 We are live and it is so great to connect with you here I love the bright yellow color like we were saying before you're in Michigan i'm in boulder and today we usually have sunshine but today it's about one degree. And outside, and it is very, very, very cold and there's no sunshine so and probably same in Michigan right. In Michigan, we don't see the sun for a few months right now. I grew up in Illinois and so I remember there was like six months of mostly Gray so. doing the little my call it doing bloom season. yeah so we'll just intro for the little house keeping if you haven't watched our YouTube lives and Facebook lives here, you can catch all of them on my YouTube channel just under Jill Carnahan. On the YouTube and if you want more information on free blogs information, you can go to my website just Jill Carnahan.com and Dr Jill health.com but today I want to introduce our guest speaker. Sehar so Dan, who is a farm D and she obtained her doctor pharmacology degree and completed three years in biopharmaceutical research fellowship at the University of Michigan. She started her career as a clinical pharmacist for the inpatient head and chronic pain service at Chelsea Community Hospital and then progressed to director pharmacy. In 2001, she founded pharmacy solutions in Ann Arbor, Michigan, a unique personal and educational specialty pharmacy and serves as president and CEO. In addition, she's clinical associate professor at the pharmacy of pharmacy at the University of Michigan College of pharmacy. She's board certified and advanced fellow and anti aging and regenerative medicine and internationally known speaker in the areas of pain management and bio identical hormone replacement. She's also the author of several books, one of which we'll be talking about today. I'm just so delighted to have you because this is a topic that we need more information on for all the people listening today and that's pain management options. And you've just got done writing a book about this. So tell us what brought you to write the book about this. Well, I always tease you know, I've written, you know, many, but you know, several books with with my colleagues book chapters and lots of research and publications. And I always sees it's like having a child, you always say you do it once and then you go, I'll never do this again. And then you end up doing it again. So with the book, it's the same thing. I really felt like mainly honestly with the humanitarian effort to really help teach a lot of, you know, advanced tools or additional tools at least in our toolbox for pain management. As we know, the opioid crisis has been really highlighted, you know, especially more recently, I really think we had an opioid crisis all along. This was nothing new, but it was very highlighted more recently. And then a lot of doctors were kind of, you know, really basically told, okay, we need to get away from opioids prescribed. We can only use them much more judiciously, which should have always been the case. But also now we really took one of the tools away and we have, we've had tons and tons of patients on these opioids for years. And now they were basically naked, if you will, you know, they had their opioids taken away. We didn't really teach our colleagues and a lot of us don't know some of the additional tools that are available into our, you know, functional, integrative, holistic medicine world, if you will. And I just really wanted to kind of provide, you know, our colleagues and clinicians and patients, some additional tools to just really look at so they can add to their arm material in the treatment of pain management, you know, and pain, you know, as you said, Jill, I mean, basically it's the, it's the number one and number two leading causes of disability worldwide. So back pain is the number one cause of disability worldwide and migraines actually number two. So, you know, I've always worked in this field and in pain management and it's very disabling. And really in school, all of us learn, you know, what do you use for pain? Well, you use, you know, non-steroidal anti-inflammatories, if you will, opioids and oh, ice and heat too, basically. And that's kind of what we were all taught. And now you kind of, the opioids came off and a lot of those patients and clinicians were really kind of stuck going, well, what else can we do? And this was really the main crux of the book where I brought some of my colleagues from around the globe that are really doing some really unique innovative additional tools that we can provide our clinicians, you know, with these additional tools that they're already aware of with the medications and physical therapy and other, you know, traditional things that they used to kind of just add to that our material to give them tools and the patient honestly tool help and hope, as I call it. And so that was mainly why it was the kind of, you know, I tease the humanitarian efforts here to bring all these clinicians that are very passionate about this and we pull out about collective mind tools and skills into this book called Advanced Therapeutics and Pain Medicine. I am so excited. And of course, we're going to link your link to your book and your website here and then on YouTube and everywhere that we show the video, we'll be sure and share so people can get more information or purchase a copy. But first of all, I'd love to hear about first we met with A4M and several other organizations where we teach for and I just love you bring such a wide breadth of knowledge. And because of your pharmacy background, what I've seen for you to someone like me as a clinician is you bring what are some ideas of how we can approach prescribing and using whether it's compounding or other things to get some unique things that will help our patients. It's like you give our toolbox more tools that we have to use. So pain management, we've got things like fibromyalgia, chronic migraines, we have just in general pain from back issues or other things. And again, what we used to have was opioids and we're getting a lot more regulations on that and difficulty prescribing. So how would you first approach someone who's had chronic pain and make recommendations around some of the tools that they would have? So say someone who had a back injury and either had surgery never fully recovered or still has chronic back pain. Let's just use that as a classic example. How would you approach that patient or make recommendations to physicians? Yeah. So even if it, you know, obviously, I was a pleasure to lecture with you and we've lectured in a lot of circles together. But I think, you know, in our word will first and foremost, we always look for root cause, right? Because a lot of times pain is the symptom and masquerader of other things that kind of lie underneath. So, you know, I always kind of just like you always, we look for root cause. What could be causing this? Now with chronic pain and pain management, and that's why honestly, you know, 20, I'll age myself now per se, you know, God, probably what, 20, 25 years ago when joint commission, you know, started that pain is the fifth vital sign. Remember that, you know, I was literally flying all over the world or the country to try to implement pain is the fifth vital sign in the regulations and things like that. And then now we're kind of honestly flying it just as fast to kind of unwind that. And I think it's important to know so, you know, we always whenever somebody complains of pain and please remember acute pain management is very different than chronic pain management, right? But that's why it's also very important when a person like injures their back, for example, let's take that as an example. You know, we want to be aggressive and treat that, find the root cause if we can fix the issue, you know, help them because the more pain that people have, the easier it is for pain to continue, flourish and expand if you will. You literally almost build like pain highways as I call it. Because if you keep bombarding that same track, so if you have a highway that's constantly being bombarded and congested, what are you going to do? You're going to go to offshoots and try to get, you know, off the exits or different exits to try to bypass that and really kind of sprout new pain pathways. And that's why, you know, sometimes we have patients that start with back pain. And then, oh, my God, you know, they got knee pain and oh, all of the sudden now, you know, they have their whole body hurts. It's like, oh my God. And then, you know, furthermore, or they have migraines or they have a lot of these comorbidities. And because once the pain becomes what we call centrally sensitized in the brain, because remember, you know, pain signals go up the spinal, you know, spinal tracts, if you will up to the branding, knock on the door and say, hey, you hurt and pain is not bad, right? The pain is the body's internal warning system of telling you, hey, something is wrong. You need to address it. But when it's that constant bombardment of pain, that knocking at the door and we're not addressing it or fixing it, the brain becomes basically centrally sensitized. And then we cause what's called neuro inflammation or kind of fire or inflammation in the brain. And so it's kind of like, that's why when people have pain, they tend to get other pain syndromes much more easily. It's kind of like when you have a cup and you keep sticking your hand in vinegar water or salt water or something is going to keep aggravating it. And that's why it's very important for acute pain to address it, fix that and stop it from continuing so we can stop the central sensitization phenomena, because then it's much harder to treat. Yeah. So say we have a, you know, acute pain and the opiates are perfectly appropriate for these kinds of conditions. It's just that the long-term use, there's, you know, other options and things. Would you start with like in my field, let's start first root cause real quickly. Let's talk just a little bit about that. Of course, autoimmune inflammation, the gut and dysbiosis and issues there, environmental toxicity like mold, infections like Lyme disease, all of these things can create pain pathways and worsening pain. I've seen mold cause neuropathies. I've seen it cause zingers and ice pick pains and severe migraines, headaches related to histamine. I've seen gut issues cause chronic pain and issues there. Of course, Lyme co-infections, all these infections can cause pain pathways. So the first thing you probably recommend is having your functional doctor look at other things that are root causes. I know that's what I do. But what about like actual prescribing or alternatives, maybe even natural? Let's talk first about prescription options and then we'll go to like natural substances and things that we might use for pain. Yeah. So, you know, and just kind of a point on opioids. So this has been well known and this is not, you know, anything new is there is a phenomenon called opioid induced hyperalgesia. And what that means is actually the opioids can cause more pain. So then we have more pain, you use more opioids to try to trump the effect, if you will. And so sometimes patients get stuck, if you will, to the cycle in this opioid induced hyperalgesia, which could be one of the propagating symptoms, you know, for the pain. And that's why it's also important to see is that the issue? The other thing in our world, obviously, Jill, as you know, is opioids can also also chronic not acute. Now, again, we're not talking acute because exactly short term use for post surgery, post dental stuff, post, you know, acute injuries, of course, you can use opioids for that, but it's the longer term. They can also cause endocrine dysfunction, which we know hormones are very helpful in modulating pain and inflammation also. So opioids can cause actually hormonal dysregulation, which can also propagate the pain, you know, the pain symptoms. So as far as you know, what do we use? So obviously, historically, you know, honestly, what we had, I always called it with band-aids, right? We had band-aid medicine, not necessarily fixing the root cause, but try to help. So some of the things that we use besides, you know, the typical anti-inflammatories, right? Like, you know, the nonsteroidal anti-inflammatories, steroidal anti-inflammatories, you know, the acetaminophen in Tylenols of the world, and those kind of things we've always used, obviously, it's kind of over the counter type, help over the counter. Some of the prescription medications, obviously, you know, people are very familiar with those. We've always used kind of the antidepressants or that class of drugs that was used, the anti-seizure or anti-epileptics were kind of repurposed, you know, for pain management. Some of our, each of these classes, because we've got physician listeners that will know those classes and we've got a lot of patients and laypersons that won't know what they're talking about. So for those classes, let's give examples of each one. Just even, so you mentioned like Tylenol, which is nonsteroidal, and then also like, yeah, you like nonsteroidal, it's kind of like your typical motrin and ibuprofen and kind of proxthiplasts, you know, the Tylenol or acetaminophen type group, you know, and that was really kind of mainly over the counter. And then you have a lot of those like icy heat, you know, cooling, warming type, you know, sabs and ointments that patients, you know, would use, obviously. Now, some of the prescription medications for the antidepressants, you know, people are familiar with those like, okay, the prozacs of the world, the packs of disembolters or galoxicine of the world. So these kind of what they do is, you know, obviously, they kind of help modulate brain chemicals, right? So the goal here is we can modulate, maybe increase your happy hormones, as I call it, increase serotonin, which kind of is in ants. So studies show exactly that lower serotonin or lower dopamine not only induced depression, but more pain. So there is a correlation with the neurotransmitters. Like you said, that lower levels may be, you may be more prone to pain syndromes. Yes. And so with pain, you know, you have what we call excitation and inhibitory pathways, right? So either you got the volume turned way up and our goal is to kind of tone the volume down. So you have these pathways in your basically spinal tracts and brain, literally that they're called excitatory and inhibitory. It's like, I amplify the signal or I turn it off. So serotonin, dopamine, it kind of help modulate it and kind of turn it off. And so our goal is to kind of turn the volume down with these drugs and increase the inhibition or the calming down of these signals. So some other things that we've used, you know, the anti-epileptic drug class or anti-seizure. So the big one that's probably used for pain, like a lot of people are familiar with is GABA pentane or Lyrica pregabalin, you know, but we've used a lot of the other anti-seizure medications, you know, like the Tegritol type class and Lamexil and things like that that we use for different pain syndromes and Kepron, those kind of medications that are used. You know, sometimes even blood pressure type medications would use the pain management in migraines, like the ACE inhibitors, like, you know, examples of Lycinoprel or Candiesartan has some data published in migraine, you know, calcium channel blockers have been used in certain, in beta blockers, you know, like verapamil and, you know, etinolol and those kind of drug class can be used in various pain syndrome and migraine syndromes and stuff like that. So that's what it was always, you know, they're definitely for something else, but we've repurposed them to try to help with kind of, and sometimes we've used it with certain pain syndromes, like, you know, CRPS, which is a specific neuropathy, probably one of the worst neuropathic, if you will, you know, or neuropathy pain of all kinds of causes, fibromyalgia, which is a really subtype of small fiber neuropathy. Sometimes we use kind of these like anti arrhythmia type drugs, things that kind of help regulate your blood or your heart conduction or your heart electrical signals, if you will, kind of to help with these pain signal transmissions that we've used also. So that's what we've always had it really at our fingertips where drugs were different things, but we tried to kind of modulate either the electrical signals, increase your happy hormones or increase the effect of the calming, you know, drugs on your calming down pathways, you know. And in that way, it's also important to continue to do that, you know, for as much as we always love to use our, you know, integrative functional medicine, you know, always do the lifestyle, find root causes, supplements and vitamins, you know, physical therapy, saunas and all this good stuff that we will talk about. You know, sometimes we really need these additional still, you know, pharmaceutical and pharmacological tools to kind of get in the brain, if you will, calm down the central sensitization. And that's how we really achieve longer lasting and true treatment of the cause and not just band-aid it. So you did a fantastic, fantastic Java kind of overviewing pharmaceutical, which again, there's such a place for those. Let's move. I want to talk about non either met or herb options, which there's a lot as well. Let's talk quickly about herbal and other options. I've seen such great benefits. And I know like the off the top of my head, turmeric and curcumin are so powerful into inflammatory. I love Boswellia and personally that one actually does better for me than turmeric. And then there's combinations of nrf2 modulators and things which are pathways for inflammation. What are some of your top like favorite herbs and combination products? And there's CBD, which is a whole other thing. I would love for you to go through just like you just did some of your favorite kind of anti-inflammatory herbal or other types of things that are natural substances. Yeah. So absolutely. I mean, we always focus on the gut, gut, gut as I always say. So when in doubt, I always start with the gut, so definitely, you know, we really need to fix that. So I love probiotics because we know they can help cut, but we know they can also modulate the immune system. And we know a lot of times it's immune dysregulation that also kind of trips the immune system and propagates the pain syndrome. So I love probiotics, digestive enzymes. Now also digestive enzymes. Yes, we use them in our world to help digest food, but actually if they're taken on an empty stomach, they're very anti-inflammatory. And there's great data out of Germany using, and there's very specific actually digestive enzymes, Wolfenstein, that there's a lot of clinical trials that were done on those as an anti-inflammatory for pain management, you know, mainly. So I love those to start with. And then some of these other herbal type stuff. So anything that exactly reduces inflammation. And unfortunately nowadays, we're all swimming in a bath of toxins, as I call it. And so our systems are all upregulated and inflamed. And so things like curcumin and curcumin does interact with certain medicines. So as a disclaimer in the beginning, always double check with your clinicians, with your healthcare provider, your doctors, and your pharmacist to make sure the medication regimens that you're on does not interact with these natural supplements because a lot of times patients think, well, these are natural. They're not going to do anything or do anything with my meds. And I always tease and remind patients, I don't, well, I say cyanide is natural, too. And look what it does to you. So it's very important to make sure they're not interacting and obviously at first waste. So curcumin, I love, as you said, Jill, it's very anti-inflammatory. It really helps. A lot of clinical trials have been done with that one, too. You know, different pain symptoms, autoimmune disorders, and it can be very helpful. Boswellia, love, love, love. We use this one tons actually more in our migraine patients because absolutely in some patients, it tends to work very much better for them, like you said, for you. But also it penetrates the blood brain barrier a bit better. So for migraines and other neuropathic type stuff, I tend to like Boswellia for those, you know, same reasons also. That's so interesting because I did not realize. And then there's one other thing with tumor. Most people do amazing. And that's even got anti-cancer benefits, anti-inflammatory benefits. But for some persons like myself who have a little bit of histamine issue, sometimes curcumin or tumor, it can be a little bit histamine inducing for the mast cell patients. And then I find like you said, the Boswellia is a better alternative just for those subset, even though I would say 90% of people do really well in tumor. Yeah. And like with the Boswellia, the five blocks in extract, like, you know, and also with supplements, as you guys know, you know, there's a huge difference in quality out there, right? It's very important to get quality vetted professional line, you know, like the jills of the world and many other, you know, people to make sure that it's a good quality supplement that's well vetted and also pharmaceutical grade, because there could be sometimes impurities that could be harmful, obviously to you, not helpful. And that's why sometimes I think it's, you know, we see a lot of the European studies, they'll show great benefit. And then when we do the trials in the United States, things show no benefit. Then I go, well, how can that be? And a lot of times it's really due to the quality of the supplement, because our process here for supplement approval is very different. And I love that you mentioned the German enzymes. So these are proteolytic enzymes and basically proteolytic enzymes have the ability to kind of, if someone has, you know, soft tissue, lipomas or tumor growth, they tend to chew up some of that tissue and in the sense of, and they're very anti-inflammatory. So in the actual vascular system, they're, I always think of them like Bill Pacmans. They're actually chewing up, enzymatically just destroying some of those inflammatory molecules. So, and that would be really any, our favorite one, like you said, Wobensheim has some of the most data, and it's from Germany, I believe, but there's lots of proteolytic enzymes that are good quality that are similar in nature. Yeah, you know, absolutely. And then, you know, the other one, obviously, you know, fish oil, as we always say, you know, you can Google any disease and you'll find a study with fish oil, you know, again, very anti-inflammatory. Now, part of the fish oil, you know, is they can contain these SPMs or pre-resolving mediators. So I love SPMs. I was totally going to mention, because that is my favorite. If you guys haven't heard of SPMs, and now there's lots of manufacturers. One of the original was Metagenix SPM active, but there's lots and lots now. Now, Megasport has a mega omega, which is fish oil plus SPMs. And I think Designs for Health has one, and I'm probably forgetting to mention some other companies. But do you know any of the other ones that might be out there that are real good quality? I mean, yeah, I mean, a lot of those, like there's Omaprim, I know, and then Omega XL is another great one, actually very high content of SPMs in them. And, you know, they're looking at that. So yeah, Omega XL is another one that I use, you know, Omaprim is the professional line for positions with high SPM doses, also that's great. And SPMs actually act as an antiprostaglandin, which is one of the main pain pathways with both mast cells. So if you have mast selectivation and pain issues, or you just have pain from inflammation, that will be like the SPMs act as an antiprostaglandin. Is there any other mechanism that you know with SPMs? Yeah, so I mean, what's really nice about SPMs, again, I love them because they're really root cause that's why they're called resolving mediators. Literally, like they're not just band-aids, they really try to kind of go like, okay, what's off kilter, if you will, in the immune system, what's viewing all these angry hormones, or these inflammatory mediators, and it tries to kind of level everything off. And that's why, you know, I really like them because of that. So that's, you know, another one that I love, you know, fish oils, SPMs, curcumin. I love also course it in, you know, you mentioned this, you know, jail with, because, you know, I always see that it's the forgotten side of the immune system. So a lot of times pain patients, like especially patients with migraines, patients that have, you know, elerdane loss or hypermobility syndromes, we tend to see mast cell activation syndrome very commonly in them. And obviously that could be caused either genetically from, you know, what's going on, whether it's mold, Lyme, and other things that cause mast cell activation syndrome. And patients with posture, you know, postural orthostatic tachycardia syndrome, we see this very commonly in them, what the crux of it in the root causes really this mast cell activation. And of course it's in, which is what you get from onions and garlic and all this good stuff that we all should be eating lots of, but great trials and kind of lowering histamine. And I always say, it's these allergy, you know, allergic type patients, you know, the patients that come into you and go, oh, I can only eat, you know, chicken, rice, and peas. And that's it. You know, really tune into mast cell activation and things like corset thing can be very helpful. And also in pain, because it's one of the inflammatory instigators of pain is another one. Methyl sulfonyl methane, I love. It's anti-inflammatory SAME, which what we call is the universal methylator. Owner, love it. Yeah, I love SAME. And SAME, just a note, it's so interesting because you talked initially about antidepressants having some anti-pain effect. SAME has been studied head to head in front of some of the major antidepressants like Prozac and Paxil, etc. And actually at the 1200 milligram dose, it really beat out symptom improvement of almost all the major SSRIs. So I love SAME for energy, mood, and anti-inflammatory pain pathways. Yeah, actually in Europe, as you mentioned, it's one, it's the number one drug antidepressant that's used. So it's approved in a lot of the European countries as a medication. And it's used by great data in pain and stuff. But again, be careful, you know, start low and go slow, because sometimes in your really toxic people, in your slow methylators, or if they have that genetic SNPs, when they're not mobilizing, you know, that wheel, if you will, sometimes because they start detoxing or over neuromethalating, and you can really cause a lot of brain excitation, they get agitated, anxious, you know, or they feel horrible, because now they start offloading all these toxins that they've been kind of begging and storing, you know. So that's an interesting thing, because I want to mention a little pathway here. And again, some of our listeners are really savvy to this. But when you over-methylate, you can, if you have an up-regulated CBS enzyme, so you might see that on your genetic detox pathways, you can produce metabolites that cause more pain. And I'll tell you, one of my little secret weapons was I do have a fast CBS. And so on urinary organic gases, I would always have high cysteine and tarine. That was one of the ways that you could tell. And because those are metabolites of that pathway. But interestingly enough, that caused more stiffness and pain. And malebdenin tends to detoxify that pathway if it's going too fast. So for me, malebdenin actually took away my pain and stiffness because of the CBS pathway. But that trace mineral malebdenin, you would never think of as a first line for pain, right? But, you know, the pathway with the CBS, for me, it was kind of magical to take that and be like, oh, my stiffness is gone. Yeah, exactly. And that's why, you know, personalized medicine, it's just, you know, we've been practicing it forever. But now it's making splashes even in mainstream, because it's exactly, it's all these little quirks that you find on genetics or epigenetics and things like, oh, we can really mobilize the different pathways and really, you know, help people. You know, the other one, like you mentioned with CBD. Yeah, you know, and so, you know, that's, that's a whole, you know, another 50 hour topic, but, but definitely CBD, I call it, it's the master orchestrator, right? It's the orchestrator doctor. So it kind of really sits on top of all your brain chemicals, inflammatory pathways, and it really tries to modulate them. And so I definitely, there is some, you know, good data on CBD modulating inflammation without, you know, the THC associated sometimes central effects that people don't like, you know, getting kind of dizzy, high, you know, and all these different things. So, and I'm not a huge fan of smoking, you know, just because of all the other additives, unfortunately, in toxins that patients will get. But I think CBD, a clean, organic CBD source that's been well made, you know, with CO2 extraction. So again, the quality here is, is, is pheromones, pheromones, you know, because there's so much garbage out there and dangerous, some of it garbage. It's very important to look for people that really know what they're doing with CBD. You know, it's organic because, you know, the marijuana plant requires a lot of pesticides and herbicides and things like that. So you want to get organic because you don't want to be increasing your toxin burden that can just continue to increase inflammation and pain. So that's another one, you know, that I love to use. The other one that I love to use, which, you know, great data out of Europe, you know, is it's called PEA, or Palmettoethanolamide, you know, that I love for pain. It's kind of like, especially for neuropathy sensitization, you know, fibromyalgia, because as you know, this heightened pain perception, yeah, because it's kind of like a CBD and a buzz wheel, yeah, and the course, it's an indicator type and kind of stuck together all and it really helps these different sensitization pathways and grade data. Like I said, we have over 35, 40 clinical trials on it. So, you know, some of these supplement companies, I think Life Extension and some of the other ones now are beginning to add it. But I love that one too, that I use a lot, especially like with fibromyalgia, total body sensitivity syndrome. One other thing I just thought of as you're talking about fibro, so one of the reasons that sometimes that tissue tenderness, this is not like a muscle specific or a joint specific pain, but it's that tissues, which is kind of like our, you know, connective tissue areas, even with acupuncture, the areas that it addresses, and that can be from lactic acidosis. So one of the things that's very simple, very cheap to help with lactic acidosis is either alkaline water or mineral water, and also calcium or magnesium lactate, which comes as cheap as can be as a supplement. And sometimes if you have that pain in your tissues and you have lactic acidosis, those very, very simple things will help some of that pain. Yeah, you know, maybe let's talk about fibromyalgia for lactic acidosis, but it's just because it's so common. Yeah. And you know, and so, you know, a lot of times really fibromyalgia, it's either usually kind of an autoimmune disorder that has not been diagnosed, thyroid dysfunction. And so then the body is kind of working on fumes, I call it, that it's not getting the cellular energy, or it's a mitochondropathy or mitochondrial dysfunction. And that's why they tend to hurt, as Jill said, so they're kind of like their cells are operating on fumes that don't have real gasoline. So a lot of times exactly, you know, magnesium, great clinical trials, you know, on magnesium helping. And I love magnesium part of here, you know, and I wanted to talk about it separately with fibro and just all pain syndrome. So, you know, when I told you kind of the brain gets sensitized in this brain inflammation, if you will, or hypersensitization. So there's these specific receptors called NMDA receptor in methyl B-sparket. So they're excitatory brain receptors, if you will, that propagate that signal. And actually magnesium is the gating ion that kind of shuts them down. And so magnesium is critical to put on board for any acute pain syndrome, unless they have heart blocks and other capable contraindications or kidney disorders where we have to be really careful and not use them and things like that. But what it does is it really decreases the likelihood of an acute pain syndrome, propagating into a chronic pain syndrome. So I love magnesium for fibro in any pain syndrome, lots of data on it in the variety, especially migraines and fibro, you know, cellular energy things. So magnesium lactate, coenzyme Q10, D ribose, you know, and then NAD, I wanted to talk for a couple of minutes about, you know, my favorite, I want to hear about NAD. So NAD because, so, you know, also I always say patients in pain are basically AMP 24-7. So cellular energy-wise, they're very deficient because remember the pain, their body is going, you hurt, you hurt, something is wrong. And literally, when something is going on like that in the body, just physiologically, your whole system is AMP'd, right? So it's in fight mode. And so they tend to be very deficient in cellular energy. And so a lot of times you'll be amazed when we give pain patients cellular energy with CoQ10 and acetyl-l-carnitine, you know, which are supplements and in D ribose and NAD, which I love, you know, you could use it, you know, like as a patch, some providers are providing obviously these IV-type infusions and more and more data is being collecting on it for opioid addiction and other types of addiction, you know, for detox. But for cellular energy, I love NAD. We have a whole chapter on that, you know, in the book, you know, low-dose, no trex zone, you know, we, you know, I love that. I always tease we should put that in the water because everybody has immune dysregulation now, unfortunately. And low-dose, no trex zone, which is a medication that was approved long time ago for opioid and alcohol, you know, addiction. But low-dose is very different. What low-dose does is it really kind of regulates what's dysfunctional in the immune system and really brings it to balance. And there's a lot of data on low-dose, no trex zone, also in a variety of different pain, autoimmune, you know, type syndromes, chronic pain symptoms, where it can be very helpful as an additional tool also. Fibromyalgia, because really we also think fibro, really more and more we're finding out it's probably a small fiber nerve, neuropathy or small fiber neuropathy. And, you know, all these other approaches that we've been talking about with fibro, like gut rehab and the inflammation and thyroid disorder and autoimmune type stuff and helping their cellular energy in their gut rehab. You know, the other tool that I use with, you know, fibro patients because, you know, if you come in and they go, well, I want you to eat, you know, paleo, organic, all clean, cook, you know, three clean meals a day. I want you to exercise an hour a day, you know, and all that stuff. And they look at you like you're nuts because they can barely move and they hurt so bad. So one simple thing in addition to these tools that we just gave you guys is go just in warm water pools. And I always tell patients to do that. I said, just go in a warm water pool. Don't move. I don't want you to even do anything. And you'll be amazed because it's even just the water pressure on the cells will actually push the lactic acid out and they just feel so much better from not even exercising like I know, because usually go, oh, I can do that. I'll go in and not move. And then when they feel a little better, I go, okay, why don't you just move your arms just a little bit, you know, and legs a little bit because we just need to get the lactic acidosis, like you said, out of their cells. And then they feel much better. And then we can ask them to do all these other, you know, good things that we want them to do. But initially, I see a lot of my colleagues do that and they just turn them off because they feel horrible and they're very painful. Warm water is just amazing for, or like if they can take, I call them detox baths, but, you know, warm water where they can put a little bit of Epsom salt baking soda. I have a huge fan of Epsom salt baths. I recommend them all the time because me first every single night, that's part of my nighttime ritual. And I'll recommend, you know, the Costco six pound bags or wherever you get them. I'll use a half a bag per bath. I mean, you saturate that water because when you saturate the water, that gradient will actually drive the magnesium sulfate into your skin and tissues a little bit more than you would if you didn't have that water saturated. And then the essential oils you can blend in there with, you know, lavender or eucalyptus. It makes a wonderful, not only stress reduction, sleep inducer for insomnia and pain management all in one. Exactly. It's like one of the best brain, you know, brain calming, you know, supplements, you know, trace mineral that we have, you know, even when you have people that are having, you know, sleep, you know, they can't sleep. That's the first thing I recommend because it's just so brain calming. I love lavender. I kind of choose lavender more than the other ones mainly because it is so calming. I mean, they've done studies on lavender essential care causing that theta wave, you know, in the brain causing that deep calm, you know, if you will. You know, oxytocin is another one, right? The love hormone for steak. And that's another one that's kind of making you. And you can get, as you know, with a compounding with your physician, you can get a component into a nasal spray or a lozinger. If you take it orally, it will not withstand the stomach. So you need to take it alternatively, either transdermal sublingual or as a nasal spray, but it does tend to be very powerful. What I found with oxytocin too is it can help to regulate ADH dysfunction in mold patients who have trouble with regulating their hydration. Yep. Yeah, you know, that's another one that's really making splashes. And it's kind of rebooting, I call it. So you know, when you have your reptile and the reptile brain part of your brain or the reptile, you know, part of the limbic system. And this is what we call, quote, unquote, the pain experience, right? Because we have patients that go, you know, my pain is really bad, but we don't see the physiological sign. And so sometimes it's really what we call this wind up and wind down phenomena of pain. And the hypothalamus, the lamic systems where oxytocin works in the limbic system are very involved. So it's kind of that, that system that gets activated, like when you are embarrassed, you flush, right? So it's an emotion that's translated into a physiological function. So kind of same thing, the limbic system gets involved in the pain experience or processing. And sometimes oxytocin and pain people are very helpful in kind of solving that. And this is related back to the serotonin pathway. It tends to be a adjuvant to serotonin as well. Let's just our last few minutes, I can't believe this is we could talk for hours. This is such a great topic. We might have to have part two. We're just like scratching the surface. But one thing I want to be sure and leave patients or listeners with that we haven't talked about is things that other than supplements and herbs and nutrients. And we talked about epsom salt baths. What are the things? Have you found any sort of other therapies that are really powerful for pain? What would be like your top three alternative types of other treatments that might be helpful for pain? Yeah. So, you know, absolutely acupuncture, right? We have a lot of data on acupuncture. And we use that a lot, you know, physical therapy, myofascial release, you know, those types of things, craniosacral, you know, I, you know, I love, you know, all of those types, you know, services. So absolutely additional type tools, you know, but I just want to comment real quick on craniosacral, because I found most of my patients, I see a lot of environmental toxicity, Lyme disease, mole toxicity, and their limbic system is upregulated all across the board. 100% of them have a limbic activation, which is the fight or flight. And that definitely if there's pain underneath will make the pain worse. So I love craniosacral for one of the ways for limbic retraining. So basically calming that limbic system. And it's a passive therapy versus going online and doing a course, which I think could be great too. But I love craniosacral for the sense of someone can actually receive the treatment versus going out and doing one more thing. Yeah, you know, absolutely. I love that, you know, just anything that activates also, you know, like meditation, you know, we want to turn up that serosympathetic response, especially in anything, but in pain patients, because they're so parasympathetically driven, like they're in the fight mode all the time. Like, you know, I love anything meditation, nature, calming prayer, you know, chitang, whatever, whatever's your happy zone, I call it, find it and do it at least twice a day, because there's a lot of data showing how we can activate the parasympathetic system. And that also modulates the pain signal, you know, it's kind of the rest of the day. So, you know, I love that we know stress reduction, definitely cortisol, you know, in adrenal dysregulation is very involved in pain and inflammation, right? So definitely, you know, so we think, you know, you know, physiological or psychological stress, whatever the body doesn't know, it just goes right fast, right? So anything that modulates the adrenals, the inflammation, the stress response, because that sprouts inflammation, we know when we have adrenal dysfunction, that also we don't have as well of a breaks on inflammatory pathways. And so definitely working on that system. So whatever your happy spots, you know, adrenal herbs that patients, if people are listening, a Brodylla is a great one. Phosphatidylcholine is another pathway, but that can be helpful too. And then Magnolia or Honocoil is another one that I just love for modulating higher cortisol levels. Yes, you know, absolutely. And that's what's nice about these adaptogens, because if cortisol is high at low, if it's low, it brings it up. And so it really kind of modulates into that happy zone along with, you know, stress reduction, better sleep, you know, sleep is critical for pain management. So getting quality of sleep, you know, we're using more and more melatonin. Obviously, if you need it, if you don't need it, you don't need it because your body makes it. But we used to think melatonin was just kind of, oh, it just puts you to sleep. And now we're finding a lot more of its anti inflammatory antioxidant and immunomodulatory effects. New studies coming out of melatonin. And melatonin. So just, you know, sleep. So that's all the good stuff that we all should be doing, you know, less stress, eating better, eating healthy, clean anti inflammatory diets, you know, acupuncture, craniosacral stress reduction, good sleep, lots of water, hydrate, hydrating pain, you know, again, you know, sometimes, you know, we forget about that simple things were made out of, you know, 75, 70, 80 percent water, right? If you don't have good lubrication in your joints, you know, that's gonna hurt. And so even just water and those, you know, typical things that we forget about that's very important to remind all of us, including us clinics, you know, to do and also, you know, help remind our patients to do, you know, and a lot of times, you know, you really have to do this into, you know, a cohesive approach, because sometimes just one, you know, tool and one dark is not going to fix it. But a lot of times we get high success levels when we really integrate a lot of these different tools and kind of hit these different pathways. The things you want, like a one size fits all. And as you heard already in this 45, 50 minutes, there are so many levels and layers and just like mass selectivation treatment or detoxification, there's usually no one pill that's going to do all the pathways. So it may take a little trial and error to get this. We have just chocked full this interview with information. Where can people find more about you? And where can they get your book? Yeah, so absolutely. Good old Amazon, like everybody writes, you can find the book on Amazon, my website. And say the title again to people who didn't hear it. The title of the book is advanced therapeutics and pain medicine. And my website specifically is sahar.world, so S-A-H-A-R dot world, W-O-R-L-D. And that's where you'll find, you know, a lot about me, the book, the skincare line that I have, you know, I get I'm very passionate about clean living, you know, kind of like Dylan. So that was my other, you know, fun side project to make, you know, skin foods that kind of speak our language with clean living, if you will. Because again, just like with anything, you don't want to be slapping, you know, all these toxins on your body that you use every day and every day, you know, whether it's your cleaning products, your skincare products, your hygiene, you know, daily hygienic products and so on. So that's where you can find all about me and all the lectures that we always do myself and Dylan in our different circles. Yeah, so I will link up here and below on YouTube, you will find those links. And like I said, I think we're in actually part two, because there's so many good questions in here. And everybody's asking about more information, so I will be sure and direct them to your book. Was it written more for patients or clinicians or both? Is there any time? Really, both, you know, both, sure. You know, there's some technical terms, just like now we will throw it out, then we explain it. So absolutely, it's for clinicians and it's for, you know, our patients, because we really wanted to provide, you know, for all to just learn these additional tools that are available to them to really help them in their healing and journey to wellness. Fantastic. Well, thank you so much for your time this Friday. Look forward to catching up with you soon. And everybody listen, thank you, and have a great day. We will be sure and include all the links we mentioned below. Thank you for having me. It was a pleasure. You're welcome.