Dr Asher Golstein, 2019 Pain Seminar (LDN, low dose naltrexone)

Dr Asher Golstein (LDN, low dose naltrexone) from LDN Research Trust on Vimeo.

Dr Asher Goldstein: My name is usher Goldstein. I'm a pain management physician, and physical medicine and rehabilitation is my first board. Anaesthesia pain is my second board. I practice in Hackensack, New Jersey, so it was a little bit of a trip to come here, but well worth it. I feel that LDN has changed my practice significantly.

I came into it three years ago, and it was sort of a disaster with one patient, didn't go anywhere, and then circled back to it about a year ago, and it's been really, really helpful. Unlike Dr Chopra, I do not seek out the complex pain patients, but, okay, Usually, I get them. And for those patients that, you know, you want to pull your hair out for, you know, so it's been very helpful and been helpful for the fibromyalgia patients, the patients who happen to have back pain and IBS or and crone or those patients with CRPS or knee pain.

 I've been treating some entities that don't directly relate to pain just because LDN has the ability to treat it. And I had a patient come to me who had fibromyalgia and had never come to me before. And, and I treated her performance. I started her on the LDN, and I'm like, two months later she comes to me, and she goes.

Does LDN treat breast cancer? And I'm like, well, what's the story behind the question? She said, well, I didn't tell you, but I had breast cancer, and I had a double mastectomy about five years ago. And they've been following my numbers, you know, for five years. I, every couple of months I go to my doctor, and they draw blood, and they look for tumour markers, and everything's been, you know, stable at 130.

And oh, we've been okay. And then, I went like, two weeks ago. And my doctor called me up and said, I need to speak to you. And I came in yesterday and she said, what are you doing? And she's like, what do you mean? She said some did you do something that changed? And so she said to her, well, why you're asking me?

She said because your numbers went from one 30 to like 22. And she said, what'd you do? And she said, nothing. I'm just taking LDN. She said, well, go back to Dr. Goldstein, ask him the question, and I said, well, you don't actually say that LDN treats cancer, but you know, it can be very helpful. And so hopefully her cancer never comes back even after five years.

But I can just say that you know. That was black and white. You know, her numbers just dropped. And the only thing that she changed; she didn't change anything else. We just added LBN on. And from her fibromyalgia perspective, it's been helpful. I've had patients that had much better response and patients that have not had a response, but her pain went from like a seven or eight in a total body pain to about a five.

So she's much more functional, and she's not taking any opiates, which is great. And I'm, she's happy. One issue that I had Dr. Chopra didn't mention is that because it's so cheap to manufacture, to make, you know about a buck a pill, or, you know, $60 for 90 days, which is what my compound pharmacy charges.

It's very hard to get money for research. And then, so you've asked about a head to head trial. Who, who's paying for that. Right. The drug, this thing has been manufactured since 1982 it's off-patent. It's very cheap. There's no money in it. When there's no money in it, nobody's paying for any trials unless you can convince the government to pay for a trial.

So there are not going to be any head to head trials because all the other drugs have money and this has no money. We always put it in like, no financial interest. Nobody has a financial interest in this because nobody's making any money on LDN. Right? So that's the catch 22, you know, it's helpful, but everybody wants to research.

They want strong research. They want, you know, a thousand patients and they want double head blinded and placebo. You can't do that. There's no money unless, you know, Bill Gates writes a check. There's no money in it, you know? So that's that. That's, you know, it's, so patients have to pay for their medication.

It's not expensive, but sometimes, you know, 30 bucks a month can make a difference. And the insurance companies, unless it's an accident, they do not cover the medication every once in a while that goes through, but very rarely. So I just, I just tell the patient straight up, but you're just going to, you have to pay for out of pocket.

Q: Is low dose naltrexone approved by the FDA for chronic pain or for pain? 

So naltrexone is approved by the FDA period at 150 milligrams dose. Okay. So do you think you need to get approval for a four and a half milligram dose? The answer is no. Not FDA approved for four and a half, but nobody's, nobody's applying for that because there's no money in it.

Right, right, right. So. 150, four and a half. And I'm going to be talking about one microgram, you know?

All right. A byproduct of what I do, I treat, I don't have a problem with treating my patients with opiates. Okay. So I still do, I, I do procedures, I do injections. I send my patients to acupuncture, the chiropractor, you know, it's like, what is Dr. Goldstein doing?

I'm doing everything because pain is not simple. And everybody, you need to have a big toolbox. And as part of what has happened in the past couple years, you know, so patients started asking me, you know, please, can you take me off the opiate? So I said, Oh, sure. And so I started, you know, doing stuff like, as best as I could. And then about a year and a half ago, I said, there's got to be a better way. So I asked some people questions, and I took a course by SAMHSA. SAMHSA is an excellent organization, and it was like an eight hour, online course and wasn't too expensive and CMEs and everything else.

And then I got certified, and I got knowledge of how to take patients off their opiates. And the bottom line is it takes me if the patients listen to me, it takes me about four hours, to take patients off their opiates. Now I'm not taking patients off complex substance abuse. I'm not taking them off cocaine and heroin, or, you know, but if it's just heroin or it's just oxycodone.

Then I can help them up. So, okay, so ultra-low-dose naltrexone and MAW, and it's me. That's what I do. I'm at Holy name Hospital, which is in Teaneck, New Jersey, which is a town that I live in, but I have a private office in the next town over, which is Hackensack, New Jersey. Okay. There we go. So no commercial interests or conflicts because there is no money to be made here.

And ultra-low-dose naltrexone is not currently, there you go, an FDA recommended treatment, all you know, but many drugs we prescribe off label because we know they have more than one use. And this is the case in this drug. Okay, what do we call it? Right? 

No. This one. Yeah, that's not working. Oh, there it is. Okay, so naltrexone is the 50 to 150 that's what it was. Prescribed them naltrexone, you know is five. You know, we talked about a 0.5 Dr Chopra talked about 12, and some people talk about 16, but the current sweet spot is about four and a half milligrams.

Then there is, we'll skip here—Ultra-low dose naltrexone. Which is a one to 20, but I actually don't go above 12, and then there's a little higher from 50 to 500 is very low dose naltrexone. So these are basically the four categories of ???naltrexone not track somewhat what we call it. And there are some of the edges of each category. tere's, you know, it's a little blurry, a little grey, but that's fine. Also just keep bear in mind with the lower levels of naltrexone, the theories of how we give it out and what dosages, and you know, where we start and where we end. It's still evolving. It's evolving. Like I said, three years ago when I started, with one patient, I ran into a disaster because I was told two milligrams, four milligrams, six milligrams, eight milligrams in one month.

And patient had no, positive response. So I stopped and, and it took me about two years to come back. Okay. So low dose naltrexone. So I use it for medication-assisted withdrawal. I tell the patients to come in to stop taking their medications 18 to 24 hours before their appointment time. They come in to see me. They're a little uncomfortable. So we want to get them, there's a scale called the COWS scale that runs from zero to 24 we want them to be uncomfortable around 15. In 12 to 18 but 15 so the reason we want that is because when we give Suboxone, we want them to feel it working.

So if they, it's too mild, they're not in enough withdrawal, and they don't feel it working. And if it's too severe, they just take a pill before they come in. Cause it does just not help cause they're just uncomfortable. So 18 to 24 hours. And so they come in and then, I start the medications to the withdrawal with Suboxone.

But that's not what we're talking about here. We're talking about ULDN. So when patients come that are my patients and they've been taking, or somebody else's patients, if they take medication for a long time and say, okay, we're ready to come off. I said, okay, when do you want to schedule this? And they say, well, we want to do it in June because I have my daughter's wedding in May.

And I'm scared to come off my opiates before June. June is like four months from that. I said, perfect. I'm not going to rush you. You're going, it's fine. We're going to start you on ultra-low dose naltrexone. Why so? Because when they, when patients go through the MAW, so they, they have sometimes had some side effects during that period of time in the office or before they offer it to us right after the office.

And one of the issues is anxiety. You know, the literature says prescribed Klonopin for the anxiety. So I'm like, why do I want to prescribe Klonopin to another controlled substance to help the side effect from this controlled substance? It's like a whole really bad cycle. So instead, I give ultra-low dose naltrexone.

They stabilize after six to eight weeks and when they come off when they do the MAW, when they come off their opiates, there are almost no side effects. Almost no side effects. So it's very helpful for that. And then in general, the second reason, besides a medication-assisted withdrawal is to enhance the analgesic effects of opiates in general.

So I find that if patients, my patients are like, Nope, I'm not coming off my Percocet, I take Percocet five times a day and I'm fine. I'm like, okay, what am I going to say? You know, just, that's what's working for you. That's what's working for you. But I give, I say, you know. Take the, ultra-low-dose naltrexone.

And what happens is that patients tend to drop one or two pills a day overtime. They just, they find that the opioid works better or they need it less. Whatever reason, they tend to drop it. So instead of five times a day are taking it three to four times a day. Okay. And then hopefully we can then convince them once they know about the molecule to come off  the opioids totally.

And then go on LDN to treat whatever their pain. Okay, so this is just a slide of inpatient detox versus office space detox. Basically inpatient detox. It's very expensive. You're away from your home. There's a lot of treatment, and you have no familial safety net. Maybe you need it for the really hard quote-unquote addicts to go away.

But you find that for most patients or mild to moderately or whatever, they're there, they have an addiction. But in the office, it's much cheaper. It's not even $5,000. It's probably around $2,000. It's 10 to 12 office visits over four weeks. And that includes both me and the mental health professional, not just me.

So it's not that bad. And then you have your family around, and you don't have to go away, and you can still work, and you can still go to school, and you can still do whatever you need to do. So I'm a big fan of Ultra low dose naltrexone. None of the commercial pharmacies will give you LDN.

So you have to go to a compounding pharmacy to get LDN. And then ultra-low-dose naltrexone don't even the compounding pharmacies have a lot of difficulty with it. So you have to go to a very good quality compounding pharmacy to get a quality ultra dose naltrexone because it's so small.

Okay. So 0.5 micrograms, right. You know, so 150 milligrams is the regular naltrexone for that, that's prescribed. And then the low, low dose naltrexone this four and a half. And then ultra-low dose naltrexone A four and a half milligrams to one microgram, like passing the floor at a very, very small dose.

And then I increase one to two micrograms every seven days to about 12 to 15 micrograms. And I tell them. Usually, it comes in a liquid. I tell them, put it up sublingual under the tongue for about a minute, then swish it around and swallow it. That's, you know, that works. Okay. So that's the ultra-low dose naltrexone.

And this is the very low dose naltrexone. I use it in two different ways. So when my patients are on Suboxone, right? So I get them onto some level of Suboxone. It stabilizes their withdrawal from the medication. Then at a certain point, I want to get them off Suboxone. I don’t want them, What? What did I do? I traded Percocet for Suboxone, so we started titrating down. So usually when they get to four milligrams of Suboxone, I then add in 100 micrograms of naltrexone. And then as the Suboxone comes down, I increase the naltrexone, and then we get to zero, and we were at 0.5 for LDN starting dose.

Now my starting dose is lower than Dr. Chopra’s starting dose. I start, and you know, as I said, it's just different. It's everybody. Eventually, we all get the 4.5 or somewhere around there, but I start my patients on 0.5 and slowly work them up over seven weeks to four and a half milligrams. I just found that that works for me, and I have less side effects, fewer complaints as headaches, but almost everybody has vivid dreams, which is, you know, most people like, they're like, cool, that works for me. The other way, is sometimes I can't get the patients to go down to four milligrams of Suboxone. They're like they're an eight or ten and just that's where they are. So I decreased the Suboxone to the lowest level tolerated, and then I begin at a hundred micrograms, and then I increase to up till I get the 400 micrograms, and then I just stop the Suboxone.

And usually that works just fine. Every once in a while, it doesn't work, but usually, that works fine. So either it's the plateau or the steady decrease, and that's how I use the very low dose naltrexone. Okay. So we talked that Dr. Chopra spoke about opioid hyperalgesia. This is my patient who had opioid hyperalgesia, and you're going to see, so 55-year-old male motor vehicle accident and crush injury to the right femur.

He was in New York city standing by a fire hydrant when a bus jumped the curb, a New York City bus and pinched him between the bus and the fire hydrant. Okay. And this was a guy who, you're the very traditional guy. He worked really hard, worked for his family. He was a man of the house. And so multiple surgeries, he had a little bit of lower back pain, but he was taking four milligrams of dilautid. That,s a lot a day.

And that's what he was on. All right. And he was telling me his pain is eight out of 10. He's still depressed, he's not working. And this is like really, you know, messing them up. So MAW was six months ago, not three and a half. I'll take this light. And MAW, I finally convinced him, it was like four years, finally convinced him that I said, you gotta just come off the medication and I'm going to, I said to him, I'm going to do a spinal cord stimulator for you, and we'll take care of the pain.

I said, because enough, enough of this, I, I know I can control the pain with a spinal cord stimulator. Or a peripheral nerve stimulator actually for him. So he came off and then he's on Suboxone six milligrams a day, and his pain is 1. So the opiates were causing his pain! Okay. Good mood participating at home, and he's looking for part-time work.

So medication-assisted withdrawal can actually not just take patients off opioids, but it can actually help with their pain. Okay. Thank you.