A Controversial Topic

I am considering whether to go forward with this post even as I type this sentence– the comments on depression and Suboxone by Kimmie and ‘Bottlecappie’ are quite thought-provoking and I thank them for their contributions.  I am going to post the one by Kimmie ‘up here’;  I first want to say though before everyone gets too excited that this topic has several different sides to it, and Kimmie’s is a persuasive version of one side of the discussion.  What discussion?  The idea that ‘exogenous opiates’– opiates from outside of the body, like oxycodone– have value for treating depression.
It has been known for centuries that opium and related compounds have euphoric or mood-elevating properties.  But it has been clear for not nearly as long that there is no way to harness this power for the ‘long run’–  whatever benefit is gained short-term must be paid back, many times over, at some point in the future.  Now we have Suboxone, and the possibility has been put forward that we can use the euphoric properties of opiates without the negative consequences.  I have comments on that idea, and some other problems with the general theory– but I will first post what Kimmie had to say:
Hi. I just began treatment of Suboxone for depression. I also, tried just about every anti-depressant out there over the last 20 years, and have felt depression since I was a child. Although an occasional pot-smoker, I have never been an abuser of pain meds or marijuana, but whenever I had thought of them or had exposure to them (even on TV or films) my brain would light up with desire. Often the cravings were unbearable, out of nowhere, leading to impulsive, harmful and illegal marijuana purchases, folllowed by guilt, remorse, etc….

I did a ton of research and found some info about refractory (treatment-resistant depression) and how perhaps 10-15% of the med-resistant population may indeed have depression due to an inherent lack of natural opiates in the brain. I instinctively suspected this about myself for years with no legal recourse, and then a recent surgery provided more clues. I was on Dilaudid and Vicodin for 5 weeks post surgery and most of my depression symptoms went away…I actually felt “normal” with just one, or even a half a Vicodin a day. My appetite normalized, my mood was clear and even, my sleep was great for a change and my self esteem was strong. And….the withdrawal, even after just 1 pill/day for the last week, was AWFUL. My brain was very sad again. Of course, no one will prescribe pain pills for this purpose….and then I read about Sudoxone. I have just begun Sudoxone, and am still tinkering with dosage as I am very drug sensitive.

I find that if I take the 2mg. Suboxone, split in quarters (.5mg.) and then put it under my tongue for a precisely timed 60 seconds before spitting out -just once a day- I am great! I have since been exposed to marijuana and have forced myself to think about the pill-opiate “high” but for the life of me, I cannot get interested. Prior to last week, I would have been “salivating” in my brain and feeling anxious about calming the urges. That part of my brain that craved the opiates is now quiet and happy. I am hopeful I have found the answer at last! No side effects either. Just a feeling of being myself and being “complete”. Many people may turn to opiates out of natural instincts to find balance, just as a malnourished person seeks just the right nutrients instinctively. I hope this treatment loses its stigma and begins to make its way more into mainstream depression treatment, especially at these minute doses. There is a study here to support my low dosage theory and practice:

http://www.thatspoppycock.com/articles/2007_05_14_bup_for_depression.htm

also, read here for a ton more info:

http://www.prohibitionkills.com/

It turns out the dose I am approximately taking fits in with the Harvard study’s determination of the optimum dose for depression as well. I just wish they made smaller dose pills so I could have more accuracy.
Hope this can help others,

Kimmie

When I first presented for addiction treatment back in 1993, I was prepared.  I had tried to treat myself through knowlege;  I already had a PhD in Neuroscience, mainly neurochemistry, I had my ‘MD’, and I was an anesthesiologist.  I also read everything I could find on addiction, including 12-step literature;  I remember going to the bookstore and finding the ‘Big Book’ of AA, scanning through the steps, pausing for a minute and thinking… Nope– didn’t work.  The 12 steps did eventually save my life– twice– but that’s a different story!  I went to one of the addictionologists I was ‘screening’–  something I now recognize for what it was– addicts (and other people) don’t want to change, so I was looking for a doctor who I would agree with.  It is sort of silly, really– I obviously needed new information, as I was getting nowhere… yet I wanted it MY way.  That is common– I see it all the time with addiction and with every condition.  Patients come in saying they want change, they they do all they can, including lying to me as they pay me my fee, so that whatever I try to do won’t work.  Anyway I remember telling this particular addiction doc that ‘I must have a deficiency of endogenous opiates– my endorphin level must be way too low’.  He got a good laugh at that.

And he was right to laugh– but this is my concern over posting this info.  Almost EVERY opiate addict comes to me and says the same thing– sometimes with big words, and sometimes with smaller words. We ALL think we need opiates!  And yet I know from experience that if those people would get clean, either using Suboxone or more importantly to this discussion by using meetings and the 12 steps, they would no longer be depressed.  In fact, almost all of the patients who felt they needed more opiates in their brains would be GREAT with recovery alone– much, much better than they were before they even got addicted!

Are there patients who have ‘low opiate levels’?  Maybe– but maybe not.  Thinking about how the brain works, it is not as if a person has more or less opiate content– just as they don’t have ‘levels’ of serotonin or other transmitters.  Yes, you can meaure ‘levels’ in spinal fluid of various chemicals including endorphins, but those are just random  molecules that have found their way from the synapse where they work to the spinal fluid– they have no correlation with FUNCTION.   The proper dynamic isn’t the amount of a substance, it rather is the action of one neuron upon the other.  To illustrate my point, in withdrawal, there are plenty of endorphins around– probably at much higher levels than normal.  But the endorphins don’t have the usual effect at the next neuron in the chain, so the brain acts as if the endorphins were not there.  Sort of like the old ‘if a tree falls and nobody hears it, did it really happen?’ argument for the old philosophy majors out there.

I have another problem with the ‘opiates for depression’ argument though–  it often doesn’t work.  There have been studies that look at the use of buprenorphine for depression and they have mixed results.  I have at least two patients who wanted bupe for depression, who were also showing strong addictive thinking patterns… and both did poorly with bupe alone.  I have one other patient who  I ‘inherited’ from another doctor, who was taking bupe for depression– and she has done well on it for three years and counting.  But she had no signs of addiction before being placed on buprenorphine.

Or did she?  The features of addiction are very similar to features of some of the personality disorders– self-centeredness, a lack of humility, a tendency to rely on others for gratification instead of finding it in ones own abilities, a lack of confidence…  a person could make a strong argument that the person who benefits from opiates, who is not an opiate user, is an ‘addict in the making’– and by ‘treating’ the person with opiates we have essentially ‘fed the beast’… and in the long run the beast will destroy the person.

Complicating things, when do we decide that a person is ‘doing well’?  Should we rely on the person’s self-assessment?  I will often have patients dragged in by a spouse who claims that the person is miserable, isolated, irritable, sick, boring, unsexy, smelly… all because of his/her addiction.  The addicted person may say ‘hey, I’m FINE!’  We usually call that ‘denial’…  admittedly this is an extreme scenario, but many using addicts will say that they are fine as long as they don’t run out of dope, while it is clear from the outside that the life they are leading is miserable by anyone’s definition.  On the other hand I see many people who look like they should be very happy– they have friends, they do well at work, they have nice families… and yet they claim to be totally miserable.

If Kimmie comes to me and says ‘I have an opiate deficiency– off Suboxone I am miserable, and on it I am great– trust me’, and then I notice that on Suboxone she stays in all the time, is moody, can’t keep a job, etc– am I doing her a service by prescribing Suboxone?

Feel free to post your own thoughts or personal experiences on the issue.  I have to approve the comments, and I will try to do that as soon as I can after you leave them.