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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 28. This is the beginning of the thread.
Posted by Jerrympls on November 5, 2002, at 0:10:05
So - I get the impression that within the worl of psychiatry that amphetamines are "ok" while opiates (hydrocodone) are viewed more as euphoric, addictive , danger-pills reserved ONLY for severe pain?
My doctors in the past have had no problem putting me on amphetamines to help combat depression, fatigue and to help augment other ADs. Of course, this is an off-label use of a Schedule II drug.
Every time I've been on a pain med - like hydrocodone (Vicodin) it's always worked better than ANY antidepressant therapy I've been on - and it's Schedule III.
If I would ask to be put on an opiate for my depression - I'd be laughed at and thought of as a drug-seeking addict. But, if I request a stimulant - off-lable and labled more addictive (schedule II than opiates) by the government - it's perfectly fine?
Hear me correctly: I'm not complaining - I'm just wondering - why? i don't supposed there are any docs on here who'd care to respond.
This leads me to this: When the last AD treatment has been reached - when 11 years of life has been lost to a depression unresponsive to all "depression" treatments and combo therapies - when seven years of cognitive/behavioral therapy yields nothing - when ECT fails - when being off medication for a while pulls you deeper into darkness - when you're friends give up and your family ignores your illness - when there's nothing else - then what?
I've read that depression is a terminal illness. Cancer is too. For cancer, one is given meds - no matter how addictive, to make life feel a little bit better while cells take over organs and then body. Elderly patients in homes are usually on one pain killer or another. What makes it different for treatment-resistant depression? If my doc has 10 years of my medical history and concludes there is nothing else to try - why not put me on something like vicodin? Answer me these:
1) What's the difference between taking Vicodin (schedule III) for depression vs. amphetamine (schedule II) for depression?
2) What's the difference between taking Vicodin for depression vs. Prozac? With Prozac you have to take it every day and if you go off of it you have to go slowly because of the severe withdrawl.
Perhaps opiates are seen as "feel good" pills and feel good pills are only FAKE good and they just cover up the depression. Hmm. But that thinking would also be true for amphetamines - would it not?
OKk- this is too long and I'm just asking too many questions.
Anyone out there have an opinion? Insight?
Thanks
Posted by judy1 on November 5, 2002, at 2:22:41
In reply to Opiates = the Devil Amphetamines = Angels?, posted by Jerrympls on November 5, 2002, at 0:10:05
First of all, in CA at least vicodin (hydrocodone) is not a schedule 3 drug (that is triplicate scripts are needed)- morphine, fentanyl, methadone et al. are. Second, I couldn't agree more with your reasoning and if anybody is a candidate for opiate therapy it is you- a treatment resistant person with depressive disorder. There ARE some (a very few) pdocs who are willing to prescribe hydrocodone to their patients with depression (particularly anxious depression), they are difficult to find, but they are out there. I think it's a cyclical thing, opiates, then benzos were considered drugs sought out by abusers. But I agree as I posted earlier that the SSRIs are much more difficult to withdraw from then opiates or benzos. I know it is discouraging, but my pdoc prescribes hydrocodone to people with your history and I know for a fact others are out there. Are you close to a teaching hospital? That may be a good place to start. If not, I hate recommending this, but I've gotten vicodin on-line, I'm sure others have- it has been very helpful with my depression. I wish you the best- judy
Posted by utopizen on November 5, 2002, at 6:41:44
In reply to Opiates = the Devil Amphetamines = Angels?, posted by Jerrympls on November 5, 2002, at 0:10:05
If I take Vikoden for a few weeks as directed by a doctor, I will get severe withdrawls for a week.
If I take Adderall or Dexedrine or even Desoxyn (methamphetamine) I don't get any withdrawls after taking them for months and months.
Amphetamines are not necessarily addictive. I believe their addiction is typical in cases of abuse, as few experience withdrawls from normal dosing and use.
Posted by Larry Hoover on November 5, 2002, at 10:27:06
In reply to Opiates = the Devil Amphetamines = Angels?, posted by Jerrympls on November 5, 2002, at 0:10:05
> 1) What's the difference between taking Vicodin (schedule III) for depression vs. amphetamine (schedule II) for depression?
>
> 2) What's the difference between taking Vicodin for depression vs. Prozac? With Prozac you have to take it every day and if you go off of it you have to go slowly because of the severe withdrawl.
> Anyone out there have an opinion? Insight?
>
> Thanks
>
The answer to your questions is exceedingly complex. I'm not going to suggest that I've mastered the complexity, but I think I understand enough about the pharmacology to say that I don't think there's a person alive who understands the whole thing. Anyway.....Your body has an emergency system that handles pain. Pain, of course, is your body telling you that you're injured. But sometimes, experiencing pain is contrary to survival. Like being able to run on a broken leg.....if it gets you away from the lion... Many people in traumatic situations feel no pain....until later.
Long ago, we figured out how to activate that system artificially, using opiates. And, like the arrogant people we really are, we labelled the receptors for these exogenous (from outside) substances opiate receptors (as if Mother Nature had anticipated the opium poppy). Those receptors really are meant to bind with a variety of hormones like endorphins and enkephalins (and probably many other substances we've yet to stumble across).
We're only just beginning to realize the variety and extent of the various classes of opiate receptors, and how they affect other aspects of our mind/body interactions aside from pain, per se.
Pain is the sort of experience that can be assessed quite readily. Western medical science has primarily focussed on the analgesic aspects of opiates. We can rank the various opiates on a scale of analgesia. Analgesia occurs because the opiates bind to, and activate, particular opiate receptors involved in what is called nociception (pain sensing). The analgesic opiates bind to these receptors much more tightly than they do other classes of opiate receptors which we associate with euphoria and other mood-altering effects. In essence, the pain receptors get theirs first, and only after those receptors are saturated does an appreciable amount bind to the other ones. One of the ways to measure analgesic opiate dosages is to assess the "buzz factor". If you're getting too much of a buzz, your pain receptors are saturated. Of course, people not experiencing pain saturate their pain receptors quite easily, and a buzz is the only appreciable result.
Even what I've said so far is simplistic, so bear with me. We've discovered a vast number of ways to modify the base alkaloids found in opium. Each different compound has a different binding profile than any of the others. That is to say, each will have a different affinity for each of the numerous types and classes of opioid receptors. Heroin is a great pain-killer, but we know it binds other receptors too.
The ideal antidepressant opiate will not bind to pain-killing opiate receptors. It will not bind to receptors in the gut (leading to constipation). Blah blah blah. And it will not cause up-regulation of receptor synthesis. That's the big problem with opiates. When receptors saturate, the body makes more of them, to return sensitivity to the system. Your body quickly accomodates to the exogenous opiate, and you have to continually increase the dose to get the same effect.
Like I said at the beginning, the opioid system of receptors seems to be fine-tuned for emergency activation. Swift up-regulation of receptor synthesis seems to support that position. Chronic activation of the system seems to be mediated by other factors, and that's a whole 'nother essay.
Do any opiates work primarily as antidepressants? Well, the jury's still out on that one. The "war on drugs" political movement is certainly supressing research in this field. Recent abuses of sustained-release oxycodone don't work in our favour, either.
There are three semi-synthetic opiates which do seem to have promise as antidepressants, but it's likely that newer versions will be more specific in mode of action (if it ever comes to pass that the research is funded). Those three are dextromethorphan, tramadol, and buprenorphine.
There may be others, but even though these seem to have mood-elevating effects, it does seem that the effect is transitory. We haven't figured out why, or what to do about it.
Posted by vincent on November 5, 2002, at 11:23:14
In reply to Opiates = the Devil Amphetamines = Angels?, posted by Jerrympls on November 5, 2002, at 0:10:05
HI,
I'm a extra-resistant to all antidepressive therapyes too.
I'm extremely unipolar depressed: everyting is sad, disinterested in everithing, and all the world is grey and useless like my life.
I've tryed all kind of therapy without any success, but with worse symptoms.
I'm searching now for an alternative, that could be the Stimulants, to help me feeling a little better and a little alive.
I've read your post about vicodin, what can you tell me about it?
How it works? What is your experience about?
It helped you?
Thanxxxxxx very much for your help!
Posted by BrittPark on November 5, 2002, at 11:54:39
In reply to More about VICODIN, please! » Jerrympls, posted by vincent on November 5, 2002, at 11:23:14
There is a company called Pain Therapeutic developing less tolerance producing formulations of morphine and oxycodone. Their formulations are based on the observations of Crain and Shen, who noted that a combination of an opiate agonist, like morphine, in combination with a small amount of an opiate antagonist, like naltrexone, increases the analgesic affect of the opiate, and stops tolerance development in rats. They are in Stage II trials (safety).
If these formulations make it to the market they may be magic bullets for TRD. Of course they may not. Perhaps the addition of naltrexone eliminates the euphoric effect, or has no effect on tolerance to the euphoric effect. In which case they are unlikely to be of use in the treatment of depression. This is assuming that the AD effect of opioids is identical to the euphoric effect of opioids.
Posted by BrittPark on November 5, 2002, at 12:00:42
In reply to Re: Opiates = the Devil Amphetamines = Angels? » Jerrympls, posted by judy1 on November 5, 2002, at 2:22:41
Actually in CA vicodin is schedule 3 and morphine etc and amphetamines are schedule 2. Schedule 2 drugs require prescriptions in triplicate. Schedules 3 and below do not.
FYI,
Britt
Posted by Kara Lynne on November 5, 2002, at 12:05:41
In reply to Re: Opiates = the Devil Amphetamines = Angels?, posted by Larry Hoover on November 5, 2002, at 10:27:06
My doctor says using opiates is indeed like making a deal with the devil, though through no fault of our own. It's just a tolerance issue, and addiction is inevitable until they come up with alternatives so that the doses don't have to keep on being increased.
Posted by BrittPark on November 5, 2002, at 12:23:21
In reply to Re: Opiates = the Devil Amphetamines = Angels?, posted by Kara Lynne on November 5, 2002, at 12:05:41
Boy, I'm a blabber-mouth on this topic. I don't think that addiction is inevitable with opioids. There are plenty of people with moderate to severe chronic pain (slipped disk etc.) who are able to take a stable dose of vicodin (for instance) without loosing efficacy. There are also some posts on this board from people who are using vicodin for depression and not needing to escalate. This is not to say that everybody can take opioids without dose escalation. In fact I expect that the vast majority of people do develop tolerance.
So I think your doctor is technically incorrect, even though he's correct for most people. However, its easy enough to find out whether you are one of the lucky ones. A two week trial of an opioid will expose tolerance development. At that point it's usually fairly easy to discontinue.
Britt
Posted by vincent on November 5, 2002, at 12:40:51
In reply to Re: Opiates = the Devil Amphetamines = Angels? » Kara Lynne, posted by BrittPark on November 5, 2002, at 12:23:21
HI, could you please tell me which are the most known brand names of amphetamine drugs?
I would like to know if one of them is on the market in the pharmacyes of my country.
Thank you all for your help!
Posted by Kara Lynne on November 5, 2002, at 14:15:42
In reply to Which are the brand names of Amphetamines? » BrittPark, posted by vincent on November 5, 2002, at 12:40:51
I do develop a tolerance. I do believe you that maybe some people don't, but I don't understand how it would be physically possible.
Posted by BrittPark on November 5, 2002, at 15:20:02
In reply to Reply to Britt, posted by Kara Lynne on November 5, 2002, at 14:15:42
It's still unknown how tolerance to opioids develops. It was only discovered recently, for example, that exogenous opiates like morphine caused clustering of opioid receptors, but blocked endocytosis of the clusters. The addition of a compound that causes the clusters to be endocytized actually blocks tolerance development. It used to be believed that cellular uptake of opioids was necessary for tolerance development-- exactly the opposite of what's been found.
I believe part of the mechanism for opioid tolerance is simple down-regulation of opioid receptors. There is no physical reason that some people don't down regulate when challenged, perhaps because they already have something biologically amiss that causes opioid receptors to be up-regulated or desensitized. There could also be a genetic component. This has been found to be true for alcohol (which by the way affects the opioid system). I imagine there's a genetic component to cocaine addiction too, since some people are completely take-it-or-leave it and others become addicted within 2-3 exposures.Take a look at my other post about opioid agonist / low dose antagonist drug development.
Cheers,
Britt
Posted by judy1 on November 5, 2002, at 17:16:47
In reply to Re: Opiates = the Devil Amphetamines = Angels? » judy1, posted by BrittPark on November 5, 2002, at 12:00:42
Posted by fachad on November 5, 2002, at 21:04:51
In reply to Opiates = the Devil Amphetamines = Angels?, posted by Jerrympls on November 5, 2002, at 0:10:05
The first major point my pdoc made to me about pstims being controlled substances is that the schedule classification (C-II, C-III, CIV, etc) is a purely LEGAL, not a MEDICAL classification.
Those classifications were cooked up by law enforcement personal (the DEA), not medical professionals (the AMA).
Even though the descriptions given in the Schedule list use medical sounding expressions, like "potential for dependence, withdrawal, etc.", my doc told me that the schedule number a drug was given was more related to it's diversion potential than it's addictive properties.
He maintained that benzodiazepines, which are C-IV, are plainly much more addictive than stimulants, which are C-II. Just look at someone who has abruptly stopped BZDs vs someone who has abruptly stopped pstims. And no one advocates "drug holidays" for Paxil or Effexor, but that is common practice for stims. That pretty much blows the theory that amphetamines are addictive and SSRI's are not, and shows that a C-II can be less addictive than a C-IV.
> So - I get the impression that within the worl of psychiatry that amphetamines are "ok" while opiates (hydrocodone) are viewed more as euphoric, addictive , danger-pills reserved ONLY for severe pain?
>
> My doctors in the past have had no problem putting me on amphetamines to help combat depression, fatigue and to help augment other ADs. Of course, this is an off-label use of a Schedule II drug.
>
> Every time I've been on a pain med - like hydrocodone (Vicodin) it's always worked better than ANY antidepressant therapy I've been on - and it's Schedule III.
>
> If I would ask to be put on an opiate for my depression - I'd be laughed at and thought of as a drug-seeking addict. But, if I request a stimulant - off-lable and labled more addictive (schedule II than opiates) by the government - it's perfectly fine?
>
> Hear me correctly: I'm not complaining - I'm just wondering - why? i don't supposed there are any docs on here who'd care to respond.
>
> This leads me to this: When the last AD treatment has been reached - when 11 years of life has been lost to a depression unresponsive to all "depression" treatments and combo therapies - when seven years of cognitive/behavioral therapy yields nothing - when ECT fails - when being off medication for a while pulls you deeper into darkness - when you're friends give up and your family ignores your illness - when there's nothing else - then what?
>
> I've read that depression is a terminal illness. Cancer is too. For cancer, one is given meds - no matter how addictive, to make life feel a little bit better while cells take over organs and then body. Elderly patients in homes are usually on one pain killer or another. What makes it different for treatment-resistant depression? If my doc has 10 years of my medical history and concludes there is nothing else to try - why not put me on something like vicodin? Answer me these:
>
> 1) What's the difference between taking Vicodin (schedule III) for depression vs. amphetamine (schedule II) for depression?
>
> 2) What's the difference between taking Vicodin for depression vs. Prozac? With Prozac you have to take it every day and if you go off of it you have to go slowly because of the severe withdrawl.
>
> Perhaps opiates are seen as "feel good" pills and feel good pills are only FAKE good and they just cover up the depression. Hmm. But that thinking would also be true for amphetamines - would it not?
>
> OKk- this is too long and I'm just asking too many questions.
>
> Anyone out there have an opinion? Insight?
>
> Thanks
>
Posted by Jerrympls on November 5, 2002, at 21:13:41
In reply to Legal vs. Medical Classification » Jerrympls, posted by fachad on November 5, 2002, at 21:04:51
> The first major point my pdoc made to me about pstims being controlled substances is that the schedule classification (C-II, C-III, CIV, etc) is a purely LEGAL, not a MEDICAL classification.
>
> Those classifications were cooked up by law enforcement personal (the DEA), not medical professionals (the AMA).
>
> Even though the descriptions given in the Schedule list use medical sounding expressions, like "potential for dependence, withdrawal, etc.", my doc told me that the schedule number a drug was given was more related to it's diversion potential than it's addictive properties.
>
> He maintained that benzodiazepines, which are C-IV, are plainly much more addictive than stimulants, which are C-II. Just look at someone who has abruptly stopped BZDs vs someone who has abruptly stopped pstims. And no one advocates "drug holidays" for Paxil or Effexor, but that is common practice for stims. That pretty much blows the theory that amphetamines are addictive and SSRI's are not, and shows that a C-II can be less addictive than a C-IV.
>
>That makes a lot of sense actually - because I had a pdoc once who refused to prescribe benzos to anyone - no matter what - but he easily wrote me prescriptions each month for Adderall.
Posted by Brandymac26 on November 6, 2002, at 9:51:00
In reply to Opiates = the Devil Amphetamines = Angels?, posted by Jerrympls on November 5, 2002, at 0:10:05
I have a question, now that you guys bring up opiates. I had my gallbladder removed about 4 months before I started having bad panic attacks, and slipping into depression. I'm wondering, since my doc's prescribed me opiates like vicodin, and morphine for about 2 months before the surgery, and I also took them after the surgery for pain, Do you think that these drugs may have had an effect on my panic attacks and depression starting, or is it coincidence? Thanks for any input!
Brandy
Posted by Larry Hoover on November 6, 2002, at 10:11:20
In reply to Re: Opiates = the Devil Amphetamines = Angels?, posted by Brandymac26 on November 6, 2002, at 9:51:00
The use of opiates is clearly a risk factor for depression. Hydrocodone and oxycodone have been linked to depression in the literature. I don't know about panic attacks, but I don't see any reason to discount the link.
Posted by BrittPark on November 6, 2002, at 10:52:44
In reply to Re: Opiates = the Devil Amphetamines = Angels?, posted by Brandymac26 on November 6, 2002, at 9:51:00
You were on opiates for an extended period of time long enough to have built up a physical dependency.. It seems quite possible that you might develop panic attacks from opiate discontinuation.
Posted by BrittPark on November 6, 2002, at 11:50:24
In reply to Re: Opiates = the Devil Amphetamines = Angels?, posted by Larry Hoover on November 6, 2002, at 10:11:20
I've been googling for the past hour trying to find statistics about dysphoria and opiates. The only thing I found is the prescribing information for oxycontin which doesn't even have dysphoria listed as a possible side effect. If you have informations about the frequency of dysphoria from opioids I'd be interested in a reference.
Britt
Posted by Larry Hoover on November 6, 2002, at 14:11:23
In reply to Re: Opiates = the Devil Amphetamines = Angels? » Larry Hoover, posted by BrittPark on November 6, 2002, at 11:50:24
Sorry Brett, I'm not finding my references. In '97, following some serious shoulder reconstruction, I was on morphine and oxycodone. On switching to codeine, I experienced a seriously black depression, and was hospitalized. Some months after my release, I investigated, and came up with a link to the oxycodone as a triggering event. I can't find that evidence today.
Larry
Posted by Jerrympls on November 6, 2002, at 20:33:49
In reply to Re: Opiates = the Devil Amphetamines = Angels?, posted by Larry Hoover on November 6, 2002, at 14:11:23
I was on vicodin for about 4-5 weeks a couple months ago because of surgery. I had to take 1-2 every four hours. Long story short - I didn't build up any tolerance what so ever. I had a wonderful improvement in my depression - and I never felt high or drugged. Interesting.....
Posted by jerrympls on November 6, 2002, at 22:48:01
In reply to Re: Opiates = the Devil Amphetamines = Angels? » Jerrympls, posted by judy1 on November 5, 2002, at 2:22:41
Judy - please email me
Jerry
slateman@mn.rr.com
Posted by Larry Hoover on November 7, 2002, at 18:36:34
In reply to Re: Opiates = the Devil Amphetamines = Angels? » Larry Hoover, posted by BrittPark on November 6, 2002, at 11:50:24
I started looking at opiates all over again, and I'm finding some recent studies showing bizarre and seemingly contradictory effects.....one substance simultaneously acting as an agonist, inverse agonist and antagonist, in the same signalling system....dimerization of all sorts of receptors... not just opiate/opiate, but also sigma/opiate and alpha-2 adrenergic/opiate.....simultaneous up-regulation of sensitivity with down-regulation of receptor trafficking.....I don't know how on earth one is supposed to make sense of this all.
Maybe opiates *are* the devils work....
Lar
Posted by BrittPark on November 7, 2002, at 20:00:54
In reply to Re: Opiates = very weird, Britt?, posted by Larry Hoover on November 7, 2002, at 18:36:34
> I started looking at opiates all over again, and I'm finding some recent studies showing bizarre and seemingly contradictory effects.....one substance simultaneously acting as an agonist, inverse agonist and antagonist, in the same signalling system....dimerization of all sorts of receptors... not just opiate/opiate, but also sigma/opiate and alpha-2 adrenergic/opiate.....simultaneous up-regulation of sensitivity with down-regulation of receptor trafficking.....I don't know how on earth one is supposed to make sense of this all.
>
> Maybe opiates *are* the devils work....
>
> LarYou may be right that opiates are the devils work. Morphine and friends were not evolved for our benefit. More probably as pest control for Papaver Somniferum. Of course that doesn't mean we can't make use of and learn from opiates.
The biochemistry of opiods does seem to be exceedingly complex. I'm a biochemist by training and still find myself perplexed. What I do know is that in some cells there are mu-opiate receptors attatched to both inhibitory and excitatory G proteins. Two phenomena support this. At low concentrations pure agonists like morphine can act as antagonist and result in hyperalgesia rather than analgesia. The other is the ability of low doses of opioid antagonists like naltrexone to enhance the analgesic properties of agonists and further stop or at leas delay the development of opioid tolerance. Then there are the studies that have found that opiates cause clustering of opiate receptors but prevent endocytosis of the clusters. When a compound that stimulates endocystosis is added tolerance development is lowered, at least in vitro.
There is much to learn.
Cheers,
Britt
I think of the complex biochemistry of opioids as a good thing because it means new drug targets are likely to be found, both for pain relief and, I hope, depression.
Posted by Jerrympls on November 7, 2002, at 20:06:50
In reply to Re: Opiates = very weird, Britt? » Larry Hoover, posted by BrittPark on November 7, 2002, at 20:00:54
I wonder if the "oddities" of the opioid system are cause for the severe dysphoria I experienced after a small dose of morphine post-surgery a year ago. I felt horrible. The same thing goes for codeine but not as severe. But then hydrocodone makes me feel as tho my well-being is normal. no dysphoria.
Hmm....
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