Q&A: Buprenorphine for Treatment Resistant Depression?
Q&A: Buprenorphine for Treatment Resistant Depression?
Q: Are there any recent sources talking about the use of buprenorphine (low dose) for people who were never drug addicts or abusers but who were diagnosed with treatment resistant depression? It seems to me that if stimulants are gaining popularity in treating MDD, why wouldn't we look at low dose buprenorphine which seems to have great results anecdotally for many people with MDD.
A: Buprenorphine is an only mildly abuse-liable drug that is occasionally dramatically helpful in treating depression that does not respond to conventional treatments, even including ECT and MAOIs.
Nonetheless, there has been little work published concerning the antidepressant effects of buprenorphine in treatment refractory depression in the absence of opiate dependence since my 1995 paper. I find only one report, by Nyhuis et al in 2008, looking at low-dose sublingual buprenorphine monotherapy in 6 extremely treatment refractory hospitalized patients with a very marked response to a maximum dose of 0.8 to 2.0 mg/d for a total of 7 days of open label treatment. All but one of these subjects experienced full remission acutely.
A study of buprenorphine treatment for late life treatment resistant depression may currently be under way at the University of Pittsburgh by Dr. Jordan Karp, which is described online at Clinical Trials.gov: http://clinicaltrials.gov/ct2/show/NCT01071538. This is an open-label study, using low doses (to 1.6 mg/d) for an 8-week treatment period.
An obstacle to depression research in the US may have been the requirement that since buprenorphine’s approval in 2002 as a sublingual preparation with or without naloxone for substance abuse treatment, a special DEA number must be obtained in order to prescribe it, requiring some prior drug-abuse treatment training. This removed it from ready access for most psychiatrists who specialize in treating mood disorders.
A relevant matter of mounting scientific interest is the potential role of kappa opioid receptor antagonists in depression treatment, which has been very promising in animal models (Carlezon et al, 2009). Buprenorphine is the strongest kappa-receptor antagonist currently available for human use, although it is also a partial agonist at the mu receptor, and the relative importance of the activity at these sites is currently unknown. This may encourage further work in this area in the near future.
Why do you think this will be best breakthrough in modern times ? Don't you see drawbacks in using a drug that has addiction potential in treating a chronic disease like MDD ? - Dr. P
Dr. P. , I cannot speak for John, but I can tell you that a breakthrough for treatment resistant MDD is just that, a breakthrough. If you have lived through 38 years of chronic recurrent MDD and have been told by your doctor that there is nothing more to do, then the addiction potential of a medication is irrelevant. I am already addicted to everything I am on, and I still want to kill myself. Quality of life trumps addiction. Ask a patient with 20 years of RA if they care that they are addicted to Lortab.
We definitely need breakthroughs in MRDD, but I recommend extreme caution. I was busted by the DEA 9 months ago for using pain medications to treat chronic pain in 5 patients with depression and anxiety whose pain worsened their symptoms. Psychiatrists are in the top three specialties who are considered knowledgeable enough to treat chronic pain. I am employing six attorneys, going bankrupt and still do not have my DEA# back. Doubt that I will treat with any pain medications of any kind or at any dose ever again. The DEA has no understanding of depression, ADD in adults (much less children), does not think that there is such a thing as treatment resistant depression, does not consider that where I practice pain patients have no Pain Centers to go to and so on. It is a federal agency with no oversight and limitless power. So be careful - Leah Thronson MD Child, Adolescent and Adult Psychiatry
We who suffer depression ARE addicted to our meds, period. We can't go off them cold-turkey, we have to wean off, and then we are not better. What is the difference? We will be taking something for the rest of our lives, until we die, and they find a cure afterward.
Having had depression since I was 5 years old, I never had any reduction in my severe depression with any medicine. I been going to the same Psychiatrist since 1996. I was recommended to him by a friend. I had gone to other doctors prior to using him including the VA. My died a year ago and I am all by myself while I suffer. I went back to the second half of the book I am writing. The first half was copyrighted in 1996. The title of my book. DEPRESSION FROM the CRADLE TO THE GRAVE A MEMOIR OF A LIFETIME OF DEPRESSION My wife passed away a year ago and besides my severe depression I cannot shake off my severe depression even though I went thru 16 weeks of grief help which did not put a dent into my grief which has merged with my deep depression. The loneliness has made my depression unbearable and the lonlyness has not helped. I have no one living close to me. I am now 82 years old and I do not think that I will ever have even a short period of being depression free before I die. My combat days in Korea was not as bad as what I face each day now. Thanks for reading. A great holiday to everyone Irwin Dresner
why not consider ECT or TMS, these do work for some
Irwin and all,
I have been dealing with major refractory depression with coexistent add and anxiety for 30 years myself. Nothing ever worked. I've taken most every SSRI, SSNI, SSNRI, Tricyclic, MAOI, etc., plus 9 rounds of bilateral ECT and voluntary inpatient treatment. You are doing the right thing by continuing to do research yourself.
Just about the time I had all but given up and was going to go on disability I stumbled upon hydrocodone, which worked quite well for me at high dosages of 25-30 mg per dose. It has a very short half-life, though, is illegal, and you will probably have difficulty finding enough to keep you going. It is also wickedly addictive, expensive to get on the street, and the inevitable tolerance and withdrawals are hell to deal with. Nonetheless, it got me back functioning for three years before my supply ran out and I had to quit.
Since I quit hydrocodone, and in the last year I have lost my business, house, cars, everything in chapter 7; lost a job I landed after losing the business, and was about to lose my second. I am 42 and have a wife and three kids to support.
I have been looking for a doctor to prescribe me Suboxone for about 3 years. It is off-label for depression, and the DEA has them scared to death, so you gotta find one who cares enough and has the balls to treat you. You may have to do a wink-wink deal.
4 weeks ago, I found such a Dr. They absolutely HAVE to have a special DEA # and training to prescribe it. Just Google suboxone doctors in your area and you'll find a list. Talk to the DOC ONLY directly, maybe even anonymously for both your protection. Work the list. You may have to agree to pretend to have an opiate addiction.
If you do find one, be prepared with every bit of research you can find, such as the 1995 Harvard study, and anything else from legitimate sources. Remember that for depression, the dosage is 2 mg or less! Don't let them give you any more than 2 mg, and I would try 1 mg first. I have had 4 weeks symptom free so far. It worked on the first dose.
It has some complications, but is the only drug that ever even TOUCHED my depression. I'm doing better than I have in many years.
Peace,
Arthur
If a patient is on buprenorphine for MDD or TRMD, what precautionary measures should be taken? I imagine that undergoing any type of surgery (planned or emergency) could present severe risks with concurrent anesthesia? Should the patient wear a MedID bracelet?
How would the patient deal with the need to take occasional or regular pain medications?
And how long do they remain on the buprenorphine? It is becoming readily apparent that discontinuation of buprenorphine is extremely unpleasant and very lengthy. Even with a very gradual tapering off and adjunct medications for symptom management. Just search online and you find countless horror stories of buprenorphine detox.
Depressed patients don't need that misery added to their lives.
Cuba Daugh's concerns were brought to my attention by the Psychiatric Times, and I was asked to respond. The dosage of burenorphine required for treating refractory depression is very low relative to the dosages conventionally used for detoxification and maintenance for primary opiate dependency. Thus the problems associated with buprenorphine use are minimized. The risk of interaction with benzodiazepines and other agents used in anesthesia is low, and does not require wearing a medic-alert bracelet, though a patient on buprenorphine should inform all of their treating physicians of all medications they are using. The effectiveness of conventional opiate medication for acute use in temporary pain relief is minimally interfered with by low-dose buprenorphine. And the difficulty of buprenorphine discontinuation when, as with any antidepressant, the period of high risk for depressive recurrence is considered to have passed, is much milder than is discontinuation from high dose buprenorphine treatment of opiate dependency, and probably comparable to the difficulties of discontinuation of many of the medicines used to treated major depression. Whether the risks associated with buprenorphine treatment add unneeded misery to the life of the a patient who suffers from otherwise treatment refractory depression depends entirely on how great the suffering has been from the depressive illness under treatment. This requires a careful risk-benefit analysis to be carried out mutually between patient and physician, and often other concerned parties, as with many of the serious treatment decisions encountered in the practice of medicine. J. Alexander Bodkin, M.D.
As a nurse in a Community Drug Team in the UK some years ago, I found Buprenorphine was an effective drug for patients requiring detoxification or maintenance treatment for opiate dependence. Today I write from Ireland, where Buprenorphine is not licensed for such treatment. I gather that objections were made to it being licensed (beyond a named patient basis) due to concerns about abuse (i.e. crushing and injecting), and diversion. This is unfortunate since Methadone is the only substitute prescribing option avilable to heroin users in Ireland, severely limiting their ability to make choices about their treatment. It is in this context that I find it bizarre and quite alarming that Buprenorphine should be considered for the treatment of depression. To introduce a synthetic opioid to patients (and therefore their communities) with no history of opiate use, with the attendant risks of dependence and overdose seems reckless in the extreme. Clearly opiates produce a subjective improvement in mood; that is why people take them. But I hope that developments in the treatment of depression advance in a different direction from this one.
THIS IS GOING TO PROVE TO BE THE BEST BREAKTHROUGH IN MODERN TIMES !!