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Gabapentin: The Duct Tape of Psychiatry · 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
• 0:08
  Pearls
• 0:08
  and
• 0:08
  prep
• 0:09
  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
• 0:14
  practice.
• 0:15
  Today
• 0:15
  we
• 0:15
  are
• 0:15
  going
• 0:16
  to
• 0:16
  be
• 0:16
  talking
• 0:16
  about
• 0:17
  gabapentin.
• 0:19
  Gabapentin
• 0:20
  is
• 0:21
  one
• 0:21
  of
• 0:21
  the
• 0:21
  most
• 0:21
  interesting
• 0:22
  medications
• 0:23
  I
• 0:23
  think,
• 0:23
  in
• 0:24
  all
• 0:24
  of
• 0:24
  psychiatry.
• 0:25
  I
• 0:25
  think
• 0:25
  it
• 0:26
  is
• 0:26
  misunderstood.
• 0:27
  It
• 0:27
  is
• 0:27
  probably
• 0:28
  underprescribed,
• 0:29
  it
• 0:29
  is
• 0:29
  probably
• 0:29
  overprescribed
• 0:31
  for
• 0:31
  very
• 0:31
  specific
• 0:32
  reasons.
• 0:33
  And
• 0:33
  it
• 0:33
  doesn't
• 0:34
  quite
• 0:34
  fit
• 0:35
  in
• 0:35
  with
• 0:36
  any
• 0:36
  other
• 0:36
  medication
• 0:37
  that
• 0:37
  we
• 0:37
  prescribe.
• 0:38
  It's
• 0:38
  like
• 0:38
  one
• 0:39
  of
• 0:39
  these
• 0:39
  things
• 0:40
  is
• 0:40
  not
• 0:40
  like
• 0:40
  the
• 0:41
  other.
• 0:41
  For
• 0:42
  starters,
• 0:42
  you
• 0:43
  would
• 0:43
  think
• 0:43
  that
• 0:44
  it
• 0:44
  binds
• 0:45
  to
• 0:45
  GABA
• 0:45
  receptors
• 0:46
  because
• 0:46
  it's
• 0:46
  called
• 0:47
  gabapentin.
• 0:47
  Well,
• 0:48
  it
• 0:48
  does
• 0:48
  not
• 0:48
  bind
• 0:49
  to
• 0:49
  GABA
• 0:50
  receptors.
• 0:50
  It
• 0:51
  does
• 0:51
  not
• 0:51
  affect
• 0:51
  GABA
• 0:52
  reuptake
• 0:52
  it.
• 0:53
  It
• 0:53
  is
• 0:53
  not
• 0:53
  a
• 0:53
  GABAergic
• 0:54
  drug.
• 0:55
  Okay?
• 0:56
  Its
• 0:56
  primary
• 0:56
  mechanism
• 0:57
  is
• 0:58
  actually
• 0:58
  this
• 0:58
  high
• 0:59
  affinity
• 0:59
  binding
• 1:00
  to
• 1:00
  the
• 1:00
  Alpha
• 1:01
  1
• 1:01
  subunit,
• 1:02
  voltage,
• 1:02
  gated
• 1:02
  calcium
• 1:03
  channels.
• 1:03
  And
• 1:04
  that's
• 1:04
  a
• 1:04
  mouthful,
• 1:04
  but
• 1:05
  I'll
• 1:05
  explain
• 1:05
  that
• 1:06
  in
• 1:06
  a
• 1:06
  little
• 1:06
  bit.
• 1:07
  So
• 1:07
  it's
• 1:07
  a
• 1:07
  med
• 1:08
  that
• 1:08
  doesn't
• 1:08
  really
• 1:08
  do
• 1:09
  what
• 1:09
  it
• 1:09
  says
• 1:09
  it's
• 1:09
  supposed
• 1:10
  to
• 1:10
  do,
• 1:11
  which
• 1:11
  is
• 1:11
  already
• 1:12
  kind
• 1:12
  of
• 1:13
  confusing
• 1:13
  in
• 1:14
  a
• 1:14
  sense.
• 1:15
  It's
• 1:15
  almost
• 1:15
  like
• 1:15
  there's
• 1:15
  a
• 1:16
  med
• 1:16
  called
• 1:16
  dopamopa,
• 1:17
  but
• 1:17
  it
• 1:18
  doesn't
• 1:18
  even
• 1:19
  affect
• 1:19
  dopamine
• 1:20
  at
• 1:20
  all.
• 1:20
  Okay.
• 1:21
  You
• 1:21
  know,
• 1:21
  it's
• 1:21
  like,
• 1:21
  why?
• 1:22
  Well,
• 1:22
  why
• 1:22
  is
• 1:22
  it
• 1:22
  called
• 1:22
  dopamopa?
• 1:24
  And
• 1:24
  I
• 1:24
  mean,
• 1:24
  even
• 1:25
  Levodopa
• 1:26
  had.
• 1:26
  It
• 1:26
  has
• 1:27
  something
• 1:27
  to
• 1:27
  do
• 1:27
  with
• 1:27
  dopamine,
• 1:28
  right?
• 1:28
  It
• 1:28
  increases
• 1:28
  dopamine.
• 1:29
  So
• 1:30
  why
• 1:30
  or
• 1:30
  why
• 1:30
  is
• 1:31
  this
• 1:31
  called
• 1:31
  gabapentin?
• 1:32
  And
• 1:33
  it
• 1:33
  has
• 1:33
  nothing
• 1:33
  really
• 1:34
  to
• 1:34
  do
• 1:34
  with
• 1:34
  gaba?
• 1:35
  I
• 1:35
  don't
• 1:35
  know.
• 1:35
  I
• 1:36
  didn't
• 1:36
  make
• 1:36
  it.
• 1:36
  But
• 1:37
  it's
• 1:37
  one
• 1:37
  of
• 1:37
  those
• 1:37
  other
• 1:38
  things
• 1:38
  that
• 1:38
  makes
• 1:38
  gabapentin
• 1:40
  a
• 1:40
  very
• 1:40
  unique
• 1:41
  medication.
• 1:41
  And
• 1:42
  I
• 1:42
  say
• 1:42
  that
• 1:42
  in
• 1:42
  a
• 1:42
  good
• 1:42
  and
• 1:43
  bad
• 1:43
  way.
• 1:43
  You
• 1:43
  know,
• 1:43
  I've
• 1:44
  always
• 1:44
  said
• 1:44
  that
• 1:45
  none
• 1:45
  of
• 1:45
  these
• 1:46
  medications
• 1:46
  are
• 1:46
  objectively
• 1:47
  good
• 1:47
  or
• 1:47
  bad.
• 1:48
  They
• 1:48
  are
• 1:49
  good
• 1:49
  or
• 1:50
  bad
• 1:50
  only
• 1:50
  in
• 1:50
  the
• 1:51
  context
• 1:51
  of
• 1:51
  the
• 1:52
  prescription
• 1:53
  and
• 1:53
  the
• 1:53
  patient
• 1:54
  in
• 1:54
  front
• 1:54
  of
• 1:54
  you.
• 1:55
  Right.
• 1:55
  This
• 1:55
  could
• 1:56
  be
• 1:56
  a
• 1:56
  horrible
• 1:57
  idea
• 1:58
  given
• 1:58
  a
• 1:58
  specific
• 1:59
  patient,
• 1:59
  and
• 2:00
  it
• 2:00
  could
• 2:00
  be
• 2:00
  one
• 2:00
  of
• 2:00
  the
• 2:01
  best
• 2:01
  ideas
• 2:01
  you
• 2:01
  have
• 2:02
  left
• 2:02
  in
• 2:03
  another
• 2:03
  patient.
• 2:04
  So
• 2:04
  it
• 2:05
  sort
• 2:05
  of
• 2:05
  just
• 2:05
  depends.
• 2:05
  And
• 2:06
  this
• 2:06
  is
• 2:06
  why
• 2:06
  we
• 2:06
  need
• 2:06
  to
• 2:06
  know
• 2:07
  our
• 2:07
  medications,
• 2:07
  because
• 2:08
  when
• 2:08
  we
• 2:08
  know
• 2:08
  our
• 2:08
  medications,
• 2:09
  we
• 2:09
  can
• 2:09
  tailor
• 2:10
  them
• 2:10
  to
• 2:10
  a
• 2:10
  specific
• 2:11
  patient
• 2:11
  in
• 2:11
  a
• 2:11
  specific
• 2:12
  situation.
• 2:13
  Now,
• 2:13
  I
• 2:13
  will
• 2:13
  be
• 2:13
  honest
• 2:14
  with
• 2:14
  you.
• 2:14
  Gabapentin
• 2:15
  is
• 2:15
  like
• 2:15
  duct
• 2:16
  tape
• 2:16
  in
• 2:16
  psychiatry.
• 2:17
  People
• 2:18
  prescribe
• 2:18
  it
• 2:19
  as
• 2:19
  a
• 2:20
  fix
• 2:20
  to
• 2:21
  a
• 2:21
  lot
• 2:21
  of
• 2:21
  different
• 2:22
  situations.
• 2:23
  It
• 2:23
  has
• 2:23
  a
• 2:23
  lot
• 2:23
  of
• 2:23
  different
• 2:24
  universal
• 2:25
  ways
• 2:25
  of
• 2:26
  kind
• 2:26
  of
• 2:26
  fixing
• 2:27
  things.
• 2:27
  I
• 2:27
  say
• 2:27
  kind
• 2:28
  of
• 2:28
  because
• 2:28
  these
• 2:29
  are
• 2:29
  not
• 2:29
  like
• 2:29
  naked
• 2:30
  FDA
• 2:30
  approvals.
• 2:31
  It's
• 2:31
  pro.
• 2:31
  It
• 2:32
  is
• 2:32
  probably
• 2:32
  one
• 2:32
  of
• 2:33
  the
• 2:33
  most
• 2:34
  commonly
• 2:34
  prescribed
• 2:35
  medications
• 2:35
  that
• 2:36
  is
• 2:36
  prescribed
• 2:37
  off
• 2:37
  label.
• 2:38
  In
• 2:38
  other
• 2:38
  words,
• 2:38
  not
• 2:39
  for
• 2:39
  FDA
• 2:39
  approved
• 2:40
  indications.
• 2:41
  Less
• 2:41
  than
• 2:41
  1%
• 2:42
  of
• 2:42
  all
• 2:42
  gabapentin
• 2:43
  prescriptions
• 2:44
  are
• 2:44
  for
• 2:44
  FDA
• 2:45
  approved
• 2:46
  indications.
• 2:46
  Like
• 2:47
  95%
• 2:47
  of
• 2:48
  them
• 2:48
  are.
• 2:49
  In
• 2:49
  other
• 2:50
  words,
• 2:50
  not
• 2:50
  for
• 2:51
  partial
• 2:51
  seizures
• 2:52
  or
• 2:52
  post
• 2:53
  herpetic
• 2:54
  neuralgia
• 2:54
  or
• 2:54
  restless
• 2:55
  leg
• 2:55
  syndrome.
• 2:55
  Those
• 2:55
  are
• 2:56
  the
• 2:56
  FDA
• 2:56
  approvals
• 2:57
  for
• 2:57
  gabapentin.
• 2:58
  95%
• 2:59
  of
• 2:59
  these
• 3:00
  are
• 3:00
  being
• 3:00
  written
• 3:01
  for
• 3:01
  indications
• 3:02
  that
• 3:03
  are
• 3:03
  not
• 3:04
  those
• 3:04
  three
• 3:04
  things.
• 3:05
  And
• 3:05
  so
• 3:05
  the
• 3:05
  question
• 3:06
  is,
• 3:06
  well,
• 3:06
  what
• 3:06
  the
• 3:07
  heck
• 3:07
  are
• 3:07
  we
• 3:07
  prescribing
• 3:08
  gabapentin
• 3:08
  for
• 3:09
  them?
• 3:09
  There
• 3:09
  must
• 3:09
  be
• 3:09
  a
• 3:09
  reason
• 3:11
  why
• 3:11
  is
• 3:11
  this
• 3:12
  a
• 3:12
  medication
• 3:13
  that
• 3:13
  is
• 3:13
  so
• 3:13
  frequently
• 3:14
  used?
• 3:14
  And
• 3:14
  again,
• 3:14
  I
• 3:15
  think
• 3:15
  the
• 3:15
  best
• 3:15
  analogy
• 3:16
  I
• 3:16
  can
• 3:16
  think
• 3:16
  of
• 3:17
  is
• 3:17
  that
• 3:17
  it
• 3:17
  behaves
• 3:18
  a
• 3:18
  lot
• 3:18
  like
• 3:18
  duct
• 3:19
  tape,
• 3:19
  okay?
• 3:20
  And
• 3:21
  people
• 3:21
  use
• 3:22
  this
• 3:22
  for
• 3:22
  everything
• 3:22
  in
• 3:23
  psychiatry.
• 3:23
  They
• 3:24
  use
• 3:24
  it
• 3:24
  for
• 3:24
  anxiety,
• 3:25
  they
• 3:25
  use
• 3:25
  it
• 3:25
  for
• 3:26
  social
• 3:26
  anxiety,
• 3:27
  they
• 3:27
  use
• 3:27
  it
• 3:27
  for
• 3:27
  insomnia,
• 3:28
  they
• 3:29
  use
• 3:29
  it
• 3:29
  for
• 3:29
  alcohol
• 3:30
  use
• 3:30
  disorder,
• 3:30
  relapse
• 3:31
  prevention,
• 3:31
  withdrawal.
• 3:33
  Now
• 3:33
  some
• 3:33
  people
• 3:33
  use
• 3:33
  it
• 3:34
  for
• 3:34
  bipolar,
• 3:34
  and
• 3:34
  there's
• 3:35
  very
• 3:35
  weak
• 3:35
  evidence
• 3:35
  on
• 3:36
  that.
• 3:36
  That's
• 3:36
  kind
• 3:37
  of
• 3:37
  a.
• 3:37
  A
• 3:37
  no,
• 3:37
  no,
• 3:38
  it
• 3:38
  doesn't
• 3:39
  really
• 3:39
  work
• 3:39
  there.
• 3:40
  That's
• 3:40
  at
• 3:40
  least
• 3:40
  what
• 3:40
  the
• 3:40
  evidence
• 3:41
  seems
• 3:41
  to
• 3:41
  suggest
• 3:42
  every
• 3:42
  time
• 3:42
  I
• 3:43
  dig
• 3:43
  into
• 3:43
  it.
• 3:44
  It
• 3:44
  is
• 3:44
  not
• 3:44
  a
• 3:44
  mood
• 3:45
  stabilizer
• 3:45
  and
• 3:45
  should
• 3:46
  not
• 3:46
  be
• 3:46
  treated
• 3:46
  as
• 3:46
  such.
• 3:47
  Okay?
• 3:48
  So
• 3:49
  there's
• 3:49
  definitely
• 3:49
  hard
• 3:50
  concrete
• 3:50
  walls
• 3:51
  here
• 3:51
  when
• 3:51
  we're
• 3:51
  talking
• 3:51
  about
• 3:51
  gabapentin.
• 3:52
  Things
• 3:52
  it
• 3:53
  can't
• 3:53
  do.
• 3:53
  I
• 3:54
  don't
• 3:54
  think
• 3:54
  it
• 3:54
  can
• 3:54
  regrow
• 3:55
  your
• 3:55
  hair.
• 3:55
  Again,
• 3:56
  people
• 3:56
  use
• 3:56
  it
• 3:57
  for
• 3:57
  all
• 3:57
  kinds
• 3:58
  of
• 3:58
  things,
• 3:58
  whether
• 3:58
  or
• 3:58
  not
• 3:59
  it's
• 3:59
  really
• 4:00
  effective.
• 4:01
  Now,
• 4:01
  what
• 4:01
  is
• 4:01
  gabapentin
• 4:02
  exactly?
• 4:03
  Now,
• 4:03
  we
• 4:03
  talked
• 4:04
  about
• 4:04
  the
• 4:04
  fancy
• 4:05
  schmancy
• 4:06
  calcium
• 4:06
  calcium
• 4:07
  channel,
• 4:08
  high
• 4:08
  affinity
• 4:09
  for
• 4:09
  voltage,
• 4:10
  gated
• 4:10
  calcium
• 4:11
  channels.
• 4:12
  And
• 4:12
  really,
• 4:12
  at
• 4:13
  the
• 4:13
  end
• 4:13
  of
• 4:13
  the
• 4:13
  day,
• 4:13
  my
• 4:14
  friends,
• 4:14
  if
• 4:15
  there's
• 4:15
  one
• 4:15
  thing
• 4:15
  you
• 4:15
  can
• 4:16
  remember
• 4:16
  about
• 4:16
  gabapentin,
• 4:17
  it
• 4:17
  reduces
• 4:18
  excitatory
• 4:18
  neurotransmitter
• 4:19
  release,
• 4:20
  okay?
• 4:20
  Like
• 4:21
  glutamate,
• 4:21
  norepinephrine.
• 4:22
  So
• 4:23
  hyperexcitable
• 4:24
  neurons
• 4:24
  and
• 4:24
  synapses.
• 4:25
  It
• 4:25
  kind
• 4:25
  of
• 4:25
  cools
• 4:26
  it
• 4:26
  down.
• 4:26
  It
• 4:26
  kind
• 4:26
  of
• 4:27
  turns
• 4:27
  the
• 4:28
  volume
• 4:28
  down
• 4:29
  on
• 4:30
  over
• 4:30
  excited
• 4:31
  neurons
• 4:32
  and
• 4:32
  nerve
• 4:32
  terminals,
• 4:33
  okay?
• 4:33
  So
• 4:34
  I
• 4:34
  look
• 4:34
  at
• 4:34
  this
• 4:34
  at
• 4:35
  least
• 4:35
  this
• 4:35
  is
• 4:35
  how
• 4:35
  I
• 4:35
  synthesize
• 4:36
  all
• 4:36
  this
• 4:37
  information.
• 4:38
  I
• 4:38
  look
• 4:38
  at
• 4:38
  gabapentin
• 4:39
  as
• 4:39
  just
• 4:40
  a
• 4:40
  way
• 4:40
  to
• 4:40
  crank
• 4:41
  the
• 4:41
  volume
• 4:42
  down,
• 4:43
  okay?
• 4:44
  It's
• 4:45
  less
• 4:45
  excitatory
• 4:46
  neurotransmitter
• 4:47
  meter
• 4:48
  transmission,
• 4:49
  okay?
• 4:50
  It
• 4:50
  doesn't
• 4:50
  really
• 4:51
  inhibit.
• 4:52
  It
• 4:52
  reduces
• 4:53
  excessive
• 4:54
  excitation.
• 4:55
  There's
• 4:55
  a
• 4:55
  big
• 4:55
  difference
• 4:56
  between
• 4:56
  that,
• 4:57
  right?
• 4:57
  There's
• 4:57
  a
• 4:58
  very
• 4:58
  big
• 4:58
  difference
• 4:58
  between
• 4:59
  those
• 4:59
  two
• 4:59
  things.
• 5:00
  So
• 5:00
  it
• 5:00
  reduces
• 5:01
  excess
• 5:01
  volume
• 5:02
  or
• 5:02
  excess
• 5:03
  excitation
• 5:04
  and
• 5:04
  you
• 5:05
  would,
• 5:05
  you
• 5:05
  can
• 5:05
  imagine
• 5:06
  how
• 5:06
  that's
• 5:06
  helpful
• 5:06
  if
• 5:06
  somebody's
• 5:07
  in
• 5:07
  a
• 5:07
  lot
• 5:07
  of
• 5:07
  pain,
• 5:08
  if
• 5:08
  somebody
• 5:09
  is
• 5:09
  experiencing
• 5:10
  withdrawal,
• 5:11
  if
• 5:11
  somebody's
• 5:12
  experiencing
• 5:13
  like
• 5:13
  a
• 5:13
  seizure,
• 5:14
  because
• 5:14
  those
• 5:14
  are
• 5:14
  very
• 5:14
  excitable
• 5:15
  states.
• 5:16
  So
• 5:16
  gabapentin
• 5:17
  just
• 5:17
  lowers
• 5:18
  the
• 5:18
  volume.
• 5:19
  Now,
• 5:19
  I
• 5:19
  think
• 5:20
  of
• 5:20
  psychiatry
• 5:21
  and
• 5:21
  mental
• 5:21
  illness
• 5:21
  more
• 5:22
  broadly
• 5:23
  as
• 5:23
  kind
• 5:23
  of
• 5:23
  a
• 5:23
  high
• 5:24
  volume
• 5:25
  field.
• 5:25
  Right.
• 5:26
  The
• 5:26
  volume's
• 5:26
  too
• 5:27
  high
• 5:27
  in
• 5:27
  a
• 5:27
  lot
• 5:28
  of
• 5:28
  these
• 5:28
  cases.
• 5:28
  Anxiety's
• 5:29
  too
• 5:29
  high,
• 5:30
  racing
• 5:31
  thoughts,
• 5:31
  traumatic
• 5:32
  memories,
• 5:33
  withdrawal
• 5:34
  states.
• 5:35
  Right.
• 5:35
  There's
• 5:35
  a
• 5:35
  lot
• 5:35
  going
• 5:36
  on
• 5:36
  in
• 5:36
  all
• 5:36
  of
• 5:37
  these
• 5:38
  mental
• 5:38
  health
• 5:38
  syndromes
• 5:39
  in
• 5:39
  the
• 5:39
  DSM
• 5:40
  where
• 5:40
  you
• 5:40
  could
• 5:40
  imagine
• 5:41
  that
• 5:41
  turning
• 5:42
  down
• 5:42
  the
• 5:42
  excitatory
• 5:43
  neurotransmitter
• 5:44
  volume
• 5:45
  would
• 5:45
  be
• 5:46
  very
• 5:46
  helpful.
• 5:47
  Okay.
• 5:47
  Particularly
• 5:48
  in
• 5:48
  the
• 5:48
  amygdala
• 5:49
  or
• 5:49
  places
• 5:50
  that
• 5:50
  are
• 5:50
  like
• 5:50
  fight
• 5:50
  or
• 5:51
  flighty,
• 5:52
  that
• 5:52
  are
• 5:52
  commonly
• 5:52
  implicated
• 5:53
  in
• 5:53
  our
• 5:53
  anxiety
• 5:54
  disorders
• 5:54
  and
• 5:54
  our
• 5:54
  PTSD
• 5:55
  and
• 5:56
  all
• 5:56
  of
• 5:56
  those
• 5:56
  things.
• 5:57
  So
• 5:58
  for
• 5:58
  that
• 5:58
  reason,
• 5:58
  I
• 5:59
  think
• 5:59
  it
• 5:59
  has.
• 6:00
  It
• 6:00
  actually
• 6:01
  kind
• 6:01
  of
• 6:01
  has
• 6:01
  a
• 6:02
  place.
• 6:03
  Right.
• 6:03
  Another
• 6:04
  really
• 6:04
  neat
• 6:04
  thing
• 6:05
  about
• 6:05
  gabapentin
• 6:06
  that
• 6:06
  I
• 6:06
  think
• 6:07
  is,
• 6:08
  makes
• 6:08
  it
• 6:09
  very
• 6:09
  much
• 6:09
  stand
• 6:09
  out
• 6:10
  is
• 6:10
  it
• 6:11
  has
• 6:11
  less
• 6:11
  than
• 6:11
  3%
• 6:12
  protein
• 6:13
  binding.
• 6:13
  We
• 6:13
  just
• 6:13
  did
• 6:14
  an
• 6:14
  episode
• 6:15
  that
• 6:15
  I
• 6:15
  encourage
• 6:15
  you
• 6:15
  to
• 6:16
  look
• 6:16
  at
• 6:17
  when
• 6:17
  it
• 6:17
  comes
• 6:17
  to
• 6:17
  protein
• 6:18
  binding
• 6:18
  and
• 6:18
  the
• 6:18
  pharmacokinetics
• 6:19
  of
• 6:20
  that.
• 6:20
  Right.
• 6:20
  And
• 6:20
  we,
• 6:21
  we
• 6:22
  compared
• 6:22
  protein
• 6:23
  binding
• 6:23
  to
• 6:23
  like
• 6:24
  musical
• 6:24
  chairs.
• 6:25
  Right.
• 6:25
  So
• 6:25
  basically,
• 6:26
  when
• 6:26
  your
• 6:27
  drug
• 6:27
  is
• 6:28
  bound
• 6:28
  to
• 6:28
  a
• 6:28
  protein,
• 6:29
  there
• 6:29
  is
• 6:30
  no
• 6:30
  therapeutic
• 6:31
  effect
• 6:32
  being
• 6:32
  exerted
• 6:33
  necessarily.
• 6:33
  Right.
• 6:34
  And
• 6:34
  so
• 6:35
  the
• 6:35
  problem
• 6:36
  is
• 6:36
  when
• 6:37
  you
• 6:37
  have
• 6:38
  two
• 6:38
  drugs
• 6:39
  that
• 6:39
  you're
• 6:39
  prescribing
• 6:40
  together,
• 6:41
  let's
• 6:41
  say
• 6:41
  like
• 6:42
  Cymbalta
• 6:42
  and
• 6:42
  Warfarin,
• 6:43
  and
• 6:43
  they're
• 6:44
  both
• 6:44
  highly
• 6:44
  protein
• 6:45
  bound,
• 6:45
  they're
• 6:46
  kind
• 6:46
  of
• 6:46
  knocking
• 6:46
  each
• 6:46
  other
• 6:47
  out
• 6:47
  of
• 6:47
  the
• 6:47
  musical
• 6:47
  chairs.
• 6:48
  Well,
• 6:48
  when
• 6:48
  those
• 6:48
  drugs
• 6:49
  get
• 6:49
  out
• 6:49
  of
• 6:49
  the
• 6:49
  musical
• 6:50
  chairs
• 6:50
  and
• 6:50
  they're
• 6:50
  free,
• 6:51
  they
• 6:51
  can
• 6:51
  exert
• 6:52
  effects
• 6:53
  on
• 6:53
  the
• 6:54
  brain
• 6:54
  and
• 6:54
  body.
• 6:54
  And
• 6:54
  if
• 6:55
  it's
• 6:55
  an
• 6:55
  unexpected
• 6:56
  amount
• 6:56
  of
• 6:57
  those
• 6:57
  free
• 6:57
  people
• 6:58
  out
• 6:58
  of
• 6:58
  their
• 6:58
  chairs,
• 6:59
  or
• 6:59
  drugs
• 6:59
  out
• 7:00
  of
• 7:00
  their
• 7:00
  chairs,
• 7:00
  in
• 7:01
  this
• 7:01
  case,
• 7:01
  drugs
• 7:02
  that
• 7:02
  are
• 7:02
  no
• 7:02
  longer
• 7:02
  bound
• 7:03
  to
• 7:03
  those
• 7:03
  proteins,
• 7:04
  suddenly
• 7:04
  and
• 7:04
  unpredictably,
• 7:05
  well,
• 7:05
  you
• 7:06
  could
• 7:06
  have
• 7:06
  a
• 7:06
  problem.
• 7:06
  You
• 7:06
  can
• 7:06
  have
• 7:07
  toxic
• 7:07
  side
• 7:07
  effects.
• 7:08
  Toxicity.
• 7:08
  Right.
• 7:09
  And
• 7:09
  so
• 7:09
  when
• 7:10
  you
• 7:10
  have
• 7:10
  drugs
• 7:10
  that
• 7:10
  are
• 7:11
  not
• 7:11
  very
• 7:11
  protein
• 7:11
  bound,
• 7:12
  you
• 7:12
  don't
• 7:12
  have
• 7:12
  to
• 7:13
  really
• 7:13
  worry
• 7:13
  that
• 7:14
  gabapentin
• 7:14
  is
• 7:14
  going
• 7:14
  to
• 7:15
  come
• 7:15
  in
• 7:15
  there
• 7:15
  and
• 7:15
  knock
• 7:16
  warfarin
• 7:16
  out
• 7:16
  of
• 7:17
  those
• 7:17
  musical
• 7:17
  chairs.
• 7:17
  Now,
• 7:18
  warfarin
• 7:19
  is
• 7:19
  way
• 7:20
  too
• 7:20
  much.
• 7:20
  Warfarin
• 7:21
  is
• 7:21
  circulating
• 7:22
  in
• 7:22
  the
• 7:22
  bloodstream
• 7:22
  and
• 7:23
  now
• 7:23
  you
• 7:23
  have
• 7:23
  an
• 7:23
  excess
• 7:24
  bleeding
• 7:24
  risk.
• 7:24
  Right.
• 7:25
  So
• 7:25
  gabapentin
• 7:26
  doesn't
• 7:26
  have
• 7:26
  that
• 7:26
  trauma
• 7:27
  and
• 7:27
  very.
• 7:28
  And
• 7:28
  like
• 7:28
  virtually
• 7:29
  zero
• 7:29
  displacement
• 7:30
  of
• 7:30
  other
• 7:30
  medications
• 7:31
  and,
• 7:32
  you
• 7:32
  know,
• 7:32
  including
• 7:32
  some
• 7:33
  of
• 7:33
  your
• 7:33
  SSRIs.
• 7:34
  Right.
• 7:34
  So
• 7:35
  in
• 7:35
  polypharmacy,
• 7:36
  heavy
• 7:36
  Psychiatric
• 7:37
  patients.
• 7:37
  This
• 7:37
  is
• 7:37
  a
• 7:38
  huge
• 7:38
  practical
• 7:39
  advantage.
• 7:40
  And
• 7:40
  a
• 7:41
  lot
• 7:41
  of
• 7:41
  your
• 7:41
  patients,
• 7:42
  as,
• 7:42
  you
• 7:42
  know,
• 7:43
  as
• 7:43
  they
• 7:43
  get
• 7:43
  older,
• 7:43
  they're
• 7:44
  on
• 7:44
  a
• 7:44
  lot
• 7:44
  of
• 7:44
  different
• 7:44
  medications,
• 7:45
  and
• 7:45
  maybe
• 7:45
  they
• 7:45
  have
• 7:46
  pain
• 7:46
  and.
• 7:46
  And
• 7:46
  maybe
• 7:47
  they
• 7:47
  have
• 7:47
  alcohol
• 7:47
  withdrawal,
• 7:48
  and
• 7:48
  maybe
• 7:48
  they're
• 7:48
  on
• 7:48
  an
• 7:49
  SSRI
• 7:49
  or
• 7:49
  a
• 7:50
  blood
• 7:50
  thinner.
• 7:50
  Well,
• 7:51
  it's
• 7:51
  really
• 7:51
  liberating
• 7:52
  to
• 7:53
  find
• 7:53
  a
• 7:53
  medication
• 7:54
  that
• 7:54
  doesn't
• 7:55
  compete
• 7:55
  with
• 7:55
  those
• 7:55
  things.
• 7:56
  And
• 7:56
  that's
• 7:56
  what
• 7:56
  I
• 7:56
  said.
• 7:57
  What
• 7:57
  I
• 7:57
  say
• 7:58
  all
• 7:58
  the
• 7:58
  time
• 7:58
  is
• 7:58
  gabapentin.
• 7:59
  It's
• 7:59
  not
• 7:59
  something
• 8:00
  I
• 8:00
  usually
• 8:01
  start
• 8:02
  out
• 8:02
  with
• 8:03
  a
• 8:03
  mission
• 8:03
  to
• 8:03
  prescribe.
• 8:04
  I
• 8:04
  find
• 8:04
  myself
• 8:05
  almost
• 8:05
  checkmated
• 8:06
  in
• 8:06
  session,
• 8:06
  where
• 8:07
  it
• 8:07
  is
• 8:07
  the
• 8:08
  only
• 8:08
  next
• 8:09
  practical
• 8:09
  option.
• 8:10
  Right.
• 8:10
  You
• 8:11
  have
• 8:11
  a
• 8:11
  patient
• 8:12
  who's
• 8:12
  tried
• 8:13
  everything
• 8:13
  for
• 8:13
  anxiety.
• 8:14
  They've
• 8:14
  tried
• 8:15
  everything.
• 8:16
  Let's
• 8:16
  stick
• 8:16
  with
• 8:16
  anxiety.
• 8:17
  They've
• 8:17
  tried
• 8:17
  everything
• 8:18
  for
• 8:18
  anxiety.
• 8:19
  You
• 8:19
  can't
• 8:19
  do
• 8:19
  another
• 8:19
  ssri.
• 8:21
  They
• 8:21
  don't
• 8:21
  want
• 8:21
  to
• 8:21
  do
• 8:21
  another
• 8:22
  ssri.
• 8:22
  Maybe
• 8:23
  the
• 8:23
  next
• 8:23
  step
• 8:23
  on
• 8:24
  the
• 8:24
  algorithm.
• 8:24
  They
• 8:24
  can't
• 8:25
  afford
• 8:25
  TMS
• 8:26
  or
• 8:26
  ketamine
• 8:27
  or
• 8:27
  whatever
• 8:27
  else
• 8:28
  the.
• 8:29
  The
• 8:29
  next
• 8:29
  best
• 8:30
  thing
• 8:30
  could
• 8:30
  be
• 8:31
  for
• 8:31
  them.
• 8:31
  And
• 8:31
  so
• 8:32
  it's
• 8:32
  like,
• 8:32
  okay,
• 8:32
  well,
• 8:32
  checkmate.
• 8:33
  I
• 8:33
  need
• 8:33
  to
• 8:33
  treat
• 8:34
  this
• 8:34
  patient's
• 8:34
  anxiety
• 8:35
  or
• 8:35
  their
• 8:36
  insomnia.
• 8:36
  They
• 8:37
  have,
• 8:37
  you
• 8:37
  know,
• 8:37
  treatment
• 8:38
  resistant
• 8:38
  insomnia.
• 8:39
  They've
• 8:39
  done
• 8:39
  cbt.
• 8:40
  I.
• 8:40
  They
• 8:40
  don't
• 8:41
  want
• 8:41
  to
• 8:41
  do
• 8:41
  another
• 8:41
  Z
• 8:42
  drug.
• 8:43
  They
• 8:43
  want
• 8:43
  to
• 8:43
  stay
• 8:44
  1,000
• 8:45
  miles
• 8:45
  away
• 8:46
  from
• 8:46
  benzodiazepines.
• 8:47
  And
• 8:47
  so,
• 8:47
  again,
• 8:48
  it's
• 8:48
  checkmate.
• 8:49
  Right.
• 8:49
  That's
• 8:49
  how
• 8:49
  I
• 8:49
  typically
• 8:50
  find
• 8:50
  myself
• 8:51
  prescribing
• 8:51
  gabapentin.
• 8:52
  It's
• 8:52
  not
• 8:52
  that
• 8:52
  I'm
• 8:53
  actively
• 8:53
  avoiding
• 8:53
  it.
• 8:54
  I
• 8:54
  just.
• 8:54
  I
• 8:54
  don't
• 8:55
  get
• 8:55
  the
• 8:55
  warm
• 8:55
  and
• 8:55
  fuzzies
• 8:56
  from
• 8:56
  it
• 8:56
  because
• 8:57
  it.
• 8:57
  It
• 8:58
  really
• 8:58
  has
• 8:59
  narrow
• 8:59
  FDA
• 9:00
  indications.
• 9:00
  And
• 9:01
  all
• 9:01
  the
• 9:01
  rest
• 9:01
  is.
• 9:02
  Is
• 9:02
  kind
• 9:03
  of
• 9:03
  anecdotal
• 9:04
  and
• 9:04
  personal
• 9:05
  to
• 9:05
  your
• 9:05
  patient.
• 9:06
  You
• 9:06
  know,
• 9:06
  it's
• 9:06
  not
• 9:06
  like
• 9:07
  it
• 9:07
  has
• 9:07
  clear,
• 9:08
  compelling
• 9:08
  indications
• 9:09
  for
• 9:10
  specific
• 9:10
  issues.
• 9:11
  And
• 9:11
  so
• 9:11
  I'm
• 9:11
  a
• 9:12
  little
• 9:12
  hesitant
• 9:12
  to
• 9:12
  go
• 9:13
  there
• 9:13
  first.
• 9:13
  I
• 9:13
  think
• 9:13
  anyone
• 9:14
  should
• 9:14
  be
• 9:14
  hesitant
• 9:14
  to
• 9:15
  go
• 9:15
  to
• 9:15
  gabapentin
• 9:15
  first
• 9:16
  for
• 9:16
  anything.
• 9:16
  When
• 9:17
  the
• 9:17
  first
• 9:17
  line
• 9:18
  treatments
• 9:19
  and
• 9:20
  said,
• 9:20
  you
• 9:20
  know,
• 9:20
  are
• 9:20
  pointing
• 9:21
  to
• 9:21
  CBTI
• 9:22
  or
• 9:23
  SSRIs
• 9:23
  or
• 9:23
  SNRIs
• 9:24
  or
• 9:24
  psychotherapy.
• 9:25
  Right.
• 9:25
  We
• 9:26
  shouldn't
• 9:26
  start
• 9:26
  with
• 9:26
  gabapentin.
• 9:27
  But
• 9:27
  again,
• 9:27
  we
• 9:28
  can
• 9:28
  often
• 9:28
  get
• 9:28
  checkmated
• 9:29
  and
• 9:29
  go,
• 9:30
  well,
• 9:30
  this
• 9:30
  patient's
• 9:31
  already
• 9:31
  on
• 9:32
  tons
• 9:32
  of
• 9:32
  medications
• 9:33
  that
• 9:33
  have
• 9:34
  high
• 9:34
  protein
• 9:35
  binding.
• 9:36
  Right.
• 9:36
  This
• 9:36
  patient
• 9:36
  has
• 9:37
  excess,
• 9:37
  like,
• 9:37
  extensive
• 9:38
  liver
• 9:39
  problems.
• 9:39
  Right.
• 9:40
  Alcoholic
• 9:40
  liver
• 9:41
  disease.
• 9:41
  Well,
• 9:41
  I
• 9:42
  can't
• 9:42
  necessarily
• 9:43
  go
• 9:43
  to
• 9:44
  some
• 9:44
  of
• 9:44
  these
• 9:45
  other
• 9:45
  medications
• 9:47
  because
• 9:47
  they're
• 9:47
  heavily
• 9:48
  metabolized
• 9:48
  by
• 9:48
  the
• 9:48
  liver.
• 9:49
  Well,
• 9:49
  guess
• 9:49
  What?
• 9:49
  Gabapentin
• 9:50
  is
• 9:50
  100%
• 9:51
  renally
• 9:51
  eliminated.
• 9:52
  And
• 9:53
  so
• 9:53
  it's,
• 9:54
  again,
• 9:54
  a
• 9:54
  lot
• 9:54
  more
• 9:55
  Appealing
• 9:55
  when
• 9:55
  you
• 9:55
  have
• 9:56
  the
• 9:56
  liver
• 9:56
  drama,
• 9:57
  the
• 9:57
  protein
• 9:58
  binding
• 9:58
  drama,
• 9:59
  a
• 9:59
  lot
• 10:00
  of
• 10:00
  other
• 10:00
  CYP
• 10:01
  interactions
• 10:02
  and
• 10:02
  metabolic
• 10:03
  concerns.
• 10:04
  Gabapentin,
• 10:05
  again,
• 10:05
  it
• 10:05
  becomes
• 10:05
  more
• 10:06
  like
• 10:06
  a
• 10:06
  checkmate
• 10:07
  where
• 10:07
  you
• 10:07
  can
• 10:07
  go,
• 10:07
  okay,
• 10:08
  here's
• 10:08
  a
• 10:08
  relatively
• 10:09
  low
• 10:09
  risk
• 10:10
  medication.
• 10:11
  It's
• 10:11
  a
• 10:11
  win
• 10:12
  that
• 10:12
  the
• 10:12
  patient
• 10:12
  is
• 10:13
  no
• 10:13
  longer
• 10:13
  turning
• 10:14
  to
• 10:14
  benzos
• 10:15
  for
• 10:15
  sleep
• 10:16
  or
• 10:16
  for
• 10:16
  anxiety.
• 10:17
  And
• 10:17
  so
• 10:18
  maybe
• 10:18
  gabapentin
• 10:19
  is
• 10:19
  like
• 10:19
  the
• 10:19
  next
• 10:20
  best
• 10:20
  thing.
• 10:20
  It's
• 10:20
  not
• 10:20
  exactly
• 10:21
  a
• 10:21
  vegetable,
• 10:21
  it's
• 10:22
  not
• 10:22
  broccoli.
• 10:23
  Okay.
• 10:23
  But
• 10:24
  it's
• 10:24
  maybe
• 10:24
  better
• 10:25
  than
• 10:25
  our
• 10:25
  patient
• 10:26
  getting
• 10:26
  on
• 10:26
  the
• 10:27
  benzodiazepine
• 10:28
  treadmill
• 10:28
  or
• 10:29
  retrying
• 10:29
  a
• 10:29
  medication
• 10:30
  that
• 10:30
  wasn't
• 10:30
  quite
• 10:31
  efficacious
• 10:32
  to
• 10:32
  begin
• 10:32
  with.
• 10:32
  Maybe
• 10:33
  they
• 10:33
  don't
• 10:33
  have
• 10:33
  the
• 10:33
  time.
• 10:33
  They're
• 10:34
  a
• 10:34
  high
• 10:34
  powered
• 10:34
  attorney
• 10:35
  and
• 10:35
  they
• 10:35
  can't
• 10:36
  just
• 10:36
  like
• 10:36
  come
• 10:36
  home
• 10:37
  after
• 10:37
  a
• 10:37
  16
• 10:37
  hour
• 10:38
  workday
• 10:38
  and
• 10:38
  do
• 10:38
  CBTI,
• 10:40
  right?
• 10:40
  I
• 10:40
  mean,
• 10:40
  that's
• 10:40
  possible
• 10:41
  there.
• 10:42
  Again,
• 10:42
  these
• 10:42
  are
• 10:42
  real
• 10:43
  world
• 10:43
  conversations.
• 10:44
  So
• 10:44
  again,
• 10:45
  gabapentin
• 10:45
  becomes
• 10:46
  kind
• 10:46
  of
• 10:46
  interesting
• 10:47
  as
• 10:47
  a
• 10:47
  way
• 10:47
  to
• 10:47
  quiet
• 10:47
  the
• 10:48
  noise.
• 10:48
  And
• 10:48
  you
• 10:49
  can
• 10:49
  see
• 10:49
  how
• 10:49
  that
• 10:49
  might
• 10:49
  be
• 10:50
  very
• 10:50
  effective
• 10:51
  when
• 10:51
  somebody's
• 10:52
  very
• 10:52
  anxious,
• 10:52
  when
• 10:53
  somebody
• 10:53
  has
• 10:53
  insomnia.
• 10:54
  Those
• 10:55
  are
• 10:55
  two
• 10:55
  very
• 10:56
  common
• 10:56
  mental
• 10:57
  health
• 10:58
  presentations
• 10:58
  where
• 10:59
  you
• 10:59
  will
• 10:59
  see
• 10:59
  GABA
• 11:00
  kind
• 11:00
  of
• 11:00
  being
• 11:00
  slapped
• 11:01
  on
• 11:01
  there.
• 11:01
  And
• 11:01
  again,
• 11:02
  I
• 11:02
  use
• 11:02
  it
• 11:02
  as,
• 11:02
  I
• 11:02
  keep
• 11:03
  going
• 11:03
  back
• 11:03
  to
• 11:03
  duct
• 11:04
  tape
• 11:04
  as
• 11:04
  an
• 11:04
  analogy
• 11:06
  because
• 11:07
  I'm
• 11:07
  not
• 11:07
  trying
• 11:08
  to,
• 11:08
  it's
• 11:08
  not
• 11:08
  like
• 11:08
  a
• 11:08
  disservice
• 11:09
  to
• 11:09
  duct
• 11:09
  tape.
• 11:10
  I'm
• 11:10
  not
• 11:10
  trying
• 11:10
  to
• 11:10
  say
• 11:10
  duct
• 11:11
  tape
• 11:11
  is
• 11:11
  always
• 11:11
  a
• 11:12
  bad
• 11:12
  idea,
• 11:12
  but
• 11:13
  normally
• 11:13
  when
• 11:13
  you're
• 11:14
  using
• 11:14
  duct
• 11:14
  tape
• 11:14
  in
• 11:14
  the
• 11:15
  real
• 11:15
  world,
• 11:15
  it's
• 11:16
  not
• 11:16
  a
• 11:16
  permanent
• 11:17
  solution.
• 11:17
  Right?
• 11:18
  But
• 11:18
  it
• 11:18
  works
• 11:18
  at
• 11:18
  the
• 11:18
  time
• 11:19
  and
• 11:19
  it
• 11:19
  gets
• 11:19
  the
• 11:19
  job
• 11:19
  done
• 11:20
  when
• 11:20
  you
• 11:20
  need
• 11:20
  it.
• 11:20
  But
• 11:21
  it's
• 11:21
  kind
• 11:21
  of
• 11:21
  a
• 11:22
  holding
• 11:22
  pattern.
• 11:23
  Okay.
• 11:24
  And
• 11:24
  so
• 11:24
  I
• 11:24
  look
• 11:24
  at
• 11:25
  that
• 11:25
  the
• 11:25
  same
• 11:25
  way.
• 11:25
  Now,
• 11:26
  alcohol
• 11:26
  withdrawal
• 11:27
  is
• 11:27
  a
• 11:27
  very
• 11:27
  interesting
• 11:28
  one
• 11:28
  because
• 11:29
  again,
• 11:30
  in
• 11:30
  alcohol
• 11:31
  withdrawal,
• 11:31
  normally
• 11:32
  what's
• 11:32
  happening
• 11:32
  is
• 11:33
  alcohol's
• 11:34
  hitting
• 11:34
  those
• 11:34
  GABA
• 11:34
  receptors,
• 11:35
  right?
• 11:36
  With
• 11:36
  alcohol,
• 11:37
  there's
• 11:38
  GABA
• 11:39
  that's
• 11:39
  inhibiting
• 11:40
  glutamate.
• 11:40
  But
• 11:41
  then
• 11:41
  of
• 11:41
  course,
• 11:41
  in
• 11:41
  withdrawal,
• 11:42
  it's
• 11:42
  the
• 11:42
  exact
• 11:42
  opposite.
• 11:43
  You
• 11:43
  have
• 11:43
  excitatory
• 11:44
  neurotransmission
• 11:45
  that's
• 11:45
  out
• 11:45
  of
• 11:45
  control.
• 11:46
  And
• 11:46
  that's
• 11:47
  where
• 11:47
  gabapentin
• 11:48
  shines.
• 11:48
  Right?
• 11:49
  Because
• 11:49
  gabapentin
• 11:50
  kind
• 11:50
  of
• 11:50
  restores
• 11:51
  the
• 11:52
  GABAergic
• 11:52
  and
• 11:52
  glutaminergic
• 11:54
  seesaw.
• 11:54
  And
• 11:55
  it,
• 11:55
  it,
• 11:55
  it
• 11:55
  encourages
• 11:56
  more
• 11:56
  of
• 11:56
  the
• 11:57
  GABAergic
• 11:58
  balance,
• 11:59
  which
• 12:00
  is
• 12:00
  very
• 12:00
  key.
• 12:01
  Right.
• 12:02
  And,
• 12:02
  and
• 12:02
  you
• 12:02
  really
• 12:02
  want
• 12:03
  to
• 12:04
  use
• 12:04
  that
• 12:04
  in
• 12:04
  states
• 12:05
  of
• 12:05
  alcohol
• 12:06
  withdrawal.
• 12:06
  It
• 12:06
  can
• 12:06
  be
• 12:07
  very
• 12:07
  effective.
• 12:07
  Again,
• 12:07
  is
• 12:08
  it
• 12:08
  the
• 12:08
  most
• 12:08
  important
• 12:08
  thing
• 12:09
  you
• 12:09
  can
• 12:09
  do?
• 12:09
  Is
• 12:10
  it
• 12:10
  the
• 12:10
  best
• 12:10
  evidence?
• 12:11
  Probably
• 12:11
  not,
• 12:12
  but
• 12:12
  it
• 12:13
  does.
• 12:13
  But
• 12:14
  it,
• 12:14
  again,
• 12:14
  it
• 12:14
  doesn't
• 12:15
  hit
• 12:15
  the
• 12:15
  GABA
• 12:15
  receptor.
• 12:16
  Okay.
• 12:17
  It,
• 12:17
  there
• 12:18
  is
• 12:18
  evidence
• 12:18
  that
• 12:18
  it
• 12:18
  increases
• 12:19
  GABA
• 12:19
  production
• 12:20
  and
• 12:20
  it
• 12:20
  modulates
• 12:21
  GABA
• 12:21
  tone
• 12:21
  in
• 12:21
  the
• 12:21
  amygdala,
• 12:22
  but
• 12:23
  it
• 12:23
  doesn't
• 12:23
  hit
• 12:23
  the
• 12:24
  GABA
• 12:25
  receptor
• 12:25
  itself.
• 12:26
  And
• 12:27
  that's
• 12:27
  a
• 12:27
  very
• 12:28
  key,
• 12:29
  key
• 12:29
  distinction.
• 12:31
  Okay.
• 12:31
  It
• 12:31
  does
• 12:31
  inhibit
• 12:32
  gluten,
• 12:32
  glutamate
• 12:33
  synthesis,
• 12:33
  the
• 12:34
  evidence
• 12:34
  shows.
• 12:34
  And
• 12:34
  reduces
• 12:35
  excitatory
• 12:36
  neurotransmission.
• 12:37
  That's
• 12:37
  what
• 12:38
  the
• 12:38
  evidence
• 12:38
  shows.
• 12:38
  And
• 12:39
  again,
• 12:39
  in
• 12:39
  alcohol
• 12:40
  withdrawal,
• 12:41
  that
• 12:41
  can
• 12:41
  be
• 12:42
  very
• 12:42
  important
• 12:43
  because
• 12:43
  the
• 12:44
  withdrawal
• 12:44
  state
• 12:45
  is
• 12:46
  kind
• 12:46
  of
• 12:46
  presenting
• 12:47
  as
• 12:47
  a
• 12:47
  resurgence
• 12:48
  of
• 12:48
  that
• 12:48
  glutaminergic
• 12:49
  activity
• 12:49
  that
• 12:50
  can
• 12:50
  make
• 12:50
  people
• 12:50
  feel
• 12:51
  very
• 12:51
  anxious
• 12:52
  and
• 12:53
  the
• 12:53
  whole
• 12:53
  brain
• 12:54
  and
• 12:54
  body
• 12:54
  is
• 12:54
  just
• 12:54
  way
• 12:55
  too
• 12:55
  excitable.
• 12:56
  In
• 12:56
  comes
• 12:57
  gabapentin.
• 12:58
  Very
• 12:58
  neat
• 12:59
  little
• 12:59
  mechanism
• 13:00
  there.
• 13:00
  There's
• 13:01
  evidence
• 13:01
  that
• 13:01
  it
• 13:01
  restores
• 13:02
  slow
• 13:02
  wave
• 13:02
  sleep.
• 13:03
  You
• 13:03
  know,
• 13:03
  I'm
• 13:03
  a
• 13:03
  huge
• 13:04
  stickler
• 13:04
  for
• 13:04
  sleep.
• 13:05
  This
• 13:05
  is
• 13:05
  also
• 13:05
  called
• 13:06
  deep
• 13:06
  sleep.
• 13:07
  It's
• 13:07
  the
• 13:08
  non
• 13:08
  REM
• 13:09
  sleep
• 13:10
  that
• 13:10
  we've
• 13:10
  probably
• 13:11
  all
• 13:11
  heard
• 13:11
  about.
• 13:12
  And
• 13:12
  this
• 13:13
  is
• 13:13
  really
• 13:13
  important
• 13:13
  that
• 13:14
  it
• 13:14
  restores
• 13:14
  slow
• 13:15
  wave
• 13:15
  sleep.
• 13:15
  I'm
• 13:15
  always
• 13:15
  a
• 13:16
  very
• 13:16
  big
• 13:17
  fan
• 13:17
  of
• 13:17
  medications
• 13:18
  that
• 13:18
  target
• 13:19
  these
• 13:19
  sleep
• 13:20
  stages
• 13:20
  because
• 13:20
  so
• 13:21
  much
• 13:21
  happens
• 13:21
  there.
• 13:21
  But
• 13:22
  you'll,
• 13:22
  you'll
• 13:22
  frequently
• 13:23
  see
• 13:23
  in
• 13:23
  depression
• 13:24
  and
• 13:24
  PTSD
• 13:24
  and
• 13:24
  anxiety,
• 13:25
  slow
• 13:25
  wave
• 13:25
  sleep
• 13:26
  is
• 13:26
  always
• 13:27
  taking
• 13:27
  a
• 13:27
  hit.
• 13:28
  Right?
• 13:28
  And
• 13:29
  when
• 13:29
  you
• 13:29
  disrupt
• 13:29
  slow
• 13:30
  wave
• 13:30
  sleep,
• 13:30
  it's.
• 13:31
  The
• 13:31
  evidence
• 13:31
  has
• 13:32
  shown
• 13:32
  that,
• 13:32
  that
• 13:32
  that's
• 13:33
  linked
• 13:33
  to
• 13:33
  hyperarousal,
• 13:34
  impaired
• 13:35
  fear
• 13:35
  extinction,
• 13:36
  emotional
• 13:36
  dysregulation,
• 13:38
  memory
• 13:38
  consolidation
• 13:39
  and
• 13:39
  emotional
• 13:40
  processing
• 13:40
  are
• 13:40
  all
• 13:40
  interfered
• 13:41
  with
• 13:42
  when
• 13:42
  slow
• 13:42
  wave
• 13:43
  sleep
• 13:43
  is
• 13:43
  not
• 13:43
  on
• 13:43
  board.
• 13:44
  So
• 13:44
  if
• 13:44
  you
• 13:44
  can
• 13:44
  get
• 13:46
  more
• 13:46
  slow
• 13:47
  wave
• 13:47
  sleep
• 13:47
  in
• 13:47
  the
• 13:48
  form
• 13:48
  of
• 13:48
  gabapentin,
• 13:49
  well,
• 13:50
  that's
• 13:50
  a
• 13:50
  big
• 13:51
  win
• 13:51
  because
• 13:51
  guess
• 13:51
  what?
• 13:52
  Most
• 13:52
  standard
• 13:53
  hypnotics
• 13:54
  like
• 13:54
  benzos
• 13:54
  and
• 13:54
  Z
• 13:55
  drugs
• 13:55
  actually
• 13:55
  suppress
• 13:56
  slow
• 13:56
  wave
• 13:56
  sleep.
• 13:57
  So
• 13:57
  that
• 13:58
  makes
• 13:58
  gabapentin
• 13:59
  very,
• 14:00
  very
• 14:01
  important.
• 14:01
  Actually,
• 14:02
  I
• 14:02
  would
• 14:02
  argue,
• 14:02
  at
• 14:02
  least
• 14:03
  for
• 14:03
  me
• 14:03
  as
• 14:03
  a
• 14:03
  provider,
• 14:04
  my
• 14:04
  eyebrows
• 14:05
  are
• 14:05
  raised
• 14:05
  here.
• 14:06
  And
• 14:06
  I'm
• 14:06
  very
• 14:07
  interested
• 14:07
  in
• 14:08
  any
• 14:08
  medication
• 14:08
  that
• 14:09
  my
• 14:09
  patients
• 14:09
  will
• 14:09
  tell
• 14:09
  me
• 14:10
  make
• 14:10
  them
• 14:10
  less
• 14:10
  anxious
• 14:11
  and
• 14:12
  improve
• 14:13
  their
• 14:13
  sleep
• 14:13
  architecture,
• 14:14
  because
• 14:14
  a
• 14:14
  lot
• 14:14
  of
• 14:14
  these
• 14:14
  disrupt
• 14:15
  sleep.
• 14:15
  There
• 14:16
  is
• 14:16
  evidence
• 14:16
  that
• 14:17
  SSRIs
• 14:18
  actually
• 14:19
  disrupt
• 14:20
  the
• 14:20
  REM
• 14:21
  cycle
• 14:21
  of
• 14:21
  sleep,
• 14:21
  which
• 14:22
  I
• 14:22
  have
• 14:22
  a
• 14:22
  bit
• 14:22
  of
• 14:22
  a
• 14:23
  problem
• 14:23
  with
• 14:23
  sometimes,
• 14:24
  and
• 14:24
  I
• 14:24
  don't
• 14:24
  love
• 14:25
  that.
• 14:25
  Oddly
• 14:25
  enough,
• 14:26
  there's
• 14:26
  evidence
• 14:26
  that
• 14:27
  folks
• 14:27
  with
• 14:28
  sleep
• 14:28
  paralysis,
• 14:29
  SSRIs
• 14:30
  can
• 14:30
  be
• 14:30
  efficacious
• 14:31
  in
• 14:32
  sleep
• 14:32
  paralysis
• 14:32
  for
• 14:32
  the
• 14:33
  exact
• 14:33
  reason
• 14:33
  that
• 14:34
  it
• 14:34
  disrupts
• 14:34
  the
• 14:35
  REM
• 14:35
  cycle
• 14:36
  of
• 14:36
  sleep.
• 14:36
  And
• 14:37
  I've
• 14:37
  used
• 14:37
  that
• 14:37
  clinically.
• 14:38
  Right?
• 14:39
  Because
• 14:39
  we
• 14:39
  want
• 14:39
  to
• 14:39
  disrupt
• 14:40
  that
• 14:40
  REM
• 14:40
  sleep
• 14:41
  where
• 14:41
  they're
• 14:42
  feeling,
• 14:42
  where
• 14:42
  they're
• 14:43
  consciously
• 14:43
  aware
• 14:43
  of
• 14:43
  the
• 14:44
  fact
• 14:44
  that
• 14:44
  they're
• 14:44
  in
• 14:44
  a
• 14:44
  REM
• 14:45
  sleep
• 14:45
  and
• 14:45
  they're
• 14:45
  paralyzed
• 14:46
  to
• 14:46
  do
• 14:46
  anything
• 14:46
  about
• 14:47
  it,
• 14:47
  right?
• 14:47
  And
• 14:48
  so
• 14:48
  that's
• 14:48
  very
• 14:49
  terrifying
• 14:49
  for
• 14:49
  patients.
• 14:50
  But
• 14:50
  SSRIs
• 14:51
  can
• 14:51
  stop
• 14:51
  that.
• 14:51
  Well,
• 14:52
  lo
• 14:52
  and
• 14:52
  behold,
• 14:52
  gabapentin
• 14:53
  again
• 14:54
  is
• 14:55
  really
• 14:56
  enhancing
• 14:57
  sleep
• 14:57
  and
• 14:57
  you
• 14:57
  need
• 14:58
  that
• 14:59
  to
• 14:59
  happen
• 14:59
  because
• 15:00
  the
• 15:00
  brain
• 15:01
  is
• 15:01
  doing
• 15:01
  all
• 15:01
  kinds
• 15:02
  of
• 15:02
  miracle
• 15:02
  work,
• 15:02
  right?
• 15:03
  They
• 15:03
  call
• 15:03
  sleep
• 15:03
  the
• 15:04
  nature's
• 15:04
  pharmacy.
• 15:05
  And
• 15:05
  so
• 15:06
  we
• 15:06
  definitely
• 15:07
  want
• 15:07
  our
• 15:07
  patients
• 15:08
  to
• 15:08
  have
• 15:09
  fear
• 15:09
  extinction
• 15:10
  mechanisms
• 15:11
  engaged
• 15:12
  so
• 15:12
  that
• 15:12
  their
• 15:12
  psychotherapy
• 15:13
  is
• 15:13
  more
• 15:13
  effective.
• 15:14
  They
• 15:14
  can
• 15:14
  wake
• 15:14
  up
• 15:14
  with
• 15:15
  more
• 15:15
  emotional
• 15:15
  regulation
• 15:16
  and
• 15:16
  cognitive
• 15:17
  functioning.
• 15:18
  They
• 15:18
  don't
• 15:18
  have
• 15:18
  that
• 15:19
  hyper
• 15:19
  arousal
• 15:20
  that
• 15:20
  can
• 15:20
  happen
• 15:20
  in
• 15:21
  anxiety
• 15:21
  and
• 15:21
  ptsd.
• 15:22
  It's,
• 15:23
  it's
• 15:23
  incredibly
• 15:23
  important.
• 15:24
  So
• 15:24
  again,
• 15:25
  I'm
• 15:25
  a
• 15:25
  big
• 15:25
  believer
• 15:26
  in
• 15:26
  gabapentin
• 15:27
  for
• 15:27
  those
• 15:27
  things.
• 15:28
  And
• 15:28
  just
• 15:28
  remember,
• 15:29
  my
• 15:29
  friends,
• 15:29
  no
• 15:30
  matter
• 15:30
  what
• 15:30
  the
• 15:30
  textbooks
• 15:31
  tell
• 15:31
  you,
• 15:31
  right,
• 15:31
  there
• 15:32
  are
• 15:32
  folks
• 15:32
  who
• 15:32
  simply
• 15:33
  have
• 15:34
  raging
• 15:34
  anxiety
• 15:35
  their
• 15:35
  whole
• 15:35
  lives.
• 15:35
  And
• 15:36
  for
• 15:36
  whatever
• 15:36
  reason
• 15:37
  that
• 15:37
  maybe
• 15:37
  we
• 15:37
  can't
• 15:38
  understand
• 15:38
  perfectly,
• 15:39
  they
• 15:39
  don't
• 15:39
  respond
• 15:40
  to
• 15:40
  SSRIs
• 15:41
  as
• 15:41
  the
• 15:41
  textbook
• 15:42
  would
• 15:42
  suggest
• 15:42
  they
• 15:43
  should.
• 15:43
  They've
• 15:43
  tried
• 15:44
  full
• 15:45
  trials
• 15:46
  of,
• 15:46
  of
• 15:46
  Prozac
• 15:47
  and
• 15:47
  Zoloft
• 15:48
  and
• 15:48
  Effexor,
• 15:49
  and
• 15:49
  they
• 15:49
  just
• 15:49
  don't
• 15:50
  have
• 15:50
  a
• 15:51
  remission
• 15:51
  of
• 15:51
  their
• 15:51
  anxiety
• 15:52
  symptoms.
• 15:52
  They've
• 15:52
  tried
• 15:53
  psychotherapy.
• 15:54
  And
• 15:54
  so
• 15:54
  again,
• 15:54
  when
• 15:55
  I
• 15:55
  say
• 15:55
  the
• 15:55
  word
• 15:55
  checkmate
• 15:56
  that's
• 15:56
  frequently
• 15:57
  implicated
• 15:58
  in
• 15:58
  my
• 15:58
  gabapentin
• 15:59
  prescribing
• 16:00
  philosophy.
• 16:00
  It's
• 16:01
  like,
• 16:01
  well,
• 16:01
  what
• 16:01
  else
• 16:02
  am
• 16:02
  I
• 16:02
  going
• 16:02
  to
• 16:02
  do
• 16:02
  here,
• 16:03
  right?
• 16:03
  There
• 16:04
  are
• 16:04
  just
• 16:04
  real
• 16:04
  world
• 16:05
  limitations
• 16:05
  here.
• 16:06
  And
• 16:06
  I,
• 16:06
  I,
• 16:06
  I
• 16:07
  really
• 16:07
  look
• 16:07
  at
• 16:07
  gabapentin
• 16:08
  as
• 16:08
  like
• 16:08
  the
• 16:08
  ultimate
• 16:09
  street
• 16:10
  versus
• 16:10
  textbook
• 16:11
  confrontation,
• 16:12
  right?
• 16:13
  In
• 16:13
  school,
• 16:14
  you
• 16:14
  in,
• 16:14
  in
• 16:14
  Grand
• 16:15
  Rounds,
• 16:15
  there's
• 16:15
  this,
• 16:16
  there's
• 16:17
  this
• 16:17
  emphasis
• 16:17
  on
• 16:18
  textbook
• 16:18
  learning.
• 16:19
  This
• 16:19
  is
• 16:19
  what
• 16:19
  you
• 16:19
  need
• 16:20
  to
• 16:20
  do
• 16:20
  next.
• 16:20
  This
• 16:20
  is
• 16:21
  how
• 16:21
  it's
• 16:21
  done.
• 16:22
  And
• 16:22
  I'm
• 16:22
  all
• 16:22
  about
• 16:23
  that.
• 16:23
  I
• 16:23
  follow
• 16:23
  the
• 16:23
  evidence
• 16:24
  religiously,
• 16:25
  even
• 16:25
  more
• 16:26
  than
• 16:26
  religiously
• 16:27
  at
• 16:28
  the
• 16:28
  same
• 16:28
  time,
• 16:29
  again,
• 16:30
  you,
• 16:30
  you
• 16:30
  have
• 16:30
  a
• 16:31
  patient
• 16:31
  in
• 16:31
  front
• 16:31
  of
• 16:31
  you
• 16:31
  who's
• 16:32
  tried
• 16:32
  everything
• 16:32
  and
• 16:33
  is
• 16:33
  refusing
• 16:33
  to
• 16:33
  try
• 16:34
  what
• 16:34
  the
• 16:34
  textbook
• 16:35
  says
• 16:36
  works,
• 16:36
  and
• 16:36
  it
• 16:36
  clearly
• 16:37
  didn't
• 16:37
  work
• 16:37
  in
• 16:37
  that
• 16:38
  patient.
• 16:38
  So
• 16:39
  you,
• 16:39
  you
• 16:39
  have
• 16:39
  to
• 16:39
  offer
• 16:40
  the
• 16:40
  next
• 16:40
  best
• 16:40
  thing
• 16:41
  sometimes
• 16:41
  and
• 16:42
  to
• 16:42
  give
• 16:42
  them
• 16:42
  hope
• 16:43
  and
• 16:43
  to
• 16:43
  have
• 16:43
  some
• 16:44
  form
• 16:44
  of
• 16:44
  symptom
• 16:44
  alleviation
• 16:45
  until
• 16:45
  you
• 16:46
  can
• 16:46
  think
• 16:46
  of
• 16:46
  something
• 16:46
  better.
• 16:47
  And
• 16:47
  for
• 16:47
  that
• 16:48
  reason,
• 16:48
  gabapentin
• 16:49
  makes
• 16:49
  sense.
• 16:50
  Even
• 16:50
  if
• 16:50
  it's
• 16:50
  off
• 16:50
  label,
• 16:51
  even
• 16:51
  if
• 16:52
  it's
• 16:52
  not
• 16:52
  necessarily
• 16:53
  what
• 16:53
  the
• 16:53
  FDA
• 16:53
  saw
• 16:54
  coming
• 16:54
  or
• 16:54
  intended.
• 16:55
  If
• 16:55
  it's
• 16:56
  subjectively
• 16:56
  working
• 16:57
  for
• 16:57
  the
• 16:57
  patient,
• 16:58
  then
• 16:59
  it's
• 16:59
  great.
• 16:59
  And
• 16:59
  I
• 17:00
  would
• 17:00
  argue
• 17:00
  anything
• 17:00
  that
• 17:01
  brings
• 17:01
  sleep
• 17:01
  back
• 17:01
  on
• 17:02
  board
• 17:02
  is
• 17:03
  extremely
• 17:04
  beneficial.
• 17:05
  Sleep
• 17:05
  impaired
• 17:06
  sleep
• 17:06
  is
• 17:06
  like
• 17:06
  the
• 17:06
  most
• 17:07
  transdiagnostic
• 17:08
  symptom
• 17:09
  in
• 17:09
  the
• 17:09
  whole
• 17:09
  dsm.
• 17:10
  It's
• 17:10
  implicated
• 17:11
  in
• 17:11
  every
• 17:12
  kind
• 17:12
  of
• 17:12
  mental
• 17:12
  health
• 17:12
  problem.
• 17:13
  Right.
• 17:13
  In
• 17:13
  anxiety
• 17:14
  and
• 17:14
  depression
• 17:15
  and
• 17:15
  ptsd,
• 17:16
  folks
• 17:16
  who
• 17:16
  have
• 17:17
  ADHD
• 17:17
  are
• 17:17
  always
• 17:18
  restless
• 17:18
  and
• 17:19
  kind
• 17:19
  of
• 17:19
  driven
• 17:19
  like
• 17:20
  a
• 17:20
  motor,
• 17:20
  and
• 17:20
  they
• 17:20
  can't
• 17:21
  stop
• 17:21
  their
• 17:21
  brains
• 17:21
  at
• 17:21
  night
• 17:22
  either.
• 17:22
  That's
• 17:23
  not
• 17:23
  really
• 17:23
  in
• 17:23
  the
• 17:23
  diagnostic
• 17:24
  criteria
• 17:24
  of
• 17:24
  adhd.
• 17:25
  But
• 17:25
  you
• 17:25
  will
• 17:25
  find
• 17:26
  many
• 17:26
  of
• 17:26
  your
• 17:26
  ADHD
• 17:27
  patients
• 17:28
  also
• 17:28
  have
• 17:28
  a
• 17:28
  problem
• 17:29
  with
• 17:30
  falling
• 17:30
  asleep
• 17:30
  and
• 17:31
  initiating
• 17:31
  that,
• 17:31
  that
• 17:32
  process
• 17:32
  because
• 17:32
  there's
• 17:33
  so
• 17:33
  much
• 17:33
  hyper
• 17:33
  arousal.
• 17:34
  So
• 17:34
  anything
• 17:35
  that
• 17:35
  can
• 17:35
  reliably
• 17:36
  improve
• 17:36
  sleep
• 17:37
  architecture,
• 17:37
  I
• 17:38
  think
• 17:38
  is
• 17:38
  a
• 17:38
  major,
• 17:39
  major
• 17:39
  win.
• 17:40
  Especially
• 17:41
  if
• 17:41
  some
• 17:41
  of
• 17:41
  these
• 17:42
  sleep
• 17:42
  medications
• 17:43
  we
• 17:43
  do
• 17:43
  have
• 17:44
  tend
• 17:44
  to
• 17:45
  actually
• 17:46
  interfere
• 17:47
  with
• 17:47
  those
• 17:47
  sleep
• 17:48
  stages.
• 17:48
  That's
• 17:49
  a
• 17:49
  problem.
• 17:49
  Right.
• 17:50
  Especially
• 17:50
  if
• 17:50
  they're
• 17:50
  also
• 17:51
  habit
• 17:51
  forming
• 17:52
  and
• 17:52
  you
• 17:52
  can
• 17:52
  build
• 17:52
  a
• 17:52
  tolerance
• 17:53
  to
• 17:53
  them.
• 17:53
  So
• 17:54
  I
• 17:54
  will
• 17:55
  not
• 17:55
  pretend
• 17:55
  that
• 17:56
  I
• 17:56
  am
• 17:56
  the
• 17:57
  biggest
• 17:57
  fan
• 17:57
  of
• 17:57
  gabapentin
• 17:58
  that
• 17:58
  you've
• 17:59
  ever
• 17:59
  heard
• 18:00
  about,
• 18:01
  but
• 18:01
  I
• 18:01
  think
• 18:01
  it
• 18:01
  absolutely
• 18:02
  has
• 18:02
  its
• 18:02
  place
• 18:03
  in
• 18:04
  psychiatry.
• 18:04
  The
• 18:05
  low
• 18:05
  drama
• 18:06
  with
• 18:07
  CYP
• 18:07
  interactions,
• 18:08
  the
• 18:08
  lack
• 18:09
  of
• 18:09
  major
• 18:09
  protein
• 18:10
  binding,
• 18:10
  the
• 18:11
  renal
• 18:11
  elimination,
• 18:12
  the
• 18:12
  fact
• 18:13
  that
• 18:13
  it
• 18:13
  has
• 18:13
  this
• 18:14
  broad
• 18:14
  lower
• 18:15
  volume
• 18:15
  knob
• 18:16
  that
• 18:16
  can
• 18:16
  be
• 18:16
  applied
• 18:17
  to
• 18:17
  various
• 18:18
  different
• 18:18
  psychiatric
• 18:19
  mental
• 18:20
  health
• 18:20
  illnesses.
• 18:21
  I
• 18:21
  think
• 18:21
  all
• 18:21
  of
• 18:22
  that
• 18:22
  is
• 18:23
  really
• 18:24
  handy.
• 18:24
  It's
• 18:24
  really
• 18:24
  important
• 18:25
  to
• 18:25
  have.
• 18:26
  Is
• 18:26
  it
• 18:26
  the
• 18:26
  top
• 18:27
  five
• 18:27
  medications
• 18:28
  I
• 18:28
  would
• 18:28
  include
• 18:29
  on
• 18:29
  an
• 18:29
  island
• 18:29
  with
• 18:30
  me?
• 18:30
  Maybe
• 18:31
  not.
• 18:31
  But
• 18:31
  actually,
• 18:32
  in
• 18:32
  a
• 18:32
  sense
• 18:32
  it
• 18:33
  might
• 18:33
  be
• 18:33
  kind
• 18:33
  of
• 18:33
  smart
• 18:34
  because
• 18:34
  if
• 18:34
  you
• 18:34
  only
• 18:35
  have
• 18:35
  five
• 18:36
  medications
• 18:36
  on
• 18:36
  your
• 18:37
  island,
• 18:38
  you
• 18:38
  want
• 18:38
  each
• 18:39
  of
• 18:39
  them
• 18:39
  to
• 18:39
  be
• 18:39
  kind
• 18:40
  of
• 18:40
  as
• 18:40
  broadly
• 18:40
  effective
• 18:41
  as
• 18:41
  possible.
• 18:42
  And
• 18:43
  I
• 18:43
  do
• 18:43
  feel
• 18:43
  like,
• 18:44
  you
• 18:44
  know,
• 18:45
  whether
• 18:45
  it
• 18:45
  comes
• 18:45
  to
• 18:45
  sleep
• 18:46
  and
• 18:46
  anxiety
• 18:46
  and
• 18:47
  then
• 18:47
  all
• 18:48
  the
• 18:48
  other
• 18:48
  potential
• 18:49
  interactions
• 18:49
  at
• 18:50
  play,
• 18:50
  it
• 18:51
  might
• 18:51
  make
• 18:51
  the
• 18:52
  most
• 18:52
  sense
• 18:52
  to
• 18:52
  have
• 18:52
  a
• 18:52
  medication
• 18:53
  like
• 18:53
  gabapentin.
• 18:54
  Right.
• 18:54
  So
• 18:55
  I
• 18:55
  think,
• 18:55
  I
• 18:55
  hope
• 18:55
  you
• 18:55
  appreciate
• 18:56
  this
• 18:56
  episode
• 18:57
  because
• 18:57
  you
• 18:58
  will
• 18:58
  see,
• 18:58
  in
• 18:58
  psychopharmacology,
• 18:59
  it's
• 18:59
  not
• 19:00
  as
• 19:00
  simple
• 19:00
  as
• 19:00
  what
• 19:00
  do
• 19:01
  the
• 19:01
  textbooks
• 19:01
  say,
• 19:02
  and
• 19:02
  it's
• 19:03
  not
• 19:03
  as
• 19:03
  simple
• 19:04
  as
• 19:05
  what
• 19:05
  the
• 19:05
  FDA
• 19:06
  always
• 19:06
  approves.
• 19:07
  But
• 19:07
  at
• 19:07
  the
• 19:07
  end
• 19:07
  of
• 19:07
  the
• 19:07
  day,
• 19:08
  drugs
• 19:08
  can
• 19:08
  become
• 19:09
  a
• 19:09
  lot
• 19:09
  more
• 19:09
  elegant
• 19:10
  when
• 19:11
  you
• 19:11
  factor
• 19:11
  things
• 19:12
  in
• 19:12
  such
• 19:12
  as
• 19:13
  protein
• 19:13
  binding
• 19:13
  and
• 19:14
  hepatic
• 19:14
  metabolism
• 19:15
  and
• 19:15
  kind
• 19:16
  of
• 19:16
  the
• 19:16
  mechanism
• 19:16
  of
• 19:17
  action.
• 19:17
  Right,
• 19:18
  the
• 19:18
  mechanism
• 19:18
  of
• 19:19
  action
• 19:19
  here,
• 19:19
  just
• 19:20
  quieting
• 19:21
  the
• 19:21
  excitatory
• 19:22
  nerve
• 19:22
  terminals
• 19:23
  and
• 19:23
  neurons,
• 19:24
  I
• 19:24
  think
• 19:24
  is
• 19:24
  a
• 19:24
  really
• 19:25
  cool
• 19:25
  broad
• 19:25
  way
• 19:26
  to
• 19:26
  solve
• 19:26
  a
• 19:26
  lot
• 19:27
  of
• 19:27
  problems
• 19:27
  at
• 19:27
  once,
• 19:28
  if
• 19:28
  not
• 19:28
  perfectly,
• 19:29
  but
• 19:29
  still
• 19:29
  do.
• 19:30
  Getting
• 19:30
  it
• 19:30
  done.
• 19:31
  There
• 19:31
  has
• 19:32
  been
• 19:32
  some
• 19:32
  talk
• 19:32
  about
• 19:33
  abuse
• 19:33
  potential
• 19:34
  with
• 19:34
  gabapentin
• 19:35
  to
• 19:35
  the
• 19:35
  extent
• 19:36
  that
• 19:36
  several
• 19:37
  states
• 19:37
  now
• 19:38
  have
• 19:38
  made
• 19:38
  it
• 19:39
  a
• 19:39
  Schedule
• 19:39
  5
• 19:40
  substance.
• 19:40
  So
• 19:41
  definitely
• 19:41
  keep
• 19:42
  your
• 19:42
  ear
• 19:42
  to
• 19:42
  the
• 19:43
  ground
• 19:43
  when
• 19:43
  it
• 19:43
  comes
• 19:43
  to
• 19:44
  that.
• 19:44
  That's
• 19:45
  not
• 19:45
  small
• 19:45
  potatoes.
• 19:46
  We
• 19:46
  have
• 19:46
  to
• 19:46
  take
• 19:47
  that
• 19:47
  very
• 19:47
  seriously.
• 19:48
  There
• 19:48
  has
• 19:48
  been
• 19:49
  a
• 19:49
  resurgence
• 19:49
  of
• 19:50
  gabapentin
• 19:51
  prescriptions
• 19:51
  in
• 19:51
  light
• 19:52
  of
• 19:52
  the
• 19:52
  opioid
• 19:52
  epidemic.
• 19:53
  Epidemic.
• 19:53
  I.
• 19:54
  I
• 19:54
  presume
• 19:54
  it's
• 19:54
  because
• 19:55
  we're
• 19:55
  trying
• 19:56
  to
• 19:56
  get
• 19:56
  people
• 19:56
  off
• 19:57
  of
• 19:57
  opiates
• 19:57
  and
• 19:57
  onto
• 19:58
  something
• 19:59
  that
• 19:59
  can
• 19:59
  at
• 19:59
  least
• 19:59
  alleviate
• 20:00
  some
• 20:00
  of
• 20:00
  their
• 20:01
  symptoms.
• 20:01
  And
• 20:02
  so
• 20:02
  I
• 20:02
  would
• 20:03
  imagine
• 20:03
  gabapentin
• 20:04
  is
• 20:04
  filling
• 20:04
  a
• 20:04
  void.
• 20:05
  But
• 20:05
  there
• 20:06
  has
• 20:06
  been
• 20:06
  evidence
• 20:06
  of
• 20:07
  abuse
• 20:07
  out
• 20:08
  there.
• 20:08
  And
• 20:08
  gabapentin
• 20:09
  as
• 20:10
  of
• 20:10
  right
• 20:10
  now
• 20:10
  is
• 20:10
  not
• 20:11
  federally,
• 20:12
  is
• 20:12
  not
• 20:13
  a
• 20:13
  federally
• 20:13
  scheduled
• 20:14
  drug
• 20:14
  under
• 20:14
  the
• 20:15
  Controlled
• 20:15
  Substances
• 20:15
  Act.
• 20:16
  But
• 20:16
  it
• 20:16
  is
• 20:16
  something
• 20:17
  that
• 20:17
  we
• 20:17
  want
• 20:17
  to
• 20:18
  keep
• 20:18
  looking
• 20:18
  at.
• 20:18
  And
• 20:19
  definitely
• 20:19
  the
• 20:19
  states
• 20:20
  are
• 20:20
  changing
• 20:20
  their
• 20:21
  posture
• 20:21
  towards
• 20:21
  it.
• 20:22
  So
• 20:22
  keep
• 20:22
  your
• 20:23
  ear
• 20:23
  to
• 20:23
  the
• 20:23
  ground
• 20:23
  on
• 20:23
  that.
• 20:24
  That's
• 20:24
  a
• 20:24
  whole
• 20:24
  other
• 20:24
  conversation,
• 20:25
  but
• 20:26
  I
• 20:26
  hope
• 20:26
  you
• 20:26
  appreciate
• 20:26
  gabapentin
• 20:27
  a
• 20:28
  little
• 20:28
  more.
• 20:28
  Think
• 20:29
  about
• 20:29
  where
• 20:29
  you
• 20:30
  may
• 20:30
  want
• 20:31
  to
• 20:31
  prescribe
• 20:31
  this
• 20:32
  if
• 20:32
  you're
• 20:32
  not
• 20:32
  already
• 20:32
  prescribing
• 20:33
  it,
• 20:33
  and
• 20:33
  the
• 20:34
  next
• 20:34
  time
• 20:34
  you
• 20:34
  get
• 20:34
  super
• 20:35
  stuck
• 20:35
  in
• 20:36
  clinic.
• 20:37
  This
• 20:37
  one
• 20:37
  is
• 20:37
  definitely
• 20:38
  a
• 20:38
  medication
• 20:39
  to
• 20:39
  at
• 20:39
  least
• 20:39
  think
• 20:40
  about
• 20:41
  because
• 20:41
  I
• 20:41
  know
• 20:41
  that
• 20:42
  sometimes
• 20:42
  I'll
• 20:43
  kick
• 20:43
  myself
• 20:43
  after
• 20:44
  the
• 20:44
  patient
• 20:44
  left
• 20:46
  and
• 20:46
  I'll
• 20:46
  say,
• 20:46
  you
• 20:47
  know
• 20:47
  what?
• 20:47
  That
• 20:47
  might
• 20:48
  have
• 20:48
  been
• 20:48
  one
• 20:49
  of
• 20:49
  those
• 20:49
  limited
• 20:49
  times
• 20:50
  that
• 20:50
  gabapentin
• 20:51
  was
• 20:51
  more
• 20:51
  appropriate
• 20:52
  here,
• 20:52
  if
• 20:52
  nothing
• 20:53
  else,
• 20:53
  to
• 20:53
  buy
• 20:53
  us
• 20:53
  some
• 20:54
  time
• 20:54
  to
• 20:54
  alleviate
• 20:55
  some
• 20:55
  symptoms
• 20:56
  and
• 20:57
  to
• 20:57
  keep
• 20:57
  the
• 20:57
  show
• 20:58
  rolling.
• 20:59
  All
• 20:59
  right,
• 20:59
  my
• 21:00
  friends,
• 21:00
  thank
• 21:00
  you
• 21:00
  for
• 21:01
  tuning
• 21:02
  into
• 21:02
  this
• 21:02
  one.
• 21:02
  It
• 21:03
  was
• 21:03
  a
• 21:03
  doozy.
• 21:04
  And
• 21:04
  don't
• 21:04
  forget,
• 21:05
  I
• 21:05
  always
• 21:05
  emphasize
• 21:06
  this.
• 21:06
  Don't
• 21:06
  forget
• 21:08
  that
• 21:08
  there
• 21:08
  are
• 21:09
  always
• 21:09
  two
• 21:09
  kinds
• 21:10
  of
• 21:10
  prescribers
• 21:10
  out
• 21:11
  there.
• 21:11
  The
• 21:11
  ones
• 21:11
  who
• 21:12
  just
• 21:12
  follow
• 21:12
  the
• 21:12
  algorithms
• 21:14
  and
• 21:14
  the
• 21:14
  ones
• 21:14
  who
• 21:14
  actually
• 21:15
  understand
• 21:15
  the
• 21:16
  how
• 21:16
  and
• 21:16
  the
• 21:16
  why,
• 21:17
  what
• 21:17
  they're
• 21:17
  doing.
• 21:18
  And
• 21:18
  patients
• 21:18
  can
• 21:19
  smell
• 21:19
  that
• 21:19
  a
• 21:19
  mile
• 21:20
  away.
• 21:20
  And
• 21:21
  I
• 21:21
  never
• 21:21
  liked
• 21:22
  just
• 21:22
  handing
• 21:22
  out
• 21:22
  a
• 21:22
  medication
• 21:23
  and
• 21:23
  not
• 21:23
  knowing
• 21:24
  what
• 21:24
  the
• 21:24
  heck
• 21:24
  was
• 21:25
  behind
• 21:25
  it.
• 21:25
  So
• 21:26
  I
• 21:26
  built
• 21:26
  an
• 21:26
  entire
• 21:27
  Patreon
• 21:27
  library
• 21:28
  for
• 21:28
  me
• 21:28
  and
• 21:28
  for
• 21:29
  you
• 21:29
  to
• 21:29
  nerd
• 21:30
  out
• 21:30
  on
• 21:30
  and
• 21:30
  understand
• 21:31
  the
• 21:31
  how
• 21:31
  and
• 21:31
  the
• 21:31
  why.
• 21:32
  Because
• 21:32
  patients
• 21:32
  smell
• 21:33
  that
• 21:33
  a
• 21:33
  mile
• 21:34
  away.
• 21:34
  It
• 21:34
  has
• 21:35
  transformed
• 21:35
  the
• 21:35
  way
• 21:36
  I
• 21:36
  present
• 21:36
  in
• 21:36
  clinic,
• 21:37
  how
• 21:37
  my
• 21:37
  patients
• 21:38
  receive
• 21:38
  me,
• 21:38
  our
• 21:38
  rapport
• 21:39
  together
• 21:39
  and
• 21:39
  our
• 21:39
  outcomes.
• 21:40
  I
• 21:40
  highly
• 21:41
  recommend
• 21:41
  if
• 21:41
  there's
• 21:41
  one
• 21:42
  thing
• 21:42
  you
• 21:42
  don't
• 21:42
  forget
• 21:42
  tonight,
• 21:43
  go
• 21:43
  to
• 21:43
  the
• 21:43
  show
• 21:43
  notes
• 21:44
  and
• 21:44
  click
• 21:45
  the
• 21:45
  Patreon
• 21:46
  link
• 21:46
  and
• 21:46
  become
• 21:47
  a
• 21:47
  member.
• 21:47
  It's
• 21:48
  very
• 21:48
  easy,
• 21:48
  it's
• 21:49
  very
• 21:49
  fast,
• 21:49
  and
• 21:50
  you
• 21:50
  will
• 21:50
  get
• 21:50
  a
• 21:51
  really
• 21:51
  beautiful
• 21:51
  library
• 21:52
  full
• 21:53
  of
• 21:53
  great
• 21:53
  high
• 21:53
  yield
• 21:54
  clinical
• 21:54
  pearls.
• 21:55
  Can't
• 21:55
  wait
• 21:56
  to
• 21:56
  have
• 21:56
  you
• 21:56
  there
• 21:56
  to
• 21:56
  welcome
• 21:57
  you
• 21:57
  to
• 21:57
  the
• 21:57
  Patreon
• 21:57
  family.
• 21:58
  Get
• 21:58
  it
• 21:59
  done,
• 21:59
  my
• 21:59
  friends.
• 21:59
  It's
• 21:59
  a
• 22:00
  no
• 22:00
  brainer
• 22:01
  and
• 22:01
  we
• 22:01
  will
• 22:02
  see
• 22:02
  you
• 22:02
  next
• 22:02
  time
• 22:02
  here
• 22:02
  on
• 22:03
  Pearls
• 22:03
  and
• 22:03
  Prep.
• 22:04
  Take
• 22:04
  care.
• 22:09
  Of
• 22:09
  the.