FindPeace: tapering off 21 years of Effexor XR.

[Guest H8FXR]

Brass Monkey Slide past 27.5mgai/91pw

 

 

10% taper

*all rounded to nearest mg

91mgpw/27.5mgai*90%=82mgpw/24.6mgai

 

slide

 

week 1 91−2.275 (2.5%) = 89mgpw

 

week 2 88.7 - 2.275 = 86mgpw

 

week 3 86.4 - 2.275 = 84mgpw

 

week 4 84.1 - 2.275 = 82mgpw

 

week 5 and 6 Hold

[Guest H8FXR]

@brassmonkeyHey man, I need to ask a few things of you. Recently I've really been on a research kick and pouring over the patents for Effexor XR. An issue I can't seem to resolve is whether or not each bead has the same mgai.

 

I weighed until 25mgai/83mgpw, and I have realized that what I have been doing is inaccurate. The reason I believe this to be so is because the beads vary in size, small, medium, large. If they spill out randomly into the scale it will be a different number of beads every time. I see no evidence to believe that bigger beads have more AI. In fact, it seems more likely (from reading the patents) that all the beads start out as "core" or "active" beads (a mix of venlafaxine and methyl cellulose) and then are subsequently receive an XR coat or two (ethyl cellulose and hypermellose). That would suggest they all have the same amount of API regardless of size.

 

So its seems that counting IN beads is the way to go. Taking the same number each day. But I think pharmacokinetics have also to be considered. Since the capsules are filled with an assortment of bead sizes to achieve the proper dissolution rate over 24 hours, I feel the ratio needs to be respected as the dose is reduced. There is also information to support this in the patent.

 

One of my main concerns is that as one takes fewer and fewer beads the pharmacokinetics are thrown way off. After all the medication wasn't designed to be taken that way. I see a lot of members struggling when they are down to just a few beads and I don't think it's just to to larger drops in sert occupancy. 

 

What would you say to all this, I'm curious to know?

Cheers,

H8

Effexor XR patent: 

https://patents.google.com/patent/US6274171B1/en

[brassmonkey]

I think that you will find these two articles interesting.\:

 

(PDF) Pellets and pelletization techniques: A critical review (researchgate.net)

 

Comparing Drug Layering and Direct Pelletization Processes (pharmaexcipients.com)

 

Tapering with beads is a rather course way of doing it. It is essentially a linear taper that we are expecting hyperbolic results from. By reducing one bead at a time, we taper by a fixed rate instead of a progressively smaller one. We have proved time and again that the hyperbolic model is the preferred way to go because of SERT occupancy, bioavailability and a host of other reasons, but that is just not possible with bead counting. This is especially true at the lower doses, where the decrease of one bead massively out strips the percentage required. This linear method is why people using bead counting have so much trouble at the low doses. It is impossible to measure a decrease that is within the acceptable percentage.

 

Linear tapers, in this case bead counting, can work well to a certain point, if the person is not too sensitive to the changes. It is possible to follow a modified hyperbolic taper doing bead counting, but the dose will vary widely while doing so. Once the reduction rate passes 10% by removing 1 bead a different approach is required. The best method being to cross over to a liquid and follow the 10% rules. Switching to a liquid will result in AI dumping when the dose is consumed because it bypasses the time release part of the formulation, which can be a problem for sensitive people.

 

The difference in bead size can be a problem if you are strictly counting. If you are weighing the dose of beads, then the "rounding factor" involved in getting a full bead in the dose is the main variable. If a person is strictly counting, then a good mix of bead sizes is called for. Using all of one size could lead to being under or over dosed. But graduating size can be used to "refine" things at the lower doses. Unless a person is extremely sensitive to changes in dosage the differences in bead size would hardly be noticed even at the "one bead" level.

 

As far as bioavailability, absorption rates and the like go, each bead is pretty much the same in the way they act regardless of size.

[ChessieCat]

Instead of uploading documents which need to be downloaded, please use Google docs.  This allows the document to be viewed without the need for the program to view the document and also reduces the risk of computer viruses.  Sharing the Google docs link means that people do not need an account or password to access the document.

[Guest H8FXR]

@ChessieCat thanks for the heads up - I will definately use Google Docs from now on.

 

Do you care to comment on the subject matter in my lastest post (the one above BM's)? Any input you could give would go a long way toward easing my concerns. TIA.

[Guest H8FXR]

@brassmonkey Hey, thanks for your reply and the very interesting links - much appreciated! 
 

A little background: I began to doubt the accuracy of weighing when I met a member in a different group who was not only counting AND weighing but actually sorting her beads according to size. She’s very bright - so I was sure that she must be onto something. We teamed up to research the issue of bead size and tried to find a way to taper Effexor XR which makes the most sense.

 

Although she had the hunch a long time before me - we have discovered that size likely DOES matter. The smaller beads release the medication faster than the larger ones. What’s more, the patents seem to suggest that each bead has the same amount of active ingredient. If this is the case, a random assortment of bead sizes at a specific weight would yield WIDELY varying doses of venlafaxine. In this case, taking the same number of beads daily to ensure a consistent dosage would be wise.

 

By analyzing the size, weight and number of beads in Effexor XR capsules it looks like they may contain a consistent ratio of sizes. This is likely because the capsules contain a certain amount of each size to release the right amount of medication over time. So in order to preserve this property of the capsules it could be further helpful to take a certain number of small, medium and large beads.
 

Although it’s clear to me that at a certain point one can no longer taper hyperbolically or maintain the proper range of sizes, I am leery of a switch to an IR formulation. This could be risky considering dose dumping, a higher peak in blood plasma concentration, and changes in the pharmacokinetics in general. 
 

I just wanted to share what we have found in case anyone finds it helpful or is interested in knowing how bead size may factor into tapering.

 

Regards

H8

 

 

 

 

[ChessieCat]

This is in Post #1 of the Tips for Tapering Effexor topic:

 

  

On 5/6/2011 at 1:01 PM, Altostrata said:

 

At the end of the taper: Make a liquid from venlafaxine extended-release beads

If you have generic venlafaxine XR or Pfizer Effexor XR or Efexor XR in gelatin capsules filled with tiny beads, you probably will want to reduce by counting beads for most of your taper. But when you're down to 9 beads, how do you taper by 10%?

 

You can make a liquid with water from those beads. This has been proven to be stable (for 30 days) and effective: Rosa, N. F. D., & Sharley, N. A. (2008). Stability of Venlafaxine Hydrochloride Liquid Formulations Suitable for Administration via Enteral Feeding Tubes. Journal of Pharmacy Practice and Research, 38(3), 212–215. https://doi.org/10.1002/j.2055-2335.2008.tb00841.x

 

When the beads are dissolved in water or pharmacy liquid, the drug become immediate-release venlafaxine with a much shorter half-life. You may wish to take it 2 or 3 times a day (see the section above about immediate-release venlafaxine).

 

 

[Guest H8FXR]

@ChessieCat Hey, thanks for providing link. I have already seen it and although it is great to know that it’s possible to make a liquid suspension from Effexor IR or even XR, I have several reservations for doing so.

 

First and foremost I think it is a huge change for the mind and body to adjust to. Even switching brands is disruptive for some. With XR to IR, there is a possibility of dose dumping and experiencing an unpredictable and possibly disastrous adverse reaction. Dissolution studies in the patent indicate that IR has a significantly higher peak for blood concentration over XR - I wonder how one might react to that. Also, the pharmacokinetics are very different: IR peaking in ~2hours and rapidly dropping off to sub-therapeutic levels by 12 hours, needed an additional dose - right before bed time no less. XR peaks in about 6+/-2 hours and gradually falls over 24 hours.

 

It seems feasible but I think it may be quite destabilizing and hard to predict how one will react. Wouldn’t it be better to switch to IR (crushing and weighing a mini tab for example) at a higher dosage when these kinds of changes do not have as much of an impact on serotonin occupancy? Are there many members that you know of that have had success with a switch to liquid at a low dose?

 

Regards,

H8

[ChessieCat]

I can understand your concerns, but was just letting you know about it because I had only just noticed it myself and I've been a mod for 6 years now.

 

It is good to know what options you have available when you get to the lower doses, especially if you are not able to get prescription liquid or immediate release tablets and not able to tolerate reducing by a bead at a time.  And to get used to the immediate form of the drug you could start by dosing every few hours and then gradual bring it back to 3 times a day.  Obviously you would only use this method if you really had no other options.

 

Pristiq tablets cannot be dissolved in water because they go lumpy and I did most of my taper using compounded tablets.  It wasn't until right at the very end of my taper that I discovered that I could dissolve the contents of a capsule (compounded) in water.  If I had known this at the start of my taper it would have made it easier to get my doses and probably would have ended up saving me money.

[Guest H8FXR]

@ChessieCat

I am glad I reached out to you, because you have shared something I did not think of - namely, to dose more often and scale it back. So thank you for that! 

 

it still seems like a wild ride - venlafaxine roller coaster…I guess I will have to look over more cases to get a feel for how people react, but there seems to be a dearth of info on it unfortunately.

 

I am surprised to learn that Pristiq goes lumpy in water. I know that it is made differently than Effexor. I think there are the same issues with some generic varieties of venlafaxine mini tabs. Did it go lumpy after being crushed completely to a powder first and then dispersed in water? I would think that is what the compounding pharmacy does… shear the tablet into powder and fill into capsules. Thanks again for the info.

 

Regards,

H8
 

 

[ChessieCat]

6 minutes ago, H8FXR said:

Did it go lumpy after being crushed completely to a powder first and then dispersed in water? I would think that is what the compounding pharmacy does… shear the tablet into powder and fill into capsules.

 

Yes, it's because there is a glue in the tablet which extends the release.  The pharmacy ground the tablets to a fine powder and added fillers.  When added to water I would shake it up thoroughly and then let it sit for at least an hour to settle all the bubbles caused by the fillers.  After it was made up I would just gently stir the mix before syringing out my dose.

 

And another thing with the DIY Effexor liquid is that you can always use it to take with beads to make up the dose you want if needed.

[FindPeace]

Hello, thank you for reaching out. I’ve crashed in my tapering of Effexor and I am now in a extreme situation with daily anxiety, panic and severe gastrointestinal issues. I desperately need advice.
 

Background: over the last year (since March 8 2021) I’ve been tapering brand name Pfizer Effexor XR by using the bead method under the guidance of a Facebook group. I’ve reduced from 75mg to 25mg using 10% reductions every 4-8 weeks.
 

I weighed the beads while reducing all the way from 75mg to 25mg. Unfortunately, on Jan 13 2022 - just a week out from a 10% taper - I switch and reacted badly to a generic formulation (Sandoz venlafaxine XR 25mg) which I only took for 1 day and switched back to brand name with beads. From then on I decided to count instead of weigh. I settled on 91 beads.

 

Things seem to go fine until Feb 16 I noticed I had unusual symptoms and I began to suspect I my dose was too high (nausea, vertigo, restlessness, anxiety/dysphoria); so I decided to check and see if 91 beads was a good average number for my previous pill weight of 83mg I had switched from. I weighted out 5 of my previous doses, counted the beads in each, and the average was actually 86 beads. So Feb 20 I  began to take 86 beads. 

 

Things seemed go fine with the usual withdrawal symptoms I am used to.  But on 

March 2nd and 3rd I experienced hypomania and anxiety which was unusual. On March 4 all hell broke loose and from the moment I wake up I start experiencing 

 extreme anxiety, diarrhea, nausea, dry heaving, RLS in the morning 

 

On March 5th I decided to stop all supplements because I was afraid I was destabilized. My gastrointestinal symptoms became so severe (anorexia, abdominal cramping, nausea, dry heaving, anxiety and panic) that on March 6th I admitted myself to the emergency room. They did nothing for me but refer my to a gastroenterologist (I have yet to see).

 

Since then I have been trying to hold it together but each day I wake up an anxious wreck with my stomach in knots and it doesn’t even began to ease even a little until the late afternoon. I’m terrified that I may have akathesia. On March 8th I saw my GP who prescribed Ativan 1mg just in case of panic attacks. I am so afraid I destabilized myself and scared to updose or decrease my dose or take the Ativan. I am getting desperate but I don’t want to see a doctor or psychiatrist because I’m afraid they will advise to go back to 37.5mg  of Effexor or higher; CT me, bridge me or add more drugs. I don’t want to suffer an adverse reaction from going back up or on something else and ending up polydrugged. So I’ve been just holding but each day is a battle and I’m very scared. Please help me know what I should do! 🙏

Edited July 1 by Catwoman73
Changed title- member request

[FindPeace]

Here is a day by day since March 5 to today March 10th. I’ve scored severity of symptoms out of 10 - being the worst imaginable. Ex anxiety 8. I hope it easy enough to read. Thank you 🙏 

 

3/5 

7:00 RLS 

(Vaping all day long and no appetite whatsoever)

-7:50 take: Effexor 25mg. Stuffy nose, diarrhea 8, shivering 2, tremulousness 2, ear pulses 1, weepiness 1, tight stomach 7, rls 7, anxiety 8. akathesia? Drink: peppermint tea 

-9:30 diarrhea again, anxiety 6, rls 3, fatigue 7, muscle pain 6, abdominal discomfort 7, skin crawling 4, brain fog 6, skin burning 4.

-10:20 drink: black tea. Anxiety, stomach tightness, dry heaving

-11:00 take: 1 peptobismol tablet. Eat: applesauce and peppermint tea

Same symptoms as at 10:20

-12:00 walk with friend. Anxiety/dysphoria 8, Feeling cold, Diarrhea, Upset stomach 6

-1:30 Headache 4, sore eyes, fatigue, anxiety/worry

-2:43 dry heaving, diarrhea, stomach cramps 

-3:00 eat: applesauce and egg, take 5 psyllium capsules, 1/2T fish oil

Nap - anxiety interfering 

-4:30 diarrhea, gas, stomach cramping

-6:00 take 1 probiotic, drink hydralite

-6:20 dry heaving, gas. Eat: banana

-8:00 take Dexilant 60mg (PPI) first time

Relief for 2hrs

-11:00 cramping, stomach pain, gas, anxiety, restlessness, fatigue 

12:00 sleep

——————-

3/6

 

(Vaping a day long and no appetite whatsoever)

 

-7:00 wake up to rls 7

-7:20 take: magnesium bisglycinate 200mg (doesn’t help)

-8:00 Effexor with crackers

-8:15 feeling better, rls relieved (Effexor?)

-8:30 drink: black tea

-10:00 drink: ginger tea. Solid bm

Stomach starting to cease up, cramping 6, dry heaving, anxiety 7

12.5mg take: gravol 12.5mg

-11:00 eat: oatmeal with apples, peppermint tea. Stomach pain, anxiety, crying

-12 oatmeal

12:30 ginger ale. Diziness, fatigue 7/10

 

[At hospital for GI pain, uncomfortable but not anxious]

 

-8:00 eat: pho soup. Drink: Hydralyte. Fatigue 8, anxiety 5

-12:00 sleep

——————

 

3/7 

-8:00 wake take Effexor with banana

(Vaping a day long and no appetite whatsoever)

RLS, Anxiety 7

Bm

Do vagus excercises

Go back to sleep till 10am

-10:00 Anxiety 4 , restlessness 6, stomach tightness 6; Take: Dexilant (ppi) 60mg

-11:00 drink: 1/4 cup coffee (bad idea); Anxiety 8

-12:30 Travel back home from brothers house; 

Anxiety 9

-2:00 arrive home; anxiety 9

Eat little oatmeal, peppermint tea, lie down; Anxiety 6

-3:30 measure doses, read SA. Anxiety ramping up 8, stomach in knots, headache

-4:30 eat oatmeal, take Tylenol 500mg, magnesium 200mg, peppermint tea

Lie down with hot water bottle

-5:00 anxiety 4, slight restlessness 3, stomach, fatigue, brain fog , stomach settles down

-6:00 anxiety 4, restlessness 4, stomach ok

-6:40 anxiety back 7, stomach pain (food helps); diarrhea

-7:00 eat banana and crackers

Nausea 2-4, anxiety 4-6, restlessness 3

-10:00 indigestion 3, anxiety 3 , restlessness 2

-12:00 sleep

——-

3/8 7:00 woken up to RLS 7

7:40 take magnesium; RLS 6

Bm

8:00 take Effexor 25mg

Bm

Stay in bed, anxiety 7, bloating, nausea

-8:30 drink chAmonmile tea and hot water bottle

9:00 vagus excercise

Anxiety 5, bloating same

-9:17 CBD 0.3ml

-10:00 gravol, hot bath; Stiff back, stomach upset 6, dry heaving 3, anxiety 6

-12:15 fatigue 7, abdominal pain 6, muscle stiffness 6, anxiety 6; Take Phosphatidylserine (is withdrawal from this supplement responsible via raised cortisol?)

-12:46 brainfog 7, fatigue 8, anxiety 4 need to eat!! But no appetite, sick feeling in stomach

Worried about work, worried about dr visit

-1:00 feeing of well being after eating: just brainfog

-1:20 talk w Michela on msg and get triggered, anxiety 8, curled up in bed 

-2:00 intense anxiety 9, feeling hot, dysphoria 8, face feels numb, tingling. Worried I have akathesia.

-2:05 take chlorpheniramine 1mg

 

-2:50 waves of extreme anxiety and agitation finally break into fatigue 

-3:50 saw doctor: anxiety 5, stomach 5

Tries the whole “maybe you need Effexor for an underlying anxiety disorder” routine, suggesting 37.5;a refuse and he says stay at 25mg. Resistant but finally prescribed Ativan

-5:00 drink ginger ale

anxiety 5, stomach 5: planning to call boss

0.5 Ativan

Anxiety 3, stomach 5 

-6:00p. anxiety 2, stomach 3, headache 5, fatigue 8, brainfog 7; Tylenol 500mg

Eat dinner: chicken, quinoa, vegetables

-7:15p. Headache persists (Ativan?) anxiety 3, stomach 1, fatigue 8; turmeric 450mg

-7:30 0.5mg Ativan (crumbs)—

-8:00p. Eat Pudding; headache 3, drowsy

————

 

3/9

-7:00 RLS 5, anxiety 5

Vaping all day; no appetite until noon

-7:40 anxiety 7, shaking, cold, stomach bloating/queasy 6, diarrhea. Take Effexor 25mg with crackers. Drink chamomile tea.

-8:00 anxiety 6, indigestion 5, tight muscles 6; take l theanine 200mg

-8:30 shower, anxiety ramping 7. Debating taking Ativan, but want to hold out. Read. stomach cramping: wrenching after eating pudding and banana; take buscopan (antispasmodic) 10mg

9:00 start work

-9:30 anxiety 4, stomach 6; take Dexilant 60mg

-10:00 bloating, stomach discomfort 5, dizzy, lightheaded, fatigue 7, anxiety 5

-11:00 fatigue 9, cold, drink coffee 1/4 cup, ginergale

-11:30 hungry, eat: 2 eggs, hash brown, 2 sausage, salad w avocado

-12:15. Nausea 5/10, bloating 6, anxiety 6, fatigue 7, spaced out/disoriented 6, indigestion, coughing/wrenching 3

-1:00 dizziness 5, feeling feint 6; drink: coffee 1/3c, nicotine cravings (vaping lots), stomach settled, anxiety 5

-2:00 diarrhea, anxiety 7; take L-theanine 200mg

-2:20 same restless feeling as yesterday: distress level 7, tired at the same time. Bones in legs ache - muscle aches and pain

-3:00. Achy body pain (legs mostly) 7, fatigue 9; anxiety 1, nausea 2, exhausted and really want to lie down, sit on toilet instead. Tylenol 500mg

-4:05 Fatigue 7, back pain 6

4:20 done work

 

-6:00 went on a nice walk

-7:00-8:00 ate dinner (chicken, quinoa, veg) Annoying restless feeling in head, like an itch that can’t be stratched (could be low level residual axiety which was warm flushing and tingling in the head days ago when anxiety was severe); RLS 6

-9:30 bloating, gas, stomach gurgling, bm (solid). Did stretches and percussive massage on legs for RLS - helped 3. 2nd bm 3 min later, diarrhea 

-10:30 feeling good. RLS 0, fuzzy head feeling 2

—————-

3/10

-7:20 Morning anxiety 7. RlS 0. Diarrhea. Vaping all day and appetite only after noon

-7:30 Anxiety 6

7:45 anxiety 7. Urge to go again. Abdominal cramping, chills, RLS 4. Drink Mint/Cham tea. Take Buscopan 10mg

-8:00 symptoms ramping up. Diarrhea again (liquid), cramping 7, nausea 7, anxiety 7. take Effexor 25mg with 1 cracker. 

-8:15 take 1/2 Imodium tablet

-8:30 gastro symptoms slightly improved 6. Feeling hot, anxious 6, tired 7. Force eat banana and pudding. Feels good once I get it down. 

-9:00 arrive at work after aweful nauseating drive, but feel better

-9:30 things take a turn: nausea persists 7, wrenching 8; take gravol 12.5mg

-10:00 nausea 7, bloating 6. Making it very hard to work. 

-10:15 take tums, gravol 12.5mg: a little improvement. Drink peppermint tea

-10:30 steady improvement in gastro symptoms. Fatigue begins to take hold

-11:00 massive fatigue 9/10, nausea 2

-12:15 broke down explaining what I’m going through to boss. Crying, anxious. End up taking 0.5 Ativan

-12:25 indigestion/gas 5, nausea 4, dysphoria 7, anxiety 7, fatigue 8, feeling cold

-1:00 nausea 8, fatigue 7

-1:40 abdominal discomfort 8, anxiety 7; take tums and buscopan

-2:15 two short 5-10 minute windows where things feel ok. Able to talk to coworker.

 

-2:45 last half hour vice grip on stomach has been absent-thank god; but left exhausted, fatigue 8, achey legs and feet 8

-3:00-4:30 finish up at work dead tired.

-4:30-5:30 do some grocery shopping. Stomach feels like a lead weight. Anxiety 7, dysphoria 7

-5:30 get home shower. Anxious about my condition, anxiety 8, dysphoria 8, tight chest, rigid muscles. 0.5mg Ativan

5:40 start to calm down, tightness relaxes, anxiety 5

7:40 updating diary and making SA account, anxious and legs feel crampy, achey and tired

[Frogie]

@FindPeace

 

Welcome to SA. We are a volunteer run site with members such as yourself going off antipsychotic medications or have gone off and are healing.

 

We ask that each member only have one introduction page so we can keep all your information in one place. This is where you will post questions, receive information and meet members such as yourself.

 

Thank you for creating a signature. That helps us be able to look at your medications quickly.

 

As I see, your main problem started January 13, 2022, when you changed manufacture's, is that correct? Did you go back to  Effexor XR, or keep the generic and continue?

 

That is probably your problem. You switched manufacture's without "crossing over". And your body is in wd because of it.

 

 

 

Unfortunately, most dr's don't believe in wd symptoms, they just think that you have to be on it the rest of your life.

 

How do you talk to a doctor about tapering and withdrawal?

 

I'm going to give you a couple of links to read that you may find to be helpful.

 

 

Digestive problems:  Nausea, Diarrhoea, Bloating, GERD

 

At this point, I would suggest going back to your original manufacture and holding on the dose for quite a while until your wd symptoms settle.

 

We don't suggest supplements on here because most members have sensitivity to them. We do suggest 2. You could try one of them in a small amount, wait a few days before introducing the other.

 

Magnesium

Omega-3 Fish Oil

 

I'm so sorry this is happening. I hope you reach out to us with any questions after reading this information.

 

 

 

 

 

 

 

[FindPeace]

Thank you @Frogie for your reply and for providing the links.

 

just to clarify, I only took the different brand/manufacture that one day (Jan 13) and promptly changed back to my usual brand. Things seemed to be going well for a while after that (over 1 month), so I’m wondering if something else is at play. Would your advice still remain to stay at the current dose and stabilize given my explanation or is it possible my dose is too low or too high?

 

I am wondering if I am experiencing adverse effects, withdrawal, or general CNS destabilization, since this is the worst I’ve ever felt. Accordingly I could try updosing, reducing or try and weather the storm (although it’s quite unbearable).
 

Any further input would be much appreciated,

 

thank you kindly,

FP

 

[Frogie]

@FindPeace

 

You could try a small updose and see if that helps with they symptoms. 

 

I would go back to the original dose (before all this happened) and the way you measured it before this happened. So if you weighed it, go back to weighing. If you counted the beads, then go ahead and keep counting. That is probably the problem also, you changed the way you were measuring also.

 

Then hold for a while and see if they symptoms settle a little. If not, we can do another small updose. It takes about a week to 10 days to feel it fully.

 

Let me know how you feel or if you have any other questions.

 

 

[FindPeace]

@Frogie Thank you for your last reply. I haven’t worked up the courage to change my Effexor dose as of yet and extreme anxiety has not improved and I find that the only thing which helps it to take the 1mg Ativan. No I’m worried about becoming dependent on it. Q: how long do you think it will take to become dependant, is doing so to help stabilize and then tapering it later a wise option?

 

I was also hoping you could give you opinion if cutting out all supplements (I’ve added them to my signature) right before this happened is contributing to the anxiety. Q: is it possible to become dependent on magnesium, for example, after taking it daily a year? Could phosphatidylserine and turmeric destabilized me because they affect neurotransmitters? Should I add the supplements back in?

 

I’m really frightened right now and don’t know what to do, I fear an updose while I’m like this will destabilize me further. I’m desperate for relief and so taking the Ativan but I don’t feel this is sustainable.

 

🙏

FP 

[FindPeace]

Just add: I have used benzos in the past as I have a history of alcoholism. In 2012 I had a bad experience when I used them for too long and in too high doses (+3 months) and I ended up in the hospital in intense withdrawal.

 

The doctor wrote me a script for a short two week taper and I followed it and came off. I don’t remember any PAWS from it, but I do worry that some kindling took place and subsequent withdrawal will be even harder, hence leery of using them for my present anxiety. 

 

 

[Frogie]

@Findingpeace

 

10 hours ago, FindPeace said:

Q: how long do you think it will take to become dependant, is doing so to help stabilize and then tapering it later a wise option?

It takes as little as 7 days for your to become dependent on a benzo unfortunately. You could always take it and then after you stabilize and taper off the Effexor, taper off the Ativan very slowly. You can also crossover to Diazepam and taper off of that. But if you do continue to take the Ativan you will become dependent on it. How do you feel after you take it? Do you think it is helping? After being on it before, you could have some problems with being on it again. 

 

Here is some information in kindling that might be helpful to you.

 

Post Withdrawal Nervous System Hypersensitivity/Kindling

 

10 hours ago, FindPeace said:

Q: is it possible to become dependent on magnesium, for example, after taking it daily a year? Could phosphatidylserine and turmeric destabilized me because they affect neurotransmitters? Should I add the supplements back in?

It's not possible to become dependent on magnesium. That is actually one that we recommend on this site. And Omega. You could try a little omega also. Many members find those calming to the nervous system.

 

Magnesium

Omega-3 Fish Oil

 

I don;t know much about phosphatidyslerine. What I did read on the internet was:

Phosphatidylserine provides optimal levels of these important hormones in the brain. The regulation process helps to stabilize your mood and reduce feelings of stress, depression, and anxiety. (I read this on Webmd). You could google this and read a little more about it.

 

If you take a multi-vitamin, they usually contain Vitamin B's, which can be very stimulating.

 

Did you go back to the same way you were tapering the Effexor? If you were weighing or counting beads that could be a factor also.

 

Let me know if I can help you anymore. 

 

[FindPeace]

Hey @Frogie, thank you for the further assistance. To answer your question as to how I feel after I take the Ativan, I feel that it helps reduce the anxiety by a lot. I even find that it had some carryover into the next day if I take it late enough. When it wears off I am back to square one with raging anxiety. Q: am I correct in assuming, it should not be used sporadically as needed, but steadily - if at all?
 

I’m afraid to take it especially long term and (since I would need to taper from Effexor for potentially years). I’m pretty sure this would lead to inter-dose withdrawals (of the Ativan) and dose escalation. 

I feel that cutting out all the supplements after faithfully taking them for a year has not helped. I believe phosphatidylserine may have had some synergistic effect with the Effexor and not taking it has somehow augmented the withdrawal.

 

Today I did a test up dose of ONE bead (86->87) to see in the next few days how I will react. I was too afraid to updose more initially in case what I’m suffering from are adverse effects of Effexor. 
 

I can not in good conscience go back to weighing since I discovered that tapering by weighing (Pfizer) Effexor results in a different number of beads in each dose. I believe each bead contains the same amount of medication and only varies in the quantity of XR coating so I am committed to taking the same number of them daily for stability. Q: in light of this, do you still think it would be good to go back weighing and potentially receive a fluctuating daily dose since that is what my body was used to?

Thank you. This is not easy to cope with and your help means a lot. 
 

🙏

FP

 

 

 

 

 

 

[FindPeace]

@AltostrataHonestly I don’t think I can cope with the constant anxiety. It’s been plaguing me from the moment I woke up at 8, until now at 3:00. I have been lying in bed all day, don’t feel like eating anything - my stomach is cinched up tight and constantly gurgling whenever I eat or drink anything. I tried breathing and other strategies to get it to abate but nothing works. It is relentless. In the morning it came in waves and now it is nonstop. My skin tingles with it. I feels so much stress cording through my body. I’m exhausted by it but I can’t rest. My thoughts keep steering towards the darkness: believing I’m messed up beyond repair. Wondering how I can possibly live like this. After a while I want to scream out, I want to break something, I am so troubled. 

 

I regret so much ever tapering Effexor. If I had know someone can get stuck in limbo, destabilized like this with crippling anxiety I would have never done it. It would have been better to stay on it for life that become a cripple. Now it seems I’m screwed if I go back to a regular dose - I will have an adverse reaction. And of course I can’t just stop taking it so what am I supposed to do? It takes taking 10 minutes to make one dose for god knows how long. Please help me I don’t know what to do. 

[FindPeace]

I’ve been avoiding using the Ativan and my pattern is as follows:

 

the day I end up using it my anxiety is unbearable. I wake up and endure it for as long as I can but around 4 I cave in and take it. It helps.

 

the next day I have residual effects and I can cope with my anxiety to the point that I don’t take the Ativan. I can eat and coping strategies like mediation and breathing exercises work for me.

 

the next day is back to square one with crippling anxiety from the moment I wake up until I can’t take it anymore and take an Ativan. 
 

this anxiety started long before Ativan was even in the picture as a result of messing with my dose of Effexor. 
 

I’ve been trying to take a reduced dose of magnesium and fish oil here and there out of desperation but it’s not helping. 
 

I’m trying to stay positive but I get worn down from the sheer intensity and relentless of the anxiety. Any help from anyone would be so very much appreciated. 🙏

[Altostrata]

Hello, FindPeace.

 

On 3/10/2022 at 6:39 PM, FindPeace said:

But on 

March 2nd and 3rd I experienced hypomania and anxiety which was unusual. On March 4 all hell broke loose and from the moment I wake up I start experiencing 

 extreme anxiety, diarrhea, nausea, dry heaving, RLS in the morning 

 

January 13-February 16, did you take your Effexor dose off-schedule, forget a dose, accidentally take an extra dose, add or drop any other drugs, drink alcohol, or take antibiotics?

 

How do you feel after you take your Effexor dose compared to how you feel before you take it?

 

On 3/10/2022 at 6:39 PM, FindPeace said:

so I decided to check and see if 91 beads was a good average number for my previous pill weight of 83mg I had switched from. I weighted out 5 of my previous doses, counted the beads in each, and the average was actually 86 beads. So Feb 20 I  began to take 86 beads. 

 

Things seemed go fine with the usual withdrawal symptoms I am used to.  But on 

March 2nd and 3rd I experienced hypomania and anxiety which was unusual. On March 4 all hell broke loose

 

What were "the usual withdrawal symptoms I am used to"? What was your usual pattern of symptoms when you felt your tapering was tolerable?

 

It appears you got unusual symptoms 12 days after you made a dosage reduction from 91 beads to 86 beads. What is your estimate of the dosage in milligrams of Effexor (milligrams of active ingredient or MGAI)?

 

[FindPeace]

@Altostratathank you so much for replying Alto, it means so much to me. I am eternally grateful to you and frogie for your help. 
 

1 hour ago, Altostrata said:

How do you feel after you take your Effexor dose compared to how you feel before you take it?.

I take my Effexor at 8am and I wake up usually at 7-8 so it’s hard to tell, but when I do wake up I already feel the anxiety building. After I take my Effexor it doesn’t not help to allay the anxiety and it surely gets worse later on in the day. Later around 5pm I find my anxiety lessens, not sure if because I’m exhausted from enduring it or because a good deal of the Effexor is metabolized - hence my dilemma of whether to upload, reduce or hold. 

 

1 hour ago, Altostrata said:

January 13-February 16, did you take your Effexor dose off-schedule, forget a dose, accidentally take an extra dose, add or drop any other drugs, drink alcohol, or take antibiotics?

During the period in question, none of the above took place. What I did do, is on 

Jan 13 my brand was switched and I ended up taking Sandoz Effexor XR (2 of the 3 minitabs) to get my dose of 25mg. I only took it one day and beacause I did not react well I promptly resumed taking the Pfizer Effexor XR with beads; however,  instead of continuing to weigh my dose I chose to count. I figured my current bead weight constituted 91 beads.

 

Things seemed to be going fine but by Feb 16 I started noticing unusual symptoms: nausea, vertigo, restlessness, anxiety/dysphoria. In hindsight, these symptoms look a lot like my current ones but they were more mild and sporadic. My current symptoms constitute the anxiety (dialed up to 8-9/10, nausea, abdominal pain and cramping which are also severe - and no desire to eat as a result), there is also some dizziness and vertigo. 

 

1 hour ago, Altostrata said:

What were "the usual withdrawal symptoms I am used to"? What was your usual pattern of symptoms when you felt your tapering was tolerable?

Usually my symptoms are more moderate and don’t feature anxiety or nausea/cramping too much: headaches, flu-like symptoms, fatigue, brainfog - occasional restlessness and low mood. 
 

1 hour ago, Altostrata said:

It appears you got unusual symptoms 12 days after you made a dosage reduction from 91 beads to 86 beads. What is your estimate of the dosage in milligrams of Effexor (milligrams of active ingredient or MGAI)?

I think by feb 19 I was already showing signs that this was progressing but I misinterpreted it to mean my bead count wasn’t right and so I took averages of my previous bead weight to confirm. It was closer to 86 so I changed it starting feb 20. Not much happened until March 2nd as I mentioned above. This all began after those two days where I had an unusual amount of energy and then 2 days later on March 3: sky high levels of anxiety and gastrointestinal issues. 
 

I figure my current dosage is 25mgai. I did a test updose of one bead two days ago (March 12) from 86 to 87.

 

The last weeks since this all began has been horrendous. I received 14 1mg Ativan in case of panic attacks and found that it makes my anxiety bearable (0.5mg) and I can eat; the effects last into the next day and I have an alright semi functional day. The day after that (~36 hours after Ativan) it’s back to square one but despite this I’ve chosen to try and not use it. Last dose was two days ago at 6pm March 12. It’s been terribly hard to bear the symptoms to the point I’m mostly confined to bed and having much trouble eating. 
 

🙏

FP

[FindPeace]

@Altostrata

 

Hi again, I woke up to today at 7:00 and have yet to take the 25mg of Effexor. My anxiety is not great at this time (about a 4/10) and the physical symptoms of it like flushing/tingling, adrenaline coursing, feeling of dread and panic are all but absent. 
 

11 hours ago, Altostrata said:

January 13-February 16, did you take your Effexor dose off-schedule, forget a dose, accidentally take an extra dose, add or drop any other drugs, drink alcohol, or take antibiotics?

 

I’ve been thinking a lot about this and I release that some of the supplements I was taking at the time (which I’ve since discontinued as of March 4) may have affected serotonin: 450-900mg turmeric and 100mg phosphatidylserine. 
 

I also recall that the day before all this precipitated (March 3 during the hypomanic symptoms) I consumed a BCAA workout drink with 50mg of ginseng before a hike. My mistake 😞

 

Now I’ve began to suspect serotonin toxicity as the cause of my condition. I could be wrong and it could be withdrawal but I’m at becoming very afraid of my dose of Effexor. Inal crushed and so regret taking any supplements. I will continue to monitor how I feel before and after I take it.

Q: if it is serotonin toxicity is there a suggested a way to deal with this?

 

I hope you are well, 

FP
 

 

[Altostrata]

It doesn't sound like a situation where serotonin toxicity could occur. Rather, it's more likely a measuring error.

 

14 hours ago, FindPeace said:

I did a test updose of one bead two days ago (March 12) from 86 to 87.

 

Any changes in symptom pattern from this?

[FindPeace]

4 hours ago, Altostrata said:

It doesn't sound like a situation where serotonin toxicity could occur. Rather, it's more likely a measuring error.

I’ve check many times the average bead count of doses made up of my last know bead weight 83mgpw (Jan 13) and they are all over the place (because the darn beads are different sizes). A average bead count from 10 doses of 83mgbw yielded 86. Earlier today repeated the averaging with 3 capsules weighed to 83mgbw and it was 83 beads. So really counting Pfizer beads at this weigh gives a range between 79 and 91 in any given dose. Part of the reason I wanted to count instead of weigh. But this has created trouble for me and I feel very sorry about that. 
 

4 hours ago, Altostrata said:

Any changes in symptom pattern from this?

since the up dose of one bead to 87 beads from 86, I’m inclined to say that it made things worse, although I’m told it’s early days (3 days). But I have to admit that these last two days I was trying not to use any Ativan, so they were very hard. I will think more about this but since Ativan brings a relief of symptoms it is muddying up the waters. For that I also feel very sorry. I had the distinct impression this morning as I woke up feeling somewhat decent, that taking my Effexor was going to bring on the adrenal storm. And that’s what happened.
 

I reached a point after two days of not taking it that I was just mentally and physically drained from eduring, and today midday I took an Ativan 1mg In desperation. 
I am at a loss at what to do, and as much as it pains me to become dependent on BZD, I don’t thing I can endure the intensity of symptoms. 
 

😞🙏

 

I will paste my diary from the 5 days below.

TY

[FindPeace]

Diary from 3/11/22 - 3/15/22

 

3/11

7:30 wake-up to activated feeling but anxiety is at 4 (Ativan residual effects likely … phosphatidylserine?)

8:00 take: Effexor 25mg. Tear production, stuffy nose, fatigue 4

BM 6

8:35 put on perfume (means I feeling normal) anxiety 2, stomach 0, restless/revved up 4 (realize Ativan can control the symptoms but I don’t want to use it!) Drink black tea

9:30 mood has been good and absence of anxiety and stomach issue. Drowsiness 7

10:30 anxiety creeping in, anxiety/chest tightness 5, an cramp 4

11:30 good mood. No appetite. Anxiety 6. Nervous feeling stomach and chest. Alcohol cravings.

11:45 Eat: eggs, hash, sausage, greens. Feels good to eat.

12:00 anxiety 6.5: start to worry the the benzo is masking symptoms and I will have to face the full anxiety and gastro stuff because I don’t what to become dependent on it. 

1:30 hasn’t been bad honestly. Slight headache, muscle tension 5, anxiety 5, fatigue 6.5, no stomach upset

3:22 unbelievably my anxiety has lessened throughout the day. Feeling as normal as I have since this happened. 

4:00 not w even tires or anxious, just a bit out of it and thirsty 

6:00pm sore back. What a week! Take 0.25mg Ativan and have a hot bath

9:00 bloating 6, tense 3, anxiety 2

9:40 feeling of dread, anxiety 6, rls. Ativan 0.25mg

————————-

3/12 

7:30 wake up with anxiety 6, RLS. BM (Solid). 15 minute later anxiety drops to 5

8:00 take Effexor 25mg. Sleep till 9:30. Vivid dreams.

9:30 same cycle with anxiety

10:12 Diarrhea. Anxiety 4

12:30 researched frantically for 2.5hr. Wish I hadn’t. Had anxiety (6-7) the whole time. Now I’m sleepy. Anxiety 5

2:00 anxiety was bad (7) for the last hour and a half, but I got dressed, made my bed, ate some crackers, made mint tea and started reading CBT. Found breathing excercises help. Currently: anxiety 4, dizziness 6, anorexia, headache 3

2:40 stomach nonstop gurgling. Diarrhea 

3:00 anxiety 9

4:00 anxiety was 7-9. Can’t cope with constant onslaught of anxiety. Not being able to eat because abdominal cramping and anorexia is so bad. 0.5mg Ativan

5:00 had some chicken soup. anxiety still present 5-7. Take magnesium 100mg

6:00 the anxiety feels as if there is a boa constrictor choking my heart. I just need relief! I spent all day in bed obsessively worried about my condition. Barely at le a thing. 0.25 Ativan

7:00 is vaping flaring my anxiety?

9:00-12:00 calmed down slowly by bed time. Was exhausted from fighting all day.

————————

3/13/22 (day light savings) UPDOSE 1 bead

8:00 woken up by alarm, feel fine. Take Effexor 25mg (updose) Anxiety slowly creepy back in first felt in stomach. 

8:30 anxiety 5, muscle tension; drink ginger tea with smidge of turmeric

9:10 anxiety has been manageable got up to about a 6.5 at one point. Waxes and wanes. I’m reading CBT. magnesium 50g 

10:40 muscle and joint pain 6, dizziness 3, occasional tinnitus, anxiety 4-5; Tylenol 250mg

12:00 eat oatmeal; muscle pain. Sleepiness leads to a 1 hour nap with 3-4 awakening

1:30 decide to get out of bed and have shower

2:00 feeling better. Stomach ok, anxiety 3. Spaced out 5; tired 7; anhedonia 6; crampy restless feeling in legs the last two hours

3:25 on walk around lake. Feeing ok except for occasional anxiety and restless feeling in legs 4/10.

4-5 went grocery shopping. Stopped by work. It was nice to see people. Anxiety ok

6:00 ate dinner. Headache starting. Took 250mg Tylenol

7:00 headache intensified. Sore back and tired. Took another 250mg Tylenol. I hope the Ativan is not going to be too hard to get over. So far no crazy anxiety today like yesterday.

8:00-12:00 evening went well. Had another meal. Watched tv and read. Anxiety never went above as 3.

———————-

3/14

(Diarrhea all day except BM’s except those mentioned)

8:00 wake up. Anxiety 6. Take Effexor 25mg. Bm 7. 

8:30-9:00 Wait for anxiety to come down, do a mediation and go back to sleep

10:00 wake with spike of anxiety, 6-7. Gradually abates

10:30 BM 7. anxiety coming in cycles. Up to 7. Thoughts darken to worries, but I resist. Trying magnesium: 50mg

11:30 anxiety steady up to a 7-8. Eat chia pudding. Take 1/2t fish oil in desperation. Curiously the anxiety abates right as I take it.

12:00 bad anxiety cycles every 15 minutes. Reaches an 8. Today is a lot like 3/12. Bed ridden. 

2:30. Anxiety there for the last two and half hours. A steady 7. Ate oatmeal without appetite. Back and chest muscles very tense. Took magnesium 50mg. Going to rule out anxiety from caffeine withdrawal.

Make black tea.

3:30 have an anxiety attack 8-9, causing my to reach out to alto on SA and friend . Eventually it passes leaving me wiped.

4:00 went on walk, didn’t help anxiety but felt good initially

• 4:45 really bad anxiety 7-9 until now. Small respite after watching calming video drinking ice water. Take phosphatidylserine 20g

5:30 45 minutes now the extreme rushing crushing anxiety has been absent. Just an upset stomach (phos?) and utterly wiped out

6:30 anxiety symptoms such as adrenaline and all the rest have calmed but the stomach upset and tightness persists (obviously a problem as I need to eat) try buscopan 10mg and tums. Tired legs sore knees. 

7:40 tried to induce vomiting to feel better. Nothing came out but I feel 30% better.

8:10 nausea/stomach pain 8: gravol 12.5mg

8:30 Tylenol 250mg (did it help previously?)

8:40 gravol didn’t help. Induce vomiting once again so I can eat small Amount of chicken and potatoes

9:00 eating settled stomach. Today was a really bad day. Left exhausted. 

11:00 go to sleep, stomach unsettled. Notice muscle spasms (tremor-like) in abdominal wall or stomach. 

——————

 

3/15

 

2:30a short awakening

4:30 awakening, lots of dreams

7:00 wake up tired, anxiety low 4, stomach bloated/gurgling. Worries I’m having a adverse reaction to Effexor after becoming sensitized. 

7:45 eardrum pulsing. Stomach bloating

8:00 take Effexor

8:40 shivering/cold, diarrhea, dysphoria 

8:45 crawl back into bed to warm up, now feeling uncomfortably hot. The anxiety and nausea is back at 7. RLS 4

9:30 dozing off helps calm everything. Woken up by phone. Symptoms are ok but aware stomach is still bloated.

10:30 agitation(8) and anxiety (9) is getting so bad. I can feel the blood rushing to my head. Feels like someone is drilling into my stomach and my whole body is coursing with adrenaline. I don’t think I can take this. I’m going to need to take Ativan. 0.5mg taken.

10:45 Ativan worked almost instantly. Chest tightness gone. Anxiety down to a 2. Stomach stopped hurting. 

11:00 feeing of anxiety 6, face tingling -all symptoms coming back. Ativan only took the edge off. Attempted to vomit, nothing came. 0.25mg Ativan 

11:18 trouble regulating body temp. Spaced out. Eat chia pudding.

2:00 talk to therapist. Tired 7, muscle aches 6, nausea 6, low mood 7, anxiety 5

2:20 0.25mg Ativan

4:00 , spaced out. Stomach settled. No anxiety. Tired

5:30 tired, hungry and sore back

[FindPeace]

I just found this journal entry I made on Feb 18. I will copy/paste the text. This was 2 days before I reduced from 91 to 86 beads (because I thought my symptoms came from a dose which is too high, smh). If you read it, it’s clear that the beginnings of my current predicament were taking hold…it’s just so much worse now. 
~~~~~~~~~~~~~~~~~~~~~~~~~~

Since Saturday last week I’ve been in a wicked wave. Second time through this process that I’ve actually been scared I may not make it. It’s perhaps worth mentioning that I’ve made it from 75mg to 25mg in just under a year.  It has become clear to me now that I won’t be able to keep up this progress after being on E so long. Symptoms have been twofold: physical and mental. Physically, my stomach hurts, I’ve got the runs and I’m dizzy - I walk around with so much pain and fatigue I don’t know how I’m still employed. Mentally it’s worse: really bad anxiety and dysphoria the like of which makes me worry if maybe I need help. There is also that feeling that things are not going to get better.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

 

[FindPeace]

@Frogie @Altostrata

hey guys, it’s been a few days. I understand completely that you guys are volunteers and have lives of your own and thank you so much for the work that you do. I hope it’s ok I tag you…

 

yesterday I had a so-so day symptoms (anxiety, nausea) wise but and managed to go all day without taking anything but my 87 beads of Effexor until I went to bed at 9 to get up 5 for an early shift: I experienced insomnia for the first time. I tossed and turned till past midnight and then took reluctantly 0.5mg ativan because I didn’t believe I would fall asleep other wise.
Q:  is this an indication that my every second day <1mg/day ativan use (for well over a week now) has caught up with me? What should I do - would I be better off taking it regularly and stabilizing? 

 

I had planned to go as long as I could without taking it and I really want to get off it asap but it each day looks more like I won’t be able to do it, especially seeing as I have to function for at least this week (till Sunday) while my boss is away, I felt like I had no choice. I am strongly considering getting sick leave next week. 

 

Any input guidance you could give would be much appreciated.

 

Thank you 🙏

FP

 

 

 

[Frogie]

@Findingpeace

 

51 minutes ago, FindPeace said:

 is this an indication that my every second day <1mg/day ativan use (for well over a week now) has caught up with me? What should I do - would I be better off taking it regularly and stabilizing? 

Your body will become dependent on Ativan within 2 weeks if taken regularly.  You don't want to take a benzo every other day as your body gets confused why it is not getting it every day now. If it has only been a week I would stop it now. If you think it is helping, then start taking it every day, at the same time. You can taper off of it at a later date if you feel the need to take it.

[FindPeace]

Thank you @Frogiefor your reply, Q: is it advisable to split a dose of ativan am pm?

 

@AltostrataQ: what would constitute a safe up dose of Effexor 25mg? My gp who is clueless has told me to reinstate to 37.5mg, but as far as I know that is not safe to do when not feeling stable. 
 

🙏

FP

 

 

[Frogie]

@FindPeace

 

If you do take the Ativan, you would want to split into 2 doses, about 12 hours apart.

[Altostrata]

On 3/15/2022 at 5:22 PM, FindPeace said:

these last two days I was trying not to use any Ativan

 

Over the last 2 weeks, how often have you used Ativan? If not taking it causes symptoms, you are physiologically dependent on it.

 

Some of your symptoms may be caused by irregularity in your dosing schedule. Are you a shift worker? Do your shifts move around?

 

Please settle on a regular schedule for Effexor and Ativan. Take Ativan at the bottom of your dosage range, do not add random rescue doses.

 

It may be that you will need to divide your Ativan dose to avoid interdose symptoms. @Frogie, what do you think?

[Frogie]

@FindPeace

 

As I explained, if you take the Ativan is helping, then you need to take it on a regular basis. You can not skip days/doses.

 

You need to set up a schedule so you are taking it twice a day, approximately 12 hours apart and 2 hours before or after any other medication.

 

@Altostrata What is your opinion on this?

Edited March 20, 2022 by Frogie

[Altostrata]

A regular schedule for the Ativan is imperative. We can't work with haphazard dosing.