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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 11 of 11. This is the beginning of the thread.
Posted by shelliR on April 15, 2002, at 21:45:57
Hi Elizabeth,
I wrote two posts to you on the bupe thread, but maybe you haven't been on the board recently.
Anyway, my pdoc told me today that it is too dangerous to use the fentanyl patch with nardil. Yet on the information that comes with the patch, it doesn't say "do not take this is you are taking an MAOI." In fact most drug companies will mention this first, even OTC drugs like antihistimies, etc.
So what do you think? Any knowledge that my pdoc is right. Weren't you on buprenorphine and nardil?
Shelli
Posted by Elizabeth on April 16, 2002, at 22:09:25
In reply to RE Opiates and MAOIs - Elizabeth, anyone, posted by shelliR on April 15, 2002, at 21:45:57
Shelli --
Sorry about the delay. I've been offline for a couple days, owing to extreme fatigue!
> Anyway, my pdoc told me today that it is too dangerous to use the fentanyl patch with nardil.
I don't think that's true. Some doctors believe that you shouldn't take opioids with MAOIs *at all*. Obviously this is wrong. Morphine is definitely safe, and therefore codeine is too. The semisynthetic derivatives of these two drugs -- hydrocodone, oxycodone, hydromorphone, oxymorphone, and diacetylmorphine (i.e., heroin) -- are probably safe as well. As for the synthetic opioids, the only ones that are *known* to be unsafe are Demerol, Ultram, and Talwin (pentazocine). I've read of cases where fentanyl and fentanyl analogs were given to patients on MAOIs without adverse reactions. I'd ask if your pdoc has any specific reason for believing this. It's probably just one of those unjustified assumptions that people make a lot. Definitely ask, though, just in case there's a real reason!
-elizabeth
p.s. I took buprenorphine with Parnate, not Nardil.
p.p.s. You can take antihistamines with MAOIs; it's decongestants that you need to avoid.
Posted by kazoo on April 17, 2002, at 3:08:02
In reply to Re: Opiates and MAOIs » shelliR, posted by Elizabeth on April 16, 2002, at 22:09:25
> I don't think that's true.
^^^^^^^^^^^^^^^^^^^^^^^^^^^^
But you don't know for sure.> Some doctors believe that you shouldn't take opioids with MAOIs *at all*. Obviously this is wrong.
^^^^^^^^^^^^^^^^^^^
How is this "wrong"? And "obvious" to whom?
> Morphine is definitely safe, and therefore codeine is too.
^^^^^^^^^^^^^^^
However, one can accidentally overdose on morphine, so this makes it not "safe."Elizabeth, dear, you have provided much valuable information in your area expertise re. opiate drugs; however, I feel you may be a little too dogmatic in your approach to explain what works for you, therefore, what you believe to be true.
I know from experience that it is not wise to make statements without backing up such statements with data or facts from empirical research and sources.
It is true that "conventional wisdom" doesn't always work all the time, and this is where you shine, my dear, in that you offer contrary, alternative methods and ideas to offset the blindly accepted; however, blanket statements to cover all bases can lead to some serious problems in some people.
I'm not sure what I'm trying to tell you here except maybe to be careful in making statements based on anecdotal knowledge and personal success stories.
I remain a reader and follower of your posts,
kazoo
Posted by SLS on April 17, 2002, at 22:15:26
In reply to RE Opiates and MAOIs - Elizabeth, anyone, posted by shelliR on April 15, 2002, at 21:45:57
> Anyway, my pdoc told me today that it is too dangerous to use the fentanyl patch with nardil. Yet on the information that comes with the patch, it doesn't say "do not take this is you are taking an MAOI." In fact most drug companies will mention this first, even OTC drugs like antihistimies, etc.
Hi Shelli.I didn't know that you had elected to return to Nardil. I am interested to know what you are taking currently. Are you still planning to continue with Lamictal?
I have a couple of Vicaden tablets that I might want to use as a biological probe to see what happens. How much do you think would make a good test dose? What sorts of things might I expect to feel over the course of the first few hours if it were to help?
Thanks.
- Scott
Posted by shelliR on April 18, 2002, at 12:57:23
In reply to Re: Opiates and MAOIs » shelliR, posted by Elizabeth on April 16, 2002, at 22:09:25
Hi Elizabeth,
I called up Janssen (maker of the duragesic patch) and they didn't have any documentation saying not to do the patch with an MAOI. They did say that the dose of the MAOI may need to be adjusted, but I think that may have to do with hypertension.
I am still disappointed on my results with the durgesic patch. I do feel that I may not be absorbing it as well as I did the oxycontin or bupe, because the depression is still lingering significantly and I am up to 125mcg.
This is my third day on effexor (12.5mg); tomorrow I go up to 25mg. The good news is that I haven't throw it up like I did years ago. Now I just have to see if it actually helps.
Take care,
Shelli
Posted by shelliR on April 18, 2002, at 13:21:13
In reply to Re: RE Opiates and MAOIs - Elizabeth, anyone » shelliR, posted by SLS on April 17, 2002, at 22:15:26
Hi Scott,
>
> I didn't know that you had elected to return to Nardil. I am interested to know what you are taking currently. Are you still planning to continue with Lamictal?I was deciding between nardil and effexor as an anti-depressant. Nardil because I had been successful on that plus lamictal. I had wanted to try the lamictal itself for a while, then add nardil if necessary.
Anyway, my pdoc would not approve of codeine plus nardil. I didn't push it because I was almost equally interested in trying effexor; I had never done much of a trial with it. I am continuing the lamictal at 400mg.
> I have a couple of Vicaden tablets that I might want to use as a biological probe to see what happens. How much do you think would make a good test dose? What sorts of things might I expect to feel over the course of the first few hours if it were to help?
If you've never taken opiates before, or for a long time, I'd probably cut a 7.5 tablet in half. I had full antidepressant effects on that dose for a long time, before my pdoc decided oxycontin was the way to go. If you feel no improvement in an hour, then I'd go ahead and take the rest of the pill. I think that should be enough.I don't know what you can expect to feel. If it is a good anti-depressant for you, it should definitely increase your energy. I would take a half of hydrocodone, then go out and mow my lawn.
It also just made me feel healthy. Some people feel nausea at first, but I think that mostly does go away. If you do feel nausea, cut back to even less than 1/2 of 7.5. For me I feel a general good feeling; you might expect to feel a bit high at the beginning but this does go away. Then I just felt good/normal.
Anyhow, if you decide to try it, good luck. If I were you, I'd definitely think it was worth a try.
Let me know how it turns out (if...)
Take care,
Shelli
Posted by Elizabeth on April 19, 2002, at 19:42:07
In reply to Re: Opiates and MAOIs » Elizabeth, posted by kazoo on April 17, 2002, at 3:08:02
> > I don't think that's true.
> ^^^^^^^^^^^^^^^^^^^^^^^^^^^^
> But you don't know for sure.Of course not. If I knew for sure, I simply would have said, "That's not true," or something similar. I think Shelli is smart enough to be able to distinguish facts from opinions.
> > Some doctors believe that you shouldn't take opioids with MAOIs *at all*. Obviously this is wrong.
> ^^^^^^^^^^^^^^^^^^^
> How is this "wrong"? And "obvious" to whom?It's "wrong" in the sense that it's an incorrect belief. (What else would be meant by "wrong???") It's obvious that it's incorrect because there has been plenty of research on the use of several different opioids with MAOIs, as well as a number of well-documented case reports of lack of interaction. (Morphine is the best-studied opioids in this area.)
> > Morphine is definitely safe, and therefore codeine is too.
> ^^^^^^^^^^^^^^^
> However, one can accidentally overdose on morphine, so this makes it not "safe."*sigh* It should be obvious from the context that the meaning here is that morphine poses no special risk when combined with MAOIs. By your definition, there *aren't* any "safe" drugs, since *any* drug can cause adverse reactions.
I know you're a smart person, so it's difficult to believe that you don't have enough reading comprehension skills to be able to put a remark in context, distinguish fact from opinion, etc. I don't feel a need to dumb down my writing. If someone asks for a clarification, I'm happy to provide it, as I have for you; however, I don't think you really needed any clarifications, so I'm wondering why you requested them. Maybe you're trying to be pedantic. If so, that's unnecessary and disrespectful -- find another way to make your point, a straightforward way.
> Elizabeth, dear, you have provided much valuable information in your area expertise re. opiate drugs; however, I feel you may be a little too dogmatic in your approach to explain what works for you, therefore, what you believe to be true.
(Don't call me "dear.")
No, I do not assume that what works for me will work for anyone else, and I don't see how you could have gotten that impression. Anyway, the post you're responding to was about safety, not efficacy (and no, my comments on safety issues were not based on my own experience).
When I read your post, I wondered what was going on. You appear to be bothered by something. I would like to believe that it's just a misunderstanding or something, but I can't help feeling like there's something more to it. There are lots of people on this board who are enthusiastic about things that work for them and who regularly offer information about these treatments, recommend them to other people, and sometimes even exaggerate their efficacy. I don't believe I've ever done any of these things except for offering information about opioids when someone asks, and very occasionally suggesting them as an option if someone seems to be truly treatment-resistant (rare), so I'm wondering why you're making this accusation. But even if I did make overstated claims about opioids or something else based on my personal experience, would you honestly believe that I should be singled out? I'm sure you can understand why I'm skeptical here.
> I know from experience that it is not wise to make statements without backing up such statements with data or facts from empirical research and sources.
Sometimes I don't feel it's necessary (and it can be a pain in the *ss) to dig up citations; but I *don't* state opinions as though they were facts (I've already explained this at the very beginning of this post). This is a common thing -- *lots* of posts contain statements of fact that aren't backed up by citations. This is a support group, not a peer-reviewed scientific publication. If somebody asks for a citation, I can find one, but I really don't think I should be expected to provide a citation for every little thing that I say -- especially when you don't seem to be demanding the same of anybody else on the board. Again, your choice to single me out brings your motives into question.
> It is true that "conventional wisdom" doesn't always work all the time, and this is where you shine, my dear, in that you offer contrary, alternative methods and ideas to offset the blindly accepted; however, blanket statements to cover all bases can lead to some serious problems in some people.
(Don't call me "dear.")
I offer *information* (when someone asks for it) about what you call "alternative" options because there aren't many other people here who can answer questions on these subjects. I also answer questions and participate in discussions about subjects like the differences among different drugs of the same class, the process of getting a drug approved in the USA, medications for panic disorder, the effects of psych drugs on sleep architecture, the relative merits of different antidepressants and mood stabilizers in different types of mood and anxiety disosrders, when it's appropriate to use neuroleptics in nonpsychotic disorders, and of course drug interactions. Those are just some recent ones that I can recall. But anyway, it's not like I completely shun or ignore conventional treatments. (What do you mean by "contrary, anyway? I'm certainly not encouraging people to avoid anything that's common or standard.)
Also, I did not and do not make blanket statements. What I've said in this thread is correct to the best of my knowledge. If you'd like to dispute some of the actual content of my post, feel free. I'm not convinced it's worthwhile to criticize the presentation when you have nothing to say about the actual substance. It seems nitpicky, not to mention accusatory.
> I'm not sure what I'm trying to tell you here except maybe to be careful in making statements based on anecdotal knowledge and personal success stories.
And again, I didn't do that at all. I don't do that. I don't *need* to do that. I have plenty of books that I can consult, as well as a decent memory for stuff I've read in the past.
I'm not very sure what you're trying to say either. But I do think you should be more cautious about making accusations. It's something that should not be done lightly -- you could have asked questions that would have cleared up any misunderstanding that you had. That would have been the polite way to go about this. (Not calling me "dear" would also be helpful.)
> I remain a reader and follower of your posts,
Flattered.
-elizabeth
Posted by Elizabeth on April 19, 2002, at 19:58:50
In reply to Re: RE Opiates and MAOIs - Elizabeth, anyone » shelliR, posted by SLS on April 17, 2002, at 22:15:26
> I have a couple of Vicaden tablets that I might want to use as a biological probe to see what happens. How much do you think would make a good test dose? What sorts of things might I expect to feel over the course of the first few hours if it were to help?
How many do you have, and what strength? I think that 10 mg or so is a good starting dose. I can't predict what you'll experience if it goes well, but I think it should be a profound feeling of relief (not euphoria).
-e
Posted by Elizabeth on April 19, 2002, at 20:17:48
In reply to Re: Opiates and MAOIs » Elizabeth, posted by shelliR on April 18, 2002, at 12:57:23
> I called up Janssen (maker of the duragesic patch) and they didn't have any documentation saying not to do the patch with an MAOI.
Not surprising, since there aren't any case reports in the literature involving fentanyl-MAOI interactions!
> They did say that the dose of the MAOI may need to be adjusted, but I think that may have to do with hypertension.
(You mean hypOtension, right?)
> I am still disappointed on my results with the durgesic patch. I do feel that I may not be absorbing it as well as I did the oxycontin or bupe, because the depression is still lingering significantly and I am up to 125mcg.
I'm not sure what to say about this. It's very odd. Have you called the doc about it? Also, can you remind me:
* What made you decide to switch to Duragesic?
* What dose of buprenorphine were you on before switching? (not that I have any idea how to compute the equivalent fentanyl dose)
* How long ago did you switch?BTW, how are the side effects compared with oxycodone and methadone? I've heard fentanyl is easier on the periphery than other opioids.
> This is my third day on effexor (12.5mg); tomorrow I go up to 25mg. The good news is that I haven't throw it up like I did years ago. Now I just have to see if it actually helps.
I had vomit problems with immediate-release Effexor, too; Effexor XR was a lot more tolerable, I found. Are you going to switch to the XR when you get to a high enough dose? (12.5 is small! I don't think I've heard of anyone starting that low.)
Gosh, I noticed you recommended 3.25 mg to Scott as a starting dose of Vicodin. I suggested 10! I guess he should try the average (except I don't think that there is a 6.625 mg strength). In retrospect I think that 10 is a bit on the high end, although I still think that 3.25 is kind of low. 5 or 7.5 seems pretty reasonable, though (depending what strength pills he has).
Be well.
-elizabeth
Posted by SLS on April 22, 2002, at 11:57:42
In reply to Re: Opiates and MAOIs » SLS, posted by Elizabeth on April 19, 2002, at 19:58:50
> How many do you have, and what strength? I think that 10 mg or so is a good starting dose. I can't predict what you'll experience if it goes well, but I think it should be a profound feeling of relief (not euphoria).
Hi Elizabeth.I guess I screwed-up. I only have two 5mg tablets to work with. I was a bit sheepish to ask my friend for more. It was my impression that people feel something positive after their first dose. Duh.
I am very happy to know that MAOIs and opioids can be taken concurrently. Do you know if hydrocodone is safe to use in such a combination? I will probably be starting Nardil soon. I see my doctor on Wednesday. I was originally going to try the Vicoden thing without his knowledge, but I think I'd feel more comfortable working with him on that. If nothing else, my asking him will force his hand and demonstrate to me to what lengths he is willing to go to treat me.
I'd also like to try S-AMe before beginning Nardil. I'm currently taking imipramine and Lamictal. Any thoughts? Do you think it can be safely combined with MAOIs?
Thanks.
What's the deal with you and Effexor - if you don't mind me asking? If you've already addressed this in another thread, perhaps you can redirect me there. In any case, I hope (as always) that things work out for you. Are you still taking desipramine as well? I think Effexor can cause desipramine levels to rise, as they both use P450 2D6.
- Scott
Posted by Elizabeth on April 23, 2002, at 23:56:15
In reply to Re: Opiates and MAOIs » Elizabeth, posted by SLS on April 22, 2002, at 11:57:42
> I guess I screwed-up. I only have two 5mg tablets to work with.
Well, I may be overestimating. Different people need different amounts. The one time I had hydrocodone (after having my wisdom teeth removed), I got Vicodin HP: 10 mg hydrocodone and (I think) 660 of APAP. I thought it was pretty mild. That might just be me, though.
> I am very happy to know that MAOIs and opioids can be taken concurrently. Do you know if hydrocodone is safe to use in such a combination?
I know a few people who've done it, and there aren't any reports in the literature of interactions. The semisynthetic morphine and codeine derivatives (hydrocodone, oxycodone, hydromorphone, oxymorphone) should all be okay.
> I will probably be starting Nardil soon. I see my doctor on Wednesday. I was originally going to try the Vicoden thing without his knowledge, but I think I'd feel more comfortable working with him on that. If nothing else, my asking him will force his hand and demonstrate to me to what lengths he is willing to go to treat me.
Good luck with it. Unfortunately, a lot of doctors aren't willing to go out on that limb.
> I'd also like to try S-AMe before beginning Nardil. I'm currently taking imipramine and Lamictal. Any thoughts? Do you think it can be safely combined with MAOIs?
Which "it?" (Lamictal: yes. Imipramine: maybe. S-AMe: no.)
BTW, I was never taking Effexor and a TCA at the same time (I only ever combined TCAs with MAOIs). I had a seizure (at least, that's what the doctors in the hospital thought) when I was taking desipramine, and it turned out that my serum level was way high (600 or so). Technically I could have kept taking it, but I would have needed to get the serum levels checked a lot until I found a safe dose, and then I'd still need to have the level monitored regularly. This wasn't worth it to me -- desipramine worked about as well as Parnate but I didn't need to have blood tests when taking Parnate. I decided to give Effexor XR a try before going back on Parnate, though, and it works about equally well, too (not good enough to go off buprenorphine, but good enough to substitute for Parnate). I had tried Effexor XR once before, but when I'd been on it about a month, I became very sick and was diagnosed with the serotonin syndrome. After that I was scared away from Effexor. More recently I'd been thinking about it in retrospect and decided that it might be worthwhile to try it again, with caution; there wasn't a very clear link between the Effexor and the sickness. This time it seems to be fine.
-elizabeth
This is the end of the thread.
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