Welcome And Why Ketamine Matters

Dr Andrew Greenland 0:00

So, welcome to Voices in Health and Wellness. This is the podcast where we explore fresh perspectives, challenge conventional thinking, and hear from the practitioners who are working to improve the way we approach health and well-being. I'm your host, Dr. Andrew Greenman, and today I'm joined by Dr. Jacob Silverstone, Medical Director of We Wide Catamine in Miami, Florida. Jacob brings an interesting perspective to a subject that's attracting increasing attention, but also considerable debate, the role of ketamine in health and chronic pain treatment. We'll be exploring some of the limitations of conventional treatment approaches, why certain patients continue to struggle despite receiving care, and what it takes to introduce alternative approaches into an established healthcare system. So, Jacob, I'd love to welcome you to the show and thank you very much indeed for joining me today.

Dr Jacob Silverstone 0:44

An absolute pleasure. As uh I mentioned in our early intro call, any opportunity for me to get on a podium and to uh educate and inform people on uh the subject is exciting for me. So thank you.

Dr Andrew Greenland 0:58

Great. Well, I'm looking forward to it. Now, Jacob,

From Surgeon To Ketamine Clinician

Dr Andrew Greenland 1:00

you have had an interesting journey through medicine. What led you from podiatric surgery into ketamine therapy? Because I didn't mention that in the introduction, but you've kind of changed tax. So give us a kind of insight into that.

Dr Jacob Silverstone 1:12

Yeah, so um I've been I've always been a little bit more leaning into the academic side of things. You know, in in uh in my career path, um, not only was you know I an active foot and ankle reconstructive surgeon, but I did lead the uh the department at the hospital in which I uh was affiliated with, and I was the residency and program director as an educator there for a number of years, leading you know the new students through their surgical training. I've been involved as a primary investigator in countless amounts of uh research medicines and their uh journey to to become FDA approved. So for me, um the pursuit of of new and developing has always been an interest to me. Um I would say I was first tuned into ketamine early, early stages of my residency, where anesthesiologists were using ketamine to help pediatric patients come out of anesthesia. I'm not sure or um how familiar you are with kids in anesthesia, but so many of them come out rather violently. So they were trying to use ketamine as kind of a softer, gentler approach when they were coming out to see that they um, you know, weren't so violent. And, you know, I obviously as an inquisitive individual, I kind of started exploring why ketamine that led me down the uh the literature rabbit hole, um, in which there's probably within the past 20 years a plethora of articles, I would I would enumerate them at over 200, demonstrating safety and efficacy in terms of you know, treatment resistant depression and suicidal ideation, especially within the veterans. And it just kind of always stood in the background for me. Um, following COVID, um, I don't have to tell you, I'm sure we've all experienced there was a rather sharp spike in need for uh for mental support amongst um, you know, those we know and loved. Um, and that kind of led me to start using ketamine primarily within family and friends or community structure as a part-timer. Now, the reason I was able to do that is because here in the United States we run a private health system. I actually stopped taking insurance about six, seven years ago in order for me to be able to really treat patients the way I wanted and not dictated by systems. Again, always wanting to do what's right for the patient, not necessarily what's right for the algorithm. And um I ended up having some free time. Um, you know, the attrition rate of uh of a practice when you stop taking insurance is rather sharp. And though I retained a fair number because of my credentials and my expertise, I did lose a number of patients who wanted to only participate with in-network providers. But that gave me a lot of free time. And with that free time, I started exploring other areas of medicine, including ketamine, in which for me it was uh an easy access point because of the post-COVID environment and the people around me that were looking for remedy that were not getting remedy through the traditional methods. So I started part-timing it once or twice a week, and that kind of evolved into a much more broader full-time practice. It was kind of obvious to me that the literature was, in fact, correct and what we have been reading was true. I started seeing improvement in the patients that I was administering the ketamine to and were receiving outside you know, psych support. And um, it just grew into a bigger frustration for me, you know, trying to wrap my head around why everybody isn't offering this as first line, why are we using this as last line? And um, with that, my practice grew and my continued research and uh digging into it grew with it. So that was my career path. And while it is definitely a bit of a devious uh um route from where I started, it there the the common thread that kind of runs through my entire career is um there's always got to be a better way. And that is the the essence of of medicine, right? Medicine in in its stagnancy um doesn't really offer improvement. We're always looking for a better way.

Pushback From Traditional Mental Health

Dr Andrew Greenland 5:33

Thank you. So, how did your colleagues react when you made that move? You know, your collect your colleagues in the podiatric surgery world.

Dr Jacob Silverstone 5:40

What was that kind of so they were actually quite quite supportive? It's it's my counterparts in the in the mental health world and uh the other allopaths that kind of resisted the idea because I don't fit the algorithm, right? I am out of the box. The algorithm doesn't suggest that ketamine should be included in treatment. If you're family medicine, primary cure medicine, you simply refer to psychiatry. And if psychiatry is involved, ketamine is what would be considered an off-label use or not FDA approved. So it doesn't fall within the algorithm and thus is a deviation of standard of care. So they really don't appreciate or appreciated an outsider coming in and stepping into the industry. So it wasn't well received four and a half years ago. But um, you know, four and a half years later, again, you know, how I always justify um behavior and action is the results. Um, four and a half years ago there was a tremendous amount of resistance, we're now starting to see that that is starting to fade, and we're starting to see a lifting of the stigmatization of a medication that's been around for near 70 years. Um, so initially, no, I I was I was rather um maltreated throughout the experience. I I received zero patient physician referrals. My patients came having done their due diligence and research themselves and finding me through either word of mouth or internet.

Inside The Clinic And Session Flow

Dr Andrew Greenland 7:15

So tell us a bit about um ketamine, rewide, rewide ketamine. What's the setup? What's the practice look like? What's your involvement? What happens day to day?

Dr Jacob Silverstone 7:23

Wow, um, so the the uh the clinic has evolved over the past couple of years, and we are definitively a lot more comfortable with the the um I guess the system that has now fallen into place, right? Um there is no, let me rephrase that, there are certain guidelines in reference to the ketamine space, um, where they tell you the literature suggests 0.5 milligrams per kilogram as a loading dose over six sessions. So that kind of still remains um the underbelly, but our clinic, in essence, is run 100%, very, very evidence-based medicine, super clinically informed, but covered entirely by just a luxurious experience. So there is nothing clinical about the experience for the patient. They feel like this is not a doctor's office, though the underbelly of the entire treatment is 100% medically appropriate, right? So we have to balance the experience with the treatment. And the reason why we do that is because there's two general schools of thought when it comes to ketamine. School of thought number one, which I labeled the West Coast approach. You know, in the US, the West Coast would be California, Seattle, Oregon, Colorado, um, where they believe the drug, it's the chemistry, the pathway in which it works, the 11 pathways in which it works, it's the drug. And if ketamine didn't work for you, you didn't use it for long enough or high enough dose. Where the East Coast approach, which I label it, I haven't found any other reference in that type of category or categorizing, um, is more of an approach where the ketamine itself is an appropriate tool that needs to be leveraged through integration. So if ketamine didn't work for you, um, there is a possibility that you simply didn't create the change or integrate through the ketamine. Now that's our approach. Our approach is ketamine is in fact a tool. Does it help with suicidal ideation in the first early stages? Certainly. Does it lift the mood on severe depression almost immediately? Yeah. But that's not the main benefit of it. The main benefit of it is not to use it like another chemical, another psychopharmacology. It's in order to appropriate change in the patient so we can have a behavioral result. In order to do that, the environment has to be appropriate for it. So the flow is very easy. Patients come in, our intake is all digital, takes about 15 minutes to complete. Initial patient gets taken into the room, our rooms are quite spacious, we have a very nice office suite. Uh, they sit in the room, and every single first patient that comes in here, I stay in the room with them the entirety of the treatment, metaphorically and sometimes physically, holding their hands during the process, and what I call guiding the session. Guiding is not psychotherapy, it's not any sort of uh you know, um, therapizing the patient. It's simply allowing the experience to allow the information to surface. And because of the way ketamine works and the dissociation that's sometimes appreciated, there may be a level of confusion in the treatment for the patient. So I'm there to continuously allow them to have the clarity and availability to allow that information to flow so they can process. So we guide the patients during each session, uh each initial session. Um, once they're done with the session, all of that information is is now on the surface. I spend about 10 to 15 minutes just going over the session with the patient, and then they're allowed to stay here pretty much as long as they need. Um, sometimes we transfer them into a different room uh to recover. For most patients, it's about 45 minutes to an hour. And like I always joke about it, they're usually with us within about 15 minutes after the drip has stopped. So the head is much clearer than the legs, and then the legs catch up to them usually about 45 minutes to an hour, where they're typically okay to go home either by themselves or with somebody, either through ride share, or if they stay an extra hour, they can drive themselves home. Um, it is a very, very fluid again system. Every bit of that is designed with evidence-based medicine, but procured in a very, very non-clinical way.

Dr Andrew Greenland 12:08

Thank you. That's really helpful and detailed insight into the process. So thank you.

Rethinking Treatment Resistance And Algorithms

Dr Andrew Greenland 12:12

Actually, last time when we spoke, you made a particularly interesting point about patients being labeled as treatment resistant. Yes. So do you think that sort of conventional medicine is sometimes blaming patients when it's actually the treatment approach that's for for trading?

Dr Jacob Silverstone 12:24

Well, um, the short answer is definitively. And the way that I can prove that is I am receiving the same patients that have been treatment resistant, and then through six sessions plus, they're not treatment resistant. They're doing just fine. So they are not treatment resistant. It is, in fact, the treatment that they're being offered, which isn't the right treatment for them. And with that, we can go into the whys. And it's not complicated when you start to um, I guess, unravel the system that exists within the healthcare space of uh, you know, I don't know how it is outside of the US, but I can speak of the US, right? So when we practice medicine in the United States, it has to be algorithm, must be, and it has to be an algorithm for two purposes. First, medical legal purposes, right? A doctor cannot be dinged, they cannot be sued, they cannot be held accountable for poor results, provided that they worked within the standard of care. So you follow the algorithm, patient falls off and has poor outcome. It is what it is, the disease one. Uh, the second reason is we are required to follow an algorithm when we're dealing with insurance companies in order to remit authorization and payment. Have these measures been met? If not, we will not reimburse this procedure. So we're following an algorithm. The problem is there are a lot of systems in which the algorithm works within the healthcare system, but there are some that it's not so great. And for me, the mental health landscape is the obvious one to criticize because we've been following an algorithm for about 40 plus years since you know the evolution of the DSM3 and the psychopharmacology world, you know, with prozacnation, and our results are not great in any other avenue, in any other, you know, uh what we would call arm of medicine or any other function of medicine, if after 40 years of running the algorithm, we are having poorer outcomes, we would challenge the system immensely. But when it comes to mental health, we're not challenging it, we're doubling down on it. Maybe the next generation of SSRIs, maybe dopamine and serotonin in a different level. Maybe if we stop or manipulate dopamine and serotonin in a different way, this time it'll work. But the past 40 years, we have seen anxiety and depression up, suicide up, earlier use of antidepressants, SSRIs, and bentodiazepines up, increased use, population use. We're not doing better. We're doing significantly worse. So there's to me a an obvious deep uh fault within the system. I mean, I can go into you know even more controversial topics when you dig into what the DSM stood for and the purpose of the DSM, it kind of makes you feel a little bit more uncomfortable because the DSM III was really there to justify the practice of psychiatry for them to justify depression and anxiety as medical conditions that can be managed through pills. That's what the DSM III says. We're doctors just like you. And if I can treat an infection with an antibiotic, I can treat a depression with a Prozac. But ultimately, it hasn't worked. And it's not me telling you that it hasn't worked, it's 40 years of that practice that's telling you there's a reason why there's an emerging space in the psychedelics. It's because it's testing the algorithm, and the algorithm has been failing at a pretty astronomical level. What other medication will the provider tell you, hey, take this medication indefinitely? How does this work? Well, we don't know. We'll try in six months and then we'll adjust it. How many people does this work for percentage-wise? I don't know, about 30% of the people. And we're supposed to be okay with that. And we're supposed to suggest that if you fall within the 70%, that you're treatment resistant. I mean, that shouldn't, that shouldn't sit well with any doctor. That should be something where every doctor should be challenging. And that was the early conversation I had with many of my counterpeers, right? With the primary cares and the psychiatrists. I said, if the landscape of psychiatry was successful, there'd be nobody challenging it. People are challenging currently orthopedic surgeons. Maybe the new age stuff with you know exosomes and stem cells, which are starting to really, really show their worth. Um, and they are starting to uh you know really prevail. But if you don't have a functioning hip and it's completely, completely bone on bone, your choices are fusion or replacement. They don't have a lot of challenge to that yet. Perhaps with exosomes and stem cells, they'll start to become, but they're doing a good job at what they're doing. The site guys deserve somebody to challenge them because they're not doing a great job and they refuse to acknowledge that. So are people treatment resistant? Or is the treatment that's being offered potentially not the best available? Right? So does it work for a number of people? Absolutely. Is it enough people that we should say that we shouldn't expand and look elsewhere? No. So the way that I kind of metaphor it is when people come to me and they're like, I'm label treatment resistant, like, well, if I'm constantly trying to run, you know, uh Apple software on a Windows computer and blame the software, um, I'm gonna look like a fool. You're just running the wrong software in the wrong system. Not suggesting that antidepressants don't work, they just don't work well for everybody. For those that it works for, amazing. There's science behind that. Continue to use it. I am not telling you to go off of it. I would never tell you to go off of it, but you're in the minority, not in the majority. And if there are no uh you know adverse side effects that are causing your life to be worse by taking the antidepressants, such as decreased libido and lack of intimacy in a relationship, increase in weight and feeling like garbage because you can't seem to be able to lose the weight that you're putting on, or suicidal ideation. I mean, if those things are not happening to you and you're doing well, continue to take it. But most people are not, in which case, if most people are not, explore other options. I am not suggesting that this is the silver bullet that's gonna cure all. It does not. We have a failure rate as well. But we have to offer the opportunities and we have to get out of the algorithm because if we stay with the algorithm, we're just never gonna advance. Can you imagine if we were still treating women who are having severe postpartum depression by removing their uteruses? I mean, that sounds crazy, but what's the procedure called when you remove a uterus? Uh hysterectomy. Yeah, because we remove the hysteria when we remove the lady parts. That was medicine. And if we didn't challenge that then, we'd still be doing that today. So there needs to be some level of challenge. But again, the challenge needs to come from a good place. And when you have over 200 articles over the past, I would say 15, 20 years that say this stuff works, and you look at the risk and benefits, and you're like, what's your worst? What's your worst outcome here? And the likely worst outcome in a clinical setting is the patient has living their worst outcome. That's them. Why not try it as a first line? Why are we trying that three years down the road, 10 years down the road? Man, I have patients that have been on therapy and drugs for 20 years. So yeah, do I think do I think that patients are treatment resistant? Some of them. Some of them are. Do I think most of them are? No. And the proof is in the pudding. We're doing good work, we're seeing good results. You know, they're more, way more apt to to uh behavioral change while on ketamine. So we pair them up with good therapy, we change, we, and and again, you create change and then outcome changes. And that's what people are looking for. They're looking for outcome. They're not looking to feel better, they're looking to not feel bad about the life they're living.

Safety Myths And Public Misconceptions

Dr Andrew Greenland 21:29

Thank you. So casamine has been used medically for decades, and there still seems to be a great deal of misunderstanding surrounding it. What is the biggest misconception about catamine therapy in your experience?

Dr Jacob Silverstone 21:40

Um it's risk, it's danger. Um, I think that's the biggest misconception. You know, if you speak to anesthesiologists and emergency room doctors, even paramedics, especially the military guys, they don't understand why people are making a big deal out of this. You know, um, if I were to do a massive reconstructive surgical Surgery, which I did many of, I would discharge the patient with likely a combination of three drugs in order for them to be able to sleep the night. And that would be, you know, some level of high-level opioid, whether it be oxies or perks. I would give them some benzodiazepine to break the sleep issues. And I would probably give them some other form of narcotic in order to accommodate breakthrough pain. And I would give them this prescription for at least five days before they would follow up with me. And in those bottles, if they were to consume all of that, they would die. I mean, I would give them enough medication that if they decided to overtake the medication as prescribed, it was lethal because opioids will disrupt the respiratory system. It'll just drop it. You're not going to breathe anymore, you're going to die, right? Ketamine, we're dosing it in what's called a subanesthetic level. So we're not even touching the anesthesia levels. And the anesthesia levels are super safe because there's no respiratory rate drop. Like it doesn't affect the respiratory system, right? Like it's very common for the ICU doctors to use ketamine specifically for that reason, especially during excavation, because it bronchodilates. It's a good drug, it's a very safe drug. The problem is that people see medication and treatment as high reward means and equals high risk. So because we're saying there's a lot of high reward to this medication, they're assuming that this drug is a high-risk drug. It really isn't. It's an incredibly safe medication, especially at the dosages that we give it. So we're not even going near those danger zones. I think the biggest misconception comes from, you know, a certain vernacular that is presented publicly, like, isn't that a horse tranquilizer? Well, yeah, ketamine is an anesthetic that's oftentimes used in veterinarian medicine, as is penicillin, oftentimes used in veterinary medicine for infections as well. And we don't go around saying, wait, isn't penicillin a horse drug? Well, yeah, I mean, there's lots of medications that are used both veterinarian and in uh human consumption. Um, so there's that level of derogatory connotation, and I think that comes from its history of being used in the 70s, and the way that it was available to people was through the veterinarian system. So there is a negative connotation in the sense of abuse and misuse. There's a negative connotation in the sense of danger, and then there's another misconception in the sense where, because it is classically considered a psychedelic, though it's not in the same realm as certain other psychedelics, people make an assumption that, well, this can make me go crazy. What if I come out not being me after this treatment? And the answer is no, that doesn't happen and never will happen. What we do and what we hope to acquire uh through the treatment is for you to be a clearer version of yourself, not a more confused version of yourself. It allows you to be a lot more informed about who you are, and there's a process and what how and that and why that happens, both through the experience and through the science. So I think the biggest misconceptions would be the danger, the whore stuff, and then the can it make me go crazy?

Who Benefits Most And Who Struggles

Dr Andrew Greenland 25:40

Thank you. Have you worked out um being able to stratify which patients um benefit the most from the treatment you provide from the experience you've had?

Dr Jacob Silverstone 25:49

Yeah, I'm gonna inverse that question and I can spot who my failures are gonna be a mile away. Yeah. Um, so the ones that I really struggle are the true personality disorders. Um, and there are there are patients who have I have experienced that really do require um a cocktail of medication, and those are who the psychiatrist should be really, really working on because some of these guys, like, I don't know what cocktail is gonna is gonna crack that nut, you know, for lack of better terms. It's hard. They're really, really difficult patients. They come desperate, and I look at the family and I'm like, yeah, I don't know, I don't know that's that that I'm I'm gonna be the one that helps. Um, another another group is, and I I rarely, rarely see these guys, but every once in a while a true narcissist will show up. This does not work for them, it never will, because this exposes you to you, and that is a very painful experience for a narcissist. I've had two narcissists come through my doors, both of them terminated treatment, mid-treatment. They were not okay with it. Um, it is rather uncomfortable to see yourself for the first time if you are one who is unwilling. And then my toughest, toughest patients are the true OCDers, the ones that have intrusive thoughts that they just can't shake. And that is because ultimately there's nothing that satisfies um the OCD thought. It just doesn't. Eventually, time and sitting in the discomfort will help. Um, but till now, with the exceptions of we're starting to see maybe GLPs are very, you know, early stages helpful, um, OCD is tough. For everything else, um, this is this is just like magical for your PTSDs, whether it's chronic PTSD or single event sexual assault, you know, military trauma, PTSD, firefighter trauma, PTSD, rape, mugging, violence, PTSD, really, really helpful for that. Um, you know, your run-of-the-mill, depression, which oftentimes you're not really depressed in the clinical sense. Life isn't great, and you're dissatisfied, you're frustrated. Um, your anxieties uh works really well with that because it shifts the way that you see depression and you see anxiety and gives you the ability to navigate through things and out of things. Bereavement, I deal a lot with bereavement, whether that would be loss of job, loss of spouse, loss of relationship, loss of limb, um managing through chronic pain. Oftentimes, uh, you know, chronic pain patients three, four years out, their mental health is 100% neglected, and all they're being treated on is on a single cycle of uh you know, one pathway. Um, it works really well for them. Um mostly, again, the resistance I see is true personality disorder, narcissist, and I struggle with OCD.

Dr Andrew Greenland 28:47

And how do you measure success?

Measuring Success Plus Boosters Over Time

Dr Andrew Greenland 28:49

I mean, you've talked us through the kind of the treatment journey while patients were at the clinic, but it's really interesting to know how you measure the success and what does the kind of the after treatment look like in terms of the psychological support and what happens when they leave.

Dr Jacob Silverstone 29:01

So this is this is the beauty of it, right? So, first and foremost, uh, I would say uh well over majority of my patients are the worst of the worst, meaning they've been down the road and the system has failed them. So I'm not getting the easy patients. I could only imagine if this was first-line treatment and how we would manage those guys and how our numbers would climb. We're literally getting the hardest of the hardest, the ones that you know have fallen through and and and have finally allowed themselves to take a stigmatized treatment. Um, so the way that we measure is simply subjective. There is no objective measurement when it comes to you know success with patients. They will tell you and you can see it and they will share with you. So, for instance, a patient says, I don't want to get out of bed anymore. And then they're applying for jobs. That would be a measurement of success. A patient says, I can't, I can't go on. I need this person in my life. Um, I have to get her back, I'm I'm and just obsessive over this relationship. And six months later, they check in with us, and they're uh not obsessing over this person anymore. That's a success, right? So we measure success 100% subjectively. We we in the the uh initial stages of treatment, we really push patients to say, uh, who do you want to be? Who is it that you're looking to be? What is it? Not who are you and who were you? Who are you five years from now? Where do you want to be? And if you're in motion towards that direction and those repeated patterns have been lifted, you're a success. And that's what we keep seeing over and over again. Um, I I joke about it, but we have the worst, the worst business model in the world. Our ultimate goal is to not see you. Typically, how this works is we have what's called six loading doses. So you get six sessions. Depending on where you are, we we kind of um I guess uh cater to each need. So if you're somebody who is suicidal, we're gonna want to have those sessions much, much closer together because we're also relying on the chemistry side of things. If you're somebody who is non-suicidal depressive, the first two or three are gonna be a little bit closer together, right? Takes a little bit of effort to get that boulder to budge, and then we're gonna spread out the remaining sessions over a course of you know two to three weeks. So six sessions over four to six weeks for somebody who is not suicidal. Um, and that reason is because we want life to get in the way. We want you to be challenged for the changes that you're starting to implement. So treatment is quick, and the changes happen rather rather promptly. Um, so I would say anywhere from three to six weeks, depending on the severity of where you stand. Then we do what are called boosters in the industry, that's what you refer to, or maintenance dosing. Um, and we see those roughly for the first six months to one year, anywhere from once a month to once every two to three months. And there's a reason for that. And the reason we do it is very simple because when you start implementing changes and you start creating opportunity for you to be evolving as the better version of yourself, it doesn't mean that all the other stuff that you've done up until now, your previous timeline, is erased. So oftentimes people will think, I'm doing the work, I feel better. Why am I still putting up with all the same garbage that I've been dealing with my whole life? Why aren't my relationships better? Why aren't right? And that's because the shoes dropped. You got to deal with the consequences of old behavior as you're creating new behavior. So there's oftentimes a period of frustration between six months to a year where you're dealing with old stuff while you're capitalizing on the new opportunities, the new changes with the new stuff. So the metaphor I oftentimes give with that is if you've got a failing business and you bring a consulting team to come in and they give you all the ways on how to manage your finances while you start implementing them, great, you're no longer hemorrhaging your funds and your capital. And then you eventually start profiting. You still gotta cover the debt. So that's kind of how life works. So for about six months to a year, we provide continuous support through you know the neuroplastic effects of ketamine in order to maintain the changes. And then after that, we usually just get a really nice Google review on that and we're done.

Commercialisation Risks And Investor Pressure

Dr Andrew Greenland 33:57

Thank you. And when we spoke before, you mentioned some of your frustrations around the way the ketamine industry is developing, particularly the involvement of the large investor-backed companies. So, what concerns you most about the commercialization of ketamine treatment?

Dr Jacob Silverstone 34:11

Again, once you start dealing with um spreadsheets and you start looking at finances, you're starting to work on algorithms. And the mental health industry cannot be an algorithm. It just can't. Because once you start implementing algorithms, you're gonna start to have a volume-driven industry. And in a volume-driven industry, 60%, 40%, 50%, it doesn't matter. What matters is as long as you're earning, and that that that simply is gonna disrupt the flow of how this treatment functions. Again, you can't have a fun a foundational algorithm in the mental health space. It just doesn't work that way. Can you set up systems to allow flow to be a little bit better? Certainly. But if now all you're doing is creating, you know, um initial evaluation, diagnosis, diagnosis leads to spravato, spravato leads to, you know, a patient retention of six months to a year, six months to a year of a spravato patient roughly translates into eight to ten thousand dollars yearly per patient acquisition. How much does it cost us to acquire? That's no longer medicine. Now we're back into the business world. So there's a concern that we're finally, you know, starting to get out of that landscape with mental health, and we're kind of getting sucked back into it. Now, I will be providing spravato. We are now rent certified in our centers simply because we're constantly getting phone calls for patients who want spravato, but the the industry is now trying to force ketamine back into an algorithm. And I don't love it.

Dr Andrew Greenland 36:01

So, how does an independent clinic differentiate itself based on what you've just been saying?

Dr Jacob Silverstone 36:07

Again, I I believe that currently in the early stages, um, you're not gonna notice much of a difference because a lot of the people that are in this space are passionate about it. They're they're the guys that are sticking their necks out because of the high level of stigmatization. The early guys are still gonna be the good guys. I think you're not gonna feel it for at least uh, you know, half a decade. But I do believe you're gonna see the psychedelic space being completely consumed and um and swallowed up by big pharma. It's just inevitable. And I think right now we're still in the romantic stages where big pharma is supporting it with some new medications, and you know, funds are are supporting it with finances, um, but we're not quite at the level where it's become jeopardized.

Marketing Limits And Finding New Patients

Dr Andrew Greenland 36:59

I would like to try and talk a little bit about the kind of the practicalities of running um a business in these podcast conversations. Sure. So what's working and particularly well at rewired ketamine? And what's most frustrating for you at the moment in your day-to-day?

Dr Jacob Silverstone 37:12

So the the most frustrating thing has been um the word ketamine itself. Um it is our biggest limitation, right? So um it is still considered a um a banned word from meta and Google, or not banned, excuse me, restricted term. That's the proper term. It's a restricted term through Meta, through Google. So our our capabilities of outreach to patients to inform them that this treatment exists is very limited. If you were typing suicidal ideation or depression, mental health clinic are going to pop up through your Google research. If you type in um depression, suicidal ideation, ketamine will not show up because it is a restricted term. You have to specifically be seeking out ketamine therapy, ketamine near me, ketamine IV, ketamine in Aventura, ketamine in Miami for me to show up. As such, there is a very large audience that is very unfamiliar with this. And in the business terms, patient acquisition is damn near impossible because you can be absolutely the best at what you do. But if you don't have a way to let people know you exist, it is futile. So our growth is highly dependent on education, and our education is highly limited because the site world is limiting it, the advertisement world is limiting it, and the press absolutely, for a large part of this, is not happy with this space because they continuously showcase whatever adverse effect people who misused ketamine outside of the clinics, like Matthew Perry, it's a much more exciting story for journalism. Um, so we have a lot of challenge in being able to let people know we exist. And again, we're we're this this is this is you know signing the deal with the devil because now that we are a REM certified facility and we do offer spravato, now we can go to primary care and say, hey, if you have any identifiable treatment-resistant patients, you hear the language we have to use? It's gross, it's disgusting. We are now somebody you can refer us to. So yeah, those that's the biggest limitation. Biggest limitation is is uh patient acquisition, and patient acquisition means letting people know that we are an available service to them that functions, that works, um, and is safe, and we just can't get out there and tell people.

Dr Andrew Greenland 40:00

Got it. So, with all that being said, where do most of your new patients actually come from?

Dr Jacob Silverstone 40:04

Still, till today, it's going to be through um uh Google. They're gonna search up Ketamine because they've been informed at some point or another, and they're gonna find me. That's it. That's my primary source of referrals. I have a couple of colleagues that are now warming up to it, um, but it's primarily self-referral, self-referred.

Dr Andrew Greenland 40:31

And where would you like the practice to be in the next 12 months or so? What's your kind of plans for the future?

Dr Jacob Silverstone 40:36

Um, so that's a great question. Now that we're starting to again get in bed a little bit with the devil and doing spravato and with REMS, we uh we anticipate in um hopefully shifting from a ketamine clinic to more of a mental wellness center. Uh, we now have a psych nurse practitioner who works with with us, um, and her philosophy is very much in the same alignment as ours. So perhaps to capture the patients before they're noted as treatment resistance and getting the primary referral into our system and allowing patients to not necessarily fall into psychopharmacology for the rest of their lives and at least attempt to try a better way of doing things.

A Better View Of Anxiety And Depression

Dr Andrew Greenland 41:27

And in closing, um, if you could change one thing about conventional mental health care, what would that be one thing like conventional?

Dr Jacob Silverstone 41:37

Oh um uh I I would I would get rid of the word um I I would man that's a tough one. Um I would I think I think it's still um I would I would remove a derogatory connotation to the term depression and anxiety. Um the fact that those are labeled as negative um completely, in my in my opinion, is the root cause of why we're in this mess. You cannot convince me that anxiety is bad. Um in general. There are times where, yes, anxiety is is inappropriate, but there are many times where anxiety is really appropriate. And the reason we don't like it is because it's uncomfortable and painful, but it is very appropriate for you to feel anxious when you feel a threatening body in the room approaching you is very healthy. There's nothing wrong with anxiety. There are times where it's inappropriate, so certainly that is something that we can talk about and address, but to generally call depression an anxiety in a negative sense, I don't love that. I really don't, because we are we are creating an idea that even negative emotions are always inappropriate. Dude, if you lost your grandmother and you're really, you know, you're really sad about it, and you're really suffering through the bereavement process and you're really not doing well, um, that's not depression. And in fact, if you were depressed about it, I would say that's appropriate. Go through the process. So for me, it's just understanding that anxiety and depression shouldn't be seen as negative, it should be seen as appropriate or inappropriate.

Dr Andrew Greenland 43:32

With that, Jacob, I'd love to thank you so much. It's been such a fascinating conversation. I think what makes your perspective really valuable is that you've experienced conventional medicine from the inside and you've also been willing to question some of its established practices. It's been very interesting hearing about how you use ketamine safely and responsibly and give us a very balanced and informative and educational account. So thank you so much for your time today. I really appreciate it.

Dr Jacob Silverstone 43:54

It was an absolute pleasure. Again, anytime anybody gives me the opportunity to inform and to educate, uh I don't take lightly. So I thank you in return.