Episode 47

—
empathy is knowing your own darkness

without that connection you don’t have

anything what’s the opposite of

addiction just freedom

hello and welcome to another episode of

finding peeks i’m jason friesma your

host this week joining me

is uh peaks recovery center’s chief

medical officer

dr ashley johnson and peaks chief

clinical officer

jason friesman

chief operations officer

yeah all right straight to the blooper

reel here we go um

but anyway uh

we are here to continue a conversation

with dr johnson um

and kind of the innovative approaches

she is taking in her in her practice and

and uh where i kind of want to start is

i know last week you introduced a

metaphor around a frayed rope and so if

you could maybe do a quick summary of

that in case some people are tuning into

this episode that didn’t watch the last

one and then uh and we’ll kind of go

from there okay sure

uh so last week we had we just talked

about it’s a

helpful analogy

kind of to to summarize the effect of

ketamine really all of the

neuromodulatory

treatments that was kind of the word

that we’ve lumped these treatments into

so basically just meaning we modulate

nerves

meaning we change nerves

or improve them is the hope and so

the analogy of the frayed rope

uh

helps people understand

that uh if it’s like taking a rope like

a hemp rope that’s got a lot of fibers

uh kind of braided together and twisted

together and

so

when you take something rough like a

brick maybe maybe even like a razor

blade or something and you rub it across

it it just frays the rope

in that area

and

we liken that to untreated mental health

conditions

to include chronic pain

uh and substance use disorders and so

when all of those conditions

kind of go untreated for years in most

cases um

it’s it’s like it’s fraying the ropes of

our brain so the ropes are are

synonymous with nerves so nerves are

typically long and um they’re just

elongated and like a rope is and so

when all these

kind of neurotransmitters and hormones

are

are dysregulated in our body over time

that’s usually how the ptsd or the major

depression is manifesting internally

it’s fraying the ropes of your brain and

so when we

what we found is that we have to

intervene in that process in order to

stop that process of just

destruction to the nerves

we have

over time found many different types of

treatments that work

to stop that process but then go a step

further and do what we call neuro

regeneration so meaning it helps rebuild

the nerves but it also helps

like clinton mentioned is like the the

medications the therapies

the tms

is like pouring wax on the nerve and so

it’s almost like it’s trying to help

heal it

um

not so much like a band-aid

but

to where it takes it a step further and

actually neuro regenerates and it

smooths out that rope

in a sense

and while they all of these treatments

that we talked about

ketamine infusion spravato which is s

ketamine nasal spray transcranial

magnetic stimulation which is tms

psychotherapy that targets all these

different disorders

all of them are kind of working in the

same way and also to include psychiatric

medications

in that they’re stopping the assaultive

process on our brains and then they’re

helping us to move forward and

regenerate

okay

and i wanted to talk just for a minute

specifically about tms i had the

privilege of helping you i think

hone in your machine and you put a cap

on me

and turn the dial up to 11 out of 10 and

give me a little

shot of magnets

but i’d love for you to explain it in a

way that isn’t uh so colloquial

and yeah

it’s a good way yeah we’ll understand

that yeah so um maybe we should get a

clip for this podcast absolutely yeah

[Laughter]

so what we do with uh

the machine that i use in my clinic

is

manufactured by brainsway and so

i mentioned that not to advertise for

them necessarily but because they have

patented their type of device where they

utilize a helmet so they are the only

tms

device manufacturer that utilizes a

helmet to deliver these

magnetic pulses essentially into

the brain and different areas of the

brain that correspond with some

different conditions that people suffer

from

and

all of the other types of devices out

there are what we call figure eight

devices for the most part those are all

the ones that are

on the market primarily and are fda

approved for major depressive disorder

treatment

and actually more specifically treatment

resistant major depressive disorder or

trd treatment resistant depression so

that’s kind of the new

um or terminology emerging terminology

right that that that will become

standard or is becoming standard and so

um

with

tms when it’s administered through

a helmet

we have you come and sit in a chair much

like the one you’re sitting in it’s got

a straight back

it’s not reclined

but we place the helmet we deliver a few

pulses

to to try to locate different areas of

your brain and specifically

the area

of the motor cortex which is the outer

layer of the brain is what cortex is

and motor refers to muscle and so

when we find that motor cortex by

delivering a few pulses here and there

it will

we’ll focus on

for major depression having your fingers

twitch like that and then we know okay

look we found the motor cortex if we can

get your fingers to twitch it doesn’t

hurt

unless you turn it up yeah

and the goal is to treat at the lowest

intensity possible

just

for my own

clarification the process of finding the

cortex or the motor cortex is that the

brain mapping piece that you talk about

yes is that what that’s referring to

exactly thank you that that is the term

for

the first session that you

you attend for to start tms is

essentially the intake

um and so it’s where we are learning the

most about your brain specifically

because everyone’s brain is very

different and has

nuances as to where maybe

neurons are crossing and that kind of

thing and so we have to do kind of like

a test sure

to

identify where your specific

in the case of major depression your

specific left prefrontal cortex is

and so that is what we are looking for

so that when we

place the helmet then for the treatment

session

um that is where

the it’s about right here on your brain

uh that’s where the left prefrontal

cortex is and so this helmet is is

guiding all of these magnetic forces

right here into the left prefrontal

cortex and so

that will

pulse

thousands of pulses over about a


kind of the standard for how long it

takes to go through a tms session

for major depression we now have a very

accessible um

improved

time frame that we can administer the

same treatment

with about the same efficacy meaning

this this you get the same effect pretty

much from it in three minutes

so we’ve now come over time from


week

for six weeks

to now three minutes a day

um and so that’s that’s been pretty

groundbreaking as well that’s called the

theta burst

and you may see that on websites and

such for different clinics that

administer tms they’ll call it theta

burst stimulation and uh

tbs is the way that it’s being

abbreviated now so all of this

terminology is just emerging and

becoming standard so

um

but that that frees people up a great

deal in their lives because as you can

imagine six weeks of coming into a

clinic five days a week

can be pretty cumbersome for your life

if you’re trying to work try to raise

your family trying to go to school

that kind of thing and so now that we

have a three minute

treatment session

that has

made it a little more accessible for

people so with tms the beauty of it

is that you can still go back to work

sure back to school in the same day go

back home you can drive yourself

there are no restrictions in that regard

for the most part unless you have some

very obvious

side effects which is extremely rare

so as far as being invasive it would be

would it be considered a non-invasive

considered non-invasive exactly

and the fda has approved tms now for

first was for

treatment resistant depression

trd

and

and then was ocd

with

a few select devices not all devices are

approved

to treat ocd

the brainsway device with the helmet is

approved for that specifically

and it that’s somewhat important for

people to understand because that way if

they do suffer from debilitating ocd and

they need to get tms for it

because medications are notorious for

not

um fully treating ocd

they need to look for a clinic that has

the ocd specific

tms device

they’re not all the same

and so

that that’s one way that you can look

for that

um

well i think that’s important to

identify that not all tms is the same

that not all tms devices are the same

and that um different devices will be

more efficacious for different diagnoses

and

so it’s a it’s a really i think that we

start using state you know

tms and it becomes a sort of generalized

idea or concept but the reality is that

tms is a really diverse within it within

the treatment itself is really diverse

in approach and

yeah so i think that’s really

interesting it is absolutely and there’s

more

you know every year it seems like

there’s more

uh movement and what type of devices are

coming onto the market

to treat different conditions like

migraines right now there’s

a tms like device

delivers the same type of magnetic

pulses but you hold it up behind your

head

to treat basically to abort a migraine

interesting um just with a few pulses

and you can have it at home and so you

can see that you know there’s this whole

spectrum and evolution of tms that i

think we’ll see quickly come out um as

they’re doing more studies on it how to

maybe deliver different protocols

through the day and that kind of thing

kind of like the evolution of the

computer right it starts off and it

takes up this entire room right now and

and now it’s right here on this table

exactly over time yeah exactly it’s

really interesting

so it

i find this to be so interesting and i

and it’s an emerging field and then i’m

a

counselor so i uh

my knowledge of it is very limited um

other than you know what i can read

online and everything but i i did wonder

just from your perspective i i had found

um an article talking about ketamine

um and it studied people who just got

ketamine and then people who received

ketamine and therapy and then people

received just therapy and then people

who received neither and far and away

the most efficacious

intervention

um

for depression was the was the ketamine

and therapy piece and and how do you how

do you see those

how do you see these new modalities uh

that you’re talking about um

modulating modalities i can’t remember

what the term was but uh neuromuscular

modulation yeah the neuromodulation uh

interventions how do you see that

being enhanced by clinical interventions

from from a counseling perspective

so right now i think we are very early

in this process

the protocols are still being developed

and refined

through

you know our major institutions right

now

as far as ketamine assisted therapy

goes

there are

lots of therapists out there who are

working hard at helping develop these

protocols

and and i think the reason you’re

hearing so much about it is because

they’re seeing such

improved outcomes especially in ptsd

um

and while i i don’t know that

it they’re going to be you know

complicated protocols that we’ll find i

think what we see is

is we’re really applying our principles

of therapy and the various different

modalities

um cognitive behavioral therapy

prolonged exposure um

to basically while someone’s under the

influence of ketamine

that that kind of opens up

their mind sure so that you can help

rework the memories

and

uh i’ve seen it quite a bit to where

i’ve even attempted it myself and

as a psychiatrist and in my office where

someone is is really going through the

ketamine infusion

really for more the nerve repair aspect

of it

and because we know it has a very rapid

immediate anti-depressant effect

but you can see

how pliable their mind becomes

interesting while they’re going through

the infusion and so you actually feel

especially a seasoned therapist

you actually feel a lot of confidence

that

wow we’ve got some amazing access yeah

some real space

memories yes their pain their um

you know how they’ve been experiencing

their grief um to where you can start

applying if you’ve you know in most

cases been able to build some rapport

with this patient by gathering their

history their

psychosocial history specifically

understanding diagnostically why do they

suffer from what they suffer from so

that you can then if you are present

while they’re going through the ketamine

infusion you can then intervene

in the discussion with them

they are way you know for the most part

i think

most patients that i’ve treated in this

realm

they are very willing to discuss

and as long as they feel safe that

you’re there

occasionally you know they’ll they’ll

feel like some weird dissociative

effects because it’s a dissociative

anesthetic but there are ways to kind of

comfort someone help give them tips on

you know just kind of put your hand on

the seat

sometimes they’ll feel like maybe the

bottom the floor is falling out from

under them not quickly but it’s kind of

like an odd

sensation that they might feel um

but there’s there’s some very good ways

that you can address that while you’re

talking with them

constantly reassuring them that you’re

with them who you are

um

where they are

and how much they’re they’re being

supported and that it’s a safe place to

discuss their yeah their trauma

basically it’s so interesting to think

about dissociation i mean when we talk

about it in clinical terms and generally

speaking i mean

it’s not a positive or a um it’s a

firming word or

experience for people but to think to to

use a dissociate a level of dissociation

that it makes that kind of unlocks all

of these doors that otherwise could take

i don’t know years to unlock i mean we

work uh i mean therapists can work for

months and months and months to try to

get act like you said sort of this this

access to the mind and in the way that

um

what what seems that ketamine gives us

almost instant access to through this

kind of dissociative moment associative

properties

and the another beautiful part of it is

that ketamine is so short acting

that you recover ex very quickly right

so what we typically do is we’ll have

someone

complete the infusion within about 40

minutes

and then they have about 20 minutes of

recovery time and then they’re usually

able to walk out the door

uh they can’t drive sure but

they’re able to usually safely go home

with with someone um whom they trust

um get through the evening sleep it off

and then uh the goal is to see the

antidepressant effect continue sure or

maybe in in the case of ptsd maybe see

the edge come off of the hyper vigilance

the avoidance behaviors and all of those

uh hallmark symptoms that you typically

see with ptsd maybe the intrusive

memories aren’t as intense as well so

absolutely it’s really exciting to see

that happen i have also seen it with ocd

to where people are

they feel free to become more productive

like in their job

they are less obsessing about you know

whatever it is that that they’re

obsessive about whether it’s body image

um

whether it’s it’s about you know i’m i’m

not doing this right

that kind of thing and then the

compulsions that usually follow

oftentimes we’ll just ease off

that’s pretty amazing do you have any

indication if people can remember

the experience like if

somebody does a therapeutic intervention

during the infusion or right after do

they remember it

they do some okay

i um

i think most patients that i’ve treated

with ketamine

remember most of the time okay that

they’re in the room

i actually noticed though that the parts

that they don’t remember

are insignificant

and actually good because it was the

times where maybe they felt like

where am i you know i don’t sure i don’t

know what’s going on here am i outside

of my body i mean that can be common

maybe they see the walls start to wave

that’s that’s common too

they don’t remember that typically

speaking and if you can comfort them

through it and reassure them that this

is normal let’s keep going they’re

usually um going to do fine

interesting

and then

where do you see this all headed we were

talking before the show that

um

all of your training experience with

with this modality has been since

you got out of med school so you’ve had

to teach yourself or access whatever

resources were out there to learn this

stuff but

where’s this headed i mean i think about

um psilocybin or um

lsd micro dosing these are kind of some

popular things right now i mean

psilocybin isn’t

uh criminalized in denver anymore and

and so i know people are kind of drawn

to that or where

yeah where do you see this emerging

with other

i think there is a uh

a rush to regulate now that makes sense

and

that’s what i am seeing i’m hearing

about reading about i know they’re

studying psilocybin in boulder

um

[Laughter]

unbrand

but i also was just reading this week

how

you know all the ivy league schools the

major medical institutions

there

are quickly trying to form a psychedelic

psycho

psychedelic psychiatry residency or

fellowship basically so that

like i went through a general adult

psychiatry residency right that’s four

years um well there’s many different

ways that you can then sub-specialize in

child and adolescent psychiatry sleep

medicine

or um

you know geriatric psychiatry those kind

of

um

specializations and now they’re trying

to add

psychedelics like interesting psychiatry

i still have to think about how to say

it yeah that is going to be tough

yes um so that because you can feel it’s

like this wave coming off

all of this uh momentum

to

kind of like the gold rush of

trying to find out how do we do this

safely right

because like we were talking about

before it

most of these treatments all really kind

of emerged around the same time or at

least

re-emerged lsd is a

absolutely

you know decades ago they were studying

it

um

it just didn’t quite go anywhere um

and now i think ketamine is being lumped

into the psychedelics and

interesting so i think it’s been kind of

it’s you know as far as i have seen it

it’s been kind of the trailblazer here

and so now psilocybin follows and lsd

and

mdma

exactly started in the 80s really so

exactly and so i don’t know maybe we

have more resources now to study it more

thoroughly

and safely that’s my hope um is why when

it seems like

i mean most of those drugs were

scheduled on drugs were they sure no

medical use and so

i mean you’d be punished way more for

having mushrooms than say heroin which

is a schedule two i believe if i

remember right but like i just find it

really interesting

they’re likely that war on drugs and

scheduling the drugs in that way uh

create that

um despair or put so many barriers to

researching this because it was

basically saying social stigma and on

its own i mean i think that it’s you

know there was

uh what we don’t understand we tend to

stigmatize right and then what we

stigmatize we tend to make it legal so

right now and then hopefully in the end

that regulation or over regulation maybe

of it stigmatization

as well we can find the balance

and i think for instance with ketamine i

think that’s you know it’s a schedule

too yeah yeah and uh

i think

necessarily so sure um in that it does

help keep it controlled

um

you know in in most cases except in like

this like we were talking about the

online companies that maybe it’s it’s

just easier to access oral ketamine

with some access to maybe an online

therapist as well so

seemingly that that is fairly

unregulated it’s just difficult to tell

and

also as we talked about

you know i’ve had i’ve worked with many

patients who have

felt as if that was such an unregulated

approach

to utilizing ketamine

that they actually suffered from it in

that

it kind of got them on a anxiety mood

roller coaster and that they would they

were taking ketamine as needed

which many drugs are prescribed that way

uh but the effect that they got from the

ketamine

was not what they anticipated right yeah

we’re not looking at full efficacy in

that in that manner so exactly

yeah i think it’s i’m it’s interesting

that all of these sort of new uh

approaches kind of surfaced around the

same time right like we see this sort of

like i don’t know as the second maybe

third wave of psychiatric intervention

approaches especially to mental health

um

and i’m curious what you’re i’m just

kind of from my own curiosity what what

do you think propagated that you know

like what do you think kind of initiated

or sort of started moving us into this

direction into this new wave of

psychiatry or this next wave of

psychiatry

i think uh

i think we just got tired of

or maybe stagnant’s a better word sure

of the medications

not

achieving more than

you know maybe 30 percent efficacy uh in

treating the vast majority of these

disorders that we’ve talked about

um

[Music]

and so

you know as

necessity is the mother of invention

right and so

uh i think

necessity can be equated to people

suffering really is that is what’s

driven us to keep looking is

you know i think we always had these

clues

uh in the neurologic

realm

of how the brain was working and

overlapping with

the psychiatric

conditions

so neurologic and psychiatric processes

very much overlap to include pain

and

in substance use

that

the fields have kind of converged some

and so that’s where i think tms is a

great example of that

and that’s been in development since



insurances to start covering it so right

on time yeah there we go

well i would like to

uh come out on this show as a former

employee of a big pharma company i used

to sell pharmaceuticals

and i think part of my answer to your

question is like pharmaceutical

companies

want people on medications they take

every day for the next two years

when i hear about these treatment

episodes of

tms or ketamine it’s very short and so

there isn’t

a ton of money to make for big pharma

and these are medications that aren’t

really regulated by big pharma at least

right now until they come up with

different formulations like spravata but

like i think

i think it’s interesting that uh

i i feel like psychiatry is moving away

from its reliance on big pharma and kind

of carving their own path now that’s my

weird that’s my

outsiders and as a psychiatrist that’s

very freeing yeah i’m sure

up until the last few years i i mean i

have felt like i am completely dependent

on

finding a medication that can help in

some way

and that almost no matter what whoever

comes to me

is expecting to be prescribed something

and so it’s nice to now be able to offer

different treatments that

they don’t feel like they will they have

to be reliant on it

now it doesn’t it it doesn’t necessarily

change

the trajectory for some people who have

chronic conditions they may have to stay

on their medications the rest of their

lives

but they may not have to

uh be only partially treated right

partially improved and that’s what the

vast majority of people i think have had

to suffer through

up until we’ve started finding these new

newer treatments

well when we talk about disrupting an

industry right at peaks and i think that

this is it’s great to see psychiatry as

a field have these sort of avenues of

disruption where we do get to see

innovation come forward and we and we

recognize that suffering has not gone

away nor will it ever but we can do a

better job as far as addressing it

especially

the

levels and types of suffering that are

debilitating for people and chronic and

really um really disrupt their lives in

a way that is um

really uh tragic

yeah and unmanageable for sure

i i have one more unscripted question i

might have more uh

um do you see a lane for cannabis in

this and if not why not because like we

we’re here in colorado

i mean we could probably see some

dispensaries from where we sit like i

is there a lane for cannabis because

that’s all the popular thing right is

and we also treat cannabis use disorder

yeah as part of our yeah in our clinics

and certainly at some levels it

exacerbates a lot of mental health

issues but i’m wondering if there’s a

lane for it as a medicine too i’m

curious

i think there will be okay i think we’re

trying to get there

uh again it’s kind of like this just

ever-evolving process to regulate sure

the dosing of thc

um

you know now we understand a little bit

more about cbd and

how it’s not psychoactive and that kind

of thing and it can treat some of the

things that marijuana in particular we

were relying on to try to treat um like

insomnia or pain or

even ptsd which there are no

you know if you if you rely on the fda

to put out these indications

cannabis is not approved for anything

sure

by the fda

and i i am passionate about letting

people know it’s absolutely not

indicated for ptsd for major depression

for really any psychiatric

uh condition

but the word on the street is that it is

and you can act you know you can find

justification pretty much anywhere

online um

if you want for literally anything right

and so there is a lot to be found out

there

of

um

people and companies and institutions

trying to justify it but none of it has

ever been

proven safe

and effective to treat those specific

conditions

because guaranteed the va would be

you know

advocating for that for ptsd if it were

if the studies were there and the

evidence was there that it was well

treated that way

and so i think

cannabis in particular

is going to

follow a different path because we know

so much about it and its side effects

now whether or not people believe the

side effects

because of this legalization process i

think maybe it can cloud that

somewhat is that that gives people a

false sense of security is that oh well

it’s legal it must be safe

it’s kind of like with alcohol right is

yeah it’s legal

but it’s not safe yeah absolutely um

and it depends on the level of use when

do you start using it

and actually now that i’m saying this

out loud it’s kind of

very similar to the trajectory of

alcohol use in someone’s life if they

start as a child

drinking alcohol that it’s probably

indicative of the problems they’re going

to have later in life

or as a teenager

we know that if if you start drinking

regularly at age 15

or earlier

you have a much much higher risk of

developing alcoholism or alcohol use

disorder

you know within the next decade of your

life pretty much and

similarities could be discussed about

cannabis in that

uh we know that

if you start using cannabis in your

teens

adolescents in general and regularly you

have about a 15

percent chance of

developing schizophrenia from it

meaning permanent psychosis it never

goes away

and it could be a low level of it

i’ve seen it in many people where they

just kind of carry around a low level of

paranoia

they just constantly have to do reality

checking and

[Music]

but it is disruptive in their life and

so usually you can go back and you can

take a history to find that they started

using cannabis very early in life

usually in early high school or middle

school and

and just continued from there and so

and if you have an underlying genetic

predisposition for a psychotic disorder

or a mood disorder like bipolar you are

a much higher risk of just opening that

box

through cannabis use

and a lot of people just don’t realize

that they don’t understand it

we’ve also found

some very good evidence that

people who have used cannabis off and on

since adolescence

if they

continue to use it in their

later decades of life

starting in their 40s 50s and 60s

if they’re using it consistently then

even if they’ve taken a break from it

like in their 20s and 30s potentially

and then they go back to regular use of

cannabis the cognitive decline is

very significant

and in that age group specifically and

um whereas

if someone who has never touched

cannabis

or rarely

up until their


they have a much less

they have a lesser chance of having that

significant of a cognitive decline

uh

in those age groups so

there’s just there is a lot to consider

there’s so many caveats to to that

question it sounds like yeah yeah there

are

the difference of course with alcohol is

like alcohol is a licorice you get it

from the liquor store

these dispensaries put you know little

green crosses and act like

yeah there’s a medical

reason and justification that it’s

somehow

um

safe or approved or whatever and i think

that that’s

i mean unlike the other

medications we were talking about

earlier and interventions like tms

marijuana is much more ready shoot aim

we’re like we’ve already shot it now

we’re trying to aim it

right uh probably the wrong order there

um

so i

we are at it out of time and i just hit

my mic um

i really i really appreciate you coming

in and joining us i this i think is a

really exciting

direction that we’re headed and and i

think um you know having been in this

field a long time and like i said even

worked in the pharmaceutical field it is

refreshing to think about something

other than

um you know a lifetime of a medication

cocktail that constantly needs

adjustment and all that but if there

could be things that either augment the

medications or even can help people come

off of them or whatever to to treat

mental health illness i think that’d be

great so

with that we will sign off um

thank you all for tuning in i i hope you

enjoyed the discussion i certainly did

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[Laughter]

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uh

thank you and

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