![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 173 to 197 of 262. Go back in thread:
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
Posted by maree on July 22, 2008, at 21:32:13
In reply to Re: opiates and major depression, posted by androog on October 19, 2001, at 23:26:35
> There's no doubt in my mind that my depression is at the root of my substance abuse, not the other way around. It's just a guess, but I'd say a good majority of substance abusers are suffering from some form of depression. I further believe that the reason we abuse certain substances is that we're trying to make up for something lacking in our brain chemistry - something that occurs naturally in others. I know all the talk is about serotonin, but I'd bet the house that what we substance abusers are lacking in are endorphins.
Hi Androog/Peter
I have often thought the above, since I know that i have a very addictive personality, AND that I only love life when I am on a permanent endorphin high.
Years ago, I discover alcohol, unfortunately because it destroyed an incredible memory, and it was likely 10 years after the alcohol abuse that I realized that the drinking was why I had suddenly had difficulties remembering stuff at work, which, previously had never been a problem. I thought that I had got away with the drinking, unlike other people who get a lot of health problems, but, it also awoke the likelihood that I would have a CVA, which I did. Since then, 12 years ago, I have NEVER been able to get an endorphin rush, not even from alcohol, so you can imagine that life is pretty dismal for me.
I point out to many of my treating docs (psyches & neuros) that it is the lack of an endorphin rush that, not only makes me so unhappy and unfulfilled, but is also likely responsible for many of my physical problems, in particular the ongoing fatigue, lowered pain threshold, short term memory loss (even worse then after the drinking) and lowered immune system. Are they interested? Of course not. Who do I think I am? A retarded stroke victim, who only just finished high school, not some erudite personage who went to medical school, who has experience with dozens of patients over a period of many years. Experience? I have lived with a broken, disabled, body and brain for 12 years, I think THAT counts for experience far more than anything that they might have done.
So, what my long diatribe is saying that, yes, yes, yes, I think that you are so right in your statement, and when you find some doctor who actually listens to what you say, please tell me.
Regards, and good luck in your quest for happiness.
Posted by Crotale on July 25, 2008, at 22:34:00
In reply to Re: opiates and major depression » androog, posted by maree on July 22, 2008, at 21:32:13
I'm just adding my agreement with what has already been said; I think most (not all) substance abusers are, or at least, started out, self-medicating. I believe that the way to prevent this self-medication from transforming into abuse is for a doctor to prescribe and supervise the opioid rather than simply condemning opioid use. Ideally you want to stick with the lowest possible dose. I think Ultram is the best to start with, unless you are on MAOIs or have a history of seizures. Beyond that, I'm not sure. Ideally you want to use Temgesic (0.2mg buprenorphine SL). Most doctors aren't likely to be comfortable with having a patient self-inject Buprenex (IM) (0.3mg/mL). Buprenex also works IN with a metered-dose inhaler. Subutex and Suboxone, the sublingual formulations designed for drug addicts, are much higher doses. (Supposedly bioavailability is the same or close SL and IM.)
The lowest available dose in a single pill of Subutex is 4mg, which I'm sure would make me sick to my stomach.My personal experience: I never felt anything that I'd descrine as a "high" from opioids; They just make me feel more clear (jittery initially), itchy, and sometimes nauseated. Careful because they have heavy side effects.
-Crotale
Posted by Crotale on July 25, 2008, at 22:44:13
In reply to Re: opiates and major depression » androog, posted by maree on July 22, 2008, at 21:32:13
BTW, my experience with drug addicts who had tried "bupe" is that it relieved withdrawal symptoms but wasn't especially euphoric.
-Crotale
Posted by Nieko on August 27, 2008, at 15:32:29
In reply to Re: opiates and major depression » androog, posted by maree on July 22, 2008, at 21:32:13
Hi Maree,
I have read your story and you have my total sympathy. I believe you are right regarding your belief that endorphins are at the root of many depressive problems. I have suffered with depression from childhood to the age of 43. Through sheer luck (maybe a Hower power looking out for me) I found a Dr. who was familiar with Suboxone in the treatment of depression. His theory was that endorphins were lacking in certain people. Considering the fact that I had tried every anti-depressant on the market with absolutely no success, he agreed with the theory. He also had a few other patients who were on Suboxone for the treatment of depression and was having excellent results. This medication absolutely changed my life. I too had been living in a world of dark despair, suicidal thoughts on a regular basis, and unable to maintain employment. Literally it took only a few minutes for the drug to start working. I started feeling as if the black cloud was lifting and actually felt alive for the first time ever! I am sorry that I am nowhere near your area so that I could help you to find a doc. I also went the Ultram route. I found that it was relieving my depression. I had no idea it would work in this way, I was simply prescibed it for another reason. Suboxone works somewhat in the same manner, just a thousand times better. It falls under the name of "buprenorphine." Physician are required to take a special course in order to prescribe it. I think more and more dr's are beginning to see the light and hopefully many more will soon. Good luck in your efforts and I hope this information will be of some help.
Posted by safire4hope on October 18, 2011, at 7:29:01
In reply to Re: opiates and major depression » crazyamy, posted by Aurora on October 30, 2003, at 23:55:41
I don't know if anyone is reading this thread anymore, but I just want to say that I was self medicating with opiates after years of searching for an AD, of which nothing worked. I finally found opiates to target just the right symptoms and I was finally able to function in society normally. I know some may say or think this is just an excuse to use drugs, but I would love to NOT have to use ANY drugs, but my brain is not wired the same way yours is. I have been on suboxone now for about 4 months and it is saving my life. I have a medication for my depression and I am receiving it legally, and i have to say a lot cheaper than if I bought it outside of a pharmacy....I believe this is one of many treatments for depression, bc yes we all have different needs and symptoms and our bodies react differently to EVERYTHING, but if their is anyone else out there that is in a similiar situation, just know you are not alone.
Posted by Chairman_MAO on October 18, 2011, at 7:36:12
In reply to Re: opiates and major depression » Aurora, posted by safire4hope on October 18, 2011, at 7:29:01
I'd have to identify myself as an "addict" and present for "treatment" in order to receive buprenorphine, something which I am presently not willing to do.
I have been on it before and it is an amazing antidepressant. It is not you who should have to justify your taking the drug to feel better, but rather people who believe in pharmaco-mythology and make bald-faced assertions about which drugs are "good" and "bad".
Posted by safire4hope on October 18, 2011, at 8:43:16
In reply to Re: opiates and major depression » safire4hope, posted by Chairman_MAO on October 18, 2011, at 7:36:12
I understand completely, thank you for your reply, and if I were not an addict myself I would feel the same way, but after years of taking opiates to self medicated I became physically dependent. I started the suboxone to gradually move to another AD because I was tired of being in "that type of situation" even if it did help my depression. It wasn't a legal solution and that is not how I want to live my life. It was only after I started the treatment that I realized the suboxone treated my depression just as well if not better.That also led me to the knowledge that there have actually been studies done concerning depression and this medication. Studies that had postive results! When I realized I wasn't the only one to have the same results with the drug I started to research it further which led me to my present state of mind: this is a good treatment for certain people with depression and it should continue to be researched in that regard.
Posted by Chairman_MAO on October 18, 2011, at 12:07:42
In reply to Re: opiates and major depression » Chairman_MAO, posted by safire4hope on October 18, 2011, at 8:43:16
> I understand completely, thank you for your reply, and if I were not an addict myself
I've abused drugs before. In fact, I've used illicit opiates just to test positive to get on Suboxone for depression (via an addiction clinic). I would still be taking it if it didn't mean stigmatizing myself as an "addict", which really screws you in the long-term in many respects. I don't care about people's classifications of drugs. I care about my own well-being. If I am not hurting anyone else, I deserve to be left alone. The medico-statists and their apologists can go take a flying ...
Of course opiates work for depression. Everyone knows this. You don't need any more "research", there is plenty of research.
http://opioids.com/antidepressant/
The only reason they aren't used more is drug law.
Buprenorphine is ideal for depression for many reasons, one being that if you take too much of it, it starts antagonizing its own effect, making it way safer in overdose than many over-the-counter medications.
Posted by CaptainAmerica1967 on October 18, 2011, at 18:54:54
In reply to Re: opiates and major depression » Aurora, posted by safire4hope on October 18, 2011, at 7:29:01
I've found success with buprenorphine because of it's kappa antagonist as everyone with depression has an overactive brain based upon Helen Mayberg's study with PET scans showing too much glucose consumption in even minor depression and the Pet Scans remain overactive until the patient goes into remission and for Dr. Mayberg, remission was with doing deep brain stimulation. Those that stayed depression still showed an overactive brain or too much glucose consumption.
Posted by safire4hope on October 18, 2011, at 19:27:21
In reply to Re: opiates and major depression » safire4hope, posted by Chairman_MAO on October 18, 2011, at 12:07:42
My views are changing completely after reading and researching. I believed myself to be an addict just because I took a drug that helped my symptoms but "everyone else" said was illegal and "not right". I went for treatment because of all the trouble my self medicating was causing, and I now believe that I am not an addict, because I never "abused" any medication, but am only physically dependent which is something all people on certain meds have to deal with. Either be dependent or be depressed. If i have to choose I would choose dependent. I appreciate and agree with your statement of not caring what others think and only of your own well being. At this point I am ok with my depression and my "treatment for addiction" because I now know they are one in the same, but eventually I will have to deal with "what others think" when the doctors feel it is time for me to come off the suboxone. I only hope my own doctor or one I can locate will work with me and help me as much as possible. I don't ever want to be back in my "depressed" state again. It was not a pretty picture and cause my family a great deal of pain for a long time.
Posted by Chairman_MAO on October 18, 2011, at 20:33:47
In reply to Re: opiates and major depression » safire4hope, posted by CaptainAmerica1967 on October 18, 2011, at 18:54:54
> I've found success with buprenorphine because of it's kappa antagonist as everyone with depression has an overactive [... snip ...]
You found success with it because it is a mu-opioid agonist. You'd have just as much success with morphine. The kappa antagonist effect is good, but let's keep it real here.
Posted by sigismund on October 19, 2011, at 2:50:30
In reply to Re: opiates and major depression » CaptainAmerica1967, posted by Chairman_MAO on October 18, 2011, at 20:33:47
When compared with methadone I have heard people report some kind of elevation with bupe, once the changeover has been achieved.
But that is compared to methadone which is toxic enough.
Posted by CaptainAmerica1967 on October 19, 2011, at 8:29:28
In reply to Re: opiates and major depression » CaptainAmerica1967, posted by Chairman_MAO on October 18, 2011, at 20:33:47
Yes, I cannot deny that the opioid Mu receptor made me feel a little better but no more than any of the 100's of medications I've taken over the past 28 years of my life. I've tried tramadol and other Mu receptors meds and they only minimally helped as all meds have in my (TRD) treatment resistant depression /c anxiety and have had IV morphine after a car accident in 1986 from a seizure caused by high dose trazodone (1000 mg) that was very serious killing my Mother even after she told the psychiatrist I was having blank out spells, but he ignored my Mother's concern and said it was anxiety attacks causing me to faint and didn't believe trazodone could cause seizures even at a super high dose.
However, morphine did not make me feel like the buprenorphine. Pharmaceutical companies are working on several kappa antagonists and even addiction specialist, the head of NAABT, Richard Gracer, MD said depressed patients feel better on buprenorphine because of the kappa receptor antongism and believes that individuals /c depression have an impaired or overactive kappa system. Difference in treating refractory depression (TRD) vs opiate addiction is the dose SL tablets; TRD .5 mg - 4 mg QD vs addiction TX up to 20 mg of buprenorphine day. Gracer states that taking buprenorphine for depression isn't a weakness and is no different than patients who must take an antidepressant for a lifetime and shouldn't feel ashamed about that. I always told my depressed patients that it's no different that some of my diabetic patients that must remain on insulin for a lifetime.
I have developed osteoarthritis in the left knee from being an extreme athlete in trying to control my depression via endorphins, enkephalins release from extreme workouts all of these years and buprenorphine has a similar effect of calming my brain down after a hard workout and buprenorphine is indicated for osteoarthritis, but only the liquid injectable form which I refuse to take as injecting buprenorphine can really make one addictted and have severe withdrawal so I pay for the sublingual tablets off label 2 mg BID or $100 for 60 tablets, a months supply; Butrans patch by Purdue Pharma recently came out with their buprenorphine patch and is indicated for osteoarthritis pain but Medicare is denying it currently. The original buprenorphine study on TRD by Bodkin et al, used the liquid form but either used the buprenorphine liquid intranasally (60% bioavailability) or liquid sublingually (50% bioavailability) which is better than the sublingual tablets (40% bioavailabity) but the cost of the liquid is about 3x as much as the tablets and am not sure of the cost of the Butrans patch yet (50% bioavailabity).
I've had 70 ECT's when I was 18y/o-19y/o right /p high school graduation in '85 over a yr. period, tried over 100 medications since I was 16y/o in 1983, studied medicine as a PA to try to research TRD more on my own and have for years even prior to studying medicine in the early '90s and the MAOI type A antidepressants seem to work the best. Parnate is the best in my personal opinion at least for me with the comorbid depression with anxiety even though I took Nardil (has GABA inhibitor but mroe toxic to body) for 12yrs but Parnate has less side effects and boosts libdo, but I personally need clonazepam for the anxiety, for seizure prevention of high dose antidepressants in which I'm taking 100 mg of Parnate (high dose of trazodone, 1000 mg caused the seizure in 1986 and could have sued my psychiatrist but it wasn't going to bring back my Mother), and lastly need clonazepam for my REM sleep disorder; muscles aren't paralyzed during REM sleep, stage 5 as I sleepwalk, thrash, kick, punch-last girlfriend got a black eye-has made me hesitant towards longterm dating, talk all while sleeping and go directly into REM sleep instead of the 90 minutes it normally takes to go through the typical sleep phases-shoretned REM latency which is really more related to TRD. I just started taking Xyrem (known as GHB or sodium oxybate) for my REM sleep disorder which helps tremendously in getting at least 3-4 hours of sleep without before waking up as I used to sleep for one to two hours and wake up from thrashing, sleepwalking or talking in my sleep and Xyrem also helps /c the depression and anxiety.
My depression is definitely an overactive brain as sleep deprivation works wonders for me (as do cold showers/baths) and calms my brain down (reduces glucose levels in the brain? Increases monoamines? Increases libido-increased dopamine?) but as soon as I get any amount of sleep, the depression/anxiety/hot flashes/difficulty concentrating returns.
Neurolgist Helen Mayberg of Emory Univeristy has shown that everyone with depression has certain parts of the brain that use too much glucose consumption-hyperactivity, areas around Broadmann's area 25 or the subgenual cingulate which controls serotonin transporters and controls the hypothalamus that in turn controls various mood areas of the brain like the amygdala. Additional studies with deep brain stimulation have shown that stimulating the white matter surrounding area 25 is just as effective in treating TRD and all of these areas are hyperactive to meaning too much glucose consumption is being used as shown on the PET Scan..
Posted by europerep on October 19, 2011, at 8:32:45
In reply to Re: opiates and major depression » CaptainAmerica1967, posted by Chairman_MAO on October 18, 2011, at 20:33:47
> You found success with it because it is a mu-opioid agonist. You'd have just as much success with morphine. The kappa antagonist effect is good, but let's keep it real here.
>Actually, buprenorphine is a partial mu-opioid agonist. Furthermore, research on kappa-antagonism shows its potential for treating depression, so this component of buprenorphine may well play a role. Lastly, buprenorphine's metabolite norbuprenorphine is a delta-agonist, which may as well contribute to buprenorphine's antidepressant potential.
Posted by Chairman_MAO on October 19, 2011, at 13:50:09
In reply to Re: opiates and major depression » Chairman_MAO, posted by europerep on October 19, 2011, at 8:32:45
>
> > You found success with it because it is a mu-opioid agonist. You'd have just as much success with morphine. The kappa antagonist effect is good, but let's keep it real here.
> >
>
> Actually, buprenorphine is a partial mu-opioid agonist. Furthermore, research on kappa-antagonism shows its potential for treating depression, so this component of buprenorphine may well play a role. Lastly, buprenorphine's metabolite norbuprenorphine is a delta-agonist, which may as well contribute to buprenorphine's antidepressant potential.
>Yes, I know it is a partial mu-opioid agonist, but you can get equipotent analgesia comparable to any other mu agonist so long as you don't go over buprenorphine's "ceiling", beyond which efficacy drops (but you already know this, I'm sure, because you bothered to "call me out" on its being a partial agonist). There is ample literature using conventional mu agonists to treat depression effectively.
I think that buprenorphine makes an excellent candidate for use as an antidepressant for many reasons--the number one reason being its safety in overdose. It has more than antidepressant potential, it _is_ an antidepressant. It's wonderful to have all of these hypothetical discussions about which receptor subtypes do what, but it's not very useful clinically. What matters is what works.
Posted by Chairman_MAO on October 19, 2011, at 14:09:38
In reply to Re: opiates and major depression » Chairman_MAO, posted by CaptainAmerica1967 on October 19, 2011, at 8:29:28
> Yes, I cannot deny that the opioid Mu receptor made me feel a little better but no more than any of the 100's of medications I've taken over the past 28 years of my life.
That is highly individualized, and not everyone feels that way (I am not speaking for myself here).
> However, morphine did not make me feel like the buprenorphine. Pharmaceutical companies are working on several kappa antagonists and even addiction specialist, the head of NAABT, Richard Gracer, MD said depressed patients feel better on buprenorphine because of the kappa receptor antongism and believes that individuals /c depression have an impaired or overactive kappa system.
Kappa antagonism is promising, but bootstrapping from psychopharmacology to some sort of pathophysiology is absurd. You can "believe" whatever about whatever you want in this field with virtually no evidence.
> Difference in treating refractory depression (TRD) vs opiate addiction is the dose SL tablets; TRD .5 mg - 4 mg QD vs addiction TX up to 20 mg of buprenorphine day.
That's funny, I got on it for depression and got the best effect at 4mg qid (sublingually of course), which is where, in most people, it seems to have the greatest analgesic effect. Taking it four times daily is different than taking it once or twice daily.
> Gracer states that taking buprenorphine for depression isn't a weakness and is no different than patients who must take an antidepressant for a lifetime and shouldn't feel ashamed about that.
I don't think that anyone should feel ashamed for using any drug for any reason unless there are negative consequences--especially if it has _positive_ results.
> I always told my depressed patients that it's no different that some of my diabetic patients that must remain on insulin for a lifetime.
That's a quaint narrative, but it belies reality. You know it doesn't work like insulin. I am really tired of http://en.wikipedia.org/wiki/Pharmacological_Calvinism
You could make it _metaphorically_ like taking insulin, but it is not like taking insulin.
>> I have developed osteoarthritis in the left knee from being an extreme athlete in trying to control my depression via endorphins, enkephalins release from extreme workouts all of these years and buprenorphine has a similar effect of calming my brain down after a hard workout
You mean calming your mind down?
>and buprenorphine is indicated for osteoarthritis, but only the liquid injectable form which I refuse to take as injecting buprenorphine can really make one addictted and have severe withdrawal so I pay for the sublingual tablets off label 2 mg BID or $100 for 60 tablets,
Injection vs. sublingual administration is just a matter of convenience. The SL bioavailability is so poor, that is why the doses of the SL tablets is so high. This has nothing to do with "addiction".
> a months supply; Butrans patch by Purdue Pharma recently came out with their buprenorphine patch and is indicated for osteoarthritis pain but Medicare is denying it currently.
That's a shame.
> The original buprenorphine study on TRD by Bodkin et al, used the liquid form but either used the buprenorphine liquid intranasally (60% bioavailability) or liquid sublingually (50% bioavailability) which is better than the sublingual tablets (40% bioavailabity) but the cost of the liquid is about 3x as much as the tablets and am not sure of the cost of the Butrans patch yet (50% bioavailabity).
>The sublingual bioavailability varies, but for the tablets it is about 30%.
> I've had 70 ECT's when I was 18y/o-19y/o right /p high school graduation in '85 over a yr. period, tried over 100 medications since I was 16y/o in 1983, studied medicine as a PA to try to research TRD more on my own and have for years even prior to studying medicine in the early '90s and the MAOI type A antidepressants seem to work the best. Parnate is the best in my personal opinion at least for me with the comorbid depression with anxiety even though I took Nardil (has GABA inhibitor but mroe toxic to body) for 12yrs but Parnate has less side effects and boosts libdo, but I personally need clonazepam for the anxiety, for seizure prevention of high dose antidepressants in which I'm taking 100 mg of ParnateUnless you are epileptic, you're unlikely to get a seizure from 100mg/day of tranylcypromine. Plus, you don't use a benzo as a primary anticonvulsant--certainly not in seizure-prone people--because they lose effectiveness over time and as tolerance and dependence sets in, they become less useful in status epilepticus.
That is because MAOIs are the best antidepressants --at least among drugs labelled as such. Good dose for "high-dose" tranylcypromine is 1.5mg/kg/day or a max of 200mg/day. The major concern AFAIK is thrombocytopenia if you keep going higher plus inhibition of other enzymes. I think knocking out MAO-A and MAO-B produces a more robust effect; knocking out MAO-B has a cascade of effects from letting more trace amines (namely PEA) remain around.> (high dose of trazodone, 1000 mg caused the seizure in 1986 and could have sued my psychiatrist but it wasn't going to bring back my Mother),
1000mg? Insane. I'm sorry to hear that.
> and lastly need clonazepam for my REM sleep disorder; muscles aren't paralyzed during REM sleep, stage 5 as I sleepwalk, thrash, kick, punch-last girlfriend got a black eye-has made me hesitant towards longterm dating, talk all while sleeping and go directly into REM sleep instead of the 90 minutes it normally takes to go through the typical sleep phases-shoretned REM latency which is really more related to TRD. I just started taking Xyrem (known as GHB or sodium oxybate) for my REM sleep disorder which helps tremendously in getting at least 3-4 hours of sleep without before waking up as I used to sleep for one to two hours and wake up from thrashing, sleepwalking or talking in my sleep and Xyrem also helps /c the depression and anxiety.
GHB is good stuff. Really non-toxic, too.
>
> My depression is definitely an overactive brain as sleep deprivation works wonders for me (as do cold showers/baths) and calms my brain down (reduces glucose levels in the brain? Increases monoamines? Increases libido-increased dopamine?) but as soon as I get any amount of sleep, the depression/anxiety/hot flashes/difficulty concentrating returns.
>What is "overactive brain"?
> Neurolgist Helen Mayberg of Emory Univeristy has shown that everyone with depression has certain parts of the brain that use too much glucose consumption-hyperactivity, areas around Broadmann's area 25 or the subgenual cingulate which controls serotonin transporters and controls the hypothalamus that in turn controls various mood areas of the brain like the amygdala. Additional studies with deep brain stimulation have shown that stimulating the white matter surrounding area 25 is just as effective in treating TRD and all of these areas are hyperactive to meaning too much glucose consumption is being used as shown on the PET Scan..
Could you provide me with citations of these papers, please? I am interested.
Posted by safire4hope on October 19, 2011, at 16:22:10
In reply to Re: opiates and major depression » Chairman_MAO, posted by CaptainAmerica1967 on October 19, 2011, at 8:29:28
I am not a doctor, but taking in all that everyone is stating and what I've researched so far, I do believe that the buprenorphine is working "for me" with my depression and obviously a lot of others. I would never have found this out if not for "using" opiates for years to self medicate and eventually believing myself to be an "addict" (even though I only took up to 20mg a day depending on my depression symptoms) and going into treatment for addiction. I let everyone else's view of what was right and wrong eventually cause me to believe badly of myself when I should have went with my very first belief that the pills were helping my depression. The suboxone I am on now (about 4mg a day) is def. better than taking pain pills for my symptoms and obviously safer as I saw someone else post because of the cap, although I don't abuse my medication to get to the point of overdose. I was on Methadone at one point and that did help but I don't care for it. It isn't safe and they had me on a dose that was way too high and I was falling asleep at times. I thank everyone for their help/input and facts. It has helped me greatly in my effort to find an AD that works for me and given me info I can use when speaking with my doctor. Having said all that, I am sorry to hear of all the things you've had to go through in your journey to find "the right fit" for you, and to hear of your mother's passing in such a way. I am sorry for that, and pray for you. Thanks to all who read this who've given feedback in any kind. It has helped. I've always asked the question "If it works, why change it?" and I was overall correct in saying that, in my opinion.
Posted by europerep on October 20, 2011, at 15:30:27
In reply to Re: opiates and major depression » europerep, posted by Chairman_MAO on October 19, 2011, at 13:50:09
My point was simply this: pharmacology matters.
It matters when explaining to a doctor why giving buprenorphine to a patient with TRD is not like prescribing morphine, or for that matter, heroin. It matters when trying to point out why the risk-benefit ratio with buprenorphine is better than with oxycodone or hydromorphone. And lastly, it matters when looking at what future drug treatments could or should look like.
That's all I wanted to say.
Posted by CaptainAmerica1967 on October 20, 2011, at 17:52:15
In reply to Re: opiates and major depression, posted by sigismund on October 19, 2011, at 2:50:30
I just wanted to write this note down and wish pharmaceutical companies would take this note seriously:
By 2020, which is less than nine years away nearing eight, the second leading cause of death in the USA will be suicide and second only to heart disease and possibly the number one killer for women. This has been predicted by WHO (World Health Organization predicted this as far back as the late 1990's or early 2000's I believe).
Obviously not all suicides are caused by psychiatric diseases, but a large percent are; Others causes of suicide follow along reasons for individuals getting "reactive depression" such as death of a family member/loved one, loss of a job, divorce/breakup, longterm/lifelong chronic illness, and more which are tough enough situations but "in my opinion" don't compared to those who struggle from "daily, chronically treatment resistant depression" as I've had or have all of the above situations happen to me.
Maybe the economy is going to get really bad producing more financial hardships, divorces, loses of jobs/homes, the baby boomer ('46-'64) parents will die causing grief on their children or Social Security Disabilty will be taken away (fortunate that I saved enough money throughout my career hopefully to last a lifetime if SSD goes away or if I'm never fixed to feel confident enough to work again) by the Republicans or that's what Rick Perry wants as well as many other Republicans want to do, and this will place too much pressure or stress causing suicides to become number two or maybe it's just more genetics passed down with depression as the number of RX antidepressants have skyrocked throughout the past 10 years. I would have liked to have kids as it's only my Brother (he had a girl) and I remaining but I would never wish TRD on anyone if mine is indeed genetic (I was a 12pd baby boy and OBGYN may have damaged my temporal lobe-limbic system while trying to deliver me vaginally with too much pressure, force being placed with the foreceps on temporal lobes as I had blood on both side and still have a scar on my right temple; Neurologist gave me this hypothesis of depression as he had seen this happen quite a bit in his career prior to retiring) so I don't want children, but could always adopt.
I think the pharmaceuticals companies need to wake up and are too focused purely on the monoamine hypothesis of depression and wish they'd start focusing on other mechanisms. Prior to the first antidepressant developed in the 1950's which was discovered purely by chance when a MAOI drug used to treat tuberculosis was given to patients, the patients started feeling much better; (Other drugs are discovered this way, ie testing Viagra for heart disease, but found out Viagra worked for erectile dysfunction). Physicians used to prescribe morphine, or opiates and the opiates worked for everyone and not just a select percentage, but the fear of addiction lead to the downfall or replacement by antidepressant drugs.
Present day, upto about 45% of patients who take antidepressants don't respond or do respond but don't get completely better. Some patients may respond better to the older meds like MAOIs or tricylics as they block REM sleep better compared to the SSRI's, but probably not the SNRI but Parnate is the most potent REM blocker available (why it helps my REM sleep disorder too) and keeps the brain less active, or from being over active/hyperactive during REM sleep in which all patients with depression show this overactivity or too much glucose uptake or excessive cerebral blood flow shown on PET scans or SPECT imaging; both my pyschiatric and I believe deep brain stimulation for those with the most severe TRD will make ECT obsolete because DBS really works and hits the root cause of the depression, overactivity by stimulating the specific area every so often, it calms the brain just like DBS would for overactive brain conditions like Bipolar, ADHD, Parkinson's (DBS first used for), Anxiety, OCD, Anorexia Nervosa, Epilepsy (over and under active), hot flashes?, possibly Alheimer's whereas ECT just makes the patient have a seizure hoping that the brain corrects itself via various mechanisms. ECT didn't help me at all and probably made me feel worse as I hated the thought and feeling of being knocked out as it's a total different feeling than slowly drifting off to sleep which is a nice feeling and I felt groggy half the day from the anaesthetics and worn out.
So why do pharmaceutical companies keep coming out with tweaked or slightly changed medications like Effexor to Effexor XR to Pristiq which if the Effexor didn't work then why Effexor XR or Pristiq? Money is the reason because the company is extending the life of the medication from becoming generic and will sometimes make them into a liquid or patch therefore still extending the patent but this is not trying to necessarily really help the struggling depressed patient.
I hope to enter into a ketamine study ASAP but most likely early next year as I've been much better this past year on buprenorphine, "SUBUTEX" (not "SUBOXONE"), but still not 100% everyday and an hoping the ketamine will get me there or I'm able to start working out again, otherwise I'll try to get into a deep brain stimulation again, but was excluded twice because of one psychiatrist's mistake of giving me too much trazodone and having a medication induced seizure therefore excluding me from two DBS studies (Dallas, Emory-Mayberg at Emory) as they want patients with who've never had a seizure regardless of the reason (you can have a seizure by getting knocked over the head-knew a patient that had a seizure after a coconut fell out of a tree and hit him on the head) and I even spoke to Helen Mayberg (pioneer of DBS for TRD) regarding my situation and said I was an excellent candidate but the reviewing psychiatrist who does the inclusions/exclusions is very thorough, rigid with the rules of DBS for depression still being an investigational study.
Ketamine, from what I've read, increases brain derived neurotrophic factor (BDNF) or increases the synapses, synaptogensis. I know ketamine works as an antagonist of the glutamate NMDA receptor, a proposed mechanism for depression but have already tried meds like Namenda (Alheimer's and detxromethorphan, the newest being Nuedexta (indicated for a disease that makes individuals breakout into crying or laughing spells-pseudobulbar affect that has quinidine to elevate the detxromethorphan levels) even while on the Parnate (normally a psychiatrist or pharmacist wouldn't dare combine the two but after what TRD patient has tried everything, taking cautious risks by slowly adding a medication might be worth it but the med didn't have the desired effect either.
My goal is to conquer this as everyone's goal is an to write an autobiography in the hopes of saving individuals lives before 2020.
Best wishes to all!
Posted by SLS on October 20, 2011, at 18:47:41
In reply to Re: opiates and major depression, posted by CaptainAmerica1967 on October 20, 2011, at 17:52:15
Nice post.
I don't know if excessive neural activity in Brodman's Area 25 is the root cause of depressive illness or a consequence of it, but DBS works. Outside of this structure, brain activity (FDG uptake) is reduced almost globally as rendered in PET scans. One day soon, we will understand the functions of, and the relationships between, brain circuits.
I am not refuting the idea that overactivity in the subgenual cingulate might be the cause of depressive illness. I just haven't seen evidence that is accepted as being conclusive yet.
- Scott
Posted by JohnLA on October 20, 2011, at 23:29:42
In reply to Re: opiates and major depression, posted by CaptainAmerica1967 on October 20, 2011, at 17:52:15
capatain america-
like your post very much. but, over half a million die from cancer each year in this country. not sure where you got your info. even more from heart disease. suicide deaths i believe are a little over 30,000.
suicide is not even in the top 10 causes of death in the usa. i'm not trying to make lite of our conditions. it's just a little bothersome when inaccurate info is posted regarding depression.
maybe i misunderstood that part of your post?
regardless, like i said, i agree whole-heartedly w/the rest of your post.
john
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