![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 152 to 176 of 262. Go back in thread:
Posted by Questionmark on March 7, 2003, at 22:33:39
In reply to Glory be to thailand, posted by blah on March 5, 2003, at 23:42:13
Hey, Ultram is an opioid right? If not, nevermind this. .. i don't have much first or 2nd hand experience with opiates, but from what i have experienced, it seems that tolerance to the nice psychological effects develops extremely fast (within weeks or even days). Maybe this isn't true with all people, but i think it is with most. For that reason (and since it can be addicting of course), i would think about just taking it every other day, or even once or twice a week or something. This might not leave you feeling good all the time, but at least you might be able to feel good, for sure, however many times a week. i dunno. i hope this drug helps you.
Posted by blah on March 9, 2003, at 7:42:46
In reply to Re: Glory be to thailand, posted by Questionmark on March 7, 2003, at 22:33:39
OK, after a few days my reaction to the Ultram hasn't been great. I got sweats and other problems. I'm not sure whether to just lower the dose or not, but I'm scarred to keep taking it now. I'm not really sure what to do I feel so alone. It seems no drug will work for me. I may have withdrawl for a few days but don't know whether to taper off or not. Maybe nothing will work for me. Maybe I'm just lost.
Posted by androog on March 9, 2003, at 13:16:19
In reply to Just tired, posted by blah on March 9, 2003, at 7:42:46
sorry to hear the tramadol is not doing it for you. i have to admit that i had my doubts since your depression seems to be part of a larger packet of problems. i think tramadol does the trick mainly for people who have depression as their primary problem. also, i think that people who have experienced relief from depression when taking opiod painkillers like vicodin or percodan are the ones most likely to have success with ultram.
as far as tapering off tramadol, i'd take one less per day until you're off. if you feel like you may be going through withdrawal, try taking one less every two days.
if anyone in the group has a more educated recommendation for getting off tramadol, please feel free to chime in. i only know what i have experienced personally and i realize that different people react in different ways.
Posted by ShelliR on March 9, 2003, at 16:32:15
In reply to Just tired, posted by blah on March 9, 2003, at 7:42:46
I know Elizabeth (who has been taking buprenorphine with effexor) found no relief when she tried to substitute ultram for buprenorphine.
I think the best idea is to go to a pain specialist, show him/her the buprenorphine article and proceed from there. I think pain specialists are more sympathetic when it comes to pain, than are pdocs. Even my present pdoc, who doesn't have a problem with me taking methadone, still won't prescribe it so I still go to both doctors--one for ADs and one for methadone.
Shelli
Posted by Questionmark on March 10, 2003, at 23:18:58
In reply to Just tired, posted by blah on March 9, 2003, at 7:42:46
That's too bad that it doesnt help much at all.
i know you said you took Nardil before, without much benefit, but another MAOI trial might be good. Do you have anxiety components as well? Maybe even if you do, or especially if you do not, low dose selegeline (l-deprenyl) could be a big help for you. i'm not sure, but check it out.
Posted by blah on March 23, 2003, at 14:09:37
In reply to Re: Just tired, posted by Questionmark on March 10, 2003, at 23:18:58
Well I went to the hospital for about a week and a half. They tryed two more antipsychotics on me(geodon-seroquil), and like zyprexa they increased my depression and anxiety, killed my concentration, made me more suseptable to pain, and put me in a plastic fog. My "specialist pdoc" has an unwavering faith in them but i told him no more. It's obvious these drugs won't work, and are counter productive. I'm on a low dose of lamictal now but it so far does nothing. I met a girl in the hospital, it was forbiden love, we weren't alowed to touch. I left when she got out, and we spent the night together. She said she loved me, and that she couldn't belive she wasn't alone anymore, but its been three days and she still hasn't called me back. I called twice on the day after to invite her out and then once today. I don't think i'll call again, and i dought she will ever call me back. Despite her happieness and insecurity I guess my insecurity was still too scary. I don't want to go back to the hospital, that authoritarian atmosphere was getting me down anyway. But there is no where for me to go. I can't do anything anymore, my only goal seems to be get through the day, and i don't know how long i can keep that up. Survival doesn't seem realistic anymore. Even sleep is frightning. Soon I may be left with the only choice left for me to make. It just hurts so much, and i don't have the strength to fight anymore. I don't know what to do. I just want it all to stop.
Posted by ejaustin on July 20, 2003, at 23:50:02
In reply to Re: chat room » Dr. Bob, posted by Ilene on February 27, 2003, at 13:57:51
For those trying to make a connection without revealing their personal information like email address, there is an anonymous remailer service available at http://anon.twwells.com/help/index.html
They've been around for years and years and they have a good reputation. I've never used them, but I've known several people on on-line support groups who have. If the instructions are confusing, I'll see if I can get a copy of the simplified instructions that are posted periodically.
Oh, yeah... it's free.
Posted by crazyamy on August 20, 2003, at 22:41:42
In reply to Re: opiates and major depression, posted by androog on October 28, 2001, at 14:35:18
>>>>>>it is SO frustrating to me to know that there is something out there that will free me, but that our society has placed such powerful sanctions against it that one needs to become a criminal to obtain it. why should society care what i put in my body? we can place liquor. tobacco and double cheeseburgers with fries into our systems anytime we want, and well we should. but when it comes to opiates the attitude is stick 'em in prison or refer 'em to another doc >>>>
the reason is that "they" (read government) would rather have us all high on crack and cocaine. we as a society are much more productive for them (read more tax money coming in) when we are going and going from the high those types of drugs provide. they also make us angry and therefore we are out killing each other, which means there are more laws they can make, more jobs blah blah blah. think about it like this, if you wanted to go out and buy drugs, which would be easier to find- opium or speed?? we are living the american dream, go to work, buy a house, have some kids, spend your money (BUY SPEND SHOP), pay your taxes, work some more... and the REALLY REALLY sad part is that we are so beaten down by life that we are destroying OUR children. go look at a newspaper, how many children have been killed or abused in your local town. and the governments answer- it is the drugs...but who is supplying them to us??? if that isn't enough to make you depressed...."thou art but slave to fate", you only think you have a choice.... I wish you the best of luck in your life!! thanks for reading my rambling!! CrazyAmy
Posted by Craig Allen on August 21, 2003, at 16:27:37
In reply to Re: opiates and major depression, posted by crazyamy on August 20, 2003, at 22:41:42
> >>>>>>it is SO frustrating to me to know that there is something out there that will free me, but that our society has placed such powerful sanctions against it that one needs to become a criminal to obtain it. why should society care what i put in my body? we can place liquor. tobacco and double cheeseburgers with fries into our systems anytime we want, and well we should. but when it comes to opiates the attitude is stick 'em in prison or refer 'em to another doc >>>>
>
> the reason is that "they" (read government) would rather have us all high on crack and cocaine. we as a society are much more productive for them (read more tax money coming in) when we are going and going from the high those types of drugs provide. they also make us angry and therefore we are out killing each other, which means there are more laws they can make, more jobs blah blah blah. think about it like this, if you wanted to go out and buy drugs, which would be easier to find- opium or speed?? we are living the american dream, go to work, buy a house, have some kids, spend your money (BUY SPEND SHOP), pay your taxes, work some more... and the REALLY REALLY sad part is that we are so beaten down by life that we are destroying OUR children. go look at a newspaper, how many children have been killed or abused in your local town. and the governments answer- it is the drugs...but who is supplying them to us??? if that isn't enough to make you depressed...."thou art but slave to fate", you only think you have a choice.... I wish you the best of luck in your life!! thanks for reading my rambling!! CrazyAmy
what the hell are you talking about? the government has a whole plan on how to make money on us if we're on cocaine? absurd.
Posted by Dr. Bob on August 21, 2003, at 19:16:56
In reply to Re: opiates and major depression » crazyamy, posted by Craig Allen on August 21, 2003, at 16:27:37
> what the hell are you talking about? the government has a whole plan on how to make money on us if we're on cocaine? absurd.
First, please respect the views of others, be sensitive to their feelings, and don't post anything that could lead them to feel put down:
http://www.dr-bob.org/babble/faq.html#civil
Also, follow-ups regarding the government should be redirected to Psycho-Social-Babble. Thanks,
Bob
Posted by Dr. Bob on August 22, 2003, at 0:48:10
In reply to Redirect: and please be civil » Craig Allen, posted by Dr. Bob on August 21, 2003, at 19:16:56
> follow-ups regarding the government should be redirected to Psycho-Social-Babble.
Here's a link:
http://www.dr-bob.org/babble/social/20030818/msgs/252983.html
Bob
Posted by Ima on August 23, 2003, at 16:07:05
In reply to Redirect: and please be civil » Craig Allen, posted by Dr. Bob on August 21, 2003, at 19:16:56
Wow, where were all you supportive people when I started a controversy with the thread ..good drugs, bad drugs? Oh well, I guess I came off less deserving of sympathy.
Im glad to see the support.
What I meant by the title good drug/ bad drug was just this hypocritical response you've gotten, androog, from docs, esp. pdocs about opiates. It isn't on the pet drug list. Sorry if I sound cynical.
I too, started taking opiates when I injured my back last year. As I've gotten better and tried to wean myself I've noticed my mood swings resurfacing. I hadnt thought about them for a while because, while taking percocet, I havent had them.
Now, I haven't tried all the ADS you've tried, but for different reasons, they scare me. The opiates dont mess up my head. I don't have to try 8 or 10 different ones to find one that works and suffer withdraws from each one. (as Ive read about on this site) Most opiates are pretty straight forward.(synthetic and other wise)Im on ultram now. But the percocet was stronger. I didnt have any problem withdrawing from the percocet. I went a little over a month with out pain meds to see if I could. The only problem was my back pain. The first 10 days I was really achy but with fibro, Im usually achy, so it wasn't a surprise. The research Ive read indicates that less than 2 % of pain med users end up "addicted"
I think that addiction is a subjective term.(phisycal dependency is more accurate) My father in law could diet in stead of taking high blood pressure meds. But there is no stigma associated with such medication so no one judges him. Is he addicted?
He would probably die without them.
I read a good article on a fibromyalgia site that said the difference between abuse and use is the user takes meds (anykind) to function. The abuser takes them to not function (cop out).
I don't want to go through the emotional turmoil of trying to convince someone I'm not a drug abuser (as even a few on this site have accused me of).
So my heart goes out to you. I am in the same predicament.
Just be careful. Keep your wife in the loop so she can help you monitor your outlook on the whole thing. My husband has been super. He's never believed I have a problem with this.Maybe the day will come when the pharm industries and pdocs will see the financial value in honesty (dont hold your breath). The only bad drugs are the ones they dont prescribe.
Good luck
Peace
Ima
Percocet is definately stronger, and you could take lower doses, but like you said, you have to find a doc that will help first.
Posted by Aurora on October 30, 2003, at 23:55:41
In reply to Re: opiates and major depression, posted by crazyamy on August 20, 2003, at 22:41:42
> >>>>>>it is SO frustrating to me to know that there is something out there that will free me, but that our society has placed such powerful sanctions against it that one needs to become a criminal to obtain it. why should society care what i put in my body? we can place liquor. tobacco and double cheeseburgers with fries into our systems anytime we want, and well we should. but when it comes to opiates the attitude is stick 'em in prison or refer 'em to another doc >>>>
>
Amy, (hope it's OK with you if I omit the "Crazy" in front of your name), I've got some good news for you. The FDA approved Suboxone (buprenorphine with naloxone) last October. The indication is for treatment of opioid dependence, but there is a fair amount of clinical articles and some research (Harvard 1995, for one) about buprenorphine's efficacy in treating depression. For lots more information on Suboxone and treatment of depression, please read my posting of earlier today, which I'm cut-and-pasting here:
Elizabeth-re opiates: Buprenorphine for depression » Chuckie
Posted by Aurora on October 30, 2003, at 22:36:22In reply to Re: elizabeth about dosing on opiates/ anyone, posted by Chuckie on October 30, 2003, at 15:10:05
Dear Chuckie and "reese1" (posted on October 24, 2002 "elizabeth about dosing on opiates/anyone")
I'm a new member and can share new information on buprenorphine. It is now available in sublingual tablet form, under the trade name of Suboxone (a 4:1 combination of buprenorphine and naloxone). Naloxone has no clinical effect when taken sublingually as directed--but if made into solution and injected, it induces immediate painful opiate withdrawal. Naloxone was added to prevent diversion to the street as a cash drug, and has been very successful in these first 9 months, according to the DEA.
A wealth of information is available on the government's website: www.buprenorphine.samhsa.gov including a "Physician Locator". Also, you can call 1-877-SUBOXONE and clinical staff will answer your questions.
The FDA's indication is for treatment of opioid dependence, so you may need to educate your physician regarding treatment for depression with the clinical article's in Chuckie's posting of 10/30/03. A University of California psychiatrist (director of that UC's Dept. of Psychiatry), said he anticipates their greatest use of Suboxone will be for treatment of depression, not opioid dependence or pain (other possible uses). He had read the 1996 editorial published in "Biological Psychiatry", entitled "Buprenorphine for Depression: The Un-adoptable Orphan", which Chuckie included in his 10/30/03 posting. He said buprenorphine apparently has a very fast onset of AD action (2-4 hours) and with insurance companies' pressure for fast discharges from the hospital, it could be helpful both to patients (faster relief) and insurance companies (shorter hospital stays). He would then taper patients off buprenorphine (Suboxone) after a few weeks when their conventional AD had time to take effect.
The tablets come in 2 mg and 8 mg and it's once-a-day dosing (half-life ranges from 37-92 hours). It's probably too early to know what the average dosing is for depression (range is 4-32 mg for opioid dependence). Bottom line is: dose to effect. As a partial mu opioid agonist, buprenorpohine has a ceiling effect: taken alone, overdosing will not result in respiratory lethality, unlike full opioid agonists.
Another psychiatrist has successfully treated two patients with treatment resistant depression using Suboxone. They had tried everything. Nothing had worked. They had very fast results with Suboxone and have been on it about three months.
Obviously there is no one medication for everyone. Suboxone is working from some, and it's helpful to have another option when there are patients who haven't received relief from existing medications, or who have had incomplete response with an AD.
I hope this may be helpful to some. In any case, never give up your search for a successful treatment. As long as there's life, there's hope. We have to care enough about ourselves to keep trying. After decades of struggling with major depression, I met a pdoc I trusted and finally agreed to try ADs (since exercizing alone wasn't enough). It took trials on five ADs before I found the one right for me, and two years later, I needed to add Provigil for energy. It's a whole new life. I feel grateful and blessed--definitely worth the long journey.
Sending wishes for your healing,
Aurora
Posted by mbutka on April 8, 2004, at 7:10:32
In reply to Re: Buprenorphine-- bee happy, posted by androog on January 26, 2003, at 22:30:05
Briefly, the main problem with buprenorphine is it is not approved for treatment of depression, and cannot be used off-label. I am a family doctor who prescribes it and I have seen it work very well for depression related to drug abuse, but any doctor who prescribes it for anything other than addiction risks losing their license to prescribe it. Technically this is probably true for other opioids or Ultram, but in reality the DEA does not watch them closely.
Yes opioids may work, but while there are other treatments available with which we have more experience, I understand a psychiatrist's reluctance to prescribe something that has risk of addiction or overdose and with street value. That doesn't mean it shouldn't be an option, but I would limit it to someone I already know well.
Posted by buddhi on July 28, 2005, at 15:47:18
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!
>
> --Michaelwondering how much marinol you took or are taking???? Thanks so much buddhi!!! you can write me back on this board or amy@pause.com
Posted by pseudoname on October 31, 2005, at 12:18:38
In reply to Re: Buprenorphine-- bee happy » androog, posted by mbutka on April 8, 2004, at 7:10:32
mbutka said:
> Briefly, the main problem with buprenorphine is it is not approved for treatment of depression, and cannot be used off-label. ... any doctor who prescribes it for anything other than addiction risks losing their license
Perhaps this is true in some other country, but it is NOT the case in the U.S. The following statement is from the U.S. Substance Abuse and Mental Health Services Administration at http://buprenorphine.samhsa.gov/faq.html#21
<quote>
21. Can Subutex® or Suboxone® be prescribed for conditions other than opioid addiction, e.g., pain control?Subutex® and Suboxone® have received FDA approval only for the treatment of opioid addiction. However, once approved, a drug product may be prescribed by a licensed physician for any use that, based on the physician’s professional opinion, is deemed to be appropriate. Neither the FDA nor the Federal government regulates the practice of medicine. Any approved product may be used by a licensed practitioner for uses other than those stated in the product label. Off-label use is not illegal, but it means that the data to support that use has not been independently reviewed by the FDA. Information on FDA policy regarding off-label use of pharmaceuticals is available on the FDA Web site, http://www.fda.gov/cder/cancer/tour.htm, or http://www.fda.gov/cder/present/diamontreal/regappr/index.htm
<unquote>I just don't want anyone to get discouraged (as I almost was) if they saw mbutka's post in the archive. The only restriction mentioned in those FDA links is that pharma manufacturers cannot actively promote off-label uses.
Posted by bigcat on November 4, 2005, at 0:45:45
In reply to Re: Buprenorphine-- bee happy, posted by bee happy on January 27, 2003, at 15:19:02
I've read some very encouraging case reports recently regarding treatment-resistant patients with severe depression finding relief with Buprenorphine. My depression, depsair, and failed med trials have brought me to the point where I'll try anything. My concern is less for my own well-being as for the potential risk my doctor would be taking in prescribing this medication for me. He has never been investigated or challenged before, but he (from proven clinical experience) has written scripts for meds like Dexedrine or Desoxyn, that could, while wholly viable and used effectively for decades, be judged "radical" or too readily abused. I have no history of substance abuse (legal or illegal) whatsoever.
I realize that the FDA and other agencies can investigate my pdoc and potentially prosecute his compassionate soul, and have his/her liscence revoked or even worse. My pdoc has become my close (only) friend, and is adamantly committed to pusuing new, untraditional treatment options for me. This pdoc is aggressive and open-minded, but I would'nt dare bring up the Buprenorphine idea if writing the script could even remotely put him at any legal or professional risk. It would forever ruin what little life I have left in me. Sooo... as I have no history of opiate or other drug abuse or addiction, could my pdoc safely prescribe this medication for me, without fear of unjust, but potentially devastating, repurcussions?
For the treatmnet of pain, I've received codeine, valium, and percocets in the past which have done little to help the physical pain, or provide any of the mental calming or antidepressant effect that other kids rave about. Would this lead you to believe that Buprenorphine wouldn't have much of an effect on me as an antidepressant? How about addiction, tolerance, long-term use, and the (I would imagine) hellish withdrawal process if I eventually have to come off it or can't get another pdoc to prescribe it for me? (Am I flirting with the devil, and could I be getting in way over my head? I hope I'm wrong, but isn't Bupe a close relative of heroin?) I'd appreciate any information or advice you could offer.
Still Fighting,
-matt-
Posted by pseudoname on November 4, 2005, at 12:24:41
In reply to Re: Buprenorphine Concerns, posted by bigcat on November 4, 2005, at 0:45:45
> could my pdoc safely prescribe this medication for me, without fear of unjust, but potentially devastating, repurcussions?
Matt, see my post in the other thread. I'm just finding this stuff out, and that post is the best answer I can give today: ("ANYONE can Rx bupe") http://www.dr-bob.org/babble/20051031/msgs/575345.html
> I would'nt dare bring up the Buprenorphine idea if writing the script could even remotely put him at any legal or professional risk.
I know the feeling, but your doc is a grown-up. As a doctor, he is accustomed to taking risks. In fact, he cannot help you unless you allow him to take at least some risk. Besides, maybe you can blaze a trail that helps him treat other patients.
> Am I flirting with the devil, and could I be getting in way over my head?
Bupe is not a close relative of heroin. Third cousins twice removed. Bupe may or may not work for you, but it seems clear that it doesn't put people in over their heads. It sounds like you trust your doc's clinical judgment. Go ahead and talk to him about it.
Please post back what he says & what you try.
Posted by ed_uk on November 5, 2005, at 10:13:58
In reply to Re: Buprenorphine Concerns, posted by bigcat on November 4, 2005, at 0:45:45
Hi Matt
>My concern is less for my own well-being as for the potential risk my doctor would be taking in prescribing this medication for me.
Show this to your doc. He will come to his own decision on whether or not he wants you to try buprenorphine.
J 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.
>I hope I'm wrong, but isn't Bupe a close relative of heroin?
Heroin and buprenorphine are both opioid analgesics but their pharmacological properties differ somewhat. Heroin is closely related to codeine and morphine.
>I've received codeine, valium, and percocets in the past which have done little to help the physical pain, or provide any of the mental calming or antidepressant effect that other kids rave about. Would this lead you to believe that Buprenorphine wouldn't have much of an effect on me as an antidepressant?
Diazepam (Valium) is a benzodiazepine, it's not related to buprenorphine in any way. Codeine and oxycodone (present in Percocet) are opioids, like buprenorphine, but buprenorphine's psychological effects are different (variably so). Some people find buprenorphine to be subjectively very similar to other opioids (eg. codeine) whereas others find it to be very different.
Kind regards
Ed
Posted by pseudoname on November 5, 2005, at 20:06:45
In reply to Re: Buprenorphine Concerns, posted by bigcat on November 4, 2005, at 0:45:45
> I would'nt dare bring up the Buprenorphine idea if writing the script could even remotely put him at any legal or professional risk
It's perfectly legal for docs to write bupe scripts for depression, and I don't think we even have to worry about overzealous prosecution.
All of the problems I could find by Googling – including what seemed like horrific injustices – involved Schedule II drugs (like OxyContin), which are more "dangerous" and restricted than buprenorphines Suboxone (Sch III) or Buprenex (Sch V). They also involved HUGE amounts and many patients, even when seemingly justified.
I found these statements from the DEA (I assume you're in the U.S.). They're in "Prescription Pain Medications: Frequently Asked Questions and Answers for Health Care Professionals and Law Enforcement Personnel" (2004) – which DEA has since withdrawn for errors in other sections:
Word FAQ: http://headaches.allinfoabout.com/articles/PRESCRIPTION%20PAIN%20MEDICATIONS.doc
PDF FAQ: http://headaches.allinfoabout.com/articles/pain_meds_faqs.pdfThe DEA says, "The DEA focuses its limited manpower and resources on the most flagrant violators." –pg 42
DEA explicitly says that even *methadone* (let alone bupe) can be prescribed by ANY physician with a Schedule II registration. "An additional separate DEA registration is needed only when dispensing methadone for outpatient maintenance or detoxification, not when prescribing it for pain." –pg 41
In 2003 the DEA sanctioned 584 doctors, dentists, veterinarians, and nurses. Of those, 434 WERE NO LONGER LICENSED to practice when they were writing the scripts. Most sanctions were just the loss of registration (and remember, most of the docs were already out of business). –pg 42
The DEA gives these as examples of questions an investigator might ask a physician about an opioid prescription. (Substitute "depression" for "pain".)
• How can you tell this patient has a chronic pain problem?
• Is there justification for the drugs that have been prescribed?
• Are the prescribed amounts appropriate?
• If a patient is displaying drug-seeking behaviors, is this a sign of undertreated pain, addiction, or involvement in diversion? –pg 46<quote>
Characteristics of a practitioner or pharmacy that warrant further inquiry that could lead to an investigation include:
• A large proportion of prescriptions being paid for in cash.
• Large distances between the doctor, patients, and pharmacy, particularly if a sizable proportion of a doctor’s prescriptions are being filled at a pharmacy not conveniently located to either the doctor or the patients.
• Drugs and doses being prescribed are not individualized.
• One physician writing multiple prescriptions for numerous patients that are filled consecutively in one pharmacy, indicating that either one person is presenting multiple prescriptions, or several people are filling similar prescriptions at the same time.
• A high frequency of prescriptions to replace lost prescriptions or medications.
• Frequent premature renewal or refilling of prescriptions.
• Frequent prescribing of unusual combinations of drugs, such as stimulants and depressants.
<unquote> –pg 46Matt, I hope this helps. It reassured me. I'm going to print out the FAQ for my pdoc. The biggest point is that it's completely LEGAL for your doc to give you a bupe script for depression. It won't even get on the DEA's radar.
Posted by bigcat on November 6, 2005, at 22:05:39
In reply to DEA prosecution guidelines » bigcat, posted by pseudoname on November 5, 2005, at 20:06:45
Thanks for the reassuring info psuedo! That took a great deal of the weight off, and it looks like a green light ahead. Is it you're belief, or have you read, that administering Buprenorphine in cases of severe treatment- resistant depressions have often proven sucessful in creating a ROBUST AND LASTING REMISSION for depressive cases highlighted by the following list of personal symptoms (hey, what the heck!):
cognitive impairment/retardation [never alert, poor memory, inablity to synthesize ideas or verbalize thoughts], inablity to focus or socialize, severe anxiety, inablity to express thoughts or speak clearly, fluidly, and spontaneously, comprehensive lack of energy, interest, or patience in anything whatsoever, inablity to experience love or enjoyment, obssesive worrying, self-loathing, and a paralyzing self-absorbtion and isolation.I realize I'm being neurotic (or extremely cautious at least), but I don't want to feel "drugged," or have a kind of body high or unnatural lift. "Comfortably numb" is not what I'm seeking (not to suggest that this is what others who have boldly taken this route are after, as I'm entirely convinced that all anyone truly wants is for the depression to receed). I guess you'll never know unless you try, I'm just a bit concerned that I'll "like it", rather than simply find it an efficacious drug to treat this illness.
I have never abused drugs legal or illegal, and I recognize that my concerns may sound like just the kind of crap and propaganda that holds viable treatments back because of unfounded stigmatization, but I would just like some reassurance that the Bupe isn't going to put me at risk for developing some type of addiction problem, or render me powerless to come off it, or live without it because of insurmountable withdrawal symptoms. I hope my concerns don't incite anger or frustration at what could be seen as my "brainwashing" from unsubstantiated and erroneous parallels that non-physicians create to incite mass hysteria and unjust regulation policies. I hope anyone reading this can appreciate my concerns, and while there may be no guarantees, I do feel many friends posting on this board are somehow "in the know" and UNDERSTAND OR HAVE FIRST-HAND EXPERIENCE. While I now feel comfortable in speaking with my pdoc about the Bupe and the unlikelihood that a script could stir up any problems, I'm still kinda' scared sh*tless, as I have the feeling that this is powerful stuff and I shouldn't jump in without undertsanding the inherent, or potential risks. Thank you one and all.
-matt-
Posted by pseudoname on November 8, 2005, at 17:33:06
In reply to Re: DEA prosecution guidelines/GENERAL CONCERNS!!! » pseudoname, posted by bigcat on November 6, 2005, at 22:05:39
Matt,
I still don't have any personal experience with it, so I can't yet answer "first-hand". Check around in the Babble archive. This was posted in 2001 by Elizabeth (whom Declan called the "psychopharmacological goddess"):
<quote>
Buprenorphine really does not cause a high. There is a pretty low ceiling on its effect. ... So it's not much of a drug of abuse. I've been taking buprenorphine (as an antidepressant) for a year or so. ... I continue to be impressed by its efficacy, especially after all the treatments that have failed. I haven't become tolerant to the antidepressant effects (although most of the side effects have subsided with time). The physical dependence seems to be mild: missing a dose of Nardil (when I was taking it, that is) was much more unpleasant than missing a dose of buprenorphine is. I don't experience "cravings," nor do I feel tempted to increase the dose. Most people who take full-agonist opioids for pain [which are much "stonger" than buprenorphine] do not become addicted to them...
<unquote>
–http://www.dr-bob.org/babble/20011025/msgs/82287.htmlIt may or may not work for you, but it's not exactly likely to turn you into a drug fiend.
Please post back what your doctor says. Thanks.
Posted by pseudoname on November 10, 2005, at 12:03:45
In reply to Re: Buprenorphine Concerns, posted by bigcat on November 4, 2005, at 0:45:45
> I would'nt dare bring up the Buprenorphine idea if writing the script could even remotely put him at any legal or professional risk.
I've come across this stuff in the last few days:
Eliot Cole, MD. "Prescribing opioids, relieving patient suffering and staying out of personal trouble with regulators." The Pain Practitioner, Fall 2002, 12(3): 5-8. http://www.aapainmanage.org/literature/PainPrac/V12N3_Cole_PrescribingOpioids.pdf
<quote>
WHAT CAN GET YOU INTO TROUBLE?
During the past few years, I have found several common practices that have gotten physicians into trouble regarding opioid prescribing:
1. Failure to evaluate patients (i.e. no history or physical examination)
2. Failure to make any diagnosis prior to the initiation of treatment
3. Failure to obtain outside medical records or to talk with previous practitioners (any verification at all)
4. Failure to establish goals for treatment (i.e. reduction in pain, improvement in function)
5. Failure to suspect misbehavior or substance abuse (i.e. no screen for addictive potential and no monitoring through treatment)
6. Failure to document the diagnosis, treatment plan, goals for treatment, continuing need for medication and lab results
7. Failure to understand what drug testing can and cannot tell you
8. Deviation from the “contract” (i.e. misbehavior is never addressed either verbally or written)
9. Blind acceptance of whatever is said by patients
10. Trying to bully law enforcement or regulatory agents or assuming an arrogant “I-know-best” attitude when confronted by them
This ... is a fair representation of what I have seen in the records that have been submitted to the Academy for review through the Second Opinion Utilization Review program.TEN TIPS FOR STAYING OUT OF TROUBLE
1. Obtain a thorough history and perform a first rate physical examination...
2. Chart everything you see, think, feel and hear about your patients. Leave nothing to the imagination of the future reader. ... Explain what you are doing, why you believe opioid analgesics will be helpful, what alternative have been considered, that your patient agrees to the treatment, and how you intend to follow your patient over time.
3. Obtain informed consent from your patients so there is no doubt about the treatment proposed....
4. Get your patients to agree to use only one pharmacy.....
5. If you are seeing your patients in the capacity of a primary care practitioner ... get a second opinion.... Share the responsibility to prescribe opioid analgesics....
6. Prescribe long acting opioid analgesics on a time contingent basis so that stable levels are achieved. Avoid "as needed" medications...
7. See your patients who are receiving opioid analgesics on a regular basis. ...
8. Determine the minimum dose necessary to maintain function and useful activities of daily living....
9. Order urine drug screens for your patients of concern to document that you are able to recover their prescribed medications (to rule out
significant diversion) and that you are thinking about their potential use of illicit substances....
10. Continue to receive opioid analgesic education by attending recognized...[DEA suggestions include...]
• perform a thorough examination appropriate to the condition
• document examination results and questions you asked the patient
• request picture I.D., or other I.D. and Social Security number. Photocopy these documents and include them in the patient's record
• call a previous practitioner, pharmacist or hospital to confirm patient's story
• confirm a telephone number, if provided by the patient
• confirm the current address at each visit
• write prescriptions for limited quantities.
<unquote>——————
A lot of places recommend written "opioid agreements" between the doc and the patient, spelling out treatment goals and agreeing that "lost" pills won't be replaced and that urine testing may be done to make sure the patient is actually the one taking the meds.
——————
This article tells how drug agencies conduct opioid "sting" operations on physicians. They send in a healthy-looking person as a new, unreferred patient with vague pain complaints who asks for an opioid but doesn't cooperate with getting further tests or prior medical records. Or he tells the doc at the second visit that he gave some of the med to his girlfriend. If the doc continues to write opioid prescriptions for such a patient, the doc could get charged: http://www.aapainmanage.org/literature/PainPrac/V13N2_Cole_PrescribersUpdate.pdf
——————
The only buprenorphine charge I could find was a Colorado doctor who HANDED bupe to someone who wasn't his patient. (He also prescribed the stimulant Phentermine to a woman intending that it actually be given to her husband, an NFL player. That was the heart of the charge.) http://rockymountainnews.com/drmn/local/article/0,1299,DRMN_15_2481985,00.html
Posted by Nieko on July 19, 2008, at 20:18:58
In reply to Re: opiates and major depression » crazyamy, posted by Aurora on October 30, 2003, at 23:55:41
I have been taking Suboxone for nine months now. I have NEVER felt better. After years of trying every new (as well as old) antidepressant out there, I had all but given up hope. The hope of a happy life was becoming increasingly hopeless. Suicide was not an option because I simply didn't have enough energy to do anything! I got really lucky; I found out about Suboxone and then found a Dr. willing to prescribe. It was almost immediate relief. Within a day I felt 100% better, and I am not exaggerating. The cost of this drug is the setback. If their were a campaign put together to get Reckitt-Benckiser Pharmaceuticals (maker of Suboxone) to recognize the use of their drug for depression. I realize the major use of Suboxone is to withdraw heroin addicts and I also know that even this is not the major source of their profit. Perhaps if they realized the significance of using their drug for depression, they would begin targeting this population. It appears as though Reckitt-Benckiser has a monopoly on Suboxone. What can we, as depression survivors do to make this an available drug to the masses? Let's get together and see what our now alert minds can do.
Posted by Crotale on July 21, 2008, at 12:33:55
In reply to keeping opioid prescribers out of trouble, posted by pseudoname on November 10, 2005, at 12:03:45
A couple suggestions not only for keeping your doc out of trouble if s/he prescribes opioids, but also for demonstrating your own trustworthiness:
* offer to sign a contract
* try to keep the dose as low as possible (also because these drugs have quite a lot of side effects)
* give your pdoc the phone number for the pharmacy you use (always get it filled at the same place; I recommend a local, independent pharmacy rather than a chain)
* if you're asking your pdoc to continue a prescription started by another doc, give him/her the phone # for that doc; call the original prescriber and give him/her permission to tell your current doc about the prescription (you may have to write a note or something of that sort)
* get advice from your doc about how to use the med properly
* keep your doc regularly informed about your use of the med, and make it clear that you're not abusing it (note that the definition of "drug abuse" is "whatever your doctor says it is")There have been some other good suggestions here (although IMO a few of them, like some of the DEA's recommendations, are way over the top). I'm pretty sure that as long as you're not misusing the drug in any way, your doc
Be careful not to do anything your doc would consider "abuse" even if you don't agree about how s/he defines that. (Try to find a doc whose attitudes you're comfortable with, of course, but be careful to avoid "doctor shopping" - that is, switching doctors repeatedly with the exclusive purpose of finding someone willing to prescribe an opioid.)Oh, one other thing: it's better to ask for a lower-schedule opioid like tramadol or buprenorphine. Make it clear that you're concerned about avoiding becoming addicted. (And if you're not, you should be. It's a serious risk. That's why I've stuck to buprenorphine - I would have gone with Ultram if I weren't also taking Parnate.) It also can't hurt to let your doc know that you don't want to get him/her in trouble. Exactly how to address the issue depends on your relationship with your doc, how long you've been seeing him/her, etc.
-Crotale
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