Emsam, Opioids and Depression
We seem to still live in the dark ages when it comes to MAOI's and contraindications. Physicians and particularly psychiatrists, who once prescribed Parnate, Nardil and Marplan, for depression ( somewhat more effectively than modern SSRI type antidepressants), remember the days when hypertensive crises and even subsequent hemorrhagic CVAs were not uncommon, most often caused by tyramine related reasons due to aged foods, or cold medications like PPA or pseudoephedrine. However, there were somewhere around three (yes, 3) deaths which were possibly related to the concomitant use of an MAOI and meperidine (and only meperidine--no other phenylpiperidines or propionanilides {fentanyl}, and especially diphenylheptanones {methadone} were ever concluded to have a possible causative etiology, yet with all the hemorrhagic CVAs and any resulting litigation, along with the comparative efficacy of non-selective MAOIs and their widespread use, all opioids were absolutely verboten in patients receiving MAOIs.)
While non-selective MAOIs that inhibit both MAO-A (which metabolizes NE and 5-HT) and MAO-B (which metabolizes DA and PEA --phenethylamine for those of you not familiar with this less common acronym ) are not very common, especially outside of institutional settings, the selective MAO-B inhibitors like selegiline (Deprenyl capsules and Emsam patches) do not share these contraindications in standard doses ( up to 10 mgs per day po and 6 mgs per day transdermally ) are becoming a more common treatment for depression, in addition to selegiline's effectiveness as an antiparkinson medication.
My personal experience with selegiline and particularly the 6 mg Emsam patches has been truly remarkable, and I can say that this is only antidepressant that has ever completely eliminated my depression, which I had suffered from all my adult life. Occasionally, I came across an SSRI that induced temporary hypomania and seemed to work initially, but as soon as the hypomania went away, so did the drug's efficacy. The Emsam patches do not induce hypomania, but make it such that I do not need to take my morning methadone, alprazolam and Desoxsyn before I get up and shower. In other words, my state is relatively constant and I am not taking recreational drugs anymore, period (except for a very rare ketamine or DMT trip.) Even parafluorofentanyl, my previous absolute drug of choice, is not in jeopardy of being diverted from my lab (by me at least.) I have recommended Emsam to dozens of people who suffered from refractory depression and anecdotally, it is very effective in people that have anhedonic type depression with a substance abuse history (making it hard to tell your doctor.) It does not seem to work on the anxiety ridden type of depression where people just lie in bed all day long and worry and cry. I have been surprised how effective Emsam has been in substance abusers, and it is ashamed that a valid study is hard to do in people who are not in drug treatment but used controlled substances because of the ostracization factor. I am lucky to have found an amazing shrink who trusts me and believes what I tell him, because in the past, my advice was to never divulge drug use to your shrink.
My shrink and I have discussed the rest of the cocktail I am on and decided it is not a good idea to come off of them quickly or at all if I do not feel like it is necessary. I have however, decreased my methadone from 100 mgs a day to 60 mgs a day, and decreased my alprazolam from 2 mgs or more a day of Xanax to 0.5 mgs qd - 1.0 mgs bid of Niravam (an ODT --oral dissolving tablet-- version of alprazolam. Now I am prescribed 45 mgs per day of Desoxyn, but I take only 20 mgs bid. I find that the Desoxyn makes my thoughts clearer than I have ever experienced and they do not race from thought to thought constantly, so I do feel that I will be on that permanently because it is treating an ADD-like syndrome.
But, every single month, I must get Blue Cross/Blue Shield to give the pharmacist an override code each time I get my prescription for methadone filled and my prescription for Desoxyn (methamphetamine) filled because of the 6 mg Emsam patch. I am used to it now, after about a year of being on all these drugs (but oxycodone and oxymorphone do not cause a contraindication to come up on Walgreen's computer and no, I do not take these two drugs, but continue to get them because of past difficulties and my concern that if my depression came back, I would need to have easy access.) Every time there is a new pharmacist that fills the script, I often have to explain to him why a MAO-B selective MAOI should not be contraindicated, but as we continue with drug discovery, the problem of the limited capacity of human knowledge keeps arising (at physicians offices too.)
At the doses previously discussed, selegiline is almost completely selective for MAO-B, and as long as you do not suffer from hypertension, there is likely to be no problems taking Desoxyn or any amphetamine type drug with it, provided that you monitor your blood pressure daily. If you do have HTN, then you would want to make sure that the added drug does not increase either the systolic or diastolic pressure. But as far as opioids go, the contraindication warning is IMHO, nonsense. Methadone, which is a fairly strange opioid insofar as it affects NMDA and serotonin systems as well as opioidergic systems, is not going to cause any problems with a selective dose of selegiline. And meperidine in high doses has been known to cause convulsions due to a buildup of normeperidine. It has been suggested that this may be due to serotonin, but that idea IMHO is all but dead. Methadone, which has a direct agonistic effect on serotonin, has never caused a reported case pf serotonin syndrome, so it is hard for me to buy the rationale that serotonin is responsible for meperidine.
I do not remember if you said you were given prochlorperazine (Compazine), or promethazine (Phenergan), but these phenothiazine and phenothiazine-like anti-nausea medications have idiopathic side effects in far more people than meperidine. Meperidine is becoming less and less common in the US, but it is still used by older physicians that do not keep up with literature.
One of the reasons I am not on Bluelight and ADH much these days is that I am mostly focusing on my research and my writing. Recreational drug use no longer holds a place of importance in my life other than to help people who want to stop using drugs to self-medicate their depression.
MobiusDick