I recently received the following note from a reader:
I am aware of historical and recent studies where Subutex (a ‘partial agonist’ opioid called buprenorphine) was used very successfully in the treatment of depression. I am wondering if you have experience prescribing it for that, and what the success rate is? Can it be taken long-term? I am battling a very bad depression; what are my options on Subutex? Are you aware of any doctors in Michigan who work with Subutex for depression?
The gentleman raises a number of interesting questions. He also provides a glimpse into the desperation experienced by people with treatment-refractory depression. Patients with that condition describe one painful day after another, waiting endlessly for a ray of light to brighten the darkness.
People in that situation become understandably desperate, similar in some respects to those who suffer with severe chronic pain. From either position it sounds nonsensical– even cruel– to debate ‘risk to benefit ratios.’ But it is BECAUSE of that desperation, that people working in the medical field must be particularly careful to avoid taking advantage of someone who is not in a position to accurately see the downside of certain treatments.
In other words, while misery argues for fast action, it also calls for caution against those who profit from desperation. And make no mistake—there are many people out there who profit from desperation! It doesn’t take much time on self-help-oriented web sites before one’s i.p. address is registered and tracked by something as innocuous-sounding as a ‘cookie’, and the person owning the computer is officially tagged as one of THOSE people—someone who is desperate for relief from a horrible condition, who is tired of the failures of modern medicine, and who is starting to wonder if anything will help. Talk about ripe for the picking—and in no time, the spam e-mails begin to appear.
I’m torn between writing on two different topics. On one hand, I’d like to answer the reader’s question about Subutex. At the same time, I’d like to poke my finger in the eye of the people who seem to be popping up all over the place lately, offering cures from depression, addiction, anxiety. ADD, and pretty much everything in between.
Maybe it would be best to evaluate the medication that the writer asked about, being careful to remain skeptical as we consider the use of this new medication.
Opioids have ‘euphoric’ actions on mood—of that there is no argument. But there ARE questions whether opioids—in this case buprenorphine—can raise mood for an extended period of time. Most of the actions of opioids are subject to tolerance. The pain-relieving effects are clearly among that group. But there is some hope that the mood effects of buprenorphine are carried through actions on a different type of receptor—- one that does not develop tolerance. Now THAT would be a significant advancement.
There is another issue of concern. If mood is raised by buprenorphine, is the effect natural enough that the person feels normal? Or, on the other hand, is the person in a state of mania or hypomania.
The addiction issue is the elephant in the living room with the use of buprenorphine for depression. Is it worth developing a physical, and perhaps psychological, dependence on opioids for the sake of relieving the depression? Will some patients be left worse off, lacking improvement from depression but no struggling with a new addictive disorder?
I have concerns about all of these issues, and more. Some antidepressants cause long-term changes in brain function, improving depression in ways far beyond raising mood. Buprenorphine may raise mood, but if the other hallmarks of depression in the brain are not addressed, the mood elevation would be short-lived.
There are currently research trials looking at the use of buprenorphine for depression. When evaluating those trials be sure to look only at the type of research that makes it into a peer-reviewed journal. Such studies are reviewed by others who know the things to look for, to tell the hucksters from serious medical scientists. For example, I recently read about the ‘research’ into the effectiveness of ‘Prometa’, the mixture of several common drugs touted as a cure for addiction to amphetamines—provided you pony up $15,000 for the secret recipe! The studies were ‘open label trials;’ a major red flag, meaning that both the person giving the medication and the person taking it were aware of what was being taken. A proper study would use a ‘double blind’ format, where the people taking and GIVING the experimental medication have no idea whether it was the drug or sugar pills. This weeds out the placebo effect and other biases, such as the feeling most patients have of wanting to be ‘good patients’ and to do well on the medicine.
I see ads on the internet for all sorts of cocktails to relieve withdrawal, eliminate pain, and prevent anxiety; Without fail they describe open label trials and no control group—meaning that they go straight to my trash bin.
Other things to look for include the ‘power’ of the study, i.e. were enough people involved to separate the results from chance, and to make a real conclusion? A ‘study’ that shows individual patients, rather than averages from large collections of data, is unlikely to offer predictive findings. Also, who PAID for the study—an independent agency, or the manufacturer of the medication?
You get the idea. The writer mentioned a web site called clinical trials.gov; any study listed there will have the basic hallmarks of good research. If you visit the site, you’ll see that a number of important studies are underway. Unfortunately, medical science is SLOW- VERY slow.
Bottom line, my own biggest concern about the use of buprenorphine for depression is that while depression is a serious condition, so is opioid dependence. I cannot recommend starting a patient on an opioid in order to treat depression, no matter how severe the depressive symptoms. Depression is associated with suicidality- but opioid dependence is associated with overdose, and also with suicidality.
I don’t know any doctors who prescribe Subutex or buprenorphine for depression. I’m sure there are a couple out there, and if you call around enough you’ll find someone. The chance that someone not familiar with buprenorphine would prescribe the medication is low, so you would likely do best starting with doctors at the NAABT.org web site.
I realize you are in a very tough situation. Please be careful, and recognize the added risk that desperation brings to the equation. The most common antidepressants are the most common for a reason: they tend to work the best for most people. Please follow up, and let me know how things work out for you.
Photo by Tanmoy Acharjee, available under a Creative Commons attribution license.