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Dr. Bob is Robert Hsiung, MD,
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Posted by ed_uk on November 21, 2005, at 15:41:10
In reply to nausea / constipation....NOT! :-) » ed_uk, posted by pseudoname on November 20, 2005, at 15:47:48
Hi PN,
>Taking a smaller dose of bupe (just 0.1mg) has helped a lot.
:-)
>My target dose is........
........whatever dose provides the best balance between efficacy and side effects for YOU! :-)
>Elizabeth had enduring problems with it that way, so I guess that worried me. But on the reduced dose (circa 0.1 mg), so far no problem. In fact I think I'll hold off on buying the Reglan unless I actually develop constipation.
I wouldn't recommend taking Reglan to treat constipation - it's unlikely to be effective and it generally causes more side effects than laxatives.
>I'm shocked. Bad experience with Haldol, so I think I'll pass, LOL.
What dose did you take? How did you find it? Haldol tends to be very unpleasant at high doses but tolerable at small doses - at least in the short term. Haldol is very similar to Compazine - a widely prescribed antiemetic and neuroleptic. Low doses are used to treat nausea/vomiting.
Kind regards
Ed
Posted by pseudoname on November 21, 2005, at 16:02:00
In reply to Re: nausea / constipation....NOT! :-) » pseudoname, posted by ed_uk on November 21, 2005, at 15:41:10
>> Bad experience with Haldol...
> What dose did you take?Don't remember the dose, but many moons ago, I was trying Haldol to treat depression (this was before atypical antipsychotics, I think). On the 2nd or 3rd day, I suddenly got very confused and set about knocking holes in the wall with my head. For several years we covered the biggest one up with a picture of Durham Cathedral.
The dose was probably increased too quickly. But I'm now permanently Haldol-averse.
Posted by ed_uk on November 21, 2005, at 16:52:26
In reply to Haldol aversion » ed_uk, posted by pseudoname on November 21, 2005, at 16:02:00
Hi PN
>On the 2nd or 3rd day, I suddenly got very confused and set about knocking holes in the wall with my head. For several years we covered the biggest one up with a picture of Durham Cathedral. The dose was probably increased too quickly. But I'm now permanently Haldol-averse.
Were you extremely restless? Couldn't stay still, had to keep moving? It could have been akathisia. The dose was probably much too high.
Haldol, Compazine and Reglan are all dopamine antagonists. Given your bad reaction to Haldol, I wouldn't recommend any of them!
Kind regards
Ed
Posted by pseudoname on November 23, 2005, at 19:43:41
In reply to Re: buprenorphine trial !, posted by Peter S. on November 17, 2005, at 1:22:04
This was my fifth day on buprenorphine (Subutex).
Day 1: 0.1mg
Day 2: 0.1
Day 3: 0.2
Day 4: 0.4
Day 5: 0.6Today I took about 0.2mg at 6 AM, noon, & 4 PM. (See http://www.dr-bob.org/babble/subs/20051106/msgs/580668.html for my dosing technique.)
The nausea is gone. Dizziness is slight, but I'm not driving. Very slight increase in itchiness (or is that my imagination?). I nod off a little late in afternoon. No insomnia last night – quite the reverse.
As far as depression goes, I can tentatively say that bupe seems to be somewhat uplifting, I think. A few hard-to-describe cognitive/emotional areas seem noticeably improved, but it's WAY too early to say anything for sure. Except I can say for sure that I have NOT experienced "euphoria;" even caffeine gives a better buzz.
Posted by ed_uk on November 24, 2005, at 13:44:35
In reply to Update: bupe Day 5, posted by pseudoname on November 23, 2005, at 19:43:41
Hi PN :-)
>The nausea is gone.
Excellent, I didn't think it would be a problem with slow titration.
So how is bupe affecting your sleep?
Are you finding it constipating?
>As far as depression goes, I can tentatively say that bupe seems to be somewhat uplifting, I think.
:-)
>A few hard-to-describe cognitive/emotional areas seem noticeably improved, but it's WAY too early to say anything for sure.
I agree. I'm hopeful :-)
Kind regards
Ed
Posted by pseudoname on November 27, 2005, at 17:36:57
In reply to Re: buprenorphine trial !, posted by Peter S. on November 17, 2005, at 1:22:04
At this point, I have no buprenorphine benefits to report.
Day 6: 0.6 mg total, in divided doses
Day 7: 0.6
Day 8: 1.0
Day 9: 1.0
Day 10: 1.4On Day 6 in the evening, my diary says "I feel unusually good," and situations seemed manageable that would typically freak me out. But on Day 7 (Thanksgiving) & later, I was depressed & stressed as usual, and despite dose increases I now see no cognitive or mood benefit at all.
In all journal & Web reports of bupe-for-depression, it works quickly (0-3 days) if it works at all. Callaway said "most patients experience benefits of an adequate dose within three hours" !! So "an adequate dose" is the real question. The thing is, most of the responders got at least *some* benefit with lower doses than I'm already taking even if they needed higher doses for complete benefit. So I'm not hopeful. But I'll go to 3 mg/day for 3 days before giving up.
When I first take an increased dose and feel slightly dizzy, I also have some minor happy-feelings. But I'm disregarding those as non-therapeutic and part of the dizziness; they're like the brief mood-lift alcohol initially gives me. If they persisted that'd be great, but they don't even last as long as the dizziness.
Side effects: headaches come & go; mild itchiness; splotchy rash on my face. Constipation may be a problem. I haven't had to poop since yesterday morning, when it was pretty hard.
Posted by Declan on November 27, 2005, at 20:08:48
In reply to discouraged—bupe DAY 10, posted by pseudoname on November 27, 2005, at 17:36:57
Hi there
Why do you take bupe in divided doses throughout the day? Being a long acting drug, might a once a day doseage give you a small nice feeling? (That's what happens on methadone.) But maybe you want more out of it than a small nice feeling for 2 hours a day.
Or would you be glad to have even that?
Declan
Posted by pseudoname on November 28, 2005, at 9:50:51
In reply to Re: discouraged—bupe DAY 10, posted by Declan on November 27, 2005, at 20:08:48
Hey, Declan.
> Why do you take bupe in divided doses throughout the day?
This is a good question. My only reason was that other people said they did. Elizabeth took it 3 times a day. (And she had to lie on the floor and drip it into her nose.) A few others in the archives also. And the only 2 papers on bupe-for-depression used divided doses. Supposedly for addiction, bupe's effect is long-lasting; as an antidepressant, it wears off within 6 hours. I hadn't questioned it.
But this morning I took 1.8 mg, my highest dose yet, and I took it all at once. (Actually, I divided it over 2 hours just to make sure I wouldn't puke.) It kicked in. I had forgotten what bupe's relief felt like last week when I first went up to 0.6 mg.
But will it last??
> ...a small nice feeling for 2 hours a day. Or would you be glad to have even that?
I'll take what I can get, even 2 hours – if they could be reliable. This morning I've had 4 hours so far. I've decided that when it starts to wear off, I'll hit it again with about 0.5 mg and hope that my problem isn't rapid tolerance but just that I need a high dose. No one else has reported needing to take so much to get a response so soon after beginning with buprenorphine. I mean no one who was opioid-naive when starting treatment: former users go way higher (16 mg).
There's just not enough published experience with it. Maybe the fact that bupe only worked with about 50% of TRD people in those studies is that they didn't try enough right away.
You gotta do what you gotta do.
Posted by ed_uk on November 28, 2005, at 13:14:32
In reply to divided doses » Declan, posted by pseudoname on November 28, 2005, at 9:50:51
Hi PN
>You gotta do what you gotta do.
Keep experimenting PN. There aren't any guidelines on what dose is likely to be appropriate for the treatment of depression.
>This morning I've had 4 hours so far.
How long did it last?
Have you tried any other opioids btw?
Ed
Posted by ed_uk on November 28, 2005, at 16:20:44
In reply to discouraged—bupe DAY 10, posted by pseudoname on November 27, 2005, at 17:36:57
Hi PN :-)
>On Day 6 in the evening, my diary says "I feel unusually good," and situations seemed manageable that would typically freak me out. But on Day 7 (Thanksgiving) & later, I was depressed & stressed as usual, and despite dose increases I now see no cognitive or mood benefit at all.
Tolerance? Perhaps. I'm hoping that you'll reach a dose where the benefit is maintained :-)
>Constipation may be a problem. I haven't had to poop since yesterday morning, when it was pretty hard.
Hard stools = time for a dose of MiraLax? Probably. If left untreated, opioid-induced constipation may necessitate the use of suppositories and enemas.
Warm regards
Ed
Posted by pseudoname on November 29, 2005, at 14:58:31
In reply to divided doses » Declan, posted by pseudoname on November 28, 2005, at 9:50:51
In many ways a complete failure in an antidepressant trial is easier to take than benefit-followed-by-loss-of-benefit. The "Flowers for Algernon" thing.
Day 11 was 1.8 mg AM; it brought a remarkable level of relief from depression. When it started to wear off later in the day, another 0.5 mg brought flat-out REMISSION.
Day 12 (today), I had to go to 2 mg before my acidic thoughts even receded. Not a lot of benefit. This afternoon I took *another* 0.5 mg trying to get the relief I had yesterday but.....
[…later…]
When I started to compose this post an hour ago, things were not good. But I guess that last 0.5 mg kicked in a few minutes ago – about 1 hr 40 min after I took it. I've noticed this with me & bupe: it takes almost 2 hours for a dose to affect me (except for dizziness, which comes on fast).So all my bitter resentful paragraphs get crumpled & tossed. And now, since I'm feeling that it's possible, I have to go outside & get a little work done before it gets dark! I'll comment more tonight.
THANKS to everyone for your ongoing interest & support. I'll reply to your specific posts tonight.
Posted by pseudoname on November 29, 2005, at 22:24:12
In reply to Re: buprenorphine trial !, posted by Peter S. on November 17, 2005, at 1:22:04
Ed asked,
> Hard stools = time for a dose of MiraLax?My pdoc agreed with you, Ed. So far no action. I also added milk of magnesia, and I already eat a high-fiber diet.
> Have you tried any other opioids btw?
I was given morphine injection once for an injury. I felt momentarily (t<3 sec) buzzy, similar to my initial effect from alcohol, but it went away quickly and wasn't a feeling I'd seek out to repeat. But it was *some* psychoactive response however slight...
¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯
Saw my pdoc today, who refused to set an upper limit on my buprenorphine dose. She said there is no basis. I told her the GP I saw for my physical last week had no problem with me taking an opioid for depression. Pdoc said, "Well, no; it's no skin off his nose if you sue ME."
I gave her printouts of Ed's, Larry's & Marsha's advice. She said she was now considering another TRD patient who'd tried everything; I told her to START WITH A #%*$@ing LOWER DOSE.Today (even before I saw pdoc) I was discouraged again about my bupe response. After what amounted to FULL REMISSION yesterday (if "remission" can last just 8 hours), this morning's 40% lift on the same dose seemed like failure. Of course, two weeks ago I would've killed for 40% improvement!
So then I increased today's total to 2.5 mg – and went over the Significant Crest. That's a definite point below/before which moods go up & down, variously better & worse – but everything is ALWAYS saturated with depression, and rancid, fiendish thoughts are always at least touching my consciousness. After the Significant Crest (which I've now gone over twice), things are just things, not tinted by anything, and the rancid thoughts completely VANISHED. I was free! When over the Significant Crest my moods have been neutral, fine, quiet, or pleasant and happy, but not joyous or even enthusiastic. I enjoy the other people I meet without needing their approval or imagining their thoughts about me. No euphoria, hypomania, or extra energy. This neutral peaceful freedom is worth constipation, if that's what it takes. It is worth a COLOSTOMY, compared to my everyday life for the last 22 years.
I assume there are others who are/will be reading this thread to weigh bupe for themselves. I guess that's one advantage for me in trying something hard-to-get: a fantasy of civic duty to TRDs everywhere will keep me on track to doing the trial fully, despite setbacks and tolerance.
Posted by ed_uk on November 30, 2005, at 15:18:28
In reply to the Significant Crest, posted by pseudoname on November 29, 2005, at 22:24:12
Hi PN
>My pdoc agreed with you, Ed. So far no action. I also added milk of magnesia, and I already eat a high-fiber diet.
Milk of magnesia is fine for short-term use but isn't the best laxative to use on long-term basis. Magnesium intoxication and other electrolyte imbalances might occur. Other laxatives are available which are safer in the long term.
>Saw my pdoc today, who refused to set an upper limit on my buprenorphine dose. She said there is no basis.
In the UK, the maximum approved dose for the treatment of opioid dependence is 32mg/day. 16mg/day is a fairly 'standard' maintenance dose - but many people take less.
>This neutral peaceful freedom is worth constipation, if that's what it takes. It is worth a COLOSTOMY, compared to my everyday life for the last 22 years.
LOL, you certainly won't be needing a colostomy ;-) How is the milk of magnesia working?
>I assume there are others who are/will be reading this thread to weigh bupe for themselves. I guess that's one advantage for me in trying something hard-to-get: a fantasy of civic duty to TRDs everywhere will keep me on track to doing the trial fully, despite setbacks and tolerance.
Think of yourself as a pioneer.
Kind regards
Ed
Posted by pseudoname on December 3, 2005, at 20:46:34
In reply to Re: the Significant Crest » pseudoname, posted by ed_uk on November 30, 2005, at 15:18:28
I've been on buprenorphine for depression for 2½ weeks. I'm now at 2-3 mg/day, which is WORKING(!) and tolerable but not scot-free. I'm cautiously optimistic.
I took a drug holiday Thursday for various reasons, but mostly so that I could POOP. It was an ordeal. For the constipation, I'm doing Miralax, milk of magnesia (only 1 week, I know), lots of water, a high-fiber diet... Wax suppositories don't quite seem to reach the problem, but I stocked up on 'em just in case. I haven't pooped again in the last 48 hours.
MOOD & COGNITION:
Buprenorphine helps me a lot. It varies unpredictably from about 40% to 100% relief, but I hope I will recognize what level I'm getting as each day goes on and maybe figure out how to optimize that degree of relief to improve my life that day. That's I can't have 90+% every day!It only works for 4-10 hourse at a time. It's still quite possible that tolerance to the good effect will set in, and bupe will poop out.
But this week I have seen what my thoughts are like without the depressive poison I've lived with for over 20 years. During one period of bupe's 100% effectiveness, for example, I spoke with a neighbor, and for once I wasn't imagining what she thought about me. I just talked to her. I enjoyed her company, but I didn't need for her to like me.
I can't convey how huge this difference is for me. Typically, 80% of my brain would be overheating with relentless, panicky ruminations in that situation and for 3 years after it. This time, they were just..... not there.
Also on bupe, when I thought about my childhood or my parents, I instantly realized things that I'd never noticed before. Despite years of psychoanalysis and obsessive psychologizing, I had never realized, for example, "I have a problem with my mother."
I'd actually done everything I could to step around this observation. If pressed in just the right way, after another 20 years I might've admitted that I was avoiding some issues there. But the other day, on bupe, it was as plain as day. I saw how that problem's framework goes through my whole adult history. I simply saw it instantly, without fear or sweating. Without evasion.
This was not recovered memory, catharsis, buried emotions, or "working through." It was buprenorphine. I was amazed.
Bupe is, for me, FOR NOW, a magic pill.
Posted by ed_uk on December 5, 2005, at 16:26:07
In reply to buprenorphine: Week 3, posted by pseudoname on December 3, 2005, at 20:46:34
Hi PN :-)
I'm so pleased to hear that bupe is helping! Please continue to post how you're doing :-)
>For the constipation, I'm doing Miralax, milk of magnesia (only 1 week, I know), lots of water, a high-fiber diet...
If you're on MiraLax, adding Milk of Magnesia probably isn't necessary. MiraLax and Milk of Magnesia are both osmotic laxatives: they work in the same way. Opioid-induced constipation usually requires a 'stimulant' laxative such as standardised senna extract, sodium picosulfate or bisacodyl. Don't be afraid of 'stimulant' laxatives. Despite the bad press they've received, few people run into problems with them. MiraLax + a stimulant laxative is an excellent combination.
Warm regards
Ed
Posted by pseudoname on December 5, 2005, at 17:09:46
In reply to Re: buprenorphine: Week 3 » pseudoname, posted by ed_uk on December 5, 2005, at 16:26:07
> MiraLax and Milk of Magnesia are both osmotic laxatives: they work in the same way.
I had wondered about that. I've actually now discontinued the MoM since I finally pooped 4 times yesterday and 4 times today. (YES, you all needed to know that!! LOL!!)
No need for the stimulants at this point.
Questions: When do you think I should try going without the Miralax? And when I do, should I taper down, using it every other day or using half as much, etc?
Thanks for your support of my opioid trial. As I get more experience, I'll post more about it. When I went skipped bupe for a day last week (my drug holiday), depression & ALL the old demons had returned by the 36-hour point.
Ed: I hope you're doing well!
Posted by ed_uk on December 6, 2005, at 14:03:38
In reply to laxatives, opioids » ed_uk, posted by pseudoname on December 5, 2005, at 17:09:46
Hi PN
>When do you think I should try going without the Miralax?
In all honesty.......... never! Tolerance to the constipating effect of opioids doesn't usually develop.
>.........should I taper down, using it every other day or using half as much, etc?
Aim for a dose of MiraLax which allows you to painlessly pass soft stools on a regular (!) basis ie. similar to your usual frequency in the unmedicated state.
>Ed: I hope you're doing well!
Not bad thank you :-) .......but I've got a mild virus :-(
Warm regards
Ed
Posted by pseudoname on December 6, 2005, at 16:23:15
In reply to Re: laxatives, opioids » pseudoname, posted by ed_uk on December 6, 2005, at 14:03:38
>> When do you think I should try going without the Miralax?
> In all honesty.......... never! Tolerance to the constipating effect of opioids doesn't usually develop.Thank you, Ed; this is good to know. I think Elizabeth was still complaining about this problem after more than a year.
I'll get my Miralax by the case, then. ;-)
Posted by bigcat on December 8, 2005, at 19:24:11
In reply to Re: laxatives, opioids » ed_uk, posted by pseudoname on December 6, 2005, at 16:23:15
Magnesium Citrate works wonders for me. Dulcolax, suppositories, and stool softeners don't help. A bottle of magnesium citrate (2$) gets the job done within hours.
Posted by pseudoname on December 8, 2005, at 20:24:09
In reply to MAGNESIUM CITRATE FOR CONSTIPATION » pseudoname, posted by bigcat on December 8, 2005, at 19:24:11
> Magnesium Citrate works wonders for me
Hey, thanks, Matt. At $2 a bottle (!) it's certainly worth a try. "Within hours"...! :o My Miralax seems to have paused a little at the moment. I should be able to get some mag cit tomorrow (and I'll have the afternoon free...).
Have you talked yet to your doc about buprenorphin? Or are you waiting to see if I crash to smithereens, LOL! It is consistently working for me on mood 40-90% (or better). This is from 0-15% on anything else. It is especially helping with thinking about certain "scary" thoughts: I can think about them now. It's worth it to me for that alone, constipation or not.
Take care.
Posted by bigcat on December 10, 2005, at 21:09:40
In reply to Thank you! » bigcat, posted by pseudoname on December 8, 2005, at 20:24:09
Hey There Psuedoname-
Your buprenorphine trial sounds like it is going very well, and I hope with time you will gain the confidence that it will continue to bring you relief. I was so pleased with what I read earlier, about you talking with your neighbor "like it was no big deal" and that it seemed very natural. It's amazing when something starts working how little things are no longer such monumental stresses. I particularly related to how you described your "usual" experience in such situations, replaying the encounter and obsessing about what she may be thinking of you for weeks afterwards.I also liked how you said that you could "rise above" your thought patterns and acknowledge truths, even hurtful truths, that you were blocked from adressing earlier. This is sometimes painful, but also very liberating, as truly "feeling" pain is an indication that your emotions are returning. And accepting, without attaching, to this pain is a sure sign of progress. This change in perspective indicates that your reality has changed. I am very happy for you and commend your relentless determination to find something that will make you better.
I started the Effexor recently and while I'm currently immersed in the depression, I have had a brief taste of remission upon starting the med, so I'm sticking with it for now. But stories like your Bupe trial are encouraging, reminding me that there are always still options available.
I see people like you and me as fighters, not labrats (I'd try the bupe in second, and wouldn't wait to see how your trial turned out before diving in). There is so much misinformation out there that hinders psychopharmacology, and the "whatever it takes" philosophy is one that we have both dedicated our lives to.
I swear by the Magnesium Citrate. It is the one constant I can rely on the alleviate what amounts to the most acute side effect I get from AD's. Hope it treats you equally as well.
-matt-
Posted by pseudoname on December 10, 2005, at 21:54:05
In reply to Re: Thank you! » pseudoname, posted by bigcat on December 10, 2005, at 21:09:40
Posted by ed_uk on December 14, 2005, at 16:19:17
In reply to What a great post to read. Thanks (nm) » bigcat, posted by pseudoname on December 10, 2005, at 21:54:05
Hi PN!
Hope things are going well :-)
How is your mood? What dose are you taking right now?
And I have to ask.......
How's the constipation and which laxatives/doses are you taking?!
Ed
Posted by pseudoname on December 15, 2005, at 13:39:23
In reply to Re: What a great post to read. Thanks » pseudoname, posted by ed_uk on December 14, 2005, at 16:19:17
> How is your mood? What dose are you taking right now?
My mood – on buprenorphine – is pretty good. I'd say bupe gives me 40-95% mood improvement every day. But another key benefit for my particular problem: when I accomplish something good in the course of a day, ON BUPE I don't freak out about it later. It's hard to explain, but bupe keeps that bizarre post-success panic away. Not even benzos did that for me.
That is what I've wanted for 10+ years.
I take 2 mg Subutex tablet early in the morning and about 1 mg about 1:00 PM. (Oh! Be right back.....) It takes 1-2 hours to get any mood/thought benefit. The first dose wears off after 4-8 hours, but the second dose can last into the night.
I've taken a few drug holidays (36-48 hrs without bupe), and the worst foul thoughts come back toward the end. Off bupe, I'm always semi-suicidal. The only physiological withdrawal symptom I've had so far is headache.
> How's the constipation and which laxatives/doses are you taking?!
LOL. My drug holidays were mostly for pooping, but constipation is a little less recently.
I bought the stimulant Dulcolax® (bisacodyl) at your encouragement and magnesium citrate (at Matt's suggestion). So far I haven't had to open either one. I also stocked up on wax suppositories, which aren't much help.I'm still taking 17g of Miralax every day. I haven't taken milk of magnesia in 2 weeks or so.
OTHER SIDE EFFECTS: My mental ability is better now. I can read books, which I couldn't do at first on bupe at all.
Two different times off bupe, I had absent-minded cognitive problems. I did little things on the computer that I never realized at all! A couple weird things like that. Definitely worth noting.
I still have no real drive or interests. Until a couple years ago, I had dreams & plans even when I was very depressed. Maybe I'm just getting old. Maybe another AD or some other drug on top of the bupe might work now? Maybe if I keep working, exposing myself to rewarding situations, etc, I'll start coming alive again.
Thanks for asking. Peace to you, Ed.
Posted by ed_uk on December 17, 2005, at 14:15:04
In reply to buprenorphine ongoing » ed_uk, posted by pseudoname on December 15, 2005, at 13:39:23
Hi PN :-)
Sorry for the delay in responding - my new internet connection is currently very tempremental, I'm not sure what's wrong. Most days I can't log on to the internet at all.
>It's hard to explain, but bupe keeps that bizarre post-success panic away.
Do you worry about the possibility of 'poop out'?
>I take 2 mg Subutex tablet early in the morning and about 1 mg about 1:00 PM. (Oh! Be right back.....) It takes 1-2 hours to get any mood/thought benefit. The first dose wears off after 4-8 hours, but the second dose can last into the night.
Perhaps you could get a more consistent effect by taking it in three divided doses - which is often necessary when it's used as an analgesic. What do you think? You could take 2mg when you wake up in the morning, 0.5mg four hours later and another 0.5mg after a further four hours.
>magnesium citrate
Mag citrate is an osmotic laxative - it works in the same way as MiraLax, you won't need to combine them. MiraLax is probably a bit safer than mag citrate though, which is why I recommended it.
Bisacodyl will be useful if your constipation worsens and an increased dose of MiraLax doesn't help.
>I'm still taking 17g of Miralax every day.
It is adequate at this dose? Any side effects?
>I still have no real drive or interests.
Ever tried nortriptyline?
>Maybe if I keep working, exposing myself to rewarding situations, etc, I'll start coming alive again.
I do believe you will :-)
Love
Ed
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