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 Post subject: Is my Dose too High
PostPosted: Thu Apr 29, 2010 10:14 am 
After reading a lot of posts over the past several weeks I'm again questioning my dose. After my induction I leveled out at 10mg/day. When I was struggling over the holidays the doc raised my dose to 12mg/day. After I admitted to the doc that I had attempted to get high on my former DOC he suggested I take 16mg/day. He said at this level 94% of the opiate receptors are covered so it should eliminate all cravings. I've pretty much been sticking to 12mg, despite his advice.

The thing that bothers me is that I read stories of people who were using similar amounts of opiates to what I was taking and are on doses of 4mg/day or less. I feel like I've actually increased my opiate tolerance being on the Sub. Also, I'm tired a lot of the time. I sleep usu. over 8 hours a night and often fall asleep during the day. Now that my youngest has started school I swore I would return to work, but ever since this fall when I went on Sub I've had zero motivation. I haven't even worked on my resume, let alone work a job. I feel like a loser telling you all this, because I worked all my life, starting with my first babysitting job at 11. My addiction took off after the birth of my second child, which seemed like a reasonable time to stay home with the kids, especially with the cost of sending 2 to daycare. Having had good jobs all of my adult life and putting off having kids until my late 30's, we were financially secure enough for me to do this - and no one around me even questionned it. The thing is it gave me the opportunity to become a full blown pill head with no job to report to and my husband out of the house working full time, I had no accountability.

I'm sorry, I just got so far off the topic. I guess I'm just feeling like I'm not moving forward. I'm grateful that I'm off the roller coaster of opiate abuse, but I'm just in a real rut and I have no motivation to get out of it. I feel like the high dose of Sub is adding to my complacency. The doc also put my on Lexapro 3 weeks ago, and that does seem to be helping.
Any input, especially from those on higher doses, would be greatly appreciated.
Lilly


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PostPosted: Thu Apr 29, 2010 10:55 am 
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Hi Lilly! (Love that name by the way, it's my daughters name, except spelled Lily) anyway, I also have a problem with motivation. In my opinion I think it may not be from your sub dose. I know I still sometimes have that mindset that I can't accomplish things, cleaning, projects, etc unless I'm all high on pills. It's the biggest part of my addiction that I fight daily. The hardest part is getting started on something, but once I make myself start I'm good and it feels great to get it done. For example, I'm starting to wean off my subs. Im down to 8mgs a day (hoping to stay there for while) and just this morning I was sitting here after my boys got on the bus and my daughter went down for a nap, feeling no motivation and dreading the thought of actually getting up and doing cleaning and laundry. BUT, I made myself do it and once I started I felt better. Cleaned the bathroom, did some laundry and even started on my boys room....which is constantly a disaster.
Since it's been 3 weeks on the Lexapro and it seems to be helping a bit maybe talk to your doc about upping the dose on that as well. Do you live in an area of the country where the weather is starting to get warmer? I know that helps me a lot. I get pretty down and out during the winter but once the weather turns and I get outside in the sun it helps as well. Are you doing any counseling? I hope you start to feel better. Keep us posted!


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PostPosted: Thu Apr 29, 2010 11:13 am 
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Lilly,
I'm sorry you're feeling so bad right now. I would, however, caution you against comparing your dose to that of other people. We're all unique and so are our medical needs, including suboxone. You are not by any means on a massive dose. I take 24 mgs and have for the past 16 months. Of course I also take it for pain control, so I take 8 mg three times per day. So my situation is a bit different.

I'm not really sure what you're describing is due to suboxone. Forgive me, but I don't recall how long you've been on it. Being on a stable dose that controls your cravings is the most important thing. The dose you're on is just a number, try not to get too hung up over it. What else are you doing as part of your recovery? Do you go to therapy/counseling at all or support groups/meetings? A therapist would be a great person to discuss lack of motivation with. As for the Lexapro, if it's been only three weeks it may not be working at its full capacity quite yet. And as RTLmom said, they can always raise the dose. Because remember, sleeping too much and lack of motivation can be part of depression.

So please, don't be so hard on yourself. Get yourself stabilized and knee-deep into a healthy recovery plan before you decide to get to a lower dose -but that's just my opinion.

Take care and keep us posted on how you're doing.

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PostPosted: Thu Apr 29, 2010 11:47 am 
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Hi Lilly,

I also feel this way. I am on 16 mgs a day which I take once a day in the am. I pretty much could sleep all day if I wanted too. I also just asked my doc for an anti depression med although I am not sad at all just not motivated either. He gave me a script for cymbalta (because i use to be on that a while back) but after taking just one dose I had to stop. it was just too much for me. Made me feel wigged out. I think I might try the lexapro again too. If I remember right It was a bit more milder. I recently posted about the apathy I am experiencing. I think some of it is the subs and some of it is that I've been numb and mellow for so long that I need to learn to function again. I too use to feel like I could not clean house, do laundry or be social if I did not have pills to take. So yeah I think we need to just make ourselve do it! Whatever "it" may be. Once I am comfortable with where I am in my life I will try to lower my dose. mostly because of the cost but for other reasons as well. Hope you feel better!!

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PostPosted: Thu Apr 29, 2010 12:20 pm 
RTL, thanks for your reply. It's good to know that another at-home Mom is on this forum. I think you could be right that I'm blaming the Sub. I guess I'm really not feeling too good about myself at this point in my life. When I was first getting ready to go back to work I considered getting more education. My background is in science and I found out that courses I had already taken were no good if they were over 10 years old. I graduated from college in 1988!
I feel like my skills are obsolete. I used to be so confident. Now suddenly I'm in my early 40's and I'm almost afraid to put myself out there.
I don't think I've ever really been comfortable in the at-home mom role in the first place. I never planned on doing it, but my husband got an excellent job shortly after I got a "package" in a corporate downsizing. So it just kind of ended up this way. When the kids were little the focus was on them, but now that they're older the focus is more on cooking, laundry and cleaning - all things that need to be done over and over and over with (for me) very little sense of accomplishment. When I was working I would do a project, write a report and get feedback. I would complete something and move on to the next thing. Now I feel like I'm in an endless grind that isn't even valued by society.

Sorry if I'm going overboard. I guess writing all this out is really making me see for myself my negative thinking and why I feel so unmotivated. Just re-reading what I wrote makes me cringe - I thought about deleting it. But it is an honest outpouring of what's been swimming around my mind lately.
Anyway, thanks for your feedback and encouragement.
Lilly


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PostPosted: Thu Apr 29, 2010 3:33 pm 
Lilly....Please don't feel bad for sharing that you're feeling this way. You have helped me by doing so!
I've been feeling the same way for a good while! In fact, I've brought it up here and there on other threads and have not gotten a whole lot of feedback.....just a reply or two (which was great don't get me wrong.) Maybe I didn't communicate my feelings as well as you have on this thread. In any case.....you all are saying the same thing I'm feeling!
Here's the thing though.....I'm only on 2mg right now! So I've been feeling like this stuff might be because my dose is getting so low!! I will say that I don't think the fact that we are questioning Sub's role in this is so far off. Nor do I think we're trying to blame Sub. At least I know that I'm not. I'm just looking for answers.
I realize that I have a lot to be sad or depressed about too. There may be an element of that involved. At the very least, I'm sure I've got some situational depression. I do not have a history of depression or anxiety, however, so I'm not going to be quick to jump on it and start medication for it. I'm not anti.....not whatsoever. I just don't want to go on meds if I can ride it out for a few months and be okay. If that makes any sense.
I so related to what you were saying about being an 'at-home mom.' My kids are big now....youngest is 15. I have been an insanely busy, multi-tasking nut for so long that I don't think I even know how to be comfortable being still! I lived so many years working my ass off, most of it on 12-hour night shifts, managing a lot of mostly newer nurses and taking care of my own patients in life and death situations. I was an adrenaline junkie long before I became an opiate junkie!! ha ha! Anyway....Yes, I took pride in making a difference in people's lives, feeling important, teaching people because I knew a little more than most, and making a decent income as well. I didn't require much sleep, seldom got much sleep or rest and seemed to thrive on it......until I didn't anymore.
So, huge adjustments and causes to be sad or depressed, no doubt. I think we can all own that. I think we all know we have to work on this stuff in our recovery. I'm trying to look at everything I can to try to figure this out and make improvements. You all help me a lot. I am anxious to see what happens as I continue on with my taper. I will definitely let everybody know. I can't help thinking that no matter what our dose is......any type of opiate carries with it sedation as a side effect and I think the Sub plays a role. God knows when in w/d from full-agonists, I couldn't sleep at all....begged for sleep! Now I can sleep and sleep and sleep! I always want the opposite of what I've got!! Seriously, I'm glad for the chance to talk (type) it out. Thanks guys.....I understand exactly what you're saying!


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PostPosted: Thu Apr 29, 2010 6:30 pm 
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It is true that everyone is different, because I am on 4mg per day and feel like I should go UP a little on my dose because I don't have the motivation I had when I was on 6 or 8mg. And not only do I not sleep all that well, I usually take an ambien two or three times a week to help with sleep, but when I was up on a higher dose of the subs, I slept a lot better. So I'm going to talk to my doctor about it this month when I go in for my appointment, because I don't want to add more drugs to my regimen, and I think a slightly higher dose of suboxone will have that positive impact on my mood. I did very, very well on about 6 to 8mg, but on 4mg, I feel kind of blah.....

Anyway, I don't know if that helps you at all, I guess the main point I was trying to make is we're all different and you shouldn't beat yourself up about your dose or compare to others, you are an individual with individual needs.


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PostPosted: Thu Apr 29, 2010 8:10 pm 
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Hi Lily. I know how you feel in so many ways. The life of a stay at home mom can be so redundant. The same thing day after day REALLY gets to me sometimes, and then battling with my addiction on top of it, ugh! I guess I just want to encourage you to do what you love. If it means going back to a career you should do it! If it means a new hobby or volunteering you should do it!
I have to say that before I found this forum I was just kinda blindly making my way through suboxone and recovery. Just going through the motions. But, I have to say that just in the past couple weeks or so I have made a huge turn around, I think anyway. I am setting goals for myself and figuring out what makes my life satisfying. It does help having children b/c everyday I have 3 huge reminders looking me in the face of how important my recovery and mental health really is. I don't have health insurance right now (I was laid off in Jan) so Im really glad I found this forum. It may sound corny, but it's kinda like therapy for me. I really hope things start to look up for you. Talk to your doc about your Lexapro dosage and your feelings and see if maybe he/she thinks increasing it could help. Wishing you the best of luck. And don't be afraid to get out there and do what you want to do.


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PostPosted: Fri Apr 30, 2010 11:04 am 
Thanks everybody for your replies. I think this forum really is therapeutic. Just the act of typing out your issues helps to clarify things, and then you get helpful feedback on top of it. I think I am going to try to cut back on my dose slightly, just to see if I'm a little less drowsy. And I am trying to get up and out a little more - I've been walking every morning with my neighbor. The recovery is in the little things, I guess. We can't expect to go out an conquer the world after 6 month of sobriety.
Setmefree I wanted to respond to your post specifically, but my battery is running out on my laptop. More later...
Lilly


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PostPosted: Tue Aug 10, 2010 11:48 pm 
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I started out with a very strict doctor and he had me on 16mg/day. This was not working out very well for me and I started taking some extra ones which led to me running out a week before I could get my next script every time, which led to me borrowing some from my buddy who is also on them, which led to me being even DEEPER in the hole since I had to pay him back out of each script after I borrowed.

Finally, this doctor actually told me "you've been on for 6 months now, time to start tapering down' and actually forced me to drop to 1.5 a day which was the opposite of what I wanted!

Needless to say, that was the last time I saw him. I scouted out a new doc, and actually interviewed these people to make sure their policies were legit and they knew what they were doing. I got a great doctor (well, compared to the old one) and he actually asked me what I felt comfortable taking and I told him 24mg per day. I then asked for 3.5 per day a few months later because once in a while I'd take an extra half and didn't want to run out.

This worked out great if I split them up, but if I took all 3 in the morning or 3.5 in the morning sometimes I would get TERRIBLE headaches, nausea, irritability, tired and groggy. I figured out that if I just take 2 in the morning and one 9 or 10 hours later it works out great. Sometimes to make them a little more efficient without taking extra, I'll just pop 2 or 3 Benadryls about 15 minutes before dosing and it seems to work better.

But recently I've definitely come to realize that it was all in my head when I thought I needed 3 or 3.5 in the AM and it actually caused worse feelings and made me not get much done at work, but if I just take 2 I feel great and can concentrate. I'm also 6'3 290 lbs so it might affect me differently than smaller people.


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PostPosted: Wed Aug 11, 2010 12:28 am 
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While I recognize that everybody is different and occasionally there will be an exceptional case, most people are taking more buprenorphine than 'needed.' After starting several hundred people on the medication I see something very clearly; almost everyone initially feels like they need more. If a person doses once in the AM (which is how the program is taught and what I strongly recommend for reasons I've discussed elsewhere), I tell the person that he/she will almost surely have feelings of 'withdrawal' near the end of the day. If the person takes a tab of Suboxone the feelings go away within 30 minutes-- even though the uptake of buprenorphine generally takes twice as long. If the person having those symptoms of w/d gets distracted, the feelings go 'poof!' and disappear... unless the person happens to THINK of them again, in which case they come back. They are nothing like REAL w/d, where the symtoms get worse and worse until a dose is taken.

If the person trusts me enough to use 'distraction' when the feelings occur and quickly think of something else, and never act on them by dosing, they almost always go away in a few days. The ones that don't go away in a few days go away in a week or two. I've seen this process occur hundreds of times, literally. On the other hand, if the person 'treats' the w/d by dosing, that reinforces the symptoms, and guarantees that the w/d will continue every night.

Studies have been done looking at the effects of dosing every other day. I saw the results at a meeting with RB folks a couple years ago, before I realized that the RB people were more about selling Suboxone than about treating opioid dependence... but that is another story. Anyway, people dosed every other day with 8 mg of buprenorphine can't tell the difference from dosing every day-- as long as they are 'blinded' to what they are taking. If a person KNOWS he is getting it only every other day and other doses are a placebo, he feels lousy. But if he THINKS he is dosing every day, he does fine. The half-life of buprenorphine at these high doses (8 mg is 8000 micrograms, and a typical pain dose is 50 micrograms) is very long, so that extra evening dose does almost nothing to the blood level of buprenorphine. Over the first week of treatment the buprenorphine is taken faster than the halflife of elimination, so the drug accumulates and the blood level rises. Each dose, then, does little to the blood level; if graphed out you would see a level at, say, 10 units per deciliter, rising maybe to 11 for 12 hours after a dose and then dropping down to 10 by the next dose.

In other words, in most cases that little feeling that people get from taking buprenorphine is psychological, not chemical.

Feelings of a 'buzz' and of w/d are 'remembered,' and will play back after certain cues. Alcoholics know of a similar effect when they feel buzzed by a virgin margarita.

Understand that there are also strong pressures against prescribing over 16 mg per day. First, diversion studies show a markedly higher incidence of sharing and diversion by people who receive higher doses. So from a public health standpoint (depending I suppose on whether you consider it appropriate for people to 'treat themselves' with buprenorphine from the street), doses above 16 mg per day are increasing the risks of diversion. Doctors receive reports each month about buprenorphine, and they have included, every month, a warning about prescribing greater than 16 mg per day. Higher doses are to be used only short term, for unusual circumstances, and using higher levels of monitoring. You could say that a doc who won't prescribe more than 16 mg is 'strict', but on the other hand many docs have had their certifications pulled for perceived carelessness in prescribing, or from being linked to cases of diversion-- so the doc is really just protecting his/her ability to keep on seeing you.

On the other hand, I am a proponent of long-term buprenorphine for most people-- particularly young people-- so I would probably not have agreed with lowering a person's dose arbitrarily, when that person feels that cravings are not yet under control.

Finally-- the headaches and other symptoms described at higher doses of Suboxone likely are coming from naloxone. Naloxone is not generally active orally, as it is broken down in the liver quickly after absorption. But at high doses-- and 6-8 mg of naloxone is getting up there-- you will have spillover of naloxone into the systemic circulation, causing headaches, stomach cramps, sweats, and other w/d symptoms. This is especially likely if you are taking an antidepressant or other medication that blocks the breakdown of naloxone at the liver.

JJ


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PostPosted: Wed Aug 11, 2010 7:16 am 
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Thanks, Dr. J!! As usual, you've given us so much valuable information. I very much appreciate you taking the time to share your knowledge and expertise with us.

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PostPosted: Thu Aug 12, 2010 9:17 pm 
I don't know if Dr. Junig will take another look at this thread or not, but I also wanted to say "thanks" to him for that reply. It really reinforces what the, admittedly limited, amount of research I've done on this drug has led me to conclude. That being that there are a lot of people who are being prescribed way more buprenorphine than is necessary. Having worked in the medical field for so long, I was always under the impression that it is best practice to take the least amount of drug necessary to combat whatever disease or illness one is being treated for.....most of the time anyway. In fact, more often than not, taking more drug than is necessary can be quite detrimental at worst and just a waste of money and resources at least.
Why, then, are there still doctors writing scripts for patients for anything more than 16mg/day? To take it a step further, I've not heard of too many people who are working a solid recovery program, find any problems tapering down to 12mg/day or even 8mg/day. To me, taking more drug than necessary is just continuing one aspect of addictive behavior.....overmedicating to squelch some perceived psychological w/d symptom or craving. Don't get me wrong, I've done it and have had a hard time with this concept at times. But I believe it as the science Dr. J presents makes perfect sense. The other thing I can't wrap my mind around is why, when this drug is prescribed for pain it is prescribed in terms of 'micro'gram doses, yet there are people out there who are taking it for pain and/or addiction at doses at or over 24mg/day. I get that an addict with chronic pain has huge tolerance issues and we also tend to suffer from 'hyperalgesia', but that still in my mind, doesn't explain such high doses of bupe. Especially given the fact that this drug has a ceiling effect and if I understand correctly, taking anything over 16mg (at the higher end) isn't going to make an actual difference in pain management. I suppose it could be argued that it doesn't hurt anything or anyone to take so much above the ceiling dose and of course, I'm not suggesting that anyone go against doctor's orders, and I know there are exceptions to every rule, but I just don't really get it.
I guess it's just always been something I've questioned. I mean, we're working on getting better, escaping the madness of drug addiction, drug abuse, and all that goes along with it. So why not work more on getting the focus off the drugs. Even the 'good' drug, Suboxone. It would seem logical to me that taking the lowest dose which keeps the addiction in remission, taking it once a day and never dosing 'as needed' would be an important part of that process. It's definitely something I've had to work on throughout my treatment with bupe. But Dr J is right on, in my opinion, when he says that our need to dose more than once a day or more than 8-16mg/day, is more psychological than anything else.....or heck we could even dose every other day and do just fine!
I'm glad Dr. Junig put this information out there for us. It just goes to show, again, that if you're taking bupe and doing nothing else towards your recovery, a drug is still your primary focus. And in my mind, anyway, that's not optimal....better than taking the former DOC, but still not optimal. Anyway....thanks Dr. J!


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PostPosted: Thu Aug 12, 2010 9:46 pm 
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There are lots of people who are prescribed 24 mgs a day for pain management. My husband will be one in another week or so. Obviously DR's have a reason to do it. I don't think this forum is the place to be questioning it. Sub has proven to be excellent for pain management as well as addiction, and I don't think questioning those on it or their doses is a very nice thing to do.

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PostPosted: Thu Aug 12, 2010 10:01 pm 
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Since the subject of taking sub for pain in too high of doses has come up I felt the need to reply. As some of you may know, I'm one of the those on this forum who also take it for pain. I dose at 8 mg, two-three times daily. I hear what's being said here, however, and I'm not arguing with the science - I definitely don't have the education for that. I'm not saying anyone is wrong either, I'm merely stating my experience, which simply doesn't coincide with this. I'm doing so because I may not be the only person with this same experience on this forum and I certainly don't want anyone to feel badly for taking their prescribed dose.

On more than one occasion I've tried cutting my dose down to 4 mg (or lower), still dosing 2-3 times daily. It's been my continued experience that it simply does not treat my pain. I cannot explain it, it just is. And I certainly don't feel that I'm addressing some psychological withdrawal symptom by dosing at 8 mg or that I'm continuing some aspect of addictive behavior. I'm not saying these statements were directed at me, but I think to suggest it about anyone is lacking in sympathy and empathy. How can one person say what another person should dose for pain or what their pain level is? It certainly does not mean anyone is not in healthy recovery. To suggest that is borderline offensive and may serve to misinform instead of to help.

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PostPosted: Thu Aug 12, 2010 10:08 pm 
I didn't intend to upset anyone. Actually though, I don't think I broke any forum rules, and I think that this type of discussion is actually exacty what the forum is here for, at least in part. If you read the entire post, you'd see that all I did was agree with what Dr. Junig presented in his post, and then go on with the discussion. I also said that I would never suggest that anyone go against doctor's orders and that there are exceptions to every rule. If I "questioned" anyone, it certainly wasn't any individual, but possibly some of the doctors who over-prescribe according to the recommended guidelines. I was simply presenting questions that had arisen in my mind that were along the lines of what Dr. Junig had posted. I don't think I'm alone in feeling that Suboxone alone does not equal recovery, in and of itself. I believe I also stated that using it alone at whatever dose is still far better than being in active addiction. I don't know what part of that you found offensive, but it wasn't intended to be. I'm sorry the post rubbed you the wrong way. I sincerely hope the best for your husband's treatment and yours as well!


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PostPosted: Thu Aug 12, 2010 10:16 pm 
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This is the part that rubbed me the wrong way....

"Why, then, are there still doctors writing scripts for patients for anything more than 16mg/day? To take it a step further, I've not heard of too many people who are working a solid recovery program, find any problems tapering down to 12mg/day or even 8mg/day. To me, taking more drug than necessary is just continuing one aspect of addictive behavior.....overmedicating to squelch some perceived psychological w/d symptom or craving."


But really, the whole post seemed to be screaming "debate"

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PostPosted: Thu Aug 12, 2010 10:22 pm 
Hatmaker....I know your situation is unique and I know you've tried before to lower your dose without success. And you're absolutely right.....only YOU know what YOU feel. And only you (with your doctor's help) can choose what is best for you. As I said before, I didn't mean to imply that you or anyone else who takes a high dose is doing anything wrong when such is prescribed for them and works for them. Everyone on the forum knows that your situation is different and that you certainly have recovery practices in place beyond your medication. I meant you no disrespect.....sincerely. Just felt that I could add to the discussion at hand. My mistake!


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PostPosted: Thu Aug 12, 2010 10:26 pm 
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My dr said it perfectly to me yesterday when I saw him. I'm have super issues getting below 8 mgs and he said "that's ok. Everyone is different. You have to do what works for you to stay clean" So, yeah. I guess that's my issue. Everyone is different, in their cravings, their liver, etc. Their whole body and mind and that's what bothers me about your post. Just being honest.

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PostPosted: Thu Aug 12, 2010 10:37 pm 
Again, sorry I offended you. In reality, though, all I did was say the same basic thing Dr. Junig said up to including that there are exceptions to the rule. Funny, nobody accused him of starting a debate or being unsympathetic. I am quite sympathetic actually and I find these topics interesting and thought-provoking and wanted to share. Obviously I shouldn't have. Last time I checked we were free to post as long as no forum rules were broken. I can only say "I'm sorry I hurt your feelings" sincerely. The rest of where you go with it is up to you. Hatmaker, if you feel my post needs to be deleted...go right ahead and do so. The last thing I'd ever want to do is "mislead" anyone seeking treatment or help. Hope you both have a lovely night.


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Fond Du Lac Psychiatry
Dr. Jeffrey Junig, M.D., Ph.D.

  • Board Certified Psychiatrist
  • Asst Clinical Professor, Medical College of Wisconsin

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