LDN Video Interviews and Presentations

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Today we're joined by pharmacist Dr Dawn Ipsen who's the owner of two pharmacies in Washington State, Kuslers Pharmacy and Clark Pharmacy. Could you tell us what it was that inspired you to become a pharmacist? 

I knew early on as a high schooler that I wanted to have a doctorate degree in something and was sort of a little bit torn between pharmacy and optometry and with long heartfelt discussions and soul-searching I became a pharmacist and very early on in my career not only was I trending towards being a pharmacist but I had an opportunity to intern at a compounding pharmacy and just absolutely completely fell in love. It was the art and the science and the way of being able to help individual patients in manner of which no other pharmacist in my area was able to do so, of providing very personalized therapies. I was able to really listen to patient needs and work with their doctors, to formulate the exact therapeutic tool that they needed to improve their quality of life. That is really what has driven me in my career. 

When did you open your first pharmacy? 

I had been a pharmacy compounding lab manager for about 10 years for the Kusler family. When they were ready to go do other things in their life I was given the opportunity to purchase Kusler's Compounding Pharmacy. It had been a pharmacy I had worked at as a staff member for 10 years and took over as the owner and I've now owned that pharmacy for almost 10 years. In January it will be 10 years. That was my first pharmacy. I was doing all my good work up at my Snohomish Pharmacy and suddenly had a random phone call on a Friday afternoon in which the Clark family was looking for a new owner for their pharmacy. They were ready to retire and go do other things as well. I've also owned Clark's Compounding Pharmacy down in Bellevue Washington for six years. I've been an owner for almost 10 years total and have had multiple locations now for about six years. We service not only the entire state of Washington but we also work within nine other states as well. Our boundaries go quite deep and it's a really great way to help all types of patients all over the nation. 

What would you say is the most popular form of LDN that you use the most? 

I would say primarily we use the most customized strengths of capsule formulations of low dose naltrexone (LDN). It gives patients really great consistency yet opportunity to get the doses titrated in appropriately where they need it to be. What's really great about how we approach our making of capsules: we use hypoallergenic fillers. We're also able to work specifically with patients who have sensitivities. We can customize what that filler might be and I think that's really what sets our pharmacies apart and why doctors and patients choose to work with us. We are experts in autoimmune and chronic inflammatory diseases and therefore we're very used to working with patients where the normal just isn't what they need and isn't what's best for them. We can customize that to be appropriate for them. Along with capsules of course, we are able to do transdermals. That's really popular in pediatrics, especially for patients with an autism spectrum disorder. We are able to make flavored liquid tinctures of it so patients are able to use various small doses to titrate up doses. We also make sublinguals. I would say capsules are pretty popular for us. 

What kind of fillers are you asked to use? 

Most of the time I will steer a patient towards microcrystalline cellulose (which is a tree-based cellulose). It is very hypoallergenic for a lot of patients. However, some patients know they have tree allergies and those patients primarily prefer rice flour. I do have a couple of patients, but very very rare, that actually do better on lactose filler. They tend to not be my autoimmune patients. They tend to be patients in the chronic pain spectrum area. We have also worked with other fillers, like tapioca flour. We can be very customized into our approach of how patients need it. I've got one patient that comes to mind that loves magnesium as their filler and that's very relaxing for their muscles. I've also seen probiotics being used. There is not one right answer to how we do things. We are that pharmacy that is able to have a conversation with a patient. We talk about what their needs are and customize it based on that approach. 

From the prescribers that you work with, do you have many consultants that you fill scripts for? 

We definitely do. That's also kind of a little side thing that I do. I've always been very passionate about teaching. I'm on faculty at University of Washington School of Pharmacy and also Bastyr University, which is one of the top naturopathic doctor schools in the nation. I teach there during summer quarter. I teach nationally to providers continuing ed-based content that is often LDN in nature, or ties into LDN. Especially with autoimmune and chronic pain and chronic inflammatory conditions. We consult a lot with doctors. I probably work with three or four hundred functional med type providers on any monthly basis, even on being able to customize therapies for their patients. We are really big in the post-COVID syndrome arena of helping patients that are really struggling and LDN. We're finding it pairing quite nicely in that condition as it's very inflammatory based. We work quite heavily within the MCAS arena for patients who have a lot of mast cell instability and need other therapies. LDN is one of the tools that is used quite frequently by those types of providers and for those specific kinds of patients. 

Do you work with any pain specialists, dermatologists, rheumatologists, gastroenterologists? 

We do. Honestly, I’m quite proud of our little Seattle area of Washington because we do have MDs that are pain specialists that are now really turning towards using LDN in their toolbox of things they have available for patients. They're getting quite savvy at it. They're doing a really great job. It is super exciting. I have some dermatologists. I consult a lot with my functional med providers that are seeing dermatology conditions like psoriasis. I have an email I need to work with a doctor on after this to help them with this patient with a psoriasis case. We are seeing it in the GI world as well for Crohn's and irritable bowel disorder. Those chronic inflammatory conditions. I would say the MD pain specialists are really turning around over here. Obviously with the opiate crisis that has occurred in our nation I think most doctors of any type of credentialing or medical training or experience are quite interested in what LDN is doing for their communities and what opportunities it affords for patients who are trying to make sure they aren’t addicted to opiates but yet have something to improve quality of life and their day-to-day living. Low dose naltrexone has been an amazing tool for that. 

I'm always excited to meet different LDN prescribers and nurse practitioners who are providing lots of scripts. When you get an MD or a DO that is prescribing LDN and it is completely out of their comfort zone, I always think yes, you know we've got another one on board. We're making it right. We're getting it. MDs are already working outside of the box. That is normal for them to look into LDN; it's not normal for MDs to look at LDN but as you know, I've interviewed so many people and so many MDs when they have a patient that they can't help, and fix their issues. They've tried everything and they feel as if they've failed this patient, and then they try LDN. Once they have had amazing results with the first person it's then so easy for them to look into prescribing, not only for other patients with that condition but for any autoimmune disease, chronic pain, mental health, etc. 

I mean it's really amazing and this is where people like yourself come into play. The hand-holding with doctors because a lot of them haven't got time to do the homework. They're very busy and they need somebody to tell them exactly what it is, how to prescribe it, what to look for, what to do and have somebody on hand to say, like you said, I've got a patient with psoriasis. What do I do? Can you help me? That is the way to get more doctors involved is the pharmacist doing the hand holding. 

There is a local psychiatrist in our area that works with younger adults with substance abuse disorders and teenagers that are having a lot of trouble with mental health. I had an opportunity to get him thinking about LDN and his patient population. I love when I get to reconnect with him every few months because he just raves He finally has a tool that actually does something. He felt the antidepressants and all these other things were not really fixing any of the issues or fixing the symptomatology. We still have the same abuse issues, we still have the same addiction issues and we still have the same levels of depression and suicide risk. But with LDN he's finding that he's actually causing positive change in his patient population, and that's the only thing he really changed within his practice. We're really affecting the health of our community in a very positive manner with something that's really safe and low risk and not expensive. It doesn't get any better than that. It's the best compliment I could ever have. 

It's really nice when patients take all their information to the doctor. Once you've got a doctor really hooked on prescribing LDN they can change the lives of hundreds of patients. Dr Phil Boyle uses LDN in his fertility clinic. He also uses it in women's health for things like endometriosis, polycystic ovary, painful periods, heavy periods. Right across the board he uses LDN. He gets patients coming to see him with women's health problems who also have Hashimoto's or long COVID etc. I refer to his work all the time. He gets questions a lot from local providers such as we have somebody who wants to become pregnant, or they did become pregnant and they're on LDN and they want to know what the standard of care is and can we continue, and what's the risk and benefit are. It is so great to have providers like him out there that have been doing this work for so long that we can very confidently share those case experiences and history of using the medication long term for those patients. 

There have been so many of our members who were skeptical about using LDN during pregnancy. Doctor Boyle is always very generous with his time. I will send him details and he will answer the patient and share his experience. You know we used it once up until birth rather and breastfeeding, etc. We have those people who have done two or three pregnancies using LDN who are happy to talk to other people. This is my experience with 20 years as the charity next year, which is totally amazing, but I’ve found that word of mouth and with the education it is just spreading. 

Linda, you've done an amazing job with the LDN Research Trust and I thank you for that. You have made the Research Trust, its website, resources and its books into a trusted referral point that I can use with our doctors and our patients who are wanting that next level of information beyond what I'm able to say to them. They want to go see those studies themselves. They want to go read the book themselves and I know that without a doubt I can send them to your resources for them to receive complete in-depth and correct information. Thank you Linda. You're doing amazing things and this is all because of you. 

How can people contact you? 

We have two locations in Washington State. We have Kusler's Compounding Pharmacy in Snohomish Washington and the website there is www.Kuslers.com; and then we have Clarks Compounding Pharmacy in Bellevue Washington. That website is www.clarkspharmacywa.com. The WA stands for Washington. We are happy to help patients all over and talk with doctors that need guidance and assistance in learning more. I love being an educator and I love being here to support my community. 
 

 

Welcome to the LDN Radio Show brought to you by the LDN Research Trust. I'm your host Linda Elsegood. 

Dr Steve Zielinski is here today. Can you tell us who are you? What made you decide you wanted to be a pharmacist? 

I wanted to be a pharmacist because my dad was a pharmacist, and I liked it when he'd take me to work when I was a kid. I got to see him work and how he helped people. People really appreciated it. I wanted to do the same thing. 

How did you get into compounding? 

When I was in pharmacy school we were learning how to make stuff in the lab, and I was interested in making stuff. I like to cook a little bit, and compounding was just like cooking to me. That is what got me into compounding. 

Could you tell us what forms you make of LDN? 

We buy it as a bulk powder and we can make it into anything essentially. The forms of LDN we typically make are capsules, which are pretty standard. We also do a troche and we do a liquid, like an oral solution. Now we're working on transmucosal films. Those are films that you can put on the inside of your gum and it gets absorbed through the cheek. Some people complain about the troche taking a long time to dissolve and having to sit under their tongue for a long period of time. One of the things that we've started to learn to make are films that go on the inside of your gum or on the inside of your lip, almost like chew or something similar. It then gets absorbed through the skin. 

Did you learn about LDN in pharmacy school? 

I learned about naltrexone in pharmacy school. I heard it was great at 50 milligrams for treating alcohol and drug dependencies. I never learned about it at the doses that I'm using it for or the conditions that we're seeing it be beneficial for in pharmacy school. 

So how did you hear about LDN? 

Being a compounding pharmacy people would ask me, "Hey do you make low dose naltrexone?" That’s how I heard about it a lot of times. I often hear about things from other people that are wanting to learn more about it. Then it makes me learn more about it; or I get stuck in a position where I need to learn more about it because I don't know much about it, to be honest. I definitely don't claim to know everything about pharmacy, or medicine, or drugs, but when I get a question and I want to find out the answer I go and look it up. That's what I did. That's how I got started with low dose naltrexone. 

How long ago was that? 

I want to say close to five years ago. People were coming in looking for it for different conditions, and specifically pain, and I suggested this because it is low dose, not habit forming. I thought I'd give it a shot for somebody. We did and it worked. 

How many patients do you think you have on low dose naltrexone right now? 

Probably about 30 or so patients on it. 

How many doctors are sending scripts to you? 

About 10 or 11 right now. 

If you have 10 or 11 then they haven't got many patients each on LDN. What would you say is the stumbling block for them not to prescribe it more widely? 

I don't think they're aware of all the different things it can be used for. I think that's the biggest issue. I think the biggest stumbling blocks are having a good understanding of it for what they could be using it for, and then I think another stumbling block is the dosing of the medication. There's not a package insert that comes with this like there is for every other medication. You can't look this little drug up in the Physician Desk Reference and see how you prescribe low dose naltrexone. 

That's not there, but you know if you look up naltrexone, you're going to see a 50 milligrams dose and how to use it, but you're not going to see the different doses that could be used for in a different dosage forms. That's available from a compounding pharmacy. I think that's one of the hindrances that we see with this medication being prescribed. 

Did you know the LDN Research Trusts have three guides on our website. 

Those are great references that I'd love to make available to the prescribers that I work with. 

It's on the LDN Research Trust.org website under resources called LDN Guides that might be a benefit to you and your doctors. Many pharmacists that have been doing LDN for many years will have a seminar in their pharmacy and have an evening where they invite doctors to come. You give them a presentation and explain it to them.
Can you explain what conditions LDN could be used for treatment? Pick a couple and give some case studies. Tell them that you are available to answer their questions. I'm sure there are thousands of people in your area who have either chronic pain, mental health issues, autoimmune disease or cancer. The number of people you know that could be using LDN is endless. Anybody who's in your area who would like to help you expand the client database to get more doctors prescribing LDN in your area would be amazing. It would be great to see yourself grow. 

I think we end up using it as an option a lot of times when other things fail. I think that's how we get people started on it for the most part. The most interesting one has been with hair loss post COVID. I think it has been really interesting to see when people have been having their hair falling out. Whether it's from having COVID or exposed to COVID or don’t know what it is, I don't know the diagnosis but we try treating hair loss and nothing's working and then we try low dose naltrexone and it works. It has been a new one for me. 

Having COVID happen and the pandemic and everything has been a springboard for low dose naltrexone because LDN works so really well for long COVID. There are two chapters in the LDN Book Three that address long COVID, and you can hear Professor Angus Dalgleish saying that he's a cancer oncologist. He also is a virologist. He treats people with long COVID and he says that it should be a first line of treatment because patients do so well on LDN. He said some people have said it's placebo and that there's nothing to this treatment. He says that once they stop LDN all their symptoms come back. When they restart the symptoms go away. You then know it can't be placebo. It should be a first line of treatment. When people have COVID, you know they are worried about getting long COVID. They should take LDN. It really a game changer for them. There are people who have had chronic fatigue for years. Years ago they were dismissed as being imaginary or told it's depression. There is nothing wrong with you. Deal with it. Now COVID has come along and some have similar symptoms and all these people are saying who've got long COVID. Fatigue is terrible. It's absolutely awful and that's been around for a long time. People who had it were not believed. I think it is going to raise awareness that will help people with chronic fatigue syndrome. People recognize it as a condition and not just an imaginary condition. 

You said with chronic pain, are people using it to wean off of opioids? Are they using it once they're off the opioids? What I'm trying to say is, are you using micro-dosing LDN alongside of opioids to get patients off the opioids? 

Yes and it's really interesting to see because there's a lot of hesitation and nervousness by the prescribers to do that, because but it's such a low dose that you can wean somebody off of opioids and morphine with it. We've been successful with it and it's been pretty neat, because when you're dealing with long-term chronic pain, to use something that doesn't cause you the side effects, constipation and things like that, on top of the opioid addiction. It's pretty nice to have that in your in your toolbox as not every doctor has that, because they have that tool in their toolbox they could use, but they hesitate because of not understanding how low dose naltrexone is going to work in combination with a stronger pain medication like an opioid. It always amazes me that there are people who have had chronic pain for 20 years and they have taken the highest dose of Oxycodone, they then have another fentanyl patch put on and they end up with this cocktail of pain medication. They have to take other medications to combat the side effects that these medications have caused and their pain is still a nine to a ten every day. This time they can't come off those pain medications. They're addicted to them, although they're not working and my understanding being non-medical that these high doses of pain medications are very bad for your organs. They are damaging themselves at the same time as it's not working. 

To actually take a micro dose alongside of those medications where you don't have to reduce the dose initially everything stays the same. You're not going to go through withdrawal. You're not going to feel your security blanket has been taken away from you, but it does make the opioids you're on more effective. That means you can titrate the opioids down while titrating up the naltrexone and people come off it and I'm happy when people say for 20 years they've suffered. They've come off the opioids. They didn't go through withdrawal. People say that they feel no pain anymore but some will say I still have pain but it's a three or a four and I know it's there but it doesn't stop me from carrying on to live a normal life. I can still achieve what I want to achieve. The pain isn't stopping me and I think from the LDN point of view that is just totally mind-blowing because you think of these opioids as being like a sledgehammer. The LDN being a feather, you think how can it properly be effective but you've seen it too. I have seen it and I think it's really very interesting because people don't just come off of their opiates when they go on LDN. 

That's where they start. They start coming off of their pain medications with the hardest ones first but then the longer and longer they stay on the low dose naltrexone more things can start falling off after that as well. It's really interesting to see the same doctors that are hesitant to start the low dose naltrexone for people on chronic pain medications to be the ones that would be the one recommending that and not the next pain medication. I had a patient that was on a morphine equivalent and maybe an oxycodone or Oxycontin or something like that at the same time for chronic pain and it wasn't going away and he was on there for about two years and then something about nerve pain was mentioned and neuropathy. I had recommended using low dose naltrexone and he used it and then the doctor started titrating the doses of these medications away and it wasn't just those two it was also other things. There was Topamax for pain that wasn't needed anymore. You're not just relieving a couple of medications, it's a lot of medications. It starts with a couple and we titrated it up slowly at the same time of weaning them off of one of the pain medications. Then once he was comfortable without one of the pain medications then he learned that he could also stop a second pain medication. This was a period of maybe six to eight months and over six to eight months that he was opioid free. No morphine, no opiates. Strictly just using low dose naltrexone with other muscle relaxants as well. Then a year later or two years after that he was even able to stop some of those. It's not just stopping opiates it's stopping other medications as well. 

I know some people who had fibromyalgia or who have fibromyalgia who were taking like 14 different medications a day and some of them have got down to just taking two or three including LDN. That has to be better for your system. The less medication you're putting in your body the better. Obviously medications are important when your body isn't working correctly and you are in a lot of pain. Sometimes if the necessary evil is but I think it's a good starting point to see what alternative dosage forms and treatments can do. I think that's what I really like about it is because I kind of play and not play, but I kind of work in a pharmacy where I'm doing both nutrient depletion compounding and traditional medicine. It's not one side or the other, but how do you use them both together, and I think when you can use something that can get an effect that the doctor wasn't aware about, or wasn't completely knowledgeable about, and it works, it starts getting people interested in their own health and seeing what else is out there. I think that's the best thing about low dose naltrexone. It's one of those things that does just that because it's okay what is possible because my pain was forever and now it's gone. I had to use these opiates forever and now I don't. Once you do this and they get that X they get exposed to that then they start taking their health in their own hands. 

The favorite part of this drug is people start taking control of their own health. They can bring questions and stuff, but ultimately they take control of their health back in their own hands. Doctors if they were listening to you and work out, I think that's something we do well is we only have about 30 to 35 people. I think low dose naltrexone, but I think that's one thing we do is we run into all those stumbling blocks, those challenges. We can make the recommendation that they should do it but it's something that their doctor ultimately has to make the decision on, and so we try to equip them, to empower them to have the right information in their hands. This is where it's worked before. How can I start trying this or how can I take this step? I think that's what we do pretty well. Not with just low dose naltrexone, but all medications. If a patient has a high blood pressure and they're not sure which medication is causing it, maybe they have two or three different blood pressure medications, pharmacists are in a great position to be the advocate of saying talk to your doctor about this blood pressure medication and see all the time these medications have a risk and reward. If a medication has more risk or more downside than the actual benefit but low dose naltrexone there is a lot of good literature out there. Whether it's a case study or a larger study on multiple people or case reports or controlled trials they're out there. The data's out there. There's plenty of evidence to support using it to where it's still evidence-based medicine that we're practicing. 
 

 

 

Asher Goldstein, MD - His experience with LDN as a Pain Specialist; LDN Radio Show 2022. (LDN; low dose naltrexone)

 

 

The LDN 3: To Purchase with discounts before 1st September 2022 Go to ldnresearchtrust.org/ldn-book-3 for full details

 

 

Asher Goldstein, MD - LDN Radio Show 2022 (LDN; low dose naltrexone)

SUMMARY
Over the past 2.5 years that Dr. Goldstein has been prescribing low-dose naltrexone (LDN), he has shifted to a much lower and slower titration pack. He uses it for many applications in addition to pain, such as fibromyalgia, Crohn's, rheumatoid arthritis, multiple sclerosis, Hailey-Hailey, polycystic ovary syndrome (PCOS). He gets referrals for LDN prescriptions from pharmacies. He is quite impressed with how LDN works against pain, and discusses prescribing for pain. Onset of action can be short, or months, depending on various factors. He is very open to help educate healthcare professionals about LDN.

TRANSCRIPT
Linda Elsegood: Welcome to the LDN Radio Show brought to you by the LDN Research Trust. I'm your host, Linda Elsegood. I have an exciting lineup of guest speakers who are LDN experts in their field. We will be discussing low-dose naltrexone and its many uses in autoimmune diseases, cancers, etc. Thank you for joining us.

Today we joined pain specialist Dr Asher Goldstein from New Jersey. Thank you for joining us today.

Dr. Goldstein: Good afternoon, Linda, how are you?

Linda Elsegood: Good thank you. So, could you tell us what's been happening in your practice with LDN and pain?

Dr. Goldstein: I've been practicing now just about 15 years and only started using LDN about two and a half years ago. What's actually interesting is that I just attended a conference on Friday, two days ago, and when I last attended that conference in 2019, which was you know BC - before COVID – I had not even thought of LDN. I remember just flashing back to those three years previously. There was nothing about LDN said. I had nothing in my recollection about LDN. And interestingly enough, three years ago I went as an attendee, and this year I was invited to speak about LDN. So, they were very curious, and out of about a hundred doctors, pain specialists only about five had even heard about LDN. So, it was a very receptive audience with a lot of questions and answers during the non-technical sessions, just floating around. So, it was very good, and hopefully there'll be 95 other doctors that can help their patients as well in regards to LDN use and prescribing in the pharmacy.

It has developed and transformed dramatically over the past two and a half years that I've been using it. I've shifted in how I prescribe low-dose naltrexone.  I've gone to a much lower and slower titration pack. I start at half milligram, and I only go up by a half milligram a week. I have a compounding pharmacy that has made a Dr Goldstein titration pack, and by and large, the issues that patients had previously with side effects are 99% gone. I think I've had one or two patients stop LDN because of side effects in the last year, and that's nearly none. Everybody reports dreams at some point in time, but when they're warned about it, it's usually not an issue, and most patients will move their once-a-day medication to the morning, as opposed to the evening; and then generally, those patients move it back to the evening a few weeks later.

I really branched out and started using LDN in in many many applications, especially with patients that have come to me, not necessarily all the time with a specific diagnosis. I'll have patients come who have been in pain for 15 years 20 years. They've had a rheumatologic test here or there that sometimes shows something, sometimes doesn't. They don't have anything specific. They're feeling run down, they're feeling exhausted, and they're in pain and nothing else has worked. LDN seems to work very much for these patients even though they don't have specific diagnoses. I'm not even counting the patients that we're treating from a pain perspective, you know, rheumatoid arthritis, multiple sclerosis, fibromyalgia, Crohn's, you know the list is big. It's big and hopefully we'll get bigger. The list that we have has people that we can treat. I'm treating people even with non-painful conditions. I have a patient with Hailey-Hailey. My dermatologist friend was very upset with me because that's supposed to be his field. I'm like, I use LDN. He's like, hey I use LDN too. How did you know that it was very good? And then, polycystic ovary syndrome. Some patients have become referred from different pharmacies, so even patients without pain are coming just for the LDN.

I read extensively about it in the beginning, and you're like okay, I think I should use this. But then as a practitioner, once you actually see the proof in the pudding, it's amazing, just amazing. For me it has completely transformed my practice, and where some of the patients with difficult to treat pain syndromes are less difficult to treat pain syndromes now. So, it's been fantastic.

Linda Elsegood: So, the million dollar question that everybody asks is, I've been on pain medications for the last 20 years. Those pain medications aren't working. I'd like to try LDN. How can I go about starting?

Dr. Goldstein:  I tell the patient, but they'll usually say to me, the pain medications help me get around, but they don't really treat me well enough. They allow me to get out of bed. I tell them, a hammer can also put a screw into the to the wall, but a much better tool will be the screwdriver, right? And it makes less of a mess. So the opiates are the hammer, and it's hard, so you can either go the quick way, which is a little more difficult, or you can go the slower way, which is difficult in its own way. But look, if somebody's been on opiate medication 50, 20 years, they have to significantly reduce their load. Some doctors will want them to be completely off pain medication. I find that if we can reduce it to maybe 40 or 50 morphine milligram equivalents (MME) and people can look up what MMEs are online in regard to their particular medication, and how to convert it to MMEs. There are conversion calculators. But usually about 40 to 50 MMEs can still be handled with LDN as long as it's not extended-release medication. For example, oxycodone, a combination of acetaminophen, also sometimes known as Endocet, or Percocet in the United States. If somebody's taking seven and a half milligrams twice a day, three times a day, I can actually work that in together with LDN. I tell my patients as long as you're not taking the opiate medication four hours before or four hours after LDN, you should be okay. You can take it the other 16 hours of the day as long as you need, if you need to. For example, if they go to sleep at 10 pm and that's when they take their LDN, their last Percocet can be at 6 pm and the first one could be at 2 am if they wake up in the middle of the night. But between 8 pm and 2 am, this particular example, they can't take it. Now if somebody's on a higher dosage of that, they have to reduce it or eliminate it, and that could either be done over time with slow titration, or that could be done through medication withdrawal using suboxone. Both of them have their pluses and minuses. The suboxone is quicker, but it usually requires a patient to go through 24 to 36 hours of moderate discomfort. I call it going through the ring of fire, as until the suboxone kicks in. In order to help the patients, the other way is two to three months taper of lowering the opiates while not getting the LDN yet, which can also be uncomfortable, but it can be done. The bottom line is you don't have to eliminate it completely. It just has to be reduced.

Linda Elsegood: Okay, so what have the outcomes been, as in a time frame for LDN to actually start to work?

Dr. Goldstein: It's a huge variety of time for onset. I've seen as quick as a week. I've seen as long as six months.  The main thing is talking to the patients, realistic expectations, and setting an education, meaning patients have to understand that there are many different ways that people respond to the medication. Typically, patients with fibromyalgia go quicker; patients with things like polycystic ovary syndrome (PCOS) take longer. I've seen the patients with Crohn's - those go pretty quick. In general, the medication helps patients whose diseases have two things in common:  the immune system dysfunction - I don't like to say autoimmune, I like the “immune system dysfunction”; as well as an inflammatory state. In those patients that have more inflammation than immune system dysfunction, I find that the medication works quicker. And those patients that have more immune system dysfunction than inflammation, it takes longer. That's been my sort of empiric view of what I've seen.

And again, DNA is what really rules everything, so you can have the same disease in two different patients and they respond completely differently. My lowest dose to start LDN has been 0.3 milligrams, and I actually have one patient now, with polycystic ovary syndrome, at six and a half in the evening and two milligrams in the morning, so eight and a half milligrams. In the beginning I would have never even thought that a patient could respond at so low or so high, but what one thing I've learned about LDN is that don't ever put yourself in a box. You could, because LDN constantly is evolving in my mind, its use and how patients respond to it.

Linda Elsegood: You were saying there about the dosing range - have you gone higher than six and a half milligrams?

Dr. Goldstein: Not me personally. I have not had the need to. In a single dose, I haven't done higher than six and a half, but I have done the daily dose high of six and a half.

Linda Elsegood: Do you ever prescribe it more than twice a day?

Dr. Goldstein: Twice a day, okay, I'm open to it, but with those patients that I've found the need for the twice a day is usually where the second dose is having to deal with mood or energy versus pain. So those patients, once we get the second dose in the morning, that usually stabilizes them. That's typically why I'm giving a second dose. It's not necessarily for the pain, but more for the mood and energy. and as you say, everybody is individual, the dosing is individual. There are some doctors that are getting the patient stable, let's say on 4.5 milligrams, and then they will do a second dose in the morning of 4.5

Linda Elsegood: And you're doing it at a lower dose in the morning, but higher in the evening. It is so patient dependent, on what works best for that patient. How long would you say it takes to find that right dose for a patient?

Dr. Goldstein:  The right dose can work in as quick as a week. It's highly unusual - but that's the quickest. And I actually didn't believe the patient, so I sort of pushed them to go higher. Then they felt worse, and then I'm like okay, listen to your own advice, listen to the patient. We went back down to half milligram. It can take as long as six plus months. There's just a huge variety of responses. But like I said, the inflammatory-state patients respond quicker; the more immune dysfunction patients take longer. But the majority of patients that I've seen, that they're having their disease 5, 10, 15 years, so these patients have a lot of patience, typically, and as long as they perceive that the doctor is working together with them, listening to them, acknowledging, a lot of patients say to me, my family thinks I'm crazy, my doctors think I'm crazy. I'm like, you're not crazy, you have an atypical medication and an atypical issue, and atypical issues are sometimes difficult to deal with. When people don't want to deal with them, then sometimes we put names and labels on them.

Linda Elsegood: So for those patients who are on a very low dose, and LDN is working fine for them, do you try further down the road to increase that dose, or do you just…

Dr. Goldstein:  I mean, if it ain't broke, don't fix it kind of person, so usually not. I actually had a patient in this morning who said to me, and this is a person with a lot of both back issues as well as immune dysfunction issues, and basically it was fibromyalgia when he came in, and fibromyalgia is not a typical diagnosis in men, but this gentleman came in and I examined him. He was operating, he said, at 20% capacity when he started, and now he's at three milligrams and he's operating at 70% capacity, and he says, I'm happy where I am. He says, I don't want to push it any further up or further down. I'm worried that if I go up it'll be worse. He says 70% is a huge change from where he was. So again, if a patient wants me to push a little bit, I always tell them we can always move. I can write quarter milligram pills. If you can gently push it up or down, you have that ability. It's not a medication that's fixed in any which way. And then I speak to them that their need for the dose may increase or decrease with time, so they should just be aware that it's not fixed in stone. I even tell patients four and a half milligrams is just an aiming point. We have to aim somewhere.

Linda Elsegood: So, you can't see all the patients with pain around the world. What would you say to doctors who are presented with patients with pain, who don't really know anything about LDN, and don't feel confident prescribing it?

Dr. Goldstein: If I was able to spend a half an hour of educating a doctor, I get much more return on investment than half an hour educating the patient, right, because I can help one patient, but that doctor can help 100 patients a week. That's why I really want to go to the conferences that are not LDN conferences, and speak about LDN, and encourage doctors. I say, you know the upside is that it's relatively inexpensive, there are very few if any side effects, and very few if any drug-drug interactions. The downside for doctors is that you got to talk to your patients, but some doctors don't like to do that, strangely enough, as bizarre as that sounds. But that's really the downside - having sometimes to convince a doctor when they're like, I don't have the eight minutes to spend with the patient additionally, to speak with them about LDN. But I'm like, well first of all, you invest those eight minutes and they're going to wind up coming to you much less, complaining much less, taking up less of your time, because their pain is less, and if you can't do it, send me your Nurse Practitioner or your Physician Assistant. Let me educate them, and they can help the patients. It doesn't have to be you. As long as you're a doctor, there can be things that they don't quite understand, and you can help. You don't always have an exact formula on how to treat a patient. Sometimes, if the disease is not exact, then the medication doesn't have to be exact.

Linda Elsegood: So how can people get hold of you?

Dr. Goldstein: They can call my office, Asher Goldstein, 201-645-4336, and make an appointment, then we can take it from there. If there are physicians that are listening to this, and you want to spend some additional time with me, I'll spend half an hour or an hour. I'll go out to dinner, I'll have coffee; we'll figure something out, because for me to help a medical professional understand that this is about as benign of a medication as possible, and it can help all those patients, that when you see those patients on the list and you're like oh my god how am I going to help this person today?

I wish I found this medication years ago. Maybe I would have ripped the hair out of my head. I tell my patients this medication doesn't do anything to you, which is why there are no side effects. They're like well, why am I going to take it if it doesn't do anything to me? So, I say, this medication allows your body to start working for itself again. That's all it does. It blocks a receptor for three to four hours, that's it, nothing else. And it does that for three to four hours, then the whole magic happens - the magic of normal level of endorphins, that is. That is the secret sauce, right? Bring the endorphin levels back up to normal, and then the body has the fuel that it needs to do the myriad of chemical reactions that normal levels of endorphins allow.

Linda Elsegood: Well, thank you so much for sharing your experience with us today. I mean, it's fantastic what you've done in such a short period of time.

Dr. Goldstein: I look forward to helping more patients, and I look forward educating more medical professionals.

Linda Elsegood: Thank you, thank you. Good to see you. Hopefully next time, in real life

Dr. Goldstein:  Yes, thank you, and take care. You know, I give your story when I lecture. I say look, there was this woman who was told to park herself at the corner, and she refused to take that for an answer, and because of her, I'm here today.

Linda Elsegood: Any questions or comments you may have, please email me, Linda, at contact@ldnresearchtrust.org. I look forward to hearing from you. Thank you for joining us today. We really appreciated your company. Until next time, stay safe and keep well.

 

 

LDN Webinar Presentation 18 May 2022: Dr Masoud Rashidi - LDN, Dosing, Fillers and Compounded Options. LDN, ULDN and Pain/Opioid Issues

Sponsored by Innovative Compounding Pharmacy https://icpfolsom.com/

 

LDN Webinar Presentation 18 May 2022: Dr Mathewson - LDN as supportive care for Oncology and Autoimmune patients: Case Reviews

Sponsored by Innovative Compounding Pharmacy https://icpfolsom.com/

 

 

LDN Webinar Presentation 18 May 2022: Dr Sato-Re - How and why I prescribe LDN in my integrative and general practice

Sponsored by Innovative Compounding Pharmacy https://icpfolsom.com/

 

LDN Webinar 18 May 2022 (LDN; low dose naltrexone)

LDN Questions Answered Live by

Pharmacist Dr Masoud Rashidi - LDN Specialist
Dr Sato-Re
Dr Mathewson

Sponsored by Innovative Compounding Pharmacy icpfolsom.com

 

 

Pharmacist Michelle Moser, LDN Key to Success (LDN, low dose naltrexone)

Review: Michelle Moser has 35 years experience as a Pharmacist and is very experienced with the utilization of LDN (Low one Naltrexone). She volunteers her knowledge as an a LDN specialist with the LDNresearchtrust.org. Her 21 minute presentation covers how they supply a thorough service to their customers, with advice and council on dosing and related help for a variety of conditions. She explains how LDN can be used along with most other drugs, even opioids if the LDN is micro dosed and immediate release. All autoimmune conditions can benefit from LDN.

Review by Ken Bruce

Linda Elsegood: Welcome to the LDN Radio Show brought to you by the LDN Research Trust. I'm your host Linda Elsegood. I have an exciting lineup of guest speakers who are LDN experts in their field. We will be discussing low dose naltrexone and its many uses in autoimmune diseases, cancers, etc. Thank you for joining us.

Linda Elsegood: Today I'd like to welcome back our guest pharmacist, Michelle Moser who's also one of our LDN Specialists. Thank you for joining us today, Michelle.

Michelle Moser: Oh, thank you so much for having me. It's certainly my pleasure.

Linda Elsegood: So we're all keen and eager, and as people can see, you've put “Keys To Success” up there, so take it away.

Michelle Moser: Thank you, thank you very much. I appreciate the opportunity to share some information with everybody today that really goes over not only how patients can find their success, but how providers can also enhance patient outcomes. So here we go. The first thing I want wanted to address is that low dose naltrexone plays really well with other therapies. It's not necessarily medication that is used all by itself all the time, and that is a question that comes up from not only patients, but from providers as well, wanting to know, well, the patient is taking this this and this. Can I use LDN? And the answer almost always is yes, and the main reason is that even if we are using or prescribing opiates for patients with chronic pain, depending on how those opiates are being utilized throughout the day, LDN might still be an option. Very few times is it that LDN is not something you can start. It doesn't have very many drug interactions, so LDN is brilliant for a wide variety of indications. And as we know, as so many more autoimmune diagnoses are being found every year, I think now there's something like 100, 120 some, maybe even 140 autoimmune disorders, low dose naltrexone is a wonderful fit for most of those patients.

But we also have other dosing, such as very-low-dose, which is 50 to maybe 250 micrograms. And then we have ultra-low dosing, which stems from the oxytrial study where we were using only microgram dosing, one, two, three, four micrograms, alongside short-acting opiate medications to help reduce the need for those opiates and replace it with low dose naltrexone. Because we know that low dose naltrexone not only helps to intermittently block those pain receptors, but also helps to reduce not only inflammation and those pro-inflammatory cytokines, but we can also see that low dose naltrexone helps to modulate the immune system. And there's a wide variety of studies that have been published to emphasize exactly those parameters. So if you're needing those, either reach out to the LDN Research Trust or your local compounding pharmacist. Sometimes we have those available, as well some of the other things that we use in our compounding lab and compound on literally a daily basis, because low dose naltrexone is used for a lot of inflammation issues, autoimmune, chronic pain.

We can also use low dose naltrexone for some of those other nuanced areas such as traumatic brain injury PTSD, depression, and anxiety; and we've heard from a wide variety of wonderful practitioners during the LDN Research Trust conferences on those specific areas. But when we're able to use other medications in combination with LDN; I don't mean like in the same capsule or in the same liquid, I just mean side-by-side dosing; we can see that oxytocin, especially in a nasal spray, is incredibly helpful to help build that sense of connection, to help alleviate depression and grief, as well as go after some of those imposed pain areas. And oxytocin is one of those medications that is very easy to administer in a nasal spray, even in sublingual drops. But it is very sensitive to heat, so we have to be very careful about what dosage forms we're using. We don't use oral capsules with oxytocin. The stomach acid kind of wipes out its activity. So we need to find alternative forms for that.

But also if you're needing low dose naltrexone for dermatology issues then we can combine it with mast cell stabilizers like ketotin or either other anti-inflammatories, even tranexamic acid, to help decrease some of the redness, in that dermatology issue. And even the autoimmune dermatology products, we're very careful about the bases that we put low dose naltrexone in so that we can control exactly how deep we want that therapy to go. So not every base is going to work, because we really need to individualize that therapy for that condition.
Of course we use low dose naltrexone in a situation with ketamine, which is a non-opiate pain medication as well. And because ketamine works on different receptors than low dose naltrexone we don't see the withdrawal. We actually see the enhancement of that pain control. So there's a a lot of options here.

And lastly, I wanted to address synapsin, which is this wonderful combination of medications. It's a ginseng derivative along with an NAD that again helps to reduce the central inflammation in the brain. And when we use it in a nasal spray, of course that helps with the neural transmission directly to the brain.

As a pharmacist, when a patient is new to low dose naltrexone, or even comes to us because a provider would prefer to use our pharmacy, we emphasize that low dose naltrexone is not a cure-all drug. It actually doesn't really cure anything, but what it does do is it helps to trick the body to work on its own pathways, and much more effectively, and much more efficiently.

So when we set up the expectations, we want patients to know that this isn't like taking something like an aspirin or a Tylenol. It's going to take a little while for this medication to provide full benefit. And we also know that low dose naltrexone isn't for everybody. But when we start low with the dosing and slowly increase, that we can actually see patient outcomes in greater than 50, actually approaching 80 to 90 percent of the time, which as a pharmacist, I've been a pharmacist for over 35 years, I don't recall any other medication providing that high of patient outcome, and that high patient benefit. So we also let patients know that this is a therapy that we're going to start with a low dose, slowly increase over time, and when we find their happy dose, which may be 4.5 milligrams, might be less than that; in some situations we might actually split the dose and take some in the morning and some at night; again completely individualized therapies. We let them know that most respond in about 60 days, so you got to give it some time. And with that I try to emphasize that most of the time, by the time patients are finding low dose naltrexone either through their provider or through the suggestion of their pharmacists or other chat groups, that they have been years into their therapy without great outcomes, without great success. They've used maybe even a wide variety of providers, a wide variety of alternative therapies, and now they're going to give low dose naltrexone a shot. So don't expect everything to just magically go away in a week. That's not going to happen. And in some situations, even when we're dealing with the same disease state - so let's say we're talking about fibromyalgia patients - some respond very quickly, others do take about four to six months to respond. Even with Crohn's disease, we've heard from Dr Leonard Weinstock during the LDN Research Trust conferences, that most of his patients really respond somewhere around the four-month mark. So that is very important, so that we make sure that patients are compliant on their therapies, and that they understand that the pharmacy and the provider will be checking in with them to make sure that they're still doing well, and then if there are any questions, that come up, we can answer those right then and there rather than answering them after they've stopped their therapy.

One thing we've also learned over the years with low dose naltrexone is that often less is more. So increasing the dose frequency beyond twice a day is not necessarily very helpful, and certainly going above maybe even six milligrams isn't usually as effective as lower doses, especially when we're dealing with autoimmune conditions. Now if we're dealing with weight loss, then we then we move into a little bit different realm. But again that therapy is taken once or twice a day, so again it's about treating that individual and making sure that that individual is heard, is listened to, and is able to express their goals so that we can effectively meet those.

And I wanted to throw this in there too, that we had a gal who slowly increased her dose, and when she was at 3 milligrams she felt great. She got up to 3.5, she wasn't feeling as good, and she went up to 4 and she still wasn't feeling very good. So we bumped her back down to 3 and then we slowly increased with 0.1 milligram dosing, which is itty-bitty, but sometimes even that 0.1 milligram makes all the difference in the world. And her happy dose was 3.1 milligrams. So it was great, and that's where she stayed, and she's been at that dose now for a couple of years. We also let patients know that yes, the pharmacy will check in with you periodically, usually around week 3 or 4, but don't wait for us. If something comes up, please get a hold of us, please let us know how we can help you, because we'd much rather answer those questions sooner than later, or have them stop therapy altogether, and really have to start all back at square one. So when we're slowly increasing these doses, we try to make it as easy as possible for the patient to understand. So whether we're dealing with capsules or liquids, we've built these great handouts so that patients understand how to slowly increase their dose without taking literally a handful of capsules at a time. That isn't necessarily the best way to go about it, because then they have to wash it down with a lot of water, and if dosing is at bedtime, that could very much disrupt their sleep because they've got to get up in the middle of the night to use the restroom. So we provide these handouts, and we color code them, because we provide two different strengths in two different colored bottles, and we emphasize that as we are reading from left to right rather than using the columns top to bottom. Then we're going to be able to use a little bit of out of one bottle or the other bottle concurrently as we slowly increase that dose. But we also have liquids that we use, and this liquid starter kit includes a lot more color, mainly because we slowly associate the color with the gradation, and this is actually a twice a day dosing starter kit that we use with a liquid base, because liquids are a lot easier to manipulate and find those doses that are going to be specific to them. Not everybody uses doses that are the same in the morning or at night. Sometimes one end is higher than the other.

Also, using an oil suspension is going to give a longer dating for the patient. Their bottle is going to last longer than 30 days, and that's also very pleasing to the patient, because they're very cost conscious, as they should be, because the majority of the time these medications are out of pocket expenditures. We offer an almond oil base, an olive oil base, or an MCT oil base which is derived from coconut oil. We can splash it with a natural flavor like tangerine, lemon, mint, cinnamon; and then in some situations we might actually add a little natural sweetener like a Stevia. W at this pharmacy really steer away from artificial sweeteners because we find that sometimes that actually increases inflammation, and we're also really careful about the oils that we are using. These are not cosmetic or traditional food-grade, these are bases that are backed by the United States Pharmacopoeia with a national monograph behind those.

We also are really careful about the fillers that we put in our capsules, and we work again with that individual to ensure that we're using a filler that is going to best meet their needs. All of the capsules are immediately released. We do not use any extended-release product, because that does slow down the absorption. A lot of times there's absorption issues to begin with, and certainly if we do extend the release of the naltrexone, we are actually bypassing and negating the science behind how naltrexone actually works at that receptor site. Most of the time we're using a microcrystalline cellulose, but we do have other fillers as well, so again we let them know we try to make this as easy as possible. But if it is at all confusing when the patient goes over their medication, we ask that they call the pharmacy. Let's go over those questions right away to make sure that they are getting the best information for the greatest success possible

So with our patient follow-up programs, we identify those individuals who have recently received their medications, and we kind of look at where they're at in their in their dosing schedule. We give them a call or we send them a text, “Hey we'd like to check in with you. We want to make sure everything is going well”. And we also realize that not all patients are available 9 to 5 when the pharmacy is open. Sometimes we need to schedule conversations outside of business hours, and so we make sure that that is available to a patient so that all of their needs are being met. We check in with them at least once during their first month, but we always reiterate to the patient if something comes up, get a hold of us, and this is how. We have an email option, we have a texting option, and we have a phone call option as well.

We also let them know that as dosing adjustments are being made. sometimes side effects might crop up. and so we let them know exactly what those are. Sometimes it is vivid dreams, but often when we have vivid dreams we know LDN is working, because it's helping us get into that REM sleep cycle. But if those vivid dreams become disturbing or change our sleep patterns, then we want to move the dosing schedule. We also let them know that if there's a little bit of a headache, how to alleviate that, and how long that those side effects might persist, and when they should expect those to go away. And if they're having issues with perhaps constipation, we explain that as well, because sometimes even these very small side effects can allow a patient or cause a patient to back off of their therapy and abruptly stop.

Answering the questions as they come up again are keys to success. This is how we allow our patients to communicate so that we are acknowledging what is going on with them, and they feel heard and understood. Anytime that we can alleviate side effects only allows for a better health program and for greater success, and this is when really their prescriber or their provider becomes the hero in all of this, because they suggested a therapy that is finally working for them, maybe even after years or decades of them searching for a really good way to feel better, perhaps even feel normal.

When we enhance compliance, of course we see better outcomes. When a patient is heard, when they are allowed the time to explain what's going on with them, they take ownership of their own care, and in our experience at our pharmacy, we find that when a patient takes ownership over their care, they're more likely to then be fully engaged and follow other processes or programs that may be in place by the provider. Often that leads to less phone calls to the provider office, less insignificant or issues that could be dealt with over a simple phone call, maybe even less visits to the emergency room mental health, which is always a concern, and especially in the last couple of years with stress and anxiety and depression, we see that even using low dose naltrexone can be beneficial in helping some of those areas where patients may not have been using low dose naltrexone as a primary concern, but they realize that oh my gosh, these other symptoms have disappeared too. And that's always a great benefit. We see increased patient compliance, and always better patient outcomes.

But truly, because low dose naltrexone is such a low-risk, low-side-effect, it's a low dose and honestly, it's a very low cost medication. That safety margin is much better than most commercially available prescription medications. The minimal drug interactions make it a prime candidate for the use of low dose naltrexone in the majority of health concerns and diagnoses, and quite honestly, we have over 30 years of research behind low dose naltrexone. So if you're looking for great science in using a medication that is beneficial for many many people not just in the short term but over decades. This is where we really say, “Why not try low dose naltrexone. It's a fabulous way to really get after some of those chronic issues that maybe will enhance a lifestyle, and be able to allow somebody to cross things off of their bucket list.

So here we are. I want to thank Linda for the opportunity to chat with everyone today and certainly, if there's any questions that I can help with, please let me know. This is my personal email, and these are questions, and my cell, as well as my store phone number. So I'm happy to help. Thanks so much Linda.

Linda Elsegood: Thank you! Any questions or comments you may have, please email me, Linda, at linda@ldnrt.org I look forward to hearing from you. Thank you for joining us today. We really appreciated your company. Until next time, stay safe and keep well.