Ketamine May Help the Brain Get Unstuck - The Science of Neuroplasticity Trauma and Mental Health with Dr. James Leathem | E171

Ketamine gets you unstuck. So if you feel stuck, nothing's gonna work more rapidly from like an antidepressant standpoint than ketamine. And so it's get unstuck. And now once we're unstuck, okay, now how do we rebuild? So generally my analogy is imagine your house, your mental health house is on fire when you come into the clinic. I will likely be able to put that house fire out for you, but I cannot rebuild the house for you. Only you can do that.

Welcome back once again to another exciting episode of Made for Health. We are going to have an amazing discussion. We've already been talking for almost 30 minutes and haven't started. So after a quick introduction, we're going to hop in today's episode. What if relief from depression, PTSD, or chronic pain didn't have to take weeks or years? What if you could begin in a matter of hours? My guest today, Dr. James Letham, is going to answer this question for you today. Dr. Latham is a board-certified anesthesiologist who spent more than 13 years in medicine, including 9 years in anesthesiology, where he personally administered more than 10,000 anesthetics. His path into medicine was anything but ordinary. He started out in business and marketing, but everything changed in 2002 when he survived a near-death experience following a ruptured appendix. That's going to be part of his introduction we'll talk about here shortly here. That moment sent him on an entirely new course in medicine and his life. And he went on to earn his medical degree and build a career in anesthesia. But after years in the operating room, he felt drawn towards something different. And in 2020, he co-founded the Advanced Wellness and Pain Institute in Arizona, along with Dr. Deepak Sharma and Dr. Gregory Wand, where they now devote their work to ketamine, psychedelic medicine, helping people heal from depression, anxiety, PTSD, chronic pain, and a whole bunch of other stuff that we're going to dive into today. He's also certified as a psychedelic integration coach, and he sums up his approach in one memorable line. He doesn't just administer ketamine, he curates a journey. James, welcome to today's show. I'm so excited to have you.

Yeah, thank you, Aaron, for the opportunity to share my story and raise awareness, educate, entertain a little bit. You know, thank you. Appreciate it.

Well, you definitely entertain, that's for sure. When I heard you talk on stage, uh, Genius, you were, you know, you gave us a rap, man, which was pretty, it was pretty cool.

I did. Yeah, I do the Dr. James rap. We're not going to start out with that.

No, we're not. Yeah.

But maybe we might get into some sort of flow. I tend to kind of rhyme my words a little bit, you know, as they say, like words are spells. That's why you call it spelling. So we'll see.

There we go.

I'll spell, kind of come up with that.

So I want you to talk a little bit about how you got, cuz going from anesthesia to psychedelics, I actually can see how that can work. And it's particularly ketamine, which is gonna be the focus of our conversation today, like its uses. Tell us a little bit about yourself, Molly. Most of them are probably not familiar with you. Like what got you into medicine? What got you into what you're doing now? And just tell us about yourself.

Yeah, so I'm a board-certified anesthesiologist, first doctor in my family, definitely an unconventional or circuitous route to kind of get to where I am today. And as you kind of alluded to in that introduction, in 2002, I had a ruptured appendicitis and, you know, almost died. I was in the hospital for a week. And then during that hospitalization, I had a realization or an epiphany of sorts that I want to become a doctor. Now, a little before that was actually 2 weeks prior. My dad drowned, and he was 47 years old. So that's the part we don't have on the website. But it was like October 2002, my dad drowns. 2 weeks later, my appendix ruptured. And on October 27th, 2002, that very date, the Giants played the Angels in the World Series. It was Game 7 of the World Series. That's the last time the Angels won the World Series. And that very night, I decided I want to become a doctor. So pretty wild, you know, thought at 21 years old. And The next day, when I kind of woke up from all this, you know, insight, I was like, man, do I still want to do that? And I was like, yeah, I do. And you know, I was 21. You haven't really failed at enough things. So you're like a dreamer. And well, I didn't get into med school till 5 years later. So it was 2002. I want to become a doctor. 2007, I started med school and first doctor in my family. First one to graduate college on my dad's side of the family. And I'm a bit of a trailblazer, I would say, in my family. And That's the thing is like, know that as a human being, you know, I have to get out of my own way and get rid of those self-limiting beliefs. I realized that anyone that's done anything of significance on planet Earth, what are they? They're a human. And then what are you? You're a human. So it's that you can do it. It's not that you can't do it and you have to get out of your own way. So like, don't be afraid to fail, be afraid not to fail. I always say fail, first attempt in learning, right? So fail forward, essentially everything is data points. And so then, you know, obviously became a doctor. Why did I go into anesthesia? I love working with my hands. I love the operating room environment. I like to, uh, real-time results of your actions. I really enjoy pharmacology and physiology, and I also really like, like one patient at a time. And the operating room, I thought I was gonna be a surgeon, but then over time my interest went from like that surgical side of the curtain to the anesthesia side. And if you think about it, like anesthesia, we're literally rendering people unconscious or changing their state of consciousness. And so now, like moving into the psychedelic medicine space, we did that in 2020 as a COVID pivot. I literally am giving you a non-ordinary state of consciousness by utilizing an anesthetic, but at a sub-anesthetic dose. So ketamine is only a federally legal psychedelic and it is a dissociative anesthetic with psychedelic properties. And so I think it's also important kind of early on to just define that word psychedelic. Psyche, mind or spirit. Delic from the Greek word delos, to reveal meaning, to manifest, or to show. And so psychedelic literally means, you know, soul revealing, mind revealing, mind manifesting, right? And so you're revealing parts of your subconscious mind to your conscious mind. And then we're doing this at a subanesthetic level. So you remember everything. And then we also have a program around the medicines. There's integration coaching and a workbook that I coauthored. And so we're partnered with a company called Being True to You. So it's not just doing the medicine and expecting you're going to shift. It's preparing for the journey and then having the medicine experience, integrating what comes up, always setting intention before we go into the medicine, and then cultivating what comes up for you. And that can help lead to a conscious transformation. And so over time, you know, I always like was into psychedelic medicines for my own personal healing journey, trying to heal like my loss of my dad and other things that I'd gone through in life. And then during COVID you know, our job changed because I was doing a lot of elective anesthesia. And so a lot of the elective cases stopped during COVID only like emergency cases happened. And so then I pivoted into ketamine because I knew there was ketamine clinics out there and I felt that I had a lot of knowledge around it and I could probably do it better than how it was being done. And, you know, at this point we've done over 15,000 ketamine infusions since 2020, and we're the highest rated ketamine clinic on Google in Arizona. And we have a really unique process and I do free in-person consultations so people can kind of see Come feel the environment, see if the energy feels right. So that's, you know, in a nutshell, kind of the journey that got me here. COVID pivoted, and this is— I feel like, you know, we have free will and we have destiny. And so like, I felt like I was called into medicine, and I still had the free will to say no to that, but I chose to embark on that journey. It took me 3 times to get into med school as well, so I was persistent. You know, I wasn't giving up, and that's usually the difference between success and failure is persistence. You have not failed until you stop trying. So never stop trying. You know, those listening out there, if you want to make something happen, you want to bet on your brain, more likely than not, you can make it happen. Just don't give up on you.

And you also learn a lot more from failure than you do from success.

I think so.

For sure.

Yeah.

Now, one thing you said about anesthesia, because you're anesthesiologist, I never thought about it like this way, but you actually are altering people's consciousness.

Yeah.

Like, so let's briefly talk about regular anesthesia when you put people under and they literally don't feel anything, they're unconscious, about that process. And then I want to kind of go into ketamine a little bit because it is anesthetic, but we're using it, like you said, subanesthetic doses, intranasal, sublingual, IV, a bunch of different ways. But tell us about general anesthesia and then kind of go into ketamine.

Yeah. So look at anesthesia as kind of like a spectrum, right? So you could have really light sedation. A lot of people will call that Twilight, maybe you give something called Versed or midazolam, maybe a little bit of fentanyl. So they're still like aware of what's happening, but they're not forming new memories. So you can have something called anterograde amnesia. And then if we wanna look at the end of the spectrum, it'd be general anesthesia where you're completely out, right? And then you also have things like regional anesthesia, like doing an epidural or a nerve block or a spinal, right? So I can just anesthetize or numb parts of your body so that you can't really communicate pain back to your brain. And so one of the things, you know, like you even mentioned there, you said, you know, so you don't feel anything. Well, the thing I always tell patients is that, is I don't want to feel anything during surgery. Okay. Well, you're going to feel everything. You're just not going to remember having felt it. Or if I do a nerve block, your body's still going to feel it, but it's not going to be able to communicate the signal up the spinal cord to your brain. Right? Because I blocked the nerves of the spinal cord essentially with the spinal. And so generally when you do general anesthetic, that's You place an airway on someone to be intubated. So whether it's endotracheal tube or a laryngeal mask airway, after they're then put to sleep, you're also paralyzing them a lot of times with generally like rocuronium or succinylcholine. And then you're using an anesthetic inhalation agent called sevoflurane, um, is the most commonly used inhalation agent on planet Earth. And there's other ones like desflurane and isoflurane, but generally sevoflurane is the most commonly used inhalation agent. And so propofol generally puts you to sleep. And a lot of people think, oh, that's it, right? No, the propofol just gets you to sleep and then the gas is what keeps you to sleep. Now you can also do like a total intravenous anesthetic, or known as a TIVA, and you could do that with something like a propofol. 'Cause some people actually have a very rare condition called malignant hyperthermia where they can't get an inhalation agent like sevoflurane. So you literally have to do a completely, you know, IV anesthetic where you're just doing propofol, very high dose, as well as narcotics and things like that. So the thing about anesthesia, it's an art and a science. Like there's no one way to do a surgery or the anesthesia for the surgery. It's like, as long as you can get the patient through that procedure safely and their pain is controlled and they don't remember it, that was a success. And so I really kind of like that, you know, approach that it's like, well, there's not just one way to do it. You can kind of bring your own art and science and, you know, curate this journey essentially with the anesthesia. And now here I am. curating psychedelic journeys in a subanesthetic dose of ketamine. But it also changes the way in which I do the ketamine. Like I always do IV infusion. I can do intramuscular as well, but generally, you know, IV infusion's 100% bioavailability. And so bioavailability is what percent of the medicine gets to the cells that gets to the brain. And so IV, that's 100%, right? Whereas someone does like a nasal spray ketamine, like a Spravato, which is an FDA-approved version of ketamine. You're on 40% generally, right? There's gonna be some, you know, margin there based on like how well they did the inhalation and the spray and, you know, how's their nasal mucosa and things of that nature. So IV is the most efficacious. It's also the most controllable cuz I can just press stop and I could bring you out of a deep psychedelic journey in less than 10 minutes. So if someone's completely naive to psychedelics and they want to experience a non-ordinary state and start to heal, you know, versus just doing the regular, you know, go on the SSRI, do talk therapy approach to depression or trauma. Then I think IV ketamine might sound extreme, but I think it's the best place to start because it's so controllable and I can gently walk you into the procedure and the experience and then know that you're in control. And then being an anesthesiologist, I bring other little things to the table. So I give a little propofol right before the ketamine infusion. Most places don't do that. They're also not legally allowed to do it 'cause they're not a doctor, an anesthesiologist. And so that has a nice anxiolytic property to it and it works on the GABA receptor just for about 5 minutes. It gets Rapidly redistributed in your body. Whereas a lot of places will give you like a Versed or an Ativan or some sort of benzodiazepine if you're anxious before the ketamine, but then you're blocking some of the neuroplastic changes of the ketamine. So you're actually like unknowingly, you know, kind of not doing what's right for the patient. It hangs around too long, half-life's too long, right? So other things is that we'll do a little bolus dosing. So B-O-L-U-S, little bolus or a push dose so that when you're in the medicine. I don't want to just get you in the ballpark. I'm trying to get you in the front row seat. And so I can always give you like a little 5, 10 milligram, you know, a little push. And so this is like bringing the art of ketamine administration from the art of anesthesia, you know, the operating room skills into our own clinic essentially. So ketamine's done so different from clinic to clinic. It's really like the Wild West right now. And there's a lot of at-home ketamine as well that people, you know, have access to. And that's a whole nother topic for discussion. But the way in which we do it, I believe, is the most optimal way. But I'm always aware of my paradigm and open to kind of shifting that if other evidence kind of presents it to me. And then also IV, I can add in Zofran IV for nausea, 'cause that's a very common side effect of ketamine. I can add in IV Toradol if they're having a headache. I can add in magnesium as well to kind of calm the neuromuscular junction and relax the nervous system. I can add in different vitamins or NAD+ to help with fatigue. So when you do IV, I can create this very unique proprietary blend in the medicine versus just relying on the ketamine alone. A lot of places think intramuscular is the way, and I would say if you're doing group, you know, healing, then sure, intramuscular, I would agree, is the best modality or lozenges because you have a lot of people at once. But if you're doing one-on-one individualized ketamine, I really like IV for the controllability of it. It would just be very difficult to do a group setting with IV cuz you need the pumps and And all that kind of stuff. So just the implementation will be tough. But when you do not intramuscular, all you can do is take sublingual Zofran and then you're gonna give that shot, you know, of the, the ketamine. Of course you could give intramuscular Zofran, but that's no fun. That's a lot of volume going into the muscle. And same thing with the Toradol, stings a lot when you go into the muscle as well. So I personally prefer IV as the route of administration. I've also personally experienced the different routes of administration, so I speak from, you know, firsthand patient experience as well as practitioner. And, you know, having done over 15,000 infusions and we have not had a single adverse event in our clinic, you know, we have a really a tried and true process and very safe. It's me and my 2 partners, Dr. Wong, Dr. Sharma. We're all board certified anesthesiologists and this is our passion. I mean, this is my life's work. I was talking to a surgeon actually a few weeks ago and he's like, man, listening to you talk, he's like, if you would have stayed in the operating room, you would have like really like not lived up to your full potential. Like people need to hear you speak. They need to hear you talk. Like, this is your true calling, you know? But the anesthesia experience that, you know, that was like what laid the foundation for me to be able to do what I do now. So I definitely don't regret that past at all. If anything, it was like what was the perfect beginning for what I'm into now.

Well, it's kind of interesting because, you know, there's a lot of places doing ketamine and it's usually a protocol like you start, you know, 5 milligrams per kg and work your way up and blah, blah, blah. I'm sorry, half a half a milligram. Maybe it's 30 to 40, up to 50 or 60 milligrams, I guess would be what you're doing in a—

Generally, yeah. And I like to do a 60-minute infusion instead of a 40 or 45-minute infusion.

60. Okay.

Yeah, I do 60 as the shortest infusion length. Just, it's just too quick. You know, I've experienced the 45-minute infusion and then, you know, it's 25% shorter, you know, than if doing 60 minutes. It generally takes people, unless you give a bolus in the beginning, about, you know, 10 to 15 minutes to kind of get into the medicine. And so I'm all about like, there's, I could show you different curves, obviously we can't do this, but showing kind of like the time in the medicine where you're reaching like a plasma steady state. And that's where I really feel like you can navigate the medicine versus having the, the waviness, like intramuscular. It's a big intense experience.

Yeah.

Then you're kind of coming down. So it's all about like intensity over time, essentially like intensity on the Y-axis and then time on the X-axis. And so I want you to have you in that steady state. steady state of plasma concentration, because that's where you can navigate that non-ordinary state and tend to get more insight. So now the experience matters, but also it's really that I'm giving you a neuroplastic change. That's the key. The neuroplasticity window that's generally most robust, 24 to 72 hours post-ketamine infusion. That's when like the neural circuits are kind of primed for change. So a lot of people think that the experience doesn't matter as much. It's the neuroplasticity after. from both schools. I think the experience matters. Set and setting. If you have an epiphany or a breakthrough in the medicine, amazing. But also don't feel like you failed anything if you don't have that big breakthrough in the medicine. Did not miss the opportunity for healing. That's that neuroplastic window after. And that's why we do integration coaching the day after your infusions. You have a virtual session with your coach so you can start to process and unpack what came up for you and start to connect the dots. And then It's all about the daily practice. So I have an equation on our workbook is ketamine plus daily integration practice equals a consciousness transformation. It's not just ketamine equals transformation. You got to put that work in. I call like, you know, the saying is that abs are made in the kitchen. They're not made in the gym. And so like this clinic is the gym. When you go home, it's the kitchen. You know, so what are you eating? Not just with your mouth, with your eyes and your ears at all times. What are you allowing into your nervous system? Are you doom scrolling, watching the news, engaging in an argument with your significant other, not getting proper sleep, not journaling, not meditating, not practicing metacognition, which is thinking about what you're thinking, right? Having a mindfulness practice. You know, there's just so many different pieces to the puzzle. Ketamine gets you unstuck. So if you feel stuck, nothing's gonna work more rapidly from like an antidepressant standpoint than ketamine. And so it's get unstuck, and now once we're unstuck, Okay, now how do we rebuild? So generally my analogy is, imagine your house, your mental health house is on fire when you come into the clinic. I will likely be able to put that house fire out for you, but I cannot rebuild the house for you. Only you can do that. And then that's after we stabilize you with the initial series of 6 infusions. That's known as induction or stabilization. But you're correct, you do start off at half milligram per kilo per hour, generally about there. But I do tailor it to every person. 'Cause if I have someone that comes in here that's done the ayahuasca, you know, the psilocybin, all the different things, they're gonna be like, uh, half milligram per kilo, I don't feel anything. And you just charged me a lot of money. You're wasting my time. So, you know, I can use that as a starting point, but I also want to deviate from the algorithm and the protocol. So I might start them off at 0.7 or 0.8 milligrams per kilo and then have the bolus opportunity to then dial the dose in really good for them. Majority of people will go, you know, have an out-of-body experience or dissociative experience at around 1.5 to 2 milligrams per kilo per hour. But you don't start there. You'll freak people out. You gotta start nice and slow. I tell people the first infusion, I'm just trying to relax your nervous system. We're just dipping the toe in the psychedelic pool. I would rather underwhelm you than ever overwhelm you, right? I'm your advocate. I'm your ketamine Sherpa. I'm on this journey with you. And we want to have a positive first experience so you can get confidence in the medicine. So then we can continue to rise the dose each time if deemed appropriate. I'm always telling them what their dose was. We're having that conversation. They're always intimately involved in their, their healing process versus just coming in and getting in the chair, treating them and treating them. That's not, that's not how we do things here.

Every fall, the schedule tightens and most of our attention goes to getting the kids ready. Almost none of it goes to the person holding the whole thing together. So I've put together these 3 things just for that. A daily multivitamin in the active forms your body can actually use, quercetin and nettles to support your immune and respiratory health without the drowsiness, and NAC and acetylcysteine to help your body rebuild its own antioxidant reserve. This is what I take every fall.

That's aaronhartmanmd.com/backtoschool. So I've got lots of questions from what you said, James.

Hold on.

Yeah.

What's the first?

Oh yeah. First, first question is the dosing you're talking about, 0.5 to 0.7 to 0.8 milligrams per kilogram being the starting dose and then getting a dissociation, you know, maybe at 1.5 or 2.

Yeah.

Just so people can understand, you're doing that over an hour, 60 minutes.

Correct.

Like what's the toxic dose where someone would like stop breathing? What, what dose is that over what time for just for people to have a—

Well, it's way, way higher. I mean, I don't even know the LD50 of ketamine off the top of my head. I will tell you this, that the highest dose I've given a patient in our clinic over the course of 60 minutes is 450 milligrams. And that is his dose. And it's around 4 milligrams per kilo. And I like, we, that's over the course of like 40 infusions we've gone up to that dose. That's the dose that works for him. Comes back once a month. Nothing else has touched him. Just as a comparison, he went down to Mexico, did ibogaine. He felt nothing. I talked to the practitioner down there. He said he gave him the highest dose of ibogaine. He's ever given a human and he felt nothing. This is a guy that can eat 19 grams of psilocybin and it lasts about an hour. So we're just dealing with a very different, you know, human being. Everyone's different. So, you know, generally if someone's like, say you're a paramedic and you're gonna stabilize someone for like a long bone fracture or something like that, you might give a, you know, 100 to 200 milligrams of ketamine intramuscular depending on the size of that person, which is all at once, right?

Yeah.

Okay. So the one person that I heard of having a death around ketamine There's a story of a number of years ago, it was out of, I think, Colorado, a guy Elijah McClain, and he was a young kid in his 20s, and I guess he was exhibiting like excited delirium, or at least that's what the reports say. I think he was just scared because the, you know, cops and paramedics came up on him and he was alone and they injected 500 milligrams of ketamine, and I believe it was in his neck. And that's why he died because he had like a hypertensive, you know, emergency essentially and stroked out. And it's likely they got into a big vessel in his neck. I mean, if you were to put a needle in someone's neck and not hit the jugular or carotid or some other sensitive vascular structure, it would be quite rare. And so ketamine, it's not a respiratory depressant, you know, like it's very, very safe as long as you don't have like opioids or benzodiazepines or alcohol in your system. So we're talking at, these are very, very low numbers, very, very, very safe. You know, even if someone got Just to do the math, say someone's 220 pounds, so they're 100 kilograms, right? And you start 'em off at half milligram per kilo. They're getting 50 milligrams in 1 hour on their first infusion. So that's less than 1 milligram per minute, right? Whereas, you know, someone that's out in the field that has a broken femur and you wanna stabilize them versus giving 'em morphine, you could give them, you know, 100 to 200 milligrams of ketamine intramuscular in 1 second, you know, or 5 seconds, right?

Yeah.

And they're not gonna stop breathing and you're gonna stabilize them. You're gonna obviously also optimize cardiac output because ketamine's a sympathomimetic. They used it a lot in the Vietnam War to stabilize, you know, people on the battlefield. You know, a lot of people would carry the ketamine on them and they could give it an intramuscular shot, stabilize the pain, stabilize blood pressure, you know, put the tourniquet on, you know, and help transport that, you know, patient, that soldier. It did not decrease drive to breathe, whereas the morphine, that's gonna decrease your drive to breathe.

Yeah.

And it's gonna drop your blood pressure. So, it's not the thing you want to use. So, exceedingly safe medicine, very, very safe.

So, safe enough that's used in the field.

Yes.

When people have issues, you can do it IM, 100, 200 milligrams. So, I think that's an important thing for people to think about because I think about anesthetic, you're going to stop breathing in the clinic. And literally, that's not the thing. You won't stop. The worst thing would be if you got in the neck and then you'd be a hypertensive crisis, your blood pressure shoots up because you're getting— it's almost like a A massive adrenaline rush. Yeah. And you die from that, not— so it's, it's, that's like, no one's doing that, right? So it's, it's really—

Yeah, that was that one. And I read up on the case because I was like, you know, it was the wintertime in Colorado, so he had all the winter clothing on. And so I think the only part available was his neck, and that's why they injected him there. If he would've got the same dose, 500 milligrams in his quadricep or deltoid, the guy's probably still alive.

Yeah.

You know, so it just, I think it was the route of administration where it was given specifically and the dose. That really kind of did a man.

So I think that's important for people to think that it's really, really, really safe. The other thing was like, that's interesting because I've now heard of other clinics doing this actually. You're doing the ketamine plus NAD, which can be helpful with some resetting neurotransmitter stuff, B vitamins, a lot of different things. You're, depending on the patient, you're really tailoring it to them. It's not just simply, you know, you got the 0.5 milligrams per kilogram. You know, your protocols are actually super individualized, it sounds like.

Yeah. I want to practice precision medicine, individualized medicine. Like, If people are cookie cutter, what they're going to do is like, you know, and this still works better than giving someone SSRI. They're just going to go, okay, first infusion, 0.5 milligrams per kilo. Second infusion, 0.6. Next one, 0.7, 0.8, 0.9, 1. A lot of places stop at 1 milligram per kilo per hour. A lot won't even go over 1.5. Now you'll catch like probably 70% of people going up to 1.5 milligrams per kilo, but you're going to have like, you know, 30% or more people That are not going to respond. And you shouldn't like have that arbitrary cutoff. It should be the way the patient's responding to the medicine. Like I had that one guy, granted he's an outlier, the 450 milligrams in an hour, that's an outlier. The next highest below that is 300 milligrams, just to show you how much of a difference there is there. We also will do like pain infusions that can be 2 to 3 hours long, and then they're getting, you know, quite a few hundred milligrams over the course of, you know, 2 to 3 hours. Half-life of ketamine is 2.5 to 3 hours. So, you know, as long as you're in that 3-hour window, you're not just continuing to stack up, stack up. Like, you know, you're, you're getting like, um, a cumulative dosing effect essentially, right? Versus them being able to metabolize.

Yeah.

So some places will even do inpatient and give like a 24-hour ketamine infusion at a really low dose. I've had patients go do that and actually find it less helpful than doing the 2 to 3-hour pain infusion because it's just such a low dose and you're like, okay, I still have to go to the bathroom. I have to do all these things and eat food over the course of it. 24 hours is really weird for them. You know, so.

So how does ketamine actually work? Talk to us about, 'cause I love the science when you start talking about, you know, default mode network that works on NMDA receptors and, you know, neural pathways and, you know, neuroplasticity and all that kind of stuff. All of a sudden you're like, wow, this is like, that's like a brain food almost. So why don't you talk about that a bit?

Yeah. So ketamine, dissociative anesthetic, primary mechanism of action is it blocks the NMDA receptor. And so the NMDA receptor is where glutamate would normally bind to. Glutamate generally binds to 3 different receptors, NMDA, AMPA, and kainate. We don't know a ton about AMPA and kainate. We know mostly about NMDA. And so when ketamine comes in there and it blocks the NMDA receptor, then glutamate can't bind that receptor. And so now the glutamate's gonna go and bind the AMPA receptor. And when it then binds the AMPA receptor, you get an increase in something called brain-derived neurotrophic factor. And so that's like, think of it like Miracle-Gro for your own neural circuits essentially. So you get synaptic plasticity, neurogenesis, neuroplasticity, cuz really like where is life happening? You have over 80 billion neurons in the adult human brain. That's where life is actually happening. And we're now experiencing as our emotions, our thoughts, our level of consciousness. And so ketamine is working on the glutamatergic system by blocking NMDA, that extra glutamate. And this is at a subanesthetic level. When you give a general anesthetic level of ketamine, you actually get a decrease in glutamate. And so when you give a subanesthetic level, you have an increase in glutamate that's binding AMPA. You get this downstream effect of the increase in brain-derived neurotrophic factor via another receptor system called tyrosine kinase B and a bunch of other things. I don't wanna get too much into the minutia, but it's very fascinating and it works very rapidly. Within hours of an infusion, you're getting dendritic spine formation on the neurons. And so think of dendritic spines as like little tree branches on your neurons, essentially new pathways. So a lot of times what I'll tell people as an analogy, just kind of simplify it, is think of like, you know, serotonin, norepinephrine, you know, dopamine. These are like cars, right? These are neurotransmitters or monoamines essentially. And this was the monoamine hypothesis for depression that you have a deficiency of serotonin or norepinephrine or dopamine. That's why you're depressed. That's been disproven. That was more of a marketing tactic of the '90s. And so I think it's more neural circuitry versus just the monoamines. Otherwise, if you gave people SSRIs or increased serotonin, they wouldn't be depressed anymore, but that's not what we see. So it's, it's more advanced than that. So imagine basically your cars are dysfunctional. You have a decrease of serotonin, so they give you the, the Prozac. You increase your serotonin with an SSRI. Yeah, but really what's happening is your roadways are damaged. The neural circuits, the dendritic spines, the synapses, those are damaged with long-term depression, anxiety, stress, and trauma. And so if your roadways are damaged and I'm just giving you more cars, I'm just causing traffic jams. Whereas ketamine comes in and I'm giving you new roadways, new dendritic spines, right? I'm also helping to modulate the serotonin system and other, you know, systems a little bit as well. Not just glutamate. Ketamine, we call it a dirty drug. It works on Several different mechanisms through different receptors. It's, it's very fascinating. There's, it's like an amazing medicine. It's the only medicine I know of that has its own society, the American Society of Ketamine Physicians, the ASKP3. And so I don't know of any other drug that has its literally its own society. Maybe there's one out there, but I'm not aware of it. So it's just so, this, like the applications of it are immense from mental health to anesthesia to chronic pain. It's incredible. Um, so that's, you know, essentially how it's working is through the glutamate by blocking that NMDA receptor and then also giving you that neuroplastic window that's giving you this opportunity for change. You're still gonna have a shift and a boost in your mood even if you didn't do integration work, but you're missing the opportunity to really get durability to the treatment if you're not doing integration. So we really emphasize that and it's required in our clinic. You can't go through our process. Unless you do a minimum of 3 hours of integration work, and we break that into 5 sessions. So everyone does a 1-hour prep session with an integration coach that is experienced in psychedelics, and they do it virtually so it's more convenient. And then you have that same coach the day after infusion 1, 2, 4, and 6. And that's our protocol so that you're doing that work and we're laying that foundation. And then after that, we talk about, you know, what would maintenance be? Because everything in life requires maintenance. I don't know of a single thing in life That doesn't require maintenance. You know, exercising's great, stop doing it, then it doesn't work anymore. Brushing your teeth works great, stop doing it, then it doesn't work anymore, right? So look at this as like the daily practice, and then people generally will come back to ketamine like once a month for booster infusions. And then in time, I try to get you to have some distance between you and the medicine. It's there if you need it. And if you're trying to come off your SSRIs or something after you've stabilized through ketamine, we might do more frequent infusions. 'Cause it definitely helps with, you know, modulating some of the withdrawal symptoms, you know, with the serotonergic system. But it's, we, everything's highly individualized and it's a very fascinating medication. It's an honor and privilege to be able to do what I do. And it's really cool that, you know, we kind of carved out this niche and here we are, you know, now 6 years into this and many thousands of infusions. I, I still remember infusion number 1 like it was yesterday. I really do.

That's so cool. Yeah. It's really interesting you mentioned the, mono means. I think, you know, medicine's interesting in that, you know, how I treat blood pressure has totally changed in the last 10 or 15 years. How I treat diabetics—

Yeah.

Has changed a lot in the last 5 years. But yet, you know, our model for psychiatric medicine, the neurotransmitter theory from the 1950s hasn't changed in 75 years. Right. And so either we got it right the first time or we were kind of off. We haven't figured out we're off. And I think That the mind is more complicated than simple neurotransmitters. There's other things going on you kind of alluded to. And it's interesting how even when you do brain mapping, a lot of testing, they're looking at other things to estimate brain activity, depression, anxiety, Alzheimer's, bipolar, stuff like that. They're not really doing serotonin scans per se to pick up those kinds of things. I kind of think, you know, the monoamine theory is probably not as accurate as we would like to think it is.

Yeah. I mean, also, you know, we look at ketamine as working in different ways where it's decreasing something called your default mode network. And so that's where we would think the ego resides. Essentially, if the ego had a mailing address, it's the default mode network. And how do we know that? They'll do like functional MRI scans, you know, while people are under psychedelic journeys and after, and they see a decrease in those areas where we think the default mode and ego lives. And then you see more of a, a global connectivity or like what we call like neural anarchy. You know, during these scans when people are on psychedelics, whether it's psilocybin, LSD, ketamine, you get like a lighting up of other areas of the brain. And that's also leading to some of the, you know, getting unstuck. Also, there's a spiritual component to it as well. Like regardless of what people, you know, believe in, you definitely generally will feel like a connection to something greater than yourself, whether you want to call that God, universe, what have you. I definitely think a spiritual practice is important for overall mind, body, spirit, you know, health. And so that can come up for people. It's not just, you know, looking at blocking NMDA. It's also looking at, you know, how it's also kind of working on the ego and getting into the subconscious mind and quieting the default mode network and having a potentially spiritual experience. And the other psychedelics, especially the classic ones like LSD, the psilocybin, the DMT, the mescaline, those are known as entheogens. And the word entheogen means to generate the God within. And so these are literally, that's what they're known as, entheogenic substances. And so it allows you to kind of tap into this, like this remembering, this knowing, this deep wisdom. I think a philosopher, William James, coined the term. It's called a noetic quality, N-O-E-T-I-C. And a noetic quality is when you experience something and it's like a profound, deep wisdom or knowing at a level that like you've never experienced before. And you could be told that same thing in a sober state, but then when you're in the psychedelic state, Having this noetic experience, you're like, oh, this is a deep, profound knowing, and it can get people to shift their lives, you know, and have a very profound change, you know, that sometimes can last a lifetime. People always ask, how long does the ketamine last for? I'm like, well, I have 2 answers. If you just look at like, how long does it, you know, mechanism of action, active metabolites like hydroxy noradrenaline and noradrenaline, you know, sure, about a month, maybe a little longer if you're lucky. But if you look at like, can it change your perception of reality? Can it kind of shift your paradigm? Well, then that could last a lifetime. You know, the biggest question of this life is what is after this life? I mean, it's a different topic than this podcast, but that's the biggest question. So that's what it really kind of comes down to is like, health is wealth. You know that you're here right now. The only thing that you can control in this life is your present moment. I don't know what's next, but I try to look at this as preparation for what's next. And if ketamine or psychedelics done responsibly with preparation, intention, and integration could get you unstuck so you can finally start living and enjoying this human experience, that's priceless. And I want everyone, my goal for every human being that comes across my path is I want you to find your inner peace. And that only resides within you. And then you change the world around you. That's really world peace. You're not going to get 8 billion people to get along most likely. I mean, I like to be a lofty You know, have hopes for that. But if you can get your inner peace and change the media world around you, that could be your world peace, essentially. So, you know, no one has a ketamine deficiency as well. Nobody, you know, the deficiency of connecting to themselves, you know.

So James, quick question here. One of the things that happens with clinical medicine is you read a textbook. Ketamine is, you know, used for anxiety, depression, PTSD, pain syndromes, migraines. You have a list of like 5, 6 things. But then you actually start using it and you do it and you realize, wait a second, it helps with all of these other things. What are some of the insights you as a clinician, medical doctor, seeing patients coming in for, you know, probably POTS, dysautonomia, you know, brain on fire, you know, mold, Lyme, would've been surprised? What have been some other things you've seen pop up clinically? You know, not FDA approved, of course, but clinically things you've seen people respond to that outside of the known indications for ketamine. What have been some, what's been your clinical experience with some of the things that can do?

That's the interesting question. I gotta kind of think about it. So it's like things that has worked for that we weren't expecting it to work for, right? I mean, the general use is like the suicidal ideation. I would want everyone to know that the most rapid acting anti-suicidal agent in all of medicine is ketamine. And I would probably say if you asked 100 doctors, I mean, at least half of them probably have no clue of that. It is one of the indications though, you know, Spravato, the nasal spray version of ketamine that is FDA approved. Now even as monotherapy for depression and suicidal ideation. So other things I have seen benefit from is like we've treated a number of Lyme patients. There's a, a place nearby us called Invita and they do a really big Lyme protocol. And then sure, it's helping to kind of detoxify the system, but it's not really getting to the mental health component of things. Another thing is like they do a lot of cancer treatments as well. So a lot of like existential crisis and coming to terms with like our mortality. The ketamine can be helpful with that. So that's where I've seen people like all of a sudden get to a level of peace that, you know what, like I feel like everything's gonna be okay no matter that I'm suffering right now in this human form with my cancer that's terminal, with the Lyme disease that I'm dealing with right now. Like I've had people go through these very big rigorous Lyme and cancer protocols and they're like, the only thing that really kind of like gave me hope as I went through the whole thing was the ketamine infusions. So that's what I would say is like people that have this existential dread and, you know, coming to terms with reality and what is next, the ketamine can kind of help with those things. You know, I guess personal evolution, you know, like people like just seeing life through a new lens. I mean, one of my favorite quotes in psychedelics is from a psychiatrist, Stanislav Grof, you know, is in his 90s. And he said, what the telescope did for astronomy and what the microscope did for biology and medicine. That's what psychedelics will do for psychiatry and psychology and human consciousness. That is the next lens through which we're able to view our realities. I mean, just think as a listener right now, or a viewer of this podcast, what would your view of world be like if you never looked through a telescope or a microscope? Vastly different. And so I'm just telling you that I think psychedelic medicines are the next lens through which we can start to view our human condition. And I think they're a key element of the healing process of our global collective species. Honestly. And, I think we're seeing that too, like a lot of press around psychedelics are occurring. I could get into those things too, but—

Every fall, the schedule tightens and most of our attention goes to getting the kids ready. Almost none of it goes to the person holding the whole thing together. So, I put together these 3 things just for that: a daily multivitamin in the active forms your body can actually use, quercetin and nettles to support your immune and respiratory health without the drowsiness, And NAC, N-acetylcysteine, to help your body rebuild its own antioxidant reserve. This is what I take every fall. That's aaronhartmanmd.com/backtoschool.

Yeah, I guess my question was more because in my world, I see a lot of Lyme mold, POTS, dysautonomia, people with, you know, PTSD trauma, but it's resulted in chronic health issues from cancer to autoimmune issues. And a lot of patients, we work with them and Get them like 60, 70% better and they'll get stuck and you kind of, what am I missing? And you kind of wash and repeat. And eventually you get to the point where it's like, I think your nervous system is stuck in fight or flight. It's, it's not letting your body heal. And so I haven't had this happen to any of my patients yet, but I've heard up in New England area of starting to use ketamine with some POTS patients to try to numb you out.

Yeah, I would agree. I think you could get patients like so far with your protocols. And then people that are getting stuck consider, you know, ketamine as well. Ketamine also has antimicrobial properties. That was something I actually learned from one of my patients. I had no clue. And she's like, oh, I'm here because it basically, it's going through my bloodstream, crosses the blood-brain barrier and has antimicrobial properties to it. Anti-inflammatory properties to it. It's a very, I mean, I wouldn't use it just for the antimicrobial, you know, aspect of it, but it still has that. And yeah, it definitely helps with the POTS, you know, dysautonomia. But that's where we've talked. You know, before we started recording, I like layering in stellate ganglion blocks, uh, what we call a dual sympathetic reset. We're blocking C6 and C4, cervical 6, cervical 4 bilaterally on different days in conjunction with a ketamine infusion program to really reset the hardware and the software of the nervous system. So to make it simple, just think of the stellate ganglion block as a hardware reset. The ketamine infusion is a software reset, and together that's the human operating system.

And you're using an ultrasound to actually guide this. It's not blind. You're using some kind of imaging thing to actually see the bone structures and get to the ganglia.

Live ultrasound. I can literally see, you know, the longus colli muscle with the fascia over the top. You get through that fascia layer and you can oftentimes see the stellate ganglion on the ultrasound and like block right there. You block at C6, really the stellate's at about C7, but you have this cervical sympathetic chain. That runs up the side of your neck, and that's what connects your body to your brain, right? So I'm blocking basically the way in which your sympathetics are conveyed from the brain to the body or body to the brain. And so a lot of people, like, they can feel this robust, rapid shift. Some people it's more, you know, hours to days or even weeks later, but some people can get like a light switch effect. So it's been really transformational in our practice to layer on that modality along with the infusions. Because I will tell you straight up, like, I told you before the podcast recorded, like ketamine's not amazing for anxiety. It's really good for PTSD and depression, suicidal ideation, some chronic pain syndromes. Anxiety in and of itself is not, it's amazing, not amazing for that. But generally the anxiety is not occurring in itself. It's having like trauma, depression, and then co-occurring anxiety. So when you help the trauma or the depression, you generally will also help the anxiety. But when you do the block with it, that helps the autonomic dysregulation.

How about traumatic brain injuries? Have you seen it having any kind of response in the patients who've had like traumatic brain injury and developed chronic health issues after that?

Yeah, I have treated some like former NFL players that have had obviously lots of concussions and traumatic brain injury over the years and seen some benefit there as well. You know, so I think it's helpful in that since you're getting the neuroplasticity and that dendritic spine formation and kind of re-arborization of some of the prefrontal cortex. So, you know, I have had some success with that. Generally, we're not going just after the TBI. It's generally you've had history of TBI, but you have co-occurring depression and trauma and anxiety. And then we see an elevation of your mood. And then maybe by default, it's also helping with the TBI to a certain degree. I think what we're going to find in time is that psilocybin is probably way more effective for TBI. If you look at like what the mycelial network looks like, it looks just like our neural networks.

Yeah.

Additionally, ibogaine is being looked at for TBI. It's like we're gonna find more benefit with those modalities, but I think you can have some benefit with ketamine, especially like the symptomatology around the TBI.

Something kind of curious with the dendritic wiring, networking, and the elevation of BDNF. I'd be curious if there's any data or literature on it being helped with patients post-stroke. We have brain damage, brain injury, cuz things like hyperbaric oxygen, one of the ways it works is actually increasing Stem cells, but also increases brain-derived neurotrophic factor as well. Do you have any thoughts on that?

Yeah, I would say why not? I mean, especially it depends like what else have you tried? A lot of times people like they've tried everything and they come to ketamine. It's like as a last resort. So then it's like, you know, why not give it a shot? I would always do it on a case-by-case basis. If someone had a stroke, it's like, was it a hemorrhagic stroke? Was like your blood pressure too high? Like what caused this? Was it a TIA? You know, so like, are you old and now you have like cognitive decline along with that stroke? Like, What kind of deficits are going with it. I would be open to trying it at a low dose to see if it can be helpful. It's always case-by-case basis, but you know, sure. I don't know if there's a lot of literature out there supporting ketamine in the use of like, you know, post-stroke patients, but on a case-by-case basis, if someone had all their faculties and they were like desperate and they wanted to try it, then, you know, sure, why not? Why should I keep them from accessing, you know, something that could potentially be helpful for them? Especially if they're dealing with, the thing is like, If you have the stroke, but then you have now depression, right? And you have anxiety and you have like, you're traumatized from what you went through in the medical environment, then we can help those things. So if we're help— it depends like, what are we helping specifically? If we look at it as like helping the symptoms, that's how I kind of would look at it, you know, generally speaking.

Gotcha.

You know?

So, and you know, before we started recording our conversation, you, we, you went off, you know, to start talking about ibogaine, psilocybin. Ayahuasca. Why don't you give us a world tour of all the other psychedelics?

Well, there's hundreds of psychedelic substances. I'll give you kind of the overview.

Well, hundreds. I had no idea there were hundreds. That's actually, that's interesting.

So, yeah, hundreds and are discovering new ones like probably weekly, you know, depending on what lab they're working in. Yeah, hundreds. There's so many psychedelic substances out there. So, really what you want to do is kind of break it down to like classic psychedelics, psilocybin, LSD, DMT, mescaline. They all work on the serotonin 5-HT2A receptor as an agonist. And then you have the atypical or non-classic psychedelics. Now it'll be things like MDMA, the ketamine, 5-MeO-DMT, you know, things of this nature, essentially 2C-B. The list goes on and on, and there's just so many different, you know, psychedelic substances out there. But generally those are like the, the dominant ones that people would kind of know about, the classic ones. And so it's all about what receptor system it works on, right? And that's why ketamine, it's only a federally legal psychedelic in that you could start it even if you're on an SSRI. If you're on an SSRI, you should not go do psilocybin, ayahuasca, you know, mescaline, cuz they're all working on the serotonergic system and you could have the risk of serotonin syndrome, or they just don't work because you've modulated the serotonin system for so long. So that's why ketamine, you can just add it in as this one new variable. That's why I always encourage patients, like, I don't really like when, say they come in and they're like, oh, I'm titrating off my SSRI right now. I'm adding on, you know, another mood stabilizer and I want to do ketamine. I'm like, well, we're changing too many variables at once. You don't know what's helping or what's hindering. I like to change one variable at a time and then we see what we know is helping or hindering essentially the patient. So I'm like, keep everything the same, add on the ketamine, see what kind of benefit we get. You know, in the course of 2 to 3 weeks, generally doing 2 infusions a week for 3 weeks. If someone's suicidal and so depressed they're not leaving their house, then I'll do 3 infusions a week for 2 weeks. So it kind of varies there. Also depends on like logistics, you know, like do they live far from the clinic? They do have to come in person, you know, can they get a ride? All these things matter. And so just, I want it to like work with their life, not make it a very stressful thing for them to go through. And then add the ketamine in and see what kind of shift we get. You don't get worse. Like, I'm gonna give you a very like curated, safe experience in the clinic. And then it's generally how much better do you get? And then did you engage the process? You know, I always tell people like, you have a workbook, there's a lot of stuff to fill out. If at the end of the entire 6-infusion series, your workbook is blank and you didn't fill out any of the blocks, just ask yourself like, did you put in the right amount of effort? Life tends to be, you get out what you put in. You know, so like, you know, that's the general overview. And like I said, I go off on little tangents essentially too. But yeah, the classic psychedelics. I mean, also there's a great series if you want to kind of get knowledge about these. Michael Pollan's How to Change Your Mind. It's on Netflix, I believe still. It's a 4-part docuseries. First episode's on LSD and it alludes to the fact that if Steve Jobs never did LSD, we probably don't have an iPhone, you know, which is pretty wild. Second episode's on psilocybin, shows an 84-year-old lady I believe in the episode with like stage 4 terminal cancer, does a big psilocybin journey and comes to terms with her mortality and her, you know, existential, you know, dread and crisis around, you know, having stage 4 terminal cancer. Third episode's on MDMA, and that was, I think came out prior to it being blocked by the FDA for approval of PTSD. And that was happened in 2023. And then the fourth episode's on mescaline, and that's things like peyote and San Pedro and things like that. And generally speaking, You know, we should allow like peyote to be used only by Native Americans cuz it is definitely, you know, in low supply. You know, it's a pretty rare, you know, endangered plant and takes a long time to grow. And there's things like San Pedro out there that are definitely more plentiful. So if someone's wanting to access mescaline, I would, you know, say unless you're a Native American in a tribe, maybe leave, you know, the peyote for them, you know, and use the San Pedro, you know, in essence. But those are high doses, you know, and every one of them depending on set and setting and the preparation and the dose. And the amount of therapy, you know, before, during, and after is gonna kind of dictate how well they do with it, you know? And you wanna definitely, like, even Michael Pollan in his book, How to Change Your Mind, he didn't do MDMA because it has a big effect on the heart. You know, it's methylenedioxymethamphetamine, right? So it's, you know, has amphetamine qualities. And so his, uh, doctor was like, nah, you probably shouldn't do the MDMA. He did other things instead. He did the psilocybin and I think breathwork and things of that nature.

Yeah.

You know, you can just check out that 4-part docuseries and get into the book. If you watch my other favorite, you know, psychedelic basically documentary is Fantastic Fungi. It's amazing. I think everyone should watch that. It's real. It shows like, you know, time-lapse cinematography of the mycelial network and just realizing like the largest organism on planet Earth is the mycelial network. They're kind of like an alien species. I mean, we're more closely related to fungi than fungi are related to plants. Which is pretty bizarre. You know, it's just even looking at the concept of like consciousness, you know, plants even have a consciousness. You can anesthetize a Venus flytrap. So like, is it conscious? You know, to a certain degree. I mean, plants just demonstrate a heliotropism, so they grow towards the sun, right? So it's very interesting how they kind of do those different things. So, you know, we think consciousness is, uh, exclusive to humans, but it's not. That's also Michael Pollan's latest book that deals with that.

James, we've talked, had a very interesting conversation today. I want to respect your time because I know it's actually, you're in Arizona and you're 3 hours ahead of me. If you had parting words for us, what would the takeaway, if someone could leave this conversation with 1 or 2 takeaways, what would you say? What would you hope or pray or expect or wish those 2 or 3, 2 takeaways that people get from this conversation?

Yeah. That, you know, you are the medicine. Your thoughts, Dictate your reality, you know? So just ask yourself, are your behaviors and things that you're doing, like, you know, part of the cause of why you're experiencing, you know, a negative health situation? Well, then they can also be the cure if you start to change your behaviors and your thoughts. So for the listeners out there, I'm gonna tell you the 2 things, but for the 3rd time.

3rd time.

All right. And it was more than 2 things. It was like many things. So my 2 little rants, I guess we'll put at the end of here. Things to know that your thoughts dictate your reality. You are the medicine, right? So just ask yourself every second of the day, your thoughts are water. Your mind is the garden. Are you watering the weeds, the negative self-limiting beliefs, the past you can't change, the worrying of the future that may or may not happen? Or are you watering the flowers, the things we can have gratitude for, the things that are going well in your life, right? Just realize every moment, what am I watering right now? Because whatever you water is going to grow. The other thing I want people to, you know, really realize is that like you have not failed until you stop trying. And so try not to be disenfranchised with the Western medical model. If you haven't felt healing or found healing through that, you know, discipline, there are other things out there like your clinic, Aaron, or my clinic as well. So look out there, like just research it. I do free in-person consultations with people as well, so it's not going to cost you anything but your time. The other thing I add in at the end is You know, if you want to find me, you can go on advancedwellnessandpain.com or find me on Instagram, psychedelic_drs, or you can just call our clinic, 480-631-4800. And just know that there's people out there that want to help you. And you're an example of that. I'm an example of that. And be the change you wish to see in this world. Ask yourself, is my behaviors in life, am I perpetuating my illness? So am I part of the cause? Of why I'm feeling dis-ease, essentially. Well, then it can also be the cure if I start to change my behaviors and my thoughts and my patterns. I think, as I also talked about, is that there's no U-Haul behind the hearse. You can't take any of this stuff with you, right? But what you might be able to take with you is the memories, the experiences, the wisdom. So make some great ones while you're here. One of my favorite poems out there is by James McCrae, and it's called Instructions Before Visiting Earth. Check it out. Google it. It's really good, and it kind of hits home at that soul level. I look at this human incarnation as soul school. We're here to learn lessons, and so it's trauma plus healing equals wisdom. In short, no rain, no rainbow, no mud, no lotus, no pain, no gain. So how do you transmute the trauma and the suffering that you're going through into wisdom, into empowerment, into growth? So you know that was our third rendition. You got to hear each different. So. Out there, I hope you were entertained and you got some information. Reach out. We're here for you.

Just a reminder, your clinic is the highest rated ketamine clinic in the state of Arizona. So that, that's saying something.

On Google, 155 5-star reviews on Google. People pouring their hearts out. Just read your reviews and reach out. We actually have more than that. It's just that Google, it's weird. It like deprioritizes, you know, reviews. So it drops down. We have a Gilbert clinic as well as we're in Gilbert and Scottsdale, Arizona. And, you know, we're here to help you realize there is hope out there. And you haven't turned over every stone or opened every door until you, you know, call a clinic like yours or mine and see what is out there to help you. You know, we're following our life's path, you know, our life's calling. You got heart, man. It's in the name.

We're doing what we're supposed to be doing. So I wouldn't be doing anything else. And I think from what you said, you wouldn't be doing anything else either.

So. Correct. Be the change you wish to see in this world. And I think we are living proof of that. I really appreciate you, Aaron. You know, thank you for doing what you're doing, creating a podcast, being an entrepreneur. It's not easy. You know, all, you know, your family, your kids, like you really, like, you literally have brought heart to this world and you are definitely like part of the change out there that makes the world a better place. So thank you for doing what you're doing and give me an opportunity to have a voice and a platform here for a little bit.

Thanks for those words. I really, really appreciate your time today and you sharing your time and we'll see you soon, man. Yeah, man.

Until next time.