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Thread: Opiates and MAOIs: Contradicted?

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    Opiates and MAOIs: Contradicted? 
    #1
    Ex-Bluelighter Gaian Planes's Avatar
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    Question
    Opiates (Heroin, Codeine, Vicodin, Oxy etc): It is NOT SAFE to use opiates while on a MAOI. Combining these drugs could lead to hyper or hypotensive crises, as well as respiratory complications. Avoid these drugs if you are taking a MAOI, PLEASE!
    The anti-depressant/MAOI FAQ on this site claims that opiates are contradicted with MAOIs.

    Can somebody please explain the mechanism underlying this? I tried searching on google scholar and all I came up with is that MAOIs can potentiate opiates and also another article stating that the combo could result in a hypertensive crisis.

    Thanks, to be informed is to be armed,

    samadhi
     

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    #2
    Some opiates are completely contraindicated. Demerol being a major one.
     

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    #3
    Ex-Bluelighter Gaian Planes's Avatar
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    For the sake of this discussion lets consider the alkaloids found in poppy tea.
     

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    #4
    Ex-Bluelighter Gaian Planes's Avatar
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    Can nobody answer the question about the mechanism underpinning the contradiction? I didn't think this was a complicated question, but perhaps if nobody here can answer it can I request a move to ADD?
     

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    #5
    http://www.drugdigest.org/DD/Interac...+%22Nardil%22+
    but, http://health.discovery.com/webapps/...teraction=true

    So thats up in the air, according to those websites (I never trust them anyway).


    I'll leave this thread here for a little while to see what happens, but if nothing comes up soon then I'll shift it over to ADD. You may want to reword the question for those ADDers.
     

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    #6
    Ex-Bluelighter Gaian Planes's Avatar
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    Thanks Johanneschimpo. I didn't think it would be that hard an explanation but now the more I look the more confusing/contradictory information is out there.

    I am interested specifically in MAO-A inhibition and opiates (though I think most of the MAOI that inhibit mainly MAO-a also inhibit MAO-b to a certain extent?).
     

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    #7
    Bluelighter egor's Avatar
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    This paper seems to say its the phenylpiperidines that are causing the interaction with the maoi, But I have not been able to find anything legitimate for the "natural" opiates, or the other freak salvinorin analogues that are highly potent k-opoid antaganists I believe.

    "Toxicity resulting from excessive intra-synaptic serotonin, historically referred to as serotonin syndrome, is now understood to be an intra-synaptic serotonin concentration-related phenomenon. Recent research more clearly delineates serotonin toxicity as a discreet toxidrome characterized by clonus, hyper-reflexia, hyperthermia and agitation. Serotonergic side-effects occur with serotonergic drugs, and overdoses of serotonin re-uptake inhibitors (SRIs) frequently produce marked serotonergic side-effects, and in 15% of cases, moderate serotonergic toxicity, but not to a severe degree, which produces hyperthermia and risk of death. It is only combinations of serotonergic drugs acting by different mechanisms that are capable of raising intra-synaptic serotonin to a level that is life threatening. The combination that most commonly does this is a monoamine oxidase inhibitor (MAOI) drug combined with any SRI. There are a number of lesser-known drugs that are MAOIs, such as linezolid and moclobemide; and some opioid analgesics have serotonergic activity. These properties when combined can precipitate life threatening serotonin toxicity. Possibly preventable deaths are still occurring. Knowledge of the properties of these drugs will therefore help to ensure that problems can be avoided in most clinical situations, and treated appropriately (with 5-HT(2A) antagonists for severe cases) if they occur. The phenylpiperidine series opioids, pethidine (meperidine), tramadol, methadone and dextromethorphan and propoxyphene, appear to be weak serotonin re-uptake inhibitors and have all been involved in serotonin toxicity reactions with MAOIs (including some fatalities). Morphine, codeine, oxycodone and buprenorphine are known not to be SRIs, and do not precipitate serotonin toxicity with MAOIs."



    From >
    Monoamine oxidase inhibitors, opioid analgesics and serotonin toxicity.

    Gillman PK.




    This one seems to say that morphine is safe, as long as you take potentiation into account

    "There has been a recent renewal of interest in the use of monoamine oxidase inhibitors, but the concurrent administration of narcotic analgesics is often a cause for concern. This review clarifies the different types of MAOI/narcotic interactions and offers guidelines for the use of narcotic analgesics in the presence of MAOIs. The MAOI/pethidine interaction has two distinct forms: an excitatory and a depressive form. Pethidine must never be used in the presence of MAOIs because of the risk of a fatal excitatory interaction. Morphine does not cause this excitatory interaction, and is the drug of choice provided an allowance is made for possible potentiation of the depressive narcotic effect. It is inevitable that strong analgesia will occasionally be required as an emergency measure in patients on MAOIs, and insufficient attention is paid in psychiatric textbooks to the two different types of interactions and their therapeutic implications"


    From>
    Monoamine oxidase inhibitors and narcotic analgesics. A critical review of the implications for treatment.

    Browne B, Linter S.


    I'm going to look a bit further into this, let me see what else I can dig up
    Last edited by egor; 18-04-2008 at 06:59.
     

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    #8
    Ex-Bluelighter Gaian Planes's Avatar
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    Thanks egor. OD mods can you please move this to ADD.

    I would really like help finding out if potentiating opiates with MAOIs is not toxic.

    Thanks.

    ps poppy tea + small tokes of b caapi infused with DMT = gooooooood (but STRONG).
     

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    #9
    Bluelighter egor's Avatar
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    ^I'll let you know what else I find on the subject, I'm not done looking just yet
     

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    #10
    Ex-Bluelighter Gaian Planes's Avatar
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    hmm, I dont recommend anybody combine poppy tea and MAOIs as I have been high still all day today from last night and slightly trembling.

    I think if my dose were higher I might would have had to get help as I was very out of it last night (blacking out sorta and seeing stars when I stood up).

    It was very good though when I just laid on the couch and zoned.
     

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    #11
    Bluelighter egor's Avatar
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    ^what were the doses??
     

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    #12
    I don't believe they are too dangerous, if carefully combined.

    There are always warnings of possible contra indications, if MAOI's and opiate will becombined (in pharmaca books which I know)
     

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    #13
    Ex-Bluelighter Gaian Planes's Avatar
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    Bump, OD mods can you PLEASE move this thread to ADD. Hopefully somebody could tell me the underlying mechanism there.

    Peace!

    ps egor, the dose of b caapi was small I dont remember how many grams, it was like 3-4 hits though (DMT was probably about 30mg but it was taken 10mg at a time so I never really tripped).
     

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    #14
    Apparently all opioids (classic morphinan) can cause convulsions, and are involved in seritoninic pathways as well. We're learning more and more every day. It is no coincidence of the convulsions reported from codeine. And of course, oripavine, and thebaine. The methyl ether (methoxy) grouping seems to be somewhat key.
     

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    #15
    Good point, although morphine may well be low risk the varied alkaloidal content of PST will probably introduce way to many unknow chemical variables into this equation. My gut reaction was also that PST/opium was a bad canidate for this experiement.
     

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    #16
    Bluelighter egor's Avatar
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    Still not to ADD?!?!?
     

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    #17
    Quote Originally Posted by samadhi_smiles
    Thanks egor. OD mods can you please move this to ADD.
    Whoa. Sorry, I didn't notice that before. Off it goes:


    AD============== D ~~~
     

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    Emsam+Demerol = close call at emergency room 
    #18
    Needle
    Last Saturday night I had to pay a visit to my local hospital's emergency room because of severe muscle spasm's as a result of a lower back injury.

    During the usual intake procedure, I gave the nurse a list of the medications I was currently taking. Of course I mentioned Emsam, and even stated that it was Selegeline, an MAOI.

    After describing my symptoms to the doctor, he proceeded to administer an IM injection of Demerol+Vistral to ease the muscle spasms. Needless to say, within 4 or 5 minutes I started to feel really bad - profuse cold sweat w/ dripping face and soaked t-shirt, feeling shaky & faint like the bottom was dropping out of my soul, and extreme nausea. My wife said my color was sort of a greenish-grey!

    I said to my wife, "Oh sh**, I think I now remember that Demerol is an MAOI no-no, and I'm having a reaction to it. Please go get the doctor or somebody right now!"

    After describing things to the nurse, he was rather non-chalant and said that it was probably just a normal reaction to the Demerol. I explained the MAOI issue and requested that he please get the doctor. The only thing he did was give me a "hurl bucket" at my request - he didn't offer to check my BP, pulse, or temp.

    The doctor himself was very dismissive and pretty much echoed the nurse: Demerol is a strong medication and this is probably a normal reaction. I further explained the possibilty of an MAOI interaction (as best I could, considering the condition I was in). I even said that, now that I think about it, I believe I remember seeing Demerol listed in the Emsam monograph as one of the "must avoid" drugs. I urged him to please double-check, at least to make sure that I wasn't going to die or have a stroke or something.

    After a few minutes, he returned to say that he had checked the literature and that there was no such known interaction between Demerol and Emsam!

    After about 15 minutes, the acute reaction seemed to subside & I started feeling better. At my urging, I had that the doctor take my BP & pulse. By this time, it was evidently pretty much normal. After another 5 minutes, I was told that I was fine and could go home.

    Needless to say, the next morning I checked the Emsam lit & discovered just how potentially serious the interaction could have been. On Monday morning I called my prescribing doc & explained the whole story - he was livid. According to him, the reaction could have been much more serious, or even fatal, were it not for the fact that I take the lowest possible dose of Emsam (the 6mg/24-hr patch), and that I only use 1 patch every other day. If my Selegeline level had been any higher, I might well be pushing up daisies right now!

    For me, here is perhaps the most troubling aspest of this whole incident: after I specifically urged the ER doctor to please double-check, he came back and stated that there was no such known drug interaction! That means one of several things, all of which indicate gross incompetence on his part:

    1) Either he was so dismissive and arrogant that he didn't even bother to actually look it up. Or...

    2) He did look it up and came across the interaction warning, but decided to lie to me about it to cover his a**. Or...

    3) He searched the existing literature incorrectly and never came across the necessary information.

    I have filed a complaint with the hospital itself, and I've also filed an incident report with the NY State Department of Health. Mainly, I want to make sure that the hospital changes their existing procedures so that this same type of thing doesn't happen to someone else in the future (with more dire consequences).

    As I said to the hospital rep: if things had transpired a little differently, you would be hearing from my lawyer right now - or my widow!

    best,
    JohnB

    ps: My back is feeling much better. If it doesn't kill you, Demerol is great!
     

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    #19
    @johnnyzero: My goodness!!! Interesting and frightening story indeed. My own experience with doctors (and medical students) is that the majority tends toward being arrogant assholes when some is "trying to tell them" what to do, even if it's only a nice hint... a nice hint with a very serious own interest in this case. You're really lucky man, as you said: Death was awaitening you already.

    Wishing you fast amelioration!!!

    Murphy
     

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    #20
    Ex-Bluelighter Gaian Planes's Avatar
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    Is it like a serotonin syndrome that occurs? I still am searching and can find no answer. I would like to combine opiates (morphine and diacetylmorphine) with various RCs that are known MAOIs, but feel unsafe doing it now.

    It felt like what I think serotonin syndrome sounds like (and seems close to what the above poster is describing, ugh that sounds horrible).

    I guess unless there is something substantive/confirmatory of a contradiction I will just steer clear of opiates and MAOIs (though it really could be lovely to smoke some opium or tar at the tailend of an intense trip on some MAOI psychedelic).
     

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    #21
    Quote Originally Posted by samadhi_smiles
    Is it like a serotonin syndrome that occurs?
    From what I've been able to find out, there are several different types of drug interactions that can occur with MAOI's. One is a hypertensive crisis (which I also experienced about 20 years ago when I was stupid enough to take a CoTylenol tablet along with Nardil); and the other type seems to be more of an autonomic nervous system crisis, more along the lines of what I described in my Demerol-related post above.

    As I've seen suggested on these boards and elsewhere, from now on whenever I go to a doctor and they ask me if I'm allergic to any drugs, I'm just gonna say "Yes, I'm allergic to Demerol". Even though I'm technically not "allergic" to it, at least it will get their attention and ensure that they won't give me Demerol. They seem to pay lots of attention to potential drug allergies, but, as I found out, they tend to dismiss or ignore the dangers of MAOI drug interactions.

    JohnB
     

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    #22
    Ex-Bluelighter Gaian Planes's Avatar
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    Yes, Demerol in particular seems to be contradicted. Is this something to do with demerol's Mechanism in comparison to a more simple morphine type opiate. Demerol is 'sloppier' I gather in its physiologic fx?
     

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    #23
    Here's what little I could find about the mechanism of the Demerol-MAOI interaction:

    "MAOIs retard metabolism of pethidine [Demerol], but not its demethylation; therefore excess norpethidine is formed."

    I'm no expert on this stuff, but it sounds like it results from a dangerous buildup of a pethidine (Demerol) metabolite, norpethidine. Perhaps this doesn't occur with other types of opiates. Make sense?

    JohnB
     

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    #24
    MAO will increase levels of synaptic dopamine, althoughI have not noticed any contradictions with opium based alkaloids and moclebemide except at least 50% potentiating...I would still recommend to BE CAREFUL. half both doses and know how your body responds to MAOI.
     

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    #25
    Norpethidine isn't even an opioid. I dunno anything about it.

    Johnnyzero- if ever there was a case where suing a doctor was justified, it's this case. What a fucking moron, I can't believe that any doctor would be stupid enough to actually administer pethidine AFTER he was warned!

    There's plenty of warnings about this combination, he is definitely incompetent.
     

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