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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 12 of 12. This is the beginning of the thread.
Posted by shelliR on September 11, 2001, at 18:03:52
Hi Cam.
Before I get to the question, some background:
I am in the unusual position of having a pdoc who is prescribing oxycontin for me, to literally get me through life until an antidepressant works. (I took hydrocodone for premenstral depression and sickness for several years, with great success, and no increase.) He is a very respected physician, but known as a non-conformist. I took nardil successfully for years and in the past almost two years, its benefit pettered out. In the past year and a half, I have tried a dozen adjuncts, then prozac, now wellbutrin. I have gotten up to 300 with no side effects, and today started very slowly to add nardil to the wellbutrin. (I am watching carefully for any signs of a hypertensive reaction)Re the opiate part:
Once another psychiatrist told me that opiates could interfere with the success of antidepressants. When I asked my pdoc about this, he said that was the thinking in the 1970s, but not anymore. There is no interference. My depression has not abated at all in the last year, and I am beginning to wonder if there is a possiblity that there *is* some interference. I am not worried about addiction; I feel that if anti-depressant kicks in, I can slowly begin to taper off the oxycontin. And I will continue to go up on the wellbutrin once the nardil is in place. I do, however, worry some that the other psychiatrist was correct, although I cannot find any information on the internet to support it; only info on addiction, etc. Have you ever come across any mention of opiates interferring with anti-depressants, in your reading?Thanks (in advance)
BTW, is Cam short for Cameron? Just curious.Shelli
Posted by SalArmy4me on September 11, 2001, at 18:38:46
In reply to CAM: question about codeine and antidepressants, posted by shelliR on September 11, 2001, at 18:03:52
Romach MK, Sproule BA, Sellers EM, Somer G, Busto UE Long-term codeine use is associated with depressive symptoms. J Clin Psychopharmacol 1999;19:373-6
"We found that long-term codeine users had elevated scores on a general measure of psychologic distress and that depressive symptoms were very common. Although it is not clear from our survey how much of this symptomatology preceded the codeine use and may have been an initiating factor and how much was a consequence of codeine use, we speculate that regardless, codeine was being used by many of these individuals to modulate mood in the absence of more appropriate interventions. The majority of users described using codeine for management of chronic pain, and chronic pain has been reported to be closely associated with depression, particularly in women. [14] The strong family history of depressive disturbances and the fact that more than half of the respondents had sought professional help for mental health problems (most often depression) support the importance of dysphoric mood states in association with long-term codeine use. Whether depression and anxiety in substance-dependent individuals are "independent" states or secondary drug-induced disorders, the clinical significance of making such a distinction with respect to treatment is unclear..."
Posted by Waterlily on September 11, 2001, at 18:49:09
In reply to CAM: question about codeine and antidepressants, posted by shelliR on September 11, 2001, at 18:03:52
I wouldn't be surprised if codeine does block the effects of antidepressants. I had two elective surgeries last year which did not adversly affect my quality of life, but I became depressed after both surgeries. Maybe it's the anesthesia (general both times), but if I ever have another surgery I will take something other than codeine.
Posted by shelliR on September 11, 2001, at 19:16:37
In reply to Re: CAM: question about codeine and antidepressants » shelliR, posted by SalArmy4me on September 11, 2001, at 18:38:46
< Although it is not clear from our survey how much of this symptomatology preceded the codeine use and may have been an initiating factor and how much was a consequence of codeine use, we speculate that regardless, codeine was being used by many of these individuals to modulate mood in the absence of more appropriate interventions.
Sal--Not particularly relevant to concurrant use of codeine (Contin) with appropriate interventions.Shelli
Posted by Cam W. on September 12, 2001, at 1:43:05
In reply to CAM: question about codeine and antidepressants, posted by shelliR on September 11, 2001, at 18:03:52
Shelli - I don't think that opiates interfere with the efficacy of antidepressants, but some antidepressants interfere with codeine (ie. stop the conversion of codeine to morphine, in the body). This may be a problem with the inhibition of certain cytochrome enzymes (2D6?).
Also, certain SSRIs need to be used with caution with Demerol™ (meperidine)(can't remember why, but I think that it has something to do with hypertensive crisis via serotonin syndrome).
The endorphin system and the HPA axis (the body's stress control system) are strongly linked, but I do not know enough about it to make a definitive statement about it. It would seem that certain subtypes of depression could result as a breakdown in the endorphin system. I did read this somewhere, but I can't find the reference paper in my files.
Perhaps Elizabeth may have a better understanding of this. Hopefully, she can help shed more a accurate light on your situation.
Sorry that I cannot be of more help. - Cam W (just a user name).
Posted by Elizabeth on September 12, 2001, at 4:56:03
In reply to CAM: question about codeine and antidepressants, posted by shelliR on September 11, 2001, at 18:03:52
> My depression has not abated at all in the last year, and I am beginning to wonder if there is a possiblity that there *is* some interference.
That may be due to tolerance (this doesn't always happen, but apparently it is possible).
Cam is right that the effects of codeine can be blocked by some ADs, though. Its effect is mainly due to metabolism into morphine via cytochrome P450 2D6 (not 2D7 :-) ). Lack of response to codeine can be an indicator of possible CYP 2D6 deficiency.
Short-term use of opioids (at least, of full agonists or mu-selective agonists) is unlikely to cause problems.
General anaesthesia -- particularly the barbiturates which are used for induction -- can most certainly exacerbate depression.
Cam:
The problem with Demerol is that it's a monoamine reuptake inhibitor as well as an opioid agonist. Together with enzyme inhibition by some SSRIs, this can result in the serotonin syndrome.BTW, if you do find that paper, I'd be very interested in what it has to say. What subtypes of depression are implicated?
-elizabeth
Posted by shelliR on September 12, 2001, at 13:03:42
In reply to Re: CAM: question about codeine and antidepressants, posted by Elizabeth on September 12, 2001, at 4:56:03
Thanks, guys for taking the time to response.
> > My depression has not abated at all in the last year, and I am beginning to wonder if there is a possiblity that there *is* some interference.
> That may be due to tolerance (this doesn't always happen, but apparently it is possible).Elizabeth,
Well, I definitely have developed a tolerance to oxycontin, but my pdoc is letting me continue to go up. (He doesn't want to switch to bupe (or buph) as I've seen it appreviated before on the web. The thing that made me wonder if oxycontin is making my depression worse, is how horrible I feel when I wake up in the morning. Before my first dose, I have the worst consistent depressant I have ever had in my life, except perhaps before I started taking nardil, many years ago.
>
Shelli
Posted by Elizabeth on September 12, 2001, at 13:40:32
In reply to Cam, Elizabeth Waterlily, Thanks for responses, posted by shelliR on September 12, 2001, at 13:03:42
> Well, I definitely have developed a tolerance to oxycontin, but my pdoc is letting me continue to go up.
That sort of scares me. They used to give addicts methadone in whopping doses, increasing so high that the effect plateaued. The idea was to make the addict completely chained, enslaved really, to the clinic. It's probably still going on in some places.
> (He doesn't want to switch to bupe (or buph)
I'd pronounce "buph" as "buff." :-)
> The thing that made me wonder if oxycontin is making my depression worse, is how horrible I feel when I wake up in the morning.
What time do you take it at night? It sounds like rebound to me.
-elizabeth
Posted by SLS on September 12, 2001, at 20:58:30
In reply to Re: Cam, Elizabeth Waterlily, Thanks for responses » shelliR, posted by Elizabeth on September 12, 2001, at 13:40:32
> > The thing that made me wonder if oxycontin is making my depression worse, is how horrible I feel when I wake up in the morning.
>
> What time do you take it at night? It sounds like rebound to me.
Hi Shelli.For what it's worth, I agree. If this is indeed the case, you don't have to be worried that the oxycodone is somehow creating a tangled mess of your brain neurochemistry leading to a worsening of your baseline depression. In other words, you are probably experiencing a "crash" upon the loss of oxycodone activity such that the downward momentum of the crash actually leaves you temporarily below your unmedicated baseline. Were you not to reintroduce the oxycodone, you would soon recover and stabilize at a more familiar level of depression.
- Scott
Posted by shelliR on September 12, 2001, at 22:45:01
In reply to Re: Cam, Elizabeth Waterlily, Thanks for responses, posted by SLS on September 12, 2001, at 20:58:30
> > > The thing that made me wonder if oxycontin is making my depression worse, is how horrible I feel when I wake up in the morning.
> >
> > What time do you take it at night? It sounds like rebound to me.
>
>
> Hi Shelli.
>
> For what it's worth, I agree. If this is indeed the case, you don't have to be worried that the oxycodone is somehow creating a tangled mess of your brain neurochemistry leading to a worsening of your baseline depression. In other words, you are probably experiencing a "crash" upon the loss of oxycodone activity such that the downward momentum of the crash actually leaves you temporarily below your unmedicated baseline. Were you not to reintroduce the oxycodone, you would soon recover and stabilize at a more familiar level of depression.
>
>
> - ScottThanks Scott,
Your opinion *is* reassuring to me. This morning, I actually paged the hopital pdoc who told me that opiates can interfere with anti-depressant effect. He called me back within five minutes. I specifically asked him if he had any sources he could refer me to that supported what he had said, besides the random studies , similar to the one that Sal pointed out. This pdoc admitted those studies were not particularly enlightening to my situation. And he said that my pdoc, who he has worked with, knows a lot more about biochemistry than he does, so he would defer to my pdoc. That was also reassuring.
I suppose it is not worth it to take a small dose of oxy to try to prevent waking up everyday with suicidal thoughts. I'm not even sure that I would be able to sleep (it is very activating for me); but more importantly, it would raise my dose.
BTW, I just read the posts on ketoconazole and hypercontisolemia. Interesting stuff. Have you been tested for this?
Shelli
Posted by SLS on September 13, 2001, at 9:09:01
In reply to Re: Thanks for responses » SLS, posted by shelliR on September 12, 2001, at 22:45:01
> BTW, I just read the posts on ketoconazole and hypercontisolemia. Interesting stuff. Have you been tested for this?
Hi Shelli.Yeah. I was given the dexamethasone suppression test (DST) very early on. I tested positive. My adrenal glands did not reduce their cortisol output as would be normal in a healthy individual when challenged with a single dose of dexamethasone, a synthetic corticosteroid. This was performed as a blood-test that was given the day after ingesting the dexamethasone.
I was also given the "spit-test", and tested positive for that too. This differs from the DST in that it simply tests for the level of cortisol for any moment in time. It is not as reliable for two reasons. The levels of cortisol can fluctuate greatly over the course of a day, hours, or even minutes. It also does not give a clear picture of the functional state of the system. The DST can show whether the endocrine regulatory mechanisms are operating properly whereas the spit-test might only be reflecting a momentary level of stress. I guess it can be a good preliminary indicator of dysfunction, though.
No doctor ever mentioned cortisol, HPA, or ketoconazole, even though I was aware of its limited use eight years ago. In the past, I felt like trying things like ketaconozole was an act of foolish desperation. It was not consistent with the views of mainstream medicine, and I was more desperate to believe that mainstream medicine and my mainstream doctors had all of the answers necessary to get me well. I guess I am still trapped by mainstream medicine. I had hoped that the doctor I have been working with over this past year would have offered me some radically different and unheard of things to try. I am willing. Crap. I might need to find another doctor. This is so hard for me because I am generally too vegetative and listless to act proactively. I am left very passive, and pretty much rely on doctors to think for me. I imagine this seems hard to believe based upon the way I write.
- Scott
Posted by shelliR on September 13, 2001, at 22:55:44
In reply to Re: Thanks for responses » shelliR, posted by SLS on September 13, 2001, at 9:09:01
> No doctor ever mentioned cortisol, HPA, or ketoconazole, even though I was aware of its limited use eight years ago. In the past, I felt like trying things like ketaconozole was an act of foolish desperation. It was not consistent with the views of mainstream medicine, and I was more desperate to believe that mainstream medicine and my mainstream doctors had all of the answers necessary to get me well. I guess I am still trapped by mainstream medicine. I had hoped that the doctor I have been working with over this past year would have offered me some radically different and unheard of things to try. I am willing. Crap. I might need to find another doctor. This is so hard for me because I am generally too vegetative and listless to act proactively. I am left very passive, and pretty much rely on doctors to think for me. I imagine this seems hard to believe based upon the way I write.It *is* hard to believe, because you are on top of what is helping people on the board. And you are able to help others. I don't know what to say, how to get you to muster up enough energy to advocate for yourself. I think if I was in your situation (and I truely do mean this about me, not telling you what to do), anyway, if I had medicare and medicaid, I'd find one of the most innovative doctor in the country who is affiliated with a good hospital, and go in. I don't understand what you would have to lose. You'd get a break from taking care of yourself, and you possibly might find a solution. I can't see any negatives. Probably without more research I'd call Alexander Bodkin at McLean (acutally I have called him several times with questions) and I'd tell him your situation and ask him if you went into either his hospital McLean, or into Mass General, (which is first on Ivan Goldberg's list), what attending pdoc would he recommend for you. He actually answers his own phone when he's in his office.
Actually, if this doctor I am with now (the oxy guy) is unable to help me, that is what I will probably do. Because of my business, I'd have to plan in advance. Now when I go into the hospital it's just for a quick get-a-way. I can't tolerate my depression at home because my work is here. But for a long-term solution I'd probably go to either Boston or California.
Anyway , this ketoconazole possibility certainly seems worth trying unless your pdoc has a specific, legitimate reason why it would not be in your best interest.
>
>
Shelli
This is the end of the thread.
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