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About JustNuts

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  1. levomilnacipram (Fetzima) 120mg QD - Depression. I don't think I posted in here about titrating past 40mg, but I had titrated up to 120mg by some point in January or February and have stayed there ever since. Adderall IR 20mg QID (80mg total) - ADHD bicalutamide (Casodex) 50mg QD - HRT. New med, literally just started this today as a replacement for the spironolactone (200mg didn't agree with me at all and 100mg literally wasn't doing anything to my T levels), we'll see how it goes, but I have high hopes. Unlike spiro or CPA it isn't supposed to actually lower my T levels, instead, it just acts as a extremely effective antagonist at the androgen receptors, preventing T/DHT from binding to them. estradiol (Estrace) 2mg BID (PO/SL) (4mg total) - HRT temazepam (Restoril) 30mg QD - Sleep diazepam (Valium) 5.0mg QID PRN - Anxiety. I don't bother with splitting pills for 2.5mg doses anymore, it's easier to just take 5mg less often. pantoprazole (Protonix) 40mg QD - Ideopathic chronic gastritis ondansetron (Zofran) 4mg PRN BID - Nausea from meds The doctor I saw who prescribed the bicalutamide also gave me some sumatriptan for my semi-frequent migraines (have had them since I was a kid) as ibuprofen isn't always enough for those. I didn't really feel it was really necessary but she practically insisted on prescribing it, which felt a bit odd at the time, but in retrospect I suppose me being opposed to trying actual anti-migraine meds for a change despite my long history of (often nasty) migraines is quite stupid to begin with and I'm glad she insisted on prescribing it. I'm still a bit concerned about the side effects and interactions but next time I have a migraine that ibuprofen fails to work on I'll definitely try the sumatriptan to see if it's helpful. My psych gave me some suvorexant (Belsomra) samples to try out in place of the temazepam when I last saw her, but I haven't tried that yet. It's very likely to just be completely ineffective, but my psych says that both she and the psych who owns the practice have noticed that many of the (small) subset of their patients who've actually responded to suvorexant are the ones with long histories of failed sleep meds, and that they generally respond very well when they respond, so she said to give it a try on the off chance that it's effective for me. I've been delaying too long though, I need to try that soon... It'll be interesting to see if it does anything.
  2. Bingo! Longer acting - Vyvanse has a slight edge over Concerta in most people Lower abuse risk - Both are abuse-deterrent formulations, but Vyvanse is an actual prodrug and Shire even had the gall to ask for a Schedule III classification as a result (obviously failed, as it's nowhere near as good as the Shire marketing department likes to portray it). Money/more uses - Shire explored Vyvanse for a plethora of uses, including in major depression (failed most of those trials). The ones that it succeeded in (ADHD and later BED) were the ones they pursued for marketing. Some major (mostly Shire-sponsored) trials of LDX in the past that haven't led to indications: Adjunctive use with antipsychotics in schizophrenia (dropped initially, poor results in a later trial, another trial assessed safety) Narcolepsy (seemingly successful initial trial) Numerous studies on adjunctive use with antidepressants in MDD (spectacularly failed the first trial, results in subsequent trials mixed/discouraging) MDD subpopulation with EFIs TBI-related attention deficits (two trials, one on adults (completed), the other on children (recruiting)) "Cognitive Functioning Issues in Women Post-Oophorectomy" (two trials withdrawn, one was to use LDX alone, the other was to use LDX+estradiol) Methamphetamine dependence (yes seriously - trial currently ongoing) Bipolar Depression (trial terminated due to failure to meet enrollment goals, safety trial completed, another trial abruptly terminated with no results posted (not an encouraging sign), MRI trial terminated due to slow enrollment) Cocaine dependence (yes seriously - results appear to be pretty disappointing since they didn't even bother with a statistical analysis on them, although a difference on both outcome measures was technically demonstrated, just not a very impressive one - a second and third trial has been completed but with no results posted yet for either trial) Cognitive functioning in menopausal women (no data posted) Cognitive functioning in MS (no results yet) Interesting trial on the PK of LDX in post-bariatric patients - not sure if this is a generalized safety trial or if it could be Shire's precursor into trying to sell the drug for post-bariatric surgery use -- quite an interesting market, and with BED they certainly have precedent I guess...
  3. That's because dexmethylphenidate is a worthless evergreened drug. Zero therapeutic benefit over racemic methylphenidate.
  4. https://www.colorfulasylum.com/chat/
  5. One of my providers flat-out isn't listed anywhere in the Blue Cross directory, yet she's confirmed to me that she's quite definitely in network for them. Another provider (out of state) had no idea if she was part of a certain BCBS program (which would allow someone on a different state's BCBS PPO plan to see them as an in-network provider), neither did her office staff, and the BCBS rep I previously talked to in order to get more details about this poorly explained program had told me that she had no way of knowing if a provider was in the program and that my provider is the one who should know! Talk about ridiculous incompetence! Our current insurer isn't BCBS but we're trying to switch to an ACA exchange (ACA income-based subsidy eligible) insurer for financial reasons and they're literally the only insurer on there for our situation - every other provider has dropped completely off of the ACA exchange. Although of course the fucking exchange decided that apparently despite our change of income status that now qualifies us for subsidies rather than expanded Medicaid access, since we weren't already on the exchange we can't change plans mid-year even though we had a fucking legitimate qualifying event and were told that we would be able to change plans due to this event if we were already on the exchange! It gets even more ridiculous when you realize that we've been saving the state a significant amount of money by paying out of pocket for private insurance all this time despite technically qualifying for medicaid because medicaid here is generally shit coverage (especially for mental health, but also in other specific areas) and we had the money and could justify the expense at the time relative to the benefits and didn't feel like we should take advantage of the state coverage when we could afford to pay, etc etc (long story)...and while we've appealed (with a good argument based on these reasons) and the appeal has been "accepted for review" (which really means nothing other than that they haven't immediately binned it), we have no idea if and when we'll hear back about the appeal, if it'll even be accepted, and thus it seems we're stuck with our excellent-yet-expensive insurer and can't utilize the (very significant) subsidy now technically available to us with an exchange plan (which has about the same base premium pre-subsidy as our current private plan but has notably worse coverage than we currently have - yet it's still worth it given how large the subsidy is). Agh. The whole damn system is fucked up anyways. And it all really just comes down to the fucking irrational bullshit opposition to the ACA that's made the individual mandate almost entirely toothless (when it actually needed to have significant fangs for the whole system to operate functionally - something the people opposing it knew) and as a result on-exchange insurer profitability was massively fucked up, leading to these mass exoduses from the exchanges and skyrocketing premiums. Even despite all that the ACA has had impressive results. And yet idiots are still trying to get rid of it harder than ever, and they can point to the mass exoduses and skyrocketing premiums as "proof" of the ACA failing thanks to their earlier opposition to the individual mandate that eventually crippled the entire system exactly the way it was expected to. Of course everyone on this site is biased since many of us are benefiting from things like mandatory mental health coverage, the elimination of restrictions based on pre-existing conditions, etc etc -- but isn't that the point of all this? To improve health care coverage and quality? To fix critical issues with the previous system?
  6. Make sure you're eating, drinking, and sleeping enough. If that's addressed, perhaps its your antidepressants (duloxetine in particular) wearing off? Or perhaps you're feeling depressed because of IRL issues? Those are other likely possibilities. If you've been taking the methylphenidate more frequently than usual and/or at higher doses than usual (especially if it's been consistently like this recently), you should try taking a day off of it to see if it's in any part a tolerance-related issue.
  7. It is impossible to tell you what dose will translate to a specific blood level. The therapeutic range for blood levels is "commonly considered to be" 50-100 mcg/mL. Divalproex sodium is available in 125mg "sprinkle" capsules, 125mg/250mg/500mg delayed-release capsules, and 250mg/500mg extended-release capsules. The DR capsules are normally dosed TID. The ER capsules are normally dosed QD and were intended for use in migraine suffers specifically but can be used for other uses. Initial doses of DR/ER for mania are 750mg and 25mg/kg respectively, and the maximum dose for either form is 60mg/kg. There is also valproate sodium and valproic acid. The first isn't used much. The second is available as 250mg capsules or 125mg/250mg/500mg delayed-release capsules, is indicated for mania/migraine only as far as I can tell, and seems less commonly used. BTW this drug is pretty hard on your stomach, so take it with food. Also, the 250mg and especially 500mg pills are a bit ridiculously large and thus somewhat hard to swallow. Sudden discontinuation of this drug is dangerous due to the risk of seizures and it must be titrated up and down somewhat slowly (although not as slow as stuff like lamotrigine). Note that most of this information is from my hardcopy of the 2013 Nursing Drug Handbook (33rd edition), and thus the available forms information may be somewhat outdated.
  8. In the US pharmacists are more-or-less always allowed (exact details depend on individual state laws) to automatically substitute any (non-DAW) prescription for a brand-name drug with an AB-rated generic (or any other equivalent equivalence rating - AB is simply the most common equivalence rating in use) if one is available. A prescription for the drug itself rather than the brand name (if one exists) is filled with any AB-rated generic of said drug. In theory they may use any available AB-rated generic on the market, however the choice of generic manufacturer is typically determined by which generic manufacturer (directly or via a supplier) can give their chain the best price for that drug in the volume they require at the moment. Pharmacists are effectively required to substitute AB-rated generics for the brand-name because it's considered best practice to do so for a long list of reasons and insurers also generally require this as well. If you have a prescription for a brand-name drug and no AB-rated generics are available, the prescription is always filled with the brand name. If you want the brand-name form for a drug with AB-rated generics (for whatever reason), you either need to request the brand-name form from the pharmacist (I'm not completely sure that the pharmacist is actually obliged to honor this request without DAW, especially if the RX is for the drug rather than its brand name), or have your doctor write a DAW script explicitly for the brand-name form (in which case they are definitely required to honor that request). I do not advise doing this because outside of extremely niche cases there is absolutely no reason to pay much more for the brand-name form when a cheaper AB-rated generic is available. In Canada, substitution is handled somewhat differently. Expanded practice laws for pharmacists in many Canadian provinces give pharmacists a broader scope of practice, which usually includes permission to actually significantly modify a provider's prescriptions (changing dosage, form, quantity/dosing, etc), renew prescriptions, make therapeutic substitutions with a broader scope than US pharmacists can, override DAW (in certain cases with patient agreement), and a number of other interesting things. However patients can usually request brand-name formulations (which results in modified cost sharing that vary based on their drug coverage - often they have to pay the difference between the brand-name drug's cost and the generic's cost), but there are a number of very strong initiatives encouraging automatic substitutions with generic forms in most provinces at multiple levels, and again the advanced practice laws can result in very different results. One interesting thing about Canada is that due to regulated drug pricing, the price difference between generic forms and brand-name forms is generally significantly smaller than it is in the US, and cash prices are also usually much lower. Patients are exposed to the cash prices more often and insurers handle reimbursement in different ways. Provincial drug plans in particular benefit from an even higher level of regulation on what they pay, while third-party plans may handle things differently. In my case when I was in Quebec my insurer reimbursed me a flat 80% of RX costs after the fact (I paid for the drug in cash up front, then gave a special type of receipt from the pharmacy to the insurer, then they issued me a cheque for 80% of the amount I paid), and they had no restrictions on reimbursing for brand-name drugs - I'd just have to pay more because 20% of the cash price of a brand-name drug is higher than 20% of the cash price of a generic drug. I was actually on Concerta at the time, which was available as two generics in Canada, but neither generic was actually therapeutically equivalent (yet they were still being substituted on some provincial plans), and when I asked for the brand-name at the pharmacy without giving any details the pharmacist remarked that they normally filled Concerta with the brand-name form anyways because they were aware of the issues with the Canadian generics and that the pharmacy didn't even keep any stock of the generic forms on hand. That's something that you could never see in the US even though the Concerta generic inequivalence issues (different manufacturers but the same issues) were happening there too on a much broader scale at the same time and were very poorly handled until the FDA finally stepped in and downgraded the therapeutic equivalence for the two inequivalent US Concerta generics to BX (alongside a bunch of other stuff happening and other details that I'll omit unless someone wants me to recount the entire long saga of Concerta's various generic woes again - it was such a huge mess). Then again Health Canada never did anything about their inequivalent Concerta generics, which is still a disgrace. Anyways, that's the rough overview of how the US and Canadian systems work. If anyone's curious I have some detailed calculated data on my pharmacy's profit margins for medications I was on back then, numerous fine details on how drug reimbursement and pricing in Canada/Quebec works, and a whole lot of information on Concerta's history and the generic issues in particular. I've posted it all before on other sites (CrazyMeds' forum for example before that went down), but I don't think I've posted any significant amount of it on here. I also have a fairly detailed blog entry on this site that I wrote up a while ago on how drug pricing and reimbursement works in the US:
  9. As I've explained already, your site is nothing special when it comes to the DMCA, the forum I was involved with had literally orders of magnitude higher risk at stake with far more actionable circumstances and yet they didn't resort to immature and irrational overreactions. The forum was also almost exclusively volunteer-ran, with approximately 110-130 active volunteer moderators and admins combined at any point in time and only a single paid staff member in charge of broad-scale community management. It also happened to be owned/controlled by a major company that would be extremely sensitive to DMCA issues for a number of reasons and yet didn't give a shit because they knew that the community was already clearly complying with their obligations under the DMCA via appropriate enforcement actions. My point once again is that you have completely mishandled the situation, you have the most ridiculous views about what's actually appropriate or what's actually happened, and whenever it's brought up you revert right back to the same poorly-thought-out (and refuted) arguments combined with outright ad hominem attacks and thinly-veiled threats while flat-out ignoring, dismissing, or otherwise brushing aside everything any other forum member says. "Batshit insane" or not, there's no excuse for acting like this. It's not the right way to run a community. It's not professional. Let me remind you that I was not the one to bring this topic back up in here, I merely briefly summarized the reasons why nobody can send me private messages when a member asked why the private message button wouldn't show up on my profile. You guys are the ones who decided that this conversation deserved to be resurrected again beyond that point. So don't even try to blame me for that.
  10. PAs generally save insurers money, or rarely, they may not save them money but may lead to improved care. Of course in this case I have no idea what they were thinking but not having to pay for benzos may have saved them money? Idk. The staff here aren't reasonable about stuff like that, so it's pointless. I'm not sure why they'd do it for benzos but in other situations it's generally to save the insurer money in the long run - PAs aren't free to process but they do allow the insurer to avoid paying for some care and avoid overuse of expensive things. Yeah once again you guys didn't get any of my points from that thread and clearly have no experience with the DMCA. I have extensive experience moderating on a far larger site than this (actually one of the largest forums on the internet and by far the single largest IPB one at the time) where we took much less restrictive approaches and would never have removed a member's ability to access the PM system even for far more severe infractions of this type. We had far more realistic fears over being subject to the DMCA than this little site does for numerous reasons and yet our policies were entirely different - which was not due to our size, but simply due to the fact that the site was actually ran by people who actually understood requirements for DMCA compliance and didn't unnecessarily overreact to minor issues. I mean Jesus Christ the level of overreaction and unprofessionalism you have compared to how we handled things is utterly batshit insane.
  11. The message link is missing because the site mods massively overreacted to something extremely minor and decided that completely disabling my ability to send or receive private messages was a rational response. The state is Illinois. Interestingly, after some research, I discovered that there are a few other cases across the country of health insurers (including certain state Medicaid plans) requiring blanket PAs for benzos immediately, or blanket PAs for benzos after/if certain criteria (like X number of benzo Rx fills) is met.
  12. Buspirone is quite rightly classified as having a "Low level of support" on https://en.wikipedia.org/wiki/Attention_deficit_hyperactivity_disorder_management#Comparative_efficacy.2C_tolerability_and_regulatory_status (which is a very good comparison of virtually every currently-available on- and off-label ADHD medication out there that is generally kept quite up to date and does a pretty good job of assessing scientific evidence in support of off-label ADHD medications). Thus it is really quite a poor choice for ADHD, and if you are unable to tolerate stimulants, "non-stimulant" options such as atomoxetine (Strattera), clonidine (Catapres/Dixarit/Kapvay), guanfacine (Intuniv/Tenex), modafinil (Provigil/Modavigil), and bupropion (Wellbutrin) would all be much better options to try if your intent is treating ADHD.
  13. I was in this situation with gabapentin. Was super worried about the possibility of discontinuation-related side effects since withdrawal from gabapentin is notoriously bad, and wasn't sure if going off it would worsen my anxiety (even though other meds having been directly addressing that for months at this point - although given gabapentin's MOA I did have a good reason to suspect that it could be potentiating the benzos). In the end I asked to stop it and to my pleasant surprise I had no discontinuation-related side effects (likely due to also being on benzos), no increase in anxiety (so much for that potentiation theory!), and a few fewer or less intense annoying side effects to endure in addition to the obvious bonus of not having to take or pay for the three extra pills a day.
  14. This is somewhat on-topic: Last time I saw my pdoc we discussed her experience with different insurers, and she mentioned something that I found startling. One of the major insurers in my state started requiring prior authorizations for every benzodiazepine from January onwards. She said that her and the other practitioners in this group practice (which also literally runs the area's psych ward and so collectively has a massive patient caseload) literally could not handle that insane of a volume of additional prior authorizations on top of the number they already have to file routinely and the psych who owns/runs this group practice decided that they would just tell all of the patients on that insurer that they'd have to pay cash for their benzodiazepines as a result.