CEimpact Podcast

Is Ketamine the Next Wonder Drug?

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Did you know that ketamine, once known only as an anesthetic, is now being hailed as a game-changer in mental health and pain management? This episode dives into the surprising ways ketamine is revolutionizing treatments for depression, migraine headaches, and more. Get ready for a mind-blowing exploration of how this "wonder drug" could transform your pharmacy practice—don't miss out!

HOST
Joshua Davis Kinsey, PharmD
VP, Education
CEimpact

GUEST
Geoff Wall, PharmD, BCPS FCCP
Professor of Pharmacy Practice
Drake University

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CPE INFORMATION
Learning Objectives
Upon successful completion of this knowledge-based activity, participants should be able to:
1. Recall the pharmacological mechanisms of ketamine and its emerging therapeutic uses in mental health and pain management.
2. Discuss the potential clinical benefits and risks of incorporating ketamine into pharmacy practice.

0.05 CEU/0.5 Hr
UAN: 0107-0000-24-296-H01-P
Initial release date: 11/25/2024
Expiration date: 11/25/2025
Additional CPE details can be found here.

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Speaker 1:

Hey, ce Impact subscribers, welcome to the Game Changers Clinical Conversations podcast. I'm your host, josh Kinsey, and as always, I'm super excited about our conversation today. If you pay attention at all to the news, then you've probably heard ketamine mentioned a lot lately. It's gone from a well-known anesthetic to an unexpected contender in the fight against depression, ptsd, chronic pain, migraine headaches, and the list can go on and on. In today's episode we'll explore the fascinating science behind its resurgence, the opportunities it presents in pharmacy practice and the challenges ahead. It is so great to have Jeff Wallace my guest expert for this episode. If you've listened to our podcast before, then you are no stranger to Jeff. We are so excited to have him back with us today to discuss this topic. Welcome, jeff.

Speaker 2:

Thank you, I'm glad to be back. Seems like it's been a while since I've been on, so it's nice to be back.

Speaker 1:

Well, it's nice to have you back. Thanks again. So yeah, before we jump in, in case there are any learners who haven't listened to previous podcasts and if you haven't, then there's plenty of them on where you're listening currently from you can go back and listen to old episodes. If there is anyone that hasn't met you before, just give us a little bit about yourself, jeff, and maybe your practice site and your current role.

Speaker 2:

Absolutely. So yeah again, Jeff Wall, I'm a professor of pharmacy practice at Drake University in Des Moines, Iowa. Jeff Wall, I'm a professor of pharmacy practice at Drake University in Des Moines, Iowa. My practice site is at Iowa Methodist Medical Center here in Des Moines. It's a large tertiary care hospital where I'm the internal medicine clinical pharmacist. I kind of split my time between the medicine service and the ICU and then I'm also director of the Drake Drug Information Center. So when we get questions kind of thrown at us from various providers, my DI student and I try to handle that. So yeah, so kind of a busy job. But it's my 25th year here at Drake and Methodist it's hard to believe, yeah. So it's been really enjoyable and I'm glad to be able to do what I do.

Speaker 1:

That's great. I think I knew about the DI part, but I think for some reason that seems like a shock to me right now, so maybe I didn't really know about it. I don't know, but that's fascinating.

Speaker 2:

It's interesting that you know there aren't too many DI centers anymore anyway, right, I mean a lot of them have closed their doors, and so I'm grateful for the ability to you know, be able to do that right, because, I mean so, even a lot of drug information centers for colleges of pharmacy have closed, and because there's just there's just not a lot of data out there or not a lot of work out there, when you can look up everything on Google, yeah, but but that being said, we we've also learned a lot that you can. Actually there's still a lot of misinformation out there.

Speaker 1:

I'm sure you're well aware, and and so sometimes Google isn't your friend, and so it's the misinformation part that is so true, because you know, yes, anybody can Google anything, but also really just you know, digging through the information, making sure that it's coming from a reputable source and making sure you understand, you know the translation of something or the impact of something, or the the impact of something. So, yeah, I think it's great that there's still a DI center. I remember I did a rotation in my fourth year of pharmacy school, many moons ago, uh, in the DI center, when we still had one at my alma mater, and it was one of my favorites because it was just, it was always very I felt just like I was always like research, you digging around and like really trying to figure out answers to questions that were, you know, posing issues for practitioners. So I really enjoyed it Good to hear Yep.

Speaker 1:

All right, awesome. Well, back to our subject for today Again, another just really interesting topic. I feel like it's really just kind of hit the airwaves recently and just it's really back in front of everyone and it's such a fascinating topic because it's it just kind of came out of nowhere, in my opinion. So can you give us a little bit of a brief history, maybe about ketamine and its traditional uses, just under foundational understanding?

Speaker 2:

So ketamine is an interesting drug. It's one of those everything old is new again sort of phenomena that you do see sometimes, and I mean, I certainly think in my practice career I've seen drugs that kind of swung from, you know, whoever heard of this then now everybody's interested in it sort of thing, and ketamine certainly fits that mark. It was a drug that was actually initially made in the 1960s. It was synthesized in the 1960s as a derivative or a less potent version of LSD. So in the 1960s Sandoz Pharmaceuticals, which doesn't exist anymore, was kind of the pioneer in psychedelic drugs, and of course at the time, you know, psychedelics were being considered for use for all sorts of things. But LSD of course ended up having a lot of side effects and a lot of issues associated with it. And so ketamine was kind of designed as a kind of a milder version of a psychedelic.

Speaker 2:

But what they discovered during their trials was that it had far more use as an anesthetic than it did as a psychedelic. And so, even though it retains some of those psychoactive properties, it was actually first used on a broad basis in Vietnam, and actually medics in Vietnam would commonly use ketamine as a pain medication. They would also use it to help facilitate intubation in the field. And so it was. You know, that's really where it first started to get used.

Speaker 2:

And then, you know, throughout the 1970s it's used, kind of waxed and waned, and it ended up being kind of abandoned for human use throughout the 1980s and early 1990s, being kind of abandoned for human use throughout the 1980s and early 1990s, and was actually used primarily by veterinarians as an anesthetic for their procedures and stuff like that. So I mean, we went from a drug that was initially thought that, you know, this would be an interesting drug for mental health issues and other issues that psychedelics were purported to have a benefit for, to be used as an anesthetic in the field in a war situation, to being used more in animals than in humans. And now here we are again in the 21st century where it's being used for all sorts of different things. So again, everything old is new again.

Speaker 1:

I was going to say, yeah, it all comes full circle. So, yeah, so I don't know. For me, I think when I originally started hearing about it coming back up in the news and, you know, hitting social media platforms and whatever I felt like to me, what I remembered of ketamine was illicit use. Did it ever really have? Did it ever really get in that phase like LSD or whatever?

Speaker 2:

Yeah, absolutely Absolutely. And and of course you know it was called special K or vitamin.

Speaker 2:

K or all that sort of stuff. So yeah, so, so ketamine, like all psychoactive drugs you know, can be a drug of abuse, but it was pretty low, frankly, on the totem pole of drugs in the United States. That was abused. Psychedelics kind of fell out of major use as a drug of abuse in the 1980s anyway, I guess cocaine kind of took over for that, which probably isn't a good thing, you know. Yes, it has been a drug of abuse ever since its release in the market, but that's always been a pretty small, you know, percentage of patients who use it. But yes, it absolutely is and it is a controlled substance, sure sure, okay, yeah, all right.

Speaker 1:

So you touched on this briefly, but just because you mentioned that it was very similar to LSD, but we really didn't dig into like the pharmacology of it or the mechanism of action or something like that. So maybe just briefly tell us a little bit about why I guess it has such good anesthetic properties and maybe what it does.

Speaker 2:

So you know, like all drugs that seem to have multiple uses, ketamine has multiple mechanisms of action but it primarily is an NMDA receptor antagonist, and so we know that NMDA is a receptor that plays a role in a wide variety of disease states.

Speaker 2:

It stimulates substance P, so it's a prime mover in the response to pain. Particularly neuropathic pain seems to be mediated a lot by NMDA. We know that it plays a role in neurotransmitter release, and so the thought is that, again, blockade of it taps down neurotransmitter release, particularly serotonin and GABA. So the thought is that if I block that from happening, you get more serotonin release and you get more GABA release, which of course might lead to some of the benefits that we're seeing in some of the disease states we're going to talk about. And it probably has some effect directly on opioid receptors as well, although that, as I understand it, has not been studied to the degree that it is. So I mean, the bottom line is that any drug that seems to have so many different indications, as you might imagine, doesn't just hit one area, so it has a broad mechanism of action. But primarily, I think if you were to look in a pharmacology class, they would describe ketamine as an NMDA antagonist.

Speaker 1:

Got it. Okay, that makes sense. So where do you think, or why do you think, the reemergence of this drug occurred? Were we looking for alternatives? Would you give it a happen chance?

Speaker 2:

Why I like, why I think you know, I think there's a couple of reasons.

Speaker 2:

I think that primarily, I think ketamine started to see the resurgence they were not using for anesthesia right, for that they weren't using for operations or surgery or procedures, that it still had this NMDA blocking ability and still had its blocking ability of substance P, so it could be used as a possible treatment for pain again, particularly neuropathic pain.

Speaker 2:

And then with the opioid crisis in the 1990s and early 2000s, I think everybody was kind of reaching around for you know, what could we use for patients with chronic pain that isn't an opioid right, and so I think that's where the door kind of cracked open for the modern use of ketamine. That I think that ketamine you know that people were looking for a pain treatment for both somatic pain and for neuropathic pain that wasn't an opioid. And so there started to be some small experiments with it and you know case studies, case series I mean to this day there still aren't large randomized controlled trials really with ketamine and many of its indications, control trials really with ketamine and many of its indications but it garnered a pretty good reputation, I think, in the course of about a decade of being a drug that, at lower doses, has pretty decent pain-modulating abilities and the evidence that is out there suggests that, especially in single doses, it's probably as effective as, say, an opioid injection for the treatment of acute pain.

Speaker 1:

Okay, how is it tolerated by patients, like do they have like this after groggy effect? Or you know, like, how are patients responding to it?

Speaker 2:

So one of the big concerns with ketamine is because of its psychedelic effects. You can get, even at lower doses, something called a disassociative effect, where people kind of have like kind of almost. I mean it's been described as kind of an out-of-body experience and of course that can be frightening to patients and that had been known for a long time, and so researchers have suggested that okay. Well, if we're going to use these lower doses for other indications, we need to think about this dissociative state that some people can have and we may need to treat that preemptively with benzodiazepines. And that's still done in some indication. I think if you talk to people who are using it at lower again these low doses for depression, for pain, they have found that the disassociative effects are rare at the doses that they're using and so they keep some benzo on standby in case they need it.

Speaker 2:

But it isn't routinely given to patients who receive ketamine, unless they start to say, wow, I'm feeling really weird here. You know that's going on. And then of course, yeah, I mean you know it does have some CNS depressant properties, though interestingly in my world, in the ICU, it actually doesn't have any respiratory depressant properties. It actually doesn't have any respiratory depressant properties and in fact ketamine actually increases heart rate, increases blood pressure and increases respiration. It actually drives as a respiratory stimulus and so in the ICU we will sometimes use ketamine. For example, I just used it last week in a patient who had status asthmaticus right so had a really, really bad asthma attack. Bad enough they had to be in the ICU. Ketamine is a bronchodilator and we often will use it in patients who are, you know, threatening to have to be on mechanical ventilation or on mechanical ventilation as a preferential sedative in those patients.

Speaker 1:

Okay, so my brain immediately did this whole path of was it used a lot during COVID when we had people who were yeah, yeah.

Speaker 2:

No, it's a great question. And yes, though, I think we use that less for its bronchodilatory effects and more just for the fact that we had a lot of really, really, really sick patients that we had to deeply sedate for them to be compliant with the ventilator, really sick patients that we had to deeply sedate for them to be compliant with the ventilator, and unfortunately we were, you know, I mean, I you know many, many times we were giving people so much propofol that their triglycerides were going crazy and all that other stuff, and so we needed we needed to pull all the eggs out of the basket we could to sedate these patients. So I think it was less about the bronchodilatory effects and more about the sedative effects.

Speaker 1:

Got it, got it.

Speaker 2:

Okay, that was just a side note, that was a good question, but you know, but anesthesiologists have started to reincorporate ketamine in their sedative protocols and they have found that the combination of ketamine and propofol as an induction agent actually works really good because they cancel each other's side effects out. So you know, where propofol tends to drop people's blood pressure and heart rate, ketamine tends to increase and so they kind of cancel each other out and you'll hear anesthesiologists call it ketofol. Right, so that's the combination of ketamine and propofol, so ketofol you'll hear.

Speaker 1:

So yeah, Okay, okay, very fascinating. All right, let's talk then about some of the new emerging areas. So clearly, I think it's garnered a on in the mental health space and pain management. Let's talk a little bit about its reemergence and maybe the mental health space, like how is it being utilized there?

Speaker 2:

We should point out that, you know I mean no psychoactive drug you know that has these kind of properties should be used about. You know, some sort of supervision, Unfortunately, you know, as we've now learned, matthew Perry did not do that. I mean he did, but he had. You know, as we've now learned, matthew Perry did not do that. Well, I mean he did, but he had, you know, doctors who apparently didn't really care. So that's a whole other issue, right. But ketamine as an antidepressant, as I said, you know, had garnered some interest because of this ability to increase GABA and increased release of serotonin and other neurotransmitters. And so for treatment-resistant depression, right, people who tried multiple antidepressants and they weren't getting much of an effect of it. What we traditionally do, of course, is get those patients ready if they're candidates for electroconvulsive therapy. But unfortunately, ct still has some pretty negative connotations with it because of popular media perceptions of it, even though that's not true anymore in the 21st century, and we could do an entire podcast on that. It's actually safe and effective, but people are leery of doing that, and so people were saying well, we know these potential benefits of ketamine, can we give this a shot in patients? And so that's exactly what happened.

Speaker 2:

There was a number of case reports and case series that came out in the early 2000s where patients who had treatment-resistant depression, particularly depression with suicidal ideation. So we had patients who had severe depression, who had high levels of suicidal ideation, who again, normally we would immediately put in the hospital, put them on a regimen of antipsychotics and antidepressants or send them to ECP. They tried ketamine on and, anecdotally, they were finding these tremendous responses that people were feeling much better, they weren't feeling suicidal anymore. When they did scales of depression, like the Hamilton Depression Score, they found that the numbers were incredible and you know that garnered, I think, some initial excitement. Numbers were incredible and you know that garnered, I think, some initial excitement. And so the thing that the case series and case studies had a real strike against was that one. They weren't randomized controlled trials. We were just trying ketamine people and seeing what was happening.

Speaker 2:

And in mental health studies that's always, you know, concerning. I mean, you really need to have a well-done, you know control arm. You know when you're talking about depression or anxiety and stuff like that. The other problem was the patients that it did work for. It didn't last very long. The benefits seemed to last anywhere from one to three weeks and then all of a sudden they were kind of back to where they were before. So even though ketamine seemed to have some potential benefit as a drug to treat depression, there was some concern that the effects weren't long-lasting and that we might be overplaying or overstating its benefit In the interim.

Speaker 2:

In the second decade of the 21st century we have had some randomized control trials that have looked at ketamine for, again, treatment-resistant depression, and probably the best study was a study done a couple years ago in the New England Journal of Medicine where they compared ketamine to ECT directly in treatment-resistant depression. And again, ect has long been considered the gold standard treatment for that because it is so effective. And so this study basically looked at giving regular infusions of ketamine compared to ECT treatment and basically, even though you know again, the study wasn't perfect and there have been some criticisms of the study, particularly that the ECT protocol they used is not probably the standardized protocol everybody uses. But you know, without getting into the weeds too much on that, they basically found that ketamine was non-inferior to ECT. So we now actually had data that showed that it was probably at least as effective for the gold standard and that with regular infusions this-depressant effect was long lasting that people did do well over the long term with it so that was that was my questions.

Speaker 1:

Real quick was um on the previous studies where you said that they saw it wax and wane after, you know, one to three weeks. Was that like the initial dose? Or were they on a consistent dose and they saw the effects go? So they were?

Speaker 2:

yeah good questions. They were on a single dose and they saw the effects go away. So they were on yeah, good questions, they were on a single dose and then it kind of faded away. So in this case in the ECT study they did look at a standardized dose over a period of time. So currently ketamine is not FDA approved for depression and probably never will be right. But it is worth noting that there is a nasal spray derivative of ketamine called S-ketamine that is FDA approved for treatment-resistant depression and some psychiatrist offices are offering it. So there is an FDA kind of cousin of ketamine that could be used, but it's really expensive, there's a lot for the pharmacists out there, there's a REMS program associated with it, et cetera, et cetera, et cetera. So it just frankly, the path of least resistance has been for a lot of psychiatrists to basically start ketamine clinics, essentially where patients would go in and receive regular doses of intravenous ketamine.

Speaker 1:

Okay. So going back to the nasal medication, why did they do it as a nasal spray? What was the reasoning for that?

Speaker 2:

So, as I understand it, oral ketamine is not well absorbed. I mean you can, if you use higher doses of it, you can overwhelm that and get some absorption, but oral ketamine is just not well absorbed. So they had to bypass the oral route and and do it instead of.

Speaker 1:

Instead of doing an injection where they had to come in, then it was more of a nasal where they could do it at home or whatever.

Speaker 2:

Okay, or again, where these are psychiatrist offices we're talking about. So they're probably not not going to have infusion centers and then stuff like that, so right okay, that's kind of where we've seen it come back for the depression.

Speaker 1:

Is there there anywhere else in the mental health space that we've seen kind of a resurgence, where now they're kind of like oh, let's test it here too. Maybe this is how.

Speaker 2:

I think that the studies that have looked at its use in patients with treatment-resistant depression have also found benefits in anxiety as well. I don't know if ketamine is ever going to be used only for anxiety or panic disorder, but I think in patients who have concomitant depression and anxiety, which many people do, they might see a benefit in both. But the cousin related to that is post-traumatic stress disorder and we've struggled for decades to find effective pharmacologic therapy for PTSD. Many of these patients are on antidepressants, they're on antipsychotic drugs. A lot of them are on alpha blockers because there's some evidence to suggest that helps with the nightmares that are associated with patients with significant PTSD. So you know again, anything we can use that might help with PTSD might be beneficial. And again it seems that drugs that have a psychedelic component to them seems to help. If you do them with intensive therapy like intensive psychotherapy along with them, they seem to be beneficial.

Speaker 2:

There's ongoing studies right now looking at whether ketamine or esketamine will be beneficial for PTSD. I'm sure it's being used off-label even as we speak. For this I think there's been a little more caution. Mdma or ecstasy was going to be approved for PTSD but FDA actually denied the company the approval for it because they felt the data wasn't very good, wasn't very strong. So that's put a little bit of the brakes on wholeheartedly embracing psychedelics for PTSD. But we'll see what happens. I think ketamine is being used, I'm sure off-label for PTSD, but we'll see what happens. I think ketamine is being used, I'm sure, off-label for PTSD. But there's currently ongoing studies that will help answer that question.

Speaker 1:

Okay, so let's segue into a couple of other opportunities that we've seen kind of for ketamine, one being migraine headaches. Do you want to talk about that a little?

Speaker 2:

bit Again, any acute pain stage so migraines, kidney stones, anything along those lines it's reasonable to assume that ketamine is going to have effects kind of similar to opioids, and that's pretty much exactly what we've seen. Again, very little randomized control trial data or anything like that. Case series and retrospective studies that have suggested that ketamine is probably as effective for the pain associated with acute pain states again, such as acute migraine, kidney stones, even like dislocated shoulder trauma, things along those lines, and many emergency rooms my own one at Methodist included are routinely using ketamine as acute dosing for many of these indications and they're finding, again, very, very good effects. No randomized controlled trial data but I think, anecdotally and in the evidence that we've got so far, a single dose of ketamine seems to be as effective as, say, a dose of morphine or a dose of Dilaudid for treating acute pain.

Speaker 1:

Okay. Okay, you touched on briefly the potential for misuse and abuse and how. Maybe you know previously that that was the case for this, but as far as now it sounds like it's either going to be an infusion clinic or it's going to be. It's not like you're going to just get a pill of bottle of 30 pills of ketamine, right? Because-.

Speaker 2:

No, there are some compounding pharmacies that are making ketamine, troches right, or sublingual ketamine. I don't have a problem with that, but, as you might imagine, what's the dose? How much, how frequently, is anybody's guess.

Speaker 1:

basically, right right, okay, so you also touched on how, even with the cousin drug, the nasal version, and how there's a REMS program and whatever. So talking about pharmacy practice, obviously we want to be sure that we highlight, you know, what's ketamine's role in that, like, are we going to see it really flourish or is it still going to be mostly in, you know, the psych visits and stuff like that, visits and stuff like that.

Speaker 2:

So I think it's a good question. I think, given its formulation, that unless somebody comes up with a commercially available enteral or oral version of it, I don't see the average community pharmacist having to deal with this. I think if they're a compounding pharmacist and they're making this up, that's something different. Most community pharmacists will be aware of it, but they won't be mixing the ketamine up. They won't be. You know, the S-ketamine nasal spray is administered right in the psychiatrist's office. So my guess would be that until an oral version or oral derivative comes out, that probably won't be a big thing. However, I think that pharmacists do need to be aware that people are using this medication and we don't have long-term data. We don't know what's going to happen long-term with these medications.

Speaker 2:

If someone's getting a ketamine infusion every month for six months, what are some of the issues? And one of the big ones that has popped up with ketamine has been non-infectious cystitis. And if there's a big long-term side effect that has been reported with ketamine, it's basically an interstitial or non-infectious cystitis. So these people get symptoms just like they've got a urinary tract infection, right. So frequency, urgency, dysuria, the whole nine yards. But it's not infectious and that has been well-reported with long-term use of ketamine. And so again, a community pharmacist, you know someone, comes in and says, yeah, I've been having these symptoms, I don't know what's going on. And the pharmacist, you know I went to the doctor and they say I don't have a urinary tract infection.

Speaker 1:

You know a provider may not make that connection right, that you know ketamine that's a common side effect of ketamine, and so I think community pharmacists still need to be aware that their patients are on these medications Well, and I think that's a good call out in general to the fact that you know. It's so important to make sure that you're asking the right questions, to know what all medications are you on or what are you taking that maybe I'm not feeling like. Are you getting something from?

Speaker 1:

a mental health facility or are you getting something else mail order? You know that's a special drug that I don't stock or whatever. So I think that's just a call on in general that the pharmacy needs to be thorough in every discussion that we're having with our patients.

Speaker 2:

And it's worth noting that a lot of these ketamine infusion clinics are standalone clinics, right? So they're not really linked up with an infusion center or traditional infusion center or a health system. In my town we've got a couple of independent practitioners I don't think they're even psychiatrists, they're mid-level nurse practitioners who've decided to kind of throw out their shingle and start ketamine clinics, and again, there's no connection with the health systems in town. So again, does the primary care doc know that you're getting this? That's a good question.

Speaker 1:

Yeah, definitely making sure that we're continuing with the continuity of care and making sure that it's that it's optimal. So that's great. Well, I think we are. I think we could go on for 30 more minutes on the subject, as you told me when I initially proposed it and you were like, yeah, that we're gonna have to narrow that down.

Speaker 1:

We could go on and on and on so, but we're running out of time for today. What we'd like to do at the end is just to kind of bring it back and you kind of have said this throughout and summarized it even recently. But what's the game changer here, Like for our listeners, what do they need to know and what's the take home for today?

Speaker 2:

Right.

Speaker 2:

I think that that for for depression, I think, is where we have ketamine has the strongest data and I think that you know letting patients know if they have treatment-resistant depression.

Speaker 2:

There is an option now, and I think that there's enough evidence out there that, as long as they're not looking up ketamine on the internet and finding some person in their town who has no connection with their healthcare system, as long as someone you know is monitoring what they're doing, it is a reasonable option and I think it's something we really should consider, especially in patients who maybe have a high level of suicidal ideation, because that's where it really seems to have a lot of benefit. I think if you're going to be in the emergency room because you have an acute migraine, because you have a kidney stone, because you dislocated your shoulder or broke your ankle or something along those lines, don't be surprised if a single dose of ketamine is used for those patients, because for acute pain and for procedures too, a lot of my docs are using it for bronchoscopies and endoscopies and stuff like that. You're going to see ketamine being used more and more for that sort of thing. So I think that's really the game changer.

Speaker 1:

Yeah, and I think that's good to know, because if you weren't in the know and you had a patient come in and say, oh, I was given a shot of ketamine, I feel like you might question that ER if you weren't in the know.

Speaker 2:

So yeah, exactly correct, exactly correct yeah.

Speaker 1:

Okay, well, great Well, that's all we have time for this week. Jeff, thanks again for joining. As always, it's a pleasure. Thank you, Thank.

Speaker 2:

Thank you. Thank you for having me.

Speaker 1:

If you're a CE plan subscriber, be sure to claim your CE credit for this episode of Game Changers by logging in at ceimpactcom and, as always, have a great week and keep learning. I can't wait to dig into another game changing topic with you all next week.