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The Good, the Bad & the Weird of Z-Drugs · 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
• 0:08
  npz.
• 0:09
  Here
• 0:09
  your
• 0:09
  preceptor
• 0:10
  in
• 0:10
  your
• 0:10
  pocket,
• 0:11
  your
• 0:11
  go
• 0:11
  to
• 0:11
  place
• 0:12
  for
• 0:12
  pearls
• 0:13
  that
• 0:13
  prep
• 0:13
  you
• 0:13
  to
• 0:14
  practice.
• 0:14
  My
• 0:15
  friends,
• 0:15
  today
• 0:16
  I
• 0:16
  want
• 0:16
  to
• 0:16
  talk
• 0:17
  to
• 0:17
  you
• 0:17
  about
• 0:18
  Z
• 0:18
  drugs.
• 0:19
  What
• 0:19
  they
• 0:19
  are,
• 0:20
  what
• 0:20
  they
• 0:20
  are
• 0:21
  not,
• 0:21
  and
• 0:22
  where
• 0:22
  you
• 0:22
  might
• 0:23
  find
• 0:23
  yourself
• 0:24
  prescribing
• 0:24
  Z
• 0:25
  drugs
• 0:26
  in
• 0:26
  clinical
• 0:27
  practice.
• 0:28
  And
• 0:28
  you
• 0:28
  know
• 0:28
  how
• 0:29
  I
• 0:29
  roll.
• 0:29
  This
• 0:30
  is
• 0:30
  not
• 0:30
  a
• 0:31
  lecture
• 0:32
  where
• 0:33
  I'm
• 0:33
  going
• 0:33
  to
• 0:33
  whip
• 0:33
  out
• 0:33
  a
• 0:34
  PowerPoint
• 0:35
  and
• 0:35
  spank
• 0:35
  you
• 0:35
  if
• 0:36
  you
• 0:36
  get
• 0:36
  the
• 0:36
  wrong
• 0:36
  answer.
• 0:37
  This
• 0:37
  is
• 0:37
  a
• 0:38
  fun.
• 0:38
  I'm
• 0:39
  in
• 0:39
  your
• 0:39
  living
• 0:39
  room,
• 0:40
  I'm
• 0:40
  your
• 0:40
  preceptor.
• 0:41
  We're
• 0:41
  chatting
• 0:42
  about
• 0:42
  meds
• 0:43
  and
• 0:44
  my
• 0:44
  personal
• 0:44
  experiences
• 0:45
  and
• 0:45
  what
• 0:46
  these
• 0:46
  medications
• 0:47
  mean
• 0:47
  in
• 0:48
  real
• 0:48
  life
• 0:48
  practice.
• 0:49
  I
• 0:49
  find
• 0:49
  those
• 0:50
  kinds
• 0:50
  of
• 0:50
  conversations
• 0:51
  the
• 0:51
  most
• 0:51
  high
• 0:51
  yield
• 0:52
  and
• 0:52
  the
• 0:52
  most
• 0:52
  practical.
• 0:53
  When
• 0:53
  I
• 0:53
  was
• 0:53
  in
• 0:54
  school,
• 0:54
  I
• 0:54
  remember
• 0:55
  literally
• 0:56
  spending
• 0:56
  time
• 0:57
  with
• 0:57
  my
• 0:57
  clinical
• 0:58
  instructor,
• 0:58
  sometimes
• 0:59
  in
• 0:59
  their
• 0:59
  living
• 0:59
  room
• 1:01
  and
• 1:01
  literally
• 1:01
  in
• 1:01
  their
• 1:02
  living
• 1:02
  room
• 1:02
  talking
• 1:02
  about
• 1:03
  meds
• 1:03
  and
• 1:03
  how
• 1:03
  passionate
• 1:04
  we
• 1:04
  were
• 1:04
  and
• 1:05
  all
• 1:05
  the
• 1:05
  nuances
• 1:05
  and
• 1:06
  picking
• 1:06
  her
• 1:06
  brain
• 1:06
  on
• 1:07
  when
• 1:07
  they're
• 1:07
  prescribed
• 1:08
  and
• 1:08
  why.
• 1:08
  And
• 1:08
  I
• 1:09
  found
• 1:09
  those
• 1:09
  conversations
• 1:10
  so
• 1:10
  valuable
• 1:10
  because
• 1:11
  they're
• 1:11
  beyond
• 1:12
  the
• 1:12
  textbook.
• 1:12
  Right?
• 1:12
  They
• 1:13
  put
• 1:13
  it,
• 1:14
  they,
• 1:14
  they
• 1:14
  put
• 1:14
  psychiatry
• 1:15
  through
• 1:15
  the
• 1:15
  filter
• 1:16
  of
• 1:16
  actual
• 1:16
  human
• 1:17
  experience.
• 1:17
  And,
• 1:18
  and
• 1:18
  we
• 1:19
  talk
• 1:19
  about,
• 1:19
  you
• 1:20
  know,
• 1:20
  why
• 1:20
  these
• 1:21
  are
• 1:21
  prescribed,
• 1:22
  what
• 1:22
  you've
• 1:22
  seen
• 1:22
  go
• 1:23
  wrong
• 1:23
  with
• 1:23
  them,
• 1:23
  what
• 1:24
  you've
• 1:24
  seen
• 1:24
  go
• 1:24
  right
• 1:24
  with
• 1:24
  them.
• 1:25
  I
• 1:25
  just
• 1:25
  love
• 1:25
  these
• 1:25
  conversations.
• 1:26
  And
• 1:26
  so
• 1:27
  I
• 1:27
  hope
• 1:27
  to
• 1:28
  kind
• 1:28
  of
• 1:29
  build
• 1:29
  that
• 1:29
  same
• 1:29
  relationship
• 1:30
  with
• 1:30
  you
• 1:30
  right
• 1:31
  now
• 1:31
  where
• 1:31
  we're
• 1:31
  just
• 1:32
  chatting
• 1:32
  in
• 1:33
  your
• 1:33
  living
• 1:33
  room,
• 1:33
  except
• 1:34
  for
• 1:34
  the
• 1:34
  fact
• 1:34
  that
• 1:35
  you
• 1:35
  don't
• 1:35
  get
• 1:35
  to
• 1:35
  talk.
• 1:36
  You
• 1:36
  don't
• 1:37
  get
• 1:37
  to
• 1:37
  talk
• 1:37
  at
• 1:37
  all,
• 1:37
  in
• 1:37
  fact.
• 1:38
  So
• 1:39
  it's
• 1:39
  really
• 1:39
  kind
• 1:39
  of
• 1:39
  a.
• 1:39
  Maybe
• 1:40
  a
• 1:40
  boring
• 1:40
  conversation
• 1:41
  for
• 1:41
  you
• 1:41
  in
• 1:42
  that
• 1:42
  even
• 1:43
  if
• 1:43
  you
• 1:43
  talked
• 1:43
  right
• 1:43
  now,
• 1:44
  I
• 1:44
  couldn't
• 1:44
  hear
• 1:44
  you.
• 1:45
  Um,
• 1:45
  but
• 1:45
  you
• 1:46
  get
• 1:46
  my
• 1:46
  vibe,
• 1:46
  right?
• 1:46
  You
• 1:46
  get
• 1:47
  my.
• 1:47
  You
• 1:47
  get.
• 1:48
  The
• 1:48
  point
• 1:48
  of
• 1:48
  I'm
• 1:48
  trying
• 1:48
  to
• 1:49
  make
• 1:49
  here
• 1:49
  is
• 1:49
  that
• 1:49
  this
• 1:50
  is
• 1:50
  going
• 1:50
  to
• 1:50
  be
• 1:50
  conversational.
• 1:51
  Now
• 1:52
  let's
• 1:52
  talk
• 1:52
  about
• 1:52
  Z
• 1:53
  drugs.
• 1:53
  Now,
• 1:54
  you've
• 1:54
  heard
• 1:55
  the
• 1:55
  term
• 1:56
  Z
• 1:56
  drugs
• 1:57
  probably
• 1:57
  before,
• 1:58
  and
• 1:59
  these
• 2:00
  are
• 2:00
  non
• 2:01
  benzodiazepine
• 2:02
  hypnotics.
• 2:04
  Now,
• 2:04
  what
• 2:05
  does
• 2:05
  that
• 2:05
  really
• 2:05
  mean
• 2:05
  in
• 2:06
  practice?
• 2:06
  It's
• 2:06
  kind
• 2:06
  of
• 2:07
  confusing
• 2:07
  because
• 2:08
  they
• 2:08
  are
• 2:08
  potentially
• 2:09
  habit
• 2:10
  forming,
• 2:10
  just
• 2:10
  like
• 2:10
  benzodiazepines,
• 2:11
  but
• 2:12
  they're
• 2:12
  a
• 2:12
  little
• 2:12
  bit
• 2:12
  less
• 2:13
  habit
• 2:13
  forming.
• 2:14
  And
• 2:14
  the
• 2:14
  reason
• 2:15
  for
• 2:15
  that
• 2:15
  is
• 2:16
  the
• 2:16
  GABA
• 2:17
  receptor
• 2:18
  is
• 2:19
  not
• 2:20
  so
• 2:20
  simple.
• 2:20
  It
• 2:20
  has
• 2:21
  subunits.
• 2:22
  Okay,
• 2:23
  Receptors
• 2:23
  have
• 2:24
  subunits.
• 2:24
  They're
• 2:24
  not
• 2:24
  just
• 2:25
  simple
• 2:25
  receptors.
• 2:26
  You
• 2:26
  could
• 2:26
  think
• 2:27
  of
• 2:27
  maybe
• 2:27
  a
• 2:27
  subunit
• 2:28
  as
• 2:28
  like.
• 2:28
  It's
• 2:29
  not,
• 2:29
  it's
• 2:29
  not
• 2:29
  like
• 2:29
  a.
• 2:30
  The
• 2:30
  receptor
• 2:31
  might
• 2:31
  be
• 2:31
  a
• 2:31
  doorknob
• 2:32
  that
• 2:32
  you
• 2:32
  turn
• 2:32
  to
• 2:33
  open
• 2:33
  the
• 2:33
  door,
• 2:34
  but
• 2:34
  on
• 2:34
  that
• 2:34
  doorknob
• 2:35
  there's
• 2:35
  like
• 2:36
  little
• 2:36
  buttons
• 2:37
  that
• 2:37
  can
• 2:37
  do
• 2:37
  different
• 2:38
  things.
• 2:38
  Maybe
• 2:38
  one
• 2:39
  you
• 2:39
  press
• 2:39
  one
• 2:39
  button,
• 2:39
  the
• 2:40
  door
• 2:40
  opens
• 2:40
  really
• 2:40
  slowly
• 2:41
  or
• 2:41
  really
• 2:41
  quickly
• 2:42
  or
• 2:42
  it
• 2:43
  changes
• 2:43
  colors.
• 2:43
  It
• 2:44
  doesn't
• 2:44
  matter
• 2:44
  what
• 2:44
  it
• 2:44
  does
• 2:45
  per
• 2:45
  se,
• 2:45
  but
• 2:46
  just
• 2:46
  the
• 2:46
  fact
• 2:46
  that
• 2:47
  certain
• 2:47
  receptors
• 2:48
  have
• 2:48
  subunits
• 2:49
  that
• 2:50
  do
• 2:51
  different
• 2:51
  things.
• 2:51
  So
• 2:52
  that's
• 2:52
  kind
• 2:52
  of
• 2:52
  important
• 2:53
  for
• 2:53
  you
• 2:53
  to
• 2:54
  understand.
• 2:54
  Now
• 2:55
  what
• 2:56
  I
• 2:56
  think
• 2:56
  is
• 2:56
  really
• 2:56
  cool
• 2:57
  about
• 2:58
  Z
• 2:59
  drugs
• 2:59
  is
• 2:59
  that
• 3:00
  they
• 3:00
  are
• 3:00
  a
• 3:00
  little
• 3:00
  bit
• 3:00
  less
• 3:01
  habit
• 3:01
  forming
• 3:01
  than
• 3:02
  benzo.
• 3:02
  So
• 3:02
  you
• 3:03
  feel
• 3:03
  a
• 3:03
  little
• 3:03
  bit
• 3:03
  more
• 3:04
  comfortable
• 3:04
  prescribing
• 3:05
  them.
• 3:05
  But
• 3:06
  at
• 3:06
  the
• 3:06
  same
• 3:06
  time,
• 3:07
  you
• 3:08
  still
• 3:08
  have
• 3:08
  to
• 3:08
  kind
• 3:08
  of
• 3:08
  have
• 3:08
  that
• 3:09
  conversation
• 3:09
  prescribed.
• 3:10
  That
• 3:10
  these
• 3:10
  patients
• 3:10
  can
• 3:11
  build
• 3:11
  up
• 3:11
  a
• 3:11
  tolerance
• 3:12
  that
• 3:12
  might
• 3:13
  not
• 3:13
  be
• 3:13
  as
• 3:13
  efficacious
• 3:14
  a
• 3:14
  few
• 3:14
  months
• 3:15
  down
• 3:15
  the
• 3:15
  road
• 3:15
  when
• 3:15
  they're
• 3:16
  trying
• 3:16
  to
• 3:16
  sleep
• 3:16
  with
• 3:17
  the
• 3:17
  same
• 3:17
  dose
• 3:17
  of
• 3:17
  this
• 3:18
  medication.
• 3:18
  And
• 3:18
  that
• 3:18
  can
• 3:18
  be
• 3:19
  frustrating.
• 3:19
  There
• 3:19
  might
• 3:19
  be
• 3:20
  rebound
• 3:20
  insomnia,
• 3:21
  there
• 3:21
  might
• 3:21
  be
• 3:21
  complex
• 3:22
  sleep
• 3:22
  behaviors.
• 3:23
  None
• 3:23
  of
• 3:23
  those
• 3:23
  things
• 3:24
  are
• 3:24
  fun
• 3:24
  or
• 3:25
  friendly.
• 3:25
  And
• 3:25
  you
• 3:25
  have
• 3:25
  to
• 3:26
  have
• 3:26
  that
• 3:26
  conversation
• 3:26
  with
• 3:27
  your
• 3:27
  patients.
• 3:27
  So
• 3:28
  I
• 3:28
  don't
• 3:28
  have
• 3:28
  the
• 3:28
  warm
• 3:28
  and
• 3:29
  fuzzies
• 3:29
  when
• 3:29
  I
• 3:30
  prescribe
• 3:30
  Z
• 3:30
  drugs,
• 3:31
  but
• 3:31
  there
• 3:32
  is
• 3:32
  one
• 3:32
  Z
• 3:32
  drug
• 3:32
  I
• 3:33
  go
• 3:33
  to
• 3:33
  more
• 3:33
  routinely
• 3:34
  than
• 3:34
  others
• 3:34
  that
• 3:34
  I'm
• 3:35
  excited
• 3:35
  to
• 3:35
  share
• 3:35
  with
• 3:35
  you
• 3:36
  shortly.
• 3:37
  Now
• 3:38
  you
• 3:38
  might
• 3:38
  say,
• 3:39
  well,
• 3:39
  okay,
• 3:41
  NPZ
• 3:42
  Z
• 3:42
  drugs
• 3:43
  are
• 3:43
  all
• 3:43
  fine
• 3:43
  and
• 3:43
  dandy,
• 3:44
  but
• 3:44
  I
• 3:44
  thought
• 3:45
  that
• 3:45
  CBTI
• 3:46
  was
• 3:46
  like
• 3:47
  the
• 3:47
  gold
• 3:47
  standard
• 3:48
  for
• 3:50
  sleep
• 3:50
  issues.
• 3:50
  You
• 3:51
  know
• 3:51
  the
• 3:51
  American
• 3:52
  Academy
• 3:52
  of
• 3:52
  Sleep
• 3:53
  Medicine,
• 3:53
  right?
• 3:53
  The
• 3:53
  guidelines,
• 3:54
  cbti,
• 3:55
  sleep
• 3:55
  restriction,
• 3:57
  cold,
• 3:57
  dark
• 3:57
  environment,
• 3:58
  only
• 3:59
  use
• 3:59
  the
• 3:59
  bed
• 4:00
  for
• 4:00
  sleep
• 4:00
  and
• 4:00
  sexual,
• 4:02
  set
• 4:02
  an
• 4:03
  alarm
• 4:03
  every
• 4:03
  day.
• 4:04
  Right.
• 4:06
  Only
• 4:06
  associate
• 4:07
  that
• 4:07
  bed
• 4:08
  with
• 4:08
  rest
• 4:09
  and
• 4:10
  not
• 4:11
  whipping
• 4:11
  out
• 4:11
  your
• 4:12
  phone
• 4:12
  and
• 4:12
  avoiding
• 4:12
  blue
• 4:13
  light
• 4:13
  and
• 4:13
  all
• 4:13
  that
• 4:14
  good
• 4:14
  stuff.
• 4:14
  Okay.
• 4:15
  And
• 4:15
  that's
• 4:15
  true.
• 4:15
  CBTI
• 4:16
  is
• 4:16
  fantastic.
• 4:18
  Going
• 4:19
  over
• 4:19
  the
• 4:20
  kinds
• 4:20
  of
• 4:20
  altcognitions
• 4:21
  that
• 4:22
  run
• 4:22
  through
• 4:22
  your
• 4:23
  head
• 4:23
  and
• 4:23
  challenging
• 4:24
  them
• 4:24
  about
• 4:25
  how
• 4:25
  you
• 4:25
  view
• 4:25
  sleep
• 4:26
  and
• 4:26
  behavioral
• 4:27
  changes
• 4:27
  associated
• 4:28
  with
• 4:28
  sleep.
• 4:28
  All
• 4:28
  of
• 4:28
  those
• 4:28
  things
• 4:29
  are
• 4:29
  first
• 4:29
  line
• 4:29
  gold
• 4:30
  standard.
• 4:31
  But
• 4:31
  as
• 4:31
  many
• 4:31
  of
• 4:31
  you
• 4:32
  will
• 4:32
  see
• 4:32
  when
• 4:32
  you
• 4:32
  actually
• 4:33
  get
• 4:33
  out
• 4:33
  into
• 4:34
  practice,
• 4:35
  a
• 4:35
  lot
• 4:35
  of
• 4:35
  the
• 4:35
  patients
• 4:36
  that
• 4:36
  may
• 4:36
  need
• 4:37
  a
• 4:37
  Z
• 4:37
  drug
• 4:37
  or
• 4:37
  want
• 4:37
  a
• 4:38
  Z
• 4:38
  drug
• 4:38
  or
• 4:38
  would
• 4:38
  be
• 4:39
  appropriate
• 4:39
  for
• 4:39
  a
• 4:39
  Z
• 4:40
  drug
• 4:40
  in
• 4:40
  your
• 4:40
  office,
• 4:41
  they
• 4:41
  will
• 4:41
  have
• 4:42
  either
• 4:42
  tried
• 4:42
  CBT
• 4:43
  I
• 4:43
  50
• 4:44
  times
• 4:44
  in
• 4:44
  their
• 4:44
  life
• 4:44
  and
• 4:45
  they
• 4:45
  say
• 4:45
  it
• 4:46
  just
• 4:46
  hasn't
• 4:46
  worked
• 4:47
  or
• 4:48
  they
• 4:48
  don't
• 4:48
  have
• 4:48
  the
• 4:49
  bandwidth
• 4:49
  in
• 4:50
  their
• 4:50
  schedule.
• 4:50
  Maybe
• 4:52
  they're
• 4:52
  like
• 4:52
  a
• 4:52
  tech
• 4:53
  CEO
• 4:53
  that
• 4:53
  just
• 4:53
  doesn't
• 4:54
  have
• 4:54
  the
• 4:54
  time
• 4:55
  to
• 4:55
  do
• 4:55
  CBT
• 4:56
  I.
• 4:56
  They
• 4:56
  outright
• 4:56
  refuse
• 4:57
  to
• 4:57
  do
• 4:57
  cbti.
• 4:58
  Um,
• 4:59
  they,
• 5:00
  their
• 5:00
  insurance
• 5:00
  may
• 5:01
  not
• 5:01
  cover
• 5:01
  that
• 5:02
  kind
• 5:02
  of
• 5:02
  thing.
• 5:03
  So
• 5:03
  you
• 5:03
  will
• 5:04
  run
• 5:04
  into
• 5:04
  actual
• 5:05
  limitations
• 5:06
  where
• 5:07
  you're
• 5:07
  going
• 5:07
  to
• 5:08
  feel
• 5:08
  kind
• 5:08
  of
• 5:08
  helpless
• 5:08
  or
• 5:09
  clueless
• 5:09
  if
• 5:09
  you
• 5:10
  only
• 5:10
  look
• 5:10
  at
• 5:10
  the
• 5:10
  textbook
• 5:11
  answer
• 5:11
  because
• 5:12
  it's
• 5:12
  not
• 5:12
  always
• 5:12
  viable.
• 5:13
  Right.
• 5:14
  And
• 5:15
  I
• 5:15
  find
• 5:15
  my
• 5:15
  sleep
• 5:16
  patients
• 5:16
  particularly
• 5:19
  challenging
• 5:20
  at
• 5:20
  times
• 5:21
  because
• 5:21
  they
• 5:22
  are
• 5:22
  the
• 5:22
  ones
• 5:22
  who
• 5:22
  normally
• 5:23
  have
• 5:24
  already
• 5:24
  tried
• 5:25
  all
• 5:25
  of
• 5:26
  the
• 5:26
  other
• 5:26
  options,
• 5:27
  you
• 5:27
  know,
• 5:28
  as
• 5:28
  opposed
• 5:29
  to
• 5:29
  maybe
• 5:29
  depression
• 5:30
  or
• 5:30
  someone
• 5:31
  who's
• 5:31
  never
• 5:31
  been
• 5:32
  treated
• 5:32
  for
• 5:32
  adhd.
• 5:33
  It's,
• 5:33
  it's
• 5:34
  a
• 5:34
  little
• 5:34
  bit
• 5:34
  more
• 5:35
  empowering
• 5:35
  because
• 5:36
  you're
• 5:36
  introducing
• 5:36
  them
• 5:37
  to
• 5:37
  Prozac,
• 5:37
  you're
• 5:37
  introducing
• 5:38
  them
• 5:38
  to
• 5:38
  Adderall,
• 5:39
  you're
• 5:39
  going
• 5:40
  over
• 5:40
  the
• 5:40
  informed
• 5:40
  consent,
• 5:41
  and
• 5:42
  it's
• 5:42
  a
• 5:43
  pretty
• 5:43
  good
• 5:43
  chance
• 5:43
  that
• 5:44
  some
• 5:45
  of
• 5:45
  your
• 5:45
  interventions
• 5:45
  will
• 5:46
  work
• 5:46
  because
• 5:47
  they've
• 5:47
  never
• 5:47
  really
• 5:47
  tried
• 5:47
  this
• 5:48
  before.
• 5:48
  And
• 5:48
  that
• 5:49
  could
• 5:49
  make
• 5:49
  a
• 5:49
  big
• 5:49
  difference
• 5:50
  because
• 5:50
  it's
• 5:50
  this
• 5:50
  new
• 5:50
  change.
• 5:51
  Right.
• 5:51
  They've
• 5:51
  been
• 5:51
  depressed
• 5:52
  and
• 5:52
  they've
• 5:52
  never
• 5:52
  been
• 5:52
  medicated.
• 5:53
  Well,
• 5:54
  here
• 5:54
  we
• 5:54
  go.
• 5:54
  Now
• 5:54
  we
• 5:55
  have
• 5:55
  an
• 5:55
  opportunity
• 5:55
  to
• 5:55
  really
• 5:56
  feel
• 5:56
  a
• 5:56
  difference.
• 5:57
  Not
• 5:57
  so
• 5:57
  the
• 5:58
  case
• 5:58
  with
• 5:58
  your
• 5:58
  insomnia
• 5:59
  patients.
• 5:59
  My
• 5:59
  typical
• 6:00
  insomnia
• 6:00
  patients,
• 6:01
  they'll
• 6:01
  kind
• 6:01
  of
• 6:01
  snicker
• 6:02
  when
• 6:02
  I
• 6:02
  suggest
• 6:02
  melatonin
• 6:03
  at
• 6:03
  first
• 6:04
  or
• 6:04
  trazodone.
• 6:05
  In
• 6:05
  fact,
• 6:05
  I'm
• 6:05
  very
• 6:05
  careful
• 6:06
  not
• 6:06
  even
• 6:06
  to
• 6:07
  suggest
• 6:07
  that
• 6:08
  right
• 6:08
  away.
• 6:09
  I
• 6:09
  first
• 6:10
  really
• 6:10
  just
• 6:11
  assume
• 6:11
  or
• 6:11
  confirm
• 6:12
  with
• 6:12
  them.
• 6:12
  Of
• 6:13
  course,
• 6:13
  I
• 6:13
  always
• 6:13
  do
• 6:13
  the
• 6:13
  assessment,
• 6:14
  but
• 6:14
  I,
• 6:15
  I,
• 6:16
  I,
• 6:16
  I,
• 6:16
  I
• 6:17
  assume
• 6:17
  in
• 6:17
  my
• 6:17
  mind
• 6:18
  that
• 6:18
  they
• 6:18
  already
• 6:18
  have
• 6:19
  tried
• 6:19
  those
• 6:19
  things.
• 6:19
  And
• 6:19
  then
• 6:20
  when
• 6:20
  I
• 6:20
  confirm
• 6:20
  it,
• 6:20
  sure
• 6:21
  enough,
• 6:21
  they
• 6:21
  do
• 6:22
  kind
• 6:22
  of
• 6:22
  snicker
• 6:22
  and
• 6:22
  go,
• 6:22
  yeah,
• 6:23
  yeah,
• 6:23
  I
• 6:23
  have
• 6:23
  tried
• 6:23
  melatonin,
• 6:24
  of
• 6:24
  course.
• 6:25
  I've
• 6:25
  tried
• 6:25
  Trazodone
• 6:26
  again.
• 6:26
  I've
• 6:27
  tried,
• 6:27
  I've
• 6:27
  tried,
• 6:27
  I've
• 6:27
  tried
• 6:28
  most
• 6:28
  of
• 6:28
  the
• 6:28
  patients
• 6:28
  I
• 6:29
  see
• 6:29
  they're
• 6:30
  not
• 6:30
  oblivious
• 6:30
  to
• 6:31
  all
• 6:31
  of
• 6:31
  the
• 6:31
  things
• 6:31
  we
• 6:31
  just
• 6:32
  talked
• 6:32
  about
• 6:32
  with
• 6:33
  CBTI
• 6:34
  and
• 6:34
  those
• 6:35
  kind
• 6:35
  of
• 6:35
  entry
• 6:36
  level
• 6:36
  hypnotics.
• 6:37
  They've
• 6:37
  been
• 6:37
  there,
• 6:38
  done
• 6:38
  that.
• 6:38
  Okay.
• 6:39
  And
• 6:39
  if
• 6:39
  they
• 6:39
  haven't,
• 6:39
  feel
• 6:40
  free
• 6:40
  to
• 6:40
  peruse
• 6:41
  through
• 6:41
  those
• 6:41
  and
• 6:41
  try
• 6:41
  them.
• 6:42
  I'll
• 6:42
  try
• 6:42
  people
• 6:42
  on
• 6:42
  doxepin
• 6:43
  and
• 6:43
  remeltion,
• 6:44
  depending
• 6:45
  on,
• 6:46
  you
• 6:46
  know,
• 6:46
  what
• 6:46
  stage
• 6:47
  of
• 6:47
  sleep
• 6:47
  they're
• 6:47
  struggling
• 6:48
  with.
• 6:48
  Doxypin,
• 6:49
  3
• 6:49
  milligrams,
• 6:49
  move
• 6:50
  up
• 6:50
  to
• 6:50
  6
• 6:50
  milligrams
• 6:51
  in
• 6:51
  a
• 6:51
  week
• 6:51
  or
• 6:51
  so.
• 6:52
  If
• 6:52
  the
• 6:52
  patient
• 6:52
  has
• 6:53
  middle
• 6:53
  incest
• 6:53
  insomnia,
• 6:53
  you
• 6:54
  know,
• 6:54
  it's
• 6:54
  FDA
• 6:54
  approved
• 6:54
  for
• 6:55
  middle
• 6:55
  insomnia
• 6:55
  or
• 6:56
  the
• 6:56
  type
• 6:56
  of
• 6:56
  insomnia
• 6:57
  where
• 6:57
  you
• 6:57
  wake
• 6:57
  up
• 6:57
  in
• 6:58
  the
• 6:58
  middle
• 6:58
  of
• 6:58
  the
• 6:58
  night
• 6:58
  and
• 6:59
  can't
• 6:59
  go
• 6:59
  back
• 6:59
  to
• 6:59
  sleep
• 6:59
  for
• 7:00
  30
• 7:00
  minutes
• 7:00
  or
• 7:00
  more.
• 7:01
  That
• 7:01
  kind
• 7:01
  of
• 7:01
  thing.
• 7:02
  Sure,
• 7:02
  you
• 7:03
  can
• 7:03
  play
• 7:03
  with
• 7:03
  that
• 7:04
  and
• 7:04
  explore
• 7:04
  what
• 7:04
  they
• 7:05
  haven't
• 7:05
  tried,
• 7:06
  see
• 7:06
  if
• 7:06
  it's
• 7:07
  pain
• 7:07
  related,
• 7:07
  see
• 7:07
  if
• 7:07
  there's
• 7:08
  sleep
• 7:08
  apnea,
• 7:08
  you
• 7:08
  know,
• 7:09
  do
• 7:09
  a
• 7:09
  sleep
• 7:09
  study.
• 7:10
  There's
• 7:10
  a
• 7:10
  lot
• 7:10
  of
• 7:10
  different
• 7:10
  things
• 7:11
  you
• 7:11
  can
• 7:12
  rule
• 7:12
  out
• 7:12
  and
• 7:12
  look
• 7:12
  at
• 7:13
  before
• 7:13
  you
• 7:14
  start
• 7:14
  a
• 7:14
  Z
• 7:14
  drug.
• 7:15
  But
• 7:15
  most
• 7:16
  of
• 7:16
  the
• 7:16
  time,
• 7:16
  in
• 7:16
  my
• 7:16
  experience,
• 7:17
  they
• 7:17
  have
• 7:17
  tried
• 7:18
  everything.
• 7:18
  And,
• 7:19
  um,
• 7:19
  now
• 7:20
  if
• 7:20
  not,
• 7:20
  you
• 7:20
  could
• 7:20
  also
• 7:21
  explore,
• 7:21
  does
• 7:22
  this
• 7:22
  person
• 7:22
  have
• 7:22
  an
• 7:22
  underlying
• 7:23
  depressive
• 7:23
  disorder,
• 7:24
  anxiety
• 7:24
  disorder?
• 7:24
  Are
• 7:25
  they
• 7:25
  worrying
• 7:25
  before
• 7:25
  bed
• 7:26
  a
• 7:26
  lot?
• 7:26
  Are
• 7:26
  they
• 7:27
  ruminating
• 7:28
  about
• 7:28
  the
• 7:28
  past?
• 7:28
  Do
• 7:28
  they
• 7:29
  feel
• 7:29
  like
• 7:29
  they're
• 7:29
  a
• 7:29
  failure?
• 7:30
  And
• 7:30
  they,
• 7:30
  they're
• 7:30
  just
• 7:30
  replaying
• 7:31
  embarrassing
• 7:31
  moments
• 7:32
  from
• 7:32
  the
• 7:32
  past.
• 7:32
  That's
• 7:33
  pretty
• 7:33
  common
• 7:33
  in,
• 7:34
  in
• 7:34
  depression,
• 7:34
  that
• 7:35
  sense
• 7:35
  of
• 7:35
  worthlessness,
• 7:36
  that
• 7:36
  could
• 7:36
  be
• 7:36
  the
• 7:36
  case.
• 7:37
  And
• 7:37
  if
• 7:37
  you
• 7:37
  have
• 7:37
  that,
• 7:38
  and
• 7:38
  if
• 7:38
  that's
• 7:38
  the
• 7:38
  main
• 7:39
  driver
• 7:39
  for
• 7:39
  why
• 7:40
  they
• 7:40
  say
• 7:40
  they
• 7:40
  can't
• 7:40
  go
• 7:40
  to
• 7:41
  sleep
• 7:41
  and
• 7:41
  you
• 7:41
  connect
• 7:41
  those
• 7:42
  dots,
• 7:42
  then
• 7:43
  a
• 7:43
  Z
• 7:43
  drug
• 7:43
  would
• 7:44
  not
• 7:44
  be
• 7:44
  appropriate.
• 7:45
  Right?
• 7:45
  It
• 7:45
  would
• 7:45
  be
• 7:46
  initiating
• 7:47
  some
• 7:47
  sort
• 7:47
  of
• 7:47
  antidepressant
• 7:48
  if
• 7:48
  they
• 7:48
  meet
• 7:48
  a
• 7:49
  broader
• 7:49
  criteria
• 7:49
  for
• 7:50
  those
• 7:50
  diagnoses.
• 7:52
  So
• 7:52
  at
• 7:52
  any
• 7:53
  rate,
• 7:53
  you
• 7:53
  will
• 7:53
  often
• 7:54
  find
• 7:54
  yourselves
• 7:55
  in
• 7:55
  checkmate
• 7:56
  territory.
• 7:56
  I
• 7:56
  say
• 7:56
  that
• 7:57
  a
• 7:57
  lot
• 7:57
  on
• 7:57
  these
• 7:57
  episodes.
• 7:58
  Right?
• 7:58
  Checkmate
• 7:59
  territory
• 7:59
  where,
• 8:00
  you
• 8:01
  know,
• 8:01
  you
• 8:01
  ruled
• 8:01
  out
• 8:01
  depression,
• 8:02
  you
• 8:02
  ruled
• 8:02
  out
• 8:02
  anxiety.
• 8:03
  They've
• 8:03
  done
• 8:03
  a
• 8:03
  sleep
• 8:04
  study,
• 8:04
  they've
• 8:04
  tried
• 8:04
  melatonin,
• 8:05
  ramel,
• 8:05
  on
• 8:06
  doxepin,
• 8:06
  trazodone,
• 8:07
  they've
• 8:07
  tried
• 8:07
  it
• 8:07
  all
• 8:08
  and
• 8:08
  bam,
• 8:09
  here
• 8:09
  you
• 8:09
  are
• 8:09
  in
• 8:10
  Z
• 8:10
  drug
• 8:10
  territory.
• 8:11
  Now
• 8:12
  every
• 8:12
  prescriber
• 8:13
  has
• 8:13
  their
• 8:13
  own
• 8:15
  way
• 8:16
  of
• 8:16
  doing
• 8:16
  things.
• 8:17
  It's
• 8:18
  always
• 8:18
  important
• 8:18
  that
• 8:18
  we
• 8:19
  maintain
• 8:20
  as
• 8:20
  much
• 8:20
  consistency
• 8:21
  as
• 8:21
  we
• 8:21
  can
• 8:21
  within
• 8:21
  the
• 8:22
  guidelines,
• 8:22
  of
• 8:22
  course,
• 8:23
  but
• 8:23
  every
• 8:23
  patient
• 8:24
  is
• 8:24
  a
• 8:24
  little
• 8:24
  different
• 8:24
  and
• 8:24
  it
• 8:25
  calls
• 8:25
  upon
• 8:25
  us
• 8:26
  to
• 8:26
  often
• 8:27
  do
• 8:27
  the
• 8:27
  right
• 8:27
  thing
• 8:28
  for
• 8:28
  that
• 8:28
  patient
• 8:28
  in
• 8:28
  front
• 8:29
  of
• 8:29
  us
• 8:29
  at
• 8:29
  the
• 8:29
  right
• 8:29
  time.
• 8:30
  That
• 8:30
  being
• 8:31
  said,
• 8:31
  I
• 8:31
  typically
• 8:32
  reach
• 8:32
  for
• 8:32
  lunesta
• 8:33
  or
• 8:33
  ezopiclone
• 8:34
  when
• 8:34
  I'm
• 8:35
  in
• 8:35
  these
• 8:35
  cases.
• 8:36
  And
• 8:36
  the
• 8:36
  reason
• 8:36
  I
• 8:37
  reach
• 8:37
  for
• 8:37
  lunesta,
• 8:38
  there's
• 8:39
  actually
• 8:39
  a
• 8:39
  few
• 8:39
  reasons
• 8:40
  I
• 8:40
  reach
• 8:41
  for
• 8:41
  it.
• 8:41
  Number
• 8:41
  one,
• 8:41
  I
• 8:42
  have
• 8:42
  just
• 8:42
  found
• 8:42
  throughout
• 8:43
  my
• 8:44
  career
• 8:44
  that
• 8:45
  it
• 8:45
  tends
• 8:45
  to
• 8:45
  be
• 8:45
  the
• 8:46
  most
• 8:46
  well
• 8:46
  tolerated.
• 8:47
  I
• 8:47
  have
• 8:47
  yet
• 8:48
  to
• 8:48
  really
• 8:48
  have
• 8:48
  anyone
• 8:49
  complain
• 8:50
  of
• 8:50
  complex
• 8:50
  sleep
• 8:51
  behaviors
• 8:52
  on
• 8:52
  Lunesta.
• 8:53
  It
• 8:53
  has
• 8:54
  definitely
• 8:54
  been
• 8:55
  documented
• 8:55
  in
• 8:56
  the
• 8:56
  literature
• 8:56
  that
• 8:56
  that
• 8:57
  can
• 8:57
  happen
• 8:58
  for
• 8:59
  reasons
• 8:59
  we
• 8:59
  can
• 8:59
  explain
• 9:00
  a
• 9:00
  little
• 9:00
  later.
• 9:01
  But
• 9:01
  in
• 9:01
  my
• 9:01
  experience,
• 9:02
  it's
• 9:02
  very
• 9:02
  well
• 9:03
  tolerated.
• 9:04
  And
• 9:06
  though
• 9:06
  it
• 9:06
  can
• 9:06
  cause
• 9:07
  a
• 9:07
  dependence,
• 9:07
  and
• 9:07
  sure
• 9:08
  enough,
• 9:08
  some
• 9:08
  people
• 9:09
  can
• 9:09
  certainly
• 9:10
  be
• 9:10
  physiologically
• 9:11
  dependent
• 9:11
  and
• 9:11
  develop
• 9:11
  a
• 9:12
  tolerance
• 9:12
  to
• 9:12
  it,
• 9:13
  there
• 9:14
  is
• 9:14
  also
• 9:16
  some
• 9:16
  FDA
• 9:16
  verbiage
• 9:17
  in
• 9:17
  there
• 9:19
  that
• 9:20
  during
• 9:20
  the
• 9:21
  clinical
• 9:21
  trials,
• 9:22
  Lunesta's
• 9:23
  long
• 9:23
  term
• 9:24
  clinical
• 9:24
  trials,
• 9:25
  the
• 9:26
  FDA
• 9:26
  wrote,
• 9:27
  quote,
• 9:27
  no
• 9:27
  development
• 9:27
  of
• 9:28
  tolerance
• 9:28
  to
• 9:28
  any
• 9:29
  parameter
• 9:29
  of
• 9:29
  sleep
• 9:29
  measurement
• 9:30
  was
• 9:30
  observed
• 9:31
  over
• 9:31
  six
• 9:31
  months.
• 9:32
  So
• 9:32
  that's
• 9:33
  pretty
• 9:33
  amazing
• 9:33
  because
• 9:33
  that's
• 9:34
  not
• 9:34
  the
• 9:34
  case
• 9:34
  for
• 9:34
  a
• 9:35
  lot
• 9:35
  of
• 9:35
  these
• 9:35
  other
• 9:35
  Z
• 9:35
  drugs.
• 9:36
  And
• 9:37
  so
• 9:37
  if
• 9:37
  a
• 9:38
  patient
• 9:38
  who
• 9:38
  has
• 9:38
  chronic
• 9:39
  insomnia,
• 9:39
  nothing
• 9:40
  else
• 9:40
  has
• 9:40
  worked,
• 9:41
  is
• 9:41
  on
• 9:41
  a
• 9:41
  Z
• 9:42
  drug
• 9:42
  like
• 9:42
  Lunesta,
• 9:43
  and
• 9:43
  the
• 9:44
  FDA
• 9:44
  specifically
• 9:46
  mentions
• 9:47
  that
• 9:47
  no
• 9:47
  development
• 9:48
  of
• 9:48
  tolerance
• 9:48
  to
• 9:49
  any
• 9:49
  parameter
• 9:49
  of
• 9:49
  sleep
• 9:50
  measurement
• 9:50
  was
• 9:50
  observed
• 9:51
  over
• 9:51
  six
• 9:51
  months,
• 9:51
  well,
• 9:52
  that's
• 9:52
  Kind
• 9:52
  of
• 9:52
  nice
• 9:52
  because
• 9:53
  you
• 9:53
  don't
• 9:53
  want
• 9:53
  to
• 9:53
  waste
• 9:53
  your
• 9:54
  patient's
• 9:54
  time
• 9:54
  and
• 9:54
  go,
• 9:55
  okay,
• 9:55
  well,
• 9:55
  I'll
• 9:55
  give
• 9:55
  you
• 9:55
  this
• 9:55
  one
• 9:56
  med
• 9:56
  for
• 9:56
  three
• 9:57
  months,
• 9:57
  and
• 9:57
  then
• 9:57
  you're
• 9:57
  going
• 9:58
  to
• 9:58
  just
• 9:58
  develop
• 9:58
  a
• 9:58
  tolerance.
• 9:59
  You're
• 9:59
  going
• 9:59
  to
• 9:59
  need
• 9:59
  more
• 9:59
  and
• 9:59
  more.
• 10:00
  Then
• 10:00
  you're
• 10:00
  going
• 10:00
  to
• 10:00
  have
• 10:00
  rebound
• 10:01
  insomnia
• 10:01
  and
• 10:02
  all
• 10:02
  these
• 10:02
  complex
• 10:02
  sleep
• 10:03
  behaviors.
• 10:03
  Well,
• 10:03
  there's
• 10:04
  not
• 10:04
  a
• 10:04
  lot
• 10:04
  of
• 10:04
  juice
• 10:05
  in
• 10:05
  the
• 10:05
  orange
• 10:05
  for
• 10:06
  a
• 10:06
  patient
• 10:06
  in
• 10:07
  that
• 10:07
  scenario.
• 10:08
  So
• 10:08
  again,
• 10:08
  I
• 10:09
  like
• 10:10
  Lunesta
• 10:10
  because
• 10:10
  it
• 10:11
  has
• 10:11
  that
• 10:11
  unique
• 10:11
  FDA
• 10:12
  verbiage
• 10:12
  where,
• 10:12
  though
• 10:13
  it
• 10:13
  can
• 10:13
  develop
• 10:13
  a
• 10:13
  tolerance,
• 10:14
  it
• 10:14
  doesn't
• 10:14
  always
• 10:15
  do
• 10:15
  that.
• 10:15
  And
• 10:15
  that's
• 10:16
  at
• 10:16
  least
• 10:16
  something
• 10:17
  that
• 10:17
  is
• 10:17
  a
• 10:17
  little
• 10:18
  more
• 10:18
  promising
• 10:19
  than
• 10:19
  a
• 10:19
  temporary
• 10:20
  band
• 10:20
  aid.
• 10:21
  Okay.
• 10:21
  And
• 10:21
  I
• 10:22
  like
• 10:22
  that.
• 10:23
  And
• 10:23
  I
• 10:23
  think
• 10:23
  that's
• 10:23
  worth
• 10:24
  looking
• 10:24
  at.
• 10:25
  Now,
• 10:26
  the
• 10:26
  goal
• 10:26
  of
• 10:26
  these
• 10:26
  Z
• 10:27
  drugs
• 10:27
  is,
• 10:28
  of
• 10:28
  course,
• 10:29
  to
• 10:29
  reduce
• 10:30
  the
• 10:30
  amount
• 10:30
  of
• 10:30
  time
• 10:31
  for
• 10:31
  sleep
• 10:31
  onset.
• 10:32
  So
• 10:32
  you
• 10:32
  want
• 10:32
  people
• 10:33
  to
• 10:33
  go
• 10:33
  to
• 10:33
  bed
• 10:34
  a
• 10:34
  little
• 10:34
  faster
• 10:35
  than
• 10:35
  it
• 10:35
  normally
• 10:35
  takes
• 10:36
  them,
• 10:36
  and
• 10:36
  you
• 10:36
  want
• 10:36
  them
• 10:37
  to
• 10:37
  stay
• 10:37
  asleep
• 10:37
  or
• 10:38
  encourage
• 10:38
  sleep
• 10:39
  maintenance.
• 10:39
  Okay.
• 10:40
  And
• 10:40
  you
• 10:40
  obviously
• 10:40
  want
• 10:41
  that
• 10:41
  sleep
• 10:41
  to
• 10:41
  be
• 10:41
  a
• 10:42
  little
• 10:42
  bit
• 10:42
  more
• 10:43
  restorative,
• 10:43
  which
• 10:44
  I
• 10:44
  think
• 10:44
  is
• 10:44
  also
• 10:45
  the
• 10:45
  case.
• 10:46
  Well,
• 10:46
  Z
• 10:46
  drugs
• 10:47
  are
• 10:47
  pretty
• 10:47
  good
• 10:47
  at
• 10:47
  that.
• 10:47
  And
• 10:48
  even
• 10:48
  though
• 10:49
  these
• 10:49
  are
• 10:49
  this
• 10:49
  very.
• 10:50
  They
• 10:50
  have
• 10:50
  a
• 10:50
  very
• 10:51
  similar
• 10:51
  property
• 10:52
  to
• 10:52
  benzodiazepines
• 10:53
  in
• 10:53
  that
• 10:53
  they
• 10:54
  are
• 10:54
  positive
• 10:54
  allosteric
• 10:55
  modulators,
• 10:56
  they're
• 10:56
  also
• 10:57
  different.
• 10:57
  Okay.
• 10:58
  And
• 10:59
  one
• 10:59
  key
• 10:59
  distinction
• 11:00
  we've
• 11:00
  talked
• 11:00
  about
• 11:00
  before
• 11:01
  is
• 11:02
  that
• 11:02
  Z
• 11:02
  drugs
• 11:03
  do
• 11:03
  not
• 11:03
  reduce
• 11:04
  slow
• 11:04
  wave
• 11:05
  sleep
• 11:05
  to
• 11:06
  the
• 11:06
  extent
• 11:06
  that
• 11:06
  benzodiazepines
• 11:08
  do.
• 11:08
  Okay.
• 11:09
  And
• 11:09
  that's
• 11:10
  really
• 11:10
  important
• 11:10
  because
• 11:11
  a
• 11:11
  lot
• 11:11
  of
• 11:11
  really
• 11:11
  important
• 11:12
  things
• 11:12
  happen
• 11:13
  during
• 11:13
  slow
• 11:14
  wave
• 11:14
  sleep.
• 11:15
  We've
• 11:15
  talked
• 11:15
  about
• 11:15
  this.
• 11:15
  It's
• 11:16
  so
• 11:16
  important,
• 11:16
  right?
• 11:17
  Your
• 11:17
  memories
• 11:18
  are
• 11:18
  consolidated.
• 11:19
  Okay.
• 11:19
  So
• 11:20
  short
• 11:20
  term
• 11:21
  memories
• 11:21
  kind
• 11:22
  of
• 11:22
  transfer
• 11:22
  to
• 11:22
  long
• 11:23
  term
• 11:23
  memories.
• 11:23
  It's
• 11:23
  almost
• 11:24
  like
• 11:24
  your
• 11:24
  iPhone
• 11:25
  updating
• 11:25
  at
• 11:25
  night.
• 11:25
  Right.
• 11:26
  That's
• 11:26
  happening
• 11:28
  during
• 11:29
  slow
• 11:29
  wave
• 11:29
  sleep.
• 11:30
  A
• 11:30
  lot
• 11:30
  of
• 11:30
  your
• 11:30
  patients
• 11:30
  who
• 11:31
  are
• 11:31
  dealing
• 11:31
  with
• 11:32
  trauma
• 11:32
  and
• 11:32
  trying
• 11:32
  to
• 11:33
  repair
• 11:33
  trauma
• 11:34
  memories
• 11:34
  and
• 11:35
  reconsolidate
• 11:35
  their
• 11:36
  memories,
• 11:36
  they
• 11:36
  need
• 11:37
  slow
• 11:37
  wave
• 11:37
  sleep
• 11:38
  to
• 11:38
  take
• 11:38
  place
• 11:38
  in
• 11:38
  particular.
• 11:39
  Right.
• 11:40
  That's
• 11:40
  very
• 11:41
  important.
• 11:41
  There's
• 11:42
  also
• 11:42
  glymphatic
• 11:43
  clearance
• 11:44
  or
• 11:44
  metabolic
• 11:44
  waste
• 11:45
  is
• 11:45
  being
• 11:45
  cleared
• 11:46
  during
• 11:46
  slow
• 11:46
  wave
• 11:47
  sleep,
• 11:47
  including
• 11:48
  those
• 11:48
  amyloid
• 11:48
  beta
• 11:49
  tau
• 11:50
  proteins
• 11:50
  that
• 11:51
  are
• 11:51
  implicated
• 11:51
  in
• 11:52
  Alzheimer's.
• 11:52
  There's
• 11:52
  a
• 11:52
  lot
• 11:52
  of
• 11:53
  research
• 11:53
  on
• 11:53
  that,
• 11:53
  but,
• 11:53
  hey,
• 11:54
  just
• 11:54
  kind
• 11:55
  of
• 11:55
  cleaning
• 11:55
  out
• 11:56
  the
• 11:57
  waste.
• 11:57
  The
• 11:57
  metabolic
• 11:58
  waste
• 11:58
  in
• 11:59
  the
• 11:59
  brain
• 12:00
  is
• 12:00
  happening
• 12:00
  during
• 12:01
  slow
• 12:01
  wave
• 12:01
  sleep.
• 12:02
  It
• 12:02
  supports
• 12:03
  your
• 12:03
  immune
• 12:03
  function,
• 12:04
  it
• 12:04
  reduces
• 12:04
  your
• 12:04
  cortisol.
• 12:05
  Right.
• 12:06
  These
• 12:06
  are
• 12:06
  huge
• 12:07
  things
• 12:07
  when
• 12:07
  it
• 12:07
  comes
• 12:07
  to
• 12:07
  your
• 12:08
  mental
• 12:08
  health.
• 12:08
  We
• 12:08
  know
• 12:08
  cortisol,
• 12:09
  when
• 12:09
  it's
• 12:09
  out
• 12:09
  of
• 12:09
  control,
• 12:10
  can
• 12:10
  destroy
• 12:10
  neurotransmitters.
• 12:12
  And
• 12:12
  so
• 12:13
  slow
• 12:14
  wave
• 12:14
  Sleep
• 12:14
  does
• 12:15
  all
• 12:15
  of
• 12:15
  those
• 12:15
  good
• 12:15
  things
• 12:16
  and
• 12:16
  even
• 12:16
  kind
• 12:16
  of
• 12:17
  prevents
• 12:17
  synaptic
• 12:18
  overload.
• 12:18
  So
• 12:19
  it
• 12:19
  kind
• 12:19
  of
• 12:19
  cleans
• 12:20
  out
• 12:20
  a
• 12:20
  lot
• 12:20
  of
• 12:20
  parts
• 12:21
  of
• 12:21
  the
• 12:21
  brain
• 12:21
  that
• 12:21
  don't
• 12:21
  need
• 12:22
  to
• 12:22
  be
• 12:22
  there
• 12:22
  anymore.
• 12:22
  It's
• 12:23
  just,
• 12:23
  you
• 12:23
  know,
• 12:23
  useless
• 12:23
  stuff
• 12:23
  you
• 12:24
  don't
• 12:24
  need
• 12:24
  in
• 12:25
  there
• 12:25
  so
• 12:25
  you
• 12:25
  can
• 12:25
  start
• 12:25
  the
• 12:26
  next
• 12:26
  day
• 12:26
  fresh.
• 12:27
  And
• 12:27
  if
• 12:27
  you
• 12:27
  don't
• 12:27
  do
• 12:27
  that,
• 12:28
  if
• 12:28
  you
• 12:28
  don't
• 12:28
  go
• 12:28
  through
• 12:28
  that
• 12:29
  like
• 12:29
  recycling
• 12:30
  and
• 12:30
  that
• 12:30
  short
• 12:30
  to
• 12:30
  long
• 12:31
  term
• 12:31
  memory
• 12:31
  storage
• 12:32
  and
• 12:32
  the
• 12:32
  immunity
• 12:32
  and
• 12:33
  removing
• 12:33
  the
• 12:33
  metabolic
• 12:34
  waste,
• 12:34
  you
• 12:34
  wake
• 12:35
  up
• 12:35
  kind
• 12:35
  of
• 12:36
  just
• 12:36
  not
• 12:36
  in
• 12:37
  a
• 12:37
  good,
• 12:37
  not
• 12:37
  in
• 12:37
  a
• 12:38
  good
• 12:38
  place.
• 12:38
  Right.
• 12:38
  Your
• 12:38
  sleep
• 12:39
  isn't
• 12:39
  really
• 12:39
  refreshed.
• 12:40
  Well,
• 12:40
  Z
• 12:40
  drugs
• 12:41
  restore
• 12:42
  your
• 12:42
  slow
• 12:42
  wave
• 12:43
  sleep.
• 12:44
  It's
• 12:44
  the
• 12:44
  most
• 12:44
  restorative
• 12:45
  sleep
• 12:45
  stage.
• 12:46
  Okay.
• 12:46
  And
• 12:47
  benzodiazepines
• 12:49
  do
• 12:49
  not
• 12:49
  do
• 12:49
  that.
• 12:50
  And
• 12:50
  they
• 12:50
  can
• 12:51
  actually
• 12:51
  interfere
• 12:51
  with
• 12:52
  that,
• 12:52
  which
• 12:52
  is
• 12:52
  a
• 12:52
  very
• 12:53
  big
• 12:53
  problem.
• 12:54
  So
• 12:55
  they
• 12:55
  don't,
• 12:56
  they,
• 12:56
  you
• 12:56
  know,
• 12:56
  they
• 12:56
  don't
• 12:57
  reduce
• 12:57
  slow
• 12:57
  wave
• 12:57
  sleep
• 12:58
  to
• 12:58
  the
• 12:58
  same
• 12:58
  degree
• 12:58
  as
• 12:59
  benzos.
• 13:00
  And
• 13:00
  I
• 13:01
  think
• 13:01
  that's
• 13:01
  also
• 13:01
  a
• 13:02
  really
• 13:02
  big
• 13:03
  distinction
• 13:03
  and
• 13:04
  a
• 13:04
  reason
• 13:04
  why
• 13:05
  this
• 13:05
  is
• 13:05
  different
• 13:06
  than
• 13:06
  just
• 13:06
  giving
• 13:06
  someone
• 13:07
  Klonopin.
• 13:07
  And
• 13:08
  I've
• 13:08
  seen
• 13:08
  tons
• 13:08
  of
• 13:08
  patients,
• 13:09
  for
• 13:09
  God
• 13:10
  knows
• 13:10
  what
• 13:10
  reasons
• 13:11
  diagnosed
• 13:11
  or
• 13:12
  prescribed
• 13:13
  Klonopin
• 13:13
  for
• 13:13
  sleep.
• 13:14
  Right,
• 13:14
  I
• 13:15
  get
• 13:15
  that,
• 13:15
  you
• 13:15
  know,
• 13:15
  you
• 13:16
  might
• 13:16
  be
• 13:16
  on
• 13:16
  it
• 13:16
  because
• 13:16
  you
• 13:16
  have
• 13:17
  anxiety
• 13:17
  at
• 13:17
  night
• 13:17
  and
• 13:18
  that's
• 13:18
  kind
• 13:18
  of
• 13:18
  a
• 13:18
  different
• 13:18
  ball
• 13:19
  game.
• 13:19
  And
• 13:19
  maybe
• 13:19
  nothing
• 13:20
  else
• 13:20
  worked,
• 13:21
  but
• 13:21
  there's
• 13:22
  really
• 13:22
  not
• 13:22
  a
• 13:22
  whole
• 13:22
  lot
• 13:23
  of
• 13:23
  evidence
• 13:23
  for
• 13:23
  that
• 13:25
  in
• 13:25
  that
• 13:25
  context.
• 13:26
  You
• 13:26
  know,
• 13:26
  I'll
• 13:27
  let
• 13:27
  again,
• 13:27
  every
• 13:27
  patient's
• 13:28
  a
• 13:28
  little
• 13:28
  different.
• 13:28
  But,
• 13:30
  but,
• 13:30
  but,
• 13:30
  yeah,
• 13:31
  I
• 13:31
  mean,
• 13:31
  you
• 13:31
  know,
• 13:32
  and
• 13:32
  that
• 13:32
  is
• 13:32
  the
• 13:32
  thing,
• 13:32
  right?
• 13:33
  We've
• 13:33
  got
• 13:33
  to
• 13:33
  talk
• 13:33
  about
• 13:34
  subunits,
• 13:35
  right?
• 13:35
  That's
• 13:35
  a,
• 13:36
  that's
• 13:36
  a
• 13:36
  big
• 13:36
  part
• 13:36
  of
• 13:36
  this
• 13:37
  conversation,
• 13:37
  right?
• 13:38
  So
• 13:38
  let's,
• 13:38
  this
• 13:38
  is,
• 13:39
  what
• 13:39
  I
• 13:39
  just
• 13:39
  said
• 13:40
  is
• 13:40
  a
• 13:40
  good
• 13:40
  time
• 13:40
  to
• 13:41
  segue
• 13:41
  into
• 13:42
  subunits
• 13:43
  because
• 13:43
  benzodiazepines
• 13:45
  are
• 13:45
  non
• 13:45
  selective.
• 13:46
  Okay?
• 13:47
  So
• 13:47
  they
• 13:47
  will
• 13:47
  bind
• 13:48
  across
• 13:49
  these
• 13:49
  GABA
• 13:50
  A
• 13:50
  receptor
• 13:51
  subunits,
• 13:52
  alpha
• 13:52
  1,
• 13:52
  alpha
• 13:53
  2,
• 13:53
  alpha
• 13:54
  3,
• 13:54
  alpha
• 13:54
  5.
• 13:55
  Don't
• 13:55
  worry
• 13:55
  what
• 13:55
  that
• 13:55
  means,
• 13:56
  but
• 13:56
  what
• 13:56
  that
• 13:56
  basically
• 13:57
  means
• 13:57
  is
• 13:59
  benzos
• 13:59
  are
• 14:00
  like
• 14:00
  this
• 14:00
  broad
• 14:00
  tool.
• 14:01
  They're
• 14:01
  going
• 14:02
  to
• 14:02
  make
• 14:02
  you
• 14:02
  sedated,
• 14:03
  they're
• 14:03
  going
• 14:03
  to
• 14:03
  make
• 14:03
  you
• 14:04
  less
• 14:04
  anxious,
• 14:04
  they're
• 14:04
  going
• 14:04
  to
• 14:04
  relax
• 14:05
  your
• 14:05
  muscles,
• 14:06
  okay?
• 14:07
  And
• 14:08
  they
• 14:08
  might
• 14:08
  make
• 14:08
  you
• 14:08
  kind
• 14:09
  of
• 14:09
  impair
• 14:09
  your
• 14:09
  memory.
• 14:10
  And
• 14:10
  that's
• 14:10
  because
• 14:10
  they
• 14:10
  hit
• 14:11
  all
• 14:11
  of
• 14:11
  those
• 14:11
  alpha
• 14:12
  subunits
• 14:13
  on
• 14:13
  the
• 14:13
  GABA
• 14:13
  receptor
• 14:14
  as
• 14:14
  opposed
• 14:15
  to
• 14:15
  your
• 14:15
  Z
• 14:15
  drugs.
• 14:16
  And
• 14:16
  they
• 14:17
  bind
• 14:17
  preferentially
• 14:18
  to
• 14:19
  the
• 14:19
  alpha
• 14:19
  1
• 14:20
  subunits
• 14:20
  which
• 14:21
  are
• 14:21
  really
• 14:21
  selective
• 14:22
  for
• 14:22
  like
• 14:22
  sedation.
• 14:23
  Now
• 14:23
  lunesta
• 14:24
  is
• 14:24
  again,
• 14:25
  kind
• 14:25
  of
• 14:25
  my
• 14:25
  friend
• 14:26
  because
• 14:27
  it's,
• 14:28
  it
• 14:28
  has
• 14:28
  more
• 14:29
  preferential
• 14:30
  binding
• 14:30
  to
• 14:32
  those
• 14:33
  anxiolytic
• 14:34
  subunits
• 14:34
  like
• 14:34
  Alpha
• 14:35
  2
• 14:35
  and
• 14:35
  3
• 14:35
  than
• 14:36
  Ambien
• 14:37
  or
• 14:37
  Sonata.
• 15:32
  Okay.
• 15:33
  I'm
• 15:33
  not
• 15:33
  sure.
• 15:33
  That's
• 15:33
  why
• 15:34
  I
• 15:34
  like
• 15:34
  it
• 15:34
  more
• 15:34
  and,
• 15:35
  And.
• 15:35
  And
• 15:35
  why
• 15:35
  my
• 15:36
  patients
• 15:36
  seem
• 15:36
  to
• 15:36
  like
• 15:36
  it
• 15:37
  more.
• 15:37
  I'm
• 15:37
  not
• 15:37
  sure.
• 15:38
  But
• 15:38
  that
• 15:38
  might
• 15:38
  be
• 15:39
  part
• 15:39
  of
• 15:39
  the
• 15:39
  answer,
• 15:40
  that
• 15:40
  it's
• 15:40
  not
• 15:41
  strictly
• 15:41
  sedating
• 15:42
  you.
• 15:42
  It's
• 15:43
  actually
• 15:43
  providing
• 15:43
  some
• 15:43
  anxiolysis
• 15:44
  on
• 15:45
  top
• 15:45
  of
• 15:45
  that.
• 15:45
  And
• 15:46
  I
• 15:46
  think
• 15:46
  that's
• 15:46
  pretty
• 15:47
  cool
• 15:47
  that
• 15:47
  lunesta
• 15:48
  does
• 15:48
  that,
• 15:48
  but
• 15:48
  not
• 15:48
  to
• 15:49
  the
• 15:49
  extent
• 15:49
  that
• 15:49
  a
• 15:49
  benzo
• 15:50
  does
• 15:50
  it.
• 15:50
  Right.
• 15:51
  Because
• 15:52
  benzos,
• 15:52
  like
• 15:53
  I
• 15:53
  said,
• 15:53
  they
• 15:53
  broad.
• 15:54
  They
• 15:55
  broadly
• 15:55
  bind
• 15:55
  to
• 15:56
  all
• 15:56
  those
• 15:56
  subunits,
• 15:57
  and
• 15:57
  alpha
• 15:58
  5
• 15:58
  is
• 15:58
  the
• 15:59
  cognitive
• 15:59
  reward
• 16:01
  subunit
• 16:02
  where
• 16:02
  it
• 16:02
  can
• 16:02
  actually
• 16:03
  drive
• 16:03
  addiction.
• 16:04
  Right.
• 16:05
  And
• 16:05
  so
• 16:05
  Z
• 16:05
  drugs
• 16:06
  do
• 16:06
  not
• 16:07
  preferentially
• 16:07
  bind
• 16:08
  to
• 16:08
  Alpha
• 16:08
  5
• 16:09
  subunits.
• 16:10
  Okay.
• 16:10
  And
• 16:11
  so
• 16:11
  the.
• 16:12
  The
• 16:12
  main
• 16:12
  takeaway
• 16:13
  here
• 16:13
  is
• 16:13
  that
• 16:13
  benzos
• 16:14
  are,
• 16:14
  in
• 16:14
  a
• 16:14
  sense,
• 16:15
  a
• 16:15
  little
• 16:15
  bit
• 16:15
  dirtier.
• 16:15
  They're
• 16:16
  doing
• 16:16
  many
• 16:16
  different
• 16:16
  things
• 16:17
  at
• 16:17
  once.
• 16:17
  They're
• 16:17
  sedating
• 16:18
  you,
• 16:18
  they're
• 16:18
  making
• 16:19
  you
• 16:19
  less
• 16:19
  anxious,
• 16:19
  but
• 16:19
  your
• 16:20
  muscles
• 16:20
  are
• 16:20
  really
• 16:20
  relaxed.
• 16:21
  You
• 16:21
  can't
• 16:21
  remember
• 16:21
  stuff.
• 16:22
  Oh,
• 16:22
  and
• 16:22
  by
• 16:22
  the
• 16:22
  way,
• 16:23
  you
• 16:23
  might
• 16:23
  get
• 16:23
  addicted
• 16:24
  and
• 16:24
  feel
• 16:24
  very
• 16:25
  rewarded
• 16:25
  by
• 16:25
  it
• 16:26
  because
• 16:26
  of
• 16:26
  alpha
• 16:26
  5
• 16:27
  subunit
• 16:27
  of
• 16:27
  the
• 16:27
  GABA
• 16:28
  receptor.
• 16:28
  While
• 16:29
  Z
• 16:29
  drugs
• 16:29
  are
• 16:29
  not
• 16:30
  as.
• 16:30
  There's
• 16:30
  not
• 16:30
  as
• 16:31
  much
• 16:31
  drama
• 16:31
  there.
• 16:32
  They're
• 16:32
  mainly
• 16:32
  sedating
• 16:33
  you.
• 16:33
  But
• 16:33
  lunesta
• 16:34
  gives
• 16:34
  you
• 16:34
  that
• 16:34
  little
• 16:35
  bit
• 16:35
  of
• 16:35
  a
• 16:35
  boost
• 16:36
  with
• 16:37
  anxiety
• 16:38
  without
• 16:39
  so
• 16:39
  much
• 16:39
  of
• 16:39
  the
• 16:39
  addiction
• 16:40
  drama.
• 16:40
  And
• 16:41
  so,
• 16:41
  again,
• 16:41
  that's
• 16:41
  kind
• 16:42
  of
• 16:42
  why
• 16:42
  I
• 16:42
  think
• 16:42
  lunesta
• 16:43
  is
• 16:43
  more
• 16:43
  of
• 16:43
  a
• 16:43
  Goldilocks.
• 16:44
  You
• 16:44
  add
• 16:44
  in
• 16:44
  the
• 16:44
  half
• 16:45
  life,
• 16:45
  where,
• 16:46
  you
• 16:46
  know,
• 16:46
  the
• 16:46
  half
• 16:46
  life
• 16:46
  is
• 16:47
  six
• 16:47
  hours
• 16:47
  of
• 16:47
  lunesta,
• 16:48
  which,
• 16:48
  again,
• 16:49
  I
• 16:49
  think
• 16:49
  more
• 16:49
  broadly
• 16:50
  covers
• 16:50
  your
• 16:50
  patients
• 16:51
  who
• 16:51
  have
• 16:51
  issues
• 16:52
  staying
• 16:52
  asleep
• 16:52
  and
• 16:53
  falling
• 16:53
  asleep,
• 16:54
  as.
• 16:54
  As
• 16:55
  opposed
• 16:55
  to,
• 16:55
  you
• 16:56
  know,
• 16:56
  a
• 16:57
  minority
• 16:57
  of
• 16:57
  patients,
• 16:58
  at
• 16:58
  least
• 16:58
  in
• 16:58
  my
• 16:58
  office,
• 16:59
  who
• 17:00
  maybe
• 17:00
  just
• 17:00
  have
• 17:00
  problems
• 17:01
  falling
• 17:01
  asleep.
• 17:02
  Right.
• 17:02
  If
• 17:03
  you
• 17:03
  just
• 17:03
  have
• 17:03
  problems
• 17:04
  falling
• 17:04
  asleep,
• 17:04
  find
• 17:05
  a.
• 17:05
  Find
• 17:06
  a
• 17:06
  faster
• 17:06
  half
• 17:06
  life
• 17:07
  like
• 17:07
  Sonata
• 17:08
  or
• 17:08
  Ambien.
• 17:09
  That
• 17:09
  way,
• 17:10
  maybe
• 17:10
  they're
• 17:10
  not
• 17:10
  as
• 17:11
  groggy
• 17:11
  the
• 17:11
  next
• 17:11
  day.
• 17:12
  But
• 17:13
  you
• 17:13
  will
• 17:14
  also
• 17:14
  see,
• 17:14
  of
• 17:14
  course,
• 17:14
  that
• 17:15
  a
• 17:15
  lot
• 17:15
  of
• 17:15
  people
• 17:15
  on
• 17:15
  Ambien
• 17:16
  are
• 17:16
  very
• 17:16
  much
• 17:17
  groggy
• 17:18
  the
• 17:18
  next
• 17:18
  day,
• 17:19
  even
• 17:19
  though
• 17:20
  the
• 17:20
  half
• 17:20
  life
• 17:21
  is
• 17:21
  pretty
• 17:21
  short.
• 17:21
  So
• 17:22
  we
• 17:22
  won't
• 17:22
  get
• 17:22
  into
• 17:23
  that
• 17:23
  complicated
• 17:24
  thing.
• 17:24
  But
• 17:24
  the
• 17:25
  bottom
• 17:25
  line
• 17:25
  is,
• 17:26
  I
• 17:26
  do
• 17:27
  look
• 17:27
  at
• 17:27
  the
• 17:27
  half
• 17:27
  life.
• 17:27
  Lunesta
• 17:28
  has
• 17:28
  a
• 17:28
  fatter
• 17:29
  half
• 17:29
  life
• 17:29
  than
• 17:30
  Ambien
• 17:30
  and
• 17:30
  Sonata.
• 17:31
  And
• 17:33
  that
• 17:34
  is
• 17:34
  kind
• 17:34
  of
• 17:34
  why
• 17:35
  I
• 17:35
  like
• 17:35
  it,
• 17:35
  because
• 17:35
  it
• 17:36
  covers
• 17:36
  sleep
• 17:36
  onset
• 17:37
  and
• 17:37
  maintenance.
• 17:38
  The
• 17:38
  one
• 17:39
  thing
• 17:39
  about
• 17:39
  lunesta
• 17:40
  that
• 17:40
  we
• 17:40
  do
• 17:40
  need
• 17:41
  to
• 17:41
  talk
• 17:41
  about
• 17:41
  is
• 17:42
  it
• 17:42
  has
• 17:42
  this
• 17:42
  kind
• 17:42
  of
• 17:42
  unpleasant
• 17:43
  metallic
• 17:44
  taste.
• 17:44
  And
• 17:44
  about
• 17:44
  a
• 17:44
  third
• 17:44
  of
• 17:45
  your
• 17:45
  patients
• 17:45
  are
• 17:45
  going
• 17:45
  to
• 17:45
  tell
• 17:46
  you
• 17:46
  it's
• 17:46
  really
• 17:46
  nasty.
• 17:47
  I
• 17:48
  have
• 17:48
  heard
• 17:48
  that,
• 17:48
  personally.
• 17:49
  Keep
• 17:49
  that
• 17:50
  in
• 17:50
  mind.
• 17:51
  I
• 17:51
  wouldn't
• 17:51
  say
• 17:51
  it's
• 17:52
  a
• 17:52
  deal
• 17:52
  breaker.
• 17:53
  I
• 17:53
  think
• 17:53
  patients
• 17:53
  are
• 17:54
  much
• 17:54
  more
• 17:54
  disturbed
• 17:55
  by
• 17:55
  their
• 17:55
  lack
• 17:55
  of
• 17:55
  ability
• 17:56
  to
• 17:56
  sleep
• 17:56
  for
• 17:56
  two
• 17:57
  decades
• 17:58
  than
• 17:58
  that
• 17:58
  metallic
• 17:59
  taste.
• 17:59
  But
• 17:59
  that
• 17:59
  metallic
• 18:00
  taste
• 18:01
  certainly
• 18:01
  doesn't
• 18:02
  help
• 18:02
  things.
• 18:02
  It
• 18:03
  makes
• 18:03
  things
• 18:03
  a
• 18:03
  lot
• 18:03
  more
• 18:04
  challenging.
• 18:04
  Okay.
• 18:05
  So
• 18:05
  just
• 18:06
  keep
• 18:06
  that
• 18:06
  in
• 18:06
  mind.
• 18:08
  But
• 18:08
  there's
• 18:09
  a
• 18:09
  place
• 18:09
  for
• 18:09
  these
• 18:09
  Z
• 18:10
  drugs,
• 18:10
  I
• 18:10
  think.
• 18:11
  I
• 18:11
  think
• 18:11
  there's
• 18:11
  especially
• 18:11
  a
• 18:12
  place
• 18:12
  for
• 18:12
  lunesta
• 18:14
  in.
• 18:14
  In
• 18:14
  the
• 18:15
  sense
• 18:15
  that
• 18:15
  it
• 18:15
  might
• 18:16
  last
• 18:16
  a
• 18:16
  little
• 18:16
  bit
• 18:17
  longer
• 18:18
  and
• 18:19
  it
• 18:19
  may
• 18:19
  not
• 18:20
  develop
• 18:21
  that
• 18:22
  tolerance
• 18:23
  over
• 18:23
  time
• 18:24
  where
• 18:25
  you're
• 18:25
  kind
• 18:25
  of
• 18:25
  struck
• 18:25
  out
• 18:26
  in
• 18:26
  six
• 18:27
  months.
• 18:27
  Remember
• 18:28
  that
• 18:28
  whether
• 18:29
  we're
• 18:29
  talking
• 18:29
  about
• 18:30
  Klonopin
• 18:31
  or
• 18:31
  Lunesta.
• 18:32
  Right.
• 18:34
  Benzos
• 18:35
  or
• 18:35
  non
• 18:35
  benzos,
• 18:37
  that
• 18:37
  these
• 18:37
  are
• 18:38
  positive
• 18:38
  allosteric
• 18:39
  modulators.
• 18:39
  And
• 18:40
  if
• 18:40
  you're
• 18:40
  a
• 18:40
  member
• 18:40
  of
• 18:40
  our
• 18:41
  Patreon
• 18:41
  page,
• 18:42
  you
• 18:43
  will
• 18:43
  see
• 18:43
  our
• 18:43
  really
• 18:43
  cool
• 18:44
  infographic.
• 18:45
  We
• 18:45
  make
• 18:45
  psychiatry
• 18:46
  really
• 18:46
  sticky
• 18:47
  and
• 18:47
  fun
• 18:47
  and
• 18:48
  easy
• 18:48
  to
• 18:48
  learn.
• 18:48
  If
• 18:48
  you.
• 18:49
  If
• 18:49
  you
• 18:49
  go
• 18:49
  to
• 18:49
  our
• 18:49
  show
• 18:49
  notes
• 18:50
  and
• 18:50
  become
• 18:50
  a
• 18:50
  member
• 18:51
  or
• 18:51
  go
• 18:51
  to
• 18:51
  patreon.com
• 18:53
  pearls
• 18:53
  and
• 18:53
  prep.
• 18:54
  You'll
• 18:54
  just
• 18:55
  love
• 18:55
  being
• 18:55
  a
• 18:55
  member.
• 18:55
  It's
• 18:56
  so
• 18:56
  fun.
• 18:57
  And
• 18:57
  the
• 18:57
  positive
• 18:58
  allosteric
• 18:58
  modulator
• 18:59
  is
• 19:00
  a
• 19:00
  wing
• 19:00
  girl
• 19:01
  in
• 19:01
  our.
• 19:02
  In
• 19:02
  our
• 19:02
  cartoon,
• 19:03
  right?
• 19:03
  So
• 19:04
  the
• 19:04
  wing
• 19:04
  girl
• 19:04
  kind
• 19:05
  of
• 19:05
  makes
• 19:05
  it
• 19:05
  easier
• 19:07
  for
• 19:07
  your
• 19:08
  existing
• 19:09
  GABA
• 19:10
  to
• 19:12
  enter
• 19:12
  the
• 19:13
  neuron
• 19:13
  and
• 19:14
  let
• 19:14
  the
• 19:14
  chloride
• 19:15
  ions
• 19:15
  flow
• 19:16
  and
• 19:16
  make
• 19:16
  the
• 19:16
  neuron
• 19:17
  quieter
• 19:17
  and
• 19:17
  less
• 19:18
  likely
• 19:18
  to
• 19:18
  fire.
• 19:19
  So
• 19:19
  the
• 19:19
  positive
• 19:19
  allosteric
• 19:20
  modulator,
• 19:21
  again,
• 19:21
  is
• 19:21
  a
• 19:21
  wing
• 19:21
  girl.
• 19:21
  Okay.
• 19:22
  Doesn't.
• 19:23
  It
• 19:23
  doesn't
• 19:23
  open
• 19:23
  the
• 19:24
  gate
• 19:24
  by
• 19:25
  itself.
• 19:25
  It
• 19:25
  sits
• 19:26
  on
• 19:26
  a
• 19:26
  different
• 19:27
  spot
• 19:27
  on
• 19:27
  the
• 19:27
  receptor.
• 19:28
  So
• 19:28
  in
• 19:28
  our
• 19:28
  little
• 19:29
  cartoon,
• 19:29
  you'll
• 19:30
  have
• 19:30
  to
• 19:30
  look
• 19:30
  at
• 19:30
  it.
• 19:31
  The
• 19:31
  wing
• 19:31
  girl's
• 19:32
  kind
• 19:32
  of
• 19:32
  off
• 19:32
  to
• 19:32
  the
• 19:32
  side.
• 19:33
  She's
• 19:33
  introducing
• 19:34
  GABA
• 19:35
  to.
• 19:37
  To
• 19:38
  the.
• 19:38
  To
• 19:38
  the
• 19:38
  guy.
• 19:39
  Okay.
• 19:40
  And
• 19:41
  it
• 19:42
  just
• 19:42
  sort
• 19:42
  of.
• 19:42
  By
• 19:43
  introducing
• 19:43
  GABA
• 19:44
  to
• 19:44
  the
• 19:44
  guy,
• 19:46
  it's
• 19:47
  just
• 19:47
  a
• 19:47
  little
• 19:47
  bit
• 19:47
  more
• 19:48
  natural
• 19:48
  and
• 19:48
  a
• 19:48
  little
• 19:48
  bit
• 19:49
  more
• 19:49
  smooth.
• 19:49
  And
• 19:49
  that's
• 19:50
  exactly
• 19:50
  what
• 19:50
  positive
• 19:51
  allosteric
• 19:51
  modulation
• 19:52
  is,
• 19:53
  right?
• 19:54
  They.
• 19:54
  They.
• 19:54
  They
• 19:55
  don't
• 19:55
  really
• 19:56
  make
• 19:57
  the.
• 19:58
  Like,
• 19:58
  they
• 19:58
  don't.
• 19:59
  They
• 19:59
  don't
• 20:00
  get
• 20:00
  the
• 20:01
  man
• 20:01
  and
• 20:01
  woman
• 20:02
  to
• 20:02
  like,
• 20:02
  date
• 20:02
  right
• 20:02
  away
• 20:03
  in
• 20:03
  my
• 20:03
  cartoon,
• 20:04
  right?
• 20:04
  But
• 20:04
  they.
• 20:05
  The
• 20:05
  positive
• 20:05
  allosteric
• 20:06
  modulator
• 20:07
  kind
• 20:07
  of
• 20:07
  introduces
• 20:08
  the
• 20:08
  GABA
• 20:09
  to
• 20:09
  the
• 20:10
  receptor,
• 20:10
  and
• 20:10
  that
• 20:10
  receptor
• 20:11
  changes
• 20:12
  conformationally
• 20:13
  and
• 20:13
  is
• 20:14
  more
• 20:14
  receptive
• 20:14
  now
• 20:15
  to
• 20:15
  the
• 20:15
  GABA
• 20:16
  that's
• 20:16
  already
• 20:16
  there.
• 20:17
  And
• 20:17
  so
• 20:17
  your
• 20:18
  neuron
• 20:18
  is
• 20:18
  more
• 20:18
  relaxed.
• 20:19
  So
• 20:19
  a
• 20:19
  wing
• 20:19
  girl
• 20:19
  makes
• 20:20
  the
• 20:20
  relationship
• 20:20
  a
• 20:21
  lot
• 20:21
  smoother
• 20:21
  and
• 20:21
  more
• 20:21
  relaxed.
• 20:22
  And,
• 20:22
  um,
• 20:23
  again,
• 20:23
  the
• 20:23
  wing
• 20:23
  girl
• 20:23
  isn't
• 20:24
  forcing
• 20:25
  the.
• 20:26
  The
• 20:26
  bond,
• 20:27
  but
• 20:27
  she's
• 20:27
  facilitating
• 20:28
  the
• 20:28
  bond.
• 20:29
  And
• 20:29
  that's
• 20:29
  similar
• 20:30
  to
• 20:30
  what
• 20:30
  these
• 20:30
  benzos
• 20:31
  do.
• 20:31
  So
• 20:31
  I
• 20:32
  highly
• 20:32
  recommend
• 20:32
  you
• 20:32
  look
• 20:33
  at
• 20:33
  that
• 20:33
  cartoon.
• 20:33
  Cause
• 20:33
  it's
• 20:34
  pretty
• 20:34
  cool.
• 20:34
  And,
• 20:35
  and
• 20:35
  that's
• 20:36
  exactly
• 20:36
  what
• 20:36
  PAMs
• 20:37
  or
• 20:37
  positive
• 20:37
  allosteric
• 20:38
  modulators
• 20:39
  do.
• 20:40
  Okay?
• 20:40
  They
• 20:41
  just
• 20:41
  promote
• 20:42
  sedation
• 20:43
  by
• 20:43
  enhancing
• 20:43
  that
• 20:44
  inhibitory
• 20:44
  neurotransmission,
• 20:46
  making
• 20:46
  it
• 20:46
  easier
• 20:47
  for
• 20:47
  your
• 20:47
  existing
• 20:48
  GABA
• 20:49
  to,
• 20:50
  you
• 20:51
  know,
• 20:51
  bind
• 20:51
  to
• 20:52
  that
• 20:52
  receptor
• 20:52
  and
• 20:53
  open
• 20:53
  the
• 20:53
  floodgates
• 20:54
  for
• 20:54
  that,
• 20:54
  those
• 20:54
  chloride
• 20:55
  ions
• 20:56
  to
• 20:56
  come
• 20:56
  through
• 20:56
  the
• 20:57
  neuron
• 20:57
  and
• 20:57
  make
• 20:57
  the
• 20:58
  cell
• 20:59
  a
• 20:59
  little
• 21:00
  bit
• 21:00
  calmer
• 21:00
  and
• 21:00
  promote
• 21:01
  sedation.
• 21:01
  So
• 21:02
  it's,
• 21:02
  it's
• 21:02
  pretty
• 21:03
  cool.
• 21:04
  And,
• 21:05
  and
• 21:05
  so,
• 21:05
  you
• 21:05
  know,
• 21:06
  now
• 21:07
  you
• 21:07
  kind
• 21:07
  of
• 21:07
  have
• 21:07
  an
• 21:07
  appreciation
• 21:08
  probably
• 21:08
  if
• 21:09
  somebody
• 21:09
  says,
• 21:09
  well,
• 21:09
  what's
• 21:10
  the
• 21:10
  difference
• 21:10
  between
• 21:11
  a
• 21:12
  Z
• 21:12
  drug
• 21:13
  and
• 21:13
  a
• 21:13
  benzodiazepine?
• 21:15
  And
• 21:15
  you
• 21:15
  kind
• 21:15
  of,
• 21:16
  you
• 21:16
  kind
• 21:16
  of
• 21:16
  get
• 21:16
  the
• 21:17
  point,
• 21:17
  right?
• 21:18
  There's
• 21:19
  a
• 21:19
  difference
• 21:20
  in
• 21:20
  the
• 21:20
  subunits
• 21:21
  of
• 21:21
  the
• 21:21
  GABA
• 21:22
  receptors
• 21:23
  where
• 21:24
  the
• 21:24
  alpha
• 21:25
  5
• 21:25
  subunit
• 21:26
  of
• 21:26
  benzos
• 21:27
  make
• 21:27
  these
• 21:28
  a
• 21:28
  little
• 21:28
  more
• 21:28
  addicting
• 21:29
  potentially.
• 21:30
  And
• 21:30
  the
• 21:30
  Z
• 21:31
  drugs
• 21:31
  are
• 21:31
  far
• 21:31
  more
• 21:32
  selective.
• 21:32
  They're
• 21:32
  targeting
• 21:33
  sedation,
• 21:35
  and
• 21:36
  so
• 21:36
  they're
• 21:37
  a
• 21:37
  little
• 21:37
  more
• 21:37
  intentional
• 21:38
  to
• 21:38
  try
• 21:38
  and
• 21:38
  help
• 21:38
  you
• 21:39
  sleep.
• 21:39
  Now,
• 21:39
  there
• 21:39
  are
• 21:40
  complex
• 21:41
  sleep
• 21:42
  behaviors
• 21:42
  on
• 21:43
  these
• 21:43
  Z
• 21:43
  drugs
• 21:44
  that
• 21:44
  we
• 21:44
  really
• 21:45
  need
• 21:45
  to
• 21:46
  be
• 21:46
  careful
• 21:47
  about.
• 21:47
  Okay?
• 21:48
  Ambien,
• 21:49
  of
• 21:49
  course,
• 21:50
  is
• 21:50
  all
• 21:50
  over
• 21:50
  the
• 21:51
  medical
• 21:51
  literature.
• 21:52
  People
• 21:52
  making
• 21:52
  omelets
• 21:53
  on
• 21:53
  the
• 21:53
  highway
• 21:54
  or
• 21:54
  whatever.
• 21:54
  All
• 21:54
  these
• 21:54
  crazy
• 21:55
  stories
• 21:55
  you've
• 21:55
  heard.
• 21:56
  I
• 21:56
  don't
• 21:56
  know
• 21:56
  if
• 21:56
  that
• 21:56
  one's
• 21:56
  true,
• 21:57
  but
• 21:57
  there's
• 21:58
  just
• 21:58
  all
• 21:58
  kinds
• 21:59
  of
• 21:59
  crazy
• 21:59
  stories
• 22:00
  where
• 22:00
  people
• 22:00
  will,
• 22:02
  you
• 22:02
  know,
• 22:02
  walk
• 22:02
  out
• 22:03
  of
• 22:03
  their
• 22:03
  houses
• 22:03
  onto
• 22:04
  traffic.
• 22:05
  And
• 22:05
  that's
• 22:05
  very
• 22:05
  scary
• 22:06
  stuff.
• 22:06
  So
• 22:07
  just
• 22:07
  make
• 22:07
  sure
• 22:07
  you
• 22:07
  warn
• 22:08
  your
• 22:08
  patients
• 22:08
  about
• 22:09
  complex
• 22:09
  sleep
• 22:09
  behaviors
• 22:10
  and
• 22:10
  absolutely
• 22:11
  stop
• 22:12
  a
• 22:13
  medication
• 22:13
  immediately.
• 22:14
  At
• 22:14
  least
• 22:14
  I
• 22:14
  would
• 22:15
  when
• 22:15
  I
• 22:15
  see
• 22:15
  a
• 22:16
  complex
• 22:16
  sleep
• 22:16
  behavior
• 22:17
  that's
• 22:17
  starting
• 22:18
  to
• 22:18
  happen
• 22:18
  because
• 22:20
  of
• 22:21
  all
• 22:21
  the
• 22:21
  folks
• 22:21
  who
• 22:22
  do
• 22:22
  have
• 22:22
  serious
• 22:22
  injuries
• 22:23
  and
• 22:23
  comp,
• 22:24
  you
• 22:24
  know,
• 22:24
  as
• 22:24
  a
• 22:25
  result
• 22:25
  of
• 22:25
  a
• 22:25
  complex
• 22:25
  sleep
• 22:26
  behavior,
• 22:27
  the
• 22:27
  evidence
• 22:28
  suggests
• 22:28
  that
• 22:28
  about
• 22:29
  33%
• 22:29
  of
• 22:30
  them
• 22:30
  have
• 22:31
  had
• 22:31
  one
• 22:31
  before.
• 22:32
  So
• 22:33
  there,
• 22:33
  there's
• 22:33
  a
• 22:34
  great
• 22:34
  way
• 22:34
  for
• 22:34
  you
• 22:34
  to
• 22:35
  nip
• 22:35
  that
• 22:36
  in
• 22:36
  the
• 22:36
  bud
• 22:36
  and
• 22:36
  prevent
• 22:36
  that
• 22:37
  by
• 22:37
  just
• 22:38
  discontinuing
• 22:38
  it
• 22:39
  at
• 22:39
  the,
• 22:39
  at
• 22:39
  the
• 22:40
  first
• 22:40
  whiff
• 22:41
  of
• 22:42
  anything
• 22:42
  related
• 22:43
  to
• 22:44
  a
• 22:44
  sleep
• 22:44
  behavior
• 22:45
  on
• 22:45
  these
• 22:45
  medications.
• 22:46
  So
• 22:46
  definitely
• 22:46
  warn
• 22:47
  them.
• 22:48
  This
• 22:48
  is
• 22:48
  not
• 22:48
  the
• 22:48
  medication.
• 22:49
  If
• 22:49
  your
• 22:49
  patient
• 22:50
  has
• 22:50
  had
• 22:50
  that
• 22:50
  problem
• 22:50
  before,
• 22:51
  you've
• 22:51
  got
• 22:51
  to
• 22:51
  look
• 22:51
  at
• 22:52
  other
• 22:52
  alternatives
• 22:53
  because
• 22:53
  that
• 22:53
  could
• 22:53
  very
• 22:54
  well
• 22:54
  be
• 22:54
  a
• 22:54
  problem.
• 22:55
  And
• 22:55
  do
• 22:55
  your,
• 22:55
  you
• 22:56
  know,
• 22:56
  do
• 22:56
  your
• 22:56
  good
• 22:56
  informed
• 22:57
  consent.
• 22:57
  And
• 22:58
  like
• 22:58
  everything
• 22:58
  else
• 22:59
  in
• 22:59
  psychiatry,
• 22:59
  you
• 22:59
  know,
• 23:00
  there
• 23:00
  are
• 23:00
  risks
• 23:01
  and
• 23:01
  benefits,
• 23:02
  there's
• 23:02
  trade
• 23:02
  offs.
• 23:04
  And
• 23:04
  it's
• 23:05
  not
• 23:05
  about
• 23:05
  eliminating
• 23:06
  risk,
• 23:06
  it's
• 23:06
  about
• 23:06
  managing
• 23:07
  risk.
• 23:07
  It's
• 23:07
  about
• 23:08
  making
• 23:08
  sure
• 23:08
  your
• 23:08
  patient
• 23:09
  is
• 23:09
  fully
• 23:09
  informed
• 23:10
  and
• 23:10
  empowered
• 23:10
  about
• 23:11
  those
• 23:11
  risks
• 23:12
  and
• 23:12
  then
• 23:13
  monitoring
• 23:14
  them
• 23:14
  closely
• 23:15
  so
• 23:15
  you
• 23:15
  can
• 23:15
  engage
• 23:16
  in
• 23:16
  risk
• 23:16
  mitigation.
• 23:17
  And
• 23:18
  that's
• 23:18
  really
• 23:18
  the
• 23:18
  key
• 23:18
  here.
• 23:19
  So
• 23:19
  I
• 23:19
  hope
• 23:19
  you
• 23:20
  really
• 23:20
  enjoyed
• 23:20
  this
• 23:20
  conversation
• 23:21
  about
• 23:21
  Z
• 23:22
  drugs.
• 23:23
  You
• 23:23
  know,
• 23:23
  just
• 23:23
  know
• 23:24
  that
• 23:24
  you
• 23:24
  may
• 23:24
  find
• 23:24
  yourself
• 23:25
  prescribing
• 23:25
  these
• 23:26
  at
• 23:26
  times
• 23:28
  when
• 23:28
  you
• 23:28
  didn't
• 23:28
  necessarily
• 23:29
  want
• 23:29
  to,
• 23:29
  but
• 23:29
  you
• 23:30
  feel
• 23:30
  you
• 23:30
  needed
• 23:30
  to
• 23:31
  look
• 23:31
  at
• 23:32
  the
• 23:32
  half
• 23:32
  lives.
• 23:34
  Pick
• 23:34
  the
• 23:34
  one
• 23:34
  you
• 23:34
  think
• 23:35
  would
• 23:35
  work
• 23:35
  the
• 23:35
  best
• 23:35
  given
• 23:36
  the,
• 23:38
  you
• 23:38
  know,
• 23:38
  given
• 23:38
  the
• 23:39
  patient's
• 23:39
  presentation.
• 23:41
  Give
• 23:41
  good
• 23:41
  education,
• 23:42
  understand
• 23:43
  the
• 23:43
  difference.
• 23:44
  You
• 23:44
  know,
• 23:44
  if
• 23:45
  you
• 23:45
  have
• 23:45
  a
• 23:45
  patient
• 23:45
  on
• 23:45
  Klonopin
• 23:47
  and
• 23:47
  you
• 23:47
  want
• 23:47
  to
• 23:47
  switch
• 23:48
  them
• 23:48
  to
• 23:48
  Lunesta
• 23:49
  or
• 23:49
  something,
• 23:50
  it
• 23:50
  might
• 23:50
  be
• 23:50
  worth
• 23:51
  describing
• 23:52
  the
• 23:52
  difference
• 23:52
  as
• 23:53
  to
• 23:53
  why
• 23:53
  you're
• 23:53
  changing
• 23:54
  it
• 23:54
  and
• 23:54
  how
• 23:54
  these
• 23:54
  two
• 23:54
  meds
• 23:55
  are
• 23:55
  different
• 23:55
  and
• 23:56
  what's
• 23:56
  going
• 23:56
  on,
• 23:58
  dispelling
• 23:58
  some
• 23:59
  of
• 23:59
  the
• 23:59
  myths.
• 23:59
  It's
• 24:00
  just
• 24:00
  very
• 24:00
  important
• 24:01
  that
• 24:01
  we
• 24:01
  have
• 24:02
  those
• 24:02
  good
• 24:02
  conversations
• 24:03
  with
• 24:03
  our
• 24:03
  patients
• 24:03
  and
• 24:04
  we
• 24:04
  know
• 24:04
  what
• 24:04
  we're
• 24:04
  doing.
• 24:06
  And
• 24:07
  you
• 24:07
  know,
• 24:07
  this
• 24:08
  is
• 24:08
  probably
• 24:08
  not
• 24:08
  a
• 24:09
  long
• 24:09
  term
• 24:09
  solution.
• 24:11
  Just,
• 24:11
  just
• 24:11
  throwing
• 24:12
  that
• 24:12
  out
• 24:12
  there.
• 24:12
  You
• 24:13
  know,
• 24:13
  the,
• 24:13
  the
• 24:13
  VA
• 24:14
  guidelines
• 24:14
  from
• 24:14
  2019
• 24:15
  recommend
• 24:16
  that
• 24:16
  Z
• 24:16
  drugs
• 24:17
  at
• 24:17
  the
• 24:17
  lowest
• 24:18
  effective
• 24:18
  dose
• 24:18
  for
• 24:18
  the
• 24:19
  shortest
• 24:19
  possible
• 24:19
  duration
• 24:20
  are
• 24:20
  more
• 24:21
  ideal
• 24:22
  because
• 24:23
  there
• 24:23
  are
• 24:23
  long
• 24:24
  term
• 24:24
  solutions
• 24:24
  for
• 24:24
  this
• 24:25
  that
• 24:25
  we've
• 24:25
  already
• 24:25
  talked
• 24:26
  about
• 24:27
  that
• 24:27
  are
• 24:27
  more
• 24:27
  appropriate.
• 24:28
  So
• 24:29
  with
• 24:30
  that,
• 24:30
  my
• 24:30
  friends,
• 24:31
  again
• 24:32
  we,
• 24:32
  I
• 24:32
  can't
• 24:33
  emphasize
• 24:33
  enough
• 24:33
  to
• 24:34
  go
• 24:34
  in
• 24:34
  the
• 24:34
  show
• 24:34
  notes
• 24:35
  and
• 24:35
  become
• 24:35
  a
• 24:36
  patreon
• 24:36
  member.
• 24:36
  That's
• 24:37
  patreon.com
• 24:38
  pearlsandprep
• 24:39
  we
• 24:39
  have
• 24:40
  a
• 24:40
  full
• 24:40
  clinical
• 24:41
  library
• 24:41
  of
• 24:41
  sticky
• 24:42
  visual
• 24:42
  psychiatry
• 24:43
  that
• 24:43
  helps
• 24:44
  you
• 24:44
  get
• 24:44
  this
• 24:44
  so
• 24:44
  fast
• 24:45
  and
• 24:45
  it's
• 24:46
  so
• 24:46
  fun
• 24:47
  and
• 24:47
  it
• 24:47
  really
• 24:47
  just
• 24:48
  transforms
• 24:48
  you
• 24:49
  as
• 24:49
  a,
• 24:49
  as
• 24:50
  a
• 24:50
  clinician.
• 24:50
  I
• 24:51
  don't
• 24:51
  know
• 24:51
  where
• 24:51
  I
• 24:51
  would
• 24:51
  be
• 24:52
  without
• 24:52
  that
• 24:52
  library
• 24:53
  to
• 24:53
  refer
• 24:54
  back
• 24:54
  to,
• 24:54
  to
• 24:55
  make
• 24:55
  this
• 24:55
  stick.
• 24:56
  Patients
• 24:57
  can
• 24:57
  smell
• 24:57
  you
• 24:57
  a
• 24:57
  mile
• 24:58
  away
• 24:58
  when
• 24:58
  you,
• 24:59
  when
• 24:59
  you
• 24:59
  kind
• 24:59
  of
• 24:59
  know
• 24:59
  the
• 24:59
  how
• 25:00
  and
• 25:00
  why
• 25:00
  of
• 25:00
  what
• 25:00
  you're
• 25:00
  doing,
• 25:01
  why
• 25:01
  you're
• 25:01
  making
• 25:02
  a
• 25:02
  medication
• 25:02
  change,
• 25:03
  why
• 25:03
  they're
• 25:03
  having
• 25:03
  a
• 25:03
  particular
• 25:04
  side
• 25:04
  effect.
• 25:05
  They
• 25:05
  really
• 25:06
  appreciate
• 25:06
  that
• 25:06
  next
• 25:07
  level
• 25:07
  knowledge
• 25:07
  and
• 25:08
  that's
• 25:08
  why
• 25:09
  we
• 25:09
  built
• 25:09
  the
• 25:09
  library.
• 25:10
  So
• 25:10
  have
• 25:10
  some
• 25:10
  fun
• 25:10
  with
• 25:10
  that.
• 25:11
  And
• 25:12
  if
• 25:12
  you
• 25:12
  want
• 25:12
  a
• 25:12
  bigger
• 25:12
  deep
• 25:13
  dive
• 25:13
  on
• 25:13
  what
• 25:13
  we
• 25:13
  talked
• 25:14
  about
• 25:14
  today
• 25:14
  too,
• 25:14
  there
• 25:14
  will
• 25:15
  be
• 25:15
  a
• 25:16
  beautiful
• 25:17
  presentation
• 25:17
  of
• 25:17
  this
• 25:18
  again
• 25:18
  on
• 25:18
  the,
• 25:19
  in
• 25:19
  the
• 25:19
  full
• 25:19
  clinical
• 25:19
  library,
• 25:20
  which
• 25:20
  is
• 25:20
  really
• 25:21
  a
• 25:21
  must,
• 25:22
  a
• 25:22
  must
• 25:22
  have
• 25:23
  if
• 25:23
  you're
• 25:23
  a
• 25:23
  student
• 25:24
  with
• 25:24
  the
• 25:25
  amount
• 25:25
  of
• 25:25
  resources
• 25:25
  there,
• 25:26
  it
• 25:26
  just
• 25:26
  saves
• 25:26
  you
• 25:26
  so
• 25:27
  much
• 25:27
  time
• 25:27
  in
• 25:28
  being
• 25:28
  able
• 25:28
  to
• 25:28
  understand
• 25:29
  this
• 25:29
  quickly.
• 25:29
  Thank
• 25:30
  you
• 25:30
  all
• 25:30
  very
• 25:30
  much
• 25:30
  for
• 25:30
  tuning
• 25:31
  in.
• 25:31
  Until
• 25:32
  next
• 25:32
  time
• 25:32
  here
• 25:32
  on
• 25:33
  Pearls
• 25:33
  and
• 25:33
  Prep.
• 25:34
  Bye
• 25:34
  bye.