GW Integrative Medicine Podcast

GW Integrative Medicine Podcast 2

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Janette:                               Welcome to GW Integrative Medicine, the podcast about disease prevention and health promotion from the Office of Integrative Medicine and Health at the George Washington University School of Medicine and Health Sciences.

Dr. Misha Kogan:              I’m Dr. Misha Kogan, Associate Professor of Medicine here at GW and medical director of the GW Center for Integrative Medicine.

Janette:                               Today we’re joined by physician-scientist and medical geographer, Sunil Aggarwal, MD, who’s the co-founder and co-director of Advanced Integrative Medical Science Institute in Seattle, Washington.

Dr. Misha Kogan:              Dr. Aggarwal’s primary clinical and research work is in palliative care, rehabilitation medicine, medical cannabis care integration, and psychedelic integrative medicine.

Janette:                               Board certified in physical medicine and rehabilitation, as well as hospice and palliative medicine. He has served as the chair of the Integrative Medicine Special Interest Group at the American Academy of Hospice and Palliative Medicine.

Dr. Misha Kogan:              Welcome to GW Integrative Medicine podcast, Sunil. I’ve always wanted to do this podcast with you. I have been following your work now for quite some time. It’s so exciting. So, welcome.

Dr. Sunil K. Aggarwal:     Thank you so much, Misha. It’s an honor to be with you, and I’ve been looking forward to this for a long time as well.

Dr. Misha Kogan:              Great. So, Sunil, what are entheogenic and psychedelic-assisted therapies?

Dr. Sunil K. Aggarwal:     Yes. Well, let me explain to your audience that the term entheogen, which is a term that was actually coined in 1979, and it was to try to sort of retire words like psychedelic or hallucinogen which the researchers felt carried lots of sort of baggage because of the politics of the 60s. And entheogen, which it means basically to that a substance which generates the sense of divine or god within or occasions that. And they were specifically referring to substances that had been used throughout history, back to prehistory that had been used in ritual or shamanic contexts, and substances that are like them like the congeners, like chemical versions or similarities. So that’s what an entheogen is.

And then the psychedelic, we still use that term. That was coined in the 1960s by a Canadian doctor named Humphry Osmond, and he was trying to come up with a word. He was basing it on Aldous Huxley’s writings, the famous philosopher and writer in the early 20th century who also wrote a lot about these substances. And he said, “Okay, well, why don’t we use a word that helps says manifesting the mind or expanding the mind?” And that’s what psychedelic means. So, the use of these types of substances in therapeutic purposes, in healing, in growth, in spiritual development, in treatment of trauma, in treatment of life threatening existential distress. That’s what we mean with the use of these as a therapy. And that involves medical evaluation, preparation, guidance, and integration.

Dr. Misha Kogan:              Sunil, why did you get involved in medical cannabis and entheogenic psychedelic-assisted therapies?

Dr. Sunil K. Aggarwal:     Well, because I found them useful in my own healing, first of all. I’m not a robot, I’m a human being. I’ve gone through my own challenges. And when I was in my 20s, I found that these substances were very helpful for me to deal with different aspects of trauma I had growing up and healing. And then as a student, I was really interested in chemistry and the brain and mind, and I was fascinated to understand that more and more research was being done to start to understand the way in which for example, cannabis and cannabinoids interact with the brain and nervous system. A whole new receptor system had been discovered. A whole new method of neurological signaling basically, which was a kind of a feedback system which was widespread, and I thought that was such a huge finding.

So, and then with psychedelic therapies, same thing. There was more and more being discovered and understood about the nature of consciousness and what we call the default mode network. And kind of the way in which standard egoic frameworks, sometimes the somatic: the way in which the body can somaticize or get into a sort of a defensive posture. And then the way that psychedelics or medicines that disrupted the default mode can help lead to new ways of being in the body, interoception: awareness of yourself.

So all of that to me was a big scientific breakthrough in healing, and I thought that these kind of substances really need to be utilized in medicine. And I did an MD-PhD, so I wanted to do research, I wanted to develop new treatments. I didn’t want to just use the same treatments that were being utilized. So that’s how I tried to find a way to stitch them into my research and work in ultimately advocacy as well. That’s a big part of what’s been needed to move this forward because of the law that I was mentioning earlier in the 60s.

Dr. Misha Kogan:              Great. And Sunil, just despite the fact that the all these substances we’re discussing still DEA Schedule I, meaning that they don’t have a official therapeutic use in clinical care, but their popularity and their use is growing rapidly. Just recently in the last election, this past fall, DC had essentially decriminalized psilocybin mushrooms. But can you briefly discuss the current evidence for use even though they’re not formally legal in the whole country, but definitely evidence is increasing? And maybe say what you think, where do you think the kind of the next step of evidence is going to be going to?

Dr. Sunil K. Aggarwal:     Certainly. Let me just first start by saying that there is one substance. There’s actually probably a few psychedelic substances or entheogenic substances that are not highly controlled, and those are being utilized in therapeutic care. So one example being ketamine. Ketamine is a synthetic substance. It was made in early 60s by Parke-Davis, the pharmaceutical company, but it really at certain doses below… It’s used as an anesthetic in medicine. It’s a potently approved anesthetic for decades. It’s on a WHO Essential Medicine List. But at subanesthetic doses, people can certainly have psychedelic experiences for a couple of hours, like two hours, one and a half, two hours, and that can be very profound. And actually a lot of work in palliative medicine, people are interested in the use of ketamine because it actually can simulate what’s called the near death experience without actually having to go through a dying process. So that’s a very important tool to have.

And then the other substance I was going to mention is Salvia Divinorum, and that’s actually a substance that’s been used in Mexico, the Mazatec Oaxaca region for a long time, and it actually has some unique psychedelic properties. And right now, it’s not controlled, but it has such unusual psychedelic properties people haven’t really found a way or there’s not a whole lot of protocols around using it clinically, but it could be done and there’s research at Hopkins right now where they’re actually using one of the active chemicals in Salvia Salvinorin A and studying its effects in healthy subjects. And I believe they’re going to be looking at depression and other indications.

But anyway, so that being said, most of the other substances, and I didn’t really mention them yet, but you mentioned one, mushrooms or psilocybin containing mushrooms. Another one is Peyote, which is mescaline containing cactus. Another substance is a DMT, dimethyltryptamine, which is found in the South American tea called Ayahuasca, which is a combination of a DMT containing flour or herbs and a vine, Banisteriopsis caapi, which contains an MAO inhibitor which allows the DMT to be taken up in the gut. So those are three big examples. There are other substances as well, Iboga, Ibogaine.

So all of those substances or their active chemicals are listed in Schedule I of the DEA, and yes, there is a huge move now to decriminalize them in various cities throughout the country. And I’m sure that’s going to continue and at higher levels. And actually the state of Oregon just this week decriminalized all substances. It’s sort of like a parking ticket infraction. So it’s not exactly like zero penalty, but it’s not again a criminal penalty for certain amounts, and that includes all of these substances as well. So that’s the way the trend is going in terms of policy. And I know that this is going to be taken up I think at the national level as well with the national policy. At least there’s signs of that. We’ll see.

But so then the other context in which access is happening is in the clinical trials that you mentioned. So more and more settings, scientists, clinical scientists are giving these substances to both healthy subjects and ill patients. And already, I think, just dozens of trials really, both in the US and around the world have been done since the freeze was lifted. And that’s sort of actually in the 90s you started seeing some of the earliest studies on the use of substances like psilocybin in end of life care, and the use of psilocybin in obsessive compulsive disorder were some of the early studies that were done in the US in the 90s in LA, UCLA and University of New Mexico.

And then, the big push happened at Johns Hopkins that was they really started a much more robust research group there, Roland Griffiths, and they did many studies, and really were able to show in a longitudinal data, like they were the first ones to show that 14 months after a psilocybin experience in healthy subjects that they continued to report that it was one of the most significant experiences of their lifetime. And persistent antidepressant effects have been demonstrated. That’s been shown in other studies now as well longitudinally at the other centers that are involved, which are many academic centers: NYU, University of Wisconsin, UCLA, and the list is growing. And there are psychedelic research centers popping up at Harvard and UC Berkeley, and I’m sure more to come.

So it’s kind of a very fertile time, the evidence phase, there’s a lot of phase two studies happening. So and then phase three study is underway right now, which is a much larger study with a larger population. That’s happening with the substance, MDMA, which I haven’t mentioned yet. That’s again, another pharmaceutical psychedelic that was invented in Germany in the early 20th century, but then repopularized in the 60s and 70s by a chemist in Berkeley. And it’s already been given breakthrough therapy status by the FDA for PTSD, and it’s really a remarkable entheogen that helps people process trauma and improve the ability to connect with others, we think through oxytocin. Anyway, so that’s going through phase three trials right now. And I’ve heard the preliminary data, it’s very good. So I think more will be coming out.

And I’m sure that psilocybin is going to be going through phase three studies, if they haven’t already started. There are many now private companies that are studying. One company called COMPASS, one company called Usona. They are funding a development of psilocybin for depression, and I think it’s their studies are underway. Already we have some nice data that have been presented in the studies that have already been done showing remarkable like above the standard thresholds of response in depression. And this is with psilocybin-assisted therapy.

So it’s not just you give people psilocybin, it’s they have preparation sessions, they have an experiential session, they have integration which means they follow up and talk about the experience with the person that was… Person or sometimes persons that were with them during the session. And then they do it again a couple of times. So it could be to two or three cycles. And then they have a remarkable off the charts response to depression is what was reported at the American Psychiatric Association a couple years ago. So that that kind of data is out there.

There’s data on smoking cessation that Hopkins has published as well, and that’s very impressive to help people quit nicotine addiction is very hard, and psilocybin seems to really help. And then what else is there? There are studies on alcoholism that are underway. And then I’ve mentioned a few times the cancer anxiety or end of life anxiety, very impressive responses on spiritual well being and sense of mood and quality of life that also is persistent. There’s been I think three clinical trials now done in advanced cancer patients that have been published. So we have lots of good data, and more is going to come with the conclusion of these larger studies.

And then finally, I want to mention one more pathway that we’re still trying to work on. This is not a research pathway formally. It’s called the Right to Try. And this is a federal law that was passed I think in 2017, which in many states, so over 40 states have laws like this too. This allows patients that are terminally ill, who are medically defined to have a terminal illness to have access under the Right to Try to any substance that could potentially help them that has completed a phase one clinical trial and is still in development. Advocates who passed this law felt that terminally ill patients don’t have time to wait for the sometimes very multi-year process of developing a drug, and it’s a drug that could potentially help them with their terminal illness. They should be able to have immediate access or much more less encumbered.

And so under Right to Try, psilocybin, because it’s completed clinical trials and actually MDMA as well, these would both be what they call eligible investigational drugs. And right now, my clinic and I’m working with an attorney named Katherine Tucker who is taking this on and we’re raising, it’s like a public interest effort. We’re raising money through a nonprofit in Colorado called The Nowak Society to support our lots of legal efforts, and we have law firms trying to help too. And I have some patients that want to try this who have advanced cancer. And so we’re asking the DEA for permission to buy it from one of the producers who are producing it for research, that these patients should be able to have access without all the encumbrances of a formal clinical trial. So we’re waiting to hear back on that. And if they don’t let us, then we want to also get permission to cultivate the mushrooms ourselves. So that’s another that’s another pathway that should open up.

And finally, this is just the US. The US is a very unusual country in our drug laws, and many other places have moved far beyond us. And Jamaica and Holland, The Netherlands are two places where people can go today and have legally administered psilocybin therapy. In psilocybin sessions, psilocybin is not controlled in those contexts. And there are other places in the world that have actually moved ahead. So hopefully, we’ll… And I have patients that have actually traveled to other parts of the world to access this care. This is also happening with Ayahuasca in South America. In many countries there, it’s legal and allowed, Ayahuasca retreat centers. But there is a problem with too much medical tourism happening in these places and we need to start to do our own work here.

Dr. Misha Kogan:              That’s such an amazing information. I think I was just kind of reflecting while you were talking. Both you and I we have lots of patients who clearly can benefit from this, but I don’t really have any practical information to give them at this point outside of what you just said, basically traveling outside. I get regular emails asking, “How can I access psilocybin?” What do you tell to those patients? Are you putting them on your wait-list? Are you referring them to Hopkins to see if they can qualify for the study or just how do you approach this?

Dr. Sunil K. Aggarwal:     That’s a very good question, Misha. I would say that we have and I think you and I have spoken in the past about the use of ketamine, and so we still try to encourage patients well, in the meantime this is a psychedelic modality, this is an entheogenic-assisted therapy which will disrupt your default mode network and has neurogenic properties, so they can lead to long term changes. And we use the same protocols with eyeshades and music, and preparation and integration that are being used in the whole family of psychedelic-assisted therapies. So that’s one thing.

We try to say, “Hey, listen, this is something that’s available now. Even though insurance won’t cover the experiential sessions themselves, they still model as not in the usual wheelhouse of what insurance companies consider acceptable services, but many of the other parts of it can be covered, and patients can get pretty remarkable results, and there’s lots of nice data already on ketamine. So I always do we already have a program at our clinic where we offer this and we have different therapists and naturopathic physicians and psychiatric nurse… We have a whole team of folks who know how to work with ketamine and we even have a group, a ketamine group that with COVID times we’ve had to reduce quite a bit for social distancing, but it’s those are things that are available, and patients can use ketamine at home if they are good candidates. So that’s one thing I always tell patients.

And then, for many people they want to use psilocybin and they want to use natural medicines because well, they have a longer track record, and it’s more attuned to how they want to approach their health. And right now we have no legal access here, so we have taken what we call the harm reduction approach. And I was happy to see that I saw the news that the people that are joining the Biden administration’s Office of National Drug Control Policy, they have a formal harm reduction initiative now. For a long time the government even fought the idea of harm reduction. They didn’t want it because they felt like oh, that means that you’re not really you’re sick.

What harm reduction means is, okay, well, we know that people are using substances, but let’s try to minimize the harm to the patient, to the person, to the public and not just okay, we have to eliminate the use of those substances entirely by using more law enforcement or more punitive measures. Harm reduction is about meeting people where they’re at and trying to give them good education, good information, access to resources to minimize harm and frankly, maximize benefit too, which is the opposite of what comes from reducing harm.

So that’s one approach you can use for patients because there are many ways that people can access these substances. They’re in nature. You can cultivate them. There are places that people go, and that’s how it’s always been, and it’s been like that for like I said, since prehistory. People have been using mushrooms, we have so much evidence of it. And so if patients want to talk to us about that, and want to seek it out on their own in that regard, I think that’s we support them in terms of like well, that’s normal behavior, but here are some of the things to look out for: adulterated substances, the issues around in setting, it’s very important to have lots of safety rails around.

Psychedelic therapy is generally very safe, but it is very sensitive to the conditions that people are in. So if you’re not in a safe environment, you don’t feel protected, you don’t have good time to recover, et cetera, you’re not planning integration or preparation, those are ways that the process could be more potentially harmful or less productive.

So, and then there are some medical pitfalls to watch out for, some drug interactions if patients are on other types of medicines. And there are actually doctors now that are specializing their practices on helping giving people sort of medical evaluations so that they feel more comfortable about doing this work, this psychedelic work on their own. So those are ways that doctors can support patients and clinics can help to minimize the harm. And also normalize their behavior. I have some of my therapy colleagues, they do see patients for integration that will come and talk about their experiences. And it’s much more meaningful for patients to have a professional to share that experience with rather than what it has been, “What are you doing? I don’t know what that’s about. I don’t understand that mode.” There’s a lot of stigma and ignorance because of all the war on drugs. A lot of doctors don’t have any idea about this. I think that’s changing now, like you mentioned.

So anyway, that’s kind of what… And then finally the Right to Try, if we get that allowed, I think that’ll for patients who meet criteria of terminal illness, potentially that could be a way to open up legal access to many, many patients. So that’s something that I’m hoping we get resolved soon. Stay tuned on that.

Dr. Misha Kogan:              That’s great. So that would be the Right to Try, that would be a national done initiative or it’ll be still through each individual state under like a physician supervision?

Dr. Sunil K. Aggarwal:     It seems like the federal law, everybody’s protected under the federal law. So it would be nationally applicable. The states’ laws are still on the books, but those were passed before the federal law because there was no federal law. And in most states, there’s a couple of states, I think it’s Missouri, one of the states says, “Oh, we allow Right to Try except for Schedule I substances.” So that’s very unusual, but most states don’t have that provision. So I think it would be accessible. I think DC being a federal jurisdiction it would just be the federal law controlling there, and that would be…

We actually, we’ve written and had phone calls with the really higher level officials in the DEA. They didn’t even know about this law, but this law is being used, I should mention to your listeners, for access to experimental therapies for ALS and cancer. It’s already being used. The patients have gotten it from suppliers under this. So I think it’s just a matter of getting the regulations updated, which sometimes that can take some time, but Katherine is prepared to go to court to really raise the issue because they don’t have all the time to wait.

Dr. Misha Kogan:              So I guess stay tuned then. At some point, we’ll need to catch up with you on this as this continues marching forward. So let’s switch to talk a little bit about medical cannabis. I know you have a pretty advanced expertise in this, especially in palliative care. But maybe you could just kind of overview for our listeners how do you see a role of cannabis in managing complex symptoms in patients near the end of life?

Dr. Sunil K. Aggarwal:     Absolutely, Misha. And I should let our listeners know that part of the way you and I have connected over the years when we were both students of medicine, that we were part of American Medical Student Association’s groups of medical students who were interested in integrative medicine or humanistic approaches to medicine. And that was back in the early 2000s. Already there was data coming out that cannabis could be helpful for managing symptoms such as pain, nausea and muscle spasms, and we were really trying to talk to our colleagues, you and I were, about that data and how to approach it. And there was already laws in place, medical cannabis laws. The first laws were from the 1996 onward, but and now it’s so widespread.

And so yeah, I think in over the last 20 years there’s been so much more refinement. Cannabis, it’s such a complex phytomedicine which means that it’s not just sort of like one variety, there’s more varieties of cannabis types than there are dogs, species of dogs. So and there’s just so many different variations in the chemical phenotype. So high cannabinoids are like CBD, THC, CBG, CBN. There’s almost 100 of them that have been identified. And then there’s the terpenes or terpenoids: limonene, pinene, myrcene, linalool, caryophyllene. So many different substances that are found in other plants that are known to have medicinal value. Or pinene is named pinene because pine trees smell like secreted pinene. So that’s a second layer of medicinally active substances.

So there’s now so much development on well, what variety of cannabis and how to approach how much CBD, how much THC, who should have what variety of terpenes? That’s sort of the level of botanical medicine that is being utilized. And then there are so many different modes of ingestion, whether it’s tinctures, topicals, lotions, inhalation. I’m sure most of your listeners are familiar with this. So I think the way to work in palliative care patient population, is it’s really, it’s the same principles of starting low going slow, and kind of trying to get a sense of based on the initial conditions what might a symptom cluster? I mean, palliative care, it’s always not just one symptom, it’s a cluster of symptoms.

What will be the best way to start to tackle that? Is it something that they really need a stronger THC where it’s immediate onset, it’s with stronger pain killing effect, it has more of a psychoactive edge, might that be helpful in stronger with nausea, stronger with muscle spasms? Or do we need to start more on a higher CBD edge, a much stronger anxiety component present, a different type of pain, a desire to not have any kind of potential psychoactive effect? And then or do you want a blend of the two? And I’m kind of describing what are called the typologies of cannabis. There’s type one, type two and type three, which are delineated by which ones have high CBD, low THC, or one to one which is type two, or high CBD, low THC, which is type three.

So kind of knowing which of those three buckets in general your patients might fit in, and then having them start on a product or preparation that moves in that direction. We’ve described that in a kind of consensus article in the Annals of Palliative Medicine, which is actually an open access article on practical guidelines for cannabis and palliative care, which your listeners can take a look at. We have some tables in there that’ll help with decision making.

Cannabis is remarkably versatile. People sort of oftentimes it’s individualized titrations. It’s not like dealing with methadone, which is a medicine that we use in palliative care where you have to be really specific about your doses. And if miss one or use too much, you can be overly sedated, or there’s safety issues. There’s much more about patient autonomy I think that drives the use. And so I always tell my patients to really feel empowered, try a couple of things. We have a cannabis education clinic that sort of shares the space with us or health coaches in our clinic. And they have a nice program that we like patients to try to go through. And they can do a lot more individualized dose titrations even through text messaging or emails. And because they are not medically licensed, they can actually offer samples which allow the patients to have a few things to try so that they can determine what’s right for them. That’s really the best way to if the conditions were right and laws didn’t interfere, this is how you would do it.

Then in hospice care, those patients are harder to reach because of the hospice usually covers all your medicines, but I know of companies that are trying to get high dose CBD tinctures onto hospice formularies, and I think there’ll be a lot of patients who will opt to try CBD before they try morphine or other opioids for pain. And I think that’s still to be seen, but I think it’s very promising. I’ve seen patients who are really hospice patients who are seeking out these substances on their own and finding what we call opioid sparing effects. So that’s been very, I think that’s going to grow.

Dr. Misha Kogan:              Yeah, I think that cannabis is really the only substance I can think of when you mentioned the clusters in palliative care. I think that’s really the sort of the most important subject. We don’t really have in palliative medicine something that could treat three, four or five symptoms simultaneously. I mean, if the patient comes in with a cluster of five symptoms, we’re going to have to prescribe five medications and here comes cannabis where literally all of those symptoms can be addressed simultaneously when you pick the right dosing, right product, right delivery system. And just what you said, I mean, the capacity for different delivery and different dosing and different titration schemes is basically limitless. I mean, and infinite in essence with the strains. And so-

Dr. Sunil K. Aggarwal:     That’s right.

Dr. Misha Kogan:              So do you think the sort of future of cannabinoid medicine at least in palliative care, let’s just say it’s already here, or do you think are we still sort of just kind of in a baby steps entering and we haven’t really gotten there yet?

Dr. Sunil K. Aggarwal:     Well, yeah, there’s always there’s still so much to go. I mean, number one, any form of medicine is going to be… We’re such a unfortunately, heavily regulated practice in society, and it’s really hard to do, and we all have different forms of state and federal, and this and that, and even international standards and norms. And so it’s really important that if a possible scenario is possible in medicine, like a certain type of patient issue restriction, it’s going to show up. And so that’s why you have to have really universal uniform systems that protect all possible scenarios.

And because cannabis’ status as a Schedule I drug, it’s still very limited in terms of how it can get into places like nursing homes or hospitals or settings which are really difficult without really good regulation. So it’s still very much an outpatient preparation. It’s still very much, there are still access barriers for people who can’t afford the costs of dispensaries or aren’t able to grow it or seek it that way. So we’re still very much I think early stages.

That being said, I mean, we’re still way better than we were 20 years ago when you and I first started talking about this, because there’s a lot more awareness in various state levels, a lot more acceptance. And I think it’s really important to note, I think last month the international treaty, the drug control conventions, which is kind of every country in the world almost is a member of this treaty, the WHO formerly said that cannabis should be removed from the most restrictive category. And the UN adopted that last month. So now if you go online and look at the list of schedules of drugs and where they all fall in the international law, cannabis is no longer in the equivalent of Schedule I in international law. That’s a huge change.

So that just happened last month, so how is this going to impact cannabis care access in other smaller countries in the world that who take the UN treaties much more robustly than the US does, unfortunately. The US uses the treaties when we want to. Anyway, that’s some politics aside of there, but I think we’re going to see some more. And then the Congress is now going to pass, I keep hearing that they’re planning this year to do comprehensive legislation to remove cannabis from Schedule I now that the Democrats are in power. So that’ll really move things forward if we can get that, especially to access to the more vulnerable patients in settings like I mentioned, hospitals and nursing homes, and that kind of thing. So I think that’s what’s going to come in.

The other thing I want to mention Misha is I’m really excited to see more and more cannabis falling back into the family of botanical medicines. For a long time we’ve kind of treated it as a special plant. I mean, it is a really remarkable plant, don’t get me wrong. But historically, in traditional medicine, traditional Indian medicine, or traditional Chinese medicine where cannabis has been used for thousands of years, it was rarely used as a single agent. It was combined with other plants. And I think because we know so much about other plant medicines, I’ve already seen formulations where cannabis is being combined with things like melatonin or things like valerian and other types of plants that we know have safe and gentle effects in pain or anxiety or insomnia. And that actually might lower the dose of CBD and THC that is needed, which will make it even more tolerable for patients. So I think that’s going to be another future wave.

Dr. Misha Kogan:              Well, I think that is all the time we have. I think ending on this positive note, I love it. I think hoping that we will see some political efforts going at removing it from Schedule I and making it more accessible, I think we all can agree on this podcast would be most likely a good thing assuming that we can maintain good quality control and remove bad players so to speak from the market. So I think with that, that’s all the time we have. Thank you, Sunil so, so much for joining us. I hope we’ll bring you back.

Janette:                               We’ll definitely bring him back.

Dr. Misha Kogan:              So yes, thank you.

Dr. Sunil K. Aggarwal:     It’s been a pleasure. Thank you so much. I really enjoyed our conversation. I look forward to future conversations.

Janette:                               This is the GW Integrative Medicine podcast from the GW Office of Integrative Medicine and Health.

Dr. Misha Kogan:              I’m Dr. Misha Kogan.

Janette:                               And I’m Janette Rodrigues.

Dr. Kogan & Janette:      Thanks for listening.

 

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