Source: American Journal of Psychiatry
Date: 156:2017, December 1999
Date: 156:2017, December 1999
Treatment Augmentation With Opiates in Severe and Refractory Major Depression
ANDREW L. STOLL, M.D. and STEPHANIE RUETER, B.A.
Belmont, Mass.
To the Editor: Substantial evidence supports the antidepressant efficacy of opiates (1). This report summarizes our open-label experience using the µ-opiate agonists oxycodone or oxymorphone in patients with highly refractory and chronic major depression.Letter to the Editor
Mr. A was a 44-year-old man with severe and chronic depression. Numerous
trials of antidepressants produced only limited benefit. Mr. A also had an
extensive history of opiate abuse, and he noted that the only times he ever
felt normal and not depressed was during opiate use. Because of the refractory
nature of his depressive symptoms and his apparent self-medication with
opiates, Mr. A was given a trial of oxycodone under strict supervision. After
18 months of oxycodone treatment (10 mg/day), Mr. A remained in his longest
remission from depression without the emergence of opiate tolerance or abuse.
Ms. B was a 45-year-old woman with bipolar disorder and opiate abuse (in
remission for 2 years). A trial with standard mood stabilizers had failed, and
she had experienced mania with several standard antidepressant drugs. As with
Mr. A, Ms. B reported feeling well only when taking opiates, particularly
oxymorphone. Oxymorphone (8 mg/day) was thus cautiously added to ongoing
lamotrigine therapy (as a mood stabilizer), and she remained well for a minimum
of 20 months without drug tolerance or abuse.
Mr. C was a 43-year-old man with chronic major depression that was
unresponsive to numerous antidepressants with and without augmentation.
Detailed questioning revealed that he once experienced marked antidepressant
effects from opiates that he received after a dental procedure. There was no
history of opiate abuse, and a cautious trial of oxycodone was initiated. Mr. C
experienced a dramatic and gratifying antidepressant response from oxycodone
(10 mg t.i.d. for 9 months) without opiate tolerance or abuse.
This report describes three patients with chronic and refractory major
depression who were treated with the µ-opiate agonists oxycodone or
oxymorphone. All three patients experienced a sustained moderate to marked
antidepressant effect from the opiates. The patients described a reduction in
psychic pain and distress, much as they would describe the analgesic effects of
opiates in treating nocioceptive pain (pain arising from the stimulation of nerve cells).
Two of the three patients described in this report were previous abusers
of opiates. Although the clinical use of opiates in patients with a history of
opiate addiction is usually contraindicated, in these cases there was a strong
indication that they were self-medicating their mood disorders (2) with illicit
opiates. None of the patients abused the opiates, developed tolerance, or
started using other illicit substances.
We used oxycodone in three additional patients without histories of
opiate abuse. In two of these three patients, oxycodone produced a similar
sustained antidepressant effect. Two of these patients experienced
mild-to-moderate constipation, and one experienced daytime drowsiness from the
opiates. Opiates should be considered a reasonable option in carefully selected
patients who are desperately ill with major depression that is refractory to
standard therapies.
REFERENCES
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Khantzian EJ: Self-regulation and self-medication
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