Need advice antidepressants while also taking Opioids

[ColoradoBoy90]

(PLEASE MOVE TO OTHER DRUGS AS I GET AN ERROR TRYING TO POST THERE)

I need advice here big time!! Here's my problem in short:
I take Hydro 6X daily and oxy 2X daily. I have found that everyday I am feel EXTREMELY depressed without taking another dosage again (wears off after only 1 hour due to tolerance and being on pain meds for years. Sometimes only 10-20 mins do I "feel good".
Problem is I'm chasing it and cannot stop chasing it because 2 hours without taking any pain meds I feel so horribly mentally I can't even smile my face FORCES itself to frown heavily without my control!! Now I DO NOT
go into withdrawal until 4-6 hours of taking no pain meds --- but because my mood gets so quickly shot I take another pain med every 30 mins to 2 hours (and 2 hours is the longest j go without taking another pill) . BUT IF WASNT FOR THE EXTREME MENTAL DEPRESSION/NO MOTIVATION/NO HOPE/NO ENERGY I could then go 6 hours between dosages!! This would help me a lot in my long term goal of quiting them, and also i'm sure it's MUCH better for my mental health to take a pain pill every 6 hours instead of every 30 mins!! So I thought: maybe vitamins/exercise will help and I won't need a pain pill constantly to even smile or feel somewhat happy. Nope. Tried all vitamins a-z, including l-tryrosine, DPLA, 5HTP, and others. Zero help at all. So I wondered: IF I TOOK ANTIDEPRESSANTS WHILE STILL ON MY PAIN MEDS (I can NOT quit pain meds now must wait 6 months before I get vacation from job so I can take 1 month vacation for the withdrawals). So I need something to help me need to stop taking another pain pill every hour just to even be capable of a smile!

So here's WHAT I REALLY NEED TO KNOW:
if I take antidepressants while currently on these pain meds would it help out at for the
mental feelings I explained above? Now here are 4 antidepressants I can take (doctor said which every one works the best for me, some can be taken together others no).
The choices are:
Effexor ER
Prozac (small dosage of 10mg to 20mg)
Wellbutrin ER/XR or whatever it's called
Mirtazapine (Remeron)

Now do you think these will HELP me?? I thought the Prozac + Wellbutrin combo might work as neither gave me side effects in past (before pain meds). Also I was on addersll for 4 years and burnt out myself so bad it started to cause "reverse effect" and that's when j switched to pain meds. I heard Wellbutrin is good for PAWS for addersll so maybe it can hell while I take pain meds? OR I thought Effexor XR + Remeron as I heard that's a really good combo for severe depression (which I have it's just opiate/opioid induced and also I naturally have had pretty bad depression and OCD since a teen). QUESTION is will they still help me while I continue to take pain Meds on a daily basis? Again I cannot attempt to quit pain meds for 6 months, but I NEED something to get me feeling better mentally or my life will be run into the ground and I WILL lose everything. Please please any advice on if antidepressants if they will will work or help or just makes things worse while on pain meds (again I tried every vitamin even proglumide nothing has helped! It seems I need something stronger like antidepressants not vitamins). Remember: I also do have severe depression which is why I am started opioids.

 

[PotatoMan]

Cannabis Discussion ----> Other Drugs

 

[Larc]

Believe it or not the depression will probably go away when you quit drugs as you are obviously mentally and i assume physically addicted aswell.

Your post suggests that cessation of adderal wasn't fun and caused depression. You in turn started taking opiates to replace your previous addiction to adderal. How much oxy/hydro do you take per day?

I wouldn't start taking an anti depressant until your are actually able to locate the cause of your drepression.

I tried lexapro and after, welbutrin for the same reasons more or less as you are thinking about. For me, it markedly reduced the euphoria from opiates and really just put me on a roller coaster ride.

 

[Larc]

Anti depressants are a very personal thing btw. While they didn't do a damnthing for me, they are an absolute god send for some people. I dont think they will help your current situation.

 

[Hodor]

SNRIs seem to have some effect in pain management, especially since depression tends to further exacerbate chronic pain. Mirtazapine acts as an SNRI as well as a sleep aid, so that's always a good choice.

Keep in mind that some AD's may interact with your opiate metabolism though. Specifically, we've recently had a few posts where people complained about Prozac ruining their Hydro/Oxy buzz, presumably because it specifically prevents your body from processing a portion of the Codeine/Hydrocodone/Oxycodone into the more powerful Morphine/Hydromorphone/Oxymorphone.... on the other hand, the inhibition of other liver enzymes might prevent your Hydro or Oxy from being to converted into less active forms, so any increased pain relief you feel might simply be the result of the opiates being potentiated by having their metabolism slowed down (not trying to give you any ideas though. Yes, I am very much familiar with the thrill of downing a glass of grapefruit juice to get just a few extra minutes of a benzo buzz, but don't... please, just don't).

Oh, and keep in mind that Tramadol and Tapentadol also act as reuptake inhibitors (Tramadol is an SNRI, Tapentadol a NARI), so it is not a good idea to abuse those while on AD's.

 

[ColoradoBoy90]

Believe it or not the depression will probably go away when you quit drugs as you are obviously mentally and i assume physically addicted aswell.

Your post suggests that cessation of adderal wasn't fun and caused depression. You in turn started taking opiates to replace your previous addiction to adderal. How much oxy/hydro do you take per day?

I wouldn't start taking an anti depressant until your are actually able to locate the cause of your drepression.

I tried lexapro and after, welbutrin for the same reasons more or less as you are thinking about. For me, it markedly reduced the euphoria from opiates and really just put me on a roller coaster ride.

Spot on!

For those who don't want to read my entire post, please at least read my summary below because I need all the advice I can get!
Remember: I CANNOT quit my pain meds for 6+ Months due to my job, so quitting isn't an option until I get my 1 month vacation in March next year. UNTIL THEN I need something to help me mentally or my life will fall apart as I have so little motivation/happiness/etc I cannot put it I to words:

summary:

I want to feel Mentally more okay/more motivation/etc. Antidepressants In the past HAVE worked Great for me feeling better mentally BEFORE I was on pain meds though. My only concern is taking pain
Meds + antidepressants maybe would be messing up my brain chemistry a little TOO MUCH.. Now The ONLY way I can get that feeling now is taking a pain pill EVERY HOUR! My THEORY IS THIS: since I don't go into withdrawal until the six hour to seven hour mark, what if I take say Effexor ER in morning (OR Wellbutrin XR, whichever would help me better I don't know. ALL I know is because of the pain meds I'm now lacking in serotonin, noreoprhrine or however it's spelled (NE) and also lacking in dopamine a lot. I'm pretty sure serotonin and dopamine for me are the lowest, NE still is too but not as badly.) and then take Remeron at bed, along with vitamins and exercise (while STILL taking my pain meds it's just IF the antidepressants work then I will only have to take a pill every 6 hours instead of every 1 hour!! This will greatly help in me quiting opioids for good! As I only take a pain pill every 1-2 hours because it's the only way to mentally feel okay. I'm hoping antidepressants can fill that void and make me feel at least okay/somewhat better mentally, therefore still taking my pain meds but cutting down on them a lot and taking 1 pain pill every 6 hours vs every 1-2 hours.

Note: Prozac/Effexor ER and Remeron are the only AD meds I can tolerate the other ones make me sick. LASTLY: I don't take Tramadol but it DOES work for me, I had 45 tablets that I took on and off, but when on Tramadol I could go UP TO 8+ hours without an hydro or Roxi before W/D came in!!! At one point I actually quit opiates entirely for 7 days and took ONLY Tramadol!! And only 3-4 of the 50mg tablets per day. Too bad I messed up and went back on hydros/Oxy.
So WHAT IF INSTEAD I took: Tramadol only 50mg X4 per day and quit hydro and oxy entirely (after Tampering down on the hydro and oxy and last time it took me only
2 weeks no problem) and then took Remeron at night?? This to me seems like the best option, as I'd be Opoiod free (mostly as
Tramadol is weak on mu receptors). Or can I take Tramadol and Wellbutrin together? And if not enough depression relief then I can add on remeron at night? Any ideas/thoughts?!

-------------------------------------------------------


Now here's the full story if anyone cares to know:

Yup, Lark, you are right, once adderall stop working and I reached total burnout I turned to Hydro first. Why pain meds? Because I was depressed, OCD, and I wanted to numb the pain and stop caring. But then felt the buzz it gave me and was like whoa! I feel totally alive, talkative, confident, happy -- my depression was gone from the pain meds. So I kept taking them and it went from there, and after about a year of constant use of the pain meds (I was at around 40mg Roxis per day) then suddenly all the good feelings went away. The Roxis used to give me energy, now when taking them I would get EXTREME fatigue and no good feelings. Now I just kept taking them to avoid W/D and just hope for a short buzz which sometimes still happened.

Now fast forward 3+ years and now it's about 50mg hydro per day +30mg oxy slow release per day (15mg tablets slow release X2 per day). I started to take DLPA and on day 1 of DLPA I got a major buzz I haven't had in a couple years! Day 2 also same thing. Then day 3 on DLPA it didn't help boost it anymore at all. Which is WEIRD because how did the DLPA work so fast? I read countless topics that "give it 3-4 weeks to build up before you feel effects". Yet for me it was instant same day, and only lasted 2 days. My guess is I was so depleted on dopamine/endorphins that my body saw the DLPA and desperately ate it up ASAP.
Then I tried proglumide (spelling?) which showed a lot of promise for tolerance. When taking it I was able to reduce my dosage by 10mg hydro a day, but that didn't last as I kept wanting to feel mentally better so I started to instead cut the pills in half and take less more often so I would have the buzz prolonged. The proglumide didn't do anything to help bring back a buzz or reverse tolerance at all (which is kinda a good thing as that would have got me more addicted). The dxm idea did nothing either tried to take 30mg 45 mins to 2 hours before dosage and nothing. I felt a weird buzz from 30mg of dxm which I didn't like but it did nothing for tolerance.

So now here I am: I was depressed BEFORE adderall and hydro/roxis. I had no confidence, motivation was gone/etc. Something worth noting that may be very important: WHEN I FIRST TOOK PROZAC (this was before ever doing any other drugs like addersll and Roxis though): IT BOOSTED MY MOOD LIKE CRAZY IN THE FIRST FEW DAYS ONLY! I always figured I had extreme serotonin depletion so maybe that's why it worked so well and so fast. I felt so happy I actually even was singing to myself songs out loud and wanted to talk to all my friends again, etc!! I don't remember if that feeling stayed or not, I'm guessing it died down once my serotonin leveled out, as I wouldn't have went to addersll if Prozac had me feeling that way all the time. ALSO: I took Wellbutrin before any of this, and 1 hour after my first dosage I got a rush, I was full of energy and talkative even to strangers while out shopping! It only lasted a couple hours or so then went away, never to return. That CLUE to me means I probably also was HEAVILY depleted in dopamine also, which is why Wellbutrin gave me such a boost on day 1..

In summary: I have taken every antidepressant there is, and lexapro and Zoloft make me sick. My doctor, knowing I've been on all modern antidepressants and taken all benzos and all that, left the choice TO ME. He said: since you have tried them all, whichever one provides you the most relief from depression then we'll keep you on that one. Prozac I have no side effects besides it does seem to delay the "kick in" time of the pain meds as normally they kick in within 20-30 mins but while on Prozac it's an hour + and it feels weaker. My other option is Effexor ER. I had no side effects from it really, and don't recall it interfering with my pain meds. Remeron I only took it 1 time because it knocked me out to sleep and only side effect was I woke up in middle of night hungry, but dizzy from it's sedating effects. Now that I have CNS depressants 24/7 I doubt It would knock me that much, but I also have trouble sleeping so maybe Remeron is worth a try...

 

[SKR]

Hi ColoradoBoy.......I had pretty much the same issue. The Anti-depressant Sertraline (Zoloft) has been a miracle drug for me. Cutting down on oxy has been so much easier because I don't get anxiety anymore and that means I'm not reaching for more oxycodone to try and deal with the panic/depression and anxiety.

It corrected whatever chemical imbalance I had and has allowed me to function properly again. It also seems to have increased my pain threshold considerably.

I didn't see mention of Sertraline in your post so I'm not sure how your Doctor views the drug but it has been the best decision I have made in a long time.

Hope this helps somewhat mate.

 

[ColoradoBoy90]

Thanks man! I'm glad to hear it worked for you, it gives me hope! Also a side note: does anyone know if Remeron increases dopamine or acts on it? Or does on Wellbutrin only work on dopamine? Because I need something to work on both serotonin and dopamine (even NE too) but if I take Effexor it doesn't work on dopamine until jigj dosages off 300mg+..

 

[SKR]

Mate it truly changed my life, in the sense it gave me back to myself. As my wife says "I've got my husband back again!"
I used to have a very negative view towards anti-depressants and even the folks who take them, I still think it is best to treat depression and anxiety at the cause if there is an obvious one without throwing drugs at the issue but I had run out of ways to treat myself and needed a leg up - and it worked immediately for me. I'm still shocked at it's effectiveness with no obvious negative side effects - I know that I am somewhat detached from my emotions but I needed to stop crying at the drop of a hat, and needed to be able to handle the normal stresses and pressures that my job and life throw at me....I couldn't cry to save myself now which for the most part is great but there are moments when such an emotional display is healthy and helpful to me (positively motivated tears rather than negative)....but I will keep working towards being drug free again one day, that certainly is my goal, and with my anxiety under control I can reduce my oxy doses without falling apart. Good luck ColoradoBoy.

 

[silverwheel]

Thanks man! I'm glad to hear it worked for you, it gives me hope! Also a side note: does anyone know if Remeron increases dopamine or acts on it? Or does on Wellbutrin only work on dopamine? Because I need something to work on both serotonin and dopamine (even NE too) but if I take Effexor it doesn't work on dopamine until jigj dosages off 300mg+..

Remeron does increase dopamine release as well as work on serotonin. I have personally had very good experience with Remeron helping the quality of my sleep.

 

[ColoradoBoy90]

Thanks SKR and also Silver for the info. But amount the Remeron -- if I take it at night will it still increase and help my dopamine during the day (for motivation and energy/etc)?

I'm thinking of Remeron at night for mood and to bell me sleep -- but also a morning antidepressant because I don't think Remeron is enough as I'm EXTREMELY low in both serotonin and dopamine (and probably NE too) and I know this because it take 5-HTP I feel better within 2 hours but it doesn't work as well or strong as actual serotonin reuptake inhibitors. Also if I take l-tyrosine I can feel it too, but it doesn't last and isn't strong enough.
So those are signs I'm low on them + I have all the symptoms of it.

NOW: any of you guys (or anyone else reading this please throw in your advice or 2 cents) have an idea for this:

Should I take:
(Number 2 seems like the best idea but I don't know if Tramadol is a "true" antidepressant and balances out chemicals in your brain like other antidepressants do).

1.) Wellbutrin + either: Effexor XR OR Remeron. I don't know if the Wellbutrin will interfere with either of the meds and cause too much serotonin reuptake or too much NE up take. I REALLY do like the idea of taking Wellbutrin though as I know it works on NE and dopamine which I really need to be balanced out, but I also need a med to balance out my serotonin... I would do Prozac but it badly messes with my pain meds. Lexapro make me sick, and all the generic Zolofts made me sick but brand name wasn't as bad but cannot afford brand name so can't do that. Even old Brand name Prozac is insanely expensive. But Effexor XR is know for its bad withdrawals so I'm weary of Effexor XR...


2.) Tramadol 50mg X 4 per day and cut out the hydros and keep taking the oxy to avoid W/D? I've done it before and was fine Tramadol helps the WD a lot for me (and Tramadol Is suppose to be an antideperrssnt too working on serotonin and NE). But will Tramadol work as a long term antidepressant or no? PLUS possibly Remeron at night to work on my dopamine... OR ALSO TAKE WELLBUTRIN XR ONCE PER DAY so j get something to balance out my dopamine? Personally I think this would work the best for me but I don't know if Tramadol works as a "true" antidepressant and bells to reuptake and BALANCE serotonin and NE or if it just releases it for a short time.. Anyone know?

2.) Effexor XR (low dosage, I won't to up to 300mg that's too much and unfortunately it takes 300mg+ for Effexor to work on dopamine) so probably would be 75mg of Effexor which would just be working on serotonin and NE. Plus I may take Remeron at night if needed.

 

[Nuli]

I take Lexapro 20mg daily and I don't think it does anything at all for opiate related depression. When I withdraw, I still get depressed as fk and I have gone through withdraw on Lexapro and off of it. I believe its because opiates work more with dopamine, as opposed to Lexapro which is an SSRI and only acts on serotonin. I honestly don't believe you will get any relief from an SSRI or even SNRI. I would try to get the doctor to do this, first being the best option.

1. Tell your doctor that you aren't getting the same relief from the hydrocodone as you were before and it is starting to effect your work ability and well being. If these are the Hydros with Tyenol in them, tell him you recently read a news article on daily Tylenol consumption and you are having some pain near your liver after you take your pills.
2. Discuss Zohydro with him which is ER hydrocodone dosed all the way to 50mg per pill and has NO Tylenol or other harmful fillers. Def don't straight up and ask for it, after doing number 1, I would say something along the lines, "You my golfing buddy was having a similar situation with his liver, and it turned out because of the norcos he was taking. Now he takes something call zhydro or zeebrahydro, something like that". NEVER say the real name, especially on such a new drug.
3. If 1 and 2 don't work your best bet is getting on Tramadol or wellbutrin which works on dopamine instead of serotonin and I've hear it helping people during the PAWS phase of their opiate withdraw. I would give these a try before jumping on an SSRI/SNRI, as both have a very high rate of sexual side effects( I get them myself), but wellbutrin actually helps in that department and has a very low side effect profile.

 

[Kittycat5]

Tramadol primarily acts as an inhibitor of the reuptake of serotonin and norepinephrine, effectively allowing the neurotransmitters to be available at their sight of action longer. It does have some serotonin releasing properties but do not think it has much to do with its antidepressant effects. I am not sure how it compares to the traditional antidepressants in terms of binding affinties, potency etc. but it is doubtful you will build tolerance to these effects anymore than antidepressants or as you would with opiates.

Can I ask why you think you are deficient on NE, dopamine and serotonin? It is not known to be true that decrease levels necessarily correlates to the symptomatology of depression and the whole chemical imbalance thing is no longer really respected to be true.

 

[Snake_Eyes]

SNRIs seem to have some effect in pain management, especially since depression tends to further exacerbate chronic pain. Mirtazapine acts as an SNRI as well as a sleep aid, so that's always a good choice.

Keep in mind that some AD's may interact with your opiate metabolism though. Specifically, we've recently had a few posts where people complained about Prozac ruining their Hydro/Oxy buzz, presumably because it specifically prevents your body from processing a portion of the Codeine/Hydrocodone/Oxycodone into the more powerful Morphine/Hydromorphone/Oxymorphone.... on the other hand, the inhibition of other liver enzymes might prevent your Hydro or Oxy from being to converted into less active forms, so any increased pain relief you feel might simply be the result of the opiates being potentiated by having their metabolism slowed down (not trying to give you any ideas though. Yes, I am very much familiar with the thrill of downing a glass of grapefruit juice to get just a few extra minutes of a benzo buzz, but don't... please, just don't).

Oh, and keep in mind that Tramadol and Tapentadol also act as reuptake inhibitors (Tramadol is an SNRI, Tapentadol a NARI), so it is not a good idea to abuse those while on AD's.

Mirtazapine isn't and SNRI or SSRI it's an tetracyclic.

 

[ColoradoBoy90]

Tramadol primarily acts as an inhibitor of the reuptake of serotonin and norepinephrine, effectively allowing the neurotransmitters to be available at their sight of action longer. It does have some serotonin releasing properties but do not think it has much to do with its antidepressant effects. I am not sure how it compares to the traditional antidepressants in terms of binding affinties, potency etc. but it is doubtful you will build tolerance to these effects anymore than antidepressants or as you would with opiates.

Can I ask why you think you are deficient on NE, dopamine and serotonin? It is not known to be true that decrease levels necessarily correlates to the symptomatology of depression and the whole chemical imbalance thing is no longer really respected to be true.

Thanks Nuli I may give that a try.

And that's good to know about Tramadol, and while we aren't certain how it's affinity, etc is vs say Effexor which works on the two same chemicals.

So since Tramadol is kinda like an SNRI, that means I could take Wellbutrin + Tramadol right? That way it hits all three.

And I think I'm low on all three (serotonin for certain and dopamine seems certain too) because if I take 5HTP I get mild relief, and when I took Prozac for the first time I went from shy/depressed/etc so suddenly feeling great and happy, even enough to actually sing out loud! It also reduced my OCD quite a bit, and increased my confidence A LOT and I no longer was a shy person at all. So that's why I'm pretty postive I'm lacking in serotonin after taking adderall/benzos/Cigarettes/hydro/oxy for years I can feel they burnt my out.

I cannot even smile anymore that's how burnt out I am, unless I take a pain pill OR like 2G of DLPA or L-Tryosine then sometimes I can slightly smile, and since L-Tryosine is for dopamine production that fact I can feel it work means I'm likely lacking in it. Also, years ago before I took all these things I was on Wellbutrin and after the first dosage roughly 2 hours later I got a major rush of energy, uplifting mood, everything I did felt pleasurable, I was talkative, etc. I talked to a few others who where depressed and they had the same reaction, and we figured it's because our dopamine was so low that when taking the Wellbutrin (or L-tryrosine) that we felt the effects so strong because even a tiny dopamine boost to us was noticeable. A person with normal dopamine levels I don't think would have such reactions.

 

[Kittycat5]

I should add I did not want to trivialize how you are feeling. Just was curious as why you thought this without professional investigation and that it is not entirely known fully the cause of depression.

And I am sure someone knows how tramadol compares to antidepressants, just I am not sure.

Wellbutrin also may act on NE and has been associated in rare case reports of Serotonin Syndrome together with other agents. It probably is through some metabolic pathways though, not because it inhibits reuptake or causes release of serotonin. Therapeutic doses of tramadol and a single antidepressant are usually ok though.

 

[dez79]

Night time mirtazapine day time codiene n oxazepam this works great for me n I have GAD n chronic knee pain

 

[Hodor]

Mirtazapine isn't and SNRI or SSRI it's an tetracyclic.

Whoops, I just looked it up, you're right - I'd thought Tetracyclics shared the Tricyclics' mechanism of action (i.e. Serotonin-Noradrenaline Reuptake Inhibition + Histamine antagonism), but it turns out that NaSSA's (Noradrenergic and Specific Serotonergic Antidepressants, the alternative term for Tetracyclics based on their mechanism of action) do indeed exert their effects on neurotransmitter levels by antagonizing inhibitory receptors rather than blocking neurotransmitter reuptake.

So thanks for the correction

 

[Snake_Eyes]

No problem other than tramadol mirtazapine has been the only antidepressant I've been on. It's fantastic for sleep and pretty decent for anxiety. I had been on it for a few months before I got into opiates so I know it doesn't seem to negatively affect them.

 

[ColoradoBoy90]

No problem other than tramadol mirtazapine has been the only antidepressant I've been on. It's fantastic for sleep and pretty decent for anxiety. I had been on it for a few months before I got into opiates so I know it doesn't seem to negatively affect them.

So you think the mirtazapine is a good idea but not the Tramadol? Why is the Tramadol a bad idea? I want to get OFF Hydros and oxy, and Tramadol should be able to help me get off them + work as an antidepressant on serotonin and NE -- which my doctor thinks I need and am low in.
As My doctor has diagnosed me with depression due to chemical imbalance and once I told him how I reacted to the Prozac and 5HTP and l-tryrosine and Wellbutrin that just confirmed to him more I have a chemical
Inbalance.

My doctor has had me on all these meds and says whichever one seemed to work best for you is what I want you on, I don't want to have to go through all the different ones again and you know better then anyone which made you feel the most relief. Now I just need to think of some antidepressant that works on both serotonin and dopamine (Working on NE I'm sure would be a plus as I have zero energy and it's so hard to get out of bed. Remeron seems to act on all 3, but from what I gather it acts in a weird unknown way and often times needs an SSRI or SNRI if serotonin is believed to be low)
and ALSO what the best antidepressant would be to take that will NOT MESS or interfere with my current hydro/oxy pain meds not yet, I need to wait until I have vacation off work before I get off them. BUT I need to have mental relief soon, because I cannot remain this super depressed needing a hydro pill every 1-2 hours just so I can not feel mentally depressed and unable to feel any happiness, unless I take a hydro constantly. So while I already have depression to begin with, I now also am going through OPIOID INDUCDED CHEMICAL INBALANCE to make matters worse -- which I'm 100% positive is the case and so does my doctor. I know at least I could probably cut back on some of the hydro/oxy if taking Tramadol which is always a plus.

So the ball is in my court on what to take, as on the meds he said I could take are either Tramadol/Prozac/Effexor ER during the day and then if needed and I'm not feeling better then also add Remeron at night.