Breakthroughs in Alcohol & Addiction Recovery – Featuring John Umhau, M.D.

John Umhau, M.D.: This is what we need to be moving for as a society, just moving, doing things together, recognizing that you don't get endorphins from scrolling on your cell phone. You get endorphins from really through interacting with other people. That's what we want for a long term recovery from alcohol problems. I really press all my patients to do the work that it's required to really replace the alcohol with something else that will last them for lifetime. So they are never tempted again, to think about a need to drink, because they have alcohol replaced by something that produces the healthy endorphins.

Announcer: Thanks for tuning into the Elevation Recovery podcast your hub for addiction, recovery strategies posted by Chris Scott, Matt Finch.

Chris Scott: Welcome everyone to the Elevation Recovery podcast. Today. I have a very special guest. It'll be a brief concise, and I'm sure illuminating episode. This is Dr. John Umhau, I think what is this, your third or fourth time on the podcast. But it's been at least six months.

John Umhau, M.D.: Yeah. Yeah. It's great to see you.

Chris Scott: Welcome back to the show. Thank you for being here.

John Umhau, M.D.: It's great to talk. I really enjoy talking to you and your folks that listen in. It's really a great opportunity to share new ideas about research that really impacts people with alcohol use disorder and always look forward to these opportunities.

Chris Scott: Right? Well, you have some exciting insights that we've haven't discussed before and maybe some new studies that have come out and I should, before I proceed, just I'll tell everyone a little bit about your background. You worked at the NIH for a long time. You're an epidemiologist and also in alcohol researcher. So you have two very relevant areas of expertise for people right now, given that we are in a pandemic at the moment and also alcohol use rates and abuse rates are skyrocketing. And you do, at the end, we'll tell people where to find you because you're also an expert on the Sinclair method and other modalities for helping people fill in those missing links for alcohol recovery. And I recommend people to you all the time, especially if they need help with the Sinclair method. So let's talk a little bit about, I think you had mentioned the calcium, which is a nutrient that I've never really discussed nor recommended in the past.

John Umhau, M.D.: Right? Right. Yeah. So this is really fascinating. I was at NIH for 20 years and one of the studies that we did was using a drug called acamprosate in Campral which is the medicine that's given mostly to help people who are trying to be abstinent. It really works great in some cases, but the theory came out, my boss, Dr. Highlicht thought, well, maybe this drug works not because of its amino acid part, but because it's connected to calcium, it's joined with calcium. And so they did some studies in animals. And recently there's a study that came out from Germany where they gave calcium carbonate 800 milligrams, plus a little bit of vitamin D versus placebo to a number of people that were in recovery, who went through detox or going through detox and low and behold, it reduced the withdrawal symptoms and reduced alcohol craving, just this calcium addition. And there's also consistent with studies that show that the more calcium in your bloodstream, the less you crave alcohol.

John Umhau, M.D.: And I thought that was fascinating, because here is this simple intervention, calcium carbonate is available in the dime store, it's not a expensive modality at all and it's safe. And I thought this was really fascinating. Here's one more thing that people can do on their own without depending on the doctors to prescribe, that would really help reduce craving.

Chris Scott: Now here's my first question, which is that I had heard that especially women at risk of osteoporosis used to be advised to take a certain amount of calcium, until there had been studies. And I didn't read these studies, but I had heard that there were studies showing that it may actually increase the risk of heart attack by promoting calcification of arteries in some people. And so that piece of guidance had been rescinded by some health experts. And I didn't know what to make of that. I had always had great success telling people about magnesium, which is another electrolyte that people need and also is severely diminished. And from my rudimentary understanding and remembering of biology, I recall thinking that, all right, there's maybe some calcium and magnesium and sodium, you need these things, but it seemed to me and maybe there's some competition between some of these nutrients, but I always thought, all right, we need to fix the magnesium thing first. So what exactly do you think is going on with the calcium? Why do you think people might be benefiting from that for alcohol withdrawal?

John Umhau, M.D.: Well, magnesium, as you mentioned, is really critical for alcohol withdrawal because people are deficient in magnesium, if they've been drinking heavy. And the blood levels that people measure are not really accurate because the blood levels only slowly reflect what's in the body. And so if you give somebody some magnesium, it takes a long time to get the whole body stores up to normal. And the that's really important when somebody is in withdrawal because the low magnesium can allow them to be more likely have a seizure and to get severe delirium tremors from the alcohol withdrawal and these are basic building blocks of all our nerve transmissions of our whole body is calcium, magnesium is everywhere in the body. And we don't understand exactly what the deficits of these nutrients will manifest as, it could be all kinds of things. But certainly when we are heavy drinkers and we want to restore our brain, it's important to make sure you have plenty of this.

John Umhau, M.D.: There's another study that I read, that's really fascinating that that is looking at brain recovery. And they did a study looking at people six weeks after they were detoxed from alcohol and they measured the brain volume. Now people have heard that you lose nerve cell, brain cells when you drink too heavy. And it's true you get atrophy, you get shrinkage of the brain, particularly the white matter. So what happens after six weeks is your brain volume increases by 2%. That's a huge brain volume increase in just six weeks. Your brain is growing back after being basically atrophied by heavy drinking. And what's really fascinating is that what grows back is white matter. White matter is the connecting fibers from different parts of the brain, from the cortex to the amygdala and lower brain stem. And this white matter allows rapid communications from different parts of your brain, where you're thinking about, I want to quit alcohol.

John Umhau, M.D.: That's great to have that thought. But if the power of that thought doesn't get to the lower brain stem, which is the sort of the subconscious automatic drinking behavior. Your willpower doesn't do any good. So essentially what happens when you go through a detox program for six weeks is that you restore, your will power through restoring your brain volume and your white matter, and your white matter connectivity tracks with the frontal lobes and the rest of your brain. And I think this is really fascinating, because it really explains what's going on when somebody's a heavy drinker, they don't have the same kind of quality of thought. They could still do math perhaps, but they don't have the same forward looking vision. They don't have imagination. They don't have the same insight, they are in denial. Well, what is denial? It's a ability to reflect on your own brain state, but that requires this connectivity, this white matter.

John Umhau, M.D.: And so as we recover from alcohol, if we, if we maximize our brain regrowth, our brain recovery, we're going to maximize our chances to be able to overcome the craving, this crazy denial, that is such a hard thing for people to overcome.

Chris Scott: That's extremely interesting. And I have a lot to think about there, but so you're saying basically that calcium could be an important and ignored ingredients thus far in helping the gray matter or the white matter of the brain grow back. Is that kind of a the thesis?

John Umhau, M.D.: Calcium. So it's a multitude of nutrients that are depleted when people are heavy drinkers for one they're taking in their calories from alcohol and not from high quality food sources. So they don't naturally get nutrients in their food that they would normally get a otherwise. And then there's also the fact that the heavy load of alcohol is causing oxidative stress to liver and other organs, which requires more nutrients. So when I treat my patients, people come to me on the internet, my alcohol recovery medicine website, they click on the button, they make an appointment. And the first thing I'll talk to about is all the nutrients that need to be replaced because of alcohol problems. Now people know about B vitamins, but there's also things that we don't haven't studied that well.

John Umhau, M.D.: Maybe small, tiny doses of lithium are really helpful for alcoholism. Maybe vitamin D is really helpful. We know vitamin D can be really helpful for the immune system and possibly for even preventing COVID. But it's also a neurosteroid that means it turns on genes in the brain. And some people have found that it's helpful for preventing depression or treating seasonal effective disorder and all that can promote heavy drinking. Now the B vitamins been known for years, some of the prior researchers from decades ago, I'm thinking Roger Williams particularly, who discovered some of these B vitamins. He really thought of alcoholism as a nutritional disease. That was what was going on. And there's some studies, they're not very well, but they're very suggestive that some of these B vitamins can really be transformative for people.

John Umhau, M.D.: And so calcium, magnesium, all of these work together, and for any particular person, we don't know what's going to make the big difference. I have been amazed over the past year since I've started recommending a high dose omega-3 fatty acids following the research that Dr. Andrew Stoll did a couple of decades ago. And in his studies, he gave a lot of omega-3s, the kind of dose of omega-3 fish oil that would reduce inflammation.

Chris Scott: And do you know what that dosage might have been?

John Umhau, M.D.: Yeah, it's hard to say it's way more than, I'm not going to say right now, because it's going to be different for each person. But it's generally more than is commonly used because this omega-3s act as an anti-inflammatory agent on the gut. So if you take a high dose, it's going to be able to do things that a low dose won't do.

John Umhau, M.D.: So I've had people on the standard dose of omega-3s for years and they go to the higher dose and now they stop drinking and they attribute it not to the anything else I'm doing. They don't attribute to the naltrexone or anything else. They attribute it to the omega-3s. I had a guy that's just tried like five different medicines that we use for alcoholism. I think he tried baclofen, he tried a acamprosate, he tried naltrexone and topiramate, nothing worked. I gave him the high dose omega-3s and he's gone from 10 ounces of alcohol a day to one to zero. So, and that's been in the two weeks that I've talked to him. So he can't believe it. And he's an engineer, he tracks everything really carefully.

John Umhau, M.D.: So he's really aware of what's going on. He wonders whether it's a placebo effect, but not too much because if it had been the placebo effect, something else would've also worked too. And that's what we see when we do science is that is we give someone something for these studies, we'll do lead in studies. We'll give a placebo lead in and we'll exclude people from our study who respond to placebos. And then the rest of the people have already been exposed to the placebo effect. And then we can do the actual randomization of the drug or the placebo to get a stronger study out of it. And that's what this guy basically done. He tried everything, the omega-3s high dose, that's what made the trick. And we know from arthritis studies that it takes like five grams a day for three months to really show a difference in the effect on arthritis pain, for instance. And it's the smaller doses just don't seem to do the trick.

Chris Scott: Interesting. Yeah. I think if I can zoom out and generalize for a minute, as someone who went through the process of trying to quit and consulting experts, I used to have a very naive idea of my drinking problem. I remember the first time I set up an appointment with a psychiatrist and I thought, "Well, I'm sure you can prescribe a drug. That'll just solve, it'll wipe away my drinking problem. So I can't wait to get whatever this drug is and to hear about it." And so I had this idea that there's a very simple mechanism of action that obviously that scientists and doctors know all about, who'll give me a pill, it'll go away. My life will return to normal. And now looking back on that, I see like, no, it's actually, it's a holistic process of repair involving many nutrients and even things beyond a biochemical realm, getting outside, getting sunlight for your vitamin D, the fresh air, things that Matt Finch and I talk about the basics.

Chris Scott: It sounds simple minded, but if you take just one nutrient like magnesium, for example, has 300 identified biological processes in the body that it's involved in. I'm sure there's many more. And so we don't know which of those is most helpful. I would assume for people with alcohol, we want all of them. And so we need all of these nutrients that we evolved with for millions of years. And so I have to chuckle when I look back at them, it's kind of tragic as well, I think maybe a widespread cultural role phenomenon in the west now to assume that there's one mechanism of action and one drug that has to have the solution. And we just take that and the problem goes away. When in reality, we are highly, highly complex machines and we don't even necessarily have to understand the mechanism of action.

Chris Scott: There's probably multiple, involving multiple nutrients in regrowing that brain matter, which as you said, is likely one of the ways, important ways in which we regain our free will from that state of severe addiction. And that's why I love talking to you because every time we talk, there's a new nutrient that you're excited about, and there's this vast universe of things. And I hope you live to be a thousand because I'm sure there'll be many, many more. And our understanding of this will just increase exponentially. And I also always try to revise whatever it is that I'm helping people with, whatever the nutritional guidelines are, science progresses.

Chris Scott: I'll have to think now about maybe putting calcium back in a regimen. And I didn't think that I would do that, but I'd want to understand what the dosage might be and where the studies are, because the people who tend to be in my course or who listen to the podcast are very intelligent and scientific minds. So they're going to want to look for themselves at the studies. Do you happen to recall what the dosage was for the calcium?

John Umhau, M.D.: It's 800 milligrams of calcium carbonate and it was, I believe 2000 international units of vitamin D.

Chris Scott: Wow. Okay. So that seems like a lot of calcium and a modest amount of vitamin D. Okay. Do you know what the duration was of the calcium?

John Umhau, M.D.: I think it was just maybe four to six week study.

Chris Scott: Okay. So it's not something you keep taking forever.

John Umhau, M.D.: I mean, this is like the first study. It's the first study. So as like any studies, you have to replicate it and make sure it works, but it's a fascinating insight into how simple things might really help people stop drinking so much.

Chris Scott: Right. Awesome. Well, I want to ask you about Iceland before I...

John Umhau, M.D.: Yeah, so Iceland is a fascinating story because a few decades ago, the youth in Iceland were all starting heavy drinking when they were teenagers. And it was really profoundly affecting the outlook for the whole country because so many of them had started drinking at very young age and the place is small. And so they could really get together with the communities and the political leaders and figure out what they might be able to do. And they did some interventions where they just made it fun to be a kid. And they provided lots of activities for the youth. Whatever the youth wanted to do, the society promoted. So they had a strict curfew. So the kids couldn't go out late at night and get in trouble, but they had lots of fun for the kids to do that wasn't related to drinking behavior.

John Umhau, M.D.: And the whole outlook on alcoholism in the youth just went between night and day, the whole, all of the youth that were heavy drinkers, they grew up, over the time course of this, what turned out to be a big social experiment, but it drastically cut the amount of alcohol consumption in the country. It's been trying to reproduce a number of other places too, but sometimes there's not enough political will or the communities don't come together around it. But it's really fascinating how replacing the alcohol with a more happy or healthy way to get endorphins is really important, which brings me to the other fascinating thing that I've been looking into. And a lot of my patients that they come to me on alcohol recovery medicine are interested in Sinclair method and that's works great for most people.

John Umhau, M.D.: I treat the other ones, the course that it doesn't work for with other medications. But the point that Sinclair made was that to replace alcohol behavior, drinking behavior, you need to have other behaviors that also induce endorphins and people just kind of blindly say, "Okay, well, go have fun." And that's what you do when you're not drinking. And that's going to help retrain your brain, rewire your brain and so forth. Well, I was really curious what actually does induce endorphins? I mean, what does science tell us about endorphin production? And there's quite a lot of research about it. It doesn't show up in the alcohol literature, but it shows up in other psychological literature and to measure endorphins that are applicable, you would naturally want to measure the endorphins in the brain, which requires cerebral spinal fluid measurements, which is science that I've done before.

John Umhau, M.D.: But it's not practical. You can do very similar measurement or not done completely differently, but you can also measure the amount of endorphins by the amount of pain tolerance that you get from a certain activity. So for instance, if you do an endorphin producing activity, it will increase your pain tolerance. So you can tolerate a blood pressure, cuff pressure, more where you can to, you can sit in a squat position longer, if you have more endorphins, it reduces the pain of that position. It's safe, but it's a very robust measure. So that's what they use in a lot of these studies to determine what induces endorphins. So it turns out, we think about endorphins being produced by eating sweet foods or spicy foods and maybe sexual activity. But there's also exercise. But what we have found recently is that it's not just these nice activities that make us feel good.

John Umhau, M.D.: It's activities that draw us to other humans. It's fascinating, it's synchronous human activity that drives endorphins. And the endorphins, like they're were designed to work in communities and group with other people. And that's how we get endorphins, not by just lifting weights in the basement by ourselves. We get endorphins by exercising with other people in synchrony. Think about the Chinese guys doing Tai Chi in the park, all in synchrony, they're getting endorphins. All right. So they did an experiment to kind of illustrate this. They had two conditions. The first condition, the study subject was moving his hands in synchrony, back and forth, back and forth with another subject at a distance on a video screen. So they were moving their hands back and forth, back and forth quite a bit and that induced endorphins. The second, the guy, the study was moving his hands back and forth in the same way as before.

John Umhau, M.D.: But the guy at a distance in the monitor was out of coordination. His hands were discoordinated, they weren't in sync at all, no endorphins. That was the only difference is one subject was in sync, one subject in one time they were not in sync. And it's the synchrony of human behavior that causes endorphins. So you can row by yourself. But when you row with other people on a rowing team, you can get rowers high, rowing in synchrony gives people endorphins, or you can exercise. You can ride bikes, but if you're in a spin class, you get the endorphins with other people bicycling with you. You can dance by yourself on the dance floor. But if you're dancing in synchrony with other people, that's the endorphin producing behavior. You can make music by yourself, but it's when you're with others, making music together, that's what's endorphins and you can laugh.

John Umhau, M.D.: You can laugh. You can watch a funny movie and you laugh, but think how much more you laugh when you're laughing with other people, okay. The endorphins are maximized being with other people. And I think this is really very important for us going forward to be able to recognize that this is exactly what we need to recommend. We need to recommend human interaction. And that's what the people in Iceland were doing. They were getting their youth together, doing healthy activities, where they were interacting. And that was what was causing the endorphin production, that was replacing the alcohol desire. Because remember alcohol is a molecule that probably doesn't reduce endorphins by itself. It has to be metabolized to the aldehyde and the metabolites that are endorphin like, and if someone is in pain, they need to feel pain relief.

John Umhau, M.D.: And so what do they do? They gather their friends about them and they commiserate with each other. If you're bereaved, you want people to come over and bring you meals, to be sit with you and to talk with you about life. If you don't don't have that, you drink or something like that, maybe, and it makes the alcohol much more desirable when you don't have a personal interaction. That's what's so devastating about the pandemic and the mask wearing and the isolation is that you don't have the natural human source of endorphins that were designed to get. And so for the pain relief, whether it's physical, emotional pain, we lend ourselves to these key ways of getting endorphins from chemicals like alcohol.

Chris Scott: Ancient neural circuitry that we ignore at our own peril. And actually, I mean, I can say that, I sometimes will do a solo cast, in other words, a podcast by myself. I haven't done one in a while, but my co-host Matt Finch has, often because I'm running around with various things and I feel bad, but sometimes I can't do a recording with him. I know that when I do a solo cast, I don't have the same high that I have after a podcast. And I also know that if we were doing this podcast in person and I shook your hand, gave you a hug, I'd have a way better high than I would from, endorphin high. I had always written that up to oxytocin. And maybe there's some, I mean, I'm sure there's always multiple neurotransmitter systems involved, but it definitely, it makes sense that it's endorphins.

Chris Scott: I did. I transitioned from doing heavy deadlifts often by myself to doing MMA training. So mixed martial arts, boxing, muay thai, jujitsu, wrestling. So, and I think one of the subconscious reasons I did that is that I had moved from Atlanta where I had a group of three guys, including myself, we would all do heavy deadlifts together. And it was great. We had the best high, I would wait for them to get off of their finance jobs. We hit the gym at 10:00 PM. It was the atmosphere you would have at like a party in college, except we weren't drinking. And they didn't have any problems with alcohol, that we weren't talking about not drinking. We just didn't happen to be drinking. So I literally forgot about it. That's how alcohol became, that's one of the ways alcohol became a moot substance for me.

Chris Scott: And I'm sure if I had been, well, maybe commiserating with people about the absence of alcohol. It wouldn't have been as good, but I was getting it endorphin rush from the deadlifts and from the being with these great guys. When I moved to Savannah, I didn't have that crew anymore. So it was me doing deadlifts by myself. So I found myself, as much as I loved deadlifts, even in isolation, I found myself realizing that I needed to find a group of people to work out with. I got back into mixed martial arts. My neck is still really sore right now from being put in multiple forms of headlocks by my coach yesterday, but it was so worth it. And I didn't feel anything when it was happening. It hurts now. And I'm going back there today and I won't feel the second I walk in there.

Chris Scott: It's like, "Let's go," it's the same feeling that I get. I can tell it's the same neurotransmitter system as when I was in college and I'd walk into a party and I would falsely attribute all the pleasure I was getting to this toxic substance called alcohol. But really it was that I was with my tribe at the tribe. And now I'm with my tribe when I walk in and broad daylight, which is way better to hang out with your tribe in broad daylight, getting endorphin high and actually sleep at night rather than disrupting your REM sleep and all of that. But that's extremely interesting. And then one other thing that I'll say is that I often, I don't think it's a coincidence that I found D-phenylalanine, which is an amino acid that helps to reduce the breakdown of endorphins.

Chris Scott: I think it inhibits an enzyme. It's often combined with L-phenylalanine, which is a dopamine precursor, similar to tyrosine. I took both of those DLPA for a year after I quit drinking. And when I didn't take them, I noticed that I felt a little more blah, life. It didn't go back to the black and white kind of sense, that's the best way I can describe my drinking years when I wasn't drinking. But it was like life lost a little bit of color. And then with that help probably because as it happened to increase endorphins a bit, I did feel like life was in full color and I was able to get the most out of my activities. So there's yet another nutrient that maybe we'll have some interesting studies on in the future. Yeah.

John Umhau, M.D.: Yeah. So, the practical take home message for your listeners is do things with other of people. I will say that if you're stuck by yourself, the other thing that gives you endorphins is interacting with dogs. So I tell most of my patients, they need to get a dog. There's no research on cats, but I do know that there is research that shows that playing with your dog would induce endorphins.

Chris Scott: I was going to say there's no peer reviewed double blind placebo controlled research on cats. So that means the cats do not increase endorphins, right?

John Umhau, M.D.: I don't. No, no, no, no, no, no.

Chris Scott: I had a cat growing up. I love cats too. I have my two dogs here. One of them was grooming his nether regions a minute ago. And I was trying to figure out whether to tell him to stop or not, but he seems to have gone sleep, but no, having these two dogs around has definitely, I mean, I just feel like I have my own little dog pack party all the time, which is further... I'm sure. And I also subconsciously I adopted the dogs in the, probably during what was the worst part of the lockdowns here. And I can't imagine what the pandemic would've been, even though it's been a lot more livable in Savannah than some other places, especially up north, what it would've been like without these dogs around, we're definitely social creature.

John Umhau, M.D.: Right. And I think the dogs pick up on the humans need to do endorphins. And they're really a gift, dogs are a gift to us. One of the things that I recommended to my patients therefore, is that they do racket sports with their spouse. So ping pong, but I've got a number of people that have described getting off alcohol by placing the activity of drinking with pickle ball, with just the racket sport back and forth. And they really get high on playing that or tennis, I'm sure we do the same, but it's really a very practical thing to know that doing something with somebody else. I have a patient that just plays catch with his wife. That's what they like to do. Totally endorphin producing kind of activity. And I think that's what we need to be moving for as a society.

John Umhau, M.D.: Just moving, doing things together, recognizing that you don't get endorphins from scrolling on your cell phone. You get endorphins from really true interacting with other people. And that's what we want for a long term recovery from alcohol problems. I really press all my patients to do the work that's required to really replace the alcohol with something else that will last them for lifetime. So they are never tempted again to the think about a need to drink, because they have the alcohol replaced by something that produces the healthy endorphins.

Chris Scott: Right. Yeah. Something that I've been thinking about the last few months is that there's a lot of obsession about so-called negative consequences and costs of drinking. And yet you'll see people lose their jobs or their families and continue to engage in the same activity that they know. It's not like they don't know that these costs aren't there. What seems to me to be happening is that well, A there's the biochemical hurdle that they usually don't address. And so perhaps the gray matter just never grows back. The white matter, the brain has shrunk. And the prefrontal cortex is not connected to the rest of the brain. However, there also seems to be that there's no preference change. There's no change in desire. And in other words, you can't live in a vacuum where there's drinking and then this vague idea of not drinking.

Chris Scott: If you've never harnessed your imagination to figure out what that means, what not drinking could mean, then it's actually, it's going to be worse than a vacuum. It's going to be this scary specter of something that you don't understand that you've never done. You've never greased neural pathways with that. You've never constructed new neurons in association with, so for me, there was never drinking or not drinking. Well, it was when I was a drinker after I quit, it was, "Well, I could drink, obviously I could drink." It's always an option, but I could also go do deadlifts with my friends. I could go to the park, I could go play golf. I could get back into martial arts. I could go to this rock climbing gym with a buddy, who's been wanting to do it for a year.

Chris Scott: There's an infinite number of things. It takes some imagination to figure out what works for everyone. So as with everything else, there's no one size fits all solution. Some people might not enjoy a rock climbing gym or not be able to do it, for some people pickle ball could be the solution, but it does seem that the most practical alternative to drinking is a fun activity that can be done with other people.

John Umhau, M.D.: Absolutely. Absolutely. There's so much that we're learning about alcoholism. I want to talk to you sometime, I don't have time today about aldosterone and some of the other new medicines that have been really helpful for my patients in my practice. But I've got to look forward to talking to you again, Chris, you have a wonderful ability to help people see a future beyond drinking and I commend you for your podcast.

Chris Scott: I really appreciate that. It means it's a lot coming from you Dr. Umhau, thank you so much for your time. I'm looking forward to part two. And can you briefly tell people where they can find you.

John Umhau, M.D.: Sure I'm at the alcoholrecoverymedicine.com site, and you have to type that into the address bar, alcoholrecoverymedicine.com. And I do telemedicine in a number of states and I look forward to meeting folks and talking to about the science behind the treatment for alcohols and particularly folks that have a hard time with the Sinclair method, that I know a lot of medicines that aren't typically appreciated for folks and sometimes naltrexone doesn't work for folks. And I like to help those people, especially.

Chris Scott: Well, you've helped a lot of people. I really appreciate your time. I'll let you go. But looking forward to next time. Thank you so much, Dr. Umhau.

John Umhau, M.D.: Thank you Chris.