18.1 How We Should Be Practicing Psychiatry with Cara Hoepner, PMHNP

[00:00:00] So, welcome to the podcast. Today, I have Cara Hoepner. I bet your patients might call you Hopener.

[00:00:09] They call me all kinds of things.

[00:00:13] So, first off, I want to say that I don't know a whole lot about our next guest, Cara Hoepner, who is an RN, a psychiatric mental health nurse practitioner, or a PMHNP.

[00:00:25] We are both actually on an email chain with essentially some of the world's most influential, intelligent, best critically thinking, and psychiatric professionals and psychopharmacologists.

[00:00:41] And one of the big reasons why I asked you on the podcast is because I've seen some of your very detailed and very nuanced responses to some of the clinical questions that get posed on there.

[00:00:54] That indicates to me that, you know, you have some of the qualities of a really good psychiatric practitioner.

[00:01:01] You individualize treatment.

[00:01:04] You critically think about each patient and each case in front of you.

[00:01:08] You meet people where they're at in terms of your treatment recommendations.

[00:01:12] It is not a, you know, like a historically maternalistic or paternalistic approach.

[00:01:19] You're curious, you're inquisitive about people and their problems.

[00:01:23] And then maybe the most importantly, you don't just focus on treating symptoms.

[00:01:29] You really want to get to the root cause of the patient's distress, which may not always be possible to get there.

[00:01:39] But trying to understand the root cause is so important with what we do.

[00:01:43] You don't seem to see psych patients as any different than anybody else.

[00:01:48] And it seems like you recognize that there's a lot of unknown and a lot of gray area with what we do.

[00:01:54] And so when the company that I was working for refused to fill a prescription for Xanax in a patient in florid Xanax withdrawal,

[00:02:03] I reached out to the email group to get their opinions on something that historically is pretty decently recognized phenomenon.

[00:02:12] And if you understand psychopharmacology of benzodiazepines, then you know that alprazolam is a unique chemical structure with unique properties.

[00:02:22] And so you sent a very kind and supportive message encouraging me to find my way into private practice and away from corporate run health care

[00:02:33] so that I can make the treatment decisions that I see fit for my patients without that undue influence from a non-clinical administrator,

[00:02:42] administrators within one of these companies.

[00:02:45] So somebody get this guy some help.

[00:02:58] Disclaimer. This podcast is for informational purposes only.

[00:03:00] The information provided in this podcast and related materials are meant only to educate.

[00:03:03] This information is not intended as a substitute for professional medical advice.

[00:03:05] While I am a medical doctor and many of my guests have extensive medical training and experience,

[00:03:09] nothing stated in this podcast nor materials related to this podcast, including recommended websites, texts, graphics, images,

[00:03:13] or any other materials should be treated as a substitute for professional medical or psychological advice, diagnosis, or treatment.

[00:03:18] All listeners should consult with a medical professional, licensed mental health provider,

[00:03:21] or other health care provider if seeking medical advice, diagnosis, or treatment.

[00:03:24] I thank you for that.

[00:03:26] And I thank you for coming on the program here with me.

[00:03:28] I'm excited to hear about your professional journey and the philosophy and how you practice psychiatry and medicine.

[00:03:36] But before we get into all that, can we do a few rapid fire questions about Kara, the person?

[00:03:42] Sure.

[00:03:44] Awesome.

[00:03:44] So where were you born and raised?

[00:03:46] I was born in a little town called Los Alamitos, California.

[00:03:51] So I grew up in this ideal situation in the 1970s where you could play outdoors until 10 p.m.

[00:03:57] You knew all your neighbors for blocks around, ran around on your bikes.

[00:04:00] There were like no, there was no fear, no restrictions, no media, no, I mean, your neighbors didn't call.

[00:04:07] They just knocked on your door.

[00:04:09] And it was a really great way to grow up.

[00:04:11] Yeah.

[00:04:11] And growing up in that time period where you didn't have all this media, you didn't carry a cell phone around.

[00:04:20] It's just interesting that you mentioned that because my friends and I find ourselves talking about the fact that we really straddled that line generationally where we grew up and we didn't have the cell phones.

[00:04:33] And we went and played outside.

[00:04:35] But then right as we were kind of hitting adolescence and into adulthood is right when the iPhone came out initially and kind of changed the game with that.

[00:04:46] It was really cool as a young person.

[00:04:49] But as I get older, it becomes, I guess, less and less cool or, you know, I recognize the negative impact of really essentially all of this massive overload of information that we are subjecting ourselves to nowadays.

[00:05:07] So if we are.

[00:05:09] Yeah.

[00:05:09] Yes.

[00:05:10] Yes.

[00:05:11] I haven't had a television in 30 years.

[00:05:13] I have friends that haven't.

[00:05:14] What do you like to do when you need to get away from work?

[00:05:19] I travel constantly.

[00:05:21] Yeah.

[00:05:21] Where have you been lately?

[00:05:23] I live in Colorado and my business is in California.

[00:05:27] So I go back to San Francisco often to see patients in person.

[00:05:31] When I'm there, I'll probably see 10 friends on each trip.

[00:05:34] So I go and I see all my friends and just run around down there.

[00:05:37] This fall, I'm going to Texas, Boston, and Arizona.

[00:05:43] I'm going to Arizona next week.

[00:05:45] I don't plan where I'm going.

[00:05:47] It, you know, friends and meetings and all kinds of things just take me places.

[00:05:54] Nice.

[00:05:54] Where are you at in Denver?

[00:05:56] I'm actually in Colorado.

[00:05:58] I mean, in Boulder.

[00:05:59] I am moving back to San Francisco.

[00:06:01] This amount of travel is killing me.

[00:06:03] Yeah.

[00:06:04] So I am moving back.

[00:06:05] Yeah.

[00:06:05] So you seem kind of like a free spirit in terms of, you know, like you said, growing

[00:06:13] up and having the flexibility.

[00:06:17] And it sounds like that extends into your adult life now, just being flexible with what's

[00:06:21] going to happen when you go on a trip here or a trip there.

[00:06:24] So we got a little bit more background about Kara, but tell us a little bit about your professional

[00:06:30] journey.

[00:06:31] I understand you've had multiple careers prior to psychiatry.

[00:06:35] I'm curious to hear about those and how they influence the way that you practice psychiatry

[00:06:41] and what, what experiences kind of led you to pursuing.

[00:06:45] I think you said a third career as a psychiatric practitioner.

[00:06:49] It was my third career.

[00:06:51] I worked in film, television and live theater for 15 years.

[00:06:55] So, and I designed scenery.

[00:06:58] And I loved the live theater.

[00:07:00] I probably did 200 shows before I stopped.

[00:07:02] It just wasn't workable financially.

[00:07:05] I didn't love the film industry.

[00:07:08] It was okay.

[00:07:09] It was a way to make a living with my skillset.

[00:07:11] I kind of did it and felt dead for many years.

[00:07:14] And when there was a really large threatened strike in 1999, remember when Survivor came

[00:07:21] out?

[00:07:22] Yeah.

[00:07:22] Oh yeah.

[00:07:23] Survivor didn't require actors or writers and that's who was going on strike.

[00:07:28] And then all our work went to Canada and businesses that have been open for a hundred years closed.

[00:07:34] My friends lost their homes.

[00:07:36] It was, and I, in this, you know, we have a strike of some magnitude in Hollywood, at least

[00:07:42] every five years.

[00:07:44] And I'm sick of it.

[00:07:45] And I also know that it's a, it's, it's not a good business for people who are older.

[00:07:51] You have to be absolutely a list to work into your fifties and sixties and seventies.

[00:07:56] And I didn't see a future for myself in it.

[00:07:59] And as a transition, I practiced architecture.

[00:08:01] So I did that for four years.

[00:08:03] I designed homes, remodels all over Southern California.

[00:08:08] Did that for a while while I was trying to decide what to do next.

[00:08:16] It's how did I get into psychiatry?

[00:08:18] I mean, I actually, I don't think the first two careers, uh, uh, bear on what I do in psychiatry

[00:08:24] much at all, except that, um, people ask me if I feel like what I do now is less creative.

[00:08:30] And I actually don't feel that at all.

[00:08:32] I feel like it's more creative.

[00:08:33] I have more tools and less number of tools.

[00:08:37] And I feel like when I interview someone and I'm looking for the circuitry of what's going

[00:08:43] on with them.

[00:08:44] And I'm looking, I'm looking for, um, uh, a constellation of symptoms and how those draw

[00:08:51] together and how they, how they like naturally will form groupings.

[00:08:55] It's like, it's like entropy happens.

[00:08:57] And then suddenly everything coalesces and crystallizes for you in your mind.

[00:09:00] And I can be interviewing on eight or 10 different topics at the same time, formulating a multidimensional

[00:09:08] whole person treatment.

[00:09:09] I can be doing all of this in my mind all at once.

[00:09:12] Um, and it, it, it feels like sculpting.

[00:09:16] It feels like it's, it doesn't feel any different than making art though.

[00:09:22] I'm curious, um, something that I've noticed in, in terms of my kind of, I guess, clinical

[00:09:28] acumen, uh, over the years is obviously, you know, what we do requires a lot of conscious,

[00:09:36] you know, critical thought.

[00:09:37] Um, but the other piece that I've found that I've gotten a lot better at is when I allow

[00:09:43] myself to consciously go away from thinking about a patient's case and almost kind of let

[00:09:48] my subconscious, let my mind kind of toil it over kind of behind the veil or behind the

[00:09:53] curtain and then coming back to it.

[00:09:56] And it seems like the, the ideas or the pattern recognition is it's popping up more naturally,

[00:10:04] uh, the more patients that I see.

[00:10:07] And, and I'm, I'm getting better at being able to put the words to, uh, the symptoms and the

[00:10:13] patterns that I am recognizing.

[00:10:15] Do you notice that in your, cause again, I mean, just, I'm, I'm thinking about you as,

[00:10:20] uh, somebody who is, has this psychological flexibility and, you know, like when, when we

[00:10:26] can't figure out a problem and it seems like we're banging our heads against a brick wall,

[00:10:30] trying to think about it consciously.

[00:10:32] Obviously I've just found that going away from it for a little bit can really, you know, like, uh, um, open the floodgates of, of, of thought and allow that subconscious, conscious, uh, communication to exist and help me get closer to the answer.

[00:10:48] Is that, is that all a little bit too out there or?

[00:10:52] No, I don't, I don't think it's a little out there.

[00:10:53] It just doesn't happen for me.

[00:10:55] Everything for me does happen to happen in the moment.

[00:10:57] I occasionally change my mind later based on a conversation with a patient, but not usually based on my own thought.

[00:11:03] Like when I'm finishing a chart after an intake and I'm putting all the things together, often the stuff that will pop up for me that I didn't get before are questions.

[00:11:12] There are things I want to ask or the things I want to do.

[00:11:15] It's like, Oh, I want to test this.

[00:11:16] I want to, I want to do, you know, like all these testing and like various things that I haven't thought of in the moment.

[00:11:21] And so I'm making a big list of to-dos for the next visit with that person to address that with them and ask them, you know,

[00:11:27] are you amenable to X?

[00:11:29] Like what, what are you attracted to?

[00:11:30] Which direction would you like to go?

[00:11:32] But in terms of my conceptualization of the case, I can think part of it is I don't do psychotherapy and I'm not particularly psychodynamically oriented.

[00:11:43] I'm a highly technical person.

[00:11:45] So when I'm thinking about a case later on, it's usually like really technical aspects of it.

[00:11:50] Do you interview the patient and then later do your documentation?

[00:11:54] I'm doing a hundred percent of it in real time.

[00:11:57] I do finishing touches at the end.

[00:11:59] Right, right.

[00:12:00] And that's something that I noticed too, is when you were describing that is I will see the patient.

[00:12:04] I'm poor with my time management with patients.

[00:12:07] I don't give myself enough time to document after the encounter.

[00:12:11] But I think that also allows me to have a little bit of more kind of free-flowing subconscious thought when I'm working on their assessment.

[00:12:19] Just like you described, questions will pop up like, oh, I should ask that.

[00:12:24] Now I want to know this.

[00:12:25] Or this could be a potential treatment option or recommendation.

[00:12:30] And so I find that kind of solidifying a lot in that time space between seeing the person and documenting.

[00:12:37] And then other times I'll be laying in bed trying to go to sleep and something will pop up from like a patient encounter.

[00:12:43] And it's like, oh, you forgot to ask this thing.

[00:12:46] This could be really important to their care.

[00:12:48] Yeah, I don't have time limits.

[00:12:51] Yeah.

[00:12:52] I think the longest interview, initial interview I did was seven hours.

[00:12:56] Oh, wow.

[00:12:57] Yeah, I don't do that in one sitting.

[00:12:58] My initial is an hour and a half because it's hard to find more than that on both of our calendars, right?

[00:13:04] And also people's attention span.

[00:13:07] So I could probably do two hours.

[00:13:08] But I'll do that.

[00:13:09] And then I will continue into following sessions still interviewing.

[00:13:13] Yeah, the guy that was seven hours, he's got autism and is extremely precise as a result.

[00:13:18] He also has OCD and he has just right OCD.

[00:13:21] And it has to feel just right to him.

[00:13:22] If it doesn't, he's going to write you a four-page paper about it until it feels right.

[00:13:27] And then he also has ADHD with slow processing speed.

[00:13:31] He's got his cognitive tempo.

[00:13:33] So all of those things together just made it last a very long time.

[00:13:38] And that wasn't a problem for either of us.

[00:13:40] And I just kept checking in with him going, is this okay?

[00:13:43] And he's like, yeah.

[00:13:44] So yeah.

[00:13:45] One of the little nuances that I've really noticed with some of my OCD patients is when I will ask,

[00:13:52] and obviously there are different forms or manifest stations or phenotypes of what I see with OCD.

[00:13:58] But one of the ones is it's in their speech.

[00:14:01] It is like you just described, I ask a question and I can see them turning internally, trying to find the exact right way to answer the question.

[00:14:12] They don't want to answer it incorrectly or imprecisely.

[00:14:15] So there can be that long delay.

[00:14:17] And for me now, it's one of those patterns that I'm like, hmm, this, you know, within just a few questions of asking the person, I'm already like, is this what I'm, what condition?

[00:14:29] Or again, you and I have talked about diagnoses being kind of secondary to what we do.

[00:14:34] But is this the cluster that I am now organizing this patient into?

[00:14:38] I notice a lot of that vocal hesitation, not necessarily because they are not able to process that information.

[00:14:45] They're just trying to find the perfect way to say what they want to say.

[00:14:49] Right.

[00:14:51] Now, I want to point out, Kara, you are not following the guidelines, the official psychiatric guidelines,

[00:14:58] which state that, you know, from anything from generalized anxiety, which I don't believe is its own condition.

[00:15:06] It is a symptom of so many other conditions.

[00:15:09] It has poor validity.

[00:15:10] To depression, whether you want to call it MDD or bipolar depression or to OCD.

[00:15:17] You know, the guidelines say that you use SSRIs for everything.

[00:15:20] I can't believe you're not following the, obviously I'm being sarcastic, but tell me, tell my listeners why you don't use SSRIs.

[00:15:28] Because this is probably one of the porous understanding that the general public has and has really fallen into this media.

[00:15:36] And there's a lot of research out there that talks about how effective SSRIs are.

[00:15:42] And a lot of it can be manipulated.

[00:15:44] And the kind of bad evidence or bad research about SSRIs is kind of seems to be hidden.

[00:15:52] Tell me more about why you don't use those SSRIs very often.

[00:15:55] The original clinical trial data is not hard to access.

[00:15:58] The FDA has it and anyone can get it.

[00:16:00] And there are people who publish on this.

[00:16:02] And David Healy,

[00:16:07] Healy's been on here before.

[00:16:08] Healy's amazing.

[00:16:09] He is.

[00:16:10] I love him.

[00:16:11] First of all, something I have to say about guidelines is their expert opinion.

[00:16:15] And those experts are no different than you and me.

[00:16:17] They're just people who have managed to get into positions where they have a voice.

[00:16:21] And so I get to decide whether or not I respect their opinion.

[00:16:26] And SSRIs, the reason that I don't use them, weight gain, diabetes risk is now coming out on that.

[00:16:33] And hoffe элемent osteoporosis, long-term sleep fragmentation causing a lack of a band of emotion, like a thin band of emotion.

[00:16:43] Sexual side effects in 40 to 70% of people.

[00:16:47] But it's really, it's on the upper end if you're looking at the studies after the 90s where they're using the ASEX instrument in probing that.

[00:16:55] and I could keep going on.

[00:16:56] There's lots of side effects

[00:16:57] and I would say side effects

[00:16:59] that's as our eyes are usual.

[00:17:00] I do meet people who don't have them

[00:17:03] but I would say that it's usual

[00:17:04] that people will get side effects on them

[00:17:06] and that coming off of them,

[00:17:09] there's like a 15 to 30% risk

[00:17:12] of a difficult withdrawal.

[00:17:15] And as someone who specializes in withdrawal,

[00:17:19] I've just watched people suffer

[00:17:20] and be on disability from it

[00:17:22] and sometimes have symptoms

[00:17:23] for as long as nine or 10 years.

[00:17:26] Actually, one guy never got to see me.

[00:17:28] He was on, he had an appointment with me

[00:17:30] like in a month and he killed himself

[00:17:33] because of his post-acute withdrawal syndrome.

[00:17:35] He was having dystonia in his stomach

[00:17:38] amongst other things.

[00:17:39] He had many symptoms.

[00:17:40] He couldn't handle it anymore.

[00:17:42] I have so many other tools I can use.

[00:17:45] I have like an endless list of stuff

[00:17:48] that I find extremely helpful

[00:17:51] for folks I get great results with without side effects.

[00:17:55] I have no reason to use an SSRI.

[00:17:58] I, if for no other reason in my training,

[00:18:02] and I've always been somewhat of a skeptical person.

[00:18:07] And in my training, I'm just,

[00:18:09] I'm sitting there and I'm seeing,

[00:18:11] you know, especially seeing young people

[00:18:13] that are depressed and suicidal.

[00:18:15] And I'm told that my first line option

[00:18:20] is to add a drug that carries a black box warning

[00:18:24] for increasing suicidality.

[00:18:27] And, you know, Kara, I'm not that smart.

[00:18:30] I really am not.

[00:18:31] But I am skeptical.

[00:18:32] And when I see somebody that's depressed and suicidal,

[00:18:36] do I want to add a drug

[00:18:38] that may increase their risk of suicide?

[00:18:41] And therefore there is no treatment after that.

[00:18:44] Paired with the fact that

[00:18:46] so many of my patients have told me that

[00:18:50] certain SSRIs when they've had trials in the past,

[00:18:53] that they felt more suicidal on them.

[00:18:56] So I don't know where you stand on that.

[00:18:58] I forgot that part.

[00:18:59] Yeah.

[00:19:00] Yeah.

[00:19:00] Okay.

[00:19:01] No, no, no.

[00:19:01] I'll tell you where I'm at with that.

[00:19:03] Actually, interestingly, as it turns out,

[00:19:06] when all of that data is analyzed,

[00:19:08] actual suicides don't increase.

[00:19:09] But suicidal thoughts and acts

[00:19:13] definitely go up in young people.

[00:19:15] Why is that?

[00:19:16] Young people are still forming their prefrontal cortex.

[00:19:18] They still are glutamate dominant.

[00:19:21] They have a lot of glutamate neurons.

[00:19:25] And SSRIs are a break-a-like glutamated ampum.

[00:19:28] You mentioned unipolar and bipolar.

[00:19:30] And that's how DSM-5 thinks.

[00:19:33] It does allow an in-between,

[00:19:36] but we don't often discuss the in-between.

[00:19:38] Now, if we go back to DSM-2 before 1980,

[00:19:43] we had manic depressive illness.

[00:19:46] We didn't have unipolar and bipolar.

[00:19:49] And so manic depressive illness was inspired by

[00:19:51] Emil Kraepelin's work,

[00:19:52] and he held cyclicity as prime.

[00:19:54] So you looked at,

[00:19:55] does this person cycle?

[00:19:56] That was number one.

[00:19:58] They didn't ever have to get manic, right?

[00:20:00] Right.

[00:20:01] They could just cycle between depression

[00:20:02] and normal mood, right?

[00:20:04] Yeah.

[00:20:05] And then below that,

[00:20:06] you would parse other things.

[00:20:08] To me, what's important is,

[00:20:10] do they cycle?

[00:20:11] Are they mixed?

[00:20:12] Are they rapid cycling?

[00:20:13] Because that actually helps me choose agents.

[00:20:15] That helps me choose tools.

[00:20:17] I'm not looking at the construct as it's written,

[00:20:20] the DSM,

[00:20:20] which largely is not based on biology.

[00:20:22] I'm looking at which symptoms and historical correlates

[00:20:27] and patterns,

[00:20:29] like line up in the literature with the tools that I've got

[00:20:33] and whether that tool would be effective there.

[00:20:36] Yeah.

[00:20:37] SSRIs,

[00:20:38] I think have created a lot of the rapid cycling

[00:20:40] and mixed features that we see.

[00:20:43] It used to be that people with bipolar disorder

[00:20:45] had an episode maybe every couple of years.

[00:20:49] This is,

[00:20:49] you know,

[00:20:49] years and years ago now.

[00:20:50] It's like,

[00:20:51] I mean,

[00:20:52] I see people who cycle like weekly,

[00:20:54] sometimes daily.

[00:20:56] It's common that I see people who cycle monthly.

[00:20:59] Yes,

[00:21:00] absolutely.

[00:21:01] Absolutely.

[00:21:02] I think one of the worst things in that,

[00:21:05] that has come out in healthcare data wise

[00:21:07] was that women's health initiative study,

[00:21:11] which in a matter of like six months,

[00:21:14] transition half of women in the United States

[00:21:16] from hormone therapy,

[00:21:18] replacement therapy,

[00:21:19] but to SSRIs is the first line.

[00:21:23] Literally 50% of women within six months of the media

[00:21:26] widely reporting on that study,

[00:21:29] which stated that there was,

[00:21:31] you know,

[00:21:32] pretty significant increases in cancer risk

[00:21:35] with staying on hormone therapy.

[00:21:37] What they didn't state and what the media didn't cover

[00:21:40] is a few months down the road,

[00:21:42] there was a lot of criticism that the average age of women in this study

[00:21:46] was like 65 years old.

[00:21:48] And they hadn't had,

[00:21:50] they'd been off of hormones or through menopause for five to 10 years.

[00:21:54] And adding back in those hormones after that period of time,

[00:21:57] certainly increases cancer risk.

[00:22:00] But when you substratify that data,

[00:22:03] and you look at the women who were in that perimenopausal period,

[00:22:08] they had great outcomes.

[00:22:10] Their increased risk of,

[00:22:12] I believe it was breast cancer,

[00:22:13] was offset by a reduced risk of colon cancer,

[00:22:16] actually.

[00:22:16] And then when you consider all the other factors and improvements that,

[00:22:21] that they had with other symptoms and systems,

[00:22:25] the data was pretty obvious,

[00:22:27] but again,

[00:22:28] the media reported widely on the original conclusions drawn.

[00:22:33] And then a few months later,

[00:22:36] when the criticism was out and they kind of,

[00:22:38] I don't know if they issued a revision or if there was just enough.

[00:22:41] There was a revision.

[00:22:43] Yeah.

[00:22:44] The UHR is still being analyzed.

[00:22:46] A paper came out on it in terms of Alzheimer's risk last year.

[00:22:50] The one major problem with it is that some women were on bioidenticals and

[00:22:53] some were on synthetics and none of that was separated out.

[00:22:56] So it's,

[00:22:58] it's a deeply flawed study and it's the only large study that we have.

[00:23:01] I talked to Yosef Witt during,

[00:23:04] he runs a podcast life on less meds and runs a multi-state

[00:23:10] deprescribing clinic called the taper clinic.

[00:23:12] Okay.

[00:23:13] You know,

[00:23:14] the taper clinic.

[00:23:15] I don't,

[00:23:16] I know that there's a,

[00:23:18] there's an online clinic called outro.

[00:23:22] That,

[00:23:23] yeah,

[00:23:24] I don't know that one.

[00:23:24] Um,

[00:23:26] the woman who founded the website,

[00:23:30] surviving antidepressants.com,

[00:23:32] Alta Strada,

[00:23:33] she formed it along with,

[00:23:35] and now I'm going to forget his name,

[00:23:36] but he publishes with Joanna Moncrief.

[00:23:40] And they wrote that paper right at the end of the serotonin.

[00:23:44] Yeah.

[00:23:46] Yeah.

[00:23:46] That was so,

[00:23:46] yeah,

[00:23:47] that was so controversial.

[00:23:48] Um,

[00:23:49] he was,

[00:23:50] I believe the last author on that.

[00:23:52] They have,

[00:23:53] but they're the way they're rolling.

[00:23:55] Cause it's online and it's,

[00:23:56] it is somewhat automated.

[00:23:57] So it's the,

[00:23:59] the principles of their program are fantastic.

[00:24:02] But I know from working with many,

[00:24:05] many people doing tapers that you have to individualize.

[00:24:09] I had one guy who's tapering Prozac by 0.01 milligrams at a time.

[00:24:14] Wow.

[00:24:16] And if he had caffeine or sugar,

[00:24:18] it was over.

[00:24:20] And it was like,

[00:24:21] we,

[00:24:21] we had like the amount of customization we did to his lifestyle and his

[00:24:25] supplementation to get him through that taper was wild.

[00:24:28] So it's,

[00:24:29] it really does take a one-on-one,

[00:24:33] you know?

[00:24:34] Yeah.

[00:24:34] I mean,

[00:24:35] that,

[00:24:35] that was my biggest criticism at the company that I was,

[00:24:39] well,

[00:24:39] I'm still working there,

[00:24:40] but my time there is limited,

[00:24:42] uh,

[00:24:42] was I just kept telling him,

[00:24:44] you cannot have a five day volume taper for every alcohol or benzo withdrawal

[00:24:50] patient and no extending the taper.

[00:24:53] That can't be the only other exception or option for the patient.

[00:24:57] I mean,

[00:24:57] you know,

[00:24:58] the,

[00:24:58] some of these 30 day programs are so hell bent on getting the person off of

[00:25:05] the drug in this limited timeframe.

[00:25:07] And I think so that they can say we're successful in getting this person off

[00:25:12] of the drug,

[00:25:13] drug,

[00:25:13] but then they go home and then they struggle with post acute withdrawal.

[00:25:18] And they may have,

[00:25:19] they may have even had a permanent damage done to their brain because again,

[00:25:26] one of my like personal,

[00:25:27] uh,

[00:25:27] professional philosophies is our brains do not like these big waves of,

[00:25:34] of,

[00:25:34] of change.

[00:25:35] And so when we make things more gradual,

[00:25:39] you're limiting,

[00:25:40] I think the risk of some of that long-term damage.

[00:25:43] Um,

[00:25:43] but I'm not very good in those situations when it comes to patient care of

[00:25:48] holding my tongue.

[00:25:49] Yeah.

[00:25:50] Um,

[00:25:50] so,

[00:25:51] you know,

[00:25:51] I,

[00:25:52] I think I was maybe a little bit overly critical,

[00:25:54] but nobody even wanted to have a conversation about it.

[00:25:57] And I,

[00:25:58] and I just,

[00:25:58] that bothers me to the core.

[00:26:01] No,

[00:26:02] I,

[00:26:02] I,

[00:26:02] I have never been in that position.

[00:26:06] And,

[00:26:07] and I have,

[00:26:07] I have two other jobs and I'm not in that position ever with those two other

[00:26:11] jobs.

[00:26:12] One of which is,

[00:26:13] you know,

[00:26:13] working with another MD and his private practice.

[00:26:16] Um,

[00:26:17] but yeah,

[00:26:18] it's,

[00:26:18] it's been the addiction recovery centers,

[00:26:21] which,

[00:26:22] you know,

[00:26:22] if,

[00:26:23] if you know anything about Kentucky's,

[00:26:25] uh,

[00:26:25] struggle with addiction,

[00:26:27] it is right at the epicenter of this whole crisis.

[00:26:30] And I mean,

[00:26:32] I,

[00:26:32] there are so many friends and classmates from my middle school,

[00:26:37] high school days,

[00:26:38] college days that either aren't with us or have struggled mightily with

[00:26:43] addiction.

[00:26:44] And so it's something I'm really passionate about,

[00:26:46] but it's also like,

[00:26:48] I'm,

[00:26:48] I'm losing my passion to a degree because I just keep hitting these roadblocks

[00:26:55] with these cookie cutter style addiction recovery centers,

[00:27:00] putting people on.

[00:27:01] I mean,

[00:27:02] I shit you not Kara putting people on 10 to 15 withdrawal meds and every

[00:27:09] patient gets the same protocol.

[00:27:12] Yeah.

[00:27:12] It doesn't matter.

[00:27:14] It doesn't matter.

[00:27:15] And TID.

[00:27:16] I mean,

[00:27:16] just things that,

[00:27:17] that are,

[00:27:18] that the patient can't function on.

[00:27:20] Um,

[00:27:21] and that are not,

[00:27:23] there's no transition to outpatient.

[00:27:25] Right.

[00:27:26] And it's,

[00:27:27] yeah,

[00:27:27] there's transition to sober living.

[00:27:30] That's not even connected to the original program.

[00:27:33] So then you go see a whole nother set of providers that may change the,

[00:27:39] uh,

[00:27:39] treatment program.

[00:27:40] But like the,

[00:27:41] the,

[00:27:41] the greatest,

[00:27:42] um,

[00:27:43] example of this that I have is they would put somebody with chronic kidney

[00:27:49] disease,

[00:27:50] stage three,

[00:27:51] they would still add both ibuprofen and Tylenol for pain.

[00:27:55] Like not even to going to the degree of saying,

[00:27:59] okay,

[00:28:00] let's figure out based on your,

[00:28:02] uh,

[00:28:03] health,

[00:28:03] um,

[00:28:04] history and background and characteristics.

[00:28:06] Should we try to utilize ibuprofen if you're in pain or should we try to

[00:28:10] use it,

[00:28:10] utilize Tylenol?

[00:28:12] No,

[00:28:12] we're going to put both of them on there because that's the easier thing to

[00:28:15] do.

[00:28:16] And I can hit my one button,

[00:28:17] start the entire protocol and I don't have to think about it.

[00:28:23] But yeah,

[00:28:24] they're probably not considering drug interactions also.

[00:28:28] Absolutely not.

[00:28:29] They're not even considering the,

[00:28:31] you know,

[00:28:32] half life or the time to elimination of the illicit drug.

[00:28:36] Because people coming off of an illicit drug can be,

[00:28:39] uh,

[00:28:40] behaviorally can be somewhat erratic and want to be out of that state.

[00:28:45] And sometimes they need the counseling of,

[00:28:47] Hey,

[00:28:47] we could make this worse if we give you a bunch of Seroquel when you still have

[00:28:51] fentanyl in your system.

[00:28:53] Yeah.

[00:28:54] You know,

[00:28:54] I know that you want to sleep.

[00:28:55] I know that you have,

[00:28:56] you know,

[00:28:57] already started,

[00:28:58] uh,

[00:28:58] in your withdrawal,

[00:28:59] but I don't want you to die here.

[00:29:02] I want you to live with that little bit more discomfort so that we can treat

[00:29:08] your condition more.

[00:29:09] So in the longterm,

[00:29:11] you know,

[00:29:11] get through this difficult short-term period of discomfort,

[00:29:14] but really try to focus on the longterm.

[00:29:17] And,

[00:29:17] uh,

[00:29:18] like you talk about treating the disease,

[00:29:20] not just the symptoms that you're having.

[00:29:23] I really like your stated goal of your patients,

[00:29:26] not needing to see you frequently,

[00:29:27] or that's what,

[00:29:28] that's what you would prefer.

[00:29:29] Uh,

[00:29:30] I share that they're,

[00:29:31] they're seeing me every three months and we check in sometimes after a

[00:29:36] couple of years,

[00:29:36] somebody will have a new project they want to work on.

[00:29:38] By the way,

[00:29:39] I don't see myself as a healer.

[00:29:40] I just,

[00:29:41] I don't like that concept at all.

[00:29:43] That's not my job.

[00:29:44] That's their job.

[00:29:46] I'm a consultant.

[00:29:48] I offer tools,

[00:29:50] knowledge,

[00:29:50] access.

[00:29:51] I have a,

[00:29:52] um,

[00:29:53] uh,

[00:29:53] database about 750 professionals and clinics that I refer to.

[00:30:00] Uh,

[00:30:00] none of them are just okay.

[00:30:01] They all have like advanced training and what they do and they,

[00:30:06] and they like produce killer results.

[00:30:08] If I include all the residentials and IOPs that I refer to,

[00:30:11] it's probably closer to 800 or more,

[00:30:13] or more.

[00:30:14] And so that's it's,

[00:30:16] I will build teams for people,

[00:30:17] you know,

[00:30:18] I'll introduce them to all kinds of like medicine,

[00:30:20] supplements,

[00:30:21] nutrient reflation,

[00:30:22] hooking them up with specialists.

[00:30:24] Like,

[00:30:25] but they do the work.

[00:30:27] They get themselves better.

[00:30:28] And one thing I interviewed for when I meet with clients initially,

[00:30:31] before I take them on as a client is,

[00:30:33] are they motivated?

[00:30:34] You know,

[00:30:34] how motivated are they?

[00:30:35] How,

[00:30:35] what do they want to get out of this and how they want to do it?

[00:30:38] And are they curious?

[00:30:39] And are they aggressive and demanding?

[00:30:42] I don't want to work with people who just want to take Prozac and Adderall,

[00:30:46] you know,

[00:30:47] not going to get them anywhere.

[00:30:50] Yeah.

[00:30:50] No,

[00:30:51] they'll feel better for,

[00:30:52] you know,

[00:30:52] the,

[00:30:53] the,

[00:30:53] the time that they did the clinical trials on those things like,

[00:30:56] you know,

[00:30:56] Xanax for six weeks.

[00:30:57] Yeah.

[00:30:58] Somebody will have a reduction in their anxiety and maybe even function a

[00:31:02] little bit as an antidepressant over that time period.

[00:31:04] But there's a reason why they only studied it for six weeks and then took

[00:31:08] people off of it for six weeks and said,

[00:31:10] Hey,

[00:31:10] there's not any significant withdrawal,

[00:31:12] but obviously if you look at the kind of,

[00:31:15] or in my experience,

[00:31:17] and I think the good literature out there says that the long-term high dose

[00:31:21] benzos,

[00:31:22] that they lead to all this rebound anxiety between doses.

[00:31:26] They lead to poor sleep architecture.

[00:31:28] Again,

[00:31:29] there are.

[00:31:30] Yes.

[00:31:31] Hazard ratio on cancer for one to 18 pills used for sleep.

[00:31:35] One to 18 pills per year.

[00:31:37] Hazard ratio 3.84.

[00:31:39] Wow.

[00:31:40] Yeah.

[00:31:42] There are short-term uses and benefits for things like those.

[00:31:47] And that can be difficult with managing patient expectations because they,

[00:31:52] they say,

[00:31:52] Oh,

[00:31:53] I had such a good response to that.

[00:31:55] No,

[00:31:55] I don't ever have that problem actually.

[00:31:57] Oh,

[00:31:57] really?

[00:31:58] No.

[00:31:58] I,

[00:31:59] when I prescribe it,

[00:32:00] I let them know they're going to get 10 pills per month and they get to

[00:32:04] choose when to spend it.

[00:32:05] And we get to develop other skills and ways of managing anxiety when it's

[00:32:09] not heavy enough to want to spend one of their precious benzodiazepine pills.

[00:32:13] Yeah.

[00:32:14] Yeah.

[00:32:14] I like that.

[00:32:15] There's no negotiation around it.

[00:32:17] And they get that from the initial discussion.

[00:32:19] So the topic never comes up.

[00:32:22] I do have people who are on daily benzos.

[00:32:24] They came into my practice on them.

[00:32:26] The agreement I have with folks coming in on a daily benzo is that within two

[00:32:30] years,

[00:32:31] they will make the decision to taper or I will transition their care.

[00:32:35] I want to,

[00:32:36] I,

[00:32:37] I not causing harm is my first responsibility.

[00:32:40] Keeping them on those drugs long-term is not helpful to them.

[00:32:43] Um,

[00:32:43] I do give them a two-year window to make a decision.

[00:32:45] When's a good time to start this taper.

[00:32:47] I do ultra long,

[00:32:49] slow tapers.

[00:32:49] I've done tapers that go on as long as three years or more.

[00:32:52] So I'm,

[00:32:52] I'm willing to like,

[00:32:54] you know,

[00:32:54] write it out with somebody in a way that's not going to cause them problems.

[00:32:58] Uh,

[00:32:58] but I do expect them to come off the drug.

[00:33:01] Yeah.

[00:33:02] And to go back to the original,

[00:33:03] uh,

[00:33:04] question or point,

[00:33:05] you know,

[00:33:05] I share that with you that I like,

[00:33:08] and I tell my patients,

[00:33:09] my goals are to see you infrequently to,

[00:33:12] you know,

[00:33:13] find a,

[00:33:13] a red treatment regimen that is helping to make your life easier and more

[00:33:18] fulfilling.

[00:33:19] But actually that's bad for both of us from a financial perspective.

[00:33:23] And I don't really think it's bad.

[00:33:25] Cause I think that that feeds back that this person is actually working to get

[00:33:29] people better.

[00:33:30] But I think there is an idea out there,

[00:33:33] maybe more kind of a corporate medicine that it's bad from a financial

[00:33:36] perspective.

[00:33:37] But for me personally,

[00:33:39] and probably for you too,

[00:33:40] it allows us to lay our heads on our pillows at night,

[00:33:43] knowing that we are trying to put good into the world and trying to help

[00:33:47] people find the things that are important to them and live more meaningful

[00:33:52] lives.

[00:33:52] I think a big part of the pharmaceutical,

[00:33:56] medical insurance.

[00:33:58] So complex is treating symptoms over treating diseases.

[00:34:02] And you and I,

[00:34:03] or the via the outlines have said that it kind of plays out in the DSM three

[00:34:08] through five.

[00:34:09] You and I share a lot of criticisms about the DSM diagnostic inflation.

[00:34:14] How do you explain that diagnostic inflation to patients who sometimes may

[00:34:20] believe that some of these large and really influential professional

[00:34:24] organizations only speak the truth and don't have any ulterior motives behind

[00:34:29] all of those diagnoses embedded within the DSM?

[00:34:32] I actually don't get those patients.

[00:34:35] They don't show up my practice.

[00:34:37] I tend to attract critical thinkers.

[00:34:40] My average patient is an engineer,

[00:34:43] a company founder,

[00:34:44] or an attorney who like has been through this a lot.

[00:34:48] And they realize that they're an individual and that they're not their disease.

[00:34:52] I don't have to discuss with them like diagnostic inflation.

[00:34:55] I don't think I go into that with,

[00:34:57] with patients.

[00:34:58] It's,

[00:34:58] I mean,

[00:34:59] it's certainly a concept I'm familiar with because I've just run into it over

[00:35:03] time.

[00:35:03] But no,

[00:35:04] the way I discuss the DSM with clients is that it is,

[00:35:07] it's something that we use for payment and that it has evolved from what was

[00:35:13] originally a psychodynamic,

[00:35:14] the finer criteria DSM two was built on neuroses and psychoses.

[00:35:19] And there were only 14,

[00:35:20] you know,

[00:35:22] diseases in originally.

[00:35:24] And then,

[00:35:25] you know,

[00:35:25] over the years,

[00:35:27] mostly people in ivory towers who aren't seeing patients have developed these

[00:35:32] illnesses.

[00:35:33] A lot of it has been political,

[00:35:34] how they've developed very little of it is based in biology.

[00:35:39] Our doc thinking is not widespread.

[00:35:42] The research diagnostic criteria,

[00:35:44] which is based in biology,

[00:35:45] but we're,

[00:35:46] I mean,

[00:35:46] we're just not unfortunately ready for prime time with a lot of things.

[00:35:50] Genetics has not played out as being predictive.

[00:35:53] You can't,

[00:35:54] you can't use imaging.

[00:35:55] The signal to noise ratio is too great when you're using an individual versus

[00:35:59] scans of 5,000 brains.

[00:36:01] And we still are stuck mostly interviewing in order to diagnose someone.

[00:36:07] It's mostly subjective information that we're using,

[00:36:10] but if we're going by a manual,

[00:36:13] you know,

[00:36:13] or by guidelines,

[00:36:14] right?

[00:36:15] I mean,

[00:36:15] these are just people's ideas.

[00:36:16] It's it.

[00:36:17] And I think once you're in practice for a long time and you've seen thousands

[00:36:20] of people,

[00:36:21] as you've been describing in this conversation,

[00:36:23] you see patterns and you see your own patterns.

[00:36:27] Can you develop your own conceptualization of how some things work and it

[00:36:30] doesn't have to line up with a diagnostic manual.

[00:36:33] Yeah.

[00:36:34] Actually the first guest I ever had on here was Ken Gilman.

[00:36:38] Yeah.

[00:36:38] Yeah.

[00:36:39] Yeah.

[00:36:39] Yeah.

[00:36:39] And I wish I'd have had him on video because he's so animated and he's just

[00:36:43] so much fun to talk to.

[00:36:44] Um,

[00:36:46] but we,

[00:36:47] we talked about,

[00:36:48] uh,

[00:36:48] a lot about the DSM and he had some very,

[00:36:52] uh,

[00:36:53] interesting criticism,

[00:36:54] very interesting historical information going back to the origins of the

[00:36:58] DSM and some of the quote unquote research that revealed some of these

[00:37:03] diagnoses,

[00:37:04] these valid diagnoses.

[00:37:06] And then I had a Nasir,

[00:37:08] uh,

[00:37:08] Gami on as well.

[00:37:10] And he's just great in terms of talking about reliability and validity of

[00:37:15] these different diagnoses.

[00:37:17] And what he means by that is,

[00:37:19] are there enough objective findings that separate out the diagnosis from any

[00:37:25] other DSM diagnosis?

[00:37:27] And if not,

[00:37:28] then you can't really say it's a valid diagnosis.

[00:37:31] If the course of illness,

[00:37:32] the family history,

[00:37:33] or our,

[00:37:34] our semi objective look into,

[00:37:37] uh,

[00:37:38] what the genetics are,

[00:37:39] um,

[00:37:40] as well as the response to medications.

[00:37:43] If you do not have a distinct profile for those three,

[00:37:47] um,

[00:37:48] evaluations,

[00:37:49] then it's hard to say that a diagnosis is valid.

[00:37:52] Well,

[00:37:52] in DSM five,

[00:37:54] the validity trials never happened.

[00:37:56] They were rushing it to press for APA 2013.

[00:38:01] And it never,

[00:38:03] never went through its validity trials.

[00:38:07] So that's,

[00:38:07] it's not there.

[00:38:08] Yeah.

[00:38:09] I mean,

[00:38:10] it's,

[00:38:10] it's not,

[00:38:11] uh,

[00:38:12] not surprising.

[00:38:13] So I often,

[00:38:15] I think come off as anti-industry.

[00:38:17] My stated belief is that there's a lot of historical and ongoing examples of

[00:38:23] industry manipulation of data and research.

[00:38:26] One that I've talked about a lot is the beta amyloid theory and all of these

[00:38:30] canimabs that are coming out that,

[00:38:32] you know,

[00:38:33] the FDA scientific advisory panel,

[00:38:35] when the first,

[00:38:36] uh,

[00:38:36] at a canimab,

[00:38:37] I don't know if that was the first one,

[00:38:39] but when at a canimab or adju helm came out,

[00:38:42] there were,

[00:38:43] I think nine or 10 out of 11 on that scientific advisory committee or panel

[00:38:48] that said,

[00:38:48] this should not be FDA approved.

[00:38:51] And that got FDA approved anyway.

[00:38:53] And several of them ended up resigning.

[00:38:55] That is one example of,

[00:38:56] uh,

[00:38:57] a theory being shoved down our throats.

[00:38:59] It's when there's a pretty decent amount of evidence that we don't fully

[00:39:03] understand the role of beta amyloid in Alzheimer's.

[00:39:06] It may just be a,

[00:39:08] a marker of the dysfunction that is either once it is laid down in the brain

[00:39:13] that creates the dysfunction.

[00:39:14] If it's there for a certain amount of time,

[00:39:17] or it may just be a,

[00:39:18] a,

[00:39:19] a incidental finding,

[00:39:20] uh,

[00:39:20] related to Alzheimer's.

[00:39:22] But I think that these medications,

[00:39:24] they haven't really,

[00:39:25] uh,

[00:39:25] led to a significant improvement over the already existing treatments.

[00:39:30] I just read a paper two weeks ago saying that amyloid beta is scaffolding.

[00:39:34] It's there and it creates scaffolding for tau protein to grow,

[00:39:38] for other things to happen on,

[00:39:39] but that it itself is not the problem.

[00:39:41] Maybe.

[00:39:42] So there,

[00:39:43] so there,

[00:39:44] there are new data coming out on this all the time.

[00:39:47] And that,

[00:39:48] that,

[00:39:48] that helps to give explanation for why these low or even supplemental doses of

[00:39:53] lithium can be stabilizing for dementia patients.

[00:39:56] Um,

[00:39:57] I think there's more and more information coming out about that.

[00:40:02] I've had so much success with using really low doses of lithium or even

[00:40:07] supplemental doses of it.

[00:40:08] One of those examples from residency that I was like,

[00:40:12] so give them an SSRI or give them a low dose of something that's safe

[00:40:17] and natural and may actually reduce their risk of suicide.

[00:40:21] Huh?

[00:40:22] And that it,

[00:40:23] that actually produces useful cortical thickening.

[00:40:26] Yes.

[00:40:28] Yeah.

[00:40:28] And actually can create neurogenesis in the hippocampus.

[00:40:31] I saw one study on intellectual disability and actually patients who had been on a low dose of lithium,

[00:40:39] or maybe it was moderate dose for either three or six months had improvement in their IQ scores to a pretty significant degree.

[00:40:47] I don't,

[00:40:48] I don't know about that,

[00:40:49] but it's interesting.

[00:40:50] Um,

[00:40:51] I don't see that.

[00:40:51] I haven't seen that before.

[00:40:53] Yeah.

[00:40:53] I'll have to send you.

[00:40:54] I've got a,

[00:40:55] I've got a huge,

[00:40:56] a database of lithium,

[00:40:57] uh,

[00:40:58] research and all these different areas.

[00:41:00] And I think that it primarily like,

[00:41:03] it helps to stabilize that astroglial matrix.

[00:41:06] It helps our neuro immune system to function more optimally and not go overboard.

[00:41:12] Um,

[00:41:13] it's got that,

[00:41:13] that GSK three inhibition,

[00:41:16] three beta inhibition that leads to all of these downstream anti-inflammatory effects that you don't really get that same anti-inflammatory effect on that system to that degree that I know of with.

[00:41:29] A whole lot of other drugs.

[00:41:32] I mean,

[00:41:32] some people say lithium is the only substance that affects that pathway to that degree.

[00:41:37] Anyway,

[00:41:38] again,

[00:41:38] I'm going off the beaten path here talking about coming off as anti-industry.

[00:41:44] And there are a lot of historical ongoing examples of industry manipulation of data and research.

[00:41:50] A lot of the SSRI clinical trials,

[00:41:54] cherry picking,

[00:41:55] as you call it for the purpose,

[00:41:56] for the purposes of really,

[00:41:58] I mean,

[00:41:58] their job is to appease their shareholders.

[00:42:00] Um,

[00:42:01] that's their primary responsibility.

[00:42:02] And I understand that,

[00:42:05] but,

[00:42:05] you know,

[00:42:06] I also think industry's responsible for a lot of innovation in healthcare treatment.

[00:42:11] I don't see it as inherently evil,

[00:42:13] though.

[00:42:14] So I have to acknowledge that there are certain individuals and or companies that can be immoral and unscientific in their approaches.

[00:42:23] I wish there was more regulation.

[00:42:26] I wish there was more independent scientific evaluation of the purported evidence,

[00:42:32] AKA like that,

[00:42:33] you know,

[00:42:34] doctors,

[00:42:34] providers,

[00:42:35] scientists are the ones that determine validity and reliability.

[00:42:40] But from my perspective,

[00:42:42] what happens is the doctors and providers that are more willing to play ball from the financial side of things,

[00:42:47] they get promoted to the top positions in industry.

[00:42:51] They are the ones who are,

[00:42:53] or who set out to create these guidelines that are then shoved down our throats as scientific dogma.

[00:42:59] And,

[00:43:00] and,

[00:43:01] you know,

[00:43:01] you're the example I want to use for you is using oxytocin for social phobia is considered probably bad practice by some of those guideline folks.

[00:43:11] That's the first thing I do.

[00:43:13] I know,

[00:43:13] I know.

[00:43:14] And I'm,

[00:43:14] I'm excited.

[00:43:15] Uh,

[00:43:16] I'm excited to,

[00:43:17] to look into that and,

[00:43:18] and investigate it.

[00:43:20] But yeah,

[00:43:20] what are your thoughts on,

[00:43:22] on the role of industry?

[00:43:24] And can we still hold on to all the innovation without,

[00:43:29] having all this manipulation without having this,

[00:43:32] you know,

[00:43:32] for,

[00:43:32] to go back to the beta amyloid,

[00:43:34] there was that kind of original research that was found that the,

[00:43:38] the researcher was photoshopping hundreds of,

[00:43:42] of images in,

[00:43:43] in one of those original beta amyloid papers.

[00:43:46] And that goes back to the early two thousands.

[00:43:48] Here we are 20 something years later,

[00:43:51] and probably partly based on the length of a patent,

[00:43:55] they're still trying to shove these same drugs down our throats.

[00:43:59] And they've got to be way behind financially in terms of research and,

[00:44:03] and development of these compared to what they have actually sold in terms

[00:44:07] of the numbers of these canumab drugs.

[00:44:10] But anyway,

[00:44:10] again,

[00:44:11] I'm rambling,

[00:44:11] but what,

[00:44:12] what are your thoughts on,

[00:44:13] on that?

[00:44:13] Oh,

[00:44:14] on industry.

[00:44:14] I,

[00:44:15] you know,

[00:44:15] I,

[00:44:15] I'm actually very pragmatic and a realist.

[00:44:18] And I also say,

[00:44:19] it's just really not my job.

[00:44:21] I conserve my time,

[00:44:23] energy,

[00:44:23] and resources for the things that I find valuable in my life.

[00:44:27] And criticizing a big industry is not going to get me anywhere.

[00:44:29] And it's not going to change them.

[00:44:31] I've worked for industry.

[00:44:33] I've worked for a bunch of companies.

[00:44:35] I learned not most,

[00:44:38] but a lot of what I know about ADHD,

[00:44:40] actually,

[00:44:41] by working with some of the finest minds in the world on ADHD.

[00:44:44] And the way I got in the room with them is somebody hired me.

[00:44:47] So I'm grateful to,

[00:44:48] to industry for that.

[00:44:50] I'm grateful that for the years when being a speaker was actually fun,

[00:44:54] when you could actually teach,

[00:44:55] I'm grateful for all the people I met in all those rooms.

[00:44:58] I'm still close,

[00:44:59] close friends with drug reps.

[00:45:02] I met during those years with clinicians.

[00:45:04] I wouldn't have met in my community without those dinners.

[00:45:06] My,

[00:45:07] my very first mentor probably spoke for 12 drugs and he didn't just give

[00:45:12] whatever samples he happened to have.

[00:45:14] He had every sample,

[00:45:16] so it didn't change his mind about what he was prescribing.

[00:45:20] And he was a big influence on me.

[00:45:22] And I have not,

[00:45:23] I'm not pro or anti industry.

[00:45:27] I mean,

[00:45:27] I look at it the same as I look at the oil industry,

[00:45:29] the banking industry,

[00:45:30] we are a capitalist country and yes,

[00:45:32] we,

[00:45:32] we please our shareholders and that's going to roll down to causing some bad

[00:45:37] behavior in some people.

[00:45:38] And unfortunately some folks where they're,

[00:45:41] I mean,

[00:45:41] I wouldn't want to be in a responsible position in a drug company.

[00:45:44] I wouldn't want to have to show up in a suit like that every day.

[00:45:47] I wouldn't want to have to be that person.

[00:45:49] That's never going to be me.

[00:45:51] The person who does want to do that,

[00:45:54] they've got motives,

[00:45:56] right?

[00:45:56] So it's just going to come with it.

[00:45:58] I I'm not going to change that.

[00:45:59] I'm not going to change how this country's run.

[00:46:01] There's a lot.

[00:46:01] I'm not going to change.

[00:46:03] And what I can change is the lives of my patients.

[00:46:07] I can be focused on what's small,

[00:46:10] what's real,

[00:46:11] what's right in front of me and where I can actually make a material difference.

[00:46:16] Complaining about pharma just doesn't get me there.

[00:46:18] The interactions I've personally have with the industry have been amazingly

[00:46:21] wonderful and a big value add to my life.

[00:46:25] When you said when you could actually teach as a speaker,

[00:46:29] expound upon that a little bit.

[00:46:30] What do you mean by that?

[00:46:31] Well,

[00:46:32] for one thing,

[00:46:32] there's a big separation between medical and marketing in,

[00:46:36] in the industry.

[00:46:37] Like for instance,

[00:46:38] it used to be that their drug reps could tell you a lot about the medicine.

[00:46:41] Now,

[00:46:42] if they hand you a paper,

[00:46:43] it has to be wrapped in plastic to show that they haven't discussed it with

[00:46:46] you.

[00:46:48] So they're allowed to say very few things.

[00:46:50] I used to meet with reps a lot.

[00:46:52] I don't anymore because now the only value that I get from meeting with them

[00:46:55] is finding out about the coupon and how,

[00:46:57] how does that coupon work?

[00:46:59] Sometimes it's a complicated coupon.

[00:47:01] So,

[00:47:01] you know,

[00:47:02] if I want to talk about anything medical about the drug,

[00:47:04] I have to talk to medical affairs.

[00:47:05] I have to talk to medical science liaison.

[00:47:08] I actually talk to those guys all the time.

[00:47:10] Like very often I'm on with one of them.

[00:47:12] And when I go to major meetings,

[00:47:13] one of the major reasons that I go is to go and meet with the MSLs of most of

[00:47:18] the companies there.

[00:47:20] Um,

[00:47:20] I probably have 10 lunches and dinners with industry.

[00:47:24] Every time I go to a meeting to find out what's in their pipeline,

[00:47:27] discuss off-label applications of their products.

[00:47:30] So those people are there to help you with that,

[00:47:32] but there's this big separation between marketing and medical and a dinner is

[00:47:37] marketing.

[00:47:38] And you are allowed to discuss very few things.

[00:47:41] It used to be that I could really go down a rabbit hole into disease state.

[00:47:45] If I wanted to add a person,

[00:47:47] there are disease state presentations,

[00:47:49] but like,

[00:47:49] let's say that I'm actually supposed to be presenting on the drug.

[00:47:52] I used to be able to like talk disease state.

[00:47:54] I also used to be able to talk about peripheral studies associated with the

[00:47:59] topic.

[00:47:59] I'm,

[00:47:59] I'm discussing about the drug.

[00:48:01] Um,

[00:48:01] at this point,

[00:48:02] you can talk about what's on that screen.

[00:48:05] You're not allowed to even talk about the study that's on that screen.

[00:48:08] Unless the data is on the screen.

[00:48:10] And so you're not allowed to really teach.

[00:48:12] I think the last time I gave a talk for industry was like maybe 2017.

[00:48:17] And I was still able to talk for a couple hours with people,

[00:48:20] but it was all case studies.

[00:48:22] I was allowed to bring my own personal experience into it.

[00:48:25] Um,

[00:48:26] and that was like,

[00:48:27] if I was going to actually bring some value,

[00:48:29] I had to figure out how to do that while staying within guidelines.

[00:48:33] This is not the,

[00:48:36] it's not the company's fault.

[00:48:37] This is FDA regulation.

[00:48:39] And some companies are a little looser than others.

[00:48:42] And it really depends on whether they're,

[00:48:44] um,

[00:48:46] what's it called on a CIA corporate integrity agreement or not.

[00:48:49] If they've gotten in trouble and they're being watched,

[00:48:52] they're very,

[00:48:53] very,

[00:48:53] very careful.

[00:48:55] Yeah.

[00:48:55] And,

[00:48:56] and from my perspective,

[00:48:57] I come from a place where,

[00:48:59] like I mentioned earlier,

[00:49:00] like I have friends that are dead from addiction and,

[00:49:05] you know,

[00:49:07] being in around Appalachia,

[00:49:10] that is where Purdue very aggressively started their marketing campaign for Oxycontin.

[00:49:16] Yeah.

[00:49:17] Um,

[00:49:17] that's a prime example.

[00:49:18] I mean,

[00:49:19] you and I could,

[00:49:19] could reel off a bunch of different examples.

[00:49:22] And one of the things that I brought up earlier with Ken Gilman that I didn't get around to is,

[00:49:27] you know,

[00:49:28] we talked about the usefulness of evaluating what we see in our patients as the,

[00:49:35] the most high yield pieces of evidence,

[00:49:38] because we are directly firsthand observing symptoms,

[00:49:43] treating them or observing,

[00:49:45] uh,

[00:49:45] symptoms in a cluster and diagnosing them with something.

[00:49:49] And that is the most direct pieces of evidence that you can have.

[00:49:53] It doesn't mean that you don't read,

[00:49:54] uh,

[00:49:55] you know,

[00:49:55] meta analyses and,

[00:49:56] and some of these larger reviews,

[00:49:59] but I guess my criticism of your take on that.

[00:50:02] And again,

[00:50:03] I,

[00:50:03] I absolutely understand.

[00:50:05] And sometimes I think that my life would be a little bit smoother and easier if I were to let go of some of the industry and the regulatory agency criticism,

[00:50:17] which I,

[00:50:18] you're right,

[00:50:18] just kind of like politics.

[00:50:20] I don't really have some major pull there and it may not be very likely for me to move the needle on those fronts,

[00:50:28] but it's so important to me.

[00:50:31] And I guess I would say if I'm not critical,

[00:50:35] how will it ever change?

[00:50:37] Cause it seems to me like it's getting worse and capitalism is,

[00:50:42] there's nothing inherently wrong with capitalism,

[00:50:44] but there is something inherently wrong with capitalism in medicine because medicine is a scientific pursuit.

[00:50:51] And folks like you and I,

[00:50:53] at least I like to think most of us come into it because we want to further our understanding,

[00:50:58] understanding our knowledge of disease and effective treatment.

[00:51:03] But,

[00:51:04] you know,

[00:51:04] you see this revolving door of industry and regulation.

[00:51:09] That's probably my biggest criticism.

[00:51:11] I mean,

[00:51:11] people in my position being trained or that's another criticism that,

[00:51:15] that I think GAMI is most critical of medical education,

[00:51:19] which is another piece of it.

[00:51:21] And then you have the patient in our society and how it,

[00:51:24] you know,

[00:51:24] tries to promote these easy fixes and these treating of symptoms.

[00:51:28] So it's a,

[00:51:28] a multifactorial issue,

[00:51:31] but I guess,

[00:51:32] yeah,

[00:51:32] I just feel like it's important for me to state some of these things and try to tip the scales of people,

[00:51:40] general public understanding better that just because a study comes out,

[00:51:46] just because the media reports on a study does not mean that it is scientifically proven.

[00:51:53] Oh,

[00:51:53] well,

[00:51:53] there's no such thing as proof.

[00:51:55] I mean,

[00:51:55] it's all hypothesis.

[00:51:57] And when I talk with clients about the literature,

[00:51:59] I tell them that if I haven't read something at least three times,

[00:52:03] and I prefer that it not be industry funded.

[00:52:06] And I prefer that my colleagues have used it.

[00:52:09] And maybe I've discussed it on a listserv.

[00:52:11] In other words,

[00:52:12] I'm getting information from many,

[00:52:13] many,

[00:52:14] many different sources before I make a decision to expose someone's life to a new intervention.

[00:52:19] And so we talk about like all the different ways we gather data and information.

[00:52:23] And I mean,

[00:52:24] in terms of criticizing industry,

[00:52:25] I'm just not there.

[00:52:26] I'm also not involved in politics.

[00:52:28] I'll tell you about my week.

[00:52:29] Last week,

[00:52:30] I saw like 50 people in person in San Francisco.

[00:52:33] This week,

[00:52:33] I had a light week.

[00:52:34] I spent three hours interviewing new therapists.

[00:52:37] I want to work with people I'm interested in.

[00:52:39] I'm moving into a new electronic health record.

[00:52:42] I spent concentrated amount of time on that.

[00:52:44] I saw probably 20 patients.

[00:52:47] I read a book.

[00:52:49] I talked to my mom on the phone.

[00:52:50] I talked to my best friend.

[00:52:51] I planned a trip in December.

[00:52:53] I did things that give value to me,

[00:52:58] to my patients,

[00:52:59] to the people I love,

[00:53:00] direct value.

[00:53:01] That's where I spend my time.

[00:53:03] I don't spend it on negativity.

[00:53:06] Absolutely.

[00:53:06] And yes,

[00:53:07] I mean,

[00:53:07] we have to do what we value.

[00:53:10] I guess for me,

[00:53:12] the value,

[00:53:13] and it's not all that we talk about on here.

[00:53:15] I try to bring on people who I truly consider to be experts in their fields,

[00:53:21] not just people who are promoted as experts,

[00:53:24] but those folks that understand the nuance that,

[00:53:27] like you mentioned,

[00:53:29] that don't fall into this trap of things being proven.

[00:53:31] Because I 100% agree with you there.

[00:53:34] And I think our minds naturally want to try to order and organize information into neat boxes with a little bow on top.

[00:53:43] And I think that's part of the reason why we see a significant amount of black or white,

[00:53:48] all or nothing type of thinking in our society.

[00:53:50] I see it,

[00:53:51] you know,

[00:53:51] in myself and kind of how my mind operates.

[00:53:55] But,

[00:53:56] but I guess for me,

[00:53:57] I value putting this out there and I guess putting pressure again.

[00:54:01] I don't know that what I do will have any sort of overall impact,

[00:54:05] but I feel like it's a way to honor the memories of,

[00:54:09] of some of the people that I know that are no longer with us or who have,

[00:54:13] you know,

[00:54:14] had their lives derailed because they were told that an opiate is not addictive.

[00:54:19] And that was shoved down again,

[00:54:22] people's throats that this substance that has knowingly been addictive since the middle ages is now all of a sudden touted as,

[00:54:31] as not addictive.

[00:54:32] And so I guess for me,

[00:54:34] that's,

[00:54:34] that's where I come from is,

[00:54:36] you know,

[00:54:36] my goal is to change the way that industry and regulation function,

[00:54:44] but the value behind it is in honoring those patients who have been harmed by the,

[00:54:50] the failures of the system.

[00:54:52] It's a very complex multifactorial issue that has a lot of different areas that,

[00:54:58] that probably need change in our society.

[00:55:01] First and foremost,

[00:55:03] that again is not something I can directly change.

[00:55:05] And I,

[00:55:06] I understand where you're coming from too,

[00:55:08] that as individuals and in terms of living our most fulfilling lives,

[00:55:14] we want to be able to impact the systems that we can impact.

[00:55:18] So,

[00:55:19] yeah,

[00:55:19] that's kind of my take on it.

[00:55:20] It's if I'm not critical,

[00:55:22] if I don't,

[00:55:23] you know,

[00:55:23] try to help people become aware of it,

[00:55:26] then how will the system change over time?

[00:55:31] We have to choose what,

[00:55:32] like for instance,

[00:55:33] there are probably thousands of patients suffering in France right now.

[00:55:36] I can't do anything for any of them.

[00:55:38] There are many things.

[00:55:39] I don't have the agency to do.

[00:55:42] I choose what I can do effectively.

[00:55:45] There,

[00:55:46] there's something else I did this week,

[00:55:47] which I always do.

[00:55:48] I didn't mention it because it's just my habit,

[00:55:49] but I probably consume material about an hour,

[00:55:55] two hours a day.

[00:55:56] So I'm listening to things and reading things like every morning I do my light

[00:56:00] therapy while I read the,

[00:56:01] read the literature.

[00:56:02] And then every,

[00:56:03] every moment that I am working out,

[00:56:07] cooking,

[00:56:08] caring for myself,

[00:56:09] I'm listening to something,

[00:56:11] right?

[00:56:11] So I get to choose what that content is.

[00:56:14] If it doesn't add value to myself or someone I care about,

[00:56:20] I don't do it.

[00:56:22] Yeah,

[00:56:22] absolutely.

[00:56:23] I forgot to ask you and I'm not,

[00:56:25] I'm not,

[00:56:26] I'm not trying to give you a hard time or anything.

[00:56:27] I ask everybody this because I do think it's important.

[00:56:30] Do you have any sort of financial disclosures?

[00:56:34] No.

[00:56:34] Are you?

[00:56:35] Okay.

[00:56:35] Yeah.

[00:56:37] I'm not working for industry right now.

[00:56:39] And all of my investments are in index funds.

[00:56:42] So there's probably some pharma in there,

[00:56:44] but I don't know about it.

[00:56:45] Yeah.

[00:56:46] I guess I'm,

[00:56:47] there's an idealistic side of me that envisions the way that medicine should run

[00:56:52] in a very,

[00:56:52] you know,

[00:56:53] a hundred percent scientific pursuit.

[00:56:56] But I think that it's tough for,

[00:56:58] again,

[00:56:59] to go back to the can of maps.

[00:57:00] It's tough when you've poured billions of dollars into this drug development

[00:57:05] based on what turns out to be a little bit of sketchy research.

[00:57:10] And then you're really behind the eight ball financially.

[00:57:13] It's you're in a tough spot trying to appease both the scientific pursuit and the financial

[00:57:19] pursuit,

[00:57:20] which is just inherently should not be how medicine operates.

[00:57:25] And it historically,

[00:57:25] I would say that has been less of an influence historically than I think it has been in the

[00:57:30] last 25 years,

[00:57:32] especially since the emergence of direct to consumer advertising,

[00:57:36] which was maybe one of the worst things that could have happened in our healthcare system

[00:57:40] back in,

[00:57:41] I think it was 1997.

[00:57:42] Thanks again for watching and or listening.

[00:57:47] If you're passionate about the subjects that I discuss on the channel,

[00:57:51] do me a favor and like comment,

[00:57:55] subscribe,

[00:57:57] do whatever you can to make your voice heard that these are problems that must be addressed in our society.

[00:58:05] If you have any questions,

[00:58:07] comments or concerns,

[00:58:08] I want to hear them.

[00:58:11] Feel free to reach out on social media or email us at renegadesyke at gmail.com.

[00:58:18] And if you'd like to be a guest of the show or you have a connection to somebody that you think would be a good

[00:58:23] guest,

[00:58:24] let us know.

[00:58:26] Thanks again for listening.

[00:58:36] Disclaimer.

[00:58:36] This podcast is for informational purposes only.

[00:58:38] The information provided in this podcast and related materials are meant only to

[00:58:40] educate.

[00:58:41] This information is not intended as a substitute for professional medical advice.

[00:58:44] While I am a medical doctor and many of my guests have extensive medical training and experience,

[00:58:47] nothing stated in this podcast,

[00:58:48] nor materials related to this podcast,

[00:58:49] including recommended websites,

[00:58:50] texts,

[00:58:51] graphics,

[00:58:51] images,

[00:58:52] or any other materials should be treated as a substitute for professional medical or psychological

[00:58:55] advice,

[00:58:55] diagnosis,

[00:58:56] or treatment.

[00:58:57] All listeners should consult with a medical professional licensed mental health provider

[00:58:59] or other healthcare provider.

[00:59:00] If seeking medical advice,

[00:59:01] diagnosis,

[00:59:02] or treatment.