Linda Elsegood: Today I'm joined by pharmacist John Herr, and he's from New Jersey in the US. Thanks for joining me today. John.
John Herr: Oh, you're welcome. Glad to be able to spend this time with you.
Linda Elsegood: Good. And I didn't mention where you're from and you're from Town and Country Compounding. So first of all, tell us how you got into working as a pharmacist.
I mean, had you always been interested in pharmacy as a child?
John Herr: Well, I've always been interested in pharmacy, and I've always been interested in like natural medicine or integrative, we now call it integrative medicine or functional medicine. But back in the day, I think we called it natural, and I was just lucky I went to a think John's University in New York City and, and uh, I made the acquaintance of a physician who was, she was actually from, uh, were really a pioneer in bringing natural or bioidentical progesterone into the United States. So back then, I was still in pharmacy school and, and I started to like working with patients with bioidentical progesterone.
And it just kinda changed the way that kind of, I thought as a pharmacist and I, I really consider myself a, you know, really like a, uh, like an integrative pharmacist now. So low dose naltrexone to me was just a natural progression of, you know, my knowledge and my interests.
Linda Elsegood: so how long would you say that you've been compounding LDN now.
John Herr: Oh my God, I think it's gotta be around two, maybe around 2000 or 2002. You know, just when it was really becoming, you know, uh, old people were starting to understand it. It's interesting. I had a, um. One of my patients, you know, when I had my retail pharmacy, she ended up writing a book about it, uh, about her husband.
It was called “Up the Creek with a Paddle”. and Mary Bradley and I, she had been in my pharmacy and her husband at the time had MS, and we were talking about, and I recommended the low dose naltrexone to her, and then she went and sought out Dr Bahari. And you know, she started, you know, they started her husband on that for his MS and that, that's where my original interest was.
And she ended up writing the book, you know, “Up the Creek with a Paddle”. And my biggest claim to fame is I’m mentioned in the book as the one who told her about researching low dose naltrexone. And then. Subsequently, after that, I became acquainted with a gentleman named Fritz Bell, who started, uh, you know, a website, uh, good shape because back then people were just, you know, going on the internet and they were buying the 50-milligram tablet and trying to, you know, create their own.
So, you know, Fritz had a big interest in that and, you know, uh, I, I filled prescriptions for his wife, but I also filled prescriptions for people where, you know, we, you know, basically, you know, Fritz donated it to them because he wanted people to be able to take the medication and not have to compound their own.
So if they qualified to his standards, we would make it up and send it out, no charge. So those patients could start on the low dose naltrexone. So I go back way to the beginning. And you know, I think back then we just thought of low dose naltrexone and honestly for MS. But you know, subsequently, over the years we've just learned, you know, how vast the, uh, you know, the different disease states we can treat and manage with low dose naltrexone.
Linda Elsegood: And what forms do you compound LDN in?
John Herr: Well, the most typical is a capsule, uh, which we do an immediate release capsule. Um, we're in the process of buying a, uh, switching over to like a tablet so that we can, uh, you know, meet the need, you know, with a tablet machine. But right now we make capsules. We also make, um, we've actually done a transdermally.
I treat a lot of children on the autistic spectrum disorder. You know, we've had to do it in sublingual liquid for some of the children. Uh, we have a couple of patients on it right now, believe it or not, for a vaginal cream. We've also used it transdermally for like neuropathic pain on different areas of the body.
And I've been researching some articles recently. I'm using it as an Automic drop for chronic dry eye, but I've been talking to a couple of different integrative physicians about using it. But, uh, up to this point, we haven't, um, having anybody try it for the ophthalmic. But I'll, I'll keep everybody appraised when we do because there is, there's a lot of interest in using it for that function as well.
Linda Elsegood: And I know that there are some dentists that are also using LDN, so that's another interesting one. And how about ultra-low-dose naltrexone? Is that used in your area that you cover? ,
John Herr: yeah, we have some patients on it. We also do a lot of pain management. We have, uh, we've managed intrathecal pumps in the home.
So I worked with a lot of doctors who, um, you know, pain doctors and I actually work with a doctor, a doctor speaking at the next conference in Portland. And so I work with his patients, and we have to start a lot lower on his patients because many of them are on opioids. And I've worked with some pain physicians where we've actually compounded as low as 100 microgram capsules because I think you really need a physician who is trained in pain management because they're actually weaning the patient off of the opioids as they're bringing the LDN up very gradually.
And it's a real balancing act because. You are going to detox that patient. So that's not something I would recommend for you, you know, like a general practice physician to you. Um, but we do have a lot of patients that are using it that way where they're getting off of this. And then I just, we just get tremendous feedback when they're off of the opioids, how they're then maintaining the pain with these, with, you know, LDN that we consider, you know, on that standard dose that we consider for pain.
But it is a little tricky to get them off of those. Um. Yeah. Off the opioid, while you're bringing the low dose naltrexone up to the appropriate dose.
Linda Elsegood: I mean, I've interviewed several pain specialists, and they seem to be using 0.001 which must be like a grain of sugar of naltrexone, and they explain, sorry,
John Herr: carry on.
Zero one micrograms,
Linda Elsegood: Linda. Yes. Wow. Yeah, so
John Herr: I mean,
Linda Elsegood: exactly, but by doing that and using it alongside the opioid, it makes the opioid stronger so that they can reduce the opioid and slowly increase the by 0.001 sorts of the thing. They do like sort everyday kind of thing, until they can bring the opioid really down and the LDN can take over.
And they have it by doing it so slowly, as you can imagine. Well, slowly by my thinking, um. Or, or rather fast by my thinking. They say it's slow, but it does seem to happen quite quickly where they get them off the opioids, and they have gone, they haven't gone through withdrawal, they haven't had any side effects.
And you know, the LDN, like you were saying, can be used in place of the opioids and give pain relief. It's just amazing to me that something so small that's not harmful or toxic or even expensive can work so well.
John Herr: Yeah, it is amazing. I mean, I think we just, as I said, when I first started working with it, we just kind of thought of it for like autoimmune.
But how we, you know, now that we know that it's working on the immune system when we know it's working on, you know, with the upregulation of endorphins and we know that it's working on the toll like receptors for inflammation. And now that we see how it affects dopamine for depression, I just think the, I mean it's just amazing to me how many opportunities there are out there for physicians to learn how they can better treat their patients for numerous, you know, disease states,
Linda Elsegood: and of course, most people that have an autoimmune condition, one of the underlying problems is the inflammation, isn't it?
So by reducing that inflammation alone helps the person feel so much better anyway, especially with the boost of endorphins as well.
John Herr: Oh, yeah. Actually, my wife, who's a pharmacist, is a perfect example. Like she went and had all this blood work done in her, what they call her ANA level was through the roof.
So your traditional physician would look at that and say, Oh, you must have rheumatoid arthritis. Because she was getting, wasn't really achy joints, but she was getting pain, almost like fibromyalgia pain. So we knew it was inflammation, and at the same time, her blood pressure was uncontrollable. It was, you know, we actually had her on a heart monitor, and then one of the physicians that we work with, when they did, you know, we really started working more in-depth than they did the food allergies.
We found out she was severely allergic to dairy. So, you know, started her on, you know, obviously an elimination diet, and then low dose naltrexone, which she titrated up gradually to a dose about 4.5 milligrams, but the ANA level came down, you know, uh, you know, obviously with inflammation, all the inflammation markers went down. The pain went away. And the funny thing is like we had to get her off that blood pressure medication really quick. The pressure was just dropping. So now she's just on LDN and you know, obviously supplements and you know, dietary changes, but there's no more blood pressure medication needed, and she doesn't have the pain anymore.
So it's an example of, you know, the LDN is a tool, but you still have to take into account all of the other things that are going on. But the diet, nutrition, exercise, I always try to tell people it's a package deal. You know, the LDN is one of the most important pieces, but there are other things that you can do for your health.
Linda Elsegood: Oh, definitely. Um, I used to have to take, um, Omeprazole for Acid reflux, and if I didn't take it, I was in trouble. It's that severe, but by going gluten-free I now don't have any problems at all. I don't have to take the medication. I don't have any acid reflux at all. But if I go out to eat and you know what it's like you're going through the menu and say, you know, it doesn't look as though there'd be any gluten-free in this. Could you check with the chef for me? And they'll come back and say, no, there's no gluten in it. If there is, I don't sleep that night. The acid reflux is so bad. And I have to sit up. Right. If not, I'm just going to vomit. It's terrible. So I don't always believe people when they tell me there's no gluten, cause I know if there's any gluten in it. Yeah. So it's amazing, isn't it? How you can just eliminate other medications just by diet. My husband has problems with these. The skin on his hands. He's allergic to milk, and he'd seen so many different doctors in the past, and nobody could tell him why the palms of his hands would go like white and dry.
But when he eliminates dairy, his skin is completely normal. And that was like 30 years of trying to find out what was wrong with his skin and never had an answer. .
John Herr: Yeah, that's what I, my thing, when I'd give talks on this, I always tell people, patients, or if I'm talking to groups of physicians, you know, whoever it might be, I, I say at least I know in the United States, I say, we say that we're in healthcare in the United States, but we really are not.
We're in sick care, you know, our, our system in this country is, I hate to say it, but it's run by big pharma. So you know where our physicians are, a lot, many of them are trained to wait until the patient presents with the disease and then give a pharmaceutical remedy for that disease, whereas an integrative medicine, or you can take like LDN, I think, you know, we're trying to get at the underlying cause and how can we correct that so that we can live healthier.
Linda Elsegood: yes. It's, um, quite common for people to tell me that. The doctors are only treating their symptoms, but not the root cause. So of course, you then end up with all these medications and some people are taking in between 14 even 22 different medications a day, and some of those are only needed because of the cocktail of drugs that they're taking cause side effects.
But that's okay cause they'll give you another tablet which will combat the side effects from the cocktail you're taking.
John Herr: Yeah. Well, I think Linda your example was the perfect example there. You know, that drug was originally made for somebody who had an active ulcer and then you theoretically would take it for, you know, two or three months, to allow it to heal and then change your diet and, and you know, go on. But now people just live on that drug, you know, the purple pill. It's like they have to take it forever, which you know, it affects, then you're affecting your gastric pH, your digestion. It's a slippery slope. I agree with you. 100%
Linda Elsegood: Hmm.
And of course, I also have people telling me that it's expensive to eat healthily, and especially when you've got children, it seems. So sad, and I can understand if you only have a limited amount of money and you've got several children, they all need feeding. But - we call them crisps - you call them chips over there, and we have biscuits, you call them cookies, but you, you, you get where I'm coming from. That is cheaper than buying apples, some pears and bananas and oranges and such, which would be a healthier option. But the price difference is quite amazing, isn't it? And especially if you have. Uh, mass-produced meat from a supermarket or you're buying organic local meat or vegetables.
Uh, the price difference is quite high, isn't it.
John Herr: Oh, yeah. It's much harder to try and eat organic and healthy. You're right. And then you see the commercials where McDonald's is our friend. The dollar meal menu. Oh, please don't just don't even eat there. But do you want you to understand? Some people though, socioeconomics, they don't, they don't have that choice.
But you know, everybody can make little changes, I believe. Do you know? Uh, and then that's what we try to educate them on. And as you mentioned, I mean, just the cost of medication, like, uh, it's gotten, even when they're covered by insurance in our country, many patients can't afford their medications with their copays.
So I, whereas the low dose naltrexone, you know, I'm such a big believer in it. I, you know. Okay. I worked with Dr Dahda who, you know, explains to me that, you know, his patients are chronic pain patients. So a lot of them are, you know, disabled or they, you know, they don't have a large income. So, you know, we, you know, once we have them too, they're titrated to their dose that the dose that they're going to be on for their pain, then we dispense like a 90 day supply.
It, you know, at a cost that in most cases is lower than their copay. Uh, cause we just believe in the therapy so much that we want to, you know, help it help patients and make it available to them.
Linda Elsegood: What about shelf life on your capsules? How long do they last?
John Herr: Well, you know, the UFP governs that in our country, so I imagine they would last longer, but where, you know, only allowed to put 180 days on, on there.
Once we, from the date that we make it now, certainly at the pharmacist, I think it would last a lot longer. But because it's compounded, you know, the USP United, which is the United States pharmacopoeia, which is basically overseen by the, you know, the FDA, the food and drug administration, and then that's up to 180.
Yeah, a day, what we call the beyond use date or expiration date. So that's what most people are getting a 90 day supply. They'll certainly going to fall within that date range.
Linda Elsegood: I understand. And so that would be the same for the tablets as well once you start making those if that is the rules and regulations of the land. The 180 days?
John Herr: Yeah that’s correct that’s a solid dosage form and then once you go into anything that was a liquid, for example, um, now if you'd like for it to stop, I had to make it into for a young tile than a liquid format, you know, then we would be restricted, believe it or not, to a 14 day supply? You can also do testing, you know, so you can test that it's stable to extend that beyond use date. But most of the patients we see are, are using the, you know, the solid oral dosage forms, the capsules or the tablets. Yes. So it's usually not that much of a problem.
Linda Elsegood: and what fillers do you use.
John Herr: Well, typically, like most people, we use avicell, which is just an inert starch that people do not have any problems with.
But because we, we, you know, my pharmacy, it's, you know, we were only compounding. So we work with a lot of functional medicine and integrative practitioners. So we have a person who did have like what we call chemical sensitivities. A lot of times I don't think that they're going to be allergic to the, uh, you know, to the low dose naltrexone or it, but it could be the filler.
So sometimes what we'll do is we'll give them different filler. We might give them some avicill capsules, we might give them some acidipholis capsules, or sometimes we'll use a vitamin, you know, nutritional that we know that they can take. And then we'll have them take the, you know, capsule, you know, for about a week or so with actually, without, with no now trucks on it.
Just to make sure that they're not having any type of re, you know, reaction to the, uh, to the filler. So, you know, typically we do avicell, but you know, for specific patients, you know, if they have chemical sensitivity, we will adapt it too, you know, whatever will agree with that particular patient, especially if they practice kinesiology.
I have a couple patients and practitioners, you know, practising aetiology so they can kind of, sometimes they can tell which filters are, you know, will react to a patient even. Just from the, you know, if you understand, can aetiology, how it works in the body versus even half the taking it to see if they have a side effect.
Linda Elsegood: Okay. And what about the capsules? Are they sort of, um, a vegan free capsule?
John Herr: Yes, we can get a, um, they're, they're a vegetable base, so now they're not a, typically they come gelatin or, or, or vegetables. So we can, you know, we can get either, our goal is to go. At least eventually to the tablets once we, um, you don't have the tablet machine running correctly, but with the tablet you're, you know, unfortunately, you have to kind of make a couple of strengths.
It's not that you can go, oh, I can just run or, you know, or make a runoff, you know if it was a strange or an odd strength, you know, let me just make 30 or a hundred of that. What you have to do that in bigger batches, I don't think I will ever not be also making capsules. You said if you have the patients that need them, the ultra-low dose or patients who.
Everybody used to think it was 4.5 milligrams like religion, but now we know some patients do better with nine milligrams, some patients do better on three milligrams. So I envisioned that will always be, you know, compounding capsules. But we'll also, for those patients that are taking the more common dose, we'll have the availability of the, you know, tablets that we can keep up with the demand because you know, myself being, and.
in this metropolitan area of New York City, New Jersey. There are so many patients who need this, uh, need this treatment.
Linda Elsegood: And what area do you cover? Um, before we started, you said the Manhattan area, so. Could you just explain exactly where you, you cover?
John Herr: Oh, sure, sure. Yeah. And in the United States, uh, again, the FDA requires that you have to be licensed as a pharmacist in any state that you're going to send, you know, medication into and low dose naltrexone is considered a, you know, prescription medication in our country. So, you know, you have to be licensed in those States. So I, I've concentrated my licenses in the Northeast, so I, you know, work in areas such as, you know, Massachusetts, Rhode Island, Connecticut, New York, New Jersey, Ohio, Pennsylvania, Delaware, Maryland, you know, the, in this area of the Northeast.
But, uh, you know, previously I was president of IACT, which is the international Academy of compounding pharmacists. So I know pharmacists all over the country. And a lot of times I'll get a request for, you know, low dose naltrexone in another state. So I always know, you know, a good colleague that I can refer to that prescription to if no, if I get, I have a request and, uh, to state that I'm not licensed then.
And compounding pharmacists generally kinda like to network and share ideas with one another, which, you know, it's very collegial, which is something that, you know, really makes me enjoy the profession. So I do many instances I send prescriptions that I get to people I know in other States because I'm not licensed in that state, so we always try to make sure the patient gets their medication.
Linda Elsegood: And since you've been compounding LDN for so many years, has anybody ever reported to you any adverse effects that may be unusual?
John Herr: I have like one patient and that she's come to like three of my seminars and her husband's a physician, but she just has a funny reaction to the naltrexone, and we've tried it.
We've tried ultra-low-dose and, and everything, but it really just upsets her, you know, upsets her stomach or her head. She just doesn't feel right on it. And I mean, she's tried it so many times because of it just, she's read so much about it, and her husband's been a practitioner. She's all one patient that's just tough to treat. But other than that, we get the typical side effects you see, which are the, uh, you know, the vivid dreams, the stomach upset, you know, maybe like a slight little headache. But typically we just work with those patients and tell them that you need to start the dose slowly and titrate up gradually.
So we've actually put together a, a, you know, like a titration kit. You know, for patients, cause many of the doctors don't realize that many doctors hear about low dose naltrexone and they just, you know, they think they can simply write a prescription for a four milligram or a 4.5 milligram. So we'll, we'll go in and educate those physicians that we have, this titration kit that we go up gradually once the patient gets to be on, you know, the dose that seems effective for he or she, well, they then compounded into that particular strength. So I think that's really helped a lot for patients to, you know, avoid the side effects and, uh, you know, get to their particular individualized dosage.
Linda Elsegood: Well, I've been on LDN since 2003, and at that time over here anyway, we were given three milligrams for a month, and then you went on to 4.5, and that was it.
But the dropout rate was really high starting on three milligrams because we have found now that some people, you know, two milligrams is as high as they can go. So you can imagine starting on three it was a no go from the start, you know, it was far too high for them. But now, depending on what the condition is, It might be as low as 0.5 milligrams starting or 1.5 but doing it gradually and slowly. We find that not many people drop out of taking it. They seem to tolerate it really well and notice benefits quite quickly.
John Herr: Oh, I agree with you, Linda. 100% on that. And then the other thing, like I always try to caution patients on it is that don't give up on it.
Because sometimes, even though maybe they didn't get any side effects, the patient thinks they're not getting the effects from the low dose naltrexone. And it's funny, we had two women, they were, you know, they were, you know, they were girlfriend, you know, and they both had a similar condition around the same age, and they went to the same physician, both started on the titration kit and, and the one woman that she got to 3.5 mg and she was just feeling wonderful. And the other lady kept going up and she got to like 4.5 and wasn't experiencing any, um, any relief from her. Uh, you know, what she was trying to treat, but we just told her, you know, you gotta stick with it, stick with it. And you know, she was discouraged because the girlfriend was, you know, she was not even 30, you know, it's about 30 days. And she was feeling well, and she wasn't getting any benefit that she perceived. And lo and behold, it took four months.
And then she started to get the relief. So the other thing is like, even though you know you start low on the dose and titrate, which you know, we agree 100%, you also have to make sure that the patient realizes that sometimes you need it can take six months before the low dose naltrexone really start to show differences in their body.
And I always try to caution patients, you know, depending on the disease that they're trying to treat or the condition they're talking to trying to treat, I tell them, look, this didn't happen to you overnight. You know, this whole thing was probably going on your own, in your body for a long period of time.
So, you know, you're thinking traditional medicine, like, you know, you had a toothache and somebody gave you Tylenol with Codeine, and of course, it's going to work immediately. But with this, we're trying to upregulate your body and get your body to correct what's going on. So you do have to caution patients that, you know, give it time.
I usually recommend, give it a good six months before you say it's not doing anything for you.
Linda Elsegood: well, we noticed, um, when we did a survey that some people said they had no symptom relief, but their disease stabilized. So I mean, that's a win in my book if you've managed to stop progression, but then between 15 and 18 months there was, um, 2% of people, whatever it was, didn't find symptom relief until they'd been taking it 15 to 18 months, which is a really long time. But they had stabilized before then. Um, and only 5% of people at that time or have any side effects at all. But the number of people who have stopped LDN because it probably wasn't working, or it was too expensive, but they stopped. And those people normally come back to me in about three, four weeks and say, in actual fact, the LDN was working for me. I'd forgotten that my bladder used to play up. I'd forgotten the pain that I had, “I’d forgotten …..”. You know, it wasn't until they'd stopped that they noticed that LDN in actual fact was working for them.
John Herr: yeah. I agree with that 100%. I've, you know, I've had like another woman, we would just counselling who hang out with her. Uh, you know, general, like almost like fibromyalgia pain and everything. Had ah It's totally a had gone away while she's been on the low dose naltrexone, but then all of a sudden she started to get pain in that.
And uh, you know, she's gotten real nervous. Like, Oh no, but I held the end isn't working for me anymore. I have to have this. This is how it is. This has been a miracle for me. What's going on? But then again, you know, functional, integrative medicine, when we talked to the patient with what's going on in your life, he starts to see that, Oh, you know, now you're going through, you know, you're right at the, into perimenopause, going into menopause, you have the pain.
Oh, it's right around my menstrual cycle. Okay, what's happening there? You're probably. Your estrogen level isn't where it used to be. And we know when women, particularly that when their estrogen and the estrodile goes down, they tend to get aches and pains. Hmm. So maybe it's a matter of, you know, adjusting your estrogen at this point.
It's not that the LDN stopped working, so you always have to look at your patients, and that's why the patient always has to go back and, uh, you know, consult with there, either their compounding pharmacist who can send them back to their physician or their physician. But it's not always just the, uh, you can't always blame it on the LDN.
Other things, you know, are happening in your life are happening with your body as, as we, as we age. So it's, uh, that's why I say it's a package.
Linda Elsegood: I was asked a question this week, and a gentleman said,
it would appear on the forums that he's been reading that LDN doesn't work as well for men as it does for women. And was this a hormonal problem? Have you noticed it doesn't work as well for men as women, it seems,
John Herr: you know, you're right. We have more of women that, uh, that are on low dose naltrexone, but I, I don't know why, but I thought like when we were talking pain, you know, certainly the, um, I think it works for both men and women equally well, but when we have other conditions such as fibromyalgia, that it makes you wonder, is it, is it also something going on with the hormones or, I think I have a great interest now in, in like Lyme disease and low dose naltrexone. And, and we know surely that Lyme disease, you know, uh, affects the pituitary, which is signalling in the body to produce hormones. And also, if you think about chronic pain, when people are in chronic pain, they're not producing their hormones the same.
So that's where I think we have to not just think that it's just a panacea and then we can just give low dose naltrexone, but we have to measure those patients hormone levels. And adjust them accordingly. So, and I think. You know, honestly, that may be what you, what you just elucidated is that you know, women will tend to, you know, go through menopause or their hormones will change at a much earlier age than men.
So, you know, for a woman, you know, we usually say around age 50 our hormones are trying to change. Men won't happen later on in life. So maybe it's not a difference, you know, in between males and females as much as, is it also something that has to do with the relationship between the hormonal changes.
And women getting them at an earlier age than then we're associating that more women do better than men, but reality maybe. Cause it's that man still has this testosterone in his body.
Linda Elsegood: Oh, okay. It does. It does. And we're now out of time, but I have to have you back another day. We could have carried on talking there forever.
Could you tell people how they can contact you?
John Herr: Well, certainly, uh, you can call us at our pharmacy directly, which is a 201 447 2020, and then you can always find us on the internet. Our, uh, pharmacy is https://tccompound.com/ and from there you can even email the pharmacist a question or, you know, call us directly.
And we just love talking to patients, and that's what we do. And we, and we do hold seminars, usually monthly on low dose naltrexone, which we will post on Facebook and on our website. And, you know, make people aware that if they're, you know, in the area that they can come in and see it.
Linda Elsegood: Wow. Amazing. Well, thank you very much for all your hard work and for promoting LDN to your patients all these years.
Um, absolutely fantastic. And for educating people, so thank you very much.
John Herr: Oh, thank you, Linda. I love talking with you and, uh, looking forward to doing it again.
Linda Elsegood: Thank you.
At the town, a country compounding pharmacy in Ringwood, New Jersey, owner, pharmacist, John Herr 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.
any questions or comments you may have. Please email me Linda@ldnrt.org I look forward to hearing from you. Thank you for joining us today. We really appreciate your company. Until next time, stay safe and keep well.