Innovation

[Upbeat Guitar Music]

Mike: Welcome everybody. This is Avoiding the Addiction Affliction, brought to you by Westwords Consulting. I'm Mike McGowan.

Mike: Innovation is the ability to see change as an opportunity rather than a threat. Well, I'll tell you what. The field of addiction and medicine and mental health has seen some incredible innovation over the last two decades.

Mike: We're gonna talk about where we're at, how we got there, where we might go. Our guest is Dr. Mark Hrymoc, the founder of the Mental Health Center in Los Angeles, California. I'm envious already. Dr. Hrymoc has extensive expertise in the psychopharmacology of addiction and other mental health disorders.

Mike: He is double board certified in general psychiatry and addiction psychiatry, and was previously board certified in addiction medicine. Dr. Hrymoc previously held a position of assistant clinical professor of psychiatry at UCLA. A team my badgers beat in the Rose Bowl, where he supervised training psychiatrists at their addiction psychiatry clinic.

Mike: Welcome, Mark.

Mark: Thanks for having me, Mike.

Mike: Yeah, sorry I threw that in. But we don't win all that often, so have to do it. You know, I've been working in this field like you for a long time and a lifetime ago I worked in a hospital that had the addiction treatment on the third floor.

Mike: Mental health was on the fifth floor, and maternity was stuck in between on the fourth floor. We've come a long way since then.

Mark: Yep. Yep. Yeah. They were seen as two different disorders. Now we see, you know, addiction actually is a mental health issue and they often feed each other.

Mike: Well, how did we get there?

Mike: Because it wasn't that way, not that long ago.

Mark: Yeah. I guess the founding of the field kind of came from two different places. You know, mental health, psychiatry being more informed by conventional medicine, so a lot of the kinda like western medicine values and, you know, thoughts on emphasis on medication to treat conditions like, you know, depression, schizophrenia, bipolar disorder, et cetera.

Mark: And addiction treatment really started with AA in the 1930s, so it was seen more of, you know, coming from, you know, general society. And yeah, there was a physician involved in the founding of AA, but it was also a lay person bought and, and so they together, you know, just, just found, came from a different place.

Mark: So ultimately they did meet in the middle.

Mike: Well, it just makes sense, right? That addiction and mental health go hand in hand. I, I've yet to, I love it when somebody says, well, yeah, I've got alcoholism and I'm clinically depressed. It's like, really?

Mark: Right, right.

Mike: I mean, what you take has to do with your mental health,

Mark: Right. Right. Yeah. I mean, alcohol is a depressant. It can lower mood too, and then that even might drive more drinking if a person is self-medicating. So that's definitely one example of how they can feed each other.

Mike: Well, that's the easy one. But you and I have worked a long time with people who take a bunch of substances stacked on top of one another, and that can lead the brain in all sorts of weird places.

Mark: Right, right.

Mark: For sure. Yeah. And behaviors too. You know, sometimes substance use leads to problematic behaviors that are compulsive, whether it's, yeah, gambling or sex and love addiction or, or things like that can, you know, so addictions can feed each other as well.

Mike: I think this is a silly question to even ask somebody like you, but I still get into discussions with people in the field about this.

Mike: It's difficult to treat substance use disorders without also treating mental health. Right?

Mark: Right.

Mike: But I still have people who insist if you treat one the other goes away.

Mark: Mm-hmm. Mm-hmm.

Mike: Your thought.

Mark: Yeah. They both need to be treated simultaneously because they can affect each other. And if a person isn't doing well in one arena, then it's going to destabilize the other.

Mark: So yeah, for sure. They need to be both accounted for and each have their own kind of treatment plan and ideally simultaneously treated.

Mike: Well, how do you come at that? Do you get to the, there's an old tape. You're younger than me. So I watched an old tape where when I was getting trained by Father Martin, right.

Mike: And it was old black and white tapes. He called them chalk talks. And he used a thing about, well, if your aunt was going into surgery and she was pipe full of ether, you wouldn't do a mental health assessment at that point. You wanna get her off the ether before you assess where she's at.

Mike: Are we still at that same place with with drugs? You want to be sober and detox before we see where their mental health is at?

Mark: No, because even the detox process can trigger symptoms like anxiety and insomnia, let's say. So part of actually treating detox includes treating things that come up which count as mental health issues.

Mark: They might be transient, they might be related to the actual process of coming off of the substance, but. They also might suggest that a person has an underlying condition in that area too. So yes, a person coming off of alcohol might have high anxiety, but it might be that they had an anxiety disorder or significant insomnia in the first place that even made them predisposed to developing an alcohol problem.

Mark: And so there might be a short term anxiety component that we have to treat. And then even after the detox period, which usually is about seven days max or so, then there could still be residual anxiety that we would think of as more of like the chronic long-term baseline anxiety. And that deserves attention to.

Mike: We've seen some incredible innovations that we would've never thought of a couple of decades ago.

Mike: Talk about some of them, ketamine and the rest of them.

Mark: Sure. So, I mean, I think even just to take 'em in sort of chronological order you know, medications being used to treat addiction specifically started with an abuse. But by this point, 40, 50 years ago kind of came out.

Mark: The one that makes you sick if you drink, is always how people describe it. And my follow up to that is like, it's not supposed to make you sick because you're not supposed to drink on it. It's supposed to act as a psychological deterrent to drinking. So that was the one of the first medications that came out to treat addiction.

Mark: And then methadone for opioid addiction. Also at this point out for 50 years or so you know, definitely helped a lot of people get off of very problematic opioids. Heroin, namely but also perpetuated a physiologic dependence on opioids but ultimately does reduce risk, health risk, other risks, et cetera.

Mark: And then as we kind of go a few more decades naltrexone is an opioid blocker that it was developed in the nineties that ultimately was found to treat both opioid and alcohol addiction. And so that now is a available as a long-acting injection called Vivitrol which has now been out for about 20 years.

Mark: And there've been a handful of other meds. Suboxone also buprenorphine, you know, is definitely an improvement upon methadone, still ultimately a replacement therapy, we'd call it. And we also need to talk about nicotine, tobacco addiction or now just calling it nicotine 'cause a lot of people are vaping.

Mark: You know, nicotine replacement therapy. So analogous mechanism of action to methadone and buprenorphine. It is a replacement. It works on the same receptors and it's sort of the same way, but reduces risk. And so Chantix has also been a varenicline is a new medication used to treat nicotine addiction.

Mark: That is twice as effective as nicotine replacement. Works actually analogously to Suboxone, which many people don't know. Suboxone works on the opioid receptors in exactly the same way that Chantix or Varenicline work on the nicotine receptor, they sit on the receptor. They stimulate it a little bit just so a person doesn't go into withdrawal and doesn't have craving, also has a high binding affinity.

Mark: It binds to the receptors so that nicotine or whatever, or the opioids in the case of Suboxone, really can't even access the receptor in order to work. So a person might decide that they want to smoke a cigarette or vape, and then they just don't even feel the nicotine because that Chantix is blocking it out.

Mark: So these are examples of a lot of the different, like, mechanisms of action, of medications used specifically to, to treat addiction. You mentioned yeah, ketamine so that it is a kind of different league, different ballpark. Not used to treat addiction, certainly not in in any mainstream setting but has really been a great medication for treatment resistant depression.

Mark: And other treatment resistant mood disorders like anxiety and PTSD, post-traumatic stress disorder. These types of interventions are what are offered when conventional pills don't work. So someone you know, takes a few antidepressants and they either don't work as well as they should or have side effects or problems related to them.

Mark: Then we would consider either TMS, Transcranial Magnetic Stimulation or ECT Electroconvulsive Therapy, commonly known as shock therapy, is still done, not very commonly, often thought of as a last resort. And then ketamine treatment. So in my mind, these are the three interventional treatments for depression.

Mark: They are procedures as opposed to pills that you take done in a medical setting. And ketamine really has helped a lot of people even though, so it's came out in 1970 initially as a anesthetic and pain medication, was around for decades, widely used. Considered one of the top 100 most essential medications according to the World Health Organization.

Mark: So it is just in general in medicine, a very important foundational medicine. But then in the 2000's, research started coming out about its benefit for mood and definitely in the last 15 years there's just been a litany of research coming out really supporting its use as a medication to treat depression that doesn't respond to conventional medications.

Mark: And so the nice thing about it is it is six treatments as opposed to 30 or more, which is what you need for TMS. It doesn't require taking a month or so off of work like ECT. Really well tolerated, works biologically as an antidepressant. But also experientially, and there's a lot of interest in ketamine being used as a medication to kinda help give people different outlook on life, maybe reinterpret things that may have happened to them so that they can process things that they've gotten stuck on.

Mark: And see things in a different way. Maybe be able to exhibit new ways of thinking, new ways of behaving, et cetera. So I could go on and on, but...

Mike: That was, that, that was great.

Mark: An answer to your question as I could make it, and I still know it was really long.

Mike: No, it was great. I, that's, that's, tremendous summary, but it begs for me about a dozen questions. So, you know, it's not that long ago that law enforcement was talking about ketamine is, you know, Special K and people were taking it on the street and cat tranquilizer. I remember getting, you know, flyers that way and now we see billboards for it, right?

Mike: Ketamine therapy. So my questions for that are, you said six treatments. How did we get to know that? And how do you determine if somebody is a candidate for these? Third, you can lump them together 'cause you're very good at that. Do you get blowback from people who still remember well, what, isn't that one of those drugs I'm supposed to stay away from?

Mark: Right, right. Yeah. I think the important principle is that the same chemical can be a medicine or a drug. So the context really does matter. And I kind of think of them as two columns, you know, and even using ketamine as an example under the drug column is what you're describing.

Mark: Like how is it used, the setting to make it a drug is, that's recreational use. It's not prescribed, it's given to people by their friends or, you know, some stranger off the street or whatever. You know, so the, the, the way in which it's, it's obtained and, and the reason that the person is even using it for the first place as opposed to a medicine is done with a good faith visit between a physician and a patient where everyone is honest.

Mark: No one has any ulterior agenda except to help that person with a diagnosed disorder like depression or anxiety, et cetera. And so. You know, if it comes out of a good faith visit, then that's, you know then qualifies then as, as a medicine. So, you know, similarly, Xanax, you know, can be a medicine or a drug.

Mark: Opioids can be a medicine or a drug. You know, if you have a knee replacement you're gonna need some sort of pain relief. So there you go. And, and even if a person has had a history with addiction, you know, we, we don't want to make people suffer needlessly. I mean, we are merciful and compassionate in the medical business, and we do want to, you know, treat any anticipated pain or pain that comes up.

Mark: And so opioids are appropriate if, you know the context calls for it. I mean that, I think that's, that's the main kind of difference between medicine and a drug.

Mike: Well, okay, so how did we get to six rather than 7, 9, 12?

Mark: Yeah. Through research studies one, ketamine treatment can have a mood benefit that lasts up to a week or so.

Mark: So it is a procedure. A person has to come in the office. It's a two hour appointment. They need to be there, take time. Also the rest of the day you, we can't really have a lot of stressful things or deadlines, you know, you're not gonna getting sent back to work after having ketamine treatment.

Mark: We do encourage you to. Kind of just take it easy, et cetera. So, you know, there was an interest in having a schedule that would allow for ketamine to have benefits that last more like months instead of just a week or so. And so they basically found by getting six treatments within a three week period leads to a benefit that lasts longer.

Mark: And I kind of think of it as. Like, if you're gonna paint something, you want to put multiple coats of paint, if you want that effect to stay. And so, you know, getting the, the treatments in a repeated basis is the most potent way and leads to the longest acting benefit. More treatments might make it last somewhat longer, but there's diminishing returns.

Mark: So, you know, research has basically found that six is the number that a person would need to, you know, really kind of optimize the fewest number of treatments to last the longest amount of time

Mike: I would think I may be wrong, but I would think that, as a standalone, it works somewhat, but if you couple it with talk therapy or other sorts of therapy, it has a better effect.

Mark: There's some research suggesting that yes. Not enough yet to officially make it standard. But there are a lot of believers in psychedelic assisted psychotherapy in general. Ketamine being the first medicine with psychedelic properties that is actually legal and available to prescribe. And so there is a treatment modality or treatment type called ketamine assisted psychotherapy, where a person will have a ketamine treatment and a therapist will have actually had a session or two before to kind of prepare them for the medication treatment, and then they'll sit with them during the appointment or to guide them through the experience. Also be there to listen and interpret things, you know, jot things down for later discussion. The goal being to implement the new perspectives that a person experiences under ketamine and to most effectively convert them into long lasting changes in a person's life.

Mark: And so, yes, there is a belief that this helps and you know, being a straight shooter and a doctor. You know, I also need to highlight that whenever we make recommendations in medicine, they do have to be based on evidence. You know, and so there's a belief, there's a suggestion, there's a hunch, and definitely anecdotal evidence.

Mark: I mean. I and other clinicians working in the field have seen this benefit exactly exist where a person who gets therapy with ketamine does better than even just ketamine alone or psychotherapy alone. And so I think of it as like a synergistic effect where the total is actually greater than the sum of its parts, like one plus one equals three.

Mike: We're using that now. And you said something about first clinical. Back in the previous century. Oh God. I like saying that, we heard anecdotally similar reports about LSD and then at the turn of the century we heard it about ecstasy, methylene, doxy methamphetamine, and people were using it in a therapeutic way.

Mike: But we don't have those studies to show that it does the same way. Do you think we have other chemicals coming on the backside of ketamine down the road a little bit.

Mark: Oh yeah. There is a ton of research currently being done, honestly, looking at almost every single psychedelic being used for almost any psychiatric indication that you can think of.

Mark: You know, including LSD, being studied as a treatment for anxiety, which you would never expect.

Mike: Right.

Mark: MDMA, ecstasy being used as a to help with certain symptoms of schizophrenia or other psychotic disorders. So, this is research. It's a research interest. It is by no means a recommendation and certainly there's no recommendation for people to attempt to have their own, to treat it.

Mike: Right.

Mark: And yeah, if, even if a patient asks me, I mean the, the big one that there's actually a good amount of research on that people have heard about is, is like, psilocybin, you know, doc, what do you think of me taking mushrooms for depression or for alcoholism or, or things like that? And, and my standard answer is, there's def there's, you know, a, a, a signal of interest there.

Mark: You know, there's maybe an effect that researchers are interested in examining and looking at, but it's nowhere near the level of being incorporated into clinical practice guidelines. The guidelines that doctors would use to assess, diagnose and actually recommend a treatment for a person. So it's, you know, too early for primetime, basically,

Mike: You know, I'm from Wisconsin where we have a, a football team that's kind of good.

Mike: So that would include ayahuasca and some of the other substances too. And more research needs to be done.

Mark: Yes, yes. And yeah, active ingredient, ayahuasca being DMT. And then there's a related compound called 5-MeO-DMT that both of which are also being studied as treatments for depression and other things too.

Mike: May is Mental Health Month, Awareness Month. What are you seeing at the mental health center regarding we, we have all these reports of increased doom and gloom, and we're surrounded by negativity and, you know, therapists that I talk to are booked to the nth degree.

Mike: There are no opening, no opening, no opening. What are you seeing among your patients and, and what would you say to people that are experiencing some pretty much deep depression and anxiety?

Mark: Depression and anxiety are medical conditions that deserve attention, that a person should not feel guilt or shame about seeking treatment for. They're more than just quote, normal sadness or stress. There is a difference between normal human emotion, which we do not consider a disorder, hence the word normal and mood disorders, conditions, diseases that ultimately can be diagnosed.

Mark: They run in families. You know, a lot of the things that are, we think of as medical illnesses. Physical medical illnesses are consistently true for mental health issues too. And there are treatments that work, psychotherapy and medications, and the combination of the two also yields a more potent result.

Mark: So, I mean, I'm a big advocate of de-stigmatizing mental health conditions, helping people understand them, helping their families understand them too, that. You know, this isn't just, you know, dad being lazy or mom being a nervous wreck or, you know, anything like that. Like they, they, they have a condition that deserves identification and deserves treatment, and they can get better and the family system actually gets better too. You know, mental health issues, whether it's addiction or anything else, are conditions that affect the whole family. Not only the person that actually has it, but the people in their orbit, you know, definitely in their immediate family that are also affected by it.

Mark: And so the system can can use help too.

Mike: I know you formed the mental health center or founded it with your, your wife, right? Dr. Ellie Mizani.

Mark: That's right.

Mike: And I'm not asking you to steal her thunder, but I read that her expertise is child psychiatry and adolescent psychiatry, and I've worked with them my entire life.

Mike: We're seeing a huge spike in concerns for adolescent, young adult mental health. Are you seeing that in your practice as well?

Mark: Definitely you know, especially with the pandemic schools shut down. That was a huge social stressor on so many people and changed the way that kids even develop socially, you know, I think of a developing person sort of as like wet concrete, and in those first like 18 or 25 years, you know, if you make an impression or things happen, they can actually have a longer lasting impact than if they happen when a person is in their thirties or forties, you know, because their brains are still sort of solidifying their behaviors are their sense of self, their relatedness to other people, and so definitely the pandemic alone has been responsible for a lot of mental health issues coming up and also a lot of de-stigmatization of mental health treatment, maybe for a lot of people that really?

Mark: Got so bad that it became undeniable that they needed help, whereas before, like you'd hear things like, oh yeah, my dad doesn't believe in depression. Or, you know, I, my dad just thinks I have a weed problem and I smoke too much weed. But it's actually, you know, a, a cannabis addiction. So, you know that definitely society is evolving too.

Mike: Well, I wanted to ask you that and, and circle back to our original, because, you know. The research that we talked about. Again, I'll just reference it to the point, the six ketamine visits. Right. One, how do you determine medications for adolescents whose brains are still developing? And what I find is that a lot of kids who experience that are self-medicating and especially with cannabis, and they like the, what I hear Dr. Hrymoc is I'd rather smoke a joint than take that crap they have me on. They don't like the side effects of some of the drugs they get prescribed.

Mark: Right. Yeah. The goal of a good relationship with a patient and doctor is for there to be transparency about benefits and side effects, unintended ones, and we always want to choose medications that have maximal benefit with minimal side effects.

Mark: And so there does need to be a dialogue. But sometimes people aren't able to see their doc as often as could entail, and so they might just try for a month or two, and then without a follow-up visit, they just kind of go off it on their own. You know, on some level they're, they're making the decision instead of, again, the, the having that collaborative process.

Mark: So it's, and whether it's cannabis or alcohol, like we think of the, you know, nicotine, the substances that are more common for teens to get into and perhaps even be self-medicating with. They have an immediate effect. So people in general are wired to be biased towards short-term benefits.

Mark: And so if there's an immediate benefit reduction in anxiety, let's say, or, or depression with use of a substance, that's a really potent reinforcer. You know, like, okay, when I did this, like I felt better instantly as opposed to. You know that if we think of traditional SSRI antidepressant medications like Zoloft, et cetera, you know, they need to take at least a week or two to kick in if you're lucky.

Mark: Four to six weeks to really have full effect. And so there's already a discrepancy between like the fast acting benefit versus the longer term, you know? But as we all know, short term benefits don't always have the same long term benefits, and there is actually value in investing that time and energy into finding a medicine because.

Mark: These, these medicines actually do work. There's actually been a lot of research on cannabis for medical purposes, and it's interesting that it has not shown consistently to benefit any mental health issue, including depression, anxiety, insomnia. People will say like, oh, it helps me. And when they do, I don't argue with them.

Mark: I can't argue with personal experience, you know, and I'm open to listening to, to their experience and, and believing them that, you know, maybe that works for them, but you know, it hasn't helped enough people, not in the way that medications has and, and been demonstrated also in research studies to, you know, help like up to 70% of people that might start Zoloft for, you know, depression or anxiety.

Mike: That's, that's (laughs) a cards and letter coming at you. You know, every time I mention stuff like that, I get a lot of, whoa, you know, the, the pro weed community comes at me, but CBD and the gummies are not cheap, first of all. Right.

Mark: Right.

Mike: And the research isn't quite there and I, I hear a lot of anecdotal stuff, but I don't see, like, you, I keep looking for the studies and I haven't found 'em.

Mark: Right. Right. Yeah. Yeah. I mean, the conditions that there's medical grade evidence to support its use are for things like muscle spasticity and ms. Decreased appetite with cancer, nausea associated with chemotherapy. You know, there the glaucoma there, there's, there's certain types of pediatric seizures have been like, there's seven or eight conditions like that, but again, not depression or anxiety. That's been, again, show shown in large scale. You know, the gold standard is placebo controlled, double blind studies. Like that's what we look for in, in medicine to be able to then say, okay, this is a treatment that we're gonna be recommending to people that have, you know, these conditions.

Mike: Where do you think we go from here? Like we're we're talking about the innovations. I'm not asking you to, to know, but where do you think we'll go next?

Mark: In terms of treatment for...

Mike: Yeah, like what's on the horizon?

Mark: Yeah, I, I mean the, I think a, an exciting new chapter in psychiatry that is opening up are the psychedelic treatments. You know, I think on a, on a certain level, we've plateaued with development of traditional antidepressant and anti-anxiety medications to the extent that big pharma has really scaled back on their investments in studying those types of medications in the last 10 or 15 years.

Mark: And so the, the, but you know, psychedelics in terms of being used both as medication treatments alone and, and some of the studies that I was talking about earlier, or do look at them as a medication alone treatment done in a controlled setting, in a supportive way, but not necessarily combined with therapy.

Mark: And then there also is interest in therapy being combined with it too. And, and there's a lot of interest and belief that a person going through an experience like that might have a different reference point on their life. And instead of, you know, always kind of looking at things from a certain perspective for a few hours anyway, can have the experience of standing somewhere else and looking with the assistance of their therapist on events that may have happened to them, their current life, relationships, work situation, et cetera, and being able to put things into perspective for at least a different perspective for a few hours. And also, I'm, I'm, yeah, I, I think it's important not to be biased and become a zealot about it either that there might be false perspectives or erroneous perspectives that then a person can at least consider and evaluate after they come back and think about what they do wanna incorporate in their lives.

Mark: Because you know, we, wanna help them implement 'em in their, those benefits into their general lives, not just the times that they might be using that, those substances, let's say.

Mike: Right. You know, this is so well balanced. It's really been fascinating. I'm gonna give you a little walk off here.

Mike: Every time I talk to somebody who is in your area of expertise, I gotta ask this, right? You're surrounded by doom and gloom as well. You know, you read the news, you hear all the stuff, the negativity, and you're surrounded with people with trauma. We have a lot of therapists who listen to this, who struggle with their own secondary trauma.

Mike: How do you, and Dr. Ellie too, how did the, how do you keep your own life balance, life work balance, and how do you keep the, from absorbing the stuff that you're around every day?

Mark: Sure. I mean, own life balance, you know, sleep, diet, exercise I always talk about to patients and try my hardest to adhere to as well.

Mark: I just, you know, think of like taking care of your body physically and mind as well as the important foundation upon which you can then launch into other things in life that are gonna be good and healthy for you. Otherwise, taking time to develop relationships. You know, Freud said love and work are the two functions of a person psychologically.

Mark: And so yeah, placing emphasis on relationships with your significant others, your family, and developing a friend group, that can also be supportive to you is vital too. And then, yeah, work, I mean, people do well with some meaning, purpose in their life. Something that you know, gives them a sense of wellbeing and feeling like they're doing something important for themselves and for the world.

Mark: And so developing a vocation of some type and also hobbies that they're interested in too is really important as well.

Mike: You are doing something really important for the world.

Mike: For those of you who listen, you know, we have links to the Mental Health Center of Los Angeles. Dr. Hrymoc is attached to this podcast.

Mike: You can ask him questions or research what they do. Thanks for being with us today. This was, excellent. Well, well done, well done. I really enjoyed this.

Mike: For those of you listening, thanks for listening. Thanks for watching. If you're watching this on our YouTube channel. Wherever you are, I hope with the you find love, courage, strength, support, wherever you are.

Mike: Thanks for listening. Be safe and keep looking. I think it's right in front of you.