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Delic Radio: Ketamine Therapy with Dr David Feifel

Delic Radio Ketamine Therapy
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Hello boys and girls, ladies and gentlemen. My name’s Jackee. You’re listening to Delic Radio. Thanks for coming back. Thanks for all your well wishes. We really love doing this for you guys. How are you guys doing? How are you all doing there? How are you hanging in? It’s March 2020. It’s fucking COVID time or as they’re calling it now, C-19. It’s heavy out there, but there’s many silver linings to discuss. People are coming together. We are seeing the beauty in human nature on the front lines with our healthcare workers, with innovators who have access to create more masks, to create more ventilators. Shout out to Elon Musk, Elon Musk for president, maybe not. That might be weird. Let’s perhaps just keep him where he’s at because he’s doing a great job, but there’s a lot of positive things coming out of this mess.

For those of you who don’t feel that way now, I hope that you will. For those voiceless that are in pain all across the world, you’re not alone. We feel you, we hear you, we see you, we are with you. We are you. On today’s episode, we have a very talented doctor. I’m so grateful to speak to so many talented physician scientists. This is fun. This is super fun guys. As a podcast producer for many years, it is just a dream to be able to come on here and interview people that I think are interesting related to psychedelics and psychedelic culture and just the world, because man, I love it. Podcasts save my spirit and I hope you feel that way too.

Okay. Dr. David Feifel. Yeah. You all remember that movie Feifel? I know. It was all sad. It was just sad. Oh [inaudible 00:03:14]. Anyway, Dr. David Feifel. He is many things. He runs Kadima Neuropsychiatry down near San Diego in California. He’s the Director of Neuropsychiatry and Behavioral Medicine, at his clinic Kadima – and he has used ketamine treatment for resistant PTSD, resistant depression, anxiety, all of these things. He’s used it in his clinic for many, many years to treat those mental health conditions and he’s made a lot of people better. He uses other modalities, but he’s a really interesting mix of science, medicine, psychiatry. Yes, I very intentionally separated those. He’s also a practical guy and you can tell just an artist.

I think that we forget that in those mediums and those crafts, that it is an artistic thing to do anything well, including business. That’s for another podcast. But yes, ladies and gentlemen, believe it or not business is an art form and I love it. But ketamine, ketamine, ketamine, you’ve heard a few bits about my personal experiences with pharmaceutical ketamine to treat anxiety and depression with our Dr. Cook episodes. It is a wildly effective tool in my toolbox to treat and stop my depression in its tracks, for about seven days, depending on when I do it. it is an entirely different experience than the handful of times I’ve tried ketamine recreationally. I tend to not make any recommendations because I am not a doctor nor do I work for the FDA. We all have our own free will and ability to make choices. But if somebody were to ask me, I would say unless you’re a super scientist, psycho not, and you made the ketamine or you watched somebody make it. I just really don’t think it’s a substance that recreationally is useful, but maybe I’m wrong.

I just think that safety is super cool. Safety is super cool and we don’t have the tools as a culture to be able to test what we’re consuming and take ownership of it. So since we can’t do that, let’s not do any substances that might put us in harm’s way and instead focus our energies towards the medicinal route because it’s helping a lot of people. As always thanks for listening to Delic Radio, thanks for all your love and support. Likewise, we love and support you. Hang in there. We will get through this. Imagine a better future for all of us.

Full Transcript

Jackee: Hello, ladies and gentlemen, thank you for listening to Delic Radio. I am your host, Jackee Stang in these uncertain times. We’re very excited that you took time while possibly quarantined to sit here and listen with us. I’m very excited today to bring you Dr. Feifel. Dr. Feifel is a master clinician certified neuropsychiatrist and accomplished brain scientist. Dr. Feifel was a full Professor of Psychiatry at UC San Diego for over 20 years during which he established several successful clinical and research programs focusing on advanced treatments. In 2017, Dr. Feifel decided to resign his full-time tenured position appointment at UCSD and established Kadima to more effectively pursue his vision of creating a center focused on developing and utilizing innovative noninvasive treatments. Dr. Feifel maintains an active appointment as Professor Emeritus of Psychiatry within UCSD’s School of Medicine. Dr. Feifel, welcome.

Dr. David Feifel: Well, thank you very much. And mom, thank you for writing that great bio.

Jackee: Thanks mom.

Dr. David Feifel: Okay.

Jackee: Do you mind if I call you David?

DF: Not at all.

Jackee: Excellent. Okay, cool. So let’s start at the beginning or at least at the beginning of this story of the Kadima story. What is Kadima? What does it stand for? And I have to be honest, neuropsychiatry, this is the first time I’ve ever seen that word.

DF: I made it up.

Jackee: Oh, excellent.

DF: No, I didn’t.

Jackee: Well, so get into it. Tell us about Kadima and neuropsychiatry.

DF: Kadima is the formal name of our practice here, the Kadima Neuropsychiatry Institute. We lovingly refer to it just as Kadima, but Kadima, actually when I was thinking, when I was thinking about what am I going to name my new baby, what do I want to reflect? I was thinking about something is progressive and forward. Not only in terms of the things that we do, but also moving the people that we try to help forward in their lives. So often stuck. And of course, things come to mind as forward mental health or advancement. It’s so common. I chose Kadima because Kadima is Hebrew for forward or advance. If you want to say, if you want to tell somebody, “Come on, let’s go. Let’s move, let’s advance.” You’d say, “Kadima.” And so I thought that was a little bit more exotic than Forward Neuropsychiatry Institute. I figured it would sort of probably get people to ask the question you were asking and then I got a chance to explain it. So it works.

So Kadima means essentially forward or move ahead. Neuropsychiatry is the sort of a… It’s a sub field of psychiatry that specializes in looking at psychiatric illnesses based in the brain, in the function of the three and a half pound piece of tissue that sits above our neck. Sort of more taking a modern medical approach to trying to understand. We’re still being informed by the tradition of psychiatry and so forth. So, that’s what neuropsychometry means to me. And there is actually a subspecialty where you can get certified in that, through the powers that be.

Jackee: Well, it seems like the best of both worlds to me and treating the other epidemic outside of the current one, COVID-19 but the mental health crisis and the suicide epidemic and opioid crisis and opioid epidemic.

DF: Yeah.

Jackee: Yeah. You seem to be at the forefront of really effecting change within people in that regard. You also are, I’ll just say you’re down in San Diego, is that correct? That’s where your offices are?

DF: Mm-hmm (affirmative).

Jackee: Yeah.

DF: That’s correct.

Jackee: I was recommended to you initially a couple of years ago, because I was searching for ketamine treatments to treat my own anxiety and depression. Ketamine is not the new kid on the block, right? We’ve had physicians on here before any physiologists talk about the origins of it and what it was originally intended for and it’s definitely not new in terms of a psychedelic-like substance that people use recreationally. But I think it’s resurging in popularity. And so I wanted to talk to you about that and how you see ketamine and how you use it to treat certain psychiatric… I was about to say malfunctions, brain conditions.

DF: Disorders, yeah.

Jackee: Disorders in people, because you have such a breadth of knowledge. Talk to me, talk to me about ketamine.

DF: Sure. Yeah. Well, ketamine you’re right. It’s not the new kid on the block, but it’s sort of the new, old kid on the block in a way. I mean, it’s been around for half a century in its original manifestation as an anesthetic drug. It’s kind of having a renewed… It’s been being repurposed in a way that we never anticipated. So those of us in the medical field ketamine is very familiar to us, because it’s used every day in every hospital and every emergency rooms. Even after 50 years, it’s still one of the most widely used anesthetic, because it has a unique property that doesn’t suppress your respiration, which is a relatively unusual for anesthetics. So can be given quite safely without the usual heavy monitoring that you would usually do for normal anesthesia.

So for example, kids, children tend to be a big target population for giving this because yes, in the emergency room, if a child comes in, dislocated their shoulder, it’s a lot easier just to give them a little ketamine and IV or intramuscularly, rather than take them to the OR and put them out and put a tube down their throat and have an anesthesiologist monitor to make sure that they’re not getting… Their breathing is okay. And same thing, the veterinarians picked up on that cool aspect of it. So it’s still very widely used. What is interesting was that around 2000, I would say, 13 years ago, there was a couple of studies looking at lower doses of ketamine, doses that we would call sub-anesthetic, don’t put you out. In patients who had clinical depression that was not responding to the traditional treatments like the antidepressants.

To everyone’s surprise, those studies showed remarkable improvements, which is pretty cool by itself because that’s a population of people who have pretty tough depression. They’ve been on several antidepressants. They’ve been through talk therapy for many times and the depression’s not getting better. So it’s already a tough foe and to get anything that works is pretty remarkable, but what made it even more remarkable, these small studies that were done first out of Mount Sinai Hospital in New York, with some investigators associated with Yale, and then later at the National Institute of Mental Health was replicated. What added benefit to it was that a lot of people felt better quickly, almost immediately, within 24 hours, which is in psychiatry, unheard of. Because usually, prescribe an antidepressant, you tell people, “Well, you may get the side effects right away, but you’re going to have to wait weeks before you start feeling better, if you do start feeling better.”

That was really unprecedented. In fact, a lot of people looked at those original studies of very few people and thought, “Too good to be true.” I have to admit I was one of them until it was replicated the second one at NIMH. That was in 2006. When I looked at that, I said, “Either this is just one…” Sometimes in science, we get these studies that just don’t pan out. Small group, it just happened to work that way, but then nobody else can replicate it. And so I figured, “Either this one of those situations or this is one of the biggest breakthroughs.” I went to the powers that be at UC San Diego, where I was on faculty. I said, “Hey, if this is even half as true, as it seems based on these published studies, we need to start looking at this, giving. There’s so many patients that come to me that have been referred from their doctors that have been tried everything and I have very little to offer them.”

It took me about nine months. I convinced very conservative bureaucracy to allow me to do it and we started doing it. We were the first program in the world to give ketamine infusions at the time, intravenous fusions for psychiatric illnesses. That was 2008. Since then, I’ve been doing it and still astounded by what it is now. How does it have to deal with sort of topic of psychedelics? Well, it turns out that at the doses that we give it, the sub-anesthetic doses, it very much produces a psychedelic like experience and a lot of us think and I certainly am one of those that, that psychedelic experience is part of its remarkable therapeutic effects.

Jackee: Wow.

DF: So you can consider it like the only legally prescribable psychedelic available today.

Jackee: Yeah. Right. I have to remind people of that a lot. Because of its popularity on the streets, so to speak, a lot of people are shocked to learn that, “Oh, wow. You can get ketamine prescribed in a physician’s office?” Yes, you can. Wow. Okay. So glad to be talking to you specifically, because you were at the beginning of this revolutionary way of treating using ketamine, treating psychiatric conditions using ketamine. A conversation I have all the time lately is standard of care when it comes to ketamine therapy, or psychedelic therapy. From what I gather as not a doctor or an official scientist, is that nobody can agree and the jury is still out. We’re still sort of deciding, but obviously you have the breadth of experience too. I’m sure I’ve come up with the standard of care that you’re proud of and that works. So I’m wondering if you can tell us about what you’ve discovered in terms of how to administer, how often? When? Dose and before and after care.

DF: Well, you’re right. It’s still a work in progress where we’re still trying to catch up to the use of ketamine that has kind of exploded. As I mentioned, when I started, people looked at what I was doing and thought it was… Some people thought it was outrageous. I was glad that I was in a university context that gave it a lot of credibility. Then the opposite happened, more time passed and just more studies came out, including studies that we published. Then people jumped on the bandwagon and ketamine clinics opened up left and right. And now I think we’re in a situation where it’s caveat emptor, you got to be careful where you go, but a couple of things I would say about standard of care.

One of the big issues with the ketamine treatments for psychiatric illnesses is the provider. A lot of the clinics, especially early on, that provided the jump on the bandwagon were run by anesthesiologists. The idea was, “Well, we have a lot of experience with ketamine.” But I personally feel, and I think that the psychiatry establishment, the American Psychiatric Association has come out with a sort of consensus recommendations that this is really… The bottom line is that we’re treating a very complex mental illness, not even your standard kind of depression or PTSD, but people who come from ketamine are usually people who have the most complex. They’ve not responded to standard treatments.

The most important thing is to have a provider driving the treatment that understands the disease, the specialty of mental illness, understands depression, intimately understands all the other factors. Because it’s not just about giving this drug it’s about the context and understanding the patient’s medications and there’s their individual psychological context. So it’s a bit of a controversy. The anesthesiologist and I do not mean to, by any chance, denigrate my anesthesiology, brothers and sisters, but I wouldn’t treat a cardiac condition just because let’s say Prozac became known to be helpful for certain kinds of things.

I think that’s the big thing. Now, I know a lot of anesthesiologists who have great practices because they work very tightly in conjunction with psychiatrists and that’s wonderful. But I think at the end of the day, this is a mental illness and you need to be a specialist in the mental illness, not in the end… Anesthesiologists, it is true they have experience with ketamine. They have experience with ketamine, putting people to sleep, and we don’t want people to go to sleep. In fact, that would be bad. We try to avoid that and the doses are much lower. Other than that, I see a lot of cookie-cutter kinds of protocols where they’ll say, “Well, you come in three times a week for two weeks and you get pretty much the same dose.” I think that we see such individual differences. We don’t have a standard number for our initial and we don’t have a standard dose and we adjust according to each patient to get them into that sweet spot. That’s the most therapeutic.

So, I think experience is really the key, a place where you’ve got people who understand the condition that’s being treated and understand… Intimately have been doing this for a long time, using ketamine for the condition and understand that a lot of times people just won’t be getting the right effect and they’re stuck. I can leverage my 12 years of doing this with certain kind of tricks, if you will, or I get a sense that I think this is what you need, I think you need. Longer experience, or we need to do this with the dose, or it needs to be… I think you need to actually go in with this kind of intention.

So, it’s not the kind of treatment where you just write a prescription and standard for everybody. It’s very individualized and the content… I mean, Jackee, what makes, I feel makes ketamine and the psychedelics so much fun is that it moves, it’s a medical treatment that moves us away from the standard medical model. The paradigm in medicine is, if I give you a drug, if I prescribe a drug, that drug is a molecule. It’s got a chemical structure and you take it and it goes in your body and it interacts with molecules in your body and you don’t really play that much of a role. You’re just a vessel. You can take it before… Most medicines, you can take right before you go to sleep. If you were God forbid, in a comma, in the ICU, and you had a blood infection, we could give you an antibiotic and we would expect it to work, even though you will be completely unaware of what’s going on.

That’s sort of the standard model but with drugs like ketamine and the psychedelics that we are coming down the road, I hope will soon be approved, you really… The patient has to be present. An old concept in psychiatry has been revitalize and that’s the concept of set and setting. The mental set the patient comes in and the setting.

Jackee: Also that’s a psychotherapy concept.

DF: Yes. Psychotherapy that kind of has gone, I don’t even know if a lot of the residents, over the last decade learn much about that. Because as we went into the more pharmacological model and we went more into the traditional medicine model, we kind of stopped talking about that. But in the psychotherapy days, it was very important what the patient’s intention was, what their mental set was coming in and the setting. The setting played a big role of that. You have to factor in, which makes it a lot more complex than. “Here’s the medication. I don’t care if you take it before you go to sleep or when you wake up or somebody pops it in your mouth or gives it to you in an injection.” If you’re unconscious, we need you and we need to kind of prepare you. We need you to… So the example I give to people is I could tell them I could drop a dose of ketamine in your water as you’re walking down the mall surreptitiously and it would be horrible.

You would think you’re losing your mind. You wouldn’t know what’s happening to be embarrassed. You’d be trying to sort of normal, but you’d find it very hard. It would be just be very long… And couldn’t wait till it’s over. But if you come, let’s say to Kadima where you’re sitting in a room with her with a leather reclining chair and we’ve got a noise canceling headphones and the music is curated to be conducive and you know why you’re coming and you’ve got a team that really, you feel very trusting towards them. You feel safe, you can really let go. Nothing surprises you. You know what to expect and it starts to happen and you can let go and really benefit from all that a drug like ketamine can offer you. Rather than try and stave it off and just get through this and survive.

You can’t really have a therapeutic effect when you’re just trying to make the hour or so pass. Whereas if you’re like soaking it all up and saying, “Oh my gosh, this is so cool. Look at the insights I’m getting. Oh, wow.” Then you come out, in one hand, “I never want to do that again. I’m traumatized.” The other hand is, “Oh my gosh, that was incredible. I didn’t want it to end.” So same medicine. Could be same dose, but the difference is you. Your intention and the setting and your mental state. So that’s fun for me. It makes it a lot less simple, but much more interesting and exciting as a psychiatrist.

Jackee: Yeah. I can say as a patient who’s consumed ketamine under a physician’s care, unlike any other substance I’ve ever consumed, the difference in how I feel per dose per setting, I think I had an experience and I hope you can talk us through kind of what’s happening when somebody goes into a K-Hole biologically. I think back in the ’90s, out of rave, I accidentally took ketamine, I didn’t know what it was. Typical teenager experience that I would not recommend at all to anyone listening to this. But yeah, I wanted to die, basically. I wanted it to stop. It was one of the worst experiences of my life. And I had avoided ketamine, recreationally for the next 25 years until I started to really seek out new ways of affecting my childhood trauma and anxieties, because a typical talk therapy didn’t work.

I refuse to take antidepressants because when I took them in my 20s, it was never a good experience. So I’m like, “What do I do?” So I come back around to ketamine and even just the difference in the doses I get under a physician’s care and how the experiences are so vast. A 50 milligram, you could correct me if that doesn’t sound-

DF: Yeah.

Jackee: Yeah. A 50 milligram feels entirely different to me than 70 milligram, lying down versus sitting down. I haven’t done it intramuscularly or taking it orally. I’ve only had it intravenously. I’d love for you to explain the different methods of consumption as well. But I love that you talk about, there isn’t really a one standard of care because every patient is different. I think that is the key, whether you’re consuming ketamine or anything under a physician’s care, thank you. Every person is different. And so the doctor, the physician needs to care enough to acclimate what they’re doing specific to the patient.

DF: You’re right on about that. There’s no easy way to do it. There’s no cookie-cutter formula. This is your dose. Frankly I think that’s even true. Even when I was practicing with the other medications I found out that my success was much different if I would really, really customize it for a patient who couldn’t tolerate dose of a medication, could have possibly given it up altogether and lost the opportunity to benefit. But if I’d spent some time and found that sweet spot for them, made a difference. Even more so with ketamine, even more so. You’re right about every individual being different, but here’s the other thing we find that even among individuals who come in and have a dose that we’ve already established as being incredibly therapeutic, it can be different from time-to-time.

It can be sometimes they’re like, “It was really kind of so mild.” Sometimes it’s, “Wow.” And sometimes it’s, “Wow. It was beautiful.” And sometimes, we can hear them just falling, crying, which can also be therapeutic, but it’s obviously taking a different place. So that not only is everyone a different person, but every time you come in, you’re a different person in some ways. You had a different day. Something provokes you, right before. So we’ve learned a lot about preparing patients and I spent a lot of time thinking about how do I position a patient mentally, psychologically, right before, when they’re coming in and they’re coming in, they’re sitting in our chairs and we’ve got the blanket on them if they wanted and how do I get them so that their mind isn’t optimal place to have the best outcome from that session.

It’s still something I’m working on and it’s still something that nobody has pinned down, but we learn, you learn by experience. So yeah, it’s a lot tougher type of medicine, but it’s a lot more interesting and fun. I almost forgot what your original question was-

Jackee: No, it’s fine. I remember. So the different mediums and how to consume, how you can consume ketamine, because again, I will say just taking it back to rec because it can’t be denied. It’s extremely popular on the streets.

DF: Right.

Jackee: And we’re talking about apples and oranges as far as I’m concerned, because then you get to the conversation of purity and you only know if it’s pure, if a doctor has prescribed it to you, under the FDA’s rules and regulations. And so yeah, so there’s intravenous intramuscular, there’s oral and now there’s nasal.

DF: Right. Good. So, great question. So probably the biggest difference is what we call bio availability. That’s a term that means what percentage of the actual drug that we’re administering, whether it’s a pill or an intravenous infusion, what actually gets into the bloodstream. Because essentially what gets into the bloodstream for the most part gets into the brain where obviously we need to get it. There’s big differences. Now, there’s three routes to administer ketamine that collectively we call them parenteral. That is intravenous intramuscular, like a flu shot, or it could be a shot in your butt. Then there’s subcutaneous, which for example, people who self-administer insulin, that’s an injection that’s just in the folds of your… In the fat of your side or you’re pinching your arm.

Those three routes give you a very high bioavailability, over 90%. That almost all the drug that we give gets into your bloodstream. And why is that important? Because in order to have the therapeutic effect, we feel that patients really need to experience the dissociative psychedelic experience. If the dose is too low, they won’t. When you go to other routes like intra-nasal, the bioavailability is in the thirties. When you go to oral it’s in the teens. So most of what you’re actually ingesting is not making it to your bloodstream and therefore not making it to your brain. Therefore it’s very difficult without giving massive doses to get you get that therapeutic experience that we’re talking about.

So now, most places will do intravenous and we do intravenous. Intravenous is the standard and it’s the way that the first research studies were done. It’s a very well controlled way. You put an IV with a tube and you infuse it, meaning there’s a pump that regulates how much it goes in at a time. Because if you would just give it all at once, that dose would be overwhelming, because it goes directly into your veins and directly. So it would just be too much. So we slow it down and the classic way they were doing it in the research which a lot of cookie-cutter places will follow, is by weight, half a milligram per kilogram, over 40 minutes. And there’s a pump that has it. The lights just went off. I don’t know if that’s a bad omen. I think I need to move or something.

Oh, well. Fortunately, it’s a non-rainy day in California and I’ve got lots of light coming through, but anyway… So it’s stripped in very slowly into your veins. The intramuscular uses your muscle, mostly your deltoid muscle as sort of a pump. All the drug gets injected and then it leaches out because you have a lot of blood vessels in your muscle and it leaches out into your blood system. So with intravenous, you get like 100% goes into your vein, because it’s being directly put into your vein. With intramuscular, it’s about 95%. With subcutaneous injections is about a 92%. The difference… There’s pros and cons, because I’ve been doing it for so long, I’ve had a chance to explore all the options with my patients, intra-nasal, oral, intravenous, intramuscular.

The three top ones, the parental ones are the best because you get the- . And truthfully we do mostly IM because that’s what our patients end up mostly preferring and getting great effects. I think one of the reasons they like it is, it’s less medical. A lot of people have anxieties about having a nurse trying… The pain in threading a needle. And then you need to have the pump in the room with you because there’s a motor, it makes a noise and if you block off the tubing, it’ll alarm. And patients are aware when they move their hands, that they’ve got this thing tied to them. With the IM we’re in and out. We come in, give you the shot, we’re out and there’s no reminder continuously through the experience that you’re hooked up or hearing a motor.

I think there’s also differences in how quickly it’s absorbed. I think, for example, with the IM, we get a quicker absorption. The peak is a little bit higher, the infusion it’s a little bit slower to get you into that psychedelic place. But those three are the best three ways and they’re all good, but the most important thing is that somebody who knows how to use them, how to use whatever method he’s using to achieve the goal that you’re getting a very deep and meaningful experience.

Also in terms of timidness, a lot of the doctors, because they haven’t been doing it very long or haven’t had chance to really feel comfortable with the drug for this purpose will stick to a certain dose range. And for us, we tend to have a wider dose range that most providers, because we’ve doing it for so long and we have a system where we won’t go straight to a high dose, but if a patient is relatively insensitive, then we’ll take the steps up to get them to that place. Whereas most people will just say, “This is the dose, and this is as high as we go.” And that’s all that-

Jackee: What’s a high dose? I know I’ve heard of practitioners going up to 150 milligrams for severe PTSD patients, and then as low as five.

DF: Yeah. Five is, again, we go because weight does affect- But generally for the average person, five would be a minuscule dose. I don’t think you would even know that you got ketamine. 150 milligrams for a petite a woman would be a pretty strong dose. We’ve gotten even higher than that. Most importantly, we gauge it by… I’ve had patients who… We get vets who are referred by the VA who have PTSD and depression and strong suicidal thoughts. They send them here after they’ve tried everything and it just not working. They’ll say, “I mean, this is keeping me here..” It’s funny because we have… I can think of a couple of elderly ladies who get higher doses than some of those Marines and are affected less by it.

It’s just really interesting. Your metabolism and your receptors. So we don’t stand on dose, we stand on… We have guidelines we start with, but eventually we’re titrating it based on how deep was that? How therapeutic was that? How mild? And we have a tool we call it the PES, the Psychedelic Experience Survey. It’s a short survey we get everybody afterwards and they rate how intense was it? How positive? How much negative content and they write out a little narrative of what their experience was. And so we’re looking at that. We’re debriefing with them. We’re helping them… It helps them also consolidate what they experienced, because as you know, these things can be very fleeting and you have this profound insight and then eight hours later, you’re like, “What exactly… I don’t feel it the same way.”

So when they write it down and we talked to them about it, it helps consolidate it, but it also helps us understand, “Well, you’re getting a fairly high dose, but you’re only getting a very mild effect and you’re not having any… You’re not having a dissociative experience. You’re not having this. So it’s not surprising that you’re not having sort of an antidepressant effect. That’s not because it’s not working. It’s just that you are less sensitive than the other people. We have to account for that adjust and that’s what we’ll do.” So again, it’s going by patient’s response to it rather than some preset notion of a dose.

Jackee: I love that. That makes a lot of sense. I wish that more people would think that way in terms of their patients. It seems like we’re on the road to getting more physicians and psychiatrists who think the way you do. So thank you for leading the charge. Okay. So in terms of a K-Hole, which is street language for taking enough ketamine or something that a person thinks is ketamine, because I will say that likely what people are consuming is not pure ketamine. They’re taking enough of it to not be able to function. So they go into a hole in their headspace or a rabbit hole and it’s not great. And so what do you think is happening? I’ve never really actually asked this question. What is a K-Hole in your body?

DF: Well, I think a K-Hole… And by the way, I’ve been doing this for as you know, over a decade, but I’m still not sure that we’re all talking about the same thing when we use the term K-Hole. But there is a phenomenon that people who do ketamine and we experience it sometimes here too, the high doses. Where people experience this deep and can be scary experience. To me it’s nothing… Sort of… it’s not like it’s a different thing that’s happening. It’s just an extreme version of what’s happening with less intense experiences. One of the things that happens with ketamine and I think with all the psychedelics is there’s this thing called ego disintegration. What happens is our brains work hard to create a sense of differentiation of ourselves from others. “This is me, I’m in here.” And that’s what we call the, the ego, the boundary around self separate from the world, separate from other people.

With psychedelic drugs and we see this most definitely with ketamine, that loosens, that gets loosened up and one of our patients always will write down very consistently in their PES forms and tell us, “There was a sense of unification with other people and the world.” And it’s a very uplifting… Because I had one patient who told me after the ketamine experience that they realize that depression is about feeling isolated. You’re going through this alone. You’re separate, you’re isolated. And ketamine shows you that’s false. You can’t be disconnected. You’re part of the universe. You’re part of everything. The boundaries become porous. To me, what happens at a K-Hole is people become so un-self, they don’t even know. They don’t feel that they’re alive anymore.

As one patient who went to the K-Hole told me, “I didn’t know where I ended and the universe began.” Now, we usually hear about K-Holes as a really horrifying, terrible thing. But again, it’s the set and setting. We have patients who go into what I think is being referred to as the K-Hole in street vernacular. And it’s okay, because we’ve led them up there. We haven’t hit them with the first dose. We always start with a milder experience, so they know what it is and they come back and they get increasing doses. And so then it’s not completely new, but it’s an extreme version of it and they’re okay. One patient said to me, “I realized I was dying.” I said, “Was that scary?” He says, “No, it was actually kind of liberating because I realized I can’t die. I realized I’m part of this eternal… The universe, I’m connected to everything and even down to the atomic level. That was strange.”

Like I said, I guess they’re not watching my blood pressure and they’re not realizing that I’m dying, but it was kind of… So K-Holes can be not terrifying. They can actually be… I actually had a patient who went into a K-Hole and then stopped needing to come back. Because the K-Hole was so profoundly… Reoriented his thinking that he kind of saw what the end was and he saw how connected it was and it stuck with him so much that he just didn’t feel he had the depression.

Whenever he was feeling that way. He could conjure that feeling up and, and nothing seemed that important. Nothing seemed that… So, K-Holes don’t have to be horrifying. I mean, we don’t deliberately put people to K-Hole but they don’t have to be negative… Certainly if you’re doing it, if you’re a teen and somebody gives you ketamine, whatever ketamine actually is and you’re experienced and you go into it and it’s not in a context where you feel you’re safe and being watched and secure that you can just… It’s all about opening yourself to experiencing it. Not being afraid because you’re okay, you’re safe. Your body is going to come back. It’s like lucid dreaming, realizing you’re in a dream that was very stressful and somebody goes, “Oh, this is a dream, Oh, this is wonderful. I mean, this is liberating. I can’t die.” Again, set and setting makes all the difference.

Jackee: I love that reframe, thank you so much. I’ve not heard it reframed that way. So I think that can be very useful. Well reframing any conversation around psychedelics or anything stigmatized is useful. Okay. Do the vital signs change with a person’s… If somebody was in a K-Hole, can you tell or is it just neurological in their mind, if you will.

DF: I think what you’re saying is there evidence in the bottom of a K-Hole?

Jackee: Yes.

DF: Well, getting back to the vitals, which is a very kind of crude measure just of blood pressure, your heart rate. Yes. And in fact, it doesn’t even need a K-Hole to get people there. Typically heart rates will go up, blood pressure will go up. There’s two reasons for that. Ketamine tends to increase blood pressure and that’s why we monitor it, but also it’s really exciting. Your blood pressure, it’s supposed to go up when you’re stimulated. And if you’re going to see a really exciting movie, if it’s a thriller or it’s an action, your heart rate will be up and your blood pressure will be up. It could be up to a point… I could tell you a number where you might get to just under normal circumstances of being at a sporting event or something like that. That would be… In the clinical, you’d say, “Oh my gosh, that’s hypertension. You need to have that treated. That could…” But no that’s temporary. Your body is reacting. And so we don’t get too worried about these transient increases.

You can’t tell if somebody is in a K-Hole just from their vitals, because their vitals could be up and sometimes K-Hole is more relaxing than some of the less intense. But what we do know happens and we do know some things that happen in the brain scans. Brain scans have been done with people on psychedelics, including ketamine and there is a really interesting thing that occurs where, let me back up a little bit and tell you about a little bit about sort of how our brain works under normal circumstances. When we’re not doing something, we’re not engaged in something where we’re concentrating, or maybe having a nice conversation like that. When we’re kind of on our own reflecting, the brain doesn’t shut down.

We’ve learned over the past 15 years that there’s actually, when we’re sort of just introspecting and just chilling, if you will, there’s a few hubs in the brain that light up and they’re connected to each other and we call this the default mode network. It seems like the default mode network plays a role in creating that concept that I just mentioned, the ego, the self. It’s what glues you together, psychologically. Not only in space, but also in time. Like, I’m the same person I was yesterday. And that I’m the same person that I was a month ago. And here I am in space and that’s not me. This is me.

So that default mode network pops up when we’re not distracted by doing something engaging, where we’re concentrating or interacting with others. Now, when we’re doing psychedelics, the psychedelics seem to mess up that default mode network. Instead of just those certain areas lighting up, the whole brain lights up and there’s activity going on throughout the brain, which is very irregular because that doesn’t… You would think of that as unorganized. In terms of neuroscience that’s chaotic, that’s unorganized. But it seems to be what opens the door to new understanding and the best way, the best analogy I try to think of a way to explain it to my patients. It’s like, when we travel, especially with doing long distance travel by car, going on these freeways, we’re always going on certain routes and we’re bypassing a lot of local stuff on this freeway.

Imagine if tomorrow, the way things are going, it might happen they closed out all the freeways in the United States. And if you want to get… If you have to want to go visit your family in Detroit, you have to only take surface streets. You’d feel so much more in contact with your citizens, you fellow citizens, you’d be going… Everyone would be traveling. It may not be great for traffic, but that’s sort of what’s happening in the brain rather than just going through these certain loops, these super highways with fibers between them, everything is lighting up. All the brain parts are talking to each other, and that messes up the concept the brain is always trying working on, is to make us feel you are just this limited thing and suddenly you feel like I’m part of everything. “I know everything that’s going on.”

A lot of my patients will say, “Being in ketamine is this experience of all knowing. You know every… You just know it, you can’t explain it, you have all the knowledge of what life is and what the university is even for a few moments, it’s all revealed to you.” Now, whether you can hang on to that is another thing. So that’s what we see happen in the brain very consistently with ketamine, with psilocybin, with LSD, with MDMA. They all will have this… Even though they work through different receptors and mechanisms, it seems to be one of the commonalities among all that will be called the psychedelics.

Jackee: Yeah. There’s some images of those brain scans you’re referencing out on the internet guy. So I will make sure to put those up when we post this episode, because they’re pretty astonishing and very, very simple. But it can’t be denied how impactful just seeing the brain on ketamine is all lit up red and green. No, I think it’s red and orange and it’s inspiring. Yeah, so I’ll put those up. Okay. So you run a pretty intense practice. What other types of treatments do you offer or are new and that you’re excited about and that you’re obviously finding effective?

DF: Well, in the psychedelic category, we are starting to do clinical research under sort of an FDA umbrella with psilocybin for depression and that is with a company called COMPASS Pathways. It’s a-

Jackee: We love COMPASS.

DF: Oh, there you go. They are very much Kadima-ish, forward looking and developing this as a medicine, breakthrough medicine for mental disorders starting with depression. So, we’re doing those in clinical trials. Obviously that’s very limited. It’s not something that is available to all our patients because it’s under just a limited clinical trial, but that’s exciting for us because it’s part of what I feel is the revolution, that’s ongoing in psychiatry and is going to change the landscape, all these medications in there and it takes companies like COMPASS Pathways and organizations like MAPS to really pioneer these things. Because it’s not just a matter of doing the drugs, we do have to bring it into sort of the structure of our society and do it in a way that’s regulated of the quality and has some standardization from the knowledge that we learn from each other. So, we do have to marry the idea of these psychedelics, which are… That can’t be fit into medicine categories very easily, like our other medicines, but there is still some realities.

We’re going to get this out to a lot of people and make a big difference. There is some realities that we have to work through, like getting an FDA approved and so forth. In terms of treatments that are here and now, there’s a whole nother area of psychiatry that is very exciting and is also kind of revolutionizing psychiatry. That is this idea of neuromodulation. It’s this idea that we can change people’s thinking for the better, their moods, when they’re not proper, their obsessions or traumas for the better by directly changing the firing of the brain and the brain just to remind your audiences is this complex computer really with 85 billion wires talking to each other.

In mental disorders, some parts of that computer, some parts of it are not firing right. We’ve used sort of the antidepressant medication, anti-psychotics is a very indirect way to change that firing. It helps some people, doesn’t help… But now for the past 15 years or so, there are techniques. The most well-developed one is something called transcranial magnetic stimulation or TMS, that allows us by using pulsing magnets, which we know from physics will cause the brain areas underneath in the pathway of those pulsing magnets to fire and what we can do is we can exercise parts of the brain that… Those parts of those circuits that aren’t functioning correctly to kind of get them on board, to get them in shape. It’s like a personal trainer.

So TMS aside from Academy treatments, is one of our other tools that we use. It’s FDA approved. It’s been FDA approved for major depression since 2008 and more recently, it’s gotten approved for OCD and we’ve got studies going on for PTSD and just all kinds of things. Once we get better and better at that, it’s going to be… We can theoretically do what… In theory, we can do what the psychedelics are doing, in a very controlled fashion, by replicating that through the TMS device. I think there’s going to be some marriage down the road of pharmaceuticals and these psychedelics and these neuro-modulations. It’s wide open, Jackee. It’s wide open.

Jackee: Good as it should be. I can’t wait till it all comes together and it’s married and more people have access to more options. I know as a patient with extreme anxiety disorder and depression, in my family medicine or taking a pharmaceutical was never an option for me longterm. And so I’m just super grateful to have these other options. Yeah, so I was going to jump back for a second to ketamine, because this just came up recently about ketamine use and liver function. I didn’t quite read the study or sorry, the article. Are you familiar with what I’m talking about?

DF: I am. Yes.

Jackee: Okay. It was a New York Times article.

DF: No, it might’ve been New York Times article about a scientific paper that was published, because the Times will often review latest in science. I didn’t read the New York Times version.

Jackee: It’s relevant, I just want to say quickly, because while we’re all very excited about the potential of psychedelics to treat mental illness and their active effectiveness in doing that, there’s not a lot of talk about the safety of some of them and the use longterm. Because unfortunately we don’t have longterm studies on let’s say daily use or frequent use. Tell us about what I just referenced?

DF: Well, it’s a good point because all substances have the potential to do damage and disrupt our bodies. Ketamine is no exception, although on the whole it’s quite safe and we don’t have… As an anesthetic it’s been used in higher doses than we use for psychiatry, but it’s not typically uses anesthetic as frequently is we will use it in a person being treated for mental illness over and over again, every couple of weeks or months or whatever.

That is a new kind of aspect to ketamine that we were rightfully concerned about. It turns out, on the whole does not the doses that we use, there’s not too much harm. A lot of the harm we were worried we would see with the repeated use for psychiatric illness was extrapolated from the things that we saw happening to people who were using it, abusing it recreationally and so forth. So, for example, you mentioned liver. There’s a potential for liver damage. It’s actually not as big as the potential for bladder damage. Bladder damage was well known, almost all of it from chronic street users if you will, or people using it not for therapeutic means, using it on their own and in getting it in ways that were not completely pure probably.

Jackee: Right. Because even then you can’t prove or identify exactly what people were consuming.

DF: Exactly. Not only in the ketamine but also what else they were taking at the time and so forth. So we were worried, we were worried that if we see this occurring occasionally in people who are using it, would this happen in therapy? Fortunately, we don’t see this. In fact, my colleagues and I recently did a study where we surveyed some of the top ketamine providers with their experiences and these things almost never occur in a controlled setting at the doses that we use with the frequency that we use it. So yes, it has a potential to… Things you’ve got to worry about, blood pressure and heart rate, as I mentioned can be elevated during the treatment, not sort of between treatments, but during the treatment, which if somebody has a fragile cardiovascular system, if they have a heart condition, if they have some sort of very, very strong risk for stroke, we have to be careful and occasionally we’ll lower it, we’ll give a drug to counter it. Very rarely we need to do that.

It has the potential for damaging bladder, but again, thank goodness, that’s not really been a common occurrence in the therapeutic setting for a psychiatric illness with the drugs. It has a potential for liver damage, less so than bladder. But again, we don’t really see it. And honestly, I think we probably have patients that get it more frequently than at any place that I can imagine. We have patients that will get it more than once a week. It’s been for years and it’s done because the alternative for them would be a very… We got to that point very carefully. I would never have done that when I started, I didn’t know. I started out very conservative and then I saw the safety, and then we kind of pushed the envelope a little bit. When there was a good rationale for a patient, the alternative was worse. Then we had a rational decision to kind of push.

Slowly, slowly, we, we gained this experience. So we have people who come in honestly, twice a week for, for over and over again, and by everyone’s account, their families and everybody, they are as a whole more healthy than they were without it and we obviously watched them very closely in terms of their body as well as their mental effects. It’s a lifesaver for them

Jackee: I believe it. It’s been really essential for me as well. Okay. Thank you for that clarification. Before we close, we are in the time of Coronavirus and as a psychiatrist who better to give tips or advice, or a few thoughts to people at home, dealing with a new found stress as if we didn’t have enough already.

DF: Right.

Jackee: But new stresses, and then being physically confined, and not only physically confined, but separated from the thing that makes us human, which is our communal nature. What are your thoughts on, on what’s going on with the world right now with coronavirus and COVID-19?

DF: Well, it’s very interesting. A lot of things come to my mind. I think these are… We spend most of our days, the average person, feeling in control, feeling that we know what the threats out there are, down the road, whatever it is. Then suddenly something like this will come along and make us realize that we’re all so fragile and vulnerable in one respect. But in the other respect, as a community of humans, it has the potential to really… There are a lot of silver line potentials, if we respond the right way, if we don’t go into a shell and every man and woman for themselves kind of a thing, and say, “Hey, this just shows that no matter what socioeconomic strata you’re on or what ethnic background you’re on or how you vote, we are all vulnerable to the same things and in the same boat.”

If there can be some, and I’m just hoping that there’ll be some really positive outcome of this, because right now I know it looks like nothing on the surface, other than just a real negative all around. From my patient’s point of view, it’s really interesting because I think my patients, I see kind of fall into two categories. There are those who are not… To them, this is not an issue. They’re not concerned. The depression that they struggle with, the anxiety they struggle every day is so much more threatening to them. So this is… It’s not on their radar. They’re calling us and saying, “I’m so scared that you are not to come in because I could get exposed. But that you won’t be there, that this treatment won’t be there. I’m finally doing well and I know what happened the last time I stopped this.” Or whatever.

So we’re actually putting people at ease, that we’re doing our best, where we’ll be here as long as we can. We’re taking extra measures to keep people safe and our staff safe and wipe down things and so forth. But we know, in the mental health field, we know that not providing these treatments is such a danger to our patients, because I think this is the problem that a lot of people who don’t understand mental illness don’t have it, don’t know somebody close to them who’s struggling with, don’t realize how pernicious and deadly mental illnesses.

I can’t tell you and I’m sure this is true, every psychiatrist, every therapist… I’ve had patients who have serious medical conditions, including cancer and anxiety or depression or both. And they will almost to a person say, “Look, if I was given a choice right now, I could eliminate one, I could cure one.” They would almost say that they would take a cure for the depression or anxiety, rather than the cure for the cancer or heart disease. Because they say, “If I had my mind, if I was in control of my mind, I could whatever this is or I could deal with it.” But when you’re just wrapped by struggling to just function and get out of bed and not be scared of the world and anxious, or come up with a reason why you want to go through another day of misery, there’s no bandwidth left to deal with a medical condition.

So that, it probably won’t surprise you that people would make that choice. But I think for a lot of other people, they are shocked by that. Therefore, I think a lot of COVID, the response where we’re doing to this is this based on sort of this a real threat, but people don’t realize that if done wrongly, we could actually… There could be a more casualties on the other side of things.

Jackee: I think so. Yeah. I mean, and I don’t think most people would be surprised. Suicide and mental health, especially in the younger generations is no joke. And it’s not a quiet thing. I think George from COMPASS actually, taught me the metric that every 40 seconds somebody commits suicide in the world and that’s real and sobering.

DF: And increasing, which is the scary thing. So many other things are decreasing. We’re making a dent in the rates of cardiovascular disease and of cancer, but with suicide, we haven’t. It’s been a big failure of psychiatry because I think it’s part of also the way our society grows more and more. We’re more isolated and depression has become more prevalent. So we’re so hopeful that these new things like ketamine and the drugs that George and Katya are working on and others will finally make that difference in that suicide rate and the neuromodulation. We need… I mean, I started Kadima, I left my tenured position at UCSD, because I just felt that we need really, really new breakthrough medications and I felt this was the best. It had the most freedom to pursue those innovative things, doing that. Because it’s such a need, Jackee. The treatments that we’ve had up to now, just not good enough given the foe that we’re dealing with. So this is what Kadima is all about.

Jackee: Yeah. Amazing. David, I feel like we just scratched the surface. Will you please come back soon?

DF: I promise.

Jackee: Yay.

DF: I promise.

Jackee: Okay. Thank you so much. People can find out more about you and your work at kadimanp.com.

DF: Right.

Jackee: That’s Kadima N for Nancy P for Paul .com. I’ll put that in the show notes of course, as well. Thank you so much. We can’t wait to talk to you again.

DF: I really enjoyed it. Thank you.

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