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The Benzo Boarding Pass: The Pharmacokinetics of Fear at 35,000 Feet · Pearls and Prep

• 0:00
  Foreign.
• 0:05
  Welcome
• 0:05
  back,
• 0:06
  my
• 0:06
  friends,
• 0:06
  to
• 0:06
  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
• 0:14
  to
• 0:14
  practice.
• 0:15
  Well,
• 0:16
  my
• 0:16
  friends,
• 0:17
  we
• 0:17
  are
• 0:17
  preparing
• 0:19
  for
• 0:19
  a
• 0:20
  flight
• 0:21
  from
• 0:21
  New
• 0:21
  York
• 0:22
  City
• 0:23
  to
• 0:23
  Sydney.
• 0:24
  Oh,
• 0:24
  how
• 0:24
  exciting.
• 0:25
  All.
• 0:25
  All
• 0:25
  of
• 0:25
  us
• 0:25
  could
• 0:26
  use
• 0:26
  a
• 0:26
  little
• 0:26
  bit
• 0:26
  of
• 0:26
  a
• 0:27
  vacation,
• 0:27
  right?
• 0:28
  But
• 0:28
  the
• 0:28
  problem
• 0:29
  is
• 0:30
  one
• 0:30
  of
• 0:30
  us
• 0:30
  is
• 0:31
  super
• 0:32
  nervous
• 0:33
  to
• 0:33
  fly.
• 0:34
  That's
• 0:34
  right.
• 0:34
  What
• 0:35
  do
• 0:35
  you
• 0:35
  do
• 0:35
  when
• 0:36
  you
• 0:36
  have
• 0:36
  a
• 0:36
  patient
• 0:37
  in
• 0:37
  your
• 0:37
  office
• 0:38
  who
• 0:38
  has
• 0:38
  extreme
• 0:39
  flying
• 0:40
  phobia?
• 0:41
  They
• 0:41
  don't
• 0:41
  like
• 0:42
  to
• 0:42
  fly.
• 0:42
  They
• 0:42
  have
• 0:42
  panic
• 0:43
  attacks
• 0:44
  when
• 0:44
  they're
• 0:44
  taxiing,
• 0:45
  when
• 0:45
  they
• 0:45
  take
• 0:45
  off,
• 0:46
  when
• 0:46
  they
• 0:46
  land,
• 0:47
  they're
• 0:47
  afraid
• 0:48
  they're
• 0:48
  going
• 0:48
  to
• 0:48
  divert
• 0:48
  the
• 0:49
  flight
• 0:49
  back
• 0:50
  in
• 0:51
  the
• 0:51
  middle
• 0:51
  of
• 0:51
  the
• 0:51
  Atlantic
• 0:51
  Ocean
• 0:53
  all
• 0:53
  the
• 0:53
  way
• 0:54
  around
• 0:54
  to
• 0:54
  Bangor
• 0:55
  airport
• 0:55
  in
• 0:55
  Maine.
• 0:56
  Oh,
• 0:56
  that's
• 0:57
  a
• 0:57
  pain
• 0:57
  in
• 0:57
  the
• 0:57
  butt.
• 0:57
  No
• 0:58
  one
• 0:58
  wants
• 0:58
  to
• 0:58
  be
• 0:58
  that
• 0:59
  guy.
• 0:59
  And
• 0:59
  so
• 0:59
  they're
• 1:00
  coming
• 1:00
  to
• 1:00
  you
• 1:00
  for
• 1:01
  assistance.
• 1:02
  And
• 1:02
  this
• 1:02
  patient,
• 1:03
  this
• 1:03
  mock
• 1:04
  patient
• 1:04
  named
• 1:04
  Aaron,
• 1:05
  is
• 1:05
  going
• 1:05
  from
• 1:06
  New
• 1:06
  York
• 1:06
  City
• 1:07
  to
• 1:08
  Sydney,
• 1:09
  Australia.
• 1:10
  This
• 1:10
  is
• 1:11
  a
• 1:11
  very
• 1:11
  long
• 1:12
  flight.
• 1:13
  Okay.
• 1:14
  It's
• 1:14
  roughly
• 1:15
  16
• 1:16
  to
• 1:16
  17
• 1:16
  hours.
• 1:17
  Let's
• 1:17
  say
• 1:18
  it's.
• 1:18
  It's
• 1:18
  direct.
• 1:19
  There's
• 1:19
  no
• 1:19
  layovers,
• 1:20
  and
• 1:20
  he's
• 1:21
  asking
• 1:21
  you
• 1:21
  for
• 1:21
  assistance.
• 1:22
  What
• 1:23
  do
• 1:23
  we
• 1:23
  do
• 1:23
  here?
• 1:24
  Well,
• 1:25
  we're
• 1:25
  gonna
• 1:25
  learn
• 1:25
  a
• 1:25
  lot
• 1:25
  about
• 1:26
  psychopharmacology
• 1:27
  today.
• 1:28
  We're
• 1:28
  gonna
• 1:28
  sprinkle
• 1:29
  in
• 1:29
  a
• 1:29
  few
• 1:29
  other
• 1:29
  pearls,
• 1:30
  and
• 1:30
  I
• 1:30
  think
• 1:30
  you're
• 1:30
  gonna
• 1:31
  have
• 1:31
  an
• 1:31
  absolute
• 1:32
  blast.
• 1:33
  Let's
• 1:34
  get
• 1:34
  into
• 1:34
  it.
• 1:35
  So,
• 1:36
  my
• 1:36
  friends,
• 1:36
  you
• 1:37
  may
• 1:37
  be
• 1:37
  thinking,
• 1:37
  and
• 1:38
  you
• 1:38
  would
• 1:38
  be
• 1:38
  right
• 1:38
  to
• 1:39
  think
• 1:39
  this,
• 1:39
  that
• 1:41
  you
• 1:41
  have
• 1:41
  to
• 1:41
  find
• 1:42
  a
• 1:42
  medication
• 1:43
  with
• 1:43
  a
• 1:43
  really
• 1:43
  good
• 1:44
  half
• 1:44
  life
• 1:45
  in
• 1:45
  order
• 1:46
  to
• 1:46
  cover
• 1:46
  Aaron's
• 1:47
  journey
• 1:47
  from
• 1:47
  New
• 1:47
  York
• 1:48
  City
• 1:48
  to
• 1:49
  Sydney.
• 1:50
  And
• 1:50
  you
• 1:50
  would.
• 1:51
  You
• 1:51
  would
• 1:51
  be
• 1:51
  correct.
• 1:52
  But
• 1:52
  there
• 1:53
  would
• 1:53
  be
• 1:53
  caveats
• 1:53
  to
• 1:54
  that,
• 1:54
  and
• 1:54
  they're
• 1:55
  very
• 1:55
  important
• 1:55
  caveats.
• 1:56
  And
• 1:56
  understanding
• 1:57
  psychopharmacology
• 1:58
  is
• 1:58
  really
• 1:58
  key
• 1:59
  in
• 1:59
  being
• 2:00
  able
• 2:00
  to
• 2:01
  explain
• 2:01
  those
• 2:01
  caveats.
• 2:03
  But
• 2:03
  that's
• 2:03
  not
• 2:03
  a
• 2:04
  crazy
• 2:04
  assumption
• 2:05
  to
• 2:05
  start
• 2:05
  with,
• 2:06
  right?
• 2:06
  You
• 2:06
  probably
• 2:07
  want
• 2:07
  to
• 2:07
  stray
• 2:07
  away
• 2:08
  from
• 2:08
  something
• 2:08
  like
• 2:09
  Xanax,
• 2:10
  and
• 2:10
  you
• 2:10
  probably
• 2:11
  want
• 2:11
  to
• 2:11
  position
• 2:11
  yourself
• 2:12
  more
• 2:12
  towards
• 2:13
  something
• 2:13
  like
• 2:13
  Valium
• 2:14
  or
• 2:14
  Klonopin.
• 2:15
  Although
• 2:16
  I
• 2:16
  will
• 2:16
  tell
• 2:16
  you
• 2:16
  as
• 2:17
  a
• 2:17
  little
• 2:17
  spoiler
• 2:17
  alert
• 2:18
  that
• 2:19
  one
• 2:19
  of
• 2:19
  those
• 2:19
  choices,
• 2:20
  Valium
• 2:21
  or
• 2:21
  Klonopin,
• 2:22
  is
• 2:22
  not
• 2:22
  a
• 2:22
  good
• 2:22
  choice
• 2:23
  for
• 2:23
  this
• 2:23
  flight.
• 2:23
  And
• 2:23
  we're
• 2:24
  going
• 2:24
  to
• 2:24
  go
• 2:24
  into
• 2:24
  why
• 2:24
  that
• 2:24
  is
• 2:25
  in
• 2:25
  a
• 2:25
  little
• 2:26
  bit.
• 2:26
  But
• 2:26
  Aaron
• 2:27
  needs
• 2:27
  your
• 2:27
  help.
• 2:28
  Okay.
• 2:28
  He's
• 2:29
  worried
• 2:29
  about
• 2:29
  takeoff.
• 2:30
  He's
• 2:30
  nervous
• 2:31
  in
• 2:31
  the
• 2:31
  air,
• 2:31
  even
• 2:31
  at
• 2:32
  35,000ft.
• 2:33
  He
• 2:33
  doesn't
• 2:33
  like
• 2:34
  being
• 2:34
  up
• 2:34
  there.
• 2:34
  He
• 2:34
  doesn't
• 2:35
  like
• 2:35
  getting
• 2:35
  down
• 2:35
  there
• 2:36
  via
• 2:36
  landing.
• 2:37
  The
• 2:37
  whole
• 2:37
  thing
• 2:38
  kind
• 2:38
  of
• 2:38
  spooks
• 2:38
  him.
• 2:39
  And
• 2:39
  so
• 2:39
  we
• 2:40
  need
• 2:40
  to
• 2:40
  have
• 2:40
  an
• 2:40
  appreciation
• 2:41
  for
• 2:41
  many
• 2:41
  things
• 2:41
  at
• 2:42
  once.
• 2:42
  In
• 2:42
  addition
• 2:43
  to
• 2:43
  half
• 2:44
  life,
• 2:44
  we
• 2:45
  need
• 2:45
  to
• 2:45
  have
• 2:45
  an
• 2:45
  appreciation
• 2:46
  for
• 2:47
  onset
• 2:47
  of
• 2:47
  action.
• 2:48
  Right.
• 2:48
  How
• 2:48
  quickly
• 2:49
  do
• 2:49
  these
• 2:50
  medications
• 2:50
  exert
• 2:51
  a
• 2:51
  therapeutic
• 2:52
  effect?
• 2:52
  Do
• 2:53
  they.
• 2:53
  They
• 2:53
  enter
• 2:53
  a
• 2:54
  therapeutic
• 2:54
  threshold?
• 2:55
  We
• 2:55
  need
• 2:55
  to
• 2:55
  have
• 2:56
  an
• 2:56
  appreciation
• 2:56
  for
• 2:57
  Tmax,
• 2:58
  the
• 2:58
  exact
• 2:59
  moment
• 2:59
  the
• 2:59
  drug
• 2:59
  reaches
• 3:00
  its
• 3:00
  highest
• 3:00
  level
• 3:01
  in
• 3:01
  the
• 3:01
  blood
• 3:01
  and
• 3:01
  the
• 3:02
  brain.
• 3:02
  That's
• 3:02
  also
• 3:03
  very
• 3:03
  important.
• 3:04
  Right.
• 3:05
  The
• 3:05
  point
• 3:05
  by
• 3:06
  which
• 3:06
  Aaron
• 3:06
  is
• 3:06
  going
• 3:07
  to
• 3:07
  receive
• 3:08
  the
• 3:08
  maximum
• 3:08
  amount
• 3:09
  of
• 3:09
  calm
• 3:10
  and
• 3:11
  anxiolysis
• 3:12
  that
• 3:12
  he
• 3:12
  can.
• 3:12
  That's
• 3:13
  really
• 3:13
  key
• 3:14
  here.
• 3:14
  We
• 3:14
  also
• 3:14
  want
• 3:15
  to
• 3:15
  understand
• 3:15
  the
• 3:15
  clinical
• 3:16
  duration
• 3:16
  of
• 3:16
  these
• 3:16
  medications,
• 3:18
  how
• 3:18
  long
• 3:19
  the
• 3:19
  drug
• 3:19
  is
• 3:19
  going
• 3:20
  to
• 3:20
  actively
• 3:20
  relieve
• 3:21
  his
• 3:21
  symptoms.
• 3:22
  That's
• 3:22
  very
• 3:22
  key
• 3:23
  because
• 3:23
  that
• 3:23
  can
• 3:23
  be
• 3:24
  very
• 3:24
  different
• 3:24
  than
• 3:24
  a
• 3:24
  half
• 3:25
  life.
• 3:25
  And
• 3:25
  we'll
• 3:25
  explain
• 3:26
  that
• 3:26
  shortly.
• 3:27
  Right.
• 3:27
  It's
• 3:27
  not
• 3:27
  all
• 3:27
  about
• 3:27
  the
• 3:28
  half
• 3:28
  life.
• 3:28
  We
• 3:28
  can't
• 3:28
  just
• 3:29
  understand
• 3:29
  the
• 3:29
  half
• 3:30
  life
• 3:31
  if
• 3:31
  we
• 3:31
  want
• 3:31
  to
• 3:31
  understand
• 3:32
  the
• 3:32
  entire
• 3:33
  medication
• 3:33
  and
• 3:33
  what
• 3:34
  we're
• 3:34
  looking
• 3:34
  at
• 3:34
  here.
• 3:35
  Okay.
• 3:36
  And
• 3:37
  we
• 3:37
  need
• 3:37
  to
• 3:37
  understand
• 3:38
  terms
• 3:38
  like
• 3:39
  lipophilicity
• 3:40
  and
• 3:41
  therapeutic
• 3:41
  window.
• 3:42
  Okay?
• 3:43
  Lipophilicity
• 3:43
  meaning
• 3:44
  how
• 3:44
  easily
• 3:44
  a
• 3:45
  drug
• 3:45
  dissolves
• 3:45
  in
• 3:45
  fats
• 3:46
  or
• 3:47
  basically
• 3:47
  how
• 3:47
  fast
• 3:48
  the
• 3:48
  drug
• 3:48
  can
• 3:48
  enter
• 3:48
  your
• 3:49
  brain.
• 3:49
  Our
• 3:49
  brain
• 3:49
  is
• 3:50
  about
• 3:50
  60%
• 3:50
  fat,
• 3:51
  so
• 3:51
  we
• 3:51
  know
• 3:52
  drugs
• 3:52
  that
• 3:52
  are
• 3:53
  highly
• 3:53
  lipophilic
• 3:55
  tend
• 3:55
  to
• 3:55
  enter
• 3:56
  the
• 3:56
  brain
• 3:56
  faster.
• 3:57
  They
• 3:57
  also
• 3:57
  tend
• 3:57
  to
• 3:58
  exit
• 3:58
  the
• 3:58
  brain
• 3:58
  faster.
• 3:59
  And
• 3:59
  that's
• 3:59
  kind
• 3:59
  of
• 3:59
  a
• 3:59
  double
• 4:00
  edged
• 4:00
  sword.
• 4:01
  So
• 4:02
  these
• 4:02
  are
• 4:02
  the
• 4:02
  operative
• 4:03
  terms
• 4:03
  we
• 4:03
  need
• 4:03
  to
• 4:03
  be
• 4:04
  familiar
• 4:04
  with
• 4:04
  and
• 4:04
  we
• 4:05
  need
• 4:05
  to
• 4:05
  get
• 4:05
  excited
• 4:06
  about
• 4:06
  because
• 4:07
  if
• 4:07
  we
• 4:07
  understand
• 4:07
  them,
• 4:08
  we
• 4:08
  are
• 4:08
  now
• 4:08
  empowered
• 4:09
  to
• 4:09
  explain
• 4:10
  and
• 4:10
  reassure
• 4:11
  Aaron
• 4:12
  about
• 4:13
  his
• 4:13
  medication
• 4:13
  and
• 4:14
  what
• 4:14
  to
• 4:14
  expect.
• 4:15
  Now,
• 4:15
  we're
• 4:16
  going
• 4:16
  to
• 4:16
  talk
• 4:16
  about
• 4:16
  benzos
• 4:17
  in
• 4:17
  particular
• 4:18
  in
• 4:18
  this
• 4:18
  le.
• 4:19
  In
• 4:19
  this
• 4:19
  discussion
• 4:20
  today.
• 4:20
  And
• 4:21
  that
• 4:21
  is
• 4:21
  not
• 4:21
  to
• 4:22
  say
• 4:22
  that
• 4:22
  benzos
• 4:23
  are
• 4:24
  a
• 4:24
  first
• 4:24
  line
• 4:25
  decision
• 4:25
  in
• 4:25
  this
• 4:26
  case.
• 4:26
  It's
• 4:26
  more
• 4:26
  for
• 4:27
  you
• 4:28
  to
• 4:28
  have
• 4:29
  a
• 4:30
  conceptual
• 4:31
  appreciation
• 4:32
  of
• 4:33
  these
• 4:33
  terms
• 4:33
  like
• 4:34
  half
• 4:34
  life
• 4:35
  and
• 4:36
  onset
• 4:37
  of
• 4:37
  action
• 4:37
  and
• 4:37
  lipophilicity.
• 4:38
  This
• 4:38
  is
• 4:39
  a
• 4:39
  good
• 4:39
  learning
• 4:40
  opportunity
• 4:41
  for
• 4:41
  us
• 4:41
  to
• 4:41
  think
• 4:41
  about
• 4:41
  this
• 4:42
  through
• 4:42
  the
• 4:42
  context
• 4:42
  of
• 4:43
  flying.
• 4:43
  Okay.
• 4:44
  But
• 4:44
  that
• 4:44
  doesn't
• 4:45
  mean
• 4:45
  that
• 4:45
  a
• 4:46
  benzo
• 4:46
  is
• 4:47
  the
• 4:47
  be
• 4:47
  all,
• 4:47
  end
• 4:47
  all
• 4:48
  solution
• 4:48
  here
• 4:49
  in
• 4:49
  a
• 4:49
  case
• 4:49
  with
• 4:50
  somebody
• 4:50
  who
• 4:50
  has
• 4:51
  like
• 4:51
  a
• 4:51
  flying
• 4:52
  phobia.
• 4:53
  Okay.
• 4:53
  I
• 4:53
  will
• 4:54
  tell
• 4:54
  you
• 4:54
  that
• 4:55
  I
• 4:55
  have
• 4:55
  prescribed
• 4:56
  benzos
• 4:56
  before
• 4:57
  for
• 4:57
  people
• 4:58
  with
• 4:58
  isolated
• 4:59
  flying
• 4:59
  phobias,
• 5:00
  but
• 5:00
  my
• 5:01
  philosophy
• 5:01
  is
• 5:02
  you,
• 5:03
  you
• 5:03
  don't
• 5:03
  really
• 5:03
  just
• 5:04
  get
• 5:04
  a
• 5:04
  benzo
• 5:05
  without
• 5:05
  something
• 5:06
  in
• 5:06
  return.
• 5:06
  And
• 5:07
  what
• 5:07
  I
• 5:07
  mean
• 5:07
  by
• 5:07
  that
• 5:08
  is
• 5:09
  it's
• 5:09
  unfair
• 5:10
  to
• 5:10
  the
• 5:10
  patient
• 5:10
  to
• 5:10
  just
• 5:11
  receive
• 5:11
  this
• 5:12
  quick
• 5:13
  solution
• 5:13
  that
• 5:13
  might
• 5:14
  get
• 5:14
  him
• 5:14
  through
• 5:14
  the
• 5:14
  flight
• 5:15
  tomorrow,
• 5:17
  but
• 5:17
  at
• 5:17
  the
• 5:17
  same
• 5:17
  time,
• 5:18
  it's
• 5:18
  not
• 5:18
  a,
• 5:19
  an
• 5:19
  enduring
• 5:20
  fix
• 5:21
  for
• 5:21
  his
• 5:21
  flight
• 5:22
  phobia.
• 5:22
  Right.
• 5:23
  That
• 5:23
  would
• 5:23
  be
• 5:23
  more
• 5:24
  like
• 5:24
  cbt
• 5:25
  or
• 5:25
  exposure
• 5:26
  therapy,
• 5:28
  I
• 5:28
  wouldn't
• 5:29
  go
• 5:29
  as
• 5:29
  far
• 5:29
  to
• 5:29
  say
• 5:29
  as
• 5:30
  SSRIs
• 5:30
  because
• 5:32
  SSRIs
• 5:33
  are
• 5:33
  not
• 5:33
  FDA
• 5:34
  approved
• 5:34
  to
• 5:34
  my
• 5:34
  knowledge
• 5:35
  for
• 5:35
  any
• 5:35
  kind
• 5:35
  of
• 5:36
  specific
• 5:36
  phobia.
• 5:37
  I
• 5:37
  don't
• 5:37
  believe
• 5:37
  anything
• 5:37
  is.
• 5:37
  It's
• 5:38
  exposure
• 5:38
  therapy.
• 5:39
  Right.
• 5:39
  We
• 5:39
  talked
• 5:40
  about
• 5:40
  in
• 5:40
  previous
• 5:41
  episodes
• 5:42
  that
• 5:43
  specific
• 5:43
  phobia
• 5:44
  is
• 5:44
  actually
• 5:44
  the
• 5:44
  most
• 5:44
  common
• 5:45
  anxiety
• 5:45
  disorder
• 5:46
  out
• 5:46
  there
• 5:47
  and
• 5:47
  it's
• 5:47
  also
• 5:47
  the
• 5:47
  one
• 5:47
  least
• 5:48
  likely
• 5:48
  to
• 5:48
  come
• 5:48
  into
• 5:48
  your
• 5:49
  clinic.
• 5:49
  So
• 5:50
  most
• 5:50
  people,
• 5:51
  thankfully
• 5:52
  or
• 5:52
  not
• 5:52
  thankfully,
• 5:53
  don't
• 5:53
  even
• 5:53
  show
• 5:53
  up
• 5:53
  in
• 5:53
  your
• 5:54
  clinic
• 5:54
  with
• 5:54
  flight
• 5:55
  phobia
• 5:55
  because
• 5:55
  their
• 5:56
  best
• 5:56
  medicine
• 5:57
  is
• 5:57
  they
• 5:57
  just
• 5:57
  never
• 5:57
  fly.
• 5:58
  But
• 5:58
  you
• 5:59
  will
• 5:59
  find
• 5:59
  people
• 5:59
  who
• 5:59
  have
• 6:00
  work
• 6:00
  conferences
• 6:01
  in
• 6:01
  order
• 6:01
  to
• 6:01
  excel
• 6:02
  in
• 6:02
  their
• 6:02
  career,
• 6:02
  they
• 6:03
  need
• 6:03
  to
• 6:03
  make
• 6:03
  PowerPoint
• 6:04
  presentations
• 6:04
  and
• 6:05
  fly
• 6:05
  from
• 6:06
  New
• 6:06
  York
• 6:06
  to
• 6:06
  San
• 6:06
  Francisco
• 6:07
  four
• 6:07
  times
• 6:07
  a
• 6:08
  year.
• 6:08
  They
• 6:08
  don't
• 6:08
  meet
• 6:09
  criteria
• 6:09
  for
• 6:09
  GAD,
• 6:10
  they
• 6:10
  don't
• 6:10
  meet
• 6:10
  criteria
• 6:11
  for
• 6:11
  MDD.
• 6:12
  And
• 6:12
  so
• 6:12
  giving
• 6:12
  them
• 6:12
  an
• 6:13
  SSRI
• 6:13
  is
• 6:13
  not
• 6:14
  exactly
• 6:14
  evidence
• 6:15
  based.
• 6:15
  It's
• 6:16
  not
• 6:16
  exactly
• 6:16
  the
• 6:16
  best
• 6:17
  way
• 6:17
  to
• 6:17
  solve
• 6:17
  the
• 6:17
  problem.
• 6:18
  You're
• 6:18
  giving
• 6:18
  them
• 6:19
  sexual
• 6:19
  dysfunction
• 6:20
  potentially
• 6:20
  for
• 6:21
  12
• 6:21
  months
• 6:21
  out
• 6:21
  of
• 6:21
  the
• 6:22
  year
• 6:22
  when
• 6:22
  they're
• 6:22
  only
• 6:23
  flying
• 6:23
  four
• 6:23
  times
• 6:24
  out
• 6:24
  of
• 6:24
  the
• 6:24
  year.
• 6:25
  And
• 6:25
  so
• 6:25
  some
• 6:25
  of
• 6:26
  these
• 6:26
  are
• 6:26
  busy
• 6:26
  professionals.
• 6:27
  They
• 6:27
  will
• 6:27
  tell
• 6:27
  you
• 6:27
  to
• 6:27
  your
• 6:28
  face,
• 6:28
  they
• 6:28
  don't
• 6:28
  have
• 6:28
  time
• 6:29
  to
• 6:29
  do
• 6:30
  exposure
• 6:30
  therapy.
• 6:31
  They
• 6:31
  don't
• 6:31
  have
• 6:31
  a
• 6:31
  desire
• 6:32
  to
• 6:32
  do
• 6:32
  exposure
• 6:33
  therapy.
• 6:33
  And
• 6:34
  so
• 6:34
  welcome
• 6:35
  to
• 6:35
  the
• 6:35
  messy
• 6:35
  world
• 6:36
  of
• 6:37
  mental
• 6:37
  health
• 6:37
  where
• 6:38
  yes,
• 6:38
  there
• 6:38
  is
• 6:39
  a
• 6:39
  textbook
• 6:39
  answer.
• 6:40
  Exposure
• 6:40
  therapy.
• 6:41
  You
• 6:41
  stare
• 6:41
  at
• 6:41
  pictures
• 6:41
  of
• 6:42
  airplanes,
• 6:42
  maybe
• 6:42
  you
• 6:43
  hear
• 6:43
  an
• 6:43
  engine
• 6:44
  on
• 6:44
  week
• 6:44
  two,
• 6:45
  maybe
• 6:45
  you
• 6:45
  drive
• 6:46
  to
• 6:46
  the
• 6:46
  airport
• 6:46
  week
• 6:47
  three,
• 6:48
  right?
• 6:48
  It
• 6:48
  gets
• 6:48
  progressively
• 6:49
  more
• 6:50
  terrifying
• 6:50
  for
• 6:51
  that
• 6:51
  person.
• 6:51
  But
• 6:51
  who
• 6:52
  necessarily
• 6:52
  has
• 6:53
  the
• 6:55
  motivation
• 6:56
  to
• 6:56
  do
• 6:56
  that?
• 6:56
  It's
• 6:56
  not
• 6:57
  going
• 6:57
  to
• 6:57
  be
• 6:57
  all
• 6:57
  of
• 6:57
  your
• 6:57
  patients.
• 6:58
  And
• 6:58
  if
• 6:58
  they're
• 6:58
  flying
• 6:58
  infrequently
• 6:59
  just
• 7:00
  for
• 7:00
  funerals,
• 7:01
  and
• 7:01
  they
• 7:01
  have
• 7:02
  a
• 7:02
  relatively
• 7:02
  healthy
• 7:03
  family
• 7:03
  that
• 7:03
  doesn't
• 7:03
  die
• 7:04
  that
• 7:04
  often
• 7:04
  and
• 7:05
  they
• 7:05
  don't
• 7:05
  have
• 7:05
  a
• 7:05
  job
• 7:06
  that
• 7:06
  where
• 7:06
  they
• 7:06
  have
• 7:06
  to
• 7:06
  speak
• 7:06
  very,
• 7:07
  very
• 7:07
  often
• 7:08
  around
• 7:08
  the
• 7:08
  world,
• 7:08
  they
• 7:09
  may
• 7:09
  need
• 7:09
  onesie
• 7:10
  twosies.
• 7:11
  And
• 7:11
  so
• 7:12
  yeah,
• 7:13
  that's
• 7:13
  my
• 7:13
  long
• 7:14
  and
• 7:14
  fun,
• 7:14
  hopefully
• 7:15
  entertaining
• 7:15
  way
• 7:15
  of
• 7:16
  telling
• 7:16
  you
• 7:16
  that
• 7:17
  I
• 7:18
  don't
• 7:18
  love
• 7:18
  prescribing
• 7:19
  benzos
• 7:19
  at
• 7:20
  all
• 7:20
  in
• 7:20
  general.
• 7:21
  But
• 7:21
  there
• 7:21
  is
• 7:21
  a
• 7:21
  time
• 7:22
  and
• 7:22
  place
• 7:22
  and
• 7:22
  sometimes
• 7:24
  it
• 7:24
  makes
• 7:24
  sense
• 7:24
  in
• 7:25
  limited
• 7:25
  circumstances.
• 7:26
  But
• 7:26
  I
• 7:26
  like
• 7:26
  to
• 7:27
  ask
• 7:27
  for
• 7:27
  something
• 7:27
  back.
• 7:28
  So
• 7:28
  especially
• 7:29
  if
• 7:29
  you
• 7:29
  have
• 7:29
  a
• 7:29
  patient
• 7:30
  who
• 7:31
  has
• 7:31
  to,
• 7:32
  has
• 7:33
  to
• 7:34
  give
• 7:34
  presentations
• 7:35
  pretty
• 7:35
  often,
• 7:36
  I
• 7:36
  will
• 7:36
  remind
• 7:36
  them.
• 7:37
  And
• 7:37
  if
• 7:37
  you
• 7:37
  know,
• 7:37
  in
• 7:37
  a
• 7:38
  very
• 7:38
  collaborative
• 7:38
  way,
• 7:39
  compassionate
• 7:39
  way,
• 7:40
  hey
• 7:40
  buddy,
• 7:40
  this
• 7:41
  is
• 7:41
  gonna
• 7:41
  be
• 7:41
  an
• 7:41
  ongoing
• 7:42
  issue
• 7:42
  and
• 7:43
  we
• 7:43
  don't
• 7:43
  want
• 7:43
  you
• 7:43
  to
• 7:43
  build
• 7:43
  up
• 7:44
  a
• 7:44
  tolerance
• 7:45
  or
• 7:45
  a
• 7:46
  dependency
• 7:46
  to
• 7:46
  benzodiazepines.
• 7:48
  And
• 7:49
  if
• 7:49
  we
• 7:49
  really
• 7:49
  wanna
• 7:49
  get
• 7:49
  to
• 7:50
  the
• 7:50
  root
• 7:50
  core
• 7:51
  fear
• 7:51
  here
• 7:51
  and
• 7:52
  Ex
• 7:52
  and
• 7:52
  extinguish
• 7:53
  it.
• 7:53
  Benzos
• 7:54
  can
• 7:54
  actually
• 7:54
  get
• 7:54
  in
• 7:54
  the
• 7:54
  way
• 7:55
  of
• 7:55
  that.
• 7:55
  They
• 7:55
  can
• 7:55
  get
• 7:55
  in
• 7:55
  the
• 7:56
  way
• 7:56
  of
• 7:56
  fear
• 7:56
  extinction.
• 7:57
  And
• 7:57
  that
• 7:58
  is
• 7:58
  definitely
• 7:58
  not
• 7:59
  at
• 7:59
  all
• 7:59
  what
• 7:59
  we
• 7:59
  want
• 8:00
  to
• 8:00
  do
• 8:00
  with
• 8:01
  any
• 8:01
  kind
• 8:01
  of
• 8:01
  phobia
• 8:02
  or
• 8:02
  with
• 8:02
  ptsd.
• 8:03
  There's
• 8:03
  a
• 8:03
  lot
• 8:04
  of
• 8:04
  evidence
• 8:04
  against
• 8:05
  doing
• 8:05
  that.
• 8:06
  It's
• 8:06
  not
• 8:06
  a
• 8:06
  good
• 8:06
  idea.
• 8:07
  Um,
• 8:07
  so
• 8:09
  the
• 8:09
  point
• 8:09
  of
• 8:09
  this
• 8:09
  lecture
• 8:10
  is
• 8:10
  really
• 8:11
  not
• 8:11
  to
• 8:12
  say
• 8:12
  benzos
• 8:13
  are
• 8:13
  the
• 8:13
  best
• 8:13
  for
• 8:13
  flight
• 8:14
  phobia,
• 8:15
  because
• 8:15
  they're
• 8:15
  not.
• 8:16
  But
• 8:17
  hopefully
• 8:18
  this
• 8:18
  will
• 8:18
  give
• 8:18
  you
• 8:18
  an
• 8:18
  appreciation
• 8:19
  for
• 8:19
  how
• 8:19
  to
• 8:19
  dose
• 8:20
  these
• 8:20
  and
• 8:20
  what
• 8:20
  to
• 8:20
  think
• 8:21
  about
• 8:21
  when
• 8:21
  you
• 8:21
  are
• 8:21
  dosing
• 8:22
  them,
• 8:22
  which
• 8:22
  I
• 8:22
  think
• 8:22
  is
• 8:23
  pretty
• 8:23
  entertaining
• 8:23
  and
• 8:24
  pretty
• 8:24
  exciting.
• 8:25
  So
• 8:25
  he
• 8:26
  has
• 8:26
  a
• 8:26
  long
• 8:26
  flight.
• 8:26
  We're
• 8:27
  going
• 8:27
  to
• 8:27
  say
• 8:27
  it's
• 8:27
  17
• 8:27
  hours.
• 8:29
  The
• 8:29
  longest
• 8:30
  one
• 8:30
  I've
• 8:30
  ever
• 8:30
  been
• 8:30
  on
• 8:30
  is
• 8:31
  14.
• 8:32
  That's
• 8:32
  a
• 8:32
  long
• 8:32
  flight.
• 8:33
  Okay.
• 8:33
  He's
• 8:34
  got
• 8:34
  to
• 8:34
  worry
• 8:34
  about
• 8:34
  blood
• 8:34
  clots
• 8:35
  too,
• 8:35
  but
• 8:35
  I'm
• 8:35
  going
• 8:36
  to
• 8:36
  leave
• 8:36
  that
• 8:36
  to
• 8:36
  a
• 8:36
  different
• 8:36
  podcast.
• 8:38
  But
• 8:38
  we
• 8:39
  probably
• 8:39
  need
• 8:39
  to
• 8:40
  pick
• 8:40
  a
• 8:41
  medication
• 8:42
  that
• 8:42
  is
• 8:42
  going
• 8:42
  to
• 8:42
  cover
• 8:43
  him
• 8:44
  this
• 8:44
  whole
• 8:44
  flight.
• 8:45
  Okay,
• 8:45
  so
• 8:46
  Xanax
• 8:47
  is
• 8:47
  one
• 8:47
  we
• 8:47
  definitely
• 8:48
  don't
• 8:48
  want
• 8:48
  to
• 8:48
  look
• 8:49
  at
• 8:49
  here
• 8:49
  because
• 8:50
  Xanax
• 8:52
  has
• 8:52
  a
• 8:52
  clinical
• 8:52
  duration
• 8:53
  roughly
• 8:54
  between
• 8:55
  four
• 8:55
  and
• 8:55
  six
• 8:55
  hours.
• 8:56
  It's
• 8:56
  in
• 8:56
  and
• 8:56
  out
• 8:56
  of
• 8:56
  your
• 8:57
  system
• 8:57
  very
• 8:57
  quickly.
• 8:58
  It's
• 8:58
  really
• 8:58
  good
• 8:58
  for
• 8:59
  a
• 8:59
  two
• 8:59
  hour
• 8:59
  flight
• 9:00
  and
• 9:01
  it's
• 9:01
  just
• 9:02
  not
• 9:02
  really
• 9:02
  good
• 9:02
  and
• 9:03
  a
• 9:03
  good
• 9:03
  idea
• 9:03
  for
• 9:03
  a
• 9:04
  16
• 9:04
  or
• 9:04
  17
• 9:05
  hour
• 9:05
  flight.
• 9:05
  You're
• 9:06
  going
• 9:06
  to
• 9:06
  need
• 9:06
  multiple
• 9:07
  doses.
• 9:08
  The
• 9:08
  problem
• 9:08
  with
• 9:08
  that
• 9:09
  is
• 9:10
  pretty
• 9:10
  obvious,
• 9:10
  but
• 9:11
  you're
• 9:11
  going
• 9:12
  to
• 9:12
  accumulate
• 9:13
  a
• 9:13
  lot
• 9:13
  of
• 9:13
  side
• 9:13
  effects.
• 9:14
  You're
• 9:14
  going
• 9:14
  to
• 9:14
  stack
• 9:14
  those
• 9:14
  doses
• 9:15
  on
• 9:15
  each
• 9:15
  other.
• 9:16
  So
• 9:16
  even
• 9:17
  though
• 9:17
  the,
• 9:17
  your
• 9:18
  brain
• 9:18
  is
• 9:18
  not
• 9:19
  really
• 9:19
  being
• 9:20
  treated
• 9:20
  with
• 9:20
  the
• 9:20
  Xanax
• 9:21
  because
• 9:21
  it's
• 9:21
  kind
• 9:22
  of
• 9:22
  quick,
• 9:22
  it's
• 9:23
  very
• 9:23
  lipophilic.
• 9:24
  So
• 9:24
  it's,
• 9:24
  it
• 9:24
  crosses
• 9:25
  the
• 9:25
  blood
• 9:25
  brain
• 9:25
  barrier
• 9:26
  and
• 9:26
  then
• 9:26
  leaves
• 9:26
  the
• 9:26
  blood
• 9:27
  brain
• 9:27
  barrier
• 9:27
  rather
• 9:27
  quickly.
• 9:28
  So
• 9:29
  even
• 9:29
  though
• 9:29
  the
• 9:29
  therapeutic
• 9:30
  effects
• 9:30
  are
• 9:30
  going
• 9:31
  to
• 9:31
  be
• 9:31
  out
• 9:31
  of
• 9:31
  your
• 9:31
  system
• 9:32
  rather
• 9:32
  quickly,
• 9:34
  you're
• 9:34
  going
• 9:34
  to
• 9:34
  be
• 9:35
  linked.
• 9:35
  The
• 9:35
  sedation
• 9:36
  piece,
• 9:36
  those,
• 9:36
  those
• 9:37
  extra
• 9:37
  effects
• 9:37
  are
• 9:38
  going
• 9:38
  to
• 9:38
  kind
• 9:38
  of
• 9:38
  stay
• 9:39
  in
• 9:39
  your
• 9:39
  bloodstream
• 9:40
  longer.
• 9:41
  And
• 9:41
  so
• 9:41
  the
• 9:41
  more
• 9:41
  you
• 9:42
  stack
• 9:42
  this,
• 9:42
  you
• 9:42
  take
• 9:43
  it
• 9:43
  three
• 9:43
  or
• 9:43
  four
• 9:43
  times
• 9:43
  in
• 9:44
  a
• 9:44
  17
• 9:44
  hour
• 9:44
  flight,
• 9:45
  you're
• 9:45
  going
• 9:45
  to
• 9:45
  be
• 9:45
  a
• 9:45
  zombie
• 9:46
  when
• 9:46
  you
• 9:46
  get
• 9:46
  back.
• 9:47
  It's
• 9:47
  going
• 9:47
  to
• 9:48
  be
• 9:48
  very
• 9:48
  unpleasant.
• 9:49
  You
• 9:49
  might
• 9:49
  have
• 9:49
  some
• 9:50
  amnesia,
• 9:51
  ataxia,
• 9:52
  you
• 9:52
  might
• 9:52
  fall
• 9:52
  on
• 9:53
  your
• 9:53
  way
• 9:53
  to
• 9:53
  the
• 9:53
  bathroom
• 9:54
  on
• 9:54
  somebody
• 9:54
  else
• 9:55
  and
• 9:55
  that's
• 9:56
  going
• 9:56
  to
• 9:56
  cause
• 9:56
  a
• 9:56
  fist
• 9:56
  fight
• 9:57
  and
• 9:57
  you're
• 9:57
  going
• 9:57
  to
• 9:57
  go
• 9:57
  viral.
• 9:58
  So
• 9:58
  Xanax
• 9:59
  is
• 9:59
  not
• 9:59
  a
• 9:59
  good
• 10:00
  idea
• 10:00
  for
• 10:00
  a
• 10:01
  flight
• 10:01
  this
• 10:01
  long.
• 10:02
  I
• 10:02
  would
• 10:02
  say
• 10:02
  short
• 10:03
  flights
• 10:03
  are
• 10:03
  pretty
• 10:03
  good.
• 10:04
  New
• 10:04
  York
• 10:05
  to
• 10:05
  Washington
• 10:05
  D.C.
• 10:06
  makes
• 10:06
  some
• 10:06
  sense.
• 10:07
  D.C.
• 10:07
  to
• 10:07
  Boston,
• 10:08
  San
• 10:08
  Fran
• 10:08
  to
• 10:08
  LA.
• 10:09
  Probably
• 10:09
  a
• 10:10
  much
• 10:10
  more
• 10:10
  appropriate
• 10:12
  duration
• 10:12
  if
• 10:12
  you're
• 10:13
  flying
• 10:13
  from
• 10:14
  Los
• 10:14
  Angeles
• 10:14
  to
• 10:14
  Kuala
• 10:15
  Lumpur
• 10:15
  and
• 10:16
  you
• 10:16
  give
• 10:16
  someone
• 10:16
  Xanax.
• 10:17
  I
• 10:17
  hope
• 10:17
  you
• 10:17
  have
• 10:18
  a
• 10:18
  really
• 10:18
  good
• 10:18
  lawyer.
• 10:19
  Now,
• 10:21
  what
• 10:21
  about
• 10:22
  Ativan?
• 10:22
  Ativan?
• 10:24
  You
• 10:24
  know,
• 10:24
  it's
• 10:25
  been
• 10:25
  a
• 10:25
  long
• 10:25
  time
• 10:25
  since
• 10:26
  I
• 10:26
  read
• 10:26
  Goldilocks
• 10:27
  and
• 10:27
  the
• 10:27
  Three
• 10:27
  Bears,
• 10:28
  but
• 10:28
  I
• 10:28
  think
• 10:28
  this
• 10:28
  is
• 10:29
  closer
• 10:29
  to
• 10:29
  baby
• 10:30
  bear
• 10:30
  or
• 10:30
  Goldilocks.
• 10:31
  Kind
• 10:31
  of
• 10:32
  forgot
• 10:32
  the
• 10:32
  story.
• 10:32
  You
• 10:32
  might
• 10:32
  have
• 10:33
  to
• 10:33
  help
• 10:33
  me.
• 10:33
  But
• 10:34
  Ativan
• 10:35
  has
• 10:35
  a
• 10:35
  clinical
• 10:36
  duration
• 10:36
  of
• 10:36
  action
• 10:36
  of
• 10:37
  around
• 10:37
  six
• 10:37
  to
• 10:37
  eight
• 10:38
  hours.
• 10:38
  Okay.
• 10:39
  It's
• 10:39
  better
• 10:40
  for
• 10:40
  middle
• 10:40
  distance
• 10:41
  flying
• 10:41
  and
• 10:43
  it's,
• 10:43
  you
• 10:43
  know,
• 10:44
  I
• 10:44
  would
• 10:44
  say
• 10:44
  more
• 10:44
  of
• 10:44
  an
• 10:44
  eight
• 10:44
  hour
• 10:45
  flight.
• 10:45
  This
• 10:45
  is
• 10:45
  probably
• 10:45
  an
• 10:46
  ideal
• 10:46
  medication
• 10:46
  if
• 10:47
  you're
• 10:47
  flying
• 10:47
  from
• 10:48
  LA
• 10:48
  to
• 10:48
  New
• 10:49
  York.
• 10:49
  Right?
• 10:49
  Much
• 10:50
  better.
• 10:51
  Maybe.
• 10:52
  Yeah,
• 10:52
  I
• 10:52
  was
• 10:52
  gonna
• 10:52
  say
• 10:53
  maybe
• 10:53
  New
• 10:53
  York
• 10:53
  to
• 10:53
  London,
• 10:54
  but
• 10:54
  that's
• 10:55
  iffy.
• 10:55
  But
• 10:55
  it
• 10:55
  would
• 10:55
  probably
• 10:56
  cover
• 10:56
  a
• 10:56
  lot
• 10:57
  of
• 10:57
  it.
• 10:57
  And
• 10:57
  you'd
• 10:57
  probably
• 10:58
  want
• 10:58
  to
• 10:58
  pinpoint
• 10:59
  with
• 10:59
  your
• 10:59
  patient
• 11:01
  where
• 11:01
  their
• 11:01
  anxiety
• 11:02
  specifically
• 11:03
  lies.
• 11:03
  I
• 11:03
  would
• 11:03
  say
• 11:04
  most
• 11:04
  patients
• 11:04
  are
• 11:05
  just
• 11:05
  afraid
• 11:05
  of
• 11:05
  being
• 11:06
  up
• 11:07
  even
• 11:07
  10ft
• 11:08
  in
• 11:08
  the
• 11:08
  air.
• 11:08
  Plus,
• 11:09
  so
• 11:09
  you'd
• 11:09
  want
• 11:10
  the
• 11:10
  duration
• 11:10
  of
• 11:10
  the
• 11:10
  whole
• 11:11
  flight.
• 11:11
  But
• 11:11
  some
• 11:11
  patients
• 11:11
  might
• 11:12
  tell
• 11:12
  you
• 11:12
  they
• 11:12
  just
• 11:12
  can't
• 11:12
  stand
• 11:13
  takeoff,
• 11:13
  they
• 11:13
  just
• 11:13
  can't
• 11:14
  stand
• 11:14
  landing.
• 11:15
  Once
• 11:15
  they're
• 11:15
  up
• 11:15
  there,
• 11:15
  they're
• 11:16
  okay.
• 11:17
  But
• 11:17
  you,
• 11:18
  you
• 11:18
  really
• 11:18
  want
• 11:18
  to
• 11:18
  get
• 11:19
  a
• 11:19
  feel
• 11:19
  for
• 11:19
  that
• 11:19
  even
• 11:20
  before
• 11:20
  you
• 11:20
  start
• 11:20
  choosing
• 11:21
  medications.
• 11:22
  But
• 11:22
  you
• 11:22
  know,
• 11:22
  Ativan
• 11:23
  is
• 11:23
  better
• 11:23
  for
• 11:23
  the
• 11:24
  six
• 11:24
  to
• 11:24
  eight
• 11:25
  hour
• 11:25
  flights.
• 11:25
  Middle
• 11:26
  distance,
• 11:27
  a
• 11:28
  long
• 11:28
  continental
• 11:29
  American
• 11:29
  flight,
• 11:30
  maybe
• 11:30
  not
• 11:30
  international
• 11:31
  flight.
• 11:31
  The
• 11:32
  international
• 11:32
  flights
• 11:33
  are
• 11:33
  probably
• 11:34
  best
• 11:34
  for
• 11:34
  Klonopin.
• 11:35
  Okay.
• 11:36
  The
• 11:36
  clinical
• 11:36
  duration
• 11:37
  is
• 11:37
  8
• 11:37
  to
• 11:37
  12
• 11:38
  hours.
• 11:39
  It's
• 11:39
  a,
• 11:40
  it's
• 11:40
  a
• 11:40
  pretty
• 11:40
  decent
• 11:41
  medication.
• 11:41
  Now
• 11:41
  the
• 11:42
  key
• 11:42
  here
• 11:42
  is,
• 11:42
  is
• 11:43
  understanding
• 11:44
  lipophilicity.
• 11:45
  Okay.
• 11:45
  Lipophilicity.
• 11:46
  Okay.
• 11:47
  How
• 11:47
  quickly
• 11:48
  a
• 11:48
  medication
• 11:48
  crosses
• 11:49
  the
• 11:49
  blood
• 11:49
  brain
• 11:50
  barrier
• 11:50
  is
• 11:50
  really
• 11:51
  the
• 11:51
  deciding
• 11:51
  factor
• 11:52
  here
• 11:52
  rather
• 11:53
  than
• 11:53
  the
• 11:53
  half
• 11:53
  life
• 11:54
  in
• 11:54
  why
• 11:55
  these
• 11:55
  benzos
• 11:55
  are
• 11:56
  ideal
• 11:56
  in
• 11:56
  certain
• 11:57
  situations
• 11:57
  or
• 11:58
  certain
• 11:58
  flights.
• 11:59
  Okay.
• 11:59
  Xanax
• 12:00
  has
• 12:00
  very
• 12:01
  high
• 12:02
  lipophilicity.
• 12:03
  It
• 12:03
  crosses
• 12:03
  the
• 12:03
  blood
• 12:04
  brain
• 12:04
  barrier
• 12:04
  very
• 12:04
  quickly.
• 12:59
  That
• 13:00
  means
• 13:00
  it
• 13:00
  also
• 13:00
  gets
• 13:01
  out
• 13:01
  of
• 13:01
  your
• 13:01
  brain
• 13:01
  very
• 13:01
  quickly
• 13:02
  and
• 13:02
  you
• 13:02
  have
• 13:02
  this
• 13:02
  rebound
• 13:03
  anxiety.
• 13:04
  So.
• 13:04
  So
• 13:04
  it's
• 13:05
  fast
• 13:06
  because
• 13:06
  it's
• 13:06
  very
• 13:06
  lipophilic.
• 13:07
  It
• 13:07
  doesn't
• 13:08
  exert
• 13:08
  a
• 13:08
  very
• 13:08
  long
• 13:08
  therapeutic
• 13:09
  effect
• 13:10
  and
• 13:10
  you
• 13:10
  have
• 13:10
  that
• 13:10
  rebound
• 13:11
  problem
• 13:11
  again.
• 13:12
  That's
• 13:12
  really
• 13:12
  bad.
• 13:13
  If
• 13:13
  you're
• 13:13
  in
• 13:13
  the
• 13:13
  middle
• 13:14
  of
• 13:14
  the
• 13:14
  Pacific
• 13:14
  Ocean
• 13:15
  and
• 13:15
  you
• 13:15
  are
• 13:16
  35,000ft
• 13:17
  in
• 13:17
  the
• 13:17
  air
• 13:18
  and
• 13:18
  having
• 13:18
  a
• 13:18
  panic
• 13:19
  attack,
• 13:19
  now
• 13:19
  you've
• 13:19
  got
• 13:19
  to
• 13:20
  deal
• 13:20
  with,
• 13:20
  what
• 13:20
  am
• 13:20
  I
• 13:20
  going
• 13:20
  to
• 13:20
  do?
• 13:21
  It's
• 13:21
  wearing
• 13:21
  off.
• 13:22
  Right.
• 13:22
  That's
• 13:22
  a
• 13:22
  really
• 13:23
  big
• 13:23
  problem.
• 13:23
  But
• 13:24
  Klonopin
• 13:25
  has
• 13:25
  Low
• 13:25
  to
• 13:25
  moderate
• 13:26
  lipophilicity.
• 13:27
  So
• 13:28
  it's
• 13:28
  kind
• 13:29
  of
• 13:29
  slowly,
• 13:31
  slowly.
• 13:32
  It's
• 13:32
  like
• 13:32
  a
• 13:32
  little
• 13:32
  old
• 13:32
  lady.
• 13:33
  Maybe
• 13:33
  not
• 13:33
  too
• 13:34
  old
• 13:34
  of
• 13:34
  a
• 13:34
  lady,
• 13:35
  but
• 13:35
  like
• 13:35
  a
• 13:35
  little
• 13:35
  old
• 13:36
  lady
• 13:36
  that
• 13:36
  works
• 13:36
  out
• 13:37
  and
• 13:37
  can
• 13:37
  bench
• 13:37
  press
• 13:38
  buck
• 13:39
  25,
• 13:40
  run
• 13:40
  a
• 13:40
  mile
• 13:40
  in
• 13:40
  under
• 13:41
  10
• 13:41
  minutes.
• 13:42
  We're
• 13:42
  not
• 13:42
  talking
• 13:43
  about,
• 13:43
  like
• 13:43
  a
• 13:43
  brittle,
• 13:44
  frail
• 13:44
  old
• 13:44
  lady.
• 13:44
  We're
• 13:45
  talking
• 13:45
  just
• 13:45
  about
• 13:45
  a
• 13:46
  very
• 13:46
  zesty,
• 13:48
  sprite
• 13:49
  old
• 13:49
  lady
• 13:50
  that
• 13:50
  can
• 13:51
  get
• 13:51
  on
• 13:51
  like
• 13:51
  my,
• 13:51
  my.
• 13:52
  My
• 13:52
  German
• 13:52
  grandmother
• 13:53
  is
• 13:53
  a
• 13:53
  very
• 13:53
  good
• 13:53
  example
• 13:54
  of
• 13:54
  this.
• 13:54
  Okay?
• 13:54
  Very
• 13:55
  strong,
• 13:55
  very,
• 13:56
  very
• 13:56
  strong
• 13:56
  woman
• 13:57
  physically
• 13:58
  and
• 13:58
  emotionally,
• 13:59
  but
• 13:59
  someone
• 14:00
  who
• 14:00
  can,
• 14:01
  you
• 14:01
  know,
• 14:01
  kind
• 14:02
  of
• 14:02
  get
• 14:02
  on
• 14:02
  the
• 14:02
  bus
• 14:02
  pretty
• 14:03
  quickly
• 14:04
  or,
• 14:04
  you
• 14:05
  know,
• 14:05
  slow.
• 14:05
  Slowly
• 14:06
  to
• 14:06
  moderately,
• 14:06
  okay?
• 14:07
  It's
• 14:07
  a
• 14:07
  slow
• 14:07
  trickle,
• 14:08
  okay?
• 14:09
  Not
• 14:09
  a
• 14:09
  nervous
• 14:10
  trickle.
• 14:10
  It's
• 14:10
  a
• 14:11
  slow
• 14:11
  to
• 14:11
  moderate
• 14:12
  trickle.
• 14:12
  So
• 14:12
  the
• 14:12
  brain's
• 14:13
  getting
• 14:13
  this
• 14:13
  slow
• 14:14
  but
• 14:14
  moderate
• 14:15
  trickle
• 14:16
  of
• 14:18
  therapeutic
• 14:18
  effect
• 14:19
  through
• 14:20
  Klonopin.
• 14:21
  Not
• 14:21
  so
• 14:21
  slow,
• 14:22
  but
• 14:22
  that
• 14:23
  you're
• 14:23
  waiting
• 14:23
  for
• 14:23
  hours
• 14:24
  and
• 14:24
  hours
• 14:24
  and
• 14:24
  hours
• 14:24
  for
• 14:25
  an
• 14:25
  effect,
• 14:25
  but
• 14:26
  slow
• 14:26
  enough
• 14:26
  to
• 14:26
  where
• 14:27
  it's.
• 14:29
  You're.
• 14:30
  You're
• 14:30
  getting
• 14:30
  a
• 14:30
  therapeutic
• 14:31
  effect
• 14:32
  pretty
• 14:32
  steadily.
• 14:33
  And
• 14:33
  it's
• 14:33
  not
• 14:33
  this
• 14:34
  wham,
• 14:34
  bam,
• 14:34
  bam,
• 14:35
  Xanax
• 14:36
  effect
• 14:36
  where
• 14:36
  you're
• 14:37
  sitting
• 14:37
  there
• 14:37
  wondering
• 14:38
  where
• 14:38
  your
• 14:38
  medication
• 14:39
  is,
• 14:39
  okay?
• 14:40
  So
• 14:40
  that's
• 14:40
  one
• 14:40
  of
• 14:40
  the
• 14:41
  reasons,
• 14:41
  in
• 14:41
  addition
• 14:41
  to
• 14:41
  a
• 14:42
  much
• 14:42
  longer
• 14:42
  half
• 14:42
  life
• 14:44
  that
• 14:44
  Klonopin
• 14:45
  has,
• 14:45
  which
• 14:45
  is,
• 14:45
  I
• 14:46
  believe,
• 14:46
  around
• 14:46
  34
• 14:46
  hours,
• 14:47
  you
• 14:47
  have
• 14:48
  the
• 14:48
  fact
• 14:48
  that
• 14:49
  it's
• 14:49
  not
• 14:49
  as
• 14:49
  lipophilic.
• 14:50
  It
• 14:50
  is
• 14:50
  still
• 14:50
  a
• 14:50
  little
• 14:50
  bit
• 14:51
  lipophilic,
• 14:52
  but
• 14:52
  it's
• 14:52
  not
• 14:53
  as
• 14:53
  lipophilic.
• 14:54
  And
• 14:54
  so
• 14:55
  it's
• 14:55
  staying
• 14:56
  active
• 14:56
  in
• 14:57
  the
• 14:57
  cns,
• 14:58
  in
• 14:58
  the
• 14:58
  central
• 14:59
  nervous
• 14:59
  system,
• 14:59
  without
• 15:00
  being
• 15:00
  rapidly
• 15:01
  redistributed
• 15:02
  to
• 15:02
  your
• 15:02
  fat
• 15:02
  tissues.
• 15:03
  Because,
• 15:03
  see,
• 15:04
  medications
• 15:05
  with
• 15:05
  high
• 15:05
  lipophilicity,
• 15:07
  they
• 15:07
  enter
• 15:07
  the
• 15:08
  blood
• 15:08
  brain
• 15:08
  barrier.
• 15:08
  They
• 15:09
  cross
• 15:09
  the
• 15:09
  blood
• 15:09
  brain
• 15:09
  barrier
• 15:10
  very
• 15:10
  quickly,
• 15:11
  okay?
• 15:11
  It's
• 15:11
  almost
• 15:12
  like
• 15:12
  they
• 15:12
  have
• 15:12
  a
• 15:12
  VIP
• 15:13
  pass
• 15:13
  to
• 15:13
  a
• 15:13
  nightclub.
• 15:14
  They
• 15:14
  just
• 15:14
  bypass
• 15:15
  the
• 15:15
  line.
• 15:15
  They
• 15:15
  get
• 15:15
  into
• 15:15
  the
• 15:16
  nightclub,
• 15:16
  they
• 15:16
  get
• 15:16
  into
• 15:16
  the
• 15:17
  brain
• 15:17
  quickly,
• 15:17
  and
• 15:18
  they
• 15:18
  leave
• 15:18
  quickly
• 15:19
  back
• 15:19
  into
• 15:19
  the
• 15:20
  fat
• 15:20
  stores,
• 15:21
  okay?
• 15:21
  And
• 15:21
  they
• 15:22
  sit
• 15:22
  there
• 15:22
  in
• 15:22
  the
• 15:22
  fat
• 15:22
  stores.
• 15:23
  And
• 15:24
  this
• 15:24
  is
• 15:25
  actually
• 15:25
  a
• 15:25
  reason
• 15:26
  that
• 15:27
  Valium
• 15:27
  is
• 15:27
  not
• 15:28
  a
• 15:28
  very
• 15:28
  good
• 15:29
  medication
• 15:30
  here,
• 15:30
  because
• 15:31
  it's
• 15:31
  highly
• 15:32
  lipophilic.
• 15:33
  Okay?
• 15:33
  It
• 15:33
  does
• 15:33
  have
• 15:34
  a
• 15:34
  long
• 15:34
  half
• 15:34
  life.
• 15:34
  And
• 15:34
  so
• 15:35
  it
• 15:35
  could
• 15:35
  be
• 15:35
  very
• 15:35
  deceiving
• 15:36
  to
• 15:36
  you.
• 15:36
  Like,
• 15:36
  why
• 15:36
  not
• 15:36
  Valium?
• 15:37
  I
• 15:37
  thought
• 15:37
  that's
• 15:38
  what
• 15:38
  they
• 15:38
  do
• 15:38
  for
• 15:38
  benzo
• 15:39
  tapers.
• 15:39
  That's
• 15:40
  true.
• 15:40
  That's
• 15:40
  another
• 15:41
  episode.
• 15:42
  But
• 15:42
  Valium's
• 15:43
  downfall
• 15:44
  when
• 15:44
  it
• 15:44
  comes
• 15:44
  to
• 15:44
  flying
• 15:45
  is
• 15:45
  it's
• 15:45
  in
• 15:45
  and
• 15:46
  out
• 15:46
  very
• 15:46
  fast.
• 15:47
  The
• 15:47
  therapeutic
• 15:48
  effect
• 15:48
  is
• 15:48
  really
• 15:49
  quick,
• 15:49
  and
• 15:49
  then
• 15:50
  it
• 15:50
  kind
• 15:50
  of
• 15:50
  lingers
• 15:50
  in
• 15:51
  your
• 15:51
  fat
• 15:51
  for
• 15:52
  a
• 15:52
  very
• 15:52
  long
• 15:52
  time.
• 15:53
  For
• 15:53
  an
• 15:53
  exorbitant
• 15:54
  amount
• 15:54
  of
• 15:54
  time
• 15:54
  where
• 15:55
  you
• 15:55
  can
• 15:55
  be
• 15:55
  sedated,
• 15:56
  you
• 15:56
  can
• 15:56
  have
• 15:57
  all
• 15:57
  these
• 15:57
  other
• 15:57
  side
• 15:57
  effects.
• 15:58
  Okay?
• 15:58
  And
• 15:58
  it's
• 15:59
  not
• 15:59
  really
• 15:59
  what
• 15:59
  we're
• 15:59
  going
• 15:59
  for
• 16:00
  here,
• 16:00
  because
• 16:00
  we
• 16:00
  want.
• 16:00
  We
• 16:01
  specifically
• 16:01
  want
• 16:01
  a
• 16:02
  central
• 16:02
  nervous
• 16:02
  system
• 16:03
  agent
• 16:04
  to,
• 16:06
  you
• 16:06
  know,
• 16:06
  act
• 16:06
  as
• 16:07
  a
• 16:08
  positive
• 16:08
  allosteric
• 16:09
  modulator
• 16:10
  to
• 16:11
  those
• 16:11
  chloride
• 16:12
  channels
• 16:12
  that
• 16:14
  basically
• 16:14
  make
• 16:15
  your
• 16:15
  neurons
• 16:15
  a
• 16:15
  lot
• 16:16
  less
• 16:16
  likely
• 16:17
  to
• 16:17
  fire
• 16:18
  and
• 16:18
  to
• 16:18
  calm
• 16:18
  your
• 16:19
  amygdala
• 16:19
  and
• 16:20
  thereby
• 16:20
  reduce
• 16:21
  your
• 16:21
  anxiety.
• 16:21
  Okay?
• 16:22
  Again,
• 16:22
  that
• 16:22
  is
• 16:23
  specifically
• 16:23
  something
• 16:24
  for
• 16:24
  this
• 16:24
  flight
• 16:25
  that
• 16:25
  we
• 16:25
  will
• 16:25
  find
• 16:26
  with
• 16:26
  Klonopin.
• 16:27
  Now,
• 16:27
  you.
• 16:27
  You
• 16:28
  have
• 16:28
  to
• 16:28
  focus
• 16:28
  on
• 16:29
  the
• 16:29
  onset
• 16:30
  of
• 16:30
  action.
• 16:30
  We've
• 16:31
  talked
• 16:31
  about
• 16:31
  that
• 16:31
  a
• 16:31
  little
• 16:32
  bit,
• 16:32
  but,
• 16:33
  you
• 16:33
  know,
• 16:33
  generally
• 16:34
  Speaking,
• 16:34
  anywhere
• 16:35
  from
• 16:35
  15
• 16:36
  to
• 16:36
  30
• 16:36
  minutes,
• 16:37
  Klonopin
• 16:38
  is
• 16:38
  probably
• 16:38
  more
• 16:38
  like
• 16:39
  60
• 16:39
  minutes
• 16:40
  for
• 16:40
  an
• 16:40
  onset
• 16:40
  of
• 16:41
  action.
• 16:41
  You
• 16:41
  have
• 16:41
  to
• 16:41
  be
• 16:42
  familiar
• 16:42
  with
• 16:42
  when
• 16:42
  these
• 16:43
  medications
• 16:43
  take
• 16:43
  effect,
• 16:45
  because
• 16:45
  if
• 16:45
  your
• 16:45
  patient
• 16:46
  is
• 16:46
  petrified
• 16:46
  of
• 16:46
  takeoff,
• 16:47
  you
• 16:47
  want
• 16:48
  to
• 16:48
  warn
• 16:48
  them
• 16:49
  that
• 16:49
  they
• 16:49
  want
• 16:49
  to
• 16:49
  take
• 16:50
  these
• 16:50
  medications
• 16:50
  maybe
• 16:51
  30
• 16:51
  minutes
• 16:52
  before
• 16:52
  takeoff
• 16:53
  or
• 16:53
  an
• 16:53
  hour
• 16:53
  before
• 16:54
  takeoff.
• 16:54
  And
• 16:54
  they
• 16:54
  have
• 16:54
  to
• 16:54
  kind
• 16:55
  of
• 16:55
  time
• 16:55
  that
• 16:55
  appropriately.
• 16:56
  Okay?
• 16:57
  Now,
• 16:58
  T
• 16:58
  max,
• 16:59
  you
• 16:59
  know,
• 16:59
  the
• 16:59
  maximum
• 17:00
  amount
• 17:00
  of.
• 17:01
  Of
• 17:01
  serum,
• 17:01
  drug
• 17:02
  or
• 17:02
  drug
• 17:03
  in
• 17:03
  your
• 17:03
  serum,
• 17:04
  you
• 17:04
  want
• 17:04
  to
• 17:04
  also
• 17:05
  time
• 17:05
  that,
• 17:05
  because
• 17:06
  if
• 17:07
  Ativan
• 17:07
  has
• 17:08
  a
• 17:08
  TMax
• 17:08
  of
• 17:08
  around
• 17:09
  two
• 17:09
  hours,
• 17:10
  and
• 17:10
  the
• 17:10
  most
• 17:10
  terrifying
• 17:11
  part
• 17:11
  of
• 17:12
  the
• 17:12
  patient's
• 17:12
  flight
• 17:13
  is
• 17:14
  takeoff,
• 17:15
  well,
• 17:15
  you
• 17:15
  want
• 17:15
  to
• 17:16
  time
• 17:16
  it.
• 17:16
  So
• 17:16
  maybe
• 17:17
  they
• 17:17
  take
• 17:17
  that
• 17:17
  Ativan
• 17:18
  roughly
• 17:18
  two
• 17:19
  hours
• 17:19
  before
• 17:20
  takeoff.
• 17:21
  Right?
• 17:21
  So
• 17:21
  they
• 17:21
  might
• 17:21
  still
• 17:22
  be
• 17:22
  kind
• 17:22
  of
• 17:23
  wandering
• 17:23
  around
• 17:23
  the
• 17:23
  gate
• 17:24
  or
• 17:24
  through
• 17:24
  security.
• 17:25
  And
• 17:25
  then
• 17:25
  bam,
• 17:25
  right.
• 17:26
  At
• 17:26
  two
• 17:26
  hours
• 17:26
  later,
• 17:27
  they're
• 17:27
  taking
• 17:27
  off,
• 17:28
  and
• 17:28
  it's
• 17:28
  a
• 17:28
  maximum
• 17:29
  amount
• 17:29
  of
• 17:29
  medication
• 17:30
  in
• 17:30
  their
• 17:30
  bloodstream.
• 17:31
  And
• 17:31
  then,
• 17:31
  of
• 17:32
  course,
• 17:32
  you
• 17:32
  want
• 17:32
  to
• 17:32
  make
• 17:32
  sure
• 17:32
  also
• 17:33
  that
• 17:33
  flight
• 17:33
  isn't
• 17:34
  so
• 17:34
  long,
• 17:34
  because
• 17:34
  if
• 17:34
  it's
• 17:34
  too
• 17:35
  long
• 17:35
  now,
• 17:36
  you're.
• 17:36
  You
• 17:36
  know,
• 17:36
  the
• 17:36
  clock
• 17:37
  has
• 17:37
  already
• 17:37
  been
• 17:37
  ticking
• 17:38
  for
• 17:38
  two
• 17:38
  hours.
• 17:39
  So
• 17:39
  if
• 17:39
  the
• 17:39
  clinical
• 17:39
  duration
• 17:40
  is
• 17:40
  like
• 17:40
  six,
• 17:40
  you've
• 17:41
  got
• 17:41
  four
• 17:41
  more
• 17:41
  hours
• 17:42
  there
• 17:42
  for
• 17:43
  the.
• 17:43
  The
• 17:44
  patient
• 17:44
  to
• 17:44
  still
• 17:45
  feel
• 17:45
  the
• 17:45
  effects.
• 17:46
  So
• 17:46
  you
• 17:47
  asked
• 17:47
  him
• 17:47
  to
• 17:47
  take
• 17:47
  it
• 17:48
  two
• 17:48
  hours
• 17:48
  before
• 17:49
  takeoff.
• 17:49
  So
• 17:49
  bam
• 17:50
  is
• 17:50
  takeoff
• 17:50
  is
• 17:50
  great,
• 17:51
  but
• 17:51
  he's
• 17:51
  got,
• 17:52
  like,
• 17:52
  10
• 17:52
  more
• 17:52
  hours
• 17:52
  in
• 17:52
  his
• 17:53
  flight.
• 17:53
  He's
• 17:53
  going
• 17:54
  from
• 17:54
  Dallas
• 17:54
  to
• 17:54
  London,
• 17:55
  and
• 17:55
  you
• 17:56
  got
• 17:56
  him
• 17:56
  through
• 17:56
  takeoff.
• 17:57
  And
• 17:57
  then
• 17:57
  somewhere,
• 17:59
  somewhere
• 18:00
  near
• 18:00
  Maine
• 18:01
  when
• 18:01
  he's
• 18:01
  right
• 18:01
  across,
• 18:02
  about
• 18:02
  to
• 18:02
  cross
• 18:02
  the
• 18:02
  Atlantic
• 18:03
  Ocean,
• 18:03
  he's
• 18:04
  going
• 18:04
  to
• 18:04
  ring
• 18:04
  the
• 18:04
  flight
• 18:05
  attendants
• 18:06
  because
• 18:06
  he's
• 18:07
  hyperventilating,
• 18:08
  and
• 18:08
  they're
• 18:08
  going
• 18:08
  to
• 18:09
  turn
• 18:09
  around,
• 18:09
  and
• 18:09
  everybody's
• 18:10
  going
• 18:10
  to
• 18:11
  beat
• 18:11
  him
• 18:11
  with
• 18:11
  sticks.
• 18:12
  It's
• 18:12
  never
• 18:13
  that
• 18:13
  catastrophic.
• 18:14
  If
• 18:14
  you're
• 18:14
  listening
• 18:14
  to
• 18:15
  this,
• 18:15
  please
• 18:15
  know
• 18:15
  we
• 18:15
  all
• 18:16
  have
• 18:16
  compassion
• 18:16
  for
• 18:16
  you.
• 18:16
  If
• 18:17
  you
• 18:17
  have
• 18:17
  panic
• 18:17
  attacks
• 18:18
  on
• 18:18
  an
• 18:18
  airplane,
• 18:18
  nobody's
• 18:19
  judging
• 18:19
  you.
• 18:20
  We
• 18:20
  all
• 18:20
  love
• 18:20
  you,
• 18:21
  and
• 18:21
  we
• 18:21
  will
• 18:21
  all
• 18:22
  be
• 18:23
  actually
• 18:23
  grateful
• 18:24
  that
• 18:24
  we're
• 18:25
  not
• 18:25
  getting
• 18:25
  to
• 18:25
  our
• 18:25
  destination
• 18:26
  on
• 18:26
  time
• 18:27
  if
• 18:27
  it
• 18:27
  means
• 18:27
  you're
• 18:28
  getting
• 18:28
  the
• 18:28
  care
• 18:28
  that
• 18:28
  you
• 18:28
  need.
• 18:29
  So.
• 18:30
  So
• 18:30
  really
• 18:31
  time
• 18:31
  your
• 18:31
  onset
• 18:31
  of
• 18:32
  action.
• 18:32
  That
• 18:32
  is
• 18:32
  very,
• 18:33
  very
• 18:33
  important.
• 18:35
  You
• 18:35
  know,
• 18:35
  again,
• 18:36
  for
• 18:36
  the
• 18:36
  oral
• 18:37
  medications,
• 18:37
  you're
• 18:37
  looking
• 18:38
  anywhere
• 18:38
  between
• 18:38
  15
• 18:39
  and
• 18:39
  30
• 18:39
  minutes,
• 18:39
  up
• 18:40
  to
• 18:40
  60
• 18:40
  minutes,
• 18:40
  maybe
• 18:41
  with
• 18:41
  Klonopin.
• 18:41
  But
• 18:42
  Tmax,
• 18:42
  you
• 18:42
  need
• 18:43
  to
• 18:43
  target
• 18:43
  that.
• 18:43
  And
• 18:44
  you
• 18:44
  need
• 18:44
  to
• 18:44
  also
• 18:44
  make
• 18:44
  sure
• 18:45
  the
• 18:45
  duration
• 18:45
  of
• 18:45
  action
• 18:46
  is.
• 18:47
  Makes
• 18:48
  sense
• 18:48
  for
• 18:48
  your
• 18:48
  patient.
• 18:49
  And
• 18:50
  it's
• 18:50
  always
• 18:50
  important
• 18:51
  also
• 18:51
  to
• 18:51
  have
• 18:51
  an
• 18:51
  appreciation
• 18:52
  for
• 18:52
  the
• 18:52
  fact
• 18:52
  that
• 18:53
  everybody's
• 18:53
  different,
• 18:54
  right?
• 18:55
  Everybody
• 18:56
  is
• 18:56
  a
• 18:56
  little
• 18:56
  bit
• 18:57
  different.
• 18:58
  So
• 18:58
  the
• 18:59
  amount
• 18:59
  of
• 18:59
  fat
• 18:59
  that
• 18:59
  they
• 19:00
  have,
• 19:00
  the
• 19:00
  age,
• 19:01
  you
• 19:01
  know,
• 19:01
  their
• 19:01
  age,
• 19:01
  if
• 19:02
  they're
• 19:02
  older,
• 19:02
  they
• 19:02
  might
• 19:02
  not
• 19:03
  metabolize
• 19:03
  these
• 19:03
  medications
• 19:04
  as
• 19:04
  efficiently,
• 19:05
  and
• 19:05
  the
• 19:06
  side
• 19:06
  effects
• 19:06
  might
• 19:07
  hit
• 19:07
  them
• 19:08
  a
• 19:08
  lot
• 19:08
  harder.
• 19:08
  They
• 19:08
  might
• 19:09
  get
• 19:09
  more
• 19:09
  sedated,
• 19:10
  more
• 19:10
  confused,
• 19:11
  difficult,
• 19:12
  you
• 19:13
  know,
• 19:13
  difficulty
• 19:14
  with
• 19:14
  kind
• 19:14
  of
• 19:14
  coordinating
• 19:15
  themselves
• 19:15
  on
• 19:15
  their
• 19:15
  way
• 19:16
  to
• 19:16
  the
• 19:16
  bathroom.
• 19:17
  You
• 19:17
  know,
• 19:17
  if
• 19:17
  you're
• 19:17
  older,
• 19:18
  if
• 19:18
  you
• 19:18
  have
• 19:19
  liver
• 19:19
  issues,
• 19:21
  at
• 19:21
  least
• 19:21
  for,
• 19:21
  you
• 19:21
  know,
• 19:22
  Xanax
• 19:22
  and
• 19:22
  Klonopin,
• 19:24
  you've
• 19:25
  got
• 19:25
  to
• 19:25
  watch
• 19:25
  out
• 19:25
  for
• 19:25
  those.
• 19:26
  Those,
• 19:26
  you
• 19:26
  know.
• 19:26
  And
• 19:27
  aside
• 19:27
  from
• 19:27
  age,
• 19:27
  just
• 19:28
  genetic
• 19:28
  variations,
• 19:28
  right?
• 19:29
  You
• 19:29
  might
• 19:29
  have
• 19:29
  people
• 19:29
  who
• 19:29
  hyper
• 19:30
  metabolize
• 19:31
  some
• 19:31
  of
• 19:31
  these
• 19:31
  medications.
• 19:32
  Well,
• 19:32
  that's
• 19:32
  frustrating,
• 19:33
  right?
• 19:33
  Because
• 19:33
  here
• 19:33
  you
• 19:33
  are
• 19:34
  trying
• 19:34
  to
• 19:34
  tease
• 19:35
  somebody
• 19:35
  up
• 19:35
  with
• 19:36
  a
• 19:36
  flight
• 19:36
  from
• 19:36
  New
• 19:37
  York
• 19:37
  to
• 19:37
  LA
• 19:38
  and
• 19:38
  Bamboo,
• 19:39
  they're
• 19:39
  hyper
• 19:39
  metabolizing
• 19:40
  your
• 19:40
  Ativan
• 19:41
  and
• 19:41
  what
• 19:41
  was
• 19:42
  supposed
• 19:42
  to
• 19:42
  be
• 19:42
  six
• 19:42
  hours
• 19:43
  of
• 19:43
  coverage
• 19:43
  to
• 19:43
  perfectly
• 19:44
  handle
• 19:44
  a
• 19:44
  five
• 19:45
  and
• 19:45
  a
• 19:45
  half
• 19:45
  hour
• 19:45
  flight.
• 19:46
  They've
• 19:47
  churned
• 19:47
  through
• 19:47
  it
• 19:48
  in
• 19:48
  three
• 19:48
  or
• 19:48
  four
• 19:49
  and
• 19:49
  they're
• 19:49
  in
• 19:49
  the
• 19:49
  middle
• 19:50
  of
• 19:50
  Nebraska
• 19:51
  begging
• 19:52
  the
• 19:53
  banging
• 19:53
  on
• 19:53
  the
• 19:54
  cockpit
• 19:54
  to
• 19:55
  get
• 19:55
  the
• 19:55
  pilot
• 19:55
  to
• 19:55
  land
• 19:56
  in
• 19:56
  Omaha.
• 19:57
  And
• 19:57
  everybody's
• 19:58
  screaming
• 19:58
  and
• 19:59
  it's
• 19:59
  just
• 19:59
  a
• 19:59
  crazy
• 20:00
  scene
• 20:01
  because
• 20:01
  of
• 20:01
  you,
• 20:01
  because
• 20:02
  you
• 20:03
  didn't
• 20:04
  appreciate
• 20:05
  the
• 20:05
  fact
• 20:05
  that
• 20:06
  they
• 20:06
  are
• 20:07
  hyper
• 20:07
  metabolizers.
• 20:08
  And
• 20:08
  had
• 20:08
  you
• 20:08
  give
• 20:09
  them,
• 20:09
  given
• 20:09
  them
• 20:09
  a
• 20:09
  dry
• 20:10
  run
• 20:10
  and
• 20:11
  before
• 20:11
  they
• 20:12
  took
• 20:12
  the
• 20:12
  medication,
• 20:12
  you
• 20:13
  we
• 20:13
  would
• 20:13
  know
• 20:13
  that,
• 20:13
  right?
• 20:14
  If
• 20:14
  we
• 20:14
  give
• 20:14
  our
• 20:15
  patients
• 20:15
  a
• 20:15
  dry
• 20:15
  run,
• 20:16
  you
• 20:17
  know,
• 20:17
  during
• 20:17
  the
• 20:17
  weekend
• 20:18
  so
• 20:18
  that
• 20:18
  we
• 20:18
  can
• 20:18
  understand
• 20:19
  that
• 20:19
  they're
• 20:19
  taking
• 20:20
  the
• 20:20
  medication,
• 20:20
  it's
• 20:21
  therapeutic.
• 20:21
  They
• 20:22
  don't
• 20:22
  get
• 20:22
  too
• 20:22
  disinhibited
• 20:23
  or
• 20:23
  groggy
• 20:24
  or
• 20:24
  they
• 20:25
  churn
• 20:25
  through
• 20:25
  it
• 20:25
  and
• 20:25
  they
• 20:25
  hyper
• 20:26
  metabolize
• 20:26
  it,
• 20:27
  like,
• 20:27
  that's
• 20:27
  why
• 20:27
  we
• 20:27
  do
• 20:28
  those
• 20:28
  things.
• 20:28
  And
• 20:28
  if
• 20:29
  we
• 20:29
  do
• 20:29
  those
• 20:29
  things,
• 20:30
  we
• 20:30
  have
• 20:30
  more
• 20:30
  confidence
• 20:30
  that
• 20:31
  35,000ft
• 20:32
  later,
• 20:32
  they're
• 20:33
  gonna
• 20:33
  react
• 20:34
  just
• 20:34
  as
• 20:35
  well
• 20:35
  as
• 20:35
  they
• 20:35
  did
• 20:35
  on
• 20:35
  the
• 20:36
  couch,
• 20:36
  right?
• 20:36
  So
• 20:37
  these
• 20:37
  are
• 20:37
  the
• 20:37
  things
• 20:37
  we
• 20:37
  have
• 20:38
  to
• 20:38
  keep
• 20:38
  in
• 20:38
  mind,
• 20:38
  right?
• 20:38
  Drug
• 20:39
  interactions.
• 20:40
  Do
• 20:40
  they
• 20:40
  chug
• 20:41
  grapefruit
• 20:41
  juice
• 20:41
  in
• 20:42
  the
• 20:42
  morning,
• 20:42
  you
• 20:42
  know,
• 20:44
  and
• 20:44
  Thereby
• 20:45
  elevate
• 20:46
  the
• 20:46
  levels
• 20:46
  of
• 20:46
  drug
• 20:46
  in
• 20:47
  their
• 20:47
  bloodstream.
• 20:48
  Have
• 20:48
  they
• 20:48
  ever
• 20:48
  tried
• 20:49
  benzos
• 20:49
  before?
• 20:49
  A
• 20:50
  benzo
• 20:50
  naive
• 20:51
  patient
• 20:51
  might
• 20:51
  have
• 20:51
  prolonged
• 20:52
  effects
• 20:53
  where
• 20:53
  they're
• 20:54
  super
• 20:54
  sedated
• 20:54
  and
• 20:55
  wiped
• 20:55
  out
• 20:55
  and
• 20:56
  amnesiac
• 20:57
  and
• 20:57
  all
• 20:57
  these
• 20:57
  other
• 20:57
  things.
• 20:58
  Um,
• 20:58
  so
• 20:58
  we
• 20:59
  really
• 20:59
  want
• 20:59
  to
• 20:59
  make
• 20:59
  sure
• 21:00
  we
• 21:00
  know
• 21:00
  what
• 21:00
  we're
• 21:00
  doing
• 21:01
  and
• 21:01
  why
• 21:01
  we're
• 21:02
  doing
• 21:02
  it.
• 21:02
  And
• 21:03
  so
• 21:04
  to
• 21:04
  come
• 21:04
  full
• 21:04
  circle,
• 21:05
  I
• 21:05
  think
• 21:05
  Klonopin
• 21:06
  is
• 21:06
  the
• 21:06
  best
• 21:06
  choice
• 21:07
  in
• 21:07
  this
• 21:09
  particular
• 21:09
  case
• 21:09
  study.
• 21:10
  Aaron
• 21:10
  will
• 21:10
  get
• 21:11
  to
• 21:11
  New
• 21:11
  York.
• 21:12
  He
• 21:12
  will
• 21:12
  get
• 21:12
  from
• 21:13
  New
• 21:13
  York
• 21:13
  to
• 21:13
  Sydney
• 21:14
  safely.
• 21:15
  Um,
• 21:15
  I
• 21:15
  think
• 21:16
  if
• 21:16
  you
• 21:16
  give
• 21:16
  him
• 21:16
  probably
• 21:17
  one
• 21:17
  tablet
• 21:17
  about
• 21:18
  60
• 21:18
  minutes
• 21:18
  before
• 21:19
  he
• 21:19
  boards.
• 21:20
  You
• 21:20
  may
• 21:20
  need
• 21:21
  to
• 21:21
  adjust
• 21:21
  that
• 21:21
  based
• 21:21
  on
• 21:22
  his
• 21:22
  specific
• 21:23
  fear
• 21:23
  trigger.
• 21:23
  And
• 21:24
  what
• 21:24
  part
• 21:24
  of
• 21:24
  the
• 21:24
  flight
• 21:24
  is
• 21:24
  the
• 21:25
  worst
• 21:25
  for
• 21:25
  him.
• 21:26
  I
• 21:26
  would
• 21:26
  give
• 21:26
  him
• 21:26
  some
• 21:27
  backup
• 21:27
  tablets
• 21:27
  just
• 21:28
  in
• 21:28
  case
• 21:28
  there
• 21:28
  are
• 21:28
  flight
• 21:29
  delays.
• 21:30
  He
• 21:30
  gets
• 21:30
  rerouted
• 21:31
  because,
• 21:33
  you
• 21:33
  know,
• 21:33
  whatever
• 21:34
  reason
• 21:35
  the
• 21:35
  price
• 21:35
  of
• 21:35
  fuel
• 21:36
  is
• 21:36
  too
• 21:36
  high
• 21:38
  or
• 21:39
  you
• 21:39
  know,
• 21:40
  there's
• 21:40
  an
• 21:40
  emergency,
• 21:41
  that's
• 21:41
  not
• 21:42
  his
• 21:42
  panic
• 21:42
  attack
• 21:42
  on
• 21:43
  flight
• 21:43
  and
• 21:43
  he
• 21:43
  gets
• 21:44
  delayed
• 21:44
  and
• 21:44
  he
• 21:44
  has
• 21:44
  to
• 21:44
  spend
• 21:44
  the
• 21:45
  night
• 21:45
  in
• 21:45
  Denver
• 21:45
  at
• 21:45
  a
• 21:46
  Holiday
• 21:46
  Inn
• 21:47
  and
• 21:47
  he's
• 21:47
  got
• 21:47
  to
• 21:47
  get
• 21:47
  up
• 21:48
  the
• 21:48
  next
• 21:48
  day
• 21:48
  and
• 21:48
  connect
• 21:49
  in
• 21:49
  San
• 21:49
  Francisco
• 21:50
  and
• 21:50
  then
• 21:51
  American
• 21:51
  Airlines
• 21:51
  loses
• 21:52
  his
• 21:52
  bags.
• 21:52
  Right.
• 21:53
  I'm
• 21:53
  not
• 21:53
  speaking
• 21:54
  from
• 21:54
  personal
• 21:54
  experience,
• 21:55
  but
• 21:56
  my
• 21:56
  point
• 21:56
  is
• 21:57
  you
• 21:57
  might
• 21:57
  want
• 21:57
  to
• 21:58
  give
• 21:58
  him
• 21:58
  some
• 21:58
  insurance
• 21:58
  because
• 21:59
  flying
• 21:59
  is
• 21:59
  not
• 22:00
  always
• 22:00
  like
• 22:01
  an
• 22:01
  A
• 22:01
  to
• 22:01
  B
• 22:01
  evolution.
• 22:02
  Right.
• 22:04
  Make
• 22:04
  sure
• 22:04
  he
• 22:04
  takes
• 22:05
  that
• 22:05
  test
• 22:05
  dose
• 22:06
  and
• 22:07
  educate
• 22:07
  him
• 22:07
  that
• 22:07
  alcohol
• 22:08
  on
• 22:08
  flight
• 22:09
  is
• 22:09
  an
• 22:09
  absolute.
• 22:10
  No,
• 22:10
  no.
• 22:10
  There's
• 22:10
  synergy
• 22:11
  with
• 22:11
  sedation.
• 22:12
  The
• 22:12
  cabin
• 22:13
  altitude
• 22:13
  and
• 22:14
  the
• 22:14
  pressures
• 22:14
  can.
• 22:15
  Can
• 22:15
  dangerously
• 22:16
  cause
• 22:17
  some
• 22:17
  dangerous
• 22:17
  conditions
• 22:18
  where
• 22:18
  you
• 22:18
  can
• 22:18
  blackout,
• 22:18
  have
• 22:19
  respiratory
• 22:19
  depression
• 22:20
  and
• 22:20
  make
• 22:21
  sure
• 22:21
  you
• 22:21
  know
• 22:21
  that
• 22:21
  he's
• 22:22
  not
• 22:22
  driving
• 22:22
  when
• 22:22
  he
• 22:22
  gets
• 22:22
  to
• 22:23
  Sydney.
• 22:24
  It's
• 22:25
  probably
• 22:25
  hard
• 22:25
  enough
• 22:26
  to
• 22:26
  drive
• 22:26
  there
• 22:26
  when
• 22:26
  it's
• 22:27
  on
• 22:27
  the
• 22:27
  other
• 22:27
  side
• 22:27
  of
• 22:28
  the
• 22:28
  road.
• 22:29
  If
• 22:29
  that's
• 22:29
  the
• 22:29
  case.
• 22:29
  I
• 22:30
  feel
• 22:30
  like
• 22:30
  it
• 22:30
  might
• 22:30
  be
• 22:30
  the
• 22:31
  case
• 22:31
  over
• 22:31
  there.
• 22:32
  But
• 22:32
  now
• 22:32
  you're
• 22:32
  asking
• 22:33
  him
• 22:33
  to
• 22:33
  drive
• 22:33
  on
• 22:33
  the
• 22:33
  other
• 22:34
  side
• 22:34
  of
• 22:34
  the
• 22:34
  road
• 22:34
  when
• 22:35
  he
• 22:35
  still
• 22:35
  has
• 22:35
  Klonopin
• 22:36
  in
• 22:36
  his
• 22:36
  system.
• 22:39
  It's
• 22:39
  not
• 22:39
  a
• 22:40
  good
• 22:40
  idea.
• 22:40
  So
• 22:41
  provide
• 22:41
  that
• 22:41
  guidance,
• 22:42
  that
• 22:42
  education.
• 22:42
  Remember,
• 22:43
  this
• 22:43
  isn't
• 22:43
  really
• 22:44
  first
• 22:44
  line,
• 22:44
  but
• 22:45
  in
• 22:45
  practice
• 22:46
  you
• 22:46
  might
• 22:46
  find
• 22:46
  yourself
• 22:46
  here.
• 22:47
  And
• 22:47
  good
• 22:47
  luck
• 22:48
  to
• 22:48
  all
• 22:48
  of
• 22:48
  you.
• 22:48
  You
• 22:49
  know,
• 22:49
  fly
• 22:49
  safe.
• 22:50
  Right,
• 22:50
  Fly
• 22:51
  safe.
• 22:51
  I
• 22:52
  appreciate
• 22:52
  all
• 22:52
  of
• 22:52
  you.
• 22:53
  And
• 22:53
  let
• 22:53
  me
• 22:53
  tell
• 22:53
  you
• 22:53
  all
• 22:53
  something.
• 22:54
  One
• 22:54
  last
• 22:54
  thing
• 22:55
  before
• 22:55
  you
• 22:55
  go.
• 22:55
  If
• 22:56
  there's
• 22:56
  one
• 22:56
  thing
• 22:56
  you
• 22:57
  don't
• 22:57
  forget
• 22:57
  before
• 22:58
  you
• 22:58
  go
• 22:58
  to
• 22:58
  bed
• 22:58
  tonight,
• 22:59
  that
• 23:00
  one
• 23:00
  little
• 23:00
  thing.
• 23:00
  Oh,
• 23:00
  what
• 23:01
  am
• 23:01
  I
• 23:01
  forgetting?
• 23:01
  What
• 23:01
  am
• 23:01
  I
• 23:02
  forgetting?
• 23:03
  It
• 23:03
  would
• 23:03
  be
• 23:03
  really
• 23:04
  awesome
• 23:05
  if
• 23:05
  you
• 23:05
  went
• 23:05
  to
• 23:06
  the
• 23:06
  show
• 23:06
  Notes
• 23:06
  and
• 23:06
  became
• 23:07
  a
• 23:07
  Patreon
• 23:07
  member.
• 23:08
  And
• 23:08
  I'll
• 23:08
  tell
• 23:08
  you
• 23:08
  why.
• 23:09
  Because
• 23:09
  the
• 23:09
  difference
• 23:10
  between
• 23:10
  good
• 23:10
  clinicians
• 23:11
  and
• 23:11
  great
• 23:11
  clinicians
• 23:12
  are
• 23:12
  that
• 23:12
  great
• 23:13
  clinicians
• 23:13
  understand
• 23:14
  the
• 23:14
  how
• 23:14
  and
• 23:14
  the
• 23:14
  why
• 23:15
  of
• 23:15
  what
• 23:15
  they're
• 23:15
  prescribing.
• 23:16
  They
• 23:16
  don't
• 23:16
  just
• 23:16
  hand
• 23:16
  out
• 23:16
  a
• 23:17
  pill.
• 23:17
  They.
• 23:17
  They
• 23:17
  don't
• 23:18
  just
• 23:18
  come
• 23:18
  down
• 23:18
  with
• 23:18
  a
• 23:19
  diagnosis,
• 23:19
  but
• 23:19
  they
• 23:19
  really
• 23:20
  understand
• 23:20
  the
• 23:20
  how
• 23:21
  and
• 23:21
  why.
• 23:21
  And
• 23:21
  the
• 23:21
  nitty
• 23:22
  gritty
• 23:22
  behind
• 23:22
  things.
• 23:23
  Patients
• 23:24
  smell
• 23:24
  that
• 23:24
  a
• 23:24
  mile
• 23:24
  away.
• 23:25
  They
• 23:25
  trust
• 23:25
  you
• 23:26
  more.
• 23:26
  It
• 23:26
  leads
• 23:27
  to
• 23:27
  better
• 23:27
  outcomes.
• 23:27
  And
• 23:28
  I
• 23:28
  built
• 23:29
  a
• 23:29
  whole
• 23:29
  Patreon
• 23:30
  library
• 23:32
  full
• 23:32
  of
• 23:32
  visually
• 23:33
  sticky,
• 23:34
  beautiful
• 23:35
  ways
• 23:35
  to
• 23:35
  understand
• 23:36
  psychiatry.
• 23:37
  It's
• 23:37
  growing
• 23:38
  fast.
• 23:38
  People
• 23:38
  love
• 23:38
  it.
• 23:39
  Our
• 23:39
  feedback
• 23:39
  is
• 23:39
  great.
• 23:40
  We'd
• 23:40
  love
• 23:40
  to
• 23:40
  welcome
• 23:41
  you.
• 23:41
  I
• 23:41
  am
• 23:42
  genuinely
• 23:42
  terrified
• 23:43
  where
• 23:43
  I
• 23:43
  would
• 23:43
  be
• 23:44
  without
• 23:44
  this
• 23:44
  library.
• 23:45
  I
• 23:45
  rely
• 23:46
  on
• 23:46
  it
• 23:46
  all
• 23:46
  the
• 23:46
  time
• 23:46
  to
• 23:47
  stay
• 23:47
  fresh,
• 23:47
  and
• 23:48
  I
• 23:48
  just
• 23:48
  feel
• 23:48
  empowered
• 23:49
  as
• 23:49
  a
• 23:49
  clinician
• 23:50
  because
• 23:50
  I
• 23:50
  have
• 23:50
  this
• 23:50
  at
• 23:50
  my
• 23:50
  fingertips.
• 23:51
  So
• 23:51
  definitely
• 23:52
  go
• 23:52
  to
• 23:52
  the
• 23:52
  show
• 23:52
  Notes
• 23:53
  if
• 23:53
  you
• 23:53
  can.
• 23:54
  We'd
• 23:54
  love
• 23:54
  to
• 23:54
  have
• 23:54
  you
• 23:55
  and
• 23:55
  become
• 23:55
  a
• 23:55
  member
• 23:56
  and
• 23:56
  join
• 23:57
  our.
• 23:57
  Join
• 23:57
  our.
• 23:58
  I
• 23:58
  was
• 23:58
  going
• 23:59
  to
• 23:59
  say
• 23:59
  cult.
• 23:59
  That
• 23:59
  is
• 23:59
  not
• 23:59
  the
• 24:00
  direction
• 24:00
  I
• 24:00
  want
• 24:00
  to
• 24:00
  go
• 24:00
  in
• 24:01
  at
• 24:01
  all.
• 24:01
  Join
• 24:01
  our
• 24:02
  club.
• 24:02
  I
• 24:02
  think
• 24:03
  that's
• 24:03
  a
• 24:03
  much,
• 24:03
  much
• 24:04
  more
• 24:04
  apt
• 24:04
  term.
• 24:05
  And
• 24:05
  we
• 24:05
  do
• 24:05
  serious
• 24:06
  seriously
• 24:06
  appreciate
• 24:07
  everybody
• 24:07
  listening
• 24:08
  to
• 24:08
  this.
• 24:08
  You
• 24:08
  guys
• 24:08
  are
• 24:08
  awesome.
• 24:10
  We'll
• 24:10
  catch
• 24:10
  you
• 24:10
  next
• 24:10
  time
• 24:11
  here
• 24:11
  on
• 24:11
  Pearls
• 24:12
  and
• 24:12
  Prep.
• 24:12
  Bye.
• 24:12
  Bye.