June 9, 2025 • 46 mins
In this episode of the Meaning Project Podcast, Dr. Daniel A. Franz engages in a comprehensive discussion with Dr. Mark Hrymoc, a double board-certified psychiatrist specializing in addiction medicine. They explore the current landscape of addiction treatment, including the effectiveness of traditional methods like AA and the integration of modern medications. The conversation delves into the complexities of addiction, the role of genetics, and the emergence of behavioral addictions. They also discuss the impact of vaping, the potential of psychedelics in therapy, and the importance of destigmatizing mental health treatment.
Takeaways
Dr. Hrymoc completed his psychiatric residency training at Harbor-UCLA Medical Center and also trained at UCLA Medical Center and the West Los Angeles Veterans Administration Hospital. He obtained an MD degree at Rutgers New Jersey Medical School and did his undergraduate studies at the University of Pennsylvania. He has worked in a variety of treatment settings, from non-profit community mental health clinics to federally-sponsored multi-site medication development studies.
In addition to his clinical work, Dr. Hrymoc continues to be active in the local addiction treatment community. In September 2008, he founded Perspectives on Addiction, an interdisciplinary educational group for addiction professionals in Los Angeles. Dr. Hrymoc has served as the representative of the states of California, Alaska, and Hawaii to the American Academy of Addiction Psychiatry and was a member of the education committee of the California Society of Addiction Medicine. Dr. Hrymoc co-authored a chapter in Principles of Addiction Medicine, the main textbook of the American Society of Addiction Medicine and has been published in several academic journals.
Takeaways
- Addiction treatment is evolving with modern science.
- AA 12-step recovery remains foundational in addiction treatment.
- Listening to clients is crucial for effective treatment.
- Behavioral addictions are increasingly recognized and treated.
- Medications like naltrexone and Suboxone are game-changers.
- Genetics play a significant role in addiction susceptibility.
- Vaping poses new challenges in addiction treatment.
- Psychedelics show promise in treating mental health issues.
- Destigmatizing mental health treatment is essential for recovery.
- Long-term treatment may be necessary for chronic conditions.
Dr. Hrymoc completed his psychiatric residency training at Harbor-UCLA Medical Center and also trained at UCLA Medical Center and the West Los Angeles Veterans Administration Hospital. He obtained an MD degree at Rutgers New Jersey Medical School and did his undergraduate studies at the University of Pennsylvania. He has worked in a variety of treatment settings, from non-profit community mental health clinics to federally-sponsored multi-site medication development studies.
In addition to his clinical work, Dr. Hrymoc continues to be active in the local addiction treatment community. In September 2008, he founded Perspectives on Addiction, an interdisciplinary educational group for addiction professionals in Los Angeles. Dr. Hrymoc has served as the representative of the states of California, Alaska, and Hawaii to the American Academy of Addiction Psychiatry and was a member of the education committee of the California Society of Addiction Medicine. Dr. Hrymoc co-authored a chapter in Principles of Addiction Medicine, the main textbook of the American Society of Addiction Medicine and has been published in several academic journals.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:19):
Hello and welcome to the Meaning Project podcast. I'm your host,
doctor daniel A. Friends, and as always, thank you for
this opportunity to bring a little bit of mental health meaning,
purpose and resilience to.
Speaker 2 (00:28):
Your day today.
Speaker 1 (00:30):
Man.
Speaker 2 (00:31):
Awesome guest doctor Mark Reimach, MD, double board certified psychiatrist
practicing out on the West Coast, specializing in addiction medicine.
Speaker 1 (00:44):
Just a depth of knowledge, man, he had some you know,
it was great to talk to somebody that can really
have his wisdom and experience in medicine and addictions treatment.
And so we just kind of had a good chat
about what works for what mental health and addictions issues.
Speaker 2 (01:07):
So I hope you enjoy. Here's my conversation with doctor
Mark Rimon.
Speaker 1 (01:15):
Good morning, doctor Rymark. Thank you so much for taking
the time to come be on the Meeting Project podcast
and share your perspectives on addiction with my audience.
Speaker 3 (01:25):
Good morning. Yeah, thank you so much for having me.
Please call me.
Speaker 1 (01:28):
Mark Mark Great. Well, Mark, I was going over your
center's website and your information and your experience and addiction
is extensive and really just wanted to dive into your
perspective and well what you know about what we're doing right,
and what we're doing wrong in working with addiction today.
Speaker 4 (01:51):
Sure, what we're doing doing a lot of things right, certainly,
I mean addiction treatment. The foundation lies in AA twelve
step recovery and that's been shown through research and millions
of people's experience to really be helpful for treating addiction issues.
(02:13):
And with advancement in modern science, medications have also proven
themselves to be useful too, and increasingly with each decade,
we're seeing more and more adoption of medication treatment, both
for addiction and the conditions that underlie it that could
predispose a person to developing a substance issue. Things like depression, anxiety,
(02:38):
insomnia are all treatable medical conditions that do respond to medications,
and we also have a whole bunch of other supports
that are.
Speaker 3 (02:51):
Available individual psychotherapy.
Speaker 4 (02:54):
Many people prefer to other forms of psychosocial treatment, which
is what we would call, you know, twelve step or
any other talk type therapy, group therapies.
Speaker 1 (03:06):
You know.
Speaker 4 (03:06):
So there's also a lot of understanding that you know,
not it's not a cookie cutter approach, not necessarily the
same approach works for every person that we so we
now we do listen to the client slash patient and
get a sense of what resonates with them and what
they can buy into. So I think that's something also
(03:26):
that's been working better and better as time passes. What's
not working, you know, I guess the specific causes are debatable,
but definitely there are still relapses.
Speaker 3 (03:41):
There are still.
Speaker 4 (03:43):
You know, a lot of conflict, struggle, you know, false
starts and stops in any person's trajectory towards recovery. And
addiction is still a deadly disease and people are still
succumbing to it too, So clearly there's room for improvement there.
Speaker 1 (04:06):
Do you feel in your experience we're dealing with more
addiction or there's been an increase in recent times?
Speaker 4 (04:15):
Definitely during the pandemic there was a spike up, and
in general, if you look at graphs of you know,
the last five decades, let's say that there has been
a slow, steady trend up. The last few years are
looking more promising. So but you know, I I think
(04:36):
things can change, and they go in either direction every
five years or so.
Speaker 1 (04:40):
When you say more promising, as in we've done better since.
Speaker 3 (04:44):
Yeah, we've done better.
Speaker 4 (04:45):
Yeah, lower incidences of addiction and overdoses and other statistics
that we keep track of to measure the toll of
addiction on our society.
Speaker 1 (04:56):
Now does your office do you work in other forms
of addiction? I mean, today we have obviously substance abuse
and alcoholism and so many substances to become addicted to,
but also the proliferation of pornography and online spending and
gambling and things like that. Do you see similarities there?
You do you work in those realms?
Speaker 3 (05:18):
Sure? Yeah.
Speaker 4 (05:19):
We call those behavioral addictions as opposed to chemical addictions
or substance addictions, and you know they are mood altering
behaviors analogous to mood altering substances. So yeah, you pointed
out spending, gambling, sex, and love screen addiction.
Speaker 3 (05:41):
You are concepts.
Speaker 4 (05:43):
Not all of those are officially recognized by the DSM,
the sort of the bible of modern psychiatry, but definitely
clinicians in the field recognize these patterns and we see
that people are struggling with it.
Speaker 3 (05:57):
So I think it's just a matter of time.
Speaker 1 (06:00):
With all I mean, just off the top of your head,
it was great to hear you list all the different
possibilities for treatment, right A A behavioral, pharmacological How should
people go about discerning what might fit for them with
all these possibilities available, what's the best way to go?
(06:21):
How would you recommend somebody discern.
Speaker 4 (06:24):
That in general, try everything if you're open to it,
you know, be an informed consumer of psychological psychiatric services,
so that you also have an idea of what's out there.
So I think there's like an education process that comes
(06:44):
along with what the treatment options even are. So if
a person's open to it, you know, trying a little
bit of everything and seeing what they like, and you know,
if they're not sure, still keep trying it, you know,
and if they you know, use after let's say eight
to twelve sessions of therapy is when we would say
(07:05):
that's how much you need before you can even begin
to judge is this going to work for you?
Speaker 3 (07:10):
Is there improvement that's happening related to that?
Speaker 1 (07:13):
You know?
Speaker 4 (07:14):
And likewise, you know, ninety meetings in ninety days is
like the standard AA recommendation, and so we're coming upon
you know, this general recommendation of try try things for
like three months, Like three months is kind of how
long you need to do something to really kind of
get like a good you know, quote dose of it.
If we're going to consider this a treatment, you know,
that being the dose of the psychological treatment. And with medications,
(07:38):
you know, different ones have kind of different durations that
they might need to be tried for before we can
judge if they're working for a person or not.
Speaker 1 (07:46):
I think that's such a good point. So many people
we live in a time of quick fixes, and the
idea of three months to start doing better and feeling
better can be a little overwhelming. But I think you
make a great point. Try everything addiction that can be
a lifelong issue for people. Ups and downs as you're
pointing out, But yeah, try aam ninety meetings and ninety days. Boy,
(08:09):
that sounds overwhelming for a lot of people, but you know,
once you get into it and find that there's connection
and opportunity and growth, it works for a lot of people.
Speaking of what works, what medications are you finding helpful
for addiction's.
Speaker 3 (08:24):
Treatment for alcoholism?
Speaker 4 (08:29):
The standard one first try it often is now trek Zone,
an opioid blocker that comes as a pill form that's
either taken once a day, or there's an injection, long
acting that lasts one month called vivitrol.
Speaker 3 (08:44):
So that's a mainstay of treatment of alcohol issues.
Speaker 4 (08:49):
I still do prescribe anti use dysolfram, which people always
if they've heard of it, they always say, oh, that's
what makes you sick if you drink, And you know,
it's not supposed to make you sick because you're not
supposed to drink on it. It is supposed to act
as a psychological deterrent to drinking, not a physical or
(09:10):
aversive one.
Speaker 3 (09:12):
But for people who are motivated that actually.
Speaker 4 (09:14):
Take it, it is a useful medication, especially when their
goal is complete abstinence. So for opioid addiction, suboxone subutechs.
Speaker 3 (09:28):
Are is a useful medication.
Speaker 4 (09:31):
Bupern Orphine is the active ingredient in both, so that
they are lumped together. That's really changed the game and
the treatment of opioid addiction because it can be used
to detox a person even on an outpatient basis, which
is where I work. You know, I I'm seeing people
that come to me who are still working, going to
(09:51):
school and living their lives, but you know, they.
Speaker 3 (09:54):
Have an outpatient visit with me.
Speaker 4 (09:57):
So with that we can basically a transition to person
off of opioids, whether prescription or not onto this medication,
stabilize them and basically then gently taper them down to
whatever at whatever rate is really going to be beneficial
for them. Some people need to stay on it for
some time, you know, as a maintenance treatment, just while
(10:20):
they kind of get their stuff together in their lives
and in their minds, you know, establish proper psychological support
and establish a good foundation for which then they can
later taper off of. But now track Zone again can
be used for opioid addiction too, because it is an
(10:41):
opioid blocker, so it can reduce craving for opioids and
even block the effect of an opioid if a person
does slip too, So it takes away some of the
risk associated even with a person who's having craved makes
to the extent that they relapse and slip.
Speaker 3 (11:02):
It kind of takes.
Speaker 4 (11:02):
Away the the euphoria, the joy of what a person
may otherwise experience.
Speaker 3 (11:07):
With an opioid.
Speaker 1 (11:09):
Yeah, with with the now the mal Trek zone, I
was just working with the young man yesterday who was
reporting you know, very good results. He was was a
two timer in the old doctor Dan Men's substance abuse group,
and this time around was more serious and really wanted
to be sober, and he said the maltrexone was just
(11:31):
working miracles for him. What how does that work for
somebody when we see so much alcohol addiction out there?
How how does the maltrexone serve to help people fight
those cravings and to change their lifestyle.
Speaker 4 (11:46):
Yeah, even though alcohol is not an opioid, it's activity
in the brain, especially it's the euphoric buzz. The reinforcing
part of alcohol is mediated by the opioid systems in
a person's brain, and so by taking this medication, which
(12:07):
is an opioid blocker, it just kind of tamps down
on the activity of a person's opioid system, so it
reduces cravings for alcohol. A person has less thoughts of
using or especially if they're stressed or other things happen
in their lives that can trigger cravings. There tends to
be just less of those. And if a person does
(12:31):
slip and even have some alcohol, it tends to block
that euphoric buzz associated with alcohol as well. So it's
just less reinforcing to the extent that sometimes people say
they might even pour themselves an alcoholic drink, take a sip,
leave it on the counter and then just kind of
forget about it the way they might forget.
Speaker 3 (12:53):
About like a glass of water or juice or anything else.
Speaker 4 (12:55):
So it really can remove the special salience of alcohol,
we would say, you know, the specialness of it, and
so on some level it can.
Speaker 3 (13:05):
Become like just another beverage, you know. So that's that's
the goal, that's the ideal response.
Speaker 4 (13:10):
It doesn't exactly work that way for everyone, but it
can work that way for many people, and that's part
of why we use it for a lot of people.
Speaker 1 (13:21):
This might be a little bit of a philosophical question,
but what in your experience, what is the difference between
somebody who becomes an alcoholic or is an alcoholic and
those that can drink normally or socially appropriately or in moderation,
and what differs there.
Speaker 4 (13:42):
Yeah, genetics is definitely a big part of it. Addiction
is more heritable than even standard mental health issues like
depression or anxiety. For depression anxiety, we say it's fifty
to fifty genes and environment. For addiction issues it's sixty forty,
(14:02):
with genes being the majority there. So genetics are the
majority of the reason, but the other forty percent environment
can come from adverse childhood experiences, so you know, trauma
modeling also by parents or caretakers.
Speaker 3 (14:25):
If a child.
Speaker 4 (14:27):
Sees that a a adult copes with stress in their
lives by pouring themselves a drink at the end of
the day, that's kind of how they unwind that they
do learn just through observation that you know, this can
be used to cope with stress, deal with life, and
then that does get ingrained.
Speaker 3 (14:47):
And I always think.
Speaker 4 (14:48):
Of the human brain throughout its development as kind of
like wet concrete. And you know, the younger someone is
when they are exposed to anything, whether chemical or behavioral
as I'm describing, the more a chance of that imprint
kind of lasting throughout the life. There's this actually fascinating
(15:08):
stat about, you know, cigarette smoking. If someone tries smoking
cigarettes before the age of fourteen, they have something like
fourteen times the risk of becoming a lifelong smoker than
someone who just waits until they're eighteen and up, you know,
And so even that four year period in the mid
teens is a very kind of deterministic window in a
(15:31):
person's development.
Speaker 1 (15:32):
Wow. Did you you said fourteen times more likely.
Speaker 3 (15:36):
Something like that?
Speaker 1 (15:37):
Yes, that's wow. Well, and that's you know, no wonder
we have age requirements on purchasing and using some of these,
but right, yeah, I mean, in my experience it happens
sadly all the time. I know there's a large effort
in my community to prevent kids from finding cigarettes and
vapes and all these things. And I right, inherently, intuitively
(15:58):
always knew, well there's a good reason. But to recognize
that that is that significantly greater chance of becoming a
lifelong smoker is astounding. Wow. So other is we're talking
about suboxone, now treksone. What other forms of addiction are
you seeing in your office out on the West coast
or substances of abuse? Maybe?
Speaker 4 (16:20):
Yeah, I mean, honestly, alcohol and opioids are the big two.
They represent eighty five percent of addiction issues that I see.
So other ones that kind of make up the remaining
fifteen percent. Let's say, cannabis is a big one, even
(16:43):
though it's not as addictive in terms of the percentage
of people that ever try that actually meet qualifying criteria
to be considered addicted is low, like around nine percent
compared to others are like twenty or thirty percent for
alcohol and things like that there's so many people and
(17:05):
that are trying it, and now it's so readily available
at potencies that are greater than ever before that it
does create significant issues for many people, especially young people
in their teens and early twenties, just when you know,
the main mission in their life is to launch into
their individual self.
Speaker 3 (17:25):
And their way.
Speaker 4 (17:27):
That's when they determine how they're going to form relationships
in their lives and their career path or vocation, and
a lot of socialization that their individuation as a person
happens in those ages. It can really hold a person
back in that way. So other substances can be the
(17:48):
stimulants you know, methamphetamine, cocaine, other quote club drugs tend
to be associated with those two and in the background
all so is nicotine. Cigarettes vaping are all you know,
widely used in people with people that have addictions even
(18:09):
to other things. You know, just off the top of
my head, it looks like three quarters of people that
are addicted to some other substance the one that brings
them into my office.
Speaker 3 (18:16):
The main problem.
Speaker 4 (18:17):
Substance are also you know, using nicotine vaping, which also
takes this toll on a person's health absolutely.
Speaker 1 (18:24):
What do you think about this, this trend of vaping.
It was I don't know if it's still advertised that
way anymore, but it was once advertised is the alternative
to smoking, right, use this to help get off of cigarettes.
But in my experience, it's so much more harmful than
nicotine or than cigarette. Sorry tobacko.
Speaker 4 (18:42):
Yeah, yeah, so it's it's all. Nicotine and cigarettes are
clearly bad. Those have been around the longest, so you know,
we society has proven to itself with research and just
observation of the toll that can come from smoking and
it being a carcinogen. Vaping is probably not as bad
(19:05):
but still causes long irritation. What I always tell patients
is your lungs were not designed as a drug delivery mechanism.
They were meant to take in air, extract oxygen, breathe
out carbon dioxide and and that's all. But so yeah, definitely,
(19:25):
And because vaping is so easy to do even indoors now,
and the limits on it are less, a person can
actually end up vaping a lot more the equivalent of
a lot more than with cigarettes. And I definitely have
a lot of people when they tackle their main substance
that's bringing them to my office that then turn their
(19:47):
attention to nicotine, and we ultimately treat it the same way.
And you know, there are medications used for that. You know,
chantis or veronic clean is the best one that's out
there in terms of its effectiveness, and there can be
some side effects, but in general, people do tend to
target it well. And then it's so good that I
(20:08):
almost think of it as like if a person wants
to quit, they will quit using this medicine. Like the
main reason you a person fails to quit using that
is they are aren't taking the medicine basically, and then yeah,
nictine replacement therapy, patches, gum things like that. Still nicotine
still have that physiologic dependence associated with them, but don't
(20:31):
really have the any other health consequences.
Speaker 3 (20:35):
You know, maybe raise blood pressure a little bit.
Speaker 4 (20:37):
It's sort of ironic that the nicotine itself is not
actually all that harmful. What's unhealthy about it is the
way in which people take it, so most dangerous being cigarettes, tobacco,
even chewing tobacco, and then you know, followed by vayping.
So you know, if a person needs to stay on
patches are gum. I say, okay, as long as you
(20:59):
need to, you know, take your time, and usually they
do come off it within a year or two. I
also find that just helps in my building the relationship
with the patient in terms of me not coming off
as a nag or forcing them off of things, and you.
Speaker 3 (21:15):
Know it's just them being engaged in treatment.
Speaker 4 (21:17):
Is actually one of the most important things about treatment
with me or any other health professional.
Speaker 1 (21:23):
Yeah, I think that's such a good point. For many
of the people struggling with different kinds of addiction, it's
often the cigarettes or the vape or the last thing
that goes like, hey, let's not try to do all
the changes at one time. Maybe just a little bit,
you know, moving forward and as you said, try a
little bit of everything treatment wise, but maybe even with
(21:43):
cigarettes and vaping. You know, it's a slower process for
a lot of people. Chantis that's an interesting one. You know.
I was hearing about it a lot, maybe five or
ten years ago, not so much these days. It kind
of got a bad rap for a while because of
its you know, potential side effects. What does that do
to help people, How does that impact the brain to
help people quit smoking?
Speaker 4 (22:06):
Yeah, you're probably not hearing about it as much because
it's generic now.
Speaker 3 (22:10):
So that's a phenomenon in the US.
Speaker 4 (22:12):
You know, when there's something that's brand named, pharmaceutical companies
advertise it, so you see it in print and TV
and online, et cetera. But yeah, Chantix is again a
really useful medication, helps so many people, and it works
and entirely analogously to the way that suboxone puprin orphine
(22:36):
works for opioids.
Speaker 3 (22:38):
So it is we would.
Speaker 4 (22:40):
Say a partial agonist at the nicotine receptor, so that
means it partially stimulates the nicotine receptor, stimulates it a
little bit, not quite as much as nicotine, but stimulates
it enough that a person doesn't go into a withdrawal
if they are not taking in other nicotine. It basically
(23:01):
helps prevent withdrawal. And it's also very long acting in
the system. And it also has a very high binding affinity,
so magnetism or hold on the nicotine receptor. So it
I think of it as putting gum in a key
hole nicket. Chantis is the gum that you can put
(23:22):
in the key hole, which is the nicotine receptor that
even if there was nicotine floating around, it could not.
Speaker 3 (23:28):
Access the key hole.
Speaker 4 (23:30):
It just blocks the receptor while stimulating it somewhat, so
a person doesn't go into withdrawal. And so it just
almost like puts the nicotine system on ice. And you know,
I also kind of think of it that way. It just,
you know, if we think of addiction as like a
daily cycle or even hourly cycle of a person using
a substance and then it gets filtered out of their systems,
(23:51):
they crave it again and then they use it again,
so they're in this kind of seesaw pattern throughout the
day with their blood levels. And you know, with chantis
analogously bupern orphine suboxone.
Speaker 3 (24:02):
It just stays there and it's like at a very steady.
Speaker 4 (24:05):
Level, so a person can go on and do other
things and they're not slaves to that up and down
cycle that there otherwise.
Speaker 1 (24:11):
Would be right right, beautiful metaphor there. I love the
gum and the keyhole, and I'm going to take that
with me and he sat in the opposite. That's a
really good way to say it. You mentioned. Okay, so
nicotine in itself not terrible for us, but it's the
mechanisms by which we acquire it. Can you talk a
little bit about that in what way? What are the
different ways that those mechanisms can harm us.
Speaker 4 (24:36):
Yeah, so the route of administration of any drug or
medication is relevant to a lot of different things. With
nicotine specifically, you know, if we think of again the
most dangerous burning tobacco, carcinogens are created, you know, so
(24:57):
that contacts your lips, your entire respiratory tract going from
your lips to the bottom of your lungs. And so
that's why we see cigarette smoking predisposing to mouth cancers
and pharyngeal cancers and cancer of the lung obviously too,
(25:18):
and other forms they had. Chewing tobacco, there's trans mucosal
absorption through the mucous membranes of your mouth, but that
tobacco is still sitting there against your cheeks or gum,
and so that's why the oral cancers have are increased
in people that are chewing tobacco. And with vaping, you know,
(25:41):
it's it's still an irritant. You know, there's nicotine there.
It's also unregulated, so we don't know what other other
industrial chemicals, solvents of other things are actually in vapes.
And they can vary across products, and there's no standardization.
So because it's unregulated, you know, we don't know exactly
(26:03):
what the risks are. I mean, the assumption is it
definitely causes bronchitis, like an irritation of the innerlining of
the lungs, so that that becomes relevant too. But then yeah,
we just think of other ways nicotine can be absorbed,
like you just yeah, pure chemical nicotine can be put
in a patch applied against the skin, so transdermal absorption
(26:24):
is you know, relatively harmless. And some also with like
there's nicotine lozenges, nicotine spray exists, I mean, it's not
as commonly used usually it's patches are gum that people
are using, and so you know that's just pure nicotine
without the carriers. You know, it's the kind of the
carriers associated with that nicotine can cause wreaks, some havoc
(26:48):
on the system.
Speaker 1 (26:49):
Okay, so this may not be socially appropriate, but I'm
going to try it anyway because we see so much.
I see so much of these, uh, the zin pouches, right,
the nicotine pouches. So if nicotine is not too terrible
for us, does that mean these pouches and I see
(27:10):
them with kids so much. It's it's crazy. But does
that mean those maybe aren't as bad or they're still
pretty bad for you?
Speaker 3 (27:19):
Yeah? My understanding is zin does not contain tobacco.
Speaker 1 (27:23):
Right, Okay, just straight nicotine? Yeah, I think mostly nicotine.
Don't know what else is.
Speaker 4 (27:28):
Yeah, there's also other pouches that do, and I'm the ones. Yeah,
might need to actually just double check about brand names
and all. But if the tobacco is in it, then
it is dangerous basically ultimately equivalent to chewing tobacco, you know,
(27:49):
pure nicotine on its own. If it's like yeah, transmucosal absorption,
I would assume is actually the same as like a
nicotine lozenge, which exists as a way of quitting nickedin
too interesting.
Speaker 1 (28:01):
Interesting, Okay, what I know On your website it mentions
using ketamine assisted therapy for addictions. I just just yesterday
completed a pretty extensive course in psychedelic therapy with ketamine
as well as other substances. What kind of results are
(28:23):
you getting with the ketemine assisted therapy?
Speaker 4 (28:27):
So to clarify, and I'm pretty sure our website doesn't
specifically say using ketamine to treat addictions.
Speaker 3 (28:34):
Okay, sorry, I would say is used.
Speaker 4 (28:37):
To treat mood issues, depression anxiety, BTSD that potentially it
can have all sorts of secondary consequences in a person's life.
But ketamine is mainly a treatment for mood issues. There's
definitely interest research interest in it being used as a
(28:59):
treatment for addiction, and there's even some small studies suggesting
that it could be helpful for alcohol and cocaine or
the substances that there are small studies about. But for
the most part, ketamine is not in that we'd say
the clinical practice guidelines, you know, the marching orders, the
(29:20):
directives that a doctor would actually use to recommend treatments
to a specific person. But if a person happens to
be in recovery and not using any substance, even though
they may have had a history of using substances, and
still struggle with significant depression anxiety PTSD that could result
(29:41):
in relapse, then an argument can be made that it
can protect them from a relapse if we treat their
primary mood issue and it works really well, really quickly,
both biologically and experientially, we would say so it can make.
Speaker 3 (30:03):
Therapy more effective too.
Speaker 4 (30:05):
We've definitely had patients who say they've been in therapy
on and off throughout their lives for many years, but
when they have ketamine assisted psychotherapy, they feel like they
get a lot more out of it.
Speaker 3 (30:17):
There's more potency there.
Speaker 4 (30:18):
Maybe they're even able to access thoughts, feelings, emotions that
they can't access in their typical conscious state. And by
being in that non ordinary state that ketamine induces, it
can help them address certain issues and have insights.
Speaker 3 (30:34):
That they can then implement in their regular day to
day lives.
Speaker 1 (30:39):
Got it. So not necessarily specific for addiction treatment, but
to treat the as you said, the mood issues that
may impact or relate to addiction, kenmy can be helpful. God,
it's sorry for the most that. Yeah, that makes a
lot of sense. That makes more sense. So it's not
directly for addiction, and that.
Speaker 4 (30:59):
State is out there and they're definitely practitioners. Websites that will,
you know, advertise using ketamine for addiction issues.
Speaker 3 (31:08):
But you know, I do.
Speaker 4 (31:10):
Feel strongly about my role as a doctor being one
where society trusts me, like the state of California gives
me a medical license and trust me to be you know,
accurate with my words and portrayals, and so I do
think it's really important to highlight that it's not any
(31:31):
sort of standard treatment for addiction issues, but for mood
issues there's a different story.
Speaker 1 (31:36):
Absolutely that makes complete sense. Thank you for clarifying that.
Any thoughts. I know, California, the West Coast in general, Oregon,
Washington really hotbeds for research in alternative medicines for moods
and addiction. Any thoughts on that research, what what is
(31:58):
coming out of that area when it relates to d
MDMA trials, psilocybinus back up, even I think it may
be Colorado. I'm not sure about California experimenting with LSD
for different treatments. These are things that were used in
the fifties and sixties that we're seeing re emerge. Any
thoughts on those.
Speaker 3 (32:18):
Definitely?
Speaker 4 (32:18):
Yeah, there really does seem to be a new chapter
opening up in psychiatry where many psychedelics are currently being
studied for almost every single psychiatric indication diagnosis basically, so
including things you wouldn't intuitively think of. Like you said,
(32:42):
LSD for the treatment of generalized anxiety disorder is actually
like one of the biggest studies that's happening right now,
and we think of LSD, we think of people who
may have had bad experiences that triggered anxiety. But yet
you know, there's a big difference in context. You know,
the saying is set and setting, So your mindset going
into a psychedelic experience, and the setting, both in terms
(33:04):
of physical environment and the people around you, actually are
really important in determining the subjective experience there.
Speaker 3 (33:12):
And so I think what it's.
Speaker 4 (33:14):
Really demonstrating that specific trial with LSD for anxiety is
that with the right foundation of good environment, supportive people
around you, people even that you know you've met, And
some of these studies actually have therapists as a part
of it and others don't.
Speaker 3 (33:30):
Others are kind of medication alone.
Speaker 4 (33:32):
So but that can make something like LSD even potentially
helpful for anxiety. So, you know, it's not standard clinical
treatment yet and their research is still being done. LSD
is still not legal for use in any sort of
(33:54):
medical scenario, but there's definitely a lot of promising research
with psyched elex and yeah.
Speaker 3 (34:01):
Psilocybin is the main one.
Speaker 1 (34:03):
Now.
Speaker 3 (34:03):
It seems like you know, m D m A, there
were they did not get FDA approval.
Speaker 4 (34:10):
Last summer, and everyone was looking forward to that being approved,
and basically the FDA told them they have to redo
a bunch of studies and do better next time, basically
for their next attempt at approval, which I'm sure will happen,
but it will be a few years from now. And
(34:30):
psilocybin is the research is coming out really does show
it being promising for depression primarily and also to some
degree alcohol use disorder alcoholism, so, you know, and many
other psychedelics like d m T five me e O,
d m T type A gain you know, are are
(34:53):
being studied for so many different psychiatric communications.
Speaker 1 (34:57):
Yeah, a lot of a lot of great research. I
had no idea l he was being studied specifically for anxiety.
As you pointed out that most people associate LSD with
a bad trip that you know, poorly chosen set and setting,
maybe not having the right people around and therefore inducing anxiety.
I didn't realize we're looking at it for anxiety. That is,
(35:19):
it's pretty interesting, quite spectacular. So any any further information
on psilocybin for alcoholic use, is that specifically related to mood?
Therefore improved mood maybe decreased alcohol users, or some other
relationship there.
Speaker 4 (35:39):
That's still being determined. You know, when research on specifically
any kind of psychiatric medication is done, it's very simple
and basic, and it really just looks at a group
of people that have a condition and then they're either
given the active drug or some placebo, and then we
(36:02):
look at the outcome in terms of a few outcome measures,
which can include, you know, sobriety, rates of relapse, or
in the case of depression, like depressive symptoms like low energy,
low motivation, depressed mood, et cetera, suicidal thinking. So they're
only looking at the before and after effects of getting
(36:25):
a certain treatment. As far as mechanism that you're asking about,
we can speculate, you know, and a lot of these things.
I mean, certainly with ketamine, appears that they have both
biological actions as a medication and even the again, not
all of the current psychedelic trials are incorporating psychotherapy.
Speaker 3 (36:46):
Many are just medication alone.
Speaker 4 (36:49):
So the medication kind of a biological effect, but also
there's probably an experiential effect. I mean, the experience of
a psychedelic can be so profound. I mean, there are
also stats where when people have a psychedelic you know,
I think this one comes from psilocybin specifically. You know,
they will commonly rank it as one of the ten
(37:11):
most meaningful experiences of their lives.
Speaker 1 (37:13):
You know.
Speaker 4 (37:14):
And a lot of these studies are showing beneficial effects
that last six to twelve months, like well beyond even
like the biological impact of a medication. And so you know,
the thinking is that, yes, there is something happening with
a person's perspective on things, on themselves, on the world
and their role in it.
Speaker 3 (37:33):
And you know, and that all helps basically.
Speaker 1 (37:37):
Yeah, well, interesting stuff that we'll be seeing in the future. Yes,
I know a lot of people are disappointed by the
failure of MDMA to be approved, and they're going right
back to work to try to do it. I've heard
stories of many, especially for veterans, going south of the
border to Mexico for different kinds of treatment and coming
back with excellent results but not quite legal here yet soon. Wow,
(38:04):
we've been all over the place, just kind of You've
listened a lot of good questions from me, other things
you want the audience to know, just things off the
top of your head, or you know, sorry, I've been
kind of leading this conversation you wanted to share.
Speaker 4 (38:16):
Noah, I appreciate your your lead. Enjoy answering the questions too.
Speaker 1 (38:25):
You know.
Speaker 4 (38:26):
I mean a big cause that I really believe in
and communicate to patients that I work with is to
destigmatize the treatment of mental health issues.
Speaker 1 (38:40):
You know.
Speaker 3 (38:40):
Even the people that are coming into.
Speaker 4 (38:42):
My doors who have gone through their own process too,
you know, feel comfortable doing that. I recognize there's a
lot of people that suffer and struggle on their own
without reaching out for help for a long time. But
once they do come in and they we start talking
about things, I do notice stigma operating in the background,
(39:03):
even people have been seeing for years, you know. And
that's illustrated by people who may have had a successful
round of treatment with some conventional antidepressant like zoloft or
lexipro let's say, and they're doing well for two years
and the issues that they came in with are no
longer there. And I'm seeing them every six months, mainly
(39:25):
just to check in and make sure everything is still
going okay. But you know, they do start asking questions like,
you know, when can I come off this?
Speaker 3 (39:35):
And I don't want to be on this forever.
Speaker 4 (39:39):
And those are totally reasonable questions, and I, you know,
don't don't follow anyone for asking questions. But I have
all sorts of patients asking this, And in psychiatry, the
ones that have had just kind of one episode, the
milder cases, those are the ones where we say, Okay,
(39:59):
after six or twelve months, we'll try you off it,
see how it goes.
Speaker 3 (40:03):
At that point, there's kind of.
Speaker 4 (40:04):
Like a fifty to fifty chance of recurrence of their issue.
But I also have people that have had, you know,
lifelong struggles with chronic and severe depression, you know, pulling
at wanting to come off their medications, which you know,
I've seen them at their worst, and many times they'll
tell me, yeah, I've been like this, like on and
(40:25):
off since my teens, and my first visit with them
might be in their forties, and they have this recurring issue,
and yet they still kind of have this idea in
their mind, like they don't want to take a medication
for a mental health issue. Taking a medication means that
they're inherently weak or of poor moral character or some
(40:47):
other A lot of times unconscious.
Speaker 3 (40:51):
Programming is operating in the background. There so I you.
Speaker 4 (40:56):
Know, really try to encourage those people that, look, we
you have a medical condition just equivalent to high blood
pressure or asthma, things that we may think of as
having a pure quote medical basis.
Speaker 3 (41:10):
And you know, before you had wheezing when you exercised
with and now you have an inhaler.
Speaker 4 (41:17):
Or other medicine, and you know, you exercise and you
live as if you don't have asthma. You know, likewise,
for depression anxiety trauma, if a person has recurrent, especially
a severe history with that, there are chances of a
recurrence are.
Speaker 3 (41:32):
Ninety percent or more.
Speaker 4 (41:33):
And so we always weigh kind of the risks and
benefits and medicine of.
Speaker 3 (41:37):
Continuing a treatment or not.
Speaker 4 (41:40):
And depression itself is so debilitating, and the medicines are
so safe that it almost is a no brainer to
just kind of stay on the medicine. Think of it
as a vitamin that you take every day for optimal functioning,
and you live your life and you're doing well. So
you know, I think stigma is still alive and well,
(42:04):
and even in people who've bought into treatment with conventional
psychiatric medications or other forms of mental health treatment, you know,
really do struggle with that. So I think that's definitely
a soapbox that I stand on.
Speaker 1 (42:19):
Yeah, and I appreciate that soapbox, but the destigmatization, you know,
I usually I love using the hero's journey metaphor for
mental health and treatment. That you know, we've studied the
hero's journey through mythology and ancient stories and even you know,
great modern storytelling usually follows that path. That you know,
(42:40):
every hero has a mentor that teaches, you know, gives
them the lightsaber or the golden ring or whatever it
might be. And you know, there's nothing wrong with you know,
having that mentor having you know, therapy on and off
as needed, you know, mentorship throughout life. But the same
goes for that that lightsaber, right, that medication from time
(43:02):
to time that we may need to help us get
over the hump, or you know, for those who are
struggling significantly or frequently, like yeah, it may be something
that you have to keep an eye on, you know,
throughout throughout your life too, to function optimally, right, And
so I definitely appreciate that perspective. Well, hopefully you're enjoying
(43:26):
a beautiful sunny day in la I know here in
the Midwest. We're dealing with gray and clouds again as
we usually do, so I will thank you for your
time and I mean just such a great perspective and
in depth knowledge. I love, you know, from a therapy perspective,
it's it's great to have that kind of in depth
medical knowledge that you provided. So thank you. Thank you
(43:49):
for the time today and sharing anything else you want
to leave the audience with before we part.
Speaker 3 (43:57):
Thanks for listening.
Speaker 4 (43:58):
And I really hope that you all are able to
live fully to your highest potential, including personal relationships and
work and physical health. And you know, we all have
that same challenge in front of us to really be
all that we can be and make the most of
our lives. So I hope each of you are able
(44:20):
to do that in your day to day life.
Speaker 1 (44:23):
Beautifully stated. Once again, thank you so much for your time.
Speaker 3 (44:26):
Take care all right, Thank you so much, doctor dan Man.
Speaker 2 (44:33):
That was that was a good time.
Speaker 1 (44:34):
It's interesting, you know, usually here on the Meaning Project
we kind of riff and just go in different directions.
But I appreciate how mark doctor Reimoch, how specific and
scientific he was. Yeah, maybe that's the word for.
Speaker 2 (44:55):
It, you know, when I when I.
Speaker 1 (44:58):
He probably shouldn't be using manufacturers' names for nicotine patches
like I did there, So it was just kind of
interesting that there are different ones out there and not
just that so in comedy on the idea. Like I've
mentioned this before, occasional use of nicotine and tobacco not
(45:19):
always a terrible thing, you know, same with alcohol, you know,
always in moderation, some things can be all right, I'm
not going to stay healthy, but it can be maybe
beneficial for us.
Speaker 2 (45:32):
But what a great.
Speaker 1 (45:33):
Conversation and what a depth of knowledge and experience. So
for those of you interested in working with doctor Oh,
that was one of the post discussions. I love a
good psychiatrist that spends time with his clients, and that's
what we were talking about afterwards. Doctor Reimark definitely gets
to know the people he works with and spends time
(45:55):
with them. So if you're interested in working with him,
you can look him up. I will leave his information
in the show notes. Meanwhile, as always, thank you for
this opportunity to bring a little bit of mental health
meaning purpose and resilience to your day.
Speaker 2 (46:09):
Take care,
Hello and welcome to the Meaning Project podcast. I'm your host,
doctor daniel A. Friends, and as always, thank you for
this opportunity to bring a little bit of mental health meaning,
purpose and resilience to.
Speaker 2 (00:28):
Your day today.
Speaker 1 (00:30):
Man.
Speaker 2 (00:31):
Awesome guest doctor Mark Reimach, MD, double board certified psychiatrist
practicing out on the West Coast, specializing in addiction medicine.
Speaker 1 (00:44):
Just a depth of knowledge, man, he had some you know,
it was great to talk to somebody that can really
have his wisdom and experience in medicine and addictions treatment.
And so we just kind of had a good chat
about what works for what mental health and addictions issues.
Speaker 2 (01:07):
So I hope you enjoy. Here's my conversation with doctor
Mark Rimon.
Speaker 1 (01:15):
Good morning, doctor Rymark. Thank you so much for taking
the time to come be on the Meeting Project podcast
and share your perspectives on addiction with my audience.
Speaker 3 (01:25):
Good morning. Yeah, thank you so much for having me.
Please call me.
Speaker 1 (01:28):
Mark Mark Great. Well, Mark, I was going over your
center's website and your information and your experience and addiction
is extensive and really just wanted to dive into your
perspective and well what you know about what we're doing right,
and what we're doing wrong in working with addiction today.
Speaker 4 (01:51):
Sure, what we're doing doing a lot of things right, certainly,
I mean addiction treatment. The foundation lies in AA twelve
step recovery and that's been shown through research and millions
of people's experience to really be helpful for treating addiction issues.
(02:13):
And with advancement in modern science, medications have also proven
themselves to be useful too, and increasingly with each decade,
we're seeing more and more adoption of medication treatment, both
for addiction and the conditions that underlie it that could
predispose a person to developing a substance issue. Things like depression, anxiety,
(02:38):
insomnia are all treatable medical conditions that do respond to medications,
and we also have a whole bunch of other supports
that are.
Speaker 3 (02:51):
Available individual psychotherapy.
Speaker 4 (02:54):
Many people prefer to other forms of psychosocial treatment, which
is what we would call, you know, twelve step or
any other talk type therapy, group therapies.
Speaker 1 (03:06):
You know.
Speaker 4 (03:06):
So there's also a lot of understanding that you know,
not it's not a cookie cutter approach, not necessarily the
same approach works for every person that we so we
now we do listen to the client slash patient and
get a sense of what resonates with them and what
they can buy into. So I think that's something also
(03:26):
that's been working better and better as time passes. What's
not working, you know, I guess the specific causes are debatable,
but definitely there are still relapses.
Speaker 3 (03:41):
There are still.
Speaker 4 (03:43):
You know, a lot of conflict, struggle, you know, false
starts and stops in any person's trajectory towards recovery. And
addiction is still a deadly disease and people are still
succumbing to it too, So clearly there's room for improvement there.
Speaker 1 (04:06):
Do you feel in your experience we're dealing with more
addiction or there's been an increase in recent times?
Speaker 4 (04:15):
Definitely during the pandemic there was a spike up, and
in general, if you look at graphs of you know,
the last five decades, let's say that there has been
a slow, steady trend up. The last few years are
looking more promising. So but you know, I I think
(04:36):
things can change, and they go in either direction every
five years or so.
Speaker 1 (04:40):
When you say more promising, as in we've done better since.
Speaker 3 (04:44):
Yeah, we've done better.
Speaker 4 (04:45):
Yeah, lower incidences of addiction and overdoses and other statistics
that we keep track of to measure the toll of
addiction on our society.
Speaker 1 (04:56):
Now does your office do you work in other forms
of addiction? I mean, today we have obviously substance abuse
and alcoholism and so many substances to become addicted to,
but also the proliferation of pornography and online spending and
gambling and things like that. Do you see similarities there?
You do you work in those realms?
Speaker 3 (05:18):
Sure? Yeah.
Speaker 4 (05:19):
We call those behavioral addictions as opposed to chemical addictions
or substance addictions, and you know they are mood altering
behaviors analogous to mood altering substances. So yeah, you pointed
out spending, gambling, sex, and love screen addiction.
Speaker 3 (05:41):
You are concepts.
Speaker 4 (05:43):
Not all of those are officially recognized by the DSM,
the sort of the bible of modern psychiatry, but definitely
clinicians in the field recognize these patterns and we see
that people are struggling with it.
Speaker 3 (05:57):
So I think it's just a matter of time.
Speaker 1 (06:00):
With all I mean, just off the top of your head,
it was great to hear you list all the different
possibilities for treatment, right A A behavioral, pharmacological How should
people go about discerning what might fit for them with
all these possibilities available, what's the best way to go?
(06:21):
How would you recommend somebody discern.
Speaker 4 (06:24):
That in general, try everything if you're open to it,
you know, be an informed consumer of psychological psychiatric services,
so that you also have an idea of what's out there.
So I think there's like an education process that comes
(06:44):
along with what the treatment options even are. So if
a person's open to it, you know, trying a little
bit of everything and seeing what they like, and you know,
if they're not sure, still keep trying it, you know,
and if they you know, use after let's say eight
to twelve sessions of therapy is when we would say
(07:05):
that's how much you need before you can even begin
to judge is this going to work for you?
Speaker 3 (07:10):
Is there improvement that's happening related to that?
Speaker 1 (07:13):
You know?
Speaker 4 (07:14):
And likewise, you know, ninety meetings in ninety days is
like the standard AA recommendation, and so we're coming upon
you know, this general recommendation of try try things for
like three months, Like three months is kind of how
long you need to do something to really kind of
get like a good you know, quote dose of it.
If we're going to consider this a treatment, you know,
that being the dose of the psychological treatment. And with medications,
(07:38):
you know, different ones have kind of different durations that
they might need to be tried for before we can
judge if they're working for a person or not.
Speaker 1 (07:46):
I think that's such a good point. So many people
we live in a time of quick fixes, and the
idea of three months to start doing better and feeling
better can be a little overwhelming. But I think you
make a great point. Try everything addiction that can be
a lifelong issue for people. Ups and downs as you're
pointing out, But yeah, try aam ninety meetings and ninety days. Boy,
(08:09):
that sounds overwhelming for a lot of people, but you know,
once you get into it and find that there's connection
and opportunity and growth, it works for a lot of people.
Speaking of what works, what medications are you finding helpful
for addiction's.
Speaker 3 (08:24):
Treatment for alcoholism?
Speaker 4 (08:29):
The standard one first try it often is now trek Zone,
an opioid blocker that comes as a pill form that's
either taken once a day, or there's an injection, long
acting that lasts one month called vivitrol.
Speaker 3 (08:44):
So that's a mainstay of treatment of alcohol issues.
Speaker 4 (08:49):
I still do prescribe anti use dysolfram, which people always
if they've heard of it, they always say, oh, that's
what makes you sick if you drink, And you know,
it's not supposed to make you sick because you're not
supposed to drink on it. It is supposed to act
as a psychological deterrent to drinking, not a physical or
(09:10):
aversive one.
Speaker 3 (09:12):
But for people who are motivated that actually.
Speaker 4 (09:14):
Take it, it is a useful medication, especially when their
goal is complete abstinence. So for opioid addiction, suboxone subutechs.
Speaker 3 (09:28):
Are is a useful medication.
Speaker 4 (09:31):
Bupern Orphine is the active ingredient in both, so that
they are lumped together. That's really changed the game and
the treatment of opioid addiction because it can be used
to detox a person even on an outpatient basis, which
is where I work. You know, I I'm seeing people
that come to me who are still working, going to
(09:51):
school and living their lives, but you know, they.
Speaker 3 (09:54):
Have an outpatient visit with me.
Speaker 4 (09:57):
So with that we can basically a transition to person
off of opioids, whether prescription or not onto this medication,
stabilize them and basically then gently taper them down to
whatever at whatever rate is really going to be beneficial
for them. Some people need to stay on it for
some time, you know, as a maintenance treatment, just while
(10:20):
they kind of get their stuff together in their lives
and in their minds, you know, establish proper psychological support
and establish a good foundation for which then they can
later taper off of. But now track Zone again can
be used for opioid addiction too, because it is an
(10:41):
opioid blocker, so it can reduce craving for opioids and
even block the effect of an opioid if a person
does slip too, So it takes away some of the
risk associated even with a person who's having craved makes
to the extent that they relapse and slip.
Speaker 3 (11:02):
It kind of takes.
Speaker 4 (11:02):
Away the the euphoria, the joy of what a person
may otherwise experience.
Speaker 3 (11:07):
With an opioid.
Speaker 1 (11:09):
Yeah, with with the now the mal Trek zone, I
was just working with the young man yesterday who was
reporting you know, very good results. He was was a
two timer in the old doctor Dan Men's substance abuse group,
and this time around was more serious and really wanted
to be sober, and he said the maltrexone was just
(11:31):
working miracles for him. What how does that work for
somebody when we see so much alcohol addiction out there?
How how does the maltrexone serve to help people fight
those cravings and to change their lifestyle.
Speaker 4 (11:46):
Yeah, even though alcohol is not an opioid, it's activity
in the brain, especially it's the euphoric buzz. The reinforcing
part of alcohol is mediated by the opioid systems in
a person's brain, and so by taking this medication, which
(12:07):
is an opioid blocker, it just kind of tamps down
on the activity of a person's opioid system, so it
reduces cravings for alcohol. A person has less thoughts of
using or especially if they're stressed or other things happen
in their lives that can trigger cravings. There tends to
be just less of those. And if a person does
(12:31):
slip and even have some alcohol, it tends to block
that euphoric buzz associated with alcohol as well. So it's
just less reinforcing to the extent that sometimes people say
they might even pour themselves an alcoholic drink, take a sip,
leave it on the counter and then just kind of
forget about it the way they might forget.
Speaker 3 (12:53):
About like a glass of water or juice or anything else.
Speaker 4 (12:55):
So it really can remove the special salience of alcohol,
we would say, you know, the specialness of it, and
so on some level it can.
Speaker 3 (13:05):
Become like just another beverage, you know. So that's that's
the goal, that's the ideal response.
Speaker 4 (13:10):
It doesn't exactly work that way for everyone, but it
can work that way for many people, and that's part
of why we use it for a lot of people.
Speaker 1 (13:21):
This might be a little bit of a philosophical question,
but what in your experience, what is the difference between
somebody who becomes an alcoholic or is an alcoholic and
those that can drink normally or socially appropriately or in moderation,
and what differs there.
Speaker 4 (13:42):
Yeah, genetics is definitely a big part of it. Addiction
is more heritable than even standard mental health issues like
depression or anxiety. For depression anxiety, we say it's fifty
to fifty genes and environment. For addiction issues it's sixty forty,
(14:02):
with genes being the majority there. So genetics are the
majority of the reason, but the other forty percent environment
can come from adverse childhood experiences, so you know, trauma
modeling also by parents or caretakers.
Speaker 3 (14:25):
If a child.
Speaker 4 (14:27):
Sees that a a adult copes with stress in their
lives by pouring themselves a drink at the end of
the day, that's kind of how they unwind that they
do learn just through observation that you know, this can
be used to cope with stress, deal with life, and
then that does get ingrained.
Speaker 3 (14:47):
And I always think.
Speaker 4 (14:48):
Of the human brain throughout its development as kind of
like wet concrete. And you know, the younger someone is
when they are exposed to anything, whether chemical or behavioral
as I'm describing, the more a chance of that imprint
kind of lasting throughout the life. There's this actually fascinating
(15:08):
stat about, you know, cigarette smoking. If someone tries smoking
cigarettes before the age of fourteen, they have something like
fourteen times the risk of becoming a lifelong smoker than
someone who just waits until they're eighteen and up, you know,
And so even that four year period in the mid
teens is a very kind of deterministic window in a
(15:31):
person's development.
Speaker 1 (15:32):
Wow. Did you you said fourteen times more likely.
Speaker 3 (15:36):
Something like that?
Speaker 1 (15:37):
Yes, that's wow. Well, and that's you know, no wonder
we have age requirements on purchasing and using some of these,
but right, yeah, I mean, in my experience it happens
sadly all the time. I know there's a large effort
in my community to prevent kids from finding cigarettes and
vapes and all these things. And I right, inherently, intuitively
(15:58):
always knew, well there's a good reason. But to recognize
that that is that significantly greater chance of becoming a
lifelong smoker is astounding. Wow. So other is we're talking
about suboxone, now treksone. What other forms of addiction are
you seeing in your office out on the West coast
or substances of abuse? Maybe?
Speaker 4 (16:20):
Yeah, I mean, honestly, alcohol and opioids are the big two.
They represent eighty five percent of addiction issues that I see.
So other ones that kind of make up the remaining
fifteen percent. Let's say, cannabis is a big one, even
(16:43):
though it's not as addictive in terms of the percentage
of people that ever try that actually meet qualifying criteria
to be considered addicted is low, like around nine percent
compared to others are like twenty or thirty percent for
alcohol and things like that there's so many people and
(17:05):
that are trying it, and now it's so readily available
at potencies that are greater than ever before that it
does create significant issues for many people, especially young people
in their teens and early twenties, just when you know,
the main mission in their life is to launch into
their individual self.
Speaker 3 (17:25):
And their way.
Speaker 4 (17:27):
That's when they determine how they're going to form relationships
in their lives and their career path or vocation, and
a lot of socialization that their individuation as a person
happens in those ages. It can really hold a person
back in that way. So other substances can be the
(17:48):
stimulants you know, methamphetamine, cocaine, other quote club drugs tend
to be associated with those two and in the background
all so is nicotine. Cigarettes vaping are all you know,
widely used in people with people that have addictions even
(18:09):
to other things. You know, just off the top of
my head, it looks like three quarters of people that
are addicted to some other substance the one that brings
them into my office.
Speaker 3 (18:16):
The main problem.
Speaker 4 (18:17):
Substance are also you know, using nicotine vaping, which also
takes this toll on a person's health absolutely.
Speaker 1 (18:24):
What do you think about this, this trend of vaping.
It was I don't know if it's still advertised that
way anymore, but it was once advertised is the alternative
to smoking, right, use this to help get off of cigarettes.
But in my experience, it's so much more harmful than
nicotine or than cigarette. Sorry tobacko.
Speaker 4 (18:42):
Yeah, yeah, so it's it's all. Nicotine and cigarettes are
clearly bad. Those have been around the longest, so you know,
we society has proven to itself with research and just
observation of the toll that can come from smoking and
it being a carcinogen. Vaping is probably not as bad
(19:05):
but still causes long irritation. What I always tell patients
is your lungs were not designed as a drug delivery mechanism.
They were meant to take in air, extract oxygen, breathe
out carbon dioxide and and that's all. But so yeah, definitely,
(19:25):
And because vaping is so easy to do even indoors now,
and the limits on it are less, a person can
actually end up vaping a lot more the equivalent of
a lot more than with cigarettes. And I definitely have
a lot of people when they tackle their main substance
that's bringing them to my office that then turn their
(19:47):
attention to nicotine, and we ultimately treat it the same way.
And you know, there are medications used for that. You know,
chantis or veronic clean is the best one that's out
there in terms of its effectiveness, and there can be
some side effects, but in general, people do tend to
target it well. And then it's so good that I
(20:08):
almost think of it as like if a person wants
to quit, they will quit using this medicine. Like the
main reason you a person fails to quit using that
is they are aren't taking the medicine basically, and then yeah,
nictine replacement therapy, patches, gum things like that. Still nicotine
still have that physiologic dependence associated with them, but don't
(20:31):
really have the any other health consequences.
Speaker 3 (20:35):
You know, maybe raise blood pressure a little bit.
Speaker 4 (20:37):
It's sort of ironic that the nicotine itself is not
actually all that harmful. What's unhealthy about it is the
way in which people take it, so most dangerous being cigarettes, tobacco,
even chewing tobacco, and then you know, followed by vayping.
So you know, if a person needs to stay on
patches are gum. I say, okay, as long as you
(20:59):
need to, you know, take your time, and usually they
do come off it within a year or two. I
also find that just helps in my building the relationship
with the patient in terms of me not coming off
as a nag or forcing them off of things, and you.
Speaker 3 (21:15):
Know it's just them being engaged in treatment.
Speaker 4 (21:17):
Is actually one of the most important things about treatment
with me or any other health professional.
Speaker 1 (21:23):
Yeah, I think that's such a good point. For many
of the people struggling with different kinds of addiction, it's
often the cigarettes or the vape or the last thing
that goes like, hey, let's not try to do all
the changes at one time. Maybe just a little bit,
you know, moving forward and as you said, try a
little bit of everything treatment wise, but maybe even with
(21:43):
cigarettes and vaping. You know, it's a slower process for
a lot of people. Chantis that's an interesting one. You know.
I was hearing about it a lot, maybe five or
ten years ago, not so much these days. It kind
of got a bad rap for a while because of
its you know, potential side effects. What does that do
to help people, How does that impact the brain to
help people quit smoking?
Speaker 4 (22:06):
Yeah, you're probably not hearing about it as much because
it's generic now.
Speaker 3 (22:10):
So that's a phenomenon in the US.
Speaker 4 (22:12):
You know, when there's something that's brand named, pharmaceutical companies
advertise it, so you see it in print and TV
and online, et cetera. But yeah, Chantix is again a
really useful medication, helps so many people, and it works
and entirely analogously to the way that suboxone puprin orphine
(22:36):
works for opioids.
Speaker 3 (22:38):
So it is we would.
Speaker 4 (22:40):
Say a partial agonist at the nicotine receptor, so that
means it partially stimulates the nicotine receptor, stimulates it a
little bit, not quite as much as nicotine, but stimulates
it enough that a person doesn't go into a withdrawal
if they are not taking in other nicotine. It basically
(23:01):
helps prevent withdrawal. And it's also very long acting in
the system. And it also has a very high binding affinity,
so magnetism or hold on the nicotine receptor. So it
I think of it as putting gum in a key
hole nicket. Chantis is the gum that you can put
(23:22):
in the key hole, which is the nicotine receptor that
even if there was nicotine floating around, it could not.
Speaker 3 (23:28):
Access the key hole.
Speaker 4 (23:30):
It just blocks the receptor while stimulating it somewhat, so
a person doesn't go into withdrawal. And so it just
almost like puts the nicotine system on ice. And you know,
I also kind of think of it that way. It just,
you know, if we think of addiction as like a
daily cycle or even hourly cycle of a person using
a substance and then it gets filtered out of their systems,
(23:51):
they crave it again and then they use it again,
so they're in this kind of seesaw pattern throughout the
day with their blood levels. And you know, with chantis
analogously bupern orphine suboxone.
Speaker 3 (24:02):
It just stays there and it's like at a very steady.
Speaker 4 (24:05):
Level, so a person can go on and do other
things and they're not slaves to that up and down
cycle that there otherwise.
Speaker 1 (24:11):
Would be right right, beautiful metaphor there. I love the
gum and the keyhole, and I'm going to take that
with me and he sat in the opposite. That's a
really good way to say it. You mentioned. Okay, so
nicotine in itself not terrible for us, but it's the
mechanisms by which we acquire it. Can you talk a
little bit about that in what way? What are the
different ways that those mechanisms can harm us.
Speaker 4 (24:36):
Yeah, so the route of administration of any drug or
medication is relevant to a lot of different things. With
nicotine specifically, you know, if we think of again the
most dangerous burning tobacco, carcinogens are created, you know, so
(24:57):
that contacts your lips, your entire respiratory tract going from
your lips to the bottom of your lungs. And so
that's why we see cigarette smoking predisposing to mouth cancers
and pharyngeal cancers and cancer of the lung obviously too,
(25:18):
and other forms they had. Chewing tobacco, there's trans mucosal
absorption through the mucous membranes of your mouth, but that
tobacco is still sitting there against your cheeks or gum,
and so that's why the oral cancers have are increased
in people that are chewing tobacco. And with vaping, you know,
(25:41):
it's it's still an irritant. You know, there's nicotine there.
It's also unregulated, so we don't know what other other
industrial chemicals, solvents of other things are actually in vapes.
And they can vary across products, and there's no standardization.
So because it's unregulated, you know, we don't know exactly
(26:03):
what the risks are. I mean, the assumption is it
definitely causes bronchitis, like an irritation of the innerlining of
the lungs, so that that becomes relevant too. But then yeah,
we just think of other ways nicotine can be absorbed,
like you just yeah, pure chemical nicotine can be put
in a patch applied against the skin, so transdermal absorption
(26:24):
is you know, relatively harmless. And some also with like
there's nicotine lozenges, nicotine spray exists, I mean, it's not
as commonly used usually it's patches are gum that people
are using, and so you know that's just pure nicotine
without the carriers. You know, it's the kind of the
carriers associated with that nicotine can cause wreaks, some havoc
(26:48):
on the system.
Speaker 1 (26:49):
Okay, so this may not be socially appropriate, but I'm
going to try it anyway because we see so much.
I see so much of these, uh, the zin pouches, right,
the nicotine pouches. So if nicotine is not too terrible
for us, does that mean these pouches and I see
(27:10):
them with kids so much. It's it's crazy. But does
that mean those maybe aren't as bad or they're still
pretty bad for you?
Speaker 3 (27:19):
Yeah? My understanding is zin does not contain tobacco.
Speaker 1 (27:23):
Right, Okay, just straight nicotine? Yeah, I think mostly nicotine.
Don't know what else is.
Speaker 4 (27:28):
Yeah, there's also other pouches that do, and I'm the ones. Yeah,
might need to actually just double check about brand names
and all. But if the tobacco is in it, then
it is dangerous basically ultimately equivalent to chewing tobacco, you know,
(27:49):
pure nicotine on its own. If it's like yeah, transmucosal absorption,
I would assume is actually the same as like a
nicotine lozenge, which exists as a way of quitting nickedin
too interesting.
Speaker 1 (28:01):
Interesting, Okay, what I know On your website it mentions
using ketamine assisted therapy for addictions. I just just yesterday
completed a pretty extensive course in psychedelic therapy with ketamine
as well as other substances. What kind of results are
(28:23):
you getting with the ketemine assisted therapy?
Speaker 4 (28:27):
So to clarify, and I'm pretty sure our website doesn't
specifically say using ketamine to treat addictions.
Speaker 3 (28:34):
Okay, sorry, I would say is used.
Speaker 4 (28:37):
To treat mood issues, depression anxiety, BTSD that potentially it
can have all sorts of secondary consequences in a person's life.
But ketamine is mainly a treatment for mood issues. There's
definitely interest research interest in it being used as a
(28:59):
treatment for addiction, and there's even some small studies suggesting
that it could be helpful for alcohol and cocaine or
the substances that there are small studies about. But for
the most part, ketamine is not in that we'd say
the clinical practice guidelines, you know, the marching orders, the
(29:20):
directives that a doctor would actually use to recommend treatments
to a specific person. But if a person happens to
be in recovery and not using any substance, even though
they may have had a history of using substances, and
still struggle with significant depression anxiety PTSD that could result
(29:41):
in relapse, then an argument can be made that it
can protect them from a relapse if we treat their
primary mood issue and it works really well, really quickly,
both biologically and experientially, we would say so it can make.
Speaker 3 (30:03):
Therapy more effective too.
Speaker 4 (30:05):
We've definitely had patients who say they've been in therapy
on and off throughout their lives for many years, but
when they have ketamine assisted psychotherapy, they feel like they
get a lot more out of it.
Speaker 3 (30:17):
There's more potency there.
Speaker 4 (30:18):
Maybe they're even able to access thoughts, feelings, emotions that
they can't access in their typical conscious state. And by
being in that non ordinary state that ketamine induces, it
can help them address certain issues and have insights.
Speaker 3 (30:34):
That they can then implement in their regular day to
day lives.
Speaker 1 (30:39):
Got it. So not necessarily specific for addiction treatment, but
to treat the as you said, the mood issues that
may impact or relate to addiction, kenmy can be helpful. God,
it's sorry for the most that. Yeah, that makes a
lot of sense. That makes more sense. So it's not
directly for addiction, and that.
Speaker 4 (30:59):
State is out there and they're definitely practitioners. Websites that will,
you know, advertise using ketamine for addiction issues.
Speaker 3 (31:08):
But you know, I do.
Speaker 4 (31:10):
Feel strongly about my role as a doctor being one
where society trusts me, like the state of California gives
me a medical license and trust me to be you know,
accurate with my words and portrayals, and so I do
think it's really important to highlight that it's not any
(31:31):
sort of standard treatment for addiction issues, but for mood
issues there's a different story.
Speaker 1 (31:36):
Absolutely that makes complete sense. Thank you for clarifying that.
Any thoughts. I know, California, the West Coast in general, Oregon,
Washington really hotbeds for research in alternative medicines for moods
and addiction. Any thoughts on that research, what what is
(31:58):
coming out of that area when it relates to d
MDMA trials, psilocybinus back up, even I think it may
be Colorado. I'm not sure about California experimenting with LSD
for different treatments. These are things that were used in
the fifties and sixties that we're seeing re emerge. Any
thoughts on those.
Speaker 3 (32:18):
Definitely?
Speaker 4 (32:18):
Yeah, there really does seem to be a new chapter
opening up in psychiatry where many psychedelics are currently being
studied for almost every single psychiatric indication diagnosis basically, so
including things you wouldn't intuitively think of. Like you said,
(32:42):
LSD for the treatment of generalized anxiety disorder is actually
like one of the biggest studies that's happening right now,
and we think of LSD, we think of people who
may have had bad experiences that triggered anxiety. But yet
you know, there's a big difference in context. You know,
the saying is set and setting, So your mindset going
into a psychedelic experience, and the setting, both in terms
(33:04):
of physical environment and the people around you, actually are
really important in determining the subjective experience there.
Speaker 3 (33:12):
And so I think what it's.
Speaker 4 (33:14):
Really demonstrating that specific trial with LSD for anxiety is
that with the right foundation of good environment, supportive people
around you, people even that you know you've met, And
some of these studies actually have therapists as a part
of it and others don't.
Speaker 3 (33:30):
Others are kind of medication alone.
Speaker 4 (33:32):
So but that can make something like LSD even potentially
helpful for anxiety. So, you know, it's not standard clinical
treatment yet and their research is still being done. LSD
is still not legal for use in any sort of
(33:54):
medical scenario, but there's definitely a lot of promising research
with psyched elex and yeah.
Speaker 3 (34:01):
Psilocybin is the main one.
Speaker 1 (34:03):
Now.
Speaker 3 (34:03):
It seems like you know, m D m A, there
were they did not get FDA approval.
Speaker 4 (34:10):
Last summer, and everyone was looking forward to that being approved,
and basically the FDA told them they have to redo
a bunch of studies and do better next time, basically
for their next attempt at approval, which I'm sure will happen,
but it will be a few years from now. And
(34:30):
psilocybin is the research is coming out really does show
it being promising for depression primarily and also to some
degree alcohol use disorder alcoholism, so, you know, and many
other psychedelics like d m T five me e O,
d m T type A gain you know, are are
(34:53):
being studied for so many different psychiatric communications.
Speaker 1 (34:57):
Yeah, a lot of a lot of great research. I
had no idea l he was being studied specifically for anxiety.
As you pointed out that most people associate LSD with
a bad trip that you know, poorly chosen set and setting,
maybe not having the right people around and therefore inducing anxiety.
I didn't realize we're looking at it for anxiety. That is,
(35:19):
it's pretty interesting, quite spectacular. So any any further information
on psilocybin for alcoholic use, is that specifically related to mood?
Therefore improved mood maybe decreased alcohol users, or some other
relationship there.
Speaker 4 (35:39):
That's still being determined. You know, when research on specifically
any kind of psychiatric medication is done, it's very simple
and basic, and it really just looks at a group
of people that have a condition and then they're either
given the active drug or some placebo, and then we
(36:02):
look at the outcome in terms of a few outcome measures,
which can include, you know, sobriety, rates of relapse, or
in the case of depression, like depressive symptoms like low energy,
low motivation, depressed mood, et cetera, suicidal thinking. So they're
only looking at the before and after effects of getting
(36:25):
a certain treatment. As far as mechanism that you're asking about,
we can speculate, you know, and a lot of these things.
I mean, certainly with ketamine, appears that they have both
biological actions as a medication and even the again, not
all of the current psychedelic trials are incorporating psychotherapy.
Speaker 3 (36:46):
Many are just medication alone.
Speaker 4 (36:49):
So the medication kind of a biological effect, but also
there's probably an experiential effect. I mean, the experience of
a psychedelic can be so profound. I mean, there are
also stats where when people have a psychedelic you know,
I think this one comes from psilocybin specifically. You know,
they will commonly rank it as one of the ten
(37:11):
most meaningful experiences of their lives.
Speaker 1 (37:13):
You know.
Speaker 4 (37:14):
And a lot of these studies are showing beneficial effects
that last six to twelve months, like well beyond even
like the biological impact of a medication. And so you know,
the thinking is that, yes, there is something happening with
a person's perspective on things, on themselves, on the world
and their role in it.
Speaker 3 (37:33):
And you know, and that all helps basically.
Speaker 1 (37:37):
Yeah, well, interesting stuff that we'll be seeing in the future. Yes,
I know a lot of people are disappointed by the
failure of MDMA to be approved, and they're going right
back to work to try to do it. I've heard
stories of many, especially for veterans, going south of the
border to Mexico for different kinds of treatment and coming
back with excellent results but not quite legal here yet soon. Wow,
(38:04):
we've been all over the place, just kind of You've
listened a lot of good questions from me, other things
you want the audience to know, just things off the
top of your head, or you know, sorry, I've been
kind of leading this conversation you wanted to share.
Speaker 4 (38:16):
Noah, I appreciate your your lead. Enjoy answering the questions too.
Speaker 1 (38:25):
You know.
Speaker 4 (38:26):
I mean a big cause that I really believe in
and communicate to patients that I work with is to
destigmatize the treatment of mental health issues.
Speaker 1 (38:40):
You know.
Speaker 3 (38:40):
Even the people that are coming into.
Speaker 4 (38:42):
My doors who have gone through their own process too,
you know, feel comfortable doing that. I recognize there's a
lot of people that suffer and struggle on their own
without reaching out for help for a long time. But
once they do come in and they we start talking
about things, I do notice stigma operating in the background,
(39:03):
even people have been seeing for years, you know. And
that's illustrated by people who may have had a successful
round of treatment with some conventional antidepressant like zoloft or
lexipro let's say, and they're doing well for two years
and the issues that they came in with are no
longer there. And I'm seeing them every six months, mainly
(39:25):
just to check in and make sure everything is still
going okay. But you know, they do start asking questions like,
you know, when can I come off this?
Speaker 3 (39:35):
And I don't want to be on this forever.
Speaker 4 (39:39):
And those are totally reasonable questions, and I, you know,
don't don't follow anyone for asking questions. But I have
all sorts of patients asking this, And in psychiatry, the
ones that have had just kind of one episode, the
milder cases, those are the ones where we say, Okay,
(39:59):
after six or twelve months, we'll try you off it,
see how it goes.
Speaker 3 (40:03):
At that point, there's kind of.
Speaker 4 (40:04):
Like a fifty to fifty chance of recurrence of their issue.
But I also have people that have had, you know,
lifelong struggles with chronic and severe depression, you know, pulling
at wanting to come off their medications, which you know,
I've seen them at their worst, and many times they'll
tell me, yeah, I've been like this, like on and
(40:25):
off since my teens, and my first visit with them
might be in their forties, and they have this recurring issue,
and yet they still kind of have this idea in
their mind, like they don't want to take a medication
for a mental health issue. Taking a medication means that
they're inherently weak or of poor moral character or some
(40:47):
other A lot of times unconscious.
Speaker 3 (40:51):
Programming is operating in the background. There so I you.
Speaker 4 (40:56):
Know, really try to encourage those people that, look, we
you have a medical condition just equivalent to high blood
pressure or asthma, things that we may think of as
having a pure quote medical basis.
Speaker 3 (41:10):
And you know, before you had wheezing when you exercised
with and now you have an inhaler.
Speaker 4 (41:17):
Or other medicine, and you know, you exercise and you
live as if you don't have asthma. You know, likewise,
for depression anxiety trauma, if a person has recurrent, especially
a severe history with that, there are chances of a
recurrence are.
Speaker 3 (41:32):
Ninety percent or more.
Speaker 4 (41:33):
And so we always weigh kind of the risks and
benefits and medicine of.
Speaker 3 (41:37):
Continuing a treatment or not.
Speaker 4 (41:40):
And depression itself is so debilitating, and the medicines are
so safe that it almost is a no brainer to
just kind of stay on the medicine. Think of it
as a vitamin that you take every day for optimal functioning,
and you live your life and you're doing well. So
you know, I think stigma is still alive and well,
(42:04):
and even in people who've bought into treatment with conventional
psychiatric medications or other forms of mental health treatment, you know,
really do struggle with that. So I think that's definitely
a soapbox that I stand on.
Speaker 1 (42:19):
Yeah, and I appreciate that soapbox, but the destigmatization, you know,
I usually I love using the hero's journey metaphor for
mental health and treatment. That you know, we've studied the
hero's journey through mythology and ancient stories and even you know,
great modern storytelling usually follows that path. That you know,
(42:40):
every hero has a mentor that teaches, you know, gives
them the lightsaber or the golden ring or whatever it
might be. And you know, there's nothing wrong with you know,
having that mentor having you know, therapy on and off
as needed, you know, mentorship throughout life. But the same
goes for that that lightsaber, right, that medication from time
(43:02):
to time that we may need to help us get
over the hump, or you know, for those who are
struggling significantly or frequently, like yeah, it may be something
that you have to keep an eye on, you know,
throughout throughout your life too, to function optimally, right, And
so I definitely appreciate that perspective. Well, hopefully you're enjoying
(43:26):
a beautiful sunny day in la I know here in
the Midwest. We're dealing with gray and clouds again as
we usually do, so I will thank you for your
time and I mean just such a great perspective and
in depth knowledge. I love, you know, from a therapy perspective,
it's it's great to have that kind of in depth
medical knowledge that you provided. So thank you. Thank you
(43:49):
for the time today and sharing anything else you want
to leave the audience with before we part.
Speaker 3 (43:57):
Thanks for listening.
Speaker 4 (43:58):
And I really hope that you all are able to
live fully to your highest potential, including personal relationships and
work and physical health. And you know, we all have
that same challenge in front of us to really be
all that we can be and make the most of
our lives. So I hope each of you are able
(44:20):
to do that in your day to day life.
Speaker 1 (44:23):
Beautifully stated. Once again, thank you so much for your time.
Speaker 3 (44:26):
Take care all right, Thank you so much, doctor dan Man.
Speaker 2 (44:33):
That was that was a good time.
Speaker 1 (44:34):
It's interesting, you know, usually here on the Meaning Project
we kind of riff and just go in different directions.
But I appreciate how mark doctor Reimoch, how specific and
scientific he was. Yeah, maybe that's the word for.
Speaker 2 (44:55):
It, you know, when I when I.
Speaker 1 (44:58):
He probably shouldn't be using manufacturers' names for nicotine patches
like I did there, So it was just kind of
interesting that there are different ones out there and not
just that so in comedy on the idea. Like I've
mentioned this before, occasional use of nicotine and tobacco not
(45:19):
always a terrible thing, you know, same with alcohol, you know,
always in moderation, some things can be all right, I'm
not going to stay healthy, but it can be maybe
beneficial for us.
Speaker 2 (45:32):
But what a great.
Speaker 1 (45:33):
Conversation and what a depth of knowledge and experience. So
for those of you interested in working with doctor Oh,
that was one of the post discussions. I love a
good psychiatrist that spends time with his clients, and that's
what we were talking about afterwards. Doctor Reimark definitely gets
to know the people he works with and spends time
(45:55):
with them. So if you're interested in working with him,
you can look him up. I will leave his information
in the show notes. Meanwhile, as always, thank you for
this opportunity to bring a little bit of mental health
meaning purpose and resilience to your day.
Speaker 2 (46:09):
Take care,
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