrists usually have no real experience with chronic opioid therapy.
> BTW, I have had to go up several times on oxycontin and it is still a question whether my body will finally get to a level and settle in so I don't have to go up and up and up. So there is the real possibility of developing an opiate habit. I guess you would have to decide how bad your depression is to take that chance.
I'd be much more worried about the possibility of one day having to "detox" if I were taking oxycodone, personally. Another advantage of buprenorphine is that the withdrawal symptoms are pretty mild, certainly not worse than what I experienced going off MAOIs! In contrast, oxycodone discontinuation could be extremely difficult.
-elizabeth
Posted by Elizabeth on November 19, 2001, at 17:03:56
In reply to Re: Morphine for depression. » shelliR, posted by SLS on November 19, 2001, at 10:59:55
> Do you think nausea or feeling wierd are predictors of non-response?
I know you're not asking me, but I decided to answer anyway. :-} Plenty of people who respond positively to opioids also get side effects. I couldn't start out at a fully-effective dose of buprenorphine (0.3 mg q. 4-6 hours) because it made me vomit. Also, I did feel sort of dizzy and lightheaded when I first started taking it.
> I found something on the Internet that described that most people using methadone for depression begin to experience improvements by the end of the first week. Some took two weeks.
Some feel their depression remitting after only a dose or two.
> At my last visit, I was happy to see that he was somewhat receptive to the possibility that opioids might be worth considering. I mentioned oxycodone and buprenorphine. I didn't know about methadone at the time.
Dr. Andy Stoll (yes, the OmegaBrite guy) published a letter in some journal in which he described a series of cases in which he and a colleague had successfully used oxycodone and oxymorphone to treat depression, including in some patients with histories of opioid abuse. (!) The cite is:
Stoll AL, Rueter S. Treatment augmentation with opiates in severe and refractory major depression. Am J Psychiatry 1999 Dec;156(12):2017.
HTH
-elizabeth
Posted by Elizabeth on November 19, 2001, at 17:12:19
In reply to Re: Methadone/opiates for depression-shelli, scott, posted by nightlight on November 19, 2001, at 8:05:31
> But, more pertinently, the only way I have gotten thru the past many years was thru the use of an opiate/barbiturate drug that I was prescribed for chronic pain from a herniated cervical disc.
Which drug was that (what were the active ingredients, that is -- the narcotic and the barbiturate)? Back/neck/shoulder pain is notoriously hard to treat. I have relatively minor back pain myself, and one nice bonus effect of the buprenorphine I take for my depression is that it does away with the back pain.
> I am now on a very low-dose narcotic, 60 mgs. stimulent, 2 mgs. klonopin and apotent muscle relaxer.
Again...which narcotic and which muscle relaxant, and what are the doses? (just curious)
> I haave only recently been diagnosed ADD w/endogenous depression,
Did the doctor call it "endogenous depression," or was the exact diagnosis something else. I'm curious because "endogenous depression" is an expression that's not used much anymore in psychiatry. Do you live in the USA?
> Stimulents are what I have needed all along, but, couldn't seem to convince docs why (another story).
For me, opioids act like I would expect stimulants to act!
-elizabeth
Posted by SLS on November 19, 2001, at 17:53:01
In reply to Re: Morphine for depression. » SLS, posted by Elizabeth on November 19, 2001, at 17:03:56
Posted by nightlight on November 20, 2001, at 7:54:32
In reply to Re: Methadone/opiates for depression » nightlight, posted by Elizabeth on November 19, 2001, at 17:12:19
> > But, more pertinently, the only way I have gotten thru the past many years was thru the use of an opiate/barbiturate drug that I was prescribed for chronic pain from a herniated cervical disc.
>
> Which drug was that (what were the active ingredients, that is -- the narcotic and the barbiturate)? Back/neck/shoulder pain is notoriously hard to treat. I have relatively minor back pain myself, and one nice bonus effect of the buprenorphine I take for my depression is that it does away with the back pain.Elizabeth~
Will reply in more detail later-running late for pre-school drop-off and work...I used Fiorinal #3-a combo of codeine, butalbital, caffeine and aspirin. It was originally prescribed for persistent headaches. It also comes in an acetemenophen (sp) formula-Fioricette #3 and, both are available w/o the codeine.
I actually found the drug listed in a PDR, suggested it to a dr., who prescribed it for me, and I took it intermittently for 15 years.
More later.
nightlight
Posted by shelliR on November 20, 2001, at 12:14:24
In reply to Re: Methadone for depression. » judy1, posted by shelliR on November 18, 2001, at 20:41:53
Posted by JahL on November 20, 2001, at 17:36:47
In reply to Re: Morphine for depression. » JahL, posted by shelliR on November 13, 2001, at 10:43:20
> > Lamictal just about stops me from being an ex-Jah .
> well, that's pretty important. You're just a young lad, so holding on till the right thing helps is imperative. You find the right drug and you still have 80% of your life left to live and enjoy.I'd love to live to 130-odd but 60% is nearer the mark. And less of the 'young lad'... :-)
> When are your appointments?Next month sometime.
>Can you slip bupe or methadone into the conversation, somehow.
I'll do more than slip it into the conversation...I'm at the stage where I'm not bothered about offending the sensibilities of pdocs.
>How does this appointment stuff work? Do you see these specialists only once, or do they follow up until the problem is resolved?
If you make enough noise the NHS is obliged to continue treating you. However it is often the case that pdocs will tell you (or at least me) "there is nothing further I can do for you", at which point you get referred back to yr regular pdoc (again). Back to square one-stylee.
> BTW, remember sweet marie (Anna) who spent months ina UK hospital and was still pretty depressed when she got out. I think about her alot and hope she's okay.Yeah me too. I would refuse to go to hospital on grounds of principle (it's been offered a few times). NHS='One Flew Over The Cuckoo's Nest' whilst the private clinics seem to farm institutionalised types unable to function in the real world. Sad but true. I'm sure they're [the clinics] a haven for some tho'.
>Her experience is one of the reasons that I am letting myself get habituated to a narcotic.
Those that would criticise you have the luxury of not going thru what you are. Simple as that. You go girl! :-)> > Interestingly I tried Methadone recently. Initially it improved my mood & energy levels but seemed to lose affect after a few days. I didn't go too high (only about 5ml); I thought I'd find out more on this site before going any further. Like you tho', I'm hesitant to bring this up for fear of being jumped on by the Thought Police.
> How did you get methodone? (An answer is not required).Ask me no questions & I'll tell you no lies ;-)
> Let us know about your appointments. I hope these big-wigs can help you out.Thanx. Me too.
I'm v. pleased to hear that Methadone seems to be doing the trick; pls keep us all updated.
Best of luck,
J.
Posted by JahL on November 20, 2001, at 17:56:23
In reply to Re: Morphine for depression. » SLS, posted by Elizabeth on November 19, 2001, at 17:03:56
> Plenty of people who respond positively to opioids also get side effects. I couldn't start out at a fully-effective dose of buprenorphine (0.3 mg q. 4-6 hours) because it made me vomit. Also, I did feel sort of dizzy and lightheaded when I first started taking it.
> > I found something on the Internet that described that most people using methadone for depression begin to experience improvements by the end of the first week. Some took two weeks.
>
> Some feel their depression remitting after only a dose or two.Hi Elizabeth. Keep the posts comin'; I don't have to read any text books with you around :-)
I have a Q if you don't mind. I know it's all guess work but *what would you consider to be a therapeutic dose of Methadone for an opioid-naive individual*?
I tried around 5ml a few times recently. Interesting. A bit dreamy in a not unpleasant kinda way. Good sleep. Bad constipation :-(
I wanted to find out a bit more (ie about dose ramping/contraindications etc) before pursuing this any further. Any thoughts (by anyone) greatly appreciated...
Ta as always,
J.
Posted by Mair on November 20, 2001, at 21:28:36
In reply to Re: Methadone for depression (DOSES) » Elizabeth, posted by JahL on November 20, 2001, at 17:56:23
Posted by shelliR on November 21, 2001, at 9:17:39
In reply to Re: Methadone for depression (DOSES) » Elizabeth, posted by JahL on November 20, 2001, at 17:56:23
Hi Jah,
> I have a Q if you don't mind. I know it's all guess work but *what would you consider to be a therapeutic dose of Methadone for an opioid-naive individual*?
>
I started on 10mg of oxycontinue twice a day, when I was fairly opiate-naive, (except for small doses of vicodin). I probably would have started even lower, but the smallest pill is 10mg and it wore off after about
eight hours. I think methodone dosing is 1/3 or less of oxycontin, so I will predict starting dose to be at only about 5mg or 2 1/2 mg twice a day.The meth dose is supposed to last 24 hours, but I could feel a let down in the early evening when I took my second dose. I also woke up with a similar depression as with oxy and had the same pattern of waiting about an hour til it kicked in.
Shelli
Posted by shelliR on November 21, 2001, at 9:53:40
In reply to Re: Morphine for depression » shelliR, posted by Elizabeth on November 19, 2001, at 13:02:38
> > I'm sorry, I got so mixed up. It's methodone he's written the prescription for: methadone 10mg tabs; 4 tabs three times daily.
> That's a **lot** of methadone! Then again it might be the right amount, since you do have some tolerance from taking the oxycodone.
Unfortunately, I have a lot of tolerance, which I was not expecting. And although he wrote 3x a day, he told me to take it only twice. So total of 80mg.
I wouldn't mind taking 10-20mg before bed in order to not wake up depressed. I'm not sure why the effects are not lasting longer--it's supposed to be a 24 hour drug. (Of course oxy was supposed to be 12hr and it lasted 8; but this is an even larger discrepency.) I felt a let down (again in my chest) in the early evening--again after about 8 hours.>
> No, but I bet opioid combinations are often used to control pain for dying patients (cancer, etc.). But methadone binds very tightly to opioid receptors (like buprenorphine, only methadone is a full agonist), and as a result it tends to prevent other opioids from doing anything. (This makes it particularly useful for people with heroin dependence.)So if I'm ever injured or in great pain, they would have to give me more methadone? Oxy or morphine would not be at all effective while I'm on methadone?
>
>.... I suppose you could rationalize your use of it by saying that depression is just emotional pain (and honestly, I don't think that depressive pain and nociceptive pain are all that different).My depression absolutely feels like physical pain.
It's like a huge heavy weight pressing on my chest.
I am in therapy, but working on issues that don't feel related to that pain. More about dissociating, not being able to control bad feelings, etc.
It feels almost identical to my oxy dose; there's a tiny bit of high. Yesterday first I took 30mg and didn't feel as good as with my oxy dose, so I added 10mg. The pills are scored so probably should have started at 35mg twice a day. I am hoping to stay at this dose so I didn't want to start at 35 and have to ask my pdoc to raise to 40 so I would feel a little better. I was scared that I felt too good yesterday: (of course it was a beautiful 70 degree day here and I finally taking a break from work to plant bulbs). But at first on oxycontin I felt too high at the lowest dose, and then of course I got too used to them, and had to go up. My measure of how much to take is the pain/pressure in my chest. Its absence is all I am looking for.
When people are on methadone maintenance, do they generally become habituated to their dose and have to raise it (like my experience on oxycontin), or is it a more stable opiate?I hope you are doing well on your combo.
Shelli
Posted by shelliR on November 21, 2001, at 10:48:47
In reply to Re: Methadone/opiates for depression-shelli, scott, posted by nightlight on November 19, 2001, at 8:05:31
Hi Nightlight,
Sorry it took me so long to respond.> But, I couldn't use it daily, supply and side-effect problems. However, knowing that I wd. have a few days (maybe 8-9) that I wanted to rise from my bed helped me 'go on' & keep the faith that I wd. eventually find what was right for me.
I'm sorry that you have a problem around supply. You say you have two wonderful doctors, so I wonder why you are having a supply problem. Maybe this
is something you can work on with them; let them know. Advocate for yourself as much as possible.
You deserve more than 9 good days.I can't speak to the stimulent problem--why they are not prescribing, but hopefully you'll get that all resolved.
Good luck to you,
Shelli
Posted by Elizabeth on November 21, 2001, at 18:39:53
In reply to Re: Methadone/opiates for depression » Elizabeth, posted by nightlight on November 20, 2001, at 7:54:32
> I used Fiorinal #3-a combo of codeine, butalbital, caffeine and aspirin.
Oh, of course! I got Fioricet (the acetaminophen-containing version) for back pain once. Butalbital (the barbiturate ingredient) is one of only a couple barbiturates that are still used much (phenobarbital is also sometimes used as an anticonvulsant).
I tried taking Fioricet more recently (again, for back pain), but I got *really* depressed, which definitely hadn't happened before. My pdoc thought it might have been an interaction with the desipramine I'm taking.
Did you ever try plain codeine, and if so, do you think that Fiorinal w/codeine was any more or less effective (for pain or for depression) than codeine by itself?
-e
Posted by Elizabeth on November 21, 2001, at 19:25:39
In reply to Re: Methadone for depression. » shelliR, posted by JahL on November 20, 2001, at 17:36:47
> I'll do more than slip it into the conversation...I'm at the stage where I'm not bothered about offending the sensibilities of pdocs.
Hey, you're in the UK, aren't you? So you can get Temgesic? I'm sure I've mentioned before that US doctors are reluctant to prescribe injectable drugs to outpatients (especially psychiatric outpatients, regardless of whether there's any history of drug abuse).
> If you make enough noise the NHS is obliged to continue treating you. However it is often the case that pdocs will tell you (or at least me) "there is nothing further I can do for you", at which point you get referred back to yr regular pdoc (again). Back to square one-stylee.
That's so irritating! You know that what they mean is, "There's nothing further that I'm *willing* to do for you."
> Yeah me too. I would refuse to go to hospital on grounds of principle (it's been offered a few times). NHS='One Flew Over The Cuckoo's Nest' whilst the private clinics seem to farm institutionalised types unable to function in the real world. Sad but true. I'm sure they're [the clinics] a haven for some tho'.
I'm not sure I get what you mean about the private hospitals. Can you rephrase/elaborate?
> Those that would criticise you have the luxury of not going thru what you are.
Isn't that true all too often?
> I don't have to read any text books with you around :-)
Thanks, I think! < g >
> I have a Q if you don't mind.
Of course I don't mind!
> I know it's all guess work but *what would you consider to be a therapeutic dose of Methadone for an opioid-naive individual*?
I don't know much about methadone -- it's used sometimes for pain, but far more for opioid dependence, and the latter always requires shockingly big doses. I happen to know an opioid-naive guy who tried 10 mg (orally) a while back and says he was "better than well" for a full day. (He was also puking his guts out.) The recommended dose for pain, according to the PDR, is 2.5-10 mg every 3-4 hours, so I was surprised that it lasted so long for him. On the other hand, when addicts are treated with it, they usually need only one dose a day. Confusing.
> I tried around 5ml a few times recently.
How many mg/mL?
> Interesting. A bit dreamy in a not unpleasant kinda way. Good sleep. Bad constipation :-(
Sleep? Opioids (not just bupe) keep me awake! The constipation is an unavoidable and heinous problem. Some people also say that methadone makes them sweat a lot. I think that the best opioid, in terms of ease of use and minimal side effects, is Duragesic, the transdermal fentanyl patch (although wearing a patch for three days, which is how long it's supposed to last, sounds like it could get pretty grody).
-elizabeth
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