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I'm not sure that it's currently working as much as it should from an anxiety standpoint, although much better then when i was in the hospital outpatient program. Currently taking 225 Effexor XR due to depression and anxiety, 2 MG of Klonopin daily due to severe anxiety and panic attacks. Pycdoc just added 60MG of Buspar 13 days ago. I feel no really benefit yet, other than maybe a little bit more energy in the afternoons. It seems to be kind of patchy. Sometimes it helps, sometimes it doesn't. I don't quite think it's enough. I'm willing to put in the work with changing my life style- eating healthy, exercising, meditating, etc. but really need my nervous system to calm down. I forgot to add that I take seroquel 25 for sleep, and sometimes a half tablet of that. I'd like to eventually stop taking that. I feel like i NEED it to sleep now.

Someone on hear mentioned Lyrica. Does that actually help calm the body? If so, how? Will i feel drugged?  I remember trying Gabapentin, but only lasted a week. I think i might have been scared of taking it. Now i'm open to other meds. I'm just sick of feeling depressed when i wake up, along with the jittery/trembling feeling. Any suggestions? I see the doctor next week.

Thank you all for your support!

PS- how do i add my meds to a signature?

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9 minutes ago, Ethansmom said:

PS- how do i add my meds to a signature?

Under account settings then signature. 

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The increased buspar doasage is making me so anxious and shaky. Today I woke up with my head buzzing and trembling all over. I went to a work meeting today and was with a bunch of people , however I felt like I was shaking so much that I was ready to explode. I started tearing up. Took a klonopin and called the pyscdoc. Left a message since she won’t be in until tomorrow. The klonopin is not enough. I may need to take my Xanax as a break through med in an hour or two. Trying to hold off, but feeling intense anxiety. What would you all do?? I have had a stressful week in general . Shouldn’t buspar be helping that. Can buspar cause depression?

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Is the Xanax for breakthrough Rx’d for that purpose? If so you should do what you feel you need to 

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If you look around these forums you will find all kinds of cocktails, some are more “normal” than others, but there are some weird ones that do work.

Lyrica and Gabapentin should, in theory, be pretty similar so I would expect the same effect, more or less. You mentioned that you have been on Gabapentin for a week so it is possible that you just didn't give it enough time to work.

Generally, GABA and its relation to Glutamate have a lot to do with anxiety. Klonopon/Xanax are benzodiazepines, that means that they enhance the calming effect of GABA. Meds like Lyrica/Gabapentin that are GABA analogues. The two types can work well together.

There are also mood stabilizers like Lamictal that also affect GABA through a different mechanism.

The thing I find strange about your cocktail is that it is mainly focused on Serotonin, that seems, from your posts here, that it is not the problem. Buspar and SNRI (Effexor) are good for depression, but it is clear that anxiety is your main issue.

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Anxiety is my main issue.  I get anxiety so bad that I get panic attacks. Buspar is supposed to be for GAD, however it’s not doing anything. I just took my second dose and have high anxiety levels again and just took a Xanax. Yes, I was prescribed Xanax for PRN. I take klonopin daily and that helps, but the buspar is over powering the klonopin.

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Buspar is not a prn like med. supposedly its like an ssri where it takes weeks to work. 13 days seems a bit early to throw in the towel at this point. Maybe give it at least a month?

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On 5/1/2019 at 8:50 PM, argh said:

Buspar is not a prn like med. supposedly its like an ssri where it takes weeks to work. 13 days seems a bit early to throw in the towel at this point. Maybe give it at least a month?

This is fairly correct. I don't think it takes as much time as an SSRI/SNRI to start working but it can still take a few weeks of consistent, regular dosing to determine how it's working. You are changing receptor sensitivity after all.

Dizziness and increased heart rate are normal on Buspar from what I understand. Maybe even some pressure headaches. They may go away with time.

However, this does beg the question if it's the right direction. Effexor, particularly at 225mg, will really ramp up norepinephrine signaling, but buspirone is broken down in the body into a piperazine metabolite that blocks alpha adrenergic receptors, theoretically further enhancing adrenergic output (norepinephrine/epinephrine). From what I understand, the anxiolytic effects of an SNRI come from the adrenergic densensitization that comes from increased noradrenergic signaling. So if buspirone is preventing this desensitization it may not work as intended. I think the red flag is that you're 2mg of clonazepam deep each day and still need alprazolam.

Have you ever tried any anti-convulsants like lamotrigine, carbamazepine/oxcarbazepine or valproate?

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Just an update: my doctor said to go back to 30mg of buspar and my increased anxiety has subsided . I haven’t tried any anticonvulsants. I wonder if that is something she will try next. Any thoughts on adding CBD oil? I tried a drop yesterday and seemed more sleeping and calm, but that’s about it!

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17 minutes ago, Ethansmom said:

Just an update: my doctor said to go back to 30mg of buspar and my increased anxiety has subsided . I haven’t tried any anticonvulsants. I wonder if that is something she will try next. Any thoughts on adding CBD oil? I tried a drop yesterday and seemed more sleeping and calm, but that’s about it!

This makes a lot of sense. Anxiolytic effects from 5HT1A agonists have a bell-curve effect where there is both a too low AND a too high. Start low and you don't find relief, increase and it goes away, increase again and the anxiety comes back. This is not surprising because there needs to be a balancing of the signaling at those receptors. Additionally, at a 60mg dose there would be considerable dopamine partial agonism which could temper some of the anxiolytic effects.

I'm a big fan of CBD for anxiety and mood. It's worked well for me in the past. I would fill up a 2-3ml tank with about 16mg/mL (~50mg) of CBD. Vape the whole tank in the morning and be fine for a good portion of the day when it comes to feeling calm and balanced.

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I love CBD oil. I vape 1000 mg (not sure the mg per quantity) as needed throughout the day. It even helps my tremors.

Klonopin 2 mg is a lot, and to need a breakthrough anxiety benzo still is concerning. Perhaps Klonopin isn't doing it for you? Or maybe you need smaller doses more often (0.5 mg 4x/day, 0.5 mg 2x/day + 1 mg in the evening/at night). You could also try increasing it up to 4 mg/day (the max dose for anxiety/panic). Otherwise, maybe Valium, Tranxene, or Xanax XR would be a better benzo? None are quite as potent as Klonopin (Xanax I think comes closest), but just because Klonopin is potent doesn't mean it's going to work for everybody. Valium can be dosed up to 4 times a day at a max of 40 mg/day, Tranxene 15 mg 3x/day is the max (45 mg, although for seizure disorders it can go up to 90 mg), and Xanax XR 3 mg up to twice daily for 6 mg/day (that's a ton of Xanax!).

As for a breakthrough benzo, I think Xanax is probably the best one to go for. Ativan works for many people but not me, and takes longer to work, but can be dosed up to 10 mg/day (but that would probably be on its own!). I loved Serax. It was very calming in a different way than any benzo ever caused me to feel, but I needed the max dose (30 mg) up to 3x/day. Xanax, for me, is the best though.

I agree with @browri about the BuSpar, but as for @HydroCat's response, targeting serotonin for anxiety is quite normal. Higher dosages of SSRI's are used for anxiety, while lower dosages tend to work better for depression. SNRI's are a whole different animal though, as @browri explained. The higher the dose, normally, the higher the norepinephrine, with the exception of Fetzima, which works the opposite way... It's primarily noradrenergic, and the higher the dose, the higher the serotonergic neurotransmission.

If you need an SNRI, for anxiety, I think Cymbalta would be a better medication, that is in my experience. Pristiq did nothing for anything. Fetzima made me a weepy mess.

Combining an SSRI with an NRI is also a good idea, because you can tweak the dosages of the serotonin and norepinephrine reuptake inhibition individually for your own custom "formula." I take Zoloft + Norpramin (desipramine), a TCA that is probably the most potent and selective NRI on the US market. Zoloft 150 mg + Norpramin 50 mg seems to be my happy spot for now. I've also taken Prozac + Strattera, and that was very good until Strattera went generic, and then all hell broke loose.

I agree with @HydroCat about combining something that modulates GABA in a different way than benzos but still modulates GABA, as they would be synergistic. Neurontin/Lyrica I believe (I could be mistaken) actually increase GABA concentrations in the brain. Lamictal inhibits glutamate release, but does modulate GABA through a different mechanism as aforementioned. Trileptal, as @browri mentioned does wonders for my anxiety. I take 600 mg twice daily, and it wasn't until I got to that dose that it actually really did something for my anxiety. Keppra is also used for anxiety, but depression and suicidality as well as anger, hostility, and irritability (known as the "Keppra rage") can be side effects of Keppra, so start low and go slow if you take it for psychiatric reasons.

Stelazine is an old-school antipsychotic (first generation or typical antipsychotic) that can be used short-term for anxiety in low, low doses, starting at 1 mg 2x/day and up to 2 mg 3x/day. It worked wonders for my anxiety, especially paired with the benzo Serax (oxazepam, a short-acting benzo). Serax is one of the active metabolites of Valium, but is a very clean benzo as it, itself, has no metabolites. I also paired it with Vistaril and that was a magical "triad" of anxiety meds for me. Unfortunately I did gain a good bit of weight, but I think it was because I was on the keto diet for 5 months and suddenly started ingesting a ton of carbs and my body was like "whoa what do I do with all this?" Stelazine itself is not likely increase appetite or weight typically, but it isn't unheard of. In fact, it's less likely to do so than the newer antipsychotics; however, it will increase prolactin more than the modern antipsychotics. I personally didn't develop gynecomastia or galactorrhea or anything like that, but some people do on the typical antipsychotics. Other first-gen antipsychotics that can be used for anxiety are Compazine (also an anti-nausea med) and Trilafon (not as commonly used), all of which synergize the effect of benzos.

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3 hours ago, mikl_pls said:

I vape 1000 mg (not sure the mg per quantity) as needed throughout the day.

Chances are if it's a bottle labeled 1000mg, it's a 30ml bottle. So 33.33mg/mL. So it's nice to have a 3mL tank and basically just vape it all at once in the morning like it's a routing "nebulizer" and you know you're getting ~100mg in the morning. It's nice to be able to plan it because it's good to be consistent if you're looking for positive effects on mood or anxiety. Find a good dose that works for you. CBD would have the same bell curve effect when it comes to anxiety. THC seems to have better effects on anxiety and insomnia at lower dosages in combination with moderate to high dose CBD to modulate the effect.

3 hours ago, mikl_pls said:

Klonopin 2 mg is a lot, and to need a breakthrough anxiety benzo still is concerning. Perhaps Klonopin isn't doing it for you? Or maybe you need smaller doses more often (0.5 mg 4x/day, 0.5 mg 2x/day + 1 mg in the evening/at night). You could also try increasing it up to 4 mg/day (the max dose for anxiety/panic). Otherwise, maybe Valium, Tranxene, or Xanax XR would be a better benzo? None are quite as potent as Klonopin (Xanax I think comes closest), but just because Klonopin is potent doesn't mean it's going to work for everybody. Valium can be dosed up to 4 times a day at a max of 40 mg/day, Tranxene 15 mg 3x/day is the max (45 mg, although for seizure disorders it can go up to 90 mg), and Xanax XR 3 mg up to twice daily for 6 mg/day (that's a ton of Xanax!).

Well the key thing with clonazepam is the half-life. Makes it suitable for regular consistent dosing. Would probably be best to have an evenly divided dose AM and PM. Going for 3 times a day or 4 times a day works better with lorazepam and alprazolam because of their shorter half-lives. Less time to kick in and to reach steady state.

3 hours ago, mikl_pls said:

As for a breakthrough benzo, I think Xanax is probably the best one to go for. Ativan works for many people but not me, and takes longer to work, but can be dosed up to 10 mg/day (but that would probably be on its own!). I loved Serax. It was very calming in a different way than any benzo ever caused me to feel, but I needed the max dose (30 mg) up to 3x/day. Xanax, for me, is the best though.

I would like to try Serax, my pdoc is conservative with the benzos as it is and probably wouldn't be willing to go off the beaten path. Alprazolam 0.5mg serves me well though if I need to just chill out.

3 hours ago, mikl_pls said:

I agree with @browri about the BuSpar, but as for @HydroCat's response, targeting serotonin for anxiety is quite normal. Higher dosages of SSRI's are used for anxiety, while lower dosages tend to work better for depression. SNRI's are a whole different animal though, as @browri explained. The higher the dose, normally, the higher the norepinephrine, with the exception of Fetzima, which works the opposite way... It's primarily noradrenergic, and the higher the dose, the higher the serotonergic neurotransmission.

If you need an SNRI, for anxiety, I think Cymbalta would be a better medication, that is in my experience. Pristiq did nothing for anything. Fetzima made me a weepy mess.

Agreed on duloxetine (Cymbalta). Although I would have to counter on desvenlafaxine (Pristiq). I definitely got a good effect from 50mg, and they can dose it to 100mg. They don't make a larger tablet than that though, and it's not usually worth going higher than 50mg for most people anyway. If you needed to go higher than 100mg on desvenlafaxine, then you should probably be on regular venlafaxine ER (Effexor XR) at like 300mg. And it wouldn't be half bad to augment that with a modest dose of mirtazapine.

3 hours ago, mikl_pls said:

Combining an SSRI with an NRI is also a good idea, because you can tweak the dosages of the serotonin and norepinephrine reuptake inhibition individually for your own custom "formula." I take Zoloft + Norpramin (desipramine), a TCA that is probably the most potent and selective NRI on the US market. Zoloft 150 mg + Norpramin 50 mg seems to be my happy spot for now. I've also taken Prozac + Strattera, and that was very good until Strattera went generic, and then all hell broke loose.

Yeah I hear the atomoxetine (Strattera) generics really suck. That being said, my mother-in-law hasn't reported any issues with it.

3 hours ago, mikl_pls said:

I agree with @HydroCat about combining something that modulates GABA in a different way than benzos but still modulates GABA, as they would be synergistic. Neurontin/Lyrica I believe (I could be mistaken) actually increase GABA concentrations in the brain. Lamictal inhibits glutamate release, but does modulate GABA through a different mechanism as aforementioned. Trileptal, as @browri mentioned does wonders for my anxiety. I take 600 mg twice daily, and it wasn't until I got to that dose that it actually really did something for my anxiety. Keppra is also used for anxiety, but depression and suicidality as well as anger, hostility, and irritability (known as the "Keppra rage") can be side effects of Keppra, so start low and go slow if you take it for psychiatric reasons.

Yeah I would think that going with either lamotrigine (Lamictal) or oxcarbazepine (Trileptal) in this case would make the most sense. I know levetiracetam (Keppra) has some evidence of working, but it targets the AMPA receptors more specifically and doesn't have as broad of a stabilizing effect on the glutamate system (then again oxcarbazepine doesn't really either but...)

3 hours ago, mikl_pls said:

Stelazine is an old-school antipsychotic (first generation or typical antipsychotic) that can be used short-term for anxiety in low, low doses, starting at 1 mg 2x/day and up to 2 mg 3x/day. It worked wonders for my anxiety, especially paired with the benzo Serax (oxazepam, a short-acting benzo). Serax is one of the active metabolites of Valium, but is a very clean benzo as it, itself, has no metabolites. I also paired it with Vistaril and that was a magical "triad" of anxiety meds for me. Unfortunately I did gain a good bit of weight, but I think it was because I was on the keto diet for 5 months and suddenly started ingesting a ton of carbs and my body was like "whoa what do I do with all this?" Stelazine itself is not likely increase appetite or weight typically, but it isn't unheard of. In fact, it's less likely to do so than the newer antipsychotics; however, it will increase prolactin more than the modern antipsychotics. I personally didn't develop gynecomastia or galactorrhea or anything like that, but some people do on the typical antipsychotics. Other first-gen antipsychotics that can be used for anxiety are Compazine (also an anti-nausea med) and Trilafon (not as commonly used), all of which synergize the effect of benzos.

I would recommend loxapine (Loxitane) as well for a PRN anxiety med at just 5mg. There's minimal risk at that dose of any sort of movement-related side effects that are associated with typicals. Although I don't seem to recall @mikl_pls ever mentioning having those kinds of issues with trifluoperazine (Stelazine).

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Does CBD interact with my psyc meds though? I read all sorts of things online about it increasing the potency of the meds already in your system? Is this true?

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16 hours ago, Ethansmom said:

Does CBD interact with my psyc meds though? I read all sorts of things online about it increasing the potency of the meds already in your system? Is this true?

There is evidence that CBD inhibits CYP2C9, CYP2C19, and CYP3A4 to a point that actually "registers", but the few pharmacokinetic interaction studies that have been done on CBD combined with other major medications found that the effect CBD had on the other medications that were metabolized by those enzymes wasn't really all that statistically significant, and in some scenarios it can actually be just downright helpful, and I'll explain that further. So we can look at it a bit more scientifically based on your specific medications:

quetiapine (Seroquel) is metabolized by CYP3A4, which means you would have an interaction here. But this could be the first example of a GOOD interaction. You only take 25mg of Seroquel, and you take it at night. That's immediate release, which means it has a pretty short half-life. With CBD on board, you can expect the half-life of Seroquel to get a tad bit longer because CBD makes Seroquel persist in your system longer. If you were on like 600mg of Seroquel, I would say this may be cause for concern. But in this case, CBD helps your body to use that 25mg of Seroquel for a longer period of time. It may make the next-day sedation from Seroquel a bit stronger, but the positive antidepressant effects of that dose persisting longer into the day should have a positive effect. Not to mention CBD is a 5HT1A agonist, which should theoretically potentiate Seroquel's effects

venlafaxine (Effexor XR) is metabolized by CYP2D6 which is NOT appreciably affected by CBD the way that CBD affects 2C9, 2C19, or 3A4. However, there may be some inhibitory effect. This COULD be a problem if you are already a 2D6 poor metabolizer, which is statistically actually quite common. Genetic testing can determine this. If this is the case, your body may be unable to metabolize venlafaxine into O-desmethylvenlafaxine (aka desvenlafaxine (Pristiq)), which is venlafaxine's chief active metabolite. If you switched from 225mg of venlafaxine to 50-100mg of desvenlafaxine, then you would bypass this metabolic process altogether.

clonazepam (Klonopin) is metabolized by CYP3A4. Here's an example of a CBD-drug interaction that I would be curious to look at, and kind of loops around to what @mikl_pls was saying earlier. 2mg of clonazepam is quite a bit. In addition, clonazepam has a very wide-ranging half-life of about 19-60 hours depending on the person and a wide range of variables like age, weight, etc. CBD might make the clonazepam persist even longer. At 2mg, that might cause quite a bit of sedation if CBD is causing the clonazepam to accumulate more readily in your system. You may find after adding CBD that you need to go down on clonazepam because you're tired. Then again, you may not notice any problems at all, and this may in fact help your persistent anxiety issues.

buspirone (Buspar) is also metabolized by CYP3A4. Here's where I might be concerned. If you were taking 60mg of Buspar in divided doses throughout the day, CBD may cause that to persist a bit longer. Additionally, as I said earlier, CBD is a 5HT1A agonist as well just like Buspar. So really, taking Buspar AND CBD is therapeutically duplicative. If I recall correctly from this thread you actually decreased back down from 60mg on the Buspar recently? With CBD, you very well could decrease it even further. For example, based on this interaction, theoretically someone taking 60mg dosed 20mg tid (three times daily) could instead reduce to 30-40mg dosed 15-20mg bid (two times daily). The 5HT1A receptor is something that needs to be properly balanced, and high doses of Buspar and CBD combined may work against each other. It's really hard to say though.

With this in mind, I would say that whatever you do, make sure your pdoc knows you're doing it. My pdoc knows that I smoke cannabis flower (consuming both THC and CBD among others cannabinoids). What he's told me is that if I'm going to use cannabis, try and get either the same strain or a strain with similar effect and chemical makeup, and consume the same amount every day. Don't deviate. Consistency is key, and my pdoc needs to know that there isn't any inconsistency in my cannabis use while he's treating me. CBD would be the same. If you start consume CBD whether by vape or sublingually and you notice any returning anxiety, what you likely need to do is talk with your pdoc about going down on Buspar further. Just be sure to start low and go slow with the CBD until you know how it affects you.

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Thank you so much for your detailed explanation. I just got back from the psydoc and she gave me her blessing. She said that it shouldn’t be a problem adding it to my meds and just to follow the instructions like any other med. 

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18 hours ago, Ethansmom said:

Thank you so much for your detailed explanation. I just got back from the psydoc and she gave me her blessing. She said that it shouldn’t be a problem adding it to my meds and just to follow the instructions like any other med. 

That's great! And your pdoc is right. Respect that CBD. Treat it like another medication and not casually as you would a natural supplement. Find a good routine with how you administer it. What kind of CBD preparation will you be using?

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I have NuLeaf CBD 250mg?? I think I can take it twice a day. She also has me taking 45mg if buspar- taking for one month to see if that helps. I don’t think she knows what to try after that. I mentioned trying gabapentin again, and say she wasn’t sure if we would add that to the mix or delete the buspar. and just add gabapentin? She doesn’t want me on too many things , but I haven’t found the right mix yet. I was a little disappointed in her reaction. 

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55 minutes ago, Ethansmom said:

I have NuLeaf CBD 250mg??

Just checked it out. It looks like it's actually 240mg/5mL. They claim that for 5mL, there are about 100 drops, which means each drop contains ~2.4mg of CBD or around 50mg per mL. Another nice thing about this particular product is that while it doesn't contain THC, it is otherwise a full-spectrum, whole-plant extract containing other cannabinoids and terpenes which are important for therapeutic response. So in regards to product choice, it looks like you made a good decision.

I assume you're putting drops under the tongue (sublingually)? That makes for the most optimal bioavailability. If she gave you the go-ahead, then follow the instructions they provide and experiment a little, but not too much. Always make slight changes. I'm thinking start out with 2-4 drops under the tongue and see how you feel throughout the day and maybe do another 2-4 around bedtime.

I actually wrote a blog on here about cannabidiol and using it for mood stabilizing properties in bipolar disorder, feel free to check it out on my profile and you can basically read a day-by-day of how the experience went for me. Couple things that I learned though was that there is definitely a too much with CBD. Like use a ton of it, and it is possible to feel slightly stoned on CBD. Generally very high doses are reserved for epilepsy because they don't work AS well for anxiety. low to moderate doses are better for mood but higher doses could be used for mood stabilization. The other thing I learned is that I preferred doing it in sessions, where I would dose myself to 10-20mg in the morning and maybe 30-40mg at night (I was vaping, not sublingually). But vaping throughout the day just made me feel kinda funny. CBD has a long half-life. So a morning dose could THEORETICALLY last all day but twice daily dosing seems to work better for CBD with a higher dose in the evening to help  with sleep.

55 minutes ago, Ethansmom said:

I think I can take it twice a day. She also has me taking 45mg if buspar- taking for one month to see if that helps. I don’t think she knows what to try after that. I mentioned trying gabapentin again, and say she wasn’t sure if we would add that to the mix or delete the buspar. and just add gabapentin? She doesn’t want me on too many things , but I haven’t found the right mix yet. I was a little disappointed in her reaction. 

If you're going to continue to use CBD, if it were me and my pdoc was okay with it, I would slowly work my way off Buspar and replace it with the CBD and add in gabapentin at a low dose. Titrate up as needed keeping in mind that CBD may be pulling some of the weight at that point and you may not need as much gabapentin as you did before.

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You have great ideas! I appreciate it! I took CBD oil this evening and felt awesome.  I haven’t tried taking it during the day, but I think I’ll give it a whirl tomorrow. I’ll keep you posted. The bottle says 15 drops. Mind you the drops come out super slow. I Felt nice and fuzzy after that. If you suggest 4 drops, I’ll try that during the day. 

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