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Annabel

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Its quite awhile since my last post. I am checking in to record my decrease in Effexor. The same pattern occurs each time i decrease which i am now used to and manage myself gently until it passes (each time it feels like it never will)!! 

My overall tapering is going well with some side effects but by following the small decrease of 5% each month i am managing to live well. My next decrease was this morning and for a whole month I get to ditch the scales and take 3 x 37.5mg capsules!! After the decrease my brain makes some adjustments that throw me into depression but each time it passes and the window that follows (until the next decrease) feels a little bit more like my real self is in there somewhere and almost within reach!! This in itself is exciting enough to keep me sticking with the regime and helps me to be patient with the taper.

I hope others are doing ok and taking it easy. 

March 2012 Fluoxetine 20mg

June 2012 change to Escitalopram 20mg

August 2012 change to Venlafaxine, Effexor XR 150mg

March 2013 add Ropinirole 0.5mg for restless legs syndrome seriously disturbing sleep

Feb 10th 2014 begin tapering off Effexor 150mg by 25% as per Dr.

Feb 19th 2014 Bad headaches..relief in finding SA site.

Feb 20th Increase Effexor to 131.25mg. Head improves over next few days.

March 28th decrease Effexor by 5 % to 125mg. Brain fog + depression after 10 days but passes by.

May 6th decrease Effexor to 118.75mg depression + brain fog lasting 10 days

June4th-112.5mg, July 21st-106mg,August 30th-101mg

2015 - 5% decrease as able, January 2016-50mg + struggling.

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Hi Annabel when you decrease how long do these depression waves last? Everytime I make a small decrease I can feel it right away..

I have Been having a wave of depression or mood swings or the past week. I'm so afraid I won't come out if it.

Started Effexor August 2012 Sept'12-150mg=extreme anxiety Oct'12 cut half-75mg severe wds

Feb 2013 68.5mg. Mar'13- 65mg. Apr'13-59mg. May'13-57mg. June '13-52mg Aug'13 49.75mg.

Sep'13-48.75. Nov'13-47mg Dec'13-45..5mg

May 2014 42mg. Jun'14 40mg (depressive mood started). Aug'14 -40mg/ started brintellix 2.5mg

Oct '14 -39 Nov'14 36.89 Dec'14 34.45

Jan 2015- 31 Feb'15 29mg. Mar'15 26.72. Apr'15 24.48. May'15 22.31mg. Jun'15 20.30mg

Aug'15-18.89. Oct'15 16.96. Nov/16- 16.10. Dec/15- 15mg

Jan 2016-14.22. May'16 11.45. Aug'16-9.60. Sep/16- 8.88mg. Oct/16- 8.39mg. Nov/16- 8.13. Dec/16- 7.89

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Hi Lexy,

Sorry to hear you're struggling, it will likely pass when your body is ready. Decreasing tends to throw things off balance again, for me I was having trouble with the 10% decrease so I am now only going down by 5%. I think that makes the wave of depression easier, perhaps even shorter. That was the situation with the last decrease, hopefully it will be the same this as well. Within the first day or so I start to feel a difference then a week into it the depression starts to intensify. It lasts a week...roughly and then gradually lessens off until one day (about 3 weeks post decrease) I notice I am feeling quite good!!

 

I also find that when there is stress in my life the depression is more intense, the fatigue is worse and I generally feel worse. Maybe stress etc.. has caused your nervous system to be agitated and you need some "calm" time like walking, sleeping, eating well, relaxation?? I think this all helps at some level!

Annabel

March 2012 Fluoxetine 20mg

June 2012 change to Escitalopram 20mg

August 2012 change to Venlafaxine, Effexor XR 150mg

March 2013 add Ropinirole 0.5mg for restless legs syndrome seriously disturbing sleep

Feb 10th 2014 begin tapering off Effexor 150mg by 25% as per Dr.

Feb 19th 2014 Bad headaches..relief in finding SA site.

Feb 20th Increase Effexor to 131.25mg. Head improves over next few days.

March 28th decrease Effexor by 5 % to 125mg. Brain fog + depression after 10 days but passes by.

May 6th decrease Effexor to 118.75mg depression + brain fog lasting 10 days

June4th-112.5mg, July 21st-106mg,August 30th-101mg

2015 - 5% decrease as able, January 2016-50mg + struggling.

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Thanks

I appreciate your words.

I realize I'm so sensitized....It's frustrating because I am micro tapering and I still get like this. However I did make a couple decreases to soon this last time.

Started Effexor August 2012 Sept'12-150mg=extreme anxiety Oct'12 cut half-75mg severe wds

Feb 2013 68.5mg. Mar'13- 65mg. Apr'13-59mg. May'13-57mg. June '13-52mg Aug'13 49.75mg.

Sep'13-48.75. Nov'13-47mg Dec'13-45..5mg

May 2014 42mg. Jun'14 40mg (depressive mood started). Aug'14 -40mg/ started brintellix 2.5mg

Oct '14 -39 Nov'14 36.89 Dec'14 34.45

Jan 2015- 31 Feb'15 29mg. Mar'15 26.72. Apr'15 24.48. May'15 22.31mg. Jun'15 20.30mg

Aug'15-18.89. Oct'15 16.96. Nov/16- 16.10. Dec/15- 15mg

Jan 2016-14.22. May'16 11.45. Aug'16-9.60. Sep/16- 8.88mg. Oct/16- 8.39mg. Nov/16- 8.13. Dec/16- 7.89

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  • 2 weeks later...

About 2 weeks post my last decrease and here they are.. headaches, brain fog, a dizzy/heady feeling and fatigue +++. Keep lying down and getting up and lying down again. Can't get comfortable, feel like I need to be doing something and when I get started on a small task the fatigue is too much. Lucky its not a work day for me!! My post a couple of weeks back sounds so positive, where is that positivity now?? Ok i will breathe, accept its all withdrawal and it will pass....easier said than done. I went to the lake near our house for a walk, couldn't face it and came home...  today is nearly done down here in NZ, its mid afternoon, tomorrow is another day..... :unsure:

March 2012 Fluoxetine 20mg

June 2012 change to Escitalopram 20mg

August 2012 change to Venlafaxine, Effexor XR 150mg

March 2013 add Ropinirole 0.5mg for restless legs syndrome seriously disturbing sleep

Feb 10th 2014 begin tapering off Effexor 150mg by 25% as per Dr.

Feb 19th 2014 Bad headaches..relief in finding SA site.

Feb 20th Increase Effexor to 131.25mg. Head improves over next few days.

March 28th decrease Effexor by 5 % to 125mg. Brain fog + depression after 10 days but passes by.

May 6th decrease Effexor to 118.75mg depression + brain fog lasting 10 days

June4th-112.5mg, July 21st-106mg,August 30th-101mg

2015 - 5% decrease as able, January 2016-50mg + struggling.

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Keep in mind the lower you get the slower the taper. I feel my mistake was doing a 3 % cut.

Don't be hasty. I am paying the price for my impatience.

Started Effexor August 2012 Sept'12-150mg=extreme anxiety Oct'12 cut half-75mg severe wds

Feb 2013 68.5mg. Mar'13- 65mg. Apr'13-59mg. May'13-57mg. June '13-52mg Aug'13 49.75mg.

Sep'13-48.75. Nov'13-47mg Dec'13-45..5mg

May 2014 42mg. Jun'14 40mg (depressive mood started). Aug'14 -40mg/ started brintellix 2.5mg

Oct '14 -39 Nov'14 36.89 Dec'14 34.45

Jan 2015- 31 Feb'15 29mg. Mar'15 26.72. Apr'15 24.48. May'15 22.31mg. Jun'15 20.30mg

Aug'15-18.89. Oct'15 16.96. Nov/16- 16.10. Dec/15- 15mg

Jan 2016-14.22. May'16 11.45. Aug'16-9.60. Sep/16- 8.88mg. Oct/16- 8.39mg. Nov/16- 8.13. Dec/16- 7.89

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  • Moderator Emeritus

About 2 weeks post my last decrease and here they are.. headaches, brain fog, a dizzy/heady feeling and fatigue +++. Keep lying down and getting up and lying down again. Can't get comfortable, feel like I need to be doing something and when I get started on a small task the fatigue is too much. Lucky its not a work day for me!! My post a couple of weeks back sounds so positive, where is that positivity now?? Ok i will breathe, accept its all withdrawal and it will pass....easier said than done. I went to the lake near our house for a walk, couldn't face it and came home...  today is nearly done down here in NZ, its mid afternoon, tomorrow is another day..... :unsure:

 

You would think after tapering for four years, that when I get withdrawal symptoms I would be able to stay positive and remember that they're going to pass soon. But no, I find myself feeling hopeless and discouraged every time.

 

I think it's just another withdrawal symptom--that complex of thoughts and emotions that says "this time it's forever, and it's really never been very much better than this even though you think you remember saying that it was better."

 

I am very humbled by how these drugs have shown me that I have much less control over my thoughts and emotions than I ever thought I did.

 

Hang in there, it WILL pass and you'll have some good days again. Don't cling too tightly to a preplanned "once a month" schedule; listen to your symptoms and don't cut until you've felt well for a while.

Started on Prozac and Xanax in 1992 for PTSD after an assault. One drug led to more, the usual story. Got sicker and sicker, but believed I needed the drugs for my "underlying disease". Long story...lost everything. Life savings, home, physical and mental health, relationships, friendships, ability to work, everything. Amitryptiline, Prozac, bupropion, buspirone, flurazepam, diazepam, alprazolam, Paxil, citalopram, lamotrigine, gabapentin...probably more I've forgotten. 

Started multidrug taper in Feb 2010.  Doing a very slow microtaper, down to low doses now and feeling SO much better, getting my old personality and my brain back! Able to work full time, have a full social life, and cope with stress better than ever. Not perfect, but much better. After 23 lost years. Big Pharma has a lot to answer for. And "medicine for profit" is just not a great idea.

 

Feb 15 2010:  300 mg Neurontin  200 Lamictal   10 Celexa      0.65 Xanax   and 5 mg Ambien 

Feb 10 2014:   62 Lamictal    1.1 Celexa         0.135 Xanax    1.8 Valium

Feb 10 2015:   50 Lamictal      0.875 Celexa    0.11 Xanax      1.5 Valium

Feb 15 2016:   47.5 Lamictal   0.75 Celexa      0.0875 Xanax    1.42 Valium    

2/12/20             12                       0.045               0.007                   1 

May 2021            7                       0.01                  0.0037                1

Feb 2022            6                      0!!!                     0.00167               0.98                2.5 mg Ambien

Oct 2022       4.5 mg Lamictal    (off Celexa, off Xanax)   0.95 Valium    Ambien, 1/4 to 1/2 of a 5 mg tablet 

 

I'm not a doctor. Any advice I give is just my civilian opinion.

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  • 1 month later...

Thanks Rhi for your kind thoughts, I decided not to cut the dose again until I was feeling well enough! So it was about 6 weeks and I decreased again, that was 2 and a half weeks ago. Brain is doing its usual "You can't cut your dose, I wont allow it" behaviour in the form of headaches and fog....I know its withdrawal and I am using mindfulness skills this time to deal with it. Meditation in the form of just sitting and being with this feeling as my brain tries to adjust. I am less frustrated and more accepting of it today. Of course its not always this way, there are those bad days too!!

Recently I read a book called "Self Compassion" by Kristin Neff, I think I gained a lot from this book. Self compassion doesn't come easily to those of us who feel like we are the cause of our own problems, however its kind of a liberating concept!! I'm wondering if this has something to do with feeling less frustrated and trapped by the withdrawal process.

March 2012 Fluoxetine 20mg

June 2012 change to Escitalopram 20mg

August 2012 change to Venlafaxine, Effexor XR 150mg

March 2013 add Ropinirole 0.5mg for restless legs syndrome seriously disturbing sleep

Feb 10th 2014 begin tapering off Effexor 150mg by 25% as per Dr.

Feb 19th 2014 Bad headaches..relief in finding SA site.

Feb 20th Increase Effexor to 131.25mg. Head improves over next few days.

March 28th decrease Effexor by 5 % to 125mg. Brain fog + depression after 10 days but passes by.

May 6th decrease Effexor to 118.75mg depression + brain fog lasting 10 days

June4th-112.5mg, July 21st-106mg,August 30th-101mg

2015 - 5% decrease as able, January 2016-50mg + struggling.

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  • 1 year later...

*new topic merged with original intro thread

 

5% Effexor decrease -Update

I came here 2 years ago hoping to find help with my decrease of Effexor and I did! Great support from the staff and others and have been decreasing at 5% of current dose ever since. Sometimes I hold for months due to things going on in my life, other times i am reckless and impatient and go a whole 10%...It seems the struggle continues and despite trying different things to ease the process it's always noticeable and more often than not it causes all the usual side effects. I have found meditation has been the best thing to calm and balance the brain. However the last 3 months I have had 2 jobs and completely abandoned the "taking care of yourself" thing which has left me wanting to just go cold turkey on the rest of this drug or maybe cross over the last part with St Johns Wort. Can you cross over these 2 drugs and is St Johns Wort even a good idea? I know there's threads on St Johns Wort here somewhere, I will go and find it. Hoping someone will comment or reply to me as I am feeling so frustrated and defeated by this whole depression/ effexor mess!

Edited by Petunia
added note and title from new topic

March 2012 Fluoxetine 20mg

June 2012 change to Escitalopram 20mg

August 2012 change to Venlafaxine, Effexor XR 150mg

March 2013 add Ropinirole 0.5mg for restless legs syndrome seriously disturbing sleep

Feb 10th 2014 begin tapering off Effexor 150mg by 25% as per Dr.

Feb 19th 2014 Bad headaches..relief in finding SA site.

Feb 20th Increase Effexor to 131.25mg. Head improves over next few days.

March 28th decrease Effexor by 5 % to 125mg. Brain fog + depression after 10 days but passes by.

May 6th decrease Effexor to 118.75mg depression + brain fog lasting 10 days

June4th-112.5mg, July 21st-106mg,August 30th-101mg

2015 - 5% decrease as able, January 2016-50mg + struggling.

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  • Moderator Emeritus

Hi Annabel (I love your pic or should I say pec???),

 

Welcome back to SA.  This is your original Intro topic introducing-annabel and the mods will merge this new topic with your original.  If you click Follow this Topic (top right) you will be notified when someone replies.

 

St Johns Wort is similar to Prozac.  Personally I would not be wanting to introduce it into the mix.  Here is the link st-johns-wort.

 

Not sure if you seen these, but they helped me:  Video: Healing from Antidepressants: Patterns of Recovery and Brain Remodelling

 

It sounds like you have been doing a very sensible taper.  Please don't undo all that hard work by CTing.  It is just not worth it (although I can understand your frustration).

 

Somebody who can make suggestions should be along soon.  Try and stay positive.  It's hard, but it helps.  Take care.  CC

Edited by Petunia
topics merged

* NO LONGER ACTIVE on SA *

MISSION ACCOMPLISHED:  (6 year taper)      0mg Pristiq  on 13th November 2021

ADs since ~1992:  25+ years - 1 unknown, Prozac (muscle weakness), Zoloft; citalopram (pooped out) CTed (very sick for 2.5 wks a few months after); Pristiq:  50mg 2012, 100mg beg 2013 (Serotonin Toxicity)  Tapering from Oct 2015 - 13 Nov 2021   LAST DOSE 0.0025mg

Post 0 updates start here    My tapering program     My Intro (goes to tapering graph)

 VIDEO:   Antidepressant Withdrawal Syndrome and its Management

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  • Moderator Emeritus

Hi Annabel,

 

After posting on your new topic (which will be merged here), I found Hudgen's Success Story which you might be interested in.  He has successfully tapered off Effexor.

CC

* NO LONGER ACTIVE on SA *

MISSION ACCOMPLISHED:  (6 year taper)      0mg Pristiq  on 13th November 2021

ADs since ~1992:  25+ years - 1 unknown, Prozac (muscle weakness), Zoloft; citalopram (pooped out) CTed (very sick for 2.5 wks a few months after); Pristiq:  50mg 2012, 100mg beg 2013 (Serotonin Toxicity)  Tapering from Oct 2015 - 13 Nov 2021   LAST DOSE 0.0025mg

Post 0 updates start here    My tapering program     My Intro (goes to tapering graph)

 VIDEO:   Antidepressant Withdrawal Syndrome and its Management

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  • Moderator

Hi Annabel and welcome back.  It's very exciting to see that you're having such good luck with your taper, well done so far.  I have to echo CC concerns, you've come so far please don't cause your self trouble by getting impatient.

 

I would avoid SJW.  It basically is an herbal SSRI and has all the attached problems.  It tends to reach tolerance in a matter of weeks and has to be tapered off of very carefully.  Because it is an herb it is unregulated so you can't really know what kind of dose you're getting and with some manufacturers if you're getting any at all.  Trying to switch would pretty much count a s a CT and give you all the resultant problems while the SJW won't cover them up and will add problems of it's own. It is best to stay with the devil you know.

20 years on Paxil starting at 20mg and working up to 40mg. Sept 2011 started 10% every 6 weeks taper (2.5% every week for 4 weeks then hold for 2 additional weeks), currently at 7.9mg. Oct 2011 CTed 15oz vodka a night, to only drinking 2 beers most nights, totally sober Feb 2013.

Since I wrote this I have continued to decrease my dose by 10% every 6 weeks (2.5% every week for 4 weeks and then hold for an additional 2 weeks). I added in an extra 6 week hold when I hit 10mg to let things settle out even more. When I hit 3mgpw it became hard to split the drop into 4 parts so I switched to dropping 1mgpw (pill weight) every week for 3 weeks and then holding for another 3 weeks.  The 3 + 3 schedule turned out to be too harsh so I cut back to dropping 1mgpw every 4 weeks which is working better.

Final Dose 0.016mg.     Current dose 0.000mg 04-15-2017

 

"It's also important not to become angry, no matter how difficult life is, because you can loose all hope if you can't laugh at yourself and at life in general."  Stephen Hawking

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  • Moderator Emeritus

Welcome back Annabel,

I merged your new topic with your original, its one intro/update topic per member. You can use this thread to add updates. Thanks Chessie for finding the original topic. Bookmarking or following will make it easier to find in future.

 

Annabel, I'm sorry you are getting despondent with your taper. But as the others have said, you have come so far and it would be such a waste to give up all your hard work now.

 

Perhaps a nice long hold is in order and spend a couple of months getting your self care back on track.

I'm not a doctor.  My comments are not medical advise. These are my opinions based on my own experience and what I've learned. Please discuss your situation with a medical practitioner who has knowledge of tapering and withdrawal...if you are lucky enough to find one.

My Introduction Thread

Full Drug and Withdrawal History

Brief Summary

Several SSRIs for 13 years starting 1997 (for mild to moderate partly situational anxiety) Xanax PRN ~ Various other drugs over the years for side effects

2 month 'taper' off Lexapro 2010

Short acute withdrawal, followed by 2 -3 months of improvement then delayed protracted withdrawal

DX ADHD followed by several years of stimulants and other drugs trying to manage increasing symptoms

Failed reinstatement of Lexapro and trial of Prozac (became suicidal)

May 2013 Found SA, learned about withdrawal, stopped taking drugs...healing begins.

Protracted withdrawal, with a very sensitized nervous system, slowly recovering as time passes

Supplements which have helped: Vitamin C, Magnesium, Taurine

Bad reactions: Many supplements but mostly fish oil and Vitamin D

June 2016 - Started daily juicing, mostly vegetables and lots of greens.

Aug 2016 - Oct 2016 Best window ever, felt almost completely recovered

Oct 2016 -Symptoms returned - bad days and less bad days.

April 2018 - No windows, but significant improvement, it feels like permanent full recovery is close.

VIDEO: Where did the chemical imbalance theory come from?



VIDEO: How are psychiatric diagnoses made?



VIDEO: Why do psychiatric drugs have withdrawal syndromes?



VIDEO: Can psychiatric drugs cause long-lasting negative effects?

VIDEO: Dr. Claire Weekes

 

 

 

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Hi there,

Thanks for the replies. I had forgotten so many others are struggling with the tapering and all that goes with it. It's true I have come a fair way now so must try my best to hang in there. I will hold at this dose for awhile and try to change the daily grind into more of a glide! Easy to write huh? Anyway, i have read some of the links, Thank you I really appreciate the support, you guys are great! Am starting back at work tomorrow after some time off over the Christmas break, the plan is to take it slow and pace myself as much as work allows so I can conserve some energy for myself. Will check in again soon.  :)

March 2012 Fluoxetine 20mg

June 2012 change to Escitalopram 20mg

August 2012 change to Venlafaxine, Effexor XR 150mg

March 2013 add Ropinirole 0.5mg for restless legs syndrome seriously disturbing sleep

Feb 10th 2014 begin tapering off Effexor 150mg by 25% as per Dr.

Feb 19th 2014 Bad headaches..relief in finding SA site.

Feb 20th Increase Effexor to 131.25mg. Head improves over next few days.

March 28th decrease Effexor by 5 % to 125mg. Brain fog + depression after 10 days but passes by.

May 6th decrease Effexor to 118.75mg depression + brain fog lasting 10 days

June4th-112.5mg, July 21st-106mg,August 30th-101mg

2015 - 5% decrease as able, January 2016-50mg + struggling.

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  • Moderator Emeritus

HI Annabel 

 

Are you still having the same pattern of the week of depression after a cut?  Do you feel it has gotten worse the lower you go?  You have been so patient with the 5% cuts and I know that feeling of just getting fed up with the whole process and can't this just be over?  I was just having those feelings last weekend when I went into the hole a bit after a cut of my mirt.  I totally get it!  And yet I know that going faster or heaven forbid a cold turkey would be disastrous!  I think you are pretty sensitive so a cold turkey would really be a mistake.  I think it is natural, though, to go through the frustration you are feeling now and again. I think it was my update over the weekend where I said I was going backwards in the stages of grief...back at anger when I had been at acceptance LOL!  And it is like grief, mourning the days where things were simpler.  For me, I mourn the years that I'd been on these drugs, wishing I had never taken the first one.  

 

I'm curious, how are you measuring your doses?  Do you measure every day, or do you measure a bunch at once?  I weigh out the beads for two weeks' worth of doses at a time, putting the beads in empty gel caps.  This eliminates some of the obsession and hyper-focus on the taper day to day.  

 

I agree with the recommendation of getting back to self-care if you can.  Are you taking magnesium and fish oil?  Some of us are trying inositol powder.  I have found that aside from a blip for a couple of days that I generally feel pretty good on it, 15 or so grams a day of the powder form.   

 

I know at some point I went up to a pretty high dose of Effexor, I think 225 mg, and then went back down again, probably by 75 mg, pretty big drops.  I have no recollection of what I did when, and that is the nature of the beast for me, really messed with my memory.  I feel like I've been caught in a time warp with no concrete memories of my life and who I was as I travelled through it.  I do know that I had some pretty crappy times which probably coincided with the drops but I was too numb to even figure it out.  Lots of cognitive issues with that, poor concentration, blow ups with friendships ending, and now I wonder if I was the one at fault in that.

 

Anyway, just wanted to say hi as a fellow Effexor taperer.  We gotta stick together :-)  Actually, that's not true - everyone here on SA no matter what their poison, is in the Club ;-)

 

Cheers!

SG

Started ADs back around 1995 after bad break-up, starting with Prozac.  Switched to Wellbutrin, and then to Effexor in 2002
Effexor XR 2002-2014 up to 225 mg at one point, down to 37.5 mg towards end but back up to 75 mg in 2014; now realize I had W/D as I dropped down, memory very poor about history.  Extreme emotions, poor concentration as I stepped back down, didn't connect the dots!
Summer 2014 reduced to 0 very quickly, was sick of anhedonia/sexual dysfunction due to meds, depression never controlled if not worse. Didn't recognize WD since symptoms built slowly (thought I had ADD! and menopausal on top of it), starting with severe sweats, very bad cog-fog and memory issues, culminating in weight loss, severe anxiety and depression, panic, severe apathy and insomnia by eight months off.  Saw p-doc who put me on Remeron, increased from 7.5 mg/day to 37.5 mg by May 22, 2015; still doing very badly though able to sleep.

June 1. 2015 Reinstated Effexor XR 37.5 mg, Remeron dropped to 30 mg PM. Immediate relief of symptoms, like nothing had ever happened!  Joined SA and began on advice of friend who recognized it was WD all along! Began tapering in July 2015.

Been tapering both meds ever since, focusing on one more than the other or doing no more than 5% of each per month.

12 mg Effexor and 5.8 mg Remeron (mirtazapine SolTabs to make a solution with OraPlus) as of 5/4/2017 

Update 3/14/18: 2.9 mg Remeron and 6 mg Effexor; 6/10/18:  2.6 mg Remeron and 4.9 mg Effexor

 

My intro: http://survivingantidepressants.org/index.php?/topic/9313-squirrellygirl-effexor-withdrawal-etc/page-2#entry196679

This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

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