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Taking multiple psych drugs? Which drug to taper first?

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Shep

Bubble and Elbee, this is an article I came across dealing with antidepressants and benzodiazepines (and other drugs) and how they can increase / decrease blood levels of each other:

 

What are some drug interactions for anti-anxiety drugs?

 

From the article:

__________________________________________________________________________

 

Alprazolam increases blood levels of the antidepressants imipramine and desipramine. Alprazolam may also interact with some calcium channel blockers and with grapefruit juice. Carbamazepine decreases blood levels of alprazolam.

 

Combining benzodiazepines with alcohol or other central nervous system depressants can cause increased sedation and potentially dangerous respiratory depression.

 

Fluoxetine, propoxyphene, and oral contraceptives increase blood levels of alprazolam (Xanax), as do ketoconazole, itraconazole, nefazodone, fluvoxamine, and erythromycin.

 

Oral antifungal agents such as ketoconazole and itraconazole may significantly decrease blood levels of clonazepam (Klonopin).

 

Serious side effects, including respiratory arrest, may occur if lorazepam (Ativan) is combined with clozapine. Dosage of lorazepam should be halved when taken with valproate or probenecid.

__________________________________________________________________________

 

The article lists a number of other interactions involving psych drugs and other drugs. It also mentions the fact that Wellbutrin lowers the seizure threshold, so people tapering off a combination of Wellbutrin and a benzo need to keep that in mind. 

 

So these drugs do play off each other. 

 

There are also some articles in PubMed about this:

 

A Case of Suicidal Thoughts With Alprazolam

 

From the article, citing how fluoxetine (Prozac) interacts with alprazolam (Xanax): 

__________________________________________________________________________

 

Fluoxetine significantly increased the half-life of alprazolam from 17 hours to 20 hours and significantly decreased its clearance from 61 mL/min to 48 mL/min. The mechanism of action is thought to be through inhibition of the cytochrome P450 3A4 isoenzyme, which is responsible for alprazolam metabolism.

 

__________________________________________________________________________

 

And you can probably find other articles out there, as well. 

 

 

Edited by Shep
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elbee

Thanks for your reply, Shep. I don't see anything in that article specifically about Zoloft and Klonopin. Here is one that does . . .

 

"Ambien, Ativan, Neurontin, and Klonopin should all be avoided while taking Zoloft. The risk of central nervous system and respiratory depressant effects are greatly increased if these medications are combined. This can lead to confusion, decreased motor function, difficulty breathing, blurred vision, low oxygen levels and even sudden death. These side effects are greatly increased in elderly and debilitated patients. If a patient is prescribed one of these medications while on Zoloft, they should talk with their doctor to ensure safety."

Source: Zoloft Drug Interactions (Sertraline) - Drugsdb.com http://www.drugsdb.com/rx/zoloft/zoloft-drug-interactions/#ixzz4l41pN1he

 

However, I never see any specific research cited on these "curation-based" public websites. Also, the warnings that are proclaimed differ from site to site. I really haven't found a source for cumulative researched-based information yet that I trust. I know some folks on this site have gone deep into looking at the actual research published, but I haven't done that.

 

In short, I've no doubt there are probably interactions between the two drugs I'm on. I just don't trust any source out there to tell me what they are likely to be, and how likely it is that I might experience the effects. So again, I guess I'm just trying to listen to my body, which is generally easier when I'm tapering more slowly and much harder when I've picked up the pace.

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savinggrace

Hi Elbee,

I have not been actively participating for almost a year now, though I recently started getting emails about threads I had been following.  This lead me to your topic which I am very interested in.

 

As you can see from my signature, I have been poly-drugged for many years, with the current three for almost 15 years.

 

You are right.  As you taper one drug, it changes everything.  The ratio of the drugs to each other changes, thus, what you are feeling is either withdrawal or increased or decreased side effects from any or all of your drugs.

 

Three years ago when I hit the wall tapering valium, I researched the heck out of my drugs, and drug interactions in general.  I came to a conclusion about my combo that has proven to be true.  Trileptal (oxcarbazepine) is an inducer of many drugs.  It is metabolized extensively by the CYP450 3A4 enzyme, which metabolizes about 50% of all drugs.  BTW, trileptal is second generation tegretol, so in researching its induction effects, it does not always show up on all of the CYP450 interaction charts, but it does most of the time.  I hypothesized that since trileptal was an "inducer" of valium, and possibly even remeron (depends on which chart you look at) it means that my trileptal dose was speeding up the metabolism of valium and remeron, rendering them less effective.  An inducer of a drug increases its potency for a very short time but then it clears it out very quickly.  So, I thought, hmmm, if trileptal is clearing the valium and remeron out of my system too quickly (depending on the drugs, the clearance rate can be increased by 80%), what if I lowered my trileptal?  Wouldn't that make my valium and remeron stick around longer, either making them more effective or at least not causing withdrawal between doses?

 

So I took a chance and tapered now nearly half of my trileptal in 2 1/2 years.  (yeah, I know that's slow but for me it's huge)  What did I notice?  After the first 75 mg. were gone, I was sleeping significantly better. This was huge for me because sleep is my Achilles' heel and always has been.  The valium and remeron are indeed staying in my system longer.   I had to take a break after cutting 75 mg. (25 at a time) and have tapered the next 60 very slowly.  That said, I have still been very sick and in withdrawal, but I have NEVER felt well, even way back when I started on these drugs. Frankly, I think it is time for me to take a long break and perhaps start micro-tapering the remeron next (I want to make it to 150mg trileptal first; half a 300 pill)

 

I will write more later and clarify if you have questions.  I have spent  hundreds of hours studying drug interaction and you are so right.  When we reduce one drug, we are messing with all of them.  If only all of us had been wise enough to do what Rhiannon is doing right from the start.  None of this means I know what to do next...are the side effects of valium and remeron getting worse now that they are sticking around longer?  Am I ill because of my trileptal taper or the change in drug-drug interaction?  I suspect all of these things are true.  There are no easy answers, but there is some science and logic to consider (even though doctors and pharmacists are clueless)

 

Congrats on your journey off remeron and  tackling klonopin...I admire your determination.  When I get a chance I may look at the CYP450 charts to see what kind of drug interactions there are between zoloft and klonopin.  Also, it is very wise to take information, consider it, but then ultimately listen to your body.  NOBODY is living w/ your brain, body, genetics, environment, and when poly-drugging is in place, it always a bit of russian roulette.  Sometimes we just have to make a choice and live with it, until we get a clue to do something different.

 

I wish you well,

Grace

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savinggrace

Hi Elbee,

 

Perhaps I should have done my homework first.  Google searches on these drug interactions bring up conflicted findings, but I always look at multiple sites to get the best idea of what is currently known.

 

A somewhat short search for zoloft and klonopin found zoloft as a CYP3A4 inhibitor with klonopin as a CYP3A4 substrate.  This means klonopin needs the 3A4 enzyme pathway to metabolize the drug and the zoloft can inhibit that, making the drug build up in your system faster, thus, perhaps, making side effects worse.  Now, to be clear, there are hundreds of chart out there, and they all don't agree on which drugs are substrates, inhibitors and inducers.  One thing I have learned for sure, though.  If anyone is taking an AED, like tegretol, trileptal, etc., they are taking a strong CYP3A4 inducer, which is why I am choosing to get this trileptal out of my system first.  No one should be put on these drugs with other pysch drugs.  It took me 12 years to figure this out.

 

The long and the short of it, Elbee, is there is probably something going on between your two drugs, and it is likely not good either way, but the only solution for us is to get these dang drugs out of our systems. 

 

I know this is all pretty technical, but I have spent a lot of time trying to understand it.  Here is a link that is pretty easy to understand about interactions in general. https://liferaftgroup.org/long-list-of-inhibitors-and-inducers-of-cyp3a4-and-cyp2d6/

 

As I said there are hundreds of charts listing all classes of drugs and which enzyme pathway metabolizes them.  It is important to remember that much of this research is not exhaustive and could not possibly test every drug and every drug-drug interaction.  At least you are way ahead of this game by having eliminated remeron which would have thrown another monkey wrench into the formula.  I see my psychiatrist in a few days, and I would like to rant and rave at him about how he has ruined my life, but I will do what I have to do to get the drugs I need to follow the (current) very slow taper that I know is all I can handle.  If this is all too much to digest, then just go with your gut and hope that your intuition and thoughtful consideration of the ifs and buts is right.

Grace

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elbee

Thanks for sharing your thoughts, experiences and references Grace. You've obviously put a lot of effort into understanding enzyme metabolism! I took a look at some of the charts you mentioned and yes, there are discrepancies. It's also not always clear to me who has been doing the research that the data is based upon, nor methodology. I saw some data by the Mayo Clinic Labs so it does appear that there are some "big players" involved in looking at this. Is that a "good" thing? Who knows. What I do know is that conflicts of interest abound and I generally assume self/corporate interest plays some role in most information I come across.

 

What frustrates me (scares me) is that the stakes are so high. What could be more relevant to me than my own consciousness and how I experience the world? We know so definitively little about it all, regardless of vantage point (biological, physiological, evolutionary, genetic, psychological, spiritual, etc.). And of course, there are countless variables involved. So while I try to continue to educate myself because ultimately it's up to me to discern and make the best decisions for myself, I also have to keep in mind that there are SO MANY more "moving parts" here that I (and we as humans) have no clue about. At some level, I have to "let go" of trying to control, fix, and/or figure things out. There is a time and place for my thinking brain to be involved, no doubt. And I'm also learning that I can also get in my own way . . . that I need to open myself to other "resources/wisdom beyond my current awareness." At some level, I have to accept that I'm going to continue to experience discomfort through this process, I'm going to make "mistakes" and all I can do is the best I can do to take care of myself. 

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savinggrace

Hi Elbee,

 

i strongly agree that "over-thinking" and rumination often does more harm than good. The sad fact is, there is no easy way out of this mess, perhaps though, we can help make our journey smoother. 

 

For me, this understanding of drug interactions has explained a lot in my past, and will help me make all decisions in the future. (It basically reinforced my belief that most times drugs do as much harm, or even more harm than good)

 

i think the big players need  to be involved in this. I am not at all questioning their motives other than to stop ineffective, harmful, or even fatal drug interactions. 

 

I am glad I learned about  trileptal and what it has been doing to my other drug levels. That knowledge helped me reduce  it by nearly half. When I get to 150 mg. I plan to hold, let my brain do its adjusting, and then maybe try reducing one of the others. (Which I don't have to decide today...progress!)

 

Meanwhile, cheers to being at peace with your decision. 

 

Grace

 

 

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Peculiar
On 04/05/2012 at 10:52 PM, Nikki said:

I know people who are on cocktails of meds, and not feeling any better. From the knowledge I gained here I really see how dangerous these cocktails are. These doctors will take a patient off of one & immediately start another. When the patient complains they aren't responding the doctor's never really seem to realize that the poor patient is in WD from the pill they just took them off.

 

I can also see how, over time, there really is a sensitivity which develops, rendering the meds ineffective...

 

Alto this site will be up for years with people being prescribed these cocktails....

 

Hugs

 wise words from Nikki over 5 years ago! Sadly she was spot on !

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erer

Can anyone help me understand this segment that James Harper writes:
 

If you are also taking a benzodiazepine, anti-anxiety drug or sleep medication, taper these drugs first, before you reduce any other class of drug. The antidepressants, antipsychotics, ADD, ADHD, stimulants increase the clearance time of the benzodiazepines by as much as 50% and if you reduce these other drugs first you will go in withdrawal with the benzodiazepine, even though the benzodiazepine dosage was not reduced.

 

I literally don't understand it. How can it be that reducing something that increases benzo'z clearance time send you to benzo withdrawal? Shouldn't it lead to a build-up of benzos in the system and make the drug's influence stronger? Sorry, feeling really dumb at the moment.

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savinggrace

Erer,

I JUST read this post, and what this guy writes makes absolutely no sense. You are not dumb; in fact, the very point you raise is one that many doctors don't understand or try to.   For me, reducing trileptal, an AED, that increases the clearance time of my valium and remeron has helped me get some sleep again.  When I tried tapering the benzo first, I stopped sleeping completely and was completely dysfunctional.  The trileptal drop of nearly 50% has helped my sleep.  I admit it may have increased the side effects of the remeron and valium, but as I explained in a post yesterday, this trileptal hypothesis of mine turned out to be right.  Not all drugs named by this author are such potent inducers (speeding clearance of many drugs) but any drugs in combination will affect the clearance rate and metabolism.  There are many CYP450 charts now.  They can be confusing.  A drug is a substrate is it uses one enzyme pathway.  If you are on 2 or 3 or 4 substrates, using the same pathway, they will compete with each other for the enzymes.  I believe more than the 6-8 typically named inducers are indeed inducers or inhibitors...the research hasn't caught up yet.  That said,  some drugs (in my case trileptal or oxcarbazepine) induces up to 50% of drugs increasing the clearance rate from 50-80%.  I would like to know this guy's reasoning.  I really would.  I am walking testimony that one drug clearing another too fast will make it harder to taper that drug.  I choose to get the trileptal out to HOPEFULLY help me get rid of the valium and remeron (if I have enough time left).

 

I am going to look up this guy and see his point of view.

 

savinggrace

 

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savinggrace

Erer,

I just looked up James Harper.  Is this the guy associated with THE ROAD BACK program.  In a very weakened desperate state, I called and talked to someone at The Road Back a few years ago.   When I explained my sensitivities and inability to get off drugs with the use of any supplements, etc.  I was basically told that "you are not a good candidate for our program."  The thing is the person I was talking to was combative, insinuating that 'it is all in my head" and that if I had a "can do" attitude I could tolerate all the expensive supplements this program throws at you.

 

So if this is the James Harper you are referring to, I am not surprised at all that he would make such an erroneous statement.  Basically, he is affiliated with a program that is likely hurting people like us (over-sensitized) rather than helping us.  In my opinion, this Road Back program preys on people like us and it is all about convincing us that we can buy our way out of our withdrawal.  Well, we can't.  If I have the wrong James Harper,  please let me know.

 

Grace

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Jony

Hi @savinggrace

 

I've been thinking about it and I found a "little" issue.

 

If you taper 2 or more drugs at sametime, how can you control  WD symptoms? I mean how can you know wich  absence drug cause a particular symptom? And wich drug you have to reinstate?

 

Understand what I'm saying?

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savinggrace

Precisely Jony!  That is why SA doesn’t recommend tapering more than one drug at a time. You can read Rhiannon’s posts; somewhere she describes how she manages but it is definitely tricky business. That said, tapering my trileptal has strengthened my other drugs. I have had newer side effects from those drugs as a result. With only one other drug to taper, you are better-positioned to figure this out than I am on 3 drugs. If I had micro-tapered all 3 of my drugs right from the start, I think I wouldn’t be having worsening side effects. Too late now for me...I have upset the apple cart too much already. 

 

Did you ever ever consider a cross-over to a longer acting benzo to even out your blood levels, especially as you go lower?  I crossed over from klonopin to valium with little trouble but Ativan to diazepam may be harder, but worth it in the long run.  Just a thought...

 

Grace

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Jony
2 hours ago, savinggrace said:

Precisely Jony!  That is why SA doesn’t recommend tapering more than one drug at a time. You can read Rhiannon’s posts; somewhere she describes how she manages but it is definitely tricky business. That said, tapering my trileptal has strengthened my other drugs. I have had newer side effects from those drugs as a result. With only one other drug to taper, you are better-positioned to figure this out than I am on 3 drugs. If I had micro-tapered all 3 of my drugs right from the start, I think I wouldn’t be having worsening side effects. Too late now for me...I have upset the apple cart too much already. 

 

Did you ever ever consider a cross-over to a longer acting benzo to even out your blood levels, especially as you go lower?  I crossed over from klonopin to valium with little trouble but Ativan to diazepam may be harder, but worth it in the long run.  Just a thought...

 

Grace

 

I take Victan, wich is a long half-life benzo, at least compared to Ativan...

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savinggrace

Oh, I am sorry I misunderstood, Jony.  I reread the last 10 posts and it is another member taking ativan (activan she said) and you responded.  So I responded to you to as though you had/are tapering the way she is.  I apologize.  When I got the email telling me there was a response, I clearly didn't read the thread thoroughly before I responded.  It is really best to be on my computer when responding.  On my phone, I can't seee drug histories.

 

That said, I still stand by my response about tapering drugs together following Rhiannon's lead, IF you are ultra-sensitive to changes and can adjust accordingly someone may be able to pull it off.    That said, I think when you occasionally add in drugs that would really muddy the waters.  Our brains are already highly-sensitized to changes.  Looks like you chose to start tapering escitalopram a few days ago, so I guess you are sticking with the one drug at a time choice.  I am just about at the 50% mark with one of my activating drugs.  I am going to hold for a good long time, and then try to taper at least a little benzo and see what happens.  Perhaps now that the inducer is reduced by half I will be more tolerant to a benzo reduction.  Fingers crossed..  It's another option you always have.  Taper some of one.  Hold.  Taper some of another. Hold....patience...

 

Sorry for mixing you up with someone else.  Good luck with the taper.  It's not easy no matter how you choose to do it.  The key is to keep as few variables as possible, so trying not to add or subtract something now and then is probably not a good way for your brain to find homeostasis.

 

Grace

 

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Jony

@savinggrace

 

 Actually I'm not stuck on the idea of one drug at a time. After I'm off of Clonazepam and Levomepromazine, I'll start thinking about it better.

 

 

I found Rhi's approach very interesting and I'm going to work on it.  Perhaps with some minor adjustments, as he even wrote somewhere out there.

 

Start tapering a few miligrams of one drug, then a few miligrams of another one, and so on...let's see...

 

 

 

 

 

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savinggrace

As I said, I wish I had started my entire taper treating all 3 drugs as one. I know have a very lop-sided balance of drugs from where I started, and I think, as a result, I have new side effects. One thing we know for sure is that what works for one may not for another, which is why tapering is such tricky business. 

 

I hope you get some sleep tonight. 

 

Grace

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Jony
14 hours ago, savinggrace said:

As I said, I wish I had started my entire taper treating all 3 drugs as one. I know have a very lop-sided balance of drugs from where I started, and I think, as a result, I have new side effects. One thing we know for sure is that what works for one may not for another, which is why tapering is such tricky business. 

 

I hope you get some sleep tonight. 

 

Grace

 

Yesterday I fell asleep easily. Hope today will be the same...

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erer
On 10/12/2017 at 8:17 PM, savinggrace said:

Erer,

I just looked up James Harper.  Is this the guy associated with THE ROAD BACK program.  In a very weakened desperate state, I called and talked to someone at The Road Back a few years ago.   When I explained my sensitivities and inability to get off drugs with the use of any supplements, etc.  I was basically told that "you are not a good candidate for our program."  The thing is the person I was talking to was combative, insinuating that 'it is all in my head" and that if I had a "can do" attitude I could tolerate all the expensive supplements this program throws at you.

 

So if this is the James Harper you are referring to, I am not surprised at all that he would make such an erroneous statement.  Basically, he is affiliated with a program that is likely hurting people like us (over-sensitized) rather than helping us.  In my opinion, this Road Back program preys on people like us and it is all about convincing us that we can buy our way out of our withdrawal.  Well, we can't.  If I have the wrong James Harper,  please let me know.

 

Grace

Nope, you are not mistaking. That's the same James Harper. I was just reading his e-book, looking past the sales talk regarding the supplements and trying to see if there was any real usable piece of information there regarding tapering.

I am actually not too surprised that you had such an experience with them. They seem to be all about the money. Sorry you had to deal with them in your fragile state.

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savinggrace

Erer,

 

For the life life of me, I cannot figure out any kind of logic that this guy used in making this statement.  Have you figured that out?  If you do, please let me know because I am doing the exact opposite of what he advocates. If you read the latter part of my thread, you will see why, I believe, his logic and information is completely wrong. 

 

Even the the smallest change (a tad of one supplement) affects my other drug levels. I can’t imagine what following their enormous supplement protocol would do to me. Silly me, when I called them I thought they might actually care and understand people like me. Nope...I am not naive enough,  and I don't just trust them because they have a program.  “Not a good candidate!”  I consider that a compliment now. 

 

Keep going with with your gut. Your reasoning was right and your instinct is they are all about money. I repeat.  We cannot buy our way out of this mess. 

 

Keep thinking and good luck,

Grace

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erer
On 22/12/2017 at 1:53 AM, savinggrace said:

 

For the life life of me, I cannot figure out any kind of logic that this guy used in making this statement.  Have you figured that out?  If you do, please let me know because I am doing the exact opposite of what he advocates. If you read the latter part of my thread, you will see why, I believe, his logic and information is completely wrong. 

 

From what I understand from a later chapter in that brochure, is exactly the opposite to that first sentence. He writes something on the lines of if you have two (or more) drugs that use the same pathway for clearing out of the system, then they are constantly competing for that. So if you reduce one drug, it takes up less "room" on that pathway, so the other drug can clear the system faster, thus leading to the withdrawal of that drug.

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savinggrace

Hi Erer,

 

Well, this muddies the waters of my brain even more.   While this second statement makes more sense, and I have considered this idea quite a bit, I think it is still quite vague and really depends on which drugs you are talking about.  In other words, which drugs are competing for the same enzyme pathway.  For example, carbamezepine (tegretol) is listed on every chart as inducing 50% or more of drugs at a rate of 50-80% faster than if the drug were taken alone.  I take trileptal which is second generation tegretol (oxcarbazepine) and now listed on most charts (research is increasing but still has a long way to go with this drug interaction business) as inducing the same drugs, perhaps at a slower rate, perhaps not.  SO, while I think James Harper might have the right idea,  without knowing exactly which drugs are competing with each other, it is somewhat of a "blanket statement" that can only be verified by actual research trials with many combinations of drugs....which is never gonna happen because the variables (drugs, doses, number of drugs, genetics of individual, etc) are too many to test and the outcomes are exponential.   I sure hope that tapering my trileptal hasn't made it more difficult for me to taper my other two drugs down the road.  That is EXACTLY the opposite of what I am trying to accomplish.  I think trileptal and the other 6-8 commonly named inducers may be exceptions to the general rule.  I am basing my hypothesis on logic and experience.  As noted in previous posts,  I started sleeping better (which is my bottom line for w/d) almost immediately when reducing the trileptal, which would make the case for the valium and/or the remeron clearing more slowly.  However, I think I am experiencing increased side effects or is it withdrawal??? That is what James Harper would ask.  I think because I continue to sleep significantly better, though, the valium and/or remeron are not clearing faster.  My primary w/d symptom when I was tapering the benzo was insomnia, night sweats, etc.  While I don't sleep normally at all now, my  sleep onset is a couple hours sooner and my insomnia nights are far fewer. 

 

There is also the issue of varying half-lives of these drugs, but that is so complicated.  Let me know if you have any thoughts on what I have shared.  I am always looking for someone to find fault in my logic though empirically I think I have experienced some evidence that at least some of what I say is true.

 

I looked up valdoxan.  Was that added to help with your w/d?  Do you think it has?

 

I appreciate that you are giving time and thought to this complex mess we are in and that you are sharing your thoughts with me.

 

Grace

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Altostrata
On 12/3/2017 at 10:15 AM, erer said:

Can anyone help me understand this segment that James Harper writes:
 

If you are also taking a benzodiazepine, anti-anxiety drug or sleep medication, taper these drugs first, before you reduce any other class of drug. The antidepressants, antipsychotics, ADD, ADHD, stimulants increase the clearance time of the benzodiazepines by as much as 50% and if you reduce these other drugs first you will go in withdrawal with the benzodiazepine, even though the benzodiazepine dosage was not reduced.

 

I literally don't understand it. How can it be that reducing something that increases benzo'z clearance time send you to benzo withdrawal? Shouldn't it lead to a build-up of benzos in the system and make the drug's influence stronger? Sorry, feeling really dumb at the moment.

 

We do not recommend The Road Back, James Harper's e-book, or any advice from James Harper. I think you know that, Erer.

 

If James Harper or his company had the key to getting people off drugs, I'd be happy to close this site and hand the problem over to him.

 

As explained early in this topic, we recommend tapering the *activating* drugs first because if you remove the "brakes" first, you can get adverse effects from the "accelerators."

 

For example, many people have been prescribed benzos, anti-psychotics, or anti-seizure drugs to counteract activation or sleeplessness that is an adverse effect from the "accelerators" they're taking. If you reduce the "brake" first, you're going to get the activation or sleeplessness or sleeplessness again. This is a deal-breaker for many people and they go back on the full drug cocktail again.

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Altostrata
On 12/15/2017 at 2:36 AM, Jony said:

Hi @savinggrace

 

I've been thinking about it and I found a "little" issue.

 

If you taper 2 or more drugs at sametime, how can you control  WD symptoms? I mean how can you know wich  absence drug cause a particular symptom? And wich drug you have to reinstate?

 

Understand what I'm saying?

 

The main reason we urge people to taper only one drug at a time is that if you get withdrawal symptoms or other adverse effects you'll have a good idea what caused it.

 

When you change more than one drug at time and you get a bad reaction, what do you do? Updose one drug, updose the other drug, updose both drugs? What if the bad reaction was caused by something else altogether? You'll get yourself into a snarl of drug adjustments that will lead to a great deal of angst, confusion, and wasted time.

 

Please note the mods probably won't be able to make any better guesses than you can if you get yourself into this predicament. Most likely, you'll have to dig your way out yourself.

 

Rhiannon's micro-tapering of more than one drug at a time was based on her very close monitoring for a long time of the reactions she got from tapering *each* drug. That is what you need to know if you do multiple micro-tapering.

 

Making decisions about your tapering strategy depends on a lot of things that are individual to you, such as the combination of drugs you're taking and the side effects you're currently experiencing. This is why we ask people to post "what should I do?" questions in their own Introductions topic, where we can get into detail without throwing the topic off track.

 

This topic is about a general principle of tapering. It's not one-size-fits-all by any means.

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erer
12 hours ago, Altostrata said:

 

We do not recommend The Road Back, James Harper's e-book, or any advice from James Harper. I think you know that, Erer.

 

 

No, Altostrata, I did not know that.

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erer
On 23/12/2017 at 9:39 PM, savinggrace said:

 

 

I looked up valdoxan.  Was that added to help with your w/d?  Do you think it has?

 

No, I don't really think Valdoxan has helped me any, that was never my intention. I was switched on it when in hospital and the nice resident chose this drug, because it is said to cause no sexual dysfunction. 

I know it regulates melatonin, so perhaps it is helping some with sleep, but I couldn't tell. I take a mix of 3 drugs, so this is quite a mess and it's hard to tell how any of those drugs are affecting me.

Valdoxan is likely to cause liver damage, so I need to get blood tests done regularly, at least these have been fine so far.

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Jony
13 hours ago, Altostrata said:

 

The main reason we urge people to taper only one drug at a time is that if you get withdrawal symptoms or other adverse effects you'll have a good idea what caused it.

 

When you change more than one drug at time and you get a bad reaction, what do you do? Updose one drug, updose the other drug, updose both drugs? What if the bad reaction was caused by something else altogether? You'll get yourself into a snarl of drug adjustments that will lead to a great deal of angst, confusion, and wasted time.

 

Please note the mods probably won't be able to make any better guesses than you can if you get yourself into this predicament. Most likely, you'll have to dig your way out yourself.

 

Rhiannon's micro-tapering of more than one drug at a time was based on her very close monitoring for a long time of the reactions she got from tapering *each* drug. That is what you need to know if you do multiple micro-tapering.

 

Making decisions about your tapering strategy depends on a lot of things that are individual to you, such as the combination of drugs you're taking and the side effects you're currently experiencing. This is why we ask people to post "what should I do?" questions in their own Introductions topic, where we can get into detail without throwing the topic off track.

 

This topic is about a general principle of tapering. It's not one-size-fits-all by any means.

 

@Altostrata

 

I'm aware about that. It was just a thought...

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kesh

I was wondering about how to fit nicotine into this. I view my smoking as another psych drug I will have to taper off. I'm guessing many people here smoke. I'm fairly sure that it will be the one I want to taper last because it is such a crutch to me, but not sure if this is wisest in terms of brain chemistry. Is nicotine a break or an accelerator? Withdrawal typically increases agitation, anxiety, restlessness, unstable moods.

 

Switching to patches or vaping is obviously best to do, and I will be doing it soon.

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erer
1 hour ago, kesh said:

I was wondering about how to fit nicotine into this. I view my smoking as another psych drug I will have to taper off. I'm guessing many people here smoke. I'm fairly sure that it will be the one I want to taper last because it is such a crutch to me, but not sure if this is wisest in terms of brain chemistry. Is nicotine a break or an accelerator? Withdrawal typically increases agitation, anxiety, restlessness, unstable moods.

 

Switching to patches or vaping is obviously best to do, and I will be doing it soon.

 

If I remember correctly (sorry, cannot recall the source) the thing about nicotine can be, that it interferes with the metabolism of the drugs severely, so if you quit smoking there will be a sudden change in the metabolism of your psych drugs. I think it was that the serum levels of the drug will rise when you quit smoking. A specific study was made using Cymbalta: https://www.ncbi.nlm.nih.gov/pubmed/18651344

 

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erer

Also see: http://www.psychiatryadvisor.com/depressive-disorder/antidepressant-levels-in-patients-who-smoke-cigarettes/article/649368/

And: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5340025/

 

Results

Twenty-one studies met inclusion criteria; seven involved fluvoxamine, two evaluated fluoxetine, sertraline, venlafaxine, duloxetine or mirtazapine, and escitalopram, citalopram, trazodone and bupropion were the subject of a single study. No trials were found involving other common antidepressants such as paroxetine or agomelatine. Serum levels of fluvoxamine, duloxetine, mirtazapine and trazodone were significantly higher in nonsmokers compared with smokers.

Conclusions

There is evidence showing a reduction in the concentration of serum levels of fluvoxamine, duloxetine, mirtazapine and trazodone in smoking patients as compared to nonsmokers. The evidence regarding other commonly used antidepressants is scarce. Nonetheless, smoking status should be considered when choosing an antidepressant treatment, given the risk of pharmacokinetic interactions.

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kesh

Thanks. Interesting. 

 

My antidepressant, citalopram, seems to be mentioned, but no conclusions drawn.

 

I wonder if it also decreases benzos.

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savinggrace

Hi Kesh,

i am on 3 psych drugs but do not smoke. I have done a lot of research on drug interactions. There are many charts that list drugs and their inducers and inhibitors and they seldom agree. What I have learned through experience though, that if a drug is listed as an inducer,  as nicotine is, it is definitely affecting the serum levels of your other drugs. I just read something that says nicotine induces (speeds the clearance) of diazepam. Another article did not mention diazepam. The point is, the research is so new, many of the studies have not, and cannot, study all the possible drug interactions and their effect on each other. I have been tapering trileptal for 3 years but I noticed that I slept better with the first cut. Why? Because trileptal has been inducing either the diazepam, the mirtazapine or both all along. My serum levels of these sedating drugs have risen as I cut the trileptal. That said, now I have side effects from higher serum levels so I am going to stop tapering trileptal and start one of the others after I get through one more small cut. 

 

This is is going to be a tough decision.  There is no definitive  answer for you...only opinions and guesses. 

 

The less you smoke the longer some of your other drugs will stay in your system which may make for an easier taper or may not because when you change one thing, you change everything. 

 

I wish there was an easy way out of this mess we are in, but there’s not. You are wise to have considered this though as you decide what and how to taper. 

 

Good luck,

Grace

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elbee

I would definitely view nicotine as another drug to consider as part of your withdrawal / tapering process. When I actually quit (CT), it was because my panic attacks were so bad I thought, what the hell, quitting now isn't going to make anything worse. AND, it worked, but I would not necessarily recommend that approach! Because there is such a strong behavioral component associated with nicotine addiction, and because the drug has such immediate and intense effects, I didn't consider it in the same category of my taper as sertraline. I thought of it more like alcohol which I also had been cutting back on over months, but eventually quit CT. I'm not sure I could have "tapered" alcohol (nor nicotine), but perhaps that's just because I've never really considered it. As I think about it, perhaps it actually makes sense in terms of using patches . . . isn't that basically a taper (plus removal of the behavioral  / habitual, immediate gratification component)? I'm definitely no expert, just sharing my thoughts and experience. Good luck!

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kesh

For those interested in the drug metabolism side of smoking, it's not actually the nicotine itself that affects your liver enzymes and so changes the levels of any other drugs you take. It's another tobacco smoke component called Polycyclic Aromatics, iirc. So if you switch to patches or vaping you might suddenly see an increase in the blood levels of your other drugs. Maybe cross tapering from cigarettes to vaping/patches may be the thing to do.

 

Elbee, yes I am wondering how much the behavioural aspect is dominant in my smoking addiction. I get a spike of symptoms, I go for a cigarette as a distraction. 

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savinggrace

 I am pretty sure it is. It is prescribed as anti-anxiety medication in lieu of benzodiazepines. It has a much weaker effect. That said, as with ANY psych drug, it has the potential for dependence, tolerance and withdrawal.  I am relatively certain it is not an accelerator but combined with other drugs it’s anybody’s guess what it does.  Depending on dosage, and length of time on it, I would think tapering would be wise. 

 

Grace

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HAa

I am pretty sure it is. It is prescribed as anti-anxiety medication in lieu of benzodiazepines. It has a much weaker effect. That said, as with ANY psych drug, it has the potential for dependence, tolerance and withdrawal.  I am relatively certain it is not an accelerator but combined with other drugs it’s anybody’s guess what it does.  Depending on dosage, and length of time on it, I would think tapering would be wise. Thank you for your reply. :-)

I do want to taper this. I was just unsure if I should wait until I have tapered Effexor either completely og to a much lower dosis than the 75 mg I have been on for 20 years :-)

I think I know the answer - but Buspar is as you say different from benzo, and somewhat like SSNRI like effexor.

So effexor it is with the recommended 10 % every 4 th week, depending on how it goes?

 

Edited by ChessieCat
I forgot to qoute/cc removed bold font

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