Fascinating pt/conundrum

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Psychodocshound

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Hey gang
I'm a chief psych res closing in on the final months of residency, and soon will be on my own with all the autonomy and associated responsibility that comes with leaving the nest.

With that in mind, I'd like to discuss a pt I encountered several months ago as a resident, as the details of his sad, but fascinating case, have left me in a bit of a tailspin as I've begun to question tenets of medicine that I thought were firmly established in my mind, and not subject to question.

I will call the pt "T" and his hx is far too long and complex for a thorough recap here, but I do want to discuss the few salient aspects that have left me on unfirm ground, just as I'm set to strike out on my own in private practice.

In short, T is an addict, specifically opioids. He is 40, extremely bright and charming, and had no hx of substance abuse at all until 10 years ago. T claims, and has compelling documentation, that since his teenage years he has sought medical help in nearly every specialty, to address a debilitating and constant depression that he's suffered with since teenage years. His depression made him completely disinterested in doing literally anything. His anhedonia was off the charts. He found no joy in anything, and wished for nothing in life, as he couldn't even conjure hypothetical scenarios which would bring him any joy. His thorough medical records support all of this.

Then....at age 30 T had a minor injury and was prescribed Percocet for the first time, and it was life changing for him. He describes it as "the first time I felt human since 17. I felt like i did before I got sick. I was hopeful,and I cried for an hour because it's something I thought I'd never feel again".

I know, I know....of course he felt like that, big boy was high-and that was my initial impression. T found a pain doc w very loose prescribing practices, so In short, T has been getting opioids legally through this doc for a decade, and freely admits that while he does suffer some physical pain, he takes the pain meds as a means to treat his depression. So T is not drug seeking from me, he's already getting more than he needs, but what he wants to know is why is he forced to exaggerate his physical pain to get the meds that help his debilitating depression. Why can't he just be honest about his symptom, and the relief he receives from this class of meds where all other Tx has failed (staggering assortment of SSRI's, And other antidepressants tried over the decades, ECT, therapy, even ketamine infusions..no benefit anywhere).

At first blush it's easy to counter that while these opioids may seem to help his depression, they are addictive, highly controlled, dangerous, and not indicated for Depression as no reputable study has shown opioids to benefit depression in the long run. But since when are we gun shy to write for drugs that have these downsides previously mentioned? Benzos are a prime example. While ideally we try another class of drugs to tx anxiety first, if the pt doesn't benefit, here come the benzos....and of course we all follow the strict recommendations that benzos are not to be given for longer than 6 weeks.

So getting back to my pt. The last thing I want to do is get any pt hooked on narcotics and so tx depression w opioids is simply out of the question...well that's how I used to feel, and I still feel this way..almost always

But right now I am having a hard time coming up with a compelling argument for why it would be bad medicine to give opioids to a pt with documented debilitating depression for decades which is refractory to everything...except the one thing I'm not supposed to give him. Yes he will become dependent, yes he will likely become tolerant which could lead to dose escalation, yes these drugs can be dangerous/fatal when abused. But do these risks justify denying the pt the only thing that works for him. Were he not to have access to these meds through his pain doc, is sending him back to a life of misery truly the right thing to do as a doctor?

So in short, assuming we believe such a pt has faithfully explored all known options, but to no avail, and if we accept that opioids provide long term relief of symptoms and improve quality of life, by what justification do we deny this treatment option, and beyond that, how could we call it anything but cruel to do so.

The risks of this class of meds are well known and don't need to be reviewed. However, we prescribe daily drugs with similar risks, including dependence and abuse. We constantly weigh these risks against the benefits and from there we arrive at a logical decision. How many of us would give this man what seems to help him when nothing else does? What am I missing that would allow the majority of us to send this man back to his misery rather than provide him this particular class of drugs?


I know I've put a lot of questions out there, and it's likely clear that my opinion is such a pt has the right, and thus we have the duty to provide ANY drug which we feel will benefit the pt. provided we deem the benefits outweigh the potential risks. At this moment..i would sleep fine giving a pt with the above hx a fentanyl jumpsuit if I found it provided sufficient relief, as I'm hard pressed to think of any potential risk of the drug outweighing the harm that would result from sending our friend back for a few more decades of miserable depression.

NOTE: It's not rare for me to be as convinced of something as strongly as I seem to be on this matter, only to be pointed towards something I'd not considered and consequently realize how truly off I was. I welcome All opinions and insight that would give me reason to reconsider my current convictions.

Thanks guys-

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Double post home slice!

IMO Lighting up those opioid receptors can only last for so long. Is it the role of the physician to play Dr. Feelgood, dig deep to get to the root of the matter, or both? Does the patient wish to dig along as well (a necessary co requisite for real results IMO) Or would he rather just pop a pill and call it a day on the short road?

I have very little experience, almost nothing compared to most folks on this board, but I question many patients' (and even some physicians') perspective of medicine's role and purpose. That is, do they see the physician (and the system in general) as the sole entity responsible for a return (or an attempt to return) to wellness or do they perceive the role of the physician (and medicine prescribed) as a major adjunct to attaining an improved state of being while most of the responsibility to reach this place actually rests on the shoulders of the one in need? (Little effort little reward). I'm not convinced that most want to put in the effort necessary. Pop a pill and continue with the standard M.O. "I don't like this magic bean let me try another."

I don't know, maybe I'm just ranting. I'm a bit off topic there but these are questions that have often come to mind when dealing with certain patients across multiple specialities. Certainly comes to mind when I'm sitting here reading about this patient above.

Then again, maybe there is something that the medication provides for a certain subset of patients w depression? Or maybe he just likes feeling that high?

Tough one. I wouldn't prescribe the itchies for depression regardlessly.
 
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He is lying to his pain doc to get opioids and now no longer feels depressed. Then why is he seeing you?
 
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He is lying to his pain doc to get opioids and now no longer feels depressed. Then why is he seeing you?

Yeah, this. Plus I'm sure he can put you contact with all these other Doctors he's seen who have tried everything for his severe and refractory depression and nothing has worked, you know, because his tale of woe is so heart wrenchingly legitimate.

+pity+

Just to switch to my non snarky mode for a moment. I'm one of the Psych patients who lurks and posts around these boards; I'm also 12 years clean from an addiction to Heroin (plus Methadone taper program). Your patient positively reeks of drug seeking from what you've said. Believe me we can get very good at getting what our addictions are driving us to want, a well seasoned addict, a lot of the time, you won't even see us coming, or even if you do we'll still manage to snare you enough that you'll practically be falling over yourself to write out that script. Don't allow yourself to be manipulated by a well crafted sob story.
 
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Comorbid personality disorders and substance use disorders can often interfere with appropriate diagnosis and effective treatment for unipolar depression.

Has a personality disorder diagnosis been ruled out in this patient?

On a different note, If this patient has a problem with addiction, and he feels that opiate maintenance is effective for his addiction, why not refer him to a methadone clinic (or buprenorphine prescriber) ?
 
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I've encountered several patients over the years who upon their first taste of opiate finally feel they've discovered the missing cure for their long-term dysthymia. They then, like your patient, set themselves up for a life spent "chasing the dragon"-- a process that becomes progressively more difficult as tolerance, opiate-induced hyperalgesia, and negative social consequences mount. Tempting as it may be, we do them no favors by continuing the process. Better to call it opiate dependence and get them off the short-acting agonists with methadone or preferably Suboxone, and try to help them rebuild the life they've put on hold while feeding their mu receptors.
 
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I've encountered several patients over the years who upon their first taste of opiate finally feel they've discovered the missing cure for their long-term dysthymia. They then, like your patient, set themselves up for a life spent "chasing the dragon"-- a process that becomes progressively more difficult as tolerance, opiate-induced hyperalgesia, and negative social consequences mount. Tempting as it may be, we do them no favors by continuing the process. Better to call it opiate dependence and get them off the short-acting agonists with methadone or preferably Suboxone, and try to help them rebuild the life they've put on hold while feeding their mu receptors.

One of the biggest problems with opiates, in my experience, is that they both relieve and create depression at the same time, so you end up chasing your tail trying to medicate something that what you're taking to medicate that something is causing in the first place. When you're on Heroin for example (that is once you've taken it enough times that you go into that nodding out dream state, as opposed to just puking your guts up in between falling asleep), it feels like it takes everything away, all the pain, all the emotional messes inside your head, it takes it all whilst you're high - once you come down though, even before physical dependence sets in, you fall straight back into that pit you're trying to get out of only it's a hundred times worse than when you first fell in and you know the only thing that's gonna get you out is more narcotics. And so the cycle starts - emotional pain -> use -> relieve emotional pain -> come down, emotional pain worsens -> use again -> relieve emotional pain -> come down, emotional pain worsens -> use again...and on, and on, and on. You don't get out of that trap by continuing to feed the cycle.
 
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I've had some cases like this, as well as patients who felt "cured from depression" when they first had a benzo, and even a couple when they first tried dextromethorphan. I even had a friend with some refractory depression that he noticed went away when he had a cold and couldn't figure out why until we talked out what he was taking (dextromethorphan). I suspect these are some novel avenues for treating depression that if properly studied might be viable. But sometimes the risk outweighs the benefits. Stimulants for example help some people with depression, but the abuse risk outweighs using them as even third line meds IMPO.
 
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Stimulants for example help some people with depression, but the abuse risk outweighs using them as even third line meds IMPO.

That reminds me of the (not so) brilliant depression treatment idea I had a few years ago:

(closely paraphrased conversation)

Me: "Okay, look, I've worked something out...I react badly to most antidepressants, but I have ADD as well so just give me Dexamphetamine and I'll have more energy and motivation and we can deal with my depressive symptoms that way"

Psychiatrist: "Yes, but you have a strong family history of Psychosis and you're currently experiencing Psychotic symptoms so giving you an Amphetamine isn't a good idea."

Me: "Oh I thought you could just throw some antipsychotics on top of it and it'd cancel all that stuff out.

I swear my Psychiatrist was about one second away from face planting his desk at that point.

:eggface:
 
I'm not a historian, but I feel like there was a time in recent history (Thomas Jefferon's period) when opiates and amphetamines were commonly used for life's ups and downs. I vaguely recall that Jefferson took some sort of tincture regularly of uppers and downers. It doesn't seem surprising that they would make people feel better. I suppose it's whatever is culturally appropriate at any point in history. I don't know the risk/benefit ratio, but to me it seems like the treatments that are used across medicine aren't always evaluated just based on risk/benefit but also on cultural and political factors (and also depending on the marketing and direction of pharmaceutical companies). For example, how can be marijuana be Schedule I, testosterone be Schedule III, and benzodiazepines be Schedule IV and cigarettes and alcohol be Schedule nothing? Those are political/cultural distinctions. Not saying I'd want to take opiates, but it is an interesting case when the depression has been refractory to so many treatments.
 
Without further history, like ruling out a personality disorder, quantification and diagnosis of depression on the basis of information given is difficult. Personality traits/ patterns of behavior sometimes can help with diagnostic clarity. I have been treating opiate addiction for some time and as mentioned above they have some preliminary evidence.
 
I am not sure what is so fascinating with about this case except perhaps you seem to be oblivious as to your own countertransference reactions, wishes and (potential) enactments.

The patient apparently has some sort of depressive illness and probably some sort of personality disorder (as is often the case with chronic depression and dysthymia). Sorry but no treatment that we have is going to make your patient feel as good as opioids. It is not our job to make people happy, but to get the most out of their lives, achieve their goals ("I want to happy" is NOT a goal), and as Freud put it "to transform hysterical misery into common unhappiness". Our first duty is also to do no harm. This is true for all physicians but especially psychiatrists. You don't want to harm your patients anymore than they have been.

why did the patient first become depressed? (hint: didn't just come out of the blue)
let me guess: has this patient been on a TCA, MAOI, and TCA + lithium, MAOI + lithium, TCA + T3, TCA + MAOI? Has the patient had a course of psychotherapy such as CBT, ACT, mindfulness-based CBT, psychodynamic psychotherapy? Is the patient currently engaged in psychotherapy? If these answer is no, no, no, no, no then clearly the patient has not run the mill of standard therapies for treatment-resistant depression?
Is the patient able to function on opiates? i.e. able to hold down a job, have meaningful relationships, do the tasks of everyday living such as paying the bills? If the answer is no, then clearly the opiates are not an effective treatment. The problem with opiates for chronic pain is they do not improve functioning. In fact people are often as or more impaired on a functional basis on opiates. It would be very surprising if your patient is functioning better on opiates. If he really is, then and only then I might consider putting this patient on suboxone.

I sometimes joke I practice "gonzo psychiatry" and am certainly happy to entertain unconventional treatments if they will help my patients. But you need to evaluate your own countertransference reactions and wishes, and consider the ethical and medicolegal ramifications of your decisions. And if your patient is making you consider doing something you wouldn't ordinarily do, that is pretty diagnostic in itself...

In terms of whether he has an opioid use disorder, I don't think this should be assumed unless he has tolerance, craving, withdrawal, salience, and persistent use despite desire to stop or negative legal, medical, and relational consequences.

Psychiatrists should not be prescribing opiates to patients on an outpatient basis with the exception of methadone and suboxone. It would look very shady indeed. If you were going to give this patient an opioid it would be suboxone. There was a theory in vogue some years ago that some depressions were the result of dysregulation of the endogenous opioid system and there have been some small studies of buprenorphine and other opioids in treatment-resistant depression but nothing seems to have come of this. here is the abstract for a presentation: www.sciencedirect.com./science/article/pii/S0924977X06703285 and I think the McLean guys did a study on bupe in TRD many years ago but again it is telling that nothing has come of this.
 
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The impressive part about this patient is his skillful use of rationalization and intellectualization. Anyone who can make us question some of our hard tenants like “it isn’t OK to use opiates at doses over those required for pain”, has remarkable projective identification skills. Lots of things that make us feel better are not a good idea, even if there is another doctor saying it is.
 
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I'll bet if you kicked him in the testicles, his reported mood state would change too.

It's still not a treatment for MDD though.
 
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The impressive part about this patient is his skillful use of rationalization and intellectualization. Anyone who can make us question some of our hard tenants like “it isn’t OK to use opiates at doses over those required for pain”, has remarkable projective identification skills. Lots of things that make us feel better are not a good idea, even if there is another doctor saying it is.

This. That's why it is oh so important to have a set of guidelines to follow (both practice guidelines, and your own). In residency, you get faulted for following your own, in practice, you get faulted for not.

Example:
Residency - No benzos if you're on an opiate. Fine rule to have. Some practitioners don't have a problem, give them what you want, "don't be too strict."
Practice - No benzos if you're on an opiate. "But they seem like a really nice person, I can't fault their logic." Benzo given. +/- negative outcome. Personal boundary broken. Therapeutic goals nullified.

Alliance goes a long way with patients, but especially this population in my opinion. Sometimes, you gotta sell the seller. How? I put myself down a lot, obviously they know better than me, but, I have these silly recommendations of which I have more long-term confidence in. I could be wrong, because I clearly know nothing compared to their life experiences. Also, calling out someone's BS is sometimes therapeutic too ("So, come on, I'm supposed to believe Opiates made you all better? But you're seeing me, so something isn't going all that well now is it? Look, I could be like everyone else, and just agree with you, because I imagine you're used to that. Or, I can be honest, and offer the longer but more fruitful road. I can only help, you have to do the work. It's your choice afterall").
 
So to recap, for this guy from his teens to 30 he was devastatingly depressed to the point that he was nonfunctional (reading into the anhedonia and amotivation). He tried therapy in various incarnations, many pharm options, and ECT without relief. Then at 30 he found opiates and his depression went into full and sustained remission for a decade?

I, like Splik, am interested in his life function and any adverse effects of the opiates. Is there any other suggestion of misuse aside from lying to his prescriber? You have extensive record collateral, have you spoken with old providers, family members, close friends to verify the account and to corroborate his story? That would be an absolute must in my book. I would approach this with the skepticism of a forensic psychiatrist and demand collateral from anywhere I could get it.

And here's where I diverge from most of these responses: assuming all of the above checks out as you seem to indicate, I'm not sure that continuing opiates is as crazy as people are making it sound. Obviously you would need to document extensively your rationale for doing so and keep a very close watch since it is not at all standard of practice, but I don't think that we fully understand depression or even that depression is one single disease (it's just a syndrome). If this guy has some very odd variant that truly is opiate-responsive, I believe it would be a tremendous shame to return him to a state of being mentally crippled just on principle. I do think trying to wean the opiates and seeing what happens (who knows if he needs maintenance still?) should be tried at some point, and I think a transition to suboxone would be way better than the status quo. But if the choice actually comes down to severe and intractable depression or taking moderate dose long-term opiates, which is really worse?

Again, this all takes on face value that you have explored every angle of this case as a skeptic and truly believe the story as presented. I would not even consider placing opiates on any kind of standard treatment algorithm for depression, nor would I buy into the story as you are presenting it without the kind of extensive and rock-solid documentation you describe. Still, I am willing to believe that I don't know everything and once in a while a very unusual treatment approach may work for a given patient. It all comes down to risks and benefits.

Also for those encouraging therapy, I am a big therapy fan myself and I agree that it should be standard for pretty much any anxiety or depressive disorder. Still, therapy isn't magic and will likely never work for 100% of cases no matter how the theory advances. Every treatment has its limitations, and sending a decade-plus long depression into full remission for a full decade by even atypical means is not something to be taken lightly or given up easily.
 
So to recap, for this guy from his teens to 30 he was devastatingly depressed to the point that he was nonfunctional (reading into the anhedonia and amotivation). He tried therapy in various incarnations, many pharm options, and ECT without relief. Then at 30 he found opiates and his depression went into full and sustained remission for a decade?

I, like Splik, am interested in his life function and any adverse effects of the opiates. Is there any other suggestion of misuse aside from lying to his prescriber? You have extensive record collateral, have you spoken with old providers, family members, close friends to verify the account and to corroborate his story? That would be an absolute must in my book. I would approach this with the skepticism of a forensic psychiatrist and demand collateral from anywhere I could get it.

And here's where I diverge from most of these responses: assuming all of the above checks out as you seem to indicate, I'm not sure that continuing opiates is as crazy as people are making it sound. Obviously you would need to document extensively your rationale for doing so and keep a very close watch since it is not at all standard of practice, but I don't think that we fully understand depression or even that depression is one single disease (it's just a syndrome). If this guy has some very odd variant that truly is opiate-responsive, I believe it would be a tremendous shame to return him to a state of being mentally crippled just on principle. I do think trying to wean the opiates and seeing what happens (who knows if he needs maintenance still?) should be tried at some point, and I think a transition to suboxone would be way better than the status quo. But if the choice actually comes down to severe and intractable depression or taking moderate dose long-term opiates, which is really worse?

Again, this all takes on face value that you have explored every angle of this case as a skeptic and truly believe the story as presented. I would not even consider placing opiates on any kind of standard treatment algorithm for depression, nor would I buy into the story as you are presenting it without the kind of extensive and rock-solid documentation you describe. Still, I am willing to believe that I don't know everything and once in a while a very unusual treatment approach may work for a given patient. It all comes down to risks and benefits.

Also for those encouraging therapy, I am a big therapy fan myself and I agree that it should be standard for pretty much any anxiety or depressive disorder. Still, therapy isn't magic and will likely never work for 100% of cases no matter how the theory advances. Every treatment has its limitations, and sending a decade-plus long depression into full remission for a full decade by even atypical means is not something to be taken lightly or given up easily.

I get what you're saying and I actually agree in that obviously if I was a Doctor and IF this patient was able to fully document and back up his claims then maybe, just maybe I'd weigh the risk/benefit ratio in regards to allowing him to stay on Opioids for treatment of depressive symptoms and come down on the side of 'Okay, the opiates are working when nothing else has, let's not fix what isn't broken'. Having said that though if this patient was on the up and up I would have expected him to have already come prepared to the appointment, not just turn up making a bunch of claims it sounds like he's yet to actually substantiate. Just to use myself as an example for a moment, I am prescribed a limited amount of Morphine (MS Contin) every month for treatment of severe endometriosis related pain. Any long term prescribing of Narcotic medications, regardless of dosage or amount prescribed, must be handled and authorised by the South Australian Health Department's 'Drugs of Dependency' unit. In order for me to get an authorisation in order to be prescribed MS Contin, I had to undergo a years worth of tests, including exploratory surgery, have a Doctor provide evidence that previously successful surgical interventions had failed, or were not possible second time around, have a Doctor provide evidence that ALL other treatment/pain relief methods had been thoroughly explored and deemed unsuitable, and then I had to provide a letter from my GP at the time, a letter from one of the treating Doctors at the hospital I was required to attend, along with a letter from the Professor of Gynaecology at said hospital, all stating that authorising long term prescriptions of limited amounts of Morphine per month was the only workable option they could recommend for me. On top of that I had to have one main GP nominated to be my authorised prescriber, if I need to see other GPs to obtain a script for any reason (eg, my main GP is on extended leave) then they have to be added to a list of sub-authorised prescribers, plus I have to nominate a single Pharmacy where I am planning to pick the scripts up from and that Pharmacy must agree and authorise my prescription pick ups and have their information registered with the Drugs of Dependency unit along with a statement that they are to be my authorised pharmacy (I can't go anywhere else, not without the system throwing up a red flag).

Now considering all of the above, a few years ago I made the decision to change clinics (and GPs, obviously) for ease of travel distance. I did not just turn up to the new clinic and present myself to one of the Doctors there with a sob story about how I'd tried everything else, even surgery, and 'you've gotta prescribe me Morphine, Doc, it's the only thing that works'. No, I had my complete set of notes transferred to the new clinic before I even brokered the subject of having the 'authorisation to prescribe a drug of dependence' transferred to another Doctor who was willing to take over as my main authorised prescriber. At any time, if there are any questions regarding my legitimacy, I can provide access to the letter of authorisation given by the Drugs of Dependency Unit, the required letters provided by the three other Physicians, my hospital records, my surgical records, all records of past treatments and why they were not ultimately deemed suitable, and so on. I do not, have not, and never would just rock up to an appointment with a Doctor who didn't even know me and start pulling out the whole hearts and strings routine over how I simply *must* be prescribed this particular Narcotic medication - not without wheeling in a barrel load of substantiated evidence to back myself up with.

No substantiated evidence, no prescription - it's as simple as that as far as I'm concerned.
 
Without further history, like ruling out a personality disorder, quantification and diagnosis of depression on the basis of information given is difficult. Personality traits/ patterns of behavior sometimes can help with diagnostic clarity. I have been treating opiate addiction for some time and as mentioned above they have some preliminary evidence.

Correct. I had looked into this as well for evidence. However, if there is a bad outcome, at the end of the day it is not standard of care and the doc will be hung out to dry.
 
I am not sure what is so fascinating with about this case except perhaps you seem to be oblivious as to your own countertransference reactions, wishes and (potential) enactments.

The patient apparently has some sort of depressive illness and probably some sort of personality disorder (as is often the case with chronic depression and dysthymia). Sorry but no treatment that we have is going to make your patient feel as good as opioids. It is not our job to make people happy, but to get the most out of their lives, achieve their goals ("I want to happy" is NOT a goal), and as Freud put it "to transform hysterical misery into common unhappiness". Our first duty is also to do no harm. This is true for all physicians but especially psychiatrists. You don't want to harm your patients anymore than they have been.

why did the patient first become depressed? (hint: didn't just come out of the blue)
let me guess: has this patient been on a TCA, MAOI, and TCA + lithium, MAOI + lithium, TCA + T3, TCA + MAOI? Has the patient had a course of psychotherapy such as CBT, ACT, mindfulness-based CBT, psychodynamic psychotherapy? Is the patient currently engaged in psychotherapy? If these answer is no, no, no, no, no then clearly the patient has not run the mill of standard therapies for treatment-resistant depression?
Is the patient able to function on opiates? i.e. able to hold down a job, have meaningful relationships, do the tasks of everyday living such as paying the bills? If the answer is no, then clearly the opiates are not an effective treatment. The problem with opiates for chronic pain is they do not improve functioning. In fact people are often as or more impaired on a functional basis on opiates. It would be very surprising if your patient is functioning better on opiates. If he really is, then and only then I might consider putting this patient on suboxone.

I sometimes joke I practice "gonzo psychiatry" and am certainly happy to entertain unconventional treatments if they will help my patients. But you need to evaluate your own countertransference reactions and wishes, and consider the ethical and medicolegal ramifications of your decisions. And if your patient is making you consider doing something you wouldn't ordinarily do, that is pretty diagnostic in itself...

In terms of whether he has an opioid use disorder, I don't think this should be assumed unless he has tolerance, craving, withdrawal, salience, and persistent use despite desire to stop or negative legal, medical, and relational consequences.

Psychiatrists should not be prescribing opiates to patients on an outpatient basis with the exception of methadone and suboxone. It would look very shady indeed. If you were going to give this patient an opioid it would be suboxone. There was a theory in vogue some years ago that some depressions were the result of dysregulation of the endogenous opioid system and there have been some small studies of buprenorphine and other opioids in treatment-resistant depression but nothing seems to have come of this. here is the abstract for a presentation: www.sciencedirect.com./science/article/pii/S0924977X06703285 and I think the McLean guys did a study on bupe in TRD many years ago but again it is telling that nothing has come of this.
Local psychiatrist had DEA in this office and lost his medical license for prescribing opioids...as deaths had ensued..
 
Medical Board and DEA don't look into rationale if bad outcome ensues in cases like this. There is a reason that they are closely monitored controlled substances with specific indications. I struggle at times with transference with opiate dependent patients, very hard to stay in boundaries when dealing with personality disorders/ traits in some specific patient population.Frequently the patients tell that only adderall or xanax has given them their life back and everything else has been tried and failed over the years. It is hard to balance restoration of function, symptom relief with rational evidence based treatment.

I think OP should clarify if he is asking a general question, It is hard to understand that this patient has tried ECT, ketamine, appropriate psychotherapy and other multiple treatments.
 
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There have been some small trials in Europe showing efficacy of buprenorphine for treatment-resistant depression. These are short-term studies, so it's hard to address the issues resulting from tolerance etc. This patient would certainly be a candidate for Suboxone, given his opioid dependence. The question is whether his depression would remain remitted, or even improve on Suboxone maintenance because he would no longer be on the short-acting opioid roller coaster. Maybe he would do well. That's at least what I would tell him if he came to me asking for opioids. Definitely his depression will not get better in the short term with detoxification.
 
I have a related question... so I've always heard and accepted that opiates cause/worsen depression. But I've tried looking up the mechanism on WHY this is, and I can't find an answer.

So, does anyone know what long-term (>6 month) use of opiates increase the risk of developing depression, or worsens it if one is already depressed?
 
I have a related question... so I've always heard and accepted that opiates cause/worsen depression. But I've tried looking up the mechanism on WHY this is, and I can't find an answer.

So, does anyone know what long-term (>6 month) use of opiates increase the risk of developing depression, or worsens it if one is already depressed?

Lots of things in psychiatry and medicine don't have well defined mechanisms..
 
Hey everyone. Thanks for your thoughtful and insightful replies. I apologize for the delay. I would just like to clarify some questions that have been posed and perhaps that might better frame my predicament.

First, as to why this pt is seeing me if he is getting the opioids he requires from the pain doc. and claims said opioids have put his refractory depression in long term remission-
I was skeptical about this as well. His stated reason for seeing me was simply to "pick my brain" as he put it, as to why opioids would alleviate his long term depression when nothing else has. He also wanted my opinion of continuing this "therapy" and any negative outcomes I could envision, as well as if I had encountered any pts in the past with similar stories regarding depression responding to opioids when all other tx failed.

Let me allay any concerns and assure everyone that my "sophisticated drug seeker radar" was on uber high alert. While I don't have 20 yrs experience, I'm a senior resident in a program where opioid abuse and seekers is absolutely rampant. A pt starting off the bat by telling me he doesn't want any scripts raises more flags these days than those coming in with a clear agenda. However after looking into my states controlled substances online registry, I see the picture of a perfectly stable, well controlled, pain pt (aside from the fact that he admits he exaggerates his pain to obtain the opioids). Goes to one provider, stable dose over years, never early refills, in fact often doesn't fill his script until a week after it's due. I had him bring in his pills and his count shows he takes slightly less than prescribed, and I consulted with his pain docs office and confirmed he is a current pt and has not had any issues nor has he been told he must find a new provider. So....unless I'm missing something, I can't see what secondary gain he hopes to achieve by seeing me.

Thorough collateral gathering from past providers and family thoroughly support his story. Crippling depression developed during late teens that left him essentially non-functional and I have records of every tx combo we are familiar with, all of sufficient duration, all with no significant response. Without boring everyone with the details, suffice to say that either this pt coerced 6 family members, 2 friends, and was able to someone fabricate 15+ years of med records, or his story checks out.

As to his current level of function and quality of life since starting opioids...again without going into the details, someone who could scarcely get out of bed pre opioids, despite all conventional tx, turned into a functional motivated individual who returned to school, completed law school, and is now a practicing lawyer-all corroborated by family/friends and med records. As for side effects.....the pt admits to constipation.

So assuming I'm even marginally competent in my due diligence in obtaining collateral and corroborating pts, which I feel I have demonstrated, I am faced with a practical dilemma, and a more insidious theoretical one.

Practical-Should I/am i compelled to notify the pain doc the pt admitted to exaggerating pain? The pt (being a lawyer) was careful not to state that he didn't need the opioids for pain, I believe his words were "I do have chronic pain which the pain meds address, but let's assume I'd be more inclined to try living through the pain without the meds if they weren't so effective at alleviating my depression". If I'm not legally compelled, do I really want to be the guy that gets this functional, seemingly happy/content pt kicked off his pain meds and risk his relapse into depression. Studies and theory are helpful, but in the real world, Literally everything points to the fact that long term, full agonist opioids turned a non functional, hopelessly depressed person into a happy, healthy lawyer (let's save the speculation as to whether we would be better off with one less lawyer...).

Theoretical-What is the reasoning behind the taboo for using opioids for depression under any and all circumstances? I obviously understand the concerns of dependence, abuse, escalating doses, and risk of overdose of course. And for these reasons I would never consider their use for these purposes except under the most rare, and specific set of circumstances. To me that seems reasonable, but the consensus seems to be, "no, never, not under any circumstances...ever".

Ok, but why are we so willing do dispense benzos long term despite the similar risk of dependence, abuse, escalating dose, risk of OD (debatable with benzos alone), when all reputable studies show no benefit, and in fact, likely worsening anxiety. We are willing to ignore these studies/guidelines when confronted with a pt who, in our clinical judgement, seems to be more functional/better quality of life when on benzos long term, and so nearly all of us find ourselves with pts on benzos for YEARS despite all data suggesting this is not helpful, and in fact, likely harmful.

So I suppose my concern moving forward as an autonomous provider, is when is it ok to ignore conventional wisdom/studies. Pt reports/demonstrates improved functioning and relief of anxiety only when on benzos despite the fact all major studies suggest this is bad medicine ..OK, Klonopin 1mg TID...but I'm watching you.

Pt reports/demonstrates improved functioning/relief of depression only with opioids when all other tx failed...Sorry friend, even if I believed you, my hands are tied.

So are these exceptions we allow for arbitrary and simply the acceptable cultural zeitgeist in our field at the current time, or are there solid reasons why we will set aside established protocols based on numerous studies in the case of benzos for example, and allow our clinical judgement of the individuals needs prevail, but are not willing to do the same in other cases, opioids for my pt, for example?

Tough questions I know. At this point I'm arrogant enough to ask them, but humble enough to accept I'm out of my depths, and clearly need insight from others to help me come to terms with what are likely, nuanced and complex answers.
 
I think it is an interesting question you pose as well, and I think it is useful to separate out the ethics from the legal ramifications. If (as some posters suggest) I would put my license at serious risk to continue the rx in this case I personally would chose the (in my opinion) unethical option of witholding effective treatment to save my own license. That doesn't change the ethics of the situation at all in my mind, it only means that given the cost to me I would put my own interests in front of the patient's.

As for not telling the pain doctor, I don't really know how that would be looked upon legally. I would be hesitant to share the information given the whole clinical picture, I'm interested in hearing what others think.
 
You would be on solid ground prescribing Suboxone to this patient for the rest of his life, using the rationale in your notes etc. that you are treating his opioid dependence (you would be doing this) using maintenance medication assisted treatment while continuing to feel conflicted inside about what it means that you are also treating his depression.
 
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Ok, but why are we so willing do dispense benzos long term despite the similar risk of dependence, abuse, escalating dose, risk of OD (debatable with benzos alone), when all reputable studies show no benefit, and in fact, likely worsening anxiety. We are willing to ignore these studies/guidelines when confronted with a pt who, in our clinical judgement, seems to be more functional/better quality of life when on benzos long term, and so nearly all of us find ourselves with pts on benzos for YEARS despite all data suggesting this is not helpful, and in fact, likely harmful.

So I suppose my concern moving forward as an autonomous provider, is when is it ok to ignore conventional wisdom/studies. Pt reports/demonstrates improved functioning and relief of anxiety only when on benzos despite the fact all major studies suggest this is bad medicine ..OK, Klonopin 1mg TID...but I'm watching you.

Again, I think it's cultural and political. I'm learning that it takes bad information a long time to go away. Benzodiazepines aren't even on the NIDA's radar in any meaningful way. I was on benzos from the age of 15, but it was my college psychiatrist who snowed me. He switched me from a moderate dose of Ativan to what I didn't realize was a heavy dose of Klonopin and told me he had patients on it for 20 years with no problems. Told me it was the "antidepressant" version of Ativan (meaning designed for long-term treatment) and that it was not addictive. I'm a very nervous patient--so I was asking a lot of questions. I deteriorated over the year and the next year dropped out. A new psychiatrist switched me back to Ativan, and the rest is a long story. Opioids are in the public consciousness. They're in the political consciousness. Benzodiazepines are like a huge secret problem that flies under the radar, and knowledge about them is just not there, unfortunately even for some psychiatrists.

Having said that, once a person is tolerant to benzodiazepines, there aren't easy answers. And I think the same is true for opioid addiction/dependence. It seems that the culture of abstinence with opioids has led to unintended overdoses. I think quality of life has to be considered over political and dogmatic absolutes.
 
You would be on solid ground prescribing Suboxone to this patient for the rest of his life, using the rationale in your notes etc. that you are treating his opioid dependence (you would be doing this) using maintenance medication assisted treatment while continuing to feel conflicted inside about what it means that you are also treating his depression.

I agree. It seems like opioid dependence even though he does not meet DSM criteria by his report. Most of the addicts I work with feel normal on opioids. They also report never feeling better in their life than when they first started using. There are a number of neurobiological hypotheses for this. Also with chronic use there are neuroadaptations that take place in the brain and a hijacking of the reward system that result in diminishing rewards from the natural environment.
 
My guess is that he is seeing you because he will soon need some type of letter for the bar/law license. I would get neuropsych testing to document any impairment or the absence thereof

We should start a separate thread on Psychiatrists reactions to chief complaint: "I would like to pick your brain".
 
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Another factor to consider is that substance dependence takes a lot of different forms. Not all drug users rapidly degenerate into full-fledged addiction. Depending on the tolerance profile of the substance and the ability of the user to work within the tolerance profile, they can achieve beneficial effects for years or even decades. Think "functional alcoholic" for an example of how that can look. In other words, people with sophisticated coping and favorable biochemistry can function with chemicals and these substances will make them feel better. Which drugs people can use on their own and what physicians can prescribe and for what. as others have said, is culturally determined, not scientifically determined.
 
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Hey everyone. Thanks for your thoughtful and insightful replies. I apologize for the delay. I would just like to clarify some questions that have been posed and perhaps that might better frame my predicament.

First, as to why this pt is seeing me if he is getting the opioids he requires from the pain doc. and claims said opioids have put his refractory depression in long term remission-
I was skeptical about this as well. His stated reason for seeing me was simply to "pick my brain" as he put it, as to why opioids would alleviate his long term depression when nothing else has. He also wanted my opinion of continuing this "therapy" and any negative outcomes I could envision, as well as if I had encountered any pts in the past with similar stories regarding depression responding to opioids when all other tx failed.

Let me allay any concerns and assure everyone that my "sophisticated drug seeker radar" was on uber high alert. While I don't have 20 yrs experience, I'm a senior resident in a program where opioid abuse and seekers is absolutely rampant. A pt starting off the bat by telling me he doesn't want any scripts raises more flags these days than those coming in with a clear agenda. However after looking into my states controlled substances online registry, I see the picture of a perfectly stable, well controlled, pain pt (aside from the fact that he admits he exaggerates his pain to obtain the opioids). Goes to one provider, stable dose over years, never early refills, in fact often doesn't fill his script until a week after it's due. I had him bring in his pills and his count shows he takes slightly less than prescribed, and I consulted with his pain docs office and confirmed he is a current pt and has not had any issues nor has he been told he must find a new provider. So....unless I'm missing something, I can't see what secondary gain he hopes to achieve by seeing me.

Thorough collateral gathering from past providers and family thoroughly support his story. Crippling depression developed during late teens that left him essentially non-functional and I have records of every tx combo we are familiar with, all of sufficient duration, all with no significant response. Without boring everyone with the details, suffice to say that either this pt coerced 6 family members, 2 friends, and was able to someone fabricate 15+ years of med records, or his story checks out.

As to his current level of function and quality of life since starting opioids...again without going into the details, someone who could scarcely get out of bed pre opioids, despite all conventional tx, turned into a functional motivated individual who returned to school, completed law school, and is now a practicing lawyer-all corroborated by family/friends and med records. As for side effects.....the pt admits to constipation.

So assuming I'm even marginally competent in my due diligence in obtaining collateral and corroborating pts, which I feel I have demonstrated, I am faced with a practical dilemma, and a more insidious theoretical one.

Practical-Should I/am i compelled to notify the pain doc the pt admitted to exaggerating pain? The pt (being a lawyer) was careful not to state that he didn't need the opioids for pain, I believe his words were "I do have chronic pain which the pain meds address, but let's assume I'd be more inclined to try living through the pain without the meds if they weren't so effective at alleviating my depression". If I'm not legally compelled, do I really want to be the guy that gets this functional, seemingly happy/content pt kicked off his pain meds and risk his relapse into depression. Studies and theory are helpful, but in the real world, Literally everything points to the fact that long term, full agonist opioids turned a non functional, hopelessly depressed person into a happy, healthy lawyer (let's save the speculation as to whether we would be better off with one less lawyer...).

Theoretical-What is the reasoning behind the taboo for using opioids for depression under any and all circumstances? I obviously understand the concerns of dependence, abuse, escalating doses, and risk of overdose of course. And for these reasons I would never consider their use for these purposes except under the most rare, and specific set of circumstances. To me that seems reasonable, but the consensus seems to be, "no, never, not under any circumstances...ever".

Ok, but why are we so willing do dispense benzos long term despite the similar risk of dependence, abuse, escalating dose, risk of OD (debatable with benzos alone), when all reputable studies show no benefit, and in fact, likely worsening anxiety. We are willing to ignore these studies/guidelines when confronted with a pt who, in our clinical judgement, seems to be more functional/better quality of life when on benzos long term, and so nearly all of us find ourselves with pts on benzos for YEARS despite all data suggesting this is not helpful, and in fact, likely harmful.

So I suppose my concern moving forward as an autonomous provider, is when is it ok to ignore conventional wisdom/studies. Pt reports/demonstrates improved functioning and relief of anxiety only when on benzos despite the fact all major studies suggest this is bad medicine ..OK, Klonopin 1mg TID...but I'm watching you.

Pt reports/demonstrates improved functioning/relief of depression only with opioids when all other tx failed...Sorry friend, even if I believed you, my hands are tied.

So are these exceptions we allow for arbitrary and simply the acceptable cultural zeitgeist in our field at the current time, or are there solid reasons why we will set aside established protocols based on numerous studies in the case of benzos for example, and allow our clinical judgement of the individuals needs prevail, but are not willing to do the same in other cases, opioids for my pt, for example?

Tough questions I know. At this point I'm arrogant enough to ask them, but humble enough to accept I'm out of my depths, and clearly need insight from others to help me come to terms with what are likely, nuanced and complex answers.

This is obviously coming from a non medical point of view, but if this guy has backed up his claims to the nth degree (which it sounds like he has), I would have no issue with prescribing him Opiates, but at the same time I'd do everything possible to protect myself as well (detailed charting/notes/applications for authorised prescribing permission, etc etc - cross the i's dot the t's and make sure everything was set in place properly). I do think people sometimes lose objectivity, and with my past history I am the first to admit I can be one of them, when it comes to Opioid medications. I don't mean their use, I mean just the medications alone, like the mere thought of prescribing Narcotics can send a Doctor heading for the hills when in reality they are just medications, I mean it's not the pills that are the problem necessarily it's the person who's taking them in the wrong manner - it's not like the pills just magically leap into someone's mouth.
 
Hey everyone. Thanks for your thoughtful and insightful replies. I apologize for the delay. I would just like to clarify some questions that have been posed and perhaps that might better frame my predicament.

First, as to why this pt is seeing me if he is getting the opioids he requires from the pain doc. and claims said opioids have put his refractory depression in long term remission-
I was skeptical about this as well. His stated reason for seeing me was simply to "pick my brain" as he put it, as to why opioids would alleviate his long term depression when nothing else has. He also wanted my opinion of continuing this "therapy" and any negative outcomes I could envision, as well as if I had encountered any pts in the past with similar stories regarding depression responding to opioids when all other tx failed.

Let me allay any concerns and assure everyone that my "sophisticated drug seeker radar" was on uber high alert. While I don't have 20 yrs experience, I'm a senior resident in a program where opioid abuse and seekers is absolutely rampant. A pt starting off the bat by telling me he doesn't want any scripts raises more flags these days than those coming in with a clear agenda. However after looking into my states controlled substances online registry, I see the picture of a perfectly stable, well controlled, pain pt (aside from the fact that he admits he exaggerates his pain to obtain the opioids). Goes to one provider, stable dose over years, never early refills, in fact often doesn't fill his script until a week after it's due. I had him bring in his pills and his count shows he takes slightly less than prescribed, and I consulted with his pain docs office and confirmed he is a current pt and has not had any issues nor has he been told he must find a new provider. So....unless I'm missing something, I can't see what secondary gain he hopes to achieve by seeing me.

Thorough collateral gathering from past providers and family thoroughly support his story. Crippling depression developed during late teens that left him essentially non-functional and I have records of every tx combo we are familiar with, all of sufficient duration, all with no significant response. Without boring everyone with the details, suffice to say that either this pt coerced 6 family members, 2 friends, and was able to someone fabricate 15+ years of med records, or his story checks out.

As to his current level of function and quality of life since starting opioids...again without going into the details, someone who could scarcely get out of bed pre opioids, despite all conventional tx, turned into a functional motivated individual who returned to school, completed law school, and is now a practicing lawyer-all corroborated by family/friends and med records. As for side effects.....the pt admits to constipation.

So assuming I'm even marginally competent in my due diligence in obtaining collateral and corroborating pts, which I feel I have demonstrated, I am faced with a practical dilemma, and a more insidious theoretical one.

Practical-Should I/am i compelled to notify the pain doc the pt admitted to exaggerating pain? The pt (being a lawyer) was careful not to state that he didn't need the opioids for pain, I believe his words were "I do have chronic pain which the pain meds address, but let's assume I'd be more inclined to try living through the pain without the meds if they weren't so effective at alleviating my depression". If I'm not legally compelled, do I really want to be the guy that gets this functional, seemingly happy/content pt kicked off his pain meds and risk his relapse into depression. Studies and theory are helpful, but in the real world, Literally everything points to the fact that long term, full agonist opioids turned a non functional, hopelessly depressed person into a happy, healthy lawyer (let's save the speculation as to whether we would be better off with one less lawyer...).

Theoretical-What is the reasoning behind the taboo for using opioids for depression under any and all circumstances? I obviously understand the concerns of dependence, abuse, escalating doses, and risk of overdose of course. And for these reasons I would never consider their use for these purposes except under the most rare, and specific set of circumstances. To me that seems reasonable, but the consensus seems to be, "no, never, not under any circumstances...ever".

Ok, but why are we so willing do dispense benzos long term despite the similar risk of dependence, abuse, escalating dose, risk of OD (debatable with benzos alone), when all reputable studies show no benefit, and in fact, likely worsening anxiety. We are willing to ignore these studies/guidelines when confronted with a pt who, in our clinical judgement, seems to be more functional/better quality of life when on benzos long term, and so nearly all of us find ourselves with pts on benzos for YEARS despite all data suggesting this is not helpful, and in fact, likely harmful.

So I suppose my concern moving forward as an autonomous provider, is when is it ok to ignore conventional wisdom/studies. Pt reports/demonstrates improved functioning and relief of anxiety only when on benzos despite the fact all major studies suggest this is bad medicine ..OK, Klonopin 1mg TID...but I'm watching you.

Pt reports/demonstrates improved functioning/relief of depression only with opioids when all other tx failed...Sorry friend, even if I believed you, my hands are tied.

So are these exceptions we allow for arbitrary and simply the acceptable cultural zeitgeist in our field at the current time, or are there solid reasons why we will set aside established protocols based on numerous studies in the case of benzos for example, and allow our clinical judgement of the individuals needs prevail, but are not willing to do the same in other cases, opioids for my pt, for example?

Tough questions I know. At this point I'm arrogant enough to ask them, but humble enough to accept I'm out of my depths, and clearly need insight from others to help me come to terms with what are likely, nuanced and complex answers.
Maybe he has a case he is preparing for...
And in general, just bc a person checks out on paper doesn't mean there aren't a bunch of other shenanigans.
What's his random UDS? Pain doctor was doing this right? What's your UDS show?
Why would he need a letter for the bar?
 
Hey everyone. Thanks for your thoughtful and insightful replies. I apologize for the delay. I would just like to clarify some questions that have been posed and perhaps that might better frame my predicament.

First, as to why this pt is seeing me if he is getting the opioids he requires from the pain doc. and claims said opioids have put his refractory depression in long term remission-
I was skeptical about this as well. His stated reason for seeing me was simply to "pick my brain" as he put it, as to why opioids would alleviate his long term depression when nothing else has. He also wanted my opinion of continuing this "therapy" and any negative outcomes I could envision, as well as if I had encountered any pts in the past with similar stories regarding depression responding to opioids when all other tx failed.

Let me allay any concerns and assure everyone that my "sophisticated drug seeker radar" was on uber high alert. While I don't have 20 yrs experience, I'm a senior resident in a program where opioid abuse and seekers is absolutely rampant. A pt starting off the bat by telling me he doesn't want any scripts raises more flags these days than those coming in with a clear agenda. However after looking into my states controlled substances online registry, I see the picture of a perfectly stable, well controlled, pain pt (aside from the fact that he admits he exaggerates his pain to obtain the opioids). Goes to one provider, stable dose over years, never early refills, in fact often doesn't fill his script until a week after it's due. I had him bring in his pills and his count shows he takes slightly less than prescribed, and I consulted with his pain docs office and confirmed he is a current pt and has not had any issues nor has he been told he must find a new provider. So....unless I'm missing something, I can't see what secondary gain he hopes to achieve by seeing me.

Thorough collateral gathering from past providers and family thoroughly support his story. Crippling depression developed during late teens that left him essentially non-functional and I have records of every tx combo we are familiar with, all of sufficient duration, all with no significant response. Without boring everyone with the details, suffice to say that either this pt coerced 6 family members, 2 friends, and was able to someone fabricate 15+ years of med records, or his story checks out.

As to his current level of function and quality of life since starting opioids...again without going into the details, someone who could scarcely get out of bed pre opioids, despite all conventional tx, turned into a functional motivated individual who returned to school, completed law school, and is now a practicing lawyer-all corroborated by family/friends and med records. As for side effects.....the pt admits to constipation.

So assuming I'm even marginally competent in my due diligence in obtaining collateral and corroborating pts, which I feel I have demonstrated, I am faced with a practical dilemma, and a more insidious theoretical one.

Practical-Should I/am i compelled to notify the pain doc the pt admitted to exaggerating pain? The pt (being a lawyer) was careful not to state that he didn't need the opioids for pain, I believe his words were "I do have chronic pain which the pain meds address, but let's assume I'd be more inclined to try living through the pain without the meds if they weren't so effective at alleviating my depression". If I'm not legally compelled, do I really want to be the guy that gets this functional, seemingly happy/content pt kicked off his pain meds and risk his relapse into depression. Studies and theory are helpful, but in the real world, Literally everything points to the fact that long term, full agonist opioids turned a non functional, hopelessly depressed person into a happy, healthy lawyer (let's save the speculation as to whether we would be better off with one less lawyer...).

Theoretical-What is the reasoning behind the taboo for using opioids for depression under any and all circumstances? I obviously understand the concerns of dependence, abuse, escalating doses, and risk of overdose of course. And for these reasons I would never consider their use for these purposes except under the most rare, and specific set of circumstances. To me that seems reasonable, but the consensus seems to be, "no, never, not under any circumstances...ever".

Ok, but why are we so willing do dispense benzos long term despite the similar risk of dependence, abuse, escalating dose, risk of OD (debatable with benzos alone), when all reputable studies show no benefit, and in fact, likely worsening anxiety. We are willing to ignore these studies/guidelines when confronted with a pt who, in our clinical judgement, seems to be more functional/better quality of life when on benzos long term, and so nearly all of us find ourselves with pts on benzos for YEARS despite all data suggesting this is not helpful, and in fact, likely harmful.

So I suppose my concern moving forward as an autonomous provider, is when is it ok to ignore conventional wisdom/studies. Pt reports/demonstrates improved functioning and relief of anxiety only when on benzos despite the fact all major studies suggest this is bad medicine ..OK, Klonopin 1mg TID...but I'm watching you.

Pt reports/demonstrates improved functioning/relief of depression only with opioids when all other tx failed...Sorry friend, even if I believed you, my hands are tied.

So are these exceptions we allow for arbitrary and simply the acceptable cultural zeitgeist in our field at the current time, or are there solid reasons why we will set aside established protocols based on numerous studies in the case of benzos for example, and allow our clinical judgement of the individuals needs prevail, but are not willing to do the same in other cases, opioids for my pt, for example?

Tough questions I know. At this point I'm arrogant enough to ask them, but humble enough to accept I'm out of my depths, and clearly need insight from others to help me come to terms with what are likely, nuanced and complex answers.
If you are a senior resident, who has created this acct just for this post, what does your supervising psychiatrist say? Aren't you getting support from the people whose licensing would be on the line as well?
 
Just sounds too good to be true. Take out Opiate and insert any other non-FDA approved treatment. "Doc the only thing that works for me is snorting coke/prostitutes/cutting/etc" (a little provocative on my end, i know).

Confront his BS, watch out for the wrath of his projective identification...
 
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So you state being good at spotting malingering/drug seeking behavior? Are you good at spotting it with intelligent, articulate lawyer types who flatter your ego by "wanting to pick your brain?" Just an online opinion that's likely worthless, but I agree with the others that this guy is pulling on you in some way, and it's worth examining your countertransference around him. The appeal of being the smarter provider who offers unconventional treatments can also be pretty big. He's special. You're special. We're all special. On that note, I agree with the others above that you really need to consider personality pathology. Namely narcissism.

BTW, I've seen this patient. They're not all that rare. IMO, colluding with his desire to get opioids is a problem.
 
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So you state being good at spotting malingering/drug seeking behavior? Are you good at spotting it with intelligent, articulate lawyer types who flatter your ego by "wanting to pick your brain?" Just an online opinion that's likely worthless, but I agree with the others that this guy is pulling on you in some way, and it's worth examining your countertransference around him. The appeal of being the smarter provider who offers unconventional treatments can also be pretty big. He's special. You're special. We're all special. On that note, I agree with the others above that you really need to consider personality pathology. Namely narcissism.

BTW, I've seen this patient. They're not all that rare. IMO, colluding with his desire to get opioids is a problem.
In my state, opiods require a physical exam.
And op I'm waiting for answers.
 
Just sounds too good to be true. Take out Opiate and insert any other non-FDA approved treatment. "Doc the only thing that works for me is snorting coke/prostitutes/cutting/etc" (a little provocative on my end, i know).

Confront his BS, watch out for the wrath of his projective identification...
Exactly right.
 
Just sounds too good to be true. Take out Opiate and insert any other non-FDA approved treatment. "Doc the only thing that works for me is snorting coke/prostitutes/cutting/etc" (a little provocative on my end, i know).

Confront his BS, watch out for the wrath of his projective identification...

So you state being good at spotting malingering/drug seeking behavior? Are you good at spotting it with intelligent, articulate lawyer types who flatter your ego by "wanting to pick your brain?" Just an online opinion that's likely worthless, but I agree with the others that this guy is pulling on you in some way, and it's worth examining your countertransference around him. The appeal of being the smarter provider who offers unconventional treatments can also be pretty big. He's special. You're special. We're all special. On that note, I agree with the others above that you really need to consider personality pathology. Namely narcissism.

BTW, I've seen this patient. They're not all that rare. IMO, colluding with his desire to get opioids is a problem.

Gotta agree here. Sure you might see the 1 in a million patient who is absolutely legit and backs everything up and really does need to be on Opiate medication for *insert whatever off label use* But those patients aren't going to be nearly as many as the well dressed, well educated, knows exactly what to say and do type addicts who are just looking for a fix and don't conform the to the image of a 'junkie'. Still I can see how it could be a difficult call to make, because there is always the chance that you'll end up shafting the one person who really does need to be on a Narcotic medication for off label purposes to protect yourself against the umpteen dozen who come through and are lying through their teeth (by the way the old adage about 'How can you tell a junkie is lying? When there lips are moving' is generally pretty accurate). All this discussion is one reason I actually like the way we have it set up here, with a Government Dept controlling who is authorised to be on Narcotics and who isn't, and who can and can't prescribe - it's one way of weeding the BS artists out.
 
When I got out of private practice and joined U. of Cincinnati, I took over another doctor's Suboxone caseload and she left as if she was running away from Dodge City.

Turned out she enabled several of her patients that were clearly violating treatment policies. E.g. one patient she was giving large amounts of Xanax and Suboxone. Another one she gave Suboxone to treat chronic pain. Another one had problems sleeping so she gave Suboxone as a sleep med and told the guy to keep on raising the dosage until he fell asleep. (Guy turned out to have obstructive sleep apnea).

So here I was, telling them all there's a new sheriff in town and I'm not prescribing like she did, of course diplomatically and nicely and half of them start screaming at my boss Im' not doing my job. My boss had no idea the previous doc was being Dr. Feelgood with her patients.

I also later figured out why she ran out of that job. The patients she enabled, she didn't have the gutts to kick them out, but felt like she was being manipulated when she gave in to them.

The chronic pain guy I didn't cut loose. Treating someone with chronic pain with Suboxone is off-label and I wouldn't start it, but it was working for him, and the old doc had him for months and I was the new guy and didn't just want to abruptly change things around until he had some time to react. I told him that I'd agree to keep him until he found a chronic pain doctor.

The old doc never should've taken the guy to begin with but he already was on the stuff when I got him. He actually turned out to be a very good patient.

BTW: there is some data that some opioids could act as an antidepressant but heck no am I giving an opioid for that purpose. Reason why I bring this up is along with the chorus echoing what I'm already saying, I've seen 1 patient go manic from his Suboxone, and several patients, once taken off of Suboxone, become depressed within a few weeks to a few months later despite no significant event other than getting off of Suboxone and had no prior history of depression.
 
Also just wanted to add that a significant effect of discontinuing opiates (and most substances of abuse) is depressed mood. My experience has been that this can be more persistent or delayed in opiate users than other substance users sometimes referred to as post acute withdrawal). It also seems more apparent in younger users of opiates than it is in younger users of other substances. In other words, a twenty-something who uses alcohol, meth, or cannabis will have a more normal range of affect at about 60-90 days whereas the opiate users appear to have more chronic affective flattening. It is especially surprising since the crash from meth discontinuation is so striking in the shorter term. Of course, with longer term users this all gets confounded by a lot of other variables, especially other health conditions. One other thing to add for OP is that it might help to get some corroboration. I don't like to be an investigator much myself, but when someone is feeding me something that sounds pretty fishy, it always helps to find out some more objective data. Sometimes it's surprisingly easy to find some significant holes in the story and since addiction has such a high mortality, I think digging a bit can be justified. Some would argue that not seeking corroborating evidence would not be standard of care (sorry for the double negative:().
 
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Also just wanted to add that a significant effect of discontinuing opiates (and most substances of abuse) is depressed mood. My experience has been that this can be more persistent or delayed in opiate users than other substance users sometimes referred to as post acute withdrawal). It also seems more apparent in younger users of opiates than it is in younger users of other substances. In other words, a twenty-something who uses alcohol, meth, or cannabis will have a more normal range of affect at about 60-90 days whereas the opiate users appear to have more chronic affective flattening. It is especially surprising since the crash from meth discontinuation is so striking in the shorter term. Of course, with longer term users this all gets confounded by a lot of other variables, especially other health conditions. One other thing to add for OP is that it might help to get some corroboration. I don't like to be an investigator much myself, but when someone is feeding me something that sounds pretty fishy, it always helps to find out some more objective data. Sometimes it's surprisingly easy to find some significant holes in the story and since addiction has such a high mortality, I think digging a bit can be justified. Some would argue that not seeking corroborating evidence would not be standard of care (sorry for the double negative:().

Among the recovering and recovered opiate addicts I've spoken to, myself included, there does seem to be a sort of running theme that a lot of us, at least the first few times we try to get clean, somehow expect the rewards of recovery are going to equal or even eclipse the cravings and the high from heroin. Of course when the heavens don't open up and start raining down showers of kittens and gold on us, it becomes all to easy to say 'stuff it' and just start using again. I found when I finally got clean, when I did a Methadone taper program, that I not only had to deal with learning how to feel again -- what were normal emotions, what weren't; what did being happy or sad or angry or anything really feel like without drugs--I also had to learn to really appreciate the little things and look at them like they were these enormous victories, because to me, they actually were. Something as simple as being able to sit at a Cafe, have a coffee, and just watch the world go by, or being able to go down to the beach for an afternoon and just sit on the sand and watch the waves come into shore ~ to most people things like that might not sound like a big deal, but when you're an addict and you've spent the last however many years doing nothing else, day in and day out, than either shooting heroin, trying to get money to buy more heroin, or being sick as a dog going cold turkey, you really, really learn to see the world differently when you've come out the other side. But yes, absolutely there is a huge emotional adjustment period.
 
I actually wonder what the OP would have made of me back in the day. I was deemed 'Gifted' and placed in a special program around grade 3 Primary School, my IQ might have dropped a few points or more since then but it's still around the 127-130 mark, my accent often gets mistaken for English instead of Australian because I can speak very properly when I have to, and I know how to scrub up and look completely professional when the occasion calls for it. I would have known just how much knowledge of medicine and different illnesses to expose, and how much to hold back (can't sound like too much of a know it all, because that might give you away), I would have presented as someone perfectly legitimate looking -- well dressed, well spoken, well mannered, personable even-- I would have known exactly what gestures to make, what facial expressions to use, whether flattery or flirtation was the best approach or should I go for the tugging on the heart strings with this particular Doctor. I also would have know who were the completely dodgy Doctors who handed over scripts without batting an eyelid, if they weren't available then I would have also known all of the Doctors who were a 'soft touch', and the ones who were stricter but could still be won over eventually with the right approach. Like I said before, and this is not something I'm proud of, those of us who get really good at this you're rarely likely to see coming.
 
not sure op is a doc
I knew that from the first post. Most of me thought everyone was playing along; a smaller part of me was concerned no one was playing along, indicating a lack of critical thinking. My assumption was that the OP is a person who wanted to know what to say to a doctor who would otherwise dismiss the idea of prescribing opiates, but it also seems like someone who feels compelled to be open and honest and bring this issue into the light. I pretty much believe everything he/she wrote, except that I believe the person who wrote it wrote about him/herself. He/she wrote very well about his/her experiences.

But a doctor would never describe a patient's experiences so personally, nor would they spend so much time researching past treatment. My state only requires doctors to keep medical records 6 years, and in my experience they do destroy them after that time is up. So this whole idea of vast treatment history and a doctor caring enough to go through it--it doesn't ring true. Nor would a doctor be able to talk about the patient's experience so fluidly.

That's why I phrased my responses more to the question of how a society allows or doesn't allow a person to abate pain through political and cultural forces. I still think the OP has valid questions, and I thought people were responding to them in a knowing way. I tend to be a bit paternalistic on some issues, but I also think we only have one life and there's no use living it in misery, so without knowing a lot about the alternatives, I tend to think a person like the OP should be given a safe way to do what it is that works. On the other hand, there's a need for pragmatism in his/her situation, which may be why he/she created this thread--to find out what a psychiatrist would report back to the doctor currently prescribing, etc, and what the current doctor would do if he/she understood the role that the medication plays. I can see how taking a poll is somewhat requisite before opening oneself up to a psychiatrist like that. To the OP, you're probably not going to find what you're looking for from a psychiatrist. They will probably not validate you. You sound very sincere and earnest and even a bit scrupulous (which often goes in with OCD). I am in not in your situation, but I could imagine writing what you did if I were. I would suggest pragmatism above all else. I can understand the need to want to take things into the light. But we can't always get that. I doubt that your prescribing situation with your current doctor would change if you were to just consult with a psychiatrist (though, there's a slight risk as you seem to realize), but I also doubt a psychiatrist would tell you anything you want to hear.
 
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I knew that from the first post. Most of me thought everyone was playing along; a smaller part of me was concerned no one was playing along, indicating a lack of critical thinking. My assumption was that the OP is a person who wanted to know what to say to a doctor who would otherwise dismiss the idea of prescribing opiates, but it also seems like someone who feels compelled to be open and honest and bring this issue into the light. I pretty much believe everything he/she wrote, except that I believe the person who wrote it wrote about him/herself. He/she wrote very well about his/her experiences.

But a doctor would never describe a patient's experiences so personally, nor would they spend so much time researching past treatment. My state only requires doctors to keep medical records 6 years, and in my experience they do destroy them after that time is up. So this whole idea of vast treatment history and a doctor caring enough to go through it--it doesn't ring true. Nor would a doctor be able to talk about the patient's experience so fluidly.

That's why I phrased my responses more to the question of how a society allows or doesn't allow a person to abate pain through political and cultural forces. I still think the OP has valid questions, and I thought people were responding to them in a knowing way. I tend to be a bit paternalistic on some issues, but I also think we only have one life and there's no use living it in misery, so without knowing a lot about the alternatives, I tend to think a person like the OP should be given a safe way to do what it is that works. On the other hand, there's a need for pragmatism in his/her situation, which may be why he/she created this thread--to find out what a psychiatrist would report back to the doctor currently prescribing, etc, and what the current doctor would do if he/she understood the role that the medication plays. I can see how taking a poll is somewhat requisite before opening oneself up to a psychiatrist like that. To the OP, you're probably not going to find what you're looking for from a psychiatrist. They will probably not validate you. You sound very sincere and earnest and even a bit scrupulous (which often goes in with OCD). I am in not in your situation, but I could imagine writing what you did if I were. I would suggest pragmatism above all else. I can understand the need to want to take things into the light. But we can't always get that. I doubt that your prescribing situation with your current doctor would change if you were to just consult with a psychiatrist (though, there's a slight risk as you seem to realize), but I also doubt a psychiatrist would tell you anything you want to hear.

This was very well said, and something I didn't consider from my own world viewpoint at least (ie of living outside of the US medical system).
 
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not sure op is a doc

If OP is indeed a patient looking for info under the radar then I'm a little hesitant to leave my previous post up, the one revealing just how guarded the medical profession has to be in the face of experienced drug seekers; however, upon consideration I'm happy enough to keep it up there for anyone else who's reading who is a medical professional, or about to become one, and who has yet to face these sorts of situations (I have no problem sharing past 'trade secrets' as it were, if it helps protect good Doctors from being duped and facing possible disciplinary actions.
 
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