Welcome to the Dr. Gabrielle Lyon show where cutting-edge science meets innovation and practical application for everyone. Dr. John Howe, an accomplished emergency room physician and through his own experience with burnout and the demands of being a physician found a procedure called the stellate ganglion block. He is now an advocate for the treatment of PTSD, depression and anxiety with multiple modalities. Join me in this conversation with Dr. John Howe. Dr. John Howe, welcome to the show. Thank you. I’m really excited to chat with you and funny story, do you actually know how I got connected to you? No, tell me. We had Dr. Eric Wan on the show and he was talking about trans magnetic stimulation. And I have a very good friend that I needed to facilitate a stellate ganglion block for. And this is what you’re going to talk all about how we manage trauma, PTSD, anxiety, depression, without largely medications, but an actual procedure that may provide long-term benefit. So anyway, I called him and he said, well, you got to go to this guy and here we are.

Wow. I’m glad to be here. I’m glad we made the connection. It’s awesome. Same. And I was looking at some of these statistics. I was looking at statistics on depression, treatment resistant depression, again, PTSD. Your numbers were a bit even more impressive than the ones that I have, but I’m just going to lay this out here. 280 million people in the world suffer from depression. Depression is about 50% more common among women, men, treatment resistant depression, meaning they failed multiple modalities. That is, we are looking at 30% of people with depression meet that definition. PTSD, one half of all US adults will experience at least one trauma event in their life. Most of them do not develop PTSD. Correct. 10% of Americans will develop PTSD. And we know that that’s much higher in our military population. Before we talk about all of these things, please tell me a bit about your personal journey in medicine. You were an ER doctor. Now you have a clinic that does both regenerative and stelling ganglion blocks.

Yeah, no. Well, first of all, thanks for having me. Really appreciate it. As you said, I’m an ER doc by training. And I did that job for a long time. It’s a great job, but it wears on your body and your mind. And I started looking for other things to do. One of the things I love doing or do when I was working in the emergency department was using the ultrasound for diagnostics and for procedures. We do a lot of nerve blocks in the ultrasound, I’m sorry, in the emergency department. And so sorry, for pain. Yeah, break a hip, you know, you break a rib, we’ll put put some medicine in there to make it so that pain is less. Or if we need to start something up, or if this is a broken bone. Anyway. Yeah, so then I started leaning into that passion and getting more training on doing those blocks. And that led me into studying to how to do regenerative medicine. Now, as you know, regenerative medicine is taking usually it’s an ultrasound guided procedure of some sort, putting a product that we either get from the body or get it somewhere else into an area of the body, a joint, a tendon, a ligament that’s inflamed, irritated, torn, and triggering the body’s response to try to fix it. So learning how to do that, hundreds of hours of teaching with that, going to courses, finding people that know how to do it. Part of that training was learning how to work on the neck.

Now there’s a bunch of nerves, as you know, in the neck, you got to know the anatomy pretty well to work in the neck. So part of the training for that was, hey, listen, there’s a stellate ganglion or the sympathetic chain is here. That’s something that some people do for this thing called PTSD. Great, fine. Whatever that is. I’ll learn how to do it. Didn’t think much of it. I felt super skeptical about the fact that a shot in the neck could help PTSD significantly. So I’m going along living my life, learning more things about the regenerative medicine side of things. And then I started noticing that some of the things that personally I was dealing with from a mental health standpoint, the symptoms are lining up a little bit with PTSD. So increased irritability, difficulty with focus, difficulty with sleep, those kind of hyperarousal symptoms that we see with PTSD. So one thing led to another.

I went to the guys that were teaching me how to do this. I was like, Hey, can we do the thing and see how it goes?
And I had it done and holy smokes. It was the coolest thing ever. And from then on, I’m like, well, that’s the coolest trick in medicine. I need to be doing that on a regular basis. So I had my clinic at the time I’d opened my clinic early 2020 or 2020. And I was doing regenerative medicine. I started offering Stellie Ganglion block. And I reached out just to learn more about it. I reached out to Gene Lipov, who’s the guy that kind of figured out that we can use it for PTSD. And late 2020, one thing led to another and he asked me to join his group, Stellacenter. And so I’ve been doing Stellie Ganglion blocks through Stellacenter with Stellacenter since that time, growing the team there, and then doing what I do in my clinic, growing the team to help with regenerative medicine, functional medicine, and working clinically. So that’s kind of how I split my time. And that’s how I got to where I am. It’s really cool because both of the modalities are physical, regenerative medicine, you’re actually doing something physical. Yes, you can get immediate relief. And it of course, takes time depending on what people do. But the Stellacanglion block is really, really fascinating. And I want you to explain to us to the listener, what is a Stellacanglion? Where did this procedure come from? How can we begin to think about it? Just some of the nuts and bolts for individuals that have never heard of what a Stellacanglion block is. Sure.

Yeah. So a ganglion is just a bundle of nerves. And there is a, in front of everyone’s spinal cord, all the way down, there is a chain of bundles of nerves. That’s right. That’s called your sympathetic chain. The Stellacanglion is the fusion of the bottom two cervical ganglia, if you will. And it sits right about the collarbone. There’s another one up higher called the superior cervical ganglion that we also block. And we can kind of get into the nuts and bolts of that. But a Stellacanglia is a specific bundle of nerves in the neck that is related to your flight or freeze response. So the procedure to block that is putting anesthetic medication, numbing medicine near the nerves in the neck to help to stop the flow of information from the sympathetic chain to the part of the brain that’s responsible for the flight or freeze, which is the amygdala. Which is the amygdala. And oftentimes, what happens when an individual is under stress? So let’s say, I don’t know, what are some of the most common reasons? From my perspective, I send patients to you for pretty much two reasons. Number one, I feel like they have a level of anxiety that we can’t seem to dissipate from doing training or any of these other things.

They seem to have been triggered by an event. And they are now in this hyper aroused state where they’re constantly scanning for the next problem. Or they are former military operators, military veterans that come back from deployment, very, you know, on the aroused end, there’s a door that slams, they jump, they may have depression, more anxiety, can’t seem to regulate. Right. Who are the kinds of patients or what are some of the most common cases that you’re getting? Yeah. Now, the symptoms that you kind of went over just now are the ones that we see most commonly that are related to PTSD. And those are the hyper arousal symptoms, like you said. So the world is a dangerous place. And it’s scary. And I need to stay on edge. I am because of that, I’m always irritable. And I yell at my kids or I don’t show up how I want with my wife and my family. And that doesn’t feel great. And we can kind of talk about how that can lead to other things, including death by suicide and things like that, which is a massive problem.

But yeah, feeling anxious, feeling like you can’t let down, you can’t relax, sleep disturbance is also something that’s extremely common with patients that are dealing with this kind of thing.

Intrusive thoughts, flashbacks. We see those as well as part of it. So what is the role of the actual stellate ganglion? So stellate is a bundle of nerves. These bundle of nerves are, there’s a sympathetic and a parasympathetic sides of the nervous system. And is this just always getting excitatory input or is it releasing norepinephrine? What’s happening? Yeah. So there’s always a balance in the autonomic nervous system. So there’s the parasympathetic side, which is the rest, digest, relax. And then the sympathetic side, which is the fight or freeze. And those are always in flux. They’re always going back and forth. It regulates your heart rate. It regulates your gut motility. It regulates the size of your pupils. It regulates how much sweating you’re doing and how fast your heart rate is. People that are in either get a big trauma, capital T trauma that happens, and then they get stuck on the sympathetic side, or it can be a bunch of little traumas that stack up. Frontline healthcare workers, myself included, first responders, people like that, you get a bunch of little things or moral injury where you’re asked to do things that aren’t great and don’t quite line up with you. That kind of thing can wear on you over time. And then you get into this situation where you have those. So to answer your question, the stellate or the sympathetic chain, and that’s kind of the way to think about it.

The stellate is kind of where we target it, but the sympathetic chain is the part of the body, not the mind, the brain, but the body that is responsible for that reflexive reaction and the regulation of the sympathetic nervous system. So it doesn’t address the intrusive thoughts or it doesn’t address, that’s interesting. It doesn’t address the anxiety directly, right? I mean, maybe it does. It does because what ends up happening, the block, and this is block is kind of a block comes from the history of where it came from. So when you’re doing a nerve block, you’re stopping something. And people think about by doing a stellate ganglion block, we’re blocking them. Really, that’s not what we’re doing. It is semantically, that’s what we’re doing. But to do this procedure actually resets the sympathetic nervous system and puts them back into a state of more normalcy where the parasympathetic and the sympathetic are now regulated in a normal way. So you’re not getting blocked by this. That’s important. It’s definitely important. And the other thing is people worry, am I going to lose my edge? Because people that go in harm’s way for their job, they can’t lose their edge. Otherwise, they’re going to be in trouble. And so they actually studied that.

Does the stellate ganglion block blunt your reflexes? And actually, it makes it better. It makes your reaction time better, makes your ability to show up. You can act instead of react. And it can be life-changing for people. When it looks like that the first reported stellate ganglion block, they used it for depression, 1947? I mean, that’s- I think 25, 1925, a long time ago. Okay. Yeah, almost 100 years there. Yeah. So just looking at this, I guess this was- Oh, I see. So the stellate ganglion block for psychiatric disorders, 1945 with the treatment of depression. Prior to that, it looks like it was utilized for other kind of mood dysregulation. Chronic pain is traditionally what it’s been used for a lot. Yeah, complex regional pain syndrome, specifically in the upper limb is what they’ve used it for. But yeah, it’s been known to be a thing, either doing the procedure or doing a simpifectomy, which is kind of a surgical procedure where they’ll go in and cut the sympathetic chain or something that’s seen even prior. But yeah, in short, this has been around for a long time.

The concept has been around for a long time. But 06 was when we kind of figured out that it really helped with PTSD. Yeah. And it says, I’m looking at this so complex regional pain syndrome, phantom limb pain, peripheral vascular disease, Raynaud’s, which is, I don’t even know. So Raynaud’s is when there’s vasoconstriction of the typically extremities, most likely fingers and toes. How does that work? Well, that’s a dysregulation of the autonomic nervous system. I did not know that. Yeah. And it’s regional. So sometimes you get it like in three fingers or one finger or something, or your hands are always cold. Would that be a sign that someone needs a cellulite? For Raynaud’s, maybe. It doesn’t say that they have PTSD. But yeah, it’s a similar base mechanism that presents with a different symptom. How do you think that the autonomic nervous system gets so dysregulated? We don’t really know. But what ends up happening, if you look at people that have PTSD on FMRI, you can see that the connections between the amygdala and the sympathetic chain, there’s too many. And the amount of norepinephrine in the connections is too much. So you have a normal level two input that whatever, something that’s mildly irritating comes in. And you get this massive storm of release of neurotransmitter. And that’s when you get this where your body just kind of takes over. And you know, cognitively, it’s not a big deal sometimes, especially people that have done a ton of work, you know, for PTSD or whatever. And you can kind of talk yourself out of it. But the horse is already out of the barn by that point. And you’re doing this, your heart’s going crazy.

You already yelled at your kids, you already made some kind of comment, or you did something that is not how you want to show up. Right. So it has a systemic effect. Yeah, absolutely. And you’re trying to spool it back. If mentally, you know, this is not right. And that I mean, going back to what we were talking about, that kind of the thing when you have warriors, especially that are constantly doing threat assessment, just because that’s how they live. If they’ve decided that because of the things that they’re doing on a regular basis, they are the threat, then that leads to drastic consequences. So you let’s let’s take a person that is a warfighter. And they’re now back in civilian life. And they are, they’re presented with a situation, whether it’s someone they love, or someone they’re working with, where they overreact in a way that they deem to perhaps that could go down the path of being dangerous. Then we have people who are sheepdogs, they’re watching out for everybody else. And they’re like, what’s the biggest threat? And then they decided that they are the biggest threat. That would be extremely stressful for not only extremely stressful, but these are extremely capable people. Yeah. And they know how to handle threats. And the problem is they handle a threat in a way that’s devastating to their family. Yeah. 22 veterans a day die by suicide. That’s just, it’s really, it’s really unfortunate. Yeah. It’s a massive problem. How did it, how did it help you? Well, it made it so that I, my wife thought I was less of a jerk, which is nice.

It helped me so I could show up day to day. And I was still working in the emergency department at that point. So there’s different rooms in the ED that I walk into and I get this like bag. It’s like, I go in and see an ankle sprain. It should be no big deal. And I’m start like something’s happening. Something’s weird. And I started feeling this adversarial relationship with my patients. I started feeling like everything was not right. And then I couldn’t concentrate and I couldn’t task switch, which is super important for any ERadoc. Things happen quickly. You have to go from one to the next. So it didn’t fix all that, but it sure helped it. It tapped it down. And it, it’s, there’s a lot of my patients that are very high functioning people and they know what this does now. And so it’s sort of like a every 12 to 18 months, I’m going to come in and get another one. Wow. Because life’s tough, life tough, you know? Yeah. I mean, it just sounds like that the autonomic nervous system is a bit of a runaway train. I recommend and take purey O3 ultra pure fish oil. Why? I did my training in nutritional sciences with a heavy focus on muscle health.

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There’s not a great cutoff, but if you’re above about a 30, 35, you probably have it. So that’s something you can look into. If you just feel as though the world is against you and you feel like on edge all the time, the people that get the best results are those that have already gotten that diagnosis or they kind of know what they’re dealing with. And they’ve done a ton of work, whether it’s EMDR therapy or mindfulness meditation or other molecules, things like that that can help. They’re good up here. It’s just right here, it doesn’t happen and they can’t handle it. That’s interesting. Okay. And for you guys who are listening, basically he said that they’re good cognitively. They’re good in their brain, but their heart rate or their physical responses is divergent from the way that they’re thinking. How does the procedure work? So someone comes in to your office, how does the whole thing work? Yeah. So it’s honestly pretty simple. Maybe I say that because I do it all the time, but it’s a ultrasound guided procedure. So we bring you into a treatment room. We put you on a bed, we put you on the cardiac monitor so we can see your vital signs during the entire thing. I use the ultrasound to look at your structures in your neck because everyone’s different and everyone’s different side to side.

There are things I don’t want to get anywhere near and there’s things that I want to go after. And so I find the safest path between the skin and the target and we clean up the neck real good. We make sure everything’s sterile, put the needle in there and put the anesthetic next to the nerve. I used a tiny little needle. It’s long enough to go where I need to go, but it’s very well tolerated. It seems like the best way to do it is to do two levels. So we go at C6 and at C4 as well. And that kind of goes back to what I was talking about with the superior cervical ganglia. That lives a little higher. And so there’s a paper in 2016 that said, you know, if we do both of them, we get a better result. So we go at C6 and we go up to C4. Do they know why? I think it’s more complete of a block as far as, you know, and it gives you a better chance of a reset. And what is the agent that is typically used? It’s a local anesthetic.

It can be ropivacaine. It can be bupivacaine. There’s different cocktails and ways of doing it, but those are the standard ones. And when someone gets that block, it doesn’t fully shut off that sympathetic chain, right? It just seems to blunt it. Is that, is there a penetrance? How could say we have providers that listen, how could a provider think about this if they understand it’s not a complete shutdown? How would you suggest that they begin to think about that? Well, you have two sides too, right? So we only block one side at a time during a day. We only will block one side. So the left side, we’re doing the right side, the left side is still active. Is the left side more cardiac in nature or what’s the difference between the sides? Yeah, good question. So most people, the heart’s on the left and the sympathetic fibers that go to the heart, because again, I said heart rate is regulated by this as well. They’re primarily on the left. And we could kind of talk about this more, but it seems like another reason the left is interesting or perhaps a reason to do the left side is if you’ve had trauma before the age of 15, it seems like it implants on the left side or it encodes on the left side. And I don’t have any idea why that is, but that’s something that sometimes we’ll see. If you’ve had trauma before the age of 15, does that mean that the right side is less effective?
Maybe. Everyone has a correct side to do this block on or do the procedure on. It’s not uncommon where we will do both sides because- But not at the same time, right? Correct. Not on the same day. But yeah, so the right side is where most people get the benefit. 80% of people get a benefit on the right side. And so that’s usually where we start. For a while there, we were trying to see, well, if we could go back in your history and say, did you have pediatric trauma or childhood trauma, then we treat the left side first. And it just didn’t work out to get us to where we wanted to go. So now by kind of our standard operated procedures to go on the right side first. And you put this large needle in someone’s neck, they would probably freak out. It would look very- Gabrielle, it’s not that large.

Like a six inch needle, four inch needle? No. So the one that I normally use, about two, two and a half inch needle and it’s 25 gauge, tiny little needle. And it probably doesn’t hurt that much. Is the skin, do you know the skin? No, because it’s, like I said, it’s a small needle. There’s a lot of pressure from the ultrasound because I have to see what I’m doing. And then also the jugular vein is there. And as I press with the ultrasound, I can occlude the jugular vein and keep it out of where I want to go.
And then you push the medication in. Is it based on weight? Is the size of the individual or the size of the neck? Any of that? It’s not weight based dosing, no. But when, I can see the medicine go in. I can see the structures separate. In general, I will do the same volume at the six C4 level. At the C4 level, sometimes, especially in a very small person, I can see the medicine from C6 has already tracked up to C4. And so we may not do as much of the volume at that level. If you put in more volume, sometimes you can have worse side effects or longer duration of side effects. And we can kind of talk through those. And then they’re done. How long does the procedure take? 10 minutes. Then we recover them afterward, make sure everything hangs good. The other thing is, one of the other reasons why I appreciate what you do is everything is ultrasound guided. I don’t know, when I was doing my fellowship, I was interested in sending people out for a stelate. Not everybody does it ultrasound guided. Maybe they do now, but it doesn’t seem to be the standard of care. So if you are at home listening and you are thinking, wow, this stelate ganglion block seems like this would be a great first step for me because it doesn’t have ongoing medications. There are issues, there are opportunities to use SSRIs and other as NRIs and other psychiatric medications, which no one is arguing that those are not beneficial.

However, there are side effects regardless. There’s always a cost of doing business. This is a way to regulate the nervous system that is not needed long-term. You’re not doing it every week, every day, and you’re not ingesting medication. It’s very safe. It’s almost it’s resetting homeostasis. So with that kind of construct, when you go and you do it, probably takes an hour to fill out the forms. That’s probably the long part.10, 15 minutes to do the procedure, they recover. What should they feel? It varies. It can happen it, the change can happen on the table, can happen within a couple minutes of getting the injection or sooner, or it can take a week to manifest the symptoms or the change. Most people feel an improved ability to breathe deeply and they feel peaceful, which is awesome. The change can be life changing where they want to go online and tell everybody about how this is the most amazing thing, or it can be their partner says they’re less reactive. Within that recovery room. I mean, if it’s within the recovery room, usual know if it’s a big deal and people will feel it. They’ll feel it’s kind of like a vacation in a syringe. You can start breathing again.

It’s very common. I don’t know, 30% of people will get a very strong emotional release right there. Usually it’s tears. Sometimes it’s just, you know, it’s a very specific thing. People start processing things. I had a guy who was a POW and he started verbally processing battle buddies, which was extremely challenging. You know, most of the time that doesn’t happen. Most of the times it’s just general sadness. The first time I had it, I was just very sad. No reason to sad. Or at least no reason that you’re aware of. Right. I mean, it wasn’t like, I’m thinking of this thing that’s really sad and that’s why I’m sad. It was just a release of emotion that came up as a cathartic, you know, feeling. Not everybody gets that. I’ve never seen anyone that did get that, that didn’t have a great result. So those are the ones where I’m like, yes, we really got this person. I mean, we’re going to have an awesome result. But again, sometimes, sometimes that happens. A lot of times that happens where people won’t have that response, but they still will feel the relief and the release. Is there a way to archetype the kind of person that it would work best for? I mean, obviously, it works well for everybody, but are there certain tells? It seems like the more I want it to work for somebody, the less chance it’s going to work, to be frank. But yeah, no, there’s not a way that I can say you’re going to have a great outcome.

We talked about earlier, if someone’s done a lot of work, they’re at a higher chance of having a great outcome with that. But because of the additive effects of having done other stuff, it’s not like, if you’re in this demographic age wise or gender wise, or have had this kind of trauma, or that kind of trauma, then you’re more likely to have a benefit. Maybe somebody smarter than me has figured that out. But I don’t think we can say that. When they’re on the table, there was a couple things you and I had spoken about before, where maybe they get a little nasal, a little nasally, a little of their eyes are bloodshot, maybe a little nausea. Can you talk about some of the potential side effects? Side effects. I didn’t want to use the word side effects because when we were talking, you want that. There are three things that I want. Okay. There we go. I want you to have a small pupil. A foot rub? No. That’s right. A lot of, you know, a small pupil, a bloodshot eye, and a droopy eyelid. Those three things together are called a Horner syndrome. You don’t have to know that. But if I see those things happening, that tells me that I put the medication where it’s supposed to be, to the point where I will document that it’s not a point where I will document that in the chart. I’ll take a picture of your eyes so that I can say, all right, this person had a, whatever, a good Horner’s or not. So those are the things I want. Things that can happen. You can get nasal congestion, and these are mostly on the side where the procedure is done.

So if I do the right side, it’s happened on the right side. Nasal congestion, post-nasal drip. You can have numbness of the face, neck, shoulder, sometimes. Usually it doesn’t go down the shoulder. When you sit up, you get a little disequilibrium because I’m increasing blood flow to one of your middle ears, and it takes a second for you to figure that out. The same thing happens when you stand. So you kind of have to make sure you’ve got somebody with you so they can help you walk. The other thing that happens is most people are super sleepy afterward. So kind of a goofy grin and a droopy eyelid is the perfect outcome for me.

We’re turning off your wakefulness, part of your wakefulness, and that’s why you’re going to have that. Those are the things that most people have the day of. The next day, sometimes you can have nausea, and sometimes you can have headache, and that can happen up to 20% of the time. And one wouldn’t be concerned. That would go away typically.

The side effects go away when the medicine wears off, and most of the medicine we use wears off in about six or eight hours. Oh, I’m sorry, swallow and voice. I didn’t say those. Oh, yeah, that’s right. In fact, of the things that are the side effects, the swallow is the only one that is really dangerous, and it’s only dangerous if you try to eat something when you can’t swallow. If you put something in your lungs, that can cause issues. How do you think this affects emotional regulation? Does it give someone a pause? Because interesting it, it works on the autonomic nervous system, but not necessarily the processing component. Have you thought much about that? I think it’s intimately connected. Because it’s, sure prefrontal cortex is involved in emotional regulation, or the processing centers are involved in that, but so much of the emotional side of things is a, to use a phrase, a gut level response. And oftentimes that is a sympathetic parasympathetic type of reaction.

So yeah. Do you think there are other off-label uses for a stellate? Yeah, I mean, we use it for, we’ve seen good results with patients that are suffering from long COVID. The taste and smell changes that people get with that can be improved or fixed.
Why and how? Well, we think that long COVID is a, is a dysregulation of the same system, and an overactivation of we know the clotting cascade and that kind of stuff is regulated. So it’s a, it meets the body, long COVID we think meets the body at the intersection between the immune system and the nervous system, and is really kind of messed things up there. And that can have a huge cascade down, you know, as far as what the symptoms look like. One of the most troubling things for patients that have long COVID is when they stand up, they can’t, their heart goes crazy, and they can’t, they have exertional dyspnea. So they try to walk and they just get out of breath immediately. That’s a dysregulation as far as whether your heart should go fast or not. And so that’s one reason why we think that it helps with that.

That’s, that is absolutely fascinating. Probably POTS, is it used in the treatment of POTS? Yeah, it’s, we’re looking at that. It doesn’t, it helps some people with POTS. It’s not a perfect thing by any means. And then mass cell activation syndrome, that’s, it’s kind of in the same, not in the category. Well, I don’t know if it’s in the same category or not, but there are people that struggle with that too. We’ve used it with both.

We don’t have numbers like we do with PTSD that we can say this is how many people get it, get response from it. But those are places where it has been used. You know, I was looking, again, I had just mentioned this to you. I was looking at some of the other concepts and applications. And there was one paper that says the effects of the stelic, England block on symptoms of ulcerative colitis. And I thought that was so fascinating. And it had to do with immune regulation. It had to do with when you lower the sympathetic tone, it allowed the body’s immune response to, for lack of a better word, re-regulate. Sure. That’s amazing. That’s fascinating. I haven’t seen that paper. I’ll send it to you. It’s amazing. If it’s sort of the same mechanism, or it’s the body attacking itself because it thinks it’s, you know, for whatever, for because of a dysregulation, there’s no reason why it wouldn’t work. Yeah. I mean, they, well, they, in one part, they said that there was this effect on pain regulation.

And are these all working on the same mechanisms, the pain and the autonomic nervous system? Do we know? Well, with the complex pain or the chronic pain, what ends up happening over time is that the nerves that carry the pain information, or I should say it this way, the pain information is carried in nerves other than the standard pain nerves. I’m not saying that clearly, but the sympathetic nerves become involved in pain transmission between whatever part of the body and the brain. And so the stellate, as we know, affects the autonomic nervous system and the sympathetic nerves and can down-regulate the sensation of pain that’s being transmitted through the sympathetic nerves. Is this still controversial to this two questions? Is this considered standard of care? I don’t know how to answer that question. I knew you were going to say that. Probably not yet. Yeah. Right? I think if you ask people that, well, first of all, not– But it should be. It should be. So I’m going to say this for you. Should this be considered a standard of care? Yes, it should be. Is it considered the standard of care? So the standard of care is someone comes in with PTSD, depression, anxiety.

We go to lower tier options, less expensive, less invasive. Hey, I’m going to give you medication. You should sleep more. Do all these things. Don’t use drugs. And there’s that.

As opposed to saying, which I think you and I are in alignment, and also I’ve never had this done. I have had– my husband has had it done. I’ve had multiple patients have it done. That this could be the standard of care where someone goes in, they say all these things, they meet the criteria. Because we haven’t talked about a contraindication, which I’m probably guessing the only thing would be pregnancy or seizures. And you can’t be able to blood thinners. But everything else probably is. They’re relative contraindications here and there. Yes, go ahead. I mean, it also looked like the– I was looking at the complication rates. They are so low. It’s one in every 1.7 in 1,000 procedures. And probably a complication would be a side effect or something very minimal. This is not a major procedure. But standard of care would be someone comes in with, again, anxiety, depression, PTSD. They’re offered this first. Versus having to be put on a lifetime medication, then going through having to come off of it.

Yeah, to pose it as an option is reasonable. I mean, I think there are patients that would not feel comfortable jumping in on this. Why? It’s scary when you talk about the procedure itself. And usually by the time people get to me, they’ve made it something that it’s not in their head. And when they’re done, the most common thing people say is, oh, that’s it? How do we solve that? How do we solve that barrier to entry? I’m not sure. I mean, people need to feel comfortable with the people that they’re getting healthcare from. They need to have an idea of what the risks and benefits are. And then they need to, if it’s normalized and a lot of people are doing it, then more people are more likely to get on board. I mean, if you look at the going back to should it be first or second line, antidepressants, 75% of the people that are on antidepressants stop taking the antidepressant. Now, those that are staying on the antidepressant, 20 to 30% of those patients have benefit.
So of the individuals that stay on the antidepressant doesn’t matter what kind. 20 to 30% get benefit. Which is not great. And that may be why the people don’t stay on it. Because there are side effects that are not awesome. People don’t feel the lows as much, but they don’t feel the highs as much either. Metabolic side effects, sexual side effects. Absolutely. There’s a lot of reasons why that’s not great. Talk therapy, 50% of people drop out of that. When you look at people that have done top talk therapy for the 12 to 20 sessions, whatever it is, between 50 and 66% of people have long standing benefit from that. That’s half.

So as standalone modalities, that’s super challenging. And the mental health issues in this country, in the world are getting worse. And our toolbox is fairly limited. But I mean, the reason this is so exciting to have this procedure, and then Katamyn, which we could talk about or other molecules, which we talk about, is that we have more tools in the toolbox. And it’s important that there’s a communication, there’s an interplay between people that take care of patients that have mental health challenges, and doctors or providers that can provide procedures. Psychiatrists aren’t usually proceduralists. Right. And we don’t want them to be, I did psychiatry for two years. I switched, but I did it for two years at the University of Louisville. I did.
We do not want no offense. And I have a great friend who’s an amazing psychiatrist, also fit like you. So we only have very fit doctors on the show. That is a requirement because we do pushups usually before not this time. But Dr. Dominic Sportelli, you guys, if you haven’t listened to that episode, it’s phenomenal. He is going to be coming back, you guys would get along great. That’s awesome. He’s a motocross racer. He’s just amazing. But, you know, he always says that it’s not a magic pill, that you can treat the anxiety, depression, or the medication, but it’s not a magic pill. And no Dom, love you buddy, but I don’t even want to be doing stellates. They have to be done by someone who is doing the procedure. And then the counterpart is probably that cognitive piece.

Yeah. I mean, here’s what it comes down to. It’s important to do as many things as you can to treat the condition that you’re dealing with. And if I, as a proceduralist, can team up with someone who’s not a proceduralist, but is good at whatever they do, whether it’s talk therapy or medication management or something else, and we can find a treatment plan for the patient that combines those things. That’s when the patient’s going to do the best. It just has me thinking about the space that we’re in right now. There’s a lot of talk about menopause. There’s a lot of talk about hormones. And I can’t help but think using something like this, you were saying that some of your patients do it every 12 to 18 months or 16 months, which I’m actually going to do it. I just want to see. There’s no downside.

Can it facilitate ease of life in general? Is there a reason why someone wouldn’t be doing this? I don’t want to say that there’s no downside. It is a medical procedure. There are some risks associated with it. The two major risks are seizure and heart arrhythmia. We actually use it to treat heart arrhythmia. We could talk about that too, but those are the two reasons. You use the stellate, the left side stellate. Left side stellate to treat cardiac storm. It recalcitrant ventricular fibrillation, which is pretty interesting. But going back to the side effects or the risks, it’s about 1 in 3,000 or so that one of those things could happen. Neither of those are good. Don’t get me wrong. My point being is it’s not completely without risk and it goes back to if something goes wrong, you need to have somebody that can handle it.

Having said all that, it’s a very safe procedure. It’s a very simple procedure and it’s a very well tolerated procedure that can put a person miles ahead of where they were before they had it. When someone is going in for a stellate, so they do it, are there adjunct therapies? Now, one of the things that you and I talked about is someone will go in, they’ll wait a week or two weeks and then go, will they go back for the right side or will they go back for the left side? It depends on where we start, which side we start on. To walk it back a little bit, the intake process is where we have psychiatric nurse practitioners do an intake with a person and see where they come out from a symptom standpoint. What are your diagnoses? What are we treating here? It’s not just a want to stellate, maybe hook me up. Now, that’s part of it. Usually, if someone thinks they need a stellate. I’m definitely saying that when I come in. Fair enough. We can talk about that. Okay. But the point being is it’s good to know what we’re dealing with.

So, we start there and then once that’s been cleared and we know that you have, okay, you’ve got primarily PTSD, you got primarily depression, you primarily have anxiety, then we can tailor a treatment plan, including the stellate, including other modalities that are available to target your problem specifically. What about ADHD? No. Okay, no. Interesting. Tell me about the interplay between ketamine and stellate because they seem to be, many providers seem to be doing those hand in hand. How does ketamine work? How does ketamine work with a stellate? How does someone take it? Yeah. So, ketamine is an extremely interesting molecule. It does all sorts of things, as you know, if you give somebody a little bit, it helps with pain. We have protocols in the ER for pain control. If you give them a lot, it puts them out for surgery. And kind of in the middle there is where the dosing that we find helps with depression primarily or treatment resistant depression.

So, the interplay between the two, you’ve actually anecdotally, we’ve seen that a person has stellates, has a stellate or two and ketamine, they do better than if you just have a stellate. There’s a paper coming out in the near future that is looking at that question specifically. So, we did a PCL5 and backscreen. So, it’s a PTSD screening tool and a depression screening tool on a group of patients. And we did them before and after. The improvement that we saw in the PTSD metrics was about 50% drop in the symptoms of PTSD with just the stellate. And then the depression metric dropped by about 60%, 56% or so. When we did the stellate and then we did ketamine as well, we got an additional 20% improvement on both of those metrics. So, yeah, they work together. How long does that last?

That’s a good question. I always tell people, this will help with what has come before. This does not help with what comes next. If you get sued or divorced or whatever, come on back and see me again. And that has to do with the PTSD. If you have to go to the DMV. DMV, sure. Go through another pandemic, whatever.

So, yeah, that’s with the stellate ganglion block. Ketamine, the way that it usually works when you’re doing an IV ketamine treatment series is you do six sessions over the course of a couple of weeks or so. That six sessions is the initial treatment. After that six sessions is done, you usually will need a booster. If it’s one month, three months, longer, it kind of depends on you and how you feel. So, we let patients kind of dictate when they come back for a booster. But the benefits that we see with ketamine, we know that we’re probably going to need to maintain that with a once monthly infusion instead of a once daily medication. That’s kind of a lot. I mean, don’t you think that’s kind of a lot? What do you mean? The relief that they would get from ketamine, would it be the same as the relief? For example, let me say this clearly.

Would the stellate be more likely and more effective to say, treat the PTSD component versus maybe ketamine is more likely to treat more of a depression component? Perfectly so. Absolutely. And that’s part of the screening process. If somebody comes in and they’re more PTSD heavy in their symptoms, we will recommend, let’s do the stellate gangling block and see where you go. I see. Because that can be months to years, the effects that we get for that. If they’re primarily, the symptoms they’re dealing with are depressive, then we think, well, it’s probably going to be ketamine and integration therapy that will help that person the most. And then that would make sense because whatever the reason is that they’re getting depressed might not be cognitive. It could be, who knows why? Maybe they’re predisposed at various reasons that they would need to maintain whatever it is. Because it wouldn’t be typically one thing.

So that would make sense. And it also is like to have people like you who do what you do from a functional medicine standpoint, is it a vitamin D issue? Is that a testosterone issue? There’s a bunch of other underlying things that perhaps that should be sorted out before you seek mental healthcare. But yes, that’s likely should. But yeah, that can definitely, and then some people are just more prone to depression. Are there other agents used alongside of the stellate, or maybe we move to other kinds of agents? I mean, there’s a bunch of molecules that are out there. The ones that you feel work really well for the conditions that are most meaningful to you. Maybe that’s PTSD, anxiety, depression. Yeah, I mean, those are the big three top three mental health diagnoses, obviously. There are other molecules that are extremely exciting. MDMA is out there, psilocybin is out there, ibogaine is out there.

There’s a lot of that kind of medication, or medicines that are available. There are legal challenges that come with those, if you’re staying in the country especially. And I think most of the time when we are crafting treatment plans, I usually stick to the ones that are legal and on label in the US. Now, not saying those other ones aren’t good. It’s probably just a matter of time. Yeah, MDMA just kind of got a black eye, and hopefully that will, you know, you got it. How come? Well, I was going through the regulatory process with the FDA, and it got rejected. They asked for more studies to be done.
I don’t know, it’s sad. I think it needs to be done safely, and that’s something that is true of any of these medicines, especially cadamaine. Recent events show us that it’s not completely innocuous and it needs to be done in a safe manner. I think it’s good to have regulatory oversight. It’s good to do things to keep people safe.

I agree with you too. So, I’m not, you know, it will come, as you say, the things that are supposed to come will come, and once they are ready for prime time, we’ll add those things into the armamentarium of medicines that we use to treat these conditions. For now, we’re using what we got. Do the best we can with what you got. Yeah, I totally agree with you that eventually, MDMA and ibogaine may come here, but it should go through a regulatory process. And that might offend a lot of people, but I just have seen too much that, you know, and also just because something doesn’t pass the FDA doesn’t mean it won’t ever. There was a drug called Addy, which was rejected the first time it went through FDA approval. It’s for hypo sexual desire disorder, and they went back and it got approved. Yeah. Probably is going to be the same for these other molecules. Yeah. I mean, I guess they’re drugs, but not really. Molecules. Yeah. Molecules, I think is better to say. In terms of cadamaine, are there better ways to administer it? Are there certain risks? Because it seems to me, I’m sure you’re seeing that there are cadamaine clinics popping up all over. There are thousands of them.

Yeah. It seems a little risky. Yeah. And it’s so yes, there are different ways of doing it. The two major ways that I think are most accepted are IV, but I’ll give you three. IV and IM, intramuscular. And then the third one is intranasal. So Spravato was recently approved for intranasal use for treatment-resistant depression. Is that something that someone administers at home then? No. You have to go into a doctor’s office and it has to be observed. And that’s kind of the theme that I would say- For all kind of means. Yeah. There’s plenty of patients that are doing or getting lozenges or trochees and doing therapy online. And I don’t know. I can’t speak to how smart that is or not. Maybe I’m a little neurotic about safety, but in my practice, we do intravenous cadamene and you come into our shop and we put you on the monitor and we make sure you’re safe for the entire thing. And none of the cadamene leaves the shop and that’s the safe way of doing it. Intranasal is the same way. We get the medicine, you come in. I don’t do intranasal, but some of my partners are doing that.

And it needs to be monitored. You wouldn’t want to take a medication that’s going to make you sedated to the point where if you get too much of it, like I said, you can give somebody surgery. You can do surgery on something that gets too much of this stuff. You’re out if you get too much of it. And then you get yourself in a compromising position and you can’t breathe and you can easily die, which is terrible. I’m always looking for ways to increase my nutrients as well as my families. I’m also looking for foods that have medicinal properties. Mauna cora honey puts all this together for me. Mauna cora honey comes from Manuka trees and aside from it’s tasting amazing, it has antimicrobial properties. The primary compound called MGO also comes from the nectar of the tea tree. Mauna cori is a third party tested every single harvest for MGO and makes these results available on their website. The nectar has bioactive ingredients and this honey is producing antioxidants and prebiotics three times higher than your average honey. I love it for my throat and use their small individual packs before I speak and when I travel.

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It has no added sugar and nothing GMO. Just one daily scoop provides whole body benefits like gut and immune support. I personally have been mixing it with my collagen and ketones. So start with AG1, notice the difference for yourself. It’s a great first step in investing in your health and that’s why I’m so excited to be partnering with them. Thank you AG1 for sponsoring this episode. You can try AG1 and get a free bottle of vitamin D3 K2 and five free AG1 travel packs with your first purchase at www.drinkag1.com slash lion. That’s a $48 value for free if you go to www.drinkag1.com slash lion. Check it out. And ketamine, how does ketamine work systemically? If you’re giving it IV versus a stelagingly block, which you’re giving it directly into this sympathetic chain, how does how does ketamine work? So ketamine binds to all sorts of receptors. The one that makes the sedative hypnotic effect is the NMDA receptor. And that’s part of the experience. It does bind to mTOR as well, which we think is why it causes nerve growth in the moment.

What it does is it creates a state of euphoria and dissociation. And it depends on how you give it, but it lasts for about an hour or so, can be up to two hours. The benefit we think is because it causes neuroplasticity. It causes nerve regrowth in a way that’s beneficial. And that neuroplasticity or that window of healing can last for 48 hours or longer. So it’s really a great time to have the person experience what they’re experiencing and then have integration therapy with people that know what they’re doing from integration therapy standpoint and help the person talk through and unpack what’s been going on with the ketamine. And do they remember afterwards? Do they remember what? The talk therapy while they’re in that dissociation. Well, you don’t need to talk therapy while they’re out. Yeah. I mean, you can talk to a person to depends on how deep you are or the person is. But yeah, I think the thing that makes the most sense is once the person has recovered from the experience, there’s like I said, we’ve got about two days or longer where their brain is still plastic, whether they’re still in that window of healing. And that’s when the talk therapy or the integration sessions are done.

Does it actually cause nerve genesis? Yes. Nerve regenesis? Because that would be the only thing I’ve ever heard. From what I understand, everything typically that is positive creates better connections. Right. But this actually causes nerve regeneration. Right. It’s sort of like a gardening analogy. We like fertilize the nerves with the ketamine and then we trim the bad ones with a stellate, if you will, because that’s what happens when you do a stellate. The connection between the amygdala and the sympathetic chain, the number of nerves decreases. The amount of norepinephrine in the nerves decreases. So you don’t have that same response every time that bundle fires. Who shouldn’t do ketamine? Well, you touched on a couple.

Pregnant pregnancy is probably not a great time to do it. If you have a history of psychosis that’s a little bit concerning, people with a history of seizure disorder is a relative contraindication. If your blood pressure is out of control, if you have glaucoma, the pressure on your eye is too high. If you have an allergy to ketamine, it would be a reason not to do it. People with kidney problems, we have to be careful with that because- Because the excretion? Yeah, exactly. So those are the people that we have. We kind of take a pause when those people come in. Would an individual use ketamine for something like pain? Yeah, traditionally, it’s been used for pain. Regularly, for example, an IV ketamine. I’ve only really ever heard of ketamine therapy used IV for things like depression, but people would also use that for pain as opposed to, say, a stellate. Yeah, so the IV infusions are something that have been used for a long time to treat chronic pain. The dosing is a little different, the infusion runs a little longer, but that’s absolutely something that’s used for. How did it go from pain to depression? Because my best friend, he works at Madigan Army Base, he’s four board certifications.

Sports medicine is one of them. He does a lot of regenerative stuff. He’s also board certified in pain management. Interesting. Outside of pain management, or outside of, yeah, depression, is it depression or pain? I don’t think ketamine is typically used, right? Well, sedation, in the ER we do all the time. Aside from sedation. Are you aware of the history of all of a sudden that we’re, again, because there’s ketamine clinics everywhere, and it just seems like that happened in the last, I don’t know, five years? Yeah. But before that, nobody talks about any of that. I don’t know how it went from pain to depression, but there was a study that was released that kind of laid out the protocol that I just described, the six infusions, and you dose it based on weight, and the benefits that we see between a 60 to 80% response rate to this, as far as a significant medium, 50% or more improvement in depressive symptoms in people that had treatment resistant depression. So when that came out- It must have gotten some kind of approval, right? No, it was just a study.

That’s an off-label use. Wow. That happens all the time. Botox in the face is an off-label use. That happens all the time. Yeah, but to see the amount of interest in it is very surprising. Because think about it, regenerative medicine probably doesn’t even get as much hype as ketamine. No. But regenerative medicine, we’re talking about stem cells, fat transplant, we’re talking about platelet-rich plasma. This stuff has been used for a very long time. Right. You don’t see, yeah, there are people that are doing it, but you don’t see clinics popping up everywhere and hearing so much about it like you do ketamine. Regen’s harder though. The learning curve is much higher or steeper. To put an IV in and give somebody ketamine is not that hard. To do it well is hard. You need to have the set and setting. You need to make sure you’re screening your patients. You make sure you’re doing it safely. But yeah, it takes hundreds and hundreds of hours of training to know how to do regenerative medicine well. It’s the whole body. It’s every joint ligament, tendon, nerve, whatever. So I think that’s part of what it is. It’s very fascinating. Where do you think the future of treatment is going when it comes to mental health? Because I feel like you’re very passionate about this because it seemed to have transformed you.

That’s what I’m guessing. And because it was so impactful for you, you’re like, well, everybody should have access to this. Where do you think the future is going from a mental health standpoint? Medicine, as you know, tends to be very siloed. The surgeon’s cut. The internist do the other thing. With mental health, a lot of the patients are with the psychiatrist and with the psychologist and with the mental health experts otherwise. What we need is a collaboration between people that do procedures and people that take care of mental health patients. Because when I do what I do, it’s made better by what they do. So I’ve got a fantastic colleague who’s a psychologist who works at Stella Center. And she helps me figure out what to do with patients that I’m not sure what to do with. And it’s not usually that. It’s more, this is a case that’s coming in. Let’s talk about it. Let’s figure out how to do the treatment for this patient the best. Collaboration between proceduralists, between medication management professionals, between people that do therapy, whether it’s trauma specific or talk therapy in general, or see, there’s a bunch of different ways that can be done.

Finding the best secret sauce for any one given patient and then adopting the molecules that come through regulatory processes in a safe way and plugging those in. Is it that Iboga is good for head injury? Is it that we want, psilocybin is good for things that are very super-tentorial in nature and ketamine is more lizard brain. I don’t know where that’s going to end up. But to be able to take those molecules and use them in a combined way to treat people that are suffering and make the world better, how could you not be excited about that? I mean, it is. It’s very exciting. You mentioned brain trauma. Is there a place for stellate in brain trauma? Yeah, absolutely. I don’t have the stats on the tip of my tongue, but there has been several studies that look at the symptoms of TBI and those can be pretty varied and broad. But stellate ganglion block has been shown to help with traumatic brain injury as well.

Which again, a lot of the operators are using it for both TBI and I mean, probably PTSD. Do you know, is it covered under insurance? Which one? The stellate? No, the answer is no. Depression? No. And with operators, it seems like their head injuries are different too than guys that are playing football. Shooting a weapon over and over again does things different to your brain than getting hit with something else does. So I know everyone’s, or a lot of that community anyway, is looking at a bunch of different options. But I think to have stellate as part of that treatment armamentarium makes great sense. Yeah, it does. Do you ever stack it with oral agents like methylene blue or low dose lithium? I’m not talking about therapeutic dose, but things of that nature. Not usually with the stellate. Maybe we can get there and maybe we could talk about that later and figure out how to do that. But yeah, right now, no.

Do you find that medications become more effective so an individual could lower the dose if they are on some kind of antidepressant or antipsychotic or any kind of psychiatric medication? Would they be able to lower the dose if a stellate is effective? Yeah, in fact, that’s the common conversation we have with patients is I don’t do medication management. So whoever’s prescribing your whatever it is, let’s see how you do in a week or three and talk to your psychiatrist or whoever’s adjusting these medications, primary care doctor, and see if we can start tapering because most of the medicines that you just met, both of those, you don’t want to just stop them. That can cause other problems. Right. That is not a great idea. In terms of your work, what are you hoping to see for this? For stellate, for ketamine, you’re doing both. What are you hoping? I’m hoping that people don’t give up hope. I’m hoping that people can find the combination of things that helps them and that they can have access to it. Do you also find that it reduces addiction like behavior? Drinking, food. Yeah.

I don’t have studies to back it up. Why are you drinking? Why are you avoiding? Why are you going on social media? Whatever that is. Sometimes it’s because you’re numbing and sometimes it’s because of you’re reacting to depression. You’re treating your depression, anxiety, or PTSD. If Jim beams your therapist, he’s probably not the best one for you. You got to know that having those molecules in your body isn’t helping you.

If you don’t need them as much, and there’s sort of a habituation that comes with that, and people aren’t necessarily checking in with themselves to see if they need to drink. But hopefully, if the symptoms that are bringing you to the point where you need to drink or feel like you need to drink are less, and you can notice that, if you have enough clarity to notice that, then you’d reach for the bottle less. Yeah. I think that I really do feel like this could be implemented into even traditional practices by a proceduralist. Obviously, you had mentioned that it’s been used for menopause for a very long time. Why not use that in conjunction with hormone therapy? Right. And these things like ulcerative colitis, and if someone was wanting to go back and look at the literature on autoimmune disease, the way that this autonomic regulation impacts the immune system seems to be tremendous. Yeah. And we probably need it more now than ever because everything is so sympathetic dominant. We’re running fast. Yeah. I think the way to go at that is to find someone like you who’s working with patients directly, because I know the PTSD numbers, and that’s what I’m watching. My before and afters, my follow-ups, all that has to do with that. But if somebody comes in with something else, it’s ulcerative colitis or something else like that, how do we define success with that? And what kind of a follow-up program can we do to make sure that the person’s well taken care of? So yeah, absolutely. I’m very excited about the possibility, but it needs to be done in a thoughtful way. Yeah, I agree. And really, the cadence has to be set out. What if a stellate, has a stellate ever not worked? I mean, probably for some people, it doesn’t. Yeah, about 9% of people, it doesn’t work. So 9%. We don’t know why. And will you give it how many tries? Three tries? It depends. If I do a stellate on you, you get nothing out of the right side. You come back, I do the left side, you get nothing out of it.

You’re probably a non-responder. Would you try one more time? Maybe. But here’s the conversation I usually have. This is a procedure that has risks involved. If I saw something, if you said, “I felt good for a day and then it went away,” then absolutely, we’re going to do more. But if you get zero out of it, then it probably isn’t worth the risk to do a third injection. Would certain behaviors lessen the efficacy? Heavy drinking, heavy drug use, are there certain behaviors that would lessen potentially that? Intuitively, yes. I tell people taper off anything that has any kind of psychoactive effect. Including? Decrease caffeine, stop smoking or decrease smoking. If you’re on Benzos, try to take less. Although I don’t want you coming in anxious because you didn’t have your Xanax or whatever that happens to be. And then for the next 48 hours after that, try to avoid those substances as well. Having said that, I have had a guy who had the procedure and went straight outside and smoked a cigarette and he did fine.

Needless to say, he failed the procedure. No, this can’t be true. He had a good result. But when you’re talking highest and best, how do we set somebody up for success? Decrease the things that are influencing the connection between your mind and your body during the time that we’re trying to reset the connection between your mind and your body. So this is kind of an off the wall question. Do you think that this has made you seeing what you’re seeing over and over again? Do you think that this has expanded your mind? Because again, you and I just met, we’ve spoken on the phone a few times. I feel like you’re also somewhat intuitive and very open. And that doesn’t just happen. Right.

So I’m just curious. There’s no doubt that this procedure is has helped me. I’ve had ketamine as a patient as well. I’m in a much better place than I was before. And it, I don’t know, we could talk a while about how I’m different. And my wife could probably help us with that conversation. God bless her. But yeah, I try to be as genuine as I can. I don’t try. I feel like I am just genuine talking about it. I’m super passionate about this. I’ve seen this save people’s marriages. I’ve seen this put people back in the fight they want to do. I’ve seen it keep them doing the job they want it to do. There’s very, like I said, at the beginning of the conversation, it’s the coolest trick in medicine. We can put people back in a good place where they can show up authentically, where they can act instead of react, where they can live the life that they want, where they can have relationships with their family, with their loved ones, they can have work in the jobs that they’re fantastic at. And it’s, it’s pretty, I don’t want to say it’s a nothing procedure, but it’s a very minimal procedure. Dr. John Howe, I’m excited to have you back on there’s a lot more than I want to talk about like hydrodisection and regenerative medicine. But I think that if we did that, we would really be doing a disservice to stellate and ketamine. And the message that you feel so passionate about is that the idea that mental health is so elusive is not necessarily true. Right. Thank you so much for your time, for coming on, where can people find you? So for the mental health side of things, stellacenter.com is the place to go. And for the regenerative medicine, the how clinic.com. We will link this in our show notes in our newsletter. Thank you so much for coming on. Thanks for having me.