Hanging my nasty, maudlin, sorry, bare ass out here, once again . . .
I will be 50 years-old in January, and I've struggled with "depression" most of this time. First suicide attempt at 17; several subsequent attempts, 2 of which were nearly fatal . . . numerous hospitalizations and inpatient treatment programs . . . have probably clocked a hundred thousand hours of "suicidal ideation" over the years, including many (virtually everyday) in recent months . . . a dozen or so antidressant regimens, with and without "potentiating" drugs -- most recently,
. . . 13 sessions of
(which, on balance, made things worse) . . .
I share it here in the hopes that the "magic" of any well-wishers who happen by and ponder this post will contribute to the grace I pray for.
(Also, in hanging my bare ass out here, I imagine these inquiries might benefit someone else burdened with a similar struggle.)
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[Background: Pending an appointment next week with Dr. R (scheduled several weeks ago), I have been beating the bushes for about a month on this subject, emailing several other UNM-affiliated psychiatrists familiar with the use of buprenorphine. Unable to reach Dr. R, I kinda left him "out of the loop," and he was a tiny tad of bit miffed. However, about an hour after I emailed the Director of Inpatient Services at the hospital on this subject, Dr. R called me at home. Oh!, navigating the egos and bureaucracies of health care!]
Dear Dr. Rajesh,
At the close of our recent conversation on the phone, you asked me to refrain from addressing my questions about buprenorphine to other UNM physicians, and to confine and direct my inquiries only to you. Just for the record, when I first began these inquiries, I called the the Mental Health Center twice in an effort to get in touch with you, managing only to leave messages requesting that you call me back. Also, I was unable to find your UNM email address published on any UNM websites, or anywhere else on the internet.
Further, it seems that prescribing buprenorphine requires a special "waiver," or whatever, through the Substance Abuse & Mental Health Services Administration. I was able to identify several UNM-affliliated physicians who have this SAMHSA approval, or whatever it is. And so, I set out to see if any of them are familiar with the use of buprenorphine as a treatment for refractory depression. I was just trying to be my own "case manager" or "patient advocate" (something I haven't always been
really good at).
Please, if you felt slighted or "left out the loop" by this; if i bucked protocol or transgressed "standard operating procedure," I
sincerely apologize.
Meanwhile, I remain committed to examining
buprenorphine as an option. Beyond the mounting anecdotal testimony and clinical observations I'm uncovering, I feel bolstered by the kind comments of
your UNM colleague, Dr. Nils Rosenbaum: "You've been through a great deal, and please don't give up hope.
There's always hope. Keep trying and you may find someone to
prescribe it . . . If you can't find someone locally, look
nationally."
In a similar exchange, Harvard psychiatrist Alexander J. Bodkin, co-author of the 1995 study, "Buprenorphine Treatment of Refractory Depression (1)," was equally encouraging:
"[Buprenorphine] is a relatively harmless drug, and sometimes it
really helps depression remarkably. . . You would need to prevail upon one of the local buprenorphine prescribers to step outside of convention to try it with you."
A related study, "Treatment Augmentation With Opiates in Severe and Refractory Major Depression (2)," by another Harvard psychiatrist, Andrew L. Stoll, concludes:
"Opiates should be considered a reasonable option in carefully selected patients who are desperately ill with major depression that is refractory to standard therapies."
A more recent clinical study, "Does the antidepressive response to opiate treatment describe a subtype of depression (3)," posits:
"Possibly, the response to opiates describes a special subtype of depressive disorders e.g corresponding to a dysregulation of the endogenous opioid system and not of the monaminergic system."
The study employed dexamethasone suppression testing:"Though the dexamethasone suppression test (DST) has a sensitivity of only 40-70% in severe depression, it is one of the few neuroendocrine strategies that offers insights in the pathophysiology of depression and will help define more homogeneous subgroups from a bioclinical and therapeutic viewpoint."
and concludes:"The DST in depressed patients responding to buprenorphine yielded significantly lower cortisol levels than in non-responding patients. However, cortisol secretion and failure to suppress cortisol in response to dexamethasone have been consistently associated with severe depression."
To conclude here, I have two issues I'd like to address in our next session:
1. Toward determining whether or not "dysregulation of the endogenous opioid system" underlies my depression, is a dexamethasone suppression test in order?
2. More importantly, please help me determine whether or not I can "prevail upon one of the local buprenorphine prescribers," specifically, a UNM-affiliated psychiatrist, to consider treating my depression with buprenorphine. (Two other UNM "buprenorphine prescribers" I did not contact: Vicente Tuason and Cynthia Geppert.)
Finally, I may not "present" with obvious, life-threatening, physical trauma. My guts aren't hanging out. I have all my limbs and some hold on my basic faculties. Still, I am confronting, day by day, a critical, potentially-fatal, health crisis. Grasping for an analogy here, my soul is on fire, Dr. Rajesh. Beyond suppressing or putting this fire out (perhaps with buprenorhine), I can anticipate a serious amount of behavioral (smoking cessation, diet & excercise) and cognitive work ahead, as well, in order to tackle the entire depressive syndrome that has crippled my life.
Nod toward your eastern background, I appeal here in the spirit of Ganesha -- "The Remover of Obstacles." Though it is already implicit in our relationship, I entreat you, please, help me anyway you can.
Sincerely,
Robert L.
Sandia Park, NM
2.
Treatment Augmentation With Opiates in Severe and Refractory Major Depression 3.
Does the antidepressive response to opiate treatment describe a subtype of depression
Related:
CSAT Buprenorpine FAQ #21:"Subutex® and Suboxone® [buprenorphine 'brand names'] have received FDA approval only for the treatment of opioid addiction. However, once approved, a drug product may be prescribed by a licensed physician for any use that, based on the physician's professional opinion, is deemed to be appropriate. Neither the FDA nor the Federal government regulates the practice of medicine. Any approved product may be used by a licensed practitioner for uses other than those stated in the product label. Off-label use is not illegal, but it means that the data to support that use has not been independently reviewed by the FDA." [emphasis added]
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peace!
Edit: I see alot of format/spacing errors in this post. If you see them too, I'm sorry. I'm not going to mess with it.
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ken wilber
August 2009 
rhobherto
Access: Public
