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PostPosted: Wed Oct 05, 2011 1:01 pm 
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I am not posting this link to be condescending or confrontational. I have read over and over your posts telling people they are dependant on 320mg of morphine and it simply isn't true. I posted this before about the 4mg ceiling affect and that after that dose Suboxone is no longer linear and does not increase in effect or in tolerance. Again I am not trying to start an argument with you I simply want you to see how bupe works so the misinformation can stop. I hope you will watch this so you can understand how bupe works. Thank You!

http://www.youtube.com/watch?v=Wqn5qDdp ... u_in_order


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PostPosted: Wed Oct 05, 2011 6:43 pm 
Breezy_Ann wrote:
I am not posting this link to be condescending or confrontational. I have read over and over your posts telling people they are dependant on 320mg of morphine and it simply isn't true. I posted this before about the 4mg ceiling affect and that after that dose Suboxone is no longer linear and does not increase in effect or in tolerance. Again I am not trying to start an argument with you I simply want you to see how bupe works so the misinformation can stop. I hope you will watch this so you can understand how bupe works. Thank You!

http://www.youtube.com/watch?v=Wqn5qDdp ... u_in_order


I don't mind watching it, but if you are going to quote me, please don't tell lies.

I didn't say that anyone was "dependant on 320mg of morphine." I said that if you are taking 16mg of Suboxone per day, that is equivalent to 320 mg of morphine per day, at a conservative estimate. I also provided a reputable citation, and could provide them all day long for those numbers. Therefore, while seeking pain relief for surgical purposes (which is the context in which I have made these claims), it would take an insane amount of a full-agonist that most doctors would be unwilling to prescribe to get the job done. Not 320 mg, because the pain relief dose would be IVed as opposed to taken orally, but an insane amount nonetheless.

We have already discussed the term "ceiling effect." I will not provide the definition again. Anyone who bothers to Google it can see that you are NOT talking about a "ceiling effect." You are probably talking about the blocking effect, but I don't want to put words in your mouth.

Again, feel free to quote me, but don't tell lies or put words in my mouth that I didn't say.

Just one more thing. Tolerance to Suboxone may stop increasing linearly at a certain point, but it doesn't stop increasing. It also has NOTHING to do with what your tolerance to full-agonists would be. Again, your response has NOTHING to do with what I posted regarding what someone should do in case of a needed switch to full-agonists.

If you are trying to make me look bad, try again.

P.S. YouTube is NOT a scholarly source. IMO, if you are trying to prove a point, use a medical study.


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PostPosted: Wed Oct 05, 2011 11:17 pm 
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Ok, I wasn't lying or quoting you. Notice how you used quotation marks and i did not. I didn't say that is was your words verbatim. If you say 16mg of sub equals 320mg of morphine then a person taking 16mg of sub would be dependent on 320mg of morphine. I do not know why you are so hung up on words; 4mg is a ceiling level as well. Obviously you tube is not a study, it is Dr. Junig explaining how bupe works and is no different than any of the articles you have posted which were written by drs. His is just a video. Look I was not rude, you are and are spreading misinformation. 16mg is not equivalent to 320mg of morphine.


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PostPosted: Wed Oct 05, 2011 11:29 pm 
Breezy_Ann wrote:
Ok, I wasn't lying or quoting you. Notice how you used quotation marks and i did not. I didn't say that is was your words verbatim. If you say 16mg of sub equals 320mg of morphine then a person taking 16mg of sub would be dependent on 320mg of morphine. I do not know why you are so hung up on words; 4mg is a ceiling level as well. Obviously you tube is not a study, it is Dr. Junig explaining how bupe works and is no different than any of the articles you have posted which were written by drs. His is just a video. Look I was not rude, you are and are spreading misinformation. 16mg is not equivalent to 320mg of morphine.


Clearly, you didn't read the above post.

" If you say 16mg of sub equals 320mg of morphine then a person taking 16mg of sub would be dependent on 320mg of morphine."

The person is not dependent on 320 mg of morphine, that is NOT what I said. The person is dependent on 16 mg of buprenorphine. What I continue to say is that it would probably take an oral dose of ~320 mg of morphine to achieve any real pain relief.

What if the person had to go buprenorphine ---> morphine. How much do you think it would take just to keep them out of withdrawal, let alone give them relief from severe pain??

This study puts .3 mg of IV bupe equal to 10 mg of IV morphine.

http://jpet.aspetjournals.org/content/282/3/1187.full

Therefore, how many mgs of ORAL morphine do you think equal 16 mg of Suboxone? A shiatload, that is how many.

How can you accuse me of misinformation, and the REPEATEDLY refer to 4 mg as a "ceiling" without providing evidence, when I have provided AMPLE evidence that the ceiling dose of buprenorphine is ~32 mg. Here it is.

http://buprenorphine.samhsa.gov/about.html

Please stop putting words in my mouth.

If you disagree with me, please come back with some REAL sources that refute what I am saying.

Thank you.


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PostPosted: Thu Oct 06, 2011 12:01 am 
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You are so frustrating and remember why I gave up before. Yes the ceiling dose of bupe is 32mg, I never said it wasn't. Because bup is a partial agonist you do not get an increase in opiate effect above 4mg. It doesn't matter what you call it, a ceiling or whatever. I do not understand why you continue arguing this I told you before you yourself said the same thing and I agree that 32mg is the ceiling dose of sub. We are using the same word for 2 different properties of the drug. For the last time, at doses below 4mg bupe works like a full agonist so yes .3mg of bupe would equal 10mg of morphine. You can continue to convert based on that until 4mg. At that point bupe partial agonist property kicks in and it no longer increases in opiate effect. So based on the link you provided 4mg of sub equals about 130mg of morphine, because of the whatever you want me to call it effect so does 6mg or 10mg or 16mg.


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PostPosted: Thu Oct 06, 2011 5:32 am 
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Suboxone conversion is not linear as explained briefly by Dr. Junig:
http://suboxforum.com/viewtopic.php?t=2 ... conversion

"...the problem is the non-linear kinetics of buprenorphine. You can't just extrapolate out with bupe, like you can with agonists that don't have a 'ceiling effect'.

In other words, one mg of buprenorphine is as potent as about 20 mg of methadone, 2 mg of buprenorphine is as potent as 30-40 mg of methadone, and 4 mg, 8 mg, or 24 mg of buprenorphine are all as potent as 30-40 mg of methadone! The calculator works fine as long as you use doses for buprenorphine below the 'ceiling' effect-- say down in the microgram ranges. But you cannot use those numbers to project out in a straight line-- because the potency of buprenorphine, being a 'partial agonist', doesn't follow a straight line."

Hopefully this will put things to bed once and for all.

PS - Dr. Junig is a sub specialist and he just happens to use Youtube so that he can reach people. It shouldn't take away from what he has to offer.

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PostPosted: Thu Oct 06, 2011 7:40 pm 
Breezy_Ann wrote:
You are so frustrating and remember why I gave up before. Yes the ceiling dose of bupe is 32mg, I never said it wasn't. Because bup is a partial agonist you do not get an increase in opiate effect above 4mg. It doesn't matter what you call it, a ceiling or whatever. I do not understand why you continue arguing this I told you before you yourself said the same thing and I agree that 32mg is the ceiling dose of sub. We are using the same word for 2 different properties of the drug. For the last time, at doses below 4mg bupe works like a full agonist so yes .3mg of bupe would equal 10mg of morphine. You can continue to convert based on that until 4mg. At that point bupe partial agonist property kicks in and it no longer increases in opiate effect. So based on the link you provided 4mg of sub equals about 130mg of morphine, because of the whatever you want me to call it effect so does 6mg or 10mg or 16mg.


It definitely does matter what you call it. I can't just walk around calling a duck a chicken. I would sound silly, and people wouldn't know what I was talking about.

When you call a blocking effect the "ceiling dose," you sound misinformed, and people may not know what you are talking about.

So, are you trying to tell me that someone on 2, or even 4, or even 6 mg of Suboxone wouldn't need any less pain medication than someone on 16 mg? That is your position?


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PostPosted: Thu Oct 06, 2011 7:50 pm 
hatmaker510 wrote:
Suboxone conversion is not linear as explained briefly by Dr. Junig:
http://suboxforum.com/viewtopic.php?t=2 ... conversion

"...the problem is the non-linear kinetics of buprenorphine. You can't just extrapolate out with bupe, like you can with agonists that don't have a 'ceiling effect'.

In other words, one mg of buprenorphine is as potent as about 20 mg of methadone, 2 mg of buprenorphine is as potent as 30-40 mg of methadone, and 4 mg, 8 mg, or 24 mg of buprenorphine are all as potent as 30-40 mg of methadone! The calculator works fine as long as you use doses for buprenorphine below the 'ceiling' effect-- say down in the microgram ranges. But you cannot use those numbers to project out in a straight line-- because the potency of buprenorphine, being a 'partial agonist', doesn't follow a straight line."

Hopefully this will put things to bed once and for all.

PS - Dr. Junig is a sub specialist and he just happens to use Youtube so that he can reach people. It shouldn't take away from what he has to offer.


Not according to this. I found it in Dr. Junig's own link section:
http://www.medcalc.com/narcotics.html

He says it must be wrong, but I would like to see some STUDY confirming this information that keeps being quoted. Or a medical textbook. Or even something from the a-holes at RB themselves!

How did Dr. Junig arrive at this conclusion. Observation? Personal experience? I'd like to know. I am not saying he is wrong, I would never say "I am right and this doctor is wrong" without waaaaaayyyyyy more evidence than is even out there on the topic. However, I would like to know more about how he arrived at this conclusion.


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PostPosted: Thu Oct 06, 2011 7:52 pm 
Breezy_Ann wrote:
You are so frustrating and remember why I gave up before. Yes the ceiling dose of bupe is 32mg, I never said it wasn't. Because bup is a partial agonist you do not get an increase in opiate effect above 4mg. It doesn't matter what you call it, a ceiling or whatever. I do not understand why you continue arguing this I told you before you yourself said the same thing and I agree that 32mg is the ceiling dose of sub. We are using the same word for 2 different properties of the drug. For the last time, at doses below 4mg bupe works like a full agonist so yes .3mg of bupe would equal 10mg of morphine. You can continue to convert based on that until 4mg. At that point bupe partial agonist property kicks in and it no longer increases in opiate effect. So based on the link you provided 4mg of sub equals about 130mg of morphine, because of the whatever you want me to call it effect so does 6mg or 10mg or 16mg.


This is from the SAMHSA website:

At low doses buprenorphine produces sufficient agonist effect to enable opioid-addicted individuals to discontinue the misuse of opioids without experiencing withdrawal symptoms. The agonist effects of buprenorphine increase linearly with increasing doses of the drug until at moderate doses they reach a plateau and no longer continue to increase with further increases in dose—the “ceiling effect.”

"Because of its ceiling effect and poor bioavailability, buprenorphine is safer in overdose than opioid full agonists. The maximal effects of buprenorphine appear to occur in the 16–32 mg dose range for sublingual tablets. Higher doses are unlikely to produce greater effects."

http://buprenorphine.samhsa.gov/about.html

EDIT: Sorry, I would merge/delete my multiple posts if I knew how/could.

@Breezy Ann, what makes me so frustrating? My ability to provide a cohesive logical argument complete with sources to back up my opinions?


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PostPosted: Thu Oct 06, 2011 10:03 pm 
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No, because you do not listen to anything and now you are putting words in my mouth it is not the ceiling dose that would be 32mg like you said, I said it is a ceiling effect as in you do not get anymore of an opiate effect after around 4mg. You are frustrating because you keep posting something that proves the fact that 32mg is the ceiling dose and I have never argued that and agree. The 2 things I have asked for proof for you have not provided.

1. A study that proves that low dose bup is better for treating addiction, not depression in non opiate tolerant people which is the study you posted.

2. Proof that at doses above 4mg that .3mg of bupe still is equivalent to 10mg of morphine.

These are the 2 things you claim to be true and have not supported them, instead you keep going back to the ceiling argument with which i am not even arguing. So since you can't get past this I am gonna say, fine your right. So now that's over can you please focus on the 2 above.


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PostPosted: Thu Oct 06, 2011 11:44 pm 
Breezy_Ann wrote:
No, because you do not listen to anything and now you are putting words in my mouth it is not the ceiling dose that would be 32mg like you said, I said it is a ceiling effect as in you do not get anymore of an opiate effect after around 4mg. You are frustrating because you keep posting something that proves the fact that 32mg is the ceiling dose and I have never argued that and agree. The 2 things I have asked for proof for you have not provided.

1. A study that proves that low dose bup is better for treating addiction, not depression in non opiate tolerant people which is the study you posted.

2. Proof that at doses above 4mg that .3mg of bupe still is equivalent to 10mg of morphine.

These are the 2 things you claim to be true and have not supported them, instead you keep going back to the ceiling argument with which i am not even arguing. So since you can't get past this I am gonna say, fine your right. So now that's over can you please focus on the 2 above.


First off, you don't get to redefine words, your name isn't Merriam-Webster. Just because you want to apply the word "ceiling" to a 4 mg dose doesn't mean it automatically makes sense.

You haven't asked for those two things until this moment.

1. As for your #1, define low-dose. 4 mg, is that a low dose? Because it still has a blocking effect, but many on here would consider that a low dose. I think 4 mg would work just fine.

2. I already gave you this one. Do you even read the citations I post before you argue with me?

Let's try again.

One of the things I posted was a bupe conversion calculator from Dr. Junig's own links page. He stated that he happens to disagree with it, for the record, but he still put it there and says he uses it.

From the SAMHSA website:
"The agonist effects of buprenorphine INCREASE LINEARLY WITH INCREASING DOSES of the drug until at moderate doses they reach a plateau and no longer continue to increase with further increases in dose—the “ceiling effect.”

If you read further, you will see that SAMHSA puts this "ceiling effect" dose at 16-32 mg for buprenorphine.

So does this site:
http://recoveringaddict.hubpages.com/hu ... -Methadone

Did I skip anything, or did I answer your questions?


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PostPosted: Mon Oct 31, 2011 9:48 am 
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Ironic, the ceiling dose for buprenorphine varies for each person in the same way our tolerances vary. This is why you're finding it hard to nail a concrete number for the ceiling dose.

They say the ceiling dose is the point where buprenorphine's half life starts to increase. ie - when we take our ceiling dose, buprenorphine lasts in our body approx 24 hours. But when we take double our ceiling dose, that dose holds us for approx twice that, or 48 hours. This is why some people "double dose", taking twice as much, but only have to dose every 48 hours.

Morphine is completely different. You take increasing doses of morphine, you get increasingly stoned. That's pretty much the equation.

Image

All opiates have their own strength relative to morphine, ie 100 micrograms of fentanyl is roughly on par with 10mg morphine. But to view all opiates based on this figure is incredibly simplistic and reductionist. Each drug has its own dosage/response qualities, half lives, ease in getting to the brain etc. To simply say one drug is stronger because of its relative morphine dose neglects all these other factors. In the case of buprenorphine, the ceiling-effect is one of its most appealing characteristics in the treatment of addiction. Please keep that in mind when you post your information, and try to paint the full picture.

T.


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PostPosted: Mon Oct 31, 2011 1:24 pm 
tearj3rker wrote:
Ironic, the ceiling dose for buprenorphine varies for each person in the same way our tolerances vary. This is why you're finding it hard to nail a concrete number for the ceiling dose.

They say the ceiling dose is the point where buprenorphine's half life starts to increase. ie - when we take our ceiling dose, buprenorphine lasts in our body approx 24 hours. But when we take double our ceiling dose, that dose holds us for approx twice that, or 48 hours. This is why some people "double dose", taking twice as much, but only have to dose every 48 hours.

Morphine is completely different. You take increasing doses of morphine, you get increasingly stoned. That's pretty much the equation.

Image

All opiates have their own strength relative to morphine, ie 100 micrograms of fentanyl is roughly on par with 10mg morphine. But to view all opiates based on this figure is incredibly simplistic and reductionist. Each drug has its own dosage/response qualities, half lives, ease in getting to the brain etc. To simply say one drug is stronger because of its relative morphine dose neglects all these other factors. In the case of buprenorphine, the ceiling-effect is one of its most appealing characteristics in the treatment of addiction. Please keep that in mind when you post your information, and try to paint the full picture.

T.


People keep answering this and ignoring what I said.

The point I am trying to make is that UNTIL YOU REACH THE CEILING DOSE (which is around 16 mg according to SAMHSA), SUBOXONE DOSES DO INCREASE LINEARLY. So, until you hit 16 mg, the more Sub you take, the more morphine you will need.

That is the only thing I was trying to say. People keep trying to expand on it and put words in my mouth, but my point is, was, and has been the sentence above.

"Morphine is completely different. You take increasing doses of morphine, you get increasingly stoned. That's pretty much the equation."

Who is talking about getting stoned? I am just saying that the more Suboxone you take, the more morphine you will need. The ceiling dose is listed as ~16 mg as a LOW estimate. That means that someone on 16 mg of Sub per day will need more morphine for pain relief than someone on 8 mg/day. However, someone on 20 mg/day should only need the same amount as someone on 16 mg/day. That I understand, and accept, and never questioned.

The general point of this post was actually to bring to light the fact that if you take a lot of Suboxone, and you need surgery or get into an accident, your tolerance is going to be uckfayed. I have heard plenty of people on Suboxone complain that when they went to the hospital for an accident or surgery they received NO pain relief from the doses of IV full-ags that they were given. The doctors upped the dose, and still nothing. The doctors were unwilling to up the dose high enough.

Check out this dosage calculator on Dr. Junig's links page. Because Sub is linear UP TO 16 mg, this calculator should be accurate for doses UP TO 16 mg. Look at the numbers. No doctor is going to be willing to administer that much morphine to someone who isn't terminally ill.

By the way, I just picked morphine. We can talk about dosage equivalency in terms of oxycodone, opana, dilaudid, whatever you prefer. It is still the same.

EDIT: Just wanted to add one thing. Let me start by saying that my DOC was IV oxycodone and heroin. Last time I relapsed, at the time, I was taking 1.5 mg/day of Sub. I did a 60 mg shot of IV Oxycodone and BARELY felt it. Barely felt a thing, let alone high! I am glad I didn't now, but at the time it made me wonder how much I would need if I were to be legitimately hurt and needed pain medication. I doubt the docs in the hospital would even give me 60 mg IV, they would probably give much less! So for someone taking a large dose everyday..

Let me ask the question..

How much pain medication do YOU think someone on 16 mg/day would need for adequate pain relief? In a legit, hospital setting. I'm already telling you that on 1.5 mg of Sub per day, a 60 mg shot of oxycodone did nothing. I also want to note that I am talking about a relapse from awhile ago. I actually relapsed MORE when I was on 4-8 mg/day than I have on <2!


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PostPosted: Mon Oct 31, 2011 3:13 pm 
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The pain-medication question for Suboxone patients gets tricky, not just because of the Sub patients higher tolerance for opioid medications, but because of buprenorphine's high affinity for opiate receptors. At a dose of 16mgs/day, a Sub/bupe patient basically has NO open/available opiate receptors for another full-agonist opioid medication to latch onto and activate.

Dr. Junig has explained this somewhere and I will try to find it later, but the gist of it is that whatever opioid medications are circulating in your bloodstream will be constantly in the process of "attaching" and "detaching" from your opiate receptors. Buprenorphine is unique in that it is a partial-agonist with a very high affinity for the opiate receptor. This means that while it only partially stimulates the receptor, it "bonds" very strongly with the receptor and basically out-competes most other full-agonist opioids at the receptor, never even giving them a chance to latch on and do their thing. At the same time, the fact that bupe is a partial agonist means that its analgesic effect is nowhere near as strong as an equivalent dose of morphine. Same is true for other effects like respiratory depression.

There are possibly certain opioid medications that can "out compete" buprenorphine at the receptors and thereby provide some measure of pain relief to Suboxone patients in an emergency situation. I believe Fentanyl is one, dilaudid may be another. Whether this works or not likely varies from person to person. I passed a kidney stone when I was on 4mgs of Sub daily and a 4cc shot of IV dilaudid effectively killed the pain, but it wore off more quickly than what I'd experienced in similar situations in the past. Other people report being not as lucky.

So, long story short is that if you are on a higher-end dose of bupe (like 16mgs or possibly even 8mgs) it might not matter how much of a full-agonist opioid you take, you may feel little-to-no effect from it. This is why Sub patients are encouraged to stop their medication at least a few days before surgery - in which case their tolerance will still be high, but they will be more likely to get some pain relief from full agonists.

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PostPosted: Mon Oct 31, 2011 4:36 pm 
Diary of a Quitter wrote:
The pain-medication question for Suboxone patients gets tricky, not just because of the Sub patients higher tolerance for opioid medications, but because of buprenorphine's high affinity for opiate receptors. At a dose of 16mgs/day, a Sub/bupe patient basically has NO open/available opiate receptors for another full-agonist opioid medication to latch onto and activate.

Dr. Junig has explained this somewhere and I will try to find it later, but the gist of it is that whatever opioid medications are circulating in your bloodstream will be constantly in the process of "attaching" and "detaching" from your opiate receptors. Buprenorphine is unique in that it is a partial-agonist with a very high affinity for the opiate receptor. This means that while it only partially stimulates the receptor, it "bonds" very strongly with the receptor and basically out-competes most other full-agonist opioids at the receptor, never even giving them a chance to latch on and do their thing. At the same time, the fact that bupe is a partial agonist means that its analgesic effect is nowhere near as strong as an equivalent dose of morphine. Same is true for other effects like respiratory depression.

There are possibly certain opioid medications that can "out compete" buprenorphine at the receptors and thereby provide some measure of pain relief to Suboxone patients in an emergency situation. I believe Fentanyl is one, dilaudid may be another. Whether this works or not likely varies from person to person. I passed a kidney stone when I was on 4mgs of Sub daily and a 4cc shot of IV dilaudid effectively killed the pain, but it wore off more quickly than what I'd experienced in similar situations in the past. Other people report being not as lucky.

So, long story short is that if you are on a higher-end dose of bupe (like 16mgs or possibly even 8mgs) it might not matter how much of a full-agonist opioid you take, you may feel little-to-no effect from it. This is why Sub patients are encouraged to stop their medication at least a few days before surgery - in which case their tolerance will still be high, but they will be more likely to get some pain relief from full agonists.


YES YES YES YES YES

Thank you.

I am NOT trying to pick on anyone. I am trying to make sure that people understand that there is no free lunch. Doctors will usually start people on a (too) high dose of Suboxone and not taper them on any schedule. Being on these high doses of Sub for months or years is NOT the same as being on a lower dose. At a lower doses (4 mg and under), there are many less concerns. You can still probably (your chances improve the lower you go) get pain relief from a full-agonist in a medical emergency. I have also heard that 4 mg is the dose at which your brain begins the process of downregulating the extra opiate receptors you have, which means it is healing. I would love to see concrete evidence of this.

Many people don't even think about what they would do in a medical emergency until they are in the hospital screaming in pain, with no relief possible.


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

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