Caledon Clinic Podcast
Podcast transcription
Hi everybody. This is Dr. Andrew Cooper of Caledon Clinic with a podcast today on how ketamine is given in a personalized medicine at Caledon Clinic.
What should you bring?
The first subject is what you should bring. What you should bring is your set. That means your mindset. In general, a mental attitude towards your healing process that has less expectation of what should happen and more openness to what could happen.
What to expect in the treatment room?
Next, what to expect in the treatment room is a Zen-like atmosphere. That’s the setting to promote your healing experience. You’ll be monitored with state-of-the-art Masimo anaesthesia monitoring equipment, and we personalize every aspect of your experience from the music, to the dosage, to the lighting, to your comfort. You should expect a session that lasts altogether, for about 90 minutes from door to exit.
Methods of ketamine treatment administration
Now, let’s take a little time to compare and contrast different methods of administration. Our facility is equipped to perform ketamine treatment with any method that’s currently available, including oral, sublingual, nasal, intramuscular, or intravenous. Primarily, we prefer to use intravenous administration, and this is really because there’s really no reversal agent for ketamine like there is for benzodiazepine or opiates. So if some adverse effect is occurring, the best way to terminate it is simply to stop an intravenous infusion. On the other hand, if you get ketamine by intramuscular, oral, or nasal route, it’s very committal. It’s like jumping out of an airplane. Once you have done that, all you need to do is open the parachute. So our preference for intravenous ketamine has to do with the unique pharmacokinetics, but also, the ability to adjust the medication in personalized medicine fashion towards the end-point that we need to find. And we do this with our anesthesia monitoring technology and look at the effects side directly through your brain activity.
Ketamine treatment side effects
Now, let’s look at some side effects. In general, meta-analysis of ketamine shows that there are mainly described short-term side effects that are the acute effect of the drug on the nervous system, which sometimes is described as dysphoric or scary. And there is the possibility of intra-procedure rise in blood pressure. Respiratory function is not very much affected, although there may be some irregular breathing patterns, and these are more a concern if people have preexisting sleep apnea. And also, there’s a possibility of nausea as a short-term side effect. In some studies, this is as high as one-third. In our practice here, nausea is a less than 5% rate. We give all our patients some prevention of nausea medication before we start.
Another really good thing about the intravenous route that we use here is that we’re able to administer some fluid to replace your fasting fluid loss. And this is also a factor that reduces the nausea rate in our clinic, whereas with sublingual or intramuscular administration, there may be some concerns about the appropriate administration of fluids until the drug effect is completed.
Pros and cons of ketamine treatment methods
Finally, let’s talk about what are the pros and cons of these different methods. We can really group them into different categories. The dosages that are available have different viability or uptake by the body, depending on which route this medication is given. In general, it’s more reproducible and accurate milligram per milligram with the IV route or the intramuscular route than it is for the nasal or for the oral or sublingual routes. The speed of onset is, of course, fastest for IV and we see something happening within usually about two minutes with the concentrations we use here. It’s in 5 to 10 minutes with intramuscular. With sublingual, it may be up to 30 to 40 minutes. With nasal, it may be 5 to 10 minutes. So, there’s always a lot of choice, and choice is good.
Music Credits:
This is the Day by The The
Podcast transcription
Hi, this is Dr. Andrew Cooper of Caledon Clinic, with another audio blog podcast. Today our title is Mindfulness-Based Stress Reduction and Ketamine-Assisted Psychotherapy. The purpose today is to talk about how mindfulness techniques fit into the treatment plan we recommend here at Caledon Clinic, along with ketamine treatment and ketamine-assisted psychotherapy. The reason this has come up today is because my feed contained a very interesting paper from a recent issue of “JAMA Psychiatry,” on January 1st, 2023. With the title, “Mindfulness-Based Stress Reduction vs Escitalopram for the Treatment of Adults With Anxiety Disorders, A Randomized Clinical Trial.”
About the study
So this was a well conducted study methodology, past editorial review by JAMA, which is very difficult. And what was being done was an intervention that consisted of eight weeks of treatment with liberal doses of citalopram, very commonly used antidepressant that we would call Celexa, versus mindfulness-based stress reduction. And this was in a non-inferiority design. What they showed was that, in fact these two treatments were equivalent over the course of the intervention assessment, and in secondary analysis, they were also non-inferior. They noticed that there were decreased side effects in the mindfulness group.
Intervention and mindfulness
So, this brings up the question, what was this intervention? What was this mindfulness? So if we look into the paper, we can see that they offered the subjects in the study, a program of eight weeks consisting of one lesson per week. Which was online, about one hour. A program of a daily practice of mindfulness of 45 minutes. It’s not actually shown how this is done. Also, support was a one-day retreat. The techniques were audited by an external assessor of fidelity to the plan of mindfulness-based stress reduction.
Mindfulness-based stress reduction techniques
So what were the mindfulness-based stress reduction techniques? In this case, they mentioned two things. One was awareness of breath, and another was awareness of feelings in the body. So, let’s go and talk more about that mindfulness. So mindfulness gets a lot of buzz in the popular press, and on every shopping center magazine stand, there’s some publication dedicated only to mindfulness. So what mindfulness is as a word, we would always start with a definition as a word. As a word, the first thing we notice about mindfulness is that, it’s a word which ends with S, E-S-S. Like happiness or sadness, it is a state. So what’s it a state of? It’s a state of being mindful of what one has accepted to do in terms of what to adopt, and what to reject, or what to let go of, and what to get more of. And it requires alertness to be aware of when one is not doing what is being accepted, and when one is not accumulating what one wants to accumulate. So it’s like driving. So if we were driving, we would say that our job when we’re driving is to stay inside the rules of the road, inside the road boundaries, to be aware of hazards, maintain the speed limit. And so when we’re driving, it becomes automatic. But then, the alertness function reminds us that we’ve strayed from a parameter that we set as something that we need to maintain.
There’s also a classical definition of mindfulness in terms of the four foundations of mindfulness, and that is to put the attentional focus of our awareness onto certain things, such as the body itself, feelings or emotions, the mind itself, or the features of reality. Such as its transitory nature, its unsatisfactoriness, or its emptiness. These are philosophical terms, but they almost become emotional terms too.
Meditation and mindfulness
In the context of meditation, mindfulness means, adopting a posture of the body, a way of holding your eyes, a way of settling your breath, and a way of settling your attentional focus. In terms of practice, it’s very low-tech. We recommend two 5-minutes a day sessions. And the posture is to sit with any kind of relaxed posture for your hips and for your back to be as straight and naturally straight as possible. Next, the eye position is a half open-eye position. And the focus of the gaze is not directed at anything in particular except to go into a soft focus.
The sensation of the breath exiting your body is the object of mental attention, just when it goes out of your body. So you can start off by counting, one, when the first one goes, two, when the second one goes. And continuing that cycle until you become distracted, which is inevitable. So then, you just use the alertness function and return to that technique. A pitfall that people fall into is to be too enthusiastic. So we recommend the stability of maintaining short, well-focused sessions twice a day. So five minutes, twice a day, first thing in the morning and before you fall asleep.
We wish you empowerment and more strength of mind. The traditional benefit of these techniques is to calm the disturbance of the mind, like putting oil on the waters proverbially, so that the waters that were boiling become a still lake. Thank you for your attention today.
Music Credits
Mind by Talking Heads
Podcast transcription
Dr. Cooper: Hi, this is Dr. Andrew Cooper of Caledon Clinic. And I’m here today with Jeremy Parker of Spectrum Therapeutics to have a chat about medical cannabis five years on from legalization. So, let’s get started. And we’ll ask David to just take a pause. So, Jeremy, how about if we start off just saying a few things about your role in Spectrum Therapeutics?
Jeremy: Yeah, that’s great, Dr. Cooper. My role really is to go out and educate physicians and other healthcare professionals on how medical cannabis can play a vital role in their therapeutic work with their patients.
Dr. Cooper: What would you say, like from your encounters with people who are meeting you or someone from the cannabis industry the first time, what would be the most common sort of, like, frequently asked question that you get?
Most frequently asked question about medical cannabis
Jeremy: Well, like any drug that’s on the market, every healthcare practitioner wants to know the standard dosing and the dosing and titration schedules. And, unfortunately, medical cannabis, because it works on the endocannabinoid system, which is so unique to each individual out there, we just don’t have that. There is really no standardized dosing theorem that you can apply to medical cannabis.
Methods of administration
Dr. Cooper: That’s so true, Jeremy. That is borne out by my practice. And I would have to say that one of the great things about the medical cannabis industry in Canada is that we have an ever-increasing array of methods of administration, which make it really easy to…or no, easier than ever, it’s never easy, but it makes it easier than ever to customize the treatment plan for individual patients and to use unique methods of administration we didn’t have at the outset. All we had was dried flower at the outset of the industry.
Jeremy: Exactly. Yeah. And we’ve seen that as well. I mean, we introduced oils and soft gels back about seven years ago because we didn’t really want patients smoking the product. We don’t want anything going into the lungs if we can avoid it. So, by introducing the different formats, I mean, we’ve now come so far, is that we have in our store things like soft gels, we have gummies, which are in edibles, we’ve got beverages even, which contain small amounts of cannabis, all which gives that patient the opportunity to find a product that works best in their lifestyle.
Medical cannabis products that are overutilized and underutilized
Dr. Cooper: That’s the really great thing about this time in history of medicalization of this ancient therapeutic plant. Now, what about the question from me, which would be, from your place in the cannabis industry, what products do you think are being overutilized or underutilized by doctors, like, in terms of what they recommend for the patients?
Jeremy: Well, overutilization we’ve seen a significant drop in the use of dried cannabis, and that was a big win in my opinion. We’ve come down from being 100% dried flower sales now to about 40%.
Dr. Cooper: Forty percent.
Jeremy: Yeah. So, that says patients have realized that they don’t want to smoke or vaporize, they want to move into different formats that really address their needs. And the biggest of those, of course, is oils and soft gels because it’s so convenient and so easy to dose. Underutilization is really a whole different aspect.
Probably the one that I think is most underutilized today is the vape pen. And the vape pens are ideal for things like breakthrough pain. As you know, I mean, we’ve just come through Christmas with a bad snowstorm. Well, if you are out shoveling your driveway and you tweak your back, the old course of therapy would be to go into the house, put a heating pad on, take some Tylenol or some Advil, or something even stronger, and sit there for three or four hours waiting for your back to stop spasming.
Where we’ve seen with the use of the vape pens, that they can get relief a lot quicker, and it really has introduced a new area of dosing for patients. And with the vape pens, especially for those patients who may have spasticity issues, whether through MS or Huntington’s, the vape, we know THC really can help in some patients to reduce their spasticity.
And this was brought home by one of my patients down in the London area who actually had MS and really was dead set against the use of medical cannabis until one day they had to have their six-year-old child feed them breakfast because they couldn’t hold the spoon themselves. And so, they tried vaporizing just five minutes before they ate, and now it’s given them a whole new lease on life because they’re able to actually feed themselves again. And, you know, it’s a mental thing that it really helps a patient to feel more in power of their lives.
Dr. Cooper: Yes. One thing is so true, is that the flexibility of fast onset methods is really there with the medical system and so accessible.
Jeremy: Yes.
Dr. Cooper: And as a practitioner, what I’ve noticed is that there are misconceptions about vaporizers. So, I did a little bit of questionnaire, market research sort of questionnaires, and I found out that people think they’re talking about pen vaporizer every time someone says vaporizer.
Jeremy: Yes.
The future of medical cannabis products
Dr. Cooper: And they don’t really think about dry cannabis vaporizers. But as you say, maybe we’re going down in the use of dry cannabis vaporizers. What do you think the future holds for medical cannabis products? Like, what’s gonna come around the corner in the next couple of years?
Jeremy: Well, the biggest one that we’ve seen right now is the introduction of topicals onto the market. And the topical formulations are really fantastic for those who may have small joint pain. We have a lot of patients who have arthritis in their hands and they’re finding that rather than ingesting medical cannabis, they can actually just apply it topically and get same relief. And oftentimes, that relief will last longer.
Topical product sales
Dr. Cooper: That’s great. Now, this lets me kind of pick your brain a little bit. Like, out of the topical products, we always have the three chemovars. We have CBD, we have CBD THC chemovar, and then we have THC-only chemovar. Do you find that the sales are skewing in one direction or the other with regard to those kind of topical products?
Jeremy: That’s an excellent question, Dr. Cooper. What we see the most is the balanced products, so equal amounts of THC and CBD.
Dr. Cooper: People are hedging their bets.
Jeremy: Yeah. And because both THC and CBD have multiple therapeutic properties, it really seems to be the sweet spot. But we also have noticed a large increase in the use of high CBD topicals.
Dr. Cooper: High CBD topicals.
Jeremy: So, you know, the 750-milligram topical that.
Dr. Cooper: How long would a product like that typically last someone before they need to reorder?
Jeremy: It depends on the formulation. So, we have actually brought in topicals from two or three third-party suppliers. And some of them last a good eight hours, and some of them are a little shorter acting, but it really is patient-dependent.
Dr. Cooper: Yes. I see, I see. Okay. I think I’ve almost read all the questions. I have two more questions. Do you have time for it?
Jeremy: I do. Go on ahead.
How have the challenges in the medical cannabis industry changed overtime?
Dr. Cooper: Okay. So, how would you say that your challenges in the business have changed since the early days of medical cannabis, like, say since 2017, 2018? How have the challenges in maintaining the medical side changed over that period of time from your point of view where you sit?
Jeremy: Yeah. Well, again, in my opinion, I think the biggest negative to the medical cannabis community was the introduction of the retail stores. Most of our medical cannabis users use very low-dose THC and CBD, where if you go into a retail environment, it’s often very high THC levels. So, somebody may be extremely well tolerating, you know, 5 milligrams of THC for use at bedtime, but finding 5-milligram THC in a retail environment is very, very difficult.
Dr. Cooper: Yeah. I definitely echo that. And I sometimes will recommend for patients to go to retail stores if they need, you know, something right away, but I’m never sure what they’re going to find then and maybe they’re going to be introduced to something that wouldn’t really be what I was intending.
Jeremy: Well, exactly. And I think that that’s the big issue. And, you know, we do know, because it is a plant extract, that there’s so many different compounds that impact the patient’s success with medical cannabis. So, one of the commitments that we have through our Spectrum Therapeutics branding is that our core products will be available all the time. So, you may go into a retail store and buy something that works extremely well, but next time you go back…
Chemical moieties
Dr. Cooper: Yeah. The product dropout is something that is just a very consistent theme in all of medical patients’ experience. On the topic of products and sub-components, are you starting to emphasize some of these new moieties, chemical moieties like Delta-8 THC, or even THCV in your analytics or your kind of your cultivation streams?
Jeremy: Yes, we are. As we’re slowly starting to understand more of the role of these minor cannabinoids, if you will, we’re starting to…the big challenge we’ve had is finding the extracts to do it because there’s very small quantities of some of these cannabinoids in any plant. But as we’ve gotten better, we’ve introduced, actually just yesterday, we introduced both a CBN product into the store, which CBN, while we can say scientifically, we can prove it, we do know that it does play a great role in sleep. And so, a lot of patients will be happy to see that CBN product hit the store.
Dr. Cooper: That’ll be very interesting.
Jeremy: And we’re also playing now with CBG as well. So, as time goes on, I think you’ll see that these minor cannabinoids will become critical parts…
Dr. Cooper: More a part of the formulation. Okay. Well, I think that’s probably all the time we have now. So, we’ll just fade out with the great David Bowie and say thank you very much again for taking the trouble to come to visit me here in Caledon East. And I’m wishing that sort of like Chairman Mao would say, like that the next five years will be a great leap forward for the industry and for all our patients.
Jeremy: Thank you for your time.
Dr. Cooper: My pleasure.
Music Credits:
5 Years by David Bowie