Penstemon: Simultaneous polydrug tapering

[Penstemon]

Hi Lexi.. the benzo sub forum is the last forum under the main support forum...  link

 

Yikes, I would not want to use Kindle for anything but reading books. (I'm a paper and ink sort myself).  I've heard stories about how limited Kindle is for general purposes but did not realize it would not even support cut and paste.. Good Grief Charley Brown!

 

Skyler

I am interested in hearing from anyone who has tapered(or is currently tapering) all of their drugs simultaneously.I get that it's not the norm but....... 

[mammaP]

Hi Penstemon, I don't think there are many, if any, people on here tapering multi

drugs at the same time because it's not advised to do it that way. It would depend

on which drugs are being taken I suppose but with psych drugs it's recommended to taper

the anti depressant first because that can be hellish. It's easier to adjust the dosage to

make tapering as painless as possible by tapering one at a time. If tapering more than

one it would be difficult to know which was causing withdrawal symptoms. 

[GiaK]

Rhi does it and she does it very skillfully...it's not that it's not advised so much as it's difficult to measure and people aren't practiced in it...I personally think there is good reason to consider it as an option.

 

Rhi is a member and in fact a moderator too but she works full time and is very busy...you can find her personal intro thread here: http://survivingantidepressants.org/index.php?/topic/221-rhiannons-intro/

[Altostrata]

Tapering multiple drugs simultaneously is not recommended unless you know your withdrawal symptom patterns very well -- as Rhi does.

 

The problem with tapering multiple drugs simultaneously is if you run into trouble, you won't know which dosage to adjust. This could get you deeper and deeper into withdrawal syndrome.

[Aria]

I tapered off several drugs at the same time because I didn't know any better. Trying to keep track of what cut from what drug became a mess. Some I just stopped out of frustration and got hit by withdrawals I wasn't prepared for.  I didn't have access to more prescriptions for a few of them so I reduced too quickly.

 

I have to second Altostata about tapering multiple drugs at once. My Introduction "Aria" thread tells about my experience. http://survivingantidepressants.org/index.php?/topic/2477-aria-my-psych-journey/

[tezza]

Hi Penstemon,

 

I've been multi tapering for over a year. It's not any faster than tapering only one drug, really. It has to be done very carefully and it's not the way I started out.

 

I've gotten to low dosages on most and DCd some.

 

Please tell us more about yourself. Welcome!

[TJo]

I am trying to cut two drugs at once, Remeron and Klonopin. I was advised by a doctor that it was a fine thing to do. Now I'm feeling withdrawal and I'm not sure which one is the culprit. I will probably try going back on one of them and see if that evens things out. This is hard. I applaud all of you for your patience and perseverance. 

[Rhiannon]

Hi Pens, I'm multi tapering multiple meds. I think there's a thread somewhere where Alto and I discuss it, pros and cons.

 

It can be done, and it's working great for me, but you must go VERY slowly. It will not make your taper process faster in the long run; maybe it even makes it longer. It's a bit tricky. I would say it took me about a year to really get the hang of it. I've been tapering over three years now and am mostly down to very small doses.

 

I like it because I hated all the drugs I was on and wanted to get to lower doses of all of them. It also seems to actually work better for me, more smoothly to taper them together than when I stop tapering the others and just taper one. But like I said, it's tricky and it's not for everyone.

[Rhiannon]

I keep a chart of dosages and symptoms (rated on a scale of 1 to 5, plus notes). Initially I updated it daily, for the first year and a half, then gradually I've gotten to where I can keep track in my head and now I just update it periodically or when I'm having trouble. I think if you're going to taper multiple meds it's really important to keep track of dosages and cuts and symptoms so you can detect patterns.

 

Also, you have to be careful to stop and hold as soon as symptoms ramp up AT ALL--at least that's what I've found. It's easy to get into trouble by tapering too fast even just one drug, and all the more so with multiples.

[tezza]

I've found all the same to be true. I knew very well what WD felt like before I started multi-tapering so I know right away if I need to hold.

 

I'm going excruciatingly slow at low dosages. I loathe WD symptoms and try very hard not to set them off at all.

[Rhiannon]

Hey Tezza, I see you just recently finished the Lamictal, congratulations!

 

I hate that one and unfortunately it's the slowest going for me so it will probably be the last to go.

[tezza]

Hey Rhi, yes, the Lamictal never seemed to be a good choice for me. I actually feel better without it. After I started taking it, I had extreme mood swings plus rages but didn't realize until I got to lower dosing that the Lamictal had likely caused it.

 

Congrats to you, too, Rhi! You've come a long way!

[Penstemon]

thanks to all of you for your input on tapering multiple drugs.  my partner and I have scoured all of your past posts on this topic. lots of good feedback and food for thought. we have also read up on various ways to taper and are feeling like water titration makes the most sense for me and the drugs I am on. will probably also make up some capsules for the TID Ativan for convenience. I have decided to try tapering all 4 of my drugs at once at a very slow rate.am currently doing temazepam at .3mg/day which translates to ~ 10% per month and it is going very well. I may start here with the other 3 or perhaps less. switching to water titration(from pills) without a cut for a week and then will start to cut. I am fortunate to have a supportive partner who can also do the math for me and several other folks who are keeping a close eye on me.I always keep a journal but am fine tuning it to this new taper. I plan to do frequent holds for as long as needed.to recap: the drugs I plan to come off are: traz-100mg hs,Seroquel-50 mg hs, temazepam-14mg hs. ,and Ativan-.5mg TID. happy for any tips for this forum.

[Rhiannon]

Penstemon, if you're going to be cutting multiple drugs together, in my experience you should not cut any one of them at 10% a month.  Maybe all together they could total that much (2% each of two, 3% each of two), although I would find that too fast for me.  

 

Please listen to me and Tezza, who have experience with this: if you're going to taper multiple drugs together you must. go. very. slowly.  ESPECIALLY at first, for the first 4-6 months, while you're figuring it out. 

 

Forgive me if I seem to be repeating myself, but I don't want to see you hurt.

[Penstemon]

Okay thanks Rhi. what you are saying makes good sense. If 2-3% is too fast for you, what is slow enough? I know it's a very individual thing but I need a place to start.I am not trying to rush my taper by doing multiple drugs. I know that it will still take just as long if not longer to do it this way. It just makes good sense to me. But I will admit it_I am scared.

[Altostrata]

If tapering all at once scares you, please consider tapering one at a time until you understand your withdrawal pattern.

 

I suggest holding on the benzo taper and looking at all your other drugs to see which to taper first. My preference would be trazodone, which has a bunch of adverse effects and can have a wicked rebound insomnia. Then perhaps I would taper Seroquel.

[Penstemon]

Thanks for your concern and advice Tezza. What else can I tell you about me? I was put on AD's 25 yrs ago for complaints of cognitive diffuclties. This got labeled "severe clinical depression".  It should have been labeled plain old normal grief as I had lost my boyfriend to cancer 7 months prior then moved to Alaska from my beloved Montana to be with an ex boyfriend.My 1st med was trazadone and it seemed to help-until it didn't. Then started the poludrug scene big time. On and off all classes of meds 3-4 time/yr for many yrs. Essentially c/t'd I now know. Hospitalized for ECT in 1995. Terrible experience. More depressed. At some point my dx got changed to bi-polar and more trials of mood stabilizers. Lamictal sent me into full blown mania for ~ 2 months. After that episode,I was able to look back and see other times when I had been hypomanic-mainly on maoi's ,which became my go-to meds. In 2006, I participated in a research study using VNS for "treatment refractory depression". It did not help me. I still have the implant and it is still turned on although the study ended 2 yrs ago. Have wanted to get it turned off but seemed to make sense to get off all of my drugs 1st. So why have I (or allowed docs to) put myself through all of this when I was only getting sicker? Like most-I was spellbound.  I raised a son who is now 23 through all of these years of illness. I have wanted to kill myself many times but could not do this to him.So-I just kept on trying to get "well" through psychiatry. About 2 yrs ago, I began reading Breggin's books and have come off of lithium,lamictal,emsam, 200mg of seorquel,and 15mg of temazepam. some tapers were too fast out of necessity-others out of ignorance. Despite myself,I have done reasonably well with my tapers. It wasn't until I was halfway thru my temaz taper that I began to have some physical sx's-mainly back pain and insomnia, but these have mostly resolved since I slowed my taper down. I have struggled greatly with lethargy(at times paralysis), a.m. anxiety and depression,anhedonia, cognitive impairment,intrusive and ruminating thoughts, occasional derealization ,irritability, and over-stim issues.Although I am not well,I am not completely debilitated as so many are . I have noticed that my sx's

 

have lessened  over the past week. So that's where I am at in this moment in time.I am not working at all right now. Was a physical therapist for 20 yrs prior to going on disability in 2004. I have done some odd jobs since then but just find it hard to work and do this taper thing right now.  

[Rhiannon]

Okay thanks Rhi. what you are saying makes good sense. If 2-3% is too fast for you, what is slow enough? I know it's a very individual thing but I need a place to start.I am not trying to rush my taper by doing multiple drugs. I know that it will still take just as long if not longer to do it this way. It just makes good sense to me. But I will admit it_I am scared.

Well, you'll find that I always counsel starting slow, especially for someone with a long and complex psych drug history like yours.  I think a total cut of 5% or less of all drugs put together (that is, just 1% of each one, or so) is a good place to start. Then hold until all symptoms clear up from that cut (give it time, one good day can be followed by a bad one, make sure you've had four or five good days in a row). Then try it again, and then again, and again. Keep going really slowly like that for four or five months until you've gotten a feel for your own withdrawal patterns and how they play out.

 

Stop cutting anything the second your symptoms ramp up, and hold until they've quieted down. Keep a daily log of symptoms and dosages, ranking your symptoms on a scale of 1 to 5 or something like that, with notes as to whatever else was going on in your life that might contribute to your moods/symptoms.

 

Since this is pretty much uncharted territory, you'll be your own teacher, guru and guide. Going slowly like this will allow you to gather information about your own body and what works for you, safely. If you find you can tweak it a bit faster later on, you can do that, but make only small and slow adjustments, because there's a lag time and if you do too much too fast it will come back and bite you on the bum.

 

 

If tapering all at once scares you, please consider tapering one at a time until you understand your withdrawal pattern.I suggest holding on the benzo taper and looking at all your other drugs to see which to taper first. My preference would be trazodone, which has a bunch of adverse effects and can have a wicked rebound insomnia. Then perhaps I would taper Seroquel.

 

I agree--if you're scared, maybe take one at a time.

 

You can taper one med for a bit, then taper another, then another, so that way you're bringing down the dosages of all of them gradually, alternating, rather than going all the way down on one before starting another.

 

Regardless of how you do it, I still think it's best to start really slowly, to allow yourself to learn your body's reactions and patterns in a safe way, without crashing into the wall.  Then if after a while you're confident you can speed it up a bit, you can go up slowly, in such a way that as soon as you start to feel bad you can step right back.

 

I totally understand being scared. I have been to hell too many times, from these drugs, quitting them, changing them, trying to quit, etc. But really, you do have a lot of control, and it's not that scary when you're going in a slow, controlled manner. I just emphasize the danger because so many people don't understand how slow you really need to go at first.  

 

If you take it slow, then you won't have cut too much, so when you start to feel symptoms of withdrawal, instead of that being the first harbinger of the hell to come, it's just symptoms of withdrawal. If you stop cutting anything immediately and hold, or even reinstate a bit if you feel you've cut too much, and then hold, those symptoms will fade away over time. As you continue to experiment in this way going really slowly, you'll refine things more and more.  You'll get better and better at it.  YOU will be in control of your withdrawal, and you'll have choices about it.

 

If people go too fast, though, and cut too much too soon, then sometimes when the symptoms start to hit, they're going to hit really hard, because the lag time hasn't yet kicked in fully and there's a lot of withdrawal from cuts they've already made, yet to happen. I see this all the time.

 

So, yes I totally understand how scary it can be. The trick to making it safe is to go so slowly that you are in control. Don't think about how long it's going to take, don't make schedules, don't think about calendars.  Just focus on tracking your symptoms and cuts, and learning, for now.

[Penstemon]

thanks again for the compassionate and intelligent posts. my partner and I feel so very fortunate to have found all of you.

 

a couple of specific questions: Rhi, when you counseled 1% for each of the drugs I choose to taper, are you referring to 1% per month? and, is this cut done as a micro taper, a miniscule amount per day, i.e. .033% per day? would you suggest a 1% cut one day, then a hold for the rest of the month? or two .5% cuts two weeks apart? some other scenario? I believe you are saying make a small cut, such as 1%, hold for a period or length of time determined by clear observation, then and only then make another small cut? is this what you are saying?

sorry if these questions seem elementary, but I am trying to be sure we are talking about the very same details.

[Rhiannon]

Whether you cut 1% at once and then hold, or cut less per day for a number of days in a row and then hold periodically, is up to you. I've seen people succeed either way with single-drug tapering. We don't really have enough of a history of people doing multidrug tapers for me to make any generalizations about that.  The way I do it is sort of a combination.

 

I will generally ease into a total cut of around 4% over a period of four or five days, and then hold for a while, and then ease it down again a little and hold a little, slowly, until I notice my subtle signs of withdrawal, and at that point I'll stop and hold for a couple of weeks or however long it takes. I don't really keep careful track of the numbers and percentages any more because I have a pretty good idea of what I can get away with and what I can't.

 

I don't make or "prescribe" any certain amount of cut per calendar time; I think the guide to how fast to cut is your body, not some prefabricated formula. Our bodies heal at the rate they heal at, and bumpily with ups and downs, and life stresses, and all kinds of things. So I would say "make a small cut, such as 1%, hold for a period or length of time determined by clear observation, then and only then make another small cut" is pretty close to how I do it and what I'd recommend to start with. I think 1% each of four drugs for a first cut is probably safe.  If you wanted to do even smaller cuts up to a cumulative 1% and hold that would also probably be okay.

 

The main thing is don't cut too much too soon at first until you've had time to learn how your own patterns of withdrawal and stabilization are going to play out.  Be patient with the process, but experiment, conservatively. You'll get a sense of what pattern of cuts and holds works best for you.  

 

The thing is, as long as you're going slow and staying stable, you have some flexibility. If you overdo it (and you will from time to time) you'll have a couple of rough weeks, or three, and the next time you'll know to stay under that line. But if you're basically stable and you aren't galloping along, those rough weeks will pass and you'll restabilize and be back on your feet.

[Penstemon]

thanks so much Rhi. that helped me to establish my starting point. can I just ask a little about your tapering method? do you do liquid titration or fill capsules or both? we are set up to do both. just wondering what you have found to be easiest when doing myltiple drugs. do you ever mix all of your drugs in one solution?

[Penstemon]

Okay so I finally began my multi drug taper last night. I cut 1% from each of my 3 sleep drugs-temazepam, trazadone, and Seroquel,titrating all of them in water. I switched from pills to water titration without a cut 10 days ago(traz ,ser,ativan). I had already been doing water titration with my temazepam. Tommorrow I will do a 1% cut of my Ativan for each of my 3 doses.I plan to hold at this cut for all drugs for awhile,carefully charting my symptoms.Then I will make another 1% cut until I feel the slightest sx increase. At that point I will hold for how ever long it takes to get stabilized before I cut again.

 

Please wish me luck.I will likely be calling on you folks for help and support.

 

Thanks for the help that you have given me up to this point.

 

Please notice in my drug history that I have already come off of and down on a few drugs(albeit too fast with some) so I am not starting at ground zero. I do have some knowledge base and plan to proceed more cautiously than ever.

[Penstemon]

Not clear how to do something? Post your question here!

Hi All, I have been struggling with severe depression, anhedonia, apathy,lethargy,and anxiety for quite some time now. My drug history is complicated as you can see from my signature. I started a post back in June about starting a multidrug taper and got some great advice from some of you. Despite the caution against tapering more than one drug at a time, I decided to forge ahead with tapering all 4 drugs together. I began this taper 7/11/13 at a cut of 1% of each of the 4 drugs: temazepam(13.8mg), Ativan(.5mg 3x/day), trazadone(100mg), and Seroquel(50mg). I am doing all of these in a liquid titration-taking all but Ativan at bedtime. I made another cut of 2% on 7/29 of each drug and have been holding since. Prior to starting the multidrug taper, I was tapering only temazepam  at a daily rate of .33% daily. I had been doing that micro taper for 46 days and having occasional windows but mostly waves.I am having almost all waves now and they seem worse than they have ever been. As I said, the depression is severe. Having a hard time thinking clearly right now, but I guess my question has to do with changing my taper method to reduce my symptoms. I don't know if I should go back to a microtaper, less of a taper, and/or longer holds. I have read and read and read about tapering and holds on this site and still can't get a good feel what I should do. I believe it's partly because I am so cognitively impaired but also because there is just no one size fits all way to do this. Sorry if I am not making a lot of sense. Just reaching out. Thanks for any comments.  

[Altostrata]

penstamon, this post will be moved to your Intro topic, but I'll leave it here for now so you can see it.

 

Since you've been tapering multiple drugs simultaneously, you can't know which dosage to adjust at this point. Now your situation is much more complicated.

 

If I were you, I'd hold on tapering all of them.

 

If anyone else has any other suggestions, please add them!

[Marie]

Penstamon,

 

I am no expert myself, but I do agree with Alto here. It's all such an individual thing and I myself must remember that as I'm only trying to taper klonopin, and having difficulty also.

 

So I do think that holding for now would be a good idea. Just try to regain some stability with all these meds together again where they are.

 

And after that, I think I would just try one at a time to taper. And I surely would begin with a micro taper on whichever you start with.

 

Well, having said this, I don't know how long you should hold, but feeling some sense of stability again would tell you something about that.

 

And then I do not know which drug to begin with again. If it seemed the temazepam taper was working prior to this, perhaps that is the place to start afterwards. But I would say definitely hold for now and awhile.

 

Marie

[Penstemon]

thanks Marie and Alto. I knew that you would suggest going back to one drug at a time. I had just thought that I would hold on all of them if I ran into problems. I will probably do that for now and then decide what to do next after(if) I stabilize. what do folks think about tapering my two benzos at one time and just holding on my other 2 drugs? I just feel like the benzos are causing so much of my anxiety and depression.

[Altostrata]

You'll have to assess your symptoms after you hold for a bit. Personally, I would want to be off the Seroquel, it's probably the worst for general health.

 

On the other hand, trazodone can cause anxiety.

 

Please keep notes on paper about your symptom pattern and when you take your drugs. This can help identify which is causing what side effects.

[Marie]

Penstemon,

 

Well, take this advice from a benzo user who has had their share of issues for sure. But from what I've observed, folks on 2 benzos at once usually "convert" the 2 into an equivalent dose of one benzo.

 

I just checked the Ashton equivalency charts and although we both can do this, we both can probably not determine which benzo should be converted to the other one if such is the way to go.

 

Both appear to have similar half lives which I think probably vary by individual in terms of actual duration of action within that individual, and considering these other meds you are taking.

 

I think you should consider discussing this with your doctor if you feel they might be able to get all this, and I hope we can get some other opinions on the way to go from other members.

 

But I still do think that one needs to be converted to the other if possible, so that you are only taking one benzo.

 

And one more consideration I just thought of is that temazepam is one of the 3 metabolites of Valium. Whether that bares on the conversion issue, I do not know. Hopefully others will post on this.

 

Marie

[Penstemon]

thanks Alto. I do keep good records on both sx's and meds.regarding Seroquel, I am down from 250mg to 50mg. it was prescribed for sleep-added to temazepam. I did not know think about trazadone causing anxiety. will look into that.

 

Marie, I gave some thought to crossing over to one benzo but have not gotten far with it. will give this some consideration as well. the temazepam is used for sleep-the Ativan for "anxiety".

[Meimeiquest]

Hi Penstemon,

 

The main thing that hits me looking at your sig. line is the courage and tenacity you have already demonstrated. My hat is off to you! It also makes me think that however you move ahead, it may have to be without a schedule, like holding for 2 weeks after you stabilize from a drop, not 2 weeks from a drop. You've done a wise thing in making a plan, implementing a plan, and now re-evaluating your next move. Rinse and repeat.

 

The other thing that hits me is that right now you are on all "braking" drugs, no accelerators. So if you have any moments of clarity, you might want to work on making sure you have sleep and relaxation support established in a advance. Wish I knew more!

[Penstemon]

thanks Meimequest for the boost. I needed that. I sometimes forget that I have a come a long way. I did phase 1 (I'll just call it that) with only the benefit of Breggin's books and still became spellbound during it. Now in phase 2, I am armed with a whole lot more knowledge but am ever more confused.I totally agree with you about a schedule. I have none, nor do I have any calendar goals. I just want to do this with the least amount of discomfort-however long it takes.

[Penstemon]

Hi Alto, I started a new topic entitled "depressed and need help with tapering". it just got joined with this topic where it may be confused with my multi drug taper. any reason for moving it? can it be moved back? thanks much

[Rhiannon]

Hi Penstemon--

 

To answer your question about why the post got moved: this section (intros and updates) is where we each document our own journey and ask questions about that journey, rather than having a bunch of separate threads proliferate in other sections. The other areas are for more general subjects that apply to many people in general (like, say "insomnia" under Symptoms, or "making a liquid" in Tapering). So it's not about you in any way, this is just how this forum is organized.

 

Just looking at your cuts and your current symptoms, two things stand out for me. First, you made two cuts, one in June and one in July, 1% and then 2%, and clearly this is too much for you. This is why I say start very slow. Now you know that if you're going to taper multiple meds, you're going to need to make smaller cuts and probably do longer holds. It's by this process of experimentation (and making mistakes!) that I've done my own multidrug taper (and I still make mistakes and have to adjust things).

 

Second, you were already tapering Ativan. It seems that in practice, benzo tapers have a "lag time" effect, where cuts can take a while to be fully felt and kick in fully, and this can unfold for months. So that taper may be contributing to your current symptoms.

 

I think at this point your best bet is to just hang on and change nothing. It may take you a couple of months, maybe more than a couple, but given the (small) size of cuts you made I think that if you cut nothing further you should be able to stabilize and your symptoms will improve, eventually.  

 

It's possible a slight reinstatement would be helpful, in which case I'd go back up half the amount you cut in July; it's not too late to do that and it probably wouldn't be problematic. If you do make that small reinstatement, then please hold after that and change nothing for at least a couple of months.

 

You have a complex drug history over a long period of time. In my experience it appears people with histories like that need to be particularly careful with their tapers.

 

Once you get to feeling better, wait a while longer to make sure it's a solid recovery (like I said before, sometimes you can have a good spell but then get worse again). Then you can decide where to go with your taper from there.  Right now, of course it's fine to think about that, but it's definitely not time to actually DO anything, taper-wise.

[Altostrata]

thanks Alto. I do keep good records on both sx's and meds.regarding Seroquel, I am down from 250mg to 50mg. it was prescribed for sleep-added to temazepam. I did not know think about trazadone causing anxiety. will look into that. Marie, I gave some thought to crossing over to one benzo but have not gotten far with it. will give this some consideration as well. the temazepam is used for sleep-the Ativan for "anxiety".

That's 3 drugs prescribed for sleep -- suggests to me that Seroquel or trazodone should be next to go.See http://survivingantidepressants.org/index.php?/topic/2207-taking-multiple-psych-drugs-taper-the-antidepressant-first/And, as you can see, the topic you posted in Tapering has become a very individualized discussion of your personal situation that's a continuation of your Intro topic.

[Penstemon]

Thanks Rhi for explaining about my posts. Makes total sense. So What I am hearing you advise is to hold everything where I am or reinstate a small amount. And to hold for a much longer time.I also hear what you are saying about the lag time from my ongoing temazepam taper. At one point,my cuts were too large but that was back in April before I began a microtaper.Still, I may be having sx's from that. I am wondering what you think about me dosing my temazepam during the night in addition to the bedtime dose. Not increasing but splitting it in some manner. The reason I ask is that I awaken EVERY SINGLE MORNING(and have for a very long time-before I started tapering it)with severe depression,anxiety,intrusive thoughts, and dread. It sets up the rest of my day for failure and is excrutiating to try to overcome. I dose the Ativan every 5 hrs during the day then go from 9:30pm to 6:30am on just the bedtime dose of temazepam. I know that mornings tend to be rough for most of us in w/d but this seems to be an obvious thing to try. Any thoughts on this?

Alto, I so appreciate your concern and suggestions. I am just not ready to give up on my multidrug taper until I have given it a fair shot.Or if I should decide to give it up, am wondering about crossing my two benzos to one OR tapering both of them. I would like to hear more about why you would have me taper the AP or Trazadone first.

Thanks to all of you for your help.Hoping you are doing well.

[Altostrata]

See http://survivingantidepressants.org/index.php?/topic/2207-taking-multiple-psych-drugs-taper-the-antidepressant-first/