Talk:Opioid/Archive 02

From Wikipedia, the free encyclopedia

Archive This is an archive of past discussions. Do not edit the contents of this page. If you wish to start a new discussion or revive an old one, please do so on the current talk page.

This is Archive 2, which cover discussions which began in 2005.

Contents

diamorphine (heroine)

Why does diamorphine have its streetname commented next to it? Should other opioids have their most common name next to them? such as Oxycontin - OxyCodone, Vicodin - HydroCodone, etc..

There is a difference between a "street name" and a brand name. Oxycontin and Vicodin are brand names for oxycodone and hydrocodone respectively. Heroin was once the brand name for 3,6-diacetylmorphine. Diamorphine is the International Nonproprietary Name (INN), and is the preferred naming convention for Wikipedia drug articles (see WikiProject Drugs). The name heroin, however, has come into common medical use over the last century as a generic name for diamorphine, hence the dual-naming presented on this page. I do not feel is is practical or necessary to place the "most common" brand names beside the INNs listed because these vary internationally and would prove unwieldy to list on this page. They are already listed on most of the individual pages, however, and thus a Wikipedia search would easily find the relevant page. Techelf 10:28, 31 Mar 2005 (UTC)
Ok, that makes sence.
No, it really doesn't. Many street drugs, even well-established and high-volume street drugs, such as diamorphine (why they leave the '-cetyl-' out is beyond me) or methamphetamine, have multiple street names even in one language. This problem is prevalent especially in the USA where a Floridian teenager buying 'crip' from a Californian 'grape' dealer will get the product he desires.
Moreover, Oxycontin is a brand name for controlled-release oxycodone; the typically used US brand name for stand-alone oxycodone is generally Roxicodone. DrMorelos 01:17, 25 November 2006 (UTC)

Motion Euphoria

Can opiates cause Motion euphoria?

Future Uses of Opioids

Another future use of opioids might be to protect against ischemia/reperfusion injuries, particularly in the heart. The proposed mechanisms involve actions on potassium pumps, protein kinase C, or potentially nitric oxide synthase. I'm doing a literature review on this aspect at the moment, but if someone who's already up to speed on the issue (and who knows that they want to jump in and include this in the current article) wants to put a line or two in, go right ahead :)

While this is still relatively cutting-edge stuff, it might also give readers an idea of how opioid receptors act in non-neural tissue.

For a review on opioids & cardioprotection, I'd recommend Schultz & Gross, 2001. Pharmacology & Therapeutics 89:123-137.

Cheers; Potatophysics 09:48, 9 September 2005 (UTC)




receptor types

I was reading the discussion of the definition of 'opioid' and what I was thinking is that in the age of pharmacogenomics, an opioid is any ligand that binds an opioid receptor (is that tautological?). To that end, I added some brief info on receptor types and subtypes to give a summary of info that is presented in greater detail on the pharmacology page. One other thing: in the reading I have done, the sigma opioid receptor mediates some properties of dysphoria and hallucinations and is listed as having specific agonists such as pentazocine, yet on the pharmacology page, it says that the sigma receptor has been found not to be a true opioid receptor. Am I behind the times? Thanks! Awolf1 16:46, 22 November 2005 (UTC)

anti-dysphoric effect

I found no discussion of clinical use of opioids in cancer patients without pain, so I added this paragraph: "Opioids can be used to anti-dysphoric effect (that is, to neutralize anxiety and depression) in cancer patients and other disease victims who suffer from misery but not from pain." Here's why:

I saw cancer patient A, during chemotherapy, suffer from 18 weeks of nausea, unremitting fatigue, and I-wish-I-could-die misery (but no pain, so no Vicodin).

I saw cancer patient B, during chemotherapy, feeling "pretty good" and running errands six days after the infusion. B had pain during the three worst days after infusion, but otherwise no pain before or after. Despite the lack of pain, B took 4 Vicodin (5/500) a day (doubling or tripling during the three worst days after infusion). One day B forgot to take his Vicodin for over 8 hours, and found himself curled up in a fetal position, with debilitating fatigue and a feeling of pervasive misery. This dysphoria lasted until one hour after he realized he had forgotten his Vicodin, and swallowed one pill. Two hours later he swallowed a second Vicodin and an hour after that he was running errands again. B later experimented with himself and confirmed the inverse relationship between Vicodin and debilitating misery.

I saw cancer patient C, asymptomatic, not in chemotherapy -- glum, anxious, and brooding when not on Vicodin, relatively cheerful and fully productive when on Vicodin (4 per day, 5/500). C says that SSRIs seem to do little for him; Ativan 1 mg helps; but nothing quite does the job like Vicodin. He also says that he feels no urge to increase his dosage.

I have no medical training. I have researched this issue because some friends have cancer. I leave it to the experts to correct the paragraph I added. I hope no one would simply remove my paragraph and leave the issue unaddressed. - TH

You hope too much as someone already removed it even though opioids are effective at blocking emotional pain. This is why unhappy people become hooked on them. I might suggest your friends look into psychedelic therapy using MDMA, LSD, psilocybin or ayahuasca. --Thoric 23:34, 29 November 2005 (UTC)

Thanks for the breath of humanity, Thoric.

I'll just keep replacing and improving my paragraph until (a) some owner or moderator (if such exists in the Wikipedia world) stops me, or (b) someone provides a better explanation than mine of the issue of non-pain-targeted clinical use of opioids -- an issue heretofore ignored by this Wikipedia article.

A better explanation will minimally cover all the questions discussed in this Discussion since my earlier post.

Jfdwolff's imperious and dismissive treatment of my initial paragraph inspires me to promote myself to be the judge of whether any explanation is better than mine, again unless some Wiki owner or moderator overrules me.

Those psychedelics you mention, Thoric -- they aren't big guns in the anti-misery department, are they? I mean like the "18 weeks of nausea, unremitting fatigue, and I-wish-I-could-die misery" that I mentioned. Statements such as "there is no upper limit to the dosage and the achievable pain relief" (what Wikipedia - Opioid says about opioids) don't apply to them, I believe.

Folks, help me out here. I have no medical training, as I said. So tell me "your friends A, B, and C are atypical -- opioids wouldn't help most chemo patients against non-pain chemo misery". Or tell me that "it probably would work". Or tell me that "we don't really know, but it's worth six Vicodin pills one day to see what happens".

And tell me "your issue might be valid but it's confined only to the chemo period. After the last chemo period, terminal patients feel no negative symptoms except for anxiety and depression (prescribe anxiolytics and anti-depressants) and physical pain (prescribe opioids) and miscellaneous other complaints (nausea, constipation), which opioids won't help -- but they never feel just non-pain I-wish-I-could-die misery". Or tell me otherwise.

And tell me what jfdwolff's "rv NOR" means.

I think that the medical world is afraid of moral hazard. Dependence is meaningless in the terminal world (else hospice wouldn't have a morphine drip), and addiction is too.

It's moral hazard that scares the medical world. Tell me if I'm wrong. It's moral hazard that makes jfdwolff say "one shouldn't use opioids for that". It's moral hazard that made one doctor tell my friend "we don't want you taking them for the wrong reasons". So remember that in all the cases I am referring to, THE DOCTORS HAVE THE CT SCANS of the tumors. Don't get off the track. The moral hazard in my examples is zero. - TH

It is true that in patients with fully-functional CYP2D6 and related liver enzymes, most opioids offer varying degrees of dryness, constipation, euphoria, calm, patience, temperance above and beyond those patients' typical norms. Some also feel energetic. This action is partially suggestible but mostly not so. Benzodiazepines such as Ativan (lorazepam) are known on the street as "chill-pills" for a reason; they lower a person's level of emotional upset. Professionally I would use alprazolam or oxazepam for a cancer patient presenting without seizures, as they are both a bit better about reducing emotional upset; lorazepam is better as an anti-convulsant. I apologize for inserting my response here but I really can't make sense of where someone's rambling starts and stops. Perhaps I'm getting "mentally old." I am the lowest rung on the "doctor" ladder in my position, but I am the youngest and least experienced. That doesn't make me more stupid than the rest of us, though; anyone worried about curing someone's opioid withdrawal shoud look into ibogaine which (has tremendous potential as a supplement to behavioral therapy and) is vehemently banned in the USA and will stay that way as long as methadone replacement clinics are available. Why offer a fairly quick cure when you can sell a cross-tolerant and very dangerous trade-off that the ex-heroin user must buy every day?
You should also know that as patients age, their receptor sites become more resistant to reshaping. The implications are that the same dose of morphine every 6 hours will have a higher efficacy for a substantially longer period of time in an 86-year-old patient than in a 26-year-old patient. Likewise dependency and addiction are harder to form, and in a 86-year-old terminal patient, your statement about their irrelevance is well-understood in the medical world. I hope this helps clear up a few of your questions. DrMorelos 01:29, 25 November 2006 (UTC)
Firstly, could you please be more concise? Secondly, NOR is one of our important policies. In the absence of a good reference, citation or other outside support, your contribution gave me the impression of advocating a treatment that is not proven for this indication, nor actually being used. That would be "original research", for which there are other outlets but not Wikipedia.
My rv is very common practice for material that has no outside support, and my reaction was hardly a "imperious and dismissive treatment". Please assume good faith when editing Wikipedia. It saves time. JFW | T@lk 13:24, 30 November 2005 (UTC)
I've done a quick Google, and this is what I learned: research indicates that stimulation of the κ-opioid receptor can cause dysphoria as well as nausea. Withdrawing from opioids or antagonism with naltrexone can similarly cause dysphoria. I don't dispute the stories about your friends, but on a larger scale there is no good indication that there would be any point in using Vicodin or any other opioid for low moods. Your preaching because of my simple revert was really unwarranted. JFW | T@lk 13:33, 30 November 2005 (UTC)
I would think that opioids causing dysphoria (not during withdrawal) would be a rare case. Opioids are documented to block pain, both physical and emotional. Certainly that emotional pain may come back with a vengeance as the effects of the opioids wear off, and tolerance to its effects on emotional pain may develop more quickly versus that of physical pain, I would still be as bold to say that for some people opioids provide a bonus side effect of an anti-dysphoric. It should also be noted that opiates (including opium, laudenum, morphine, heroin) have historically been prescribed for countless things, including dysphoria up until the 1930s or later. Tramadol is currently being prescribed as an anti-depressant despite being an opioid. (You may want to note that valium which was prescribed as an anti-dysphoric 30 years ago, is more addictive than heroin.) --Thoric 19:30, 30 November 2005 (UTC)
Thoric, just look at the evidence! It is reported all over the show that opiods may cause dysphoria. Evidence is better than theories. I'm happy for these assertions to be inserted into the article if you can provide the evidence. I'm not sure what your point is about valium; if it works, why avoid it, especially in cancer patients! JFW | T@lk 20:45, 30 November 2005 (UTC)
Withdrawal from opioids can cause dysphoria. Withdrawal from benzodiazepines such as valium can do the same and much worse. Opiates have historically been prescribed for mood disorders, and tramadol is currently being prescribed as an anti-depressant. Vicodin users have noted that it improves their mood, and none of these things is news, or rare cases. I'm not saying that opioids are a good choice of antidepressant. --Thoric 22:04, 30 November 2005 (UTC)
Okay. So mu agonists cause euphoria and kappa agonists dysphoria[1]. Dysphoria is a side-effect of many known opiods[2]. It follows that those opioids with more mu than kappa effect would be nice euphorics. Good. But dysphoria is certainly not limited to withdrawal, like you suggested in boldface. JFW | T@lk 22:44, 30 November 2005 (UTC)

non-pain-targeting use of opioids for physical relief

Jfdwolff at first provided nothing but a moral rationale ("should") for removing my paragraph on non-pain-targeting clinical use of opioids; that moralism kept me from assuming good faith on his or her part, which got us off the wrong foot, but I believe that is all behind us now that we are all talking facts.

The primary issue for me is physical misery -- not moods, not emotions, not physical pain.

TH 00:21, 2 December 2005 (UTC)

What do you mean with "physical misery"? I was not giving a moral rationale, by the way; "should" reflected clinical indication. I wish you wouldn't try to read my mind :-). JFW | T@lk 01:00, 2 December 2005 (UTC)

"Physical misery" or "physical suffering" to me is when my friend curls up in a fetal position and doesn't move for hours; finds, say, writing out a check to be an almost unbearable ordeal; finds the sound of someone crumpling a piece of paper to be a torment; says "I feel like shit"; says "I wish I could die"; says "This isn't worth it"; says "I feel a terrific fatigue, but this is far beyond anything I've ever thought of as fatigue"; says "I have no pain"; says "I often have nausea but not for the last several days but I'm still almost as miserable as when I had nausea". When asked "are you suffering from anxiety or depression?", answers "really no, and to the extent that I am, it's entirely secondary to the physical misery". This friend was well known to be emotionally healthy before the cancer diagnosis.

I know that the medical doctors have a taxonomy analogous to the social doctors' DSM-IV. Does that taxonomy contain a category for physical misery and suffering that is not pain, not nausea, not constipation, beyond fatigue, and so on?

TH 02:42, 2 December 2005 (UTC)

Fatigue in cancer patients is well recognised and very hard to address. I'm not sure if anyone prescribes stimulants for this indication, but opioids would simply make one drowsy and increase risk of nausea (1 in 3 for new administration). I find it plausible that people feel rotten after hearing they've got cancer, but again opioids are not the answer.
Again, most opioids carry a risk of dysphoria as a result of κ-receptor stimulation. The best answer for fatigue is counselling, taking frequent breaks, adequate nutrition and outside stimulation. JFW | T@lk 03:07, 2 December 2005 (UTC)

My definition of "'physical misery' or 'physical suffering'" a few paragraphs up from here describes, by the way, "Patient A", whom I discussed farther above. And we're in luck, because Patient B, whom I also discussed farther above, is in the 2nd week of chemo, happens to have no pain, happens to have a prescription for Vicodin (uses four 5/500 per day, spiking just after infusion). I'll keep you posted on the results of this tiny experiment. Meantime, read about Patient B above and note that the facts of B's experience so far bode ill for jfdwolff's speculations.

Patient A, two years out of chemo, gave a look of derision (sorry, just reporting) at every one of jfdwolff's four recommendations ("frequent breaks from catatonic immobility?" she asked. "He's not even addressing chemo -- he's completely out of touch").

Patient B says the anxiolytics cause some drowsiness but the four Vicodin per day either don't or are overwhelmed by B's two cups of coffee per day.

(By the way, Patient A and Patient B are friends to each other and often discuss chemo.)

Your statements such as "most opioids carry a risk of dysphoria" always confuse me. I have not figured out an interpretation other than that you're saying "the greatest euphoric known to humankind ironically causes, in a small minority, dysphoria -- conclusion: do NOT try half-a-dozen pills one day to see whether you happen to be in the majority or in the minority". Please explain.

And about your "1 in 3 for new administration" -- then does it get worse, or do most of the new administrations get used to it and nausea settles down to 1 in 10 or 1 in 20? Again, are they all incapable of deciding for themselves whether the tradeoff is net beneficial to them?

TH 04:50, 2 December 2005 (UTC)

Uhh, you are putting words in my mouth. I am more than a bit worried about your insertion that medics "deny" cancer sufferers opioids when they're not in pain[3]. What is the assumption? That a fatigued cancer patient should be on opioids? Where (apart from the small sample of your sick friends) is the evidence that this would work? What makes you think that the next patient who takes Vicodin for "non-pain cancer symptoms" does not get a dysphoric reaction? Please, please tell me why your insertions are not original research (please read this vital policy).
Again, I sympathise with your poor friends, and if they derive benefit from opioids - fine. But unless you cite strong evidence for your position this will have to stay out of the article. I'm sorry. Wikipedia policy. Really. Not just my "moralising" views, or whatever label you want to stick on me. Perhaps we should ask other Wikipedia editors what their views are (requests for comment). JFW | T@lk 08:47, 2 December 2005 (UTC)

Could you respond to my last two questions and my "Please explain"? TH 09:34, 3 December 2005 (UTC)

  1. Please explain - there are better drugs for dysphoria than opioids, which are addictive, cause constipation, nausea, hallucination and occasional paradoxical dysphoria. I will not rehash all the stuff again.
  2. Does nausea get worse? - no, the majority improves after a brief course of antiemetics. But if there are better pills then it is not very nice that your new anti-dysphoria drug makes you puke.
  3. Are they all incapable of deciding for themselves - prescription drugs are prescription drugs because their only real use is as medication. Doctors are trained to assess medical problems and to decide what type of treatment would be most suitable. The government doesn't want people to decide this for themselves, no. This is especially so with opioids, which are commonly abused. There are probably a lot of people who would be very sensible and could be trusted to prescribe themselves medication, but they are in a minority.
If you don't mind I'm going to stop responding unless you have some very significant new information, such as a solid reference. JFW | T@lk 22:53, 3 December 2005 (UTC)

ludibund

Come on, no one really uses this term "ludibund". Someone (Jonathan Ott?) made it up by pseudo-back-translating to Latin, to avoid the word "recreational", right? But it never caught on, so why is wikipedia using an unknown dodge-word as a topic heading?

TH 00:36, 2 December 2005 (UTC)

It is because "abuse" is insulting to the "recreational" community, and "recreational" is an understatement to the medical community. JFW | T@lk 01:00, 2 December 2005 (UTC)

Tramadol

Tramadol, mentioned above, seems to be US FDA-approved for pain, not for depression; and it's on Public Citizen's list at WorstPills.org, so I'm not inclined to cite it.

TH 00:41, 2 December 2005 (UTC)

What does WorstPills base itself on? JFW | T@lk 01:00, 2 December 2005 (UTC)

I have no idea -- I did not pursue it. I hold no brief for them, but because of their listing and more importantly because of the FDA indication, I decided to spend my time on issues other than Tramadol.

nonclinical use -- major reorg

The old version was fatally flawed, I believe -- starting with the fact that the two headers "Opioid Abuse" and "Ludibund use" implied that some recreational use is not abuse -- and right there in the headers you have a POV that many would disagree with.

During alcohol prohibition you could say the same about alcohol — that any non-medical use of alcohol was abuse. Today, one can drink wine with dinner without being called an alcohol abuser. Also during prohibition, a considerable number of teetotallers used opioids (opium, morphine and heroin) as an alternative to alcohol. Now things are the opposite way around. Does that negate opposing POV? I think not. --Thoric 22:20, 5 December 2005 (UTC)

Secondly, "ludibund", meaning "playful", is just an obscure synonym for "recreational", and is thus subject to all the non-neutrality of that term.

Obviously you don't understand how POV works. The article is a collection of information and points of view, and what makes the article have a neutral point of view, is by presenting all points of view without trying to favor one over another. I suggest you actually read Wikipedia:Neutral point of view. Thanks. --Thoric 23:40, 5 December 2005 (UTC)

I could go on.

WP:CITE. Please. JFW | T@lk 04:25, 4 December 2005 (UTC)

OED (uncondensed edition only). "Obsolete".

TH 19:55, 5 December 2005 (UTC)

Citation switched from Rossi to Drug Facts and Comparisons

No offense intended toward Australian readers and writers, but I clarified and added info by switching from Rossi to Drug Facts and Comparisons, widely available in the US (unlike Rossi) and therefore more meaningful to and verifiable by a larger fragment of the world population.

Drug Facts and Comparisons was indicated to me by a medical university librarian as the most authoritative and independent source of drug information. I think she said that DF&C got its information from Medex, but I'm not sure about that. DF&C is at factsandcomparisons.com.

Note added info: "sole", not "main"; anesthesia; methadone for detox; and the four "only" restrictions.

TH 17:27, 8 December 2005 (UTC)

"anxiety", "according to"

Oops -- I forgot to mention the other info change -- oxymorphone is indicted for "anxiety due to dyspnea", not "dyspnea".

I added "according to" to imply that DF&C is not the be-all-end-all -- other authorities may differ.

Why doesn't Wikipedia automatically sign my Talk for me?

TH 17:53, 8 December 2005 (UTC)

Put ~~~~ after your posts. JFW | T@lk 05:29, 9 December 2005 (UTC)

Sure I do, thanks, the 70 percent of the time that I remember. What doesn't make sense to me is that Wikipedia doesn't do it AUTOMATICALLY, as a default. The could say "type '-(four tildes)' if you do NOT want to sign".

I remembered . . . TH 07:13, 9 December 2005 (UTC)

Hmmm. Probably because the Wiki wouldn't know where to automatically put your signature. It would have to run a diff after saving the edit, putting more strain on the server than a simple transinclusion. 07:28, 9 December 2005 (UTC)

less euphoria; unequal tolerance

The more I read, the less I see evidence that "most opioids produce euphoria in most people". For example, Reynolds et al., Morphine and Allied Drugs, says codeine does not generally produce euphoria. Lacking evidence, I think we have to go with the weaker statement.

Also, I haven't found evidence that the rate of developing tolerance is the same across all effects. I've found hints to the contrary. Lacking evidence, I think we have to go with the weaker statement. I cite Weil for the exception of constipation.

TH 07:09, 9 December 2005 (UTC)

Controlled Substances Act; British system

Controlled Substances Act:

Way, E. Leong (Department of Pharmacology, School of Medicine, Universtiy of California, San Francisco, San Francisco, California, USA), "History of Opiate Use in the Orient and the United States", in Opioids in Mental Illness: Theories, Clinical Observations, and Treatment Possibilities, edited by Karl Verebey, The New York Academy of Sciences, New York, New York, 1982, p. 22.

British system:

Berridge, Virginia (Institute of Historical Research, University of London, London, England), "Opiate Use in England, 1800-1926", in Opioids in Mental Illness: Theories, Clinical Observations, and Treatment Possibilities, edited by Karl Verebey, The New York Academy of Sciences, New York, New York, 1982, p. 9.

TH 22:08, 18 December 2005 (UTC)

The DF&C table is correct now

The table from Drug Facts and Comparisons has gotten bounced around a bit and damaged. I have just fixed it and double-checked every line against my photocopy from DF&C 4.0. The photocopy that the university medical librarian made for me after recommending DF&C as the most authoritative and impartial source.

I know nothing about indications in countries other than the US.

TH 04:22, 19 December 2005 (UTC)

http://www.bnf.org.uk for the British system. JFW | T@lk 08:40, 19 December 2005 (UTC)