Iron Direct Primary Care Podcast

What happens when addiction medicine, primary care, and national drug policy collide?

On this episode of the Iron Direct Primary Care Podcast, Stefan Hartmann, PA-C sits down with Dr. Andrea Barthwell, one of the most experienced voices in American addiction medicine.

Dr. Barthwell is a past president of the American Society of Addiction Medicine (ASAM) and served in the George W. Bush White House as Deputy Director for Demand Reduction at the Office of National Drug Control Policy (ONDCP).

She is the founder of Encounter Medical Group and Two Dreams and was the founding chair of the $100 million Foundation for Opioid Response Efforts (FORE).

This wasn't a conventional addiction-medicine interview.We discuss how American drug policy has changed—from the Bush-era War on Drugs and demand-reduction strategy to modern approaches emphasizing legalization, decriminalization, and harm reduction—and what decades of experience can teach us about the consequences of those choices.

A major part of the conversation focuses on marijuana and the increasing tendency to treat cannabis as medicine or routine self-care. Dr. Barthwell explains her concerns about the medicalization of marijuana, particularly when patients assume that legalization or a medical-marijuana designation automatically means strong evidence of therapeutic benefit or long-term safety.

We also go deep into something primary-care clinicians deal with every day:Sleep.Patients frequently arrive already using or requestingmedications such as:

Eszopiclone (Lunesta)

Trazodone

Gabapentin

Hydroxyzine

Diphenhydramine (Benadryl)

Atypical antipsychotics

We discuss the tradeoffs of using psychoactive medications simply to make someone sleep, how dependence and substance-use history should change prescribing decisions, and why insomnia deserves more thoughtful evaluation than simply adding another sedating drug.

We also discuss the role of primary care in identifying addiction early. Substance-use disorders do not always walk into the office announcing themselves. Alcohol, cannabis, prescription medications, stimulants, and opioids can become part of a patient's routine long before anyone formally identifies a disorder.

Finally, Dr. Barthwell explains why she remains strongly supportive of evidence-based medications for opioid use disorder, including methadone and buprenorphine, and why these therapies should be viewed as medical treatment rather than simply substituting one drug for another.

If you would like to learn anti aging medicine for primary care check out HRTPCP.COM to take our HRT courseConnect with Dr. Barthwell at https://www.linkedin.com/in/drandreabarthwell/andtwodreams.com

To download and read the full paper check out https://www.irondpc.com/blog

To learn HRT go to HRTPCP.com

Abstract
Background
Insulin resistance and elevated apolipoprotein B (ApoB) frequently coexist in adverse cardiometabolic phenotypes. However, biologic association does not establish that fasting insulin and ApoB provide interchangeable clinical information. Whether individuals with low fasting insulin reliably demonstrate low ApoB in routine primary care remains uncertain.
Objective
To characterize the relationship and discordance between fasting insulin and ApoB among adults undergoing same-day testing in a real-world primary care population, with secondary analyses incorporating hemoglobin A1c and exploratory analyses of female age, LC-MS estradiol, and ApoB.
Methods
We conducted a retrospective observational analysis of routinely collected laboratory data from a community-based primary care practice. The primary cohort included adults aged 18 years or older with numeric ApoB and explicitly fasting insulin measurements obtained on the exact same collection date. Each patient contributed the first chronologically qualifying paired measurement to the primary analysis. The primary outcome was the Spearman correlation between fasting insulin and ApoB. Secondary analyses assessed ApoB prevalence across fasting-insulin quartiles and multivariable associations adjusted for age and sex. Hemoglobin A1c was incorporated as an additional glycemic covariate in participants with same-day measurements. An exploratory female analysis evaluated exact same-day LC-MS estradiol and ApoB measurements.
Results
The primary cohort included 365 adults (62.7% male; mean age 48.0 plus or minus 13.0 years). Mean ApoB was 100.9 plus or minus 28.6 mg/dL, and median fasting insulin was 7.7 (IQR 5.1 to 12.6). Fasting insulin and ApoB were positively but weakly correlated (Spearman rho = 0.156; p = 0.0029). After adjustment for age and sex, each doubling of fasting insulin was associated with 4.19 mg/dL higher ApoB (95% CI 1.46 to 6.93; p = 0.0028).
Despite this association, substantial discordance was observed. Among participants in the lowest fasting-insulin quartile, 59.8% had ApoB of 90 mg/dL or higher and 44.6% had ApoB of 100 mg/dL or higher.
Hemoglobin A1c was available on the same date in 347 participants (95.1%). After additional adjustment for A1c, each doubling of fasting insulin remained associated with 3.47 mg/dL higher ApoB (95% CI 0.66 to 6.28; p = 0.015). Among 79 adults with both A1c less than 5.7% and fasting insulin in the lowest quartile, 60.8% had ApoB of 90 mg/dL or higher and 46.8% had ApoB of 100 mg/dL or higher.
In an exploratory analysis of 133 adult women with exact same-day ApoB and LC-MS estradiol measurements, estradiol was modestly inversely associated with ApoB in unadjusted analysis (Spearman rho = -0.182; p = 0.036), but this association was attenuated after adjustment for age.
Conclusions
Fasting insulin was positively but weakly associated with ApoB in this real-world primary care population. Elevated ApoB remained common among patients with low fasting insulin, including patients who simultaneously had A1c less than 5.7%. These findings suggest that fasting insulin, chronic glycemia, and ApoB provide overlapping but substantially nonredundant information. Exploratory female analyses demonstrated opposing age-related trajectories of estradiol and ApoB, although a single contemporaneous estradiol measurement did not independently explain ApoB after adjustment for age.
Keywords: apolipoprotein B; ApoB; fasting insulin; hemoglobin A1c; insulin resistance; estradiol; cardiometabolic risk; primary care; discordance

Prevalence of Silent Atherosclerosis across Adult Life. NEJM, August 2026.

REACT imaged 16,808 apparently ASCVD-free adults aged 18–70 with carotid/femoral 3D ultrasound and coronary CTA. Silent atherosclerosis was already present in 57.1% overall and was detectable even at age 18–29. Plaque burden then rose dramatically with age.

What does primary care look like when you combine traditional medicine, functional medicine, hormone optimization, cardiovascular prevention, and longevity medicine under one roof?

In this conversation, I sit down with Dr. Manuel Salvadori, Biologo Nutrizionista, for a fascinating Italian-American discussion about what we do at Iron Direct Primary Care in Melbourne, Florida—and why our model looks so different from conventional healthcare in both the United States and Italy.We start with the basics:

What is a Physician Associate (PA-C)?

What is Direct Primary Care? And how can a primary care practice spend 60–90 minutes with a new patient instead of trying to solve complex problems in a seven-minute visit?

From there, the conversation goes much deeper.

We discuss:• How Iron DPC combines primary care + functional medicine + anti-aging/longevity medicine

• Why prevention should be built into primary care rather than treated as a separate specialty

• Hormone replacement therapy and the differences between replacement, optimization, and abuse

• Estradiol, progesterone, testosterone, menopause, muscle loss and healthy aging

• Why simple interventions—diet, exercise, sleep, appropriate medications and hormone management—often matter more than exotic biohacks

• My evolving view of biohacking and why constant optimization can become counterproductive

• Peptides, NAD, mitochondrial medicine and when we actually use them• Cold plunge, sauna, red-light therapy, exercise and recovery at Iron DPC

• Why I increasingly favor a little “Euromaxxing”: coffee, conversation, slower living and enjoying life

• The economics of Direct Primary Care and why patients pay a predictable monthly membership rather than paying us every time they need care

• Major differences between the American and Italian healthcare systems

• And our somewhat ambitious proposal: could Italy eventually develop its own version of the Physician Associate model with Functional Medicine combined?

One of the central ideas behind Iron Direct Primary Care is simple:Primary care should not just manage disease after it appears. It should actively work to preserve health, function, muscle, metabolic health and cardiovascular health for decades.

That means treating the knee injury that walks in today—but also thinking about the patient's cholesterol, hormones, exercise, sleep, nutrition and long-term risk.

Medicine does not have to exist in silos. This was one of my favorite international conversations because Manuel approaches these subjects from an Italian nutrition and functional-medicine perspective, while I approach them from everyday clinical practice in the United States.🇺🇸

Conversation recorded in Italian🇮🇹 with English subtitles available

Learn more about Iron Direct Primary Care on Instagram and YouTube or at ironDPC.com

For healthcare professionals interested in my complete course on hormone and anti-aging medicine: HRTPCP.com

Stefan Hartmann, PA-C

CEO, Iron Direct Primary Care Melbourne, Florida

This discussion is for educational purposes only and is not individualized medical advice.

#DirectPrimaryCare #FunctionalMedicine #LongevityMedicine #HormoneReplacementTherapy #HRT #PrimaryCare #AntiAgingMedicine #MensHealth #WomensHealth #Biohacking #Peptides #PreventiveMedicine #IronDirectPrimaryCare

Gillian Godon Perue MD on Acute Ischemic Stroke Guidelines at the FAPA conference in Daytona Beach June 26, 2026.As always, if interested in our HRT course please pre register via the linkhttps://docs.google.com/forms/d/1GoX_B7V9PxZGAPch8_MeRED5WLIVKghqSMwFhqNJo1E/edit

In this talk at The Mermaid House in Indian Harbour Beach, Ashley Curtis, MSN, APRN, FNP-C of Iron Direct Primary Care (Iron DPC) shares insights on hormone replacement therapy (HRT) for women. Ashley is a Family Nurse Practitioner with over 20 years of nursing experience. She earned her Master of Science in Nursing from Western Governors University and brings a strong background in functional medicine and integrative nutrition to her practice. Passionate about relationship-based, preventive care, she prioritizes listening to patients and partnering with them to support long-term health, optimize quality of life, and address root causes rather than simply managing symptoms. Her clinical interests include hormone optimization, women’s health, performance medicine, metabolic health, and lifestyle-based care. Outside the clinic, Ashley is a dedicated weightlifter who lives an active lifestyle focused on performance, longevity, and sustainable health alongside her family. Learn more about Ashley and the Iron DPC team: https://www.irondpc.com/about-usVisit Iron DPC: https://www.irondpc.com #WomensHealth #HormoneOptimization #Menopause #IronDPC #FunctionalMedicine #BioidenticalHormones

Kratom and suboxone treatment by Neil Nipper MD at the FAPA conference in Daytona Beach June 26, 2026.As always, if interested in our HRT course please pre register via the linkhttps://docs.google.com/forms/d/1GoX_B7V9PxZGAPch8_MeRED5WLIVKghqSMwFhqNJo1E/edit

Hormone health is one of the most misunderstood areas of medicine. In this episode, I sit down with Dr. Salome Masghati, MD, FACOG, a board-certified OB/GYN, fellowship-trained minimally invasive gynecologic surgeon, and functional medicine practitioner, to discuss the science of optimizing women's health through evidence-based hormone therapy. Dr. Masghati combines traditional gynecology with preventive, longevity-focused care and has extensive experience helping women navigate perimenopause, menopause, fertility, and individualized hormone optimization.

Together we explore:

• Why women feel "different" in their 30s, 40s, and beyond
• Perimenopause vs. menopause—what's actually happening?
• The truth about estrogen, progesterone, and testosterone
• Common myths surrounding hormone replacement therapy (HRT)
• Estrogen's role in cardiovascular, brain, and bone health
• Sexual wellness and quality of life
• Individualized hormone therapy vs. one-size-fits-all protocols
• Functional medicine and evidence-based women's healthcare
• Longevity medicine and optimizing health for decades to come

Whether you're experiencing fatigue, brain fog, weight changes, low libido, sleep problems, mood changes, or simply want to better understand your hormones, this conversation is packed with practical information and current medical evidence.

Guest
Dr. Salome Masghati, MD, FACOG
Board-Certified OB/GYN • Fellowship-Trained Gynecologic Surgeon • Anti Aging Medicine
Learn more about Dr. Masghati:
Dr. Salome Masghati's website

Follow Dr. Masghati:
Instagram: @drsalomemasghatimd

Host
Stefan Hartmann, PA-C
CEO, Iron Direct Primary Care

Learn more about Iron Direct Primary Care:
Iron Direct Primary Care

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Disclaimer: This podcast is for educational purposes only and should not be considered personal medical advice. Please consult your healthcare professional before making changes to your treatment plan.

Can we eliminate the leading cause of death and disability? Medicine in 2026 is changing faster than ever before—and the evidence for aggressive lipid lowering has never been stronger.In this lecture for the Osteopathic Society of Integrative Medicine, I review the latest science behind lipid-lowering therapy, ApoB reduction, plaque regression, and cardiovascular prevention. We'll explore why the goal of modern preventive medicine isn't just helping people live longer—it's helping them stay healthier, stronger, and independent for more years.Topics include:Why ApoB is the true driver of atherosclerosisThe newest evidence on LDL and ApoB targets for plaque stabilization and regressionStatins, ezetimibe, PCSK9 inhibitors, bempedoic acid, inclisiran, and combination therapyWhy morbidity (heart attacks, strokes, disability, hospitalizations) matters just as much as mortalityThe evidence from tens of millions of patient-years demonstrating reductions in cardiovascular eventsPrimary prevention vs. secondary preventionHow lipid lowering fits into the broader field of human optimization and longevity medicinePractical strategies for implementing evidence-based prevention in everyday clinical practiceThis lecture challenges outdated approaches to cardiovascular prevention and demonstrates why aggressively treating atherosclerosis before symptoms develop may be one of the most powerful interventions available in modern medicine.Because the goal isn't simply adding years to life—it's adding life to years.If you enjoy evidence-based discussions on preventive cardiology, longevity medicine, hormone optimization, and primary care, be sure to Like, Subscribe, and Share.

Learn the principles of wound management in this lecture by Karla McNish at the FAPA conference in Daytona Beach June 27th 2026.As always if interesting in learning and applying HRT pre register for our course here https://docs.google.com/forms/d/1GoX_B7V9PxZGAPch8_MeRED5WLIVKghqSMwFhqNJo1E/edit