Pain Medication

[migrant]

Hi All,

As I accumulate info for the future move full-time, I thought about one thing that affects me.

Do to a rather active youth, I suffer from chronic pain. Too young for the knee, and shoulder, replacements.

My doctor here gives me a rolling prescription for vicodin. Generally I go through about 30 a month, but he warns me that with age, that will probably go up.

Tried numerous other options, and, for me, this works best. Takes the edge off the pain after a hard day for sleep.

I imagine, due to the other, looser areas, in Thailand I should have no problem finding a doctor for these prescriptions (would like to keep it legal). My trips over, I always took my own.

Anyone experience problems with this?

Thanks!

Edited September 1, 2006 by migrant

[taxexile]

Vicodin

acetaminophen and hydrocodone (ah see ta MIH no fen and hye dreo KOE done)

Anexsia, Anolor DH5, Bancap HC, Dolacet, Lorcet 10/650, Lorcet HD, Lorcet Plus, Lortab, Lortab 10, Lortab 5/500, Lortab 7.5/500, Lortab Elixir, Norco, T-Gesic, Vicodin, Vicodin ES, Vicodin HP, Zydone

What is the most important information I should know about Vicodin?

• Hydrocodone is habit forming. It is possible become physically and/or psychologically dependent on the medication. Do not take more than the prescribed amount of medication or take it for longer than is directed by your doctor. Withdrawal effects may occur if Vicodin is stopped suddenly after several weeks of continuous use. Your doctor may recommend a gradual reduction in dose.

• Avoid alcohol while taking Vicodin. Alcohol can increase drowsiness and dizziness caused by the medication, possibly resulting in unconsciousness and death. Also, acetaminophen can be damaging to the liver when taken with alcohol.

• Vicodin may increase the effects of other drugs that cause drowsiness, including antidepressants, alcohol, antihistamines, pain relievers, anxiety medicines, seizure medicines, and muscle relaxants. Dangerous sedation, dizziness, or drowsiness may occur if Vicodin is taken with any of these medications. Tell your doctor about all medicines that you are taking, and do not take any medicine without first talking to your doctor.

• Vicodin may cause constipation. Drink plenty of water (six to eight full glasses a day) to lessen this side effect. Increased fiber in the diet may also help to alleviate constipation.

What is Vicodin?

• Hydrocodone (related to codeine) is in a class of drugs called narcotic analgesics. It relieves pain.

• Acetaminophen is a less potent pain reliever that increases the effects of hydrocodone.

• Together, Vicodin is used to relieve moderate-to-severe pain.

• Vicodin may also be used for purposes other than those listed in this medication guide.

What should I discuss with my healthcare provider before taking Vicodin?

• Before taking this medication, tell your doctor if you have

· a history of alcohol or drug abuse;

· kidney disease;

· liver disease;

· asthma;

· urinary retention;

· an enlarged prostate;

· hypothyroidism;

· seizures or epilepsy;

· gallbladder disease;

· a head injury; or

· Addison's disease.

• You may not be able to take Vicodin, or you may require a dosage adjustment or special monitoring during treatment if you have any of the conditions listed above.

• Vicodin is in the FDA pregnancy category C. This means that it is not known whether it will be harmful to an unborn baby. Do not take this medication without first talking to your doctor if you are pregnant or could become pregnant during treatment.

• Vicodin passes into breast milk and may affect a nursing infant. Do not take this medication without first talking to your doctor if you are breast-feeding a baby.

• If you are younger than 18 years of age or older than 60 years of age, you may be more likely to experience side effects from Vicodin. Your doctor may prescribe a lower dose.

usually you can buy almost anything over the counter at pharmacies here , over the past two or three years however , the authorities have been tightening up on the unrestricted sale of certain addictive drugs , like tranquilizers , sleeping pills etc.

vicodin is a habit forming narcotic painkiller and strictly speaking i would imagine its sale is controlled to those who have a doctors prescription for it.

however , there are many pharmacies that will sell these pharmaceuticals without prescription , you will just have to ask around.

if you want to get a prescription , then most doctors would write one for you if you gave them your medical history and showed them your usa or uk etc. prescription.

be careful if you are thinking of bringing a suitcase full of these narcotic painkillers when you arrive , have a letter from your doctor explaining your clinical need for them , in case you are challenged at the airport here on arrival.

[oilysang]

Hi All,

As I accumulate info for the future move full-time, I thought about one thing that affects me.

Do to a rather active youth, I suffer from chronic pain. Too young for the knee, and shoulder, replacements.

My doctor here gives me a rolling prescription for vicodin. Generally I go through about 30 a month, but he warns me that with age, that will probably go up.

Tried numerous other options, and, for me, this works best. Takes the edge off the pain after a hard day for sleep.

I imagine, due to the other, looser areas, in Thailand I should have no problem finding a doctor for these prescriptions (would like to keep it legal). My trips over, I always took my own.

Anyone experience problems with this?

Thanks!

I got the same problem as you two years ago, you ever go to visit chinese doc ? give it a try, not immediate cure but in long term is pretty good.

[lopburi3]

When the top Goggle hits are detox programs get a little nervous. Believe most Codeine medications are now restricted to hospital type dispensing but you should have a doctor here in any case - the normal office visit charge is only about $10 at the better hospitals so it is not a major expense.

[fxm88]

[migrant]

Thanks for quick response all.

Taxexile (being a CPA I love the name!)

You are right, I travel with only enough for each trip, keep them in the original prescription bottle, and a copy of a letter my doctor and I formulated.

oilysang,

I've done accupuncture, you are right it helps the immediate, I use it periodically if I've overstepped my limits (unfortunately I always push these limits )

lopburi3

Yes, vicodin is something I am careful with, very addictive. I generally use a couple at night for a few days in a row, then stop for 3-4 days. I try to monitor the use so I don't take too many (I leave the overages to scotch).

Again, thanks all for the info

[John K]

My advise is to see a Doctor here. There is a very good chance that some medication available here may not be available where you are from.

Has the pain been diagnosed? Also I was reading the other day there were starting some research with stem cells here. You may want to check into that. Perhaps they can regrow what is worn out if you enter the trials.

[francois]

hi'

imho ... you should go to visit a Chinese Doctor(not too young )

and find out where this pain is from, you need to find out the origin of it.

waiting for this you may try ibruprophen, it's a molecule, sold originaly under the name of nurofen, you may take up to 3 x 2 pills or 3x1 pill, be aware that it comes in 2 forms, the 200mg pills and the 400mg one, the max amount in a day is 1200mg, and at this stage this medication acts as an anti inflamatory as well, it's non addictive and works well,

in Hospital, in ER we used to give up to 600 or even 800mg for the first take to be sure to kill the pain away ....

no real danger, and commonly used now and sold under many other names,

but to be sure ask for nurofen

but, see a doctor, it could be more serious that what you may think,

chronical arthritis , or a form of it that gives unbearable pain ...

or anything else that I don't mention, the list would be far too long

francois

Edited September 2, 2006 by francois

[The Dude]

usually you can buy almost anything over the counter at pharmacies here , over the past two or three years however , the authorities have been tightening up on the unrestricted sale of certain addictive drugs , like tranquilizers , sleeping pills etc.

vicodin is a habit forming narcotic painkiller and strictly speaking i would imagine its sale is controlled to those who have a doctors prescription for it.

however , there are many pharmacies that will sell these pharmaceuticals without prescription , you will just have to ask around.

if you want to get a prescription , then most doctors would write one for you if you gave them your medical history and showed them your usa or uk etc. prescription.

be careful if you are thinking of bringing a suitcase full of these narcotic painkillers when you arrive , have a letter from your doctor explaining your clinical need for them , in case you are challenged at the airport here on arrival.

Nope, you won't be getting no vikes here, sorry. And you won't be buying and codeiene OTC either like you could 3 years ago. The best thing they ever did was pull that shit and the Morphs from being sold over the counter, even better than pulling off the Vals and the Xans. The stuff is no damned good for you. I'm sure the OP doesn't need a lesson in Ibu's like the dude above gave him bout the nurofens but Ibu beats the hel_l out of Deine. Slam dunk a couple thousand millies of Ibu everyday. I'd hate to be you when you come off those vikes dude; gonna need a whole new thread for that one. Oucharama man but I know you can do it. The Dude is always around with top shelf pointers when you're coming off that shit. That is the most brutal experience one can have in life I think, withdrawing from vikes. I don't even want to think about it. I can see why the OP needs to be set up way ahead of time. The pain from the withdraw makes any other pain feel like a mosquito bite. I think the opiate drugs like deine, morphs and oxys should only be available for terminally ill patients who are gonna die soon anyway. If you're gonna live, take Ibus or anything but opiates

[taxexile]

no real danger, and commonly used now and sold under many other names,

ibuprofen and other non steroidal anti inflammatories have upper gastro intestinal tract side effects.

and are contra indicated for anyone with a history of peptic ulcers or anyone taking aspirin

i suggest the poster consults with his doctor before coming over here , as many doctors here will prescribe high doses of anything without taking comprehensive medical histories beforehand.

[migrant]

Guys,

Appreciate the posts, and concerns. Let me clarify a little since I want to be around here and not give the wrong idea

Due to sports, etc I have had 4 operations on one shoulder, collarbone taken out, bicep cut and reattached, and 2 pins inserted (makes airport travel fun nowadays).

The knee has been opened, kneecap released, moved over and reattached.

Ankle sliced in a accident, all tendons but achilles cut, bone chipped (If I wasn't big boned, would have lost the foot.

Numerous other trauma, and stitching, enough to make a good rug.

Both the knee, and shoulder, need replacement, but at 49 I refuse until I can no longer move them, or stand the pain.

I hate the meds, so only take them at night, periodically, to ease sleep. I do not take them every day, in fact will go many days without, then go a few days with a couple at night only.

I only do this under a doctors monitoring, and yes, I have tried many many alternatives, I just hate pills, but this one works for me.

But I also refuse to slow down . If I stopped sports, working out etc I would probably be in less pain, but hey, we only have one life.

Thanks all, anyway, I just wanted to set the record straight, perhaps will one day meet some of you for a beer or so, and don't want you guys to expect a raving druggie, or a gimpy guy (expect a cross between Brad Pitt and Arnold ) ( OK, not really)

[The Dude]

Take care with those Vikes buddy. I don't need to tell you how ragingly addictive they are. I don't believe that vikes are available in Thailand so be wary of that. If you're really in that much pain, perhaps you should tell your US doc to hook you up with Oxys; then you really won't feel anything and you'll sleep like a baby even when you wanna be up. Those puppies are deadly. Nope, can't get oxys in Thailand either. Oh yeah, and dude, keep combating that pain with those Vikes for sure and rest easy. Should the day come when they are unavailable to you, we will be here for you cause it'll be a rough time. Stop taking those bad babies for a week and you'll see what I mean but I'm sure you know

Edited September 2, 2006 by The Dude

[deadman]

i think the strongest painkillers available over the counter are tromodol's.....or something like that, and these are not that strong as i understand it

[h5n1]

you cannot obtain narcotics outside hospitals -period.

your only solution is to smuggle them from cambo on a visa run. i think if you have a script them you will be fine even if questioned.

ive known many people to both become addicted and build high tolerance to vicodan. its basically heroin and paracetamol

if you really have such pain problems that need to be monitored by a proper physician, the third world is perhaps not for you.

cambodia is teh only country in asia where you MAY be able to buy narcotics AND.... they will question you - the candystoer thing is long gone. last year i sprained my ankle and the chemist would only sell mg code 16mg. i was ok laying down but had to make run for border next day. so cant even count on that.

i think ONLY way is to bring full medical records to hospital (BKKPTY) and get a doc there and get it all in order -but no way they are going to give you vicodan ES 30x per month.

i personally think if you are taking vicodan 750 a day, youre already addicted.

ps: im not making moral judgements on you, injury or even drugs.

Edited September 4, 2006 by h5n1

[Patex]

...My doctor here gives me a rolling prescription for vicodin...

Anyone experience problems with this?

Listen to the Dude - he not even handed out one f**king shovel!!

[sobe]

you cannot obtain narcotics outside hospitals -period.

your only solution is to smuggle them from cambo on a visa run. i think if you have a script them you will be fine even if questioned.

ive known many people to both become addicted and build high tolerance to vicodan. its basically heroin and paracetamol

if you really have such pain problems that need to be monitored by a proper physician, the third world is perhaps not for you.

cambodia is teh only country in asia where you MAY be able to buy narcotics AND.... they will question you - the candystoer thing is long gone. last year i sprained my ankle and the chemist would only sell mg code 16mg. i was ok laying down but had to make run for border next day. so cant even count on that.

i think ONLY way is to bring full medical records to hospital (BKKPTY) and get a doc there and get it all in order -but no way they are going to give you vicodan ES 30x per month.

i personally think if you are taking vicodan 750 a day, youre already addicted.

ps: im not making moral judgements on you, injury or even drugs.

I will be in Bangkok in November to look for medical and surgery for a condition I have ... I am now on vicodan ES every 4 hours as the pain is so bad .. how in the hel_ l am I going to get pain meds like I have in the states when I am there if the above in this thread is correct ? The Dr.'s were giving me OXY but I had them change it as they were just too strong . I am sure with the right medical records one could get the same medication living in Bangkok as they got in the states but I may be wrong as I know nothing about what to expect when I get here . Last week I had my Dr. here send all my records to the Bumrungrad International Hospital so they had them when I arrive .

Edited October 22, 2006 by sobe

[Beardog]

you cannot obtain narcotics outside hospitals -period.

your only solution is to smuggle them from cambo on a visa run. i think if you have a script them you will be fine even if questioned.

ive known many people to both become addicted and build high tolerance to vicodan. its basically heroin and paracetamol

if you really have such pain problems that need to be monitored by a proper physician, the third world is perhaps not for you.

cambodia is teh only country in asia where you MAY be able to buy narcotics AND.... they will question you - the candystoer thing is long gone. last year i sprained my ankle and the chemist would only sell mg code 16mg. i was ok laying down but had to make run for border next day. so cant even count on that.

i think ONLY way is to bring full medical records to hospital (BKKPTY) and get a doc there and get it all in order -but no way they are going to give you vicodan ES 30x per month.

i personally think if you are taking vicodan 750 a day, youre already addicted.

ps: im not making moral judgements on you, injury or even drugs.

[Sheryl]

Codeine preparations are controlled substances and cannot be sold over the counter legally in Thailand. I suggest you bringa medical summary with you (as well as any pertinent Xray films & other test results). Once here, find an orthopedic speacialist you like and you ought to be able to get what you needs from him/her. These drugs can be given for outpatient use, they just need to be from a hospital.

While here, you may want to take advantage of the affordability of other treatments as sooner or later the amount of drug you are taking will cease to work for you. There is a pain specialist at Samitivej (am MD) who does accupuncture and other treatments. Also, Bangkok General's neurology department had a chronic pain clinic. Outpatient care is very reasonable in Thailand so worth a try.

Lastly you might also want to avail of the readily available Thai massage (traditional) but before doing so, ask your doc at home if it is safe for you or if there are any limitations on the manipulations of certain joints that should be observed.

[sobe]

Codeine preparations are controlled substances and cannot be sold over the counter legally in Thailand. I suggest you bringa medical summary with you (as well as any pertinent Xray films & other test results). Once here, find an orthopedic speacialist you like and you ought to be able to get what you needs from him/her. These drugs can be given for outpatient use, they just need to be from a hospital.

While here, you may want to take advantage of the affordability of other treatments as sooner or later the amount of drug you are taking will cease to work for you. There is a pain specialist at Samitivej (am MD) who does accupuncture and other treatments. Also, Bangkok General's neurology department had a chronic pain clinic. Outpatient care is very reasonable in Thailand so worth a try.

Lastly you might also want to avail of the readily available Thai massage (traditional) but before doing so, ask your doc at home if it is safe for you or if there are any limitations on the manipulations of certain joints that should be observed.

Sheryl many thanks .. the nerve damage has caused a condition known as neuralgia and the pain medication is necessary , that is why I am going to Bangkok to try and fix the problem if possible and not just treat the symptoms .

[wpcoe]

You might also consider consulting St. Louis Hospital (on Sathorn near the BTS Surasak station).

I've not been there (yet), but friends have told me that they have a large Chinese medicine practice. They say it's a good blend of eastern/western medicine: go to a western doctor for diagosis, and consult a Chinese practitioner for treatment.

[Sheryl]

Sheryl many thanks .. the nerve damage has caused a condition known as neuralgia and the pain medication is necessary , that is why I am going to Bangkok to try and fix the problem if possible and not just treat the symptoms .

Actually my reply was for the OP who has orthopedic problems. Massage will not help neuralgia, altho accupuncture may. In addition, there are drugs other than narcotics which are often effective (carbamazepine, neurontin etc). Depending upon the nerve(s) involved, nerve block or botox injection may also be options. In some cases surgery to remove pressure from the nerve or nerve ablation (deadening of the nerve) is required. In any case would definitely start by seeing a neurologist with expertise in neurolgoa and chronic pain. Long-term use of narcotics is NOT the way to go for this.

[sobe]

Sheryl many thanks .. the nerve damage has caused a condition known as neuralgia and the pain medication is necessary , that is why I am going to Bangkok to try and fix the problem if possible and not just treat the symptoms .

Actually my reply was for the OP who has orthopedic problems. Massage will not help neuralgia, altho accupuncture may. In addition, there are drugs other than narcotics which are often effective (carbamazepine, neurontin etc). Depending upon the nerve(s) involved, nerve block or botox injection may also be options. In some cases surgery to remove pressure from the nerve or nerve ablation (deadening of the nerve) is required. In any case would definitely start by seeing a neurologist with expertise in neurolgoa and chronic pain. Long-term use of narcotics is NOT the way to go for this.

I have tried every thing you said here none work .. Surgery is the only option I see and because my problem was caused by another Dr. no one will touch me ,, so that is why I am going to Bangkok . I am on 10/325 narco every 4 hours and have no idea how i will get that in Bangkok but that is what is not only keeping the pain down but helping with the depression . When you are hurt very bad and the depression is debilitating and opiud may be one of the best drugs there are . Although this concept is not supported by most Dr. it is very valid .

Buprenorphine Treatment of Refractory Depression

J. Alexander Bodkin, MD, Gwen L. Zornberg, MD, Scott E. Lukas, PhD,

and Jonathan O. Cole, MD.

Journal of Clinical Psychopharmacology, 1995, 15, pp. 49-57

Abstract

Opiates were used to treat major depression until the mid-1950s. The advent of opioids with mixed agonist-antagonist or partial agonist activity, with reduced dependence and abuse liabilities, has made possible the reevaluation of opioids for this indication. This is of potential importance for the population of depressed patients who are unresponsive to or intolerant of conventional antidepressant agents. Ten subjects with treatment-refractory, unipolar, non-psychotic, major depression were treated with the opioid partial agonist buprenorphine in an open-label study. Three subjects were unable to tolerate more than two doses because of side-effects including malaise, nausea and dysphoria. The remaining seven completed 4 to 6 weeks of treatment and as a group showed clinically striking improvement in both subjective and objective measures of depression. Much of this improvement was observed by the end of 1 week of treatment and persisted throughout the trial. Four subjects achieved complete remission of symptoms by the end of the trial (Hamilton Rating Scale for Depression scores < 6), two were moderately improved, and one deteriorated. These findings suggest a possible role for buprenorphine in treating refractory depression.

Introduction

Throughout history, opium and its derivatives have had an important role in the pharmacologic treatment of various behavioral disorders and by 1850 were considered to be specific treatments for melancholia (1). At the turn of the century, the eminent authority Emil Kraepelin recommended tincture of opium for the acute treatment of agitated depression(2). This use of opium and its derivatives continued to be recommended in psychiatric textbooks until as recently as 1956(3). However, before the development of modern methods of treatment evaluation, opiate treatment was replaced by somatic treatments such as electroconvulsive therapy and later by monoamine oxidase inhibitors and tricyclic antidepressants. These proved to be effective treatments that lacked the opiates' potential for abuse...Thus, the historically recognized antidepressant properties of the opiates have, with a few exceptions(4-8), received little empirical evaluation.

Currently used antidepressants, all of which act on monoaminergic systems, are neither universally effective nor free from adverse effects of their own(9). For the benefit of patients unresponsive to or intolerant of these agents, who may constitute 10 to 30% of the population of patients with major depression(10), alternative drug treatments need to be evaluated. Now, with the development of opioid partial agonist and mixed agonist-antagonist drugs exhibiting much reduced abuse and dependence liabilities,(11) it has become possible to safely evaluate the antidepressant efficacy of opioids.

Among these "second-generation" opioids, buprenorphine has pharmacologic properties that make it particularly attractive as a potential antidepressant drug. Buprenorphine, an oripavine derivative of thebaine, is a partial agonist of the opioid mu receptor with kappa receptor antagonist activity(12). It has undergone considerable recent clinical investigation as a potential therapeutic agent for drug addiction(13-15). It is safe even in extreme overdosage(16), despite being 30 to 40 times more potent than morphine as an analgesic. This lack of toxicity is attributed to the its partial agonist activity at the mu receptor which results in a "ceiling effect" on respiratory depression, because it acts primarily as a mu receptor antagonist at high doses(17). It has a longer duration of action than do conventional opioids, having been studied with alternate-day dosage regimens as a maintenance drug in opiate addicts(18).The drug has modest mood-elevating effects in humans, which actually decline with increasing dose, and is devoid of the dysphoric effects seen with increasing doses of cyclazocine-like compounds(17,19). Former heroin addicts report that buprenorphine causes feelings of generalized contentment, but not the "rush" induced by heroin(20) Even after prolonged administration of high daily doses of the drug, the withdrawal syndrome has been found to be mild and quite delayed(17,19,21), although addicts aware of the absence of the drug almost immediately(21). One study that found more marked and less delayed withdrawal effects than prior investigations still noted that the peak withdrawal was only 59% of the mean previously reported over the first 10 days of the discontinuation of a significantly lower equivalent dosage of morphine(22). Furthermore, chronic treatment with buprenorphine has been shown to decrease the self-administration of cocaine in primates(23) and in humans(24).

Buprenorphine has an electroencephalographic profile in the rat similar to that of cyclazocine(25) [Figure 1], an opioid mixed agonist-antagonist with mu antagonist and kappa agonist properties. Cyclazocine was studied as an antidepressant because its encephalographic profile was similar to that of imipramine(26). It was shown in that study to have antidepressant properties in both acute and chronic depression in a mixed psychiatric population. However, it is not clear that cyclazocine has clinical properties that can be equated with buprenorphine, because the drugs have opposite actions at the mu and kappa receptors and because cyclazocine does not share its imipramine-like electroencephalographic profile with buprenorphine in humans(21). In any case, the utility of cyclazocine came into question when it was found to have psychotomimetic properties,(27) a feature that buprenorphine does not have, and it was removed from clinical use.

Motivated by recent evidence that buprenorphine appeared to be safer clinically that conventional opiates, as well as by a historical literature describing the antidepressant efficacy of opiates and more recent investigations of antidepressant properties of endogenous opiates, Emrich and colleagues(2) undertook the first published study of buprenorphine as an antidepressant. This double-blind, placebo-controlled study used an A1-B-A2 design and found that there was a robust mean improvement in depressive symptoms over 5 to 8 days of low-dose sublingual buprenorphine administration in a group of 10 depressed patients, most of whom were unresponsive to standard treatments.

Some additional evidence has accumulated subsequently that buprenorphine may have useful antidepressant properties. The drug was associated with reduced depressive symptomatology when substituted for methadone in a population of opiate dependent patients undergoing methadone maintenance(28). Buprenorphine was also successful in reducing depressive symptoms in patients with borderline personality disorder(29). Finally, in a placebo-controlled challenge study using 11 non-drug-dependent psychiatric inpatients, (8 with depression) buprenorphine induced a marked improvement mood and behavior in 73% of subjects (and 75% of those with depression); one dysphoric response was observed in a single nondepressed control subject(30)

This study was conducted to characterize more fully the nature of buprenorphine's potential antidepressant effects, including whether these are persistent beyond the 5- to 8-day period previously studied and whether the drug is effective in depression specifically found to be refractory to current standard medication therapies.

Method

Inpatients and outpatients suffering from unipolar major depression without psychotic features that had been unresponsive to adequate trials of antidepressants belonging to at least two different pharmacologic classes (i.e., tricyclic antidepressants monoamine oxidase inhibitors, selective serotonin reuptake inhibitors, etc.) were recruited. A minimum Hamilton Rating Scale for Depression (HAM-D) score of 20 and a current episode of at least 3 months' duration were required. Patients who currently met DSM-III-R criteria for psychoactive substance abuse or dependence, had significant medical illness, or had undergone electroconvulsive therapy in the previous month were excluded. Potential subjects were told of the possible risks and benefits of treatment with buprenorphine, and if they chose to be considered for the trial, they read and signed an informed consent.

Potential subjects underwent a comprehensive psychiatric evaluation, which included a review of all available records, a physical examination, a standard battery of clinical laboratory studies, and a diagnostic psychiatric interview. If study criteria were met, baseline psychopathology scales were administered. These included the 21-item HAM-D(31), the Atypical Depression Diagnostic Scale (ADDS)(32), the Profile of Mood States (POMS)(33), and the Global Assessment Scale (GAS). Patients were taken off of all psychotropic medications other than previously established benzodiazepines (four subjects, and in one patient, long-established pemoline). Buprenorphine was initiated at 0.15 mg every morning, intranasally(3) or sublingually(2). We used the preparation of buprenorphine hydrochloride solution currently marketed in the United States for parenteral administration. This comes in small ampules containing 0.3 mg of the drug in 1 ml of aqueous solution. Dosage was titrated according to tolerance and clinical benefit, with a maximum daily dosage of 1.8 mg. Repeat assessments were performed at the end of each week of buprenorphine treatment, including each scale that had been administered at baseline. Laboratory studies and physical examination were repeated after 4 weeks of treatment. Changes in scale scores were analyzed for significance by the use of paired t-tests. For all measures, p < 0.05 was considered significant.

Results

Ten subjects (five inpatients and five outpatients) met criteria for inclusion, but three could not tolerate the drug and dropped out after one or two doses because of nausea, malaise, or dysphoria. Three subjects completed 4 weeks, and four completed 6 weeks. Of the three who dropped out after 4 weeks, one did so because of nausea, one because of sedation and one as a result of personal crisis. Of those completing at least 4 weeks, four were men, three were inpatients, and the mean age was 44 (range, 24 to 70). All subjects met DSM-III-R criteria for recurrent major depression without psychotic features, with a mean age at time of onset of 23.3 years (standard deviation [sD] = 8.8) and a duration of illness of 20.7 years (SD=11.1). Concurrent DSM-II-R axis I diagnoses included Dysthymic Disorder (all subjects), Somatoform Pain Disorder (N=2), Opioid Dependence in remission (N=1), Psychoactive Substance Abuse not otherwise specified in remission (N=2), Alcohol Dependence in remission (N=2), Posttraumatic Stress Disorder (N=1), and Social Phobia (N=1). The mean number of antidepressants previously tried was 7.6 (SD = 5.7). By the ADDS(32), three subjects, including the single nonresponder, met criteria for definite atypical depression, (>50% mood reactivity plus two associated features, which may include hypersomnia, leaden paralysis, hyperphagia, and rejection sensitivity), two met criteria for probable atypical depression (>50% mood reactivity, and one associated feature), one met criteria for simple mood reactive depression (>50% mood reactivity without associated features), and one did not meet criteria for atypical depression or reactivity of mood. The mean baseline HAM-D score was 28.1 (SD = 6.6), and the GAS score was 40.1 (SD = 9.0).

Results for subjects completing at least 4 weeks of treatment are displayed in Table 1. Six of seven subjects achieved marked clinical improvement by the end of the trial, and one deteriorated. The final buprenorphine dosage averaged 1.26 mg/day (SD = 0.55). The mean endpoint HAM-D score was 10.7 (SD = 9.3), representing a 60.7% reduction from baseline (p = 0.006), and the GAS score was 58.3 (SD = 19.0), a 45.4% increase from baseline (p = 0.01). Approximately 50% improvement was seen in subjective indices of depression. (POMS subscales reflecting mood states) at the endpoint.

Statistically significant improvement in all parameters became evident at the end of one week of treatment, and there were no statistically significant differences between ratings at the end of one week and at the completion of the trial. It is notable, however, that at the endpoint, four subjects (57.1%) had HAM-D scores of six or less, whereas at 1 week, only one subject had improved to that extent. To provide more clinical information about the effects of buprenorphine on patients with refractory depression, we provide detailed vignettes on four selected responders (patients 1 to 4) and the one nonrepsonder (patient 5).

Case Reports

Patient 1

This outpatient was a 45-year-old, married, white academic physician with lifelong dysthymia, in psychotherapy since his late 20s for the treatment of chronically depressed mood, low energy, social anxiety, and pervasive pessimism. In residency training, he had extensive dental work and was treated with oxycodone and acetaminophen. This raised his energy and his mood and relieved his social anxiety. He subsequently took opiates whenever he had the opportunity, moving over time to intravenous use. On several occasions, he became mildly dependent and suffered withdrawal symptoms and a return of depression when his supply ran out. For the first several weeks of an episode of opiate use, his work performance was markedly improved, as was his enjoyment of social interactions. He would then become tolerant, requiring higher doses to achieve less effect. He obtained opiates at work and never interacted with the illicit drug scene. He was finally discovered at work with a supply of hydromorphone, and was forced to enter outpatient drug abuse treatment. His depressive symptoms immediately recurred, and his psychiatrist started him on amitriptyline, which was continued at 150 mg/day for over 5 years. This improved his sleep and reduced some of the somatic manifestations he associated with depression, especially an epigastric sensation of butterflies. However, he continued to suffer from low energy, easy fatigue, social anxiety, a pessimistic outlook, and little enjoyment in life. In addition to receiving medication, he was in intensive psychotherapy with a renowned expert in the treatment of addictions and in Narcotics Anonymous. His career and personal life moved ahead, but he gradually got discouraged that he would ever be happy in an abstinent state. After 5 years, he again began to abuse opiates intravenously. He again experienced a marked enhancement of his quality of life. Over a 6-month period, he got married, acquired a new home, and made strides in his research. He was then discovered by the hospital to be using opiates and was induced to undergo inpatient treatment and give up his medical license. Again, he relapsed into depression. A course of amoxapine gave him some relief, but this disappeared after a few months. Subsequent trials of phenelzine, bupropion, and fluoxetine were without effect, and he was returned to amitriptyline. He began to have suicidal thoughts. He withdrew from research activities and rarely left home. At this point he was referred for a trial of buprenorphine on an outpatient basis.

On initial assessment, he had a HAM-D score of 30, with prominent anxiety with diurnal variation, obvious retardation, very depressed mood, profound lethargy, and frequent middle awakenings. His affect was downcast and flat, and he made almost no eye-contact. Because of partial mood reactivity and leaden paralysis, he had criteria for probable atypical depression.

Amitriptyline was discontinued, and buprenorphine was rapidly titrated to 0.15 mg intranasally thrice daily. At the end of a week he was feeling noticeably better, with more energy and less anxiety. His HAM-D score dropped to 20. By the end of the second week on the same dose, his HAM-D score was down to 17, with markedly reduced retardation, good sleep, and a new hope for the future. His dosage was pushed slightly to 0.6 mg/day for the third week. He remained at this dosage for the remainder of the 6-week study by which time his HAM-D score had dropped to eight. By that time he had returned to his research and writing. Over the next few months, his dosage was raised to 0.3 mg thrice daily and 0.45 mg at bedtime intranasally, to maximize his subjective benefit. At this dosage, he felt he had not only recovered from depression, but had achieved a new level of well-being and hopefulness. He reported much more subtle subjective effects of buprenorphine compared with his prior experience with opiates and particularly noted both a lack of acute euphoria and an absence of tolerance to the mood-elevating effects of the drug over time.

He has remained on his present dose for over 2 years. At his wife's request, he has occasional, random, urine toxic screens and has never had metabolites of any other drug in his urine. He is developing a new career in marketing research and has taken up writing, an old ambition he has finally decided to pursue. The combination of high legal expenses and understandably unpleasant memories has discouraged him from attempting to regain his medical license.

Patient 2

This inpatient was a 41-year-old, married, white, male, high-level computer programmer with two young children. A very religious man, he was quite involved in his church and a politically active conservative. His first episode of depression was at age 15, when he left school for a semester, although he was not treated. Since that time, he never felt completely recovered for more than a few months at a time, and these intervals were years apart. The rest of the time he was, to varying degrees, depressed. His last long period of euthymia had come 14 years earlier, when he was married, but it lasted only 6 months.

His depression was characterized by lethargy, slowed thinking, impaired concentration, malaise, hypersomnia (sleeping more than 14 hours/day), and overeating, especially carbohydrates. He weighed 319 pounds. He was not particularly troubled by anxiety and never had any periods of elevated mood. He had no history of alcohol or substance abuse, nor any experience with medically prescribed opiates.

The patient had been treated initially with desipramine, which was partially effective for several years but then lost efficacy. An amoxapine trial failed. The patient experienced partial improvement for 6 months on fluoxetine, but then relapsed. A trial of bupropion was then begun and seemed to help for about 3 months, followed by another relapse and another trial on fluoxetine at 80 mg. Throughout this trial, he steadily deteriorated, to the point of requiring hospitalization for the first time. A trial of monoamine oxidase inhibitors was suggested, but during the long fluoxetine washout period, he was referred for an inpatient trial of buprenorphine.

On initial evaluation, he was tearful and markedly psychomotor retarded and reported 5 months of the worst depression of his life. He complained of lethargy and complete inability to function at work or home and admitted to a strong suicidal drive. Hypersomnia and hyperphagia were not marked, so he was rated only as having probable atypical depression with a HAM-D score of 21.

He had a very rapid response to buprenorphine, feeling better after the first intranasal dose of 0.15 mg, and at the end of a week at 0.15 mg thrice daily, he reported himself to be 90% recovered. His HAM-D score was down to four; he awoke at 6:30 in the morning feeling refreshed and was no longer lethargic. His demeanor changed completely; he conversed spontaneously, with a full range of affect, and he spoke and moved at a normal pace. By the end of two weeks, he felt completely recovered, was discharged from the hospital, and returned to work a week later. For the rest of the 6 week trial, his HAM-D score was between 3 and 6. His dose regimen remained at 0.15 mg thrice daily. He reported a consistent but subtle decline in mood in the morning before his first dose of the day, although he did not feel any subjective "high" or any subjectively apparent drug effect other than a normalization of mood exceeding that produced by any previous antidepressant. He was involved in church activities with more enjoyment and energy than in the past. He also noticed the disappearance of his carbohydrate craving, and by the end of 10 weeks, he had lost 19 pounds although he was eating a normal diet. Having elected to continue on the drug, at that time, his HAM-D score was 7. Arrangements were made for him to be given buprenorphine by his HMO physician. Soon thereafter, he missed a follow-up appointment, did not return phone calls, and was lost to follow-up for almost 2 years, when we received a phone call from his HMO internist. He reported that, to maintain the patient's remission, repeated dose increases had been required at several-month interval, and he wanted to know if an increase from 3 to 3.3 mg/day would be safe. He was reassured to learn that heroin addicts were routinely treated with much larger doses. There has been no subsequent contact with the patient in the year since.

Patient 3

This outpatient was a 28-year-old, single, white man with a history of chronic fluctuating depression since age 12. His childhood adjustment was suggestive of attention deficit disorder without hyperactivity. His early home life was turbulent. He completed high school and a single semester of college before dropping out. He held a variety of jobs, sometimes working in his father's firm and at other times in unskilled jobs. He rarely held a job for long because he would soon develop tensions and conflicts with employers and quit or be fired. He was referred into the study from an outpatient psychiatric rehabilitation program where he had been engaged in sheltered employment for over a year.

His psychiatric symptoms included baseline depressed mood, chronic lethargy, hypersomnia with intense anxiety and intermittent panic attacks, and multiple forms of idiopathic pain. For back and neck pain and headache, he occasionally received narcotic pain medication, which he stated made him feel more sociable, lively, and "normal".

He was in psychotherapy almost continuously after age 17. His depressive symptoms failed to respond to trials of doxepin, trazodone, phenelzine, and lithium. The patient reported that nomifensine was very effective, but it was taken off the market. Carbamazepine was judged to be helpful by his psychiatrist, but the patient noted no benefit. Alprazolam was markedly effective, but he abused it. He did not abuse clonazepam, which reduced his chronic anxiety and panic attacks, but left him depressed and anergic. A trial of bupropion increased his anxiety, at which point he agreed to participate in the buprenorphine study.

At the beginning of the trial, his HAM-D score was 32. He could talk only about his depression, was conspicuously anxious, complained of various pains and deep lethargy, and described significant recent weight loss and diurnal variation of mood. Because he reported total anhedonia, he did not meet criteria for any degree of atypical depression. He gave the impression that he was exaggerating the severity of his distress to some extent, although he was obviously quite ill. His only concurrent psychotropic medication was clonazepam (5 mg/day in divided doses). He was not taking any medications for pain.

By the end of one week, on a total daily dose of 0.6 mg of buprenorphine, he reported dramatic improvement in mood. His HAM-D score dropped to 10, his anxiety was much diminished, his various pains persisted but were noticeably reduced, and he reported more energy and renewed vitality. He was beginning to get back in touch with neglected friends. He felt his capacity for pleasure was returning. He did complain of an end-of-dose effect, about 4 hours after administration, with a noticeable increase in his familiar symptoms. To overcome this, his dosage was increased in a stepwise fashion over the next 5 weeks to 0.6 thrice daily, given sublingually. This strategy was effective, and his mood and function continued to improve, so that at the end of 6 weeks his HAM-D score had dropped to six. He did have several exacerbations of neck pain over the course of the trial and was treated by a rheumatologist with local lidocaine injections and oral doses of oxycodone and acetaminophen, which he reported had less effect than usual on his pain and no effect on his mood.

He elected to continue on buprenorphine after the end of 6 weeks, reporting that he felt better than he had in years. He remained on the sublingual, 0.6-mg, thrice-daily dose over the ensuing 6 months, during which he reported feeling well. Then, attempts by his outpatient rehabilitation program to mobilize him back to full employment appeared to result in a return of physical complaints and anxiety. His father became quite angry at this point and markedly reduced his financial assistance to the patient.

Rapidly deteriorating now, the patient was unable to get out of his apartment to refill his prescription for buprenorphine, and he went 48 hours without the drug. He called to report acute withdrawal symptoms, with insomnia, anxiety, nausea, gooseflesh, arthralgias, and malaise. This improved 24 hours after the resumption of buprenorphine, and he concluded that he was dependent on the drug and wanted to be taken off of it. At this time, his HAM-D score had risen to 20, He was placed on a 5-week taper and was monitored closely. At his request, he was placed on fluoxetine, an antidepressant he had never tried. Throughout the taper, he complained of fluctuating withdrawal symptoms, now including sweating, trembling, diarrhea, abdominal cramping and "drug craving", but he had normal vital signs and no physical evidence of diaphoresis or tremor on repeated examination. His complaints of withdrawal persisted for a month after the discontinuation of the drug. He reported a full depressive relapse.

Patient 4

This inpatient was a married, 70-year-old, white woman with a 39-year history of recurrent major depression with typical melancholic features. In the years before this hospitalization, she had failed to show significant benefit from trials of 19 different antidepressant drugs in various combinations, including an innovative trial of methadone, as well as several courses of electroconvulsive therapy, both unilateral and bilateral, totaling 75 treatments. Before the onset of a postpartum depression at 31, she denied any history of psychiatric illness, and she had functioned well as a mother and homemaker. Since her first depressive episode, she had required many hospitalizations for severe depressive exacerbations and had made three serious suicide attempts. During interepisode intervals in the past, she had enjoyed a significant degree of improvement and had been able to assist her husband in running a small jewelry store. Since their retirement 12 years before the current hospitalization, she reported constant depression of fluctuating severity. She had no history of mania or hypomania and had never abused alcohol or drugs. Her mother had also suffered from recurrent major depression, although less severe.

The present episode had begun 2 years before she entered the study, with mounting symptoms of restless anxiety, and had progressed to include global insomnia, marked diurnal variation of mood with morning worsening, loss of appetite with a 20-pound weight loss over 6 months, pervasive hopelessness, and finally, persistent suicidal ideation, which had resulted in her re-hospitalization. Because of her discouraging history of medication non-response, she was hospitalized on a cognitive-behavioral treatment unit in the hope that she might find some benefit from the cognitive-behavioral treatments. Because of the severity of her current depression, she was found to be unable to participate in cognitive-behavior therapy, and she was referred for experimental treatment with buprenorphine.

Her baseline HAM-D score was 39. She reported 100% maximum reactivity of mood and therefore was categorized as having simple mood-reactive depression. She tolerated a steady titration of buprenorphine administered sublingually to 1.8 mg/day over 6 weeks. Within 4 days of initiating the drug, she became capable of enough interpersonal interaction to participate to a limited extent in cognitive-behavior therapy, although after 1 week her HAM-D score was still 35. Her improvement was more gradual than that of other responders. After 5 weeks, her HAM-D score had dropped to 22 and she was released from the hospital. One week after returning home, at the end of the buprenorphine trial, her HAM-D score was 11. By this time, she had returned to her former leisure activities of bridge and dining out with her husband and her friends. She continued to enjoy this remarkable improvement for 8 weeks, when she was dismayed to find herself slipping into a terribly familiar depressive state with no apparent precipitant. Her buprenorphine dosage was systematically increased every few days up to a total of 3.6 mg/day, with no benefit. The drug was then tapered over 2 weeks, and she was monitored closely for 10 days after discontinuation. The patient reported mild nausea and myalgia, but minimized the significance of these, and did not feel her depression was worsening as buprenorphine was withdrawn.

Patient 5

This inpatient was a 33-year-old, single, white man who reported unremitting depression since childhood. He could recall no periods of happiness, only varying degrees of distress. At age 10, he tried to hang himself in the context of an exceptionally chaotic and brutal family environment. He ran away from home in early adolescence and supported himself by prostitution for several years. During this period, he began to practice self-mutilation by cutting his wrists superficially at times of increased distress; this behavior had continued up to the present. He had also abused multiple drugs including cocaine, marijuana, hallucinogens and phencyclidine. He gave these up in favor of heavy alcohol abuse in his early 20s and now reported being sober for the last 8 years.

He had worked at several unskilled jobs until disabled by back injury 4 years ago. He was first hospitalized at that time, at age 29, after a suicide attempt that appeared to have been caused by worsening depression and pain resulting from his back injury. There had been three subsequent hospitalizations for similar reasons. He had been treated with multiple tricyclic antidepressants, fluoxetine, several neuroleptics, lithium, and carbamazepine -- all with minimal effects. Monoamine oxidase inhibitors were quickly abandoned because of his expressed fantasy about how easy suicide would be with these. Several psychostimulants were tried, with improvement in energy, concentration, and alertness, but they failed to change his mood. He required opioids intermittently since his back injury; two attempts to treat it had been unsuccessful. He found his mood and general level of function to be elevated by these prescribed opioids, especially oxycodone.

On initial assessment, he was receiving perphenazine, 12 mg, magnesium pemoline, 37.5 mg, and codeine and acetaminophen as needed for back pain. He was eager to try buprenorphine and agreed to discontinue perphenazine, which had no clear indication. He insisted on continuing pemoline, which had been at a constant dose for 2 years, with good effect on his energy level and alertness. He had a 21-item HAM-D score of 26, with long initial insomnia, feelings of guilt, frequent spasms of anxiety verging on panic attacks, and somatic symptoms of pain and anergia. He had no psychomotor retardation and was without any evidence of delusions or thought disorder. He reported 80% mood reactivity, severe leaden paralysis, ravenous appetite, and extreme sensitivity to rejection and therefore met criteria for definite atypical depression.

He had a dramatic initial response to buprenorphine, at the end of 1 week feeling more alert and more relaxed than in many years. His HAM-D score dropped to 11. He was much more sociable, and his initial insomnia resolved without daytime sedation. His back pain was reduced, and he dropped his use of as-needed codeine by two-thirds. He complained only of mild nausea. However, a week later he was doing less well, despite increases in dosage to 0.6 mg/day. His pain was worse, his nausea had intensified, and he developed early morning awakening with guilty ruminations; his HAM-D score was now 20. Over the subsequent 2 weeks, his condition deteriorated further. This followed his longtime therapist's revealing his decision to terminate psychotherapy with the patient, after several years of acting as his primary social support. In an effort to recapture his initial benefit, the buprenborphine dosage was increased in a stepwise fashion to 0.6 mg intranasally three times a day. His nausea subsided, and he denied any subjective awareness of buprenorphine, but he continued to feel worse, with a dramatic increase in back pain and feelings of rage and betrayal. He exhibited frequent, intense hostility and uncooperativeness toward hospital staff. He abruptly decided that no medication could help him and refused to participate further in the study. His HAM-D score on his final interview, after 4 weeks on the drug, was 30. He developed no withdrawal symptoms over the subsequent several weeks, although he complained of severe headaches.

Discussion

The degree of benefit experienced by this treatment-refractory group of depressed patients is striking. The large number of previous treatment failures experienced by these subjects and the severity of their index episodes would argue against this being a placebo response in most cases, especially given the relatively extended period of improvement observed(35). Placebo response is rare in this population, recently estimated to be approximately 10%(36).

The rapidity of onset of clinical improvement replicates that observed in prior studies(2,26,30). The pattern of slow, steady improvement customarily seen with antidepressant therapy was not observed, with most improvement noted within one week.

Patients did not feel intoxicated or euphoric, but rather, "more normal", as several remarked. The POMS contains euphoria scales that are likely to become quite elevated when the patients are in intoxicated states(37). Although these three scales (elation, friendliness and vigor) were significantly elevated from baseline, they rose to only modest absolute scores (as shown in Table 1). Of course this may simply indicate that depressed subjects are not capable of a full euphoric drug response. It is notable that, for one-third of the subjects, the effect of the drug was subjectively so unpleasant that they withdrew after one or two doses, a finding that suggests that buprenorphine does not have a high abuse potential in this population. This is even more striking if one considers that another third of the subjects chose to withdraw after 4 weeks of treatment, despite having experienced some antidepressant benefit.

It is also worth noting that the dosage of buprenorphine used in this protocol was quite low, in keeping with prior published evidence in this population(2,30). The average final dose used during the trial was 1.3 mg/day, whereas in opiate abusers, buprenorphine dosages begin at 2 mg/day and rise as high as 16 mg/day(18,38).

Although all but one of these patients met at least threshold criteria for mood reactive, atypical depression, the one patient to deteriorate (n the context of a personal crisis) met criteria for definite atypical depression on the ADDS (patient 5), and the one "typical" (i.e., non-mood reactive) melancholic (patient 3) showed an excellent, although ultimately transient, response, as did patient 4, whose clinical presentation was nearly "typical" of melancholia. Thus, these finding do not argue that the diagnostic subtype of atypical depression predicts treatment response to opioid therapy, although a larger and more heterogeneous population would required to make any strong conclusions in this regard.

An intriguing possibility is raised by the marked response to opioid treatment in this group of chronically depressed patients who had been little helped by standard antidepressant drug therapy. Perhaps the pathophysiology in a subgroup of patients is unrelated to abnormalities of central monoaminergic systems, but rather results from dysfunction of the endogenous opioid system. This might account for the resistance to treatment with standard monoaminergic antidepressants in some patients. It is also consistent with the recent finding that the brains of depressed suicide victims show up to a nine-fold increase in the number of endogenous opioid receptors over age- and sex-matched controls postmortem. This finding may suggest that opioid receptor up-regulation may be occurring in this very treatment refractory population because of a deficit of endogenous opioid neurotransmitter availability(39).

Our findings are intriguing but tentative. It is striking that, in several cases, clinical benefit did not persist through continuation treatment, raising the suspicion of either tachyphylaxis or a non-specific placebo effect in some cases(40). Placebo-controlled studies over more prolonged periods of treatment will be necessary both to rule out a primary placebo effect and to establish the degree to which the antidepressant effects of buprenorphine persist. Fixed-dose designs will be necessary to establish optimal dosing strategies, which were obscured by the steady dosage increases over the course of this trial. Comparison with standard agents in treatment-refractory patients will be necessary to establish whether buprenorphine has superior efficacy in treatment-resistant depression, and trials in nonrefractory major depression will be needed to establish whether buprenorphine's efficacy is limited to refractory illness.

References

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[sobe]

In adition to helping with pain I think opiates help depression like no other anti-depressant. Especially the "official" anti-depressants (SSRIs, in particular, but basically all of them). Not only do they take weeks upon weeks to work (assuming they are going to work at all) but their long-term effects are completely unknown. The pharmacology of these anti-depressants is largely unknown, and the side effects that come with them (including an increase of depression sometimes) are much more debilitating than the opiates.

The opiates, on the other hand, are natural chemicals existing in nature. And rather than waiting 6-8 weeks just to see whether or not they are helping, they show a significant decrease in depression on the first medication. Opiates are also the safest class of psychoactive drugs in existance in terms of not causing harm to your body. (However, consuming opiates during pregnancy or going through withdrawal during pregnancy may potentially threaten the life of the unborn child, but I haven't studied this subject enough to know how great the danger is.)

As long as you can bear to live constipated and with a non-existent sex drive, then using opiates for your entire life will not destroy your health in any way. The benefits by far outway such "negatives" (assuming you consider decreased sex drive to be a negative side effect at all).

The only reason today's anti-depressants are heralded as something "great" and "revolutionary" is because they -- unlike the opiate class -- do not produce any euphoria when administered. In other words, the pharmaceutical companies have preferred to create worthless pills and tablets that do very little or nothing for depression (and sometimes make it worse) simply because they have no "abuse potential." Is there any logic behind this?

"Abuse potential" should NEVER be a factor in producing a helpful medicine; what should be the most important factor is if the product can do its job correctly and be safe. And, apparently, this is not what's going on today in the pharmaceutical industry.

As for giving amphetamines to depressed people, how is this any better than giving them opiates instead? Amphetamines produce just as much euphoria as opiates -- just in a highly different way. They, too, have the dreaded "abuse potential." But the difference between amphetamines and opiates are this: with amphetamines you will crash and likely feel suicidal when they wear off whereas with opiates you will never crash or feel suicidal as a result of their effects diminishing. The only time you might feel suicidal is if you abruptly stopped taking your meds and went into withdrawal. But that's a choice; unlike amphetamines which force you to feel terrible every time the effects of the dose wear off. So, amphetamines are probably not the answer in curing depression with those with suicidal tendancies. And all of this does not even start to mention the dangers associated with amphetamine use over prolonged periods of time.

However, while I consider opiates to be superior to any type of anti-depressant available concerning depression, I consider benzodiazepines (as long as the right ones are used and at the right dose) to be superior to the anxiolytic effects that opiates can produce in quelling anxiety. Not to say that opiates don't do a good job in relieving anxiety -- they do; it's just that, at least in my experience with clonazepam, that benzos do the better job.

[Sheryl]

Some people actually become depressed or more so on opiates, not surprising since they are depressents.

In any case there are 2 major drawbacks to opates that you do not mention: 1)they are physically and psychologically addictive and 2) tolerance develops to them (especially to the euphoric effects) with use requiring larger and larger dosages to get the same effect. This does not happen with the SSRIs.

In any case you are entitled to your opinion but opiates are not approved for treatment of depressiobn in any country to my knowledge and you will be hard pressed to find a physician who uses them in that way, and you certainly won't in Thailand. In fact, it has been my experience that Thai doctors and hospitals are very hesitant to use opiates, much more so than is the case in the west. If you want to continue liong-term opiate use, Thailand is not going to be a very good choice for you.

[sobe]

Some people actually become depressed or more so on opiates, not surprising since they are depressents.

In any case there are 2 major drawbacks to opates that you do not mention: 1)they are physically and psychologically addictive and 2) tolerance develops to them (especially to the euphoric effects) with use requiring larger and larger dosages to get the same effect. This does not happen with the SSRIs.

In any case you are entitled to your opinion but opiates are not approved for treatment of depressiobn in any country to my knowledge and you will be hard pressed to find a physician who uses them in that way, and you certainly won't in Thailand. In fact, it has been my experience that Thai doctors and hospitals are very hesitant to use opiates, much more so than is the case in the west. If you want to continue liong-term opiate use, Thailand is not going to be a very good choice for you.

It was suggested that I bring a prescription with me while I am there looking for surgery to fix the condition . Sherry thanks for you rely you have a vast knowledge of things and I respect and value your suggestions , you do go by the book(a book I sometimes have a problem with) but again I do value your reply thanks again.

[John K]

Sobe, I am not sure but perhaps the effect for you is they cloud or distance your particular reality thus mimicking the effect you talk about. If negatives are not in your face you can cope easier. For many Happy hour has the same effect. This is a personal opinion and not a professional opinion as I am not an expert in that area. But whatever works, it may not be for everyone.

Edited October 26, 2006 by John K