My dosing theory for “scary” drugs (and a poke at the trashy values of the collective and how they affect me)

These drugs have two things in common; one is their incredible efficacy when used by rational, lucid people who want to live a full healthy life:

cocaine, amphetamine, methamphetamine, methylphenidate (narcolepsy, ADD, off-label depression)

morphine, heroin, codeine, oxy’s, opium, tramadol, buprenorphine (chronic pain, off-label depression, anxiety)

marijuana (sedation/stimulation, anxiety, pain relief, depression)

benzodiazepines, barbiturates (sedation, anxiety)

psilocybin (pain, depression)

The second thing they have in common is the difficulty getting a prescription for them because they are either illegal, or stupid people exist in the world; so instead of letting them voluntarily take themselves out of the gene pool like nature intended, the State, many moons ago, had taken upon its self the uninvited task of taking care of these dullards at the expense of my liberty and my right to procure the drug of my choice, in the name of some false “altruism” or “greater good” because maladroits get themselves into trouble with drugs (as if they wouldn’t without drugs); and somehow society would become a dangerous or less safe place otherwise, or some such nonsense.

It’s telling that, because we’re caught in this frame of nanny-statism and legalities, one of the main things drug researchers peel their eyes for, like hawks, are drugs that make us feel really good, too good, too soon. Fear of litigation is a reason we have “safe”, mediocre, usually inefficacious modern psychiatric drugs that have little value and crappy side-effects, yet are continually stuffed down the throats of trusting, half-witted souls, a few of whom actually get some benefit (bless you)… I wonder if visionary, progressive pdocs who have to dole out this junk feel any kind of guilt or frustration. I know that I would feel weary if I could not script, off-label, drugs like methamphetamine (desoxyn), laudanum (yes, it still exists in the pharm repertoire) or marijuana.

~But, I think there’s something else afoot here as well:

…”‘k, so you guys at MumsdrugCo have developed this drug that gets rid of depression. Right on; I could sure use it. Umm, can I try it? No? It makes volunteers in clinical studies too happy… so it’ll make me feel really good, and… we, don’t… want this… do we? ‘K, I guess you guys know what you’re doing… I suppose. Umm, I have to tell you though: all the antidepressants I’ve tried over the years have done nothing for me except make me feel worse. I felt better when I didn’t take them at all. I’ll tell you what did work very well, though; opium and dextroamphetamine; dextroamphetamine worked on an as-needed basis, maybe twice a week. Then I discovered that opium targeted as much of an extent what was wrong with me. Opium cycled on for a while, then cycled off for a month, then back on really does help me a lot.

“You say I shouldn’t do that? Why? I could get into trouble with it? Know something? I think you’re projecting; I think you could get into trouble with it because you would doubt yourselves in my situation. Know what else? I think, because you and the legislators who govern you don’t trust yourselves, you won’t let drugs through that could benefit so many smart people, and now we all have to suffer because of stupid people and your own self-doubt. And as usual, given the reigns of state authority, like any cop, doctor or politician, notwithstanding your fear of litigation, you feel free and qualified to impose your values upon me; and the things you value are more often than not, of little value.”

Jesus and John Galt wept.

~Certain patients who can’t take care of themselves or are not capable of thinking rationally or projecting plans for the future should follow the advice of their doctors only, and ignore the following…

…but for those of us who crave a happy productive life, “scary” drugs are, in my opinion, among the best for what ails rational people. Some get positive results from taking very small, scientific daily “lifting” doses, titrating up when necessary, then after a few months, tapering down and off for a period of time (maybe a month; maybe two); then starting again. I don’t think it’s in our interest to take any psych drug, pharm or not, continuously without cycling off (well, more serious cases like schizophrenia or bipolar might be a different story). The brain is plastic and in a state of constant homeostasis, and I think more harm than good results from a constant bombardment of exogenous chemicals… who do you want to be when you’re seventy?

…I would rather live a month or two with depression, knowing that I’m going to feel better again in a while when I resume dosing up, than take a chance that my personal chemistry hasn’t had a time of rest and a chance to get back to “normal”, as bad as “normal” might be (and who knows? maybe I’ll feel better drug-free for a while, or…?). I don’t want my neurons (at least) to be permanently twisted some day…

…so I think cycling on and off is the way to go if one doses every day. I’m in a cycling off period right now because, frankly, I think doctors are up their asses with daily scientific fixed dosing. I don’t buy into the theory that the body must take this smooth bombardment, on and on, even when the patient knows in their gut it’s time to taper off, at least for a while.

~So in one week I’ll be opiate-free, and will not take it for at least one month. I’ll keep you posted on how I feel during this time. It has not been hard to taper; I should say rather, it hasn’t been hard because I’ve had some great help from benzo’s for anxiety, trazodone to knock me for the night, and baclofen (an amazing wonder drug) for everything else; wow, this combo works well.

~Another dosing schedule is possible; if one prefers to not dose every day, dosing every three days, or twice a week can work too. It’s not “scientific”, in that the body doesn’t have a constant level of chemical within, but who can tell me that a doctor knows best what works for me if I achieve acceptable results taking a substance on an as-needed basis?… and besides, how do we know that it is not healthier to keep the body on alert and “guessing” what’s going to happen next, instead of on a predictable course of action that the body sees through, laughs at and compensates for?…

…so, when I start dosing again in about five weeks, I’m going to try this theory and let you know how it goes…

…I think we’re going to be pleasantly surprised.

~Now, if only these market products were available, unscripted, from legal vendors, would we finally be free to experiment openly and share our results with each other instead of having to skulk about on the net, like criminals. Imagine the added bonus of lower prices thanks to competition and no Organised Crime dictating cornered markets.

…oh well. I can dream for that day.

~Let me know what works for you. Feel free to talk about any drug used off-label for the last six months at least, and what your system is. I’m curious.

Separation distress and the importance of valued people

I stumbled onto two interesting authors, Jaak Panksepp and Douglas Watt…

“‘Big Pharma,’ as big business, seeks antidepressants that may become billion-dollar blockbuster drugs. Accordingly, it may neglect drugs that are off-patent (e.g., buprenorphine) as well as those that only serve a small subset of the population. Many authors (ever since Valenstein, 1998) have argued that the pharmaceutical industry may be exercising an increasingly distorting influence on prescription and treatment landscapes for the whole of medicine in the United States. This may be particularly true in relationship to depression, where many depressed patients are never referred to psychotherapy and instead are only put on first-line antidepressant drug regimens under the simplistic aegis that depression is “just a chemical imbalance.” These trends take place despite evidence that pharmacology is often only partially effective in depression (see recent STAR*D reports: Rush, 2007; Rush, Trivedi, & Fava, 2003) and despite evidence that patients suffering from trauma-related depressions do quite poorly treated alone with psychopharmacology without psychotherapy”

 Far be it from me, an academically untrained but round-eyed acolyte of the big world, to feel at all qualified to take on the authors’ implication that depression may be the result of anything but “a chemical imbalance” though an initial “trauma” may have initiated the process, and the chemical imbalance following the trauma can’t be fixed wholly pharmacologically. But I’ll state modestly that some day soon, almost every state of depression, whatever the cause, will be cured chemically sans psychotherapy…

…psychotherapy definitely has a purpose… probably always will; intelligent people understand that they have subjective limitations regarding self-awareness, and some have an interest in resolving recurring, stunting issues, or simply gaining insight for the sake of growth with the help of trained facilitators. But some day drugs will blow away our depression, regardless, with remaining only a curious interest in why we do the things we do and think what we think, for the sake of treating ourselves and others better.

~But my little declaration is not the reason for this post. Jaak Panksepp and Douglas Watt really have their stuff goin’ on, and are speaking my language. My personal theory of depression (…depression not caused by an innate anomaly) involves three roots: an unsuitable industrial diet, inappropriate exercise (not enough and chronic cardio), and stressors, including modern stressors (pollution, lifestyle etc). In this piece, the authors deal with separation stressors leading to a “protective” state of depression (do I smell the pernicious stench of dynorphin again?).

Whether or not this thesis is correct, the thing that jumps out and reminds me is the importance of keeping one’s self as engaged and socially involved as possible. Clearly (if only for the production and cultivation of calming oxytocin, which is known to sustain opioid reward in the brain), the importance of maintaining and nurturing relationships with people we value and who give us value in return can’t be overstated in a world that increasingly creates and promotes options for insularity and “aloneness”.

Equally, one must have a healthy hierarchy of values…

…if not, being depressed and alone might actually be a better situation than being depressed with people who don’t elevate us… don’t challenge us to go higher, but erode our quality of life, sense of self-esteem and our quest for happiness. In this case, until one has redeveloped a healthy sense of worth through proper diet, appropriate exercise, a low-stress lifestyle, and insight perhaps helped by psychotherapy, I think sometimes we can wait until we are in a better state to nurture rewarding relationships with quality people…

…just relax, and be good to yourself first.

Is there a case for tramadol?

Tramadol is a mild opioid analgesic with weak agonist actions at the μ receptor; it also releases serotonin and inhibits the reuptake of noradrenaline. It’s scripted for moderate pain, restless legs syndrome and fibromyalgia.

Tramadol has been prescribed for refractory depression for years, overtly in the US as a last-line drug for depression and somewhat otherwise to trusted patients by intelligent doctors in other countries. Lurking around the internet however, one finds there isn’t as much love for this drug as for its opiate cousins. Because of its unusual actions, some are fairly content to use it with a few reservations, a very few love it (maybe because they have uncommon genuine serotonin issues), and most become disillusioned with it after a time (maybe because, like so many depressives, they don’t have serotonin issues); and tolerance is kind of an issue because of potential serotonin poisoning (god, I have a hate-on for serotonin), so in my opinion long-term use is not advised…

…but, and here’s the kicker, because of lack of knowledge patients who are scripted on-label for pain get caught in a trap of dependence and withdrawal hell. The net is filled with stories like these… …be aware.

Tramadol acts as a μ-opioid receptor agonist, serotonin releasing agent, norepinephrine reuptake inhibitor, NMDA receptor antagonist, 5-HT2C receptor antagonist, (α7)5 nicotinic acetylcholine receptor antagonist, TRPV1 receptor agonist, and M1 and M3 muscarinic acetylcholine receptor antagonist. This is one hell of a mechanism of action, and the very reason I’m wary of this drug. Calling it a “mild opiate” is like calling someone the world’s tallest midget… “like, so what?” Opiate withdrawal and PAWS are bad enough; now let’s combine O withdrawal with a SNRI-type withdrawal (Effexor discontinuation syndrome, anyone?), and fun and happy-happy joy times are right around the corner (I can see the balloons, confetti and flying ribbons already). I’ve been through SNRI discontinuation syndrome, and I cannot imagine dealing with, both at once, O withdrawal and SNRI withdrawal.  If one must abruptly discontinue for any reason (there are many…) and is into this stuff up to his neck, one had better get ready to take some time off work and possibly check into a medical facility; there ain’t no staying in bed with the Thomas Recipe, benzo’s and classical guitar cd’s with this stuff.

People are more and more advocating tramadol as a possibility for refractory depression, but I wonder if they’ve done their homework or don’t take seriously the potential for pain caused by this drug. Again, I have experience with these side effects and have no problem with the thought of saying “uhh… no.” Consider too, possible seizures for some, and tramadol starts to sound like not so much fun anymore. Indeed, a growing awareness regarding seizures appears to be another of tramadol’s bad raps…

…so, if one thinks combining tramadol with most mainstream antidepressants to increase efficacy might be the ticket, I would be inclined to put that thought away; maybe I’m wrong, but possible serotonin complications make this idea hard to defend.

~If your doctor is willing to script tramadol (imo, stacked with no other ADs), and you’ve done your homework and are aware of the negatives, you might be presented with an opportunity because it’s a “mild opiate” and maybe not so stigmatised by patronising (or just simply worried about a patient) doctors; maybe it is worth trying. As long as the supply doesn’t get abruptly cut off, you don’t develop a scary tolerance and this funny little opioid works as well as other “normal” opiates for refrac-depression, maybe try it out. There is evidence that tramadol binds to kappa receptors, but no evidence of wretched κ effects; so this is a big point in its favour. Just be careful and don’t beat a dead horse if it doesn’t work the way you want it to in the long-term…

…a blog-mate recently wrote that she takes a very small dose every few days to excellent effect. Maybe this is the way to go with this stuff. Little to no tolerance is built, and the potential for bad side effects is reduced big time.

I might look more into tramadol later, if my interest is piqued; but I can’t help feeling like a bit of an opie-snob with this stuff. Because of its obscure actions, this drug may be the holy grail for someone with an obscure kind of depression, but probably not much fun for most. I just don’t know if it comes close to “real” opiates for a person with EDS/refrac-depression…

…personally, I’d try LDN before tramadol.

A strategy for EDS relief

‘K, so you took the “Do you have EDS” test, are pretty sure you need opiate therapy, have read the Recommended Posts, and are contemplating going to your doc looking for opiates. First of all, good luck with that, and if you’ve got a silver tongue and have managed to wheedle a long-term prescription, let me know; maybe you and I can go unicorn hunting some time and sell one to a zoo for some serious cash.

The only way you’ll legally get what you’re looking for, if you get it at all, is if you arm yourself with your own documented drug failure history and printed opinions from experts and primary studies from the web.

If you’re a virgin, you have to start from the start. The first thing to do is get yourself diagnosed. If you’re truly depressed the doctor will see it clearly as soon as you walk into his office and start talking. EDS sells its self, for sure.

Next, start going through the standard on-label antidepressants. Remember to give these meds a chance, and at the same time keep in mind that it can take months for meds to cease working, or adverse effects to develop, after a time of efficacy. But if you find a med that actually does the job, thank your particular magical sky fairy for your good fortune and get on with life. You probably don’t have EDS… …otherwise, other tactics must be employed.

Take the meds your doctor prescribes. Start keeping detailed records of types and efficacy. Make sure that they are clear and lucid, because if these drugs don’t work, you want to be taken seriously when eventually asking to go off-label for opiates. Sertraline (Zoloft) and fluoxetine (Prozac) are standard SSRIs and will probably be scripted first; so if the doc scripts these, try one or both. If they don’t work, go on to one or two SNRIs. Venlafaxine (Effexor) is standard and will probably be the first of these. Effexor has a unique profile in that it has somewhat of an opioid profile, though what that really means for us, I have no idea. Effexor has also some hellish side effects and withdrawal symptoms; I had a particularly nasty time with this drug (though I won’t go into my bad experience with the carnival ride of ADs. I don’t want to bias your perspective).

Bupropion (Wellbutrin), an NDRI, might be the next choice, then maybe something different like trazodone and on and on. Try to get through quite a few different types, and include some old-school ADs like the tricyclics and MAOIs. If these don’t work, perhaps suggest going off-label and trying something like lamotrigine or amphetamine. Again, if something works for you, breathe a sigh of relief and get on with the business of living. If not, at least you’ve kept meticulous records, eliminated possibilities and narrowed down your options and diagnoses… you can now make some choices and think about opiate therapy.

I recommend going to a doctor who will read your research and drug history and listen with interest and sincerity. You should be able to get a good read on his attitude right from the start; and if he isn’t into it or is an opiate dumdum, maybe tactfully ask him to refer you to someone less timid, or find someone yourself.

In my opinion, the first opiate used should be buprenorphine. It is a legal opiate with an interesting profile of action used in withdrawal therapy and is becoming relatively popular as an off-label antidepressant… if you can find a willing doc. Also, despite my reservations, low dose naltrexone (LDN) seems to be having a good effect on some depressives, though I wonder how much of this is placebo. Nevertheless, if bupe doesn’t do it or you can’t find a doc to prescribe, it can’t hurt to try it, and who knows? it might just be the ticket.

However, if everything has been done under the sun and you haven’t found relief, you might have to look for shade under the big guns. This is where the full agonist opiates/opioids come in, and where the adventure, for better or worse, begins. There are a few ways to procure opiates; some legal, some not so much, but one can with some effort find them (my blog gives some ideas). There doesn’t seem to be much difference in efficacy between opiates, though codeine doesn’t like me too much. As well, I have made it clear in this blog that when dosing, the object is to achieve relief without a shred of the nod(!). Again, if one goes into nod territory, one goes into drug abuse territory and the whole raison de plus gets shot to hell…

…don’t do this…

…just don’t.

I refuse to acquire a guilt trip because my good intentions get ignored and someone’s life goes down the tubes.

So just don’t do it. Don’t turn a potential gift into a curse.

~There is one fairly sure way to get what you’re looking for without riding the med-go-round; if you’re already addicted (and really, how many opiate abusers aren’t simply self-medicating depressives?) and don’t have the will to stay out of the nod, you can go into methadone or bupe therapy. This will help you get back on track and focus on life because you don’t have to worry about scoring and fixing, your jones is satisfied without the obsessive distraction of euphoria, and both bupe and ‘done have a fantastic anecdotal efficacy for depression; in fact, if going into ‘done therapy wasn’t such a pain in the ass, it would be my first choice above bupe, despite its troublesome half-life. And if you’re not addicted, you have to be pretty desperate for answers to try this approach and lie; but, well, who am I to judge; no one should be dictating what drugs an adult can take anyway… bloody patronising…

…which brings me to the downside of this approach. Titrating off these drugs can be more painful than heroin(!), and odds are, this therapy will become part of your medical records (which might create a different perception than scripting opiates simply for depression); also, methadone therapy requires a daily trip to the clinic which inconveniently cuts into one’s day.

Whatever you do, study and read, read and study, weigh the pros and cons and be honest with your motives. If you make your life your highest value, the choices you make should keep you on the right track.

Good luck to you…