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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 54. This is the beginning of the thread.
Posted by bsj on December 5, 2003, at 20:28:33
I'm up for some serious discussion of opiate therapy. Please check all drug war and political mythology at the door.
I firmly believe, with personal experience on my side, that depression in some people is caused wholly or partly by dysfunction of the innate
opioid systems. This makes perfect medical sense: it would be absurd to assume that the endorphin systems are immune to malfunction, when it's known that virtually all other brain systems are; and depression would logically be the result of malfunction in such systems. This point has rarely addressed in psychiatric literature, because pyschiatry is stuck in the monamine theory of depression. They probably won't get to any widely-accepted opiod theories for another decade at least.For those whose depression is rooted in opiod dysfunction, SSRIs and other mainstream antidepressants will have little or no effect: the right systems are not being targeted for rectification. It's like treating coronary heart disease with insulin. These people will take all the medications like they're supposed to, but won't get any better; according to clinical trials of antidepressants, this happens some 30% of the time (and out in the real world, response rates are even worse). These people can choke down a pharmacy full of antidepressants and not notice a single positive difference. But, lo, give them an opiate, and they suddenly start feeling like themselves again; they begin to feel normal. Notice the words I'm _not_ using: high, whacked out, unnaturally happy; no--they
start to feel normal.Given that there are no opiod-targeting antidepressants now (nor are there likely to be for some time), I feel a justified therapy for these cases are weaker opiates like codeine and hydrocodone[1]. Those are the only drugs available that target the systems which are likely malfunctioning and causing the depression. These are the only drugs which have a chance of saving these people.
Let's address the physical dependence and tolerance issues: all opiates cause physical dependence and tolerance; there's no way around it. (But so do many antidepressants.) But these phenomena can be migitaged and lessened by drug holidays. Opiate tolerance disappears in a large part after a period of abstinance--say, a week to ten days; two weeks at the most. My own
regimine is to take hydrocodone 10mg twice daily for four weeks and abstain for the following week; I don't take it one week out of every five. I certainly notice some of the classic withdrawal symptoms (anxiety, spaciness, return of
the depression), but I keep tranquilizers on hand and sleep the withdrawal away. Then, when I go back to taking hydrocodone, I notice that its effect is comparable to what it was when I first started taking it. If one can maintain this regimine, the threats of physical dependence and tolerance are severely lessened. I've managed to do it so far with little willpower; and so
I know there are others who can do it, too.I see no reason why therapy of this kind should not be tried with refractory cases of depression where all other resources have failed. The risk is no greater than with using psychostimulants like Ritalin or Dexedrine. The reasons against it are all political in nature, founded on ill-conceived notions of drug dependence and the addiction boogeyman (I've avoided this term so far because it has no clinical meaning).
[1] It would be nice if a drug manufacturer would come out with a codeine-only or hydrocodone-only pill. APAP, aspirin, et. all are unnecessary and themselves may bring risks. But there are methods for isolating the opiates from the other
ingredients; I have a chemistry background, and do this myself, but not everyone has the equipment or knowledge. I usually ground half a bottle of pills up at once (30 pills or so) and make a solution whose concentration is 2mg hydrocodone/ml. This way, one dose equals a 5ml dropper.
Posted by krazybirdlady on December 5, 2003, at 21:09:03
In reply to Disussion of Opiate Therapy, posted by bsj on December 5, 2003, at 20:28:33
BSJ, as you know i have followed your theories with much fascination. i do not dispute anything that you have stated here. given that you are the one suffering, i can only say that you are probably more skilled in your own treatment. the drug holiday is a very wise choice, and could make your regime work indefinitely if you can follow it. finally, and which makes me most frustrated is, there ARE products available which are only codeine or hydro or oxy. they are just not available in north america. not that i know of anyhow. for the amt you are taking, i really wouldn't worry too much about the APAP or aspirin. 2 pills a day really wouldn't hurt you in terms of the OTC med in it. the extraction method works but don't forget about the caffeine in some of these meds. that IS NOT extracted. not really a problem, just wondered if it might counteract the effect of the opiate? not sure..by the way...here in Canada codiene based analgesics are available OTC. only 8 mgs of codeine per tablet though.
Posted by bsj on December 5, 2003, at 21:12:20
In reply to Disussion of Opiate Therapy, posted by bsj on December 5, 2003, at 20:28:33
Of course, another option is for a Dr. Kevorkian of depression to arise and we come to accept that some of these people should be allowed to kill themselves. Maybe the U.S. Surgeon General could even get involved; he could set up Federally-funded tents at carnivals where a family can take their loved one who wants to commit suicide. You just strap yourself down and shoot a lethal dose of barbiturates. That way, no mess and no one has to find the body and get all freaked out (and you won't have to leave a note, since you can explain your reasons to your family before they take you to die).
Posted by krazybirdlady on December 5, 2003, at 21:14:44
In reply to Re: Disussion of Opiate Therapy, posted by krazybirdlady on December 5, 2003, at 21:09:03
sorry, oxycontin is pure. but you wouldn't want to go there. they are impossible to get unless you are in chronic agony and they are very strong.
Posted by krazybirdlady on December 5, 2003, at 21:18:20
In reply to Re: Disussion of Opiate Therapy, posted by bsj on December 5, 2003, at 21:12:20
sorry no..they're after him too. you WILL live damned you. assisted suicide is illegal as well as meds to prevent it. catch 22 situation????
Posted by bsj on December 5, 2003, at 21:41:57
In reply to Re: Disussion of Opiate Therapy, posted by krazybirdlady on December 5, 2003, at 21:18:20
When I'm confronted with the possible/probable lack of proper medication in the future, my first impulse is suicide; and my second impluse; and my third. Living without it is cruel and hopeless; that's just the way I feel.
The one thing that holds me back is a great big project I've been working on for most of my life. I want to get into shape so others can see it. Most of my time over the last three months (since I've been taking the hydrocodone) has been devoted to this; I feel like I'm running out of time. The project has in it all the hope that I don't have; it's an embodiment of the real me, the way I should be but aren't.
Posted by krazybirdlady on December 5, 2003, at 21:52:22
In reply to Re: Disussion of Opiate Therapy, posted by bsj on December 5, 2003, at 21:41:57
why do you feel that you are running out of time? do you feel that you will not be able to obtain your meds any longer? this project sounds like a person who is focused on what he wants and in itself can improve your emotional pain. as for the meds, one day at a time. they have been around for hundreds of years and are still around. this is because they work for pain. as you have pointed out, pain is pain (emotional or physical). Does codiene work as well for you? or have you just tried the hydro? codiene is much easier to get. just wondering..
Posted by bsj on December 5, 2003, at 21:58:39
In reply to Re: Disussion of Opiate Therapy, posted by krazybirdlady on December 5, 2003, at 21:09:03
"the extraction method works but don't forget about the caffeine in some of these meds. that IS NOT extracted. not really a problem, just wondered if it might counteract the effect of the opiate? not sure..by the way...here in Canada codiene based analgesics are available OTC. only 8 mgs of codeine per tablet though"
I could extract the caffeine; that's no problem. I have a small lab here and the knowhow.
I live 150 miles from the Canadian border; I'm seriously thinking about a trip up there. Can you just walk into drugstore and buy these codeine concoctions off the shelf? Do you have to sign anything? Do they check ID? I'm sure there are importation laws (only 30 pills allowed, blah, blah blah), but I could get around those and bring back a good supply. I'd probably have to take 70-80mg of codeine to equal the hydrocodone.
Posted by bsj on December 5, 2003, at 22:03:54
In reply to Re: Disussion of Opiate Therapy, posted by krazybirdlady on December 5, 2003, at 21:52:22
"why do you feel that you are running out of time? do you feel that you will not be able to obtain your meds any longer?"
Yeah, that's pretty much it. I fill up pages and pages of notes about future things that I don't know I'll be here to write.
"Does codiene work as well for you? or have you just tried the hydro? codiene is much easier to get."
Never tried codeine; but I may. And in the U.S., it's as hard to get as hydrocodone. Qualitatively, they're very similar and are controlled in the same way.
Posted by krazybirdlady on December 5, 2003, at 22:07:35
In reply to Re: Disussion of Opiate Therapy, posted by bsj on December 5, 2003, at 21:58:39
actually, no limit. nothing to sign. they may ask you what they are for, but just say migraines. i never ask my patients what they are using them for. they keep them behind the counter so just go up and ask. either aspirin or APAP based, you can get a bottle of up to 200 pills. most apap is 325 mg APAP, 8mg codiene, 15 mg caffeine. ASA is the same, only with ASA to replace the APAP. literally thousands of people cross over the border for this in any given week. perfectly legal given it is only a 3 month supply. thing is you must come in to get them...they can't be shipped without a script. makes no sense, does it? much cheaper though about $20.00 CDN for 200 pills.
Posted by bsj on December 5, 2003, at 22:11:19
In reply to Re: Disussion of Opiate Therapy, posted by krazybirdlady on December 5, 2003, at 22:07:35
If I wanted the aspirin-based ones, what exactly should I ask for (so I don't look like a foreigner)?
BTW, are you a doctor or nurse? You spoke of having patients.
Posted by krazybirdlady on December 5, 2003, at 22:19:09
In reply to Re: Disussion of Opiate Therapy, posted by bsj on December 5, 2003, at 22:11:19
he he i wish..i am a pharmacist. just ask for ASA with codiene. they will tell you what sizes they have in stock. 50 tabs, 100, or 200. if you feel you need more than that, for extraction, then go to another pharmacy. take empty bottles xxx.
Posted by krazybirdlady on December 5, 2003, at 22:31:43
In reply to Re: Disussion of Opiate Therapy, posted by krazybirdlady on December 5, 2003, at 22:19:09
for some people codiene may cause nausea, even if hydro doesn't. don't know why as chemical make-up is same. if this occurs, try a gravol with your dose. works wonders...
Posted by bsj on December 5, 2003, at 22:34:02
In reply to Re: Disussion of Opiate Therapy, posted by krazybirdlady on December 5, 2003, at 22:19:09
"he he i wish..i am a pharmacist."
Hey. How long you been at that particular occupation?
"take empty bottles xxx."
I'll just hide the pills in vitamin bottles. I always carry a bunch of vitamins when I travel anyway.
Thanks a lot.
Posted by bsj on December 5, 2003, at 22:36:22
In reply to just one work of caution about nausea, posted by krazybirdlady on December 5, 2003, at 22:31:43
"for some people codiene may cause nausea, even if hydro doesn't. don't know why as chemical make-up is same. if this occurs, try a gravol with your dose. works wonders..."
Hydro and codeine are similar, but Hydro has an extra H group (obviously). What is gravol? Anything like guaif? Can I get that in Canada, too? (If codeine works, I think I'll just move to Canada.)
Posted by bsj on December 5, 2003, at 22:38:26
In reply to Re: just one work of caution about nausea, posted by bsj on December 5, 2003, at 22:36:22
BTW, to make sure: is this stuff legal in all Canadian provinces? I'll be crossing from Detroit into Ontario.
Posted by krazybirdlady on December 5, 2003, at 22:40:48
In reply to Re: Disussion of Opiate Therapy, posted by bsj on December 5, 2003, at 22:34:02
no problem, that works too, i guess. i was a pharm assistant for 16 yrs. before going back to university. been a pharmacist for 4 yrs. now. may i ask what province you are close to? BC, ALTA and ONT are the easiest, although i wouldn't foresee any problems in any others either. i think Quebec asks your name and address, but not sure.
Posted by krazybirdlady on December 5, 2003, at 22:43:47
In reply to Re: just one work of caution about nausea, posted by bsj on December 5, 2003, at 22:38:26
yes in all provinces...Ontario is no problem. i live and work in Ontario. Gravol is used for travel sickness (dramimine). sold OTC at any pharmacy...
Posted by bsj on December 5, 2003, at 22:45:29
In reply to Re: just one work of caution about nausea, posted by krazybirdlady on December 5, 2003, at 22:43:47
What part of Ontario are you in? I live in central Indiana, about 150 miles from the border at Detroit.
Posted by krazybirdlady on December 5, 2003, at 22:51:38
In reply to Re: just one work of caution about nausea, posted by bsj on December 5, 2003, at 22:45:29
i am in north central ontario. you would cross over to london, ont if i am not mistaken. i am in Ottawa, our country's capital. should have no problems at all in london...
Posted by bsj on December 5, 2003, at 22:55:39
In reply to Re: just one work of caution about nausea, posted by krazybirdlady on December 5, 2003, at 22:51:38
The map says Windsor; is that place ok, too?
Posted by krazybirdlady on December 5, 2003, at 22:55:40
In reply to Re: just one work of caution about nausea, posted by krazybirdlady on December 5, 2003, at 22:51:38
woops no..i guess it would be windsor. i suck at geography. still no problem...
Posted by krazybirdlady on December 5, 2003, at 23:00:25
In reply to Re: just one work of caution about nausea, posted by krazybirdlady on December 5, 2003, at 22:55:40
if you are feeling nervous about obtaining meds so close to the border, then take an hour or so drive up to Toronto. can get lost in a sea of pharms there. nobody will give you any problem i assure you. could take a nice look around too. CN tower maybe?
Posted by bsj on December 5, 2003, at 23:06:54
In reply to Re: just one work of caution about nausea, posted by krazybirdlady on December 5, 2003, at 23:00:25
There are several places in that area; I'll probably go to a couple different towns. Maybe I'll be able to hit Toronto in time to get back home before dark.
Posted by krazybirdlady on December 5, 2003, at 23:13:31
In reply to Re: just one work of caution about nausea, posted by bsj on December 5, 2003, at 23:06:54
good luck BSJ, and stay well whatever it takes...
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