Posted by Elizabeth on May 16, 2001, at 14:01:54
In reply to Re: Whats the best opiate for depression ? » Elizabeth, posted by shelliR on May 12, 2001, at 21:27:54
> > Codeine isn't the best choice for an AD anyway, IMO -- if you need a full agonist, a longer-acting one with fewer adverse effects relative to desired effects would be preferable.
>
> Like Ultram?That wasn't what I was thinking (the fentanyl patch (Duragesic) would best meet the specifications I listed), but Ultram does seem like a good choice in some ways. It has a (*very* mild) monoamine reuptake action in addition to being an opioid agonist. I believe that it is relatively lacking in potential for abuse or physiological dependence compared with morphine, etc., and it has milder side effects. It is not a controlled substance and so it is easier to get a prescription for Ultram than typical opioids (I'd guess it would be even easier to get than, say, Tylenol #3).
The down sides of Ultram include its short duration of action, lowering of the seizure threshold (which limits the safe dose range), and potential for icky interactions with monoamine reuptake and metabolism inhibitors (in particular, SSRIs, MAOIs, and mixed reuptake inhibitors like Effexor and Meridia). It's probably not as big a risk for interactions as, say, Demerol, but there have been enough reports to warrant serious caution (an appropriate Medline search should elicit a number of published reports).
Apparently a slow-release preparation of tramadol is in the works, which is excellent news. Also, I'm not sure how long it's been around, but it might be going generic soon.
> > I've heard many stories of people suing their doctors over some pretty absurd things. Dr. Bodkin takes particular risks in that he is willing to work with patients who may be personality-disordered (which often is associated with a tendency to blame other people for one's problems -- e.g., a patient misuses or overdoses on medication, then blames the doctor). I take Dr. B's willingness to work with these "difficult" patients as a sign of exceptional compassion.
>
> Elizabeth, yes, I believe the scenario with the law suit is very close to what you described above, and I didn't take it that Dr. Bodkin had done anything wrong. If I don't find someone around here that I highly respect to consult with, I may fly up to Boston.I think that Dr. Bodkin has been willing to consult with psychiatrists in other parts of the country on this subject. (Considering how busy he always is, this is really sweet of him if it's correct.) Your best chance is to find a pdoc in your area who has ties to McLean (e.g., who worked there or did a residency there). Those guys all seem to know each other, and someone who knows Bodkin personally would be more receptive to his research, I think. Failing that, the next best option is to find someone in your area who has a research background or orientation, or who is interested specifically in creative approaches to TRD.
> I also have an old friend living in Somerset.
Somerset...? (Where's that?)
> Still, in the long run it would be best to find someone in my immediate area. He did make the suggestion of going up very high on selegiline, but I'm not really anxious to go off the nardil and start again with a new MAOI, unless perhaps it was the patch.
Going off MAOIs is hard, yup -- on top of the worst withdrawal syndrome of all the classic ADs, there's that damned "washout period." Although I generally prefer to follow the middle path (an expression I picked up from Buddhism to describe a belief system that I've carried all my life), my experience suggests that the extreme approaches may be the best way to deal with MAOI-nonMAOI switches. One way is to taper off the phenelzine extremely slowly, especially once you're down to 15mg/day (like, go to 15mg every other day and stay at that dose for a week or more). The alternative is to drop the dose very rapidly, use a lot of benzos to get yourself through the withdrawal, and go with a minimal washout period rather than the more conservative ones suggested in the PDR. It kind of depends how badly off you'll be without the MAOI. I once switched between a nonhydrazine MAOI (Parnate) and a hydrazine (Marplan) with only **3 days** between them. (Kids, don't try this at home. The risk is probably less than, say, switching between MAOI and SSRI, but there still can be problems, and MAOIs shouldn't be combined with other MAOIs.)
I think the idea of selegiline in very high doses is an excellent one, and I often wonder if it wouldn't be worth it for me to give it another shot. (I didn't use benzos or anything to deal with the panic symptoms that I got when I was on it, so I never got past 40mg.) Selegiline seems to cause very little orthostatic hypotension and does not cause weight gain.
Good luck, whatever you end up deciding to do.
-elizabeth
poster:Elizabeth
thread:61760
URL: http://www.dr-bob.org/babble/20010515/msgs/63242.html