LDN Video Interviews and Presentations

Dr Lester Lee - 13 November 2019 (LDN, low dose naltrexone) from LDN Research Trust on Vimeo.

Linda Elsegood:  Today, my guest is Dr Lester Lee, who's from California.

Thank you for joining me today.  Lester.

Lester Lee:  Thank you very much.  Appreciate being here.  Thank you.

Linda Elsegood:  Can you tell us who you are, what you do, where you're from.

Lester Lee:  Yes.  My name is Lester Lee.  I'm a physician, M.D., in Huntington Beach, Newport Beach, California.

My training in internal medicine is from the University of California, Davis, and fellowship training in sports medicine, as well as functional integrative medicine with additional training.  My practice focuses on functional medicine, people who have hormone replacement deficiencies, as well as autoimmune disorders that are related to the functional integrative component of why they present to the office.

Linda Elsegood:  And when did you first hear about LDN?

Lester Lee:  About 15 years ago piqued my interest.  My background is in pharmacy and with the pharmacy school back in '75 to '78 to PharmD program.  I didn't ever practice pharmacy, but I learned about it at that time.  Of course, a much more an experimental level.  Because that was back, well, in the mid -- the late seventies.

My interest came with working with patients who were not getting a response from their rheumatologists for autoimmune disorders.  Looking further into it and much of the -- some of the European studies, as well as here in the U.S., I think Dr Daria and another individual.  I can't remember all the different researchers' names.

But I started playing in patients who had failed the injectable biologics, who have maybe rotated to different biologics with their rheumatologists because of failure to respond to medication, or they build a tolerance.

So my thought was:  What the heck?  These individuals are very desperate.  They're in pain, they're tired, they're sick and tired, and they are -- the quality of life is just extremely poor.

So the Low Dose Naltrexone, I thought, why not?  It's worth a try.  And I was getting fabulous results with a limited number of patients originally a number of years ago.

The practice has a number or a fair number over the last ten years who I do place, which are appropriate candidates on the LDN.  And the doses range from one-and-a-half to an, oh, even seven milligrams.

So my experience came as a result of frustrated patients spending a lot of money here in the States, especially if their insurance companies do not cover that biologic item that the rheumatologists chose or oncologist.

Then I said, you know what?  This is pretty expensive.  The difficulty is -- is fine.  I am finding a reliable, consistent company pharmacy to make Naltrexone one-and-a-half, three, four-and-a-half, seven, what have you, milligram capsules.

And I was fortunate to find a pharmacy called Blue Coast Pharmacy right here in Orange County in Huntington Beach, as a matter of fact.

And they do an excellent job, and they mail a medication anywhere in the United States for no additional cost, and it's very fairly inexpensive, too.

Linda Elsegood:  So you mentioned hormone replacement, and you mentioned oncology there.  What other patients, you know, do you treat?  What conditions rather, that the patients present with?

Lester Lee:  The focus of my practice and reputation is hormone replacement therapy.  I introduced it to Orange County back in '85, when I started practising private medicine.  And a number of the patients -- again, conventional medicine is disease-oriented.  My practice is proactive.  A functional -- as I said, the individual has blood pressure or weight issues, diabetes.

We try to work with the causation of those rather than just giving them commercialized medicine to control the blood pressure, to control diabetes, the sugar.

Along with those maladies, of course, comes the coronary artery disease, excuse me.  And the quality of life issues, the weight gain, the cognition, memory.  They all send tend to diminish or decay depending on the individual as they mature.

So my patients find their way here because again, they've been frustrated with conventional medicine of treatment.  Both 50/50, men and women, in terms of the patients that we see here.  The practice is, of course, focused on hormone replacement optimization.  Women:  Estrogen, progesterone, testosterone, DHEA, pregnenolone, thyroid, adrenal support, growth hormone.  Even depending on which deficiencies and presentation symptoms depend on which protocols that I would place them on men similarly, but not quite as many different hormones.

Along with that, we also find that a fair number of people who had been to their primary carers, conventional medicine were told her thyroid was normal.  Well, if it wasn't adequately evaluated, completely a free T3, free T4, besides the TSH, reverse T3, an iodine level, a little more complete study of their thyroid.

We find out that they are clinically low in thyroid, and symptomatically low.  We placed them on compounded thyroid, sometimes T4, T3 combination, and they get remarkable results like the lights were turned on.  The cognition, the memory clears up within two or three weeks, sometimes even a shorter period of time.  The weight starts coming off, the vitality comes back, the belly fat starts decreasing.  Motivation is increased.

Similarly, with cortisol support, if we replace the cortisol because of chronic stress, your physical, psycho-emotional, and their adrenals start becoming depleted, we give him plant-based adaptogens.  Sometimes all they need to help with cortisol support during the day when it's highest, and then when they need it.

And again, the fatigue issues resolve fairly rapidly within the first two weeks, a lot of times.  And of course, cortisol adequacy is needed for the optimization of thyroid support, conversion of T4 to T3, the active form of thyroid T3 with three IDI molecules.  And most physicians in conventional medicine don't address that.

If you look like you're in the normal range, which is a wide range thyroid, you're normal.  And cortisol, they really don't address that very much.  Myself being a past '88-'92 Olympic team position for U.S. track and field, there are a fair number of athletes, intense training athletes who are clinical adrenal insufficiency and thyroid insufficient.

Remarkably, again, you place these individuals, optimize those glandular products.  Well, they remarkably do well in their performance, the training, motivation, peaking at their -- their goals.  So the hormone part is just part of the practice.

Heavy metal evaluations, detoxifications, neurotransmitters from the brain, salivary cortisol testing, organic acid testing So it's not just the hormones.

But when a patient comes in, male or female, of course, we addressed looking at the symptoms that helped me determine where the problem is it coming from the hormones, thyroids, the adrenals?  Is it coming from some kind of toxicity, environmental, chemical, no chemical toxicity?

So the whole picture is, is it autoimmune?  So that's part of it.

And synergistically, if we work with, say, the autoimmune component, let's say the LDN component, and we complement, optimize the other aspects of the thyroid, adrenals, transmitters in our brain for cognition, mood, mood swings, these individuals are remarkable.  Have a turnaround, a new lease on life, the best way to describe it.

Linda Elsegood:  Well, I'm surprised when you said your practice was 50/50.  It would seem to be the people that I speak to, women have more issues than men with autoimmune conditions.  So it's quite good that the men must be speaking up in your area and seeking health, which is a good thing.

When you start people on LDN into the protocol that you do for people that have an issue with the thyroid, do you pay particular attention?  Do you find that they then have to take less of the thyroid medication?

Lester Lee:  That's a very good question.  No, that was one of my observations10, 12 years ago.  An individual's positive thyroid antibodies, let's say their Hashimoto's, they're inflamed.

They're chronically inflamed.  We're trying to modulate the inflammatory process placing them on LDN after a couple, three months.  I do notice that they respond much more positively up, like, almost as like a positive modulation of the thyroid medication in terms of the dosage of their fair number.

Yes, we've been able to not completely take them off, but decrease the dosage or the frequency.  If they were on, say, twice a day, they got back by with maybe once a day.  And once we control the inflammatory markers and if the inflammation again, the other component of their metabolism have changed and for the better 

Linda Elsegood:  A few people out there listening and saying, Wow, seven milligrams of LDN?  Because a lot of patients only go up to 4.5.  There are doctors out there who will prescribe it as high as 12. Could you explain to us how you titrate a patient up to seven milligrams?

Lester Lee:  I usually start at -- depending on the patient and diagnosis -- between one, one-and-a-half milligrams, let's say at bedtime.  I'll have them on that dosage.  And if there's no ill, adverse response or reactions, I bumped them to three, probably within the second or even fourth week.  If there are fine, let's say, at three, control of pain, quality of sleep, insomnia resolves, they feel subjectively, they're getting better, I'll just leave them at three milligrams.

I don't tend to have a number of patients on 4.5 for my practice.  It seems like three is a magic number.  At 4.5, there are a fair number of people who may have some very vivid dreams, if not nightmares, if you want to call them that, and quality of sleep sometimes, of course, is going to be disrupted.

In those individuals who said, You know what, I do get a better response at four-and-a-half, but it's hard for me to sleep because I have these odd dreams.

The dosage, let's say, why don't we do this?  Let's go ahead and have one-half milligrams in the morning, three milligrams at bedtime.

And I never -- because I don't have a tremendous amount of patients with those like that, but they seem to resolve that adverse.  A part of the problem with, let's say, vivid dreams or accentuation of insomnia or even nausea.  I believe I have added maybe just one or two patients over the last five years said, You know what, four-and-a-half milligrams, I get a little nauseated.  So if I split the dosage up, it seems to be a little more receptive and agreeable to the patient.

I haven't reviewed a ton of the literature in regards to, is a higher dosage -- let's say, split the dosage, better response and all at once, at bedtime, or even daytime.

But by understanding, looking, reviewing the literature from many years ago, bedtime seems the most common sequence to take the medication.  So, of course, I follow that, too.

But during the years that transpired, a number of patients said, You know, I did pretty well on that dosage.  Instead of taking five milligrams -- excuse me, three milligrams at bedtime, I took one-and-a-half twice a day, and I think I slept better.

And I still had a good response.

I'm not sure how many numbers of the other listeners have had that kind of experience either.

Linda Elsegood:  Yeah, some people do do that.  There are many now that prefer to take it in the morning, and they get just as good benefits, rather than taking it at night.

But the question I'm always being asked is:  How do I know if the dose is right for me, and how do I know how high I can go up to?  Would you like to have a go at answering that?

Lester Lee:  Yes.  The question comes up many times when we're starting a patient.  Well, one, how do I know when I need a higher dosage, and two, well, how long should I stay on it?  So again, the titration, again, my usual is about that one-and-a-half milligram, a magic number.

And once I get to about 4.5, but if I don't see much of a response after a couple of months and they'd been on that, let's say 4.5, which seems to be an average top number for most practitioners that I've spoken to.  We don't seem to go higher.  But in some cases where they may be on a biologic at the same time simultaneously, let's say at 4.5, I said, why don't we do this?

Well, let's go ahead and take another one-and-a-half in the morning and take your 4.5 for the next two to three weeks, four weeks, just to see if you think you feel subjective, you have a response.

And two, if you're going to be seeing your rheumatologist, your autoimmune doctor, if it could be in drawing blood, send me a copy.  Let's look at the inflammatory markers.  Let's see how they look compared to six months ago or three months ago.

So there isn't an exact answer.  Let's say that I have four patients that, how high can it go?  I don't think I've ever gone higher than seven.  I'm aware of that.

There are some other practitioners who've done 10, 12.  Again, I don't have that experience in those higher digits, especially in double digits.  Not opposed to it.

My other thought is if I were to -- and, let's say, in a degenerative, an MS, Lou Gehrig's-type patient, and, let's say, we're already at four-and-a-half, well, I think I may do a split dosage.  Let's try.  I don't think there's going to be any adverse reaction, other than maybe some nightmares that you might have.

But let's go ahead and try a four-and-a-half morning, four-and-a-half at night.  And you let me know if, one, if you can't tolerate it for whatever reason, and after a month, let's say if you feel there's any change -- of course, it may take three, four, or five months before they notice any kind of response, depending on the severity of their autoimmune disorder, whether it be severe Rheumatoid, Lupus, MS. 

I've had a great patient who responded.  I believe he was a seven-milligram dose.  The split-dose was a polyarteritis nodosa.

And actually, another patient, currently, I'm trying at six milligrams, polymyositis.  And he's had this diagnosis for four years now and has multiple rounds of biologic injections.  And they're starting to, as he said, they're wearing off.

They're not helping me.  I'll have side effects.

So three months ago, I started him at one-and-a-half.  I escalated his dosage to four-and-a-half very rapidly over about maybe six to eight weeks.  And currently, he's now, as of last week, six milligrams.  So I'll wait for a response on how he's doing.

He's due for another round of a different biologic with his rheumatologist and urologist.  But I say, Well, let's see if this works if it really does help you.

So I'm waiting for that to come, come October, to see what kind of response that we have with the new dosage. 

Linda Elsegood:  And people always ask as well, how long will I know if LDN is working for me?  What sort of timeframe do you give your patients?

Lester Lee:  I usually tell them, Well, you may notice something very rapidly, like aches and pains and insomnia within the first couple of weeks.  It depends on the dosage.  I normally tell them, You know, what, give it a trial.  At least three months.  It may take you four, but give it at least three, depending on the diagnosis, the number of years they've had that diagnosis, and the severity of the diagnosis.

I also noticed that those individuals who have short remission periods and their flares are more frequent.  And not just frequent, but intense.  These individuals up to six months before they had a response on the LDN.

Now, is it coincidental that they may have been going into remission anyway six months later, or was it the LDN?

I'll let them know that I -- that part, I can't answer.  But either way, you're mostly symptom-free.

So is it the LDN continuum?  Assuming there's no ill reaction to, let's say, the 4.5, six milligram, seven milligram.

Linda Elsegood:  So what age ranges are your patients?

 

Lester Lee:  Let's see.  The youngest, I believe, is probably about 23.  And she is a Hashimoto's patient.  And the more senior patient I have would probably be about 80, 82.  And that's an MS patient.

Linda Elsegood:  And in your patients of advancing years, should we say, have you come across, dementia or any memory loss problems, or Parkinson's? 

Lester Lee:  You mean treating with LDN, or Parkinson's?

I would say one, and that was a year ago.  And have them up to 4.5 over about maybe six to eight-month period.  I would say that his Parkinson's, and he feels he's not progressing, and his tremor and cognition, he feels at least subjectively.  And with his neurologist is better after about eight months.

But again, it's not a significant change, but it's a positive one, and he feels he's not progressing.

Especially if a concern, not just the motor, but the cognition is major for anybody that, if I completely lose my mind, then it's not worth living at all.

So his thought is, regardless of this helping, which it should, the motor function, but if I can retard the process, not necessarily reverse it, but retard it and keep his faculties, his cognitions intact, that would be his goal.

But is there a beyond it for every set of -- if that's how we pick up like after a month.

Linda Elsegood:  Oh, good.  But it's the same, isn't it, with any progressive disease?  If all it does is hold the progression, you know, you're winning, it's working.

I've found over the years there are many people who will say even like 18 months after being on LDN, that it hasn't actually helped with symptom relief.  It's only helped to stop the progression.  Which they are very happy with.

But we did a survey a long time ago now, but it was in between 15 and 18 months, and I have no idea why after having taken it so long that they started to get symptom relief after such a long period of time, where you would think if they were going to get symptom relief, they would have received it a lot sooner.

Lester Lee:  Yeah, correct.  And the patients who did receive any feeling of relief after six to eight months, they tend to stop on their own and follow up, let's say, on the whole, I don't see my patients but every three to six months.  Especially in the hormone patients, I only see them twice a year.

Once they're dialled in and optimized it's not like I have a tremendous autoimmune, Parkinson's type practice.  If they present, actually, if how they're presenting is they are coming in, they may already have diagnosed an autoimmune elsewhere.  May have been on -- treated elsewhere for a number of years, but the hormone component is why they're presenting.

If they do, I'll discuss the interview.  You ever heard of LDN?  Google it.  It's not the high dose stuff we use for opiate overdose.  So Google it.  Here's some information, some literature, here's a site.  If you think it's appropriate, I'll get you a script.  Try it out for the next two months.  It's not that expensive.  It's like maybe a dollar, a dollar 15 a capsule.

Blue Coast Pharmacy, again, here in Huntington Beach, California.  They're very reasonably priced.  They're consistent on their compounding.  They may go anywhere in the United States.

So a fair number of them will say, Yeah, you know what, why not?

But again, creatures of habit, wanting immediate gratification after, say, six months, eight months, is a -- well, I don't notice anything.  I said, Well, that part I can't answer when you will get a response when you feel -- whether it be subjectively or objectively.

Now, a number of times when we place a patient on, and I'm getting a fresh set of labs, let's say, they've been on six months, I don't feel much difference.  Maybe.

I'm not sure we obtained lab markers, inflammatory markers.  Guess what?  This is how you were a year ago.  They were really high.  They've come down by 30, 40, 50%.  So what does that mean?

Well, it means you're supposed -- you're less inflamed.  So theoretically, cause and effect relationship, you should be feeling better.  He said, Okay.

So interestingly, that placebo effect is a strong motivator and a strong healer.  If you're looking better, I should feel better.  And there are a number of patients that, Well, I guess I do feel better.  All right?  If it's working, it's working.  But if we're showing them objective evidence that something has changed for the better.

I've had a few patients say, Well, you know what?  Yeah, you're right, I think I am feeling better.  I just -- I was under more stress.  So maybe it was the stress, or maybe it was the loss of a job, or maybe it was this, you know, the change in a lifestyle, a change in marital status, a change in financial status, moving to a different state or a country.

Perhaps that stressor alone induced a flare, or it was just the stress of that, and they couldn't tell the difference if they're getting better, or was it just that the change in the stressor, whether it be psycho, emotional, physical.

Linda Elsegood:  Have you found any of your patients who thought LDN wasn't doing anything for them and stopped and then realized LDN actually was doing something and restarted?

Lester Lee:  Yes, yes, a fair number.  I said a very good question.  Again, back to -- I was commenting about objective evidence.  Your labs are getting better.  These individuals stop.  Yes.  They are also really, You know what, boy, within a couple of weeks, my pain came back, and therefore I couldn't sleep, or I felt swollen and puffy.

So, you know, I guess I was -- so a number of times, I would just tell a patient, If you can't really tell if you're getting better, go ahead and stop it for a week.  See if you feel any different.

And a fair number of patients have said, Yeah, you know what, I'm not sure if it's in my mind, but I guess I was a lot better, so I'm going to go back on it.

I said, Okay, that's a very good observation, and a very good question -- observation, because how do we know it's helping?  Sometimes takes off it.

Linda Elsegood:  Exactly.  But I think it's good in your practice that you are not only looking for root causes, but to try and prevent conditions happening in the first place, which is thought to be a really good idea.

And how soon can a patient get to see you?  Do you have a waiting list?

Lester Lee:  Actually, I do not.  I have myself, two other full-time practitioners.  So we can normally accommodate you in less than a week.  And, in fact, most cases within 48 hours.  We take our time.  We spend anywhere from 30 minutes to an hour with a patient on initial consultations because a fair number may have a very complicated history.

And especially if our concern is your flare, your autoimmune precipitated, initiated by toxic exposure, heavy metal exposure, chemical, no chemical.

Oh, just had a lady last two weeks ago.  Her silicone breast implants -- two years ago, she was perfectly fine.  Received the silicone implants and was diagnosed autoimmune.

And she just recently, three weeks ago, had them removed and the surgeon said that, Gee, you're really inflamed, your tissues are inflamed.

We do urine testing for plastics, benzenes, a panel of chemical, non-chemical exposure.  And she was positive for eight items and chemicals having to do with plastics.

So her diagnosis, her autoimmune was triggered by chemical exposure, from all things, silicone implants.

Linda Elsegood:  No, it's funny you should say that.  In the last year, I've had must be three people who've told me the similar thing, that they will absolutely find it or they had breast implants, and that triggered an autoimmune condition.

Lester Lee:  Right?

Linda Elsegood:  Do we always know what it is we're putting in our bodies?  No. No, we don't.

Lester Lee:  And how do we know that we're going to be reactive?  Yes.  It's like the foods, the healthy foods we eat, whether it be kale, cruciferous vegetables, ginger, healthy fish and salmon.

And when Dr Sigler, I believe she spoke with you on your show a few months back.  They eat very healthily.  They only eat egg yolks.  He can eat egg white because it's healthy.  It's the gold standard for protein.

We do a food hypersensitivity panel on them.  50, 60 items.  50, 60 things come up, and highly reactive columns.  And, you know, I eat every one of those, and they're all healthy.

From kale to broccoli, to sauerkraut to bananas.  And guess what?  Eliminate all 50 of these items in your diet.  See how you feel the next two weeks.  Amazingly again, cognition, better skin quality.  It's a key.  Lights turn on again.  They feel so much better.

Again, can these be triggers just from food?  Not gluten, not Celiac, but, say, just certain foods.  I am creating a reaction, inflammation trigger autoimmune component.

So we're looking at the root causes, again, of finding where is the trigger coming from?  The trigger for weight gain, because you're chronic, inflamed, you're chronically inflamed, it's hard to lose weight if you're estrogen dominant.  And it's hard to lose weight.

So we put them on my end.  All three would put them on to lower the estrogen.  And they feel better.  They lose weight more readily.  Their breasts aren't swollen.  They're not soppy.  They're not retaining as much water.  The cycles aren't as heavy.  Their neurosis isn't bad.

So again, we're looking not just hormone replacement therapy. But if I come across, and my doctors come across, there are other components of why you're inflamed that can relate to your autoimmune, your MTFHR, DNA mutation gene is positive, two copies, things like that.

We bring into the picture.  And the whole global picture, again, is, you're inflamed.  Let's find out the reason why.  And you have an autoimmune.  It's genetics.  But you're the only person that has it in your family.  So let's see if there was some kind of a trigger that caused it.

So that's how my practice works.  They didn't come here because of autoimmune.  We may discover autoimmune.  We may be hoping to find a resolution, a mitigating factor that would cause the autoimmune.

And then LDN is one of the components that we may work with, helping with the symptoms of the autoimmune.

Linda Elsegood:  Well, we've now run out of time.

It was very interesting talking to you.  You've got so much to say.

Lester Lee:  Interesting for running on going to be half an hour.  They didn't mean to squeeze in that much information, short period of time.

Linda Elsegood:  Well, we'll have to have you back another time.  And thank you for having been our guest today.

Lester Lee:  Thank you very much.

Linda Elsegood:  This show is sponsored by Mark Drugs, who specialize in the custom compounding of medications, assuring that the client gets the proper prescriptions for their unique needs and conditions.  They work with practitioners, integrating knowledge and treatment of experts to create comprehensive health plans.

Visit MarkDrugs.com or call Roselle (630)529-3400, Deerfield (847)419-9898.

Any questions or comments you may have, please email us 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.

Pharmacist Kim Hansen, LDN Radio Show 30 Oct 2019 (LDN, low dose naltrexone) from LDN Research Trust on Vimeo.

Linda Elsegood: Today, my guest is pharmacist Kim Hansen. She's from the Town and Country Compounding Pharmacy in New Jersey. Thank you for joining us today, Kim. 

Pharmacist Kim Hansen: Oh, it's my pleasure. Thank you for having me. 

Linda Elsegood: So when did you first decide you wanted to become a pharmacist? Was it something you'd always wanted to do?

Pharmacist Kim Hansen: Absolutely.  I was working in a small independent pharmacy, a traditional retail pharmacy when I was in high school. And on occasion the pharmacist there would say, Hey, Kim, go mix these two creams. Or Hey Kim, go mix these two liquids. I was hooked. I knew that's exactly what I wanted to do. And from that point on I headed for pharmacy school and that was my path. I knew it immediately. That's what I wanted to do.  

Linda Elsegood: So where did you study?

Pharmacist Kim Hansen: Rutgers college of pharmacy in New Jersey. 

Linda Elsegood: So you haven't moved far? 

Pharmacist Kim Hansen: I've travelled far, but I haven't moved far. 

Linda Elsegood: So once you started compounding,  what were the main medications you were doing at that time?

Pharmacist Kim Hansen: Back in the day, it was usually combining a couple of creams together. That was before we had a lot of the manufactured products that we have now. A lot of times compounds start off that way, then they end up being manufactured items later. I used to have to make a topical minoxidil solution. I used to have to make up progesterone capsules way back in the day. Suppositories for progesterone. This was 20 some years ago. So it was before I knew of LDN.  I was doing compounding before that. Mostly progesterone and topical dermatological items that were not commercially available.

Linda Elsegood: How did you hear about LDN?

Pharmacist Kim Hansen: I think it was at a compounding seminar is the first time I'd ever heard of it. It was being discussed for autoimmune issues. I started seeing prescriptions for it about seven or eight years ago. Usually, it was just capsules, usually, it was the three different dose levels that we know differently now. It started gaining traction more for me within the last three years. But I did see it back seven or eight years ago.

Linda Elsegood: And what forms do you compound LDN into?

Pharmacist Kim Hansen: Right now we do capsules and oral suspensions. Most often it's the capsules that patients are happy with. We also do a cream for patients with autism, and occasionally it's added to pain gels as well.

Linda Elsegood: What is the filler of choice for people?

Pharmacist Kim Hansen: Generally speaking, patients are happy with acidophilus. I do have patients that don't want that. And then we usually use micro crystal and cellulose, but if they have a specific filler question or need, we're happy to accommodate that.

Linda Elsegood: And what strengths do you do now in the capsules? 

Pharmacist Kim Hansen: I think our lowest is a hundred microgram capsule because that patient prefers that to be in a capsule form versus the liquid form, anywhere up to 10 milligrams and anything in between. 

Linda Elsegood: And the patient population, what would you say the top conditions that LDN is treated for from your pharmacy? 

Pharmacist Kim Hansen: Hashimoto's, pain and depression. 

Linda Elsegood: So talk us through those three, Kim, the experience that you've seen from those patients. 

Pharmacist Kim Hansen: I'll start with Hashimoto's. We do notice patients are getting to a dose that is appropriate for them and are feeling better. They also require less thyroid hormone.

If someone is on thyroid hormone and start LDN, that should probably be monitored more closely than before you started the LDN, because you'll find that as the inflammation reduces, the thyroid level changes and you may need to change your dose. Usually, it's a reduction in the thyroid dose when it comes to the pain medication using it for that.

I have patients who have had their lives changed. They were in a tremendous amount of pain before, and they were put on other pain pills. Any medications usually were just adding to their pill burden, but not really giving them relief or quality of life that they were looking for. I have patients who weren't able to do any of their activities of daily life and now are doing things that they haven't done in 20 years. To me, that makes things tremendously rewarding to know we can be a part of that success story.  I should also mention when discussing pain with patients, I have patients who have become tolerant to opioids. So we also find that LDN is a way to help reduce the opioid burden and help people get off of those and still maintain their pain relief. I view those two things together like pain and sometimes patients are looking to get off the opioids for relief of their pain. So it actually does both. 

The other I  touched on was depression. I have patients who are using an increasing schedule of LDN and also weaning off usually their SSRI or antidepressant drug. And they're finding if they wean very slowly off the antidepressant and titrate upwards very slowly with the LDN, they're able to get off of the antidepressant and still maintain a non-depressed state. They're happy to be off the medication and be able to use LDN, which we know works in a different way and usually has a better overall effect than the actual medication worked for them. 

Linda Elsegood: Ultra-low-dose naltrexone helps combat the opioid crisis. Could you talk us through how, when people come to your pharmacy, whether it's been addicted to prescription drugs for many years, how LDN plays a part in getting them off the opioids, but still controlling the pain? 

Pharmacist Kim Hansen: I won't get into a specific schedule because it is so dependent on each patient. I will say that we usually start patients on the microdose or the low dose, ultra-low-dose naltrexone, usually in a suspension form, and they'll be on whatever their dose is usually for about a month. And then after they're stabilized with that, the pain management expert will slowly increase the dose of their ultra-low-dose naltrexone and also decrease their opioid dose usually by about 10%. Again I don't want to give schedules and hard limits because every patient is so different in their ability to reduce. It's very varied as far as that goes, but I have many patients who have been on rather strong doses of opioids that have been on that for years, have been able to slowly titrate up on the naltrexone and slowly wean down on the opioid and have had success and be pain-free and opioid-free. That's huge to have that happen. We had one hospice nurse  (certainly hospice nurses are very well versed in pain and pain origins and pain protocols) who herself had her own pain issue. We walked her through this process of slowly starting the ultra-low-dose naltrexone and scaling that up over time and reducing the dose of the opioid over time. Now she’s opioid-free and as pain-free. And it definitely helped her increase her quality of life and also to be able to do the things that she couldn't do before.

So that's a huge story. I mean, someone who is on opioids, to be opioid-free is huge. 

Linda Elsegood: Definitely. For people listening out there who are in a lot of pain, because I'm told nearly daily that there is somebody who is in terrible pain, but they were already on very high doses of an opioid that doesn't seem to be working, you know?  Of course, the problem with opioids is your body gets used to them, and you have to keep increasing the dose to get the effects you were having. So anybody who has chronic pain for whatever reason, or fibromyalgia or having an autoimmune disease that has a pain component to it, how would they go about.

finding a doctor who would prescribe LDN and one that would understand about the ultra-low dose, who would be able to help them transition from the opioids to the ultra-low dose?

Pharmacist Kim Hansen: Two awesome ways to find that out. One is LDN research trust. There are lists of physicians and practitioners on there that are knowledgeable in what we're talking about here. You can also ask your local compounding pharmacist because we are a treasure trove to know who is actually prescribing it in order to be able to send patients.

It works both ways. The prescriber sends the order to us as they know that we'll do a quality compounded product. I can then refer patients back to other practitioners because I know that they're knowledgeable in this and then they've attended our seminars and that we can work together with them in order to get the best outcome for the patients. So it works both ways.  

Linda Elsegood: I was quite surprised when Dr Sam was telling me how quick the process is because I thought it would be a long, slow process. But he was talking just a few weeks, which was, wow. People that had been on opioids for many years, to, find relief like that, it just amazes me that something.so small and so simple seems like tickling the pain with a feather in those ultra-low doses rather than using a really big mallet, which is the opioids, for it to work. It just is mind-blowing, isn't it? And of course, the price, LDN is not expensive, and many people have to pay for it themselves. And it's not a price out of the reach of most people. We still have people who do not have money, they're sick, they're not able to work. And if it's a choice between food or LDN, that's a problem. But we're looking at around $30 a month, depending on where you have it compounded. It's an affordable drug, isn't it? 

Pharmacist Kim Hansen: Absolutely. We try to maintain that because we do understand that patients are in pain and you don't want them to have to choose between therapy and their food or their bills or whatever that is. We want patients to get the relief that they need.

We've kept what we're doing affordable so that we can make sure that it's available to as many patients as possible. Usually, you'll find whatever pharmacy you use, if you're going to be starting a titration and working your way upwards, usually that pharmacy will put together a kit.

So you've got maybe two different doses of a capsule in there so that you can gradually increase to the dose that you are working towards. And then once you arrive at the dose that's working for you, then that pharmacy can make that dose into one pill so that it becomes more economical if that makes sense.

Linda Elsegood: Yeah. I had a lady email me this morning, I think she had Sjogren's syndrome, and she was doing really well. She'd worked up to three milligrams. It did really well. She's now on 4.5 and she's not sleeping,  not feeling as well. And I was trying to explain that with LDN it's not, the higher the dose, the better the benefit. It's what suits you best. And if at three milligrams, she felt really good, why would she need to go to 4.5? It's not working. It's making her feel ill, so she should go back to where she was in a good place. There is so much misinformation out there that people seem to think that this magic 4.5 is the goal that everybody should be on. Have you noticed that with your patients? 

Pharmacist Kim Hansen: Absolutely. I've had patients tell me the same story that you're describing here. Everybody has in their mind that more is better and that the goal is to get to a certain number because that's where the best results are.I am always cautious about making sure I explain to patients, hey, we're dispensing a kit to you. This initial kit is usually good for 49 days or seven weeks, but if at some point halfway through this kit, let one of us know that you're experiencing relief or you're not experiencing anything at all. If you are at a dose where it seems to be optimized, I don't want you to have to continue to go up because the goal isn't to make it more, the goal is to get relief, and if you're getting relief at a lower dose, then stay there because it's very easy to overshoot that and you'll lose the benefit. So, in this case, absolutely more is not better.

Linda Elsegood: Do you have any stories of people who are on a very low dose that have stuck to that's the right dose for them? 

Pharmacist Kim Hansen: Yes, a patient with diabetic neuropathy who was using the kit and they had gotten to a higher dose, and they weren't feeling so good on that. He backed off the dose he had gotten to, I think it was three milligrams. He went up to the next step, said I don't feel as good as I did on the dose before that. Then we know where you should be. And we had him go back to the dose he had come from,  he's much happier there, and he's able to function.

Whereas he was in pain and uncomfortable before. 

Linda Elsegood: What I was getting at there was, I know quite a few people that are on 1.5 or two, which I mean is low for low dose even, isn't it? People tend to think anything under three is no good, but even that is too high for some people. Not everybody gets there. As you were saying with the man with his diabetic neuropathy, you don't have to panic. Or thinking that you know you're not taking the right dose. I know some people think that it's not a therapeutic dose if it's under three, but that is a myth, isn't it? 

Pharmacist Kim Hansen: I would agree with that. Every patient is different and how they respond to it. So even if you have identical twins. A member of your trust that lectured about this, their one set of neighbours. They completely matched as people go, and the same age, same condition, same everything else. If you go down the line and, person A got results more quickly than person B. So person B was discouraged thinking that they weren't going to find the same relief that person A got.  Having to start over with patient B, and go a little bit more slowly, titration was the key for her. So whereas a lot of times you'll see dosage regimens that, every week we're going to increase by whatever the increment is. Sometimes patients will need to go even more slowly than that and maybe increasing every two weeks or maybe every month, whatever that takes. And again, not everyone is the same. So if you get to a dose rate, like, I didn't feel anything the whole way. Sometimes you can, wash it out, start over, and go more slowly and find results there. It's just so dependent on each patient and just because you haven't gotten the answer that you want and you've gone up to 4.5 sometimes the answer isn't going up a higher dose. Maybe it's starting over and going up at a slower pace.  

Linda Elsegood: Some people feel quite discouraged starting again, but by doing it very, very low and moving up very, very slowly the fallout rate isn't as high, and the success rate goes up. You know, 20% of people didn't have the relief they were looking for, but that 20% has reduced, hasn't it? We are getting a better success rate now, understanding there are people who do need to look at LDN differently. 

Pharmacist Kim Hansen: Completely agree. Back in the 80s when we were doing 1.5 and three and 4.5, that was such a rigid structure that you probably lost a lot of patients who didn't have success and or probably had side effects that they weren't pleased with. Changing our thinking with the results we have now, knowing that going more slowly and doing slower increases or lower increases is actually beneficial overall. Yes. Patients who have tried with not finding their success before; it doesn't mean you won't have success trying it in a different fashion.

Linda Elsegood: Exactly. And then there's the other school of thought where you have to take it at night. You know, it's not gonna work for you if you take it in the morning. We now know that's not true. Is that what your experience has been? 

Kim Hansen: I would say that's true.I think yes, at the beginning of the push was, Oh, you have to do it at night because your body does repair at night but you know, here's no reason why you can't do that during the day. And there are also reasons why you would want to do something twice a day and do split dosing. Some disease states and some patients do better when they're split dose.I find that is the case with using it for the antidepressant purposes, sometimes a split dose is better for that patient versus the whole dose at one time of day regardless of morning or evening. Again, individualized treatment, and you have to listen to the patient and listen to what they're saying to you so that you can work on a treatment plan together. 

Linda Elsegood: And you were saying about the topical cream for children with autism. Do you have many children with autism? 

Pharmacist Kim Hansen: We're in New Jersey, unfortunately, we have one of the highest percentages of autism in children. So yes, I do see it, not as often as I once did, but I do see it, and usually, they're not amenable to swallowing pills. So usually the parent is putting on cream at night when they go to sleep, and they don't even know what's being applied.

Even if they take a capsule and they put it into a smoothie or whatnot, kids are wise to that because they're probably on a whole bunch of stuff and they're eyeing up every meal that comes to them, making sure nothing's been hit, so they're pretty wise to it. You'll find that the cream is helpful in those cases and yes, it does work.

Linda Elsegood: And have you come across children with juvenile arthritis or pediatric Crohn’s who are taking LDN? 

Pharmacist Kim Hansen: I have heard of it, but not in my experience here. 

Linda Elsegood: And no children or adults with asthma allergies. 

Pharmacist Kim Hansen:  I had heard of it of course but no experience of that directly here.

Linda Elsegood:  It's amazing, isn't it? Initially, going back,15 and a half years when I started the trust, it was mainly people with MS. Then it went to Crohn's, then fibromyalgia, it was just exploding. But we didn't know too much at that point what it did for chronic pain that wasn't autoimmune. We knew it helped with cancers. We didn't know about all the mental health issues and of course, it's used in fertility clinics as well, and for women's health, for painful periods.  There's a name for that, PCOS, polycystic ovaries. Dr Phil Boyle uses it in his clinic to help women get pregnant. They take it during pregnancy, during breastfeeding, have really happy, contented babies, he says, and they have less chance of needing IV antibiotics for chest infections and things, which is apparently quite common in babies when they're firstborn. And he said, as a rule of thumb those babies are far more content when they come back for checkups,  than babies that haven't been exposed to LDN, which I think is quite interesting, isn't it? 

Pharmacist Kim Hansen: I agree completely with that. When I have a patient that's here, and I'm showing them the list of disease states or conditions that this is helpful for. And of course, their question is always, how could one thing be good for all of these? And I love that question because that means that you're thinking, okay. And you're sceptical, and that's fine, but then when you explain that a lot of these systems are all tied together and how pain and depression are linked by the same pathways as is your immune system, as are a lot of different things, inflammation, all tied together.

When you can explain and have them understand how the different systems in your body interplay, that's when the light bulb goes off because traditionally here in the United States you go to the foot doctor for your foot problem, you go to the GI doctor for your stomach problem, you go to the neurologist for the neurology problem. And really they're not all communicating.  When you look at the thread of symptoms that a patient is dealing with it's like you're missing the overall theme of inflammation or whatever that is. And LDN is helpful for that. So, therefore, it's helpful for all of those conditions. It's not because things are tied together. That's why it's helping you. I hope that made sense.

Linda Elsegood: It does. Now there are other things you can do to help inflammation as well as taking LDN. What do you suggest patients do?

Pharmacist Kim Hansen: For inflammation? Well, it's very important. I always remind patients that their diet is everything. If you look at the glycaemic index, it's scaled anywhere between zero and a hundred and sugar is at the top as being a hundred you would like to keep your dietary choices below a 50 because they are less likely to cause an insulin spike or have a glycaemic effect on your sugar. So if you keep your food items below a 50 more often than above 50 you're reducing the fire in your system. So the whole point of taking naltrexone is to reduce the fire in your body, as explained before.  Everything is connected. You can't expect the pill to do all of the work either. Reducing inflammation that you're adding to the system is also part of it.

You can't walk around eating the standard American diet of high carb and high sugar and poor nutritional value and not have inflammation if you're going to continue to feed the inflammation fire, of course, you're asking the LDN or the naltrexone to help with your symptoms.

Sometimes just reducing a lot of the inflammation that way is helpful and it certainly helps to augment what the LDN is doing. I also find that high-quality C-- products, the full spectrum ones are also helpful at reducing inflammation. Using the LDN in combination with the C--, you get the beneficial additive effects. I have patients who have needed to use that combination, and they've gotten their quality of life back.  

Linda Elsegood: it's funny what you were saying about fruits. My mother was in the hospital, and she was a type two diabetic, but her kidneys were in a very poor state, and she had to have insulin. She had quite a bit of insulin three or four times a day. When she was in the hospital, she asked for a banana. And they bought her a banana. And she said, Oh no, I, I don't like eating bananas a little green and underripe. I like them when the skin is going brown, and it's mottled and inside is all nice and squidgy. And they said, no, you can't have one like that because it's going to affect your insulin because it's very, very high in sugar when it's that ripe. That is correct. The nurse was trying to say very nicely, but it is higher in sugar, and I think my mother was thinking, a banana is a banana. The nurse was trying to say, you can have a banana but you mustn't have it when it's overripe.  Because it's too high in sugar. 

Pharmacist Kim Hansen: When I tried to talk to patients about that, of course, nobody ever wants to hear they have to make changes and give up their banana or wherever it is they're eating. Everybody likes what they eat, but when you explain it and say, Hey, these are inflammatory, what you're doing is adding to your inflammatory burden.  I'm not saying completely avoid the bananas, but if you know that you had had a banana that day cause you had to have it, maybe look at the bottom of the list to make sure that maybe we're balancing that out and making a choice that has less of a glycemic load than maybe the banana or something else. That's not to say that you should never have banana again, but maybe making choices to balance out your day versus choosing everything above 50 if you reduce the amount. Because they are both 50 and take below 50 reducing the amount of inflammation in your system, which is good for all sorts of things, Alzheimer's, heart disease, cancer risk, all of these things driven by inflammation. And why would you not want to reduce those risks? 

Linda Elsegood:  It's altering the way you look at food. Instead of being a diet which people don't stick to. It has to be a lifestyle change, doesn't it?  So it becomes a habit. You know you have good habits instead of bad habits. 

Pharmacist Kim Hansen: Agreed. If you call it a diet, people assume that is a restriction on their lifestyle. If it is health maintenance and it's on a different connotation or inflammation reduction. If you look at it that way, rather than, oh, I'm on a diet. Well, you know what? I'm trying to reduce the inflammation in my body. You'll find that you'll get fewer headaches if you get rid of sugar and carbs, which of course includes bread. There are healthier slices of bread that you can eat, more of the whole grains here.  I was amazed by this too. Everybody's under the misconception that, Oh well I, you know, I'll avoid the white bread cause I know that's not good for me and I'll just eat the wheat bread. It's no better. It really isn't any better. It's like a point or two different on this scale. What you need to do is either do it like a whole grain bread or switch to something that's grain-free, like Ezekiel bread, which has a low-glycemic index. If you're trying to make that effort, there are smarter choices that you can make.

So you don't feel like you're on a diet where you're restricted and being punished. There are ways to explain things.. You just have to be careful about continuing to pile inflammatory product after inflammatory product. It leads to all of the other health problems that I mentioned before.

We're all leading stressful lives, and probably you're not exercising as you should, and not resting as you should, and you're just adding more and more burden to your system to be able to detoxify. Helping your body do its best is certainly a better management tool all around.

Linda Elsegood: Well we've run out of time Kim, can you believe that's 30 minutes gone?

Pharmacist Kim Hansen:  I can't believe you wanted to listen to me. Wow. I'm so happy. 

Linda Elsegood:  Awesome. Thank you so much for having joined us. I really appreciate it. 

Pharmacist Kim Hansen: I'm so grateful to have been asked, and it's my pleasure. If you have any questions, certainly please give me a call and I'm happy to share anything I know. 

Linda Elsegood: Thank you.

At Town and Country Compounding Pharmacy in Ridgewood, New Jersey, owner, pharmacist, John and his team are passionate about low dose naltrexone. They have compounded LDN for over 15 years. And they're committed to compounding high-quality medications and serving as an educational resource for patients and practitioners alike. Visit https://tccompound.com/ or call (201) 447-2020 with any questions or comments you may have. Please email me at ontact@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.

Dr Marie Ekpema PharmD - 16th Oct 2019 on the LDN Radio Show (LDN, low dose naltrexone) from LDN Research Trust on Vimeo.

Marie Ekpema, PharmD is the clinical director and pharmacy manager at Summerwood Pharmacy and Compounding in Houston Texas in the United States. She undertook additional training in compounding and bioidentical hormone replacement therapy.

Dr. Ekpema’s grandfather was an herbalist, who inspired her to go into pharmacy. Her first 15 years were as a traditional pharmacist, but realized the need to address some of the side effects of medications, such as gut issues and drug-induced nutrient deficiencies. For example, a magnesium deficiency can cause headaches. In the US, most prediabetics are started on Metformin. But working more with doctors and patients regarding supplements and lifestyle choices has resulted in patients on fewer prescriptions, and more targeted medications.

Linda Elsegood related that she had undergone 3 courses of IV steroids in 18 months, which resulted in weight gain, and Type II diabetes. She was put on Metformin, but still was diabetic. She decided to change her diet: removed gluten, removed added sugar, and removed dairy, and at her 6 month check-up was able to stop Metformin, and has held at the pre-diabetic level.

Dr. Ekpema believes in empowering people in decisions about their healthcare. One thing they recommend is gluten, dairy, and sugar restrictions, and ask patients to try it for 60-90 days and give feedback. Medications help manage disease, but infrequently are medications a cure. When you modify diet, especially with autoimmune diseases, results happen. She has seen patients go from using 100 U insulin daily back down to using 10-20 U; and patients being able to reduce medications type and dosage.

Linda Elsegood related she has high cholesterol, likely hereditary, and was told that diet wouldn’t help. Dr. Ekpema verified that is the case in certain types of hypercholesterolemia, but there are other approaches to reduce inflammation in the vessels, such as pomegranate juice daily, garlic, exercise, and reducing inflammatory foods.

For a consultation, patients can contact the pharmacy: https://summerwoodrx.com/ or phone 281-225-4300. Depending on the season, the waiting list could be anywhere from a couple of weeks to a month, particularly during the summer. There is an intake form, and consultations are done in the pharmacy, or over the phone. They communicate with the patient’s physician as well.

The pharmacy compounds LDN capsules, anywhere from 0.5 mg to 6 mg. The also prepare topical LDN.  Most of her patients are middle-aged and older. Prescribers who graduated in the last 15-20 years tend to be more open to LDN. She notes great results with LDN: reduction of symptoms, reduction of pain; and most dramatic, was a patient with psoriasis who had a 70-80% improvement on LDN. It is important to titrate up slowly, however. Also important is gut health for those with autoimmune diseases – if bacteria is not balanced, results won’t be good because it interferes with absorption.

The most frequent side effect patients mention is trouble sleeping, and they advise the physician to titrate up more slowly, or to a lower dose. They have found others have bad dreams, and recommend including some magnesium glycinate for more restful sleep.

An issue Dr. Ekpema relates is buying prescription-only medication through sources that do not require a prescription, because the regulation and testing is not done, and the sites accept no responsibility. At a compounding pharmacy, you can be certain of the quality because it has been tested.

Dr. Ekpema gave appreciation for the LDN Research Trust, the recorded interviews, and the information it provides.

Summary from Marie Ekpema, PharmD’s LDN Radio Show from 16 Oct 2019. Listen to the video for the show.

Keywords: LDN, low dose naltrexone, compounding, bioidentical, hormone, drug-induced nutrient deficiencies, diabetes, hypercholesterolemia, autoimmune, psoriasis, gut health,

Dr. Judy Tsafrir, MD - Oct 2019 (LDN, low dose naltrexone) from LDN Research Trust on Vimeo.

Linda Elsegood: I'd like to welcome my guest today, Dr Judy Tsafrir. Thank you for joining us today Judy. 

Judy Tsafrir: Thanks for having me, Linda. 

Linda Elsegood: I mean, you were telling me you were from Boston, um, in your practice. What's the patient population that you treat with LDN? 

Judy Tsafrir: Um, I'm a psychiatrist, a holistic psychiatrist. I see both children and adults, the more adults and kids, and people seek me out because they do not want a conventional psychiatric approach to their depression or anxiety, or whatever it is that's troubling them, which is typically just the prescription of pharmaceuticals and perhaps, um, some sort of counselling. So my approach is essentially functional medicine where I am looking for the root causes of what's going on with them and having conversations with them about their diet and their lifestyle and sleep and exercise. Um, also I trained with someone named Dr William Walsh, who is a biochemist from Chicago, and he has correlated certain laboratory studies with psychiatric symptoms, for example, elevated copper or, um, high histamine, and there are protocols of nutrients that can be prescribed instead of pharmaceuticals. A lot of patients come to see me because they are chronically ill and they're not getting help from other doctors like they're, I'm not usually the first stop so they may have many patients who have autoimmune conditions, um, which often presents psychiatrically; like there's an anxiety piece. And I've developed, um, over the past couple of years interest and awareness about mold toxicity. And so patients will come to see me because they are suffering from symptoms related to mold toxins.

And, uh. When that is addressed, that can have a big positive impact on health. 

Linda Elsegood: But isn't it amazing that you could take some supplements like iron and copper instead of a pharmaceutical drug? You know, because all drugs have potential side effects, don't they?  

Judy Tsafrir: Yes, and that, you know, the model is conventionally is to identify symptoms and suppress them. And instead of seeing the symptoms as communication that there's something wrong and looking for what it is, that could be corrected. 

Linda Elsegood: But when you said that you help people with autoimmune diseases, I mean, there were so many people, um, that I know of who have had, say, fibromyalgia or chronic fatigue, MS and before they managed to get a diagnosis so many of them are told it's in your mind, you know, that there is nothing really wrong with you and that is very depressing. 

Judy Tsafrir: and very invalidating. That's an experience that many patients have when they come to see me, that somebody, there's such relief that somebody believes them.

Linda Elsegood: And it's getting people to listen to you, isn't it? Rather than just brushing you off without investigating. 

Judy Tsafrir: Right. You know, I just came back from a conference. I actually was in a conference over the weekend in California, which was all about electric hypersensitivity and the effects of electromagnetic frequencies on our health, and this was on my radar but in a much less focused way then it will be now going forward because I would tell my patients to turn off their routers at night and tell them to not carry their cell phone in their pockets. But, um, it goes much further than that. There really needs to be a lot of avoidance and awareness about the way that electromagnetic waves are impacting our health. And I think there may be a number of patients in my practice who I've been treating for mould who may have mould or who do have mould, but maybe they would be so much better if I would also be addressing the, um, electric hypersensitivity. So this is something that has newly, like really come into focus for me,  just over the weekend.

Linda Elsegood: And what about children? You said that you treat children as well, and it's very ... 

Judy Tsafrir: yes. I mean children have an attentional problem, and they have anxiety, and uh, there can be, just the same as with adults, there can be imbalances, and I think that a lot of these kids are actually tremendously affected by the electromagnetic frequencies, like all of the screen time, that kids are doing. It's really, um, there was a child psychiatrist who spoke at the meeting who, um, kids who were so behaviorally dysregulated and suffering so much, and the families were in such a terrible state because of the child being, um, so, uh, symptomatic that with the screen, you know, with the electronic “Fast” of one month, the symptoms completely resolved. 

Linda Elsegood: Wow. But if a parent had a problem with a child, with, let's say, anxiety, I mean, how old are they normally? the youngest that you see in your practice? 

Judy Tsafrir: Oh they can be very young. They can be, you know, six years old.

They can be five years old. Just a kid who's not sleeping, who, you know, can't separate. Um, you know, I'm, I'm trained originally as a psychoanalyst and my model, previous to learning all of this functional medicine, would be to really think that there was some kind of, um, psychological dynamic going on between the parent and child, which they may also be, but there is so much to be understood in terms of what can be going on biologically In addition to all of that.  

Linda Elsegood: And would bed wetting come under that umbrella as well? 

Judy Tsafrir: Of course. I mean, that is often like a, um, an immaturity of the neurological system. And that can be developmental and can improve with time. But, um, everything that is going on, you know, can be due to, um, many different factors. Including trauma and, um, adverse experiences. But it's just, it needs to be looked at from so many different angles, including the spiritual. 

Linda Elsegood: I mean, you said that you look for the root cause, but to find the root cause for a child, obviously, you listen to the child, but their communication is going to be limited.

And of course, then you'd have to listen to the parents. How do you …?

Judy Tsafrir: And the school 

Linda Elsegood: Okay. And the school, how do you get to the root cause if you know, if there's somebody listening with a child that is having problems, what would be the process you would go through to find out what you could do to help a child?

Judy Tsafrir: The most important thing is the history and to try and get a sense from the parent, you know, what is going on, what has gone on, you know, like even going as far back as ancestrally, like, was there a lot of trauma in the parent's history? Because that can also be passed along epigenetically. Um. But then to learn about the birth and the child's development and the child's diet and the whole environment.

And when did the symptoms start? You know, was there any kind of car accident or death? I mean, our whole being is so, uh, it's such a mixture of mind, body, and spirit that it's really complicated, and you can't just typically pinpoint one thing, like you may have a car accident, but then that completely dysregulates the immune system and sets off a mass cell activation disorder.

And then they're having all kinds of very weird symptoms and maybe not tolerating foods and having strange neurological things. And, and this all may be totally exacerbated by the electromagnetic frequencies. It's just. It's very complex. So you want to try and understand as much as possible what are all the factors and try and support the person from many different directions. But it's usually not like one thing. It's like a whole confluence of different things coming together to create a kind of perfect storm. 

Linda Elsegood: So your approach would be more of a natural approach rather than, um, prescription medications? 

Judy Tsafrir: Absolutely. I mean, a lot of times people seek me out because they're on medications and they want to get off of medications.

And the typical approach for a person to get off medication, many psychiatrists are not willing to take patients off of medications, they're afraid that the patient will become destabilized and then they'll reduce the dose of medications way too quickly and then a person will have a reaction, like a withdrawal symptom; a syndrome from withdrawing from the medications and then the psychiatrist will mistakenly believe that this is as proof that “you see, you do need it for your anxiety because you are having problems”. But in fact, it's like a withdrawal syndrome and not the original problem. So. Like I, if somebody calls me and they want to simply, you know, get stimulants for their attentional problems, I tell them that I'm really not the right doctor for them.

And you know, if somebody is interested in working with me to come off of their medications, that is much more what I find interesting. And, um, I'm feeling it’s like a useful, valuable thing to do. 

Linda Elsegood: And what's your success rate with getting patients of pharmaceutical drugs? 

Judy Tsafrir: I would say probably about 75%. It's not everybody. You know, like some people, it's really difficult, particularly, um, some of the antianxiety medicines can be really hard to get off of, but you know, like this is like, I recommend, um. Low dose naltrexone to all of my patients, essentially. And you know, I also make dietary recommendations to all of my patients, and I make recommendations about, you know, hygiene with their electronics equipment and about exercise and about sleep, um, and all of those things together make it much more possible to withdraw from medications rather than just trying to withdraw from the medication without supporting the person in any other way.  

Linda Elsegood: how long do you think it takes a patient with anxiety problems taking LDN for them to notice it's doing something for them? 

Judy Tsafrir: It's so variable. I mean, I feel like low dose naltrexone is really unpredictable in terms of if it's going to be helpful, how it's going to be helpful, for what it's going to be helpful. So for me, because it's so safe and inexpensive and potentially so effective that I really recommend it to everyone for whom it's not contraindicated, like if they're on, you know, some kind of cancer protocol and immune suppression or, but I recommend it to everyone. And, um, it really is variable in terms of the response, quite variable. 

Linda Elsegood: And what sort of dose do you start the patients on?

Judy Tsafrir:  0.5 and then I asked them to work their way up as tolerated, as fast as it is tolerated for them to 4.5 milligrams. And that's, you know, in some people, you know, they feel well at three, but when they go up to 3.5, then they don't feel as well. So then we stay at 3, it's really titrated according to how the individual feels.  

Linda Elsegood: I mean, that's the thing with LDN, isn't it? It’s unique to that person. You know, you can't say ..

Judy Tsafrir: Unique to the person

Linda Elsegood: Exactly. Cause some people to find that 2.5 works really well. They go up to three that don't feel as well. But 

Judy Tsafrir: right. 

Linda Elsegood: Sometimes they've read everything online, and they feel that if they're not on 4.5, they're doing something wrong, that they should push themselves. But that isn't the case, is it? 

Judy Tsafrir: No, that's a misunderstanding. And you know, it really is like so helpful for so many different things. And so it makes sense to me that the dose would also not be one size fits all.  

Linda Elsegood: exactly. I mean, some people try to justify a dose by saying how tall they are and how much they weigh but that ... 

Judy Tsafrir: Right, that doesn’t make any sense

Linda Elsegood:  it doesn't because, I mean, there are some men who are rugby players who can't get any further than three. And then a small lady who's very petite, like five foot tall can take 4.5 no problem. So I always think that's a, a good rule to tell people that you, you just can't pigeonhole people. It's how your body responds. With depression, and you were saying that you treat people with autoimmune diseases. Um, would you say depression for somebody with an autoimmune disease might be to do with all the symptoms and the things that they have to live with that cause the depression? 

Judy Tsafrir: Well, again, I think it's such a multifactorial situation. I mean, very often depression is either caused by or mediated through cellular inflammation. So like when a person has inflammation in their body, they have inflammation in their brain, and they feel depressed. But then when a person has, Um, chronic illness and they're living with chronic illness, and they can't find anybody who's going to help them, and, uh, they're being told it's all in their head, and it's a very hopeless and depressing situation. Another thing that I recommend to my patients that I haven't mentioned so far is dynamic neural retraining system, DNRs, which is, it's like a program of visualizations and meditations and affirmations and something that you do with your consciousness that, um, helps rewire and retrain the limbic system, which is the deep structure in the brain that is associated with trauma. And when it's activated, it can cause all kinds of physical problems and all kinds of psychiatric problems, anxiety, depression. So if a person works with this program, uh, consistently, very often they're able to really calm down their autonomic nervous system and they will be in a state of, um, not in a constant state of like sympathetic overdrive, fight or flight.

And they'll just feel much calmer and much better, but it's not also alone. It's also, you know, in combination with diet, in combination with low dose naltrexone, with this combination with other supplements that are helpful for inflammation and for rebalancing, whatever it is that is troubling the person and in psychotherapy can be very helpful as well, having a relationship with someone where you can talk through things and someone who understands and who can help you make connections and can help you see that you're responding to the present because of something that happened in the past and that's not really relevant to today. I mean.

Everything together and, and, and I recommend the spiritual practice to my patients. Uh, prayer can be very helpful. Performing rituals can be very helpful. Uh, gratitude journals can be very helpful. It's just - there are so many different things that need to be recruited together to heal a person holistically.

And before I take a person into my practice, I have quite a long conversation with them on the phone and try to assess how motivated they are to make all of these different kinds of changes because it's not like taking Prozac. 

Linda Elsegood: It’s definitely something you have to work at, isn't it?  

Judy Tsafrir: Absolutely. It's a lot of work, but you know, instead of, you know, your health being degraded, you're optimizing your health  

Linda Elsegood: it's very easy to keep things to yourself in like a family situation, not talking to family and friends, but to actually be able to talk to somebody outside of your circle.

You can say what you like. You're not going to upset anybody. They're not going to feel guilty.

Judy Tsafrir: You don't worry about burdening them. And also there's somebody who is hopefully very trained and experienced in listening to people and knowing about what are dynamics like in the family and understanding a lot about human nature and the way people feel. I mean, I also think that meditation and yoga and Tai Chi and all of these kinds of, um, mind, body, spirit practices are tremendously helpful and stabilizing and help one not totally identify with whatever, you know, upset emotion one is feeling at the moment, that there are more equanimity and more peace brought into the person's life.

Linda Elsegood: I used to do a lot of yoga and I learned at a very early age, to put myself to sleep. And it still works today. You know, the deep relaxation and your breathing and focusing.  And I can, you know, even if my mind is spinning, if I can just stop my mind and actually relax and focus, probably about two minutes and I can be asleep.

Judy Tsafrir: I say that that's just like a practice, something that you've learned and it can be taught and um, it's just so useful and so much better than taking Ambien, you know, instead of taking a pill, but, you know, maybe then you feel like very tired the next day and forgetful and, um, spaced out. 

Linda Elsegood: I was going to say, who would want to feel like that? Waking up feeling like that at the start of the day.

It doesn't sound like something we would want to do. But I can remember when I was very sick, and people would say, you know, family, and look at you, how are you? And I would say, Oh, I'm fine. Because you didn't want to say, well, actually I’m anything but fine. 

Judy Tsafrir: Right, right, right. And I mean, and also when you're feeling that way, you feel like you don't want to burden people and you know that you can't really turn to people for help. And there's some kind of shame involved in the whole thing. Like, what's wrong with you that you don't feel fine? And, um, I mean, a lot of times for, you know, that there's like, we're not, for many people, like in my, in Boston, we're not living in a war-torn area.

You know, like, it's not like there are food shortages and bombs going off, and yet people are feeling terrible, but there's nothing to point at like that. 

Linda Elsegood: Yes. Yeah, well, I can remember being rather concerned that every week I was deteriorating and it was noticeable. And I can remember lying on the sofa, my cat lying on my chest and it hurt. And, um, my mother was here, and she took him off me because it was uncomfortable for me. And I was thinking, if I keep going downhill like this, I'm going to die. You know? And it was really scary, and it was frightening. And I had nobody that I felt I could say that to, you know, “Am I going to die?” 

Judy Tsafrir: .. terrifying and lonely, so lonely, and yeah you know, like, it's not surprising that people become suicidal in that situation. They just feel so alone and so desperate. And there's no light at the end of the tunnel. 

Linda Elsegood: Yes. But luckily for me, there was LDN at the end of the tunnel. So I had, I had the light. So, 

Judy Tsafrir: that really just turned things around like really quickly? 

Linda Elsegood: uh, in three weeks.

I mean, I just very quickly, the left-hand side of my body was numb with pins and needles. I had cognitive problems. It was like English had become my second language, I couldn't recall vocabulary. Everything muddled. I slurred my speech like somebody had had a stroke. I started choking on my food, forgetting things, tripping, falling, stumbling over nothing.

I lost my leg. Strength in my left, like at double vision, lost the hearing in my left ear, had twitching muscles, restless legs and pain. Um, and I'd been told at that point by the neurologist who checked me over and sat me down and put his hands across the desk, shook my hands and said, “I'm really sorry you're secondary progressive now, and there's nothing more we can do” and he opened the door to show me out  

Judy Tsafrir: you had multiple sclerosis?  Terrible, that’s terrible, and you're sort of taught in medical school, If a person has one symptom, okay, then you try and help them. If they have ten symptoms involving ten different organ systems, then it's all in their head.

You know? Then it's, it can't be real, you know, not understanding that that is more and more and more common these days with all of the toxins in our environment and all of the electrosmog and the GMOs and the degraded food supply that this kind of chronic illness is more and more commonly seen with involving multiple organ systems.

And it doesn't fit any kind of classically recognized pattern. 

Linda Elsegood: But in three weeks, um, and I'd lost my bowel and bladder control as well, but in three weeks I started cognitively -  in my head, it was like a television set, not tuned in, and suddenly somebody was tuning it in - and I started to be able to process thoughts, being able to see properly.

The hearing had completely gone in my left ear, and that started to come back, and it was amazing. It was absolutely amazing, but it did take me 18 months to feel like, yeah, I mean, I still know I have MS and I have learned to work around things, but I can achieve things again, which was very devastating.

I can remember I had to go and see the company doctor and he said he sent a letter, and it said that I was, I'm a workaholic. And he said that I was unemployable for the foreseeable future, and that was just like a punch in the stomach. It physically hurt. Um, and I kept this letter for quite a while, and they don't come across it, and I'd read it, and I'd have the same reaction.

One day I thought, well, why am I reading this letter. If I shred it, I haven't got it anymore, and I won't be able to read it, and it won't depress me, you know? I know it was there, but I don't need to physically keep seeing it. But my whole point was to prove everybody wrong. 

Judy Tsafrir: Right. So I mean it was the only thing you did was Low Dose Naltrexone or did you also do other things in addition to that? Did you, I mean you attend to your diet? 

Linda Elsegood: Because I was in the situation that I couldn't cook for myself my diet actually got worse originally. My husband did the best he could do which was just to put something in the oven that was frozen but gradually he learned to cook. Um, because I couldn't get out of bed

I was asleep most of the time, which was a blessing because I really didn't feel well. But, um, as I improved and he improved, we started to get a better diet. But I didn't become gluten-free, dairy-free and process sugar-free for quite a while. Um, I was given three courses of intravenous steroids in an 18 month period, and the first two were only six weeks apart.

I'm a very pale person, and my face blew up and I looked like a tomato. I was so red, and so round. And I gained, um, 50 pounds in these 18 months. And then, Hey, I was type two diabetic. Um, so I was then put on the Metformin, but once, and it was very difficult to lose the weight, not being active enough and exercise was too tiring.  Still is to a point. Um, but there are certain things you can do. But once I changed my diet, I managed and I'm now classified as a diabetic in remission so I don't have to take the Metformin anymore. And I'm really pleased and I didn't realize I was told that I'd have to have Metformin for life. Nobody had actually said to me it can be reversed. I did not know that. 

Judy Tsafrir: Right. And nobody told you that, you know, if you limited your carbohydrate intake or you didn't, you know, eat gluten and dairy or sugar, that that would be beneficial to you? 

Linda Elsegood: No. Um, my mother, I, um, unfortunately, she had cancer, and it was lots of other issues, and LDN didn't work, which knocked my confidence in LDN a little bit because I really wanted it to work. But anyway, my mother knew that she was dying and all she was worried about was the trauma that it would cause me with her dying. You know, what's going to happen? I'm not going to be here to look after you. You know, she was completely selfless.

And the, she asked the doctor to look after me after she'd gone. So the doctor wanted to see me. I went to see her, and I said, you know, I was doing fine. Um, and that I really watch my diet. And I was telling her, and she said, why are you doing that? And I looked at her, and I was feeling very sad cause I just lost my mother and I looked at her and I thought “seriously, you're asking me why I have changed my diet?”. What do I say? 

Judy Tsafrir: Incredible. 

Linda Elsegood: And I just said, “because it makes me feel better”. I couldn't bare the thought of explaining to a doctor why I had changed my diet, but I was really pleased, the fact that I don't have to have the Metformin, but it was quite funny because I was given Metformin initially, and it was a, I don't know what brand it was, but it was so strong - the nausea was so bad - I couldn't, I really couldn't tolerate it. I couldn't bear to eat anything or move my head or talk to anybody. It was awful and I suffered with it for about two and a half weeks and I went back to the doctor because “I was going to die” in inverted commas if I didn't take this Metformin.

So I went back, and I said to her, well, I think I'm going to have to die because I really can't take it, it is making me feel so ill. I just can't do it. And she laughed, and she said, “Oh, there are other versions you can have” And I thought, well, I'll just come back sooner. And I didn't realize that, you know, after the first two or three days.

So then I had Glucophage, which was a slow-release Metformin, and I can tolerate that. That was fine, but apparently, it was far more expensive, so they tried to get people on the cheaper ones first. 

Judy Tsafrir: Right. But all the money, 

Linda Elsegood: thanks actually, luckily, but it's been amazing talking to you, and I realize we've run out of time.

Thank you for having been my guest today.

Judy Tsafrir, MD is a board-certified Harvard faculty member with a private practice of holistic adult and child psychiatry in the Boston area. A special area of interest is environmentally acquired illness, in particular, mold toxicity and the chronic inflammatory response syndrome. Her website is https://www.judytsafrirmd.com/.  Phone number (617) 965-3020.

Any questions or comments? You may have; please email me 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.

Pain Specialist Neel Mehta, MD - 2019 (LDN, low dose naltrexone) from LDN Research Trust on Vimeo.

Linda Elsegood: Today, my guest is Dr Neil Metta from New York. He's a pain specialist. And all the different things he's done are absolutely amazing. Thank you for joining us today. 

Neel Metha, MD: Thank you, Linda, for having me. This is a real pleasure. 

Linda Elsegood: So could you tell our listeners, what experience you've gained so far in the pain field?

Neel Metha, MD: Well,  I think it'd be helpful to have a little bit of background about me and understand why I've chosen this line of work. I am an anesthesiologist by training and  have gone on to do fellowship training in pain management. During my time in medical school, I was fascinated by anesthesiology and orthopaedics and had a real hard time trying to decide how I'd go forward in my career.

I ended up choosing anesthesiology for a number of reasons. During my training in anesthesiology, I had the fortune of working in a great pain management centre here at Weill Cornell. And I  learned a lot about the suffering of patients and of the limited options that we had.  I also had some time in the obstetric ward to treat women in labour and suffering from pain and saw how we had great options for them. So I saw a lot of potential.  I ended up choosing to do pain management because I thought it gave me an aspect of treating a broader range of patients rather than just women in labour. When I came out, I still was amazed that other than some nerve blocks, and some various medications that had been around for years, such as Gabapentin and Lyrica and traditional opioids, there really weren't any other novel ways to treat pain.  I was always sorting out, questing and thirsty for new and better ways that were safer and, and had fewer side effects, and really trying to minimize opioids even before this opioid crisis existed. The opportunity to do that has really been a lifelong goal and continues to drive how I work in research here.

Linda Elsegood: Well. I'm sure the ladies who were in labour really appreciated your help having been there myself. It is called labour for a reason, isn't it? 

Neel Metha, MD: The gratification that you got almost instantaneously was so rewarding. And I do miss that aspect. But now I get to treat both sexes. 

Linda Elsegood: Yes.  A question I'd like to ask. It’s been many years since I had my children and epidurals were the main thing for pain in those days. What options are there now? 

Neel Metha, MD:  So epidurals still remain the mainstay of traditional labour. But the cocktail using those epidurals has evolved. So the idea of being numb from the waist down really has, has been eliminated. And now you have what we call walking epidurals where patients can actually ambulate during their time before they're in active labour and pushing. We are trying to minimize the number of opioids that we use as well by doing things like combined spinal epidurals that allow sort of more instantaneous pain relief if someone has progressed a little bit further in labour and then have an epidural to back it up. And then the most headway's been done in C-sections where the surgical techniques have really sort of stayed the same.

But the anaesthetic techniques have improved. So using fewer opioids, doing things like transverse abdominal pain blocks, nerve blocks of the abdominal area muscles, and also realizing just how much opioid is needed and using multimodal therapy, you can almost eliminate the number of opioids. So some of my colleagues have done tremendous work where they have been able to actually cut down on the number of days that someone has to stay in the hospital just for pain, and that has made real improvement, both for the quality and cost of healthcare-related to having a baby.

Linda Elsegood: Wow. It's amazing. So now you treat both genders. Do you treat children as well, or are you just an adult physician? 

Neel Metha, MD:  I do treat children. I generally start at around age six, although the mainstay of my care is, is adult. Just recently I have had the good fortune of recruiting a great colleague,  who actually did training with me, but then was working elsewhere, and her name is Dr. Veronica Kuru Lo. And she's an anesthesiologist and a specialist in pediatric pain. So she is now our new director of pediatric pain management at Cornell, and a really unique opportunity, the only one of its kind in New York City, to have multimodal pain management therapy for paediatrics, both on an inpatient and outpatient basis.

Linda Elsegood: I myself have MS, and I used to have very bad pins and needles and very painful numbness, and people used to say about pain, I haven't got pain, but I've just got this really bad pins and needles. And then one day somebody said, well, isn't that painful? Well, yes, but I wasn't classed as pain per se, but sort of fake pain, you know, pins and needles,  but anyway, what kind of pain do you treat? Many autoimmune diseases have pain in different forms. You know, it can be a dermatological pain. It can be a fibromyalgia type pain, or an MS pain, or these pins and needles. You know, what do people present to you? What kind of pain?

Neel Metha, MD: Well, working in an academic medical centre, essentially a tertiary care centre, we see the full spectrum of pain. So the majority of my cases are going to be spine and musculoskeletal related conditions. Things like nerve-related pains due to disc herniation or sciatica in lay term or spinal stenosis or osteoarthritis of the joints, whether it be spinal joints or hips and knees and ankles. But also we treat headaches. We treat neuropathic conditions like shingles and trigeminal neuralgia, postherpetic neuralgia, postsurgical pain conditions like post-laminectomy syndrome, you know, failed surgeries for the spine that continued to have neuropathic pain or post breast mastectomy surgeries that lead to chronic pain.

Also, the things you've mentioned, like MS and fibromyalgia, so really a potpourri of conditions and the symptoms range from as simple as an ache as you've mentioned, could be paresthesias or pins and needles. It could be a burning electrical type of pain. And often, we use the description of the pain from the patient to help us focus on what is the underlying dose diagnosis and what's the underlying treatment for this particular condition. It helps us tease out just how much is coming from one condition versus another because as you know, you could have a diagnosis of MS. But also have a disc herniation. And trying to differentiate the two causes and how you would treat them may differ quite significantly. Finally, we do a lot of cancer-related pain as well, whether it is active cancer and things like a tumour, or compression of a nerve or tumour burden.

 

Also, metastatic disease to the bone, end of life care, also the survivors that have had trouble with treatment-related causes of pain such as post-chemotherapy or post-radiation-related neuropathies or postsurgical-related pains. We’re trying to help them regain their life. What's been a new phenomenon is we have always been very aggressive with opioids in the cancer population because we feel they're suffering and may have little time left, but now we've been able to successfully treat so many patients in modern-day medicine that they survive, but now have the potential for opioid addiction. And how do we help those patients come down off of medication and regain their functional lives again? The question is how do we classify pain?

It's often a real story that's developing as the patient is talking to us as we examine them, as we gather information and interpret results, and then make a little bit of systematic trial and error of treatment. Often this is a shared decision, you know, medical process with the patient. Because some may have thoughts on how they want to proceed and just how aggressively or what types of treatment they'd be open to. Some may only want to do things like acupuncture and physical therapy, which we offer, and some may say, I've been living with this for a long time. I want to be as aggressive as possible to treat this as quickly as we can. And that may require things like implantable devices or other types of treatments. 

Linda Elsegood: Do you treat Phantom limb pain?

Neel Metha, MD: Very much so,  Phantom limb pain, obviously in post-trauma, related conditions or even amputations from diabetic neuropathies or poor vascular conditions. Certainly, we have seen our fair share of those patients.

Linda Elsegood: When did you first hear about LDN? Was that during your training? 

Neel Metha, MD: It actually was after my training. I met some colleagues that have presented at the LDN conference, such as Chopra and Dr Samia, Dave Daddo. And they're great colleagues who have been visionaries in pain management. I know that they've been using LDN for a long time in the complex regional pain syndrome. And as I started to research the drug more and more, I realized how little was known in the pain community. And then shortly afterwards, we started to see some good papers coming out, such as the work done by Sean Mackey out in Stanford for fibromyalgia.And then also meeting some doctors, older physicians that knew about combination LDN and an opioid therapy to try to prevent  addiction and increase the strength of the medication—so learning a little bit from history about the drug.  As  I've read more and discovered more about it,my trainees have learned and enthusiastically tried to understand what it is and have really adopted it and use it in their practices, often differentiating themselves from a lot of other physicians and, seeing how it positions themselves to be more comprehensive in their treatment.

Linda Elsegood: So how long have you been prescribing it yourself? 

Neel Metha, MD: I have probably been prescribing about five years now, maybe a little bit over that. And the rate of usage has gone up significantly. What I am most fascinated by now is the wide variety of dosing that is being utilized. I think most recently a lot of people who have adopted the use of LDN have sort of based it on the papers that have come out of Stanford using a range of one milligram to four and a half milligrams. But we realized that's not a one size fits all and ultra-low-dose prescribing in the microgram strength. It's also something I've been increasing usage of. The frequency of usages is also something I'm fascinated by, whether to use once a day or all the way up to four times a day. And so the trouble is trying to understand this and research, this is where we are in this day and age.  

Linda Elsegood: And what would you say the patient's success rates have been with LDN?

Neel Metha, MD: So it's actually one of the drugs that have been a home run. I would say if I had to do a head to head comparison against something like Gabapentin for neuropathic pain, my anecdotal experience has been that it's more successful than those types of drugs for a number of reasons.

Number one, its overall efficacy has been good in terms of reduction of pain, but the biggest thing is compliance. So how easy is it for a patient to follow directions and use it, and also interaction in side effects is almost minimal. Some patients may describe some minimal side effects, but they tolerate it and go on with it.

 

But Gabapentin and Lyrica are more challenging with the side effects such as weight loss, weight gain, and sedation and dizziness are really challenging for them. And often it's frustrating for everybody because we'll try those drugs. And if a patient comes back a week later or two weeks later saying, I took one dose, didn't tolerate it, and I stopped it altogether. So our challenge in those treatments is that we just don't have anything equivalent until we discovered LDN and now we almost offer it to every type of neuropathic condition and the drug is cheap. We are fortunate that the compounding pharmacies that we work with have been able to offer it at a very palatable price compared to some of the other compounding drugs that we may use.

Linda Elsegood: And have you used it in Phantom pain? 

Neel Metha, MD: I've used it broadly in neuropathic pains. Phantom limb is something I have used it in, although I will say that my population of Phantom limb pain is much smaller than say, by trigeminal neuralgia or fibromyalgia or other neuropathic conditions. We've also been using it a lot in patients that have myofascial pain. That has become more of a centralized or hypersensitized type condition. So when they have central sensitization of their muscle pain, I find LDN very effective. 

Linda Elsegood: I was only asking about the Phantom limb pain because we have many members that are military who've lost limbs, and you know, it is worth the try, isn't it? You know, you've got to find someone who will prescribe it, but it's definitely worth a try. 

Neel Metha, MD: Absolutely. I see very little downside to it. I think often the patients, once they hear about it and talk about how we plan to use it, what's the potential for benefit and the minimal side effect, we have a very good success rate of having patients try it and be pleased with it. If you just do research on naltrexone alone on Google, sometimes it's a little scary, the types of things that come up associated with naltrexone.  I take the time to counsel patients on why we are using it and how it does differ from the other purposes of naltrexone itself. And that's very reassuring for patients. Phantom limb pain, I think, is one of those things that it's almost a no brainer to use in these conditions along with other multimodal therapies, including.

Mirror therapy, physical therapy, and then refractory conditions to consider things like ketamine and spinal cord stimulation or peripheral nerve stimulation. So there's a wide variety of treatments, but LDN should be one of the mainstays. 

Linda Elsegood: We've been going 15 years now, but it was mainly.to help autoimmune conditions. Such as rheumatoid arthritis, but we were saying it probably won't do anything for osteoarthritis, but that's not the case. It does work for osteoarthritis as well, which is quite amazing. A lot of our members are in their 70s or 80s and have been having very high doses of steroids throughout their years, since they were like 20, 30, and it's caused, crumbling of the spine. So nerves are getting trapped, and LDN seems to be working really well in those cases as well. But it sounds absolutely horrendous. I would hate that to happen to me. But I'd like to think steroids aren't as widely used now as they were. You know, 40 years ago. Would you say that's the case, that we're doing something different than a high dose of steroids over a long period? 

Neel Metha, MD: We certainly have an appreciation for the risk of high steroid use. So we know now what doses we can use at a time and how often those patients can get it. But unfortunately, the steroid is still a mainstay treatment for various conditions like osteoarthritis, especially in the, in the hands of an interventional specialist. We still believe in the continuum of care, such as things like physical therapy.  But also, the use of acupuncture, turmeric and when appropriate steroids, if you're going to give maybe localized steroid.And now a lot of things like platelet-rich plasma and STEM cell are starting, and it's the emergence of data, but you're right, LDN does work. And while it may not have 100% cure rate you can certainly lessen the burden of osteoarthritis enough for people to be able to do more in their physical therapy and be more active and lose weight and all the other things that come in a positive cycle, to help them overall improve their functional ability in their quality of life.

Linda Elsegood: Have you found a benefit using the ultra-low dose alongside opioids to make them more effective, to help patients withdrawal from their opioids?

Neel Metha, MD: So this is a healthy debate I have with a colleague of mine. He starts at a hundred micrograms and will consider ramping that up over time,  two, four times a day, and then slowly get up into potentially a milligram dose. And I tend to start the opposite. I may start at one milligram and decide whether I need to go up or down based on the symptoms that they're experiencing. The challenge that we have is there are patients that don't respond in the milligram dose but do respond in the microgram dose even with it and have an absence of side effects. And this is where I think to work with. Your organization and working with David on research in this to really pinpoint how we best identify dosing for patients is going to be fascinating. But to answer the question about how I have found it,  it has really helped patients with tolerance and actually prevention of tolerance. We use it quite frequently in traditional opioid receptor type drugs. But I also use it synergistically for neuropathic pain conditions when I use things like Tramadol.  My belief is that it's worth a chance to see. We start extremely low. We are able to get one of our compounding pharmacies to start at a hundred micrograms in a tablet form, which a patient can split in half and take 50 micrograms at a time. We see really interesting clinical data, and now we are just starting to try to put this together and see if we can publish our work on it.

Linda Elsegood: If you are a drug addict through no fault of your own because they are prescription drugs, but it still makes you addicted to these opioids and coming off, you've got to be so careful that you don't go into withdrawal. So if something like ultra-low-dose can be used to help wean people off without those awful withdrawal symptoms, in my book that's got to be amazing. 

Neel Metha, MD: Absolutely. If we can eliminate the usage or even cut down the doses to be in a safer range, I think it helps everyone, including the patients that are taking these medications, the prescribers who are trying to handle risks of these medications, the families that may be in the same households where these medications are being stored and trying to avoid the harm of getting these medications in the wrong hands. These are all potential benefits of downstream effects of LDN  

Linda Elsegood: And what's the long term effect to the body if you take high doses of opioids?

Neel Metha, MD: Well, there's a number of things. So number one to the patient itself that's taking the opioids, there's a very high likelihood of tolerance, and that's a very challenging and frustrating problem for everybody in that the same dose of medication has a diminished effect in terms of pain relief. So the natural thought would be to increase the dose. But eventually, even without the absence of addiction and addiction type behaviours, the same patient taking a higher dose has a much higher likelihood of achieving side effects that could make it unbearable to continue on that therapy. And what side effects am I referring to? Those are things like severe constipation,  not being able to function at work, missing days at work or being unproductive during their time, mood irritation and irritability to the point that they become very, difficult to be around the family, to the point of not being able to drive to work or drive in a car anymore because they're so impaired or that they sleep more, may gain weight, become less active. So overall, their quality of life may go down, even though they have the original intention of trying to improve their pain with a higher dose. And then you have the risk of addiction. And that is a potential for now using medication in inappropriate ways, combining it with things like alcohol and so forth, and then finally what is the risk of all this medication sitting in the home? So could a teenager in the household get into it and use it in a recreational way and cause harm and die?

Could it get in the hands of a young child? Could it get stolen and get into a drug addict's possession? All of these things are harmful. We can eliminate or reduce the amount of medication in circulation. There are so many downstream effects in addition to the ones that the patient would benefit from.

Linda Elsegood: Well, wonderful. We've just about run out of time. Can patients refer themselves to see you? Do they have to be referred by their own doctor, how do patients get to see you? 

Neel Metha, MD: So, for LDN, I think recently you've been kind enough to share some of our practice information. And just recently I've had a few, a couple of patients that actually have no pain, real related things, but wanted to talk about LDN usage.

And I've been happy to see them. So patients are able to make an appointment if they are not coming for a particular pain condition. I asked them to specify with our schedulers they are here to discuss LDN and I'm happy to meet with them. But for painful conditions, I have a team of.

eight other doctors that have experience with LDN. Some of them have been prescribing it for just as long as I have. So, we welcome these patients to see us if they're motivated to want to try to improve their lives without the use of opioids. We really welcome them if they're trying to reduce the amount that they take. LDN is a great drug, but there's a multitude of options that we want to present to them. And that's where we think our multidisciplinary practice will really help.  

Linda Elsegood: And what numbers should they call you on? 

Neel Metha, MD: So our office number is six, four, six, nine, six two seven two, four, six. We are located in Manhattan. We'll also offer video visits for follow-up visits. We're not allowed to do it for the initial ones, but if they are able to make the journey to see us even from far away, one time, then we can potentially continue to care for them virtually. We have had patients come from other countries and also from up to 48 States of the 50.  

Linda Elsegood: Wow. It's been amazing talking to you today, and we'll have you back at another time. 

Neel Metha, MD: Linda, thank you very much for the opportunity. It's really been a great collaboration that we have started on and I hope to continue to help everybody through our work together. Thank you. 

Linda Elsegood: This show is sponsored by Mark Drugs who specialize in the custom compounding of medications, assuring that the client gets the proper prescriptions for their unique needs and conditions. They work with practitioners integrating knowledge and treatment of experts to create comprehensive health plans. Visit markdrugs.com or call Roselle six three zero. Five two nine three four zero or  (847) 419-9898.

Any questions or comments you may have, please email me 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.

The Pain, Opioid and Ultra/Low Dose Naltrexone (LDN) Documentary - Opioids & Pain Management: How LDN can assist with treatment from LDN Research Trust on Vimeo.

The Pain, Opioid and Ultra/Low Dose Naltrexone (LDN) Documentary - Opiod Crisis: Is Low Dose Naltrexone the Answer? from LDN Research Trust on Vimeo.

The LDN Pain Seminars in October 2019 (low dose naltrexone) from LDN Research Trust on Vimeo.

Chris Alley from Integrative Therapeutics (LDN, low dose naltrexone) from LDN Research Trust on Vimeo.

Pharmacist Cheri Garvin from The Compounding Center (LDN, low dose naltrexone) from LDN Research Trust on Vimeo.