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Kratom Uncovered: 5 Game-Changing Pearls for Your Practice · Pearls and Prep

• 0:00
  Foreign.
• 0:05
  Welcome
• 0:06
  back,
• 0:06
  my
• 0:06
  friends,
• 0:06
  to
• 0:07
  another
• 0:07
  episode
• 0:07
  of
• 0:07
  Pearls
• 0:08
  and
• 0:08
  Prep
• 0:08
  npz.
• 0:09
  Here,
• 0:09
  your
• 0:10
  preceptor
• 0:10
  in
• 0:10
  your
• 0:11
  pocket,
• 0:11
  your
• 0:11
  go
• 0:11
  to
• 0:12
  place
• 0:12
  for
• 0:12
  pearls
• 0:13
  that
• 0:13
  prep
• 0:13
  you
• 0:13
  to
• 0:13
  practice.
• 0:14
  Today
• 0:16
  we
• 0:16
  are
• 0:16
  going
• 0:16
  to
• 0:16
  talk
• 0:17
  about
• 0:17
  Kratom.
• 0:18
  My
• 0:18
  friends
• 0:19
  and
• 0:19
  I
• 0:20
  have
• 0:20
  five
• 0:20
  shiny
• 0:21
  pearls
• 0:22
  that
• 0:22
  I
• 0:22
  have
• 0:22
  dug
• 0:23
  up
• 0:23
  from
• 0:23
  the
• 0:23
  depths
• 0:24
  of
• 0:25
  clinical
• 0:26
  research.
• 0:27
  And
• 0:27
  I'm
• 0:28
  going
• 0:28
  to
• 0:28
  share
• 0:28
  them
• 0:28
  with
• 0:28
  you
• 0:28
  because
• 0:29
  they
• 0:29
  are
• 0:29
  very
• 0:29
  high
• 0:29
  yield.
• 0:30
  They
• 0:30
  will
• 0:30
  influence
• 0:31
  the
• 0:31
  way
• 0:31
  you
• 0:31
  practice.
• 0:32
  And
• 0:32
  just
• 0:33
  like
• 0:33
  all
• 0:33
  the
• 0:33
  pearls
• 0:34
  that
• 0:34
  I
• 0:34
  choose,
• 0:35
  they're
• 0:35
  very
• 0:36
  intentional
• 0:37
  and
• 0:37
  they're
• 0:38
  very
• 0:38
  high
• 0:38
  yield.
• 0:39
  In
• 0:39
  other
• 0:39
  words,
• 0:39
  this
• 0:39
  is
• 0:40
  not
• 0:40
  just
• 0:40
  about
• 0:40
  Kratom,
• 0:41
  right?
• 0:41
  This
• 0:42
  is
• 0:42
  about
• 0:42
  what
• 0:43
  it's
• 0:43
  like
• 0:43
  to
• 0:43
  be
• 0:44
  a
• 0:44
  psychiatric
• 0:45
  provider
• 0:46
  in
• 0:46
  the
• 0:46
  context
• 0:47
  of
• 0:47
  a
• 0:47
  society
• 0:48
  where
• 0:48
  some
• 0:48
  things
• 0:48
  are
• 0:48
  regulated,
• 0:49
  some
• 0:49
  things
• 0:49
  are
• 0:50
  not.
• 0:50
  In
• 0:50
  a
• 0:50
  society
• 0:51
  where
• 0:51
  some
• 0:52
  things
• 0:52
  are
• 0:52
  marketed
• 0:53
  some
• 0:53
  way
• 0:54
  that
• 0:54
  will
• 0:54
  affect
• 0:55
  the
• 0:55
  way
• 0:55
  your
• 0:55
  patients
• 0:56
  perceive
• 0:56
  these
• 0:56
  substances
• 0:57
  and
• 0:57
  what
• 0:57
  they
• 0:58
  tell
• 0:58
  you
• 0:58
  or
• 0:58
  what
• 0:58
  they
• 0:59
  don't
• 0:59
  tell
• 0:59
  you.
• 1:00
  This
• 1:00
  is
• 1:00
  so
• 1:00
  much
• 1:01
  more
• 1:01
  than
• 1:01
  just
• 1:01
  about
• 1:02
  Kratom.
• 1:02
  It's
• 1:02
  about
• 1:02
  drug
• 1:03
  interactions,
• 1:03
  it's
• 1:04
  about
• 1:04
  receptors,
• 1:05
  and
• 1:05
  it's
• 1:05
  about
• 1:07
  psychiatric
• 1:07
  mimics
• 1:08
  that
• 1:08
  can
• 1:09
  confuse
• 1:09
  your
• 1:09
  entire
• 1:10
  treatment
• 1:10
  plan.
• 1:10
  And
• 1:11
  so
• 1:11
  I'm
• 1:11
  very
• 1:12
  intentional
• 1:12
  about
• 1:13
  the
• 1:13
  pearls
• 1:13
  that
• 1:14
  I
• 1:14
  decide
• 1:15
  to
• 1:16
  grab
• 1:16
  from
• 1:16
  the
• 1:16
  ocean
• 1:17
  floor
• 1:17
  and
• 1:17
  bring
• 1:18
  up
• 1:18
  to
• 1:18
  the
• 1:18
  surface.
• 1:19
  And
• 1:19
  so
• 1:19
  I've
• 1:19
  collected
• 1:20
  five
• 1:20
  that
• 1:20
  I
• 1:21
  think
• 1:21
  are
• 1:21
  going
• 1:21
  to
• 1:22
  be
• 1:22
  very
• 1:22
  engaging
• 1:23
  and
• 1:23
  fun
• 1:24
  and
• 1:24
  change
• 1:25
  the
• 1:25
  game
• 1:25
  here
• 1:25
  in
• 1:26
  how
• 1:26
  you
• 1:26
  look
• 1:26
  at
• 1:27
  this
• 1:27
  stuff.
• 1:27
  Now,
• 1:28
  for
• 1:28
  those
• 1:28
  of
• 1:28
  you
• 1:28
  who
• 1:29
  are
• 1:29
  unaware
• 1:29
  of
• 1:30
  what
• 1:30
  Kratom
• 1:30
  is,
• 1:31
  okay,
• 1:33
  Kratom
• 1:35
  is
• 1:35
  a
• 1:36
  tropical
• 1:37
  evergreen
• 1:37
  tree,
• 1:38
  and
• 1:38
  it's
• 1:38
  actually
• 1:39
  native
• 1:39
  to
• 1:39
  Southeast
• 1:40
  Asia.
• 1:40
  Think
• 1:41
  countries
• 1:41
  like
• 1:41
  Thailand,
• 1:42
  Malaysia,
• 1:43
  Indonesia,
• 1:43
  even
• 1:43
  Papua
• 1:44
  New
• 1:44
  Guinea.
• 1:45
  And
• 1:45
  it's
• 1:46
  a
• 1:46
  botanical
• 1:47
  cousin
• 1:47
  to
• 1:47
  coffee.
• 1:48
  Okay?
• 1:49
  Now
• 1:49
  this
• 1:50
  is
• 1:50
  where
• 1:50
  we
• 1:50
  start
• 1:51
  entering
• 1:51
  dangerous
• 1:52
  territory,
• 1:52
  because
• 1:52
  this
• 1:53
  is
• 1:53
  not
• 1:53
  coffee.
• 1:55
  The
• 1:55
  effects
• 1:55
  of
• 1:55
  Kratom
• 1:56
  can
• 1:56
  be
• 1:56
  lethal
• 1:57
  in
• 1:57
  combination
• 1:58
  with
• 1:58
  other
• 1:58
  substances.
• 2:00
  Excessive
• 2:00
  use
• 2:00
  can
• 2:01
  lead
• 2:01
  to
• 2:01
  comas.
• 2:02
  It's
• 2:02
  not
• 2:03
  a
• 2:03
  joke,
• 2:03
  right?
• 2:03
  This
• 2:04
  can
• 2:04
  be
• 2:04
  very
• 2:04
  problematic
• 2:05
  for
• 2:05
  reasons
• 2:06
  we
• 2:06
  will
• 2:06
  show
• 2:06
  you
• 2:07
  shortly.
• 2:09
  But
• 2:10
  again,
• 2:10
  it
• 2:11
  is
• 2:11
  already
• 2:12
  marketed
• 2:12
  like
• 2:13
  an
• 2:13
  energy
• 2:14
  booster
• 2:14
  or
• 2:14
  like
• 2:15
  coffee.
• 2:16
  And
• 2:16
  that's
• 2:16
  the
• 2:16
  problem,
• 2:17
  right?
• 2:17
  Because
• 2:18
  traditionally
• 2:18
  in
• 2:18
  Southeast
• 2:19
  Asian
• 2:19
  societies,
• 2:20
  this
• 2:20
  is
• 2:20
  chewed
• 2:21
  as
• 2:21
  a
• 2:21
  leaf
• 2:22
  in
• 2:23
  much
• 2:23
  lower
• 2:24
  doses,
• 2:25
  okay?
• 2:25
  But
• 2:26
  now
• 2:26
  it
• 2:26
  comes
• 2:27
  over
• 2:27
  to
• 2:27
  the
• 2:27
  United
• 2:28
  States
• 2:28
  of
• 2:28
  America
• 2:29
  and
• 2:29
  it's
• 2:29
  marketed
• 2:30
  as
• 2:30
  this
• 2:30
  natural
• 2:30
  supplement
• 2:31
  for
• 2:31
  energy
• 2:31
  and
• 2:32
  mood
• 2:32
  and
• 2:32
  pain
• 2:33
  and
• 2:33
  anxiety,
• 2:34
  even
• 2:34
  opioid
• 2:35
  withdrawal.
• 2:36
  It
• 2:36
  is
• 2:36
  not,
• 2:36
  I
• 2:36
  want
• 2:37
  to
• 2:37
  be
• 2:37
  clear,
• 2:37
  it
• 2:37
  is
• 2:37
  not
• 2:38
  FDA
• 2:38
  approved
• 2:38
  for
• 2:39
  any
• 2:39
  medical
• 2:39
  use.
• 2:40
  And
• 2:40
  the
• 2:41
  FDA
• 2:41
  has
• 2:41
  actually
• 2:42
  explicitly
• 2:42
  warned
• 2:43
  people
• 2:43
  against
• 2:43
  its
• 2:44
  use,
• 2:45
  citing
• 2:45
  risks
• 2:46
  of
• 2:46
  addiction,
• 2:46
  abuse
• 2:47
  and
• 2:47
  death.
• 2:47
  So
• 2:47
  this
• 2:47
  is
• 2:48
  nothing
• 2:48
  to
• 2:49
  be
• 2:49
  playful
• 2:50
  about.
• 2:51
  But
• 2:51
  I
• 2:51
  just
• 2:51
  want
• 2:51
  you
• 2:52
  to
• 2:52
  appreciate
• 2:53
  how
• 2:53
  culturally
• 2:54
  something
• 2:54
  can
• 2:54
  be
• 2:55
  used
• 2:55
  in
• 2:55
  an
• 2:55
  entirely
• 2:56
  different
• 2:56
  context.
• 2:57
  And
• 2:57
  then
• 2:57
  misconstrued
• 2:58
  once
• 2:58
  it
• 2:58
  comes
• 2:59
  across
• 2:59
  our
• 2:59
  border.
• 3:00
  And
• 3:00
  then,
• 3:00
  due
• 3:00
  to
• 3:00
  the
• 3:01
  lack
• 3:01
  of
• 3:01
  regulatory
• 3:02
  oversight,
• 3:03
  it
• 3:03
  can
• 3:03
  be
• 3:03
  widely
• 3:04
  accessible
• 3:04
  in
• 3:04
  the
• 3:05
  form
• 3:05
  of
• 3:07
  gas
• 3:07
  station
• 3:08
  tablets
• 3:09
  or
• 3:09
  teas
• 3:09
  or
• 3:09
  gummies.
• 3:10
  And
• 3:10
  that's
• 3:10
  the
• 3:10
  first
• 3:10
  pearl.
• 3:11
  The
• 3:11
  first
• 3:11
  pearl
• 3:12
  is
• 3:12
  that
• 3:12
  Kratom
• 3:13
  is
• 3:13
  everywhere.
• 3:14
  What
• 3:14
  began
• 3:15
  as
• 3:15
  a
• 3:15
  leaf
• 3:15
  people
• 3:16
  would
• 3:16
  chew
• 3:17
  in
• 3:18
  Southeast
• 3:18
  Asia
• 3:19
  to
• 3:19
  get
• 3:19
  mild
• 3:20
  stimulatory
• 3:20
  effects
• 3:21
  or
• 3:21
  help
• 3:21
  with
• 3:21
  pain.
• 3:23
  It
• 3:23
  has
• 3:23
  become
• 3:24
  this
• 3:24
  cheap,
• 3:25
  legal,
• 3:26
  ubiquitous
• 3:27
  thing
• 3:27
  at
• 3:28
  gas
• 3:28
  stations,
• 3:28
  vape
• 3:29
  stores,
• 3:29
  head
• 3:30
  shops,
• 3:30
  smoke
• 3:31
  shops,
• 3:31
  there's
• 3:32
  online
• 3:32
  vendors
• 3:33
  everywhere
• 3:33
  selling
• 3:34
  this
• 3:34
  stuff.
• 3:35
  Capsules,
• 3:36
  powders,
• 3:36
  teas,
• 3:36
  gummies,
• 3:37
  everything.
• 3:38
  And
• 3:38
  these
• 3:38
  are
• 3:39
  concentrated
• 3:40
  extracts,
• 3:40
  often
• 3:41
  the
• 3:41
  case.
• 3:41
  So
• 3:42
  high
• 3:42
  mega
• 3:43
  dose.
• 3:43
  And
• 3:44
  it's
• 3:44
  behaving
• 3:44
  in
• 3:45
  completely
• 3:45
  different
• 3:45
  ways
• 3:46
  because
• 3:47
  it's
• 3:47
  pharmacologically
• 3:48
  very
• 3:48
  different.
• 3:48
  Right.
• 3:49
  We
• 3:49
  go
• 3:49
  over
• 3:49
  this
• 3:49
  in
• 3:50
  so
• 3:50
  many
• 3:50
  of
• 3:50
  our
• 3:51
  previous
• 3:51
  episodes,
• 3:51
  how
• 3:52
  the
• 3:52
  doses
• 3:53
  of
• 3:53
  a
• 3:53
  lot
• 3:53
  of
• 3:54
  our
• 3:54
  medications
• 3:55
  functionally
• 3:56
  change
• 3:56
  how
• 3:56
  they
• 3:56
  behave,
• 3:57
  and
• 3:58
  they
• 3:58
  become
• 3:58
  completely
• 3:59
  different
• 3:59
  medicines.
• 3:59
  You
• 4:00
  know
• 4:00
  this
• 4:00
  already
• 4:00
  with
• 4:01
  Seroquel,
• 4:02
  right?
• 4:02
  Seroquel
• 4:03
  starts
• 4:03
  off
• 4:03
  at
• 4:03
  50
• 4:04
  milligrams
• 4:05
  as
• 4:05
  this,
• 4:05
  like,
• 4:06
  very
• 4:06
  expensive
• 4:07
  form
• 4:07
  of
• 4:07
  Benadryl.
• 4:08
  Right.
• 4:08
  It
• 4:08
  mainly
• 4:08
  hits
• 4:09
  the
• 4:09
  histamine
• 4:09
  receptor.
• 4:10
  It
• 4:10
  knocks
• 4:10
  you
• 4:10
  out.
• 4:10
  You're
• 4:11
  tired,
• 4:11
  you're
• 4:11
  sleepy,
• 4:12
  you're
• 4:12
  hungry.
• 4:13
  And
• 4:13
  then
• 4:13
  at
• 4:13
  higher
• 4:13
  doses,
• 4:15
  you
• 4:15
  have
• 4:15
  this
• 4:16
  metabolite,
• 4:17
  nor
• 4:17
  Quetiapine,
• 4:18
  that
• 4:18
  behaves
• 4:18
  like
• 4:18
  an
• 4:18
  snri.
• 4:19
  At
• 4:19
  even
• 4:19
  higher
• 4:20
  doses,
• 4:20
  it
• 4:20
  becomes
• 4:20
  an
• 4:21
  antipsychotic.
• 4:21
  Right.
• 4:22
  So
• 4:22
  our
• 4:22
  meds
• 4:23
  are
• 4:23
  a
• 4:23
  little
• 4:23
  different
• 4:23
  than
• 4:23
  Motrin,
• 4:25
  and
• 4:25
  I'm
• 4:25
  not
• 4:25
  an
• 4:25
  expert
• 4:26
  on
• 4:26
  Motrin,
• 4:26
  beyond
• 4:26
  the
• 4:27
  fact
• 4:27
  that
• 4:27
  I
• 4:27
  know
• 4:27
  it
• 4:27
  helps
• 4:28
  with
• 4:28
  headaches,
• 4:28
  but
• 4:29
  Motrin
• 4:29
  is
• 4:30
  a
• 4:30
  pain
• 4:30
  medication.
• 4:31
  Last
• 4:31
  I
• 4:31
  checked,
• 4:32
  at
• 4:32
  almost
• 4:33
  every
• 4:33
  dose,
• 4:33
  you
• 4:33
  take
• 4:33
  it.
• 4:34
  Okay,
• 4:34
  correct
• 4:34
  me
• 4:34
  if
• 4:35
  I'm
• 4:35
  wrong,
• 4:35
  not
• 4:36
  the
• 4:36
  same
• 4:36
  case
• 4:36
  with
• 4:36
  a
• 4:37
  lot
• 4:37
  of
• 4:37
  psychiatric
• 4:37
  medications
• 4:38
  like
• 4:38
  Seroquel
• 4:39
  or
• 4:39
  like
• 4:39
  Remeron.
• 4:40
  Right?
• 4:40
  Or
• 4:40
  Remeron
• 4:41
  is
• 4:41
  actually
• 4:41
  more
• 4:42
  sedating
• 4:42
  at
• 4:43
  7.5
• 4:43
  at
• 4:44
  lower
• 4:44
  doses,
• 4:44
  and
• 4:45
  at
• 4:45
  higher
• 4:45
  doses,
• 4:46
  it
• 4:46
  starts
• 4:46
  recruiting
• 4:46
  the
• 4:46
  norepinephrine
• 4:47
  or
• 4:47
  neurotransmitter,
• 4:48
  and
• 4:49
  actually
• 4:49
  can
• 4:49
  be
• 4:49
  a
• 4:49
  little
• 4:50
  more
• 4:50
  energizing
• 4:51
  and
• 4:51
  stimulating
• 4:52
  as
• 4:52
  you
• 4:52
  raise
• 4:53
  the
• 4:53
  dose,
• 4:53
  which
• 4:54
  makes
• 4:54
  no
• 4:54
  sense
• 4:55
  if
• 4:55
  you
• 4:55
  think
• 4:55
  of
• 4:55
  other
• 4:56
  sedating
• 4:56
  medications
• 4:57
  that
• 4:57
  typically
• 4:57
  get
• 4:58
  more
• 4:58
  sedating
• 4:58
  the
• 4:59
  higher
• 4:59
  you
• 4:59
  raise
• 4:59
  them.
• 5:00
  Okay,
• 5:01
  so
• 5:01
  just
• 5:01
  appreciating
• 5:02
  the
• 5:02
  pharmacology
• 5:03
  of
• 5:04
  a
• 5:04
  lot
• 5:04
  of
• 5:04
  our
• 5:04
  medications
• 5:05
  can
• 5:06
  help
• 5:06
  you
• 5:06
  understand
• 5:06
  why
• 5:07
  you
• 5:07
  put
• 5:07
  this
• 5:07
  through
• 5:08
  a
• 5:08
  filter
• 5:08
  of
• 5:09
  a
• 5:09
  medication
• 5:10
  coming
• 5:10
  from
• 5:10
  Southeast
• 5:11
  Asia.
• 5:11
  It's
• 5:11
  not
• 5:12
  really
• 5:12
  regulated
• 5:12
  by
• 5:13
  the
• 5:13
  fda.
• 5:14
  It
• 5:14
  starts
• 5:14
  getting
• 5:14
  marketed
• 5:15
  as
• 5:15
  completely
• 5:16
  different
• 5:16
  things.
• 5:17
  And
• 5:17
  now
• 5:18
  you
• 5:18
  have
• 5:18
  this
• 5:18
  game
• 5:18
  of
• 5:18
  telephone
• 5:19
  where
• 5:20
  something
• 5:20
  that,
• 5:20
  in
• 5:20
  one
• 5:21
  context,
• 5:21
  might
• 5:21
  be
• 5:22
  somewhat
• 5:22
  serviceable
• 5:23
  in
• 5:23
  a
• 5:23
  remote
• 5:24
  corner
• 5:24
  of
• 5:24
  the
• 5:24
  earth,
• 5:25
  and
• 5:25
  then
• 5:25
  it
• 5:26
  becomes
• 5:26
  this
• 5:26
  Frankenstein
• 5:28
  in
• 5:28
  a
• 5:28
  hyper
• 5:29
  concentrated
• 5:29
  form
• 5:30
  that
• 5:31
  we
• 5:31
  really
• 5:32
  don't
• 5:32
  even
• 5:32
  understand
• 5:33
  what's
• 5:34
  in
• 5:34
  it
• 5:34
  half
• 5:34
  the
• 5:34
  time
• 5:35
  because
• 5:35
  of
• 5:35
  a
• 5:35
  lack
• 5:35
  of
• 5:36
  third
• 5:36
  party
• 5:36
  testing
• 5:36
  or
• 5:37
  federal
• 5:37
  oversight.
• 5:38
  So
• 5:39
  this
• 5:39
  is
• 5:39
  where
• 5:39
  we
• 5:40
  enter
• 5:40
  this
• 5:40
  kind
• 5:40
  of
• 5:40
  cultural
• 5:41
  blind
• 5:41
  spot
• 5:42
  right
• 5:42
  now
• 5:42
  with
• 5:42
  Kratom.
• 5:43
  And
• 5:43
  it's
• 5:43
  scary
• 5:44
  because
• 5:44
  you're
• 5:44
  going
• 5:44
  to
• 5:44
  have
• 5:45
  patients
• 5:45
  who
• 5:46
  implicitly
• 5:46
  assume
• 5:47
  that
• 5:47
  this
• 5:48
  is
• 5:48
  not
• 5:48
  even
• 5:48
  worth
• 5:48
  telling
• 5:49
  you
• 5:49
  about
• 5:49
  because
• 5:49
  it's
• 5:50
  something
• 5:50
  they
• 5:50
  get
• 5:50
  at
• 5:50
  the
• 5:50
  gas
• 5:51
  station
• 5:51
  every
• 5:51
  once
• 5:51
  in
• 5:52
  a
• 5:52
  while
• 5:53
  and
• 5:54
  they're
• 5:54
  not
• 5:54
  really
• 5:54
  putting
• 5:55
  two
• 5:55
  and
• 5:55
  two
• 5:55
  together
• 5:56
  because
• 5:56
  why
• 5:56
  mention
• 5:57
  it?
• 5:57
  It's
• 5:57
  just
• 5:57
  something
• 5:58
  I
• 5:58
  take
• 5:58
  at
• 5:58
  a
• 5:58
  gas
• 5:59
  station
• 5:59
  or
• 5:59
  my
• 5:59
  friend
• 6:00
  gave
• 6:00
  me
• 6:01
  and
• 6:01
  I
• 6:01
  don't
• 6:02
  even
• 6:02
  think
• 6:02
  twice
• 6:02
  about
• 6:02
  it.
• 6:03
  And
• 6:03
  it
• 6:03
  must
• 6:03
  be
• 6:03
  fine
• 6:03
  since
• 6:04
  I
• 6:04
  get
• 6:04
  it
• 6:04
  at
• 6:04
  a
• 6:04
  gas
• 6:05
  station
• 6:05
  and
• 6:05
  I
• 6:05
  don't
• 6:06
  even
• 6:06
  necessarily
• 6:06
  mention
• 6:07
  it
• 6:07
  when
• 6:07
  you
• 6:07
  ask
• 6:07
  me
• 6:07
  about
• 6:08
  medications,
• 6:08
  I
• 6:09
  just
• 6:09
  think
• 6:09
  you're
• 6:09
  asking
• 6:09
  me
• 6:10
  about
• 6:10
  like
• 6:10
  blood
• 6:10
  pressure
• 6:11
  medications
• 6:11
  or
• 6:12
  other
• 6:13
  antidepressants.
• 6:13
  And
• 6:14
  so
• 6:14
  I'm
• 6:14
  not
• 6:14
  going
• 6:14
  to
• 6:14
  share
• 6:14
  it.
• 6:15
  So
• 6:15
  I
• 6:15
  can't
• 6:15
  tell
• 6:15
  you
• 6:16
  how
• 6:16
  many
• 6:16
  of
• 6:17
  us
• 6:17
  are
• 6:18
  losing
• 6:18
  out
• 6:19
  on
• 6:19
  really
• 6:20
  big
• 6:20
  clues
• 6:21
  in
• 6:21
  our
• 6:21
  patient
• 6:22
  presentations
• 6:22
  because
• 6:23
  we
• 6:23
  don't
• 6:23
  maybe
• 6:24
  think
• 6:24
  to
• 6:24
  ask
• 6:24
  about
• 6:24
  Kratom
• 6:25
  or
• 6:25
  it
• 6:25
  certainly
• 6:26
  isn't
• 6:26
  offered
• 6:26
  to
• 6:26
  us
• 6:27
  on
• 6:27
  a
• 6:27
  silver
• 6:28
  platter.
• 6:29
  So
• 6:29
  it's
• 6:29
  very
• 6:29
  important
• 6:30
  that
• 6:30
  you
• 6:30
  get
• 6:31
  in
• 6:31
  the
• 6:31
  habit
• 6:31
  of
• 6:31
  asking
• 6:32
  your
• 6:32
  patient,
• 6:32
  you
• 6:33
  know,
• 6:33
  do
• 6:33
  you
• 6:33
  use
• 6:33
  Kratom
• 6:34
  or
• 6:34
  other
• 6:35
  kinds
• 6:35
  of
• 6:35
  herbal
• 6:36
  supplements
• 6:36
  for
• 6:36
  energy,
• 6:37
  pain
• 6:37
  or
• 6:37
  mood?
• 6:38
  Okay.
• 6:38
  And
• 6:39
  if
• 6:39
  you
• 6:39
  don't
• 6:39
  ask
• 6:39
  them
• 6:39
  by
• 6:40
  name,
• 6:40
  you
• 6:40
  may
• 6:40
  never
• 6:40
  find
• 6:41
  out.
• 6:41
  They
• 6:42
  might
• 6:42
  not
• 6:42
  even
• 6:42
  know
• 6:43
  that
• 6:43
  this
• 6:43
  is
• 6:43
  some
• 6:44
  kind
• 6:44
  of
• 6:44
  supplement
• 6:44
  or
• 6:45
  how
• 6:45
  to
• 6:45
  even
• 6:45
  categorize
• 6:46
  it.
• 6:47
  So
• 6:47
  it's
• 6:47
  important
• 6:48
  that
• 6:48
  you
• 6:49
  ask
• 6:50
  those
• 6:50
  questions.
• 6:51
  Okay?
• 6:52
  So
• 6:53
  Kratom
• 6:53
  is
• 6:54
  legal
• 6:54
  in
• 6:54
  most
• 6:54
  states.
• 6:54
  Keep
• 6:55
  that
• 6:55
  in
• 6:55
  mind.
• 6:55
  It
• 6:55
  is
• 6:55
  banned
• 6:56
  in
• 6:56
  like
• 6:56
  Alabama,
• 6:57
  Arkansas,
• 6:57
  Indiana,
• 6:58
  Rhode
• 6:58
  Island,
• 6:59
  Vermont,
• 6:59
  Wisconsin.
• 7:00
  It's
• 7:00
  kind
• 7:00
  of
• 7:00
  a
• 7:00
  growing
• 7:01
  list,
• 7:01
  but
• 7:02
  it
• 7:02
  is
• 7:03
  still
• 7:03
  ubiquitous
• 7:04
  everywhere.
• 7:05
  It's
• 7:05
  pretty
• 7:05
  cheap
• 7:06
  too.
• 7:07
  Comes
• 7:07
  down
• 7:07
  to
• 7:07
  like
• 7:07
  one
• 7:08
  or
• 7:08
  $2
• 7:09
  for
• 7:09
  a
• 7:10
  capsule
• 7:10
  or
• 7:10
  two,
• 7:11
  you
• 7:12
  know,
• 7:12
  10
• 7:12
  to
• 7:12
  $20
• 7:13
  for
• 7:13
  like
• 7:13
  a
• 7:13
  bag
• 7:14
  of
• 7:14
  powder.
• 7:14
  And
• 7:14
  that
• 7:14
  can
• 7:14
  last
• 7:15
  days
• 7:15
  or
• 7:15
  weeks.
• 7:16
  So
• 7:17
  watch
• 7:17
  out,
• 7:18
  right?
• 7:18
  You
• 7:18
  have
• 7:18
  this
• 7:19
  infrastructure
• 7:19
  now,
• 7:19
  this
• 7:20
  globalized
• 7:20
  world
• 7:21
  where
• 7:21
  medicines
• 7:22
  are
• 7:22
  coming
• 7:22
  from
• 7:22
  everywhere,
• 7:23
  in
• 7:23
  unregulated,
• 7:25
  in
• 7:25
  unre,
• 7:26
  unregulated
• 7:26
  channels,
• 7:27
  through
• 7:27
  the
• 7:27
  Internet.
• 7:29
  Be
• 7:29
  very
• 7:29
  careful
• 7:30
  and
• 7:30
  understand
• 7:30
  the
• 7:31
  context
• 7:31
  in
• 7:31
  which
• 7:32
  you
• 7:32
  live,
• 7:32
  right?
• 7:32
  The
• 7:33
  society,
• 7:33
  the
• 7:34
  economy,
• 7:35
  those
• 7:35
  things
• 7:36
  often
• 7:36
  have
• 7:36
  a
• 7:36
  bigger
• 7:37
  effect
• 7:37
  on
• 7:38
  our
• 7:38
  treatment
• 7:38
  plans
• 7:39
  than
• 7:39
  we
• 7:39
  think.
• 7:39
  And
• 7:40
  so
• 7:40
  it's
• 7:40
  good
• 7:40
  to
• 7:40
  always
• 7:40
  zoom
• 7:41
  out,
• 7:41
  think
• 7:41
  about
• 7:41
  that
• 7:41
  stuff.
• 7:43
  Now
• 7:43
  pearl
• 7:44
  number
• 7:44
  two
• 7:44
  is
• 7:44
  that
• 7:45
  Kratom
• 7:45
  is
• 7:45
  not
• 7:45
  just
• 7:46
  this
• 7:46
  herbal
• 7:46
  tea,
• 7:46
  like
• 7:47
  it's
• 7:47
  marketed,
• 7:47
  it
• 7:47
  is
• 7:48
  a
• 7:48
  partial
• 7:48
  opioid
• 7:49
  agonist
• 7:50
  and
• 7:50
  it
• 7:50
  has
• 7:50
  this
• 7:51
  kind
• 7:51
  of
• 7:51
  dual
• 7:51
  personality
• 7:52
  where
• 7:52
  at
• 7:52
  low
• 7:53
  doses
• 7:53
  it
• 7:53
  behaves
• 7:54
  like
• 7:54
  a
• 7:54
  stimulant.
• 7:54
  At
• 7:55
  higher
• 7:55
  doses
• 7:55
  it
• 7:56
  behaves
• 7:57
  like
• 7:57
  a,
• 7:58
  an
• 7:58
  opioid
• 7:59
  partial
• 7:59
  agonist.
• 8:00
  Very
• 8:00
  similar
• 8:00
  to
• 8:00
  buprenorphine.
• 8:01
  Actually,
• 8:02
  we've,
• 8:02
  we've
• 8:03
  seen
• 8:03
  buprenorphine
• 8:05
  in
• 8:05
  opioid
• 8:05
  use
• 8:06
  disorder.
• 8:06
  Right,
• 8:06
  so
• 8:06
  it's
• 8:06
  actually
• 8:07
  very
• 8:07
  similar
• 8:08
  to
• 8:08
  that.
• 8:09
  Okay,
• 8:11
  so
• 8:11
  it,
• 8:11
  it.
• 8:12
  Now
• 8:12
  kratom
• 8:13
  has
• 8:13
  over
• 8:13
  40
• 8:14
  alkaloids
• 8:15
  that
• 8:16
  are
• 8:16
  really
• 8:16
  part
• 8:17
  of
• 8:17
  it,
• 8:17
  but
• 8:17
  the
• 8:17
  two
• 8:17
  that
• 8:17
  matter
• 8:18
  for
• 8:18
  you
• 8:19
  are,
• 8:19
  are
• 8:20
  metraginine,
• 8:21
  and
• 8:21
  that's
• 8:22
  its
• 8:22
  most
• 8:22
  abundant
• 8:22
  alkaloid.
• 8:23
  And
• 8:24
  7
• 8:24
  hydroxy
• 8:25
  mitragynine,
• 8:26
  which
• 8:26
  is
• 8:27
  13
• 8:27
  times
• 8:27
  more
• 8:28
  potent
• 8:28
  than
• 8:28
  morphine,
• 8:29
  but
• 8:29
  it's
• 8:29
  in
• 8:29
  Kratom
• 8:30
  to
• 8:30
  a
• 8:30
  small
• 8:31
  degree.
• 8:31
  Okay.
• 8:32
  Both
• 8:32
  of
• 8:32
  these
• 8:33
  are
• 8:33
  partial
• 8:33
  mu
• 8:34
  opioid
• 8:34
  receptor
• 8:35
  agonists.
• 8:36
  Okay.
• 8:36
  But
• 8:36
  they
• 8:36
  have
• 8:36
  additional
• 8:37
  activity
• 8:37
  at
• 8:38
  Kappa
• 8:38
  Delta
• 8:38
  Serotonin,
• 8:39
  5
• 8:40
  HT2A
• 8:40
  and
• 8:41
  Alpha
• 8:41
  2
• 8:42
  receptors.
• 8:42
  Okay,
• 8:43
  so
• 8:46
  we,
• 8:46
  some
• 8:47
  of
• 8:47
  these
• 8:47
  sound
• 8:47
  familiar
• 8:48
  to
• 8:48
  you,
• 8:48
  right?
• 8:48
  We've
• 8:48
  talked
• 8:49
  about
• 8:49
  Alpha
• 8:49
  2
• 8:49
  autoreceptors
• 8:50
  with
• 8:50
  Remeron
• 8:51
  and
• 8:51
  how,
• 8:51
  by
• 8:52
  how
• 8:52
  blocking
• 8:53
  that
• 8:53
  autoreceptor
• 8:54
  means
• 8:55
  a
• 8:55
  more
• 8:55
  immediate
• 8:56
  release
• 8:56
  of
• 8:56
  norepinephrine
• 8:57
  and
• 8:57
  serotonin.
• 8:58
  Right.
• 8:58
  So
• 8:58
  you
• 8:58
  have
• 8:59
  this
• 8:59
  enhancement
• 8:59
  of
• 8:59
  mood.
• 9:01
  You've
• 9:01
  heard
• 9:01
  about
• 9:01
  5ht2a
• 9:02
  a
• 9:03
  lot.
• 9:05
  And
• 9:05
  the,
• 9:05
  the,
• 9:06
  the
• 9:06
  consequences
• 9:07
  of
• 9:07
  antagonizing
• 9:08
  5ht2a
• 9:09
  receptors,
• 9:10
  it
• 9:10
  can
• 9:10
  be
• 9:10
  kind
• 9:10
  of
• 9:11
  calming,
• 9:12
  which,
• 9:13
  you
• 9:13
  know,
• 9:13
  is,
• 9:14
  is
• 9:14
  very
• 9:14
  interesting,
• 9:14
  of
• 9:15
  course.
• 9:16
  So
• 9:16
  you
• 9:16
  have
• 9:17
  a
• 9:17
  lot
• 9:17
  of
• 9:17
  different
• 9:18
  mechanisms
• 9:19
  of
• 9:19
  action
• 9:19
  here,
• 9:20
  which
• 9:20
  explain
• 9:21
  why
• 9:21
  at
• 9:21
  high
• 9:22
  doses
• 9:22
  this
• 9:23
  behaves
• 9:24
  like
• 9:24
  an,
• 9:25
  an
• 9:25
  opioid.
• 9:26
  Right.
• 9:26
  It's
• 9:26
  sedating,
• 9:27
  it
• 9:27
  takes
• 9:27
  it
• 9:27
  with,
• 9:27
  you
• 9:28
  know,
• 9:28
  it's
• 9:28
  indicated
• 9:28
  for
• 9:29
  pain
• 9:29
  relief,
• 9:29
  it
• 9:29
  can
• 9:29
  be
• 9:29
  very
• 9:30
  euphoric,
• 9:31
  and
• 9:31
  at
• 9:32
  low
• 9:32
  doses,
• 9:32
  it
• 9:32
  behaves
• 9:33
  more
• 9:33
  like
• 9:33
  a
• 9:33
  stimulant,
• 9:34
  which
• 9:34
  is
• 9:34
  very
• 9:35
  interesting.
• 9:36
  Okay.
• 9:38
  And
• 9:38
  so
• 9:39
  appreciate
• 9:39
  the
• 9:39
  pharmacology
• 9:40
  here.
• 9:41
  The
• 9:41
  closest
• 9:42
  pharmacological
• 9:43
  comparison,
• 9:43
  again,
• 9:43
  is
• 9:44
  like
• 9:44
  suboxone
• 9:44
  buprenorphine,
• 9:45
  which
• 9:46
  is
• 9:46
  also
• 9:46
  a
• 9:47
  partial
• 9:47
  mu
• 9:47
  agonist.
• 9:48
  You've
• 9:48
  again,
• 9:48
  probably
• 9:49
  heard
• 9:49
  about
• 9:49
  that
• 9:49
  a
• 9:49
  lot.
• 9:51
  So
• 9:52
  now
• 9:53
  when
• 9:53
  we
• 9:53
  talked
• 9:53
  about
• 9:54
  kappa,
• 9:54
  you
• 9:54
  don't
• 9:54
  need
• 9:55
  to
• 9:55
  memorize
• 9:55
  this
• 9:55
  too
• 9:56
  much,
• 9:56
  but
• 9:56
  the
• 9:57
  kappa
• 9:57
  opioid
• 9:58
  receptors,
• 9:58
  when
• 9:58
  you
• 9:58
  activate
• 9:59
  those,
• 9:59
  it
• 9:59
  normally
• 10:00
  causes
• 10:01
  dysphoria,
• 10:02
  like
• 10:02
  an
• 10:02
  anxious
• 10:02
  skin
• 10:03
  crawling
• 10:03
  feeling,
• 10:04
  disassociation.
• 10:05
  So
• 10:05
  Kratom
• 10:06
  antagonizes
• 10:07
  that,
• 10:08
  which
• 10:09
  is
• 10:09
  actually
• 10:10
  an
• 10:10
  area
• 10:10
  of
• 10:11
  antidepressant
• 10:12
  drug
• 10:12
  development.
• 10:13
  Right.
• 10:13
  Now
• 10:13
  they're
• 10:13
  looking
• 10:13
  at
• 10:14
  that
• 10:14
  as
• 10:14
  we
• 10:14
  speak.
• 10:15
  But
• 10:15
  again,
• 10:15
  that
• 10:16
  doesn't
• 10:16
  mean
• 10:16
  Kratom
• 10:16
  is
• 10:17
  a
• 10:17
  vegetable.
• 10:17
  It's
• 10:18
  just,
• 10:18
  it's
• 10:18
  still
• 10:18
  this
• 10:19
  wild
• 10:19
  west,
• 10:19
  potentially
• 10:20
  very
• 10:20
  dangerous,
• 10:21
  dangerous
• 10:21
  thing.
• 10:22
  Okay.
• 10:23
  But
• 10:23
  just
• 10:23
  to
• 10:24
  understand
• 10:25
  that
• 10:25
  antagonizing
• 10:26
  kappa
• 10:26
  opioid
• 10:27
  receptors
• 10:28
  might
• 10:28
  contribute
• 10:29
  to
• 10:29
  Kratom's
• 10:29
  antidepressant
• 10:30
  and
• 10:30
  anti
• 10:30
  anxiety
• 10:31
  properties.
• 10:32
  Then
• 10:32
  there's
• 10:32
  the
• 10:32
  delta
• 10:33
  opioid
• 10:33
  receptors
• 10:35
  which
• 10:35
  modulate
• 10:36
  mood
• 10:36
  and
• 10:36
  anxiety.
• 10:38
  So
• 10:39
  potentially
• 10:39
  working
• 10:40
  out
• 10:40
  there.
• 10:42
  And
• 10:42
  so
• 10:42
  at
• 10:42
  low
• 10:43
  doses,
• 10:43
  like
• 10:43
  1
• 10:43
  to
• 10:43
  5
• 10:44
  milligrams,
• 10:46
  we're
• 10:46
  getting
• 10:48
  increased
• 10:48
  energy,
• 10:49
  we're
• 10:49
  getting
• 10:49
  a
• 10:49
  little
• 10:49
  more
• 10:49
  alertness,
• 10:50
  talkativeness,
• 10:51
  sociability,
• 10:51
  kind
• 10:51
  of
• 10:52
  a
• 10:52
  stimulant.
• 10:52
  Think
• 10:53
  coffee,
• 10:53
  but
• 10:53
  different.
• 10:55
  And
• 10:56
  the
• 10:56
  opioid
• 10:56
  receptor
• 10:57
  activity
• 10:57
  at
• 10:57
  these
• 10:57
  low
• 10:58
  doses
• 10:58
  of
• 10:58
  Kratom
• 10:59
  is
• 10:59
  actually
• 10:59
  pretty
• 11:00
  minimal.
• 11:00
  Okay.
• 11:01
  At
• 11:02
  high
• 11:02
  doses,
• 11:02
  then
• 11:02
  when
• 11:03
  we
• 11:03
  get
• 11:03
  to
• 11:03
  like
• 11:03
  5
• 11:03
  to
• 11:04
  15
• 11:04
  grams
• 11:04
  of,
• 11:05
  of
• 11:05
  Kratom,
• 11:06
  the
• 11:06
  opioid
• 11:06
  receptor
• 11:07
  activity
• 11:08
  starts
• 11:08
  to
• 11:08
  dominate.
• 11:09
  So
• 11:09
  this
• 11:09
  should
• 11:09
  sound
• 11:10
  familiar,
• 11:10
  right?
• 11:11
  Where
• 11:11
  we've
• 11:12
  seen
• 11:12
  meds
• 11:12
  like
• 11:13
  Effexor,
• 11:14
  all
• 11:14
  right,
• 11:15
  it
• 11:15
  behaves
• 11:15
  like
• 11:15
  a
• 11:15
  Sarah
• 11:16
  SSRI
• 11:17
  at
• 11:18
  doses
• 11:18
  below
• 11:18
  150
• 11:19
  milligrams.
• 11:20
  As
• 11:20
  we
• 11:20
  push
• 11:21
  that
• 11:21
  higher
• 11:21
  than
• 11:21
  150mg
• 11:22
  xr,
• 11:23
  we
• 11:23
  recruit
• 11:24
  norepinephrine,
• 11:24
  it
• 11:24
  be,
• 11:25
  it's
• 11:25
  a
• 11:25
  little
• 11:25
  more
• 11:25
  energizing.
• 11:26
  It
• 11:26
  behaves
• 11:26
  more
• 11:26
  like
• 11:26
  an
• 11:26
  snri.
• 11:27
  Right.
• 11:28
  So
• 11:28
  again,
• 11:28
  medications
• 11:29
  behave
• 11:29
  differently
• 11:30
  as
• 11:30
  we
• 11:30
  raise
• 11:30
  the
• 11:31
  dose.
• 11:31
  This
• 11:31
  is
• 11:32
  no
• 11:32
  different.
• 11:32
  5
• 11:32
  to
• 11:32
  15
• 11:33
  milligrams.
• 11:34
  Opioid
• 11:35
  receptor
• 11:35
  activity
• 11:35
  dominates.
• 11:37
  And
• 11:37
  that,
• 11:38
  that
• 11:38
  opioid
• 11:38
  receptor
• 11:39
  receptor
• 11:40
  activity
• 11:40
  produces,
• 11:41
  you
• 11:41
  know,
• 11:42
  analgesia,
• 11:42
  sedation,
• 11:43
  euphoria,
• 11:44
  the
• 11:44
  stimulant
• 11:45
  effects
• 11:45
  are
• 11:45
  kind
• 11:45
  of
• 11:46
  overwhelmed
• 11:46
  and
• 11:47
  people
• 11:47
  kind
• 11:47
  of
• 11:48
  describe
• 11:48
  it
• 11:48
  more
• 11:48
  like
• 11:48
  a
• 11:49
  painkiller.
• 11:50
  At
• 11:50
  higher
• 11:50
  doses,
• 11:51
  even
• 11:51
  above
• 11:51
  15,
• 11:52
  you're
• 11:52
  talking
• 11:52
  stupor,
• 11:53
  severe
• 11:53
  sedation
• 11:54
  and
• 11:54
  rarely
• 11:55
  like
• 11:55
  a
• 11:55
  comatose
• 11:56
  state.
• 12:52
  So
• 12:52
  pretty,
• 12:53
  pretty
• 12:53
  big
• 12:53
  deal,
• 12:54
  right?
• 12:54
  This
• 12:54
  is
• 12:54
  not
• 12:55
  your
• 12:55
  grandmother's
• 12:57
  chewing
• 12:58
  leaf.
• 12:58
  Like
• 12:58
  this
• 12:58
  is
• 12:59
  a,
• 12:59
  you
• 12:59
  can
• 13:00
  see
• 13:00
  how
• 13:00
  this
• 13:00
  could
• 13:00
  be
• 13:00
  potentially
• 13:01
  problematic.
• 13:02
  And
• 13:02
  the
• 13:02
  third
• 13:02
  pearl
• 13:03
  is
• 13:03
  that
• 13:03
  this
• 13:03
  is
• 13:03
  not
• 13:04
  really
• 13:04
  visible
• 13:04
  on
• 13:04
  any
• 13:05
  standard
• 13:05
  drug
• 13:05
  screen.
• 13:06
  You
• 13:06
  have
• 13:06
  to
• 13:06
  really
• 13:07
  go
• 13:07
  out
• 13:07
  of
• 13:07
  your
• 13:07
  way
• 13:07
  to
• 13:08
  order
• 13:08
  this
• 13:08
  and
• 13:09
  test
• 13:09
  it.
• 13:09
  It's
• 13:09
  not
• 13:09
  on
• 13:10
  your
• 13:10
  standard
• 13:10
  5
• 13:10
  panel
• 13:11
  drug
• 13:11
  screen.
• 13:12
  Not
• 13:12
  on
• 13:12
  the
• 13:12
  extended
• 13:13
  10
• 13:13
  panel
• 13:13
  or
• 13:13
  12
• 13:14
  panel
• 13:14
  screens
• 13:14
  either.
• 13:15
  It's
• 13:16
  not
• 13:16
  even
• 13:16
  on
• 13:16
  the
• 13:16
  expanded
• 13:17
  opioid
• 13:18
  immunoassays.
• 13:18
  Right.
• 13:19
  Which
• 13:19
  detect
• 13:19
  like
• 13:20
  morphine
• 13:20
  and
• 13:20
  codeine
• 13:21
  and
• 13:21
  oxycodone
• 13:21
  and
• 13:22
  fentanyl.
• 13:22
  It's
• 13:22
  not
• 13:22
  even
• 13:23
  on
• 13:23
  that.
• 13:23
  Okay.
• 13:24
  They
• 13:24
  can
• 13:25
  have
• 13:25
  a
• 13:25
  patient
• 13:26
  on
• 13:26
  Kratom
• 13:26
  could
• 13:26
  have
• 13:27
  a
• 13:27
  completely
• 13:27
  clean
• 13:27
  urine
• 13:28
  drug
• 13:28
  screen.
• 13:28
  So
• 13:28
  you're
• 13:29
  trying
• 13:29
  to
• 13:29
  catch
• 13:29
  this
• 13:29
  thing
• 13:29
  and
• 13:30
  you
• 13:30
  feel
• 13:30
  confident
• 13:31
  that
• 13:31
  your
• 13:31
  patient's
• 13:31
  not
• 13:31
  on
• 13:32
  any
• 13:32
  kind
• 13:32
  of
• 13:32
  opioid
• 13:33
  and
• 13:33
  they
• 13:33
  are.
• 13:34
  And
• 13:35
  well,
• 13:35
  that's
• 13:35
  a
• 13:35
  big
• 13:36
  deal
• 13:36
  for
• 13:36
  a
• 13:36
  couple
• 13:37
  reasons
• 13:37
  in
• 13:37
  Pearl
• 13:38
  4
• 13:38
  and
• 13:38
  5
• 13:38
  that
• 13:39
  we're
• 13:39
  going
• 13:39
  to
• 13:39
  talk
• 13:39
  about.
• 13:40
  But
• 13:40
  it's,
• 13:40
  it's
• 13:40
  a
• 13:41
  real
• 13:41
  problem
• 13:41
  because
• 13:41
  you're
• 13:41
  going
• 13:41
  to
• 13:42
  have
• 13:42
  this
• 13:42
  false
• 13:42
  sense
• 13:42
  of
• 13:43
  reassurance
• 13:43
  that
• 13:44
  everything's
• 13:44
  hunky
• 13:44
  dory
• 13:45
  and
• 13:45
  there's
• 13:45
  nothing
• 13:45
  else
• 13:46
  you
• 13:46
  need
• 13:46
  to
• 13:46
  look
• 13:46
  for.
• 13:47
  And
• 13:48
  yet
• 13:48
  your
• 13:48
  patient
• 13:48
  is
• 13:49
  not
• 13:49
  substance
• 13:50
  free.
• 13:50
  Just
• 13:50
  because
• 13:50
  they
• 13:51
  have
• 13:51
  a
• 13:51
  negative
• 13:51
  drug
• 13:52
  screen,
• 13:52
  okay,
• 13:53
  it
• 13:53
  doesn't
• 13:54
  mean
• 13:54
  that
• 13:55
  you
• 13:55
  don't
• 13:55
  have
• 13:55
  massive
• 13:56
  drug
• 13:56
  interactions
• 13:57
  that
• 13:57
  could
• 13:57
  be
• 13:57
  creeping
• 13:57
  in.
• 13:58
  Um,
• 13:59
  because
• 13:59
  a
• 13:59
  lot
• 14:00
  of
• 14:00
  these
• 14:00
  designer
• 14:00
  drugs
• 14:01
  and
• 14:01
  Kratom
• 14:01
  are
• 14:01
  not
• 14:02
  gonna
• 14:02
  show
• 14:02
  up,
• 14:03
  right?
• 14:04
  Um,
• 14:05
  and
• 14:05
  that's
• 14:05
  a
• 14:06
  really,
• 14:07
  really
• 14:07
  big
• 14:07
  problem.
• 14:08
  Okay?
• 14:08
  So
• 14:09
  if
• 14:09
  you're
• 14:09
  seeing
• 14:09
  opioid
• 14:10
  withdrawal
• 14:10
  symptoms,
• 14:11
  they're,
• 14:12
  they're
• 14:12
  tearful,
• 14:14
  right?
• 14:14
  They're
• 14:14
  nauseous,
• 14:15
  they're
• 14:16
  not
• 14:16
  sleeping,
• 14:17
  they're
• 14:17
  yawning
• 14:17
  a
• 14:18
  lot,
• 14:18
  and
• 14:19
  you
• 14:19
  have
• 14:19
  a
• 14:19
  clean
• 14:19
  urine.
• 14:20
  Ask
• 14:20
  about
• 14:20
  Kratom,
• 14:22
  right?
• 14:23
  Ask
• 14:23
  about
• 14:23
  that
• 14:23
  stuff.
• 14:24
  Ask
• 14:25
  about
• 14:25
  gas
• 14:25
  station
• 14:25
  heroin,
• 14:26
  okay?
• 14:27
  Because
• 14:27
  this
• 14:27
  is
• 14:27
  all
• 14:28
  over
• 14:28
  the
• 14:28
  place
• 14:28
  right
• 14:28
  now.
• 14:29
  Now
• 14:29
  you
• 14:30
  can
• 14:30
  order
• 14:30
  a
• 14:30
  Kratom
• 14:31
  specific
• 14:31
  urine
• 14:31
  test
• 14:32
  Through
• 14:32
  Quest
• 14:32
  or
• 14:32
  LabCorp.
• 14:34
  So
• 14:34
  you
• 14:34
  can
• 14:34
  do
• 14:35
  that.
• 14:35
  Okay?
• 14:36
  Now
• 14:36
  the
• 14:36
  test
• 14:37
  is
• 14:37
  called
• 14:39
  Mitragynine
• 14:40
  urine.
• 14:40
  Okay?
• 14:41
  Mitragynine
• 14:42
  is
• 14:42
  that
• 14:43
  alkaloid
• 14:43
  name
• 14:43
  we
• 14:44
  talked
• 14:44
  about.
• 14:44
  I
• 14:45
  normally
• 14:45
  wouldn't
• 14:45
  share
• 14:45
  that
• 14:45
  with
• 14:46
  you
• 14:46
  cause
• 14:46
  it's
• 14:46
  irrelevant.
• 14:47
  But
• 14:47
  it's
• 14:47
  relevant
• 14:48
  because
• 14:49
  this
• 14:49
  isn't
• 14:49
  called
• 14:49
  the
• 14:50
  Kratom
• 14:50
  piss
• 14:50
  test.
• 14:51
  When
• 14:51
  you
• 14:52
  call
• 14:52
  QUEST
• 14:52
  or
• 14:53
  LabCorp,
• 14:53
  you're
• 14:54
  submitting
• 14:55
  usually
• 14:55
  under
• 14:56
  other.
• 14:56
  Like
• 14:56
  a
• 14:56
  lab
• 14:57
  Metragynine
• 14:59
  or
• 14:59
  Kratom
• 15:00
  panel
• 15:01
  is
• 15:01
  something
• 15:01
  you
• 15:01
  could
• 15:01
  probably
• 15:02
  put
• 15:02
  in
• 15:02
  there.
• 15:03
  It's
• 15:03
  not
• 15:03
  very
• 15:03
  expensive.
• 15:04
  But
• 15:04
  now,
• 15:05
  but,
• 15:05
  but
• 15:05
  now
• 15:06
  you
• 15:06
  know
• 15:06
  you
• 15:06
  have
• 15:06
  to
• 15:06
  order
• 15:06
  it
• 15:07
  if,
• 15:07
  if
• 15:07
  you're
• 15:07
  suspicious
• 15:08
  of
• 15:08
  it.
• 15:10
  And
• 15:10
  so
• 15:10
  I
• 15:10
  think
• 15:10
  that's
• 15:11
  really
• 15:11
  important.
• 15:11
  Okay?
• 15:12
  But
• 15:13
  this
• 15:13
  is
• 15:13
  invisible.
• 15:14
  So
• 15:14
  this
• 15:14
  is
• 15:14
  not
• 15:14
  something
• 15:14
  that's
• 15:15
  going
• 15:15
  to
• 15:15
  show
• 15:15
  up.
• 15:15
  It's
• 15:16
  invisible
• 15:16
  because
• 15:16
  your
• 15:17
  patient
• 15:17
  won't
• 15:17
  mention
• 15:17
  it.
• 15:18
  They
• 15:18
  won't
• 15:18
  know
• 15:18
  to
• 15:18
  mention
• 15:19
  it.
• 15:19
  Maybe
• 15:19
  you
• 15:19
  don't
• 15:19
  know
• 15:19
  to
• 15:19
  ask
• 15:20
  for
• 15:20
  it.
• 15:20
  And
• 15:20
  it's
• 15:20
  not
• 15:21
  going
• 15:21
  to
• 15:21
  show
• 15:21
  up
• 15:21
  on
• 15:21
  a
• 15:21
  drug
• 15:21
  test.
• 15:22
  So
• 15:22
  you
• 15:22
  don't
• 15:22
  even
• 15:23
  have
• 15:23
  the
• 15:23
  luxury
• 15:23
  of
• 15:23
  that.
• 15:24
  On
• 15:25
  top
• 15:25
  of
• 15:25
  that,
• 15:27
  Kratom
• 15:28
  can
• 15:29
  inhibit
• 15:29
  a
• 15:29
  lot
• 15:29
  of
• 15:29
  the
• 15:29
  medications
• 15:30
  you
• 15:30
  are
• 15:31
  prescribing
• 15:31
  your
• 15:31
  patient.
• 15:32
  So
• 15:32
  not
• 15:32
  only
• 15:33
  is
• 15:33
  it
• 15:33
  hidden
• 15:34
  and
• 15:34
  not
• 15:34
  told
• 15:34
  to
• 15:35
  you
• 15:35
  or
• 15:36
  showing
• 15:36
  up
• 15:36
  on
• 15:36
  a
• 15:36
  drug
• 15:36
  panel,
• 15:37
  but
• 15:37
  it
• 15:38
  could
• 15:38
  be
• 15:38
  causing
• 15:38
  aesthesia
• 15:39
  and
• 15:39
  elevating
• 15:40
  your
• 15:40
  Abilify
• 15:41
  levels.
• 15:41
  And
• 15:41
  you
• 15:41
  have
• 15:41
  no
• 15:42
  idea.
• 15:42
  And
• 15:42
  here
• 15:42
  they
• 15:42
  are
• 15:42
  not
• 15:43
  taking
• 15:43
  their
• 15:43
  Abilify,
• 15:44
  complaining
• 15:45
  of
• 15:47
  high,
• 15:47
  you
• 15:47
  know,
• 15:48
  of,
• 15:48
  of
• 15:48
  feeling
• 15:48
  like
• 15:49
  they
• 15:49
  want
• 15:49
  to
• 15:49
  jump
• 15:49
  out
• 15:49
  of
• 15:49
  their
• 15:49
  skin
• 15:50
  and
• 15:50
  they're
• 15:50
  non
• 15:51
  adherent
• 15:51
  to
• 15:51
  their
• 15:51
  Abilify.
• 15:52
  And
• 15:52
  an
• 15:52
  otherwise
• 15:53
  perfectly
• 15:53
  good
• 15:54
  medication
• 15:55
  that
• 15:55
  has
• 15:55
  minimal
• 15:56
  metabol,
• 15:56
  metabolic
• 15:57
  side
• 15:57
  effects
• 15:58
  just
• 15:58
  got
• 15:58
  Torpedoed
• 15:59
  because
• 16:00
  we
• 16:00
  didn't
• 16:00
  know
• 16:00
  Kratom
• 16:01
  was
• 16:01
  on
• 16:01
  board.
• 16:02
  And
• 16:02
  it
• 16:02
  is
• 16:02
  inhibiting
• 16:03
  via
• 16:04
  2D,
• 16:05
  via
• 16:06
  2D6.
• 16:08
  The
• 16:08
  Abilify
• 16:09
  CYP
• 16:10
  2D6
• 16:10
  has
• 16:11
  a
• 16:11
  lot
• 16:11
  of
• 16:11
  different
• 16:11
  substrates.
• 16:13
  Abilify,
• 16:13
  Risperdal,
• 16:14
  Paxil,
• 16:15
  Prozac,
• 16:15
  Effexor.
• 16:16
  It's
• 16:16
  a
• 16:16
  big
• 16:16
  one.
• 16:17
  It's
• 16:17
  probably
• 16:17
  worth
• 16:17
  memorizing
• 16:18
  Those,
• 16:18
  honestly,
• 16:19
  because
• 16:20
  2D6
• 16:20
  is
• 16:20
  so
• 16:21
  ubiquitous.
• 16:22
  Okay,
• 16:22
  so
• 16:23
  think
• 16:23
  about
• 16:23
  those
• 16:23
  other
• 16:24
  ones
• 16:24
  too.
• 16:24
  The
• 16:24
  prolactin
• 16:25
  elevation
• 16:25
  on
• 16:26
  risperidol
• 16:26
  shares
• 16:27
  the
• 16:27
  2D6,
• 16:28
  right?
• 16:28
  Haldol.
• 16:29
  Now
• 16:29
  you
• 16:29
  have
• 16:29
  QT
• 16:30
  prolongation
• 16:30
  with
• 16:30
  Haldol,
• 16:31
  Paxil,
• 16:32
  Prozac,
• 16:32
  Effexor.
• 16:33
  Serotonin
• 16:34
  syndrome
• 16:34
  risk.
• 16:34
  Right,
• 16:34
  because
• 16:35
  we're
• 16:35
  elevating
• 16:36
  levels
• 16:36
  of
• 16:36
  those
• 16:36
  medications
• 16:37
  we
• 16:37
  can
• 16:37
  call
• 16:37
  serotonin
• 16:38
  syndrome.
• 16:39
  So
• 16:39
  think
• 16:40
  of
• 16:40
  the
• 16:40
  degree
• 16:41
  of
• 16:41
  interference
• 16:42
  Kratom
• 16:43
  can
• 16:44
  hurl
• 16:45
  into
• 16:45
  your
• 16:45
  patient
• 16:46
  care.
• 16:47
  And,
• 16:47
  and
• 16:47
  it'll
• 16:48
  hurl
• 16:48
  in.
• 16:49
  Hurl
• 16:49
  it
• 16:49
  in
• 16:49
  a
• 16:49
  way
• 16:49
  that
• 16:50
  is
• 16:50
  really
• 16:50
  silent
• 16:51
  but
• 16:51
  destructive.
• 16:52
  So
• 16:53
  we've
• 16:53
  gotta
• 16:53
  look
• 16:53
  for
• 16:53
  these
• 16:54
  things,
• 16:54
  right?
• 16:57
  It
• 16:57
  can
• 16:57
  also
• 16:58
  inhibit
• 16:58
  CYP3A4.
• 16:59
  So
• 16:59
  watch
• 17:00
  out
• 17:00
  for
• 17:00
  Seroquel.
• 17:01
  Your
• 17:01
  patient
• 17:01
  might
• 17:01
  be.
• 17:02
  Patient
• 17:02
  might
• 17:02
  be
• 17:02
  more
• 17:03
  sedated.
• 17:04
  And
• 17:04
  then,
• 17:05
  of
• 17:05
  course,
• 17:05
  benzodiazepines.
• 17:07
  Okay,
• 17:07
  because
• 17:08
  that's
• 17:08
  a.
• 17:08
  That's
• 17:08
  a
• 17:08
  big
• 17:09
  deal.
• 17:10
  Like
• 17:11
  Xanax,
• 17:11
  potentially.
• 17:13
  Okay,
• 17:13
  Elevated
• 17:14
  levels
• 17:14
  of
• 17:14
  Xanax.
• 17:15
  Now
• 17:15
  you
• 17:15
  have
• 17:15
  respiratory
• 17:16
  depression.
• 17:16
  And
• 17:16
  this
• 17:17
  is
• 17:17
  how
• 17:17
  people
• 17:17
  die
• 17:17
  on
• 17:18
  Kratom,
• 17:19
  right?
• 17:20
  They.
• 17:20
  They
• 17:20
  have
• 17:21
  higher
• 17:21
  benzo
• 17:21
  levels
• 17:22
  plus
• 17:23
  Kratom's
• 17:23
  own
• 17:23
  opioid
• 17:24
  effects
• 17:25
  that
• 17:26
  3A4
• 17:27
  inhibition,
• 17:28
  and
• 17:28
  BAM.
• 17:28
  You
• 17:28
  have
• 17:28
  an
• 17:29
  overdose
• 17:30
  off
• 17:30
  of
• 17:30
  something
• 17:30
  you
• 17:30
  thought
• 17:31
  was
• 17:31
  innocent.
• 17:32
  Just
• 17:32
  something
• 17:32
  you
• 17:32
  bought
• 17:32
  at
• 17:33
  a
• 17:33
  gas
• 17:33
  station.
• 17:34
  Couldn't
• 17:34
  possibly
• 17:34
  kill
• 17:34
  me.
• 17:35
  I
• 17:35
  bought
• 17:35
  it
• 17:35
  at
• 17:35
  a
• 17:35
  gas
• 17:36
  station.
• 17:36
  Well,
• 17:37
  it
• 17:37
  can,
• 17:38
  in
• 17:39
  combination.
• 17:39
  And
• 17:39
  you
• 17:39
  have
• 17:40
  to
• 17:40
  be
• 17:40
  very
• 17:40
  careful.
• 17:41
  Okay,
• 17:42
  so
• 17:43
  that's
• 17:44
  a
• 17:44
  big
• 17:44
  deal.
• 17:45
  Interactions
• 17:46
  are
• 17:46
  a
• 17:46
  huge
• 17:47
  problem,
• 17:47
  right?
• 17:48
  Because
• 17:48
  they
• 17:48
  cause
• 17:48
  side
• 17:48
  effects
• 17:49
  which
• 17:49
  lead
• 17:49
  to
• 17:49
  non
• 17:50
  adherence,
• 17:50
  which
• 17:51
  leads
• 17:51
  to
• 17:51
  the
• 17:51
  resurgence
• 17:52
  of
• 17:52
  symptoms,
• 17:53
  morbidity,
• 17:53
  mortality,
• 17:54
  hospitalizations,
• 17:55
  and
• 17:55
  so
• 17:55
  forth.
• 17:56
  So
• 17:56
  ask
• 17:56
  these
• 17:57
  questions,
• 17:57
  be
• 17:57
  a
• 17:57
  really
• 17:58
  good
• 17:58
  detective.
• 17:59
  And.
• 17:59
  And
• 17:59
  that
• 17:59
  leads
• 18:00
  into
• 18:00
  the
• 18:00
  last
• 18:00
  pearl,
• 18:01
  that
• 18:01
  Kratom.
• 18:02
  And
• 18:02
  it
• 18:02
  may
• 18:02
  be
• 18:02
  the
• 18:03
  most
• 18:03
  important
• 18:03
  pearl,
• 18:04
  but
• 18:04
  Kratom
• 18:05
  withdrawal
• 18:05
  can
• 18:06
  mimic
• 18:06
  a
• 18:06
  psychiatric
• 18:07
  emergency,
• 18:07
  and
• 18:08
  that
• 18:08
  includes
• 18:08
  psychosis
• 18:09
  or
• 18:09
  mania,
• 18:09
  right?
• 18:11
  So
• 18:14
  just
• 18:14
  like
• 18:14
  regular
• 18:14
  opioid
• 18:15
  withdrawal,
• 18:16
  you
• 18:17
  might
• 18:17
  see,
• 18:17
  you
• 18:17
  know,
• 18:17
  joint
• 18:18
  pain
• 18:18
  and
• 18:19
  diarrhea,
• 18:20
  nausea.
• 18:20
  We
• 18:21
  talked
• 18:21
  about
• 18:21
  yawning
• 18:21
  a
• 18:22
  lot
• 18:22
  and
• 18:22
  being
• 18:22
  tearful
• 18:23
  and
• 18:23
  insomnia.
• 18:24
  Irritability
• 18:24
  is
• 18:24
  kind
• 18:24
  of
• 18:25
  a
• 18:25
  universal
• 18:25
  withdrawal
• 18:26
  symptom.
• 18:26
  But
• 18:27
  then
• 18:27
  on
• 18:27
  top
• 18:27
  of
• 18:27
  that,
• 18:29
  the
• 18:29
  unique
• 18:29
  withdrawal
• 18:30
  symptoms
• 18:31
  to
• 18:31
  Kratom
• 18:31
  are
• 18:32
  hallucinations,
• 18:33
  you
• 18:33
  know,
• 18:33
  feeling
• 18:34
  paranoid,
• 18:35
  persecutory
• 18:36
  delusions.
• 18:37
  Confusion,
• 18:38
  disorientation,
• 18:39
  just
• 18:39
  hostile
• 18:40
  and
• 18:40
  aggressive
• 18:40
  depression
• 18:41
  and
• 18:41
  anxiety.
• 18:42
  And
• 18:42
  this
• 18:42
  won't
• 18:43
  come
• 18:43
  across
• 18:43
  as
• 18:44
  obvious
• 18:44
  as
• 18:44
  you
• 18:44
  think.
• 18:44
  You
• 18:45
  know,
• 18:45
  it's
• 18:45
  not
• 18:45
  always
• 18:45
  like
• 18:45
  a
• 18:46
  Hollywood
• 18:46
  movie
• 18:46
  where
• 18:47
  bloodshot
• 18:48
  eyes
• 18:48
  and
• 18:48
  someone's
• 18:49
  thrashing
• 18:49
  and
• 18:49
  fighting
• 18:50
  you.
• 18:50
  You
• 18:51
  might
• 18:51
  just
• 18:51
  see
• 18:51
  a
• 18:51
  patient
• 18:51
  in
• 18:52
  an
• 18:52
  outpatient.
• 18:53
  You
• 18:54
  might
• 18:54
  have
• 18:54
  an
• 18:54
  outpatient
• 18:55
  routine
• 18:55
  follow
• 18:56
  up,
• 18:56
  and
• 18:56
  they're
• 18:57
  just
• 18:57
  a
• 18:57
  lot
• 18:57
  more
• 18:57
  hostile
• 18:58
  and
• 18:58
  aggressive
• 18:58
  and
• 18:58
  paranoid.
• 18:59
  And
• 18:59
  you
• 18:59
  might
• 18:59
  think
• 19:00
  like,
• 19:00
  oh
• 19:00
  my
• 19:00
  God,
• 19:00
  this
• 19:01
  is
• 19:01
  major
• 19:01
  depression
• 19:02
  with
• 19:02
  psychotic
• 19:03
  features.
• 19:03
  This
• 19:03
  is
• 19:04
  their
• 19:04
  depression
• 19:04
  worsening
• 19:05
  maybe.
• 19:05
  I'm
• 19:06
  thinking
• 19:06
  they're
• 19:06
  on
• 19:06
  the
• 19:06
  bipolar
• 19:07
  spectrum
• 19:07
  all
• 19:07
  of
• 19:08
  a
• 19:08
  sudden.
• 19:08
  And
• 19:09
  lo
• 19:09
  and
• 19:09
  behold,
• 19:10
  there's
• 19:10
  this
• 19:10
  elephant
• 19:11
  in
• 19:11
  the
• 19:11
  room
• 19:12
  and
• 19:12
  it's
• 19:12
  really
• 19:12
  just
• 19:13
  withdrawal
• 19:13
  that
• 19:13
  has
• 19:14
  been
• 19:14
  precipitated
• 19:14
  in
• 19:15
  the
• 19:15
  last
• 19:15
  one
• 19:15
  to
• 19:15
  three
• 19:15
  days.
• 19:16
  And
• 19:16
  it's
• 19:16
  Kratom.
• 19:17
  And
• 19:17
  because
• 19:17
  we
• 19:18
  didn't
• 19:18
  ask
• 19:18
  the
• 19:18
  question,
• 19:19
  we
• 19:19
  might
• 19:19
  increase
• 19:19
  their
• 19:20
  ssri.
• 19:20
  And
• 19:21
  oh
• 19:21
  my
• 19:21
  God,
• 19:21
  now
• 19:21
  they're
• 19:22
  on
• 19:22
  Kratom
• 19:22
  and
• 19:23
  it's
• 19:23
  Prozac
• 19:23
  and
• 19:24
  you
• 19:24
  just
• 19:24
  elevate,
• 19:25
  you
• 19:25
  just
• 19:25
  raise
• 19:25
  the
• 19:25
  serotonin
• 19:26
  syndrome
• 19:26
  risk
• 19:26
  because
• 19:27
  it's
• 19:27
  Kratom's
• 19:28
  inhibiting
• 19:29
  Prozac.
• 19:30
  And
• 19:30
  now
• 19:31
  you
• 19:31
  thought
• 19:31
  you
• 19:31
  were
• 19:31
  treating
• 19:32
  their
• 19:32
  psychosis
• 19:33
  by
• 19:33
  helping
• 19:33
  their
• 19:34
  depression
• 19:34
  get
• 19:34
  better
• 19:35
  because
• 19:35
  their
• 19:35
  depression
• 19:35
  usually
• 19:36
  worsens
• 19:37
  in
• 19:37
  line
• 19:37
  with
• 19:37
  their
• 19:37
  psychosis.
• 19:38
  And
• 19:38
  look
• 19:38
  what
• 19:39
  happens.
• 19:39
  Right?
• 19:39
  Look,
• 19:40
  the.
• 19:40
  About
• 19:41
  look,
• 19:42
  just
• 19:42
  reflect
• 19:42
  on
• 19:43
  the
• 19:43
  amount
• 19:43
  of
• 19:43
  destruction
• 19:44
  that
• 19:44
  can
• 19:44
  happen
• 19:45
  with,
• 19:45
  with
• 19:45
  that
• 19:45
  kind
• 19:45
  of
• 19:46
  behavior.
• 19:46
  Because
• 19:47
  now
• 19:48
  you've,
• 19:49
  you've
• 19:50
  misconstrued
• 19:50
  the
• 19:50
  diagnosis.
• 19:51
  And
• 19:52
  because
• 19:52
  of
• 19:52
  that,
• 19:52
  your
• 19:53
  treatment
• 19:53
  plan
• 19:53
  is
• 19:53
  causing
• 19:54
  even
• 19:54
  worse
• 19:55
  problems.
• 19:56
  Very
• 19:56
  dangerous
• 19:57
  problems,
• 19:57
  as
• 19:57
  a
• 19:58
  matter
• 19:58
  of
• 19:58
  fact.
• 19:59
  Right.
• 20:00
  So
• 20:00
  this
• 20:00
  is
• 20:01
  something
• 20:01
  we
• 20:01
  have
• 20:01
  to
• 20:02
  really
• 20:02
  be
• 20:02
  careful
• 20:03
  about,
• 20:03
  because
• 20:03
  the
• 20:03
  last
• 20:03
  thing
• 20:04
  we
• 20:04
  want
• 20:04
  to
• 20:04
  do
• 20:04
  is,
• 20:05
  you
• 20:06
  know,
• 20:06
  provide
• 20:06
  some
• 20:06
  unnecessary
• 20:07
  antipsychotic
• 20:08
  or
• 20:08
  mood
• 20:08
  stabilizer
• 20:09
  onto
• 20:10
  this
• 20:10
  that
• 20:10
  they
• 20:10
  don't
• 20:10
  need
• 20:11
  when
• 20:12
  just
• 20:12
  stopping
• 20:14
  a
• 20:14
  substance
• 20:14
  and
• 20:15
  waiting
• 20:15
  a
• 20:15
  few
• 20:15
  days
• 20:16
  would
• 20:16
  clear
• 20:16
  out
• 20:17
  these
• 20:17
  psychotic
• 20:17
  symptoms.
• 20:18
  Okay?
• 20:19
  So
• 20:19
  definitely
• 20:20
  watch
• 20:20
  out
• 20:20
  if
• 20:20
  this
• 20:20
  is
• 20:21
  new
• 20:21
  onset
• 20:21
  psychosis.
• 20:22
  If
• 20:22
  your
• 20:22
  patient
• 20:22
  doesn't
• 20:22
  have
• 20:23
  this
• 20:23
  long
• 20:23
  history
• 20:23
  of
• 20:23
  psychosis,
• 20:24
  all
• 20:24
  of
• 20:24
  a
• 20:24
  sudden
• 20:25
  they
• 20:25
  have
• 20:25
  dilated
• 20:25
  pupils
• 20:26
  and
• 20:26
  diarrhea
• 20:27
  and,
• 20:27
  and,
• 20:28
  and
• 20:28
  they're
• 20:28
  psychotic.
• 20:29
  Be
• 20:29
  careful
• 20:30
  and
• 20:30
  ask
• 20:30
  the
• 20:30
  questions.
• 20:31
  Especially
• 20:32
  if
• 20:33
  you
• 20:33
  have
• 20:33
  those
• 20:33
  physical
• 20:34
  symptoms.
• 20:34
  That's
• 20:34
  often
• 20:34
  the
• 20:35
  tip
• 20:35
  off,
• 20:35
  right?
• 20:35
  If
• 20:35
  you,
• 20:36
  if
• 20:36
  someone's
• 20:36
  having
• 20:36
  like
• 20:36
  a
• 20:36
  prodrome
• 20:37
  or
• 20:37
  schizophrenia,
• 20:38
  it
• 20:38
  doesn't
• 20:39
  make
• 20:39
  sense
• 20:39
  that
• 20:39
  they
• 20:39
  have
• 20:39
  sudden
• 20:40
  diarrhea
• 20:40
  and
• 20:41
  they're,
• 20:41
  and
• 20:41
  they,
• 20:41
  they're
• 20:42
  tearful
• 20:42
  and
• 20:42
  they,
• 20:43
  they're,
• 20:44
  they're,
• 20:44
  they're
• 20:44
  restless
• 20:45
  and
• 20:45
  they
• 20:45
  can't
• 20:45
  sleep
• 20:46
  and
• 20:46
  they're
• 20:46
  yawning
• 20:46
  a
• 20:46
  lot.
• 20:47
  Right?
• 20:47
  Use
• 20:47
  those
• 20:48
  physical
• 20:48
  symptoms
• 20:49
  as
• 20:49
  a
• 20:49
  tip
• 20:49
  off
• 20:49
  that
• 20:49
  this
• 20:50
  might
• 20:50
  be
• 20:50
  a
• 20:50
  substance
• 20:50
  Induced
• 20:51
  withdrawal
• 20:51
  or
• 20:52
  intoxication.
• 20:53
  Kind
• 20:53
  of
• 20:53
  do
• 20:54
  your
• 20:54
  assessment
• 20:55
  and
• 20:55
  then
• 20:55
  figure
• 20:55
  it
• 20:55
  out
• 20:56
  there.
• 20:56
  Okay.
• 20:57
  But
• 20:57
  the
• 20:58
  last
• 20:58
  thing
• 20:58
  we
• 20:58
  want
• 20:58
  to
• 20:59
  do
• 20:59
  is
• 20:59
  complicate
• 20:59
  this
• 21:00
  and
• 21:00
  just
• 21:00
  add
• 21:00
  more
• 21:00
  medications.
• 21:01
  So
• 21:02
  now.
• 21:02
  You
• 21:03
  know
• 21:03
  now.
• 21:03
  So
• 21:03
  prevention
• 21:03
  is
• 21:04
  worth
• 21:04
  a
• 21:04
  pound
• 21:04
  of
• 21:04
  cure,
• 21:05
  right?
• 21:05
  Right.
• 21:05
  That's.
• 21:05
  That's
• 21:06
  the
• 21:06
  key
• 21:06
  here.
• 21:07
  So
• 21:07
  figure
• 21:07
  it
• 21:08
  out
• 21:08
  first
• 21:08
  before
• 21:08
  we
• 21:08
  complicate
• 21:09
  the
• 21:09
  regimen.
• 21:10
  Well,
• 21:10
  I
• 21:10
  hope
• 21:11
  you
• 21:11
  guys
• 21:11
  really
• 21:11
  enjoyed
• 21:12
  this.
• 21:13
  I
• 21:13
  hope
• 21:13
  you.
• 21:13
  You
• 21:14
  got
• 21:14
  some
• 21:14
  good
• 21:14
  pearls
• 21:14
  out
• 21:15
  of
• 21:15
  this.
• 21:16
  Just
• 21:16
  one
• 21:16
  little
• 21:17
  thing
• 21:17
  like
• 21:17
  Kratom
• 21:18
  can
• 21:18
  teach
• 21:18
  us
• 21:18
  a
• 21:18
  lot
• 21:18
  about
• 21:18
  mental
• 21:19
  health.
• 21:19
  How
• 21:20
  to
• 21:20
  interview
• 21:20
  a
• 21:20
  patient,
• 21:21
  what
• 21:21
  to
• 21:21
  ask
• 21:22
  for,
• 21:23
  what.
• 21:23
  What
• 21:23
  to
• 21:23
  assume,
• 21:24
  what
• 21:24
  not
• 21:24
  to
• 21:24
  assume.
• 21:26
  To
• 21:26
  think
• 21:26
  about
• 21:26
  just
• 21:27
  the
• 21:27
  broader
• 21:28
  implications
• 21:28
  of
• 21:31
  the
• 21:31
  fact
• 21:31
  that,
• 21:31
  you
• 21:31
  know,
• 21:32
  you
• 21:32
  can
• 21:32
  go
• 21:32
  online
• 21:32
  and
• 21:33
  buy
• 21:33
  whatever
• 21:33
  and
• 21:34
  market
• 21:34
  it,
• 21:35
  however,
• 21:35
  and
• 21:36
  how
• 21:36
  state
• 21:36
  and
• 21:36
  federal
• 21:37
  laws
• 21:37
  don't
• 21:37
  always
• 21:37
  keep
• 21:37
  up
• 21:38
  with
• 21:38
  the.
• 21:39
  With
• 21:39
  what's
• 21:39
  happening
• 21:40
  economically
• 21:41
  and
• 21:41
  culturally
• 21:42
  and
• 21:42
  the
• 21:42
  implications
• 21:43
  of
• 21:43
  all
• 21:43
  of
• 21:43
  that
• 21:43
  for
• 21:43
  your
• 21:44
  patients
• 21:44
  and
• 21:45
  how
• 21:45
  they
• 21:45
  present
• 21:46
  to
• 21:46
  you.
• 21:47
  It's
• 21:47
  all
• 21:47
  really
• 21:47
  fascinating.
• 21:48
  And
• 21:49
  it's
• 21:49
  our
• 21:49
  job
• 21:49
  to
• 21:49
  be
• 21:49
  on
• 21:50
  top
• 21:50
  of
• 21:50
  this
• 21:50
  as
• 21:51
  best
• 21:51
  as
• 21:51
  we
• 21:51
  can.
• 21:52
  So
• 21:52
  please
• 21:52
  include
• 21:53
  this
• 21:53
  when
• 21:53
  you're
• 21:54
  asking
• 21:54
  about
• 21:54
  the
• 21:54
  patient's
• 21:55
  meds
• 21:55
  and
• 21:55
  supplements.
• 21:56
  Include
• 21:56
  the
• 21:56
  unusual
• 21:57
  ones
• 21:58
  and
• 21:58
  get
• 21:59
  ahead
• 21:59
  of
• 21:59
  this
• 21:59
  while
• 21:59
  you
• 21:59
  can
• 22:00
  and
• 22:00
  provide
• 22:00
  the
• 22:00
  education.
• 22:01
  They
• 22:01
  might
• 22:02
  be
• 22:02
  all
• 22:02
  about
• 22:02
  stopping
• 22:03
  Kratom.
• 22:03
  They
• 22:04
  might
• 22:04
  literally
• 22:04
  think,
• 22:05
  legitimately
• 22:06
  think
• 22:06
  it's
• 22:07
  a
• 22:07
  really
• 22:07
  good
• 22:08
  thing
• 22:08
  for
• 22:08
  them
• 22:08
  to
• 22:08
  take.
• 22:09
  Right.
• 22:09
  Most
• 22:09
  of
• 22:09
  your
• 22:09
  patients,
• 22:10
  they're
• 22:10
  not
• 22:10
  like
• 22:10
  teenage
• 22:11
  kids
• 22:11
  that
• 22:11
  are
• 22:11
  just
• 22:11
  using
• 22:11
  kratom
• 22:12
  to
• 22:12
  be
• 22:12
  cool.
• 22:13
  A
• 22:13
  lot
• 22:13
  of
• 22:14
  folks
• 22:14
  who
• 22:14
  use
• 22:14
  Kratom
• 22:14
  are
• 22:15
  in
• 22:15
  their
• 22:15
  40s
• 22:15
  and
• 22:15
  50s,
• 22:16
  and
• 22:16
  they
• 22:16
  genuinely
• 22:17
  believe
• 22:17
  it's
• 22:17
  medicinal
• 22:18
  and
• 22:18
  it
• 22:18
  helps.
• 22:19
  And
• 22:19
  then
• 22:19
  they
• 22:19
  read
• 22:19
  something
• 22:20
  about,
• 22:21
  you
• 22:21
  know,
• 22:21
  Indonesians
• 22:22
  taking
• 22:22
  this
• 22:23
  in
• 22:23
  the.
• 22:23
  In
• 22:23
  the
• 22:24
  jungles,
• 22:24
  and
• 22:24
  they
• 22:24
  think,
• 22:24
  oh,
• 22:25
  see,
• 22:25
  it's
• 22:25
  natural.
• 22:25
  It's
• 22:26
  totally
• 22:26
  innocent.
• 22:26
  I
• 22:26
  would
• 22:27
  rather
• 22:27
  do
• 22:27
  this
• 22:27
  than
• 22:27
  Prozac.
• 22:28
  But
• 22:28
  they're
• 22:29
  not
• 22:29
  reading
• 22:29
  the
• 22:29
  fine
• 22:30
  print
• 22:30
  about
• 22:31
  the
• 22:32
  concentration
• 22:33
  and
• 22:33
  the
• 22:33
  dose
• 22:33
  and
• 22:34
  the
• 22:34
  medication
• 22:34
  interactions.
• 22:35
  And
• 22:36
  so
• 22:36
  it's
• 22:36
  our
• 22:36
  job
• 22:36
  to
• 22:37
  educate
• 22:37
  and
• 22:37
  empower.
• 22:38
  Now,
• 22:38
  my
• 22:38
  friends,
• 22:39
  if
• 22:39
  you
• 22:39
  are
• 22:39
  enjoying
• 22:39
  this
• 22:40
  podcast
• 22:42
  boy,
• 22:42
  you
• 22:42
  will
• 22:43
  love
• 22:43
  our
• 22:43
  Patreon
• 22:44
  Library.
• 22:45
  I
• 22:45
  built
• 22:45
  the
• 22:45
  Patreon
• 22:46
  Library
• 22:46
  to
• 22:46
  transform
• 22:47
  the
• 22:47
  way
• 22:48
  that
• 22:48
  I
• 22:48
  practice,
• 22:49
  so
• 22:49
  I
• 22:49
  understand
• 22:50
  the
• 22:50
  how
• 22:50
  and
• 22:50
  the
• 22:50
  why
• 22:51
  of
• 22:51
  what
• 22:51
  I'm
• 22:51
  doing.
• 22:52
  Patients
• 22:52
  smell
• 22:52
  that
• 22:53
  a
• 22:53
  mile
• 22:53
  away.
• 22:54
  It
• 22:54
  builds
• 22:54
  trust.
• 22:55
  It
• 22:55
  has
• 22:55
  completely
• 22:56
  changed
• 22:56
  the
• 22:56
  way
• 22:56
  I
• 22:56
  present.
• 22:57
  I
• 22:57
  don't
• 22:57
  know
• 22:57
  where
• 22:58
  I
• 22:58
  would
• 22:58
  be
• 22:58
  without
• 22:58
  this
• 22:59
  library
• 22:59
  of
• 22:59
  information,
• 23:00
  and
• 23:00
  I
• 23:00
  built
• 23:00
  it
• 23:00
  for
• 23:01
  you.
• 23:01
  Go
• 23:02
  to
• 23:02
  patreon.com
• 23:04
  pearlsandprep
• 23:05
  it's
• 23:05
  in
• 23:05
  our
• 23:05
  show
• 23:06
  notes.
• 23:06
  You
• 23:06
  can
• 23:06
  click
• 23:06
  the
• 23:07
  link.
• 23:07
  We'd
• 23:07
  love
• 23:07
  to
• 23:07
  have
• 23:07
  you
• 23:08
  as
• 23:08
  a
• 23:08
  member.
• 23:10
  I'm
• 23:10
  telling
• 23:10
  you,
• 23:11
  the
• 23:11
  difference
• 23:11
  between
• 23:11
  a
• 23:12
  good
• 23:12
  and
• 23:12
  a
• 23:12
  great
• 23:12
  clinician
• 23:13
  are
• 23:13
  the
• 23:13
  ones
• 23:14
  that
• 23:14
  understand
• 23:14
  the
• 23:15
  how
• 23:15
  and
• 23:15
  the
• 23:15
  why
• 23:15
  behind
• 23:16
  what
• 23:16
  they're
• 23:16
  doing.
• 23:16
  They're
• 23:17
  not
• 23:17
  just
• 23:17
  pressing
• 23:17
  buttons
• 23:18
  and
• 23:18
  diagnosing,
• 23:18
  but
• 23:19
  they
• 23:19
  really
• 23:19
  get
• 23:19
  why
• 23:20
  they're
• 23:20
  doing
• 23:20
  stuff.
• 23:21
  And
• 23:21
  it's
• 23:22
  just.
• 23:22
  It
• 23:22
  just
• 23:23
  exponentially
• 23:23
  changes
• 23:24
  the
• 23:24
  way
• 23:24
  you
• 23:24
  practice.
• 23:25
  So
• 23:25
  head
• 23:26
  on
• 23:26
  over
• 23:26
  there.
• 23:26
  You'll
• 23:27
  see
• 23:27
  a
• 23:27
  bunch
• 23:27
  of
• 23:27
  sticky
• 23:28
  visual
• 23:29
  pearls
• 23:29
  and
• 23:30
  ways
• 23:30
  to
• 23:30
  digest
• 23:31
  this
• 23:31
  stuff.
• 23:31
  Really
• 23:32
  interesting
• 23:32
  information
• 23:33
  that
• 23:34
  help
• 23:34
  you
• 23:34
  absorb
• 23:34
  this
• 23:35
  quickly
• 23:35
  and
• 23:35
  empower
• 23:36
  you
• 23:36
  to
• 23:36
  get
• 23:36
  answers
• 23:37
  fast.
• 23:38
  You'll
• 23:38
  love
• 23:38
  it.
• 23:39
  It
• 23:39
  will
• 23:39
  change
• 23:40
  the
• 23:40
  way
• 23:40
  you
• 23:40
  do
• 23:40
  things,
• 23:41
  hands
• 23:41
  down.
• 23:42
  We'd
• 23:42
  love
• 23:42
  to
• 23:42
  have
• 23:42
  you
• 23:43
  until
• 23:43
  next
• 23:43
  time
• 23:43
  here
• 23:44
  on
• 23:44
  Pearls
• 23:44
  and
• 23:45
  Prep.
• 23:45
  Bye.
• 23:45
  Bye.