Opioids and Depression

The following is from the LIST serve TPPCD (The Project on Pain and Chemical Dependency)

On Mon, Aug 3, 2009 at 1:28 PM, wrote:

a separate musing thread

recently-I have been seeing sales reps trying to get me to use various psych meds for resistant depression. I hear the same thing- 1/3 get total relief of depression and up to 50% get total relief with a combo of drugs. That leaves 50% of patient with little or partial relief of depression with traditional therapies. Why is that??

The simple answer is that traditional therapies do not treat the neuro-physiologic abnormalities in these patients.

Now , I know we dont have a good grasp on the etiologies of most affective disorders but the effectiveness and mechanisms of traditional therapies have led to a belief that imbalances in seratonin, norepinephrine and/or dopamine are some how contributory. All the patients have a "chemical imbalance"

So can we conclude that in the 50% poorly treated that the "chemical imbalance" occurs in an area separate from these neurotransmitters??

15 years ago a study was published looking at a small number of resistant depressives with no history of opiate abuse. They were given buprenorphine with a significant reduction in symptoms. Could an endogenous endorphin deficiency have been at play here??? If so, how frequent does it occur in clinical practice??

I think that attempting to treat patients for depression with opiates is scary because of the stigma and risk for physical dependency. . And it should be a lesser used treatment. I wonder if that is why no one ever thought of doing the experiment. However, with buprenorphine we have a safer alternative- should it be looked at.???

Stu
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The history of psychiatry reveals that prior to the age of anti-depressant medications, the treatment of choice for depression was opiates!!

Intractable pain patients suffer depression far more frequently than the general population. Clearly this has to be related to the consequences of being disabled, but depletion of endogenous opioid substances must be a major factor.

Opiate addiction is another major clue to the connection of endogenous opioids to addiction. Of the hundreds of heroin addicts with whom I have worked over the decades, parenteral opiates were obviously self-treatment for major depression. All required an anti-depressant as a component of their treatment. Also, the efficacy of methadone suggested the role of opioids and pleasure (the opposite of depression.)

The demonization of opioids is a fascinating historical oddity. I see it as exactly analogous to the history of racism. Recall the Roman Empire. Recall Shakespeare and Othello. Black skin was not always associated with negative prejudices.

It has taken a century to make a dent in melanophobia. Probably it will require the same for opioids. Buprenorphine? Seems like a rational inquiry to me.
JSH