On codeinefreeme we are having a discussion about codeine and antidepressants - many are reporting that their antidepressants(usually SSRI's) only started to work once they had quit codeine. I've not been able to find a reason for this - but wondered if uour experience with other opiates was similar.

Jeff

I think that one of my main concerns would be with regard to the subjective nature of the experience of the antidepressants "not working". They take up to two weeks to work even in proved depressive illness that is not related to difficult background issues, and even then the NNT is quite high. I suspect (but have no validated information on this) that we overprescribe antidepressants for this client group.

Tell me about it Jim, i have asked maybe 8 clients recently in their assessment if they have depression/anxiety, they have all said no and are all on antidepressants???? i do understand that antidepressants have other uses... but all 8 of them??

Hi having been away from the forums for awhile - sometime there is no time but anyhow think this is really important topic so will add my two-penny worth:
1) Rate of anxiety and depression in people who use drugs, especially opiates is high ++. In treatment population rate of dual diagnosis in drug users is 75%, In alcohol users 85%, the bulk of these are anxiety and depression with small numbers of psychosis, bipolar etc
2) Asking people if they have anxiety is not enough. Sorry I am not sure of your occupation Clurr but in general practice we now use HAD and PHCQ-9 - too scoring systems for anxiety and depression. They are easy to use, even by me and the result is a very good indication and we even get paid on the QOF for doing them!
3) Heard an amazing good talk at BMA recently on depression and using antidepressants and its changed my practice. With antidepressants:
a. 60% of overall improvement occurs during 1st 2 weeks of taking them
b. Half of all patients who respond to a six week trial respond in 1st 2 weeks
c. Therapeutic response is greatest in the 1st week, with a subsequent decline in the rate of improvement
d. One third of the total effect seen at 6wks was apparent in the 1st week
4) Recommendation is a) SSRI 4-6 wks fluoxetine 1st choice b) if no effect change to Mirtazepine or low-dose tricyclic (but care re polydrug use, OD and DRD with these) and if no help change ot higher dose tricyclic, venlafaxine or refer to CMHT / psy
5) Counselling / CBT can help some who want it but recent evidence is not great

Recommend assess for and treat depression if found

ps forgot to answer the original question - there is no clinical reason why you can't be on anti-depressants and codeine and if you are trying to come off codeine they may help your mood and hence help you + you may have started the codeine as self-medication for depression in the first place

sorry my point was lost in my reply... my main concern is that a lot of clients are unaware of what they are being prescribed and what it is for!! I can assess clients myself regarding anxiety/depression but unfortunately although i am an RMN i work in drug treatments and my opinion regarding clients mental health is not always valued by other nurses!!!

I have a lot of misgivings about the apparently definitive answer (even if the author is a Moderator!) – I would be interested in knowing the basis of the research upon which the figures are based and how representative it is. Part of the reason I (amicably) left mainstream general practice after 20 years as a senior partner and as a diabetic GPwSI was because of the frustration engendered by the gross mismatch between apparently objective measurements aka QOF, and what REALLY happens in the life of most of my patients. I can accept that there could be some validity for the QOF process and outcome measures for Type 2 diabetes among patients that are selected to fit the pre-selected inclusion criteria for the trials, but when extrapolated to the general public it seems to me rather obvious that the bulk of the research is inappropriately quantitatively based (rather than qualitative), and with a lot of agendas, egos, and big pharma involvement thrown in (just who did fund that Diabetes UK campaign about measuring waist circumference a few years ago, seen on every bus shelter in the land? And even if you know, did the general public?). And that is for the seemingly “physical” issue of diabetes. It is when our patients’ moods and emotions come into play then my uneasiness increases further. For five years we were bombarded with Defeat Depression literature and we now know who funded that.….. http://www.critpsynet.freeuk.c...ceuticalindustry.htm provides food for thought. My son is a social anthropologist, and he has difficulty in believing how easily the medical profession has been taken in by our easy acceptance of pharmaceutical modification of behaviour short of a clear (or at least as clear as it can be) depressive illness. PHQ-9s have him rolling round the carpet, giggling. When I tell him that our masters have recently instructed us to do them again within twelve weeks he is almost apoplectic (alright, I exaggerate a bit) at how simplistic we all are. The only way to keep him quiet is to remind him how much we coin in by filling in the boxes (THAT certainly shuts him up – he just rolls his eyes instead).

quote:

Originally posted by clurr:
sorry my point was lost in my reply... my main concern is that a lot of clients are unaware of what they are being prescribed and what it is for!! I can assess clients myself regarding anxiety/depression but unfortunately although i am an RMN i work in drug treatments and my opinion regarding clients mental health is not always valued by other nurses!!!

Weird isn't it? It seems people think we've forgetten about mental health problems when we have worked in addiction for a while.
It really warms the cockles of my heart when the psychiatric emergency team think i'm an idiot.
In fact the only care I could get for a patient one weekend was from the Police and me phoning the chap from home.

this should warm your cockles further Simon... conversation the other day between myself and another rmn
ME:my ideal job would be a dual diagnosis nurse
HER: A what???

Jim although i had to look up a few of the words you used in a dictionary (haha) I understand where you are coming from, i despair of the amount of objective measurements within mental health when essentially what we are dealing with are feelings and thought processes (measurable???). I feel quite cynical when a new 'scale' suddenly comes into favour.

Dear Jim
I am really sorry you were so upset by my answer - I was sharing a bit of a talk by Dr Philip Timms, consultant psychiatrist from Maudsley. I have just gone back to his talk and it did not have references so I will email him for them. What I was trying to say, obviously badly, that his talk had made me think / rethink about what I say in my prediscussion if someone requests or I feel might benefit from antid's.
I was not in any way defending the QOF process and regret my slightly flippant remark re payment. For me we live too much in a data collection world (even more in drugs)and I feel people can not be categorised by data. I feel most of general practice is about listening to people and I get the prescription pad out surprisingly rarely

Also interesting that we have all read the original question differently 'On codeinefreeme we are having a discussion about codeine and antidepressants - many are reporting that their antidepressants(usually SSRI's) only started to work once they had quit codeine. I've not been able to find a reason for this - but wondered if your experience with other opiates was similar' All of us, especially me have missed the point about our experience with other opiates and antid!

Forgive my ignorance - but do you continue to see the clients once they have stopped using opiates?

As a locum pharmacists it's unusual for me to continue to see clients once they no longer have a prescription to collect.

As GPs, we have the wonderful privilage of seeing people from "the cradle to the grave" which generally means seeing them for many years before they start opiates (for pre-school boosters, sprained ankles etc) and for many years after they escape from opiate use (tetanus boosters for work in the allotment etc) . Actually I think community pharmacist do as well (stuff for colouring the grey hairs etc).

I don't know if there is any neurotransmitter reason why antidepressants should work better without opiates, but I do know that people often go through a period of intensely hightenned mood shortly after opiate detox (followed later by lower mood as life problems kick in) . I have vivid memories of two occasions when patients of mine became so high, post detox, that they needed to be "sectionned" with a diagnosis of hypomania.. believing they had found the answer to all the world's problems etc.. so maybe the codeine free people are experiencing a "post opiate high" rather than a new responsiveness to the antidepressants?

quote:

Originally posted by Dr Chris Ford:
Dear Jim
I am really sorry you were so upset by my answer - I was sharing a bit of a talk by Dr Philip Timms, consultant psychiatrist from Maudsley. I have just gone back to his talk and it did not have references so I will email him for them. What I was trying to say, obviously badly, that his talk had made me think / rethink about what I say in my prediscussion if someone requests or I feel might benefit from antid's.
I was not in any way defending the QOF process and regret my slightly flippant remark re payment. For me we live too much in a data collection world (even more in drugs)and I feel people can not be categorised by data. I feel most of general practice is about listening to people and I get the prescription pad out surprisingly rarely

Gosh - upset? Me? Honestly Chris, I wasn't in the slightest. Did I rant on too much? I am really sorry. That's the trouble with text rather than face-to-face conversations. I suppose that those emoticon thingys are an attempt to get round that - perhaps I will start using them.
I think that my years on the diabetic circuit made me cynical. I tend to feel that the West has lost its bearings, and one of these aspects is the way the profession is medicalising stuff - oh dear, shades of Theodore D and sounding like him too.

quote:

Originally posted by Jeff Green:
Forgive my ignorance - but do you continue to see the clients once they have stopped using opiates?

As a locum pharmacists it's unusual for me to continue to see clients once they no longer have a prescription to collect.

Unless naltrexone is involved, I myself don't continue to see them personally here at the specialist drug misuse service, as they are being followed up by the assigned keyworker. We shake hands (male equivalent to shedding a few tears, in America we no doubt we would be giving each other high fives) and I wish them well. It is a good question though, as it does go a bit against the grain. With my other GP job hat on I most certainly would continue to see them - but I feel my role is different here, being more to keep them safe rather than continue to being involved in their life. It would be different in shared care, I am sure.

quote:

Jim although i had to look up a few of the words you used in a dictionary (haha)

I know, I know. I hear it sometimes in a less polite form ie "oh do shut up Dad, you're just being pompous again"

Just a quick observation. If the people on codeinefreeme are reporting their antidepressants only work once they have come off codeine, could it possibly be that their depression could result from a subconscious sense of shame at being drug dependent?

Would it be true to say that many of those dependent on OTC codeine never thought "drug addiction" could ever have happened to them? If they have experienced incidents like a refusal by pharmacists to sell codeine products, and now find themselves making excuses to family/friends to find the time to search out new codeine sources, combined with broken resolutions to stop, the net result is bound to be the same enduring sense of shame and despair experienced by almost every heroin addict.

From my experience as a service user I know the deep feelings of depression I can be prone to because of my drug use, not least because there is an almost constant social message, both overt via the media, and hidden, from families, friends, neighbours and the general public, reinforcing the commonly held view that drug users, simply because of our drug use, are not fit to be full members of society. We are, if you will, latter day folk devils, deserving of, at best society's pity, and at worst to be physically excluded, shunned and generally despised. For these reasons it is extremely uplifting when, as a user, one encounters the rare individual who treats us as human beings first and foremost, and if medical professionals, manages our condition without recourse to the usual prejudices and disgust at our perceived "weakness".

As someone who became dependent on opiates after deliberately experimenting with illicit heroin, that rejection was hard enough to bear, and caused much isolation. I can only imagine how much more difficult coping with these feelings would be for someone who believes the all too common negative stereotypes of drug misuse that abound. Yet they now find themselves in a position where their own cravings and withdrawal symptoms drive them to engage in similar furtive behaviour, that they once considered solely the preserve of those firmly identified as being "OTHER". Since the driving force is to satisfy their own desire for drugs, do they now consider themselves to be part of that "OTHER" group, for so long despised, and if so, surely counselling and therapy would be far more appropriate, since its roots lie in definite identifiable factors; a sense of shame at having become "drug addicts or junkies", when the simple truth is that it is nobody is defined solely by their drug use, despite what the Daily Mail and News of the World would have us believe.

Alternatively, Jeff, did you mean that posters on codeinefreeme get no relief from antidepressants while going through acute withdrawal from codeine? If that is what you meant, I'm not surprised. In my experience the acute detox/withdrawal from all opiate drugs, [and I've detoxed from a veritable smorgasbord over the years -including codeine], involves lengthy bouts of depression, culminating in, as Judith correctly pointed out, post-detox euphoria.

But during acute physical withdrawal the absolute opposite is the case, and it would not surprise me at all that anti-depressants would be completely useless during this phase.

From a totally lay point of view, having heard reports that SSRI's can increase symptoms of depression before alleviating it, would it not be true to say that SSRI anti-depressants would be contra-indicated during acute withdrawal? I'm not a Dr. so am relying on those who are to express and opinion on that one.

Just my non-professional observation as someone who has struggled with opiate dependency for many years, and knows only too well the depression that accompany drug dependency. Hope this has some relevance to the subject matter to hand, and might be of some use.

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