Opioid Use Among Those with Depression

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phr

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Opioid Use Among Those with Depression
Rick Nauert
PsychCentral
11.19.09


Experts are concerned with a finding that suggests chronic pain patients with a history of depression are much more likely to receive prescriptions of opioid medications.

Opioid medication include drugs such as Vicodin, OxyContin, Percodan, and Percocet.

Researchers discovered chronic pain patients with a history of depression are three times more likely to receive a prescription for this class of drug as compared to pain patients who do not suffer from depression.

The study, published in the November-December issue of the journal General Hospital Psychiatry, analyzed the medical records of tens of thousands of patients enrolled in the Kaiser Permanente and Group Health plans between 1997 and 2005.

Together, the insurers cover about 1 percent of the U.S. population. Long-term opioid use was defined as a patient receiving a prescription for 90 days or longer.

“It’s very widespread,” said Mark Sullivan, M.D., a study co-author and professor of psychiatry at the University of Washington.

“It’s a cause for concern because depressed patients are excluded from virtually all controlled trials of opioids as a high risk group [for addiction], so the database on which clinical practice rests doesn’t include depressed patients.”

Sullivan said most clinical trials exclude people with more than one disorder, but noted the problem is more worrisome here because depression affects so many — about 10 percent to 20 percent of the population.

The connection between pain and depression is complicated. First, no one really knows how often chronic pain and depression co-occur: 46 percent of patients seeing primary care doctors for ongoing pain have a history of depression and the vast majority of those seeing pain specialists have suffered both disorders, according to the authors.

“If you study depressed people, they tend to have lot of pain complaints that are poorly responsive to a lot of things so it’s not surprising that they end up on opioids,” Sullivan said.

Being depressed might make pain hurt more. “Emotional and physical pain aren’t all that different,” Sullivan added. “The same brain zones light up [in imaging studies].”

“Depression is mediated in some significant part by the brain’s opioid receptor systems; these things run together at every level that you look at them,” said Alex DeLuca, M.D., a consultant on pain and addiction and former chief of the Smithers Addiction Research and Treatment Center. He has no affiliation with the new study.

Consequently, it is impossible to tell whether pain is causing or exacerbating depression — or vice versa. To Sullivan, the bottom line is that “it is very important that opioid treatment for chronic pain does not replace or distract from treating mental disorders. ‘Both’ works better than ‘either/or.’”

Link!
 
Consequently, it is impossible to tell whether pain is causing or exacerbating depression — or vice versa.
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... Both..

For quite a lot of people with Depression, it intensifies pain and can simply cause pain out of nowhere. Almost akin to Fibromyalgia. And a lot of people with Fibromyalgia have Depression and other conditions. Chronic pain brings about Depressive episodes.

(Low potency) Opiates have been given to me and I'm depressed and also have bouts of pain.
 
i have depression + anxiety + ADD.

a few summers ago my journey with drugs began. it started with vicodin and percocet. i started taking them about 1 a month. during the summer, i popped them 4 nights a week and had a steady schedule so i didnt get addicted. i was extremely happy by the end of that summer. i was still not addicted but i was sad to let my love, pills, out of my life.

i have found recreational drugs help my depression/anxiety way more than antidepressants or other doctor drugs. weed helps almost as much as pills, but it also gives me depression for a few hours when i wake up every once in a while.
 
Depression and pain are vitally linked indeed.

First of all, one must understand that pain is an emergent phenomenon, composed of 5 to 10 different CNS pathways all activated around the same time, by a cascade that begins with the release of chemical messengers from damaged tissue, activating small nerve fibers. One of these loops in the brain is a pathway that goes through the cingulate gyrus, which gives pain, and the stimulus we presume caused it, its aversive emotional color. All of these CNS pathways, however, can be triggered in the absence of any peripheral tissue damage, and the absence of any action potential sent up the spinothalamic tract. In fact, all of them can be triggered TOGETHER without any peripheral signal.

The CNS can actually block nociceptive signals from the spinal nerves, in a top-down fashion. That is, one can, to an extent, actually will away pain. This is something that takes practice, but is well worth it, because the more trodden those nociceptive pathways become, the easier it is to feel pain, and the more intensely it's felt. This is why parents who tell their skinned-kneed kid, "Oh, dust yourself off and get up, it's no big deal!" tend to raise kids with a higher tolerance for pain than parents who coddle their wounded kid. Depression typically involves a giving up, a relinquishing of control. It makes sense that depressed people are in no mood to resolutely rise above the aggravation of physical discomfort.

People with fibromyalgia and chronic pain syndrome, not surprisingly, are less likely than the general population to have ever harnessed this power. Their nature and nurture both have led them to giving their aches and pains free rein over their consciousness, and now they're slaves to it, because those pain pathways are just so facilitated. Even sensory stimuli that aren't painful to most of us, now feel like pain to them!

Naturally, then, such people would be drawn to drugs that do what they never trained their own endogenous chemicals to do: block the now gushing torrent of pain signals.

What they really need is ketamine or a comparable NMDA antagonist, to just push the reset button on the whole system run amok, followed by an intensive batter of cognitive behavioral therapy, perhaps with antidepressants. Once someone has chronic pain, the action potentials are a torrent, which can easily learn to flow around any dam of opiates one might put in front of it.
 
every body is a person, no matter how hard we fight it. if any of you were a MD and had a bummed out patient, your empathy would surely allow you to scribble something to cheer him or her up a bit.
 
^ Yes, but not opiates. They're a short term solution that should be used as a last resort for severe acute pain. One should not squander one's sensitivity to opiate painkillers on depression -- you want to respond well to these drugs if you ever have severe pain, like kidney stones or severe injury.

Besides, there are other treatments that have a better rate of clearing up depression than opiates, and long term, there are more effective treatments for many sources of pain too.
 
MyDoorsAreOpen said:
Depression and pain are vitally linked indeed.

First of all, one must understand that pain is an emergent phenomenon, composed of 5 to 10 different CNS pathways all activated around the same time, by a cascade that begins with the release of chemical messengers from damaged tissue, activating small nerve fibers. One of these loops in the brain is a pathway that goes through the cingulate gyrus, which gives pain, and the stimulus we presume caused it, its aversive emotional color. All of these CNS pathways, however, can be triggered in the absence of any peripheral tissue damage, and the absence of any action potential sent up the spinothalamic tract. In fact, all of them can be triggered TOGETHER without any peripheral signal.

The CNS can actually block nociceptive signals from the spinal nerves, in a top-down fashion. That is, one can, to an extent, actually will away pain. This is something that takes practice, but is well worth it, because the more trodden those nociceptive pathways become, the easier it is to feel pain, and the more intensely it's felt. This is why parents who tell their skinned-kneed kid, "Oh, dust yourself off and get up, it's no big deal!" tend to raise kids with a higher tolerance for pain than parents who coddle their wounded kid. Depression typically involves a giving up, a relinquishing of control. It makes sense that depressed people are in no mood to resolutely rise above the aggravation of physical discomfort.

People with fibromyalgia and chronic pain syndrome, not surprisingly, are less likely than the general population to have ever harnessed this power. Their nature and nurture both have led them to giving their aches and pains free rein over their consciousness, and now they're slaves to it, because those pain pathways are just so facilitated. Even sensory stimuli that aren't painful to most of us, now feel like pain to them!

Naturally, then, such people would be drawn to drugs that do what they never trained their own endogenous chemicals to do: block the now gushing torrent of pain signals.

What they really need is ketamine or a comparable NMDA antagonist, to just push the reset button on the whole system run amok, followed by an intensive batter of cognitive behavioral therapy, perhaps with antidepressants. Once someone has chronic pain, the action potentials are a torrent, which can easily learn to flow around any dam of opiates one might put in front of it.
Click to expand...

Very interesting post, what is your major or profession MDAO? In regards to ketamine being a reset button you should pm me and explain how that works neurochemically :) im curious.
 
stonerfromohio said:
Very interesting post, what is your major or profession MDAO? In regards to ketamine being a reset button you should pm me and explain how that works neurochemically :) im curious.
Click to expand...

I'm a medical student.

I won't go into great detail, not only because this is off topic, but also because there are people here on BL who are much more on top of their neuroscience than myself. But basically, neuronal pathways that fire frequently eventually get to a state where they're almost always on the brink of an action potential. I use the analogy of a well-trodden trail for this: the more it's walked, the more passable it remains over time. Ketamine blocks the NMDA receptors of sensory afferent neurons, which temporarily keeps them from depolarizing, and what's more, allows them time to repolarize to a sort of default state. Think of the NMDA receptor as a safety off-switch. As long as the patient is aggressively bombarded with lifestyle and psychosocial changes right after, one dose of ketamine therapy for treating chronic pain shows great promise.
 
^ Possibly. It's shown promise for all of the above, but only as an introductory adjunct to major lifestyle changes and therapy.

If I were to script ketamine off-label for chronic pain, depression, or addiction, it would be for only one dose, to be administered inpatient, with me or another practitioner present the entire time. I would also INSIST on intensive follow up with the appropriate therapists, physical and psychological both. I would consult my lawyer before writing such a script even once.
 
MyDoorsAreOpen said:
I'm a medical student.
As long as the patient is aggressively bombarded with lifestyle and psychosocial changes right after, one dose of ketamine therapy for treating chronic pain shows great promise.
Click to expand...

So is this just as important as the ketamine dose? Basically you reset the brain and then imprint better pathways through therapy immediately afterwords? If im understanding you right then if you dont get the imprints made after the dose then you could actually end up re-imprinting the bad pathways?
 
tathra said:
the anti-depressant effect of opioids doesnt last forever.

some people get to the point where opioids make them more depressed.
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Iddunno? if a person had a constant free suply of the best Heroin in the world, it would be hard to be depressed....... Its always the skeeming and sickness that comes along with dope that makes me depressed.
 
^ uh. i've got a buddy who did a shot of heroin and felt great for about 10 minutes, but then spent the next 8 hours suicidally depressed.

trust me, at some point, its very possible for dope to make you depressed more than anything else.
 
MyDoorsAreOpen said:
^ Yes, but not opiates. They're a short term solution that should be used as a last resort for severe acute pain. One should not squander one's sensitivity to opiate painkillers on depression -- you want to respond well to these drugs if you ever have severe pain, like kidney stones or severe injury.

Besides, there are other treatments that have a better rate of clearing up depression than opiates, and long term, there are more effective treatments for many sources of pain too.
Click to expand...

Dude If you ever get into practice I do not want to be a patient of yours, you obviously have a phobia of opiates.

Anyway I gladly traded the small tolerance for the quality of life increase offered by daily use of low dose opiates, its the difference between crying in my own filth and having a life and running a business.

And yes I tried EVERYTHING, from SSRI and every other reuptake inhibitor under the sun to dissociatives and GABA agonists and stimulants, opiates work period.
 
^ Hey, I'm just here to offer people the best advice I know for taking care of themselves. They're free to trust it and follow it if you want, and not if they don't. From a clinical perspective, there are serious drawbacks to using opiates to treat depression, making this not a long-term workable option for most patients. I wouldn't be doing my job right if I ignored this highly robust scientific finding, or failed to mention it to patients like you.

How much exercise do you get, garuda? How much were you getting at the time you first started using opiates for your depression? You don't need to answer this here with me, but these are two questions I think might be helpful to ask yourself.
 
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