![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 102 to 126 of 164. Go back in thread:
Posted by IsoM on January 16, 2002, at 13:03:41
In reply to Re: Elizabeth....please...., posted by reese scott on January 16, 2002, at 11:38:51
Reese, I don't want to presume, but Dr. Bob is a psychiatrist, right? So why not e-mail Dr. Bob personally & ask him if he could send an e-mail to your pdoc to let him know about the med.
Maybe I've overstepped my limits, but if I have, it's not with intention to interfere but help. You sound so desparate, it hurts.
> that's what is so frustration. His reasoning is that he has never prescribed it before and he wants to talk to doc who has. He even was going to send me to Yale to meet with someone there but that doctor told him he wouldn't prescribe it for depression. So at this point I think he see's it as a useless or dangerous medication which is even the more frustrating. the doctor at yale told him, who is running trials for bubrenorphine/naltraxone for opiate detox, which seems to be what they are tryiing to license it as. He wants to find someone who has used it for depression.
>
> Plus I think he's scared of prescribing it for me because he also is an addiction specialist and is concerned that they might look into him, which i think is complete bull shit. I've even had my mother call him and tell him that she wants me on it but again he just back pedals. So at this point i'm screwed. He would rather i go in for ECT then take buprenex even for a trail run of two to four weeks. It makes me sick. There is one doctor he knows in new york who would prescribe it but he no longer is in practice.
>
> It basically seems for whatever reason he doesn't feel comfortable taking responsibility with the script, cause he doesn't know much about it.
>
> I've read many of your posts and you seem to be the most knowledgable. There is no other medication left for me to try. I currently take lithium, neurontin, celexa, clonzapam, adderall, which makes it even funnier since adderall and clonzapam are both "addictive"
>
> He could just pick up the phone and call it in but he won't. I've brought all the information I've found on the internet about buprenex but it doesn't seems to help. And it's also not a great help that they've seemed to have given up on studying it for refractatory depression and gone straight for the clinical trials of detox.
>
> Do you know of any recent studies?
> Who I might talk to about find a doc in manhattan he could speak with?
>
> i'm sorry if i am being a nuissance but i've been dealing with this for the last ten years and countless hospitalizations and for the last years have been unable to even work.
>
> This situation is f*&*&*& ridiculous. He just won't take responsibility.
>
> I don't know what else to say. Thank you
Posted by Elizabeth on January 16, 2002, at 21:15:35
In reply to Elizabeth....please...., posted by reese scott on January 15, 2002, at 16:16:03
Hi. I'm sorry I missed your post -- I don't check P-B every day.
My suggestion for you would be to try and get a referral from the doctor who was going to give you the script, the one who's not practicing anymore. If he can't prescribe it for you but was willing to, he should be able to find someone who can prescribe it. I'm a little confused as to why he was going to prescribe it if he's not in practice anymore.
Also, did your pdoc give an explanation for why he won't write a script for the buprenorphine? It doesn't make sense to say it's just because he hasn't prescribed it before -- I mean, there has to be a first time for everything, right?
How did you find a pharmacy that carried Buprenex, BTW? Or did they order it for you?
The guy at Yale who claims buprenorphine is "addictive" is full of it. The FDA says it has less potential for abuse than even benzos, and for once I agree with them.
Your pdoc could try talking to Dr. Bodkin at Harvard, who has clinical research experience with buprenorphine as an antidepressant. He's seen firsthand that patients don't abuse it. (You can reach him by calling McLean Hospital (617 855 2000) and asking them to transfer you to his office.) Dr. Bodkin was the primary author of an article which your pdoc could read if he feels he doesn't know enough about buprenorphine -- the article also has a lot of references to other relevant sources.
That's really all the advice I can think of
-elizabeth
Posted by reese scott on January 17, 2002, at 0:22:34
In reply to Re: Prescription » reese scott, posted by IsoM on January 16, 2002, at 13:03:41
thank you so much, your words really touched me and you in no way over stepped your grounds, there aren't anymore.
my psych is such a whatever that he wants to have someone else be the first one to write a script for it.
but i will try to call bodkin, and i also have another number for dr. stoll i believe that is his name. he is at mclean as well.
i live in manhattan but my mother would be willing to fly me out to boston if that's what it takes. it's so pathetic but there is nothing i won't do. the alternatives are just beyond normal comprehension.
thank you so much
elizabethplease stay in touch
Posted by Elizabeth on January 18, 2002, at 10:08:12
In reply to Re: Prescription to elizabeth from reese » IsoM, posted by reese scott on January 17, 2002, at 0:22:34
Reese,
Dr. Stoll has used opioids to treat depression, although I'm not sure if he's used bupe. He has used full agonists like oxycodone (he wrote a letter to the American Journal of Psychiatry reporting on some cases where he did this successfully), so he would probably not have a problem with bupe. I'm not sure if he's still seeing patients, though (he's very into his research on omega-3 fatty acids), and he's pretty hard to reach.
Best of luck to you! You seem very persistent so I think that you will find a way to get the help you need.
-elizabeth
Posted by BarbaraCat on January 18, 2002, at 11:54:44
In reply to Re: problems getting buprenorphine » reese scott, posted by Elizabeth on January 16, 2002, at 21:15:35
Elizabeth,
I've checked past posts, but couldn't find any details on why you've found bu-orphine helpful and what your regimen is. Could you give some info as to what it's treating, results, etc? Is it an opiod, or an antagonist? It would be very helpful. Also, if you could also answer a burning question - why do opiods have such an energizing effect, at least they do for me. I've always heard of their sophorific effects, not the calm yet speedy one I get. Thanks. -- Barbara
Posted by Zo on January 22, 2002, at 4:20:42
In reply to Re: problems getting buprenorphine » Elizabeth, posted by BarbaraCat on January 18, 2002, at 11:54:44
BarbaraCat, Sounds almost like the effect the so-called stimulants, Dexedrine and Adderall have on me. But I wonder if it differs in that I felt very centered on Bupe. Of course I soon became deeply, deeply manic, but that was me, and my bipolar II was unmedicated at the time. I wonder if there are biochemical parallels.
Zo
Posted by BarbaraCat on January 22, 2002, at 13:11:11
In reply to Re: She's baaa-ck! È BarbaraCat, posted by Zo on January 22, 2002, at 4:20:42
Zo,
I'm beginning to think after all these years of being diagnosed as severe unipolar with periodic agitation that I am REALLY bipolar-II. That's why no ADs have ever maintained the effect, I get panic attacks when I first start, and 'speed' has a paradoxically calming effect on me. Gotta figure these things out for ourselves, it seems.
-- Barbara> BarbaraCat, Sounds almost like the effect the so-called stimulants, Dexedrine and Adderall have on me. But I wonder if it differs in that I felt very centered on Bupe. Of course I soon became deeply, deeply manic, but that was me, and my bipolar II was unmedicated at the time. I wonder if there are biochemical parallels.
>
> Zo
Posted by Elizabeth on January 22, 2002, at 18:37:31
In reply to Re: problems getting buprenorphine » Elizabeth, posted by BarbaraCat on January 18, 2002, at 11:54:44
Hi Barbara.
> I've checked past posts, but couldn't find any details on why you've found bu-orphine helpful and what your regimen is. Could you give some info as to what it's treating, results, etc? Is it an opiod, or an antagonist?
Buprenorphine is an opioid mixed agonist/antagonist. It's a partial agonist at the mu receptor (i.e., it activates the receptor, but less than a full agonist such as morphine would) and an antagonist at the kappa receptor. Like the full mu agonists, it's a controlled substance in the U.S., but unlike them, it's only Schedule V (minimal abuse potential). It's used in many countries for maintenance treatment of opioid dependence.
I take 1 mL (= 0.3 mg) three times a day, in addition to 900 mg/day of Trileptal and 187.5 mg/day of Effexor XR (target dose of Effexor is 300 mg/day). I also take Xanax as needed. I have unipolar depression and a possible seizure disorder (hence the Trileptal).
Buprenorphine helps with my mood, energy level, concentration, motivation, optimism, anxiety (including social anxiety), and anhedonia. The Effexor seems to be helping too; I think it is a good combination.
> Also, if you could also answer a burning question - why do opiods have such an energizing effect, at least they do for me.
I don't have an answer for that (they're activating for me, too), and I'm not sure anyone does. In general, opioids have mixed activating and sedating effects (they're not strictly inhibitory or excitatory), to varying degrees for different people. I could speculate about the neurochemical reasons for the variation, but it would just be speculation.
> I've always heard of their sophorific effects, not the calm yet speedy one I get.
"Calm yet speedy" -- that's exactly it. :-)
-elizabeth
p.s. You mentioned that you were recently diagnosed with Bipolar II disorder. There seems to be an epidemic of previously undiagnosed Bipolar II -- everybody is bipolar these days! Do you think the diagnosis is accurate in your case? (Just curious, no relevance to the discussion.)
Posted by BarbaraCat on January 22, 2002, at 20:59:47
In reply to Re: problems getting buprenorphine » BarbaraCat, posted by Elizabeth on January 22, 2002, at 18:37:31
Thanks for your info, Elizabeth,
Actually, it was me who diagnosed myself as Bipolar II (for lack of anything else to call it, and my pdoc basically saying 'Gee, I dunno, might be, couldn't hurt to try.'). I've been cycling in and out of very severe depressions beginning in my early 20's and amping up to several episodes a year (I'm 50). I have mixed very melancholic vegetatives cycling to agitated, panic, bad, bad anxiety, insomnia, crying marathons, utter bleak despair. I've had classic hypomanic episodes (Oh God, I'd like some more of those, please) but most take the form of agitation, ruminative worry, fear, starting projects, never finishing. All this compounded by severe muscle pains that have been diagnosed as 'fibromyalgia' (and BTW, I had a Stephen King horror movie kind of childhood). I've been on all of the SSRI's and most of the 'novel' ones, buproprion, some TCAs, on and on.
No AD works longer than 2-3 months and all of the SSRI's have spun me into loco hyper states in the first few days. I like opiods cause they make me feel good. Simple as that. Currently I'm on 30 mg. Remeron and 200 mg lithium, titrating up slowly, and lots and lots of knock me out sleepers. I seem to be a classic 'AD's make me worse' case with extreme lability - brain inflammation would describe it best - and personally, I'm a big proponent of the viral theory. The lithium seems to be smoothing things out and I like it's neuroprotective and antiviral putative benefits. I wonder about the Bipolar II accuracy and if it's not just jumping on another bandwagon that provides new drug regimens, new hopes, but my symptoms have not been helped by the standard severe depression Rx. I also have many prolonged bouts of very happy, productive normalcy with delightful snippets of joy and wonder thrown in. So my awful times are not constant, but very randomly cyclical (isn't this the way malaria and other cyclical malaise type illnesses present?) -- Barbara
> Hi Barbara.
>
> > I've checked past posts, but couldn't find any details on why you've found bu-orphine helpful and what your regimen is. Could you give some info as to what it's treating, results, etc? Is it an opiod, or an antagonist?
>
> Buprenorphine is an opioid mixed agonist/antagonist. It's a partial agonist at the mu receptor (i.e., it activates the receptor, but less than a full agonist such as morphine would) and an antagonist at the kappa receptor. Like the full mu agonists, it's a controlled substance in the U.S., but unlike them, it's only Schedule V (minimal abuse potential). It's used in many countries for maintenance treatment of opioid dependence.
>
> I take 1 mL (= 0.3 mg) three times a day, in addition to 900 mg/day of Trileptal and 187.5 mg/day of Effexor XR (target dose of Effexor is 300 mg/day). I also take Xanax as needed. I have unipolar depression and a possible seizure disorder (hence the Trileptal).
>
> Buprenorphine helps with my mood, energy level, concentration, motivation, optimism, anxiety (including social anxiety), and anhedonia. The Effexor seems to be helping too; I think it is a good combination.
>
> > Also, if you could also answer a burning question - why do opiods have such an energizing effect, at least they do for me.
>
> I don't have an answer for that (they're activating for me, too), and I'm not sure anyone does. In general, opioids have mixed activating and sedating effects (they're not strictly inhibitory or excitatory), to varying degrees for different people. I could speculate about the neurochemical reasons for the variation, but it would just be speculation.
>
> > I've always heard of their sophorific effects, not the calm yet speedy one I get.
>
> "Calm yet speedy" -- that's exactly it. :-)
>
> -elizabeth
>
> p.s. You mentioned that you were recently diagnosed with Bipolar II disorder. There seems to be an epidemic of previously undiagnosed Bipolar II -- everybody is bipolar these days! Do you think the diagnosis is accurate in your case? (Just curious, no relevance to the discussion.)
Posted by Elizabeth on January 23, 2002, at 13:05:36
In reply to Re: problems getting buprenorphine, posted by BarbaraCat on January 22, 2002, at 20:59:47
> Actually, it was me who diagnosed myself as Bipolar II (for lack of anything else to call it, and my pdoc basically saying 'Gee, I dunno, might be, couldn't hurt to try.').
< g > I think a lot of BP II diagnoses are made for lack of anything else to call it.
> I've been cycling in and out of very severe depressions beginning in my early 20's and amping up to several episodes a year (I'm 50).
I can't imagine living that long with this. You must be very brave.
> I have mixed very melancholic vegetatives cycling to agitated, panic, bad, bad anxiety, insomnia, crying marathons, utter bleak despair.
Can I ask what you mean by "mixed very melancholic vegetatives?" (It sounds dreadful.)
> I've had classic hypomanic episodes (Oh God, I'd like some more of those, please) but most take the form of agitation, ruminative worry, fear, starting projects, never finishing.
Mixed hypomania, in other words?
> All this compounded by severe muscle pains that have been diagnosed as 'fibromyalgia' (and BTW, I had a Stephen King horror movie kind of childhood).
I had a pretty good childhood, in general, although there were traces of depression even then. (I was first seriously depressed when I was 11, but it wasn't diagnosed until I was 14.)
> I've been on all of the SSRI's and most of the 'novel' ones, buproprion, some TCAs, on and on.
How about mood stabilizers? You said you're on lithium now (only 200 mg, though -- have you had your serum level checked?); how's that going? Have you tried any of the anticonvulsant mood stabilizers? (They're supposed to be better for mixed, atypical bipolar disorders, although of course each case is unique.)
> I wonder about the Bipolar II accuracy and if it's not just jumping on another bandwagon that provides new drug regimens, new hopes, but my symptoms have not been helped by the standard severe depression Rx.
For people who get worse on ADs, it's worth considering the possibility and trying anticonvulsants or lithium, I think. I don't generally get worse on ADs. (Nardil was an exception: I tried taking it twice, and both times it worked for perhaps 6-9 months, then I lapsed into a "mixed" state similar to your mixed hypomanias, and nothing helped.) Most ADs just don't do much for me. Effexor, desipramine (the only TCA I've been able to tolerate -- my serum level was high, and even after I decreased the dose I had what appears to have been a seizure), and Parnate have been the ones that have worked to some degree (without making things worse). I had blood pressure problems that prevented me from getting past 60 mg/day of Parnate (taking too much in a single dose made my blood pressure shoot up). I'm hoping that Effexor -- as high a dose as necessary, with Remeron to minimize side effects if there should be any -- will do the trick.
Opioids might be helpful for people with bipolar disorders (especially those with mixed states, IMO) who can't get stable on mood stabilizers or mood stabilizers + ADs. This is just speculation on my part, but opioids can help with the agitation of mania and the lethargy or anergia that often accompanies bipolar depressions. It's tricky to manage some bipolar disorders -- mood stabilizers may not help with depression, ADs may trigger cycling. Still, I think that mood stabilizers (or MS-AD combinations) are worth a try before you start resorting to opioids -- there's a good chance that you will find a mood stabilizer (or combination) that works for you, and opioids can have very difficult side effects. I don't think that buprenorphine is addictive, but my impression is that people with bipolar disorders are at increased risk for addictions.
> I also have many prolonged bouts of very happy, productive normalcy with delightful snippets of joy and wonder thrown in. So my awful times are not constant, but very randomly cyclical (isn't this the way malaria and other cyclical malaise type illnesses present?)
Many illnesses are, as you say, randomly cyclical (not just viral ones, and not all viral ones). Major depression often cycles randomly, with no apparent pattern or precursor to episodes. (My depression is "randomly cyclical," although in more recent years I've been recovering less fully between episodes. I think this is a risk of inadequately treated depression.)
best,
-elizabeth
Posted by Elizabeth on January 23, 2002, at 13:35:04
In reply to Re: problems getting buprenorphine, posted by BarbaraCat on January 22, 2002, at 20:59:47
Are you getting any treatment for the fibromyalgia? I think chronic pain is disgracefully undertreated. Compounding the problem, there are several drugs on the market that are labelled as "muscle relaxants" which are really just antihistamines/anticholinergics and don't have any particular muscle relaxant effect; they're just sedating. (Some of them are structurally similar to the tricyclic ADs.)
I have chronic musculoskeletal pain (in my back, neck, and shoulders) too, although it's not fibromyalgia (the doctor I saw at a pain clinic in Boston thinks that it's related to a slight flaw in some of my thoracic vertabrae which causes them to press against the joints in between. I had a steroid injection in the two joints in question which worked very well (for a week or so, that is), showing that the whole problem is due to those two tiny little joints! (Chronic pain is a very weird and poorly-understood phenomenon.) Unfortunately, this didn't do much good since there isn't a way to correct the problem at this time.
Buprenorphine works very well for the pain as well as for the depression, and I haven't developed any tolerance to it. Of possible interest, Nardil also relieved the pain while I was taking it. I've also found Soma helpful. Benzos can help as well, although I think they are less reliable.
-elizabeth
Posted by christophrejmc on January 23, 2002, at 20:41:22
In reply to Re: problems getting buprenorphine » reese scott, posted by Elizabeth on January 16, 2002, at 21:15:35
Is there any reason why buprenorphine would be a better choice for depression than the other opiates? Strangely, it's easier for me to get schedule IIs than the lesser controlled opiates (legally, btw). I know that some people have had good responses from morphine/oxycodone/methadone, but I'd rather not mess with anything potentially "addictive." Are there any other mixed agonists that are worth trying (and that don't require IV/IM injection)? Thanks for any information.
/* CJMC */P.S.: If this has been discussed, simply say so; I'll try to check the archives.
Posted by Elizabeth on January 24, 2002, at 12:47:08
In reply to opioids, posted by christophrejmc on January 23, 2002, at 20:41:22
> Is there any reason why buprenorphine would be a better choice for depression than the other opiates?
There are several, which are discussed in the Bodkin et al. article. The following factors make buprenorphine a better choice than a full agonist.
- less toxicity in overdose
- little or no potential for abuse or addiction
- much milder withdrawal symptoms
- lacks Ultram's potential for precipitating seizures
- action lasts longer than most opioids> Strangely, it's easier for me to get schedule IIs than the lesser controlled opiates (legally, btw).
Buprenorphine in particular, or less controlled opioids in general (e.g., Stadol, Talwin, Nubain, etc.)? Doctors often shy away from buprenorphine because it's only available (in the U.S.) in an injectable formulation.
> I know that some people have had good responses from morphine/oxycodone/methadone, but I'd rather not mess with anything potentially "addictive."
I think that's reasonable. IMO, it's a good idea to try buprenorphine first, and move on to full agonists (probably MS Contin, OxyContin, or Duragesic) only if buprenorphine benefits you, but (1) the effect of buprenorphine is not sufficient, and you need something "stronger;" or (2) you are unable to tolerate buprenorphine. (Fentanyl is probably the most tolerable of the opioids, although it's probably a bad idea to ask your doctor for it.) I don't think it's worthwhile to try full agonists if buprenorphine doesn't help at all, although it's generally worth trying different doses -- sometimes higher doses may work better, but sometimes you may actually find *lower* doses more effective. In general, because the side effects of opioids can be pretty harsh, I'd advise starting at a low-end dose. (I started at 0.5 mL t.i.d.)
> Are there any other mixed agonists that are worth trying (and that don't require IV/IM injection)? Thanks for any information.
Probably not. You might try Stadol (butorphanol), a kappa agonist/mu antagonist, especially if you're one of those people who feel worse on opioids (most people have at least tried codeine or hydrocodone at some point, so you're liable to have some idea how they affect you). But usually depressed people feel worse on kappa agonists. There was another drug on the market called Dalgan (dezocine) with a pharmacological profile similar to that of buprenorphine, but I think that dezocine is no longer available. (IIRC, Dalgan was an injection-only drug too, anyway.)
HTH
-elizabeth
Posted by Elizabeth on January 24, 2002, at 12:52:18
In reply to opioids, posted by christophrejmc on January 23, 2002, at 20:41:22
BTW, buprenorphine doesn't have to be injected. It's effective when taken intranasally and sublingually (although the dose, at least in the latter case, is much higher than the injected dose).
-e
Posted by christophrejmc on January 25, 2002, at 1:01:58
In reply to Re: opioids » christophrejmc, posted by Elizabeth on January 24, 2002, at 12:47:08
> > Is there any reason why buprenorphine would be a better choice for depression than the other opiates?
>
> There are several, which are discussed in the Bodkin et al. article. The following factors make buprenorphine a better choice than a full agonist.
>
> - less toxicity in overdose
> - little or no potential for abuse or addiction
> - much milder withdrawal symptoms
> - lacks Ultram's potential for precipitating seizures
> - action lasts longer than most opioidsThanks, although the last point is probably the only one that matters to me at this point.
> > Strangely, it's easier for me to get schedule IIs than the lesser controlled opiates (legally, btw).
>
> Buprenorphine in particular, or less controlled opioids in general (e.g., Stadol, Talwin, Nubain, etc.)? Doctors often shy away from buprenorphine because it's only available (in the U.S.) in an injectable formulation.Mostly because of the formulation (my PDR [a bit dated -- 1996] lists Stadol as the only one that comes in a non-injectable form) but also because they are not prescribed as much.
> > I know that some people have had good responses from morphine/oxycodone/methadone, but I'd rather not mess with anything potentially "addictive."
>
> I think that's reasonable. IMO, it's a good idea to try buprenorphine first, and move on to full agonists (probably MS Contin, OxyContin, or Duragesic) only if buprenorphine benefits you, but (1) the effect of buprenorphine is not sufficient, and you need something "stronger;" or (2) you are unable to tolerate buprenorphine. (Fentanyl is probably the most tolerable of the opioids, although it's probably a bad idea to ask your doctor for it.) I don't think it's worthwhile to try full agonists if buprenorphine doesn't help at all, although it's generally worth trying different doses -- sometimes higher doses may work better, but sometimes you may actually find *lower* doses more effective. In general, because the side effects of opioids can be pretty harsh, I'd advise starting at a low-end dose. (I started at 0.5 mL t.i.d.)> > Are there any other mixed agonists that are worth trying (and that don't require IV/IM injection)? Thanks for any information.
>
> Probably not. You might try Stadol (butorphanol), a kappa agonist/mu antagonist, especially if you're one of those people who feel worse on opioids (most people have at least tried codeine or hydrocodone at some point, so you're liable to have some idea how they affect you). But usually depressed people feel worse on kappa agonists. There was another drug on the market called Dalgan (dezocine) with a pharmacological profile similar to that of buprenorphine, but I think that dezocine is no longer available. (IIRC, Dalgan was an injection-only drug too, anyway.)I was going to try to get Stadol NS (Nasal Spray), but it seems like there are too few reasons not to try the "harder" opiates (Ultram doesn't seem to be very efficacious and I'm afraid of adding it to an MAOI [currently, I am taking Nardil]). The only opioids I've used were Vicodin and codeine. I remember the Vicodin making me feel somewhat better (both physically and psychically), but codeine did absolutely nothing at moderate doses (for my mood or my nasal pain).
> HTH
It does, thanks.
> BTW, buprenorphine doesn't have to be injected. It's effective when taken intranasally and sublingually (although the dose, at least in the latter case, is much higher than the injected dose).
>
> -eYeah, but it sounds like the alternative routes are a pain in the ass.
Thanks for your help,
Christophre
Posted by Kristi on January 25, 2002, at 1:05:49
In reply to Re: opioids » christophrejmc, posted by Elizabeth on January 24, 2002, at 12:47:08
Hi. I'm just curious...... you mentioned ultram is associated with seizures? I've been on it for a while, just wondering what you know. Thanks in advance, Kristi
> > Is there any reason why buprenorphine would be a better choice for depression than the other opiates?
>
> There are several, which are discussed in the Bodkin et al. article. The following factors make buprenorphine a better choice than a full agonist.
>
> - less toxicity in overdose
> - little or no potential for abuse or addiction
> - much milder withdrawal symptoms
> - lacks Ultram's potential for precipitating seizures
> - action lasts longer than most opioids
>
> > Strangely, it's easier for me to get schedule IIs than the lesser controlled opiates (legally, btw).
>
> Buprenorphine in particular, or less controlled opioids in general (e.g., Stadol, Talwin, Nubain, etc.)? Doctors often shy away from buprenorphine because it's only available (in the U.S.) in an injectable formulation.
>
> > I know that some people have had good responses from morphine/oxycodone/methadone, but I'd rather not mess with anything potentially "addictive."
>
> I think that's reasonable. IMO, it's a good idea to try buprenorphine first, and move on to full agonists (probably MS Contin, OxyContin, or Duragesic) only if buprenorphine benefits you, but (1) the effect of buprenorphine is not sufficient, and you need something "stronger;" or (2) you are unable to tolerate buprenorphine. (Fentanyl is probably the most tolerable of the opioids, although it's probably a bad idea to ask your doctor for it.) I don't think it's worthwhile to try full agonists if buprenorphine doesn't help at all, although it's generally worth trying different doses -- sometimes higher doses may work better, but sometimes you may actually find *lower* doses more effective. In general, because the side effects of opioids can be pretty harsh, I'd advise starting at a low-end dose. (I started at 0.5 mL t.i.d.)
>
> > Are there any other mixed agonists that are worth trying (and that don't require IV/IM injection)? Thanks for any information.
>
> Probably not. You might try Stadol (butorphanol), a kappa agonist/mu antagonist, especially if you're one of those people who feel worse on opioids (most people have at least tried codeine or hydrocodone at some point, so you're liable to have some idea how they affect you). But usually depressed people feel worse on kappa agonists. There was another drug on the market called Dalgan (dezocine) with a pharmacological profile similar to that of buprenorphine, but I think that dezocine is no longer available. (IIRC, Dalgan was an injection-only drug too, anyway.)
>
> HTH
>
> -elizabeth
Posted by BarbaraCat on January 25, 2002, at 14:25:01
In reply to p.s. chronic pain » BarbaraCat, posted by Elizabeth on January 23, 2002, at 13:35:04
Elizabeth
> Are you getting any treatment for the fibromyalgia?I take hydrocodone when the pain is bad, although it doesn't really help that much except to improve my general mood. I also take baclofen which supposedly relaxes the spasms. When I'm having a really bad spell about the only thing I can do is sedate myself with enough klonopin and baclofen to render myself unconscious, coming up only to eat and excrete. This, as you can imagine, is not what I'd call a life.
> Compounding the problem, there are several drugs on the market that are labelled as "muscle relaxants" which are really just antihistamines/anticholinergics and don't have any particular muscle relaxant effect; they're just sedating. (Some of them are structurally similar to the tricyclic ADs.)
Do you know of any true 'muscle relaxants'? My pain is compounded by anxiety which creates muscle armouring. Exercise is really my best therapy. If I can just get the muscles loose and my mental place in a nice alpha zone, I can usually start moving and push through the pain, but if I'm really down and hurting there's just no way I'm able to call forth the will.
> I have chronic musculoskeletal pain (in my back, neck, and shoulders) too, although it's not fibromyalgia (the doctor I saw at a pain clinic in Boston thinks that it's related to a slight flaw in some of my thoracic vertabrae which causes them to press against the joints in between. I had a steroid injection in the two joints in question which worked very well (for a week or so, that is), showing that the whole problem is due to those two tiny little joints! (Chronic pain is a very weird and poorly-understood phenomenon.) Unfortunately, this didn't do much good since there isn't a way to correct the problem at this time.
I've heard some good reports on prolo therapy. I've also received cortisone injections which help for structural related problems (old mountain climbing and car accidents), but the pain of fibromyalgia is a different animal. The pain is a migrating, all over deep muscle ache, like the pain felt with a flu. It's accompanied by severe fatigue and weakness, cognitive problems, and depression. I can't tell any longer where the division is between the fibro and the depression. I know they're interrelated, but to what extent are they the same disease? I sometimes get depression without the physical pain, but it's more the agitated sort. I wonder how many others out there are afflicted with very severe somatic complaints -- think I'll start a new poll/thread.
> Buprenorphine works very well for the pain as well as for the depression, and I haven't developed any tolerance to it. Of possible interest, Nardil also relieved the pain while I was taking it. I've also found Soma helpful. Benzos can help as well, although I think they are less reliable.
Isn't soma a benzo? BTW, are you taking the buprenorphine primarily as an antidepressant or as a pain reliever? Thanks for your input, Elizabeth. I always enjoy reading your posts.
Barbara
Posted by Elizabeth on January 30, 2002, at 5:49:59
In reply to Re: opioids » Elizabeth, posted by christophrejmc on January 25, 2002, at 1:01:58
Re pluses of buprenorphine:
> Thanks, although the last point is probably the only one that matters to me at this point.That's not surprising, but the others may be more important to your doctor!
> Mostly because of the formulation (my PDR [a bit dated -- 1996] lists Stadol as the only one that comes in a non-injectable form) but also because they are not prescribed as much.
It's true; all doctors (I'd hope) are familiar with MS Contin, whereas I've gotten some "huh?"s when I mentioned buprenorphine! Some of the slow-release formulations of some of the full agonists are longer-acting than buprenorphine. Duragesic, the fentanyl patch, is my favorite; it lasts three days, supposedly (some people find it doesn't last quite that long and need to change it every two days or so, one of the reasons I detest "one size fits all" dosing regimens). But there are good reasons to try buprenorphine before moving on to these drugs.
Say, how is the Nardil working for you? I presume you need help with residual symptoms (you don't seem "actively" depressed). That's been a chronic problem for me too; regular ADs help, but I have some symptoms that seem impervious to the standard psych drugs.
> I was going to try to get Stadol NS (Nasal Spray), but it seems like there are too few reasons not to try the "harder" opiates (Ultram doesn't seem to be very efficacious and I'm afraid of adding it to an MAOI [currently, I am taking Nardil]).
I've encountered a couple people who found that very high doses of Ultram worked even though it didn't do anything for them at the recommended doses. You're right that it shouldn't be taken with MAOIs, BTW; most other opioids are fine. (A notable exception is Demerol, but that would make a lousy AD anyway.)
> The only opioids I've used were Vicodin and codeine. I remember the Vicodin making me feel somewhat better (both physically and psychically), but codeine did absolutely nothing at moderate doses (for my mood or my nasal pain).
Codeine doesn't work for me either. I've learned recently (by way of a tricyclic serum level) that I may have a metabolic deficiency which would account for the lack of effect of codeine. (Nearly all of the analgesic effect of codeine is due to its metabolism into morphine; a deficiency in the enzyme that catalyzes this process -- which is also involved in the metabolism of TCAs -- generally makes codeine ineffective, at least at normal doses. This might be your problem as well, although it's hard to say for sure.)
> Yeah, but it sounds like the alternative routes are a pain in the ass.
I think that self-administering buprenorphine by IM injection would be easier to do in your arm rather than your ass (although both are viable sites)! :-)
-elizabeth
Posted by Elizabeth on January 30, 2002, at 6:01:48
In reply to Re: opioids-Elizabeth, posted by Kristi on January 25, 2002, at 1:05:49
> Hi. I'm just curious...... you mentioned ultram is associated with seizures? I've been on it for a while, just wondering what you know.
It has that reputation, and the potential for lowering the seizure threshold is noted in the Rx monograph (in the PDR). I've never encountered anybody who actually had seizures due to Ultram. I think it's probably a rare adverse effect, but that you should keep it in mind if you're considering taking Ultram, especially if you've had seizures in the past.
-elizabeth
Posted by Elizabeth on January 30, 2002, at 6:37:35
In reply to Re: p.s. chronic pain » Elizabeth, posted by BarbaraCat on January 25, 2002, at 14:25:01
> I take hydrocodone when the pain is bad, although it doesn't really help that much except to improve my general mood.
I think that mood, anxiety, and sleep problems are often tied up with fibromyalgia and perhaps other types of chronic pain. But anyway -- what dose of hydrocodone do you take?
> I also take baclofen which supposedly relaxes the spasms.
I tried it -- it had no effect at all, as far as I could tell. Didn't even help me sleep. It's labeled for "spasticity" (it's a direct GABA-B agonist) -- I'm not sure what that is exactly, but I think it's different from the muscle spasms which can be implicated in musculoskeletal pain.
Pretty much anything sedating can help somewhat, although I've found that things like antihistamines (which I call "incidentally" sedating) are only minimally and unreliably useful, and generally not worth the trouble.
> When I'm having a really bad spell about the only thing I can do is sedate myself with enough klonopin and baclofen to render myself unconscious, coming up only to eat and excrete. This, as you can imagine, is not what I'd call a life.
Jeez. If you have chronic pain, you need chronic treatment. (That makes sense, right?) That might mean taking a modest dose of Klonopin (or another benzo -- they might differ in muscle-relaxant effects, not sure) on a daily basis. I don't know. Chronic pain is very hard to treat, I think. Personally, I've found that buprenorphine helps *without causing tolerance*. I wonder if it would work for you too?
> Do you know of any true 'muscle relaxants'?
Soma (carisoprodol) and Miltown (meprobamate) seem to be good ones, although they can be sedating too. Benzos work for many people; I think that they could be taken on a regular basis and still work, especially since part of your problem is the pain - > anxiety - > more pain - > more anxiety ... cycle. (That is also a problem for me.) These can all be sedating, although most people will become tolerant to the sedation if they take them regularly for a little while. I can't think of anything else off the top of my head, but I'll let you know if I do.
Exercise -- just something simple like walking -- is often good, as you know. I think it's important to make a point of being active -- not necessarily becoming an exercise buff, just being active.
> I've heard some good reports on prolo therapy.
"Prolo therapy?"
> I've also received cortisone injections which help for structural related problems (old mountain climbing and car accidents), but the pain of fibromyalgia is a different animal.
Steroid injections really aren't something you should do on a regular basis, anyway.
> The pain is a migrating, all over deep muscle ache, like the pain felt with a flu.
Mine is sort of like that -- it "migrates," although it's limited to my back/neck/shoulders. In particular, it's usually concentrated on one side, although it may be either the left or the right. I don't really know much about flu pains -- I haven't had the flu in years, and these days I try to get the flu shot every year.
> It's accompanied by severe fatigue and weakness, cognitive problems, and depression.
Mine doesn't seem to be absolutely correlated with my mood or energy level, although there are some ways that my mood can affect the pain (e.g., inactivity from depression, muscle tension related to anxiety). I often have pain when I'm not depressed or anxious, though. (I recall one summer when my back pain was really bad and was present almost all the time -- that was when I decided to go to the pain clinic and got the steroid injection, the diagnosis, and the Soma -- when I was on Parnate and really wasn't doing too badly mood-wise. I was fairly active too -- did a lot of walking around Cambridge and Boston.)
> I can't tell any longer where the division is between the fibro and the depression. I know they're interrelated, but to what extent are they the same disease?
I don't know. Fibro is not very well-understood. It seems likely that there might be a common cause to the pain and the depression, though.
Have you checked out some of the fibromyalgia chat boards on the web, and if so, what sorts of things do other people find helpful?
> I wonder how many others out there are afflicted with very severe somatic complaints -- think I'll start a new poll/thread.
"Somatic complaints" is pretty broad -- it could include GI distress, skin problems such as psoriasis and eczema, appetite and sleep disturbances, and low energy (all of which are sometimes associated with anxiety and/or depression) as well as pain.
> Isn't soma a benzo?
No, although it's related to meprobamate (the predecessor to the benzos). I don't think anybody is sure how Soma works.
> BTW, are you taking the buprenorphine primarily as an antidepressant or as a pain reliever?
Antidepressant. Although maybe it would be easier to get it if I saw a pain doc. < sigh >
> Thanks for your input, Elizabeth. I always enjoy reading your posts.
Thanks :) It's nice to chat with you!
-elizabeth
Posted by therese desqueroux on January 30, 2002, at 18:14:31
In reply to Ultram » Kristi, posted by Elizabeth on January 30, 2002, at 6:01:48
Last year, a pain management specialist prescribed me Ultram for a severe back problem. My pdoc told me not to take it for the exact reasons Elizabeth noted.
Elizabeth, and some of you other folks out there, how do you know so much? (Rhetorical question).
----
> > Hi. I'm just curious...... you mentioned ultram is associated with seizures? I've been on it for a while, just wondering what you know.
>
> It has that reputation, and the potential for lowering the seizure threshold is noted in the Rx monograph (in the PDR). I've never encountered anybody who actually had seizures due to Ultram. I think it's probably a rare adverse effect, but that you should keep it in mind if you're considering taking Ultram, especially if you've had seizures in the past.
>
> -elizabeth
Posted by christophrejmc on January 31, 2002, at 1:14:13
In reply to Re: opioids » christophrejmc, posted by Elizabeth on January 30, 2002, at 5:49:59
> Re pluses of buprenorphine:
> > Thanks, although the last point is probably the only one that matters to me at this point.
>
> That's not surprising, but the others may be more important to your doctor!> > Mostly because of the formulation (my PDR [a bit dated -- 1996] lists Stadol as the only one that comes in a non-injectable form) but also because they are not prescribed as much.
>
> It's true; all doctors (I'd hope) are familiar with MS Contin, whereas I've gotten some "huh?"s when I mentioned buprenorphine! Some of the slow-release formulations of some of the full agonists are longer-acting than buprenorphine. Duragesic, the fentanyl patch, is my favorite; it lasts three days, supposedly (some people find it doesn't last quite that long and need to change it every two days or so, one of the reasons I detest "one size fits all" dosing regimens). But there are good reasons to try buprenorphine before moving on to these drugs.Fentanyl sounds great, but I'm not sure if my doctor will be able to continue prescribing it (he's not my doctor, but he's willing to let me try an opioid for my depression) -- the withdrawl would not be fun.
> Say, how is the Nardil working for you? I presume you need help with residual symptoms (you don't seem "actively" depressed). That's been a chronic problem for me too; regular ADs help, but I have some symptoms that seem impervious to the standard psych drugs.Nardil helps with some of my social phobia and it got me out of my most recent suicidal state. I still have problems with anhedonia, apathy, etc.
> > I was going to try to get Stadol NS (Nasal Spray), but it seems like there are too few reasons not to try the "harder" opiates (Ultram doesn't seem to be very efficacious and I'm afraid of adding it to an MAOI [currently, I am taking Nardil]).
>
> I've encountered a couple people who found that very high doses of Ultram worked even though it didn't do anything for them at the recommended doses. You're right that it shouldn't be taken with MAOIs, BTW; most other opioids are fine. (A notable exception is Demerol, but that would make a lousy AD anyway.)
>
> > The only opioids I've used were Vicodin and codeine. I remember the Vicodin making me feel somewhat better (both physically and psychically), but codeine did absolutely nothing at moderate doses (for my mood or my nasal pain).
>
> Codeine doesn't work for me either. I've learned recently (by way of a tricyclic serum level) that I may have a metabolic deficiency which would account for the lack of effect of codeine. (Nearly all of the analgesic effect of codeine is due to its metabolism into morphine; a deficiency in the enzyme that catalyzes this process -- which is also involved in the metabolism of TCAs -- generally makes codeine ineffective, at least at normal doses. This might be your problem as well, although it's hard to say for sure.)
>
> > Yeah, but it sounds like the alternative routes are a pain in the ass.
>
> I think that self-administering buprenorphine by IM injection would be easier to do in your arm rather than your ass (although both are viable sites)! :-)By alternative routes, I meant sublingual and intranasal (I think you knew that and were making a joke, but I thought I'd make sure). Why don't you use the IM route, btw? What are the downsides?
> -elizabeth
-christophre
Posted by Elizabeth on February 1, 2002, at 15:22:50
In reply to Re: Ultram, posted by therese desqueroux on January 30, 2002, at 18:14:31
> Last year, a pain management specialist prescribed me Ultram for a severe back problem. My pdoc told me not to take it for the exact reasons Elizabeth noted.
Do you have a history of seizures or any other reason to think you're at risk? I think that Ultram is probably okay for most people if taken in the normal dose range. Is your back doing better, BTW?
> Elizabeth, and some of you other folks out there, how do you know so much? (Rhetorical question).
I don't really know that much, but I do try to share what I know when someone has a question. Most of what I know I learned from reading stuff. I've also picked up a lot of "real life" information, about the effects meds have on people and how frequent they are and so on, in support groups (including online ones such as this one). I think that doctors would benefit a lot from reading this stuff.
-elizabeth
Posted by Elizabeth on February 1, 2002, at 15:47:02
In reply to Re: opioids » Elizabeth, posted by christophrejmc on January 31, 2002, at 1:14:13
> Fentanyl sounds great, but I'm not sure if my doctor will be able to continue prescribing it (he's not my doctor, but he's willing to let me try an opioid for my depression) -- the withdrawl would not be fun.
This is one point in favor of seeing if buprenorphine works before you start considering that full agonists: withdrawal symptoms from stopping buprenorphine are very mild.
OTOH, you don't have to take an opioid that long to find out if it works -- just long enough to figure out what dose you need.
Do you think you'd be able to get by taking an opioid on an as-needed basis, rather than continuously, and continuing with the Nardil? That might be better than taking the opioid full-time. I think there is some risk of tolerance to opioids for people taking them as ADs (although there definitely are people who don't become tolerant), and it's also a challenge to manage some of the side effects on a day-to-day basis.
> Nardil helps with some of my social phobia and it got me out of my most recent suicidal state. I still have problems with anhedonia, apathy, etc.
My residual symptoms are similar, and buprenorphine definitely helps a lot. Have you tried psychostimulants?
> > I think that self-administering buprenorphine by IM injection would be easier to do in your arm rather than your ass (although both are viable sites)! :-)
>
> By alternative routes, I meant sublingual and intranasal (I think you knew that and were making a joke, but I thought I'd make sure).The ass part was a joke. (Although it's true that buprenorphine would be absorbed by intramuscular injection in the butt, it probably wouldn't hurt much.)
But yes, there are problems with SL and IN administration. I have often thought it would be cool if buprenorphine were available in a metered-dose nasal inhaler (a la Stadol NS); that would make it very easy to take it that way. I gather that a problem with taking the injectable solution sublingually is that it isn't absorbed reliably, so it sometimes doesn't work as well as it's supposed to.
> Why don't you use the IM route, btw? What are the downsides?
I'm not sure how my pdoc would react if I asked if I could do this. I also think there might be problems with getting IM injections three times a day, every day (you could alternate which muscle you used, of course, but even then you'd be hitting the same site pretty often).
-elizabeth
Posted by christophrejmc on February 3, 2002, at 17:18:09
In reply to Re: opioids » christophrejmc, posted by Elizabeth on February 1, 2002, at 15:47:02
> Do you think you'd be able to get by taking an opioid on an as-needed basis, rather than continuously, and continuing with the Nardil? That might be better than taking the opioid full-time. I think there is some risk of tolerance to opioids for people taking them as ADs (although there definitely are people who don't become tolerant), and it's also a challenge to manage some of the side effects on a day-to-day basis.
I never even thought about that; I think I'll try that first.
> My residual symptoms are similar, and buprenorphine definitely helps a lot. Have you tried psychostimulants?
Yeah. They help, but not much. I'm currently thinking about adding a direct dopamine agonist, it seems to help some people with residual anhedonia/apathy.
> I have often thought it would be cool if buprenorphine were available in a metered-dose nasal inhaler (a la Stadol NS); that would make it very easy to take it that way.
Have you thought about filling an OTC nasal spray with buprenorphine (the good ones that control the amount of fluid sprayed)? I wonder if certain pharmacies can do this for you.
> I'm not sure how my pdoc would react if I asked if I could do this. I also think there might be problems with getting IM injections three times a day, every day (you could alternate which muscle you used, of course, but even then you'd be hitting the same site pretty often).
Yeah, I can see the problem there.
-chris
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