Treating Depression with Opioids?

I received this message today:
Hi, you probably answer this quite a bit. I’ve been depressed for as long as i can remember.
Ive been on the ssris, snris, amphetamines and methylphenadate but none of these have worked as well as opiates. (Certainly short term,I don’t take for long periods of time). But have you ever used suboxone or oxymorphone for depression.
Depression is probably a broad term, for what may be multiple conditions. For example, some people become depressed almost as if it is part of their nature—  they will get episodes of depresssion even when everything in life is going well, in spite of good marriages, healthy children, and an absence of significant baggage from the past– at least baggage that is visible.  Other people will present with depression that has developed after a series of blows to their sense of self or self-worth— after a health scare, job loss, divorce, death of a child, or perhaps from carrying around guilt or shame from abuse that occurred during their childhood.
Does it matter whether the depression is more like the first or the second category?  I think so, but I have no proof that my perception is accurate.   I will see different responses to medications by people with different types of depresssion, but I’m always challenging that perception, realizing how easy it is to be ‘fooled by randomness’, to copy a phrase from a book title.  In my experience, the second person is more likely to bounce back, providing the negative onslaught eventually stops.  But the people in the first group are more difficult to treat, especially if the depression becomes part of how a person defines him or herself—  as it is very difficult to change self-perception.
When I see someone who describes lifelong depression, my first question is whether the person was ever adequately treated with a good antidepressant.  Many times a person will say ‘I’ve taken every antidepressant out there’, but when I carefully go through the history, I find that the person has started many medications, but never took a medication long enough or in sufficient dosage to expect an effect.  I will work with such a person, coaxing the person through all of the side effects that led to stopping earlier trials of medications… and many times the person will do well on a medication that was written off years earlier.  I think it is important to get this basic info out, before launching into a discussion about more experiemental treatments.
I’ve written in an earlier post about Alkermes trials of a buprenorphine-based antidepressant;  I’m not certain where they are in the process with that medication.  I do believe that opioids play a role in depression, at least in some people.  Many of my patients on buprenorphine say that they feel better on the medication than then remember before taking it.  But I realize that all of these people went through very negative experiences as part of their opioid use, before starting buprenorphine.  I also know that recollections of emotions are extremely unreliable.  It is so important to keep good notes, as a psychiatrist, for this reason.   It is common for a patient to insist that he/she felt much better (or worse) the year before….. but then I will read through the chart with the person, and find with the patient that the perception was completely off target.
Even though buprenorphine seems to improve mood in some people, I would be extremely reluctant to prescribe the medication in a person who is not also addicted to opioids– unless or until we find a way to deal with the withdrawal that occurs when stopping buprenorphine.  That cost– the difficulty in stopping buprenorphine– is simply too high, to pass on to someone who isn’t already opioid-tolerant.
I should make it clear that I don’t buy into the complaints of people who write about being ‘stuck on buprenorphine’, who started the medication for opioid dependence.   I’ve seen enough death from opioids to recognize that buprenorphine is simply a necessary part of treating the majority of people addicted to opioids.  Most of the people who complain about being ‘addicted to Suboxone’ somehow have forgotten just how they got on Suboxone in the first place– i.e. the fact that they were stuck on opioids, usually despite multiple trials at stopping on  their own.  They also seem to have forgotten just how horrible ‘real’ addiction was– a life of getting sick every few hours, with only one true mission in mind– to find the next fix.  Being ‘addicted to Suboxone’ is nothing like that world;  the unique kinetics of buprenorphine trick the brain out of cravings for the drug, allowing the person to get on with life.    There is a huge difference between being ‘stuck’ with a tolerance to buprenorphine vs. active opioid addiction!
I am EXTREMELY interested in the recent findings about ketamine– that several infusions of the drug, in sub-anesthetic dosages, treat depression more quickly than any SSRI.  It is very possible that the actions of ketamine relate in some way to the antidepressant effects of opioids.  Ketamine acts at NMDA receptors, and also at some classes of opioid receptors.  Then again, perhaps the ketamine/NMDA system will be a novel treatment of its own.
To the writer– I noted in your message (the part I removed) that you live in my general area…  consider making an appointment, and letting me take a shot at helping you feel better.  There are SO many approaches to treating depression, that hopeless cases are rare.  I recently had a person find dramatic improvement on an MAOI, after failing everything else over a period of years.  People who take opioids now and then usually eventually become regular opioid users– and that would really be a shame.