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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 51 to 75 of 262. Go back in thread:
Posted by Mattkit on January 25, 2003, at 19:15:02
In reply to Re: opiates and major depression, posted by Blah on January 25, 2003, at 17:32:02
I sure would like to know if it is possible to take opiates in a controlled manner. As with any drugs or alcohol when one is out of control its a
problem. I know alot of people who have a couple
of drinks of wine thru the day and it is not a problem. I wish I could try doing this but with opiates because it seems to me that when they are in my system I have come "up" to the level of how
"normal" people feel. I actually feel normal for once.
Posted by ShelliR on January 25, 2003, at 19:25:40
In reply to Re: opiates and major depression, posted by Blah on January 25, 2003, at 17:32:02
>When you say pain doctor what kind of doctor do you mean, an orthopiedist? I probably spelled that wrong. What I'm asking is what would
I look under in the yellow pages?<My doctor is listed under physical medicine. I was referred to him years ago for a misdiagnosed stomach spasm years ago and more recently for the chest pain. Many of the doctors in the pain field also have a background in anesthesiology.
I just did a yahoo yellow pages search, put in physicians and pain and most specialists were listed either under pain and rehabilitation or pain management. I think I'd go for pain management out of the two, or else get a referral from your internist or primary physician.
Posted by ShelliR on January 25, 2003, at 20:36:39
In reply to Re: opiates and major depression, posted by Blah on January 25, 2003, at 17:32:02
One more thing:
My pain doc wouldn't treat me unless I also was being treated by a psychiatrist. Since my pdoc wouldn't treat me if I was on opiates, I changed pdocs to one that the pain guy recommended. I like the new pdoc; he won't prescribe opiates, but he accepts that I am taking them as part of my treatment. I am exploring other options with him and with my homeopathic doctor.
Posted by bee happy on January 26, 2003, at 21:44:50
In reply to Re: opiates and major depression » Blah, posted by ShelliR on January 25, 2003, at 20:36:39
I have been treated for depression with Buprenorphine for the last 6 months and I knew the first day that it worked for me. If you have a compassionate family doctor who knows you well you might want to ask him or her to try it just for a day or two...to see if it works for you. It is not a triplicate. This drug was studied at Harvard.Find the study on the internet and show your doctor.
Posted by Peter S. on January 26, 2003, at 22:24:18
In reply to Re: opiates and major depression, posted by bee happy on January 26, 2003, at 21:44:50
Hi bee,
Can you say a little more about your buprenorphine experience. How much do you take? HOw often? How do you take it- sublingually? Any side effects?
Thanks!
Petrer
> I have been treated for depression with Buprenorphine for the last 6 months and I knew the first day that it worked for me. If you have a compassionate family doctor who knows you well you might want to ask him or her to try it just for a day or two...to see if it works for you. It is not a triplicate. This drug was studied at Harvard.Find the study on the internet and show your doctor.
Posted by androog on January 26, 2003, at 22:30:05
In reply to Buprenorphine-- bee happy, posted by Peter S. on January 26, 2003, at 22:24:18
bee-
Can you also tell us if you have built up a tolerance for the buprenorphine?
Thanks,
androog
Posted by Luka62 on January 26, 2003, at 22:30:29
In reply to Re: opiates and major depression » Blah, posted by androog on January 21, 2003, at 13:29:13
WOW! I can't believe there's someone else out there who's had an experience with Ultram and depression. I've been taking Ultram for several years. Mind you, I've been prescribed Ultram for chronic pain. But I definitely noticed early on how it lifts my mood. I'm also on Nardil and Lamictal. Interestingly though, when I was taken off the Nardil for a trial period , the Ultram didn't seem to have any effect, so I figured it must be the interaction.
If I take more than is prescribed, I can start to have breathing difficulty though.
Recently I went to a neurosurgeon who has me taking daily, so I don't have to worry as much about whether my reg doc will rx it. (My psych. doc does not prescribe. it)
Posted by androog on January 27, 2003, at 1:49:04
In reply to Re: opiates and major depression » androog, posted by Luka62 on January 26, 2003, at 22:30:29
Watch out for that Nardil! It put me in the hospital hooked up to an EKG, sucking on nitroglycerin. They didn't tell me I couldn't use OTC nasal spray while on Nardil, just that I couldn't eat certain things.
And they think opiates are dangerous!
Glad to hear the Ultram is working for you.
androog
Posted by Ame Sans Vie on January 27, 2003, at 4:14:08
In reply to Re: opiates and major depression, posted by androog on January 27, 2003, at 1:49:04
Well, in the past I've been prescribed Hycodan (Canadian formulation), propoxyphene HCl, codeine, and hydromorphone. The Hycodan (at a dose of 15mg q8hr) worked especially well-- it both relieved the anxiety, yet didn't have me throwing up all day. I'm interested in trying buprenorphine, and it shouldn't be difficult to obtain it (or hydrocodone) seeing as my pdoc already has me on Klonopin, Valium, Ativan, Xanax, and just a few days ago called in prescriptions for BuSpar and Marinol (which works incredibly well, I might add... I'd rather not be taking it though, on the basis of drug testing for when I finally get out to look for a job. I have the feeling that most employers would frown upon finding THC in your system, even if it were backed up by a Rx). Another consideration is Stadol (butorphanol) nasal spray-- anyone have any experience at all with this stuff? I've used it recreationally years ago, but that was before my disorder(s?) hit full force. TIA!
--Michael
Posted by utopizen on January 27, 2003, at 6:12:34
In reply to Opioids and anxiety...?, posted by Ame Sans Vie on January 27, 2003, at 4:14:08
Okay, I don't know how Canada works, but I'm assuming they did model their drug schedules roughly around ours because we were the first to have them.
While benzos like Klonopin may be controlled, they're a far cry from an opioid. And Marinol is not an exciting drug. If you think this, you are having a placebo effect. It is an isolation of the anti-nausea properties of THC, and is very similar to ondanestron in effect. There's nothing exotic aboutt that.
Your doctor will laugh at you. I'm just trying to bring you down to Earth. Good luck with your anxiety. But why isn't Klonopin working??
> Well, in the past I've been prescribed Hycodan (Canadian formulation), propoxyphene HCl, codeine, and hydromorphone. The Hycodan (at a dose of 15mg q8hr) worked especially well-- it both relieved the anxiety, yet didn't have me throwing up all day. I'm interested in trying buprenorphine, and it shouldn't be difficult to obtain it (or hydrocodone) seeing as my pdoc already has me on Klonopin, Valium, Ativan, Xanax, and just a few days ago called in prescriptions for BuSpar and Marinol (which works incredibly well, I might add... I'd rather not be taking it though, on the basis of drug testing for when I finally get out to look for a job. I have the feeling that most employers would frown upon finding THC in your system, even if it were backed up by a Rx). Another consideration is Stadol (butorphanol) nasal spray-- anyone have any experience at all with this stuff? I've used it recreationally years ago, but that was before my disorder(s?) hit full force. TIA!
>
> --Michael
Posted by androog on January 27, 2003, at 11:31:06
In reply to Re: Opioids and anxiety...?, posted by utopizen on January 27, 2003, at 6:12:34
Hi Everyone,
With regards to Marinol, the makers of the drug have this to say on their website:
"A cannabinoid dose-related “high” (easy laughing, elation and heightened awareness) has been reported by patients receiving Marinol in both the antiemetic (24%) and the lower dose appetite stimulant
clinical trials (8%)..."Having been through the drug ringer, I've noticed that not everyone has the same reaction to any given drug. What might give me a boost might make someone else drowsy. That kind of thing.
So I don't think it's a stretch to believe that Ame Sans Vie (Isn't "Sans Vie" French for "without life"? Cool spooky name for a depressed person!) might experience a feeling of well-being by taking Marinol.
androog
Posted by utopizen on January 27, 2003, at 12:04:41
In reply to Re: Opioids and anxiety...?, posted by androog on January 27, 2003, at 11:31:06
This would explain the similarities in logistical transport between Marinol and Uranium security wise.
But isn't it $40 a pill? Um, I wonder if my health insurance covers it. Must be one of those "Tier 3" drugs that cost a whopping $25 in my co-payment.
> Hi Everyone,
>
> With regards to Marinol, the makers of the drug have this to say on their website:
>
> "A cannabinoid dose-related “high” (easy laughing, elation and heightened awareness) has been reported by patients receiving Marinol in both the antiemetic (24%) and the lower dose appetite stimulant
> clinical trials (8%)..."
>
> Having been through the drug ringer, I've noticed that not everyone has the same reaction to any given drug. What might give me a boost might make someone else drowsy. That kind of thing.
>
> So I don't think it's a stretch to believe that Ame Sans Vie (Isn't "Sans Vie" French for "without life"? Cool spooky name for a depressed person!) might experience a feeling of well-being by taking Marinol.
>
> androog
Posted by bee happy on January 27, 2003, at 15:19:02
In reply to Buprenorphine-- bee happy, posted by Peter S. on January 26, 2003, at 22:24:18
To elaborate on my battle with depression would only make you more depressed. The darkness fell about two years ago. After seeing a therapist for several weeks she came to the conclusion that it must be chemical,and referred me to a "pdoc" for the grueling months of trying all the new improved meds.The ones I can remember are Serzone, Wellbutrin, Prozac, Celexa, all of them made me feel worse..some of them made me physically ill.i had an alergic reaction to Serzone and was a walking mucus membrane for a week. I think I tried about 10 different things within the year. In speaking with my therapist I mentioned(in the very first visit) that I had always felt normal on codiene. That I had in fact had a problem with it in my youth and went through rehab to stop.(17 years ago). One day in session her face lit up and said she had heard of a study using opiates for depression and I should ask the pdoc about it. He had heard of it but wanted to get more information before sending me off with a prescription.Psychiatrists are busy treating some very sick psycotic patients with problems far worse than mine and I knew it would be up to me to find the research.I was very motivated. Here was someone telling me that perhaps I was not a druggie but had been self medicating depression all those years.I found the research study on the internet..right down to individual histories and results. Armed with that...he first tied Tramadol and then Buprenorphine. Tramadol seemed only to relieve the physical achiness that I felt not the anhedonia and fantasies of driving my car off a cliff on the Big Sur Hwy. It did nothing to change my mental state. You asked about dosage and weather I have built up a tolerance. I started on very small dosage .3mg 3 x's a day. and escalated to 2 mg 4 X's a day over the course of three months. It would apprear that I had built up a tolerance if I had not read that in treating with Methadone or Buprenorphine dosage is everything and too little can be as bad as too much. I have leveled off to 2 mg 3x's a day and sometimes I actually forget to take it.So that must say something, I'm not sure what. I have read that buprnorphine maintenance patients can go 2 days without their dose. So, am I just an ex opiate addict on Buprenorphine maintenance or a depression patient on the one drug that works for me? My family doctor likens it to a Diabetic...who without insulin would die. If I were not on this drug I'm not sure I'd be here writing this. It was that bad. I am on a compunded sub lingual gummy lozenge now. But Subutex and Suboxone have already been approved for addiction treatment in the U.S.and your family doctor can prescribe a drug for something other than it was approved. I think you will be hearing alot more about this in the very near future. I hope there is a backlash on this fear of prescribing. Yes there are doctors who might abuse the privilege...monitoring their writing practices is a good thing, but don't make good doctors afraid of using good medicine when necessary. I am lucky to have 2 doctors,who knowing my history, were not afraid. God bless them. Sorry to have gotten off on a moral rant...but "Blah's" story really hit me as the Catch 22 of "modern medicine". He's the reason I posted in the first place. I had been a lurker here for some time and was just checking in to see how some of the folks were doing. I am not Rececca of Sunnybrook Farm. I really do like bees. Alot. You asked about side effects. An odd one considering that opiates are known to constipate. I am a clockwork wonder now. That's all for me. No others. I wish I were better at explaining how it effects me....it's not a high...it's more a feeing of well being. I still get anxious at times and sad or angry when appropriate...it's does not numb me. It makes me feel the way I thought normal people felt all those years when I knew I was not "normal". More in the moment. Be here now. Now, I am. I hope this helps someone. It felt good to tell it. Thanks all.
Posted by juanantoniod on January 27, 2003, at 16:26:33
In reply to Re: opiates and major depression, posted by androog on January 27, 2003, at 1:49:04
I just did a search for Buprenorphine and deprssion in Medline and came up with 0 matches. Anyone else have better luck locating the studies supporting opiate use for depression?
Antonio
Posted by juanantoniod on January 27, 2003, at 18:38:27
In reply to Re: opiates and major depression, posted by juanantoniod on January 27, 2003, at 16:26:33
Forgive my ignorance. I just went to the Journal of Clinical Psychiatry's Website for this information and found the article. You may find them at psychiatrist.com.
> I just did a search for Buprenorphine and deprssion in Medline and came up with 0 matches. Anyone else have better luck locating the studies supporting opiate use for depression?
>
> Antonio
Posted by BrittPark on January 27, 2003, at 18:51:47
In reply to Re: opiates and major depression, posted by juanantoniod on January 27, 2003, at 16:26:33
I just did a medline on "buprenorphine depression" and got 161 hits. Almost all are concerned with respiratory depression. There are three relevant references:
Biol Psychiatry 1996 Jun 15;39(12):989-90
Buprenorphine for depression: the un-adoptable orphan.Callaway E.
Publication Types:
EditorialJ Clin Psychopharmacol 1995 Feb;15(1):49-57
Buprenorphine treatment of refractory depression.Bodkin JA, Zornberg GL, Lukas SE, Cole JO.
McLean Hospital, Consolidated Department of Psychiatry, Harvard Medical School, Belmont, MA 02178, USA.
Opiates were used to treat major depression until the mid-1950s. The advent of opioids with mixed agonist-antagonist or partial agonist activity, with reduced dependence and abuse liabilities, has made possible the reevaluation of opioids for this indication. This is of potential importance for the population of depressed patients who are unresponsive to or intolerant of conventional antidepressant agents. Ten subjects with treatment-refractory, unipolar, nonpsychotic, major depression were treated with the opioid partial agonist buprenorphine in an open-label study. Three subjects were unable to tolerate more than two doses because of side effects including malaise, nausea, and dysphoria. The remaining seven completed 4 to 6 weeks of treatment and as a group showed clinically striking improvement in both subjective and objective measures of depression. Much of this improvement was observed by the end of 1 week of treatment and persisted throughout the trial. Four subjects achieved complete remission of symptoms by the end of the trial (Hamilton Rating Scale for Depression scores < or = 6), two were moderately improved, and one deteriorated. These findings suggest a possible role for buprenorphine in treating refractory depression.
Lancet 1982 Sep 25;2(8300):709
Antidepressant effects of buprenorphine.
Emrich HM, Vogt P, Herz A, Kissling W.
Publication Types:
Clinical Trial
Letter
Randomized Controlled TrialAs you can see there hasn't been much research into opioids as antidepressants. My guess is that the DEA discourages the NIH from funding such studies. Sad but true for the forseeable future.
Cheers,
Britt
Posted by BrittPark on January 27, 2003, at 19:57:25
In reply to Re: opiates and major depression, posted by juanantoniod on January 27, 2003, at 18:38:27
I found a pdf of a Dr. Callaway's editorial. It pretty much sums up the sad state of opioid therapy.
It can be found at http://www.sciencething.org/Callaway.pdf
Posted by Mattkit on January 27, 2003, at 23:09:58
In reply to Re: Buprenorphine-- bee happy, posted by bee happy on January 27, 2003, at 15:19:02
Wow Bee thanks this sounded alot like my experience and gives me hope that I may also
do well on this
geez its amazing how a message board can help
your life
thanks again
Posted by bee happy on January 27, 2003, at 23:18:12
In reply to Re: opiates and major depression, posted by BrittPark on January 27, 2003, at 19:57:25
http://balder.prohosting.com/~adhpage/bupe.html The above is the internet location for the research study on Buprenorphine and depression. No spelling is not a side effect. I couldn't spell before. Or type !
Posted by Blah on January 27, 2003, at 23:18:12
In reply to Re: opiates and major depression » juanantoniod, posted by BrittPark on January 27, 2003, at 18:51:47
I know a pdoc who would rx buprenorphine, but she says it's not in stores yet, and I think she's waiting for something from the gov. too, but maybe she's just waiting for it to come to drug stores. I think I may switch to her anyway though. I'm not sure about this specialist. He expects me to try a plethera of other medications before I try an opioid, and I do not have that kind of time or energy anymore. I'm also running out of ambien, and if at my next visit he is not willing to give me an rx I will dump him. Often I find it impossible to sleep. This has been true my whole life. My body is not capable of a sleep schedule, I've tryed many times. When I can't sleep I must have ambien cause this is maybe the most depressing and dangerous time for me. If this "specialist" can't understand that , and instead drones on about addiction (which believe me is not a problem for me I only take it when I need it) then I will dump him and go to the other one. More reasources means nothing if you don't care about the suffering of your patient. However there is another problem. I know that I have many personality dissorder traits along with the depression. I have come to the conclusion that my core problem may be traits of schizotypal personality disorder, which means I'm mildly psycotic, even autistic in some ways. I don't have hallucinations or unearthly delusions, but I feel so separated from people even though I can empathise with them. When I try to do things alone I get lost in myself, this is of course much worse the more depressed I am. When I have occasionaly felt good or even when I had hope I still had difficulty, but I could still push through, and even have some succssess. However, I don't feel good at all anymore, and I have no hope left. I feel angry that after all my years in the mental health system I had to figure this out for myself. I've been told everything from 'I wasn't doing my school work or cleaning my room so I could get back at my parents' to 'I was lazy' to 'I was just trying to get attention by being different' to 'its because you have no selfesteem' I now see that all my deniles of these premesses were right, my lack of self esteem came from a knowledge of my limits contrasted with what others expected of me, and made me expect of myself. I was a fool to listen to anyone above myself, even if they did have a Phd. after their names. Supposedly the only drugs that would help my thought problems are antipsycotics. I refuse to take these drugs. They all have the possibility of PERMANANT parkinsons like symtoms (loss of motor control) I have nothing already, to loose even more control of my body would finish me. The only one that doesn't have this possibility is Clozapine, but you must get weekly drug screenings cause it will kill all your white blood cells. My Imunesystem is week enough already thank you. Antidepressants are sometimes given for the accompanying depression, but we already know they don't work for me. I'm willing to try maybe two mood stabalizers, but that's it. I will not try endless drugs from the same class ever again. I'm also thinking of experimenting with smart drugs from europe which aren't available here, but are not controled substances. The best thing for me would be a loving and supportive attmospher, but that won't exist for me while I'm in so much mental and physical pain. Maybe in this increasingly fascist world that support is never possible for me, but if an Opioid lets me feel some joy, and lets me function to some extent maybe I can find a satisfying way to be a part of it... Somehow.
Posted by Blah on January 27, 2003, at 23:42:48
In reply to Re: opiates and major depression, posted by bee happy on January 27, 2003, at 23:18:12
I showed my last pdoc that study she hardly read it an laughed in my face. She made very mocking remarks about my continuos irritable bowel symtoms, "This will probably give you diarea, ha ha." This is psyciatry not science: facts mean nothing! In the 50s homosexuality was considered psychopatic and they were given ECT and Labotomies. In the 80s and 90s people were druged and hypnotized till they showed multipe personalities, and addmitted to being ritualy abused by satanists. Today the drug companies rule even though more and more people aren't getting better, and pdocs tout genetics as the key even though not a single genetic study has been able to be repeated (like Dean Hammers infamous gay gene study). In the end consensus is not proof. Pdocs are by far the most arogant of all dr.s with very few exception. Anything out of there accepted bag of tricks usually meets with "Oh you silly silly patient", a fear of loosing control over you, or worse being chastized because you have blastfeemed against their holy faith.
I'm sorry if this sounds synical, but I used to trust pdocs. When their drugs didn't work they would blame me, and I would feel terrible guilt even though I knew I did nothing wrong. Now I take an active part of my own treatment, and they are very threatened by this, and that fear always replaces compasion, because they don't care bout me much to begin with. Except for a select few, I feel pdocs are the most defencive, insencitive, egotistical monsters on the face of the planet.
Sorry, that's just how I've come to feel.
Posted by Blah on January 28, 2003, at 0:03:26
In reply to Re: opiates and major depression » bee happy, posted by Blah on January 27, 2003, at 23:42:48
I'm sorry again if my last post was too angry. I'm in a bad place right now. I've been in both terrible mental and physical pain for the last week. The Specialist detatchment from my needs has filled me with stress, it's the same old story. There is no recovery in sight., or even a temporary release. Nothing distracts me anymore. Nothing is enjoyable anymore, and it's now that I realize my own mild psycosis. I'm so alone, and I've been alone for so long. I've been treated badly and judged by so many, especially people in power. To go to a doctor who is suppost to help you and face the same behavior when you've been hurting for so long, and are reaching your limit... I don't know what else to say. I just don't know what else I can say.
I'm Sorry
Posted by Stan on January 28, 2003, at 3:27:49
In reply to Opioids and anxiety...?, posted by Ame Sans Vie on January 27, 2003, at 4:14:08
> Well, in the past I've been prescribed Hycodan (Canadian formulation), propoxyphene HCl, codeine, and hydromorphone. The Hycodan (at a dose of 15mg q8hr) worked especially well-- it both relieved the anxiety, yet didn't have me throwing up all day. I'm interested in trying buprenorphine, and it shouldn't be difficult to obtain it (or hydrocodone) seeing as my pdoc already has me on Klonopin, Valium, Ativan, Xanax, and just a few days ago called in prescriptions for BuSpar and Marinol (which works incredibly well, I might add... I'd rather not be taking it though, on the basis of drug testing for when I finally get out to look for a job. I have the feeling that most employers would frown upon finding THC in your system, even if it were backed up by a Rx). Another consideration is Stadol (butorphanol) nasal spray-- anyone have any experience at all with this stuff? I've used it recreationally years ago, but that was before my disorder(s?) hit full force. TIA!
>
> --Michaelhi michael - does your pdoc have you taking all four of those different benzos on a daily basis? if so, what's the rationale behind that approach? (if you don't mind my asking)
have you tried settling on just one? it might simplify matters......just curious
Stan
Posted by androog on January 28, 2003, at 11:15:15
In reply to I'm Sorry » Blah, posted by Blah on January 28, 2003, at 0:03:26
Blah-
I keep hoping somebody will have some words of wisdom to help you through this awful period. I remember (barely) that I was looking for the answer from just about everyone I knew, but words were never enough.I know how alone you feel right now. I felt the same thing. I had also lost all hope and had to hang on with my fingernails. The only 2 reasons I held on were 1) fear of eternal damnation ( a side effect of my religious upbringing) and 2) I knew it would devastate my family.
There's nothing I can say that'll help you out, other than that most of us in this group have felt the same. When I was there, I thought nobody could feel worse than I did. I knew others were depressed but didn't think anyone was THAT depressed. But believe me, there are plenty out there feeling just as bad.
Please, just hang on. You will be glad you did when you finally find your way out of the pit.
If you can gather the strength, call some more docs until you get what you need. any kind of doc, not just pdocs.
Also, ease up on yourself. It's easy to start diagnosing yourself in this frame of mind, and the diagnosis is never good. That's depression at work.
You are not alone, even if you feel like you are.
androog
Posted by blah on January 28, 2003, at 20:21:32
In reply to Re: I'm Sorry, posted by androog on January 28, 2003, at 11:15:15
Thanks, I do appreciate your words, but I do know this diagnosis is correct. I also have depression, dysthymia, anxiety, and probably avoidant personality disorder traits, but I am primarily schizotypal. In a way it's what I've been telling thearapists and doctors ever since I was a child. I just didn't have the right words to explain it, and they were too arragant to both sift through what I was saying, and in some cases to believe me in the first place. No one would believe the trouble I had with physical activities like homework, housework, and exercize were real. I was too inteligent for it to be a learning dissorder. My eccentricity, or as it was usually called, "being weird" was cause for daily torture by my peers at very young ages, and on some level I am avoided, teased, or judged by most people I know to this day. When I was young the teachers and most adults accused me of just trying to get attention, but I was just interacting to only ways I knew how. Now, even after changing my behavior considerably (if only on an intellectual level) people, especially women know there is something fundamentaly wrong. They don't know what it is, they just don't want to be around it. So often I feel like I'm speaking a different language than the people around me. The more I'm alone, and the more my depression builds the more my mind drifts, even when I'm around people now, and all pdocs care about is addiction, and all friends can talk about is selfesteam. Selfesteem doesn't cure disorganized thoughts. Unless some drug works (and it won't be anything conventional) there really isn't any hope for me. I don't have the effort I once had, and ecconomic survival will soon be an omnipresant problem.
I made an appointment with that other pdoc I was talking about. She won't be able to rx opioids right away but maybe in a month or two, and maybe we'll be able to find another source like a pain doctor. I'm just having trouble holding on everything hurts so much, and there is no hope anywhere.
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