Pakadam Amitriptyline withdrawel/reinstating

[Pakadam]

Hi @Altostrata, yep sure, i will update my signature later today.

I just realised with my dosing that for the last two nights I've actually taken 2mg rather 1mg due to miscalculating the liquid. Had taken 5 nights of the 1mg dose prior.

When reviewing my daily symptoms my sleep has improved a lot on the two nights of 2mg dosing: 4 hours last night, up from the previous 6 nights of 2 hours.

Today my anxiety has been a little more present but nothing else in a significant way. Apart from the increase in anxiety my overall mood has been more stable.

My question is should I now continue with the 2mg dose or go back to the 1mg dose?

 

Thank you.

[Pakadam]

Welcome any thoughts from @composter as well. Thank you.

[Pakadam]

Hi @Altostrata, I've just updated my signature and realise how much of a mess everything is with all the changes made in the last couple of months. A lot of self-blame and regret at this point. Hopefully things will improve with the amitriptyline reinstatement. 

 

[Pakadam]

@Altostrata, perhaps a positive is that my current psychiatrist is aware of the polydrugging that can occur in this situation and is willing to work with me and the feedback that I get from this site. 

[Altostrata]

14 hours ago, Pakadam said:

I just realised with my dosing that for the last two nights I've actually taken 2mg rather 1mg

 

If 2mg works, stick with 2mg.

 

Yes, finding a cooperative psychiatrist can be difficult, good for you.

[Pakadam]

Thanks very much again for your reply @Altostrata. Very grateful for your support and advice.

The psych is suggesting to increase to 5mg next week but I think I'll be advocating to sit on 2mg for a little to see how it goes as you've advised.

 

How do you suggest finding the optimal dose to acheive stability from this point? Should I give the 2mg two weeks, reflect on my daily symptom notes and then either stay there or increase? And at what amount would I increase to?

 

Hope you don't mind my questions. 

 

Thank you again for your help.

[Altostrata]

Just now, Pakadam said:

How do you suggest finding the optimal dose to acheive stability from this point? Should I give the 2mg two weeks, reflect on my daily symptom notes and then either stay there or increase? And at what amount would I increase to?

 

That is correct. We don't know what amount you'd increase to, perhaps add 1mg at a time. Maybe no increase is needed.

[Pakadam]

Great Thanks very much @Altostrata. Given that there hasn't been an adverse reaction with 3 days of 2mg should I feel comfortable to proceed with that dose. Are any adverse reactions likely to happen on that dose as it takes full effect over the next few days? 

Sleep has been a little better again and I've been utilising some of the techniques and strategies from the SA site. Thank you for all your great work. 

[Altostrata]

On 8/12/2021 at 9:56 PM, Altostrata said:

Amitriptyline takes 3-8 days to fully take effect. It would be a good idea to see how you do for a week before making a decision to increase.

 

[Pakadam]

Thank you for reminding me @Altostrata. I'll keep a close eye on things for that time period. In the event the dose appears to be too strong as it ramps up would it be best to return to the 1mg dose?

I'm finding difficult to distinguish between the ongoing WD symptoms and what might be adverse reaction. I'm taking the approach that anything new or dramatic would be considered an adverse reaction. Am I correct here?

Thanks again. 

[Altostrata]

I don't know. You'll have to let us know how you're doing, report unusual events here day by day.

[Pakadam]

Just a quick update @Altostrata. Felt reasonably ok last night after the fourth 2mg dose: anxiety was down a bit. Sleep however wasn't great so I'm preparing myself for a challenging day and to stay strong. Will update with anything unusual. I'm guessing things will be up and down and therefore non-linear during this stabilisation period?

[Altostrata]

Correct, up and down. Reasonably okay is a good sign.

[Pakadam]

Sorry to write in again so soon @Altostrata, I'll try to avoid seeking reassurance about every symptom. Today I've been experiencing some shakiness in my hands and legs. This symptom seems new. Could possibly be from a poor nights sleep. Do you think this is anything to be concerned about? Thank you. 

[Pakadam]

Hi @Altostrata, I think as the 2mg dose ramps up it might be a little too strong. My sleep hasn't been as good, although it was good for the first 3 days on this dose, and the anxiety has increased. It's possible that the increase in anxiety was a result of lack for the sleep. On the days when sleep was ok anxiety has been manageable. Sleep has certainly been mimmnimal for the last two 2mg doses and I've had some mild nausea (could be unrelated) .

Would you advise to sit on the 2mg to see how it continues, given that progress is not linear, or would be be best to go back closer to the 1mg dose? As that was ramping up sleep was improving (day 5).

I don't want to be making frequent dose changes and having a little trouble guaging the optimal dose. 

Thank you kindly. 

[Altostrata]

This is 5 doses of amitriptyline? You may wish to decrease to 1.5mg.

[Pakadam]

Hi @Altostrata, yes, correct 5 x doses at 2mg. Sleep has been very poor for me tonight with a clear increase in anxiety. 

I think it could be wise to decrease to 1.5mg given the change in sleep. 

Do you agree?

Would I sit on this dose for another week with taking note of daily symptoms along the way?

[Altostrata]

Pakadam, I already said you might decrease to 1.5mg! Yes, you need to observe for a week. The usual process. You did a good job with this already.

[Pakadam]

Hi @Altostrata, thank you again.

Would it be worth consider decreasing to 1mg rather than 1.5mg since my symptoms suggest that this was possible working as the dose was ramping up? Or is better to make smaller changes?

Waking up this morning I am certainly clear that 2mg was too strong.

 

[Altostrata]

@Pakadam, I answered you twice.

[composter]

Hi @Pakadam I am glad to hear you found an understanding psychiatrist and that you have not had issues from discontinuing the various meds you were given while in the hospital. 
 

I see in your signature that you have Diazepam and Zopiclone as PRN. Please avoid taking these as risk of interdose  withdrawal from benzos is real. Continue to practice non-drug coping skills like going for gentle walks, mindful breathing, and ensuring you are eating nutritious foods. 
 

The key with all of this is to really listen to your body. Based on your symptoms recently and in May/June, the 2 mg was likely too much. But only you can make that determination. There is no need to ramp up the dose if you are improving on a low dose. Ramping it up beyond a point that you can tolerate could easily make things worse. Your goal is to find a dose at which you can stabilize, and hold onto that dose until your sleep and other symptoms  resolve. Your hold for stabilization could take 6 months - 1 year. It could be that 1 mg is the your dose for stability, or 1.5 mg. 
 

also be sure you are taking precisely measured doses each day. Are you creating your own liquid and tapering with a syringe, or are you using a jewelry scale to measure cuts? These are precise methods, as well as ordering from a compounding pharmacy. 

[Pakadam]

Hi @Altostrata and @composter

 

Just an update and question. I've been on 1mg for 5 days now and need some help with what to do next. Still have bouts of severe anxiety and distress, with episodes of nervous energy, shaking. Finding it very difficult to relax, tried breathing techniques PMR, guided meditations, CBD oil. Had a couple of good nights sleep but last night I only slept a couple of hours then woke and wasn't able to calm body and mind for sleep. Am I still on the right track and just need to give it time? Do you have any advice on how to cope with these symptoms in the meantime as they are very distressing.

Thank you kindly.

[Pakadam]

Hi @composter, yep confirming that I'm making my own liquid as per your instructions, so I'm confident the dose is precise. With my symptoms as mentioned above they are not like the agitated response I had when I tried to reinstate earlier so it does give me hope even though there are these other symptoms. Please let me know your thoughts. The improvement in sleep is potentially a good indicator?

[Altostrata]

Hello, @Pakadam how often have you taken diazepam or zopiclone in the last 2 weeks?

 

I am confused. Have you been taking 2mg or 1mg amitriptyline? How long have you been taking 1mg?

[Pakadam]

Hi @Altostrata, confirming that I have taken the diazapam daily during the last weeks. I will need to taper off this and have linked in with a local benzo support service who are monitoring my usage. The zopiclone for the first week was daily however this week has been three times across the seven day period. I was only taking this for a few weeks and the local benzo support service are monitoring use and ceasing of this too.

 

Confirming that the dose of amitriptyline I am taking is 1mg. I determined that 2mg was too strong and settled on 1mg given my initial positive response. 

 

Sleep has been improving however the last two nights were less and found it took longer to get to sleep.

 

Welcome your thoughts. 

 

Welcome your thoughts.

[Pakadam]

@Altostrata, confirming I have been taking 1mg of amitriptyline for 6 nights since realising the 2mg was too strong. 

[Altostrata]

What dosage of diazepam have you taken daily in the last weeks?

 

What times of day do you take each of your drugs, and their dosages?

[Pakadam]

Hi @Altostrata:

 

5:30pm: 1mg amitryptline 

6:30pm: 5mg diazepam

11:30pm: 7.5mg zopiclone (as needed)

 

Please let me know if you need more info. Welcome your additiinal thoughts.

 

 

[Altostrata]

How long have you been taking zopiclone? Have you been taking it every night?

 

Please be aware that taking a benzodiazepine such as diazepam and benzo-like drug such as zopiclone could be adding to your daily symptoms. Please keep daily notes of times of day you take your drugs, their dosages, and your symptoms throughout the day. Post 24 hours of notes at a time in this topic, in a simple list format with time of day on the left and notation (symptom or drug and dosage) on the right. This can show if your symptoms are adverse effects from one of your drugs.

[Pakadam]

Thank you @Altostrata, I have been taking the zopiclone for 4 weeks daily and this week intermittently. I consulted with a local benzo support service how work from the Aston method and they have advised me how to use more sparingly and are confident that there isn't a dependency issue. I haven't noticed any unusual symptoms since using it more sparingly. I welcome your thoughts though.

 

I will start tracking my symptoms as you've advised and post them after a couple of days of observation. 

[Altostrata]

You say

2 minutes ago, Pakadam said:

I consulted with a local benzo support service how work from the Aston method and they have advised me how to use more sparingly and are confident that there isn't a dependency issue. I haven't noticed any unusual symptoms since using it more sparingly.

 

And yet

On 8/26/2021 at 3:22 PM, Pakadam said:

Had a couple of good nights sleep but last night I only slept a couple of hours then woke and wasn't able to calm body and mind for sleep.

 

Yes, you could be dependent on zopiclone and yes, your sleep disruption could be from your introduction of intermittent zopiclone dosing.

 

We ask people not to change more than one drug at a time so we can establish a baseline symptom pattern. Every time you change one of your psychiatric drugs, that is likely to change your symptom pattern. 

 

Please stop dosing zopiclone intermittently. The way to go off zopliclone is to systematically taper it, but since you just reinstated amitriptyline, we cannot see the effect of 1mg amitriptyline if you also change other drugs. Do you understand this?

[Pakadam]

@Altostrata, yes, I understand this. One at a time. Thank you. I will keep you updated. 

[composter]

On 8/27/2021 at 3:22 AM, Pakadam said:

Hi @composter, yep confirming that I'm making my own liquid as per your instructions, so I'm confident the dose is precise. With my symptoms as mentioned above they are not like the agitated response I had when I tried to reinstate earlier so it does give me hope even though there are these other symptoms. Please let me know your thoughts. The improvement in sleep is potentially a good indicator?

Hi @Pakadam,

I will echo Altostrata that you will need to be careful and mindful of your zopiclone and diazepam use. 
 

Based on what you have shared with your 1 mg reinstatement, it seems to be keeping you steady rather than making you feel agitated like the 2 mg did. This is a good sign. If I were you I would hold steady to the 1 mg Amitriptyline and not make any dosage changes on that for 1 month or so. You may benefit from holding at 1 mg for 6-12 months, and then tapering after that. This was what I did. I found it very helpful to make a chart of my symptoms and keep a log every day be entering the severity of each symptoms while on a steady dose. This way you can see for yourself when things are improving. This way you can also taper off the benzos one at a time.

 

As for the waves of anxiety and symptoms that come, you will need to continue to practice your coping skills. Go for a gentle walk, eat fresh fruits, drink tea, take magnesium and omega 3, call a friend, write in a journal, watch a comedy special, read a quiet book. You may benefit from other things like therapy or yoga and mindful breathing. Build up this toolkit of non-drug coping tools. And most of all, be patient with this process. You will see improvements when holding on a stable dosage.