![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 5 to 29 of 47. Go back in thread:
Posted by SLS on May 22, 2005, at 20:33:11
In reply to Re: Effexor XR Withdrawl Hell » SLS, posted by JahL on May 21, 2005, at 15:56:42
Hi JahL.
> Hello Scott.
>
> How are you? OK, I hope.
>
> You seem to have moved boards!I'm glad you were able to find me.
:-)
For me, things have been tolerable. Although still severely depressed and cognitively impaired, my usual cocktail of Parnate + TCA helps me keep my head above water. Combined with Lamictal, I would say that my degree of improvement is around 15% over my unmedicated baseline. Without this improvement, I am not sure that I could maintain my independence in the apartment I have kept over the last 4 years.
JahL, I really appreciate your friendly concern for my health and happiness. You can bet that the sentiments are returned.
Have you taken any anticonvulsants since your withdrawal of Effexor?
- Scott
Posted by SLS on May 22, 2005, at 20:34:23
In reply to Re: Effexor XR Withdrawl Hell, posted by SLS on May 22, 2005, at 20:33:11
Posted by JahL on May 23, 2005, at 14:17:14
In reply to Re: Effexor XR Withdrawl Hell, posted by SLS on May 22, 2005, at 20:33:11
Hi Scott.
>
> For me, things have been tolerable. Although still severely depressed and cognitively impaired, my usual cocktail of Parnate + TCA helps me keep my head above water. Combined with Lamictal, I would say that my degree of improvement is around 15% over my unmedicated baseline.15/20 % sounds about right. Lamictal (cognition/depression) + Sulpiride (s. phobia) + Clonazepam (sleep). I've temporarily given up on the dream of full remission; I figure 50% above baseline would make life tolerable.
> Without this improvement, I am not sure that I could maintain my independence in the apartment I have kept over the last 4 years.
I know. Life is one long struggle. I take it you can work enough to support yourself? I'm lucky I have a talent for gambling (what a surprise for a Bipolar!) and can make a decent wage by going online a couple of days a week.
> JahL, I really appreciate your friendly concern for my health and happiness. You can bet that the sentiments are returned.Thanks. A lot.
> Have you taken any anticonvulsants since your withdrawal of Effexor?You know me Scott, I've tried the lot ;-)
Lamictal (good - a keeper), Valproate (slight but sustained reduction in depression), Topiramate (not again, thanks), Keppra (nothing), Gabapentin (nothing), Lithium (*never* again. paralysis, extreme paranoia, bordering on the psychotic. I was being stalked by a giant swan. Seriously), Trileptal (I think). I can't remember the name of the other one right now (duh).
This is probably worthy of a new thread, but have you given much thought to trying Mifepristone? The early reports are very encouraging (GET THIS: apparently, cognitive dysfunction has been identified as *a predictor of response*!) but unfortunately it is almost impossible to source. It also works out at about $200 a day if you do find some!
C ya,
Jah.
Posted by ed_uk on May 23, 2005, at 15:38:00
In reply to Re: Effexor XR Withdrawl Hell » SLS, posted by JahL on May 23, 2005, at 14:17:14
Hi,
>Please, if anyone knows of the whereabouts of Elizabeth - a very clued up lady - I would dearly like to know. I was in occasional email contact with her a few years back, but after an ill-judged course of ECT, I forgot who I was for a year or two. During this period I lost all my contact details..........
It was me who was looking for her. I found her email address on an old p-babble post but it had been disabled.
Kind regards,
Ed.
Posted by JahL on May 23, 2005, at 16:40:13
In reply to Re: Effexor XR Withdrawl Hell » JahL, posted by ed_uk on May 23, 2005, at 15:38:00
Thanks Ed.
I think she was midway through some kind of med school. I have no doubt she graduated with flying colours...
My commiserations go out to you that you must share with me this p***-poor excuse for a mental health system we are saddled with here in the UK. I have pretty extensive experience of the whole sytem - public and private - and I'm distinctly underwhelmed. To put it mildly.
Take care,
Jah.
> >Please, if anyone knows of the whereabouts of Elizabeth..........
>
> It was me who was looking for her. I found her email address on an old p-babble post but it had been disabled.
>
> Kind regards,
> Ed.
Posted by ed_uk on May 23, 2005, at 16:49:25
In reply to Re: Effexor XR Withdrawl Hell » ed_uk, posted by JahL on May 23, 2005, at 16:40:13
Hi Jah!
I thought you might be from the UK when you mentioned sulpiride- they don't have sulpiride in the US!
>My commiserations go out to you that you must share with me this p***-poor excuse for a mental health system we are saddled with here in the UK.
Now that put a smile on my face :-)
>I have pretty extensive experience of the whole sytem - public and private - and I'm distinctly underwhelmed. To put it mildly.
I've been to quite a few pdocs. None have been good. They've all been very restrictive ie. you can have an SSRI or nothing at all. If you don't do well on venlafaxine they have no idea what to do with you. I've given up on NHS pdocs, I just got some Parnate from a friend abroad.
Kind regards,
Ed.
Posted by JahL on May 23, 2005, at 17:52:09
In reply to Re: Effexor XR Withdrawl Hell » JahL, posted by ed_uk on May 23, 2005, at 16:49:25
> I've been to quite a few pdocs. None have been good. They've all been very restrictive ie. you can have an SSRI or nothing at all. If you don't do well on venlafaxine they have no idea what to do with you. I've given up on NHS pdocs, I just got some Parnate from a friend abroad.
Yeah, it's that 'one size fits all' approach (and the obsession with 'psychotherapy') that kills me. If you don't respond to antidepressants you're either neurotic or have a Borderline Personality, if such a thing exists.
One of the country's top professors (I'd love to out him...) tried the old 'Borderline' get-out trick with me. I rubbished his reputation so much (it's amazing how far a little knowledge goes - and I have this place to thank for that) that I was granted an audience with The National Clinical Director of the NHS! Dr B. - do you know what a git is?
I suppose I'm quite fortunate - my NHS pdoc of 7 years has finally capitulated and will give me anything he won't get in trouble for; Riluzole, Memantine,Ropinirole, even Codeine [but not Vicodin...ggrrr]! Shame he retires next month.
I too have had to get most of my meds from abroad in the past, at great expense. I should stop paying taxes...
Is the Parnate helping?
Cheers,
Jah.
Posted by ed_uk on May 23, 2005, at 18:03:14
In reply to Re: Effexor XR Withdrawl Hell » ed_uk, posted by JahL on May 23, 2005, at 17:52:09
Hi Jah,
>Yeah, it's that 'one size fits all' approach.........
'The cookie-cutter approach'
Oh yes, I forgot to mention. EVERYONE has to be on the same dose.... individual differences in dosage requirements just aren't taken into account.
>I was granted an audience with The National Clinical Director of the NHS!
Wow :-)
>Vicodin...
It not licensed in the UK :-( You might be able to get buprenorphine (Temgesic, Subutex, Transtec).
>Is the Parnate helping?
I'm starting it in a few days time. I decided to buy a BP monitor first. My pdoc has never prescribed an MAOI in his entire career, neither had my old pdoc. I doubt he'd even have heard of Parnate..... Nardil seems to be used occasionally.
Kind regards,
Ed.
Posted by JahL on May 23, 2005, at 18:15:42
In reply to Effexor XR Withdrawl Hell, posted by TO_Girl on May 20, 2005, at 21:13:28
Sorry OT_Girl, I've colonised your thread. What was the outcome?
Did you decide to taper more slowly?
Ta,
J.
> I had to stop taking the Effexor. Over the course of 7 days I went from the 250 to 0 but am still on the Wellbutrin. This is absolute physical hell!
>
> What can I do to ease these symptoms on my own? Suggestions please!!
>
> Thanks - next time I won't be so wordy :o)
Posted by JahL on May 23, 2005, at 20:34:08
In reply to Re: Effexor XR Withdrawl Hell » JahL, posted by ed_uk on May 23, 2005, at 18:03:14
Hi again.
> Oh yes, I forgot to mention. EVERYONE has to be on the same dose.... individual differences in dosage requirements just aren't taken into account.
And still they have to consult their manuals!
> >Vicodin...
>
> It not licensed in the UK :-(Double :-( . Our dentist friend said he was permitted to prescribe it. Hmm. I guess he's mistaken.
> You might be able to get buprenorphine (Temgesic, Subutex, Transtec).
Ackk. Tried it; like a 'reverse opiate'. Felt dysphoric almost instantly. I've been taking low-dose 'diverted' Methadone for a few years now. Makes most people sleepy but it actually energises my twisted Bipolar brain! I can't work out on my punch bags until I've taken it. The dog gets a longer walk too...Just goes to show how heterogenous our brains are and why the 'cookie cutter' approach is doomed to fail a significant number of people.
This is why I'm interested in a full opioid agonist such as Vicodin. I know a few people who have taken it successfully w/o any real tolerance issues. Because of my Methadone experiences I'm certain that something like Vicodin would 'help', at least to some degree. Apparently it makes some people just feel 'normal' as opposed to euphoric.
Try getting it tho'. Impossible to get so much as a single pill to try. Well, nearly (I'm working on it...).
My question to you: do you know what full opioid agonists are available in the UK, other than diamorphine??
> My pdoc has never prescribed an MAOI in his entire career, neither had my old pdoc.That's outrageous! What century do these guys come from? It's widely acknowledged that MAOIs can sometimes help where all other ADs fail.
Cheers,
J.
Posted by SLS on May 23, 2005, at 21:05:48
In reply to Re: Effexor XR Withdrawl Hell » SLS, posted by JahL on May 23, 2005, at 14:17:14
Hi JahL.
> This is probably worthy of a new thread, but have you given much thought to trying Mifepristone?
I've already filled out the paperwork for the FDA. All that needs to be done is for my doctor to add his curriculum vitae and off it goes. I have been looking at mifepristone for quite some time now.
> The early reports are very encouraging (GET THIS: apparently, cognitive dysfunction has been identified as *a predictor of response*!)
Yay! I should do quite well on it, then!
Weird. You take the stuff for a week, respond, and then discontinue it. You then live happily everafter.
By the way, how did you come across this drug? I guess great minds stink alike. ;-)
- Scott
Posted by ed_uk on May 24, 2005, at 11:22:43
In reply to Re: Effexor XR Withdrawl Hell » ed_uk, posted by JahL on May 23, 2005, at 20:34:08
Hi J,
>My question to you: do you know what full opioid agonists are available in the UK, other than diamorphine??
I certainly do! Apart from codeine and methadone we've got...........
Morphine (Oramorph, Sevredol, MST Continus, Zomorph, MXL, Morphgesic SR, Morcap SR)
Oxycodone (OxyContin, OxyNorm)
Dihydrocodeine (DF118, DHC Continus) - a low potency opioid, similar to codeine. Like codeine tablets, it's schedule 5. Potent opioids are schedule 2.
Fentanyl transdermal patch (Durogesic)
Hydromorphone (Palladone, Palladone SR)
Kind regards,
Ed.
Posted by JahL on May 24, 2005, at 16:00:15
In reply to Opioids » JahL, posted by ed_uk on May 24, 2005, at 11:22:43
... for the comprehensive list.
I'm seeing my pdoc on Thurs so it could come in handy.
Hours of fun to be had working your way through that list... ;-P
Cheers,
J.
Posted by ed_uk on May 24, 2005, at 16:45:48
In reply to Re: Opioids. Thanks Ed..., posted by JahL on May 24, 2005, at 16:00:15
Hi!
>I'm seeing my pdoc on Thurs so it could come in handy.
Tell us how it goes :-)
Oxycodone (OxyContin) might sometimes be useful in the treatment of severe TR-depression. Nevertheless, it is very difficult to get a prescription for OxyContin- even for the treatment of severe chronic pain. Doctors get VERY hot under the collar RE the possibility of addiction.
Am J Psychiatry 156(12):2017, December 1999
©1999 American Psychiatric AssociationTreatment Augmentation With Opiates in Severe and Refractory Major Depression
Andrew L. Stoll, MD, and Stephanie Rueter, BA
Belmont, Mass.To the Editor:
Substantial evidence supports the antidepressant efficacy of opiates (1). This report summarizes our open-label experience using the µ-opiate agonists oxycodone or oxymorphone in patients with highly refractory and chronic major depression.
Mr. A was a 44-year-old man with severe and chronic depression. Numerous trials of antidepressants produced only limited benefit. Mr. A also had an extensive history of opiate abuse, and he noted that the only times he ever felt normal and not depressed was during opiate use. Because of the refractory nature of his depressive symptoms and his apparent self-medication with opiates, Mr. A was given a trial of oxycodone under strict supervision. After 18 months of oxycodone treatment (10 mg/day), Mr. A remained in his longest remission from depression without the emergence of opiate tolerance or abuse.
Ms. B was a 45-year-old woman with bipolar disorder and opiate abuse (in remission for 2 years). A trial with standard mood stabilizers had failed, and she had experienced mania with several standard antidepressant drugs. As with Mr. A, Ms. B reported feeling well only when taking opiates, particularly oxymorphone. Oxymorphone (8 mg/day) was thus cautiously added to ongoing lamotrigine therapy (as a mood stabilizer), and she remained well for a minimum of 20 months without drug tolerance or abuse.
Mr. C was a 43-year-old man with chronic major depression that was unresponsive to numerous antidepressants with and without augmentation. Detailed questioning revealed that he once experienced marked antidepressant effects from opiates that he received after a dental procedure. There was no history of opiate abuse, and a cautious trial of oxycodone was initiated. Mr. C experienced a dramatic and gratifying antidepressant response from oxycodone (10 mg t.i.d. for 9 months) without opiate tolerance or abuse.
This report describes three patients with chronic and refractory major depression who were treated with the µ-opiate agonists oxycodone or oxymorphone. All three patients experienced a sustained moderate to marked antidepressant effect from the opiates. The patients described a reduction in psychic pain and distress, much as they would describe the analgesic effects of opiates in treating nocioceptive pain.
Two of the three patients described in this report were previous abusers of opiates. Although the clinical use of opiates in patients with a history of opiate addiction is usually contraindicated, in these cases there was a strong indication that they were self-medicating their mood disorders (2) with illicit opiates. None of the patients abused the opiates, developed tolerance, or started using other, illicit substances.
We used oxycodone in three additional patients without histories of opiate abuse. In two of these three patients, oxycodone produced a similar sustained antidepressant effect. Two of these patients experienced mild-to-moderate constipation, and one experienced daytime drowsiness from the opiates. Opiates should be considered a reasonable option in carefully selected patients who are desperately ill with major depression that is refractory to standard therapies.
Kind regards,
Ed.
Posted by JahL on May 24, 2005, at 16:56:09
In reply to Re: Effexor XR Withdrawl Hell » JahL, posted by SLS on May 23, 2005, at 21:05:48
Hi Scott.
> > Mifepristone?
>
> I've already filled out the paperwork for the FDA. All that needs to be done is for my doctor to add his curriculum vitae and off it goes. I have been looking at mifepristone for quite some time now.Fair play! Ahead of the game. I'm glad you're coming over all proactive!
> Weird. You take the stuff for a week, respond, and then discontinue it. You then live happily everafter.
Oh, I was under the impression that one had to continue to take it...but you're right, apparently, about the quick onset of action. Bring it on...
> By the way, how did you come across this drug? I guess great minds stink alike. ;-)You know that. ;-)
I think it first caught my attention in a Psychiatry Matters newsletter. After my ECT two years ago I ceased doing much research, but my brother took up the baton and between us we've amassed quite a bit of info on the drug.
Last year my baby brother actually got in touch with the pdoc (surprisingly obliging for a top researcher) leading the UK study into Mifepristone. Unfortunately he couldn't treat us as out-patients since:
a) we'd have to taper off all our current meds (impossible)
b) we'd have to stop abusing (or 'using', as I prefer) illicit drugs (again, an impossibility. I am psychologically hooked on Marijuana and have no intention of giving up my one comfort in life).Actually, after all this time, it may actually be worth me getting in touch again. If you like, we could ask whether the patient has to continue to take the drug indefinitely. The fella's been studying it for 2 years now so should know. Anything else you're curious about?
Please keep me/us informed as to your progress with this one. I'm very excited for all three of us.
Cheers,
J.
P.S. Psychiatry Matters site: http://www.psychiatrymatters.md/International/authfiles/index.asp?C=41757384969491203704
P.P.S. For any UK'ers, the study is being conducted at Newcastle University.
Posted by ed_uk on May 26, 2005, at 14:42:53
In reply to Re: Opioids. Thanks Ed..., posted by JahL on May 24, 2005, at 16:00:15
Hi,
Did you see the article? I guess you've seen it before, it's been posted on babble quite a few times- by me and many others.........
>Hi!
>>I'm seeing my pdoc on Thurs so it could come in handy.
>Tell us how it goes :-)
>Oxycodone (OxyContin) might sometimes be useful in the treatment of severe TR-depression. Nevertheless, it is very difficult to get a prescription for OxyContin- even for the treatment of severe chronic pain. Doctors get VERY hot under the collar RE the possibility of addiction.
>Am J Psychiatry 156(12):2017, December 1999
©1999 American Psychiatric Association>Treatment Augmentation With Opiates in Severe and Refractory Major Depression
Andrew L. Stoll, MD, and Stephanie Rueter, BA
Belmont, Mass.To the Editor:
>Substantial evidence supports the antidepressant efficacy of opiates (1). This report summarizes our open-label experience using the µ-opiate agonists oxycodone or oxymorphone in patients with highly refractory and chronic major depression.
>Mr. A was a 44-year-old man with severe and chronic depression. Numerous trials of antidepressants produced only limited benefit. Mr. A also had an extensive history of opiate abuse, and he noted that the only times he ever felt normal and not depressed was during opiate use. Because of the refractory nature of his depressive symptoms and his apparent self-medication with opiates, Mr. A was given a trial of oxycodone under strict supervision. After 18 months of oxycodone treatment (10 mg/day), Mr. A remained in his longest remission from depression without the emergence of opiate tolerance or abuse.
>Ms. B was a 45-year-old woman with bipolar disorder and opiate abuse (in remission for 2 years). A trial with standard mood stabilizers had failed, and she had experienced mania with several standard antidepressant drugs. As with Mr. A, Ms. B reported feeling well only when taking opiates, particularly oxymorphone. Oxymorphone (8 mg/day) was thus cautiously added to ongoing lamotrigine therapy (as a mood stabilizer), and she remained well for a minimum of 20 months without drug tolerance or abuse.
>Mr. C was a 43-year-old man with chronic major depression that was unresponsive to numerous antidepressants with and without augmentation. Detailed questioning revealed that he once experienced marked antidepressant effects from opiates that he received after a dental procedure. There was no history of opiate abuse, and a cautious trial of oxycodone was initiated. Mr. C experienced a dramatic and gratifying antidepressant response from oxycodone (10 mg t.i.d. for 9 months) without opiate tolerance or abuse.
>This report describes three patients with chronic and refractory major depression who were treated with the µ-opiate agonists oxycodone or oxymorphone. All three patients experienced a sustained moderate to marked antidepressant effect from the opiates. The patients described a reduction in psychic pain and distress, much as they would describe the analgesic effects of opiates in treating nocioceptive pain.
>Two of the three patients described in this report were previous abusers of opiates. Although the clinical use of opiates in patients with a history of opiate addiction is usually contraindicated, in these cases there was a strong indication that they were self-medicating their mood disorders (2) with illicit opiates. None of the patients abused the opiates, developed tolerance, or started using other, illicit substances.
>We used oxycodone in three additional patients without histories of opiate abuse. In two of these three patients, oxycodone produced a similar sustained antidepressant effect. Two of these patients experienced mild-to-moderate constipation, and one experienced daytime drowsiness from the opiates. Opiates should be considered a reasonable option in carefully selected patients who are desperately ill with major depression that is refractory to standard therapies.
>Kind regards,
Ed.
Posted by JahL on June 1, 2005, at 13:42:13
In reply to Re: Opioids. Thanks Ed... » JahL, posted by ed_uk on May 26, 2005, at 14:42:53
> Hi,
>
> Did you see the article? I guess you've seen it before, it's been posted on babble quite a few times- by me and many others.........Hi Ed.
Sorry, been in Jah-land for a week or two. I don't recommend it as a destination.
Yes I saw the article thanks, and no I hadn't seen it before. I stopped doing much research/reading after my ECT experience of two years ago. It wiped my memory banks of most of the information I had accrued over the years. I don't have the motivation to relearn everything :(
Anyway, *very* interesting. At present we (my family & I) are trying to procure a couple of tabs (it's all I need to demonstrate efficacy to my pdoc - then we're in health tribunal territory...) of Vicodin or equivalent from some American friends. Naturally, the initial reaction is one of horror ("they're highly addictive!" etc). However, your article is an excellent, easy to comprehend illustration of why opioids might be appropriate in some exceptional cases (i.e. me). It still won't be easy tho'...
I think it makes for quite compelling reading. It could prove to be very useful. So thanks again.
As for the pdoc appt, we established that Oxycodone is *only* available for post-operative cancer! Not a surprise. It strikes me that our sicko British health establishment regard pain almost as a necessary evil. In America, pain (physiological *and* psychogenic) appears to be regarded as something that can and therefore should be avoided (govt prejudice vs. consumer-led enlightenment I suppose).
I tell ya, I'm ready to go at someone if I don't soon get the treatment that is my birthright. How dare the vindictively ageist (that's anther story...) NICE tell me I can't try a medication that may well save my life? Frustating beyond belief... [rant over]
Thanks for listening,
Jah.
Posted by ed_uk on June 1, 2005, at 17:28:16
In reply to Re: Opioids. Thanks Ed... » ed_uk, posted by JahL on June 1, 2005, at 13:42:13
Hi Jah,
>As for the pdoc appt, we established that Oxycodone is *only* available for post-operative cancer!
That is not correct! OxyContin is licensed in the UK for post-op pain, cancer pain and chronic *non*-malignant pain. The British National Formulary (the BNF, the UK drug bible- which your doctor probably checked) has not yet been updated, despite the fact that OxyContin was licensed for non-malignant pain in 2004 and the BNF comes out every 6 months! I emailed the editor of the BNF a few weeks ago to point out the error!!! They said that they were sorry about the mistake and that they would update it by the next edition!!
Here is the official UK data sheet for OxyContin.......
http://emc.medicines.org.uk/emc/industry/default.asp?page=displaydoc.asp&documentid=2579
My letter to the editor................
To the editors,
I just noticed that the oxycodone monograph in the BNF states........
'Indications: moderate to severe pain in patients with cancer; postoperative pain'
There is no mention of chronic severe non-malignant pain. Since the Summary of Product Characteristics has recently been changed to describe the use of oxycodone in chronic non-malignant pain, I was wondering why the monograph had not been updated. OxyContin is now approved for chronic non-malignant pain.
From the OxyContin SPC, www.medicines.org.uk.................
Therapeutic indications
For the treatment of moderate to severe pain in patients with cancer and post-operative pain.For the treatment of severe pain requiring the use of a strong opioid.
..........................................................................................................................................Use in non-malignant pain:
Opioids are not first line therapy for chronic non-malignant pain, nor are they recommended as the only treatment. Types of chronic pain which have been shown to be alleviated by strong opioids include chronic osteoarthritic pain and intervertebral disc disease. The need for continued treatment in non-malignant pain should be assessed at regular intervals.
......................................................................................................................................................................
Although oxycodone was initially licensed only for the treatment of cancer pain and post-operative pain, this situation appears to have changed. This was reported in the Pharmaceutical Journal in 2004.
From the The Pharmaceutical Journal
Vol 272 No 7301 p667
29 May 2004SPC changes
OxyContin tablets
OxyContin (oxycodone) tablets are now licensed for the relief of severe pain requiring the use of a strong opioid (Napp Pharmaceuticals). The summary of product characteristics states that opioids are not first line therapy for chronic non-malignant pain, and they should be used as part of a comprehensive treatment programme involving other medications and treatments. Types of chronic pain which have been shown to be alleviated by strong opioids include chronic osteoarthritic pain and intervertebral disc disease. The need for continued treatment in non-malignant pain should be assessed at regular intervals. When a patient no longer requires therapy with oxycodone, it may be advisable to taper the dose gradually to prevent symptoms of withdrawal. The tablets should be used with particular care in patients with a history of alcohol and drug abuse. See SPC.Regards,
Edward Sykes.Anyway, it doesn't really matter what type of pain OxyContin is licensed for, it's not licensed for depression! Your doctor has the right to prescribe it for whatever he wants to prescribe it for. The only issue is whether he is *willing* to prescribe it!
Ed.
Posted by JahL on July 10, 2005, at 18:32:20
In reply to Re: Opioids. Thanks Ed... » JahL, posted by ed_uk on June 1, 2005, at 17:28:16
Hi Ed.
Hope this finds you well.
Thanks for your post. It's hard to know quite how to respond; it's all so very frustrating.
I have been banging on about opioids ever since I started Methadone - which heralded for me the potential of full opioid agonists - and became friends with a couple of (now ex-) posters here, who used low dose Vicodin to good effect. That was about 4 or 5 years ago. However, no pdoc, and I've seen a few, has been prepared to indulge me.
My pdoc is adamant not that he won't prescribe it, but that he can't. He tells me that the hospital pharmacy would immediately flag it up and that he would have some serious explaining to do. Aside from anything else, my history of substance *use* (not Heroin, which I always knew I would enjoy too much, just everything else) does me no favours.
I am inclined to believe him because: He is the centre director of the unit and knows the hospital and its policies inside out: He has prescribed me some 30 or so different meds over the years, many of which were of course off-label: He supports my endeavours to procure opioids in so much as he has written to two renowned American pdocs on my behalf (unfortunately both were prejudiced xenophobes): He is a man of real integrity - something almost unheard of amongst psychiatrists IMO.
On the other hand, I agree that somewhere along the line, it is ultimately a question of *will*. The problem is discovering just who has the authority to help me. I have frequently made the point you kinda do; that there is really no good reason not to prescribe, *given my situation*.
In all seriousness, if you (or anyone else for that matter) know of an enlightened pdoc that would be prepared to consider such a treatment for someone who is incredibly treatment resistant, I would give my right arm to obtain an intro. Whatever it takes. £10K contribution to the charity of your choice? Whatever...
I've just got off the phone to The Old Boy, trying to explain that I probably won't be around for much longer. However, I was able to promise that I wouldn't catch the bus until I had tried Mifepristone (very exciting; I asked my pdoc to contact the guys studying this up at Newcastle University. Apparently the results were very promising, prompting further trials) and a full opioid agonist, both of which unfortunately are seemingly impossible to source (so what's a man to do?).
It's a sad indictment of society that I can't procure a handful (that's all I need to test for efficacy. Then, if my hunch is proved to be correct, it goes to a health tribunal) of Oxycodone pills, which might transform me into a happy, productive citizen (as opposed to a wretched ball of anger and hate), but could, if I wanted to (I don't), quite easily score a kilo of Smack with a couple of phone calls.
Anyway, sorry this is so morose and meandering; I don't do Happy and Concise anymore. In fact I have no recollection of what Happy feels like.
It's the deal with me these days; nothing for a few weeks and then along comes a big'un (Scott knows all about that!). I refuse to see a therapist, partly on principle, and so always have a lot to get off my chest. Thanks for listening.
Jamie.
> >As for the pdoc appt, we established that Oxycodone is *only* available for post-operative cancer!
>
> That is not correct! OxyContin is licensed in the UK for post-op pain, cancer pain and chronic *non*-malignant pain. The British National Formulary (the BNF, the UK drug bible- which your doctor probably checked) has not yet been updated, despite the fact that OxyContin was licensed for non-malignant pain in 2004 and the BNF comes out every 6 months! > Anyway, it doesn't really matter what type of pain OxyContin is licensed for, it's not licensed for depression!> Your doctor has the right to prescribe it for whatever he wants to prescribe it for. The only issue is whether he is *willing* to prescribe it!
>
> Ed.
>
>
>
>
>
>
>
>
>
Posted by JahL on July 10, 2005, at 19:02:06
In reply to Re: Opioids as a treatment of last resort. » ed_uk, posted by JahL on July 10, 2005, at 18:32:20
Hi Bob. It's been a while. Hope you're doing well.
Thanks for keeping this board alive all these years. It has kept me alive for the same period of time.
Just to clear a few things up:
> He is a man of real integrity - something almost unheard of amongst psychiatrists IMO.
Of course, this doesn't refer to you. You're The Guv'nor ;-)
> £10K contribution to the charity of your choice? Whatever...Re-reading that, it looks like a bribe from a drug-seeking doctor shopper (I don't like either of those terms). It's not. I think you know by now I'm not a crank. Crank*y*? I'll give you that.
> I've just got off the phone to The Old Boy, trying to explain that I probably won't be around for much longer. However, I was able to promise that I wouldn't catch the bus until...On a side note, I noticed there was an exodus some time ago to a 'rival' site. I was amazed to discover that discussion of suicide is prohibited there! What?! I appreciate the fact that you don't make suicide into a taboo subject. I'm sure it helps me in some small way to be able to openly discuss this subject here.
> if I wanted to (I don't), quite easily score a kilo of Smack with a couple of phone calls.
That's not a proud boast.
Jamie.
Posted by SLS on July 10, 2005, at 22:32:47
In reply to Re: Opioids as a treatment of last resort. Dr Bob, posted by JahL on July 10, 2005, at 19:02:06
Hi Jamie.
One day at a time, right?
It really sucks.
I know.
I wish things were different.
Anyway...
How would you go about getting mifepristone? Would you need to enter a study?
One thing you might want to look into is metyrapone. Metyrapone is an antiglucocorticoid (anti-cortisol) drug that is currently prescribed in the UK for Cushings Disease and probably a few other hypercortisolemic states. I think it works by inhibiting the synthesis of cortisol via two different metabolic pathways. You can't get it in the US except as a test for cortisol and HPA function. If it doesn't work, perhaps it will give you enough of a partial or transient improvement to warrant further exploration of HPA stuff and further pursue mifepristone. Some studies of metyrapone combined it with ketoconazole.
- Scott
Posted by ed_uk on July 11, 2005, at 14:16:58
In reply to Opioids as a treatment of last resort - Metyrapone » JahL, posted by SLS on July 10, 2005, at 22:32:47
Hi Scott,
Here's the UK data sheet for metyrapone.....
http://emc.medicines.org.uk/emc/industry/default.asp?page=displaydoc.asp&documentid=126
I've never seen a prescription for metyrapone, I've read that it 'may be difficult to obtain'. I'm sure the pharmacy could get hold of it with a bit of effort. Perhaps they'd have to ring 'specials'. If in doubt ring 'specials' LOL, they can usually get hold of unusual stuff. All unlicensed (not approved) products come from 'specials', metyrapone is licensed though so I'm not sure about that. I remember ringing specials last year to order 1 kg of pure wool fat. Nice!
~Ed
Posted by ed_uk on July 11, 2005, at 14:38:55
In reply to Re: Opioids as a treatment of last resort. » ed_uk, posted by JahL on July 10, 2005, at 18:32:20
Hi Jamie,
>My pdoc is adamant not that he won't prescribe it, but that he can't.
I'm pretty sure he *can* prescribe you a sch 2 opioid - if he's willing risk upsetting the pharmacy! Even controlled drugs can be prescribed for 'un-approved' indications in the UK. For example, morphine oral solution is often used to treat severe cough due to lung cancer. When I was working at a local hospital, an elderly woman with advanced Parkinson's disease was prescribed diamorphine (heroin) to relieve her depression. She couldn't swallow, the doctor prescribed a diamorphine infusion.
>He tells me that the hospital pharmacy would immediately flag it up and that he would have some serious explaining to do.
Perhaps. He could give you a prescription to take to a 'community' pharmacy though. That's what I always asked my pdoc to do when I was taking lofepramine + citalopram. The hospital pharmacy made such a fuss and made me wait for ages so that they could find out why I was on two ADs at once. The 'community' pharmacy just dispensed it straight away.
At the moment, I'm working in a pharmacy attached to a GPs surgery. All our methadone patients are 'addicts'. I wouldn't ask your doc for methadone, it's not really used for non-addicts except in terminally ill patients. Morphine, oxycodone or fentanyl could be better alternatives. Oxycodone and fentanyl are licensed for chronic non-maligant pain. Since oxycodone has acquired a reputation for being associated with abuse, your doc might be more comfortable prescribing fentanyl (Durogesic DTrans patch).
I know you've tried codeine. Have you tried dihydrocodeine? It's a schedule 5 opioid like codeine - GPs prescribe tonnes of it. Someone came in with a prescription for 900 dihydrocodeine 30mg tablets last week! Dihydrocodeine also comes as a 12hr controlled release tablet. Tramadol is also used quite a lot, it's not scheduled, have you tried it?
Kind regards
~Ed
Posted by Declan on July 11, 2005, at 16:03:36
In reply to Re: Opioids as a treatment of last resort. » JahL, posted by ed_uk on July 11, 2005, at 14:38:55
I didn't understand clearly from your post whether you were on methadone or had tried it. At any rate I wouldn't recommend it. The effect is so smooth ie the blood levels so even, that all the effect is swallowed up by the tolerance, and most people I know on it are a bit depressed. I think it's toxic.
I've got a soft spot for hydrocodone/dihydrocodeinone (Dicodid here), I remember (it's a long time ago and body chemistry changes) that it had a nice lift to it. Not so strong, but then it's mainly for cough. Oxycodone was a bit fuzzy. OTOH half a Proladone suppository a day (15mg oxycodone) would be OK. Having a variation of codeine in the name, it seems to make the prescription process more doable, I guess. Same with the suppository thing maybe.
Declan
Posted by JahL on July 12, 2005, at 17:13:48
In reply to Re: Opioids as a treatment of last resort. » JahL, posted by ed_uk on July 11, 2005, at 14:38:55
Hi Ed.
> I'm pretty sure he *can* prescribe you a sch 2 opioid - if he's willing risk upsetting the pharmacy!He retires in one month. Perhaps he doesn't want to jeopardise his fat NHS pension? I start afresh with a new pdoc next month and so I suppose we'll see how sympathetic he is to my predicament.
> Even controlled drugs can be prescribed for 'un-approved' indications in the UK. For example, morphine oral solution is often used to treat severe cough due to lung cancer.
Maybe he's worried about how it'd look. I've heard the old 'do no harm' chestnut a couple of times. They see a youngish, ostensibly fit and intelligent guy, but with a history of drug use, and they think 'addiction risk'. The fact that I already take Methadone does not help my cause.
> When I was working at a local hospital...
I wondered if you had some kind of medical background...
> >He tells me that the hospital pharmacy would immediately flag it up and that he would have some serious explaining to do.
>
> Perhaps. He could give you a prescription to take to a 'community' pharmacy though. That's what I always asked my pdoc to do when I was taking lofepramine + citalopram. The hospital pharmacy made such a fuss...Yeah. I've also found hospital pharmacies to be an ordeal. I have a good relationship with my community pharmacist tho'. Perhaps it might be an idea, to start with, to gauge what her reaction would be to such a prescription.
> At the moment, I'm working in a pharmacy attached to a GPs surgery. All our methadone patients are 'addicts'. I wouldn't ask your doc for methadone, it's not really used for non-addicts except in terminally ill patients.
I actually take 'diverted' (and unwanted) Methadone - I have long been aware of the prescribing restrictions and so have never asked for it. However my pdoc is aware I take it, appreciates the difference it makes, and essentially has no problem with it. I only take 5ml daily, which appears to be the optimum dose for me. I originally took it just to see if opioids would help my condition, but it benefitted me almost instantly and I have taken it for around 5 years now w/o any tolerance issues.
> Morphine, oxycodone or fentanyl could be better alternatives. Oxycodone and fentanyl are licensed for chronic non-maligant pain. Since oxycodone has acquired a reputation for being associated with abuse, your doc might be more comfortable prescribing fentanyl (Durogesic DTrans patch).
>
> I know you've tried codeine. Have you tried dihydrocodeine?No. It's got to be worth a go though, in the absence of anything more potent. I'll ask.
> Tramadol is also used quite a lot, it's not scheduled, have you tried it?
Yes, years ago. No benefit - or side effects - at all.
Thanks for your as always invaluable help Ed.
J.
Go forward in thread:
Psycho-Babble Withdrawal | Extras | FAQ
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.org
Script revised: February 4, 2008
URL: http://www.dr-bob.org/cgi-bin/pb/mget.pl
Copyright 2006-17 Robert Hsiung.
Owned and operated by Dr. Bob LLC and not the University of Chicago.